clinical neuropsychology · 2013. 7. 19. · edited by laura h. goldstein and jane e. mcneil...

Edited by Laura H. Goldstein and Jane E. McNeil

CLiNiCaL NEuropsyCHoLoGy a praCtiCaL GuidE to assEssMENtaNd MaNaGEMENt for CLiNiCiaNs

sECoNd EditioN

90000

9 780470 683712

ISBN 978-0-470-68371-2

CLiNiCaL NEuropsyCHoLoGy Edited by

Goldstein and McNeil

sECoNd EditioN

‘I wish this book had been available when I began work as a clinical neuropsychologist 25 years ago – I would have been a much better clinician and researcher for reading it. This is, in my view, the best book in the field because of its deft combination of real clinical issues with the most up-to-date science. This is no ivory-tower text on neuropsychology, which was the only type available when I entered this field; it begins with a wide range of complex cases and gives the reader the essential background – neurological and neuroanatomical as well as neuropsychological – to foster the best practice and research.’

Ian Robertson, Professor of Psychology, Trinity College Dublin

While often viewed as a specialty within clinical psychology, neuropsychology and its applications remain highly relevant to all areas of clinical practice involving patients with alterations in cognitive functioning. Updated and revised to reflect the current state of knowledge in the field, the second edition of Clinical Neuropsychology provides trainee and practicing clinical psychologists with an invaluable overview of a wide range of neuropsychological assessment and rehabilitation issues in the context of recent neuropathological, neuroanatomical, neurological and neuroimaging developments.

While the primary focus continues to be on areas of knowledge and skill to enable practicing clinicians to assess the cognitive functioning of clients and consider suitable rehabilitation and treatment options, a variety of new topics are featured here. These include the evaluation of research designs and neuropsychological interventions, working with clients with very severe and profound brain injury, differentiating between clients with different subtypes of frontotemporal lobar degeneration, the proper assessment of mental capacity, and the impact of cognitive impairment on driving ability.

Laura H. Goldstein is Professor of Clinical Neuropsychology at the Institute of Psychiatry, King’s College London and Honorary Consultant Clinical Psychologist at the Maudsley Hospital, South London and Maudsley NHS Foundation Trust.

Jane E. McNeil is a Consultant Clinical Neuropsychologist with over 20 years’ experience working with neurological patients. She is Neuropsychology Service Lead for Solent NHS Trust.

Cover image: Vincent van Gogh, Tree roots in a sandy ground (‘Les racines’), 1882, 49 x 68.5 cm, pencil, chalk and wash on paper. Collection Kröller-Müller Museum, Otterlo.

Cover design: www.simonlevyassociates.co.uk

Goldstein pb artwork.indd 1 7/2/12 07:31:17

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Clinical Neuropsychology


Clinical Neuropsychology

A Practical Guide to Assessment andManagement for Clinicians

Second Edition

Edited by

Laura H. GoldsteinDepartment of Psychology, Institute of Psychiatry, King’s College London

and The Lishman Unit, Maudsley Hospital, London

Jane E. McNeilNeuropsychology Department, Queen Alexandra Hospital, Portsmouth

A John Wiley & Sons, Ltd., Publication


This edition first published 2013C© 2013 John Wiley & Sons Ltd

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Library of Congress Cataloging-in-Publication DataClinical neuropsychology : a practical guide to assessment and management for clinicians /edited by Laura H. Goldstein and Jane E. McNeil. – 2nd ed.

p. cm.Includes index.ISBN 978-0-470-68371-2 (pbk.)

1. Clinical neuropsychology. I. Goldstein, Laura H. (Laura Hilary), 1960– II. McNeil, Jane E.RC386.6.N48C52725 2012616.8–dc23

2011035236

A catalogue record for this book is available from the British Library.

Set in 10.5/13pt Minion by Aptara Inc., New Delhi, India

2 2013

http://www.wiley.com/wiley-blackwell


Contents

List of Contributors ix

Preface xv

Preface to the First Edition xix

Part 1 General Introduction

1 General Introduction: What Is the Relevance of Neuropsychologyfor Clinical Psychology Practice? 3Laura H. Goldstein and Jane E. McNeil

Part 2 Neuroscience Background

2 Neuroanatomy and Neuropathology 23Nigel J. Cairns

3 Neurological Investigations 61John D. C. Mellers and Naomi A. Sibtain

Part 3 Neuropsychological Assessment: General Issues

4 Psychological and Psychiatric Aspects of Brain Disorder: Nature,Assessment and Implications for Clinical Neuropsychology 87Richard G. Brown


vi Contents

5 The Effects of Prescribed and Recreational Drug Useon Cognitive Functioning 105Jane Powell

6 Quantitative Aspects of Neuropsychological Assessment 129John R. Crawford

Part 4 Adult Neuropsychology

7 Disorders of Memory 159Jonathan J. Evans

8 Disorders of Language and Communication 185Pat McKenna and Karen Bonham

9 Executive Dysfunction 209Paul W. Burgess and Nick Alderman

10 Acquired Disorders of Voluntary Movement 239Laura H. Goldstein

11 Visuo-Spatial and Attentional Disorders 261Tom Manly, Jessica Fish and Jason B. Mattingley

12 Disorders of Number Processing and Calculation 293Jane E. McNeil

Part 5 Neuropsychology: Specialist Areas of Work

13 Clinical Neuropsychological Assessment of Children 317Jody Warner-Rogers

14 Neuropsychological Assessment of Older Adults 347Robin G. Morris and Rebecca L. Brookes

15 Neuropsychology of Frontotemporal Lobar Degeneration:Frontotemporal Dementia, Semantic Dementia and ProgressiveNon-Fluent Aphasia 375Julie Snowden

16 Very Severe and Profound Brain Injury 397J. Graham Beaumont


Contents vii

17 Neuropsychology and the Law 415Graham E. Powell

18 Mental Capacity 445Camilla Herbert

Part 6 Rehabilitation

19 Theoretical Approaches to Cognitive Rehabilitation 463Fergus Gracey and Barbara A. Wilson

20 Planning, Delivering and Evaluating Services 483Camilla Herbert

21 Research Design and Outcome Evaluation 505Andrew Worthington

22 Interventions for Psychological Problems After Brain Injury 527Andy Tyerman and Nigel S. King

23 Neurorehabilitation Strategies for People with NeurodegenerativeConditions 549Jennifer Rusted and Esme Moniz-Cook

24 Driving in Neurological Patients 567Nadina B. Lincoln and Kate A. Radford

Index 589

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List of Contributors

Professor Nick AldermanConsultant Clinical Neuropsychologist and Specialty LeadNational Brain Injury CentreSt Andrew’s HealthcareBilling RoadNorthampton NN1 5DG

Professor J. Graham BeaumontHonorary Professor, University of RoehamptonConsultant NeuropsychologistDepartment of Clinical PsychologyRoyal Hospital for Neuro-disabilityWest HillLondon SW15 3SW

Ms Karen BonhamLead Speech and Language Therapist (Brain Injury)Rookwood HospitalLlandaffCardiff CF5 2YN

Dr Rebecca L. BrookesStroke and Dementia Research CentreSt George’s, University of LondonCranmer TerraceLondon SW17 0RE


x List of Contributors

Professor Richard G. BrownProfessor of Neuropsychology and Clinical NeuroscienceKing’s College LondonDepartment of Psychology (PO77)Institute of PsychiatryDe Crespigny ParkLondon SE5 8AF

Professor Paul W. BurgessProfessor of NeuroscienceUCL Institute of Cognitive NeuroscienceAlexandra House17 Queen SquareLondon WC1N 3AR

Dr Nigel J. CairnsResearch Associate ProfessorDepartments of Neurology and Pathology & ImmunologyWashington University School of MedicineSaint LouisMissouri 63110USA

Professor John R. CrawfordSchool of PsychologyCollege of Life Sciences and MedicineKing’s CollegeUniversity of AberdeenAberdeen AB24 2UB

Professor Jonathan J. EvansProfessor of Applied NeuropsychologyUniversity of GlasgowMental Health & Wellbeing, Institute of Health & WellbeingGartnavel Royal Hospital1055 Great Western RoadGlasgow G12 0XH

Dr Jessica FishMedical Research Council Cognition and Brain Sciences Unit15 Chaucer RoadCambridge CB2 7EF


List of Contributors xi

Professor Laura H. GoldsteinProfessor of Clinical NeuropsychologyKing’s College LondonDepartment of Psychology (PO77)Institute of PsychiatryDe Crespigny ParkLondon SE5 8AF

Dr Fergus GraceyConsultant Clinical NeuropsychologistOliver Zangwill Centre for Neuropsychological RehabilitationPrincess of Wales HospitalLynn RoadEly CB6 1DN

Dr Camilla HerbertConsultant in Neuropsychology and RehabilitationBrain Injury Rehabilitation TrustKerwin CourtHorsham RH13 0TP

Dr Nigel S. KingConsultant Clinical Neuropsychologist and Clinical TutorCommunity Head Injury ServiceBuckinghamshire Healthcare NHS TrustThe Camborne CentreJansel SquareAylesbury HP21 7ET

Professor Nadina B. LincolnProfessor of Clinical PsychologyInstitute of Work, Health & OrganisationsUniversity of Nottingham, International HouseJubilee CampusWollaton RoadNottingham NG8 1BB

Dr Pat McKenna174 Kings RoadPontcannaCardiff CF11 9DG


xii List of Contributors

Dr Jane E. McNeilConsultant Clinical NeuropsychologistNeuropsychology DepartmentQueen Alexandra HospitalCoshamPortsmouth PO6 3LY

Dr Tom ManlyClinical Psychologist and ScientistMRC Cognition and Brain Sciences UnitBox 58Addenbrooke’s HospitalHills RoadCambridge CB2 2QQ

Professor Jason B. MattingleyFoundation Chair in Cognitive NeuroscienceQueensland Brain Institute and School of PsychologyUniversity of QueenslandSt Lucia 4072Australia

Dr John D. C. MellersConsultant PsychiatristNeuropsychiatry UnitRoom 32, Outpatients DeptMaudsley HospitalDenmark HillLondon SE5 8AZ

Professor Esme Moniz-CookProfessor of Clinical PsychologyConsultant Clinical PsychologistInstitute of RehabilitationUniversity of Hullc/o 39-41 Coltman StreetHull HU3 2PG

Professor Robin G. MorrisProfessor of NeuropsychologyKing’s College LondonDepartment of Psychology (PO78)Institute of PsychiatryDe Crespigny ParkLondon SE5 8AF


List of Contributors xiii

Dr Graham E. PowellConsultant Clinical PsychologistPowell Campbell Edelmann9 Devonshire PlaceLondon WC2E 9DJ

Professor Jane PowellPro-warden (Research & Enterprise)Professor of PsychologyGoldsmiths’ CollegeLewisham WayLondon SE14 6NW

Dr Kate A. RadfordSenior Lecturer (Research)Clinical Practice Research UnitFaculty of HealthBrook Building 417University of Central LancashirePreston PR1 2HE

Professor Jennifer M. RustedProfessor of Experimental PsychologySchool of PsychologyPevensey 1Sussex UniversityBrighton BN1 9QH

Dr Naomi A. SibtainConsultant NeuroradiologistKing’s College Hospital and South London and Maudsley NHS Foundation TrustsDenmark HillLondon SE5 9RS

Professor Julie SnowdenConsultant NeuropsychologistSalford Royal Foundation Trust and University of ManchesterCerebral Function UnitGreater Manchester Neuroscience CentreSalford Royal Foundation TrustSalfordGreater Manchester M6 8HD


xiv List of Contributors

Dr Andy TyermanConsultant Clinical Neuropsychologist & Head of ServiceCommunity Head Injury ServiceBuckinghamshire Healthcare NHS TrustThe Cambourne CentreJansel SquareAylesbury HP21 7ET

Dr Jody Warner-RogersConsultant Paediatric NeuropsychologistPaediatric Neurodisability ServiceNewcomen CentreGuy’s and St Thomas’s NHS Foundation TrustSt Thomas’s StreetLondon SE1 9RT

Professor Barbara A. Wilson OBESenior Scientist (Visitor Status)MRC Cognition & Brain Sciences Unit15 Chaucer RoadCambridge CB2 7EF

Dr Andrew WorthingtonConsultant in Neuropsychology and RehabilitationHeadwiseInnovation CentreLongbridge Technology ParkBirmingham B31 2TS

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Preface

Although often viewed as a speciality within Clinical Psychology, we continue to feelthat knowledge of neuropsychology (and its applications) is relevant to all areas ofclinical work where people (across the age span) might be showing some changein their cognitive functioning. Thus, a working knowledge of neuropsychology andthe assessment and management of cognitive impairment may be necessary for thedelivery of a competent clinical service by even those practitioners who do notwish to see themselves as experts in the field of clinical neuropsychology, and whomay well have had little or no experience of clinical neuropsychology during theirtraining as Clinical Psychologists. Historically, psychometric testing (underpinnedby knowledge of psychometric principles) has been a cornerstone of the skills makingpsychologists unique as a professional group and it remains a core, essential skill ofclinical neuropsychologists. In recent years there have been increasing and multiplethreats to clinical psychology: from non-psychologist IAPT practitioners providingCBT, other neuro-professionals claiming skills in cognitive assessment and the movefrom self-management under the British Psychological Society to external regulationby non-psychologists with the Health Professions Council. We, more than everbefore, need to protect our expertise and ensure the next generation of psychologistshave the same breadth and depth of skills if the profession is to continue to existand if the public is to be protected. While we would argue that neuropsychologicalassessment should form part of the core competencies acquired by all trainee clinicalpsychologists, our compilation of this second edition is based on the more realisticappreciation of the training opportunities available to those who are both pre- andpost-qualification, an appreciation gained through many years of being activelyinvolved in both pre- and post-qualification training of clinical psychologists at theInstitute of Psychiatry and elsewhere.

There are of course different ways in which to present information on clinicalneuropsychological knowledge and practice. One is to focus on specific neurologicaldisorders, and their assessment and management. Within the scope of a relatively


xvi Preface

short book, however, we feel that this may limit the apparent relevance and general-izability of the skills, which we feel it is important for clinicians to possess. Thus, forthe current volume we have again chosen to focus on broad areas of cognitive func-tion (including those such as praxis and number processing and calculation whichare perhaps less well-developed areas of clinical neuropsychology in the UnitedKingdom) which may be relevant to assess across a wide range of neurological andpsychiatric disorders. We have also chosen to include chapters that deal with impor-tant background information relevant to those being assessed (such as the effects ofmedication and the interaction between neurological and psychiatric presentations)and, because so much of clinical neuropsychologists’ work does involve test interpre-tation, an overview of key psychometric concepts underpinning neuropsychologicalassessment. There is also a consideration of the impact of cognitive deficits on drivingskills, an area that has developed considerably since our first edition.

In addition to addressing specific cognitive functions, it is of course obvious thatclinical neuropsychology may be somewhat differently applied at different ends ofthe age spectrum, where different factors may assume particular importance. Forthis reason, we have chosen to include specific chapters that address the issue ofneuropsychological practice with children and older adults as well as a new chapteraddressing frontotemporal lobar degeneration. We have also covered the specificdifficulties encountered in working with individuals with very severe and profoundbrain injury, an area brought to the public’s attention through some recent dramaticneuroimaging studies as well as cases questioning the issues of life prolongation insituations reflecting potentially poor quality of life. At any point in the age range,neuropsychologists may be required to have an input into the medicolegal system,and for this reason we have again included a very practical chapter dealing withthe way in which such work should be undertaken as well as a chapter on theassessment of mental capacity. The latter area has become increasingly relevant toclinical neuropsychologists with the passing of new legislation.

Clinical neuropsychology is by no means all about assessment, as the chapters onspecific cognitive functions will indicate, and the delivery of good rehabilitation ser-vices requires every bit as much the generic skills acquired during clinical psychologytraining as well as neuropsychology-specific ones. However, given the considerabledevelopment of neuropsychological rehabilitation, it is important to review againthe theoretical basis for effective cognitive rehabilitation, in an attempt to main-tain an evidence-based approach to clinical practice, as well as considering howpsychotherapeutic interventions designed for use with non-brain-damaged peoplemight be modified and applied to those with acquired brain injury. While mostattempts at cognitive rehabilitation have been developed for patients with acquiredbut non-progressive brain injury, the growing literature on such approaches foradults with dementia, possibly supplemented by the so-called ‘antidementia’ drugs,opens up further areas of work for clinical psychologists. Finally, psychologists, withtheir knowledge of outcome evaluation, should increasingly see themselves as beingin a position to inform the process of service planning and should have a goodunderstanding of the service delivery models that may bring about effective care to


Preface xvii

their patients with neurological impairments. With increasing emphasis on clinicalgovernance, effective evaluation of neuropsychological interventions has assumedincreasing importance, and we have therefore included a chapter that addresses boththe relevant methodology and possible measures that may be used.

We believe, however, that clinical neuropsychological practice is most effectivewhen set in the context of more general neuroscientific knowledge, and thus feelstrongly that clinical neuropsychologists should have at least a basic understandingof neuropathology and the neurological investigations that their patients may wellundergo. It is for this reason that two of the early chapters in this book present arelatively concise overview of the central nervous system and some of its commondisorders, and how these are investigated. While psychologists should never workoutside their own area of clinical expertise, an understanding of how medical investi-gations can inform the design and interpretation of neuropsychological assessmentsand interventions can only benefit the service psychologists provide to their patients.

We are grateful to the contributors to this volume, the majority of whom con-tributed to the first edition, as well those newly contributing to this book. For thosecontributors employed in the university sector, where book-chapter writing is notencouraged in the climate of the forthcoming Research Evaluation Framework, theirtime and diligence are greatly appreciated. We continue to believe that books ofthis type make a broader contribution to the profession and have an impact thatis not captured by the formal university assessment metrics that govern many ofthe contributors’ activities. Many of our contributors have been actively involvedover many years in different aspects of the training of clinical psychologists, andattach, as do we, considerable importance to such training and the dissemination ofgood practice.

In practical terms, we are very grateful to Eleanor Janega, who helped us, inthe latter stages, bring together the new and revised chapters. Dr Tracey Newellcompiled the Index. We have retained the excellent line drawings prepared by AlexDionysiou for our first edition, and are grateful to the chapter authors for theprovision of additional original figures for this edition. Finally, we continue toexpress our considerable appreciation to our many colleagues, psychologists andnon-psychologists alike, who over the years have set us good examples of how towork effectively as clinicians in our respective clinical settings.

LHGJMcN

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Preface to the First Edition

Although often viewed as a speciality within Clinical Psychology, it should be im-mediately apparent that knowledge of neuropsychology (and its applications) isrelevant to all areas of clinical work where people (across the age span) might beshowing some change in their cognitive functioning. Thus, a working knowledgeof neuropsychology and the assessment and management of cognitive impairmentmay be necessary for the delivery of a competent clinical service by even thosepractitioners who do not wish to see themselves as experts in the field of clinicalneuropsychology, and who may well have had little or no experience of clinical neu-ropsychology during their training as Clinical Psychologists. While we would arguethat neuropsychological assessment should form part of the core skills acquired byall trainee clinical psychologists, our compilation of this volume is based on the morerealistic appreciation of the training opportunities available to those who are bothpre- and post-qualification, an appreciation gained through many years of beingactively involved in both pre- and postqualification training of clinical psychologistsat the Institute of Psychiatry.

There are of course different ways in which to present information on clinicalneuropsychological knowledge and practice. One is to focus on specific neurologicaldisorders, and their assessment and management. Within the scope of a relativelyshort book, however, we feel that this may limit the apparent relevance and gen-eralizability of the skills, which we feel it is important for clinicians to possess.Thus, for the current volume, we have chosen to focus on broad areas of cogni-tive function (including those such as praxis and number processing and calcula-tion that are perhaps less well-developed areas of clinical neuropsychology in theUnited Kingdom), which may be relevant to assess across a wide range of neuro-logical and psychiatric disorders. We have also chosen to include chapters that dealwith important background information relevant to those being assessed (such asthe effects of medication and the interaction between neurological and psychiatric


xx Preface to the First Edition

presentations) and, because so much of clinical neuropsychologists’ work does in-volve test interpretation, an overview of key psychometric concepts underpinningneuropsychological assessment.

In addition to addressing specific cognitive functions, it is of course obvious thatclinical neuropsychology may be somewhat differently applied at different ends ofthe age spectrum, where different factors may assume particular importance. Forthis reason, we have chosen to include specific chapters that address the issue ofneuropsychological practice with children and older adults. At any point in the agerange, neuropsychologists may be required to have an input into the medicolegalsystem, and for this reason we have included a very practical chapter dealing withthe way in which such work should be undertaken.

Clinical neuropsychology is by no means all about assessment, as the chapterson specific cognitive functions will indicate, and the delivery of good rehabilita-tion services requires every bit as much the generic skills acquired during clinicalpsychology training as well as neuropsychology-specific ones. However, given theconsiderable development of neuropsychological rehabilitation, it is important toreview the theoretical basis for effective cognitive rehabilitation, in an attempt tomaintain an evidence-based approach to clinical practice, as well as considering howpsychotherapeutic interventions designed for use with non-brain-damaged peoplemight be modified and applied to those with acquired brain injury. While most at-tempts at cognitive rehabilitation have been developed for patients with acquired butnon-progressive brain injury, the growing literature on such approaches for adultswith dementia, possibly supplemented by the so-called ‘antidementia’ drugs, opensup further areas of work for clinical psychologists. Finally, psychologists shouldincreasingly see themselves as being in a position to inform the process of serviceplanning and should have a good understanding of the service delivery models thatmay bring about effective care to their patients with neurological impairments.

We believe, however, that clinical neuropsychological practice is most effectivewhen set in the context of more general neuroscientific knowledge, and thus feelstrongly that clinical neuropsychologists should have at least a basic understandingof neuropathology and the neurological investigations that their patients may wellundergo. It is for this reason that two of the early chapters in this book presenta relatively concise overview of the central nervous system and some of its com-mon disorders, and how these are investigated. While psychologists should neverwork outside their own area of clinical expertise, an understanding of how medicalinvestigations can inform the design and interpretation of neuropsychological assess-ments and interventions can only benefit the service psychologists provide to theirpatients.

We are grateful to the contributors to this volume, many of whom have beenactively involved over many years in different aspects of our training of clinicalpsychologists, for the importance that they, like us, attach to such training anddissemination of good practice. In practical terms, we are very grateful to GailMillard who has, good-humouredly, enabled us to convert very differently prepared


Preface to the First Edition xxi

manuscripts into a more consistent style, and coped with our many revisions. AlexDionysiou has helped us with the preparation of many of the figures. Finally, we ex-press our appreciation to our many colleagues, psychologists and non-psychologistsalike, who over the years have set us good examples of how to work effectively asclinicians in our respective clinical settings.

LHGJMcN

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Part 1

General Introduction


1

General Introduction: What Is theRelevance of Neuropsychology for

Clinical Psychology Practice?Laura H. Goldstein and Jane E. McNeil

Why Study Clinical Neuropsychology?

At this early stage in the 21st century, clinical neuropsychology is rightly finding itsfeet as a well-delineated and expanding clinical specialty within clinical psychology.It has moved away from the purely diagnostic role it acquired after the Second WorldWar, to one in which the characterization of a person’s functional strengths andweaknesses, and the explanation of their behaviour have become central in extend-ing the range of meaningful questions that can be posed about an individual patient’spresentation. The history of neuropsychology, and its development into a clinicalspecialty, has depended heavily on theoretical innovation and the constant need todevelop a rigorous evidence base (Marshall and Gurd, 2010). Clinical neuropsychol-ogy is now very much valued as not simply involving the assessment of cognitiveabilities in patients with cerebral pathology, but also as playing a major role in therehabilitation of such people. It is also contributing to the understanding of theimpact on cognitive functioning of disorders hitherto conceptualized as psychiatricor functional (rather than organic), for example depression or schizophrenia, andis being used to understand and hence possibly conceptualise in neuropsycholog-ical terms a variety of antisocial or maladaptive behaviours. Neuropsychology hasexpanded its area of enquiry beyond the testing room, and into the implications ofcognitive impairment for everyday life, with a range of tests that are striving to bemore ecologically valid (e.g., Wilson et al., 1996) as well as environmentally based(Shallice and Burgess, 1991; Alderman et al., 2003).

It is therefore important that all clinical psychologists, and not just those workingin specialist neuropsychological settings, have a basic grounding in neuropsychology.

Clinical Neuropsychology: A Practical Guide to Assessment and Management for Clinicians, Second Edition.

Edited by L. H. Goldstein and J. E. McNeil.C© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.


4 Clinical Neuropsychology

Perhaps the simplest way of illustrating the widespread application of neuropsycho-logical skills comes from the types of questions that clinical psychologists might needto answer about their patients. Thus, a clinical psychologist working in a primary-care setting, being the first person to undertake a formal assessment of a patient,might need to determine whether their patient’s complaint of poor memory repre-sents a condition that merits referral for further investigation by a neurologist or islikely to represent the consequences of anxiety or depression. In an adult mental-health setting, just as in a neuropsychiatry service, there may be the need to decidewhether a newly developed memory disorder is psychogenically determined, per-haps even characteristic of factitious disorder or malingering. A clinical psychologistworking with people with learning disabilities might need to be able to assess whethertheir patient’s cognitive profile is indeed characteristic of a particular disorder (e.g.,Down’s Syndrome), or whether it represents the likely onset of the dementia thatis often found in older adults with Down’s Syndrome or points to the impact ofsome additional, acquired neuropathology (e.g., a recent head injury). In a forensicsetting, the question for the clinical psychologist to address may well take the formof whether the person’s offending behaviour could be accounted for by a previoushead injury leading to impulsive behaviour characteristic of executive dysfunction.Working with older adults, the clinical psychologist may not only be trying to clarifywhether the person’s cognitive decline is representative of dementia rather than af-fective disorder but also may need to detail the precise nature of any dementia (e.g.,Alzheimer’s disease or fronto-temporal dementia). In an alcohol-abuse service, theevaluation of a person’s memory and executive dysfunction may have implicationsfor their future treatment or placement. In child-psychology settings, the need maywell be to clarify the impact of developmental as well as acquired neuropathologyon educational and social development.

In all of these settings, a good grounding in the principles of neuropsychologicalassessment and test interpretation (see Chapter 6) will contribute to the deliveryof an effective and professional service. This grounding may also, given serviceconstraints, permit the formulation of appropriate interventions designed to ame-liorate the cognitive difficulties delineated by means of the assessment, as well asthrough observations of the patient’s everyday behaviour. In all such instances, theclinical psychologist should be seeking to act as a scientist-practitioner, using theever-growing neuropsychological literature on which to base hypotheses for theirassessment and gathering information from as wide a range of sources as possible.As Walsh and Darby (1999) indicate, the clinical (neuro)psychologist may be settingout to confirm that certain features of the patient’s presentation are consistent with aparticular disorder or syndrome, to generate and then test their own hypothesesabout the nature of the patient’s deficits, or to decide between competing hypothesesabout the person’s deficits and their causes, often in a medicolegal setting of either acriminal or civil nature.

One of the main reasons why the clinical neuropsychologist’s role has movedaway from a strictly diagnostic one is the dramatic development in neuroimaging


General Introduction 5

techniques that now offer markedly improved options for identifying structuraland functional cerebral abnormalities (see Chapter 3). This has left clinical neu-ropsychologists free to develop a better understanding of the nature of differentdisorders and their neuropathological correlates. One example of this developmentis the careful study of different types of dementia, whereby distinctions have beenmade between Alzheimer’s disease, vascular dementias and frontotemporal demen-tias (and their variants – see Chapter 15), based both on formal neuropsychologicaltest batteries and on behavioural rating scales (e.g., Bathgate et al., 2001; Grace andMalloy, 2001; Kertesz et al., 2000; Snowden et al., 2001) as well as between demen-tias related to other neurodegenerative diseases (e.g., Snowden, 2010). There is nowalso a much better understanding of how to assess psychogenically determined asopposed to organic memory impairment (see, for example, Chapter 7), which hasimplications both for interventions and for medicolegal work, an area where clinicalneuropsychologists can assume a very high profile (see Chapter 17).

It is inevitable that clinicians will develop differing approaches to the assessmentand documentation of (and also interventions to deal with) their patients’ cognitiveimpairments. This will arise through differing training experiences and both pre-and postqualification clinical service constraints. Below, however, we will outlinesome of the principles we consider to be essential to the development of personalcompetence in the delivery of a service that is able to answer neuropsychologicalquestions about patients. We will be focussing in large part on the assessment andinterpretation of neuropsychological impairment.

Common Issues Across Different Assessments

Irrespective of the specific referral, there are certain types of information that mustbe collected prior to the assessment in order for the clinical psychologist to maximisetheir opportunity for collecting meaningful data. Here, we will expand on, and addto, some of the very helpful suggestions made by Powell and Wilson (1994), echoedalso by Evans (2010). Thus, information should be collected on:

� the intended purpose of investigation; it is important to clarify with the refer-rer what information is being sought from an assessment, and it may well benecessary to reframe the referrer’s question into one that is neuropsychologi-cally meaningful and possible to answer, as neuropsychological assessments aretime-intensive and should not be seen as ‘trawling’ exercises;

� the patient’s demographic variables, for example, age, handedness, education/qualifications, current/previous profession and cultural background, in orderto set the context for the interpretation of current test performance; under-standing the difference between different types of educational attainments (e.g.,grades attained for GCE O levels, CSEs, GCSEs, A levels, AS and A2 examinationswithin the English educational system) will also be informative when considering


6 Clinical Neuropsychology

premorbid level of ability, and additional information concerning developmen-tal stage reached will be particularly important in the case of children (seeChapter 13);

� the patient’s previous as well as current medical history, as this may also be relevantto the development of cognitive impairment; history of alcohol and/or substanceabuse;

� the results of previous investigations, for example, neurological investigations,EEGs, CT/MRI or functional brain scans, x-rays, biochemical tests, (see Chapter 3for a description of neurological investigations) and previous (as well as cur-rent) psychiatric diagnoses, all of which can assist in the formulation of hy-potheses about the patient’s likely deficits, and so guide the assessment and itsinterpretation;

� the results of previous neuropsychological assessments; these can guide the choiceof current tests and permit evaluation of change (see below);

� the history of the person’s lesion/disorder, for example, site of trauma, age atand time since injury or onset of illness, history of epilepsy (either predatinginjury or post-traumatic) if relevant, whether or not anoxic episodes were as-sociated with injury, length of post-traumatic amnesia (PTA) and retrogradeamnesia, length of loss of consciousness, Glasgow Coma Scale scores, and op-eration reports, since again these will assist in the formulation of hypothesesabout the aetiology, nature and severity of the deficits that may be revealed bythe examination;

� factors that might affect testing , for example, drug types and levels (see Chapter 5),the timing of the assessment in relation to drug ingestion, which may have a directeffect on whether or not the person can be assessed (e.g., in the case of drugsused to treat Parkinson’s disease, where ‘off ’ periods at the end of the drug’seffectiveness may make assessment extremely difficult or impossible), recentepileptic seizure activity (if relevant), mood and motivation (see Chapter 4),motor/speech/visual problems (which may determine which tests are feasible toadminister), and the patient’s likely distractibility;

� informants’ views of the person, their deficits and if/how they have changed; manypatients with acquired brain injury will have little insight into the reason fortheir referral for assessment/treatment, and the nature and/or extent of their owncognitive deficits. Thus, informants may provide important information aboutthe areas to be explored in the neuropsychological assessment (see Chapter 9);

� the context in which the assessment takes place, that is, whether there are rele-vant compensation or other medicolegal factors that might affect the person’smotivation during the assessment.

While not all of the information will be available in every case, it is important togather as much information as possible prior to seeing the patient since, as indicatedwith respect to medicolegal work in Chapter 17; this also permits the clarificationwith the patient of inconsistencies in the history and allows what may be a limitedtime in which to undertake an assessment to be used to cover the most importantareas of that person’s cognitive function.

clinical neuropsychology · 2013. 7. 19. · edited by laura h. goldstein and jane e. mcneil...

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