Domains of Neuropsychological Function and Related Neurobehavioral Disorders Flashcards
Intelligence
Associated disorders:
Intellectual Disability
Dementia
Savantism
Intellectual Disability
Intellectual disability is a developmental disorder with onset before age 18 requiring a substantially subnormal IQ (i.e., approximately ≥ 2 standard deviations below the mean), reflecting limitations in general intellectual functioning, combined with significant deficits in two or more adaptive skills (see also Chapter 13, Intellectual Disability).
Dementia
By definition, dementia is a syndrome (i.e., a set of signs and symptoms) that stems from a disease or medical condition involving a decline in or loss of general cognitive ability or multiple areas of cognitive impairment of sufficient severity to impair social and/or occupational functioning.
Performances on tests of general intelligence decline as dementia advances; in cases of Alzheimer’s disease (AD), decline in IQ may not be evident until the middle stages
Savantism
This is a very rare syndrome in which individuals with an intellectual disability or autism spectrum disorder have one or more specific or narrow remarkable talents that exist in stark contrast to their intellectual disability.
The cause or causes of savant syndrome are unknown but may be congenital or acquired as a result of central nervous system (CNS) disease or injury.
Savant syndrome is associated with autism spectrum disorders, as well as other psychological disorders and CNS injuries/diseases.
It is approximately six times more common in males than females.
Savant skills most commonly involve exceptional memory, but can also involve exceptional calculation, calendar knowledge, artistic, and/or language abilities.
Attention/Concentration and Processing Speed
In general, attention refers to the process whereby individuals receive and subsequently process incoming information.
It is closely associated with perception, executive functioning and memory, particularly working memory (which is dependent on attention but is not synonymous).
Working memory refers to the form of processed information before it is sent to short-term memory (see also the section “Memory” later in this chapter), whereby information that is being actively maintained or rehearsed can be retained for up to several minutes.
If something is passively received (i.e., attention span) but not rehearsed or manipulated, it is lost.
AttentionProcessing Speed Associated disorders
Delirium
Attention-Deficit/Hyperactivity Disorder (ADHD)
Hemispatial Inattention (a.k.a. Neglect)
Traumatic Brain Injury (TBI)
Other Disorders and Factors Affecting Attention
- Depression and anxiety, fatigue and lack of sleep/sleep disorders, low or poor arousal, environmental factors (i.e., noise, etc.), and medications are all non-neurological factors that can negatively influence attentional processes.
- Reduced motivation or effort is another factor that can affect attention.
Factors affecting processing speed include
- conditions that diffusely impact various brain structures and white matter integrity (e.g., multiple sclerosis, TBI, vascular cognitive impairment, Parkinson’s disease).
Comprehension of Spoken and Written Language
Comprehension difficulties can be of two types: syntactic and lexical/semantic.
Lesions involving anterior speech areas can result in disturbed comprehension of phonological (syntactic) information used to construct word names.
Lesions in posterior language areas more often result in disturbed comprehension of the sequencing of meaningful word sounds to convey meaning (lexical/semantic).
Repetition
Repetition is easily tested by beginning with single, simple words then multisyllabic words, followed by short sentences and longer sentences, increasing in complexity.
Establishing whether or not repetition is intact is important because the ability to repeat typically indicates that the perisylvian language centers are functional.
Naming problems or anomia (the terms “anomia” and “dysnomia” can be used interchangeably) can be present in all types of aphasia syndromes and can involve problems naming an object, color, and body part or finding a specific word in spontaneous speech.
Word-finding difficulties can be evident in spontaneous speech when a patient pauses to search for a word or uses too many words to describe something better described in fewer words (i.e., circumlocution), or it can be elicited by presenting a stimulus and asking the patient to name it.
Anomia can occur with many of the aphasic syndromes and is, therefore, not generally useful for localization, but distinctions between anterior and posterior aphasic syndromes can often be made because patients with nonfluent syndromes may have difficulty with naming as a result of initiation or production problems, whereas patients with fluent syndromes may have difficulty as a result of selection problems or an inability to find the right word.
Reading aloud and reading silently for comprehension should each be tested separately.
All aphasic syndromes that include severe impairment of auditory language—with the exception of pure word deafness—are almost always also associated with an acquired impairment of reading or alexia.
Alexia can be seen in aphasias of all kinds and it can be seen in isolation, in which case it can be important for localization.
That alexia can be seen in isolation without other features of aphasia, including agraphia, suggests that the brain has evolved specific areas required for reading that are separate from other language areas.
transient global amnesia
medial temporal
diencephalic
anoxia/hypoxia
medial temporal
anterior communicating artery aneurysm
frontal
basal forebrain
Wernicke-Korsakoff
diencephalic
herpes encephalopathy
medial temporal
PCA infarct
medial temporal
Dementia
Whereas AD affects memory encoding
patients with dementia impacting frontal-subcortical systems (i.e., vascular dementia, multiple sclerosis, Parkinson’s disease, etc.) typically display retrieval difficulties and thus often benefit from recognition cueing
Hippocampal Pathway (or Papez circuit)
- Entorhinal cortex
- Fornix
- Mammillary bodies
- Mammillothalamic tract
- Cingulate cortex
Hypoxia and Anoxia
Amygdaloid Pathway
- Amygdala
- Dorsal medial thalamus
- Dorsomedial cortex
Herpes encephalitis
PTSD
Diencephalon
- Anterior nucleus of the thalamus
- Dorsomedial nucleus of the thalamus
- Fornix
- Mammillary bodies
- Korsakoff’s
- CVA
Basal Forebrain
- Medial septal nucleus
- Diagonal band of Broca
- Nucleus Basalis of Meynert
- Affected in AD
- ACoA aneurysm
Cortex
- Medial and anterior temporal lobe
- Frontal lobe (see basal forebrain)
- Surgical ablation
- TBI
- Herpes
- Anoxia/Hypoxia
Executive Functions
- Dorsolateral Prefrontal Syndrome (dysexecutive syndrome) Characterized by poor problem solving, word-list generation, organization, sequencing, abulia/amotivation (“pseudo depression”), and sometimes perseveration.
- Orbitofrontal Syndrome (inferior/ventral frontal syndrome) Characterized by emotional lability, impulsivity, disinhibition, childishness, personality change, and distractibility.
- Medial Frontal/Cingulate Syndrome Characterized by decreased initiation and indifference, but can also have amnesia, incontinence, and leg weakness. Cummings also identified the motor circuit (supplementary motor area) and oculomotor circuit (frontal eye fields).
Executive Function Associated Disorders
Dementias
Acquired or traumatic brain injury
addiction/impulse control disorders
focal lesions affecting frontal circuits and systems
sensorimotor associated disorders
finger agnosia
right-left disorientation
asterognosia
asomatognosia
apraxia
agraphia
Emotional Symptoms Commonly Associated with Neurological Disorders
anosodiaphoria
alexithymia
emotional lability
rumination
pseudobulbar affect
Abulia
Passive behavior wherein one exhibits little spontaneous activity and markedly delayed responses and tends to speak briefly or softly.
In the extreme the patient may be immobile, akinetic, and mute, but will continue to appear awake, sitting with their eyes open.
Circumlocution
The purposeful substitution of multiple words or descriptions for a word or other words that the patient is unable to find.
This manifests as talking around word-finding difficulties, rather than using specific words.
These are not considered paraphasic errors, and circumlocution is not the equivalent of tangentiality.
Crystallized Intelligence (Gc)
This refers to the breadth and depth of knowledge and understanding that is acquired through learning, education, experience, and acculturation; it is often resistant to the effects of aging and neurologic injury or illness.
Dysarthria
A speech disorder involving difficulty in articulation.
Not an aphasia or language disorder although sometimes confused with them.
Patients with dysarthria are able to read and write normally which readily differentiates them from patients with expressive aphasia.
Dysphonia
A speech disorder involving difficulty in vocalization.
Fluid Intelligence (Gf)
This refers to the ability to reason, adapt, solve problems, form concepts, and understand relationships in unfamiliar or novel circumstances.
Unlike Gc, it is more susceptible to the effects of aging, injury, and illness.
Literal (or Phonemic) Paraphasias
The substitution or the rearrangement of sounds or syllables in otherwise correct words (e.g., fig instead of pig).
Phonology
The underlying speech sounds in a language and the rules governing the production of speech sounds.
Pragmatics
The context in which the words are used.
Prosody
An element of speech that contributes to the conveyance of meaning through rhythm, stress, pitch, loudness, tempo, and intonation.
It can indicate the basic structure of a sentence, the emotional content, or the main point in an utterance.
Semantics
The meanings of words and the rules governing the use of words. It is the sequencing of meaningful words sounds to convey meaning.
Semantic Paraphasias
The substitution of a correct word or phrase for another semantically related word or phrase (e.g., dog instead of cat).
Semantic paraphasias in the form of multi-word paraphasic errors or “paragrammatism” is one feature that differentiates the syndrome of Wernicke’s aphasia from other fluent aphasic syndromes.
Syntax
The rules governing the structure of phrases and sentences.
Verbal Paraphasias
The substitution of one correct word for another.
Some substitutions may have no obvious semantic relationship with the correct word, while others involve substitution of a correct word or phrase for another semantically related word or phrase.
Sometimes paraphasias take the form of neologisms (e.g., “zoctor” for doctor).
A cancellation task with a single target would be a valid measure of ____.
selective attention
Selective attention is the choosing of a target from amidst distractors.
- Divided attention is concentrating on two or more tasks simultaneously.
- Attention span is similar to capacity.
- Sustained attention is maintaining attention over a period of time.
The patient is a 72-year-old man who sustained a thrombotic stroke of the left middle cerebral artery three months ago.
Examination now reveals significant word-finding difficulty but otherwise grammatically accurate, fluent, and well-formed speech and intact repetition.
His speech lacks substantive words and there are frequent circumlocutions.
The most likely type of aphasia is ____.
anomic aphasia
The characteristics of an anomic aphasia are fluent speech and intact comprehension and repetition but impaired naming.
The patient appears to recognize objects but cannot come up with their name.
They may be able to describe concepts they are trying to express but cannot come up with the specific name; for example, they might say, “The animal with a mane that lives in the jungle and roars,” but they cannot say, “lion.”
In the case described in question #2 above, where was the patient’s lesion likely to have been?
extrasylvian area
The extrasylvian lesion effectively isolates the parts of the brain needed for the interpretation of language from the parts of the brain that merely connect the interpretation of speech sounds or phonology to speech production.
Repetition is intact because speech sounds can be directly mapped into speech articulation without using the parts of the brain necessary for comprehension of speech.
In acquired prosopagnosia, ____.
spontaneous recovery has been documented in some cases
There is also preliminary evidence of possible treatments for both acquired and developmental prosopagnosia.
You are consulted to see a 79-year-old, right-handed gentleman who sustained a right thalamic stroke.
While preparing your doctoral intern for the initial assessment what might you provide in terms of education?
He may ____.
not express emotions
His right-sided CVA likely eliminates the possibility of an expressive aphasia.
B and D are indicative of orbitofrontal damage.
Right hemisphere lesions can result in aprosodias and other conditions which impact an individual’s ability to express emotion.
On examination, you find that a patient picks up a toothbrush and the toothpaste and tries to put the toothpaste on the toothbrush without taking off the cap.
This could be an example of ____.
ideational apraxia
This limb apraxia is characterized by difficulty correctly sequencing motor movements.
Your patient presents with nonfluent, sparse language and symptoms of apathy.
To differentiate this condition as an aphasia syndrome from a primary psychiatric disorder, you would want to first evaluate for the presence of ____.
motor or sensory deficits
Psychiatric conditions are rarely associated with focal motor or sensory neurologic symptoms, whereas hemiparesis is not uncommon in Broca’s aphasia.
While language errors can occur in acute psychosis as well as anosognosia but in these instances orientation will often remain intact and it is unlikely there will be a focal motor or sensory disorder.
Which brain area plays a key role in motivating selective attention toward a salient stimulus?
anterior cingulate
Motivation and saliency involve executive systems such as the anterior cingulate (limbic).
Posner and Petersen’s attentional model would predict difficulty with ____ as a result of damage to the ascending reticular activating system (ARAS).
alerting
Orienting and shifting (involves the posterior network)
detection (anterior network)
alerting and arousal (ARAS)
Classification of aphasia is based primarily on which three parts of the language assessment?
fluency, comprehension, repetition
Fluent versus nonfluent speech localizes anterior from posterior aphasic syndromes;
impairment in comprehension distinguishes Wernicke’s from conduction aphasia;
and the ability to repeat implies that perisylvian language areas are intact.
symptoms of Gerstmann’s syndrome
The four components of Gerstmann’s syndrome are
finger agnosia
acalculia
right-left disorientation
agraphia
Intact spatial abilities, but disturbed recognition of objects implies disruption in the ____ pathway.
ventral
The ventral pathway is the “what” pathway; its disruption would affect recognition of objects.
The dorsal pathway, in contrast, is the “where” pathway, which affects spatial perception.
Which of the following might you see with damage to the dorsolateral frontal lobe?
abulia
orbitofrontal damage: Emotional lability, lack of empathy, and Witzelsucht
A 5-year-old boy demonstrates delayed language, parallel play, and an obsession with electrical outlets, but can recite the day of the week of any date.
He most likely demonstrates ____.
savantism
The patient described has autistic spectrum disorder, which has some association with savantism.
You are called to evaluate a patient in the hospital with a history of alcohol abuse who tried to elope from his assisted living facility by climbing a tree two days ago.
Upon admission, his toxicology screen was negative.
Testing indicated poor orientation and attention, fair memory, and poor reasoning.
Your tentative diagnosis is ____.
delirium
The patient’s fair memory eliminates Korsakoff’s and TGA; his poor orientation and attention are consistent with delirium.
Symptoms following a true TIA would resolve quickly on the same day, which is not the case here.
