Psychopathology reading neuropathology reading

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Psychopathology reading neuropathology reading

  1. 1. PSYCHOPATHOLOGYREADING
  2. 2.  STRICTLY CONFIDENTIAL Sunday, March 18, 2012        PSYCHOLOGICAL REPORT   Name: Sex: male Age: 24 years old Birthdarte: Mar 14, 1987 Educational Attainment: First Year Medical Student Referred by: DR , PSYCHIATRY Reason for referral: Psychological evaluation for diagnostic assessment (i.e. routine psychological screening) TESTS ADMINISTERED   Wechsler Social Intelligence Scale Hand Test Millon’s Test Sack’s Sentence Completion Test Minnesota Multiphasic Personality Inventory
  3. 3. DETERMINATION OF SPECIFIC PERSONALITY DISORDERSNormal limits: BR of 75 and belowCLINICAL PERSONALITY PATTERNS 1 Schizoid 79 (5.5) 2A Avoidant 80 2B Depressive 107 (1) 3 Dependent 87 04 Histrionic 104 (2) 5 Narcissistic 100 (3) 6A Antisocial 60 6B Sadistic (Aggressive) 61 7 Compulsive 58 8A Negativistic (Passive-Aggressive) 72 8B Masochistic (Self-Defeating) 79 (5.5) S Schizotypal 66 C Borderline 83 (4) P Paranoid 63
  4. 4. Luria-Nebraska Battery - Interpretation
  5. 5. I. General Comments- Battery created by Charles Golden based on Lurian theory and, somewhat, methodology, all measures are pathognomic signs indicators;- Upper limit items and all items normal subjects couldn’t do were dropped, so the battery is not very good for premorbidly high-functioning people with mild injuries;- Items chosen on the basis of discriminating normal controls from people with severebrain damage;- Three indices were created to take into account age and education:
  6. 6. -Three indices were created to take into accountage and education:(a) Critical Level (CL)(p. 5 of the scoring booklet) =68.8 + Age Value - Educ. Value(b) Predicted Baseline (PB)= Critical Level - 10 (onestandard deviation)(c) Actual Baseline (AB)= average of the T-scores onclinical scales (C1-C11)
  7. 7. the T-scores of the scales are compared to the CriticalLevel (i.e. expected premorbid performance);-During administration one can repeat instructions andproblems for all scales but C2, C5, and C10;- C7-C9 are very dependent on education, so they shouldnot be included while inferring the presence of braindamage unless there is a suspicion of learning disability;- If localization data contradicts clinical scales - disregardit.
  8. 8. S1 PathognomonicS2 Left hemisphereS3 Right hemisphereS4 Profile ElevationS5 Impairment
  9. 9. L1 Right FrontalL2 Right SensorimotorL3 Right Parieto –OccipitalL4 Right TemporalL5 Left frontalL6 Left SensorimotorL7 Left parietal-occipitalL8 Left Temporal
  10. 10. C1 Motor functionsM1 Kinesthesia Based MovementM2 Drawing SpeedM3 Fine Motor SpeedM4 Spatial Based MovementM5 Oral Motor SkillsC2 Rhythm FunctionsRH1 Rhythm and Pitch Perception
  11. 11. C3 Tactile FunctionsT1 Simple Tactile SensationT2 StereognosisC4 Visual FunctionsV1 Visual Acuity and NamingV2 Visual Spatial OrganizationC5 Receptive SpeechR1 Phonemic DiscriminationR2 Relational conceptsR3 Concept RecognitionR4 Verbal Spatial Relation
  12. 12. C6 Expressive speech E1 Simple Phonetic Reading E2 Word Repetition E3 Reading Polysyllabic WordsC7 Writing W1 Spelling W2 Motor Writing SkillC8 Reading RE1 Reading Complex Material RE2 Reading Simple Material
  13. 13. C9 Arithmetic A1 Arithmetic Calculations A2 Number ReadingC10 Memory ME1 Verbal Memory ME2 Visual and Complex MemoryC11 Intellectual Processes I1 General Verbal Intelligence I2 Complex Verbal Arithmetic I3 Simple Verbal Airhtmetic
  14. 14. II. Presence of Brain Damage•If you are using CL calculated from demographic data:- Clinical Scales Comparisons:(a) if C1, C2, C3, C4, C5, C6, C10, or C11 > CL there’s >90%probability of brain damage or psychosis(b) if any 3 Clinical Scales (C1-C11) > CL there’s >95%probability of brain damage, esp. If there is a learningdisability;- Single Indicators of Brain Damage:(a) if any of C1-S1 > 80T - very high probability of braindamage(b) if any of C1-S1 > 70T - strong suspicion of brain damage(c) C11 and S1 are especially sensitive to brain damage- Range or Scatter of Clinical Scales (C1-C11) Indicators:(a) if Range >30 - high probability of brain damage(b) if Range >20 - strong suspicion of brain damage
  15. 15. 2) If there is a premorbid IQ score, calculate CL from itand use that for comparisons, CL (for WAIS) = 164.8 -1.09 x FSIQ + .2 x Age, CL (for WAIS-R) = 164.8 - 1.09 x(FSIQ + 8) + .2 x Age•if premorbid IQ >120 use CL-10 for Clinical Scalescomparisons and 70T for single indicators comparisons(b) if premorbid IQ 81-119 use CL for Clinical Scalescomparisons and 80T for single indicators comparisons(c) if premorbid IQ <80 use CL+10 for Clinical Scalescomparisons and 90T for single indicators comparisons
  16. 16. - One can also compare WAIS IQ with Luria-Nebraska IQ, whereLN VIQ = 158.9 - .47(C11) - .38(C8) - .20(C9),LN PIQ = 156.9 - .35(C11) - .48(C4) - .26 (C10),and LN FSIQ = 150.2 - .92(C11):(a) WAIS IQ or WAIS-R IQ + 8 = LN IQ - lowprobability of brain damage(b) WAIS IQ or WAIS-R IQ + 8 > LN IQ - highprobability of brain damage(c) WAIS IQ or WAIS-R IQ + 8 < LN IQ - lowprobability of brain damage, cultural oreducational issues lowered WAIS IQ
  17. 17. 3) If there is no demographic data, one cancalculate the AB and compare Clinical Scalescores to it.As before, the results are more certain if only C1,C2, C3, C4, C5, C6, C10, and C11 are used:- 1 Clinical Scale >10T > AB - equivocal results,there might be a subtle injury, a disease likeMultiple Sclerosis, or nothing;- 2 Clinical Scales >10T > AB - 70% probability ofbrain damage;- 3 Clinical Scales >10T > AB - 90% probability ofbrain damage.
  18. 18. III. Lateralization of the Lesion1) Clinical Scales:- C2 & C4 are right hemisphere indicators, C5 & C6 - lefthemisphere indicators, if there is more than 10T difference betweenthem - lateralized lesion is likely.2) Lateralization Scales. S2 contains sensory and motor items fromthe right side (left hemisphere) and S3 - from the left side (righthemisphere), since left hemisphere is dominant for motor functions,S3 is also elevated by left hemisphere damage. Consequently, usethe following rules:- S2>CL - left hemisphere definitely involved;- S3>CL, S2<CL & <60T - likely to be right hemisphere only;- S2&S3>CL:(a) if S2 is 10T>S3 - probably only left hemisphere(b) if S2 is 9-1T>S3 - probably both hemispheres(c) if S2=S3 - probably diffuse bilateral damage3) Localization Scales - if two highest scales are from the samehemisphere (first 4 vs. last 4), lateralization hypothesis isappropriate.
  19. 19. IV. Localization of the Lesion1) Clinical Scales (relative to each other):- C1 - anterior (frontal);- C2 - posterior (temporal, mostly right);- C3 - posterior (parietal, tactile);- C4 - posterior (visual, mostly right);- C5 - posterior (receptive speech, mostly left);- C6 - anterior (expressive speech, mostly left);-if >4 scales are >CL than thirtiary areas are more likely to beaffected by brain damage.2) Localization Scales:- if one scale is 10T> all others it’s a hit, unless all scales areelevated;- if two or more highest scores are in the ajacent areas - it’salso a hit.
  20. 20. V. Course of the Lesion & Prognosis1) S1 is most sensitive to the process, if S1>CL or >10Tabove AB the injury is likely to be acute, progressive, orsevere (if its 20T>CL - very acute, severe, or rapidlyprogressing):- at 6 months past injury, if S1>CL - poor prognosis, ifS1<CL - good prognosis;- if S1 if near AB - they are compensating, goodprognosis;- if S1>CL, but the lowest score - they have recovered asmuch as they could, don’t expect drastic improvements;- if S1<CL - stabilized, will not recover further;-if S1<CL, but is the highest score - posiible subtle braininjury or a slowly progressing condition, like MS.2) S4&S5:- if S4>CL & S5<CL - good prognosis;- if S4>S5>CL - good prognosis;- if S4<CL & S5>Cl - bad prognosis.
  21. 21. VI. Emotional Issues Differentiation•S4 - Profile Elevation - is sensitive tobrain impairment in uncompensated state(depressed, anxious, psychotic, no cog.rehab.)2) S5 - Impairment Scale - is supposed tobe a pure indicator of brain damage,without emotional overlay.
  22. 22. VII. Schizophrenia vs. “Organic” Brain Damage•Schizophrenics with no other brain damage are reliablyelevated on C2, C5, C10, &C11; so, one can subtract 7points from these scales in order to evaluate brain damageadditional to schizophrenia.2) A strategy for diagnosing presence of additional braindamage in schizophrenics (normative sample <45 years,9-15 years of education):- >4 Clinical Scales >70T => brain damage;-give 1 point for each elevation > 70T on C2, C5, C10, &C11;give 2 points for each elevation >60 for remaining clinicalscales; if the sum is >4 => brain damage;- S1>65 => brain damage.
  23. 23. VIII. Individual Scales & ItemsScales Item Functions Measured / Localization / Notes sC1 - Motor Anterior (frontal), movement & mental flexibility 1-4 Simple motor, posterior frontal lobe 5-8 Kinesthetic feedback 9-20 Spatial organization required 21-27 Complex motor (kinetic melodies) 25-27 Apraxia screen 28-35 Oral movements 28-29 Simple 30-31 Kinesthetic feedback 32-33 Complex motor (kinetic melodies) 34-35 Following of verbal directions 36-47 Constructional items (score accuracy & time) 48-51 Speech regulation of motor acts (using internal speech to guide behavior)
  24. 24. C2 - Rhythm Right temporal, sensitive to attention, cannot repeat items52-54 Compare tones55-57 Reproduce tones58-61 Evaluation of acoustic signals62 Perception/reproduction of rhythmic pattern63 Reproduction of series to verbal command (mental flexibility involved)
  25. 25. C3 - ParietalTactile 64- Levels of cutaneous sensation - 73 primary & secondary areas 74- Levels of cutaneous sensation - 79 angular gyrus 80- Muscle/joint sensation, affected by 81 callossal transfer of info 82- Stereognosis (tactile agnosia) 85
  26. 26. C4 - Visual Mostly right posterior86-87 Real & pictured object identification  88 Item identification on the scale from easy to difficult (telephone & face go   for the gestalt perception - right posterior)89 Shading  90-91 Popplereuter items - simultaneagnosia or visual   perseveration92-93 Raven’s progressive matrices - IQ   estimate (accuracy & time)94-96 Spatial orientation / directions  97-98 3-D analysis of pictures  99 Spatial rotation without speech (sensitive even to minor   impairmerment)
  27. 27. C5 - Receptive Speech Left posterior (cannot repeat items, stay behind to avoid lip reading)100-107 Comprehension of phonemes108-116 Comprehension of simple words/phrases117-132 Increasingly complex comprehension items121-131 Understanding of grammatical & logical relations, some people solve it as a visual-spatial task
  28. 28. C6 - Expressive Speech Left anterior133-142 Repetition of sounds/words spoken by examiner  143-153 Same to written stimuli  154-156 Increasingly complex sentence repetition  157 Confrontational object naming (photograph)  158 Confrontational body part naming (problems with body schema - parietal)  159 Responsive naming  160-163 Automatic (seriatim) speech  164-169 Spontaneous speech production to picture/story/topic  170-174 Complex systems of grammatical expression (frontal if errors are only on   these items)
  29. 29. C7 - Writing Education-dependent, not good neurologically175-176 Phonetic analysis of words and copying of increasing   complexity177 Copying: abstract/concrete,   verbal/phonemic knowledge178-185 Copying of increasing   complexity186-187 Narrative writing, differentiate motor/spelling   problems
  30. 30. C8 - Reading Education-dependent, not good neurologically188-189 Generate sounds from letters  190-191 Name simple letters  192 Read sounds  193 Read simple words  194 Read meaningful letter combos (error if read as   words)195 Read more complex words  196 Read more complex words, irregular spelling  197 Read simple sentences  198 Read simple sentences with incorrect (meaning) elements  199-200 Read extended passages (includes memory component)  
  31. 31. C9 - Arithmetic Education-dependent, not good neurologically, tests understanding of basic concepts rather than skills 201-202 Write arabic & roman numbers 203 Write numbers alternating positions 204-205 Write more complex #s (perseveration, like 9000845, frontal) 206-208 Read #s 209 Read #s top to bottom (stressing the system) 210-211 Compare #s - comprehension of # meaning 212-214 Simple arithmetic problems - comprehension of arithmetic operations 215-217 More complex problems that cannot be done from memory 218-220 More difficult arithmetic algorythms 221-222 Subtraction of serial 7s & 13s from 100
  32. 32. C10 - Memory Mostly verbal memory, no delayed memory (cannot repeat items)223-225 List learning, self-monitoring226 Visual memory with interference227-230 Sensory trace recall (visual/spatial/ auditory/tactile/verbal) = span of apprehension231-232 Verbal memory with interference (very sensitive items)233 Visual memory with externally supplied interference234 Anecdotal (logical) memory235 Associative memory (verbal & visual)
  33. 33. C11 - Intellectual Mini-IQ testProcesses 236-237 Understand thematic pictures 238-241 Picture arrangement tasks 242-243 Comprehension of comedy/absurd (very abstract task) 244 Interpretation of story 245 Interpretation of expressions 246-247 Free & multiple choice interpretation of proverbs 248 Concept formation 249-250 Similarities & differences 251-254 Logical relations, categorization 255 Opposites 256 Analogies 257 Categorization 258-269 Arithmetic items in story format
  34. 34. S1 - Acuity Elevation indicates that damage is acute, severe, or rapidly progressingS2 - LeftHemisphereIndicatorS3 - RightHemisphereS4 - Profile Sensitive to brain impairment inElevation uncompensated stateS5 - Impairment Supposed to be a pure indicator of brainScale damage, without emotional overlay.

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