Lecture 1: Introduction to Clinical Neuropsychology

The brain and brain disorders

In clinical neuropsychology, we can differentiate between cognition and behaviour when it comes to neuropsychological disorders. Deficits in cognition are mainly cortically based. Disorders like these are amnesia, aphasia, agnosia, apraxia and deficits in executive functioning. Also problems with attention and focusing are cortically based. Deficits in behaviour are mainly subcortically based. Damage here can lead to symptoms like anxiety and depression, apathy, delusions and hallucinations and personality changes.

The brain consists of four lobes: the parietal lobe (memory, language, sensation), the occipital lobe (visual information), the frontal lobe (motor functions) and the temporal lobe (auditory information). The cerebellum has the main function of coordination and the brainstem regulates life functions like breathing.

Brain disorders occur in 20% of the people. About 600.000 people develop a disorder in the central nervous system, and about three million people deal with a psychological disorder sometime in their lives. It is important to figure out what the location of the lesion is. Consequences of damage in either white or grey matter can differ from one another. The size of the lesion can determine when the consequences are becoming visible. It is also important to know when someone gets their brain damaged. Below some different forms of brain disorders are given.

• Genetic disorders and developmental disorders
  • Mental retardation
  • ADHD
  • Dyslexia
  • Angelman
  • Prader-Wilie
• Vascular disorders
• Neurotrauma
• Neuro-intoxications
  
  • Alcohol
  • Medication
  • Drugs
• Psychiatric disorders
  
  • Depression
  • Anxiety
  • Schizophrenia
• Neurodegenerative disorders
  
  • Lewy Body disease
  • Parkinson
  • Huntington
  • Alzheimer
• Other
  
  • HIV
  • Epilepsy
  • Encefalitis
  • Hydrocefalus
  • Lack of vitamin B12

When looking at brain scans it is important to note that when looking at the right side on the scan, you are looking at the left side of the brain and vice versa.

Tumors and brain deficits can appear in different parts of the brain. The meningioma are layers right around the brain. Oligodendroglioma is a type of tumor that can occur in the brain or spinal cord, they form from oligodendrocytes. Cerebral thrombosis is a synonym for a stroke. A cerebral haemorrhage can be seen as bright white spots when looking at a brain scan. A cerebral infarction (stroke) can be seen as a dark, grey spot when looking at a brain scan.

Main symptoms of people with a suspected brain disorder are concentration problems, memory problems, reduced ability to multitask, reduced ability to organise and anticipate, reduced ability in reading and writing, reduced ability in daily tasks (getting dressed, cooking, self-care), symptoms of depression, personality changes, fatigue, pain and somatic symptoms.

Neurocognitive domains – according to DSM V

• Perceptual motor function
  • Perception
  • Visuo-constructional reasoning
  • Perceptual-motor coordination
• Language function
  
  • Finding the right words
  • Fluency
  • Grammar and syntax
  • Receptive language
• Complex attention
  
  • Divided attention
  • Selective attention
  • Processing speed
• Executive functioning
  
  • Planning
  • Decision making
  • Working memory
  • Inhibition
  • Flexibility
• Learning and memory
  
  • Memory retrieval
  • Cued recall memory
  • Long term memory
  • Implicit learning
• Social cognition
  
  • Emotions
  • Theory of Mind
  • Insight

Distinctions

Inability comes in different forms. It usually first starts with impairment. Impairment is the loss or abnormality of psychological, physiological or anatomical structure or function, for example a brain tumor. This phase is usually the disease onset. The impairment can grow into a disability, which is the restriction in ability to perform a function that may result from an impairment, like aphasia. The signs and symptoms have started to show. A disability can cause development of a handicap, which is the disadvantage that results when a disability or impairment limits or prevents the fulfilment of a role, like social isolation caused by aphasia.

Symptom, disorder, disability and handicap

Dementia

There are three main types of dementia. Cortical dementia has a gradual start, and is the most common form of dementia. Alzheimer’s is an example of cortical dementia. To get the diagnosis the patient must suffer from memory impairment and at least one of the four: (1) aphasia, (2) apraxia, (3) agnosia, (4) disturbance in executive function. This type of dementia is very progressive. Subcortical dementia, like Huntington and Lewy Body is characterised by slow thinking and behaviour, yet it is done correctly. Besides that, there’s change in affect and disturbance in executive functioning. Frontotemporal dementia, like Pick, is characterised by inappropriate behaviour in social situations, emotional numbness, apathy and restlessness. The patient behaves differently in social situations from prior to behaviour disturbance. There’s a global impaired social cognition.

Mental Status Examination (MSE)

The aim of the MSE is to determine the extent to which the behaviour is caused by psychological vs. neurological/organic factors, when deciding on the diagnosis and treatment options of people with a (suspected) brain disorder. Its methods are observation, (hetero)anamnesis, (neuro)psychological tests and combining these. The conclusions drawn from a MSE are to differentiate between neurological/organic and psychogenic factors, and then to find the right treatment for the patient. Treatment of primary and secondary psychosocial results of a (brain) disorder mainly consists of (psycho)education for the patient and system/carers, function training, strategy training, cognitive behavioural therapy, system therapy and life style adjustment.

When sent to a neuropsychologist, the procedure starts with gaining information about the patients history and other details. When requested, a diagnoses of disease and/or care is required and indications are given. After that, the neuropsychologist will gain a general impression and will perform a (hetero)anamnesis and observe the patient while he or she is doing the tests. The tests are based on global cognitive functions, specific cognitive functions and questionnaires on behaviour and emotional status. Last, a summary and conclusion will be given, which consist of a diagnosis and recommendations. 

Indications of neuropsychological testing

• Patient and/or those close to the patient complain about (neuro)psychological functions (cognition, emotion, behaviour)
• Gradual or sudden change in neuropsychological functions with known or unknown somatic disorder(s)
• ‘normal age-related forgetfulness’ or dementia
• Dementia or depression
• Normal or pathological (neuro)psychological development
• Neuropsychological profiling in the case of (possible) brain damage, determine remaining capacity!
• Monitor neuropsychological progress before and after intervention
• Determine relative role of neurological vs. psychological factors
• Formulate neuropsychological care indicators
• Follow up after pharmacological or surgical treatment
• Forensic and insurance issues