Clinical Neuropsychological testing Flashcards
Clinical neuropsychology
Clinical neuropsychology is a specialty within
psychology that examines the relationship between behavior and brain functioning
in the realms of cognitive, motor, sensory, and emotional functioning.
Neuropsychologists integrate the medical and psychosocial history with the chief
complaint and pattern of performance on neuropsychological procedures. Such
analysis determines whether results are consistent with a particular area of
brain damage or a particular diagnosis
Projective and objective tests
There are two types of tests: objective and projective. Objective tests are
typically pencil-and-paper tests based on specific items and questions. They
yield numerical scores and profiles subject to mathematical and statistical
analysis. Projective tests present stimuli whose meaning is not immediately
obvious. Projective tests presumably have no right or wrong answers. Those being
tested impute meanings to the stimulus, based on psychological and emotional
factors
For the general population, an intelligence quotient (IQ) of 100 corresponds to intellectual ability in the A. 20th percentile B. 25th percentile C. 40th percentile D. 50th percentile E. 65th percentile
The answer is D
An intelligence quotient (IQ) of 100 corresponds to the 50th percentile in
intellectual ability for the general population. Modern psychological testing
began in the first decade of the 20th century when Alfred Binet (1857-1911), a
French psychologist, developed the first intelligence scale to identify mentally
challenged youngsters. The Stanford-Binet Scale is a standardized intelligence
test assessing both cognitive ability and intelligence from age 2 onward. It is
useful for determining the presence of a learning disability, developmental
delay, or brain damage in people with neurological insults. Its components
include general intelligence, visuospatial processing, quantitative reasoning,
fluid reasoning, knowledge, and memory
Neuropsychological deficits associated with left hemispheric damage include all of the following except A. limb apraxia B. visuospatial deficits C. finger agnosia D. aphasia E. right-left disorientation
The answer is B
Many functions are mediated by both the right and left cerebral hemispheres.
However, important qualitative differences between the two hemispheres can be
demonstrated by the presence of lateralized brain injury. Various cognitive
skills that have been linked to the left or right hemisphere in right-handed
people are listed in Table 4.1. Although language is the most obvious area that
is largely controlled by the left hemisphere (with injuries leading to
aphasias), the left hemisphere is also generally considered to be dominant for
limb praxis (i.e., performing complex movements, such as brushing teeth,
commanding, or imitation). The left hemisphere has been associated with a
cluster of deficits identified as Gerstmann syndrome (i.e., finger agnosia,
dyscalculia, dysgraphia, and right-left disorientation). In contrast, the right
hemisphere is thought to play a more important role in controlling visuospatial
abilities and hemispatial attention, which are associated with the clinical
presentations of constructional apraxia and neglect, respectively.
Although lateralized deficits such as these are typically characterized in terms
of damage to the right or left hemisphere, it is important to keep in mind that
the patient’s performance can also be characterized in terms of preserved brain
functions. In other words, it is the intact brain tissue that drives many
behavioral responses following injury to the brain.
Left hemisphere
Right Hemisphere
Aphasia
Visuospatial deficits
Right-left disorientation
Impaired visual perception
Finger agnosia
Neglect
Dysgraphia (aphasic)
Dysgraphia (spatial, neglect)
Dyscalculia (number alexia)
Dyscalculia (spatial)
Constructional apraxia (details) Constructional apraxia (Gestalt)
Limb apraxia
Dressing apraxia
” “
Anosognosia
Neuropsychological referrals are made for
A. establishing a baseline of performance
B. diagnostic purposes
C. ascertaining brain impairment
D. planning for rehabilitation
E. all of the above
The answer is E (all)
Most neuropsychological referrals are made for diagnostic purposes, to ascertain
if brain impairment is present, or to differentiate among neurological or
psychiatric disorders. Other important uses of testing include establishing a
baseline of performance for assessing future change and planning for rehabilitation
and management of behaviors affected by brain impairment. The specific methods
of neuropsychological assessment reflect the individual’s unique presentation of
symptoms and complaints, history and development, the perspective of the
neuropsychologist, and the reason for referral.
A common referral issue involves documentation of level of functioning for a
variety of purposes, including assessment of change or competence, especially in
the presence of diagnoses such as dementia, stroke, and head injury
True statements about projective personality tests include
A. They often focus on latent or unconscious aspects of personality.
B. The variety of responses is limited.
C. They tend to be more direct and structural than objective personality tests.
D. Instructions are usually specific.
E. None of the above
Projective personality tests, in contrast to objective personality instruments,
are more indirect and unstructured. Unlike objective tests, in which the patient
may simply mark "true" or "false" to given questions, the variety of
responses to projective personality tests is almost unlimited. Instructions are
usually general, allowing the patient’s fantasies to be expressed. Patients
generally do not know how their responses will be scored or analyzed, making it
difficult to obtain a desired result. Projective tests typically do not measure one particular personality characteristic such as type A personality (i.e.,
narrow-band measurement) but instead are designed to assess a personality as a
whole (i.e., broad-band measurement).
Projective tests often focus on latent or unconscious aspects of personality.
Obviously, psychologists and others differ in the degree to which they rely on
unconscious information. In many projective techniques, patients are simply
shown a picture of something and asked to tell what the picture reminds them of.
Projective techniques assume that when presented with an ambiguous stimulus such
as an inkblot, for which there are an almost unlimited number of responses, the
patients’ responses will reflect fundamental aspects of their personalities. The
ambiguous stimulus is a sort of screen on which individuals project their own
needs, thoughts, or conflicts. In particular, a schizophrenic patient’s
responses will often reflect a rather bizarre, idiosyncratic view of the world.
Hundreds of different projective techniques have been developed-most of which
are not used widely today.
After taking the Wechsler Adult Intelligence Scale (WAIS), a patient was
found to have poor concentration and attention. Select the WAIS subtest that
most likely screened the patient for these symptoms.
A. block design
B. comprehension
C. arithmetic
D. digit symbol
E. picture completion
The answer is C
The arithmetic subtest uses simple arithmetic tasks to assess attention and
concentration. The block design subtest requires a subject to arrange a series
of pictures to tell a story. This process tests performance and cognitive
styles. The digit symbol subtest requires a subject to match digits and symbols
in as little time as possible, as a test of performance. The comprehension
subtest reveals a subject’s ability to adhere to social consequences and to
understand social judgments when the subject answers questions about how people
should behave. On the picture completion subtest, a subject must complete a
picture with a missing part. Visuospatial defects appear when errors are made on
this picture completion procedure.
The Bender Visual Motor Gestalt Test is administered to assess A. maturation levels in children B. organic dysfunction C. loss of function D. visual and motor coordination E. all of the above
The Bender Visual Motor Gestalt Test, devised by the American neuropsychiatrist
Lauretta Bender in 1938, is a technique that consists of nine figures that are
copied by the subject (Fig. 4.1). It is administered as a means of evaluating
maturation levels in children and organic dysfunction. Its chief applications
are to determine retardation, loss of function, and organic brain defects in
children and adults. The designs are presented one at a time to the subject, who
is asked to copy them onto a sheet of paper. The subject is then asked to copy
the designs from memory (Figs. 4.2 and 4.3); thus, the Bender designs can be
used as a test of both visual and motor coordination and immediate visual memory.
Which is not true of the Wisconsin Card Sorting Test?
A. It assesses abstract reasoning
B. It assesses parietal lobe dysfunction
C. The patient is told during testing whether their responses are correct or
incorrect
D. The examiner records the number of trials required to achieve ten consecutive
correct responses
E. The examiner changes the principle of sorting when the task is mastered
The answer is B
Persons with damage to the frontal lobes or to the caudate nucleus, and some
patients with schizophrenia, give abnormal responses to the Wisconsin Card
Sorting Test (WCST). It does not address parietal lobe damage. This test
assesses abstract reasoning and flexibility in problem solving. Stimulus cards
are presented to patients to sort into groups according to a principle
established by the examiner but unknown to the patient. As the patient sorts the
cards, he or she is told whether the responses are correct or incorrect. The
number of trials required to achieve ten consecutive correct responses is
recorded. When or if the patient has mastered the task, the examiner changes the
principle of sorting, and the number of trials required to achieve correct
sorting is again recorded.
In the Wechsler Adult Intelligence Scale (WAIS),
A. digit span is a subtest of the verbal component of the test
B. its latest revision is designed for persons aged 16 to 60
C. mental retardation corresponds to the lowest 1% of the population
D. the average range of IQ is 100 to 120
E. the verbal scale is more sensitive to normal aging
The answer is A
The Wechsler Adult Intelligence Scale (WAIS) comprises 11 subtests made up of
six verbal (information, comprehension, arithmetic, similarities, digit span,
vocabulary), and five performance (picture completion, block design, picture
arrangement, object assembly, digit symbol) subtests, which yield a verbal IQ, a
performance IQ, and a combined full-scale IQ. The latest edition, the WAIS-III,
is designed for persons 16 to 89 years of age. There are also scales for
children ages 4 to 6.5 and 5 through 15. The average or normal range of IQ is 90
to 110; IQ scores of at least 120 are considered superior. Mental retardation,
defined as IQ below 70, corresponds to the lowest 2.2 percent of the population;
2 of every 100 people have IQ scores consistent with mental deficiency. The
performance scale is more sensitive to normal aging than the verbal scale, which
is more sensitive to education.
An 8-year-old boy is referred for psychological testing by his mathematics instructor after failing a series of examinations since the beginning of the
school year. The boy’s mother states that he complains about not being able to
read as well as the other students. He also complains of difficulty hearing the
teacher.
Which of the following tests of personality, intelligence, and achievement is
most appropriate in assessing the boy’s specific learning challenges?
A. Rorschach Test
B. Wechsler Preschool and Primary Scale of Intelligence
C. Wechsler Intelligence Scale for Children
D. Wide-Range Achievement Test
E. Minnesota Multiphasic Personality Inventory leaflong
The answer is D
The Wide-Range Achievement Test evaluates content-specific foundation in
mathematics, spelling, reading, and sciences. It may test individuals ranging
from ages 5 to 94 and is standardized to account for stratifications in gender,
ethnicity, geographic region, and socioeconomic status. The Rorschach Test is a
projective assessment test that requires interpretation of ink blots. It may be
used to interpret defense mechanisms and thought disorders. The Wechsler
Preschool and Primary Scale of Intelligence tests the ability to organize,
process, and reason by way of picture completion, verbal comprehension, and
block design. It may be completed without reading or writing and is designed for
children between the ages of 4 and 6. The Wechsler Intelligence Scale for
Children uses an identical approach for children and adolescents between the
ages of 6 and 16. The Minnesota Multiphasic Personality Inventory is the most
common objective personality test aimed at determining personality types,
including pathologies and behavioral patterns.
Rorschach Test
Thematic Apperception Test (TAT)
Assesses patient’s personality as a whole
Both
Rorschach Test
Thematic Apperception Test (TAT)
Henry Murray
B
Rorschach Test
Thematic Apperception Test (TAT)
Is often included in a battery of tests for personality assessment
Both
Rorschach Test
Thematic Apperception Test (TAT)
John E. Exner’s Comprehensive System
A
Rorschach test
The Rorschach test was created by Herman Rorschach, a Swiss psychologist, around
1910. The Rorschach test is the most frequently used projective personality
instrument. The test consists of ten ambiguous symmetrical inkblots. Using John
E. Exner’s Comprehensive System, the examiner gives the patient the following
instructions: "You’ll be given a series of inkblots. Look at each inkblot and
tell me what you see." The examiner gives the patient each card and asks,
"What might this be?" The examiner writes down verbatim what the patient says,
along with the initial reaction times and total time spent on each card. After
completion of what is called the free-association phase, the examiner conducts
an inquiry phase to determine important aspects of each response that are
crucial to scoring.
Thematic apperception test
The TAT was designed by Henry Murray and Christina Morgan as part of a normal
personality study conducted in the Harvard Psychological Clinic in 1943. The TAT
consists of a series of 30 picture cards and a blank card. Typically, a patient
is shown ten TAT cards and asked to make up stories about them. The patient is
asked to tell what is going on in the picture, what was going on before the
picture was taken, what the individuals in the picture are thinking and feeling,
and what is likely to happen in the future.
A. Brief Psychiatric Rating Scale (BPRS)
B. Schedule for Affective Disorders and Schizophrenia (SADS)
Ratings are made on the basis of mental status interview and do not
require that the examiner ask any specific questions
A
A. Brief Psychiatric Rating Scale (BPRS)
B. Schedule for Affective Disorders and Schizophrenia (SADS)
Highly structured interview
B
BPRS
To use the BPRS, the psychologist or psychiatrist completes
a mental status interview with the patient and then rates that patient on a
series of 18 psychiatric symptoms such as motor retardation, blunted affect,
conceptual disorganization, anxiety, and guilt. Expanded definitions of each of
these terms are provided to the examiner. The interviewer rates each domain on a
seven-point scale from "not present," the lowest rating, to "extremely
severe," the highest rating. An experienced interviewer can complete the ratings in 2 or 3 minutes. The BPRS has been used extensively in drug outcome
and other studies. The advantages of the BPRS are the reasonably high interrater
reliability, the ease and speed of rating, and the well-defined symptom
description. The BPRS ratings are made on the basis of a mental status interview
and do not require that the examiner ask any specific questions of the patient.
SADS
The SADS is a highly structured interview instrument. The interviewer is
required to ask each patient a series of prescribed questions to ensure that all
relevant areas are addressed. For example, a patient is asked a question similar
to the following: "Have you ever heard voices or other things that weren’t
there or that other people couldn’t hear or see?" Based on the patient’s
response, the examiner asks other detailed, prescribed follow-up questions
concerning hallucinations, or if the response was negative, the interviewer
moves on to the next question in a different area. This approach ensures that
all areas are covered in a comprehensive fashion. The SADS is especially helpful
for establishing a reliable diagnosis. The SADS can also be used as an index of
behavioral severity. Behavioral changes can be determined by repeated administration.
The advantage of the SADS is that it is comprehensive and has reasonably good
reliability. One disadvantage is its length; another is that in the structured
interview the interviewer must read questions from a lengthy booklet, which
makes it difficult to establish eye contact and rapport with the patient. The
SADS has been used for both research and clinical purposes, probably more
frequently for the former.
A. Battery Approach
B. Hypothesis Testing Approach
C. Screening Approach
D. Mental Status Examination
Determines if a diagnosis can be made with less information
C
In the screening approach, the neuropsychologist utilizes a core set of
screening procedures as a first step in determining whether a diagnosis can be
made with less information or whether additional testing is necessary.
Standardized screening approaches have the advantage of uniform normative
reference groups, although many clinicians routinely use a set of tests drawn
from many sources.
In some cases, usually involving an acute or severe cognitive impairment, it is
simply not feasible to administer extensive cognitive examination procedures.
The neuropsychologist might appropriately rely on bedside mental status
examinations or very brief cognitive screening procedures to address the
referral issues
A. Battery Approach
B. Hypothesis Testing Approach
C. Screening Approach
D. Mental Status Examination
May help identify problems that were not mentioned by the patient
A
The battery approach to neuropsychological assessment typically includes a large
variety of tests that measure most cognitive domains as well as sensory and
motor skills. The battery approach has the advantage of identifying problems
that the patient might not have mentioned and that the medical history may not necessarily predict. However, it has the disadvantage of being very time-consuming
