How does neuropsychology work in practice? - Chapter 2

When did the clinical field of neuropsychology establish?

This chapter focuses on the work of the neuropsychologist. It is a relatively young field of work: in the United States this field established itself at the beginning of the twentieth century; in the Netherlands only in the second half of the same century.

What does the Neuropsychological Examination consist of?

Diagnostic cycle

The diagnostic cycle consists of four stages: the complaints analysis, problem analysis, diagnosis and indication for treatment. After each step, hypotheses are formulated. These hypotheses are tested using data from the patient interview, observations, and neuropsychological tests and questionnaires. During the cycle, hypotheses can be adjusted or rejected. Sometimes the cycle is completed several times (in part), but sometimes it is also interrupted prematurely if further investigation does not prove useful.

Referral and research questions

It is of great importance that the referrer's question (often a medical specialist or fellow psychologist) is specific and clear. If it is not clear, it must be clarified. During the examination, the psychologist will add additional research questions if the examination renders this necessary.

Case history

During an anamnesis the patient is always interviewed about the complaints, education, work, medication use and medical history. The patient will often spontaneously list his / her complaints, after which the psychologist will discuss the development of the complaints. A standard list of questions is often used, but is not enough. Asking further is very important (with visual hallucinations you quickly think of a psychotic disorder, but not a burnout). The psychologist also gets a general first impression of the cognitive abilities, the insight into the illness and the behavior of the patient. The patient can also be reassured or motivated if necessary.

An interview with the informant

A conversation with only the patient is not enough. During the heteroanamnesis the informant, the partner, the parent, the children or even the neighbours, friends or the doctor are asked for information. As a rule, permission for this is requested from the patient. A clear case in which an interview with an informant is essential is in the case of a suspected frontotemporal dementia: there is no insight into illness and there is a change in personality that is often not spontaneously mentioned by the patient himself.

Observation

Observations can be collected at any time during the examination. It is important that the observations are independent of interpretations (so write down: "patient is crying" and not "patient is sad"). Observations can provide information about social interaction, cognitive capacities and motivations

Tests and questionnaires

There are different types of tests and questionnaires: screening tests, standardized test batteries, tests that focus on one cognitive function, behavioral neurological tests, self-assessment questionnaires, informant questionnaires, and observation scales. A fixed battery of tests is often used for scientific research; in a neuropsychological examination a flexible test battery is used more often, which takes more work because it specifically focuses on complaints and questions. The reliability and validity of tests and questionnaires, the available standard data, the distinctive character, and the presence of parallel versions must always be taken into account. The paper-and-pen tasks are still used. Advantages of computerized tests are the decrease in standardization, the accurate recording of responses, and time saving. A computerized test is especially recommended when (sustained) attention and the reaction time are being measured.

Interpretation

The interpretation involves the integration of the anamnesis, the interview with the informant, the observations and the test results. Are the results reliable and valid? Are there any factors that could have influenced the test scores, such as fatigue and nervousness? How are the standard data determined, has age and education been corrected? The differential diagnosis must also be carefully examined: are there possibly other explanations for the symptoms?

Reporting

The written report is initially drawn up for the referrer. The content and length will vary depending on personal style and on the purpose of the report. The content of a psychological report must be discussed with the patient before the findings are reported to the referrer or discussed within a multidisciplinary team. However, this is sometimes not desirable, for example when the neuropsychological examination is part of a multidisciplinary process and the diagnosis is not yet known. In such a case, the psychologist can discuss the results, but it is better not to make statements about possible causes or diagnoses: this is done in the final conclusion of the study. The patient will often ask for a copy of the report: this may only be refused in exceptional cases. The code of the Dutch professional organization for psychologists (NIP) also describes the other rights of the patient, such as the right to perusal, correction, or blocking. 

What are validity and reliability?

Reliability

The reliability of a test specifies the accuracy of the test. The test-retest is the extent to which a test yields the same results when it is taken at different times by the same person. This is indicated by a correlation coefficient. The inter-rater reliability measures the degree of agreement between the results of several researchers, which is presented as Cohen's kappa.

Validity

The validity of a test consists of different subtypes:

• Face validity: does the test seem to measure what it is supposed to measure?

• Content validity: is the test is representative of the topic that is to be measured?

  • Example: an intelligence test that consists of several subtests has a higher content validity than an intelligence test that only consists of number series.

• Construct validity: to what extent does the result of the test actually reflect the cognitive function that is measured? Example: to what extent does the score on the number series actually say something about the working memory?

• Criterion validity: to what extent does the test predict the actual behavior of a patient with regard to an external criterion (predictive validity) and what is the similarity between this test and another instrument with the same measurement pretention (concurrent validity)?

• Ecological validity: how does the score on a test predict the functioning of the patient in his / her own environment? This is very similar to predictive validity. There is much criticism of the predictive value of traditional tests since a structured test situation cannot be compared to a work situation.

Confounding factor

A confounding factor is an element that influences performance on a test but that does not fall within the measurement objective of that test. For example, sensory limitations, cultural background, limited education, fatigue, pain, emotional absence and motivational problems.

What does underperforming mean?

Underperformance - or suboptimal performance - is a disturbance factor that makes the patient perform worse than what he / she is capable of if he / she would be able to achieve if they were to make a normal effort. This can be caused by extreme tiredness or nervousness, pain, worries or financial reasons. Non-existent symptoms can also be pretended (simulated) or existing symptoms may be exaggerated. Underperformance can be assessed by looking at inconsistencies within the test profile or by noticing a clear discrepancy between the test scores and actual behavior. In some patient groups, the prevalence of underperforming is quite high (this is often the case with a whiplash where the patient benefits from underperforming in connection with insurance and sickness law). Symptom validity tests have been developed to detect underperformance. The underlying idea of ​​symptom validity testing is that performance below the level of patients with brain injury is suspicious, since the tests appear difficult but are very easy and measure a function that is still intact in almost all patients with brain damage. A reason for intentionally underperforming is for example in forensic neuropsychological examinations, with the goal of getting a sentence reduction.

What is the neuropsychological treatment?

Initially neuropsychological treatment focused on cognitive impairment, but in recent decades more attention has been given to the emotional and behavioral consequences of brain injury (such as anxiety, mourning, relationship problems, sexual problems, aggression and inhibition). The neuropsychologist not only monitors the treatment plan and the learning methods, but also the learning pace. He also advises professionals in other disciplines within the team.

What does the professional field of the neuropsychologist consist of?

What does a neuropsychologist do in a hospital?

In an academic hospital, neuropsychologists are often attached to a university and carry out more scientific research compared to neuropsychologists working in a general hospital. In the hospital the neuropsychologist collaborates closely with a number of specialties, including neurology, geriatrics, rehabilitation, neurosurgery, and internal medicine. Sometimes there is a psychiatric department with psychiatrists. The main task is to perform outpatient diagnostics. Treatment administered in a hospital is usually short term and complaint oriented. Here the emphasis is mainly on psychoeducation.

What does a neuropsychologist do in a rehabilitation center?

Within a rehabilitation center you will be part of one or more multidisciplinary teams. The emphasis is usually more on treatment than on diagnostics. Nevertheless, the diagnostics are an essential part of the work carried out in a rehabilitation center. It provides insight into neuropsychological disorders that can form an obstacle to treatment, and it also ascertains remaining abilities that can be used in treatment, such as an intact learning ability or an ability to benefit from structure. A neuropsychologist often has an important management function in the team and he / she often works closely with a cognitive trainer. The neuropsychologist focuses primarily on neurological disorders such as stroke, multiple sclerosis, and traumatic brain injury.

What does a neuropsychologist do in mental health care?

The neuropsychologist works closely with psychiatrists, psychologists, activity counselors and psychiatric nurses. The work carried out with admitted patients can be divided into acute care and chronic care. In the case of ambulatory patients, patients only come to the institution for treatment. Psychoeducation for the patient and family and friends is very important. Here the neuropsychologist will often be involved in meditative treatment, whereby he / she tries to influence the behavior of the patient positively through the environment. Diseases are mainly mood disorders, psychotic disorders, ADHD, addiction and autism spectrum disorders.

What does a neuropsychologist do in a care or nursing home or assisted living forms?

Most patients in a care home or nursing home are of an older age. The departments are often subdivided into somatic departments (physical care) and psychogeriatric departments (dementia). The neuropsychologist tests cognitive functioning, thinks about the possible causes, the prognosis and the treatment. Usually placement advice will be requested. Treatment methods can vary from cognitive rehabilitation (individually or in groups) to system therapy and drug therapy. He / she also advises on suitable living facilities and guidance of the environment.

What does a neuropsychologist do in a forensic institution?

Neuropsychologists are of importance in a forensic institution because of the is increasing evidence for the neurobiological basis of criminal behavior. The activities are always within a legal context (such as TBS, detention or imprisonment). The cognitive functions are mapped out within the legal framework. The neuropsychologist can also be asked about possible cognitive obstacles for a certain treatment. The reporting is subject to extreme requirements because of the enormous consequences that the statements of the neuropsychologist can have with regard to the deprivation of liberty.