ADULT NEUROPSYCHOLOGY:

AN UPDATE FOR CLINICAL & COUNSELING

PSYCHOLOGISTS

Philip Barry, Ph.D., ABN

June 1, 2012

OBJECTIVES

� Aspects of Evaluations

� Emerging Role in Medical Research

� Cognitive Dysfunction In Competency

OUTLINE

� Subcortical Structures

� Cognitive Domains

� Dementia/Competency Evaluations

� Comprehensive Evaluations

� Symptom Validity Testing

SUBCORTICAL STRUCTURES

� Top-down Models of Cognition

� Cortical Localization

� Frontal Lobes’ Executive Functions

� Minimal Role of Subcortical Structures

�Memory Transfer

�Fight/Flight Responses

�Vegetative Functions

BOTTOM-UP MODEL OF COGNITION

� Sensorimotor Interaction With the Environment is the Primary driver of 95% of Human Behavior

� Subcortical Structures Modulate Both Thought & Behavior in Essentially the Same Ways

� The Cartesian Mind-Body Distinction is Artificial

� Leonard Koziol, Ph.D.

BASAL GANGLIA AS MEDIATOR BETWEEN

SENSORY INPUT AND FRONTAL EXECUTIVE

FUNCTIONS

� Koziol

� Simple

� Fast

� Extremely Sensitive to Any Change in Context

� Allows Complex Learned Behaviors to Become Automatic (e.g., Driving)

� Primitive Structures Essential to Survival

� Koziol

HIPPOCAMPUS AS MEDIATOR OF LEARNING &

MEMORY

� Lateralization Corresponds to Cortical Functions

� Network of Connections Between Frontal Lobes

& Function Specific Cortical Regions

� Essential to Procedural & Declarative

Knowledge

AMYGDALA AS MEDIATOR OF EMOTIONAL

LEARNING & MEMORY

� Many More Connections Throughout the

Brain Than Hippocampus Means Emotional

Associations, especially fear, Can Override

Factual Knowledge

� David Lisak, Ph.D., 2006

PTSD

� Lisak, 2006

� Hippocampus ‘atrophies’ over time in people

with chronic PTSD due to chronic cortisol

exposure

� Reduced ability to learn & remember new input

� More easily overwhelmed by emotional responses mediated by amygdala

� Hippocampus ‘regenerates’ as symptoms subside

� Lisak, 2006

CEREBELLUM MEDIATES MOVEMENT

� It Regulates the Quality, Rate, Rhythm, Form, & Force of Actions & Responses

� Helps Us Learn New Complex Motor, Cognitive & Affective Functions

� Has Only One Neuronal Structure Which Serves Regions Throughout the Cortex

� Koziol,2012

LURIA’S NEUROPSYCHOLOGICAL FUNCTIONAL

SYSTEMS

� “Complex behavioural processes are in fact not localized, but distributed in the brain & the contribution of each cortical zone to the organization of the whole functional system is very specific.”

� A-L Christensen, Luria’s NP Investigation (1975)

HRB FACTOR ANALYSIS

et al (1992) found only 3 factors: � “Leonberger et al (1992) found only 3 factors:

� Attention

� Processing Speed

� Visuospatial Problem Solving� Larrabee, Arch. of Clin. NP, 23 (2008) p. 766

MODERN FLEXIBLE BATTERY

� “Variable but routine groups of tests for different types of patients”

� Preferred by 76% of practicing NPs

� Meets Frye & Daubert criteria for expert testimony

� Sweet et al, (2006) in Larabee (2008), p. 765

COGNITIVE DOMAINS ASSESSED

AttentionVerbal

Memory

Executive Functions

Visuospatial Skills

MORE DOMAINS

Nonverbal Memory

Intelligence

Language Construction

MATRICS

� Measurement & Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery

� To aid in the process of developing meds for improving cognition in schizophrenia

� Developed under NIMH & FDA contract (2001)

BUILDING MATRICS

Consensus on

independent cognitive

domains to be assessed;

Nominate tests for specific

domains;

Beta test 2-5 tests per domain;

Select final battery of 1-3

tests per domain.

� HIV-Associated Neurocognitive Disorders

� American Academy of Neurology

� Nat’l Institute of Mental Health

� Nat’l Inst. of Neurological Diseases & Stroke

� -Neurology, October 30, 2007

HAND

Guidelines for specific disease processes� Guidelines for specific disease processes� MS

� Mild Cognitive Impairment

� Dementia

� Standardized diagnostic criteria � Number of domains involved

� Statistical differences from age norms

� Focus on enhancing cognition

RELATED DEVELOPMENTS

PSYCHOLOGISTS WHO PERFORM DEMENTIA

EVALUATIONS SHOULD

� Be familiar with prevailing nomenclature & diagnostic criteria;

� Attempt to obtain informed consent & educate patient (family, guardian) re: nature of service, financial arrangements, potential risks, limits of confidentiality.

� APA Presidential Task Force on the Assessment of Age-Related Cognitive Decline & Dementia,

February, 1998.

COMPETENCY EVALUATIONS

� Focus on Functional Independence

� Activities of Daily Living

� Instrumental Activities of Daily Living

Ability to Make Informed, Responsible Decisions

Medical Interventions

Financial Affairs

DEMENTIA SCREENS

� MMSE is Now Copyrighted!

� Available for purchase from PAR

� Expanded version better than original

MONTREAL COGNITIVE ASSESSMENT

(MOCA)

� FREE

� Better standardized assessment

� Samples multiple cognitive functions

� Norms & Manual Online

MINIMUM GERIATRIC BATTERY

Learning & Memory

Intelligence

Processing Speed

Mental Flexibility

� Necessary in adversarial cases

� Personal injury lawsuits

� Criminal competency evaluations

� Disability benefit eligibility evaluations

SYMPTOM VALIDITY TESTING

� “Suboptimal performance may stem from

non-neurological sources that do not involve

the conscious desire to seek external gain

through deception.”

� Tombaugh (1996), Test of Memory Malingering (TOMM)

MOTIVATIONAL DISORDERS

COMMENTS

&

QUESTIONS