Diagnostics in Clinical Neuropsychology
Lectures
Table of contents
Week 1 – Introduction and basic principles ...............................................................................2
Week 2 – Stroke and traumatic brain injury ...............................................................................9
Week 3 – Dementia 1 ............................................................................................................. 19
Week 4 – Dementia 2 ............................................................................................................. 29
Week 5 – Multiple sclerosis and epilepsy ................................................................................ 39
Week 6 – Neuropsychiatry & neurodiversity ............................................................................ 47
Week 7 – Oncology and brain tumors...................................................................................... 58
, Week 1 – Introduction and basic principles
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.’
- (Neuro)psychologist → different forms of postgraduate/postmaster education with
supervised practice (1-6 years) → licensed psychologist
- After your MSc studies in the Netherlands, you are a (neuro-)psychologist, MSc = master
psychologist / ‘basispsycholoog’ = unprotected title in the Netherlands → anyone can
use the title, even if they didn’t do the educational programs
o +2 years for healthcare psychologist and +4 years for clinical (neuro)psychologist
→ additional training in scientific research, management tasks, educational
programs
▪ They do the specialized assessment and treatment (more complex ones)
o +4 years for psychotherapist → more focused on treatments, usually involves
complex patients with personality problems or a lot of comorbidity
Tasks and responsibilities (Fasotti, 2005): Hierarchy
- Clinical neuropsychologist
o Scientific research
o Management tasks
o Specialized assessment and treatment
- Health care psychologist (‘licensed psychologist’)
o Autonomous functioning professional
o After several years of experience: training and supervising others
- (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) → taking the test, but not
interpreting them
Where do (neuro)psychologists work?
- Rehabilitation centers (assessment, cognitive training, neuropsychological
rehabilitation, and research)
- Mental health care (assessment, treatment, and research)
- Hospitals (assessment, brief treatment, and research)
- Elderly care (assessment, treatment, and coaching care teams)
- Forensic care facilities (assessment and treatment)
- Expertise assessment (‘letselschade’/personal injury)
- Schools
- Note that the emphasis on the type of professional activities might differ depending on
the context
,Basic principles of diagnostics in clinical neuropsychology
Diagnostics in clinical neuropsychology: Neurospsychological Assessment
- In relationship to the dysfunctioning of the brain
The cycle starts with a referral and ‘research question’ (empirical cycle)
(Neuro)psychologist as scientist-practitioner (N=1) who is doing the empirical cycle and forming
a hypothesis about what is happening to a patient
Taxonomy of different types of questions that you might have in a psychological assessment, by
Patricia Bijttebier et al. (2018):
- 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 problem of the patient develop in the
future?
- Indication: In what way can the problems be treated?
o Also important in rehabilitation → aim the treatment at the
function that is actually impaired
- Evaluation: Are the problems sufficiently addressed by the
treatment? → e.g., in suspected dementia patients
- The diagnostic process is dynamic: hypotheses can be generated,
tested, and updated at multiple stages in the empirical cycle
Evaluation 1, analysis and hypothesis (explanatory): question/referral,
medical file investigation, history taking/anamnesis, heteroanamnesis,
first impressions/observations/formulating hypotheses (DD), making a
(neuro)psychological assessment protocol (NPA), performing the NPA:
more specific observations, scoring test results, interpretation of test
results, hypothesis testing, conclusion: integrational description of results
and answer the question(s)
Anamnesis/history taking → you have limited time (30-60min), so keep the hypotheses in mind
and ask specifically for the things that are relevant to your hypothesis
- In the form of a semi-structured conversation
- Focus on the type, course, and severity of complaints
- Focus on predictions based on the ‘first’ hypothesis → based on brain-behavior
relationships and on information before the patient enters the room
- Ask for limitations in daily life activities → do not only ask about complaints, but also
about what the effect is on daily life, and ask for examples
o Especially in rehabilitation, if you do a training or treatment, you want to be sure
that it also affects their daily life
o Self-awareness: can the patient link the complaints to their daily life functioning?
o You need to know what is going wrong in daily life to make a diagnosis of
dementia → DSM-5 criteria for dementia
- Always ask for specific examples to avoid misunderstandings
o Memory complaints
o Concept of long-term and short-term memory
Symptoms vs. syndromes
- Symptoms ≠ syndromes
- Syndrome = constellations of symptoms that tend to co-occur
, o Give guidance on what to ask for in your history taking interview
- DSM-5 is used as a background work for what symptoms belong to a particular
syndrome
- Ordering complaints and symptoms of the patients
- Recognition of syndromes and patterns of impairments
- Note 1: Do not only search for confirmation. Also, ask for symptoms that would not fit
one or more of your hypotheses to be able to reject incorrect ones.
- Note 2: Take the base-rate information (i.e., the a priori chance) into account
Heteroanamnesis
- Information from someone close or a health care professional (e.g., nurse)
o Can be difficult when someone does not have direct family members or not a
very close social system
- Informed consent by the patient is necessary
- Additional sources of information: increase
reliability
- Insight/awareness of disease
- Attention for inconsistencies
- Again: opportunity to observe!
o Behavior and interaction
You have your hypotheses, first impressions, and more information from the patient and family;
now select your instruments. There are structured and unstructured instruments.
- Structured → any test, questionnaires, and observation instruments themselves
- Unstructured → observe how a patient is doing and approaching a test; depends on the
situation
Determine the set of hypotheses you are going 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 → to be sure the
results are related to that domain rather than other factors
o Also statistical: the chance of having two very low scores is even
less likely than having one very low score
- Relationships between attention, memory, and executive functions → contribute to each
other, so test these domains selectively to find out which one is the problem
o Always include tests for these three domains
- Impossibilities of the patient (e.g., visual impairment, hearing problems, paralysis of the
dominant hand)
- Quality of the instruments
o Validity (the extent to which a test accurately measures what it is supposed to
measure)
o Reliability (small measurement error and high test-retest reliability)
o Norms (availability of an appropriate norm group based on age, gender, and
education)
o In the Netherlands: The “Commissie Testaangelegenheden Nederland” (COTAN)
reviews the quality of common (neuro)psychological tests and questionnaires
, Repeated testing: reliability
- Cognitive functions over time (disease progression, recovery…) → to
measure differences over time
- Confidence interval: significant change or not?
o Ideally, you would have a test with small confidence intervals
where small changes in test scores are already significant
o Large confidence intervals have a lot of measurement error, and the change
might not be that indicative of an actual clinically significant change
- But: practice effects (especially memory test), test wiseness
An example: The Rey Complex Figure Test → copy the figure and later draw
it again from your memory (after three minutes and/or half an hour)
- Visuospatial memory: incidental learning
- Parallel-test (Taylor Complex Figure) reduces the practice effect,
but not the test wiseness (patient is familiar with the catch of
drawing it from memory later)
COTAN evaluations
- “The ‘mission’ of the COTAN is to enhance the quality of tests and the use of tests in the
Netherlands by informing test users, developers, and publishers about the availability,
the content, and the quality of various instruments. First, this is done by reviewing the
quality of a wide range of tests and questionnaires, and second, by drawing up standards
on the use of (psychological) instruments, such as the Algemene Standaard Testgebruik
(General Standard Test Use).”
- The COTAN reviews, amongst other things, the quality of the test construction, the
manual, and the norms of tests. They also examine the psychometric qualities of tests,
such as the validity (does the test measure what it aims to measure) and the reliability
(e.g., how stable are the scores over time).
- High demands are placed on the size and composition of the norm groups (> 400
participants for a “sufficient” rating). This is not always feasible due to the relatively
small number of Dutch speakers.
- The COTAN needs time to conduct reviews. As a result, recently developed tests or
recently released new norms have often not yet been reviewed.
- Bottom line: Be aware of the limitations of instruments and, if available, choose
instruments with the highest quality
Test administration
- Order – generally no significant effects of order on test results, however:
o Interference effects
▪ For example: during a ± 30 minutes interval filled with other tests in
between a 15 words test / RAVLT learning trials and a 15 words test /
RAVLT recall and recognition, it is unsuitable to use: tests addressing
(verbal) semantic memory, such as verbal fluency tests, naming tests …
▪ To avoid interference in remembering the words
o Effects of fatigue due to long testing
o Tests addressing the same function
o Motivation and anxiety (build the tests up in difficulty or the other way around if
the patient thinks the tests are childish)
Lectures
Table of contents
Week 1 – Introduction and basic principles ...............................................................................2
Week 2 – Stroke and traumatic brain injury ...............................................................................9
Week 3 – Dementia 1 ............................................................................................................. 19
Week 4 – Dementia 2 ............................................................................................................. 29
Week 5 – Multiple sclerosis and epilepsy ................................................................................ 39
Week 6 – Neuropsychiatry & neurodiversity ............................................................................ 47
Week 7 – Oncology and brain tumors...................................................................................... 58
, Week 1 – Introduction and basic principles
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.’
- (Neuro)psychologist → different forms of postgraduate/postmaster education with
supervised practice (1-6 years) → licensed psychologist
- After your MSc studies in the Netherlands, you are a (neuro-)psychologist, MSc = master
psychologist / ‘basispsycholoog’ = unprotected title in the Netherlands → anyone can
use the title, even if they didn’t do the educational programs
o +2 years for healthcare psychologist and +4 years for clinical (neuro)psychologist
→ additional training in scientific research, management tasks, educational
programs
▪ They do the specialized assessment and treatment (more complex ones)
o +4 years for psychotherapist → more focused on treatments, usually involves
complex patients with personality problems or a lot of comorbidity
Tasks and responsibilities (Fasotti, 2005): Hierarchy
- Clinical neuropsychologist
o Scientific research
o Management tasks
o Specialized assessment and treatment
- Health care psychologist (‘licensed psychologist’)
o Autonomous functioning professional
o After several years of experience: training and supervising others
- (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) → taking the test, but not
interpreting them
Where do (neuro)psychologists work?
- Rehabilitation centers (assessment, cognitive training, neuropsychological
rehabilitation, and research)
- Mental health care (assessment, treatment, and research)
- Hospitals (assessment, brief treatment, and research)
- Elderly care (assessment, treatment, and coaching care teams)
- Forensic care facilities (assessment and treatment)
- Expertise assessment (‘letselschade’/personal injury)
- Schools
- Note that the emphasis on the type of professional activities might differ depending on
the context
,Basic principles of diagnostics in clinical neuropsychology
Diagnostics in clinical neuropsychology: Neurospsychological Assessment
- In relationship to the dysfunctioning of the brain
The cycle starts with a referral and ‘research question’ (empirical cycle)
(Neuro)psychologist as scientist-practitioner (N=1) who is doing the empirical cycle and forming
a hypothesis about what is happening to a patient
Taxonomy of different types of questions that you might have in a psychological assessment, by
Patricia Bijttebier et al. (2018):
- 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 problem of the patient develop in the
future?
- Indication: In what way can the problems be treated?
o Also important in rehabilitation → aim the treatment at the
function that is actually impaired
- Evaluation: Are the problems sufficiently addressed by the
treatment? → e.g., in suspected dementia patients
- The diagnostic process is dynamic: hypotheses can be generated,
tested, and updated at multiple stages in the empirical cycle
Evaluation 1, analysis and hypothesis (explanatory): question/referral,
medical file investigation, history taking/anamnesis, heteroanamnesis,
first impressions/observations/formulating hypotheses (DD), making a
(neuro)psychological assessment protocol (NPA), performing the NPA:
more specific observations, scoring test results, interpretation of test
results, hypothesis testing, conclusion: integrational description of results
and answer the question(s)
Anamnesis/history taking → you have limited time (30-60min), so keep the hypotheses in mind
and ask specifically for the things that are relevant to your hypothesis
- In the form of a semi-structured conversation
- Focus on the type, course, and severity of complaints
- Focus on predictions based on the ‘first’ hypothesis → based on brain-behavior
relationships and on information before the patient enters the room
- Ask for limitations in daily life activities → do not only ask about complaints, but also
about what the effect is on daily life, and ask for examples
o Especially in rehabilitation, if you do a training or treatment, you want to be sure
that it also affects their daily life
o Self-awareness: can the patient link the complaints to their daily life functioning?
o You need to know what is going wrong in daily life to make a diagnosis of
dementia → DSM-5 criteria for dementia
- Always ask for specific examples to avoid misunderstandings
o Memory complaints
o Concept of long-term and short-term memory
Symptoms vs. syndromes
- Symptoms ≠ syndromes
- Syndrome = constellations of symptoms that tend to co-occur
, o Give guidance on what to ask for in your history taking interview
- DSM-5 is used as a background work for what symptoms belong to a particular
syndrome
- Ordering complaints and symptoms of the patients
- Recognition of syndromes and patterns of impairments
- Note 1: Do not only search for confirmation. Also, ask for symptoms that would not fit
one or more of your hypotheses to be able to reject incorrect ones.
- Note 2: Take the base-rate information (i.e., the a priori chance) into account
Heteroanamnesis
- Information from someone close or a health care professional (e.g., nurse)
o Can be difficult when someone does not have direct family members or not a
very close social system
- Informed consent by the patient is necessary
- Additional sources of information: increase
reliability
- Insight/awareness of disease
- Attention for inconsistencies
- Again: opportunity to observe!
o Behavior and interaction
You have your hypotheses, first impressions, and more information from the patient and family;
now select your instruments. There are structured and unstructured instruments.
- Structured → any test, questionnaires, and observation instruments themselves
- Unstructured → observe how a patient is doing and approaching a test; depends on the
situation
Determine the set of hypotheses you are going 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 → to be sure the
results are related to that domain rather than other factors
o Also statistical: the chance of having two very low scores is even
less likely than having one very low score
- Relationships between attention, memory, and executive functions → contribute to each
other, so test these domains selectively to find out which one is the problem
o Always include tests for these three domains
- Impossibilities of the patient (e.g., visual impairment, hearing problems, paralysis of the
dominant hand)
- Quality of the instruments
o Validity (the extent to which a test accurately measures what it is supposed to
measure)
o Reliability (small measurement error and high test-retest reliability)
o Norms (availability of an appropriate norm group based on age, gender, and
education)
o In the Netherlands: The “Commissie Testaangelegenheden Nederland” (COTAN)
reviews the quality of common (neuro)psychological tests and questionnaires
, Repeated testing: reliability
- Cognitive functions over time (disease progression, recovery…) → to
measure differences over time
- Confidence interval: significant change or not?
o Ideally, you would have a test with small confidence intervals
where small changes in test scores are already significant
o Large confidence intervals have a lot of measurement error, and the change
might not be that indicative of an actual clinically significant change
- But: practice effects (especially memory test), test wiseness
An example: The Rey Complex Figure Test → copy the figure and later draw
it again from your memory (after three minutes and/or half an hour)
- Visuospatial memory: incidental learning
- Parallel-test (Taylor Complex Figure) reduces the practice effect,
but not the test wiseness (patient is familiar with the catch of
drawing it from memory later)
COTAN evaluations
- “The ‘mission’ of the COTAN is to enhance the quality of tests and the use of tests in the
Netherlands by informing test users, developers, and publishers about the availability,
the content, and the quality of various instruments. First, this is done by reviewing the
quality of a wide range of tests and questionnaires, and second, by drawing up standards
on the use of (psychological) instruments, such as the Algemene Standaard Testgebruik
(General Standard Test Use).”
- The COTAN reviews, amongst other things, the quality of the test construction, the
manual, and the norms of tests. They also examine the psychometric qualities of tests,
such as the validity (does the test measure what it aims to measure) and the reliability
(e.g., how stable are the scores over time).
- High demands are placed on the size and composition of the norm groups (> 400
participants for a “sufficient” rating). This is not always feasible due to the relatively
small number of Dutch speakers.
- The COTAN needs time to conduct reviews. As a result, recently developed tests or
recently released new norms have often not yet been reviewed.
- Bottom line: Be aware of the limitations of instruments and, if available, choose
instruments with the highest quality
Test administration
- Order – generally no significant effects of order on test results, however:
o Interference effects
▪ For example: during a ± 30 minutes interval filled with other tests in
between a 15 words test / RAVLT learning trials and a 15 words test /
RAVLT recall and recognition, it is unsuitable to use: tests addressing
(verbal) semantic memory, such as verbal fluency tests, naming tests …
▪ To avoid interference in remembering the words
o Effects of fatigue due to long testing
o Tests addressing the same function
o Motivation and anxiety (build the tests up in difficulty or the other way around if
the patient thinks the tests are childish)
