Neuropsychological Examination

Before beginning, explain:

The purpose of the examination;
The nature of examination (neuropsychological);
The use of information obtained;
Confidentiality;
Feedback which will be available;
General explanation of the test procedures;
Discuss clients’ feelings about/reactions to/attitudes toward testing.

I. Identifying data

age
handedness and changes in it
sex
ethnicity
occupation
marital status
religion
source of information if the cl. cannot cooperate

II. Reason for referral, presenting and current complaints

(verbatim if possible)

III. Relevant History

History of present illness

development of present symptoms from time of onset to present
their relation to life events, conflicts, stressors, drugs
change from previous level of functioning

Work history

longest job they had: what did they do, performance level
most recent job:
chronological listing of jobs
fired vs. laid off

Military history

promotions/demotions
type of discharge
service-connected disabilities
exposure to toxic chemicals

Legal history

arrests, being a defendant
being a plaintiff

Medical history

personal: developmental (pregnancy, delivery,wanted/unwanted, ages of standing, walking, and talking, temperament, bedwetting, nightmares) + go through all major organ systems (nervous,endocrine, respiratory, diagestive, cardiovascular, and sceleto-muscular) + medications
family: medical, psychiatric, causes of death

Psychiatric history

symptoms, changes in functioning
contacts with mental health professionals and other types of counselors
medications
ECT

Habit history

smoking: how long and how much
drinking: same
substances: same

Social history

family of origin: composition, education/occupation, separations, relationships
interpersonal relationships history: authority, friends, lovers ( sexual history including age of puberty, masturbation, sexual problems, orientation, attitudes, fantasies), children
current situation

Hobbies, leisure time pursuits, and spiritual history

Educational history

level of education and grades
best and worst subjects
special ed. and learning disabilities
friends and extracurricular activitied at school

Review of records

(mention all records + relevant records in detail)

IV. Behavioral observations (MSE – history)

(omit stuff included later in test results, put general caveats in this section)

Standard measures: Folstein MMSE (handout), Mattis Dimentia Rating Scale (geriatric), Cognistat (handout, for formal evaluation add Trails for mental flexibility testing, WRAT for writing, etc., and sensory-motor testing), Hopkins competency evaluation (for medical and financial decision-making).

behavior during the interview:
1. physical appearance (gate, dress, grooming, posture, gestures, facial expressions, apparent age, level of motor activity);
2. mood (euthemic, gloomy, tense, hopeless, extatic, resentful, happy, bashful ,sad, exultant, elated, euphoric, depressed, apathetic, anhedonic, fearful, suicidal, grandiose, nihilistic) and affect (anxious, tense, panicky, bewildered, sad, unhappy, labile, blunt, appropriate/inapropriate, flat, la belle indifference);
3. mannerisms;
4. motor problems (tics, tremors, dyscoordination, automatisms, stereotypes, negativism, apraxia, echopraxia, waxy flexibility, TD);
5. eye contact;
6. voice (faint, loud, hoarse);
7. attitude to the interviewer (irritable, aggressive, seductive, guarded, defensive, indifferent, apathetic, sarcastic);
8. level of cooperation and amount of effort put into the task.
level of consciousness:
- alert, lethargic/somnolent, obtunded, stuporous/semi-comatose, comatose, include orientation to time, place, person
- (if the pt. is not alert, examination can be only superficial)
attention/concentration
- (ask to count from 1 to 20 rapidly, calculate 2×3, 4×9, do serial 7 [serial subtraction from 100], ask how many nickels are in $1.35)
expressive and receptive language:
1. spontaneous (speech: slow, fast, pressured, garrulous, spontaneous, taciturn, stammering, stuttering, slurring, stacatto, high/low pitch, good/bad articulation, aphasia, coprolalia [Tourette’s], echolalia, incoherent, logorrhea [uncontrollable expressive speech], mute, paucity, stilted [formal, stiff], neologisms);
2. fluency;
3. comprehension;
4. repetition;
5. naming: confrontational (show object) and responsive (describe object’s function)
6. reading;
7. writing (free sample has to have a noun and a verb);
8. arithmetic.
constructional ability:
1. reproduction (draw from a picture, object);
2. command (ask to draw a shape).
memory
- check verbal and non-verbal for all areas:
1. encoding;
2. retreival;
3. storage;
4. cued response;
5. recognition;
6. immediate;
7. delayed;
8. remote.
perceptual distortions, thought content & process
1. perceptual distortions: hallucinations (olfactory, auditory, haptic [tactile], gustatory, visual), illusions, hypnopompic or hypnagogic experiences, feeling of unreality, deja vu, deja entendu [deja vu abot hearing or seeing in particular], macropsia [hallucinated objects appear small];
2. thought content: delusions (persecutory, grandiose, infidelity, somatic, sensory, thought broadcasting, thought insertion, ideas of reference, ideas of unreality, induced, infidelity, somatic), phobias, obsessions, compulsions, ambivalence, autism, blocking, suicidal or homicidal preoccupation, conflicts, nihilistic ideas, hypochondriasis, depersonalization, derealization, flight of ideas, idee fixe, magical thinking;
3. thought process: goal-directed, loose associations, illogical/logical, tangential, relevant, circumstantial, rambling, ability to abstract, flight of ideas, clang associations, perseveration.
higher cognitive functions:
1. knowledge base;
2. manipulation of knowledge (calculation, for ex.);
3. judgment and insight;
4. abstract reasoning (similarities items).
related cognitive and neurologic functions:
1. apraxias;
2. right-left orientation (self and other);
3. agnosias (finger, visual, tactile);
4. geographic disorientation.

V. Tests and procedures

(list them, basic batteries in Lezak, p.122 – L and reader, p. 61 of Milberg, Hebben, and Kaplan for Boston process approach – B; p. 11 of Reitan and Wolfson for Halstead-Reitan – HR, notes for Luria-Nebraska, Flexible or Clinical approach of Benton – Benton et al – 2nd edition – ‘Contributions to neuropsychological assessment: A clinical manual’ – Oxford University Press)

VI. Test results and interpretation

(put raw data in the summary sheet at the end and refer to it)

Screening instruments (B): Boston/Rochester Neuropsychological Screening Test (1-2 hrs., comprehensive), Geriatric Evaluation of Mental Status (15-20 min., detects cognitive impairment), and MicroCog (1 hr., computerized).

A. Intelligence

(do premorbid IQ estimate: Barona index [handout]) or Vocab. and Pict. Compl.)

B WAIS-III (developed for neuropsych.) or WAISR-NI (process)
Stanford-Binet (kids, more like a game)
Shipley Institute of Living Scale (quick, good IQ estimate)

B. Language

Test for Aphasias:

anomia/dysnomia: three step testing can be used with any stimulus set – 1) confrontation naming (show an object, ask what it is), 2) responsive naming (ask for name giving a functional description – stimulus cue), and 3) try phnemic cue (give the beginning of the word);
Verbal fluency: norm is 100-200 words/min., considered low for <50 words/min., can use Controlled Oral Word Association Test from Benton Multilingual Aphasia Exam;
Writing fluency: Thurstone Written Word Fluency Test (phonemic fluency problems – anterior lesions, semantic – posterior);
Repetition (can use BDAE or COGNISTAT);
Seriatim speech = speech that rhymes or goes in predictable order (say numbers or repeat rhymes);
Agrammatism (telegraphic speech);
Scanning speech = slow, prosody impaired;
Dysarthria = problems with motor components of speech;
Dysgraphia = problems with motor componrnt of writing;
Dyslexia = problems with reading;
Paraphasias: literal (phonemic – dropping,transposing, or substituting similar sounds), verbal (semantic – substitution of a semantically related word), extended (word salad), neologism (extended paraphasia for one word);
Circumlocutions;
Stattering (repeating first part of word or phrase);
Pallilalia (repeating last part of word or phrase);
Echolalia.

B Boston Diagnostic Aphasia Exam (BDAE) – comprehensive
B Narrative Writing Sample
B Tests of Verbal Fluency (Word List Generation)
B and L Boston Naming Test
L Information, Comprehension, Similarities (WIS)
L Controlled Oral Word Association Test
L Gates-MacGinitie Reading Test or SRA Reading Index
L Mincus Completion and Sentence-Building Test (Stanford-Binet, Forms M-L)
HR Speech-Sounds Perception Test
HR Reitan-Indiana Aphasia Screening Test (good for geriatric population)

C. Constructions (visuospatial skills)

B Automobile, Cow and Circle Puzzles (WAIS-R NI)
B Spatial Quantitative Battery
B Hooper Visual Organization Test (cutoff <26 correct)
B Judgment of Line Orientation
L Block Design (WIS)
L Complex Figure Test, copy trial
L house and/or bicycle drawing
HR Performance subtests of WIAS
HR Trail Making Test
HR Square, Cross, and Triangle from Aphasia Screening Test
Clock drawing (draw a clock showing 11:10, scoring and norms in the Journal of the American Geriatric Society – 1995-6?)
For simultanagnosia – Popplereuter figure (occipito-parietal lesions)

D. Calculations

B Wide Range Acheivement Test

E. Attention and concentration

L Sequential Operations Series
L Digit span and Arithmetic (WIS)
L Symbol Digit Modalities Test
L Trail Making Test
L Stroop Test (Dodrill format)
HR Speech-Sounds Perception Test
HR Rhythm Test

F. Memory

B California Verbal Learning Test
B Rey-Osterreith Complex Figure
B Benton Visual Recognition Test (Multiple choice form)
B Consonant Trigrams Test
B Cowboy Story Reading Memory Test
B Spatial Span
B Wechsler IMS – III
L Sentence Repetition
L Serial Digit Learning
L Auditory-Verbal Learning Test
L Story Recall (use 2 stories of similar length and difficulty)
L Recall of Symbol Digit Modalities Test pairs
L Complex Figure Test, recall trials
L Continuous Recognition Memory Test or Continuous Visual Memory Test
Warington Memory Recognition Test (words-l and faces-r included, <50% performance – suspect malingering, =50% – no effort)

G. Mental flexibility (response inhibition tasks)

B Stroop Color-Word Interference Test
Weial-Golstein-Scheerer Color-Form Sorting Test (set switching – easiest, no reading or math)
HR Trail Making Test B (set switching – medium)
B Wisconsin Card Sorting Test (set switching – hardest)

H. Reasoning, abstract thinking, problem solving, judgment, concept formation

B Standard Progressive Matrices
B Proverbs Test
B Visual Verbal Test
B Boston Evaluation of Executive Functions
B The California Proverbs Test
L and HR Category Test
L Raven’s Progressive Matrices

I. Sensory and motor functioning

Test for:

APRAXIAS:

In general terms, look at ‘how to do things’ system, ‘when to start/stop’ system, and praxicons (voluntary movement sequences representations), formally tested by Heilman’s Apraxia Test;
For ‘how to do things’ system (praxicons) assess transitive (with tools) and intransitive movements for both hands in three stages – 1) pantomime to command, 2) pantomime to imitation, and 3) do it with the object – look for content errors (semantic) and production errors (temporal and spatial);Terms: limb or melokinetic apraxia (fine finger movement problems – corticospinal); Ideomotor – probl. with transitive acts to command (spatial and temporal production errors, body part as object errors); Conduction – cannot do pantomime to imitation only; Disassociation – cannot do to verbal command only; Ideational – problems with sequencing of movements only (Alzheimer’s, large frontal lesions); Conceptual – content-related errors to command and imitation;
For ‘when to start/stop’ system: Akinesia – not being able to perform a sequence when the person knows how to do it; Hypokinesia – takes long to initiate movement; Motor extinction – can do movements with each hand separately, but have problems coordinating them; Motor impersistence – response is weakening fast; Defective response inhibition (like in Huntington’s); Motor perseveration;
Additional terms: Constructional apraxia (trouble with Block Design, Complex figures, etc.); Dress apraxia (mix up clothing while getting dressed).

AGNOSIAS:

In general terms, divided into apperceptive (stimulus does not translate into accurate percept) and associative (percept is there, the problem is with attributing meaning to it) types;
Somesthetic agnosias: Agraphesthesia (inability to distinguish shapes written on skin); Somatolopagnosia (inability to say whuich part of one’s body was touched); Astereognosis (inability to discriminate objects gby touch);
Auditory agnosias: Aphasia; Amusia; Arhythmia; Aprosodia; Environmental (sounds which carry meaning, like fire alarm);
Visual agnosias: Object; Facial (Prosopagnosia); Metamorphosia (change in object size while looking); Megalopsia (increase in object size); Prosopoaffective (inability to recognize consensual meaning in facial expressions); Visual/verbal (dyslexia);
Gustatory agnosia = Ageusia;
Smell = Anosmia.

B Porteus Maze Test
B Luria Three-Step Motor Program
B Finger Tapping
B Grooved Pegboard
L Picture Completion, Picture Arrangement (WIS)
L Judgment of Line Orientation
L Visual Search
L Hooper Visual Organization Test
L Ruff Figural Fluency Test
L Finger Tapping Test
HR Tactual Performance Test
HR Tactile Form Recognition
HR Finger Localization
HR Fingertip Number Writing Perception

J. Emotional factors

correct tests for following influences of brain damage proper:
1. Constriction of the information in the response;
2. Stimulus boundedness;
3. Seeking structure in stimuli;
4. Rigid fragmentation (concentrationg on a part of the stimlus and being unable to let go of it);
5. Simplification;
6. Confusion;
7. Confabulation;
8. Hesitancy.
MMPI (brain injury proper gives spikes on F and 8, might give spikes on 1 and 3 – somatic focus, 9 is usually low)
MCMI
Beck Depression Inventory, Beck Hopelessness Inventory, Beck Suicidality Index (has no cutoff score) and Beck Anxiety Inventory
Simptom Check List 90 – R
Geriatric Depression Scale
Spielberg State and Trait Anxiety Inventory – better than Beck
Profile of Mood States
Rorchach (According to Piotrowski, 1937, the following signs have to be corrected for in brain damaged patients, they can also be used to diagnose brain damage – if >5 categories are present brain damage, chronic schizophrenia, or severe psychotic depression are likely:
1. R<15
2. Average response time >1 minute, long delay, not much info
3. <1 movement responses, esp. no M
4. Color Naming
5. FQ o & + < 70%
6. P<20%
7. Perseveration
8. Impotency (recognition of inadequacy of one s response without ability to improve on it)
9. Perplexity (doubting one’s ability to respond)
10. Automatic phrases
Other brain injury signs:
1. Inflexibility (inability to generate alternative responses)
2. Concreteness
3. Catastrophic reaction to own impotency and perplexity (card refusal)
4. Covering parts of the card to reduce stimulation in order to come up with a response
5. Usual language problems
Thematic Apperception Test – for defenses (adaptation of Piotrowski’s corrections)
1. Fewer words/ideas
2. Longer response times
3. Card description with little action and few characters
4. Describe elements of the card at random
5. Misinterpret elements of the card
6. Few common themes
7. Perseveration
8. Automatic phrases
9. Inability to change the response
10. Expressions of self-doubt
Projective drawings – good for kids since there are developmental norms, correct for visual field cuts.