Neuropsychological Assessment PDF

Neuropsychological Assessment NEUROPSYCHOLOGICAL ASSESSMENT Fifth Edition Muriel Deutsch Lezak Diane B. Howieson Erin D. Bigler Daniel Tranel Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford Ne...

Neuropsychological Assessment NEUROPSYCHOLOGICAL ASSESSMENT Fifth Edition Muriel Deutsch Lezak Diane B. Howieson Erin D. Bigler Daniel Tranel Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright © 1976, 1983, 1995, 2004, 2012 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Neuropsychological assessment / Muriel D. Lezak … [et al.]. — 5th ed. p. cm. Includes bibliographical references and index. ISBN 978–0–19–539552–5 1. Neuropsychological tests. I. Lezak, Muriel Deutsch. RC386.6.N48L49 2012 616.8’0475—dc23 2011022190 Dedicated in gratitude for the loving support from our spouses, John Howieson, Jan Bigler, and Natalie Denburg; and in memory of Sidney Lezak whose love and encouragement made this work possible. Preface Direct observation of the fully integrated functioning of living human brains will probably always be impossible. M.D. Lezak, 1983, p. 15 What did we know of possibilities, just a little more than a quarter of a century ago? The “black box” of classical psychology is no longer impenetrable as creative neuroscientists with ever more revealing neuroimaging techniques are devising new and powerful ways of finding windows into the black box. In neuroimaging we can now trace neural pathways, relate cortical areas to aspects of thinking and feeling—even “see” free association in the “default” state—and are discovering how all this is activated and integrated in complex, reactive, and interactive neural systems. We may yet uncover the nature of (self-and other-) consciousness and how synaptic interconnections, the juices that flow from them, and the myriad other ongoing interactive neural processes get translated into the experience of experiencing. We can never again say “never” in neuroscience. Yet, as entrancing and even astonishing as are the findings the new technologies bring to neuroscience, it is important to be mindful of their roots in human observations. As these technologically enhanced observations of the brain at work open the way for new insights about brain function and its behavioral correlates they also confirm, over and over again, the foundational hypotheses of neuropsychology—hypotheses generated from direct observations by neuropsychologists and neurologists who studied and compared the behavior of both normal and brain impaired persons. These foundational hypotheses guide practitioners in the clinical neurosciences today, whether observations come from a clinician’s eyes and ears or a machine. In the clinic, observations of brain function by technological devices enhance understanding of behavioral data and sometimes aid in prediction, but cannot substitute for clinical observations. When the earliest neuroimaging techniques became available, some thought that neuropsychologists would no longer be needed as it had become unnecessary to improve the odds of guessing a lesion site, a once important task for neuropsychologists. Today’s advanced neuroimaging techniques make it possible to predict with a reasonable degree of accuracy remarkably subtle manifestations, such as the differences between socially isolated brain injured patients who will have difficulty in social interactions although actively seeking them, versus those who may be socially skilled but lack incentive to socialize. Yet this new level of prediction, rather than substituting for human observation and human intervention, only raises more questions for experienced clinical neuroscientists: e.g., what circumstances exacerbate or alleviate the problem? what compensatory abilities are available to the patient? is the patient aware of the problem and, if so, can this awareness be used constructively? is this a problem that affects employability and, if so, how? and so on. Data generated by new neurotechnologies may help identify potential problem areas: neuropsychologists can find out how these problems may play out in real life, in human terms, and what can be done about them. Thus, in the fifth incarnation of Neuropsychological Assessment, we have tried to provide a wide-ranging report on neuropsychology as science and as a clinical specialty that is as relevant today as it was when it first appeared 35 years ago. Certainly what is relevant in 2012 is somewhat different from 1976 as the scope of activities and responsibilities of neuropsychologists has enlarged and the knowledge base necessary for clinical practice as well as for research has expanded exponentially. Three major additions distinguish the first and the fifth editions of Neuropsychological Assessment. Most obvious to the experienced neuropsychologist is the proliferation of tests and the wealth of readily available substantiating data. Second, a book such as this must provide practically useful information for neuropsychologists about the generations—yes, generations—of neuroimaging techniques that have evolved in the past 30 years. Further, especially exciting and satisfying is confirmation of what once was suspected about the neural organization underlying brain functions thanks to the marriage of sensitive, focused, clinical observations with sensitive, focused, neuroimaging data. In this edition we convey what is known about the enormity of interwoven, interactive, and interdependent complexities of neuronal processing as the brain goes about its business and how this relates to our human strengths and frailties. What remains the same in 2012 as it was in 1976 is the responsibility of clinicians to treat their patients as individuals, to value their individuality, and to respect them. Ultimately, our understandings about human behavior and its neural underpinnings come from thoughtful and respectful observations of our patients, knowledge of their histories, and information about how they are living their lives. Muriel Deutsch Lezak Diane B. Howieson Erin D. Bigler Daniel Tranel Acknowledgments Once again we want to honor our neuropsychologist friends, colleagues, and mentors who have died in the past few years. Most of what is written in this text and much of contemporary neuropsychology as science or clinical profession, relies on their contributions to neuropsychology, whether directly, or indirectly through their students and colleagues. We are deeply grateful for the insightful, innovative, integrative, and helpfully practical work of William W. Beatty, Edith F. Kaplan, John C. Marshall, Paul Satz, Esther Strauss, and Tom Tombaugh. The authors gratefully acknowledge Tracy Abildskov in creating the various neuroimaging illustrations, Jo Ann Petrie’s editing, and Aubrey Scott’s artwork. Many of David W Loring’s important contributions to the fourth edition of Neuropsychological Assessment enrich this edition as well. We miss his hand in this edition but are grateful to have what he gave us. And thanks, too, to Julia Hannay for some invaluable chapter sections retained from the fourth edition. Special thanks go to Kenneth Manzell for his aid in preparing the manuscript and illustrations. We are fortunate to have many colleagues and friends in neuropsychology who—at work or in meetings—have stimulated our thinking and made available their work, their knowledge, and their expertise. The ongoing 2nd Wedns. Neuropsychology Case Conference in Portland continues to be an open-door free-for-all and you are invited. It has been a pleasure to work with our new editor, Joan Bossert, who has not only been encouraging and supportive, but has helped us through some technical hoops and taught us about e-publishing. Tracy O’Hara, Development Editor, has done the heroic task of organizing the production idiosyncrasies of four writers into a cohesive manuscript while helping with some much needed data acquisition. Book production has been carefully timed and managed by Sr. Production Editor Susan Lee who makes house calls. Thanks, OUP team, for making this book possible. Last to get involved but far from least, our gratitude goes out to Eugenia Cooper Potter, best known as Genia, whose thorough scouring and polishing of text and references greatly helped bring this book to life. Contents List of Figures List of Tables I THEORY AND PRACTICE OF NEUROPSYCHOLOGICAL ASSESSMENT 1. The Practice of Neuropsychological Assessment Examination purposes The multipurpose examination The Validity of Neuropsychological Assessment What Can We Expect of Neuropsychological Assessment in the 21st Century? 2. Basic Concepts Examining the Brain Laboratory Techniques for Assessing Brain Function Neuropsychology’s Conceptual Evolution Concerning Terminology Dimensions of Behavior Cognitive Functions Neuropsychology and the Concept of Intelligence: Brain Function Is Too Complex To Be Communicated in a Single Score Classes of Cognitive Functions Receptive Functions Memory Expressive Functions Thinking Mental Activity Variables Executive Functions  Personality/Emotionality Variables 3. The Behavioral Geography of the Brain Brain Pathology and Psychological Function The Cellular Substrate The Structure of the Brain The Hindbrain The Midbrain The Forebrain: Diencephalic Structures The Forebrain: The Cerebrum The Limbic System The Cerebral Cortex and Behavior Lateral Organization Longitudinal Organization Functional Organization of the Posterior Cortex The Occipital Lobes and Their Disorders The Posterior Association Cortices and Their Disorders The Temporal Lobes and Their Disorders Functional Organization of the Anterior Cortex Precentral Division Premotor Division Prefrontal Division Clinical Limitations of Functional Localization 4. The Rationale of Deficit Measurement Comparison Standards for Deficit Measurement Normative Comparison Standards Individual Comparison Standards The Measurement of Deficit Direct Measurement of Deficit Indirect Measurement of Deficit The Best Performance Method The Deficit Measurement Paradigm 5. The Neuropsychological Examination: Procedures Conceptual Framework of the Examination Purposes of the Examination Examination Questions Conduct of the Examination Examination Foundations Examination Procedures Procedural Considerations in Neuropsychological Assessment Testing Issues Examining Special Populations Common Assessment Problems with Brain Disorders Maximizing the Patient’s Performance Level Optimal versus Standard Conditions When Optimal Conditions Are Not Best Talking to Patients Constructive Assessment 6. The Neuropsychological Examination: Interpretation The Nature of Neuropsychological Examination Data Different Kinds of Examination Data Quantitative and Qualitative Data Common Interpretation Errors Evaluation of Neuropsychological Examination Data Qualitative Aspects of Examination Behavior Test Scores Evaluation Issues Screening Techniques Pattern Analysis Integrated Interpretation 7. Neuropathology for Neuropsychologists Traumatic Brain Injury Severity Classifications and Outcome Prediction Neuropathology of TBI  Penetrating Head Injuries Closed Head Injuries Closed Head Injury: Nature, Course, and Outcome Neuropsychological Assessment of Traumatically Brain Injured Patients Moderator Variables Affecting Severity of Traumatic Brain Injury Less Common Sources of Traumatic Brain Injury Cerebrovascular Disorders Stroke and Related Disorders Vascular Disorders Hypertension Vascular Dementia (VaD) Migraine Epilepsy Dementing Disorders Mild Cognitive Impairment Degenerative Disorders Cortical Dementias Alzheimer’s Disease (AD) Frontotemporal Lobar Degeneration (FTLD) Dementia with Lewy Bodies (DLB) Subcortical Dementias Movement Disorders Parkinson’s Disease/Parkinsonism (PD) Huntington’s Disease (HD) Progressive Supranuclear Palsy (PSP) Comparisons of the Progressive Dementias Other Progressive Disorders of the Central Nervous System Which May Have Important Neuropsychological Effects Multiple Sclerosis (MS) Normal Pressure Hydrocephalus (NPH) Toxic Conditions Alcohol-Related Disorders Street Drugs Social Drugs  Environmental and Industrial Neurotoxins Infectious Processes HIV Infection and AIDS Herpes Simplex Encephalitis (HSE) Lyme Disease Chronic Fatigue Syndrome (CFS) Brain Tumors Primary Brain Tumors Secondary (Metastatic) Brain Tumors CNS Symptoms Arising from Brain Tumors CNS Symptoms Arising from Cancer Treatment Oxygen Deprivation Acute Oxygen Deprivation Chronic Oxygen Deprivation Carbon Monoxide Poisoning Metabolic and Endocrine Disorders Diabetes Mellitus (DM) Hypothyroidism (Myxedema) Liver Disease Uremia Nutritional Deficiencies 8. Neurobehavioral Variables and Diagnostic Issues Lesion Characteristics Diffuse and Focal Effects Site and Size of Focal Lesions Depth of Lesion Distance Effects Nature of the Lesion Time Nonprogressive Brain Disorders Progressive Brain Diseases Subject Variables Age  Sex Differences Lateral Asymmetry Patient Characteristics: Race, Culture, and Ethnicity The Uses of Race/Ethnicity/Culture Designations The Language of Assessment Patient Characteristics: Psychosocial Variables Premorbid Mental Ability Education Premorbid Personality and Social Adjustment Problems of Differential Diagnosis Emotional Disturbances and Personality Disorders Psychotic Disturbances Depression Malingering II A COMPENDIUM OF TESTS AND ASSESSMENT TECHNIQUES 9. Orientation and Attention Orientation Awareness Time Place Body Orientation Finger Agnosia Directional (Right–Left) Orientation Space Attention, Processing Speed, and Working Memory Attentional Capacity Working Memory/Mental Tracking Concentration/Focused Attention Processing Speed Complex Attention Tests Divided Attention  Everyday Attention 10. Perception Visual Perception Visual Inattention Visual Scanning Color Perception Visual Recognition Visual Organization Visual Interference Auditory Perception Auditory Acuity Auditory Discrimination Auditory Inattention Auditory–Verbal Perception Nonverbal Auditory Reception Tactile Perception Tactile Sensation Tactile Inattention Tactile Recognition and Discrimination Tests Olfaction 11. Memory I: Tests Examining Memory Verbal Memory Verbal Automatisms Supraspan Words Story Recall Visual Memory Visual Recognition Memory Visual Recall: Verbal Response Visual Recall: Design Reproduction Visual Learning  Hidden Objects Tactile Memory Incidental Learning Prospective Memory Remote Memory Recall of Public Events and Famous Persons Autobiographic Memory Forgetting 12. Memory II: Batteries, Paired Memory Tests, and Questionnaires Memory Batteries Paired Memory Tests Memory Questionnaires 13. Verbal Functions and Language Skills Aphasia Aphasia Tests and Batteries Aphasia Screening Testing for Auditory Comprehension Verbal Expression Naming Vocabulary Discourse Verbal Comprehension Verbal Academic Skills Reading Writing Spelling Knowledge Acquisition and Retention 14. Construction and Motor Performance Drawing Copying  Miscellaneous Copying Tasks Free Drawing Assembling and Building Two-Dimensional Construction Three-Dimensional Construction Motor Skills Examining for Apraxia Neuropsychological Assessment of Motor Skills and Functions 15. Concept Formation and Reasoning Concept Formation Concept Formation Tests in Verbal Formats Concept Formation Tests in Visual Formats Symbol Patterns Sorting Sort and Shift Reasoning Verbal Reasoning Reasoning about Visually Presented Material Mathematical Procedures Arithmetic Reasoning Problems Calculations 16. Executive Functions The Executive Functions Volition Planning and Decision Making Purposive Action Self-Regulation Effective Performance Executive Functions: Wide Range Assessment 17. Neuropsychological Assessment Batteries Ability and Achievement  Individual Administration Paper-and-Pencil Administration Batteries Developed for Neuropsychological Assessment Batteries for General Use Batteries Composed of Preexisting Tests Batteries for Assessing Specific Conditions HIV+ Schizophrenia Neurotoxicity Dementia: Batteries Incorporating Preexisting Tests Traumatic Brain Injury Screening Batteries for General Use Computerized Neuropsychological Assessment Batteries 18. Observational Methods, Rating Scales, and Inventories The Mental Status Examination Rating Scales and Inventories Dementia Evaluation Mental Status Scales for Dementia Screening and Rating Mental Status and Observer Rating Scale Combinations Scales for Rating Observations Traumatic Brain Injury Evaluating Severity Choosing Outcome Measures Outcome Evaluation Evaluation of the Psychosocial Consequences of Head Injury Epilepsy Patient Evaluations Quality of Life Psychiatric Symptoms 19. Tests of Personal Adjustment and Emotional Functioning Objective Tests of Personality and Emotional Status Depression Scales and Inventories  Anxiety Scales and Inventories Inventories and Scales Developed for Psychiatric Conditions Projective Personality Tests Rorschach Technique Storytelling Techniques Drawing Tasks 20. Testing for Effort, Response Bias, and Malingering Research Concerns Examining Response Validity with Established Tests Multiple Assessments Test Batteries and Other Multiple Test Sets Wechsler Scales Batteries and Test Sets Developed for Neuropsychological Assessment Memory Tests Single Tests Tests with a Significant Motor Component Special Techniques to Assess Response Validity Symptom Validity Testing (SVT) Forced-Choice Tests Variations on the Forced-Choice Theme Other Special Examination Techniques Self-Report Inventories and Questionnaires Personality and Emotional Status Inventories Appendix A: Neuroimaging Primer Appendix B: Test Publishers and Distributors References Test Index Subject Index List of Figures The Behavioral Geography of the Brain FIGURE Schematic of a neuron. Photomicrograph. (See color Figure 3.1) 3.1 FIGURE (a) Axial MRI, coronal MRI, sagittal MRI of anatomical divisions of the brain. (See color Figure 3.2 3.2a, b, and c) FIGURE Lateral surface anatomy postmortem (left) with MRI of living brain (right) 3.3 FIGURE Ventricle anatomy. (See color Figure 3.4) 3.4 FIGURE Scanning electron micrograph showing an overview of corrosion casts from the occipital cortex 3.5 FIGURE Major blood vessels schematic 3.6 FIGURE Thalamo-cortical topography demonstrated by DTI tractography. (See color Figure 3.7) 3.7 FIGURE Memory and the limbic system 3.8 FIGURE Cut-away showing brain anatomy viewed from a left frontal perspective with the left frontal and 3.9 parietal lobes removed. (See color Figure 3.9) FIGURE DTI (diffusion tensor imaging) of major tracts. (See color Figure 3.10) 3.10 FIGURE DTI of major tracts through the corpus callosum. (See color Figure 3.11) 3.11 FIGURE Representative commissural DTI ‘streamlines’ showing cortical projections and cortical 3.12 terminations of corpus callosum projections. (See color Figure 3.12) FIGURE Schematic diagram of visual fields, optic tracts, and the associated brain areas, showing left and 3.13 right lateralization in humans FIGURE Diagram of a “motor homunculus” showing approximately relative sizes of specific regions of the 3.14 motor cortex FIGURE Example of global/local stimuli 3.15 FIGURE Example of spatial dyscalculia by a traumatically injured pediatrician 3.16 FIGURE Attempts of a 51-year-old right hemisphere stroke patient to copy pictured designs with colored 3.17a blocks FIGURE Attempts of a 31-year-old patient with a surgical lesion of the left visual association area to copy 3.17b the 3 × 3 pinwheel design Overwriting (hypergraphia) by a 48-year-old college-educated retired police investigator suffering FIGURE Overwriting (hypergraphia) by a 48-year-old college-educated retired police investigator suffering 3.18 right temporal lobe atrophy FIGURE Simplification and distortions of four Bender-Gestalt designs by a 45-year-old assembly line 3.19 worker FIGURE The lobe-based divisions of the human brain and their functional anatomy 3.20 FIGURE Brodmann’s cytoarchitectural map of the human brain 3.21 FIGURE Lateral view of the left hemisphere, showing the ventral “what” and dorsal “where” visual 3.22 pathways in the occipital-temporal and occipital-parietal regions FIGURE (a) This bicycle was drawn by the 51-year-old retired salesman who constructed the block designs 3.23 of Figure 3.17a FIGURE Flower drawing, illustrating left-sided inattention 3.24a FIGURE Copy of the Taylor Complex Figure (see p. 575), illustrating inattention to the left side of the 3.24b stimulus FIGURE Writing to copy, illustrating inattention to the left side of the to-be-copied sentences; written by a 3.24c 69 year-old man FIGURE Example of inattention to the left visual field 3.24d FIGURE Ventral view of H.M.’s brain ex situ using 3-D MRI reconstruction 3.25 FIGURE The major subdivisions of the human frontal lobes identified on surface 3-D MRI reconstructions 3.26 of the brain The Rationale of Deficit Measurement FIGURE Calculations test errors (circled) made by a 55-year-old dermatologist with a contre coup 4.1 The Neuropsychological Examination: Procedures FIGURE An improvised test for lexical agraphia 5.1 FIGURE Copies of the Bender-Gestalt designs drawn on one page by a 56-year-old sawmill worker with 5.2 phenytoin toxicity The Neuropsychological Examination: Interpretation FIGURE House-Tree-Person drawings of a 48-year-old advertising manager 6.1 FIGURE This bicycle was drawn by a 61-year-old who suffered a stroke involving the right parietal lobe 6.2 FIGURE The relationship of some commonly used test scores to the normal curve and to one another 6.3 Neuropathology for Neuropsychologists FIGURE This schematic is of a neuron and depicts various neuronal membrane and physiological effects 7.1 incurred during the initial stage of TBI (See color Figure 7.1) FIGURE Proteins are the building blocks of all tissues including all types of neural cells and in this diagram 7.2 the Y-axis depicts the degree of pathological changes in protein integrity with TBI FIGURE There are two pathways that lead to a breakdown in the axon from TBI, referred to as axotomy 7.3 FIGURE CT scans depicting the trajectory prior to neurosurgery depicting the trajectory and path of a bullet injury to frontotemporal areas of the brain 7.4 injury to frontotemporal areas of the brain FIGURE MRI demonstration of the effects of penetrating brain injury 7.5 FIGURE Postmortem section showing the central penetration wound from a bullet which produces a 7.6 permanent cavity in the brain FIGURE Diagram showing impulsive loading from the rear (left) and front (right) with TBI 7.7 FIGURE Mid-sagittal schematic showing the impact dynamics of angular decelerations of the brain as the 7.8 head hits a fixed object FIGURE Wave propagation and contact phenomena following impact to the head 7.9 FIGURE The colorized images represent a 3-D CT recreation of the day-of-injury hemorrhages resulting 7.10 from a severe TBI (See color Figure 7.10) FIGURE Mid-sagittal MRI with an atrophied corpus callosum and old shear lesion in the isthmus (See color 7.11 Figure 7.11) FIGURE MRI comparisons at different levels of TBI severity in children with a mean age of 13.6 7.12 FIGURE 3-D MRI reconstruction of the brain highlighting the frontal focus of traumatic hemorrhages 7.13 associated with a severe TBI.(See color Figure 7.13) FIGURE This is a case of mild TBI where conventional imaging (upper left) shows no abnormality but the 7.14 fractional anisotropy DTI map (top, middle image) does (See color Figure 7.14) FIGURE The brain regions involved in TBI that overlap with PTSD are highlighted in this schematic (See 7.15 color Figure 7.15) FIGURE “The three neurodegenerative diseases classically evoked as subcortical dementia are 7.16 Huntington’s chorea, Parkinson’s disease, and progressive supranuclear palsy FIGURE Tracings of law professor’s Complex Figure copies (see text for description of his performance) 7.17 FIGURE Immediate (upper) and delayed (lower) recall of the Complex Figure by the law professor with 7.18 Huntington’s disease FIGURE Pyramid diagram of HIV-Associated Neurocognitive Disorders (HAND) 7.19 FIGURE Schematic flow diagram showing a diagnostic decision tree for various neurocognitive disorders 7.20 associated with HiV FIGURE Autopsy-proved HIV encephalitis in an AIDS patient with dementia 7.21 FIGURE The devastating effects of structural damage from herpes simplex encephalitis 7.22 FIGURE Postmortem appearance of a glioblastoma multiforme 7.23 FIGURE Postmortem appearance of a mid-sagittal frontal meningioma (left) and a large inferior frontal 7.24 meningioma (right) FIGURE Postmortem appearance of malignant melanoma 7.25 FIGURE Postmortem appearance of pulmonary metastasis to the brain 335. 7.26 FIGURE The MRIs show bilateral ischemic hypoxic injury characteristic of anoxic brain injury 7.27 Neurobehavioral Variables and Diagnostic Issues FIGURE The handedness inventory 8.1 FIGURE The target matrix for measuring manual speed and accuracy 8.2 FIGURE Tapley and Bryden’s (1985) dotting task for measuring manual speed 8.3 Orientation and Attention FIGURE One of the five diagrams of the Personal Orientation Test 9.1 FIGURE Curtained box used by Benton to shield stimuli from the subject’s sight when testing finger 9.2 localization FIGURE Outline drawings of the right and left hands with fingers numbered for identification 9.3 FIGURE Floor plan of his home drawn by a 55-year-old mechanic injured in a traffic accident 9.4a FIGURE Floor plan of their home drawn by the mechanic’s spouse 9.4b FIGURE Topographical Localization responses by a 50-year-old engineer who had a ruptured right anterior 9.5 communicating artery FIGURE Corsi’s Block-tapping board 9.6 FIGURE The symbol-substitution format of the WIS Digit Symbol Test 9.7 FIGURE The Symbol Digit Modalities Test (SDMT) 9.8 FIGURE Practice samples of the Trail Making Test 9.9 Perception FIGURE This sample from the Pair Cancellation test (Woodcock-Johnson III Tests of Cognitive Abilities) 10.1 FIGURE The Line Bisection test 10.2 FIGURE Performance of patient with left visuospatial inattention on the Test of Visual Neglect 10.3 FIGURE The Bells Test (reduced size) 10.4 FIGURE Letter Cancellation task: “Cancel C’s and E’s” (reduced size) 10.5 FIGURE Star Cancellation test (reduced size) 10.6 FIGURE Indented Paragraph Reading Test original format for copying 10.7 FIGURE indented Paragraph Reading Test with errors made by the 45-year-old traumatically injured 10.8 pediatrician FIGURE This attempt to copy an address was made by a 66-year-old retired paper mill worker two years after he had suffered a right frontal CVA 10.9 after he had suffered a right frontal CVA FIGURE Flower drawn by patient with left visuospatial neglect 10.10 FIGURE Judgment of Line Orientation 10.11 FIGURE Focal lesions associated with JLO failures. (See color Figure 10.12) 10.12 FIGURE Test of Facial Recognition 10.13 FIGURE An item of the Visual Form Discrimination test 10.14 FIGURE Example of the subjective contour effect 10.15 FIGURE Closure Speed (Gestalt Completion) 10.16 FIGURE Two items from the Silhouettes subtest of the Visual Object and Space Perception Test 10.17 FIGURE Multiple-choice item from the Object Decision subtest of the Visual Object and Space Perception 10.18 Test FIGURE Easy items of the Hooper Visual Organization Test 10.19 FIGURE Closure Flexibility (Concealed Figures) 10.20 FIGURE Example of a Poppelreuter-type overlapping figure 10.21 FIGURE Rey’s skin-writing procedures 10.22 Memory I: Tests FIGURE Memory for Designs models 11.1 FIGURE Complex Figure Test performance of a 50-year-old hemiparetic engineer with severe right frontal 11.2 damage of 14 years’ duration FIGURE Two representative items of the Benton Visual Retention Test 11.3 FIGURE Ruff-Light Trail Learning Test (RuLiT) (reduced size) 11.4 FIGURE One of the several available versions of the Sequin-Goddard Formboard used in the Tactual 11.5 Performance Test Verbal Functions and Language Skills FIGURE Alzheimer patient’s attempt to write (a) “boat” and (b) “America.” 13.1 Construction and Motor Performance FIGURE The Hutt adaptation of the Bender-Gestalt figures 14.1 FIGURE Rey Complex Figure (actual size) 14.2 FIGURE Taylor Complex Figure (actual size) 14.3 FIGURE Modified Taylor Figure 14.4 FIGURE The four Medical College of Georgia (MCG) Complex Figures (actual size) 14.5 FIGURE An example of a Complex Figure Test Rey-Osterrieth copy 14.6 FIGURE Structural elements of the Rey Complex Figure 14.7 FIGURE Sample freehand drawings for copying 14.8 FIGURE Freehand drawing of a clock by a 54-year-old man with a history of anoxia resulting in bilateral 14.9 hippocampus damage FIGURE Block Design test 14.10 FIGURE Voxel lesion-symptom mapping on 239 patients from the iowa Patient Registry projected on the 14.11 iowa template brain FIGURE Example of a WIS-type Object Assembly puzzle item 14.12 FIGURE Test of Three-Dimensional Constructional Praxis, Form A (A.L. Benton) 14.13 FIGURE Illustrations of defective performances 14.14 FIGURE The Purdue Pegboard Test 14.15 Concept Formation and Reasoning FIGURE Identification of Common Objects stimulus card (reduced size) 15.1 FIGURE Examples of two levels of difficulty of Progressive Matrices-type items 15.2 FIGURE The Kasanin-Hanfmann Concept Formation Test 15.3 FIGURE The Wisconsin Card Sorting Test 15.4 FIGURE A simple method for recording the Wisconsin Card Sorting Test performance 15.5 FIGURE WIS-type Picture Completion test item 15.6 FIGURE WIS-type Picture Arrangement test item 15.7 FIGURE Sample items from the Block Counting task 15.8 FIGURE Example of a page of arithmetic problems laid out to provide space for written calculations 15.9 Executive Functions FIGURE Bender-Gestalt copy trial rendered by a 42-year-old interior designer a year after she had sustained a mild anterior subarachnoid hemorrhage  sustained a mild anterior subarachnoid hemorrhage 16.1 FIGURE House and Person drawings by the interior designer whose Bender-Gestalt copy trial is given in 16.2 Figure 16.1 FIGURE Two of the Porteus mazes 16.3 FIGURE Tower of London examples 16.4 FIGURE A subject performing the Iowa Gambling Task on a computer 16.5 FIGURE Card selections on the Iowa Gambling Task as a function of group (Normal Control, Brain 16.6 damaged Control, Ventromedial Prefrontal), deck type (disadvantageous v. advantageous), and trial block FIGURE A 23-year-old craftsman with a high school education made this Tinkertoy “space platform” 16.7 FIGURE “Space vehicle” was constructed by a neuropsychologist unfamiliar with Tinkertoys 16.8 FIGURE The creator of this “cannon” was a 60-year-old left-handed contractor who had had a small left 16.9 parietal stroke FIGURE This 40-year-old salesman was trying to make a “car” following a right-sided stroke 16.10 FIGURE Figural Fluency Test responses by 62-year-old man described on p. 698 16.11 FIGURE Ruff Figural Fluency Test (Parts I-V) 16.12 FIGURE Repetitive patterns which subject is asked to maintain 16.13 FIGURE Drawing of a clock, illustrating perseveration 16.14 FIGURE Signature of middle-aged man who had sustained a gunshot wound to the right frontal lobe 16.15 Neuropsychological Assessment Batteries FIGURE This figure summarizes the lesion mapping of cognitive abilities showing where abnormally low 17.1 WAIS-III Index Scores are most often associated with focal lesions FIGURE The Peabody Individual Achievement Test 17.2 FIGURE Histograms illustrating the distribution of scores for each measure in the ADC UDS 17.3 Neuropsychological Test Battery Observational Methods, Rating Scales, and Inventories FIGURE Partial items from the Montreal Cognitive Assessment 18.1 FIGURE Galveston Orientation and Amnesia Test (GOAT) record form 18.2 Tests of Personal Adjustment and Emotional Functioning FIGURE Mean MMPI profile for patients with diagnosed brain disease 19.1 FIGURE MMPI-2 profile in a patient with medically unexplained “spells” and significant psychosocial stressors  stressors 19.2 FIGURE Illustration of the ventromedial prefrontal region 19.3 APPENDIX A: Neuroimaging Primer FIGURE With computerized tomography (CT) and magnetic resonance imaging (MRI), gross brain A1 anatomy can be readily visualized. (See color Figure A1) FIGURE This scan, taken several months after a severe traumatic brain injury, shows how an old right A2 frontal contusion appears on the different imaging sequences FIGURE These horizontal scan images are from a patient with a severe TBI A3 FIGURE The postmortem coronal section in the center of this figure shows the normal symmetry of the A4 brain and the typically white appearance of normal white matter, and gray matter (See color Figure A4) FIGURE Diffusion tensor imagining (DTI) tractography is depicted in these images of the brain (See color A5 Figure A5) FIGURE DTI tractography of a patient who sustained a severe TBI showing loss of certain tracts in the A6 frontal and isthmus region (See color Figure A6) FIGURE This figure shows how structural 3-D MRI may be integrated with 3-D DTI tractography. (See A7 color Figure A7) FIGURE The MRI image on the left is at approximately the same level as the positron emission computed A8 tomogram or PET scan on the right of a 58-year-old patient (See color Figure A8) FIGURE In plotting functional MRI (fMRI) activation, the regions of statistically significant activation are A9 mapped onto a universal brain model. (See color Figure A9) List of Tables Basic Concepts TABLE 2.1 Most Commonly Defined Aphasic Syndromes The Behavioral Geography of the Brain TABLE 3.1 Functional dichotomies of left and right hemispheric dominance The Rationale of Deficit Measurement TABLE 4.1 North American Adult Reading Test (NAART): Word List The Neuropsychological Examination: Procedures TABLE 5.1 Classification of Ability Levels The Neuropsychological Examination: Interpretation TABLE 6.1 Standard Score Equivalents for 21 Percentile Scores Ranging from 1 to 99 TABLE 6.2 Behavior Changes that are Possible Indicators of a Pathological Brain Process The Neuropsychological Examination: Interpretation TABLE 7.1 Diagnostic Criteria for Mild TBI by the American Congress of Rehabilitation Medicine TABLE 7.2 Selected Signs and Symptoms of a Concussion TABLE 7.3 Estimates of Injury Severity Based on Posttraumatic Amnesia (PTA) Duration TABLE 7.4 Test Completion Codes TABLE 7.5 Exclusion Criteria for Diagnosis of Alzheimer’s Disease TABLE 7.6 Uniform Data Set of the National Alzheimer’s Coordination Center Neuropsychological Test Battery TABLE 7.7 Memory in Alzheimer’s Disease TABLE 7.8 A Comparison of Neuropsychological Features of AD, FTLD, LBD, PDD, HD, PSP, and VaD Neuropathology for Neuropsychologists TABLE 8.1 Some Lateral Preference Inventories and Their Item Characteristics Orientation and Attention TABLE 9.1 Temporal Orientation Test Scores for Control and Brain Damaged Patients TABLE 9.2 Sentence Repetition: Form 1 TABLE 9.3 Sentence Repetition (MAE): Demographic Adjustments for Raw Scores TABLE 9.4 Example of Consonant Trigrams Format TABLE 9.5 Symbol Digit Modalities Test Norms for Ages 18 to 74 perception TABLE 10.1 The Bells Test: Omissions by Age and Education TABLE 10.2 Judgment of Line Orientation: Score Corrections TABLE 10.3 Facial Recognition Score Corrections TABLE 10.4 The Face-Hand Test Skin-Writing Test Errors Made by Four Adult Groups  Skin-Writing Test Errors Made by Four Adult Groups TABLE 10.5 Memory I: Tests TABLE 11.1 Telephone Test Scores for Two Age Groups TABLE 11.2 Benson Bedside Memory Test TABLE 11.3 Rey Auditory-Verbal Learning Test Word Lists TABLE 11.4 Word Lists for Testing AVLT Recognition, Lists A-B TABLE 11.5 Multiple-Choice and Cued-Recall Items for Forms 1–4 of SRT TABLE 11.6 Norms for the Most Used SR Scores for Age Groups with 30 or More Subjects TABLE 11.7 WMS-III Logical Memory Recognition Scores as a Function of Age or LM II Scores TABLE 11.8 Expected Scores for Immediate and Delayed Recall Trials of the Babcock Story Recall Test TABLE 11.9 Percentiles for Adult Accuracy Scores on Memory Trials of the Complex Figure Test (Rey-O) TABLE Medical College of Georgia Complex Figure (MCGCF) Data for Two Older Age Groups 11.10 TABLE BVRT Norms for Administration A: Adults Expected Number Correct Scores 11.11 Verbal Functions and Language Skills TABLE 13.1 The Most Frequent Alternative Responses to Boston Naming Test Items TABLE 13.2 Normal Boston Naming Test Score Gain with Phonemic Cueing TABLE 13.3 The Token Test TABLE 13.4 A Summary of Scores Obtained by the Four Experimental Groups on The Token Test TABLE 13.5 Adjusted Scores and Grading Scheme for the “Short Version” of the Token Test TABLE 13.6 The National Adult Reading Test Construction and Motor Performance TABLE 14.1 Scoring System for the Rey Complex Figure TABLE 14.2 Scoring System for the Taylor Complex Figure TABLE 14.3 Modified Taylor Figure TABLE 14.4 Scoring Systems for the MCG Complex Figures TABLE 14.5 Scoring System of Qualitative Errors TABLE 14.6 Complex Figure Organizational Quality Scoring TABLE 14.7 Scoring System for Bicycle Drawings TABLE 14.8 Bicycle Drawing Means and Standard Deviations for 141 Blue Collar Workers TABLE 14.9 Scoring System for House Drawing TABLE WAIS-IV Block Design Score Changes with Age 14.10 TABLE Activities for Examining Practic Functions 14.11 Concept Formation and Reasoning TABLE 15.1 Matrix Reasoning and Vocabulary are Age-corrected Scaled Scores TABLE 15.2 First Series of Uncued Arithmetic Word Problems TABLE 15.3 Benton’s Battery of Arithmetic Tests Executive Functions TABLE 16.1 Items Used in the Tinkertoy Test TABLE 16.2 Tinkertoy Test: Scoring for Complexity TABLE 16.3 Comparisons Between Groups on np and Complexity Scores TABLE 16.4 Verbal Associative Frequencies for the 14 Easiest Letters Controlled Oral Word Association Test: Adjustment Formula for Males (M) and Females (F)  Controlled Oral Word Association Test: Adjustment Formula for Males (M) and Females (F) TABLE 16.5 TABLE 16.6 Controlled Oral Word Association Test: Summary Table Neuropsychological Assessment Batteries TABLE 17.1 Rapid Semantic Retrieval Mean Scores for 1-min Trial TABLE 17.2 CDEs: Traumatic Brain Injury Outcome Measures TABLE 17.3 Repeatable Battery for the Assessment of Neuropsychological Status Test Means Observational Methods, Rating Scales, and Inventories TABLE 18.1 Dementia Score TABLE 18.2 Glasgow Coma Scale TABLE 18.3 Severity Classification Criteria for the Glasgow Coma Scale (GCS) TABLE 18.4 Frequency of “Bad” and “Good” Outcomes Associated with the Glasgow Coma Scale TABLE 18.5 The Eight Levels of Cognitive Functioning of the “Rancho Scale” TABLE 18.6 Disability Rating Scale TABLE 18.7 Item Clusters and Factors from Part 1 of the Katz Adjustment Scale TABLE 18.8 Mayo-Portland Adaptability Inventory (MPAI) Items by Subscales TABLE 18.9 Satisfaction With Life Scale (SWLS) Tests of Personal Adjustment and Emotional Functioning TABLE 19.1 MMPI-2 RC Scales and corresponding Clinical Scales from MMPI-2 TABLE 19.2 Sickness Impact Profile (SIP) Categories and Composite Scales TABLE 19.3 Major Response Variables Appearing in Every Rorschach Scoring System Testing for Effort, Response Bias, and Malingering TABLE 20.1 Malingering Criteria Checklist TABLE 20.2 Confidence Intervals (CIs) for Random Responses for Several Halstead-Reitan Battery Tests TABLE 20.3 D.E. Hartman (2002) Criteria for Evaluating Stand-alone Malingering and Symptom Validity Tests … TABLE 20.4 Percentile Norms for Time (in Seconds)Taken to Count Ungrouped Dots TABLE 20.5 Percentile Norms for Time (in Seconds) Taken to Count Grouped Dots TABLE 20.6 Autobiographical Memory Interview I Theory and Practice of Neuropsychological Assessment 1 The Practice of Neuropsychological Assessment Imaging is not enough. Mortimer Mishkin, 1988 Clinical neuropsychology is an applied science concerned with the behavioral expression of brain dysfunction. It owes its primordial—and often fanciful— concepts to those who, since earliest historic times, puzzled about what made people do what they did and how. These were the philosophers, physicians, scientists, artists, tinkerers, and dreamers who first called attention to what seemed to be linkages between body—not necessarily brain—structures and people’s common responses to common situations as well as their behavioral anomalies (Castro-Caldas and Grafman, 2000; Finger, 1994, 2000; C.G. Gross, 1998; L.H. Marshall and Magoun, 1998). In the 19th century the idea of controlled observations became generally accepted, thus providing the conceptual tool with which the first generation of neuroscientists laid out the basic schema of brain-behavior relationships that hold today (Benton, 2000; Boring, 1950; M. Critchley and Critchley, 1998; Hécaen et Lanteri-Laura, 1977; N.J. Wade and Brozek, 2001). In the first half of the 20th century, war-damaged brains gave the chief impetus to the development of clinical neuropsychology. The need for screening and diagnosis of brain injured and behaviorally disturbed servicemen during the first World War and for their rehabilitation afterwards created large-scale demands for neuropsychology programs (e.g., K. Goldstein, 1995 ; Homskaya, 2001; see references in Luria, 1973b; Poppelreuter, 1990 ; W.R. Russell [see references in Newcombe, 1969]). The second World War and then the wars in east Asia and the Mideast promoted the development of many talented neuropsychologists and of increasingly sophisticated examination and treatment techniques. While clinical neuropsychology can trace its lineage directly to the clinical neurosciences, psychology contributed the two other domains of knowledge and skill that are integral to the scientific discipline and clinical practices of neuropsychology today. Educational psychologists, beginning with Binet (with Simon, 1908) and Spearman (1904), initially developed tests to capture that elusive concept “intelligence.” Following these pioneers, mental measurement specialists produced a multitude of examination techniques to screen recruits for the military and to assist in educational evaluations. Some of these techniques— such as Raven’s Progressive Matrices, the Wechsler Intelligence Scales, and the Wide Range Achievement Tests—have been incorporated into the neuropsychological test canon (W. Barr, 2008; Boake, 2002). Society’s acceptance of educational testing led to a proliferation of large- scale, statistics-dependent testing programs that provided neuropsychology with an understanding of the nature and varieties of mental abilities from a normative perspective. Educational testing has also been the source of ever more reliable measurement techniques and statistical tools for test standardization and the development of normative data, analysis of research findings, and validation studies (Mayrhauser, 1992; McFall and Townsend, 1998; Urbina, 2004). Clinical psychologists and psychologists specializing in personality and social behavior research borrowed from and further elaborated the principles and techniques of educational testing, giving neuropsychology this important assessment dimension (Cripe, 1997; G.J. Meyer et al., 2001). Psychology’s other critical contribution to neuropsychological assessment comes primarily from experimental studies of cognitive functions in both humans and other animals. In its early development, human studies of cognition mainly dealt with normal subjects—predominantly college students who sometimes earned course credits for their cooperation. Animal studies and clinical reports of brain injured persons, especially soldiers with localized wounds and stroke patients, generated much of what was known about the alterations and limitations of specific cognitive functions when one part of the brain is missing or compromised. In the latter half of the 20th century, many experimental psychologists became aware of the wealth of information about cognitive functions to be gained from studying brain injured persons, especially those with localized lesions (e.g., G. Cohen et al., 2000; Gazzaniga, 2009, passim; Tulving and Craik, 2000, passim). Similarly, neuroscientists discovered the usefulness of cognitive constructs and psychological techniques when studying brain-behavior relationships (Bilder, 2011; Fuster, 1995; Luria, 1966, 1973b). Now in the 21st century, dynamic imaging techniques permit viewing functioning brain structures, further refining understanding of the neural foundations of behavior (Friston, 2009). Functional neuroimaging gives psychological constructs the neurological bases supporting analysis and comprehension of the always unique and often anomalous multifaceted behavioral presentations of brain injured patients. When doing assessments, clinical neuropsychologists typically address a variety of questions of both neurological and psychological import. The diversity of problems and persons presents an unending challenge to examiners who want to satisfy the purposes for which the examination was undertaken and still evaluate patients at levels suited to their capacities and limitations. In this complex and expanding field, few facts or principles can be taken for granted, few techniques would not benefit from modifications, and few procedures will not be bent or broken as knowledge and experience accumulate. The practice of neuropsychology calls for flexibility, curiosity, inventiveness, and empathy even in the seemingly most routine situations (B. Caplan and Shechter, 1995; Lezak, 2002). Each neuropsychological evaluation holds the promise of new insights into the workings of the brain and the excitement of discovery. The rapid evolution of neuropsychological assessment in recent years reflects a growing sensitivity among clinicians generally to the practical problems of identification, assessment, care, and treatment of brain impaired patients. Psychologists, psychiatrists, and counselors ask for neuropsychological assistance in identifying those candidates for their services who may have underlying neurological disorders. Neurologists and neurosurgeons request behavioral evaluations to aid in diagnosis and to document the course of brain disorders or the effects of treatment. Rehabilitation specialists request neuropsychological assessments to assist in rehabilitation planning and management of a neurological condition (Malec, 2009). A fruitful interaction is taking place between neuropsychology and gerontology that enhances the knowledge and clinical applications of each discipline with the worldwide increase in longevity and the neurological problems that are associated with aging (see Chapter 8, pp. 354–361). Child neuropsychology has developed hand in hand with advances in the study of mental retardation, neurodevelopmental disorders including learning disabilities, and children’s behavior problems. As this text concerns neuropsychological issues relevant for adults, we refer the interested reader to the current child neuropsychology literature (e.g., Baron, 2004; Hunter and Donders, 2007; Semrud-Clikeman and Teeter Ellison, 2009; Yeates, Ris, et al., 2010). Adults whose cognitive and behavioral problems stem from developmental disorders or childhood onset conditions may also need neuropsychological attention. These persons are more likely to be seen in clinics or by neuropsychologists specializing in the care of adults. However, the preponderance of the literature on their problems is in books and articles dealing with developmental conditions such as attention deficit hyperactivity disorder, spina bifida, or hydrocephalus arising from a perinatal incident, or with the residuals of premature birth or childhood meningitis, or the effects of cancer treatment in childhood. When this book first appeared, much of the emphasis in clinical neuropsychology was on assessing behavioral change. In part this occurred because much of the need had been for assistance with diagnostic problems. Moreover, since many patients seen by neuropsychologists were considered too limited in their capacity to benefit from behavioral training programs and counseling, these kinds of treatment did not seem to offer practical options for their care. Yet, as one of the clinical sciences, neuropsychology has been evolving naturally: assessment tends to play a predominant role while these sciences are relatively young; treatment techniques develop as diagnostic categories and etiological relationships are defined and clarified, and the nature of the patients’ disorders become better understood. Today, treatment planning and evaluation have become not merely commonplace but often necessary considerations for neuropsychologists performing assessments. EXAMINATION PURPOSES Any of six different purposes may prompt a neuropsychological examination: diagnosis; patient care—including questions about management and planning; treatment-1: identifying treatment needs, individualizing treatment programs, and keeping abreast of patients’ changing treatment requirements; treatment-2: evaluating treatment efficacy; research, both theoretical and applied; and now in the United States and to a lesser extent elsewhere, forensic questions are frequently referred to neuropsychologists. Each purpose calls for some differences in assessment strategies. Yet many assessments serve two or more purposes, requiring the examiner to integrate the strategies in order to gain the needed information about the patient in the most focused and succinct manner possible. 1. Diagnosis. Neuropsychological assessment can be useful for discriminating between psychiatric and neurological symptoms, identifying a possible neurological disorder in a nonpsychiatric patient, helping to distinguish between different neurological conditions, and providing behavioral data for localizing the site—or at least the hemisphere side—of a lesion. However, the use of neuropsychological assessment as a diagnostic tool has diminished while its contributions to patient care and treatment and to understanding behavioral phenomena and brain function have grown. This shift is due at least in part to the development of highly sensitive and reliable noninvasive neurodiagnostic techniques (pp. 864–870, Appendix A). Today, accurate diagnosis and lesion localization are often achieved by means of the neurological examination and laboratory data. Still, conditions remain in which even the most sensitive laboratory analyses may not be diagnostically enlightening, such as toxic encephalopathies (e.g., L.A. Morrow, 1998; Rohlman et al., 2008; B. Weiss, 2010), Alzheimer’s disease and related dementing processes (e.g., Y.L. Chang et al., 2010; Derrer et al., 2001; Welsh-Bohmer et al., 2003), or some autoimmune disorders which present with psychiatric symptoms (E.K. Geary et al., 2010; Nowicka-Sauer et al., 2011; Ponsford Cameron et al., 2011). In these conditions the neuropsychological findings can be diagnostically crucial. Even when the site and extent of a brain lesion have been shown on imaging, the image will not identify the nature of residual behavioral strengths and the accompanying deficits: for this, neuropsychological assessment is needed. It has been known for decades that despite general similarities in the pattern of brain function sites, these patterns will differ more or less between people. These kinds of differences were demonstrated in three cases with localized frontal lesions that appeared quite similar on neuroimaging yet each had a distinctively different psychosocial outcome (Bigler, 2001a). Moreover, cognitive assessment can document mental abilities that are inconsistent with anatomic findings, such as the 101-year-old nun whose test scores were high but whose autopsy showed “abundant neurofibrillary tangles and senile plaques, the classic lesions of Alzheimer’s disease” (Snowdon, 1997). Markowitsch and Calabrese (1996), too, discussed instances in which patients’ level of functioning exceeded expectations based on neuroimaging. In another example, adults who had shunts to treat childhood hydrocephalus may exhibit very abnormal neuroradiological findings yet perform adequately and sometimes at superior levels on cognitive tasks (Feuillet et al., 2007; Lindquist et al., 2011).Thus, neuropsychological techniques will continue to be an essential part of the neurodiagnostic apparatus. Although limited in its applications as a primary diagnostic tool, neuropsychological assessment can aid in prodromal or early detection and prediction of dementing disorders or outcome (Seidman et al., 2010). The earliest detection of cognitive impairments during the prodrome as well as conversion to Alzheimer’s disease often comes in neuropsychological assessments (R.M. Chapman et al., 2011; Duara et al., 2011; Ewers et al., 2010). For identified carriers of the Huntington’s disease gene, the earliest impairments can show up as cognitive deficits identified in neuropsychological assessments, even before the onset of motor abnormalities (Peavy et al., 2010; Stout et al., 2011). Pharmacologic research may engage neuropsychological assessment to assist in predicting responders and best psychopharmacological treatments in mood disorders (Gudayol-Ferre et al., 2010). In patients with intractable epilepsy, neuropsychological evaluations are critical for identifying candidates for surgery as well as for implementing postsurgical programs (Baxendale and Thompson, 2010; Jones-Gotman, Smith, et al., 2010). Screening is another aspect of diagnosis. Until quite recently, screening was a rather crudely conceived affair, typically dedicated to separating out “brain damaged” patients from among a diagnostically mixed population such as might be found in long-term psychiatric care facilities. Little attention was paid to either base rate issues or the prevalence of conditions in which psychiatric and neurologic contributions were mixed and interactive (e.g., Mapou, 1988; A. Smith, 1983; C.G. Watson and Plemel, 1978; discussed this issue). Yet screening has a place in neuropsychological assessment when used in a more refined manner to identify persons most likely at risk for some specified condition or in need of further diagnostic study, and where brevity is required—whether because of the press of patients who may benefit from neuropsychological assessment (D.N. Allen et al., 1998) or because the patient’s condition may preclude a lengthy assessment (S. Walker, 1992) (also see Chapter 6, p. 175). In the last decade screening tests have been developed for identifying neurocognitive and neurobehavioral changes in TBI (traumatic brain injury) patients (Donnelly et al., 2011). 2. Patient care and planning. Whether or not diagnosis is an issue, many patients are referred for detailed information about their cognitive status, behavioral alterations, and personality characteristics—often with questions about their adjustment to their disabilities—so that they and the people responsible for their well-being may know how the neurological condition has affected their behavior. At the very least the neuropsychologist has a responsibility to describe the patient as fully as necessary for intelligent understanding and care. Descriptive evaluations may be employed in many ways in the care and treatment of brain injured patients. Precise descriptive information about cognitive and emotional status is essential for careful management of many neurological disorders. Rational planning usually depends on an understanding of patients’ capabilities and limitations, the kinds of psychological change they are undergoing, and the impact of these changes on their experiences of themselves and on their behavior. A 55-year-old right-handed management expert with a bachelor’s degree in economics was hospitalized with a stroke involving the left frontoparietal cortex three months after taking over as chief executive of a foundering firm. He had been an effective troubleshooter who devoted most of his waking hours to work. In this new post, his first as chief, his responsibilities called for abilities to analyze and integrate large amounts of information, including complex financial records and sales and manufacturing reports; creative thinking; good judgment; and rebuilding the employees’ faltering morale. Although acutely he had displayed right-sided weakness and diminished sensation involving both his arm and leg, motor and sensory functions rapidly returned to near normal levels and he was discharged from the hospital after ten days. Within five months he was walking 3 1/2 miles daily, he was using his right hand for an estimated 75% of activities, and he felt fit and ready to return to work. In questioning the wisdom of this decision, his neurologist referred him for a neuropsychological examination. This bright man achieved test scores in the high average to superior ability ranges yet his performance was punctuated by lapses of judgment (e.g., when asked what he would do if he was the first to see smoke and fire in a movie theater he said, “If you’re the first—if it’s not a dangerous fire try to put it out by yourself. However, if it’s a large fire beyond your control you should immediately alert the audience by yelling and screaming and capturing their attention.”). When directed to write what was wrong with a picture portraying two persons sitting comfortably out in the rain, he listed seven different answers such as, “Right-hand side of rain drops moves [sic] to right on right side of pict. [sic],” but completely overlooked the central problem. Impaired self- monitoring appeared in his rapid performance of a task requiring the subject to work quickly while keeping track of what has already been done (Figural Fluency Test)—he worked faster than most but left a trail of errors; in assigning numbers to symbols from memory (Symbol Digit Modalities Test) without noting that he gave the same number to two different symbols only inches apart; and in allowing two small errors to remain on a page of arithmetic calculations done without a time limit. Not surprisingly, he had word finding difficulties which showed up in his need for phonetic cueing to retrieve six words on the Boston Naming Test while not recalling two even with cueing. This problem also appeared in discourse; for example, he stated that a dog and a lion were alike in being “both members of the animal factory, I mean animal life.” On self-report of his emotional status (Beck Depression Inventory, Symptom Check List-90-R) he portrayed himself as having no qualms, suffering no emotional or psychiatric symptoms. In interview the patient assured me [mdl] that he was ready to return to a job that he relished. As his work has been his life, he had no “extracurricular” interests or activities. He denied fatigue or that his temperament had changed, insisting he was fully capable of resuming all of his managerial duties. It was concluded that the performance defects, though subtle, could be serious impediments at this occupational level. Moreover, lack of appreciation of these deficits plus the great extent to which this man’s life—and sense of dignity and self-worth—were bound up in his work suggested that he would have difficulty in understanding and accepting his condition and adapting to it in a constructive manner. His potential for serious depression seemed high. The patient was seen with his wife for a report of the examination findings with recommendations, and to evaluate his emotional situation in the light of both his wife’s reports and her capacity to understand and support him. With her present, he could no longer deny fatigue since it undermined both his efficiency and his good nature, as evident in her examples of how his efficiency and disposition were better in the morning than later in the day. She welcomed learning about fatigue as his late-day untypical irritability and cognitive lapses had puzzled her. With his neurologist’s permission, he made practical plans to return to work—for half-days only, and with an “assistant” who would review his actions and decisions. His need for this help became apparent to him after he was shown some of his failures in self-monitoring. At the same time he was given encouraging information regarding his many well-preserved abilities. Judgmental errors were not pointed out: While he could comprehend the concrete evidence of  self-monitoring errors, it would require more extensive counseling for a man with an impaired capacity for complex abstractions to grasp the complex and abstract issues involved in evaluating judgments. Moreover, learning that his stroke had rendered him careless and susceptible to fatigue was enough bad news for the patient to hear in one hour; to have given more discouraging information than was practically needed at this time would have been cruel and probably counterproductive. An interesting solution was worked out for the problem of how to get this self-acknowledged workaholic to accept a four-hour work day: If he went to work in the morning, his wife was sure he would soon begin stretching his time limit to five and six or more hours. He therefore agreed to go to work after his morning walk or a golf game and a midday rest period so that, arriving at the office after 1 PM, he was much less likely to exceed his half-day work limit. Ten months after the stroke the patient reported that he was on the job about 60 hours per week and had been told he “was doing excellent work.” He described a mild naming problem and other minor confusions. He also acknowledged some feelings of depression in the evening and a sleep disturbance for which his neurologist began medication. In many cases the neuropsychological examination can answer questions concerning patients’ capacity for self-care, reliability in following a therapeutic regimen (Galski et al., 2000), not merely the ability to drive a car but to handle traffic emergencies (J.D. Dawson et al., 2010; Marcotte Rosenthal et al., 2008; Michels et al., 2010) , or appreciation of money and of their financial situation (Cahn, Sullivan, et al., 1998; Marson et al., 2000). With all the data of a comprehensive neuropsychological examination taken together—the patient’s history, background, and present situation; the qualitative observations; and the quantitative scores—the examiner should have a realistic appreciation of how the patient reacts to deficits and can best compensate for them, and whether and how retraining could be profitably undertaken (A.-L. Christensen and Caetano, 1996; Diller, 2000; Sohlberg and Mateer, 2001). The relative sensitivity and precision of neuropsychological measurements make them well-suited for following the course of many neurological diseases and neuropsychiatric conditions (M.F. Green et al., 2004; Heaton, Grant, Butters, et al., 1995; Wild and Kaye, 1998). Neuropsychological assessment plays a key role in monitoring cognitive and neurobehavioral status following a TBI (I.H. Robertson, 2008; E.A. Wilde, Whiteneck, et al., 2010). Data from successive neuropsychological examinations repeated at regular intervals can provide reliable indications of whether the underlying neurological condition is changing, and if so, how rapidly and in what ways (e.g., Salmon, Heindel, and Lange, 1999) as, for instance, monitoring cognitive decline in dementia patients (Josephs et al., 2011; Tierney et al., 2010), since deterioration on repeated testing can identify a dementing process early in its course (J.C. Morris, McKeel, Storandt, et al., 1991; Paque and Warrington, 1995). Parenté and Anderson (1984) used repeated testing to ascertain whether brain injured candidates for rehabilitation could learn well enough to warrant cognitive retraining. Freides (1985) recommended repeated testing to evaluate performance inconsistencies in patients complaining of attentional deficits. Repeated testing may also be used to measure the effects of surgical procedures, medical treatment, or retraining. A single, 27-year-old, highly skilled logger with no history of psychiatric disturbance underwent surgical removal of a right frontotemporal subdural hematoma resulting from a car accident. Twenty months later his mother brought him, protesting but docile, to the hospital. This alert, oriented, but poorly groomed man complained of voices that came from his teeth, explaining that he received radio waves and could “communicate to their source.” He was emotionally flat with sparse speech and frequent 20-to 30-sec response latencies that occasionally disrupted his train of thought. He denied depression and sleeping or eating disturbances. He also denied delusions or hallucinations, but during an interview pointed out Ichabod Crane’s headless horseman while looking across the hospital lawn. As he became comfortable, he talked more freely and revealed that he was continually troubled by delusional ideation. His mother complained that he was almost completely reclusive, without initiative, and indifferent to his surroundings. He had some concern about being watched, and once she had heard him muttering, “I would like my mind back.” Most of his neuropsychological test scores were below those he had obtained when examined six and a half months after the injury. His only scores above average were on two tests of well-learned verbal material: background information and reading vocabulary. He received scores in the low average to borderline defective ranges on oral arithmetic, visuomotor tracking, and all visual reasoning and visuoconstructive—including drawing—tests. Although his verbal learning curve was considerably below average, immediate verbal span and verbal retention were within the average range. Immediate recall of designs was defective. Shortly after he was hospitalized and had completed a scheduled 20-month examination, he was put on trifluoperazine (Stelazine), 15 mg h.s., continuing this treatment for a month while remaining under observation. He was then reexamined. The patient was still poorly groomed, alert, and oriented. His reaction times were well within normal limits. Speech and thinking were unremarkable. While not expressing strong emotions, he smiled, complained, and displayed irritation appropriately. He reported what hallucinating had been like and related the content of some of his hallucinations. He talked about doing physical activities when he returned home but felt he was not yet ready to work. His test scores 21 months after the injury were mostly in the high average to superior ranges. Much of his gain came from faster response times which enabled him to get full credit rather than partial or no credit on timed items he had completed perfectly but slowly the previous month. Although puzzle constructions (both geometric designs and objects) were performed at a high average level, his drawing continued to be of low average quality (but better than at 20 months). All verbal memory tests were performed at average to high average levels; his visual memory test response was without error, gaining him a superior rating. He did simple visuomotor tracking tasks without error and at an average rate of speed; his score on a complex visuomotor tracking task was at the 90 th percentile. In this case, repeated testing provided documentation of both the cognitive repercussions of his psychiatric disturbance and the effects of psychotropic medication on his cognitive functioning. This case demonstrates the value of repeated testing, particularly when one or another aspect of the patient’s behavior appears to be in flux. Had testing been done only at the time of the second examination, a very distorted impression of the patient’s cognitive status would have been gained. Fortunately, since the patient was in a research project, the first examination data were available to cast doubt on the validity of the second set of tests, performed when he was acutely psychotic, and therefore the third examination was given as well. Brain impaired patients must have factual information about their functioning to understand themselves and to set realistic goals, yet their need for this information is often overlooked. Most people who sustain brain injury or disease experience changes in their selfawareness and emotional functioning; but because they are on the inside, so to speak, they may have difficulty appreciating how their behavior has changed and what about them is still the same (Prigatano and Schacter, 1991, passim). Neurological impairment may diminish a patient’s capacity for empathy (De Sousa et al., 2010) , especially when damage occurs in prefrontal regions (Bramham et al., 2009). These misperceptions tend to heighten what mental confusion may already be present as a result of altered patterns of neural activity. Distrust of their experiences, particularly their memory and perceptions, is a problem shared by many brain damaged persons, probably as a result of even very slight disruptions and alterations of the exceedingly complex neural pathways that mediate cognitive and other behavioral functions. This self- distrust seems to reflect feelings of strangeness and confusion accompanying previously familiar habits, thoughts, and sensations that are now experienced differently, and from newly acquired tendencies to make errors (T.L. Bennett and Raymond, 1997; Lezak, 1978b; see also Skloot, 2003, for a poet’s account of this experience). The selfdoubt of the brain injured person, often referred to as perplexity, is usually distinguishable from neurotic selfdoubts about life goals, values, principles, and so on, but it can be just as painful and emotionally crippling. Three years after undergoing a left frontal craniotomy for a parasagittal meningioma, a 45-year-old primary school teacher described this problem most tellingly: Perplexity, the not knowing for sure if you’re right, is difficult to cope with. Before my surgery I could repeat conversations verbatim. I knew what was said and who said it…. Since my surgery I don’t have that capability anymore. Not being able to remember for sure what was said makes me feel very insecure. Careful reporting and explanation of psychological findings can do much to allay the patient’s anxieties and dispel confusion. The following case exemplifies both patients’ needs for information about their psychological status and how disruptive even mild experiences of perplexity can be.  An attractive, unmarried 24-year-old bank teller sustained a concussion in a car accident while on a skiing trip in Europe. She appeared to have improved almost completely, with only a little residual facial numbness. When she came home, she returned to her old job but was unable to perform acceptably although she seemed capable of doing each part of it well. She lost interest in outdoor sports although her coordination and strength were essentially unimpaired. She became socially withdrawn, moody, morose, and dependent. A psychiatrist diagnosed depression, and when her unhappiness was not diminished by counseling or antidepressant drugs, he administered electroshock treatment, which gave only temporary relief. While waiting to begin a second course of shock treatment, she was given a neuropsychological examination at the request of the insurer responsible for awarding monetary compensation for her injuries. This examination demonstrated a small but definite impairment of auditory span, concentration, and mental tracking. The patient reported a pervasive sense of unsureness which she expressed in hesitancy and doubt about almost everything she did. These feelings of doubt had undermined her trust in many previously automatic responses, destroying a lively spontaneity that was once a very appealing feature of her personality. Further, like many postconcussion patients, she had compounded the problem by interpreting her inner uneasiness as symptomatic of “mental illness,” and psychiatric opinion confirmed her fears. Thus, while her cognitive impairment was not an obstacle to rehabilitation, her bewildered experience of it led to disastrous changes in her personal life. A clear explanation of her actual limitations and their implications brought immediate relief of anxiety and set the stage for sound counseling. The concerned family, too, needs to know about their patient’s condition in order to respond appropriately (D.N. Brooks, 1991; Camplair, Butler, and Lezak, 2003; Lezak, 1988a, 1996; Proulx, 1999). Family members need to understand the patient’s new, often puzzling, mental changes and what may be their psychosocial repercussions. Even quite subtle defects in motivation, in abilities to plan, organize, and carry out activities, and in self-monitoring can compromise patients’ capacities to earn a living and thus render them socially dependent. Moreover, many brain impaired patients no longer fit easily into family life as irritability, self-centeredness, impulsivity, or apathy create awesome emotional burdens on family members, generate conflicts between family members and with the patient, and strain family ties, often beyond endurance (Lezak, 1978a, 1986a; L.M. Smith and Godfrey, 1995). 3. Treatment-1: Treatment planning and remediation. Today, much more of the work of neuropsychologists is involved in treatment or research on treatment (Vanderploeg, Collins, et al., 2006). Rehabilitation programs for cognitive impairments and behavioral disorders arising from neuropathological conditions now have access to effective behavioral treatments based on neuropsychological knowledge and tested by neuropsychological techniques (for examples from different countries see: A.-L. Christensen and Uzzell, 2000; Cohadon et al., 2002; Mattioli et al., 2010; and B.[A]. Wilson, Rous, and Sopena, 2008). Of particular neuropsychological importance is the ongoing development of treatment programs for soldiers sustaining brain injuries in the Gulf, Iraq, and Afghanistan wars as well as for those injured from terrorist acts (Helmick, 2010). In the rehabilitation setting, the application of neuropsychological knowledge and neuropsychologically based treatment techniques to individual patients creates additional assessment demands: Sensitive, broadgauged, and accurate neuropsychological assessment is necessary for determining the most appropriate treatment for each rehabilitation candidate with brain dysfunction (B. Levine, Schweizer, et al., 2011; Raskin and Mateer, 2000; Sloan and Ponsford, 1995; B.[A]. Wilson, 2008). In addressing the behavioral and cognitive aspects of patient behavior, these assessments will include both delineation of problem areas and evaluation of the patient’s strengths and potential for rehabilitation. In programs of any but the shortest duration, repeated assessments will be required to adapt programs and goals to the patient’s changing needs and competencies. Since rehabilitation treatment and care is often shared by professionals from many disciplines and their subspecialties, such as psychiatrists, speech pathologists, rehabilitation counselors, and occupational and physical therapists, a current and centralized appraisal of patients’ neuropsychological status enables these treatment specialists to maintain common goals and understanding of the patient. In addition, it may clarify the problems underlying patients’ failures so that therapists know how patients might improve their performances (e.g., Greenwald and Rothi, 1998; B. [A]. Wilson, 1986). A 30-year-old lawyer, recently graduated in the top 10% of his law school class, sustained a ruptured right anterior communicating artery aneurysm. Surgical intervention stopped the bleeding but left him with memory impairments that included difficulty in retrieving stored information when searching for it and very poor prospective memory (i.e., remembering to remember some activity originally planned or agreed upon for the future, or remembering to keep track of and use needed tools such as memory aids). Other deficits associable to frontal lobe damage included diminished emotional capacity, empathic ability, selfawareness, spontaneity, drive, and initiative-taking; impaired social judgment and planning ability; and poor self-monitoring. Yet he retained verbal and academic skills and knowledge, good visuospatial and abstract reasoning abilities, appropriate social behaviors, and motor function. Following repeated failed efforts to enter the practice of law, his wife placed him in a recently organized rehabilitation program directed by a therapist whose experience had been almost exclusively with aphasic patients. The program emphasized training to enhance attentional functions and to compensate for memory deficits. This trainee learned how to keep a memory diary and notebook, which could support him through most of his usual activities and responsibilities; and he was appropriately drilled in the necessary memory and notetaking habits. What was overlooked was the overriding problem that it did not occur to him to remember what he needed to remember when he needed to remember it. (When his car keys were put aside where he could see them with instructions to get them when the examination was completed, at the end of the session he simply  left the examining room and did not think of his keys until he was outside the building and I [mdl] asked if he had forgotten something. He then demonstrated a good recall of what he had left behind and where.) One week after the conclusion of this costly eight-week program, while learning the route on a new job delivering to various mail agency offices, he laid his memory book down somewhere and never found it again—nor did he ever prepare another one for himself despite an evident need for it. An inquiry into the rehabilitation program disclosed a lack of appreciation of the nature of frontal lobe damage and the needs and limitations of persons with brain injuries of this kind. The same rehabilitation service provided a virtually identical training program to a 42-year-old civil engineer who had incurred severe attentional and memory deficits as a result of a rear-end collision in which the impact to his car threw his head forcibly back onto the head rest. This man was keenly and painfully aware of his deficits, and he retained strong emotional and motivational capacities, good social and practical judgment, and abilities for planning, initiation, and self- monitoring. He too had excellent verbal and visuospatial knowledge and skills, good reasoning ability, and no motor deficits. For him this program was very beneficial as it gave him the attentional training he needed and enhanced his spontaneously initiated efforts to compensate for his memory deficits. With this training he was able to continue doing work that was similar to what he had done before the accident, only on a relatively simplified level and a slower performance schedule. 4. Treatment-2: Treatment evaluation. With the everincreasing use of rehabilitation and retraining services must come questions regarding their worth (Kashner et al., 2003; Prigatano and Pliskin, 2003; B.[A]. Wilson, Gracey, et al., 2009). These services tend to be costly, both monetarily and in expenditure of professional time. Consumers and referring clinicians need to ask whether a given service promises more than can be delivered, or whether what is produced in terms of the patient’s behavioral changes has psychological or social value and is maintained long enough to warrant the costs. Here again, neuropsychological assessment can help answer these questions (Sohlberg and Mateer, 2001; Trexler, 2000; Vanderploeg, 1998; see also Ricker, 1998; and B. [A]. Wilson, Evans, and Keohane, 2002, for a discussion of the cost- effectiveness of neuropsychological evaluations of rehabilitation patients). Neuropsychological evaluation can often best demonstrate the neurobehavioral response—both positive and negative—to surgical interventions (e.g., B.D. Bell and Davies, 1998, temporal lobectomy for seizure control; Yoshii et al., 2008, pre-and postsurgical and radiation treatment for brain cancer; Selnes and Gottesman, 2010, coronary artery bypass surgery; McCusker et al., 2007; Vingerhoets, Van Nooten, and Jannes, 1996, open-heart surgery) or to brain stimulation (e.g., Rinehardt et al., 2010; A.E. Williams et al., 2011, to treat Parkinson’s disease; Vallar, Rusconi, and Bernardini, 1996, to improve left visuospatial awareness). Testing for drug efficacy and side effects also requires neuropsychological data (Meador, Loring, Hulihan, et al., 2003; Wilken et al., 2007). Examples of these kinds of testing programs can be found for medications for many different conditions such as cancer (C.A. Meyers, Scheibel, and Forman, 1991), HIV (human immunodeficiency virus) (Llorente, van Gorp, et al., 2001; Schifitto et al., 2007), seizure control (Wu et al., 2009), attentional deficit disorders (Kurscheidt et al., 2008; Riordan et al., 1999), multiple sclerosis (Fischer, Priore, et al., 2000; S.A. Morrow et al., 2009; Oken, Flegel, et al., 2006), hypertension (Jonas et al., 2001; Saxby et al., 2008), and psychiatric disorders (Kantrowitz et al., 2010), to list a few. 5. Research. Neuropsychological assessment has been used to study the organization of brain activity and its translation into behavior, and to investigate specific brain disorders and behavioral disabilities (this book, passim; see especially Chapters 2, 3, 7, and 8). Research with neuropsychological assessment techniques also involves their development, standardization, and evaluation. Their precision, sensitivity, and reliability make them valuable tools for studying both the large and small—and sometimes quite subtle—behavioral alterations that are then observable manifestations of underlying brain pathology. The practical foundations of clinical neuropsychology are also based to a large measure on neuropsychological research (see Hannay, Bieliauskas, et al., 1998: Houston Conference on Specialty Education and Training in Clinical Neuropsychology, 1998). Many of the tests used in neuropsychological evaluations—such as those for arithmetic or for visual memory and learning— were originally developed for the examination of normal cognitive functioning and recalibrated for neuropsychological use in the course of research on brain dysfunction. Other assessment techniques—such as certain tests of tactile identification or concept formation—were designed specifically for research on normal brain function. Their subsequent incorporation into clinical use attests to the very lively exchange between research and practice. This exchange works especially well in neuropsychology because clinician and researcher are so often one and the same. Neuropsychological research has also been crucial for understanding normal behavior and brain functions and the association of cognition with the underlying functional architecture of the brain (Mahon and Caramazza, 2009). The following areas of inquiry afford only a partial glimpse into these rapidly expanding knowledge domains. Neuropsychological assessment techniques provide the data for interpreting brain mapping studies (e.g., Friston, 2009). Cognitive status in normal aging and disease states has been tracked by neuropsychological assessments repeated over the course of years and even decades (e.g., Borghesani et al., 2010; M.E. Murray et al., 2010; Tranel, Benton, and Olson, 1997) as well as staging of dementia progression (O’Bryant et al., 2008). The contributions of demographic characteristics to the expression of mental abilities are often best delineated by neuropsychological findings (e.g., Ardila, Ostrosky-Solis, et al., 2000; Kempler et al., 1998; Vanderploeg, Axelrod, et al., 1997). Increasingly precise analyses of specific cognitive functions have been made possible by neuropsychological assessment techniques (e.g., Dollinger, 1995; Schretlen, Pearlson, et al., 2000; Troyer, Moscovitch, and Winocur, 1997). 6. Forensic neuropsychology. Neuropsychological assessment undertaken for legal proceedings has become quite commonplace in personal injury actions in which monetary compensation is sought for claims of bodily injury and loss of function (Heilbronner and Pliskin, 2003; Sweet, Meyer, et al., 2011). Although the forensic arena may be regarded as requiring some differences in assessment approaches, most questions referred to a neuropsychologist will either ask for a diagnostic opinion (e.g., “Has this person sustained brain damage as a result of … ?”) or a description of the subject’s neuropsychological status (e.g., “Will the behavioral impairment due to the subject’s neuropathological condition keep him from gainful employment? Will treatment help to return her to the workplace?”). Usually the referral for a neuropsychological evaluation will include (or at least imply) both questions (e.g., “Are the subject’s memory complaints due to … , and if so, how debilitating are they?”). In such cases, the neuropsychologist attempts to determine whether the claimant has sustained brain impairment which is associable to the injury in question. When the claimant is brain impaired, an evaluation of the type and amount of behavioral impairment sustained is intrinsically bound up with the diagnostic process. In such cases the examiner typically estimates the claimant’s rehabilitation potential along with the extent of any need for future care. Not infrequently the request for compensation may hinge on the neuropsychologist’s report. In criminal cases, a neuropsychologist may assess a defendant when there is reason to suspect that brain dysfunction contributed to the misbehavior or when there is a question about mental capacity to stand trial. The case of the murderer of President Kennedy’s alleged assailant remains as probably the most famous instance in which a psychologist determined that the defendant’s capacity for judgment and self-control was impaired by brain dysfunction (J. Kaplan and Waltz, 1965). Interestingly, the possibility that the defendant, Jack Ruby, had psychomotor epilepsy was first raised by Dr. Roy Schafer’s interpretation of the psychological test findings and subsequently confirmed by electroencephalographic (EEG) studies. At the sentencing stage of a criminal proceeding, the neuropsychologist may also be asked to give an opinion about treatment or potential for rehabilitation of a convicted defendant. Use of neuropsychologists’ examination findings, opinions, and testimony in the legal arena has engendered what, from some perspectives, seems to be a whole new industry dedicated to unearthing malingerers and exaggerators whose poor performances on neuropsychological tests make them appear to be cognitively impaired—or more impaired, in cases in which impairment may be mild. To this end, a multitude of examination techniques and new tests have been devised (Chapter 20). Whether the problem of malingering and symptom exaggeration in neuropsychological examinations is as great as the proliferation of techniques for identifying faked responding would suggest remains unanswered. Certainly, when dealing with forensic issues the examining neuropsychologist must be alert to the possibility that claimants in tort actions or defendants in criminal cases may—deliberately or unwittingly—perform below their optimal level; but the examiner must also remain mindful that for most examinees their dignity is a most prized attribute that is not readily sold. Moreover, base rates of malingering or symptom exaggeration probably vary with the population under study: TBI patients in a general clinical population would probably have a lower rate than those referred by defense lawyers who have an opportunity to screen claimants—and settle with those who are unequivocally injured—before referring the questionable cases for further study (e.g., Fox et al., 1995; see Stanczak et al., 2000, for a discussion of subject- selection biases in neuropsychological research; Ruffalo, 2003, for a discussion of examiner bias). The Multipurpose Examination Usually a neuropsychological examination serves more than one purpose. Even though the examination may be initially undertaken to answer a single question such as a diagnostic issue, the neuropsychologist may uncover vocational or family problems, or patient care needs that have been overlooked, or the patient may prove to be a suitable candidate for research. Integral to all neuropsychological assessment procedures is an evaluation of the patient’s needs and circumstances from a psychological perspective that considers quality of life, emotional status, and potential for social integration. When new information that has emerged in the course of an examination raises additional questions, the neuropsychologist will enlarge the scope of inquiry to include newly identified issues, as well as those stated in the referral. Should a single examination be required to serve several purposes— diagnosis, patient care, and research—a great deal of data may be collected about the patient and then applied selectively. For example, the examination of patients complaining of shortterm memory problems can be conducted to answer various questions. A diagnostic determination of whether shortterm memory is impaired may only require finding out if they recall significantly fewer words of a list and numbers of a series than the slowest intact adult performance. To understand how they are affected by such memory dysfunction, it is important to know the number of words they can recall freely and under what conditions, the nature of their errors, their awareness of and reactions to their deficit, and its effect on their day-to-day activities. Research might involve studying immediate memory in conjunction with a host of metabolic, neuroimaging, and electrophysiological measures that can now be performed in conjunction with neuropsychological assessment. THE VALIDITY OF NEUROPSYCHOLOGICAL ASSESSMENT A question that has been repeatedly raised about the usefulness of neuropsychological assessments concerns its “ecological” validity. Ecological validity typically refers to how well the neuropsychological assessment data reflect everyday functioning, or predict future behavior or behavioral outcomes. These questions have been partially answered—almost always affirmatively—in research that has examined relationships between neuropsychological findings and ultimate diagnoses, e.g., the detection of dementia (Salmon and Bondi, 2009), between neuropsychological findings and imaging data (Bigler, 2001b), and between neuropsychological findings and employability (Sbordone and Long, 1996; B.[A]. Wilson, 1993). Most recently very specific studies on the predictive accuracy of neuropsychological data have appeared for a variety of behavioral conditions, many focused on everyday functioning (see Marcotte and I. Grant, 2009). For example, prediction of treatment outcome for substance abuse patients rested significantly on Digit Span Backward and Beck Depression Inventory scores (Teichner et al., 2001). Hanks and colleagues (1999) found that measures of aspects of executive function (Letter-Number Sequencing, Controlled Oral Word Association Test, Trail Making Test-B, Wisconsin Card Sorting Test) along with story recall (Logical Memory) “were strongly related to measures of functional outcome six months after rehabilitation” (p. 1030) of patients with spinal cord injury, orthopedic disorders, or TBI. HIV+ patients’ employability varied with their performances on tests of memory, cognitive flexibility, and psychomotor speed (van Gorp, Baerwald, et al., 1999) as well as neuropsychological measures of multitasking (J.C. Scott et al., 2011). Test scores that correlated significantly with the functional deficits of multiple sclerosis came from the California Verbal Learning Test-long delay free recall, the Paced Auditory Serial Addition Test, the Symbol Digit Modalities Test, and two recall items from the Rivermead Behavioural Memory Test (Higginson et al., 2000). Several components of the very practical prediction of ability to perform activities of daily living (ADL) have been explored with neuropsychological assessments (A. Baird, Podell, et al., 2001; Cahn-Weiner, Boyle, and Malloy, 2002; van der Zwaluw et al., 2010) as has their accuracy for predicting real- world functional disability in neuropsychiatric disorders and predicting who is ready to drive after neurological injury or illness or at advanced ages (K.A. Ryan et al., 2009; Sommer et al., 2010; Whelihan, DiCarlo, and Paul, 2005). On reviewing several hundred examination protocols of persons referred for neuropsychological assessment, J.E. Meyers, Volbrecht, and Kaster-Bundgaard (1999) reported that discriminant function analysis of these data was 94.4% accurate in identifying competence and noncompetence in driving. Scores on an arithmetic test battery were strongly related to those on an ADL questionnaire (Deloche, Dellatolas, et al., 1996). For geriatric patients, scores from the Hooper Visual Organization Test above all, but also the Boston Naming Test and immediate recall of Logical Memory and Visual Reproduction were predictive of their safety and independence in several activity domains (E.D. Richardson, Nadler, and Malloy, 1995). A comparison of rehabilitation inpatients who fail and those who do not showed that the former made more perseverative errors on the Wisconsin Card Sorting Test and performed more poorly on the Stroop and Visual Form Discrimination tests (Rapport, Hanks, et al., 1998). A variety of neuropsychological assessment techniques have been used for TBI outcome predictions (Sherer et al., 2002). S.R. Ross and his colleagues (1997) report that two tests, the Rey Auditory Verbal Learning Test and the Trail Making Test together and “in conjunction with age significantly predicted psychosocial outcome after TBI as measured by patient report” (p. 168). A review of studies examining work status after TBI found that a number of tests used for neuropsychological assessment were predictive, especially “measures of executive functions and flexibility” (p. 23); specifically named tests were the Wisconsin Card Sorting Test, a dual—attention and memory—task, the Trail Making Test-B, and the Tinker Toy Test; findings on the predictive success (for work status) of memory tests varied considerably (Crepeau and Scherzer, 1993). Another study of TBI patients’ return to work found that “Neuropsychological test performance is related to important behavior in outpatient brain-injury survivors” (p. 382), and it further noted that “no measures of trauma severity contributed in a useful way to this prediction (of employment/unemployment)”(p. 391) (M.L. Bowman, 1996). T.W. Teasdale and colleagues (1997) also documented the validity of tests—of visuomotor speed and accuracy and complex visual learning given before entry into rehabilitation—as predictors of return to work after rehabilitation. Intact performance on verbal reasoning, speed of processing, and visuo-perceptual measures predicted functional outcome one year after the TBI event (Sigurdardottir et al., 2009). WHAT CAN WE EXPECT OF NEUROPSYCHOLOGICAL ASSESSMENT IN THE 21ST CENTURY? Neuropsychological Assessment (1976) was the first textbook to include “Neuropsychological” and “Assessment” in its title. The first citable publication with “clinical neuropsychology” in its title was Halgrim KWe’s 1963 article, followed by the first citable journal article with “neuropsychological assessment” in its title in 1970 by M.L. Schwartz and Dennerll. By early 2011, the National Library of Medicine has listed almost 56,000 articles related to neuropsychological assessment! This number alone represents a powerful acknowledgment of neuropsychological assessment’s importance for understanding brain function, cognition, and behavior. In the first chapter of the last two editions of Neuropsychological Assessment predictions were made about the futu