6.

NEUROPSYCHOLOGICALTESTING
Laetitia L. Thompsou, Ph.D

1. What is neuropsychologicaltesting? Neuropsychological testing uses behavioral measures to assess skills and abilities that relate to
brain functioning. Most neuropsychological tests have been developed to measure higher cerebral functioning, so they usually focus on cognitive skills and abilities. These tests have been developed to help diagnose brain damage or brain dysfunction in some patients and to help ascertain the behavioral effects of brain damage in others. Such evaluation can provide information about cognitive strengths and weaknesses within an individual and the areas in which an individuals functioning may differ from that of the normal population. This type of evaluation is most commonly conducted on patients with neurologic disorders.

2. How does it differ from clinical psychological evaluation? Clinical psychological evaluation uses tests designed to provide information about the personality and emotional functioning of patients. Measures may include objective personality tests or socalled projective techniques such as the Rorschach or the Thematic Apperception Test. Procedures used in clinical psychological evaluations generally differ from those used in neuropsychological evaluations, although occasionally there may be some overlap. For example, clinical evaluations frequently include an intelligence test, which is essentially a measure of cognitive function, and many neuropsychological evaluations have a personality measure to screen for emotional difficulties. The focus of the two types of evaluations differs, however, so the referring person must think about the goal of the evaluation in deciding where to refer.

3. What is neuropsychological testing like for the patient? (or, How to prepare your patient for a neuropsychologicalevaluation.) Neuropsychological tests are behavioral. They are not invasive and present no physical risk to the patient. Typically the patients works with one or two testing examiners (sometimes, all or part of the testing is done by the neuropsychologist). The tests may require reading or listening to verbal information, viewing nonverbal visual information, or palpating stimuli. Some tasks require pencil and paper, whereas others need only verbal responses from the patient. Some tasks require manipulation of objects, puzzle assembly, drawing of objects, or writing. If a patient has impaired vision or hearing, testing usually can be modified; it is helpful to discuss this with the neuropsychologist at the time of the referral. The testing can be fatiguing, and precautions should be taken to administer the tests in an order that: (1) intersperses easier and harder tests; ( 2 ) begins the testing with tasks that reduce rather than increase anxiety; and ( 3 ) places tests with demanding attentionallspeed requirements when the patient is fresh and well rested, yet past the initial anxiety. In referring a patient for neuropsychological evaluation, it can be reassuring to talk briefly with the patient about the type of situation to be encountered. Patients sometimes telephone or arrive for their appointments wondering if they are going to be stuck with needles or probed with electrodes. After they realize the testing is behavioral, they frequently are quite relieved.
4. What issues are addressed by neuropsychologicaltesting? First, it can help with diagnostic issues in certain cases, as when there are considerations of depression or dementia. In addition to overall level of performance, the neuropsychologist can look at patterns of test performance. For example, some patterns are associated more frequently
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with depression, whereas others are more likely to be seen in dementia. Of course, in some individuals, elements of both depression and dementia may co-exist, and neuropsychological evaluation may confirm this. Another type of diagnostic situation might involve a psychiatric patient for whom there is also a suspicion of a neurologic problem, such as early dementia or traumatic brain injury. Second, as views about psychopathology change and more psychiatric conditions are found to have biologic components, more interest exists in understanding the neuropsychological characteristics of psychiatric disorders. The psychiatric disorder that has received the most attention to date has been schizophrenia, but now there are also studies of neuropsychological functioning in patients with bipolar, obsessive-compulsive, panic, post-traumatic stress, attention-deficit-hyperactivity, and conduct disorders, among others. It may be helpful to obtain information about the neurocognitive strengths and weaknesses of individual patients with these disorders and to learn whether their pattern of performance is similar to those of other patients with the same disorder. Third, a practical area of concern is the everyday implications of neurocognitive function (or dysfunction) for psychiatrically ill patients. Neuropsychological evaluation helps clarify these issues and provides important information about long-term planning.

5. What are appropriate questions to consider in referring a psychiatric patient for neuropsychological testing? When referring a patient for evaluation, the referring person ought to communicate the major question(s) to the neuropsychologist rather than simply indicating neuropsychological testing on a referral form. This facilitates a more useful battery of tests, as well as a more focused report. Some specific referral questions are listed in the table.
Exumptes o f Common Referral Questions
1. Is the patient depressed, demented, or both? 2 . Does this patient with schizophrenia have cognitive impairment? Is the impairment typical of that seen in schizophrenia? 3. A 59-year-old patient has a history of schizophrenia. Is there also evidence for early dementia? 4. The patient complains of memory problems. Is there objective evidence of memory problems or other cognitive deficits? 5. Does the patient have the cognitive capabilities to: live independently? comply with a medication regimen? work in a competitive or sheltered capacity? 6. The patient does not follow through with treatment planning. Is this related to memory or other cognitive deficits?

6. What should a neuropsychological evaluation and report include? The neuropsychologist can select from many tests. The numerous options may confuse the refemng person, who sees little apparent rhyme or reason to the specific tests used. It may be helpful, in determining the comprehensiveness of a particular evaluation, to keep in mind areas of cognition that usually are covered.
Major Cognitive Areas Assessed in a Comprehensive Evaluation

General intelligence Attention and concentration Learning and memory Language Executive function

Perceptual functioning Spatial analysis Sensory motor functioning Psychological/emotionalstatus

Psychologicdemotional status may be assessed during an interview and/or through formal testing. Most neuropsychologists stress the use of standardized measures with high reliability and validity as well as normative guidelines to assist interpretation. Most emphasize that level of performance

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Neuropsychological Testing

is only part of the process of interpretation, and that the pattern of performance across several tests is important. Some psychologists emphasize the quality of the patients performance or the types of errors made. In addition to the formal testing, the evaluation ought to include history taking, either from the patient, family, physician, and/or records, paying particular attention to background information and any medical history relating to possible neuropsychological risk factors. The report should include discussion of the history, a report and discussion of the patients behavior during testing, and an assessment of whether the test results are considered valid measures of the patients neurocognitive functioning. Most reports also include a test-by-test description of the results, followed by conclusion(s), recommendations, and/or discussion of the overall meaning and implications of the results for the patient.

7. When is it appropriate to refer a patient for a neuropsychologicalscreening rather than a comprehensiveevaluation? Many times, psychiatrists and other referrers hope that a screening evaluation will suffice for their patients. In some cases, relatively brief screening (i.e., a 1- to 2-hour battery) can adequately answer the question and, in some cases, a brief evaluation will be all a patient can tolerate because of acute psychiatric symptoms. When there are questions regarding an in-patient with acute psychiatric symptoms, limited testing may be the only feasible alternative. Such testing provides information about the general level of intellectual functioning or presence of clear dementia, but it is unlikely to answer more specific questions, especially in younger adults in whom relatively subtle neurocognitive deficits may exist. Complex questions indicate the need for more comprehensive testing, and it may be better to defer testing until the patient is as stable as possible in terms of medication and psychiatric symptoms. Screening may be appropriate to answer questions about presence or absence of neurocognitive dysfunction. More intensive evaluation is necessary if there are specific questions about nature, localization, or the functional implications of deficits. Describing the patient to the neuropsychologist and discussing the issues and questions often is the best way to determine the most appropriate battery of tests to be given.

8. What are the effects of depression on neuropsychologicaltesting? The former answer to this question was that patients presenting with depression but without any organic dysfunction would show few, if any, deficits on classic neuropsychological batteries of tests such as the Halstead-Reitan. More recent studies, however, using newly developed measures of attention, information processing speed, and learning have shown that depression can cause slowing of information processing, decreased attention and concentration abilities, and learning inefficiency. Research findings are inconsistent about the existence of a high correlation between severity of depression and test performance. Groups of severely depressed patients are likely to perform more poorly than mildly depressed patients, but these findings are not sufficiently consistent to enable the clinician to predict the degree of cognitive inefficiency by knowing severity of depression. In many cases, deficits in depressed individuals are subtle, but they may still affect interpretation of results. For example, in a patient with a clinical depression who has had a mild traumatic brain injury (TBI), it can be very difficult to know whether mild deficits in areas of concentration andlor learning are caused by the TBI, the depression, or a combination. Frequently, the practical approach to such a case is to treat the depression and then reevaluate the patient for any residual neurocognitive deficits. Other areas of cognition generally are not impaired in depressed patients (language, problem solving, visual spatial analysis, executive functioning, visual or auditory perception, for example), but, of course, individual patients may present as exceptions to the rule. In a few instances, severe depression may render the patient untestable. If the patient has severe agitation or psychomotor retardation, he or she may not be able to comply with test requirements and fail to put forth sufficient effort to yield valid results. In my experience, this is not a common occurrence, but it does happen. In such instances, neuropsychological evaluation must be postponed until the acute depression improves.

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9. What are the effects of anxiety on neuropsychologicaltesting? Most people who undergo neuropsychological testing experience some anxiety about the process. Part of a good testing procedure involves establishing rapport with the patient and providing a reassuring atmosphere to minimize anxiety. In most situations, this will suffice to allow valid testing. Very little systematic investigation has been done, however, to explore the effects of especially high levels of anxiety on test performance. The few existing studies have found little in the way of specific effects. Clinically, neuropsychologists rely on behavioral observation of the patient to help determine whether unusual levels of anxiety interfere with the patients effort on the testing. Occasionally, undue anxiety may produce an invalid result (which should, of course, be noted), but in my experience, most patients can control their anxiety sufficiently to produce valid results. Frequently, putting the tests in an order to minimize stress to the patient is enough to permit the patient to complete the evaluation. Whether or not a particular evaluation is valid must be determined by the neuropsychologist. In some cases, patients with formal anxiety disorders may be referred for neuropsychological evaluation. Research into the effects of formal anxiety disorders is currently at an early stage, and few definite conclusions can be drawn, but the following provides a brief summary of select diagnoses.
10. How do specific anxiety disorders affect cognitive functioning? Patients with panic disorder typically have been found to fall below normative guidelines for impairment on a few tests, but across studies, cognitive deficits have been inconsistent. Currently, more evidence exists for memory problems than for other cognitive deficits, suggesting possible involvement of the temporal regions of the brain in panic disorder, but additional research is needed to replicate previous findings. A few studies have assessed neurocognitive functioning in patients with obsessive-compulsive disorder (OCD). Results showing impaired memory and executive functioning suggest possible bilateral frontal and temporal involvement, with considerable disagreement from study to study as to whether the left or right hemisphere is more implicated. Post-traumaticstress disorder (PTSD) is another anxiety disorder that has received attention, mostly in individuals with combat-related PTSD. Most studies have not included well-matched control groups, but rather have compared patient performance to available normative guidelines. Such studies have not found large deficits in groups of patients, but have shown that individuals may perform in the below average to borderline range on some tests of memory and attentional function. Good neuropsychological testing involves administration of the tests in a supportive way to minimize state anxiety and behavioral observation of the patient to determine whether efforts to minimize anxiety have been successful. In patients with panic disorder, OCD, or PTSD, careful analysis of the pattern of test results can help determine: (1) whether deficits appear related to the anxiety disorder alone; and (2) the extent to which any cognitive deficits will have an impact on the patients everyday life. 11. Is neuropsychological testing indicated in schizophrenia? How do patients with schizophrenia perform? Schizophrenia is now thought to be a brain disorder, and many, but not all, patients show neurocognitive impairment. Research on the neuropsychological profiles o f patients with schizophrenia has revealed considerable heterogeneity. Some patients perform normally on testing, whereas others are quite diffusely impaired. Commonly, the individual earns mildly impaired scores on a number of measures, but looks somewhat more impaired on verbal learning measures. This more pronounced verbal learning deficit superimposed upon diffuse mild impairment has now been found in several studies evaluating groups of schizophrenic patients, but specific individuals do not always, or even routinely, produce this profile. Little evidence exists for a decline in general intellectual functioning following the onset of symptoms, and it is rare for schizophrenic patients to have severe impairment without the presence of some coexisting dementia. Because of the lack of a unique neuropsychological profile in patients with schizophrenia, interest has evolved in understanding patterns of deficits in subgroups of schizophrenic patients. Groups

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Neuropsychological Testing

of paranoid patients generally perform better on neuropsychological testing than groups of non-paranoid patients. Studies of groups of patients with either predominantly positive or negative symptoms have produced similar results, with those patients showing more negative symptoms having much more significant impairment. Finally, patients with early-onset schizophrenia show more deficits than patients whose symptoms develop after adolescence. Neuropsychological test results may be useful in predicting functional outcome in patients with schizophrenia. Walker et al. looked at patients 1.5 years after assessment and found that cognitive test scores were more powerful predictors of outcome measures than were ratings of psychiatric symptoms." Therefore, extent of cognitive impairment may be important in predicting everyday functioning parameters such as treatment compliance, independent living, and employability.

12. What effects do medications have on testing? This is obviously a very complex question, the answer to which depends on what medication or medications at what dosages. Medications that have central nervous system effects may, in some cases, affect neuropsychological test results. A few guidelines exist to help determine when testing is best done. If a patient has just started a new medication and is experiencing temporary side effects, it is not a good time to evaluate the patient. If a patient is toxic or is approaching a toxic level, performance may be significantly affected. Examining specific medications is beyond the scope of this chapter. However, most studies have shown that the acute symptoms of the disease are more deleterious for cognitive performance than the medications, if the patient is taking an optimal dose. Antidepressants have not been found to cause significant adverse effects on test performance in individuals with good clinical response who are not experiencing acute side effects. Generally speaking, neuroleptics also have not been found to cause significant problems on tests of cognitive function; thus, stopping medication in an individual who is obtaining clinical benefit is not advantageous. Lithium may cause some modest decrements in upper extremity motor performance, but has not been found to produce changes in neuropsychological test scores that would result in diagnostic or interpretive error.

13. What does it mean when neuropsychological testing and the results of neuroimaging disagree? Relationships between neurobehavioral measures and neuroimaging techniques have changed dramatically over the past 25 years and likely will continue to, primarily as a result of the evolution of neuroradiologic technology. Furthermore, as the development of functional imaging advances, more opportunities will become available for understanding brain-behavior relationships. For example, research studies using functional MRI and neuropsychological testing have increased knowledge about localization of higher cerebral functions in the brain, but such research also has shown how difficult it is to make broad generalizations about localization of function for individual patients. Clinical evaluation still employs structural imaging in most cases, and in individual cases, apparent discrepancies or contradictions may exist between neurobehavioral measures and neuroimaging results. These differences may be in either direction (more abnormality on imaging than seen in behavior or vice versa). Reasons include: 1. There may be long-standing, probably congenital, abnormalities, but the patient has relatively normal neurocognitive functioning because the brain organized with the abnormality already in place. 2. The physiological changes associated with brain lesions identified by computed tomography or magnetic resonance imaging may exceed the boundaries of the structural abnormality. 3. Individual differences in functional brain organization are complex and not yet completely understood. 4. Neurobehavioral measures may be incorrectly interpreted, e.g., interpreting errors on sensory or motor tests resulting from peripheral nervous system injury as central nervous system impairment. 5. Changes at a microscopic level may cause behavioral change, but may not be visible with current imaging technology.

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As functional imaging becomes more common in clinical practice, differences between neuropsychological performance and neuroimaging may diminish. The use of functional imaging already is advancing our knowledge of brain-behavior relationships.

BI BLlOCRAPHY
1. Bigler ED: Frontal lobe damage and neuropsychological assessment. Arch Clin Neuropsychol3:279-297, 1988, 2. Bigler ED, Ye0 RA, Turkheimer E (eds): Neuropsychological Function and Brain Imaging. New York, Plenum Press, 1989. 3. Grant I, Adams KM (eds): Neuropsychological Assessment of Neuropsychiatric Disorders. New York, Oxford Press, 1996. 4. Heinrichs RW, Zakzanis KK: Neurocognitive deficit in schizophrenia: A quantitative review of the evidence. Neuropsychology 12:426-445, 1998. 5. Hill CD, Stoudemire A, Morris R, Matino-Saltzman D, Markwalter HR: Similarities and differences in memory deficits in patients with primary dementia and depression-related cognitive dysfunction. J Neuropsychiatry Clin Neurosci 5:277-282, 1993. 6 . Lezak MD: Neuropsychological Assessment, 3rd ed. New York, Oxford University Press, 1995. 7. Newman PJ, Sweet JJ: Depressive disorders. In Puente AE, McCaffrey RJ (eds): Handbook of Neuropsychological Assessment: A Biopsychosocial Perspective. New York, Plenum Press, 1992. 8. Orsillo SM, McCaffrey RJ: Anxiety disorders. In Puente AE, McCaffrey R J (eds): Handbook of Neuropsychological Assessment: A Biopsychosocial Perspective. New York, Plenum Press, 1992. 9. Reitan RM, Wolfson D: The Halstead-Reitan Neuropsychological Battery: Theory and Interpretation, 2nd ed. Tucson, AZ, Neuropsychology Press, 1993. 10. Sweet JJ, Newman P, Bell B: Significance of depression in clinical neuropsychological assessment. Clin Psycho1 Rev 12:2145, 1992. 11. Walker E, Lucas M, Lewine R: Schizophrenic disorders. In Puente AE, McCaffrey RI (eds): Handbook of Neuropsychological Assessment: A Biopsychosocial Perspective. New York, Plenum Press, 1992.

7. SELF-REPORT QUESTIONNAIRES
Garry Welch, Ph.D.
1. What are the potential uses of self-reportingpsychiatric and personality tests? There are many potential clinical and research uses, although interpretation of scores and profiles often requires a high level of expertise. These tests are helpful in: History taking and formulating clinical hypotheses Screening and diagnosis of clinical problems and mental disorders Determining appropriate referral to specialty services Monitoring change and response to treatment interventions Conducting research into factors associated with the disorders Auditing and assessing clinical services

2. What is reliability?
Reliability is whether the measure provides repeatable or reproducible test scores that accurately reflect the patients true status and contain little influence from unimportant extraneous factors. For example, if a test is supposed to detect current anxiety state, it is reliable if it mostly measures current anxiety and does not take into account other factors-such as the individuals recall of the answers given the last time the test was administered-and does not include unclear questions or poorly worded instructions.

3. What is the role of reliability in psychiatric and personality tests? Reliability of measurement is important because it sets an upper limit on the validity, or clinical usefulness, that the measure will likely have when applied to various individuals and in various