Diagnostics in Clinical
Neuropsychology
Lectures and practice questions
Table of Contents
Lecture 1: Introduction, Basic principles and ethics...............................................................................2
Lecture 2: Dementia 1............................................................................................................................7
Lecture 3: Atypical forms of dementia.................................................................................................16
Lecture 4: Neuropsychological problems in multiple sclerosis and epilepsy........................................26
Lecture 5: Stroke and Traumatic Brain Injury.......................................................................................39
Lecture 6: Neuropsychiatry..................................................................................................................51
Lecture 7: Oncology and Tumours........................................................................................................62
Practice exam.......................................................................................................................................72
Answers................................................................................................................................................85
,Lecture 1: Introduction, Basic principles and ethics
The position of the (neuro)psychologist
European psychology associations agreed that five years of psychology education plus one year of
supervised practice is the minimum for being a ‘licensed psychologist’
Tasks and responsibilities:
- Clinical neuropsychologist
o Scientific research
o Management tasks
o Specialized assessment and treatment
- Health care psychologist
o Autonomous functioning professional
- (neuro)Psychologist, MSc
o Providing psycho-education
o (neuro)psychological assessment under supervision
o (neuro)psychological treatment under supervision
- Cognitive trainer (HBO)
o Providing protocolized cognitive training
o (neuro)psychological assessment (test assistant)
Where do neuropsychologists work?
- Rehabilitation centres
o Assessment, cognitive training, neuropsychological rehabilitation and research
- Mental health care
o Assessment, treatment and research
- Hospitals
o Assessment, brief treatment and research
- Nursing homes
o Assessment, treatment and coaching care teams
- Forensic care facilities
o Assessment and treatment
- Expertise assessment
o ‘letselschade’ / personal injury
Basic Principles of diagnostics in CNP
Referral and research question (empirical cycle)
Taxonomy by Bijttebier (2013)
- Recognition/diagnosis: what are the problems, what is intact and what is impaired
- Explanation: why do the problems occur and/or in what way are they maintained
- Prediction: in what way will the problems of the patient develop in the future
- Indication: in what way can the problem be treated
- Evaluation: are the problems sufficiently addressed by the treatment?
Diagnostic process is dynamic!
o Hypotheses can be generated, tested and updated at multiple stages in the empirical
cycle
Anamnesis / history taking
- In the form of a semi-structured conversation
- Focus on the type, course and severity of complaints
, - Focus on predictions based on the ‘first’ hypotheses (based on brain-behaviour relationships)
- Ask for limitations in daily life activities
- Always ask for specific examples to avoid misunderstanding
Always observe at the same time!
Symptoms verses syndromes
- Symptoms are not syndromes!
- Ordering complaints and symptoms of the patient
- Recognition of syndromes and patterns of impairment
Do not only search for confirmation. Also ask for symptoms that would not fit one or more of
your hypotheses in order to be able to reject incorrect ones
o Take the base-rate information into account
Hetero anamnesis
- Information from someone close or otherwise health care professional
- Informed consent from the patient is needed
- Additional source of information: increase reliability
- Insight / awareness of the disease
- Attention for inconsistencies
Observe behaviours and interaction!
Determine the set of hypotheses you are going to test
o Unstructured: clinical observation
o Structured: instruments to test
Operationalization: how to test the premises of the hypotheses
Choosing instruments to measure cognitive function
- Preferably at least two tests per cognitive domain (Reliability)
- Always include tests about attention, memory and executive functions to investigate
relations between them.
o These functions are central and connected
o Memory test at the beginning and the end to investigate fatigue and attention
- Adapt tests to take the impossibilities of the patient into account
o Visual impairments, hearing problems, paralysis of the dominant hand
- Quality of the instruments
o Reliability: small measurement error and high test-retest reliability
, o Validity: the extend to which a test accurately measures what it is supposed to
measure
o Norms: Availability of an appropriate norm group based on age, gender and
education
COTAN: reviews test instrument based on statistical characteristics
If you find an impaired result, you can increase the reliability by replicating that in another test. One
impaired result can also be explained by chance.
- Repeated testing: Reliability
o Cognitive functions over time (disease progression,
recovery …)
o Confidence interval: significant change or not?
o But: practice effects, test wiseness
o Example: Rey Complex Figure test
Visuospatial memory: incidental learning
Parallel-test reduces the practice effect, but not test wiseness
Using another figure that the patient has to draw
Not all tests have a parallel version!
- Trail making test is scored insufficient by the COTAN norms
o But we still use this test a lot! There are other norms used than tested by the COTAN
Be aware about the limitations of instruments, and if available, choose instruments with the
highest quality
Test administration
- Order: generally no significant effects of the order on test results, however:
o Interference effects
15 words test: you have to recognize and remember words after a 30
minutes interval
Tests addressing (verbal) semantic memory, such as verbal fluency
tests, naming tests will interfere with the 15 words test
o Effects of fatigue due to long testing
o Tests addressing the same function
o Motivation and anxiety
Anxious patient: start with an easy test to give them confidence
Critical patient (low motivation): more difficult test
- Standardization of the test instructions
o Sometimes you have to adjust the instructions if someone is really impaired
- Testing the limits
- Quitting a test early
o If you certain that a patient is not going to fulfil all tests
- When to test? Wait at least 6 weeks in the following cases, you expect recovery each day:
o Substance abuse
o Delirium
o Stroke / TBI
Premorbid functioning: estimation based on demographics (e.g. age, gender, education)
- There are various scales to standardize the raw scores of a test
o Raw scores are not informative because they are not corrected
Percentile: 50% is the average
o These systems are to describe the scores with labels
Neuropsychology
Lectures and practice questions
Table of Contents
Lecture 1: Introduction, Basic principles and ethics...............................................................................2
Lecture 2: Dementia 1............................................................................................................................7
Lecture 3: Atypical forms of dementia.................................................................................................16
Lecture 4: Neuropsychological problems in multiple sclerosis and epilepsy........................................26
Lecture 5: Stroke and Traumatic Brain Injury.......................................................................................39
Lecture 6: Neuropsychiatry..................................................................................................................51
Lecture 7: Oncology and Tumours........................................................................................................62
Practice exam.......................................................................................................................................72
Answers................................................................................................................................................85
,Lecture 1: Introduction, Basic principles and ethics
The position of the (neuro)psychologist
European psychology associations agreed that five years of psychology education plus one year of
supervised practice is the minimum for being a ‘licensed psychologist’
Tasks and responsibilities:
- Clinical neuropsychologist
o Scientific research
o Management tasks
o Specialized assessment and treatment
- Health care psychologist
o Autonomous functioning professional
- (neuro)Psychologist, MSc
o Providing psycho-education
o (neuro)psychological assessment under supervision
o (neuro)psychological treatment under supervision
- Cognitive trainer (HBO)
o Providing protocolized cognitive training
o (neuro)psychological assessment (test assistant)
Where do neuropsychologists work?
- Rehabilitation centres
o Assessment, cognitive training, neuropsychological rehabilitation and research
- Mental health care
o Assessment, treatment and research
- Hospitals
o Assessment, brief treatment and research
- Nursing homes
o Assessment, treatment and coaching care teams
- Forensic care facilities
o Assessment and treatment
- Expertise assessment
o ‘letselschade’ / personal injury
Basic Principles of diagnostics in CNP
Referral and research question (empirical cycle)
Taxonomy by Bijttebier (2013)
- Recognition/diagnosis: what are the problems, what is intact and what is impaired
- Explanation: why do the problems occur and/or in what way are they maintained
- Prediction: in what way will the problems of the patient develop in the future
- Indication: in what way can the problem be treated
- Evaluation: are the problems sufficiently addressed by the treatment?
Diagnostic process is dynamic!
o Hypotheses can be generated, tested and updated at multiple stages in the empirical
cycle
Anamnesis / history taking
- In the form of a semi-structured conversation
- Focus on the type, course and severity of complaints
, - Focus on predictions based on the ‘first’ hypotheses (based on brain-behaviour relationships)
- Ask for limitations in daily life activities
- Always ask for specific examples to avoid misunderstanding
Always observe at the same time!
Symptoms verses syndromes
- Symptoms are not syndromes!
- Ordering complaints and symptoms of the patient
- Recognition of syndromes and patterns of impairment
Do not only search for confirmation. Also ask for symptoms that would not fit one or more of
your hypotheses in order to be able to reject incorrect ones
o Take the base-rate information into account
Hetero anamnesis
- Information from someone close or otherwise health care professional
- Informed consent from the patient is needed
- Additional source of information: increase reliability
- Insight / awareness of the disease
- Attention for inconsistencies
Observe behaviours and interaction!
Determine the set of hypotheses you are going to test
o Unstructured: clinical observation
o Structured: instruments to test
Operationalization: how to test the premises of the hypotheses
Choosing instruments to measure cognitive function
- Preferably at least two tests per cognitive domain (Reliability)
- Always include tests about attention, memory and executive functions to investigate
relations between them.
o These functions are central and connected
o Memory test at the beginning and the end to investigate fatigue and attention
- Adapt tests to take the impossibilities of the patient into account
o Visual impairments, hearing problems, paralysis of the dominant hand
- Quality of the instruments
o Reliability: small measurement error and high test-retest reliability
, o Validity: the extend to which a test accurately measures what it is supposed to
measure
o Norms: Availability of an appropriate norm group based on age, gender and
education
COTAN: reviews test instrument based on statistical characteristics
If you find an impaired result, you can increase the reliability by replicating that in another test. One
impaired result can also be explained by chance.
- Repeated testing: Reliability
o Cognitive functions over time (disease progression,
recovery …)
o Confidence interval: significant change or not?
o But: practice effects, test wiseness
o Example: Rey Complex Figure test
Visuospatial memory: incidental learning
Parallel-test reduces the practice effect, but not test wiseness
Using another figure that the patient has to draw
Not all tests have a parallel version!
- Trail making test is scored insufficient by the COTAN norms
o But we still use this test a lot! There are other norms used than tested by the COTAN
Be aware about the limitations of instruments, and if available, choose instruments with the
highest quality
Test administration
- Order: generally no significant effects of the order on test results, however:
o Interference effects
15 words test: you have to recognize and remember words after a 30
minutes interval
Tests addressing (verbal) semantic memory, such as verbal fluency
tests, naming tests will interfere with the 15 words test
o Effects of fatigue due to long testing
o Tests addressing the same function
o Motivation and anxiety
Anxious patient: start with an easy test to give them confidence
Critical patient (low motivation): more difficult test
- Standardization of the test instructions
o Sometimes you have to adjust the instructions if someone is really impaired
- Testing the limits
- Quitting a test early
o If you certain that a patient is not going to fulfil all tests
- When to test? Wait at least 6 weeks in the following cases, you expect recovery each day:
o Substance abuse
o Delirium
o Stroke / TBI
Premorbid functioning: estimation based on demographics (e.g. age, gender, education)
- There are various scales to standardize the raw scores of a test
o Raw scores are not informative because they are not corrected
Percentile: 50% is the average
o These systems are to describe the scores with labels
