Transcript Personality Disorders - Francis Marion University

Neuropsychological Assessment
William P. Wattles, Ph.D.
Francis Marion University
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Practicum Log
• Supervision Hours (coaching, feedback
sessions, etc.) (S),
• Student-contact Hours (i.e. assessment,
intervention)
(ST),
• Consultation Hours (i.e. direct contact with
consultees, interviews, meetings) (C )
• Research Hours (projects, program evaluation,
etc.)
(R)
• Administrative Hours (i.e. scheduling, record
review, scoring, report writing) (A),
• Other Hours (e.g. staff meetings, in-service,
conferences) (O)
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Neuropsychology
• Nothing more than the
study of human
brain/behavior
relationships.
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Neuropsychology goals
• Diagnosis determine the nature
of the underlying problem.
• Understand the effects of any
brain injury
• measure change in functioning
over time, such as to determine
the consequences of treatment
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Neurologist
• A physician specializing in diseases and
disorders of the brain, spinal cord, nerves,
and muscles, including stroke, Parkinson's
disease, epilepsy, Alzheimer's disease, and
muscular dystrophy
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Neuropsychologist
• A psychologist with specialized training in
the evaluation of cognitive functions.
Neuropsychologists use a battery of
standardized tests to assess specific
cognitive functions and identify areas of
cognitive impairment
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• Classically,
brain/behavior
relationships have
been inferred from the
study of individuals
with head injuries,
tumors, neurological
disease, and other
unpleasant brain
pathologies.
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Phineas Gage
• Amazingly, he was
talking and could
walk. He lost a lot of
blood, but after a bout
with infection, he not
only survived to the
ghastly lesion, but
recovered well, too.
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Phineas Gage
• He became
extravagant and antisocial, a fullmouth and
a liar with bad
manners, and could no
longer hold a job or
plan his future. "Gage
was no longer Gage",
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Phineas Gage
• His skull was
recovered and in 1994
researchers discovered
that most of the
damage was done to
the ventromedial
region of the frontal
lobes on both sides
• The part of the frontal
lobes responsible for
speech and motor
functions was apparently
spared, so they concluded
that the changes in social
behavior observed in
Phineas Gage were
probably due to this lesion
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Phineas Gage
• "Gage's story was the
historical beginnings
of the study of the
biological basis of
behavior
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Methods of Neuropsych
Assessment
• Medical History
• Clinical Interview
• Behavioral
Observations
• Psychometric
Tests
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Neuropsych assessment
• Major cognitive
domains typically
assessed include
• Attention
• Memory
• Intelligence
• Visual-SpatialPerceptual
functions
• Psychosensory
and Motor
abilities
• "Executive" or
"Frontal Lobe"
functions
• Personality or
Emotional
Functioning.
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Executive Functioning
• Elaborated functions
of
• logic,
• strategy,
• planning,
• problem solving
• reasoning.
• These capacities help
us solve problems of
all sizes in our lives.
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Executive Functioning
• Executive Functioning
difficulties relate to
planning, organizing
and strategizing
behaviors.
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Executive Functioning
• Analyze the context
and the expected
objective in order to
formulate hypotheses
on the probable
outcomes of a decision
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• Behavioral changes
are assumed to be due
to this brain tissue
damage.
– For instance, stroke
damage to the back of
brain results in visual
difficulties even
though eyes are intact.
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CNS involvement
• Behavioral
manifestation of CNS
deficits is highly
heterogeneous.
• Thus, a battery is often
called for.
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Organic Mental Disorders
• Prior to DSM-IV we had a category called
organic mental disorders for those with a
physical or organic cause.
– Suggest mind body separation
– Most disorders involve a mix of biological and
psychological factors
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Dysfunctions of the Brain
• Cause
– Head injuries
– Diseases of the brain
– Endocrinological
disorders
– Exposure to toxins
• Symptom
–
–
–
–
–
Depression
Anxiety
Delusions
Mental impairment
aggressiveness
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Substance Abuse
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•
•
•
One Tequila
Two Tequila
Three Tequila
Floor
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Goal of Neuropsychological
assessment
• Originally to
Differentiate between
organic and functional
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Distinguishing Brain Damage
• Lesion Detection
• Localization
• Lateralization
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Neuropsychologist
• A Neuropsychologist
is a psychologist who
specializes in studying
brain behavior
relationships.
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Two approaches
• Comprehensive
Battery Approach
• Qualitative
hypothesis-testing
approach
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Detect Impairment
• The first method is to
use an assessment
technique in which a
fixed battery of tests
is given and in which
we only want to
know what functions
are impaired and
what functions are
not impaired.
• The most commonly
used representative
of this type of test is
the Halstead - Reitan
Neuropsychological
Battery.
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Advantages of Battery Approach
• Advantages
• Easier to use for
research
• Better norms
• Easier to learn
•
•
•
•
Disadvantages
Time consuming
Can overlook reasons
Difficult to tailor to
client
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Assess level of impairment
• The second method is • The most common
to assess a
representative of this
hierarchical
type of test is the
arrangement of items
Luria - Nebraska.
within each subtest
so that if a function is
impaired, the level at
which it is impaired
can be determined.
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Advantages of Qualitative
approach
•
•
•
•
•
Advantages
Tailor to individual
Emphasizes process
Time efficient
More depth
• Disadvantages
• Focuses on
weaknesses
• More difficult to
research
• Requires extensive
experience
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Specificity & Sensitivity
• Specificity means
when we measure
"A" with our test, we
know that the test
does not measure
"B", "C," or "D."
• If we wish to
measure a thing "A"
then the test has to
be able to measure
"A" even when very
little of "A" is
present; this is
sensitivity.
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Specificity and Sensitivity
• Specificity- the ability
to rule out those
without the condition
• Sensitivity the ability
to provide a definitive
diagnosis
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Screening Battery
• Visuoconstructive
Abilities
• Mental Activity
(Attention and speed
of information
processing)
• Memory and Learning
• Verbal Functions and
Academic skills
• Motor Performance
• Executive Functions
• Emotional Status
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Interviewing for Brain
Impairment
• The strongest tool for
a clinician is still a
clear, thorough and
well-informed history.
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Bender Gestalt
• Developed 1938
• Narrow focus resulting
in low sensitivity and
high number of false
negatives (misses)
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Bender Gestalt
• The Bender test is a
brief, non-verbal
assessment consisting
of nine stimulus cards,
each showing a
figure.The client is
asked to reproduce the
figures.
• The task requires
visual association,
motor
coordination,and the
ability to integrate
perceptual and motor
skills to achieve
accurate reproductions
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Bender Gestalt
• The results of the
Bender Gestalt alone
are rarely sufficient to
make a differential
diagnosis between
neuropsychological
impairment and
emotional disturbance.
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RBANS
• Repeatable Battery for
Assessment of
Neuropsychological
Status (1998)
• Focuses on Verbal
skills, attention, visual
memory, and
visuoconstruction.
• 11 subtests
• 5 indices
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RBANS
• Broad band (Assesses
multiple domains)
• Brief (under 30 mins)
• Portable
• alternate forms
• moderate difficulty
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RBANS
• Standard scores with
mean of 100 and
standard deviation of
15.
• Thus, 70 represents
the 2nd percentile.
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• Utility of the RBANS
in detecting cognitive
impairment
associated with
Alzheimer’s disease:
Sensitivity,
specificity, and
positive and negative
predictive powers
• Duff, et al 2009
• Each patient with AD
was matched to a
comparison patient on
variables shown to
affect cognitive
functioning (i.e., age,
education, and gender)
(In matching patients,
age was considered first,
followed by education,
followed by gender
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• Results suggest that
RBANS scores yield
excellent estimates of
diagnostic accuracy
and that the RBANS is
a useful screening tool
in detection of
cognitive deficits
associated with AD.
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Training
• Neuropsychologists
have extensive
training in the
anatomy, physiology,
and pathology of the
nervous system.
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Changes is Neuropsych
Assessment
• Emphasis more on
application than
measurement.
– Employability
– Treatability
– Need for support
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Impairment vs. Disability
• Impairment reflects
normative
comparisons and test
data.
• Disabilty considers
context including
circumstances,
environment, interests.
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Functional assessment
Identifies the
vocational and
everyday impact of
cognitive disability,
and the real life
obstacles related to
work, school, and
daily living.
Through functional
assessment individuals
gain a better
understanding of
strengths and needs,
and the effect these
have on career choice
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Executive Functions
• Ability to effectively
regulate and direct
self-behavior.
• Most often involves
frontal lobe damage.
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•
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Volition
Planning
Purposive action
Effective performance
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Verbal Functions
• Most frequently
associated with left
hemisphere brain
damage
– Aphasia
– Speech production.
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•
•
•
Six Major Functions
Spontaneous speech
Speech repetition
Speech
comprehension
• Naming
• Reading
• Writing
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The name for the yellow
organism shown below is:
a. Yellow Jessamine
a. Gelsemium sempervirens
b. Witch's butter
a. Tremella mesenterica,
c. King Bolete
a. Boletus edulis
d. Dog Vomit Slime Mold
a. Fuligo Septica
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Aphasia
loss or impairment of the
power to use or
comprehend words usually
resulting from brain
damage
back
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