Neuropsychological Assessment

Neuropsychological assessment (NPA) is the systematic evaluation of the brain-behavior

relationships in an individual. The purpose of an NPA is to define the client's specific cognitive
strengths and weaknesses and to identify the relationships between the neuropsychological
findings and the client's medical and psychiatric condition. Tools used to complete the NPA are
measures of cognition and intelligence that have been standardized on a neurologically normal
sample. By administering the measures in the identical, systematic manner, as described in the
instruction manual for the testing instrument, the evaluator can compare the individual's
performance on the measure to the performance of a normative sample. It is optimal if the
normative sample is subdivided by gender, age, and years of education. In that way a very specific
comparison can be made. Neuropsychological test performance has been generally shown to vary
according to gender, age, and years of education in control samples.
Development of Neuropsychological Assessment
Neuropsychological assessment as a well-defined discipline began in the 1950s with the
work of Halstead, Reitan, and Goldstein in the United States; Rey in France; and Luria in the
Soviet Union. In the United States, the experimental and statistical orientation of American
psychology was reflected in test design and use. Norms were refined and used for comparison with
an individual patient’s performance. Optimal cutoff scores were developed to distinguish impaired
from normal performances. Concomitant with the developments in the United States was the work
of Alexander Luria in the Soviet Union and Rey in France. They relied extensively on close patient
observation and in-depth case histories. They were not so much interested in what score a person
might have obtained, but rather why the individual performed in a certain manner. Their work has
epitomized the flexible pathognomonic sign or qualitative approach.
From these early beginnings, two distinct strategies of approaching neuropsychological
assessment emerged. One was the comprehensive battery approach epitomized by Halstead and
Reitan and formalized into the Halstead-Reitan Neuropsychological Test Battery; the other was a
more flexible, qualitative, hypothesis-testing strategy as represented by Goldstein and Luria.
Current Status of Neuropsychological Assessment
Localization of brain injury was the intent of NPA in the 1970s but with current functional
and structural neuroimaging tools, there is a reduction in the need to “localize” the brain injury.
The purpose of neuropsychological evaluation is currently multifaceted and often is dependent on
the referral question. A complete NPA helps the client, clinician, and referral source gain an
understanding of the client's cognitive processes such as memory, language etc. In addition it can
assist in diagnosis and identification of difficulties in cognition that might be related to psychiatric
conditions and motivation. Finally, a thorough NPA can help to determine rehabilitation potential
by identifying pathways for compensation and extent of cognitive involvement.
Modern neuropsychology began by studying the localization of brain function and
cognitive and behavioral changes following large lesions to the brain. These advances are perhaps
best illustrated by the work of Broca and Wernicke in establishing the major speech areas in the
left hemisphere.
Model of Brain-Behavior Relationship

Bennett (1988) has proposed a simplified

model of brain–behavior relationships that is helpful
in organizing the seemingly chaotic profusion of
neuropsychological tests. According to this view,
each neuropsychological test or procedure evaluates
one or more of the following categories:

1. Sensory input
2. Attention and concentration
3. Learning and memory
4. Language
5. Spatial and manipulatory ability
6. Executive functions:
a. Logical analysis
b. Concept formation
c. Reasoning
d. Planning
e. Flexibility of thinking
7. Motor output

Mental Status Examination

A core part of neuropsychological assessment is the administration of neuropsychological

tests for the formal assessment of cognitive function. It is essential that neuropsychological
assessment also include an evaluation of the person's mental status.

The mental status examination (MSE) is a loosely structured interview that usually
precedes other forms of psychological and medical assessment. The purpose of the evaluation is
to provide an accurate description of the patient’s functioning in the realms of orientation, memory,
thought, feeling, and judgment. The MSE is the psychological equivalent of the general physical
examination: Just as the physician reviews all the major organ systems, looking for evidence of
disease, the psychologist reviews the major categories of personal and intellectual functioning,
looking for signs and symptoms of psychopathology. Although there is some latitude as to the
scope of the MSE, certain mental functions are almost always investigated.

Problems in Neuropsychological Assessment

The practical implication is that any one screening test for neuropsychological impairment
is likely to assess for a narrow range of abilities. If a client has deficits outside this range, the test
is not sensitive to that particular area of difficulties. The result is a high number of false negatives.
Indeed, this problem has plagued most screening devices. For example, a test such as the Bender
Gestalt is primarily a test of visuo-constructive abilities. Clients with a wide range of other
difficulties are likely to perform quite well on the Bender Gestalt with the resulting danger that the
clinician might erroneously conclude they were not organically impaired.
 The presence of false negatives (or false positives) depends in part on the “narrowness”
versus the “width” of the test. For example, a test that measures a specific function, such as ability
to name objects, is quite narrow in its focus. Clients who do poorly on such a test would most
likely be experiencing neuropsychological impairment (true positives). However, there are also
many persons who, despite being neuro-psychologically impaired, do quite well on such a test and
may be misclassified as normal (false negatives), because most neuro-psychologically impaired
persons do not experience object-naming difficulties.
The above mentioned difficulty does not invalidate the use of psychological tests for
neuropsychological assessment. However, it does highlight the importance of being aware of their
limitations and being clear on what they do measure. It also suggests that, instead of using one or
two tests, a clinician reviewing neuropsychological impairment ideally should use a number of
different tests that assess a wide number of domains
Strategies in Neuropsychological Assessment
The two general strategies in neuropsychological assessment are
a) Qualitative or pathognomonic sign approach
b) Quantitative cutoff scores.
The pathognomonic sign approach assumes the existence of distinctive behaviors
indicative of brain damage. In contrast to the sign approach is the use of cutoff scores, which
optimally separates a person’s performance into either a brain-damaged or normal range.
Sometimes a combination of both approaches is used. This can be seen on the Bender Gestalt,
which requires examinees to draw a series of designs that are presented to them. Clinicians
typically note the presence of pathognomonic signs, such as poor closure or line tremor, but also
score different aspects of the drawing to develop a quantitative rating. Scores above a certain level
indicate impaired performances.
Commonly used Tools for Neuropsychological Assessment

Behavioral Assessment of Neuropathology Assessment of Language Functions

Assessment of Mental Status Clinical Examination for Aphasia
Behavioral Rating Scales
Assessment of Sensory Input Tests of Spatial and Manipulatory Ability
Sensory-Perceptual Exam Design Copying Tests
Finger Localization Test Assembly Tests
Measures of Attention and Concentration Assessment of Executive Functions
Test of Everyday Attention Trail Making Test (TMT) Form B
Continuous Performance Test Verbal Fluency Test (VFT)

Tests of Learning and Memory Assessment of Motor Output

Wechsler Memory Scale-IV The Wolf Motor Function Test
Rey Auditory Verbal Learning Test The Motor Assessment Scale (MAS)
Fuld Object-Memory Evaluation
Rivermead Behavioral Memory Test
 Beck Anxiety Inventory
Name: Akhwand Saulat Marital Status: Married Age: 30 Gender: Male Occupation: Lecturer Education: M.Phil
Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you
have been bothered by that symptom during the past month, including today, by circling the number in the
corresponding space in the column next to each symptom.
Not At All Mildly but it Moderately - it Severely – it
didn’t bother me wasn’t pleasant at bothered me a lot
much. times
Numbness or tingling 0 1 2 3
Feeling hot 0 1 2 3
Wobbliness in legs 0 1 2 3
Unable to relax 0 1 2 3
Fear of worst 0 1 2 3
happening
Dizzy or lightheaded 0 1 2 3
Heart pounding/racing 0 1 2 3
Unsteady 0 1 2 3
Terrified or afraid 0 1 2 3
Nervous 0 1 2 3
Feeling of choking 0 1 2 3
Hands trembling 0 1 2 3
Shaky / unsteady 0 1 2 3
Fear of losing control 0 1 2 3
Difficulty in breathing 0 1 2 3
Fear of dying 0 1 2 3
Scared 0 1 2 3
Indigestion 0 1 2 3
Faint / lightheaded 0 1 2 3
Face flushed 0 1 2 3
Hot/cold sweats 0 1 2 3
Column Sum

Scoring - Sum each column. Then sum the column totals to achieve a grand score. Write thatscore
here ______01______ .
Interpretation

A grand sum between 0 – 21 indicates very low anxiety. That is usually a good thing. However, it is
possible that you might be unrealistic in either your assessment which would be denial or that you have
learned to “mask” the symptoms commonly associated with anxiety. Too little “anxiety” could indicate that
you are detached from yourself, others, or your environment.

A grand sum between 22 – 35 indicates moderate anxiety. Your body is trying to tell you something. Look
for patterns as to when and why you experience the symptoms described above. For example, if it occurs
prior to public speaking and your job requires a lot of presentations you may want to find ways to calm
yourself before speaking or let others do some of the presentations. You may have some conflict issues that
need to be resolved. Clearly, it is not “panic” time but you want to find ways to manage the stress you feel.

A grand sum that exceeds 36 is a potential cause for concern. Again, look for patterns or times when you
tend to feel the symptoms you have circled. Persistent and high anxiety is not a sign of personal weakness or
failure. It is, however, something that needs to be proactively treated or there could be significant impacts to
you mentally and physically. You may want to consult a counselor if the feelings persist.
 BECK’S DEPRESSION INVENTORY
Instructions:
Please circle the number by the response for each question that best describes how you have felt during the past
seven (7) days.
Please do not omit any questions. Make sure you check one answer for each question. If more than one answer
applies to how you have been feeling, check the higher number. If in doubt, make your best guess.
1. 0 - I do not feel sad.

1 - I feel sad.

2 - I am sad all the time and I can't snap out of it.

3 - I am so sad or unhappy that I can't stand it.

2. 0 - I am not particularly discouraged about the future.

1 - I feel discouraged about the future.

2 - I feel I have nothing to look forward to.

3 - I feel that the future is hopeless and that things cannot improve.

3. 0 - I do not feel like a failure.

1 - I feel I have failed more than the average person.

2 - As I look back on my life, all I can see is a lot of failures.

3 - I feel I am a complete failure as a person.

4. 0 - I get as much satisfaction out of things as I used to.

1 - I don't enjoy things the way I used to.

2 - I don't get real satisfaction out of anything anymore.

3 - I am dissatisfied or bored with everything.

5. 0 - I don't feel particularly guilty.

1 - I feel guilty a good part of the time.

2 - I feel quite guilty most of the time.

3 - I feel guilty all of the time.

6. 0 - I don't feel I am being punished.

1 - I feel I may be punished.

2 - I expect to be punished.

3 - I hate myself.

7. 0 - I don't feel disappointed in myself.

1 - I am disappointed in myself.

2 - I am disgusted with myself.

3 - I hate myself.

8. 0 - I don't feel I am any worse than anybody else.

1 - I am critical of myself for my weaknesses or mistakes.

2 - I blame myself all the time for my faults.

3 - I blame myself for everything bad that happens.

9. 0 - I don't have any thoughts of killing myself.

1 - I have thoughts of killing myself, but I would not carry them out.

2 - I would like to kill myself.

3 - I would kill myself if I had the chance.

10. 0 - I don't cry any more than usual.

1 - I cry more now than I used to.

2 - I cry all the time now.

3 - I used to be able to cry, but now I can't cry even though I want to.

Turn The Page Over

 BECK’S DEPRESSION INVENTORY Page 2

11. 0 - I am no more irritated by things than I ever am.

1 - I am slightly more irritated now than usual.

2 - I am quite annoyed or irritated a good deal of the time.

3 - I feel irritated all the time now.

12. 0 - I have not lost interest in other people.

1 - I am less interested in other people than I used to be.

2 - I have lost most of my interest in other people.

3 - I have lost all of my interest in other people.

13. 0 - I make decisions about as well as I ever could.

1 - I put off making decisions more than I used to.

2 - I have greater difficulty in making decisions than before.

3 - I can't make decisions at all anymore.

14. 0 - I don't feel that I look any worse than I used to.

1 - I am worried that I am looking old or unattractive.

2 - I feel that there are permanent changes in my appearance that make me look unattractive.

3 - I believe that I look ugly.

15. 0 - I can work about as well as before.

1 - It takes an extra effort to get started at doing something.

2 - I have to push myself very hard to do anything.

3 - I can't do any work at all.

16. 0 - I can sleep as well as usual.

1 - I don't sleep as well as I used to.

2 - I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.

3 - I wake up several hours earlier than I used to and cannot get back to sleep.

17. 0 - I don't get more tired than usual.

1 - I get tired more easily than I used to.

2 - I get tired from doing almost anything.

3 - I am too tired to do anything.

18. 0 - My appetite is no worse than usual.

1 - My appetite is not as good as it used to be.

2 - My appetite is much worse now.

3 - I have no appetite at all anymore.

19. 0 - I haven't lost or gained much weight, if any, lately.

1 - I have lost or gained more than five pounds.

2 - I have lost or gained more than ten pounds.

3 - I have lost or gained more that fifteen pounds.

20. 0 - I am no more worried about my health than usual.

1 - I am worried about physical problems such as aches and pains, or upset stomach, or constipation.

2 - I am very worried about physical problems and it's hard to think of much else.

3 - I am so worried about my physical problems that I cannot think of anything else.

21. 0 - I have not noticed any recent change in my interest in sex.

1 - I am less interested in sex than I used to be.

2 - I am much less interested in sex now.

3 - I have lost interest in sex completely.
Name Akhwand Abdur Raffi Saulat Date 9th June 2020 Total 01

1-10 Normal; 11-16 Mild;17+ Clinical Depression:17-20 Borderline, 21-30 Moderate, 31-40 Severe, 41+ Extreme