Lecture 7: Neuropsychiatry

Symptom validity testing

Symptom validity testing is an aspect of neuropsychological testing where separate scales are used to establish the probability that a given test is affected by a tendency to fake bad, fake good or malingering. It happens quite frequently that patients are showing signs of doing so, not always knowing they are ‘faking’ their symptoms, nor knowing why they’re doing so. It is strongly advised to do more than one symptom validity test, to figure out whether the patient’s symptoms are real or not. La belle indifference means that a patient is indifferent to his or her symptoms. This is a sign of a psychological problem.

A task example, shown by the lecturer, is to show two items, then show one of those items again and another, new item, and then ask the patient which item he or she has seen before.

Whenever you see someone showing strange behaviour, the first thing you must ask yourself is if this person is in a (potential) delirious state. This is a psychotic state with changes in attention and consciousness, due to a(n) (underlying) somatic illness. You should state this first because it needs treatment. A delirious state can range from seconds to months after, for example, waking up from a coma.

The difference between a delirious state and suffering from schizophrenia, is that when in a delirious state you are less ‘awake’ than when you’re schizophrenic. A delirious state is psychotic in nature but has a lower level of consciousness.

During the lecture, some videos are shown and discussed.

Video Wernicke-Korsakov

A man in an acute phase of delirium is Korsakov is seen. He has gotten out of bed at 11 in the morning, which is strange for a man of his age. Apparently his night and day pattern has switched. He has forgotten about the name of his illness and whatever he is saying doesn’t add up, nor make sense (incoherence/associative thinking). He doesn’t finish his sentences and expresses single words only. He doesn’t know where he is (disorientation), nor knows what year it is. To test his ability to concentrate/focus when you don’t have any specific testing material with you is to ask the patient to for example read a page and then tell what he or she has read, to count back from 20 to 1, or to count backwards the days of the week. The patient seen in the video has no trouble counting from 20 to 1, but does have trouble telling the days of the week in another sequence.

Video husband-father

A woman who thinks her husband is her father is seen in the video. Only when she looks at the right on her husband’s finger she realises the man is her husband. An MRI has shown a big white spot on the right side in the frontal area, which could be an infarct. Bigger gyri and sulci and enlarged ventricles are seen as well.

Video ‘Mr. Chocolate’

A man visits a neuropsychologist and only complains about having to wait so long to get an appointment, and sees that as his only problem. He does not speak about his symptoms. He has trouble understanding what someone is saying, for example when the neuropsychologists asks him to name some fingers, he calls them either ‘left finger’ or ‘right finger’. He says the same thing over and over again. Brain scans show atrophy in the left side of the brain. Unilateral atrophy almost always comes with frontal temporal dementia. You could ask a patient to describe a word that is not frequently used, like chocolate, sprinkler or scissors.

Video former teacher

A woman was admitted to hospital after suffering from a psychosis after coming back from a trip. She has been in the hospital for a couple months now and the questions remains whether she is in a psychotic phase or if she is suffering from dementia. She speaks very loud, leaves her mouth open when not speaking and needs a while to think before she speaks. She has lost her memory during the psychosis. When in hospital, antipsychotics are given to regulate the level of dopamine. Parkinsonism will be reduced when dopamine is given, which causes a patient to sit very still.

Her cognitive abilities are measures by showing her pictures/drawings and have her name those objects. She is also asked to generate words, for example to name as many words which start with the letter D (names not allowed), or to name as many animals. Brain scans show atrophy in her frontal lobe.