The Contribution of Neuropsycohology to Psychiatry

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1. The contribution of neuropsychology to psychiatry.......................................................................................... 1

2. Bibliography...................................................................................................................................................... 16

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Keefe, Richard S E...

The American Journal of Psychiatry 152. 1 (Jan 1995): 6-15...

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Neuropsychological test data are applied with increasing frequency in research studies and clinical

practice in psychiatry. This article addresses three popular assumptions about neuropsychological test data and

describes the limitations and contributions of neuropsychological assessment of patients with psychiatric

disorders.

All research articles from major journals in psychiatry and clinical psychology since 1991 that focused on

neuropsychological assessment of psychiatric patients were reviewed. Other journals and earlier studies were

reviewed selectively.

Neuropsychological test data have made significant contributions to the development of hypotheses about

abnormal brain structure and function in patients with psychiatric disorders, yet many findings from

neuropsychological assessments of psychiatric patients are misinterpreted. The extent to which

neuropsychological test data in psychiatric populations can be interpreted to reflect abnormalities in brain

structure and function is frequently exaggerated, as is the ability of neuropsychological measures to serve as

specific cognitive probes in imaging studies of physiological activation. On the other hand, the utility of

neuropsychological test batteries as measures of the patterns of cognitive strength and deficit in individuals with

specific psychiatric disorders is frequently underestimated.

In addition to testing models of regional brain dysfunction in psychiatric disorders, neuropsychological tests can

provide researchers in psychiatry with an improved understanding of the relation between central cognitiveimpairments and symptoms and serve to identify cognitive predictors of course of illness, and they may provide

a method for discriminating among heterogeneous forms of some psychiatric disorders. Clinically,

neuropsychological test data can be used to develop treatment strategies tailored for an individual's specific

cognitive strengths and deficits...

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Neuropsychology is generally understood to be the study of the relation between brain function

and behavior (1). Neuropsychological assessment has traditionally focused on determining specific changes in

mental processes in patients with discrete lesions following normal development. In this manner,

neuropsychology in clinical practice has enabled practitioners to determine the locus of insult or disease as well

as the functional capacities of patients in treatment. Neuroscientists have benefited from human

neuropsychological data, since studies of the relation between brain lesions and specific patterns of functional

deficit have made substantial contributions to understanding the role of specific neuroanatomic regions in

normal mental processes.

There are many applications of neuropsychology in psychiatry, including the identification of brain lesions in

psychiatric patients, the evaluation of cognitive deterioration over time, and the advancement of theories

regarding the neuroanatomic localization of the symptoms of various psychiatric disorders. The purpose of this

article is to discuss the contributions that neuropsychology and neuropsychological assessment can make to

psychiatry. It is based on a review of all research articles from major journals in psychiatry and clinical

psychology since 1991 that focused on neuropsychological assessment of psychiatric patients. Other journals

and earlier studies were reviewed selectively. The article considers the validity of three common assumptions in

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which neuropsychological data are regarded as supportive of hypotheses about the specific regions of

impairment in specific major psychiatric disorders. It also emphasizes underutilized practical applications of

neuropsychological assessment in psychiatry. One of the most important contributions of neuropsychological

assessment is that it makes possible an objective evaluation of behavior in the context of the ability to perform

basic tasks. When applied properly, a battery of neuropsychological tests yields an understanding of the

cognitive and behavioral abilities and weaknesses of an individual or group of individuals. It provides the

clinician or investigator with an objective description of what areas of behavior and cognition are likely to be a

problem for the psychiatric patient and what areas are not. In this manner, neuropsychological data serve as a

window into the everyday mental processes of the psychiatric patient.

ASSUMPTIONS ABOUT NEUROPSYCHOLOGICAL TEST PERFORMANCE DATA

Neuropsychological test performance data have made significant contributions to the development of

hypotheses about abnormalities of brain structure and function in patients with several major psychiatric

disorders, including schizophrenia, major depressive disorder, and Alzheimer's disease. While these

contributions have helped to reshape the focus of investigations into the etiology and pathophysiology of these

disorders, findings in this area have often been either exaggerated or underemphasized, and frequent

erroneous conclusions have been made about neuropsychological assessments. Three of the most common

assumptions are addressed here.

ASSUMPTION 1: Neuropsychological Tests Measure Specific Functions, and Poor Performance on a Single

Test Indicates a Specific Neuropsychological Deficit

A frequent conclusion of research reports in psychiatry and psychology is that performance on a particular

neuropsychological test (or very small number of tests) in a particular group of patients is worse than normal,

indicating impairment in the function that the test measures. This conclusion is drawn even in some of the best

research studies (2-13). Neuropsychological test batteries, when constructed properly, assess a broad range of

functions, including, among others, perception in all sensory modalities, attention, learning and memory, motor

skills, verbal and nonverbal skills, comprehension and expression of language, spatial abilities, laterality,

abstraction, and "executive" functions. There is great overlap among these categories, and many tasks include

redundant features. For example, both abstraction, as measured by the interpretation of proverbs, and verbal

memory require intact verbal comprehension. Almost all individual neuropsychological tests of higher mental

processes, because of their inherent complexity, involve a number of different functions, and poor performance

can be attributed to any variety of functional deficits. Formal neuropsychological test batteries, such as the

Halstead-Reitan (14) and the Luria-Nebraska (15), are designed to measure a broad range of functions with a

fixed set of tests. The Halstead-Reitan is based on a series of tests devised in the late 1940s to discriminate

between patients with frontal lobe lesions and control subjects. The Luria-Nebraska is an attempt to standardize

the assessment procedures used by Luria. These formal batteries are useful in making general conclusionsabout the presence of impairment in individuals without psychiatric disorder, but they are not flexible enough to

allow the investigator to assess the variety of functions that may underlie a performance deficit on a complex

cognitive task.

The level of complexity of some tests of higher mental functions can be seen clearly in a consideration of the

assessment of executive functions with the Wisconsin Card Sorting Test (16), which was originally developed

by Grant and Berg in 1948 and is currently the most extensively used neuropsychological test in psychiatry

research. The standard version of this task in clinical practice (17) requires patients to sort cards by a series of

principles that they must deduce. The cards vary in the shape, color, and number of stimuli printed on them.

There is an arbitrary correct sorting principle that patients must learn through feedback from the tester ("right" or

"wrong" after each sorting trial). The subject demonstrates knowledge of the principle by placing each card

under a set of "key" cards which differ in form, color, and number. The principle changes once the subject has

responded correctly for 10 consecutive trials, indicating that she or he has learned the principle. To perform




normally on the Wisconsin Card Sorting Test, an individual must have normal capacities for at least the

following functions: memory of the goal of the task, auditory attention to the description of the task demand and

to the feedback from the tester, visual attention to the characteristics of the sorting cards and the key cards,

adequate motor skills to allow placement of the cards where the subject intends, learning of the principles to be

acquired, proper abstraction to allow learning of the principles, categorization of the cards, maintenance of the

categorization in "working memory," and executive control of the many cognitive functions at work at the same

time. This list is only partially complete, but it serves to emphasize the complexity of functions involved in the

completion of many neuropsychological tests. Thus, conclusions about any single poor test performance must

include a consideration of the possibility that any of a number of functions may be causing the deficit.

While this reserve should be applied to any neuropsychological evaluation, it is particularly important that it be

applied to the evaluation of patients with psychiatric disorders, since there are many nonspecific reasons that

their performance may suffer. To address the many possibilities that can contribute to poor performance on a

neuropsychological test, consider further the example of using the Wisconsin Card Sorting Test as a measure of

executive functions in patients with schizophrenia. Schizophrenic patients make various types of errors on the

Wisconsin Card Sorting Test (18). One of the key measures of impairment on this test is the number of

perseverative errors committed. These are scored when a subject continues to sort according to a principle

despite feedback indicating that this strategy is incorrect. This measure has been associated with frontal lesions

in studies by Milner (19) and others (20-22), although not in all studies (23). A similarity in the number of

perseverative errors made by patients with frontal lobe damage and patients with schizophrenia has contributed

to the development of the notion that the frontal cortex is dysfunctional in schizophrenia (24, 25). Schizophrenic

patients make more perseverative errors on the Wisconsin Card Sorting Test than comparison subjects,

including patients with affective disorders, and these differences exist even when factors such as premorbid

intelligence and symptom severity are controlled (6). However, there are many mechanisms by which

schizophrenic patients can make perseverative errors on this test, even if they are cooperative and motivated to

perform well. As a result of verbal information-processing or verbal learning deficits, they may never gain a

proper understanding of the purpose of the test. Because of impaired short-term or working memory functions,

they may lose their awareness of the purpose of the test. Impaired auditory attention may lead them to

misunderstand the nature of the feedback they receive. Finally, the symptoms of psychosis may interfere with

their ability to process the feedback. While any of these possible, and not unlikely, situations would lead to a

great number of perseverative errors, none of the errors could be specifically attributable to impairment in

executive functions. Thus, the conclusion that there is a specific deficit can rarely be made on the basis of poor

performance on a single test.

A neuropsychological deficit in a psychiatric patient should be determined through a broad assessment of the

functions described above. Because of the increased likelihood of spurious poor performance on any test or setof tests by a single individual, this is especially important in a clinical evaluation. A clinical finding based on a

single test performance can be useful in generating hypotheses about areas of impairment, but such a finding

requires considerable substantiation from additional measures in the same area of functioning. Hence, one of

the important considerations in the use of standard formal test batteries such as the Halstead-Reitan is that the

clinical investigator should pursue important findings with tests outside of the limited formal battery.

In research studies of a group of patients, the time required to complete a full battery for each subject is

generally prohibitive. Any individual test performance of the patient group, however, should be compared to an

estimate of how the general population performs, as determined in the process of test standardization. (This

comparison can be problematic, however, if the standardization sample is not reflective of the general

population. For example, users of the Heaton manual for the Wisconsin Card Sorting Test [17] may note that

the average number of perseverative errors among "normal" individuals is 12.6, but since this standardization

sample had an IQ of 114--about 1 SD above the mean--and Wisconsin Card Sorting Test performance is




correlated with IQ [17], this standardization sample is not reflective of the general population.) Ideally, patient

and control groups will be shown to differ on a task that is identical to a control task with the exception of one

feature, which is matched between tasks for difficulty, ceiling effects, and floor effects. In an optimal

comparison, the scores in each group should be normally distributed, with perfect performance a rarity. This

prevents results such as spurious between-group differences due to near-perfect performance by patients and

control subjects on an extremely easy control task. A specific deficit identified in comparisons of groups'

performance in this manner has been referred to as a "differential deficit" by Chapman and Chapman (26),

since the difference between the two tests discriminates the performance of the two groups, enabling one to

conclude that a group demonstrates a performance deficit which can be accounted for by a specific feature and

not simply by general dysfunction. For example, a research finding that the performance of patients with major

depression is impaired on a neuropsychological test with a timed motor component is not of interest, because

these patients tend to perform worse than normal subjects on almost all relatively difficult tasks that are timed

(27). This general deficit may be attributable to any number of problems, including, among others, lack of

motivation, lethargy, distraction secondary to intrusive thoughts, and general motor retardation. Furthermore, it

is often not correct to conclude that the "worst" deficit in a battery of tests reflects the most basic or central

cognitive disturbance in a disorder, even if the scores on a series of tests are made statistically comparable to

one another with a "standardized residualized scores" approach (28). It is more likely that the largest differences

between a group with a disorder and a control group will occur on the most difficult tests. With the use of

appropriate statistical procedures, attempts to replicate findings of specific deficits in psychiatric disorders have

often resulted in finding that the disorders are attributable to generalized deficits (29). Control subjects may be

able to summon the energy or motivation to perform well on particularly difficult tests, whereas psychiatric

patients may not have this capacity. One of the more impressive findings in schizophrenia research is that while

schizophrenic patients may demonstrate deficits on verbal recognition tests in comparison with normal control

subjects, their verbal recall deficit is more severe (30, 31). This finding is impressive because the differential

deficit persists even when the tasks are matched for difficulty in such a way that nonschizophrenic control

subjects perform similarly on both tests (32).

Finally, a strategy to match patients and control subjects on a specific measure must consider the impact of the

psychiatric disorder on the variable chosen. For instance, since level of education and socioeconomic status

can be reduced by disorders such as schizophrenia, a strategy to compare the cognitive performance of

schizophrenic patients and control subjects matched on these variables would result in a group of schizophrenic

patients who are likely to have exceeded the level of functioning expected of the average individual with

schizophrenia, and they may thus perform better than the average schizophrenic patient on the test of interest

(26). A better strategy is to match groups on variables not affected by the illness, such as the pronunciation of

irregular words as measured by performance on the National Adult Reading Test (33), which has been foundnot to be compromised by schizophrenia (34) or Alzheimer's disease (35). Another alternative is to match

patient and control groups on the level of education or socioeconomic status of the parents of the patients and

control subjects, as long as the parents are unaffected by the disorder under study (26).

The strategy of administering to patients and control subjects a battery of tests of similar difficulty, some of

which do not differ between groups, makes possible not only a more accurate determination of changes in

mental processes associated with psychiatric disorder but also the identification of preserved functions in the

patient group. Determining normal abilities in individuals with severe psychiatric disorders can be as important

as identifying deficits. While the finding that a patient or group of patients has impairment in a specific area of

neuropsychological function but has other areas of normality may or may not lead to confirmation of a particular

model of deficient mental processes, it certainly provides data about the experience of these patients and about

which mental functions may be failing them and which are preserved.

ASSUMPTION 2: Abnormal Neuropsychological Test Performance Indicates Specific Regional Brain




Dysfunction

Possibly the most prevalent assumption made about neuropsychological test data is that if psychiatric patients'

performance on a specific test is equivalent to the performance of patients with discrete lesions in a specific

region, this suggests the presence of similar neuroanatomic abnormalities in the psychiatric patients. This

assumption is found even in many of the best published papers involving the assessment of neuropsychological

functions in psychiatric patients (2-5, 9-13, 36-40). It is very likely not to be true. Poor performance may be the

result of a broad range of possibilities, including damage to one of several areas, the accumulative effect of mild

deficits in multiple areas, or factors unrelated to specific brain dysfunction.

As I have mentioned, any individual or group of individuals may perform poorly on a neuropsychological test or

series of tests for many different reasons. The more complex the measure, the more likely it is that poor

performance will result from nonspecific factors. The best example of this phenomenon is that psychiatric

patients with reduced motivation will often demonstrate neuropsychological profiles consistent with frontal lobe

disease, since in a battery of standard neuropsychological tests, the most highly complex tasks are generally

chosen as measures of frontal lobe function. Thus, the complexity of functions involved in any single

neuropsychological test almost always prohibits the conclusion, based solely on test performance, that a

specific brain region is impaired.

Even if patients are able to comprehend and maintain the concepts required for task completion and are

motivated to perform well, poor performance on a test is not necessarily related to dysfunction of specific brain

regions. Throughout the history of the study of regional brain function, attempts have been made to isolate

specific functions of specific brain regions, but the success of these mapping efforts has been mixed with

overestimations of the capacities of the map at any given time. In 1861 Broca proposed that the third frontal

convolution of the left hemisphere, area 44, is associated with expressive speech, and damage to this region

results in expressive language deficit. This disturbance, now termed "Broca's aphasia," continues to serve as a

leading indicator of disease or insult in this region. Other findings, such as the laterality of motor perception and

movement and the role of the occipital cortex in vision, have had a tremendous impact on our current

understanding of regional brain function. In addition, data from animal studies suggest that some brain regions

mediate very specific functions. In monkeys, for example, memory of the precise spatial location of visual stimuli

has been found to be subserved by neural pathways leading to specific regions of the prefrontal cortex (41).

However, most recent data support the notion that higher brain functions cannot be isolated to a specific region.

Many important behavioral and cognitive functions are mediated by complex networks of neurons throughout

the brain, and damage to an area does not always result in impairment of the function associated with that

region, possibly due to the plasticity of regional brain function.

Luria (42) described higher mental functions in terms of complex functional systems that "cannot be localized in

narrow zones of the cortex or in isolated cell groups, but must be organized in systems of concertedly workingzones, each of which performs its role in the complex functional system, and which may be located in

completely different and often far distant areas of the brain" (p. 31). Studies of damaged cortical connectivity

(43, 44), including commissurotomy (45), and physiological studies on "neural networks" in human and

nonhuman primates (41, 46-49) have supported Luria's conceptualizations of higher cortical functions. They

suggest that higher cortical functions may be impaired by damage to any aspect of the complex system that

regulates them. These concepts have become particularly relevant for understanding brain dysfunction in

psychiatric patients (50-53), since poor neuropsychological test performance is found in many psychiatric

disorders without established regional brain dysfunction.

Studies of the organization of relations among brain regions in psychiatric patients suggest that identifying the

regional pattern of electrical activity may improve psychiatric diagnosis and treatment (46). An example of the

complexity of the relation between brain structure and neuropsychological function in psychiatric patients can be

seen in the strong positive correlation between hippocampal size and physiological activation of the dorsolateral




prefrontal cortex (but not other regions) during the Wisconsin Card Sorting Test in schizophrenic twins

compared with their normal cotwins (54). Since activation of the dorsolateral prefrontal cortex during this test is

related to task performance (55), it suggests that structural deficits may lead to performance deficits farther

"downstream" in the neural circuitry associated with a complex task. Thus, the complexity of neural networks

associated with a neuropsychological task suggests that damage to any part of the network has the potential to

impair performance on the task.

In considering the relation between neuropsychological deficit and brain impairment in psychiatric patients, it is

also important to consider the ability of the brain to adapt to damage. According to Luria (56), higher mental

functions result from a unified system of components with a complex and plastic, not concrete, structure in

which the initial and final links of the system (the task and the effect) remain constant and unchanged, and the

intermediate links (the means and the performance of the task) may be broadly modified. The functional

capacities of different brain regions are quite flexible in humans and other animals. If one area is damaged, the

functioning of different brain areas is altered to accommodate for the damage, which may lead to greater

adaptive capacities in the individual or greater impairment (57-64). Thus, it seems unwarranted to draw the

conclusion that there is specific regional damage in psychiatric patients on the basis of isolated

neuropsychological deficit.

The effect of insult to the brain may depend heavily on the stage of development at which the insult occurs (65),

which may have important implications for developmental models of psychiatric illness (58, 66). In the early

stages of development, basic functions such as visual perception depend heavily on "lower" areas of the cortex,

but in the later stages of development, the activity starts to depend on a different neural network (67). For

example, a lesion of the lower regions of the visual cortex in early childhood leads to systemic

underdevelopment of the higher regions responsible for the integration of visual concepts. In contrast, a similar

lesion in an adult causes only partial deficiencies of visual analysis and synthesis, leaving the more complex

cognitive functions, formed at an earlier stage, unaffected (42). This developmental model of brain insult and

adaptation may eventually be useful in accounting for psychiatric illnesses with developmental etiologies, since

neural network models of psychiatric disorders propose that a variety of intrinsic and extrinsic factors, even

early emotional experiences, may affect the course of brain development (68).

In sum, the assumption that abnormal neuropsychological test performance indicates specific regional brain

dysfunction is often not true in brain-injured patients with otherwise normal histories; it is even less likely to be

true in the assessment of patients with psychiatric disorders. Most mental processes, especially the higher

cognitive functions relevant to psychiatric disorders, are regulated by complex neural networks that connect

various brain regions. Therefore, deficits on neuropsychological tests may derive not only from nonspecific

factors, such as lack of motivation in psychiatric patients, but from dysfunction in any of the connected brain

regions that form the neural networks that guide higher mental processes, and even in the connectionsthemselves. Increasingly, research on the neuropsychology of psychiatric disorders needs to focus on the

function and dysfunction of these neural networks.

ASSUMPTION 3: "Hypoactivity" During Functional Imaging Procedures With Cognitive Activation Tasks

Suggests Regional Brain Dysfunction

Another frequent assumption about neuropsychological test performance and psychiatric disorders is that less

than normal regional activation during a test, as measured by a variety of functional imaging technologies

including regional cerebral blood flow, single photon emission computed tomography, and positron emission

tomography, is an indication of pathology in that region in the disorder under examination (55, 69-73). This

conclusion is viewed as bolstered by evidence that reduced metabolism is positively correlated with poor

performance on the test used for activation. This assumption, although more subtle than assumption 2

discussed above, can also be erroneous. It is likely that patients who perform poorly on a neuropsychological

test are not processing the task in the same manner as normal subjects who perform well on the task. There are




enormous differences between patient groups and normal subjects in the manner in which they approach tasks,

and these differences are almost certain to result in different patterns of activation that are correlated with

performance, especially since level of difficulty within a single task can greatly affect regional activation (74).

Thus, the correlation between poor performance and reduced activation reported in numerous functional

imaging studies may actually reflect the different approaches of patients and control subjects, possibly due to

differences in task difficulty, rather than reflecting regional brain dysfunction in the patients. Particularly striking

are reports of an absence in patient groups of the lateral asymmetry found in normal subjects. In general,

among groups of normal control subjects with left-hemisphere dominance, verbal tasks are known to activate

left-hemisphere regions in functional imaging studies, while nonverbal visual tasks activate right-hemisphere

regions (75). Schizophrenic patients, who perform worse than normal subjects on both verbal and nonverbal

visual tasks (28, 76, 77), have been reported to have less extreme laterality of physiological activation during

execution of these tasks (73, 78, 79), including the Continuous Performance Test, a test of visual attention (78,

79). It seems most parsimonious to understand these findings in terms of the inability of the patients to

approach the task in the same way as normal subjects who perform well. Specifically, if schizophrenic patients

are not completing a task such as the Continuous Performance Test effectively, or are unable to attend to the

task as well as normal subjects, it is not surprising that the brain regions that are activated during test

performance are more randomly distributed, which would result in a statistical "regression to symmetry," since

random signals would follow a symmetrical activation pattern. One method proposed for dealing with this type of

problem is to teach patients to perform the activation task as well as normal subjects do before collecting

imaging data, or to choose patients who perform as well as normal control subjects (unpublished 1993 paper by

C.D. Frith). While this strategy may result in the selection of an atypical patient group, the findings of these

studies could be compared to those from patients with more typical performance.

Finally, as with studies of brain structure, the reduced activation of a brain region as assessed by physiological

activation studies does not suggest that the underactivated region is impaired, but only that is it not activated

normally. Since there are many components of a neural network that are activated to perform a specific task,

the impairment of any of these components could lead to dysfunction and/or underactivation of the region under

study. Additionally, with functional imaging, the usual method for identifying reduced activation in a group of

patients is through calculation of the differences between activation patterns in two separate conditions. While

this method is useful in identifying mean differences between conditions, and thus in identifying isolated areas

of abnormal activity, it limits the conclusions that can be drawn from the data collected. Identification of specific

abnormal patterns of activation may provide evidence of impaired neural networks associated with specific

psychiatric disorders (73, 80). Statistical path analysis of the physiological activation of multiple areas

corresponding to a putative neural circuit associated with task performance may provide more convincing

support of a physiology-task relationship. This type of analysis can be applied to determine the functioning of this circuit in patients who are believed to have an abnormality.

Another strategy for understanding patterns of regional brain activation in psychiatric patients is to use cognitive

activation tasks that are simple enough so that the neural networks that mediate performance by normal

subjects are understood. For example, data on nonhuman primates suggest that tests of visuospatial working

memory activate neural networks connecting the primary visual centers, parietal cortex, premotor regions, and

dorsolateral prefrontal cortex (41). Preliminary imaging data suggest that this function is regulated by a similar

activation pattern in humans (81). Such a simple cognitive task may prove to be a useful probe for imaging

studies assessing hypotheses of prefrontal dysfunction in psychiatric disorders. Performance data on tests of

visuospatial working memory tasks under laboratory conditions (82) and typical clinical conditions (83) suggest

that schizophrenic patients may have relatively specific deficits in this area of functioning. This type of task may

help to refine models of specific neural network dysfunction in schizophrenia and other psychiatric disorders.

PRACTICAL CONTRIBUTIONS OF NEUROPSYCHOLOGICAL EVALUATION




The greatest contribution of the neuropsychological evaluation of patients with psychiatric disorders may be that

it provides important, objective data about the mental deficiencies that shape our patients' lives. While

neuropsychological tests may serve to inform specific neuropathological models of psychiatric disorders by

comparing the performance of psychiatric patients and patients with brain lesions, this role is likely to be

usurped in the future because of the tremendous advances in imaging technologies (84). However, images of

the structure and regional activation of the brains of our patients will not provide us with information about their

difficulties with their mental processes or about their cognitive strengths that can be used to facilitate their

treatment. The differential pattern of performance on tests of higher mental processes can be used to predict

the course of psychiatric illnesses, reduce the diagnostic heterogeneity within disorders and thus improve

diagnostic classifications, serve as an aid in the development of treatment options, and create individualized

management of patient care. Three practical ways in which neuropsychological data may be used to serve

these ends are described below.

PREDICTORS OF COURSE OF ILLNESS. The identification of specific cognitive deficits in psychiatric

disorders may be a powerful predictor of the course of illness. Naturally, patients of a particular diagnostic group

who also have global cognitive impairment are likely to have worse outcomes than similarly diagnosed patients

who perform normally on neuropsychological tests. In a group of patients assessed in a psychiatric emergency

room, cognitive deficit was the single best predictor of referral for inpatient hospitalization; it was even superior

to the patients' diagnoses (85). In some disorders, such as schizophrenia and Alzheimer's disease, cognitive

deficits as assessed by a battery of neuropsychological tests may predict the onset of illness. It has been

demonstrated that general impairment on tests assessing information, memory, and concentration (86) serves

as a better tool for the prediction of the eventual development of Alzheimer's disease in normal elderly

volunteers than prior head injury, age of the mother when the subject was born, smoking, or family history of

Alzheimer's disease (87). While these studies indicate the value of determining cognitive impairment in general

in psychiatric patients, the identification of specific cognitive deficits may be of even greater value. Patients with

major depression and particularly severe memory deficits may be unable to sustain even simple medication

regimens or may be unable to benefit from previous gains they made in psychotherapy. Schizophrenic patients

with severe learning deficits may never gain the capacity to understand the goals of their treatment and thus

may never be able to function independently. These factors may have a tremendous effect on the ability of

patients to benefit from treatment and may thus lead to a substantially worse outcome. The ability to identify

specific cognitive deficits in patients may allow better prediction of the course of illness, or, if possible, the

identification of treatment strategies to improve the course of illness (88, 89).

TOOLS FOR IMPROVING DIAGNOSTIC CLASSIFICATION. Similar to the phenomenology of many major

psychiatric disorders, the pattern of cognitive deficits among patients in a single diagnostic group is

heterogeneous. Not all schizophrenic patients perform poorly on tests of verbal memory or the Wisconsin CardSorting Test, and not all depressed patients perform poorly on tests of psychomotor speed. Although the

etiologies of the subtypes of different psychiatric disorders have been presumed to differ (90, 91), the success

of attempts to validate these distinctions made on the basis of phenomenology has been limited (92, 93). The

identification of stable patterns of deficit on neuropsychological tests within a disorder may contribute to the

development of hypotheses about the differing etiologies of the disorder (94). A subtypology based on specific

differences in cognitive functions among patients with the same diagnosis is more compelling than a scheme

based on phenomenology, since it suggests that different mechanisms lead to the common end-state of

disorder, while phenomenological distinctions are limited to differences in the appearance of a disorder.

AIDS TO TREATMENT STRATEGIES. There are few empirical data on the relation between

neuropsychological deficit and response to medication, psychotherapy, and treatment setting. However,

baseline cognitive impairment may be an important predictor of eventual response to treatment (95, 96), and

improvement in cognitive abilities during the very early stages of treatment may herald the amelioration of




symptoms weeks later (95). It seems plausible, and worthy of investigation, that the heterogeneity of response

to treatment among patients with psychotic, affective, and anxiety disorders may be related to their pretreatment

level of cognitive functioning, and that treatment regimens which are suited specifically to an individual's pattern

of cognitive deficits and abilities may be more effective.

Because of the centrality of cognitive processes in any psychotherapeutic treatment, this strategy may be

particularly applicable for psychiatric disorders that might benefit from psychotherapy. Historically,

psychotherapeutic treatment of many psychiatric disorders, including most notably schizophrenia, mania, and

anorexia nervosa, has not reflected a consideration of the significance of cognitive deficits. Any attempts to treat

schizophrenia with insight-related or even cognitive therapies that require advanced concept formation, verbal

memory and learning, and normal attentional capacities were clearly not informed by data suggesting that

schizophrenic patients are generally unable to perform these functions normally. A very basic understanding of

the cognitive deficits of a patient can prevent similar future treatment failures. An example of an improved

psychotherapeutic strategy based on data from cognitive studies can be found in the treatment of anorexia

nervosa. Recent cognitive behavioral and family treatment approaches, informed by data suggesting that

patients with severe forms of anorexia nervosa are unable to process emotionally laden and internally derived

mental events, have been far more successful than earlier approaches (97).

Recommendations regarding important environmental factors in psychiatric treatment, such as living

arrangements, work schedules, and partial hospitalization programs, may also benefit from a consideration and

assessment of cognitive deficits. This type of assessment is often performed in an informal manner, such as

observing that a patient does not have sufficient attentional capacity to participate in structured group activity or

to handle independent living circumstances. While these observations can result in improvements in patient

care, a more formalized determination of a patient's profile of neuropsychological strengths and deficits may

provide clinicians and staff members with a clearer picture of which treatments will be maximally beneficial to

their patients. In this manner, neuropsychological assessment can improve the quality of individualized

therapeutic management.

One of the specific benefits of determining a pattern of cognitive strengths and deficits associated with a

psychiatric disorder is that it may shed light for clinicians onto possible strategies of cognitive rehabilitation.

Since the range of possible cognitive deficits in psychiatric patients is broad, it is necessary to make several

determinations about the level of intervention that is most likely to be successful and the goals to be attained.

Baseline neuropsychological assessment may contribute to the development of cognitive rehabilitation

programs by laying out the specific deficits that most require treatment, and indicating whether the focus of

rehabilitation should be at the level of elementary cognitive deficits (such as those in perceptual processes),

moderately complex deficits (such as those in problem solving and verbal memory), or highly complex deficits

(such as those in interpersonal interaction) (98). In addition, since profiles of neuropsychological performancecan make possible a determination of which cognitive functions remain intact, they can point to the areas of

capacity upon which innovative rehabilitation strategies can rely. For example, one of the primary symptoms of

neurological or psychiatric disorders that involve the frontal cortex is impairment in the ability to develop

alternative coping strategies. Thus, these patients need assistance in generating such strategies, which should

be directed by cognitive rehabilitation specialists in such a manner that the utilization of identified cognitive

strengths can be optimized. An even more specific application of neuropsychological assessment to cognitive

rehabilitation programs is tailoring treatment to an individual's particular profile of cognitive deficits (99), which

may eventually be keyed to a patient's phase of illness (98).

CONCLUSIONS

The importance of investigations of the possible neuroanatomic etiology and pathophysiology of major

psychiatric disorders cannot be minimized. Findings generated from research that relate neuropsychological

deficits to neuroanatomic and neurophysiological abnormalities determined by brain imaging procedures are




likely to be a part of these eventual insights into major psychiatric illness. The important findings in this research

are likely to develop from an understanding of the neural networks that underlie specific cognitive functions and

of how this circuitry can be impaired. If properly applied, neuropsychological tests may be useful in specifying

the relation between brain function and cognitive performance in individuals with psychiatric disorders. The

abnormal changes in mental processes suggested by the performance of psychiatric patients on standardized

neuropsychological tests should also be considered as potential tools for improving currently available

treatments, especially with regard to individualizing treatment strategies. Research evidence of abnormal brain

metabolism or structure in groups of patients with a particular psychiatric disorder is a suggestion that

something specific may be wrong with a patient which may be relevant to the patient's psychiatric disorder.

Most importantly, however, cognitive deficits as revealed by impaired performance on neuropsychological tests

are a direct indication that something quite specific and tangible is wrong with the patient, which is very relevant

to the patient's disorder.

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Pergamon Press, 1991..

Psychological tests; Psychiatry; Neurology; Mental disorders;..

Brain -- physiopathology, Cognition Disorders -- diagnosis, Cognition Disorders -- physiopathology,

Cognition Disorders -- psychology, Diagnosis, Differential, Humans, Intelligence Tests,; Mental Disorders --

physiopathology, Mental Disorders -- psychology, Models, Neurological, Mental Disorders -- diagnosis

(principal), Neuropsychological Tests (principal)..

The contribution of neuropsychology to psychiatry..

Keefe, Richard S E..

The American Journal of Psychiatry..




152..

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1995..

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1995..

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