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Introduction to Neuropsychology For Psychiatry Residents PowerPoint PPT Presentation


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Introduction to Neuropsychology For Psychiatry Residents. Vaughan Bell. Course Outline. Introduction to neuropsychology Introduction to neuropsychological evaluation Referrals, reports and interpretation Evaluation of psychiatric patients. What is Neuropsychology.

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Introduction to Neuropsychology

For Psychiatry Residents

Vaughan Bell


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Course Outline

  • Introduction to neuropsychology

  • Introduction to neuropsychological evaluation

  • Referrals, reports and interpretation

  • Evaluation of psychiatric patients


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What is Neuropsychology

  • Neuropsychology is the science of how the structure and function of the brain relates to psychological processes.

  • As a basic science it tries to understand these links experimentally.

  • As a clinical science it aims to understand how specific impairments relate to impaired brain mechanisms, or vice versa.

  • In neuropsychology, these two aims are strongly linked.


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Phineas Gage

  • A railroad worker in Vermont, known for his good character and responsible attitude.

  • Suffered an injury in 1848 where a tamping iron was shot through his head when setting gunpowder to break rocks.

  • He did not lose consciousness and he walked home.

  • He was later seen by Dr Harlow who wrote up his case.


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Skull and Life Mask


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Damasio et al (1994) Reconstruction


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Effect on Gage

Dr Harlow reported:

“He is fitful, irreverent, indulging at times in the grossest profanity… capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned.”


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Link to Function

  • This was some of the first evidence that damage to specific areas of the brain could affect personality and behaviour.

  • Later Paul Broca’s autopsy on a patient with expressive aphasia found a specific lesion in the left frontal lobe, now known as Broca’s area.

  • This suggested language was not single function and could be linked to certain brain circuits.


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Trench Warfare and Scotoma


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Holmes (1916) Scotoma Lesion Map


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Modern Neuropsychology

  • Contemporary neuropsychology uses a variety of techniques to understand mind – brain links.

    • Neuroimaging

    • Computational modelling

    • Experiments on healthy participants

    • Lesions studies

    • Studies on psychiatric disorders


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Lesion Studies

  • Understanding how brain damage affects human abilities is still the most powerful tool in neuropsychology.

  • One of the key techniques in both research and clinical work is the dissociation - a difference, break or uneven performance on tasks.

  • A dissociation between patients suggests that the task is not controlled by a single cognitive process.

  • A dissociation within a patient suggests difficulties in specific abilities.


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[ Video Segment ]


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Dissociations

  • In this example each patient had a single dissociation between one ability – object perception – and another – face perception.

  • Considering both patients, there is a double dissociation – so we know they rely on different brain processes.


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Dissociations

  • The double dissociation is a scientific tool that helps us understand mind and brain function.

  • In a clinical patient, we can link deficits to what we know about neuropsychology…

  • …to understand what has gone wrong.


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A Rough and Incomplete Guide to the Brain


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Early Visual Perception Deficits

  • Damage to the early visual system will produce things such as:

    • Visual field deficits

    • Orienting difficulties

    • Impairments in shape, form or size discrimination.

    • Colour blindness

    • Motion blindness


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Efron’s (1968) Shape Task


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Dorsal Stream

The ‘where’ or ‘how’ stream

Ventral Stream

The ‘what’ stream


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Associative Agnosia

Associative Patient HJA (Riddoch and Humphreys, 1987) Copying without Naming


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Apperceptive Agnosia

Original

Patient Copy

Apperceptive Patient HC (Sparr et al., 1991) Impaired Copying of Simple Shapes


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High Level Vis Perception Deficits

  • Prosopagnosia – selective impairment in perceiving faces.

  • Simultanagnosia – difficulty perceiving more than one object.

    • Dorsal type – can identify an object but can’t locate them in space.

    • Ventral type – can perceive more than one object, but can only identify one at a time.


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Some Memory Systems

  • Working memory – less than 30s, manipulated by executive system.

  • Long-term memory

    • Semantic memory – facts

    • Episodic memory – events

  • Alternative long-term memory classification

    • Declarative memory – consciously describable information

    • Implicit – unconscious skill learning, conditioning etc


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Memory Functions

  • Encoding – perception, selection and transfer of information into memory.

  • Storage – maintenance of information in a retrievable state.

  • Retrieval – reactivating stored information for conscious retrieval or unconscious use during task performance.


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Key Memory Circuits

Hippocampi

HM (1926 – 2008)

Including a circuit with the fornix, mamillary bodies and septal nuclei.


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Key Memory Circuits


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Working Memory Problems

  • Can be caused by damage to visual or auditory storage.

  • But more usually due to executive system damage which affects how well we use these stores.

  • Double dissociation between storage and manipulation of information I working memory (Mintzer and Griffiths, 2007):

    • Lorazepam – manipulation impairment

    • Scopolamine – storage impairment


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Long-term Memory Problems

  • Amnesia for episodic memories:

    • Antereograde – inability to encode new information

    • Retrograde – loss of pre-injury information, most recent memories most likely to be affected.

  • Semantic memory impairments:

    • Semantic dementia – loss of words and meaning.

    • Selective impairments – e.g. living vs non-living things.


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[ Video Segment ]


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Long-term Memory Problems

  • Transient amnesias:

    • Post-traumatic amnesia – correlates with extent of injury

    • Transient global amnesia – sudden, dense amnesia that resolves within hours.

    • Transient epileptic amnesia – similar, shorter duration and associated with clear seizure activity.

    • Psychogenic amnesia – syndrome of ‘hysteria’, often pure retrograde amnesia, and can include loss of identity and wandering (‘fugue state’).


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What is the Executive System?

  • Mainly concerned with the co-ordination of other cognitive resources.

  • e.g. the use of attention, organisation of actions, inhibition of responses, monitoring (metacognition).

  • It is a dynamic, ‘online’ system, that may only fully engage some aspects in real world situations.

  • e.g. Saver and Damasio’s (1991) patient EVR displayed severe day-to-day executive problems but passed standard tests of executive function.


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What is the Executive System?

  • So it is particularly involved in handling new, novel or potentially risky situations.

  • Norman and Shallice (1980) outline five types of situation where routine activation would not be sufficient.


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Norman and Shallice (1980)

  • Those that involve planning or decision making.

  • Those that involve error correction or troubleshooting.

  • Situations where responses are not well-learned or contain novel action sequences.

  • Dangerous or difficult situations.

  • Situations which require the overcoming of strong habitual response or resisting temptation.


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Neuroanatomy

  • Most associated with the prefrontal cortex although there is increasing evidence that parietal interactions are important (Collette et al., 2006)


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Dysexecutive Syndrome

  • Damage can result in:

    • Problems with memory (e.g. working or episodic memory)

    • Problems with affect and social judgment (inappropriateness, emotional lability / blunting, social perception, theory of mind)

    • Problems with abstract thinking and intentions (planning, understanding rules, cognitive flexibility, inhibition)


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[ Video Segment ]


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Attention

  • Typically divided into three main types (Posner and Petersen, 1990):

    • Spatial attention – distinguish and detect sources of information in space

    • Selective or focused attention – focus in / block out certain sources.

    • Arousal / sustained attention – maintain focus


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Neglect

  • Hemi-spatial neglect is one such disorder which particularly occurs after right parietal damage.

Severe neglect

Mild neglect

From Vallar (1993)


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Copied Drawings


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Copied Drawings


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Copied Drawings


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Line Bisection

  • When asked to mark the centre point of a line, patients mark to the right.


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[ Video Segment ]


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Language

  • Language involves:

    • Production (e.g. speaking, writing, syntax, articulation)

    • Comprehension (e.g. reading, listening, syntax)

    • Knowledge (e.g. names, words)


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Wernicke’s area

Broca’s area


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Arcuate fascilulus

From Rodrido et al. (2007)


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Speech Problems

  • A few of the many aphasias:

    • Broca’s aphasia (normal comprehension, non-fluent speech).

    • Wernicke’s aphasia (impaired comprehension, fluent but meaningless)

    • Conduction aphasia (normal comprehension, fluent speech, wrong words and poor repetition)

  • …and many others.


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Reading / Writing Problems

  • Dyslexias and agraphias are broken down into two main types:

    • Peripheral dyslexia – problems with word or letter perception.

    • Central dyslexia – problems with the semantics or syntax of language

    • Peripheral agraphia – problems with motor control.

    • Central agraphia - problems with the semantics or syntax of language

  • …and various combinations.


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