Principles of Neuropsychology PDF

 Second Edition PRINCIPLES OF NEUROPSYCHOLOGY Eric A. Zillmer Drexel University Mary V. Spiers...

 Second Edition PRINCIPLES OF NEUROPSYCHOLOGY Eric A. Zillmer Drexel University Mary V. Spiers Drexel University William C. Culbertson Drexel University Australia | Brazil | Canada | Mexico | Singapore | Spain | United Kingdom | United States  Principles of Neuropsychology, Second Edition Eric A. Zillmer, Mary V. Spiers, William C. Culbertson Acquisitions Editor: Erik Evans Permissions Editor: Robert Kauser Assistant Editor: Gina Kessler Production Service: Graphic World Inc. Editorial Assistant: Christina D. Ganim Photo Researcher: Terri Wright Technology Project Manager: Lauren Keyes Copy Editor: Graphic World Inc. 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No part of this work covered by the copyright hereon may be reproduced or used in any form or by any means—graphic, electronic, or mechanical, including For more information about our products, contact us at: photocopying, recording, taping, Web distribution, informa- Thomson Learning Academic Resource Center tion storage and retrieval systems, or in any other manner— 1-800-423-0563 without the written permission of the publisher. For permission to use material from this text or product, Printed in the United States of America submit a request online at 1 2 3 4 5 6 7 11 10 09 08 07 http://www.thomsonrights.com. Any additional questions about permissions can be submit- Library of Congress Control Number: 2007920598 ted by e-mail to [email protected]. ISBN-13: 978-0-495-00376-2 ISBN-10: 0-495-00376-X  This book is dedicated to the memory of Carl R. Pacifico Drexel Alumnus, Class of ’44 Friend, Mentor, Benefactor E.A.Z. This book is dedicated to my father. His guidance as a psychologist and his personal struggle with Parkinson’s disease have brought some of my greatest lessons. M.V.S. This book is dedicated to my wife and daughter, my greatest gifts. W.C.C. This page intentionally left blank  BRIEF CONTENTS Part One Introduction 1 Chapter 1 A History of Neuropsychology 3 Chapter 2 Methods of Investigating the Brain 32 Chapter 3 Neuropsychological Assessment and Diagnosis 62 Part Two The Functioning Brain 91 Chapter 4 Cells of Thought 93 Chapter 5 Functional Neuroanatomy 114 Chapter 6 Cerebral Specialization 154 Chapter 7 Somatosensory, Chemical, and Motor Systems 176 Chapter 8 Vision and Language 199 Chapter 9 Memory, Attention, Emotion, and Executive Functioning 224 Part Three Disorders of the Brain 267 Chapter 10 Developmental Disorders of Childhood 269 Chapter 11 Learning and Neuropsychiatric Disorders of Childhood 297 Chapter 12 Cerebrovascular Disorders and Tumors 339 Chapter 13 Traumatic Head Injury and Rehabilitation 369 Chapter 14 Normal Aging and Dementia: Alzheimer’s Disease 399 Chapter 15 Subcortical Dementias 423 Chapter 16 Alterations of Consciousness 443 v This page intentionally left blank  CONTENTS Part One INTRODUCTION 1 Chapter 1 A History of Neuropsychology 3 Keep in Mind 4 Overview 4 The Brain in Antiquity: Early Hypotheses 5 Ancient Greek Perspectives 6 The Cell Doctrine 7 Anatomic Discoveries and the Role of the Spiritual Soul 8 Non-Western Attitudes 12 Localization Theory 13 Phrenology and Faculty Psychology 13 The Era of Cortical Localization 16 Critics of Cortical Localization 18 Localization versus Equipotentiality 20 Integrated Theories of Brain Function 20 Jackson’s Alternative Model 20 Luria’s Functional Model 21 Modern Neuropsychology 24 Emerging Research Areas in Neuropsychology 27 Forensic Neuropsychology 28 Sports Neuropsychology 28 Terrorism, Law Enforcement, and the Military 28 Summary 30 Critical Thinking Questions 30 Key Terms 30 Web Connections 30 Neuropsychology in Action 1.1 The Brain of a Nazi 15 1.2 Paul Broca: A Manner of Not Speaking 17 1.3 Sigmund Freud: The Neurologist 19 1.4 The Walter Freeman Lobotomies: Mind over Matter? 22 Chapter 2 Methods of Investigating the Brain 32 Keep in Mind 33 Overview 33 Neurohistology Techniques 34 Golgi Stain 34 Nissl Stain 34 Other Staining Techniques 35 vii viii Contents Radiologic Procedures 35 Skull X-Ray 36 Air Encephalography (Pneumoencephalography) 36 Computed Transaxial Tomography 36 Angiography 38 Sodium Amytal Injections (Wada Technique) 40 Electrophysiologic Procedures 40 Electroencephalography 40 Evoked Potential 44 Electrical Stimulation 45 Electromyography 47 Imaging of Brain Metabolism 47 Regional Cerebral Blood Flow 47 Single-Photon Emission Computed Tomography 48 Positron Emission Tomography 49 Magnetic Imaging Procedures 51 Magnetic Resonance Imaging 51 Magnetoencephalography 56 Cerebrospinal Fluid Studies: Lumbar Puncture 56 Behavioral Examinations 56 Neurologic Examination 56 Neuropsychological Evaluation 57 New Advances in Imaging Techniques: Mapping the Brain 57 Subtraction Procedures 57 Image Analysis and Quantification (Three-Dimensional) 57 Future Directions 58 Summary 60 Critical Thinking Questions 61 Key Terms 61 Web Connections 61 Neuropsychology in Action 2.1 Case Example of Brainstem Auditory-Evoked Response 46 2.2 Undergoing a Magnetic Resonance Imaging Procedure 52 2.3 New Frontiers in Functional Magnetic Resonance Imaging 54 2.4 Diagnostic Neuroimaging and Neuropsychology 59 Chapter 3 Neuropsychological Assessment a n d D i a g n o s i s 62 Keep in Mind 63 Overview 63 General Considerations in Neuropsychological Testing 63 Why Testing? 64 Rationale of the Neuropsychological Examination 65 Appropriate Referrals for Neuropsychological Evaluation 66 Psychometric Issues in Neuropsychological Assessment 66 Reliability 67 Validity 67 False Positives and Base Rates 67  Contents ix Neuropsychological Tests 68 Orientation (Arousal) 69 Sensation and Perception 70 Attention/Concentration 71 Motor Skills 72 Verbal Functions/Language 73 Visuospatial Organization 74 Memory 75 Judgment/Problem Solving 76 Neuropsychological Diagnosis 78 Describing Function, Adaptation, and Prognosis 79 Interpreting Neuropsychological Assessment Data 79 Approaches to Neuropsychological Interpretation 80 Assessing Level of Performance 84 Deficit Measurement 86 Lateralizing Signs 88 Pathognomonic Signs (Qualitative Observations) 88 Summary 89 Critical Thinking Questions 89 Key Terms 89 Web Connections 89 Neuropsychology in Action 3.1 Case Example: The Neuropsychology of Lyme Disease 86 Part Two THE FUNCTIONING BRAIN 91 Chapter 4 Cells of Thought 93 Keep in Mind 94 Overview 94 Neurons and Glial Cells 94 Structure and Function of the Neuron 95 Glial Cells 99 Communication within a Neuron: The Neural Impulse 102 Resting Membrane Potential 102 Action Potential 102 Communication among Neurons 105 Structure of Synapses 105 Synaptic Transmission 105 Neurotransmitters 106 Regeneration of Neurons 110 Summary 112 Critical Thinking Questions 112 Key Terms 112 Web Connections 113 Neuropsychology in Action 4.1 Short-Circuiting Neurons: Multiple Sclerosis 98 4.2 Neuronal Firing: Clinical Examples 104 x Contents 4.3 What Can We Learn from Songbirds? 109 4.4 Stem Cell Research: Science and Ethics 110 Chapter 5 Functional Neuroanatomy 114 Keep in Mind 115 Overview 115 Anatomic and Functional Development of the Brain 116 Neurogenesis and Cellular Migration 116 Axon and Dendrite Development 117 Synaptogenesis 117 Myelination 117 Pruning 118 Regional Development 118 Lobular and Convolutional Development 118 Ventricular and Spinal Cord Development 119 Postnatal Development 120 Organization of the Nervous System 121 Peripheral Nervous System 122 Central Nervous System 122 Brain 122 Spinal Cord 123 Gross Anatomy: Protection and Sustenance of the Brain 124 Skull 125 Meninges 125 Ventricular System 127 Vascular System 131 Cerebral Arteries 132 Venous System 133 Principal Divisions of the Brain 133 Brainstem and Cerebellum 134 Lower Brainstem 137 Upper Brainstem: Diencephalon 141 Cerebellum 146 Telencephalon 147 Basal Ganglia 147 Limbic System 149 Corpus Callosum 151 Summary 152 Critical Thinking Questions 152 Key Terms 152 Web Connections 153 Chapter 6 Cerebral Specialization 154 Keep in Mind 155 Overview 155 The Cerebral Hemispheres 155 Structure 155  Contents xi Function 159 Asymmetry, Lateralization, and Dominance 161 Hemispheric Anatomic and Functional Differences 163 Neuropsychological and Behavioral Cerebral Differences 166 Sex Differences and Hemispheric Specialization 167 Sexual Hormones 171 Summary 175 Critical Thinking Questions 175 Key Terms 175 Web Connections 175 Neuropsychology in Action 6.1 The Evolution of the Brain: A Focus on Brain Size 156 6.2 A Land Where Girls Rule in Math 172 Chapter 7 S o m a t o s e n s o r y, C h e m i c a l , a n d M o t o r S y s t e m s 176 Keep in Mind 177 Overview 177 Somatosensory Processing 178 Chemical Senses 184 Taste 184 Smell 187 Motor Systems 189 Cortical Motor Processing 189 The Cerebellum and Motor Processing 195 Subcortical Motor Processing 195 Summary 197 Critical Thinking Questions 197 Key Terms 197 Web Connections 198 Neuropsychology in Action 7.1 Synesthesia: Melded Sensory Integration 179 7.2 Phantoms of Feeling 184 7.3 Tourette Syndrome: Too Much Behavior 196 Chapter 8 Vision and Language 199 Keep in Mind 200 Overview 200 Visual Processing 200 Primary Visual Processing 201 Higher Visual Processing: Object Recognition and Spatial Localization 204 Auditory and Language Processing 215 Primary Auditory Processing 215 Higher Auditory Processing: Speech and Language 215 Aphasia: A Breakdown of Language 219 xii Contents Summary 221 Critical Thinking Questions 222 Key Terms 222 Web Connections 222 Neuropsychology in Action 8.1 Blindness: Helping Us See the Plasticity of the Brain 205 8.2 The Case of Jonathan 206 8.3 Case Study: Neglect 211 Chapter 9 M e m o r y, A t t e n t i o n , E m o t i o n , a n d E x e c u t i v e F u n c t i o n i n g 224 Keep in Mind 225 Overview 225 Memory Systems 225 A Framework for Conceptualizing Memory Systems 226 Long-Term Memory 227 Short-Term Memory and Working Memory 237 Attention 240 Subcortical Structures Influencing Attention 240 The Cerebral Cortex and Attention 241 Models of Attention 242 Executive Functioning 246 Development of Executive Functions 247 Frontal-Mediated Functions and Dysfunctions 252 Relation of Memory, Attention, and Executive Function 258 Neuropsychology of Emotional Processing 259 Brain Organization of Emotion 260 Summary 264 Critical Thinking Questions 264 Key Terms 265 Web Connections 265 Neuropsychology in Action 9.1 Amnesia: The Case of N.A. 227 9.2 Executive Function Tasks 248 9.3 The Case of Phineas Gage 255 Part Three DISORDERS OF THE BRAIN 267 Chapter 10 Developmental Disorders of Childhood 269 Keep in Mind 270 Overview 270 Vulnerability and Plasticity of the Developing Brain 270 Child and Adult Brain: Structural and Functional Differences 273 Specific Developmental Disorders 274 Abnormalities of Anatomic Development 274 Genetic and Chromosomal Disorders 281 Acquired Disorders 291  Contents xiii Summary 295 Critical Thinking Questions 295 Key Terms 295 Web Connections 295 Neuropsychology in Action 10.1 Principles of Assessment in Pediatric Neuropsychology 275 Chapter 11 Learning and Neuropsychiatric Disorders o f C h i l d h o o d 297 Keep in Mind 298 Overview 298 Learning Disabilities 298 Verbal Learning Disability: Dyslexia 299 Nonverbal Learning Disability Syndrome 305 Pervasive Developmental Disorders 310 Autism 311 Disruptive Behavioral Disorders 322 Attention-Deficit/Hyperactivity Disorder 322 Tic Disorders 332 Gilles de la Tourette’s Syndrome 332 Summary 337 Critical Thinking Questions 337 Key Terms 338 Web Connections 338 Neuropsychology in Action 11.1 Genetics of Learning Disabilities 300 11.2 Case Study of an Adolescent with Asperger’s Syndrome 314 11.3 Case Study of a Child with an Attention-Deficit/Hyperactivity Disorder 327 Chapter 12 C e r e b r o v a s c u l a r D i s o r d e r s a n d Tu m o r s 339 Keep in Mind 340 Overview 340 Pathologic Process of Brain Damage 340 Brain Lesions 340 Anoxia and Hypoxia: Oxygen Deprivation to the Brain 341 Hydrocephalus 342 Overview of Cerebrovascular Disorders 342 Stroke Definition 343 Impairment of Blood Supply to the Brain 344 Types of Cerebrovascular Disorders 344 Transient Ischemic Attacks 344 Infarctions 345 Hemorrhage 346 Diagnosing Cerebrovascular Disease 347 Computed Transaxial Tomography 349 Angiography 349 Other Tests 349 xiv Contents Treatment and Prognosis of Vascular Disorders 349 Factors Involved in Stroke Recovery 349 Medical Treatment 350 Preventing Stroke 350 Neuropsychological Deficits Associated with Stroke 351 Neuropsychological Risk Factors 351 Attention Deficits 352 Memory Problems 353 Deficits in Abstract Reasoning 353 Cognitive Deficits Associated with Right Brain Strokes 353 Cognitive Deficits Associated with Left Brain Damage 355 Anterior versus Posterior Strokes 356 Emotional and Behavioral Changes after a Stroke 356 Tumors of the Brain 357 Types of Intracranial Tumors 359 Infiltrating Tumors 359 Noninfiltrating Tumors 359 Childhood Tumors 361 Diagnosis of Brain Tumors 361 Treatment of Brain Tumors 362 Brain Tumors and Neuropsychology 363 Other Neurologic Disorders 363 Brain Abscess 363 Infections 363 Neurotoxins 365 Summary 367 Critical Thinking Questions 367 Key Terms 368 Web Connections 368 Neuropsychology in Action 12.1 Migraine Headache: A Vascular Disorder of the Brain 348 12.2 Case Example of a Left Stroke 354 12.3 Neuropsychology of Treatments for Individuals with Brain Tumors 364 12.4 Family and Child Adjustment to Cognitive Aspects of Cancer in Children 366 Chapter 13 Tr a u m a t i c H e a d I n j u r y a n d R e h a b i l i t a t i o n 369 Keep in Mind 370 Overview 370 Traumatic Head Injury 370 Epidemiology of Traumatic Head Injury 371 Mechanism of Impact: Neuronal Shearing, Stretching, and Tearing 371 Penetrating Head Injury 373 Closed Head Injury 373 Assessing the Severity of Brain Injury 375 Complications of Moderate and Severe Brain Injury 376 Edema 376 Brain Herniation 376 Extradural and Subdural Hemorrhage 377  Contents xv Intracranial Bleeding 378 Skull Fractures 378 Post-traumatic Epilepsy 379 Mild Head Injury: “Concussions” 379 Sports-Related Concussions: A Neuropsychological Perspective 381 Postconcussional Syndrome 385 Treatment of Head Injuries 385 Neuropsychological Manifestations 386 Recovery, Rehabilitation, and Intervention of Traumatic Brain Injury 388 Adaptation and Recovery 388 Diaschisis 388 Brain Reorganization 389 Overview of the Rehabilitation Process 389 Admission to Rehabilitation Programs 390 Evaluation of Goals and Discharge Planning 393 Treatment Planning 394 Assessment of Everyday Activities 394 Treatment Methods for Neuropsychological Rehabilitation 395 Psychotherapy in Rehabilitation 395 Summary 397 Critical Thinking Questions 398 Key Terms 398 Web Connections 398 Neuropsychology in Action 13.1 Case Study: Penetrating Head Injury 374 13.2 Can a Concussion Change Your Life? 380 13.3 Consensual Sex after Traumatic Brain Injury: Sex as a Problem-Solving Task 386 13.4 It Is More Than a Black Box 396 Chapter 14 Normal Aging and Dementia: A l z h e i m e r ’ s D i s e a s e 399 Keep in Mind 400 Overview 400 Normal Aging 400 Cognitive Changes Associated with Aging 401 Brain Changes Associated with Aging 404 Mild Cognitive Impairment 405 Summary 406 Defining Dementia 406 Diagnostic Criteria for Dementia 407 Subtypes and Classifications of Dementia 408 Alzheimer’s Disease 409 Diagnostic Problem of Alzheimer’s Disease 409 Neuropathology of Alzheimer’s Disease 411 Histologic Markers 411 Clinical Presentation and Neuropsychological Profile of Alzheimer’s Disease 413 Treatment 420 xvi Contents Treatments for Cognitive Enhancement 420 Cognitive, Behavioral, and Psychiatric Symptom Control 421 Summary 421 Critical Thinking Questions 421 Key Terms 422 Web Connections 422 Neuropsychology in Action 14.1 The Discovery of Alzheimer’s Disease 410 14.2 Differentiating between Symptoms of Alzheimer’s Disease and Normal Aging 414 Chapter 15 Subcortical Dementias 423 Keep in Mind 424 Overview 424 Parkinson’s Disease 424 Neuropathology of Parkinson’s Disease 424 Clinical Presentation and Neuropsychological Profile of Parkinson’s Disease 425 Treatments for Parkinson’s Disease 431 Huntington’s Disease 434 Neuropathology of Huntington’s Disease 434 Clinical Presentation and Neuropsychological Profile of Huntington’s Disease 435 Creutzfeldt–Jakob Disease 436 Neuropathology of Creutzfeldt–Jakob Disease 438 Clinical Presentation and Neuropsychological Profile of Creutzfeldt–Jakob Disease 439 Summary 441 Critical Thinking Questions 442 Key Terms 442 Web Connections 442 Neuropsychology in Action 15.1 Understanding Subcortical Dementia 426 15.2 Pallidotomy Surgery: A Case Report 432 15.3 Testing Fate: Would You Want to Know If You Were Going to Get Huntington’s Disease? 435 15.4 Creutzfeldt–Jakob Disease and Mad Cow Disease: What’s the Connection? 438 15.5 The Neurologic Examination for Dementia 440 Chapter 16 Alterations of Consciousness 443 Keep in Mind 444 Overview 444 Understanding Consciousness 444 Mind and Brain 445 Anatomic Correlates of Consciousness 447 Rhythms of Consciousness 449 The Brain and Mind in Sleep 451 Sleep Architecture 451 Sleep Anatomy and Physiology 456 Reticular Activating System and Rapid Eye Movement Sleep 456 Functions of Rapid Eye Movement Sleep 459 Sleep Disorders 461  Contents xvii Runaway Brain: Seizure Disorders 463 Classification of Seizure Types 464 Neuroanatomy and Neurophysiology of Seizures 467 Neuropsychological Presentation 469 Treatment of Epilepsy 472 Summary 474 Critical Thinking Questions 474 Key Terms 474 Web Connections 475 Neuropsychology in Action 16.1 Self in the Mirror 446 16.2 The Case of the Last Coronation 450 16.3 Lucid Dreaming: A Paradox of Consciousness 453 16.4 Déjà Vu and Epilepsy 465 16.5 Epilepsy and the Case of the Sweeping Lady 468 References 477 Glossary 511 Answers to Critical Thinking Questions 539 Name Index 551 Subject Index 561 This page intentionally left blank  PREFACE How can behavior make neuropsychological sense? That components, we believe it is most useful for aspiring prac- is the question we try to answer when we teach neuropsy- titioners and researchers to obtain a comprehensive view chology to our students. Like many teachers, we have had of each neurologic disorder with its multiple cognitive the experience of observing instructors and examining components. books on the topic of neuropsychology that presented the material in an esoteric manner removed from real-life sit- 2. An emphasis on integrating theory and research uations. Neuropsychology is an exciting and dynamic The integration of theory with studies of neuroanatomic field that readily stimulates and inspires students and structure and functioning is central to a dynamic under- teachers alike. It was with this goal in mind that we have standing of neuropsychology. In this respect, Principles of written a progressive and accessible text on the study of Neuropsychology reviews general theories of brain function neuropsychology. and specific theories of higher cortical functioning. A con- The goal of Principles of Neuropsychology was to write ceptual understanding of brain function is important be- an undergraduate or beginning graduate-level psychology cause it provides a foundation on which to base the study textbook that teaches brain function in a clear, interest- of complex behavioral syndromes as they correspond to ing, and progressive manner. The guiding thesis of Prin- brain regions and neuronal networks. Otherwise, nothing ciples of Neuropsychology is that all interactions in daily more than the memorization of brain anatomy and corre- life, whether adaptive or maladaptive, can be explained sponding behavioral correlates is achieved, and an inte- neuropsychologically. Thus, the text challenges the reader grated understanding of neuropsychology remains out of to consider behavior from a broader biological perspec- reach. tive. This, in turn, leads to the conceptualization of a more neuropsychologically oriented discipline within psy- 3. An emphasis on behavioral function chology. In this respect, the text covers the role of the We give special attention to presenting the function of brain in behavior as simple as a reflex and as complex as specific neuroanatomic structures. Students often do not personality. Principles of Neuropsychology stresses the fol- absorb the tremendous amount of information presented lowing specific ideas: in similar texts because the material is presented in isola- tion, out of a psychological context. In this text, we pres- 1. An emphasis on human neuropsychology, experi- ent basic neurobiology as it relates specifically to behav- mental and clinical ior. Using such a functional approach facilitates both the Human neuropsychology is most appealing to psychology absorption and comprehension of the material. students, given that approximately half of all professional psychologists identify with a clinical or counseling spe- 4. A focus on presenting real-life examples cialty. A major focus of Principles of Neuropsychology is to To facilitate the reader’s understanding of complex mate- integrate the relatively new field of human clinical neu- rial and to augment specific points, Principles of Neuropsy- ropsychology and compare it with what is known about chology includes numerous examples of clinical and nor- the normal brain. mal cases, procedures, and classic research findings at Rather than focus on a purely cognitive organization, strategic places in the text. Like many other teachers, we which characterizes brain functioning and behavior ac- find that didactic information is better understood when cording to specific aspects or components such as mem- “real-life” situations are used. Many of the cases and proce- ory, attention, or executive functioning, we chose to focus dures draw on our clinical and research experiences, which on disorders. Because neurologic disorders are multifaceted we accumulated in a variety of settings and services in- and usually involve overlapping and interacting cognitive cluding state psychiatric hospitals, sleep centers, psychiatry xix xx Preface departments, rehabilitation hospitals, and neurology and have integrated the latest studies and research to give stu- neurosurgery services. Throughout the text, we feature dents the most up-to-date information in this dynamic case examples and Neuropsychology in Action boxes, and expanding field. Furthermore, this edition includes written by prominent neuropsychologists, that focus on an increased emphasis on neuroscience coverage to pro- interesting current issues related to brain functioning. vide empirical data in support of the discussions of neu- ropsychology. Clinical examples throughout the text are 5. The presentation of didactic aids updated in support of the new research in the developing Principles of Neuropsychology differs from other texts on the field of neuropsychology. This second edition also pro- didactic dimension, because it uses unique aids to facilitate vides additional chapters and coverage on topics of So- learning. These aids include an Instructor’s Manual, which matosensory, Chemical and Motor Systems, Vision and provides outlines, class exercises, additional reference mate- Language, and Memory, Attention, and Executive Func- rials, and didactic information; Web support, which in- tioning. A reorganization of the material now places as- cludes practice examinations, exercises, and additional refer- sessment methods of the brain, both medical and psycho- ence materials; more than 200 illustrations in the text; color logical, at the beginning of the text to introduce students illustrations; boldfaced Key Terms throughout the text, to this area early in their studies. which are listed at the end of each chapter and again in the In summary, the intent of Principles of Neuropsychology Glossary at the end of the text; a Keep in Mind section at is to discuss brain functions, neurophysiology, and neu- the beginning of each chapter and Critical Thinking Ques- roanatomy in an integrated and accessible format. An in- tions at the end of each chapter; and annotations on Web depth discussion on the relation among neuroscience, sites, called Web Connections, at the end of each chapter. anatomy, and behavior is emphasized. Numerous exam- The companion Web sites for students and instructors ples of clinical and real-life examples of neuropsychology have been updated and expanded for the new edition with are provided, as is a focus on relevant scientific and theo- a format that is easier to navigate. Now you will find retical contributions in the field of neuropsychology. chapter-by-chapter glossaries and interactive flash cards, Unique to the study of neuropsychology is an organiza- plus videos and more practice exercises. To access these tion of the material from history, assessment, neu- features and more, visit http://www.thomsonedu.com/ roanatomy, to clinical assessment that makes intuitive and psychology/zillmer. For instructors, the Instructor’s Manual didactic sense. To facilitate a dynamic understanding of with Test Bank has been updated for the new edition and the field, the text emphasizes theory, functional process, contains even more sample test items. Many of the figures case examples, and research, related to what has been and tables from the book are available for instructors as learned about normal and neuropathological functioning. PowerPoint® electronic transparencies. Approaching the field from this perspective challenges This second edition was revised related to the many students to examine the field of neuropsychology as a suggestions that we have received. Specifically, the authors framework for behavior.  ABOUT THE AUTHORS Dr. Eric A. Zillmer, a licensed Clinical Psychologist, Personality, published in 1995, has been summarized received his Doctorate in Clinical Psychology from as the definitive psychological analysis of Third Reich Florida Tech in 1984 and was subsequently war criminals. He is the coauthor of the d2 Test of awarded the Outstanding Alumnus Award in 1995. Attention and the Tower of London test. Dr. Zillmer Dr. Zillmer completed internship training at Eastern serves on the editorial boards of Journal of Personality Virginia Medical School and a postdoctoral fellowship Assessment and Archives of Clinical Neuropsychology. in clinical neuropsychology at the University of Vir- His most recent book is entitled Military Psychology— ginia Medical School. A member of Drexel Univer- Clinical and Operational Applications (2006). Dr. sity’s faculty since 1988, Dr. Zillmer is a Fellow of the Zillmer currently serves as the Director of Athletics College of Physicians of Philadelphia, the American at Drexel University. Psychological Association, the Society for Personality Assessment, and the National Academy of Neuropsy- Dr. Mary V. Spiers is Associate Professor of Psychol- chology, for which he has also served as President. He ogy in the Department of Psychology at Drexel Uni- has written extensively in the area of sports psychol- versity and is a licensed Clinical Psychologist ogy, neuropsychology, and psychological assessment, specializing in Neuropsychology. She earned her having published more than 100 journal articles, book Ph.D. in Clinical Psychology from the University of chapters, and books, and he is a frequent contributor Alabama at Birmingham, where she specialized in to the local and national media on topics ranging medical psychology and neuropsychology. Dr. Spiers’s from sports psychology, forensic psychology, to the research and clinical expertise is in two areas. The first psychology of terrorism. The Quest for the Nazi area is neuropsychological assessment with a focus on xxi xxii About the Authors everyday problems of memory. She has developed assessment and treatment of childhood and adolescent tests to assess memory and cognitive problems in daily disorders, particularly those with attention-deficit/ medication taking. Recently, she has focused on the hyperactivity disorder. He received his doctorate degree development of ecologically valid spatial memory tests from Rutgers University and completed a postdoctoral within a virtual reality environment. Dr. Spiers’s second fellowship in neuropsychology at Drexel University. area of focus relates to cognitive performance and strat- Dr. Culbertson’s research interests are in the assess- egy differences related to sex and gender. She leads the ment of higher order problem-solving ability, specifi- Women’s Cognitive Health Research Group at Drexel cally as it relates to assessing frontal lobe damage, and University, whose aim is to investigate variation in brain executive functioning deficits. Dr. Culbertson has pub- functioning through the influence of sex and gender, the lished in the field of neuropsychology (e.g., Assessment, menstrual cycle, genetics/handedness, experience, and Archives of Clinical Neuropsychology) and presented at culture. She regularly teaches Neuropsychology on both professional conferences. He is an Associate Visiting the undergraduate and graduate levels. In addition, she Scholar at the University of Pennsylvania and has has taught a variety of graduate courses related to clini- taught at Drexel University, both at the undergraduate cal assessment and memory, including Neuropsycholog- and graduate level, including Counseling Psychology, ical Assessment, Neuropsychological Case Analysis, and Developmental Psychology, Cognitive Psychology, Models of Memory in Neuropsychology. Theories of Personality, and various Seminars in Neuropsychology. He is a coauthor of the Tower of Dr. William C. Culbertson is in private practice as a LondonDX, now in its second edition, which is a Clinical Neuropsychologist who specializes in the neuropsychological measure of executive function.  ACKNOWLEDGMENTS This book could not have been written without the coop- efforts. Psychology undergraduate and graduate students eration, assistance, and support of numerous individuals. who provided valuable research support on the first edi- Many students, scholars, and friends listened to us, of- tion included Barbara Holda, Priti Panchal, Dan Rosenberg, fered suggestions, and provided encouragement along the Holly Giordano, Stephanie Cosentino, Carrie Kennedy, way. Many reviewers helped shape the book from begin- Melissa Lamar, and Cate Price. Drexel University students ning to end. We are most grateful to the following review- in Dr. Spiers’s undergraduate and graduate neuropsychol- ers for their generous contributions to this second edition: ogy classes provided valuable comments on both the Joan Ballard, SUNY Geneseo; Jody Bain, University of structure and content of this second edition. Special Victoria; Robert Deysach, University of South Carolina; thanks go to Karen Friedman, who coordinated reference Kenneth Green, California State University Long Beach; updating in this second edition; to Heather McNiece, Julian Keenan, Montclair State University; Ann Marie who coordinated the Key Terms and Glossary; and to Leonard-Zabel, Curry College; Jim Nelson, Valparaiso Maiko Sakamoto, who assisted with the question bank. University; Elizabeth Seebach, Saint Mary’s University of Appreciation also goes to our colleagues Sepp Zihl and Minnesota; Pamela Stuntz, Texas Christian University; Karin Muenzel, both from the Ludwig-Maximilians Benjamin Walker, Georgetown University; Arthur Wing- University, Institute für Neuropsychologie, in Munich, field, Brandeis University; Nancy Zook, Purchase College Germany. Sepp and Karin allowed Dr. Zillmer to teach SUNY. We would also like to thank those who con- neuropsychology in an international forum. Our discus- tributed to the previous edition: Timothy Barth, Texas sions on neuropsychology have been most stimulating and Christian University; Richard Bauer, Middle Tennessee inspiring and have provided a springboard for many issues State University; Gary Berntson, Ohio State University; discussed in this text. We also want to acknowledge our col- Thomas Fikes, Westmont College; Michael R. Foy, Loyola leagues Mark Chelder and Joelle Efthimiou, who have as- Marymount University; Kenneth F. Green, California sisted us in the development of the Assessment of Impair- State University Long Beach; Gary Hanson, Francis Marion ment Measure (AIM), which we have used extensively University; Barbara Knowlton, University of California throughout the text to demonstrate the principles of neu- Los Angeles; Paul Koch, St. Ambrose University; Mark ropsychological assessment. McCourt, North Dakota State University; James Rose, Our friend Carl Pacifico played a special role in this University of Wyomong; Lawrence Ryan, Oregon State venture. He reminded us of how important it is to think University; Bennett Schwartz, Florida International Uni- about brain-behavior functioning within the context of versity; Michael Selby, California Polytechnic Institute; evolution. Carl, ever the pragmatist, also shaped our Frank Webbe, Florida Institute of Technology; and finally, thinking about the functional and applied aspects of neu- the many reviewers who did not wish to be named. We ropsychology. We especially welcomed the occasions when would also like to acknowledge those scholars who have we discussed neuropsychology and its relation to culture, contributed Neuropsychology in Action boxes to this text. religion, and philosophy. All of them are prominent neuropsychologists who have, Special recognition goes to key administrators at going beyond the call of duty, given valuable time to make Drexel University. Former Dean of the College of Arts Principles of Neuropsychology “come alive.” and Sciences Thomas Canavan provided encouragement Drexel University psychology students played an im- for our doctoral program in neuropsychology at Drexel and portant role in this project. They read initial chapters and assistance for the successful APA accreditation process. Con- provided feedback, were willing to use early versions of stantine “Taki” Papadakis, President of Drexel University, is the manuscript as their textbook in class, and provided acknowledged for revitalizing our university and, most important research assistance. Simply put, this project importantly, making Drexel an exciting and fun place to could not have been accomplished without their diligent teach and to do research. xxiii xxiv Acknowledgments Our department faculty served as an important discus- daughter, Kanya, for their support. Dr. Spiers thanks sion group, “think tank,” and sounding board; whether it her husband, Sean, for his patience and understanding. was around the copying machine, in the hallways, or over Dr. Culbertson acknowledges his wife, Nancy, who lunch, they allowed us to argue over the role of the brain provided countless hours of critical readings, tolerated his and its relation to behavior. Thanks to Doug Porpora, absences during those periods when he needed to write, David Kutzik, Tom Hewett, Elizabeth Petras, Arthur and was unwavering in her support. Shostak, Doug Chute, Lamia Barakat, and Anthony Glas- We cannot think of having had better editors for this cock. Dorota Kozinska, at the University of Warsaw, project. We thank the production editor, Dan Fitzgerald, Poland, taught us the three-dimensional imaging of brains and the psychology editor, Erik Evans, assistant editor, and provided state-of-the-art brain electrical activity map- Gina Kessler, and editorial assistant, Christina Ganim. ping pictures. Erin D. Bigler, Professor of Psychology at They took our project seriously and forced us to focus on Brigham Young University, and Frank Hillary, Assistant finishing a product of the highest quality. The assistance Professor at Penn State University, generously provided of many individuals has enabled us to publish this second three-dimensional images of the brain. Frank Ruben C. edition. We are grateful to all of them and have benefited Gur and his research group at the Department of Psychi- from their understanding, criticism, and advice. Thank atry, University of Pennsylvania, allowed us to use cere- you. bral blood flow study pictures. Any scholar with a family knows what it means to Eric A. Zillmer write a book and attempt to maintain a normal family Mary V. Spiers life. Dr. Zillmer is grateful to his wife, Rochelle, and his William C. Culbertson  STRUCTURE-FUNCTION REL ATIONSHIPS Spinal Cord Brain Anatomic features: Spinal nerves and internal organization of the spinal cord (gray and white matter) C2 Function: Relays information to and from the brain; responsible for simple reflexive behavior C5 C3 Cervical 1 2 C4 T2 3 Sensory receptor T3 4 T2 T4 5 Dorsal root 6 T5 7 C6 T6 8 T7 T8 Thoracic 1 2 C7 T9 3 T10 4 T11 5 C8 T1 T12 6 Ventral root L1 7 8 9 10 L2 11 12 Muscle Lumbar 1 Frontal L3 2 3 Parietal bone bone 4 Bregma Coronal suture Sacral 5 c. Pterion L4 1 2 Sphenoid bone 3 L5 4 5 Squamosal suture Glabella S1 b. Lambda Zygomatic bone Nasion Nasal bone a. Occipital bone Lacrimal bone Ethmoid bone Lambdoidal suture spinal cord External occipital Maxilla ganglion meninges protuberance nerve (protective Asterion vertebra coverings) Temporal bone Mandible External acoustic meatus Mastoid process Styloid Zygomatic arch process Angle of mandible Skull (location of Anatomic features: A fused connection of bony plates covering the brain intervertebral Function: Protection of the brain disk) Meninges Anatomic features: Dura mater, arachnoid membrane, and pia mater Function: Protective covering of the central nervous system, location of venous drainage, and Anterior Anterior communicating artery cerebral artery cerebrospinal fluid absorption Internal carotid artery Lateral ventricles Middle cerebral artery Third Posterior communicating Superior artery ventricle cerebellar Posterior cerebral artery artery Pontine Basilar artery arteries Labyrinthine artery Vertebral artery Cerebral or Sylvanian Fourth Anterior inferior Anterior aqueduct Central canal ventricle cerebellar artery spinal artery of spinal cord Posterior inferior cerebellar artery Ventricular System Anatomic features: Lateral (1st and 2nd), 3rd, and 4th Vascular System ventricles, choroid plexus, cerebral aqueduct, and arachnoid Anatomic features: Arteries, veins, circle of Willis granulations Function: Arteries: nourishment; supply of oxygen and nutrients Function: Balancing intracranial pressure, cerebrospinal fluid Veins: carrying away waste products production, and circulation (continued) xxv  STRUCTURE-FUNCTION REL ATIONSHIPS Optic nerve Thalamus Pineal gland (Cranial nerve II) Superior colliculus Midbrain Inferior Midbrain colliculus Tectum Cranial nerve Cranial nerve III IV Tegmentum Cranial nerve V Pons Pons Posterolateral Cranial nerve VIII Cerebellum Medulla VII view of VI brainstem IX X XI XII Medulla Lower Brainstem Anatomic features: Hindbrain: medulla oblongata (myelencephalon), Spinal nerve Spinal cord pons (metencephalon) Midbrain: tectum and tegmentum, cranial nerves, reticular activating system Cranial Nerves Function: Relays information to and from the brain; Anatomic features: Located within the brainstem responsible for simple reflexive behavior Function: Conducting specific motor and sensory information Cortex Dorsomedial nucleus Suprachiasmatic Ventral lateral nucleus nucleus Reticular formation Cerebellum Ventral posteriolateral Brainstem nucleus Pulvinar nucleus Lateral geniculate body Reticular Formation Anatomic features: Neural network within the lower brainstem Thalamus connecting the medulla and the midbrain Anatomic features: Thalamic nuclei and thalamocortical Function: Nonspecific arousal and activation, sleep and wakefulness connections Functions: Complex relay station—major sensory and motor inputs to and from the ipsilateral cerebral hemisphere Paraventricular nucleus Dorsal of hypothalamus hypothalamus Anterior commissure Dorsomedial Lateral hypothalamus hypothalamus (behind plane of view) Anterior hypothalamus Posterior hypothalamus Preoptic area Hypothalamus Supraoptic nucleus Mammillary body Anatomic features: Hypothalamic nuclei, major fiber systems, and third ventricle Ventromedial Function: Activates, controls, and integrates the peripheral autonomic Optic chiasm hypothalamus mechanisms, endocrine activity, and somatic functions, including body Anterior pituitary Posterior temperature, food intake, and the development of secondary sexual pituitary characteristics xxvi  STRUCTURE-FUNCTION REL ATIONSHIPS Putamen Caudate nucleus Globus pallidus Thalamus (lateral part) Subthalamic Cerebellar nucleus cortex Globus pallidus (medial part) Substantia nigra Deep cerebellar Fourth nuclei ventricle Pontine nuclei Cerebellum Anatomic features: Cerebellar cortex, cerebellar white matter, and glia Basal Ganglia Function: Coordination of movements, posture, antigravity, Anatomic features: Structures of the caudate nucleus, putamen, globus balance, and gait pallidus, substantia nigra, and subthalamic nuclei Function: Important relay stations in motor behavior (such as the striato–pallido–thalamic loop); connections form part of the extrapyramidal motor system (including cerebral cortex, basal nuclei, thalamus, and midbrain) and coordinate stereotyped postural and reflexive motor activity Fornix Corpus callosum Anterior nucleus of thalamus Limbic System Anatomic features: Structures of the amygdala, Septum hippocampus, parahippocampal gyrus, cingulate gyrus, fornix, septum, and olfactory bulbs Function: Closely involved in the expression of Olfactory bulb Hippocampus emotional behavior and the integration of olfactory information with visceral and somatic information Amygdala Mammillary body Hypothalamus Regulates basic biological functions, Thalamus including hunger, thirst, Switching station for temperature, and sensory information; sexual arousal; also also involved involved in emotion in memory Corpus callosum Amygdala Involved in memory, emotion, and aggression Cerebellum Controls coordinated Hippocampus movement; also Involved in learning, involved in language memory, and emotion and thinking Medulla Spinal cord Controls vital Transmits signals Corpus Callosum functions such as between brain Anatomic features: A large set of myelinated breathing and heart rate and rest of body axons connecting the right and left cerebral hemispheres Cerebral Hemispheres Function: Information exchange between the Anatomic features: Structures of the frontal, parietal, occipital, and temporal lobes two hemispheres Function: Higher cognitive functioning, cerebral specialization, and cortical localization xxvii This page intentionally left blank  Part One INTRODUCTION Chapter 1 A History of Neuropsychology Chapter 2 Methods of Investigating the Brain Chapter 3 Neuropsychological Assessment and Diagnosis This page intentionally left blank  Chapter 1 A HISTORY OF NEUROPSYCHOLOGY I think, therefore I am. —René Descartes, Discourse on Method There is no ghost in the machine. —Gilbert Ryle, The Concept of Mind The Brain in Antiquity: Early Hypotheses Localization Theory Localization versus Equipotentiality Integrated Theories of Brain Function Modern Neuropsychology Emerging Research Areas in Neuropsychology Neuropsychology in Action 1.1 The Brain of a Nazi 1.2 Paul Broca: A Manner of Not Speaking 1.3 Sigmund Freud: The Neurologist 1.4 The Walter Freeman Lobotomies: Mind over Matter? 4 PART ONE | Introduction Keep in Mind Does our brain constitute a major aspect of who we are? Is the brain the source of all behavior? Where do we go when our brain dies? What is a soul? Overview All the preceding questions concern the functions of the brain. The brain has evolved to play a particularly significant role in the human body, not only in sustaining life, but also in all thought, behavior, and reason- ing. It is the only organ completely enclosed by protective bony tissue, the skull, and it is the only organ that cannot be transplanted and still maintain the person’s self. But how exactly does brain tissue generate and constrain mental events? Efforts to understand mind–body relationships and their relative contributions to health and well-being extend back at least to the philosophies of Plato, Descartes, and Kant. Like many other sciences, neuropsy- chology has evolved from related fields, most notably psychology, neurology, neuroscience, biology, and philosophy. Psychology is the study of behavior; specifically, it seeks to describe, explain, modify, and pre- dict human and animal behavior. Neuropsychology, a subspecialty of psychology, is the study of how com- plex properties of the brain allow behavior to occur. Neuropsychologists study relationships between brain functions and behavior; specifically, changes in thought and behavior that relate to the brain’s structural or cognitive integrity. Thus, neuropsychology is one way to study the brain by examining the behavior it pro- duces. Humans read and write, compose music, and play sports. You would expect an organ that coordinates and mediates all activity to have a huge number of components. And, in fact, the brain contains billions of cells, or neurons, and an infinite number of possible connections among individual neurons, allowing us to exchange complex information. This amazing pattern of connections determines how and what the brain does. Understanding this network of neurons is the central focus of neuropsychology. Neuropsychology has grown tremendously since the 1970s, and in the 1990s, it was the fastest grow- ing subspecialty within psychology. Neuropsychologists lead the study of brain–behavior relationships and are involved in the design and development of technologies to treat diseases of the brain. They are involved in patient care and research on the brain and work in universities, research institutes, medical and psychi- atric hospitals, correctional facilities, the armed forces, and private practice. The study of neuropsychology currently is shaping our understanding of all behavior. But this has not always been true. Many previous ideas about how the brain functions did not derive from scientific evidence. In general, two doctrines have emerged. The first doctrine, vitalism, suggests that many behav- iors, such as thinking, are only partly controlled by mechanical or logical forces—they are also partially self- determined and are separate from chemical and physical determinants. Extreme proponents of vitalism argue that spirits or psychic phenomena account for much observable behavior. Sigmund Freud’s psycho- analysis would be a good example of this doctrine. The second doctrine, materialism, suggests that logical forces, such as matter in motion, determine brain–behavior functions. Materialism, in its simplest form, favors a mechanistic view of the brain (as a machine). Walter Freeman’s lobotomies embraced this idea. The history of neuropsychology is shaped by these two opposing principles. This introductory chapter provides grounding in the historical, theoretical, and philosophical aspects of neuropsychology. By charting the work of noted scholars, this chapter traces the development of neuropsy- chology from antiquity to the present.  CHAPTER 1 | A History of Neuropsychology 5 The Brain in Antiquity: Why did our ancestors perform trephination (Figure 1.1)? Did they have a reasonable understanding of the brain Early Hypotheses and its relationship to behavior? Did they use this proce- dure for medical reasons, such as trauma with swelling, or Evidence from as long ago as the time of cave draw- for other reasons? Did practitioners avoid certain areas of ings shows that people have long been aware of brain-be- the brain because they knew that permanent behavioral havior relationships. The earliest neuropsychological in- problems or death were likely to follow? vestigations recognized how diseases and blows to the Much debate focuses on the reason for trephinations. brain affect behavior. For example, trephination is an an- Researchers have suggested that some cases may have in- cient surgical operation that involves cutting, scraping, volved a medical reason, such as a skull fracture. Such in- chiseling, or drilling a pluglike piece of bone from the juries presumably occurred during hand-to-hand fighting skull. This procedure relieves pressure related to brain with stone-headed war clubs or perhaps as a result of a fall swelling. Archaeologists have recovered several thousand unconnected with warfare. On some skulls, however, trephi- such skulls worldwide. Many who underwent trephina- nation was performed on intact crania with no sign of vio- tion clearly survived the operation, because many of the lence. Thus, some investigators suggest that trephination skulls show evidence of healing (new callus tissue); other was a “magical” form of healing, perhaps for displays of skulls show no signs of healing, so the patients died dur- bizarre behaviors, including what we would now recognize ing or shortly after the operation. In some cases, the same as epilepsy or schizophrenia (Lisowski, 1967) (Figure 1.2). skull was trephined more than once. One recovered skull Similar operations are important in modern neuro- was found with seven boreholes, at least some of which surgery (Figure 1.3). Surgeons widely use two procedures. were made on separate occasions. The first procedure, similar to the ancient Peruvian Figure 1.1 Trephination scene in Peru. (Image reprinted with permission from Department of Anthropology, National Museum of Natural History, Smithsonian Institution, Washington, D.C. Photo courtesy of the San Diego Museum of Man.) 6 PART ONE | Introduction That surgeons today use an ancient surgical technique that even modern doctors once thought controversial underscores that people have often misinterpreted the his- torical context in which ancient scientists proposed certain ideas about the brain or performed specific procedures. Most ideas about the brain make more sense when consid- ered within the societal and cultural context in which they were originally developed. ANCIENT GREEK PERSPECTIVES Classical Greeks wrote the first accounts of brain–behavior relationships. Heraclitus, a philosopher of the sixth cen- tury B. C., called the mind an enormous space with boundaries that we could never reach. A group of schol- ars, including the geometer Pythagoras (about 580– 500 B.C.), was the first to suggest that the brain is at the Figure 1.2 Adult male skull showing multiple trephina- center of human reasoning and plays a crucial role in the tions by the scraping method. Evidence of inflammation indicates temporary survival. (Courtesy Mütter Museum, soul’s life. They described what is now called the brain College of Physicians of Philadelphia.) hypothesis: the idea that the brain is the source of all behavior. technique of drilling a number of small holes, involves Hippocrates (460–377 B.C.), a Greek physician hon- drilling a hole next to a depressed skull fracture to facili- ored as the founder of modern medicine (Figure 1.4), also tate the elevation and removal of depressed bone frag- believed the brain controls all senses and movements. He ments. Incidentally, modern neurosurgeons still use man- was the first to recognize that paralysis occurs on the side ual drills, which allow them more control during the of the body opposite the side of a head injury, following operation. The second surgical procedure drains internal the areas governed by the right and left hemispheres of bleeding after a blow to the head. With a special drill bit, the brain. Hippocrates suggested that pleasure, merri- the surgeon makes a hole over the site of the bleed. Then ment, laughter, and amusement, as well as grief, pain, the surgeon screws a precisely machined bolt into the skull, anxiety, and tears, all arise from the brain (Haeger, 1988). allowing excessive blood to drain from within the cranium. Furthermore, Hippocrates argued that epilepsy, once con- This procedure reduces the intracranial pressure that is a sidered the “sacred disease” (because people thought the major cause of death after a head injury (see Chapter 13). patient was possessed by gods or spirits), is, in fact, no more divine or sacred than any other disease, but has spe- cific characteristics and a definite medical cause. These were bold propositions at a time when people thought behavior was mostly under divine control. Hippocrates and his associates could not, however, discuss exactly how such brain–behavior relationships arose, perhaps because it was then sacrilegious to dissect the human body, especially the brain. Plato (420–347 B.C.) suggested in The Republic that the soul has three parts: appetite, reason, and temper. This may have served as the model for Freud’s psychoanalytic subdivision of the psyche into the id, ego, and superego (see later discussion). Plato believed the rational part of the tripartite soul lay in the brain, because it is the organ closest to the heavens. Plato also discussed the idea that Figure 1.3 Modern trephination. A surgical hole is opened in the skull to relieve the intracranial pressure often health is related to harmony between body and mind. associated with consequences of head trauma. (Courtesy Thus, historians credit Plato as being the first to propose Jeffrey T. Barth, PhD, University of Virginia.) the concept of mental health.  CHAPTER 1 | A History of Neuropsychology 7 THE CELL DOCTRINE In Egypt, during the third and fourth centuries B.C., the so-called Alexandrian school reached its height. Well- known scientists worked in physiology and anatomy. They gained considerable knowledge of the nervous system and neuroanatomy from performing public dissections, which the Ptolemaic rulers encouraged. Reports exist of scientists actually vivisecting subjects—condemned criminals were at the scientists’ disposal. These dissections allowed scientists to notice different anatomic details, and they hypothesized that specific parts of the brain control different behaviors. Furthermore, they broke new ground by distinguishing between ascending (sensory) and descending (motor) nerves, and demonstrating that all nerves connect with the central nervous system. An interesting development during this time was the erroneous suggestion that ventricular cavities within the brain control mental abilities and movement. The ven- tricular localization hypothesis postulated that mental as well as spiritual processes reside in the ventricular chambers of the brain. Indeed, gross dissection of the brain shows that the lateral ventricles are the most strik- ing features. Thus, brain autopsies might have led investi- gators to conclude that these cavities contain animal spir- its and are in large part responsible for mental faculties. This hypothesis subsequently became known as the cell doctrine (“cell” meaning a small compartment or ventri- Figure 1.4 Hippocrates suggested that all thoughts and cle), a notion that endured for 2000 years. Leonardo da emotions originated in the brain, not the heart, as Aristotle Vinci (1452–1519), an Italian painter, sculptor, architect, had believed. Here, the ancient Greek physician opens his and scientist, was a keen observer of anatomy. However, book to one of his favorite axioms, “Life is short, and the art is long.” (© Snark/Art Resource, NY.) many of his early drawings were not guided by his keen scientific acumen, but instead by the inaccurate medieval conventions of his times. For example, Figure 1.5 shows one of his drawings based on a common, but inaccurate Not all ancient philosophers believed in the impor- belief about spherical ventricles. According to the cell doc- tance of the brain to behavior. Aristotle (384–322 B.C.), trine, foremost was the cell of common sense, where peo- a disciple of Plato, was a creative thinker in fields as var- ple thought the soul resided and that connected to nerves ied as ethics, logic, psychology, poetry, and politics, and leading to the eyes and ears. he founded comparative anatomy. Aristotle, however, er- Today, people know that the cell doctrine is entirely in- roneously believed the heart to be the source of all mental accurate. The ventricles are actually the anatomic site processes. He reasoned that because the heart is warm and through which cerebrospinal fluid passes. This fluid pro- active, it is the locus of the soul. Aristotle argued that be- tects the brain and facilitates the disposal of waste material. cause the brain is bloodless, it functions as a “radiator,” It plays no role in thinking; in fact, a neurosurgeon friend cooling hot blood that ascends from the heart. The influ- of ours conceptualizes it poetically as “the urine of the ence of Aristotle’s so-called cardiac hypothesis proposing brain.” The cell doctrine was scientifically important pre- the heart as the seat of such emotions as love and anger cisely because it was in error, and thus presented an obsta- can still be seen in words such as heartbroken. Neverthe- cle to further inquiry that people did not overcome until less, Aristotle’s view of nature and his anatomic findings centuries later. However, it did focus the medical commu- dominated medical thinking and methods for the next nity on the brain and stimulated discussion of how behav- 500 years. ior, thought processes, and brain anatomy may be related. 8 PART ONE | Introduction technologic achievement of his time, the Roman system of aqueducts, which relied on hydraulic principles. Al- though Galen believed the frontal lobes (Figure 1.7) are the location of the soul, he supported the ventricular lo- calization hypothesis, describing in detail how he imag- ined human ventricles to look and function, based on his studies of the pig and the ox. Galen believed that all phys- ical function, including the brain, as well as the rest of the body, depends on the balance of bodily fluids or humors, specifically blood, mucus, and yellow and black bile, which he related to the four basic elements—air, water, fire, and earth, respectively. Given that people thought the agent that causes sickness resides in blood, doctors often bled patients as a curative procedure. Galen’s view of humors became so ingrained in Western thought that physicians barely elaborated on the role of the brain and other organs, which remained largely unquestioned for nearly the next thousand years. We still say “good humor” or “bad humor” to describe someone’s mental disposition. Terms such as melancholic (having frequent spells of sad- ness) and choleric (having a low threshold for angry out- bursts) also remain in our vocabulary (Figure 1.8). ANATOMIC DISCOVERIES AND THE ROLE Figure 1.5 Drawing by Leonardo da Vinci demonstrating, OF THE SPIRITUAL SOUL inaccurately, the placement of three spherical ventricles in accordance with the cell doctrine. (The Royal Collection During the thirteenth century, scientists began to take © 2007, Her Majesty Queen Elizabeth II.) initial steps away from the ventricular theory. For exam- ple, Albertus Magnus, a German Dominican monk, the- orized that behavior results from a combination of brain Together with Hippocrates, Galen (A.D. 130–201), a structures that includes the cortex, midbrain, and cerebel- Roman anatomist and physician, stands out as a supreme lum (Figure 1.9). figure in ancient medicine (Figure 1.6). Galen was un- Not until scientific inquiry by Andreas Vesalius doubtedly the greatest physician of his time. By signifi- (1514–1564), however, were Galen’s anatomic mistakes cantly advancing the anatomic knowledge of the brain, corrected, particularly those related to the role of the ven- Galen distinguished himself as the first experimental tricles and their effect on behavior. Galen had initially physiologist and physician. He identified many of the demonstrated the similar relative size of the ventricles in major brain structures and described behavioral changes animals and humans, whereas Vesalius placed more em- as a function of brain trauma. It was Galen’s misfortune, phasis on the relatively larger overall brain mass of hu- however, that during his life the Roman authorities for- mans as responsible for mediating mental processes. bade autopsies. He therefore based much of his clinical Through continual dissections and careful sci