Workgroup 6: Neuropsychology in psychiatry

Neuropsychological assessment in psychiatry

The purpose of NPA in psychiatry is to get insight in cognitive functioning. This is done by creating a strengths/weaknesses analysis and by evaluating limitations in daily living. Another purpose of NPA in psychiatry is to get insight into emotions and behaviour. All this is done to find the right treatment and advice for the patient. If necessary, re-assessment will be done.

Questions

Some questions can be asked when it comes to differential diagnostics. It is important to distinguish different aspects from one another: are you dealing with someone who is suffering from depression, or dementia? Is apathy due to frontal lobe damage or depression? Is the patient dealing with ADHD or does he or she have an attention disorder due to traumatic brain injury? It is also important to note that a cognitive profile could match a subtype of a disorder.

There are more factors with could influence neuropsychological assessment in psychiatry, like medication, fatigue and sleeping problems. Patients could also unconsciously or deliberately underperform. People who have been in the hospital for a while could have a decreased motivation, because they often have different average days, and with that every day feels the same.

Video of depressed woman

In the video a woman is talking about her depression. Her complaints are that she does not have any motivation, for either school or taking care of herself. She is also avoiding people, she is having trouble focusing and she has a disrupted sleep- and eating pattern.

Cognitive deficits with depression are problems in concentration, slower information processing (which affects other cognitive functions), problems in executive functioning and memory problems. Selective attention bias is when people with depression mainly focus on negative stimuli and respond differently to those than healthy people do. Cognitive deficits are often worse in elderly people. The cognitive effort hypothesis says that people who are suffering from depression often make more mistakes in more difficult tasks.

Video of anxiety disorder

In the video a woman is talking about her anxiety disorder. She often worries about small things and imagines the worst case scenario. Her anxiety influences her living her daily life. She also feels like she is locked up and she has trouble focusing, because she is constantly distracted by her own thoughts.

Cognitive deficits in anxiety disorder are problems with attention, working memory and cognitive flexibility. When doing a neuropsychological assessment, the neuropsychologist must pay attention to whether the patients feels anxiety due to time pressure, fear of failure etc.

Video of schizophrenia

In the video a man with schizophrenia is interviewed. In the background you can hear the voices he supposedly hears. He also has trouble focusing and his emotions are flattened.

Cognitive deficits in schizophrenia are mental slowness, problems in attention (more easily distracted by internal and external stimuli), problems in executive functioning (disorganisation, less initiative, inhibition etc.), memory problems and formal thought disorders (strange utterances and thoughts).

Video of bipolar disorder

In the video a man is seen visiting his psychiatrist. He talks a lot, won’t listen, has trouble focusing, his thoughts are racing, he says he is suffering from insomnia and he has delusions (like saying that he has got a cure for cancer).

Cognitive deficits in bipolar disorder are problems in attention (increased distractibility for internal and external stimuli), problems in executive functioning (disorganisation, decreased initiation, disinhibition) and problems in memory.

Treatment of psychiatric disorders

Things to take into account when treating a psychiatric disorder are slower speaking, monitoring the attention span, giving shorter therapy sessions, repeating information, giving visual support, provide information to take home, provide clear structure and offer information in parts.

Case study

The client is a 49-year old man, who is estimated to have an average premorbid intelligence level. After falling on his head while intoxicated with alcohol he was admitted to hospital, during which progressive changes in cognition and behaviour were noticed. A neuropsychological assessment was requested to examine whether there are disorders in cognition, emotion and behaviour.

The main problems found in the man were very low processing speed, moderate to severe disorders in attention and concentration, regarding selective, sustained and divided attention, and there are also severe executive function disorders. The client is very sensitive to interference, he is highly associative in his way of thinking and he has disorders in planning, cognitive flexibility and working memory.

There is also evidence for cognitive disorders/impairments in orientation in time, and visuoconstruction. There also seem to be some impairments in verbal memory, regarding learning, storing and retrieving information.

Relatively intact are his orientation in place, his short term memory, memory for events from the past and language.

Regarding emotion and behaviour there is a fluctuation between depressive and (hypo)manic episodes. There are possibly psychotic symptoms. Anamnestically, feelings of anger and agitation were reported.

A bipolar disorder could fit abovementioned symptoms. However, they could also be (partially) related to his head trauma and alcohol abuse.

Advice given is to refer the man to a psychiatrist for clarification of the diagnosis and treatment (with medication). Further psychoeducation about client’s disorder in cognition, emotion and behaviour is also recommended. Other advice is to take more time for tasks and activities, others should speak to him slowly and not provide too much information at once. The patient must do one thing at a time, in a quiet environment, in brief sessions. Do not work too long on something and take frequent breaks. It is also recommended to provide him with a fixed daily/weekly structure, with a clear overview of what he is going to do. Provide structure in a conversation or a situation. Divide tasks into subtasks and work on these step by step, with a checklist.