# 04 - 5.4 Clinical Neuropsychology and Intellectual

# 5.4 Clinical Neuropsychology and Intellectual Assessment of Adults

5.4 Clinical Neuropsychology and Intellectual Assessment
of Adults
Clinical neuropsychology is a specialty in psychology that examines the relationship
between behavior and brain functioning in the realms of cognitive, motor, sensory, and
emotional functioning. The clinical neuropsychologist integrates the medical and
psychosocial history with the reported complaints and the pattern of performance on
neuropsychological procedures in order to determine whether results are consistent with
a particular area of brain damage or a particular diagnosis.
NEUROANATOMICAL CORRELATES
The early history of neuropsychology was driven in large part by the goal of linking
behavioral deficits to specific neuroanatomical areas of dysfunction or damage.
Although this early assessment method helped to validate neuropsychological tests that
are commonly used today, the localizing function of neuropsychological assessment is
now considered less important in light of recent advances in neuroimaging techniques.
Increasing knowledge in the neurosciences has also led to a more sophisticated view of
brain–behavior relationships, in which complex cognitive, perceptual, and motor
activities are controlled by neural circuits rather than single structures within the brain.
An understanding of these brain–behavior relationships is particularly helpful when
evaluating 
patients 
with 
focal 
damage. 
It 
is 
crucial 
to 
ensure 
that 
the
neuropsychological evaluation adequately assesses relevant behavior that is likely to be
associated with that area and its interconnecting pathways.
Hemispheric Dominance and Intrahemispheric Localization
Many functions are mediated by both the right and left hemispheres. However,
important qualitative differences between the two hemispheres can be demonstrated in
the presence of lateralized brain injury. Various cognitive skills that have been linked to
the left or right hemisphere in right-handed individuals are listed in Table 5.4-1.
Although language is the most obvious function that is largely controlled by the left
hemisphere, especially among right-handed individuals, the left hemisphere is also
generally considered to be dominant for limb praxis (i.e., performing complex
movements, such as brushing teeth, to command, or imitation), and it has been
associated with the cluster of deficits identified as Gerstmann syndrome (i.e., finger
agnosia, dyscalculia, dysgraphia, and right–left disorientation). In contrast, the right
hemisphere is thought to play a more important role in controlling visuospatial abilities
and hemispatial attention, which are associated with the clinical presentations of
constructional apraxia and neglect, respectively.
Table 5.4-1

Selected Neuropsychological Deficits Associated with Left or Right Hemisphere
Damage
Although lateralized deficits such as these are typically characterized in terms of
damage to the right or left hemisphere, it is important to keep in mind that the patient’s
performance can also be characterized in terms of preserved brain functions. In other
words, it is the remaining intact brain tissue that drives many behavioral responses
following injury to the brain and not only the absence of critical brain tissue.
Language Disorders.
 Appreciation for the special role of the left hemisphere in
the control of language functions in most right-handed individuals has been validated in
many studies. These include the results of sodium amytal testing in epilepsy surgery
patients, as well as the incidence of aphasia following unilateral stroke to the left versus
right hemisphere. Although it is rare for right-handed individuals to be right hemisphere
dominant for language, it does occur in about 1 percent of the cases. Hemispheric
dominance for language in left-handed individuals is less predictable. About two-thirds
of left-handed individuals are actually left hemisphere dominant for language, while
about 20 percent each are right hemisphere dominant or bilaterally dominant.
A number of classification systems have been developed over the years for describing
various patterns of language breakdown. A common method takes into account the
presence or absence of three key features: (1) fluency, (2) comprehension, and (3)
repetition (i.e., intact ability to repeat verbally presented words or phrases).
BROCA’S APHASIA. Broca’s aphasia (also called nonfluent or expressive aphasia) has
traditionally been characterized by nonfluent speech but intact auditory comprehension
and somewhat impaired repetition. It has long been thought to be associated with
damage to Broca’s area (i.e., left inferior frontal convolution) or Brodmann area 44
(Fig. 5.4-1). However, more recent neuroimaging data in stroke patients have shown
that the full syndrome of Broca’s aphasia, including agrammatism (telegraphic speech), is
found only in the presence of more extensive damage, which encompasses the
suprasylvian area from Broca’s area to the posterior extent of the sylvian fissure.

FIGURE 5.4-1
Brodmann’s areas of the human cortex, showing convex surface (top) and medial surface
(bottom). (From Elliott HC. Textbook of Neuroanatomy. Philadelphia: Lippincott; 1969,
with permission.)
WERNICKE’S APHASIA. Wernicke’s aphasia (also called fluent or receptive aphasia) is
characterized by fluent speech, impaired comprehension, and somewhat impaired
repetition. It has been associated with damage to Wernicke’s area in the region of the
superior temporal gyrus. The impaired ability to comprehend language directly affects
the individual’s ability to self-monitor language output and may be related to a
breakdown of the syntactic structure of language. Unlike patients with Broca’s aphasia,
who are usually painfully and obviously aware of their communication difficulty,
patients with Wernicke’s aphasia are typically not aware of their communication
problems, because Wernicke’s area is critical for comprehending their own speech as

well as the language of others. This lack of insight is similar to the condition of
anosognosia, in which patients fail to appreciate their own deficits, and presents a
particularly frustrating condition for many family members and caregivers.
CONDUCTION APHASIA. Patients with conduction aphasia demonstrate relatively intact
auditory comprehension and spontaneous speech, due to the preservation of Wernicke’s
and Broca’s areas. However, the ability to repeat words and phrases is specifically
impaired and has traditionally been attributed to damage to the arcuate fasciculus,
which interconnects Wernicke’s and Broca’s areas. This type of aphasia is much more
subtle and tends to have less negative impact on daily functioning.
GLOBAL APHASIA. Another common classification, global aphasia, is characterized by
impairment in all three dimensions of fluency, comprehension, and repetition due to
damage to the core language areas on the lateral surface of the left hemisphere. In
reality many aphasic patients cannot be neatly classified within a specific system
because the pattern of deficits does not exactly fit clear descriptive categories. In fact,
detailed language assessment of most aphasic patients typically demonstrates deficits in
all three areas, although the degree of deficit among the three areas varies.
Limb Apraxia.
 Limb apraxia and other cognitive-motor skills deficits are more
commonly seen with left than with right hemisphere damage. However, Kathleen
Haaland and Deborah Harrington reviewed data showing that the difference in the
incidence of limb apraxia after left or right hemisphere damage is not as great as with
language, suggesting that left hemisphere dominance for disorders of complex
movement is not as strong as that for language. Although limb apraxia has not
traditionally been considered to be of substantial functional importance, recent data
reviewed by Leslie Rothi and Kenneth Heilman also suggest that limb apraxia
significantly affects rehabilitation outcome. Conceptual apraxia might result in using the
wrong object to perform a movement, such as attempting to use a toothbrush to eat.
Finally, sequencing errors and ideational errors can lead to disrupted activities, such as
trying to light a candle before striking the match.
Arithmetic.
 Arithmetic skills can be impaired after either left or right hemisphere
damage. Left hemisphere damage, especially of the parietal lobe, produces difficulty in
reading and appreciating the symbolic meaning of numbers (number dyslexia). Left
hemisphere damage also can be associated with impaired conceptual understanding of
the arithmetic problem (anarithmetria). In contrast, the deficits in arithmetic
computation that can accompany right hemisphere damage are more likely to be
observed in written problems. These emerge as problems with the spatial aspects of
arithmetic, such as errors resulting from hemispatial visual neglect, poor alignment of
columns, or visual misperceptions and rotations that can result in confusion of signs for
addition and multiplication.
Spatial Disorders.
 Right hemisphere damage in right-handed individuals is

frequently associated with deficits in visuospatial skills. Common assessment techniques
include drawings and constructional or spatial assembly tasks.
VISUOSPATIAL IMPAIRMENT. Distinctive qualitative errors in constructing block designs and
in drawing a complex geometric configuration (e.g., Rey-Osterrieth Complex Figure test)
can be seen with either right or left hemisphere damage. In the presence of lateralized
damage to the right hemisphere, impaired performance often reflects the patient’s
inability to appreciate the “Gestalt” or global features of a design. In the example
shown in Figure 5.4-2, this is seen in the patient’s failure to maintain the 2 × 2 matrix
of blocks and instead converting this matrix into a column of four blocks. In contrast,
damage to the left hemisphere commonly results in inaccurate reproduction of internal
details of the design, including improper orientation of individual blocks, but the 2 × 2
matrix (i.e., the Gestalt) is more likely to be preserved. Many neuropsychologists
emphasize that a neuropsychological understanding of the impairment depends not just
on a set of test scores but also on a qualitative description of the type of error. This
often allows the impairment to be linked to a specific neuroanatomical region as well as
enabling a better understanding of the mechanisms of the deficit for rehabilitation
purposes. This qualitative focus on the type of error is similar to the pathognomonic
approach that is often used by behavioral neurologists.
FIGURE 5.4-2
Examples of block design construction seen in a right hemisphere stroke patient and a
left hemisphere stroke patient. (From Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams &
Wilkins; 2009, with permission.)
In another example, damage to the right hemisphere tends to be associated with decreased appreciation of global
features of visual stimuli, while left hemisphere damage tends to be associated with decreased analysis of local features and
detail. This notion is illustrated in Figure 5.4-3, where a patient with left hemisphere damage focuses on the larger Gestalt
of the triangle or letter M with no regard for the internal characters that actually make up the designs. In contrast, the
“local” approach of a patient with right hemisphere damage emphasizes the internal details (small rectangles or letter Z)

without appreciation of the Gestalt that is formed by the internal details. This example also illustrates the important point
that behavioral responses (including errors) are driven as much by preserved regions of intact brain functioning as by the
loss of other regions of brain functioning.
FIGURE 5.4-3
Global local target stimuli with drawings from memory by a patient with right
hemisphere cerebrovascular accident (CVA) and by a patient with left hemisphere CVA.
(From Robertson LC, Lamb MR. Neuropsychological contributions to theories of
part/whole organization. Cognit Psychol. 1991;23:325, with permission from Elsevier
Science.)
NEGLECT. Neglect syndromes are characterized by failure to detect visual or tactile
stimuli or to move the limb in the contralateral hemispace. They are most commonly
associated with right hemisphere damage in the parietal region, but damage to other
areas within the cerebral cortex and subcortical areas can also produce this problem.
Although neglect syndromes have a similar incidence and may co-occur with visual field
cuts or somatosensory deficits, the neglect syndrome is distinct and not explained by
any motor or sensory problems that may be present. Visual neglect can be assessed with
line cancellation and line bisection tasks, in which the paper is placed at the patient’s
midline, and the patient is asked to either cross out all of the lines on the page or to
bisect the single line presented. The method of double simultaneous stimulation or visual
extinction is another standard procedure for demonstrating the deficit. Neglect
syndromes can have devastating functional effects on safety and the ability to live
independently and should be taken into account as a standard consideration in the
evaluation process.
DRESSING APRAXIA. The syndrome of dressing apraxia tends to arise in association with
spatial deficits following right hemisphere damage. The resulting difficulty in

coordinating the spatial and tactual demands of dressing can be seen in the patient’s
difficulty in identifying the top or bottom of a garment, as well as right–left confusion
in inserting his or her limbs into the garment. As a result, dressing time can be painfully
protracted, and the patient may actually present with a greater level of functional
dependence than might otherwise be expected from assessment of simple motor or
spatial skills alone.
Memory Disorders.
 Memory complaints constitute the most common referral to
neuropsychology. Thorough neuropsychological examination of memory considers the
modality (e.g., verbal vs. spatial) in which the material is presented, as well as
presentation formats that systematically assess different aspects of the informationprocessing and storage system that forms the basis for memory. Accumulated research
indicates that specialized processing of verbal and spatial memory material tends to be
differentially mediated by the left and right hemispheres, respectively. In addition to
interhemispheric differences in functional localization, specific memory problems can be
associated with breakdown at any stage in the information-processing model of
memory. These stages include (1) registration of the material through attention, (2)
initial processing and encoding of the material within short-term memory, also known as
working memory, (3) consolidation and storage of material in long-term memory, and (4)
retrieval processes, in which material moves from long-term memory storage back into
consciousness. A great advantage of neuropsychological assessment is that these various
types of memory problems can be readily isolated and described in the course of the
examination procedures. Once identified, the specific nature of the deficit can then have
important implications for diagnosis, treatment, and prognosis.
ENCODING. The initial encoding of new material can be influenced by a variety of
factors, including deficits in attention, language, and spatial processing abilities. It is
usually measured by immediate recall of newly learned information (e.g., narrative
stories or designs) or by demonstrating the ability to learn new material that has been
presented across multiple “learning trials” (e.g., word lists). Attention itself is a
relatively fragile cognitive function that can be affected by many factors, including
neurologically based disorders (e.g., head injury or acute confusional state) and
psychiatric disorders (e.g., depression or anxiety), so it is a crucial aspect of a proper
assessment of memory.
STORAGE AND RETRIEVAL. Deficits in recall can be associated with impaired storage of
information, or it can be due to impaired retrieval, in which case the material is still
present but not readily accessible. The best way of differentiating these problems is to
examine recognition memory, in which a patient is typically asked to choose from a set of
multiple-choice alternatives or to discriminate target words from false-positive foils. If the
patient demonstrates accurate recognition but poor recall, then the problem most likely
lies in poor retrieval. However, if recognition is impaired, then the problem is more
likely to be related to impaired storage of new information. This distinction is important
because the functions of retrieval and storage are subserved by different

neuroanatomical structures. Impaired storage is more often associated with dysfunction
of the medial temporal lobe–diencephalic systems, whereas impaired retrieval can be
associated with a variety of structures, including the frontal lobes.
Executive Function.
 The prefrontal lobes and their interconnections to the rest of
the brain are known to play an important role in executive functions, which are essential
in planning and organizing, self-monitoring, and controlling complex problem-solving
responses. Damage to the frontal lobes also has been associated with significant
personality changes. This was historically exemplified by the famous 19th-century case
of Phineas Gage, who became irresponsible, socially inappropriate, and unable to carry
out plans after a tamping iron was blown through his frontal lobes. As conceptualized
by Muriel Lezak, the executive functions include volition (i.e., formulation of a goal,
motivation to achieve the goal, and awareness of one’s own ability to achieve the goal),
planning, purposive action (response selection and initiation, maintenance, switching,
and stopping), and execution, which involves self-monitoring and self-correction as well
as control of the spatiotemporal aspects of the response. Hemispheric differences in the
control of executive functions by the frontal lobes have not been as well documented as
in the parietal and temporal lobes.
Motor Skills.
 The neuropsychological evaluation commonly includes formal tests of
motor skills, such as measures of finger tapping speed, grip strength, and fine motor
dexterity. These tests, which have demonstrated validity and reliability, are useful for
assessing lateralized motor impairment and have implications for functioning in daily
life as well as vocational planning.
GENERAL REFERRAL ISSUES
Referents turn to neuropsychology for many reasons that include differential diagnosis,
baseline measurement, and treatment planning, as well as opinions regarding causality
and decisional capacity. Because many referents have limited experience and knowledge
of the scope of neuropsychology, it is both reasonable and important for the
neuropsychologist to take an active role in refining the specific questions that are asked
and providing realistic information about the limitations of the consultation.
Level of Functioning
A common referral issue involves documentation of level of functioning for a variety of
purposes, including assessment of change or capacity to make decisions, especially in
the presence of diagnoses such as dementia, stroke, and head injury.
Differential Diagnosis
Like any other diagnostic procedure, the results of a neuropsychological examination
must be interpreted in light of all available information, including the history and any

associated medical factors that are documented or reported for the individual. Many
neurological and psychiatric disorders have similar clusters of symptoms in common,
with complaints of concentration or memory problems being among the most frequently
reported problems.
Age- or Stress-Related Cognitive Change.
 Many middle-aged and older adults
have concerns about everyday concentration and memory failures, and with heightened
public awareness about conditions such as Alzheimer’s disease, an increasing number of
these individuals seek evaluations for these concerns. Neuropsychological testing
provides a detailed, objective picture of different aspects of memory and attention,
which can be helpful in reassuring healthy persons about their abilities. It also provides
an opportunity for assessing undetected mood or anxiety disorders that may be reflected
in cognitive concerns and for offering suggestions about mnemonic strategies that can
sharpen everyday function.
A 77-year-old, left-handed man with a high school education was referred for
neuropsychological assessment by his primary care physician after the patient
mentioned a recent episode of getting turned around while driving. Results of
neuropsychological assessment indicated variable performance on tests of attention
and concentration. His performance was excellent on tests of memory, language, and
executive problem-solving abilities, but visual-spatial and constructional abilities were
moderately impaired.
Mild Traumatic Brain Injury.
 Traumatic brain injury (TBI) is usually classified
as mild, moderate, or severe. However, the vast majority of TBI cases referred for
neuropsychological consultation involve mild TBI. A significant proportion of persons
who have suffered a mild TBI complain of problems with attention and inefficient
information processing, memory, and mood, in addition to headache or other forms of
pain, for many months after the injury. Neuropsychological testing plays a crucial role
in determining the extent of objective cognitive deficit and examining the possible role
of psychological factors in perpetuating cognitive problems.
The neuropsychologist should bear in mind that many patients with mild TBI are
involved in litigation, which can complicate the neuropsychologist’s ability to identify
the causes for impairment. Although outright malingering is probably relatively
infrequent, subtle presentations of chronic illness behavior should be a prominent
consideration when potential legal settlements or disability benefits are in question.
This is a particularly important factor in the case of mild head injury, when subjective
complaints may be disproportionate to the objectively reported circumstances of the
injury, especially because most follow-up studies of mild head injury indicate return to
neuropsychological baseline with no objective evidence of significant cognitive sequelae
after 3 to 12 months following injury.

Poststroke Syndromes.
 After the acute phase of recovery from stroke, patients
may be left with residual deficits, which can affect memory, language, sensory/motor
skills, reasoning, or mood. Neuropsychological testing can help to identify areas of
strength, which can be used in planning additional rehabilitation and can provide
feedback on the functional implications of residual deficits for work or complex
activities of daily living. Assessment of functional skills can also be helpful to a
psychiatrist who is managing mood and behavioral symptoms or dealing with family
caregivers.
Detecting Early Dementia.
 Conditions that particularly warrant
neuropsychological assessment for early detection and potential treatment include HIVrelated cognitive deficits and normal pressure hydrocephalus. When concerns about a
person’s memory functioning are expressed by relatives instead of the patient, there is a
higher probability of a neurological basis for the functional problems.
Neuropsychological testing, combined with a good clinical history and other medical
screening tests, can be highly effective in distinguishing early dementia from the mild
changes in memory and executive functioning that can be seen with normal aging.
Neuropsychological evaluation is particularly helpful in documenting cognitive
deterioration and differentiating among different forms of dementia. An additional
incentive for early diagnosis of dementia now lies in the fact that a portion of patients
with early dementia may be candidates for memory-enhancing therapies (e.g.,
acetylcholinesterase inhibitors), and testing can provide an objective means of
monitoring treatment efficacy.
Distinguishing Dementia and Depression.
 A substantial minority of patients
with severe depression exhibit serious generalized impairment of cognitive functioning.
In addition to problems with attention and slowing of thought and action, there may be
significant forgetfulness and problems with reasoning. By examining the pattern of
cognitive impairment, neuropsychological testing can help to identify a dementia
syndrome that is associated with depression, usually known as pseudodementia. Mixed
presentations are also common, in which symptoms of depression coexist with various
forms of cognitive decline and exacerbate the effects of cognitive dysfunction beyond
what would be expected from the neurological impairment alone. Neuropsychological
testing in this case can be very helpful by providing a baseline for measuring the effect
of antidepressant or other therapy in alleviating cognitive and mood symptoms.
A 75-year-old man with a Ph.D. in the social sciences sought neuropsychological reexamination for ongoing memory complaints, stating that “several of my friends have
Alzheimer’s.” In an initial examination 1 year prior, he had performed in the expect
range (above average) for most procedures, despite variable performance on
measures of attention and concentration. Results of the follow-up examination again
clustered in the expected above average range with variable performance on

measures of attention. On list learning tests of memory, his initial learning of a word
list was lower than expected, but delayed retention of the material was above
average, with excellent discrimination of target items on a recognition subtest. He
also endorsed a large number of symptoms of depression on a self-report inventory.
Change in Functioning Over Time
Because many neurological diagnoses carry clear expectations regarding normal rates of
recovery and decline over time, it is frequently important to re-examine a given patient
with follow-up neuropsychological assessment after 6 months to a year. For example, it
might be important to monitor declines in independent functioning that could be
associated with a progressive dementia or to identify improvement following a stroke or
tumor resection. Follow-up examinations also provide an opportunity to objectively
examine complaints of long-standing or worsening cognitive sequelae following mild
head trauma, even though the current literature indicates that the greatest proportion of
recovery of function is likely to occur over the initial 6 months to 1 year postinjury.
Although continuing subtle signs of recovery can continue after that period, failure to
improve following the injury—or worsening of complaints—would suggest the
possibility of contributing psychological factors or the existence of a preexisting or
coexisting condition, such as substance abuse, dementia, or outright malingering.
Assessment of Decision-Making Capacity
Neuropsychologists are often asked to assist in determining an individual’s capacity to
make decisions or to manage personal affairs. Neuropsychological testing can be useful
in these cases by documenting areas of significant impairment and by identifying areas
of strength and well-preserved skills. Opinions about decision-making capacity are
seldom based on test findings alone and usually rely heavily on information gleaned
from clinical interview, collateral interviews with family or caregivers, and direct
observations (e.g., in-home assessment) of everyday function. In fact, appraisal of an
individual’s level of insight and capacity to appreciate his or her own limitations is
typically the single most important aspect of the assessment. Standards for decisionmaking capacity are generally defined by state statutes, and, of course, the ultimate
determination of competence rests in the authority of the presiding judge. However, the
neuropsychologist or other health care professional can play a significant role in
shaping the judge’s ruling by providing a professional opinion that is supported by
compelling behavioral data that have strong face validity. As a general rule of thumb,
consideration of decision-making capacity is usually best approached in the narrowest
possible sense so as to infringe as little as possible on the individual’s freedom to
represent his or her own interests. Therefore, consultation requests for assessment of
decision-making capacity should identify specific areas of decision making and behavior
that are of concern. Frequent concerns having to do with decision-making capacity
involve the areas of (1) financial and legal matters, (2) health care and medical

treatment, and (3) ability to live independently. Some capacity issues involve higher
standards, such as ability to drive, ability to work, or practice in a given profession
(e.g., air traffic controller, surgeon, or financial advisor). In such cases, it is particularly
important for the neuropsychologist to rely on normative expectations that are
appropriate for the type of activity, as well as the patient’s demographics.
Forensic Evaluation
Neuropsychological evaluation of individuals in matters pertaining to criminal or civil
law usually requires specialized knowledge beyond expertise in neuropsychology.
Neuropsychologists are frequently called upon as experts in matters involving head
injury, especially in the case of mild head injury associated with a motor vehicle
accident. As a distinct subspecialty, this area of practice requires integration of
knowledge of statutes, laws, precedents, and legal procedures as well as expertise in
identifying and describing the impact of an injury or event on cognitive, emotional, and
behavioral functioning.
APPROACHES TO NEUROPSYCHOLOGICAL ASSESSMENT
The neuropsychological examination systematically assesses functioning in the realms of
attention and concentration, memory, language, spatial skills, sensory and motor
abilities, as well as executive functioning and emotional status. Because deficits in
cognitive performance can only be interpreted in comparison to a person’s longstanding or premorbid level of functioning, overall intellectual abilities are typically
examined in order to measure the current level of overall functioning and to identify
any changes in intellectual functioning. Psychological contributions to performance are
also considered with regard to personality and coping style, emotional lability, presence
of thought disorder, developmental history, and significant past or current stressors. The
expertise of the neuropsychologist lies in integrating findings that are obtained from
many diverse sources, including the history, clinical presentation, and several dozen
discrete performance scores that make up the neuropsychological data.
Battery Approach
The battery approach, exemplified by the Halstead-Reitan Neuropsychological Test
Battery (HRNTB) or the Neuropsychological Assessment Battery (NAB), grew directly out
of the psychometric tradition in psychology. This approach typically includes a large
variety of tests that measure most cognitive domains as well as sensory and motor skills.
Traditionally, all parts of the test battery are administered regardless of the patient’s
presenting problem, although the NAB has a screening exam that covers all appropriate
domains. The battery approach has the advantage of identifying problems that the
patient might not have mentioned and that the medical history may not necessarily
predict. However, it has the disadvantage of being very time-consuming (i.e., 6- to 8hour examination for the HRNTB).

Hypothesis Testing Approach
The qualitative hypothesis testing approach is historically best exemplified by the work
of Alexander Luria and more recently developed as the Boston Process Approach by
Edith Kaplan and her colleagues. It is characterized by detailed evaluation of areas of
functioning that are related to the patient’s complaints and predicted areas of
impairment, with relatively less emphasis on aspects of functioning that are less likely
to be impaired. The hypothesis testing approach has been particularly helpful in
illuminating the differential roles of the two hemispheres, as discussed above. This
approach has the advantage of efficiently honing in on areas of impairment and
producing a detailed description of the deficits from a cognitive processing standpoint,
but it has the shortcoming of potentially overlooking unexpected areas of deficits.
Screening Approaches
Many practitioners have moved away from strict battery or hypothesis testing
approaches since the 1990s and developed more flexible and efficient screening
approaches. In this model, the neuropsychologist utilizes a core set of screening
procedures as a first step in determining whether a diagnosis can be made with less
information or whether additional testing is necessary in order to identify more subtle
problems. Therefore, a screening protocol that efficiently assesses the major areas of
neuropsychological functioning may or may not be followed by more detailed testing in
selected areas that might provide better understanding of the reasons for the deficits
demonstrated on the screening evaluation.
Mental Status Examinations
In some cases, usually involving very acute or severe cognitive impairment, it is simply
not feasible to administer extensive cognitive examination procedures, so the
neuropsychologist might appropriately rely on bedside mental status examination or
very brief cognitive screening procedures to address the referral issues. However,
research has shown that, even with brief screening procedures, the systematic use of a
structured examination format can greatly increase the accuracy of detecting cognitive
impairment.
One of the most widely used screening instruments for documenting gross changes in mental status is the Mini-Mental
State Examination (MMSE). However, it is important to note that the MMSE does have distinct limitations. Other than
serial seven counting, the MMSE does not really assess executive functions, which are often impaired in dementing
patients. In addition, the MMSE is likely to underestimate the prevalence of cognitive deficits in well-educated older
persons with early Alzheimer’s disease or in younger adults with focal brain injury, but it is more likely to overestimate
the presence of cognitive deficits in persons with little education. Therefore, cutoff scores should be adjusted for age and
education before concluding that impairment is present. Although mental status examinations can be very useful in
screening for gross signs of cognitive impairment, they do not provide a sufficient foundation for diagnosing specific
etiologies of cognitive impairment, and they are not interchangeable with neuropsychological testing.

DOMAINS OF FORMAL NEUROPSYCHOLOGICAL ASSESSMENT
The past decade has seen a virtual explosion in the growth of more sophisticated and
better standardized tests and procedures for neuropsychological evaluation. A list of
examples of common neuropsychological tests and techniques is provided in Table 5.4-2.
Table 5.4-2
Selected Tests of Neuropsychological Functioning

Interview
The clinical interview provides the single best opportunity for identifying the patient’s
concerns and questions, eliciting a direct description of current complaints from the
patient, and understanding the context of the patient’s history and current
circumstances. Although the patient typically serves as the primary interview source, it
is important to seek corroborating information for the patient’s account from interviews
with caregivers or family members as well as thorough review of relevant records, such
as medical and mental health treatment, educational, and employment experiences.
Intellectual Functioning
Assessment 
of 
intellectual 
functioning 
serves 
as 
the 
cornerstone 
of 
the
neuropsychological examination. The Wechsler Intelligence Scales have represented the

traditional gold standard in intellectual assessment for many years, based on carefully
developed normative standards. The scope and variety of subtests on which the
summary IQ values are based also provide useful benchmarks against which to compare
performance on other tests of specific abilities. The latest revision of this instrument, the
Wechsler Adult Intelligence Scale III (WAIS-III), offers the additional advantage of
greatly extended age norms (ages 16 to 89) that are directly related to normative
performances on the Wechsler Memory Scale III (WMS-III). The Wechsler Intelligence
Scales utilize a broad set of complex verbal and visuospatial tasks that have
traditionally been summarized as a verbal IQ, a performance IQ, and full-scale IQ. In
the context of a neuropsychological examination, the patient’s performance across the
procedures provides useful information regarding long-standing abilities as well as
current functioning. Most neuropsychologists recognize that the summary IQ values
provide only a ballpark range for characterizing an individual’s general level of
functioning. Therefore, it is usually more appropriate and meaningful to characterize an
individual’s intellectual functioning in terms of the range of functioning (e.g.,
borderline, low average, average, high average, or superior) that is represented by the
IQ value rather than the specific value itself.
Careful examination of the individual’s performance across the various verbal and
performance subtests can provide information regarding the patient’s pattern of
strengths and weaknesses as well as the degree to which these performance
characteristics are consistent with the history and performance on other aspects of the
neuropsychological examination. Tests of long-standing knowledge, such as for
vocabulary or general information, provide a basis for estimating an individual’s longstanding (or premorbid) level of intellectual abilities, which in turn can help to gauge
the degree to which an individual may have deteriorated.
The verbal IQ and performance IQ (VIQ and PIQ) have historically been reported to
be associated with left and right hemisphere functioning, respectively. However, more
recent research indicates that, in addition to language and spatial skills, the subtests of
the Wechsler Intelligence Scales reflect other contributions such as speed, sustained
concentration, and novel experience. Therefore, experienced neuropsychologists do not
simply assume that a discrepancy between VIQ and PIQ is due to unilateral hemispheric
damage. Important clues to the nature of the contributing problem can often be gleaned
by considering the pattern of performance across other aspects of the examination and
by carefully analyzing the types of errors that are observed.
Attention
Attention underlies performance in virtually all other areas of functioning and should
always be considered a potential contributor to impairment on any tests that require
sustained concentration and vigilance or rapid integration of new information.
Measures of attention and concentration have traditionally been included in the
Wechsler Intelligence and Wechsler Memory Scales in order to assess orientation and
“freedom from distractibility.” These procedures also provide a useful basis for

“previewing” the individual’s ability to comprehend, process information, and otherwise
engage in the assessment process. Digit span requires patients to repeat increasingly
longer strings of digits as a way of assessing ability to process relatively simple
information, while digit span backward reflects more complex simultaneous processing
and cognitive manipulation demands or working memory.
Memory
Complaints of memory problems constitute one of the most common reasons for referral
to neuropsychology. As described above, the neuropsychologist utilizes an informationprocessing approach to assess memory problems that might involve difficulty with
encoding, retrieval, or storage of new information. The WMS-III is the latest revision of
a widely used battery of subtests that utilizes several measures of attention, memory,
and new learning ability.
Language
Assessment of language examines both expressive abilities and comprehension.
However, most neuropsychologists screen for language impairment rather than
administer an extensive formal language assessment battery, such as the Boston
Diagnostic Aphasia Examination. Expressive language is commonly assessed by
measures of verbal fluency, which require the patient to rapidly generate words within
semantic (e.g., names of animals) and phonetic categories (e.g., words beginning with
specified letters of the alphabet).
Visuospatial Functions
Complex visuospatial abilities can be assessed through procedures that were developed
in Arthur Benton’s laboratory, such as facial recognition and judgment of line orientation.
Measures of visual constructional ability examine the person’s ability to draw spatial
designs or assemble two- or three-dimensional figures (see Fig. 5.4-3). In addition to the
significant visuospatial component, these tasks reflect contributions of executive
planning and organizational abilities. More impaired individuals can be asked to copy
simple geometric forms, such as a Greek cross or intersecting pentagons, in order to
examine visuospatial abilities that are less influenced by planning and organization.
The widely used technique of clock drawing provides a surprisingly sensitive measure
of planning and organization, especially for older individuals who are at risk for
dementia. Although problems involving poor organization, perseveration, and possible
neglect are obvious in the drawing that is illustrated in Figure 5.4-4, more subtle
difficulties can also be detected, especially when a patient’s performance is evaluated in
light of premorbid expectations.

FIGURE 5.4-4
Clock drawing by a patient with vascular dementia, showing poor planning and
organization, perseveration, and possible neglect. (From Sadock BJ, Sadock VA, Ruiz P.
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott
Williams & Wilkins; 2009, with permission.)
Sensory and Motor Functions
Double simultaneous stimulation in the visual, tactile, and auditory modalities is a
standard component of the HRNTB and can be useful for assessing the integrity of basic
sensory functions as well as neglect if deficits are present on one side only on the
bilateral simultaneous trials and not when stimulation is unilateral. Grip strength and
rapid finger tapping are commonly used measures of motor strength and speed that are
sensitive to lateralized brain dysfunction.
Executive Functions
One of the most important aspects of the neuropsychological examination lies in the
assessment of higher executive functions, which play an important role in the planning
and initiation of independent activities, self-monitoring of performance, inhibition of
inappropriate responses, switching between tasks, and planning and control of complex
motor and problem-solving responses. Although the prefrontal lobes have long been
regarded as an important component in mediating these functions, more recent
developments in the neurosciences have also led to an increased appreciation for the
essential role that is played by extensive cerebral interconnections between subcortical

and cortical regions of the brain.
Psychological Factors
A key component of any neuropsychological examination involves consideration of the
degree to which long-standing personality or other psychological factors (including
current stressors) might contribute to the patient’s presentation. Common techniques for
assessing personality and psychological factors include the Minnesota Multiphasic
Personality Inventory 2 (MMPI-2) and paper and pencil techniques, such as the Beck
Depression Inventory II.
Assessment of Effort and Motivation
Because the results of neuropsychological examinations may eventually be introduced as
evidence in litigation or other forensic proceedings or be used for determining disability
compensation, it is important for the neuropsychologist to address any possible concerns
about effort and motivation as a routine matter. Several instruments have been
developed recently that directly assess a patient’s level of effort and motivation to
perform at his or her best. Normative research indicates that patients with histories of
bona fide brain injury or even dementia perform close to perfect levels on many such
instruments, so poor performance suggests poor effort or tendencies to exaggerate
symptoms. Many other indicators of effort are based on the pattern of an individual’s
performance on standard procedures in a neuropsychological examination.
A 32-year-old woman with 13 years’ education was seen for disability evaluation,
claiming current “trouble remembering things.” Her account of personal history was
vague, and she “forgot” information, such as her own birth date and mother’s maiden
name. Response latencies were extremely long, even for highly familiar information
(e.g., count from 1 to 20), she could not repeat more than three digits forward
consistently, and on a word list learning procedure, she was not able to correctly
recognize more items (only five) than she could freely recall (also five). Despite
otherwise fluent language, she was only able to generate five examples of animals in
1 minute. When asked to recall 15 items on a procedure (Rey’s Memory Test) that is
presented as a challenging task, but in reality is fairly simple, her performance
demonstrated exaggerated errors of commission (Fig. 5.4-5). The evaluation
concluded that current levels of cognitive functioning could not be conclusively
established, due to overt symptoms exaggeration.

FIGURE 5.4-5
Rey’s Memory Test with example of a response that is typical of exaggerated “memory”
problems. (From Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s Comprehensive
Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009, with
permission.)
THERAPEUTIC DISCUSSION OF RESULTS
A key component of the neuropsychological examination process is found in the
opportunity to discuss results of the examination with the patient and family or other
caregivers. This meeting can represent a powerful therapeutic opportunity to educate
and clarify individual and relationship issues, which can impact the identified patient’s
functioning. If the patient’s active cooperation in the initial examination has been
appropriately enlisted, then the patient will be prepared to invest value and confidence
in the findings of the examination. At the time of the results discussion, it is useful to
review the goals of the examination with the patient and supportive family or
caregivers and to clarify the expectations of those who are present. Typically, these
sessions will include information about the patient’s diagnosis, with emphasis on the
natural course and prognosis as well as compensation and coping strategies for the
patient and family. Given the impact of chronic neurological disease on the family
system as well as the patient, explicit discussion of these issues is critical in maximizing
adjustment to brain injury. It is equally important to relate the impact of the results to
the patient’s current living circumstances, future goals, and course of adjustment. It is
not unusual for strong emotions and underlying tensions within family relationships to
come to light in the context of honest discussion, so the results discussion can represent
an important therapeutic opportunity to model effective communication and problemsolving techniques.
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