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8 Neuropsychological Testingis only part of the process of interpretation, and that the pattern of performance across several tests isimportant. So me psychologists em pha size the quality of the patients performance or the types oferrors made.In addition to the formal testing, the evaluation o ught to include history taking, either from thepatient, fam ily, physician, and/or records, paying particular attention to background information andany medical history relating to possible neuropsychological risk factors.Th e report should include discussion of the history, a report and discussion o f the patients be-havior during testing, and an assessment of whether the test results are considered valid measures ofthe patients neurocognitive functioning. Most reports also include a test-by-test description of theresults, followed by co nclusion(s), recomm endations, and/or discu ssion of the overall meaning andimplications of the results for the patient.

7. When is it appropriateto refer a patient for a neuropsychologicalscreening rather than acomprehensive evaluation?Many times, psychiatrists and other referrers hope that a screening evaluation will suffice fortheir patients. In som e cases, relatively brief screening (i.e., a 1- to 2-hour battery) can adequ atelyanswer the question and, in some cases, a brief evaluation will be all a patient c an tolerate because ofacute psychiatric sym ptoms.When there are questions regarding an in-patient with acute psychiatric symptoms, limited test-ing m ay be the only feasible alternative. Such testing provides information about the general level ofintellectua l func tionin g or presence of clear d em entia, but it is unlikely to answ er more specificquestions, especially in younger adults in whom relatively subtle neurocognitive deficits may exist.Comp lex questions indicate the need for more co mp rehensive testing, and it may be better to defertesting until the patient is as stable as possible in terms of medication and psychiatric symptoms.Screening may be ap propriate to answer questions about presence or absence of neurocognitivedysfunction . M ore intensive evaluation is necessary if there are specific questions about nature, lo-calization, or the functional implications of deficits.Describing the patient to the neuropsychologist and discussing the issues and questions often isthe best way to determ ine the m ost appropriate battery of tests to be given.8. What are the effects of depressionon neuropsychologicaltesting?The former answer to this question was that patients presenting with depression but without anyorganic dysfunction would show few, if any, deficits on classic neuropsychological batteries oftests such as the Halstead-Reitan. M ore recent studies, however, using newly developed measures ofattention, information p rocessing speed, and learning have show n that depression can cause slowing

of information processing, decreased attention and concentration abilities, and learning inefficiency.Research findings are inconsistent about the ex istence of a high correlation between severity of de-pression and test performance. Groups of severely depressed patients are likely to perform morepoorly than m ildly depressed patients, but these findings are not sufficiently consistent to enable theclinician to predict the degree of cognitive inefficiency by knowing severity of depression.In many case s, deficits in depressed individuals are su btle, but they m ay still affect interpreta-tion of results. For examp le, in a patient w ith a clin ical dep ress ion who has had a mild traumaticbrain injury TBI), it can be very difficult to know whether mild deficits in areas of concentrationandlor learning are caused by the TBI, the depression, or a combination. Frequently, the practical ap-proach to such a case is to treat the depression and then reevaluate the patient fo r any residual neu-rocognitive deficits. Other areas of cognition gen erally are not impaired in depressed p atients(language, problem solving, visual spatial analysis, executive functioning, visual or auditory percep-tion, for example), but, of course, individual patients m ay present as exceptions to the rule.In a few instances, severe depression may render the patient untestable. If the patient has severeagitation or psychomotor retardation, he o r she may not be ab le to comply with test requirementsand fail to put fo rth sufficient effort to yield valid results. In my experience, this s not a common oc-currence, but it does happen. In such instances, neuropsychological evaluation must be postponeduntil the acute d epression imp roves.

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Neuropsychological Testing 99. What are the effects of anxiety on neuropsychologicaltesting?Most people who undergo neuropsychological testing experience some anxiety about theprocess. Part of a good testing procedure involves establishing rapport with the patient and providinga reassuring atmosphere to minimize anxiety. In most situations, this will suffice to allow valid test-

ing. Very little systematic investigation has been done, however, to explore the effects of especiallyhigh levels of anx iety on test performance. Th e few existing stud ies have found little in the way ofspecific effects. Clinically, neuropsychologists rely on behavioral observation of the patient to helpdetermine whether unusual levels of anxiety interfere with the patients effort on the testing.Occasionally, undue anxiety may produce an invalid result (which should, of course, be noted), butin my experience, most patients can control their anxiety sufficiently to produce valid results.Frequently, putting the tests in an order to minimize stress to the patient is enough t o permit the pa-tient to com plete the evaluation. Whether o r not a particular evaluation is valid m ust b e determinedby the neuropsychologist.In some cases, patients with formal anxiety disorders may be referred for neuropsychologicalevaluation. Research into the effects of formal anxiety d isorders is currently at an early stage, and fewdefinite conclusions can be draw n, but the follow ing provides a brief summary of select diagnoses.10. How do specific anxiety disorders affect cognitive functioning?Patients with panic disorder typically h ave been found to fall below norm ative guidelines forimpairment on a few tests, but acro ss studies, cognitive deficits have been inco nsistent. Curren tly,more evidence exists for m emory problems than for other cognitive deficits, suggesting possible in-volvement of the temporal regions of the brain in panic disorder, but additional research is needed toreplicate previous findings.

A few studies have assessed neurocognitive functioning in patients with obsessive compulsivedisorder (OCD). R esults showing impaired mem ory and executive functioning suggest possible bi-lateral frontal and tempo ral involvement, with con siderable disagreemen t from study to study as towhether the left or right hemisphere is more implicated.Post traumatic stress disorder PTSD) is another anxiety disorder that has received attention,mostly in individuals with combat-related PT SD. M ost studies have not included well-matched con-trol groups, but rather have compared patient perform ance to available normative guidelines. Suchstudies have not found large deficits in groups of patients, but have shown that individuals may per-form in the below average to borderline range on some tests of memory and attentional function.Good neuropsychological testing involves administration of the tests in a supportive way tomin imize state anxiety and behavioral observation of the patient to determine wh ether efforts tomin imize anxiety have been successful. In patients w ith panic disorder, O CD , o r PTSD, carefulanalysis of the pattern o f test results can help determ ine: 1 ) whether deficits appear related to theanxiety disorder alone; and 2) the extent to which any cognitive deficits will have an imp act on thepatients everyday life.11. Is neuropsychological testing indicated in schizophrenia? How do patients with schizophrenia perform?Schizoph renia is now thought to be a brain disorder, and m any, but not all, patients show neu-rocognitive impairment. Research on the neuropsychological p rofiles o patients with schizophreniahas revealed considerable h eterogeneity. Some patients perform n ormally on testing, whereas othersare quite diffusely impaired. Comm only, the individual earns mildly impaired scores on a number ofmeasures, but looks somewhat more impaired on verbal learning measures. This more pronouncedverbal learning deficit superimposed upon diffuse mild impairment has now been found in severalstudies evaluating group s of schizophrenic patients, but specific individuals do not always, or evenroutinely, produce this profile. Little evidence exists for a decline in general intellectual functioningfollowing the onset of symptoms, and it is rare fo r schizophrenic patients to have severe impairmentwithout the presence of some coexisting dem entia.Because of the lack of a unique neuropsychological profile in patients with schizophrenia, inter-est has evolved in understanding patterns of deficits in subgroups of schizophrenic patients. Groups

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3 Neuropsychological Testingof paranoid patients generally perform better on neuropsychological testing than groups of non-para-noid patients. Studies of groups of patients with either predominantly positive or negative symptomshave produced similar results, with those patients showing more negative symptoms having muchmore significant impairm ent. Finally, patients with early-onset sch izophrenia show more deficits thanpatients whose symptoms d evelop after adolescence.Neuropsychological test results may be useful in predicting functional outcome in patients withschizophren ia. Walker et al. looked at patients 1.5 years after asse ssment and found that cognitive testscores were more powerful predictors of outcome measures than were ratings of psychiatric symp-toms. Therefore, extent of cognitive impairment may be important in predicting everyday function-ing parameters such as treatment compliance, independent living, and employability.12. What effects do medications have on testing?This is obviously a very complex question, the answer to which depends on what medication ormedications at what dosages. Medica tions that have central nervou s system effects may, in som ecases, affect neuropsychological test results.A few guidelines exist to help determine wh en testing is best done. If a patient has jus t started anew medication and is experiencing tempo rary side effects, it is not a go od time to evaluate the pa-tient. If a patient is toxic o r is approaching a toxic level, perform ance m ay be significantly affected.Examining specific m edications is beyond th e scope of this chapter. However, most studies haveshown that the acute symptoms of the disease are more deleterious for cognitive performance thanthe medications, if the patient is taking an optimal dose. An tidepre ssants have no t been found tocause significant adverse effects on test performance in individuals w ith good clinical response whoare not experiencing acute side effects. Generally speaking, neuroleptics also have not been foun d tocause significant problems on tests of cognitive function; thus, stopping medication in an individualwho is obtaining clinical benefit is not advantageous. Lithium may cause so m e modest decrementsin upper extremity motor performance, but has not been found t o produce changes in neuropsycho-logical test scores that would result in diagnostic or interpretive error.13. What does it mean when neuropsychological testing and the results of neuroimaging disagree?Relationships between neurobehavioral measures an d neuroimaging techniques have changeddramatically over the past 25 years an d likely will continue to, primarily as a result of the evolution ofneuroradiologic technology. Furthermore, as the development of functional imaging advances, moreopportunities w ill become available for understanding brain-behavior relationships. F or exam ple, re-search studies using functional MRI and neuropsychological testing have increased know ledge aboutlocalization of higher cerebral functions in the brain, but such research also has shown how difficult itis to make broad generalizations abou t localization of function for individual patients.Clinical evaluation still emp loys structural imag ing in most cases, and in individual cases, ap-parent discrepancies o r contradictions may exist between neurobehavioral measures a nd neuroimag-ing results. These differences m ay be in either direction (mo re abnormality on imaging than seen inbehavior or vice versa). Reaso ns include:1. Th ere may be long-standing, probably c ong enital, abn orm alities, but the patient has rela-tively normal neurocognitive fun ctioning because the brain organized w ith the abnorm ality alreadyin place.2. The physiological ch anges associated with brain lesions identified by computed tom ographyo r magnetic resonance im aging m ay exceed the boundaries of the structural abnormality.3. Individual differences in functional brain organization are complex and not yet completelyunderstood.

4. Neurobehavioral measures may be incorrectly interpreted, e.g., interpreting errors on sen-sory or motor tests resulting from peripheral nervous system injury as central nervous system im -pairment.5. Chang es at a microscopic level may caus e behavioral cha nge , but may not be visible withcurrent imaging technology.

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Self-Report Questionnaires 3As func tional imaging becomes more com mo n in clinical practice, differences between neu-ropsychological p erformance and neuroimaging m ay diminish. The use of functional imaging al-ready is advancing our kno wledge of brain-behavior relationships.

BIBLlOCRAPHY1. Bigler ED: Frontal lobe damage and neuropsycho logical assessment. A rch Clin Neurop sychol3:279-297,1988,2. Bigler ED , Ye0 RA , Turkheimer E (eds): Neuropsychological Function and Bra in Imaging. New York,Plenum Press, 1989.3 . Grant I, Adams KM (eds): Neuropsychological Assessment of Neuropsychiatric Disorders. New York,Oxford Press, 1996.4. Heinrichs RW, Zakzanis KK : Neurocognitive deficit in schizophrenia: A quantitative review of the evidence .Neuropsychology 12:426-445, 1998.5. Hill CD , Stoudemire A, M orris R, Matino-Saltzman D, M arkwalter HR: Similarit ies and differences inmemory deficits in patients with primary dementia and depression-related cognitive dysfunction.Neuropsychiatry Clin Neurosci 5:277-282, 1993.6 . Lezak M D: Neuropsychological Assessment, 3rd ed. New York, Oxford University Press, 1995.7. Newm an PJ, Sw eet JJ: Depressive disorders. In Puente AE, McCaffrey RJ (eds): Handbook of Neuropsycho-logica l Assessment: A B iopsychosocial Perspective. New York, Plenum Press, 1992.8. Orsillo S M , McCaffrey RJ: Anxiety disorders. In Puente AE , McCaffreyRJ (eds): Handbook of Neuropsy-chological Assessment: A Biopsychosocial Perspective. New York, Plenum P ress, 1992.9. Reitan RM , Wolfson D: Th e Halstead-Reitan Neurop sychological Battery: Theory and Interpretation, 2nded. Tucson, AZ, Neuropsychology Press, 1993.10. Sweet JJ , Newman P, Bell B: S ignificance of depression in clinical neuropsychological assessment. ClinPsycho1 Rev 12 :21 45, 1992.11. Walker E, L ucas M , Lewine R: Schizophrenic disorders. In Pu ente AE , McCaffrey R I (eds): Han dbook ofNeuropsychological Assessment: A Biopsychosocial Perspective. New York, Plenum Press, 1992 .

7. SELF-REPORT QUESTIONNAIRESGarry Welch, Ph.D.

1. What are the potential uses of self-reporting psychiatric and personality tests?There are m any potential clinical an d research uses, although interpretation of scores an d pro-History taking an d form ulating clinical hypothesesScreening and diagnosis of clinical problems and mental disordersDetermining appropriate referral to specialty servicesMon itoring change and response to treatment interventionsConducting research into factors associated with the disordersAuditing and assessing clinical services

files often requires a high level of expertise. These tests are helpful in :

2. What is reliability?Reliability is whethe r the measure provides repeatable or reproducible test scores that accurately re-flect the patients true status and con tain little influence from unimportant extraneous factors. For exam -ple, if a test is supposed to detect current anxiety state, it is reliable if it mostly measures current anxietyand does not take into account other factors-such as the individuals recall of the answers given the lasttime the test was administered-and does not include unclear questions or poorly worded instructions.3. What is the role of reliability in psychiatric and personality tests?Reliability of m easurem ent is imp ortant because it sets an upper limit on the validity, or clini-cal usefulness, that the measure will likely have when ap plied to various individuals an d in various