This is a chapter excerpt from Guilford Publications.

Neuropsychological Interviewing of Adults.

Edited by Yana Suchy with Justin B. Miller. Copyright © 2023.
Purchase this book now: www.guilford.com/p/suchy2

1
The Why, What, and How
of Neuropsychological Interviewing

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Yana Suchy

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Justin B. Miller

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linical interviewing, along with behavioral observations and record review, represents
a core aspect of diagnostic decision making. These information-­gathering methods
are shared by several disciplines, including clinical psychology, medicine, psychiatry, and
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other allied health care professions. Over the years, these methods have taken on a variety
of forms, including formalized procedures, such as the mental status exam often preferred
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by neurology and psychiatry, to a variety of structured, semistructured, or fairly unstruc-

tured interview protocols often employed by psychologists. Regardless of the exact format,
diagnostic determinations in all of these disciplines are based on physical or psychiatric
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findings that are placed in the context of a patient’s history and current complaints, as
well as appearance and overt behavior.
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Although widely adopted by our sister disciplines, clinical interviewing was not
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embraced by early clinical neuropsychology. In fact, early neuropsychologists posited that

a clinical interview might introduce undue bias and that test data alone (or information
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gathered via other standardized means, such as checklists) yielded more objective and
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hence more valid conclusions (Chelune & Moehle, 1986; Russell, Neuringer, & Goldstein,
1970). This thinking was particularly prevalent among clinicians subscribing to the fixed
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battery approach, which allowed collection of large amounts of actuarial data that were
used as the basis for clinical decision making. Despite these early notions, clinical neuro-
psychology has since fully come into the fold of clinical psychology, currently adhering
not only to the tried-and-true clinical practices of information gathering but also to the
American Psychological Association (APA; 2017) code of ethics, which virtually mandates
that no data be interpreted in the absence of a clinical interview and associated behavioral
observations.
In the current era, students who aspire to become clinical neuropsychologists obtain
training in foundational clinical skills, including the art of clinical interviewing and

1
2  Neuropsychological Interviewing of Adults 

behavioral observation. Such training entails learning how to build rapport, how to main-
tain control over the interview, how and when to ask follow-­up questions that maximize
the clinical utility of the patient’s report, and what domains of information are needed for
making diagnostic determinations. Additionally, this training involves identifying spe-
cific features of the patient’s appearance and behavior that are clinically and diagnosti-
cally relevant, as well as some basic understanding of how to review patients’ records. Yet,
as students progress from their general clinical training to more specialized settings in
clinical neuropsychology, they often find that their information-­gathering knowledge and
skills barely scratch the surface of the mountain of information needed in a neuropsycho-

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logical evaluation. The sheer amount of information that contributes to neuropsychologi-

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cal decision making is further compounded by the fact that the specific content of a neu-
ropsychological interview can vary dramatically based on the setting, referral question,

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population at hand, and specific diagnostic considerations. Despite these complexities,
no formalized materials are currently available to facilitate mastery of the neuropsycho-

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logical information-­gathering process. This gap in neuropsychology reference materials
served as the impetus for this book.

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ABOUT THIS BOOKG
This book is intended to serve as a resource for trainees and clinical supervisors, as well
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as for full-­f ledged clinicians at all levels of professional development. Designed to serve
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both as a quick reference and as an in-depth resource, much information throughout the
book is presented in table format, and then further elaborated in text for those desir-
ing more extensive coverage. Tables cover a variety of topics, including the distinguishing
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clinical features that contribute to a given differential diagnosis, sample interview ques-
tions, overviews of relevant behavioral observations, and even definitions of jargon terms
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or acronyms typically encountered in certain settings. To facilitate skimming at different

levels of depth, many tables are organized in such a manner so as to provide an overview of
overarching areas of inquiry (when desiring only a quick reminder of the general domains
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of information that need to be covered), as well as an overview of more specific, or more

detailed, areas of inquiry.
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Trainees with limited prior experience in neuropsychological assessment are advised

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to read this introductory chapter, followed by the chapters that focus on a given setting
or a given patient population. Relatedly, clinical supervisors in specialized clinics may
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choose to routinely assign relevant chapters to all of their trainees at the beginning of
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their externship, internship, or postdoctoral fellowship rotation, and supervisors in gen-

eralist clinics may assign relevant chapters to their trainees as needed prior to seeing a
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particular patient. In addition, the book is designed to have utility for experienced clini-
cians, especially those in generalist settings where a considerable breadth of knowledge is
required. For example, a clinician who typically sees referrals for suspected neurodegen-
erative disorders, acquired brain injury, and vague neurological issues with psychiatric
overlay may on occasion also encounter a less typical referral, such as a patient presenting
with cognitive sequelae of cancer treatment (see Chapter 11) or sequelae of hepatitis C (see
Chapter 14). In such cases, even an experienced clinician may benefit from a quick skim-
ming of tables within relevant chapters prior to seeing the patient, to ensure that all rel-
evant information is gathered. Last, experienced clinicians sometimes transition to a new
  The Why, What, and How of Interviewing  3

setting altogether, and in such cases may benefit from reading the chapters that pertain
to the new setting in their entirety.
Throughout this book, we assume that clinical interviewing is inherently coupled
with behavioral observations, with the two processes informing and complementing each
other. Additionally, we assume that the direction of a clinical interview is initially deter-
mined by the type of information made available beforehand, whether it be the wording
of the referral question or a thorough review of the patient’s available records. In line
with these assumptions, the entire process of gathering information beyond test data (i.e.,
record review, clinical interview, behavioral observations) is covered in this book, with

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dedicated chapters for discrete patient populations and common clinical settings encoun-

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tered by neuropsychologists. Each chapter begins with an overview of the setting, relevant
referral sources, and disorders encountered by neuropsychologists in that setting. Next,

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each chapter reviews the goals of a neuropsychological evaluation in that setting (along
with the types of information needed for accomplishing those goals), as well as how best

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to obtain such information via review of records, interview with a patient and/or a collat-
eral source, and behavioral observations. Last, potential red flags or pitfalls encountered

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in a given setting are highlighted.
By design, there are several topics that are omitted from this book. First, this book

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focuses on adults. Given the growing specialization within clinical neuropsychology, the
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inclusion of chapters on both adult and pediatric settings in a single volume was thought
to be unwieldy. Rather, a separate volume focusing purely on pediatric settings is pre-
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ferred. Second, this book focuses on clinical issues and settings, purposely avoiding dis-
cussion of forensic issues. Much has been written about forensic neuropsychology, and a
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single chapter on forensic interviewing would not do justice to all of the complexities and
nuances of forensic evaluations. Third, since this book focuses on clinical populations
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and clinical settings, it does not contain chapters on different formats or different social
contexts of information gathering. Thus, for example, the book does not contain a chapter
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on remote assessment or tele-­neuropsychology, the use of translators, rural outreach, or

issues related to cultural (including racial and ethnic) considerations. That said, several
chapters comment on cultural issues as relevant for a given clinical setting.
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The remainder of this chapter reviews general principles of information gathering

that are common to most adult-­focused clinical settings, so as to allow subsequent chap-
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ters to focus purely on those aspects of information gathering that are unique to each
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setting or each population. Figure 1.1 provides an overview of information-­gathering prin-

ciples presented in the remainder of this chapter.
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THE WHY OF CLINICAL INTERVIEWING

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In this section, we provide a brief overview of why it is crucial for clinicians to meet with
and interview their patient prior to initiating test administration.

Rapport Building
A clinical interview is an opportunity to build rapport with the patient and to reduce
some of the ambiguity surrounding the evaluation process. Often, simply just offering an
explanation of the clinical utility of the evaluation and how the test data will be used goes
4  Neuropsychological Interviewing of Adults 

Gathering Information
Beyond Test Data

WHY? WHAT? HOW?

(reasons) (content) (process)

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Record

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Rapport
Review
Current Fx and Sx Prior Fx/Change

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Battery
Selection Interview

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Reliability and Patient -Specific

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Validity of Test Context
Observations
Data

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Referral
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Question
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FIGURE 1.1. An overview of the main components of the why, the what, and the how of clinical infor-
mation gathering. Fx, functioning; Sx, symptoms.
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a long way toward putting an anxious patient at ease or ameliorating a skeptical patient’s
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doubts. Additionally, a clinical interview is an opportunity to discuss the patient’s hopes

or goals for the assessment (or, in some cases, concerns), which in turn allows the clinician
to more fully address the referral question and to provide specific recommendations that
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are most meaningful and most likely to benefit the patient.

A particularly important aspect of rapport building pertains to the patient’s cul-
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tural or demographic context. Some patients may feel apprehensive about the evaluation
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because of a preconceived notion about how they might be perceived by the examiner due to
their age, sex/gender, country of origin, or racial or ethnic background. Such preconceived
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notions can have a significant impact on test performance, as demonstrated by research

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on stereotype threat. A clinical interview is an opportunity to take steps toward dispelling

such harmful preconceived notions by inquiring about the patient’s expectations, fears,
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and concerns and engaging in an open, honest, and supportive conversation about the
issues at hand. Importantly, a patient who has good rapport with the clinician is not only
more likely to perform at their best during testing but is also more likely to take the time
to return for in-­person feedback and, in turn, to follow through with recommendations.

Battery Selection
As the fixed battery approach began to give way to a flexible battery (Sweet, Klipfel, ­Nelson,
& Moberg, 2021), test selection has become an important step in the assessment process.
  The Why, What, and How of Interviewing  5

Aside from the primary referral question, the clinical interview, records review, and behav-
ioral observations all play a critical role in determining the most appropriate assessment
instruments. Of note, review of records alone is not sufficient and should never be used as
a substitute for a one-on-one conversation with a patient. In fact, it is common for clini-
cians to make substantial adjustments to their battery once they meet their patient face-
to-face. Issues such as motor, sensory, or speech limitations, English as a second language,
fatigue, or behavioral problems may be unduly exaggerated or downplayed in the records,
or may not be described with the type of detail and nuance that is needed for determin-
ing the patient’s capacity to participate in all aspects of testing. For example, a note in

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the patient records of “hemiparesis in the right arm” cannot be interpreted until hand

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dominance is established. Similarly, a note that the patient is “legally blind” may fail to
acknowledge that the blindness pertains to peripheral vision and the patient can normally

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perceive written material. In other words, the degree to which motor, sensory, cognitive,
and behavioral limitations interfere with test performance can often only be gleaned from

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a face-to-face interaction.

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Reliability and Validity1 of Test Data

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Another reason for collecting information beyond test data is to determine whether test
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data are meaningful. There is much to be learned in the context of a face-to-face interaction
that simply cannot be gleaned from any other source. For example, it is important to note
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whether the patient is adequately aroused and alert, whether any sensory or motor issues
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might interfere with testing, or whether attitude toward the examiner might impact test
performance. In other words, information about these aspects of the evaluation is bound
to influence the clinical interpretation of test results. Furthermore, gross inconsistencies
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between apparent functional capacity and test results can also sometimes be gleaned from
a face-to-face interaction. For example, a patient who is moderately impaired on memory
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measures may demonstrate an exquisite capacity for using compensatory strategies while
answering interview questions.
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Answering Referral Questions

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Perhaps the most salient reason for collecting information beyond test data is that diag-
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nostic and functional decisions can never be based on test scores alone. Even for diagnoses
that are virtually defined by test scores, such as intellectual disability, it is necessary to
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ascertain the presence of a functional impairment in daily life before a diagnosis can be
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made. Additionally, while test data may indicate levels of cognitive impairment, they alone
virtually never differentiate among specific diagnoses. Typically, to arrive at a differen-
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tial diagnosis, additional information needs to be gathered from records, interview, and
behavioral observation that is specific to a given disorder. Fluctuations in a patient’s daily
functioning, changes in sleeping or eating habits, a recent loss of a loved one, inappropri-
ate behaviors, or an increase in falls are but a few examples of information beyond test data
that may have important ramifications for a differential diagnosis. Importantly, even if

1 The term validity in this context is intended to communicate general psychometric concepts of construct and

criterion validity and is not intended to be limited to a performance validity issue secondary to purposeful
feigning or exaggeration of deficits.
6  Neuropsychological Interviewing of Adults 

such information is noted in the patient’s records, the clinical interview is an opportunity
to clarify and confirm such information and to further refine initial clinical impressions.

THE WHAT OF CLINICAL INTERVIEWING

In this section, we briefly review what domains of information are routinely needed for neu-
ropsychological decision making. Once again, such information is best gathered through
a combination of a record review, face-to-face interview, and behavioral observations.

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Current Functioning

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Most diagnoses inherently require that a clinician integrate test data with information
about the patient’s functioning in daily life. For example, a formal diagnosis of dementia

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(or major neurocognitive disorder) stipulates that instrumental activities of daily living
(IADLs) be compromised secondary to the cognitive impairment evident on objective test-

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ing. Additionally, despite the fact that the clinician collects test data to address current
cognitive ability, it is important to place such data in the context of daily cognitive func-

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tioning as perceived by the patient (and perhaps also as perceived by collateral sources or
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as described in records). Such information provides a way of cross-­validating test results
and also allows the clinician to place test performance into a meaningful context in the
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clinical report or during a feedback session with the patient or family. As seen in Table
1.1, information about daily functioning should cover a variety of domains beyond cogni-
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tion and IADLs. Although many interviews cover most or all of the functional domains
listed in Table 1.1, the relative importance and degree of detail required in a given domain
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may vary across different populations and settings, which is highlighted as appropriate in
subsequent chapters—­for example, activities of daily living can be assumed to be intact in
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many high-­functioning patients.

In addition to the importance of the patient’s daily functioning for diagnostic pur-
poses, it is important to note that many neuropsychological evaluations are conducted
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with patients whose diagnoses have already been established. In such cases, evaluations
may be conducted purely for the purpose of characterizing the patient’s current cogni-
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tive abilities and for making functional determinations, such as determinations about a
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patient’s ability to continue to work or to live independently. The general type of infor-
mation gathered for this purpose is virtually identical to that gathered for diagnostic
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purposes, although functional assessments require greater depth to facilitate nuanced

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and informed determinations about the patient’s functional strengths and weaknesses,
insight, and the ability or willingness to use compensatory strategies. Chapter 2 provides
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in-depth coverage of capacity and functional evaluations.

Historical and Premorbid Functioning

Most diagnoses require not only that a current level of functioning be characterized but
also a determination of whether a current level of performance or functioning represents
a change from a historical baseline. Although neuropsychologists have tests available to
assist in estimating premorbid cognitive abilities (e.g., reading tests), such tests must be
interpreted in the context of the patient’s history. For example, a patient with an early
  The Why, What, and How of Interviewing  7

TABLE 1.1. Domains of Current Functioning

Functional domain Domain components
Educational/occupational (if relevant) • Employment (status, type, and performance)
• School (status, type, and performance)

Cognitive • Daily episodic memory

• Prospective memory
• Attention and working memory
• Language (expressive and receptive)
• Planning, organization, reasoning, and problem solving

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• Speed of processing

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• Spatial and nonverbal reasoning

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Behavioral • Impulse control
• Initiation/motivation
• Task completion/persistence

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• Social appropriateness
• Social engagement

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• Personality

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Sensory/motor • Sensory (vision, hearing, smell, and taste)
• Motor (gross and fine)
• Falls
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•
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Instrumental activities of daily livinga Shopping
• Cooking/meal preparation
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• Cleaning/household chores/home maintenance

• Finances
• Communication/Internet use
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• Medication/medical regimen management

• Schedule and appointments
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• Driving and transportation

Basic activities of daily living • Personal hygiene, dressing

• Eating
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(if relevant)b
• Mobility
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Psychological • Mood
• Anxiety
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• Stress and coping

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• Apathy/anhedonia
• Delusions/hallucinations
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• Suicidal/homicidal ideation

Vegetative • Sleep
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• Appetite (weight gain/weight loss)

• Fatigue/alertness/arousal

Social • Friends
• Family
• Romantic partners

Recreational • Type and frequency of activities

• Enjoyment of activities
(continued)
8  Neuropsychological Interviewing of Adults 

TABLE 1.1. (continued)

Functional domain Domain components
Substance use • Alcohol
• Tobacco, marijuana, vaping
• Prescription medications
• Other legal or illegal substances

Current/recent stressors • Socioeconomic status/financial distress

• Job loss
• Homelessness

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• Family distress (divorce, illness, family feud, etc.)

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• Grief (loss of a loved one, a pet, driving privileges, etc.)
• Immigration status, discrimination

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Current resources • Current social support (friends, family, acquaintances, etc.)
• Recreational outlets (hobbies, etc.)

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• Socioeconomic status/financial resources
• Health insurance

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• Transportation
a See also Table 2.3. b See also Table 2.4.

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history of a reading disorder may struggle with a reading test, which may result in an
underestimate of the patient’s overall premorbid capacity. The types of information that
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facilitate accurate estimates of premorbid functioning may include records of work and/or
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school performance, reports of interpersonal functioning, or information about the abil-

ity to manage IADLs. Job and school performance (i.e., not just the patient’s formal job title
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or attained degree) should be explored, including issues such as the ease or difficulty in
achieving those positions or degrees. Such information almost never comes from just one
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source—­rather, interviews with the patient and collateral sources, as well as record review,
may all contribute. See Table 1.2 for the most relevant aspects of premorbid functioning.
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Specific Diagnostic Criteria

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Many diagnoses require that some discrete pieces of information be gathered that are
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unique to a given diagnosis, which may be difficult or impossible to collect outside of an

interview. For example, for a diagnosis of traumatic brain injury, the clinician must gather
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information about whether a realistic trauma to the head occurred, or about the imme-
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diate sequelae of such a trauma (e.g., the extent of retrograde and anterograde amnesia).
Similarly, when evaluating a patient for a possible neurodegenerative disorder, behavioral
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changes that typify a behavioral variant of frontotemporal dementia are never captured
by testing and must instead be assessed via records review, interview, and observations.
Details about such setting- and diagnosis-­specific information are presented in subse-
quent chapters.

Broader Patient‑Specific Context and History

Last, a clinician needs to be mindful of potentially relevant contextual issues that an indi-
vidual brings to the table that may bear on the interpretation of the information about
  The Why, What, and How of Interviewing  9

premorbid and current functioning or about the specific diagnostic criteria. Contextual
information comes from a variety of sources, including psychosocial and developmental
history, educational and occupational history, medical and psychiatric history, legal his-
tory, and substance use history. Additionally, contextual factors surrounding the current
symptoms are important, such as stressors precipitating or exacerbating symptom onset.
Thus, for example, if a middle-­age patient presents with unexplained cognitive decline,
substance use history could represent a potential culprit. Similarly, if a patient reports
psychiatric difficulties following a mild concussion, the clinician needs to inquire about
any pending civil litigations related to the patient’s injury, or a history of psychiatric dif-

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ficulties prior to the accident. And if an older patient experiences a sudden decline in

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functioning, it is important to understand whether such a change was precipitated by an
unusual stressor, such as the death of a spouse or a serious medical illness. An overview

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of domains of contextual information that are typically assessed in a neuropsychological
interview can be found in Table 1.3.

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TABLE 1.2. Assessment of Historical/Premorbid Level of Functioning
Functional domains Specific topics
Educational Hx • Highest milestone completed
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| Contextualized via educational opportunities
• Objective academic performance across educational levels
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| Grades
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| Gifted program
| Academic accommodations/remediations
| Repeated or skipped grades
| Scaffolding/tutors
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| Behavioral problems

• Diagnoses of ADHD or learning disorder

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• Undiagnosed attentional/learning difficulties

| Subjective struggles or learning difficulties
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Occupational Hx • Job consistency

• Reasons for job changes
• Job title and job description (e.g., president of an international
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company vs. president of one’s own small business)

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Everyday planning, • Prior experience with and ease versus difficulty with
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reasoning, and | Planning/organizing events, parties, trips, etc.

problem solving | Solving unexpected problems, such as a broken pipe,
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plugged toilet, bills lost in the mail, etc.

• Prior experience/independence with

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Instrumental activities
of daily living | Shopping
| Cooking/meal preparation
| Cleaning/household chores/home maintenance
| Finances
| Communication/Internet use
| Medication/medical regimen management
| Schedule and appointments
| Driving and transportation

Note. Hx, history; ADHD, attention-deficit/hyperactivity disorder.

10  Neuropsychological Interviewing of Adults 

TABLE 1.3. Domains of a Patient’s History

Hx domain Specific areas of inquiry
Psychosocial and • Pre- and perinatal insults
developmental Hx • Quality of home life when growing up
• SES when growing up
• Stressors and traumas when growing up

Educational and • Highest level of education

occupational Hx • Educational performance/accommodations
• Employment

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Medical Hx • Neurological CNS disorders (seizures, multiple sclerosis, stroke,
neurodegenerative disorders, brain tumor, etc.)

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• Non-neurological disorders with CNS ramifications (e.g., hypertension,
diabetes, heart disease, cancers and cancer treatments, hormonal
disorders, liver disease, kidney disease, COPD, infections affecting CNS)

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• Other major medical illnesses and hospitalizations
• Major surgeries and adverse surgical events

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• Major injuries (including specific inquiries about ABIs)

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Psychiatric Hx • Disorders characterized by cognitive Sx (ADHD, ASD, learning
disorders, intellectual disability, etc.)
• Psychiatric diagnoses
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• Psychiatric symptoms, without diagnosis
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• Psychiatric hospitalizations
• Suicidal ideation and/or attempts
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Legal Hx • Criminal arrests, charges, and convictions

• Civil lawsuits
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Substance use Hx • Alcohol, tobacco, marijuana, and illegal substances

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• Prescription medications and other legal substances

Note. Hx, history; SES, socioeconomic status; CNS, central nervous system; COPD, chronic obstructive pulmonary
disease; ABI, acquired brain injury; Sx, symptom(s); ADHD, attention-deficit/hyperactivity disorder; ASD, autism
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spectrum disorder.
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THE HOW OF CLINICAL INTERVIEWING

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In this section, we briefly review how a clinician goes about gathering information beyond
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test data, or how different types of information can be used to answer diagnostically and
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functionally relevant questions. Specifically, this section reviews the general process of
reviewing records, gathering information in face-to-face2 interviews with patients and col-
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lateral sources, and noting relevant behavioral observations.

Records Review
Ideally, a clinician would have the opportunity to review patient records prior to the patient
arriving for the evaluation so as to begin formulating clinical hypotheses. For providers
2 Typically,
and preferred in most settings, interviews are conducted face-to-face with the patient, though tele-
medicine options are becoming more commonplace.
   The Why, What, and How of Interviewing  11

that work outside of an institutional setting, this typically requires some foresight, includ-
ing working with patients to identify the custodian(s) of the most salient records and
securing written permission to obtain such records. Additionally, since there is consider-
able variability in the ease versus difficulty of securing records from different sources,
some practitioners may need to contact other health care providers several weeks prior to
the appointment with their patient, due to a considerable lag many hospitals and clinics
experience when responding to record requests. In contrast, some settings lend themselves
to easy access to patients’ records. For example, practitioners that work in institutional
settings (e.g., Veterans Affairs hospitals, major medical centers) and see internally referred

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patients readily have access to the patient’s shared electronic medical records, as long as

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the patient’s other health care needs have been handled by the same institution. Although
in many clinical situations only medical records are reviewed, in some cases records from a

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variety of sources are made available. Table 1.4 provides an overview of the common types
of information that different record sources have to offer.

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All types of records listed in Table 1.4 have the potential to contribute to answering
questions about current and premorbid functioning, as well as specific diagnostic and

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contextual considerations. For example, school or work records, especially if spanning a
number of years, offer information about the premorbid level of functioning, and a sudden

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change in school/work performance could potentially provide insight about the timing of
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the onset of functional difficulties. Similarly, legal records may help clarify whether crimi-
nal behavior can be attributed to a particular diagnosis, or whether it was present premor-
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bidly. In the same vein, such records may help pinpoint the onset of functional changes,
evidenced by a sudden late-life onset of shoplifting, car accidents, or sexual misconduct.
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TABLE 1.4. Overview of Relevant Record Types for Determination of Premorbid and Current Functioning
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School/work records Legal records Medical/psychiatric records

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• School • Law enforcement agencies • Inpatient

| Report cards/transcripts (police, sheriff, highway patrol, | Admission and discharge
Performance on standardized etc.) summaries
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|
tests | Incident reports | EMT/ED reports
| Attendance | Traffic offenses | Physician notes
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| Incident reports | Arrests | Nursing (and other allied

| Remediation plans and | Charges professions) notes
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outcomes | Investigations/interviews | Test results (neuroradiology,

Termination/transfer if lab, etc.)
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|
• Department of Corrections
relevant | Procedure (e.g., surgery)
(jail/prison)
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summaries
• Work | Convictions/sentences
| Application form, résumé, etc. | Admission/processing/ • Outpatient
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| Test results orientation | Office visit summary

| Regular/yearly evaluations of | Work records | Letters/reports to referring
performance | Conduct/incident reports physicians
| Promotions/demotions/ | Release/parole | Test results (e.g.,
termination | Attorney neuroradiology, bloodwork)
| Incident reports | Depositions | Outpatient procedure
| Disciplinary actions/ | Evaluation reports from summaries (e.g., surgery)
remediation plans potential expert witnesses
| Exit interview summary

Note. EMT, emergency medical technician; ED, emergency department.

12  Neuropsychological Interviewing of Adults 

Last, medical and psychiatric records often provide discrete diagnosis-­specific informa-
tion (e.g., neuroimaging, psychotic episode), but may also help pinpoint the onset of a
functional change (e.g., a sudden increase in falls or accidents reported in the emergency
department records), or may again help determine whether reported difficulties are linked
to a suspected diagnosis or whether they may have been present premorbidly (e.g., chronic
headaches, psychiatric hospitalizations).

Interview with a Patient

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Typically, a neuropsychological interview begins with a thorough and detailed inquiry into

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the reason for the current evaluation, including a detailed history of the present illness or
the cognitive/functional difficulties that prompted the evaluation. Additionally, a detailed

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inquiry into how, or whether, present functioning reflects a change from a historical or pre-
morbid baseline takes place early on in the interview. These inquiries are then followed by

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gathering additional contextual information that allows the clinician to place the current
symptoms and complaints into a broader context, allowing a more nuanced interpretation.

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As is the case in any clinical interview (i.e., outside of clinical neuropsychology), skilled
clinicians follow up a patient’s responses with clarifying questions. For example, vague

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statements, such as “I don’t drink too much” or “I did great in school,” need to be followed
up with questions that gather specific information about, say, the actual number of drinks
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consumed per day or the actual grades the patient earned in school. Similarly, abstract
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statements, such as “I am depressed” or “I have an anxiety disorder,” need to be followed
up with questions about specific symptoms, as patients often come with preconceived
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(and often inaccurate) notions about what their symptoms signify. It is also important to
remain mindful of the patient’s cognitive status and their ability to comprehend verbal
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communication. Asking complex, multipart questions may need to give way to simple
questions with concrete answers in order to elicit information effectively.
20

In the course of their general clinical training, clinical neuropsychologists typically

become skilled in how and when to ask such follow-­up questions, especially in relation
to a patient’s psychosocial history or current psychological functioning. However, in the
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context of a neuropsychological evaluation, additional less obvious clarifications need to be

obtained. In particular, it is common for patients to make observations about their cogni-
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tion using lay terminology that does not necessarily map onto neurocognitive domains.
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For example, it is quite common for patients to refer to a variety of cognitive difficulties
as “memory problems,” whereas in neuropsychological parlance the patient may actually
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be describing an expressive language problem, such as word-­f inding difficulties, an atten-

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tional problem such as common losses of mental set, or a lack of motivation. Alternatively,
it is common for patients to state that their “memory is great” because they remember
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things as far back as their childhood, though when asked about recent events from earlier
in the day, they may have little recollection. Thus, clinicians must clarify statements per-
taining to cognition, rather than accept them at face value. Because memory complaints
are quite common in a variety of both clinical and healthy populations (Begum et al., 2014;
Kareken et al., 1992; Schmidt et al., 2016), and because memory complaints can reflect dif-
ficulties in other cognitive domains (e.g., executive functioning, word retrieval, processing
speed; Baker, Gibson, Georgiou-­Karistianis, & Giummarra, 2018; Minett, Da Silva, Ortiz,
& Bertolucci, 2008; Torrens-­Burton, Basoudan, Bayer, & Tales, 2017), Table 1.5 provides a
list of sample clarifying questions as they pertain to typical memory complaints.
  The Why, What, and How of Interviewing  13

TABLE 1.5. Clarifying the Nature of Cognitive Complaints: Sample Questions

Cognitive domain Clinician’s clarification of complaint
Memory versus • “When you say you forget things, do you mean you have difficulty recalling
prospective memory what you had for dinner the night before, or is it that you forget to do things
you intended to do? For example, do you forget to pick up the laundry or
stop at the post office even though you intended to do so, but then when
reminded of your intentions, you immediately recall your original plan?”

Memory retention • “When you say you forget things, do you mean you actually don’t remember
versus memory things even if reminded of them, or do you mean that you cannot retrieve

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retrieval information but recognize it if someone reminds you?”

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• “Do you find yourself misplacing things and then not being able to retrace
your steps?”

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Memory versus • “When you say you don’t remember what you read in a book or what you saw
attention in a movie, do you mean you don’t recall things no matter how hard you pay

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attention to them, or is it that your mind wanders and so you never quite
process what you read in a book or saw on TV?”

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Memory versus • “When you say you can’t remember anyone’s name, do you mean you

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word finding have trouble learning names of people you just met, or do you mean you
have trouble recalling names of people you know well but the names
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spontaneously come to you at a later time?”
• “Is it only people’s names, or do you also have trouble remembering the
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names of objects and places?”
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Memory versus • “When you say you get lost, do you mean you cannot envision a route you
spatial difficulties want to take, or is it that you don’t recall where you intended to go?”
• “Do you have trouble remembering how to get to familiar places that you’ve
23

been to before, or is it only new places that you have trouble with?”
20

Memory versus • “When you say you forgot how to cook, do you mean you literally cannot
executive recall a recipe, or do you mean you get overwhelmed by all the steps and can’t
execute them all in the correct order?”
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Interview with a Collateral Source

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Interviewing a collateral source can be highly informative in most populations, but espe-
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cially when working with populations where reduced insight or memory limitations can
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hinder accurate self-­report, such as older adults suffering from a neurodegenerative dis-
order and survivors of brain injury or stroke (especially in acute and postacute inpatient
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settings). Additionally, some patients may at times purposely choose not to be forthcom-
ing about day-to-day challenges (e.g., those worried about losing their independence or
driving privileges, or fitness for duty evaluations). Conversely, some patients may be prone
to overpathologizing normal cognitive lapses (e.g., the “worried well”; cogniform or soma-
tization disorders), and others may intentionally overreport or embellish symptoms (e.g.,
individuals with potential for secondary gain). In all of these cases, collateral informa-
tion may shed light on actual functionality or factual historical events. Last, in inpa-
tient settings, relevant hospital staff can provide invaluable information about functional
fluctuations (which themselves can be diagnostic), such as discrete periods of alertness
14  Neuropsychological Interviewing of Adults 

alternating with an acute confusional state, behavioral problems emerging during family
visits, or periods of agitation emerging when fatigued (e.g., after lunch or after a physical
therapy session). It is important to note that the accuracy of collateral informants must
not be taken for granted. For example, relatives of older patients may at times minimize
the patients’ cognitive difficulties, and other times exaggerate them for a variety of psy-
chological or even secondary-­gain reasons.

Behavioral Observations

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During a neuropsychological evaluation, one needs to be vigilant about all the same

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behavioral observations that are important during a general clinical intake. Additionally,
there are certain behavioral observations that are unique to neuropsychology (see Table

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1.6). For example, while a general clinical psychologist might describe language as “word
salad,” a clinical neuropsychologist may need to be more discriminating, noting specifi-

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cally whether a patient was exhibiting literal versus semantic paraphasias, whether the
patient’s speech was fluent or halting, and the degree to which a patient understood gram-

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mar versus nouns and verbs. Similarly, while a general clinical psychologist might simply
state that the patient had a tremor, a clinical neuropsychologist may need to describe the

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type of tremor (e.g., resting, action, or intention), as such specificity can often be impor-
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tant for a differential diagnosis. Pathognomonic signs (i.e., behavioral signs that repre-
sent clear signals of a particular type of neuropathology) span several domains of behav-
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ioral observations, including language, motor behavior, social inappropriateness, extreme
impulsivity, arousal and arousal fluctuations, thought processes, and observable memory
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issues, many of which can be readily apparent over the course of the interview. When rel-
evant, such signs are detailed further in subsequent chapters.
23
20

SUMMARY AND CONCLUSIONS

Consistent with the APA code of ethics, gathering information beyond test data represents
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a key aspect of a neuropsychological evaluation. The methods for information gather-

ing include record review, clinical interviewing, and behavioral observations. This chapter
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reviewed some of the general principles of information gathering in a number of neuropsy-

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chological contexts. See Figure 1.1 for an overview. Methods unique to different popula-
tions, settings, or referral questions are presented in subsequent chapters.
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REFERENCES
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American Psychological Association. (2017). Ethical principles for psychologists and code of conduct.
www.apa.org/ethics/code
Baker, K. S., Gibson, S. J., Georgiou-­K aristianis, N., & Giummarra, M. J. (2018). Relationship
between self-­reported cognitive difficulties, objective neuropsychological test performance
and psychological distress in chronic pain. European Journal of Pain, 22(3), 601–613.
Begum, A., Dewey, M., Hassiotis, A., Prince, M., Wessely, S., & Stewart, R. (2014). Subjective cogni-
tive complaints across the adult life span: A 14-year analysis of trends and associations using
the 1993, 2000 and 2007 English Psychiatric Morbidity Surveys. Psychological Medicine, 44(9),
1977–1987.
   The Why, What, and How of Interviewing  15

TABLE 1.6. Behavioral Domains and Observations of Interest during the Clinical Interview
Domain Observations and signs of interest Neuropsychology-specific implications
Arrival • On time? • Consider possible deficits in
• Accompanied? | Memory
| Prospective memory
| Executive functions

Physical appearance • Weight, height, gender, age • Consider implications for

• Attire | Psychiatric disorders
• Grooming/hygiene General physical health

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|

• Unusual physical characteristics

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(e.g., major scars, major facial
tattoos and piercings, deformities,

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evidence of self-harm)

Motor functioning • Ambulation and mobility aids • Consider ramifications for test selection

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• Hemiparesis and test performance
• Gait and posture • Consider implications for

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• Arm swing recommendations
• Gross motor functioning • Consider implications of gait/posture and

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• Fine motor functioning involuntary movements for:
• Involuntary movements (e.g., | Movement disorders (Chapter 7)
G
tremor, chorea, tics) | Stroke (Chapter 8)

• Weakness • Consider weakness as a possible Sx of

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multiple sclerosis (Chapter 9)
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Sensory functioning • Hearing • Consider ramifications for test selection

and aids • Vision and test performance
• Sensory aids • Consider hallucinations as possible Sx of:
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• Hallucinations (visual, auditory, | Psychotic disorder (Chapter 16)

olfactory) | Dementia (Chapter 5)
20

| Seizure disorder (Chapter 10)

• Consider sensory changes as possible Sx of

multiple sclerosis (Chapter 9)
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Arousal • Level of arousal • Consider ramifications for test

• Level and stability of alertness performance
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• Level and stability of • Consider fluctuating alertness as possible

attentiveness Sx of delirium/encephalopathy or dementia
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with Lewy bodies (Chapter 5)

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Orientation • Person • Consider possible deficits in:

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• Place | Memory
• Time | Reasoning
• Situation • Consider possible delirium
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Speech • Rate, fluency • Consider pressured speech as possible Sx of

• Tone, pitch psychiatric disorders (Chapter 16)
• Volume • Consider poor prosody as possible Sx of
• Prosody stroke (Chapter 8)
• Consider low volume as possible Sx of
Parkinson’s disease (Chapter 7)

(continued)
 16  Neuropsychological Interviewing of Adults 

TABLE 1.6. (continued)

Domain Observations and signs of interest Neuropsychology-specific implications
Language • Word finding • Consider possibility of:
• Semantic paraphasic errors | Focal insults (stroke, tumor; Chapters 8
• Phonemic paraphasic errors and 11, respectively)
• Circumlocution | Neurodevelopmental disorders (Chapter
• Poor paragraph-level structure 12)
• Agrammatism, telegraphic speech | Neurodegenerative conditions
• Auditory comprehension (Alzheimer’s disease, primary progressive
• Written comprehension aphasia; Chapters 5 and 6, respectively)

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Thought processes • Logic, linearity • Consider implications for thought disorder
and content • Perseverations (Chapter 16)

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• Coherence • Consider implications for executive
• Concreteness functioning
• Delusions

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Mood • Depressed (psychomotor • Consider implications for mood disorder

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retardation, slouched posture, • Consider implications for performance
depressed affect, tears, of highly effortful tests (executive

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verbalizations) functioning, memory retrieval)
• Manic (psychomotor agitation, G • Consider implications for processing speed
pressured speech, verbalizations)

Affect • Range • Consider implications for:

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• Quality |Mood disorder
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• Congruency with mood |Parkinsonism (Chapter 7)

• Appropriateness to situation | bvFTD (Chapter 5)

• Unprovoked, uncontrolled • Note unprovoked laughter as a possible

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laughter or crying gelastic seizure (Chapter 10)

• Consider unprovoked, uncontrolled
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laughter or crying as possible

pseudobulbar affect (Chapter 8)

Participation • Initiative • Consider implications for:

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• Persistence | Test performance and validity of test

• Approach/response style scores
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| Treatment recommendations
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Insight • Awareness of mistakes • Consider implications for:

• Awareness of behaviors and
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|Veracity of self-report
impact on others |Treatment recommendations
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• Awareness of deficits • Consider possible:

| Memory deficits
| Anosognosia
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| Anosodiaphoria

Rapport • Attitude toward examiner • Consider implications for:

• Attitude toward testing | Test performance
• Easily established versus slow to | Validity of test scores
warm up | Treatment recommendations

Note. Sx, symptom(s); bvFTD, behavioral variant of frontotemporal-lobar dementia.

  The Why, What, and How of Interviewing  17

Chelune, G. J., & Moehle, K. A. (1986). Neuropsychological assessment and everyday functioning.
In D. Wedding, A. M. Horton, & J. Webster (Eds.), The neuropsychology handbook: Behavioral and
clinical perspectives (pp. 489–525). Springer.
Kareken, D. A., Williams, J. M., Mutchnick, M. G., Harter, G., Torres, I., & George, W. E., Jr. (1992).
Self-­report of cognitive function after cardiac surgery. Neuropsychology, 6(3), 197–209.
Minett, T. S. C., Da Silva, R. V., Ortiz, K. Z., & Bertolucci, P. H. F. (2008). Subjective memory com-
plaints in an elderly sample: A cross-­sectional study. International Journal of Geriatric Psychiatry,
23(1), 49–54.
Russell, E. W., Neuringer, C., & Goldstein, G. (1970). Assessment of brain damage: A neuropsychological
key approach. Wiley-­Interscience.

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Schmidt, J. E., Beckjord, E., Bovbjerg, D. H., Low, C. A., Posluszny, D. M., Lowery, A. E., . . . Rechis,

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Results from the 2010 LIVESTRONG Survey. Journal of Cancer Survivorship, 10(2), 302–311.

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Sweet, J. J., Klipfel, K. M., Nelson, N. W., & Moberg, P. J. (2021). Professional practices, beliefs, and
incomes of U.S. neuropsychologists: The AACN, NAN, SCN 2020 practice and “salary survey.”
The Clinical Neuropsychologist, 35(1), 7–80.

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Torrens-Burton, A., Basoudan, N., Bayer, A. J., & Tales, A. (2017). Perception and reality of cognitive

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function: Information processing speed, perceived memory function, and perceived task dif-
ficulty in older adults. Journal of Alzheimer’s Disease, 60(4), 1601–1609.

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