neuropsychological assessment in SMI

PRESENTER – Dr. Harneet
MODERATOR- Dr. Nitin Gupta
23/7/2016
NEUROPSYCHOLOGICAL
ASSESSMENT IN SEVERE MENTAL
ILLNESS

NEUROPSYCHOLOGY
 Neuropsychology is a specialty in professional
psychology that applies principles of assessment
and intervention based upon the scientific study
of human behavior as it relates to normal and
abnormal functioning of the central nervous
system. The specialty is dedicated to enhancing
the understanding of brain‐behavior relationships
and the application of such knowledge to human
problems.
American Psychological
Association, 2010

NEUROPSYCHOLOGICAL
ASSESSMENT
 Neuropsychological assessment/testing is a process by
which a person’s cognitive, psychological/emotional and
behavioural functioning is comprehensively assessed.
 FOCUS is on cognitive functioning.
DETAILED
INTERVIEW
STANDARDIZED TESTING of areas
relevant to presenting problems
SCORES COMPARED TO
NORMATIVE TEST DATA
GENERATION OF
A PROFILE
IDENTIFICATION OF AREAS OF STRENGTHS
AND WEAKNESSES

COGNITION & COGNITIVE
FUNCTIONS
 Cognition refer to set of vastly complex processes,
such as language, problem solving and thinking, that
apply plans and strategies to sensations and
perceptions.
 The ability to attend to things in a selective and
focused way, to concentrate over a period of time, to
learn new information and skills, to plan, determine
strategies for actions and execute them, to
comprehend language and use verbal skills for
communication and self-expression, and to retain
information and manipulate it to solve complex
problems are examples of mental processes that are
referred to as cognitive functions.

COGNITIVE DOMAIN TESTS USED
1. ATTENTION
patient’s ability to
attend to a specific
stimulus without being
distracted by internal or
external environmental
stimuli.
Three types of attention-
1. Selective
attention/focused
attention
2. Sustained attention
3. Divided attention
1. Digit span distraction
test
2. Continuous
performance test
3. Dual task test
4. Brief test of attention
(BTA)
5. D2 test of attention
6. Gordon diagnostic
system
7. Paced auditory serial
addition task (PASAT)
8. Quotient test of
attention
9. Stroop color naming

2. MEMORY
refers to a process of
encoding, storage and
retrieval of learnt material.
•Immediate
•Recent
•Remote
(Long term memory divided
into
Explicit and implicit memory)
WORKING MEMORY
refers to the ability to hold the
stimuli ‘online’ for a short
time, then either use it
directly after a short delay or
process or manipulate it
mentally to solve cognitive
1. California verbal learning
test
2. Wechsler memory scale
3. Benton visual retention
test
4. Rey’s complex figure test
5. Boston remote memory
battery
6. Remote memory battery
by squire and co workers
7. PGI memory scale

3. INTELLIGENCE
Capacity for learning and
ability to recall, to integrate
constructively, and to apply
what one has learned; the
capacity to understand and
to think rationally
1. Wechsler adult
intelligence performance
and verbal scale – indian
adaptation.
2. Stanford binet intelligence
test
3. Bhatia’s battery of
performance of
intelligence
4. Proteus maze test
5. Raven’s standard
progressive matrices
6. Reynold’s intellectual

4. EXECUTIVE FUNCTIONS
refers to the ability to use
abstract concepts, to form an
appropriate problem-solving
test for the attainment of
future goals, to plan one's
actions, to work out
strategies for problem-
solving, and to execute these
with the self-monitoring of
one's mental and physical
processes.
Planning, sequencing,
problem solving, decision
making, emotional regulation.
1. Wisconsin card sorting
test (WCST)
2. Verbal and visual fluency
test
3. Categories test and Trail
making tests
4. Stroop colour word
interference test
5. Tower of london tasks
6. Problem solving-Porteus
maze test
7. Psychomotor Skills-
Grooved peg
board,Finger tapping.

COGNITIVE SCREENING TOOLS
FROM INDIA
1. PGI BATTERY OF BRAIN DYSFUNCTION
(PGIBBD) Parshad and Verma,1990
 Revised Bhatia’s Short Battery of Performance Tests of
Intelligence Verbal Adult Intelligence Scale
 PGI-Memory Scale
 Nahor Benson Test
 Bender Visual Motor Gestalt Test
2. Hindi Mental State Examination (HMSE) Ganguli et al., 1996
 DOMAINS ASSESSED - HMSE total Calculation Word list
learning, recall & recognition Object Naming Verbal fluency
(category – animals & fruits) Constructional praxis
3. NIMHANS Neuropsychological Battery, 2004 SL,
Subbakrishnan DK Gopulkumar K,Bangalore.

TESTS INCLUDED IN NIMHANS
BATTERY
LOBES FUNCTIONS TESTS
FRONTAL LOBE Motor functions
Motor speed
Motor coordination
Finger tapping test
(reitan 1970)
Hand tapping (luria
1966)
Attention
Sustained attention
Focused attention
Colour cancellation
Color trails test trail A
and B
Expressive speech
Repetitive speech
Nominative speech
Narrative speech
Repeating sounds
Repeating words
Categorical naming
Object naming
Sentence construction

Contd… Executive functions
Verbal fluency
Design fluency
Verbal working memory
Visuospatial working
memory
Planning
Shift of set
Phenomic fluency
(Lezak 1995)
Design fluency (Jones
gotman and miner
1977)
N back test verbal
(Smith and jonides
1996)
VSWM span task
(Miner 1971)
N back test visual
(Smith and jonides)
1995
Proteus maze (Proteus
1965)
Wisconsin card sorting
test (Heaton chelune,

PARIETAL LOBE Visuo perceptual ability Motor free visual perception test
(collarusso and Hammil, 1972)
Visuo conceptual ability Picture completion (MISIC 1969)
Visuo constructive ability Block design (MISIC 1969)
Visual recognition Recognition pictured objects (lezak
1995)
Apraxia Symbolic and sequential acts (lezak
1995)
Somatosensory perception
Tactile finger localization
Tactile form perception
Finger localization (Boil 1974)
Tactile form perception (lezak
1995)
Reading Reading a passage,Reading
comprehension
Writing Writing to dictation copying
Calculation Age appropriate sums

TEMPORAL
LOBE
Verbal comprehension Token test ((De Renzi and
Vignolo, 1962)
Verbal language and memory Rey ‘s auditory verbal
learning test(maj et al
1993)
Visual learning and memory Memory for designs (jone
sgotman and miner 1986)

PURPOSE OF
NEUROPSYCHOLOGICAL
ASSESSMENT
DIAGNOSIS
&
SCREENIN
G
NOT A
PRIMARY
DIAGNOSTIC
TOOL BUT CAN
AID IN
PREDICTION
PROVIDES
BEHAVIORAL
DATA FOR
LOCALIZING
THE SITE OF
A LESION
USEFUL IN
DISCRIMINATIN
G BETWEEN
PSYCHIATRIC
AND
NEUROLOGICA
L SYMPTOMS
TO
DISTINGUISH
BETWEEN
DIFFERENT
NEUROLOGICAL
CONDITIONS

PATIENT CARE
&
PLANNING
COGNITIVE
STATUS
&
PERSONALITY
CHARACTERIST
ICS
UNDERSTANDING OF
PATIENT’S CAPABILITIES
AND LIMITATIONS
+
PSYCHOLOGICAL CHANGES
SUCCESSIVE
NEUROPSYCHOLOGICA
L ASSESSMENTS
REPEATED AT REGULAR
INTERVALS THROUGH
OUT THE COURSE OF
AN ILLNESS
RELIABLE
INDICATOR OF
IMPROVEMENT ;
EARLY PREDICTOR
OF DEMENTING
COURSE

PSYCHOSOCIA
L
REPURCUSSIO
NS
DEFECTS IN
MOTIVATION
DEFECT IN
ABILITY TO PLAN
DEFECT IN
ORGANIZING AND
CARRYING OUT
ACTIVITIES
IMPAIRED CAPACITY
TO EARN A LIVING
SOCIAL
DEPENDENCE
Disorder of complex thinking and ideation, resulting in difficulty in dealing
with ‘psychological and social challenges’ in daily life.
Lysaker et al 2015.

REHABILITATION
& FUNCTIONAL
SKILLS
ASSESSMENT
PREDICTION
OF
REHABILITATIO
N NEEDS
PREDICTION
OF ABILITY OF
PATIENT TO
FUNCTION
INDEPENDENTL
Y
PREDICTS
PATIENT’S ABILITY
TO RESUME
NORMAL ROUTINE
ACTIVITIES
• managing a family
•Returning to
home from work
•Resuming school

 The importance of early assessment and intervention
 A comprehensive neuropsychological assessment
evaluating a full range of behavior should be completed
early.
Reitan and wolfson 2001
 Decreases the likelihood of patient’s learning
maladaptive responses as he or she attempts to cope
with cognitive impairments.
 Decreases the likelihood of a reactive depression
developing consequent to feelings of helplessness and
hopelessness.
 Determine change of function over time, for example as
a consequence of treatment or spontaneous recovery or
alternatively to monitor deterioration.

RESEARCH
TO STUDY
ORGANISATION OF
BRAIN ACTIVITIES
AND ITS
TRANSLATION TO
BEHAVIOR
INVESTIGATING
PSYCHIATRIC
ILLNESSES
DEVELOPMENT,
EVALUATION AND
STANDARDIZATION
OF
NEUROPSYCHOLOGI
CAL ASSESSMENT
TECHNIQUES

MEDICOLEGAL
PURPOSES
PERSONAL INJURY ACTIONS SEEKING OF MONETARY COMPENSATION
FOR CLAIMS OF BODILY INJURY AND LOSS OF FUNCTION
EVALUATION BY NEUROPSYCHOLOGIST
To examine the type and amount of behavioral impairment
sustained.
To estimate claimants rehabilitation potential.
To estimate the extent of need of future care.
IN CRIMINAL CASES , ASSESSMENT OF DEFENDANT BY
NEUROPSYCHOLOGIST
To rule out any brain dysfunction or any underlying pathology
contributing to the incident.

 In president Kennedy’s murder investigations, a
neuropsychologist determined that the defendant’s
capacity for judgment and self control was impaired
by brain dysfunction. The fact that the defendant
had psychomotor epilepsy was interpreted by
Doctor in charge after going through the
psychological test findings and was then confirmed
by an EEG.

DISABILITY
ASSESSMENT
ASSESSMENT OF
PERSON WITH
PHYSICAL DIFFICULTY
Motor impairment and
comorbidities
ASSESSMENT OF
PERSONS WITH
VISUAL IMPAIRMENT
OR BLINDNESS
Verbal spatial factor,
perceptual motor factor
and emotional coping
factor
ASSESSMENT OF
PERSONS WITH
HEARING
IMPAIRMENT
ASSESSMENT IN
SCHOOLS FOR
LEARNING
DISABILITY

7. OTHERS
 Recruitment in defense, federal aviation, govt setups including
arithematic performances , sports medicine which includes
assessment of
1. General Cognitive abilities
2. Academic Achievement
3. Sensory Perceptual Skills
4. Motor speed, coordination, and planning
5. Attention, Concentration and mental processing speed in
visual and auditory modalities
6. Comparison of right and left hand performance
7. Assessment of language functions such as fluency and
naming
8. Assessment of nonverbal skills such as construction
9. Assessment of verbal and nonverbal memory including
retention and learning rates
10. Assessment of executive functions and cognitive flexibility

COGNITIVE DEFICITS
Cognitive deficits may result in inability to:
 Pay attention
 Process information quickly
 Remember and recall information
 Respond to information quickly
 Think critically, plan organize and solve
problems
 Initiate speech

WHAT IS SEVERE MENTAL
ILLNESS?
 A patient has severe mental illness when he or she
has the following:
 a DIAGNOSIS of any non-organic psychosis
 a DURATION of treatment of two years or more
 DYSFUNCTION, as measured by the Global
Assessment of Functioning (GAF)( American
Psychiatric association, 1987).
Ruggeri et al, 2006
The broad definition (the ‘ two-dimensional
definition’) is based on the fulfillment of the latter

 Specifically, the two levels of dysfunction defined by
cut-off points of the GAF are tested:
 moderate or severe dysfunction
(a GAF score of 70 or less, indicating mild symptoms or some
difficulty in social, occupation or school functioning);
 or only severe dysfunction
(a GAF score of 50 or less, indicating severe symptoms or severe
difficulty in social, occupational or school functioning).
Ruggeri et al, 2006

COGNITIVE DEFICITS IN
SCHIZOPHRENIA
 Cognitive deficits are a core and stable
characteristic (i.e. trait) of schizophrenia, and they
are independent of psychotic symptoms
Banaschewski et al 2001
 More severe cognitive deficits at the time of first
episode →more likely to develop chronic and
severe functional impairment.
Keefe et al, 1989
 may precipitate psychotic and negative symptoms
Crow et al 1995
 are relatively stable over time, with progressive
deterioration after the age of 65 years in some

 Although cognitive deficits is not the part of current
diagnostic system for schizophrenia i.e. ICD-10 or
DSM-IV TR, it is a core feature of schizophrenia.
 In the recent years extensive research has suggested
that cognitive deficits associated with schizophrenia are
not a consequence of psychotic symptoms and its
treatment but rather a distinct dimension of illness.
 IT IS RELATED TO BUT NOT CAUSED BY
NEGATIVE SYMPTOMS.

 Some rating scales consider cognitive process as
negative symptoms
 Functional deficits included in negative symptoms
rating scale
 Improvement in both not proportionate to each
other
Gold et al 1992; Leffe
et al 1994
 Even prior to onset of psychotic symptoms
neuropsychological abnormalities are present.
 persist on the remission of psychotic symptoms.
Heaton,2010

 Deficits have also been documented in studies in which
sibling controls were examined.
 Off-springs of patients with schizophrenia show deficits in
overall IQ and in specific cognitive functions of attention
and short term memory in childhood and adolescence.
 A meta analysis of 37 studies found that unaffected first
degree relatives of patients with schizophrenia have a
similar profile of neurocognitive deficits found in the
patients themselves although magnitude of the deficits
was smaller.
 Thus there can be a genetic component of this symptoms
domain of schizophrenia.

COGNITIVE DEFICITS IN SCHIZOPHRENIA
Developmentally
based subtle deficits
Illness onset
related severe
deficits
Limit normal
acquisition of
cognitive skill
Compromise cognitive
skill already acquired

FOR MEMORY FOR ATTENTION
1. PGI memory
scale/verbal and
visual memory
(Pershad and Verma
1990)
2. Visual memory-
complex figure test
and design learning
test by NIMHANS
Battery –Rao et al
2004
3. California verbal
learning test
4. Wechsler memory scale
5. Benton visual retention
test
6. Rey’s complex figure
1. Digit span test
2. Focused attention by Color
trials test
3. Sustained attention by Digit
vigilance test
4. Divided attention by triad test
by NIMHANS Battery- (Rao et
al 2004)
5. Continuous performance test
6. Stroop color naming
7. Symbol digit modalities test
8. Trail making test
9. Brief test of attention (BTA)
10. D2 test of attention
11. Gordon diagnostic system
12. Paced auditory serial addition
task (PASAT)
13. Quotient test of attention
14. Symbol digit modalities test

FOR INTELLIGENCE
FOR EXECUTIVE
FUNCTONS
1. Wechsler adult intelligence
performance and verbal
scale – indian adaptation.
(Prabhalnga swami)
2. Stanford binet intelligence
test
3. Bhatia’s battery of
performance of
intelligence
4. Proteus maze test
5. Raven’s standard
progressive matrices
6. Reynold’s intellectual
assessment scale
7. Peabody pictute
1. Wisconsin card sorting
test (WCST)
2. Verbal and visual fluency
test
3. Categories test and Trail
making tests
4. Stroop colour word
interference test
5. Tower of london tasks
6. Problem solving-Porteus
maze test
7. Psychomotor Skills-
Grooved peg
board,Finger tapping.

BATTERIES USED IN
SCHIZOPHRENIA
 MCCB ( MATRICS consensus cognitive battery)
 BACS ( brief assessment of cognition in
schizophrenia)

SPECIFIC COGNITIVE
DEFICITS IN
SCHIZOPHRENIA

I. MEMORY DEFICITS
 PATIENT PRESENTATION
 Disorientation and forgetting intervening events
 Inability to recall everyday information: dependent
living
 Difficulty learning demands of job or learning new
information
 Social deficits worsened (learn names & details of
acquaintances)
Green et al, 2000

Working Memory (WM)
 Definition: System for transient holding, storing and
manipulating information in the execution of complex
cognitive tasks such as learning , reasoning and
comprehension.
Brandt et al 2014
 Relevance: There is increasing evidence that WM
dysfunction, particularly verbal WM, is a core cognitive
deficit in schizophrenia.
 Proposed Mechanism:
 As opposed to simple attention span, this skill carries more
of a “cognitive load” due to the additional demands of
manipulating the information.
 The information must be held on-line for processing, but
does not necessarily transfer to long-term storage, unlike
episodic memory.
 Findings: Verbal memory impairments are quite common

 Due to impairment in stimulus modality, verbal
characteristics, sequence and generation status-
social, occupational and communication
impairment
Hofer et al, 2005
 Working memory – same brain areas(PFC)
activated but intensity
Schizo > BPAD> controls
i.e Patient will show stronger activation even if the
task difficulty is low. Patients had to use more
cognitive resources to perform the same task.
Brandt et al 2014

 Neuropsychological and imaging studies suggest
that the WM system is of a limited capacity in
patients with schizophrenia.
 Deficits in strategic long-term memory (e.g. free
recall, memory for temporal order) could be
accounted for by deficits in WM.
Schizophrenia res treatment, 2011

II. ATTENTION DEFICITS
 Difficulty to identify and focus on information in
environment.
 Living in world where every stimulus is a new stimulus
 Inability to adjust physiological reactivity to
experience.
Harvey et al, 2002

 Impaired attention is considered a primary cognitive
deficit in schizophrenia.
 Individuals who are genetically predisposed to
schizophrenia have poor ability to maintain their
attention even prior to the first psychotic episode
Cornblatt et al
1985
 By the time patients experience their first episode of
psychosis, attentional impairments are typically
present and of moderate severity
Caspi et al 2003

 Meta-analytic studies suggest moderate to severe
impairments in this attention domain.
Reichenberg ,2010
 Deficits in attention and information processing might
be central to schizophrenia because these can
contribute to deficits in EF and WM.
 Attention deficits are also trait and vulnerability
markers seen during remission and in children of
schizophrenic parents.
Nuechterlein, 1986
 Attention deficits have been found to be robustly
associated with deficit syndrome.
Ross et al , 1997

III. EXECUTIVE FUNCTIONS
Functional disability related to all aspects and much
more severe comparative to IQ level.
 Executive functions encompass a wide range of
cognitive processes that ultimately result in
purposeful, goal-directed behavior.
 Studies using formal neuropsychological
instruments have found that many schizophrenia
patients have difficulties with most or all of these
component processes.
 Schizophrenia patients have trouble adapting to
changes in the environment that require different
behavioral responses Koren et
al 1998; Pantelis et al 1999

 This tendency toward inflexible thinking is found in a
number of studies and is highly correlated with
occupational difficulties
Lysaker et al 1995
 Another component of executive functioning often
found to be impaired in schizophrenia is planning
Goldberg et al 1990; Pantelis et al 1997; Bustini et
al 1999
 Perhaps because they encompass so many sub-
component processes, the executive functioning tasks
are consistently among the best predictors of
functional performance.

 Neurocognition, specifically the ability to perceive
and understanding the surrounding environment,
along with visuospatial processing,planning and
problem solving skills are impaired in people with
schizophrenia.
 Also have social cognitive deficits they lack the
ability to detect a faux pas and identify the person
who has committed a faux pas in the interaction.
Lam et al 2014

 Self-care, social, interpersonal and occupational
functions are all associated with executive functioning
in schizophrenia
Lysaker et al 1995; Velligan et al 2000; McGurk et al 2003;
Evans et al 2004
 Importantly, executive functions are also associated
with treatment success.
 Impairments in this domain are associated with less
engagement in therapy (McKee et al 1997),
medication compliance (Robinson et al 2002; Jeste et
al 2003), and longer hospital stays (Jackson et al
2001).

GENERAL INTELLIGENCE
 Patients with schizophrenia have, as a group, lower
Intelligence Quotient (IQ) scores than the general
population.
 This difference is evident prior to the first episode of
psychosis, with patients on the schizophrenia
spectrum showing poorer performance on general IQ
and non-verbal reasoning in particular
Reichenberg et al 2006
 As young as age 8, poor performance on the Coding
subtest of the Wechsler Intelligence Scale for
Children, which is a measure of processing speed,
distinguishes individuals who later develop
schizophrenia spectrum disorders from those who do
not

 Further evidence suggests that patients not only have
lower IQ prior to and at first episode, but declines in
IQ occur after the diagnosis
Seidman et al
2006
 Further, when matched to healthy control subjects on
full scale IQ score, patients with schizophrenia still
evidence impairment in specific neuropsychological
domains not traditionally assessed with standardized
IQ batteries
Wilket al 2005

VERBAL FLUENCY
 Patients with schizophrenia have difficulties producing
speech on demand.
 Verbal fluency tests assess their ability to produce words
from a specific phonological or semantic category.
 These tests reveal both poor storage of verbal
information (Kerns et al 1999) as well as inefficient
retrieval of information from semantic networks
Aloia et al 1996; Goldberg et al 1998
 Not surprisingly, deficits in verbal fluency are associated
with poor interpersonal functioning (Addington and Addington
2000) and community functions (Rempferet al 2003).

VERBAL LEARNING AND
MEMORY
 Poor learning and retention of verbal information is a
hallmark cognitive impairment in schizophrenia.
 Along with executive functioning deficits, impaired ability to
encode and retain verbally presented information is one of
the most consistent findings across research studies.
 These deficits tend to be more severe than other cognitive
ability domains Saykin et al 1991; Saykin et al 1994

 The pattern of deficits in schizophrenia tends to be
reduced rates of learning over multiple exposure trials
and poor recall of learned information, while encoding
of the information appears spared
Harvey et al 2002; Bowie et al
2004
 Verbal memory performance predicts success in
various forms of verbal therapy (Smith et al 1999) and
is associated with social, adaptive, and occupational
success.
Green et al, 2000

WORKING MEMORY
DEFICIT
Impaired planning,
reasoning and problem
solving
Impaired verbal fluency
Lower intelligence
Impaired attention
Impaired verbal fluency
Impaired
visuospatial
processing

MANAGEMENT
Need for intervention:-
 Negative features and neuro-cognitive impairments
can cause the greatest problems in terms of
rehabilitation.
 Better predictors of functional outcome.
 Both pharmacological and non pharmacological
interventions are applied.

Pharmacological
 Antipsychotics
 1st generations or typical or conventional.
 2nd generations or atypical.
 Cognitive enhancers

PHARMACOLOGICAL-TYPICAL
Typical antipsychotics:
 little benefit (Mishara and Goldberg 2004)
 additional requirement of anticholinergics that impairs
memory (Strauss et al 1990).
 provides modest-to-moderate gains in multiple
cognitive domains.
Mishara
et al 2004

Pharmacological-typical
Compound Effect Authors
Chlorpromazine Mixed, usually no effect Pigache 1993
Solo et al 1997
Haloperidol Mixed, usually no effect Gilbertson et al 1997
Serper et al 1990
Fluphenazine+
thioridaziene
No effect/ worsened Strauss et al 1990
Zahn et al 1994
Flupenthixol depot Mixed David 1995

Pharmacological-atypical
 Cognitive improvements are reported
Keefe and McEvoy 2001
 These changes were greater than placebo and the
conventional antipsychotic medications and found in a
number of cognitive domains.
 Clozapine, tends to result in improved motor functions
but not other cognitive domains
Bilder et al 2002

Atypical antipsychotics
Drugs Functions improved
Quetiapine Verbal fluency, recall, cognitive flexibility,
visuo- motor tracking
Olanzapine Verbal fluency, memory, vigilance, working
memory
Risperidone Episodic memory, verbal fluency, vigilance,
executive skills, visuo-motor speed
Clozapine Working memory, executive skills, motor
function

Nonpharmacological- Cognitive
rehabilitation
 Cognitive rehabilitation is a confluence of therapeutic
activities based on brain behavior relationships.
Hedge 2014
 Includes training on computerized tasks similar to
existing cognitive tests, teaching new learning strategies,
training on novel tasks, and/or performing tasks
repetitively.
 Ultimate goal is to improve day to day social functions
as well as occupational rehabilitation.
Zaytseva et al, 2013
 CR improves attention and verbal working memory.
D’souza et al,2013

HOW DOES IT WORK?
CR induced hyperactivity in PFC,
cortical midline regions , parietal and
temporal cortex.
Increased inter hemispheric information
transfer by the bilateral PFCs via the
corpus callosum.
Promotes neuroplasticity
Neuroprotective effects against grey
matter loss in temporal brain regions
associated with cognition
+
Increased serum BDNF levels
Thorsen et al,
2014
Michalopoulou et
al, 2015
Penades et al,
2013

INDIAN STUDIES IN COGNITIVE
REHABILITATION
AUTHOR SAMPLE INTERVENTION RESULT
D’souza et al, 2013 India:
104 randomized
Mixed,
double-blind,
placebo-controlled,
Stratiﬁed random
sampling by IQ.
Assessments: at 12
and 24 weeks
CRT, Computerized
(20 computer-
assisted
tasks
And placebo
Improved
attention/vigilance
and verbal working
memory only, high
placebo response.
No effect of CRT
on global cognitive
index.
Suresh kumar,
2008
DSM IV
schizophrenia
attending
vocational
rehabilitation for 6
months, controls:
no vocational
rehabilitation
Vocational
activities,
fullday, as per
ability, in the
hospital.
Cognitive
functioning
positively
correlated
With occupational
role
In patients and
negative
correlation in

AUTHOR SAMPLE INTERVENTION RESULT
Hegde et al, 2012 First
episode
schizophrenia:
ICD10 criteria,
duration of illness
<2
2-month-long
home-based
cognitive retraining
(TAU;psychoeduca
tion
And drug therapy)
for
subjects, only
TAU for controls.
Cognitive
retraining:
improved
cognition;
better motor
speed,
Verbal working
memory,concept
formation and
set-shifting ability,
Verbal learning,
visuo- constructive
ability, divided
attention, planning,
and reduced
negative
symptoms.
Bhatia et al, 2012 DSM-IV
schizophrenia,
outpatients, over
21 days, daily one
hour
yoga protocol
Signiﬁcant
improvement in
attention

YOGA as cognitive enhancement
therapy
 Number of yoga therapists exceed the number of
mental health professionals in India.
Jagannathan et al, 2015
 Practice of yoga emphasizes in focusing ones attention
on breathing so improves general attentional abilities.
 Studies available in India include studies from
NIMHANS and RMLH, New Delhi on yoga as an
adjunctive intervention in schizophrenia.
Duraiswamy et al, 2007, Jayaram et al 2013, Gangadhar 2014,
Talwadkar et al, 2014
 According to these studies yoga group as a whole
shows greater improvement in attention, abstraction,
mental flexibility.

ASSESSMENT IN
BIPOLAR AFFECTIVE
DISORDER

SPECIFIC COGNITIVE
DEFICITS IN BIPOLAR
AFFECTIVE DISORDER

INTRODUCTION
 Evidence suggests that the presence of cognitive
dysfunction in BPAD is a core and enduring
deficits of the illness.
Ferrier and
Thompson,2002
 “debilitating” cognitive impairment in different
stages of the disease.
Torres, 2010
 Deficits in cognitive function are both transitory
(acute phase of illness) and persistent
(chronic/residual symptoms)
Elshahawi,2011

COGNITIVE
DEFICITS
PROCESSING
PROCESSING
PSYCHOMOTOR
SPEED SPEED
VISUAL
MEMORY
VERBAL
LEARNING
MEMORY
ATTENTION
;SUSTAINED
ATTENTION
EXECUTIVE FUCNTIONS
Such as set shifting,
response inhibition,
verbal fluency and
working memory
Arts et al,2008; Bora et al,2009; Mann-
Wrobel et al,2011; Bourne et al,2013;
Robinson et al,2006; Torres et al,2007

MANIA
 MEMORY IMPAIRMENT- Difficulty in encoding,
consolidating and retrieving the information leads to poor
performance in neuropsychological tests of memory.
T.H.Ha et al, 2014
 ATTENTION – difficulty in sustaining attention leads to poor
performance in continuous performance tasks.
Clark et al 2005
 IMPAIRED DECISION MAKING – disturbances in the
decision making process, leads to increased impulsivity.
lewandowski., 2009
manic patients seem to have difficulty in concentrating and
to be more impulsive when making decisions.
bearden et al 2006
 Specific distortions of thinking occur ("anastrophic" thinking).

 PROCESSING SPEED AND VERBAL LEARNING is
impaired along with attention,memory and executive
functions in patients relative to HCs.
Lee et al, 2014
 IMPAIRED RESPONSE INHIBITION as seen in
performance in Stroop test as compared to healthy
controls. Daglas et al, 2015
 AFFECTIVE BIAS a change of information processing of
affective type, mostly a lower ability for perception and
recognition of negative emotions.
Lewandowski, 2009
 IMPAIRED REASONING & PROBLEM SOLVING
SKILLS as patients in mania score lower than HCs
exposed to neuropsychological tests for the same.
Clark et al 2001

MANIA VS HYPOMANIA
DOMAIN COMPARISON
COGNITIVE DYSFUNCTION BIPOLAR 1 >BIPOLAR 2
VERBAL MEMORY BIPOLAR 1 >BIPOLAR 2
WORKING MEMORY BIPOLAR 1 >BIPOLAR 2
Patients with bipolar 2 > bipolar 1 more perseverative errors on WCST which can
be relate to greater impulsivity.
Could be related to higher comorbidity related to the impulsivity spectrum in type ii
disorder
Goldberg et al 1999, vieta et al 2000
Torrent et al, 2006

EUTHYMIA
 Euthymia may not be a period of complete recovery.
Clark et al. 2002; Quraishi and FrangoU 2002; Latalova et al,2011; Malhi
et al,2007; Martinez-Aran et al,2004; Lewandowski et al, 2011
 Euthymic patients perform well on memory attention and
problem solving tasks than all the stages of illness, but
significantly lower scores than controls.
Bourne et al 2013
 WORKING MEMORY – patients have poorer working
memory capacity and spatial working memory than HCs
including declarative or long-term memory impairments.
Bora et al 2010

 patients in remission show a relatively specific
impairment in memory .The increased response latency
on the executive tasks suggests a possible small
residual impairment.
Rubinzstien 2000
 Deficits are seen in PROCESSING SPEED and
ATTENTION in euthymic stage of illness.
lee et al 2014
 DEFICITS IN EXECUTIVE FUNCTIONING AND
VERBAL LEARNING are seen in euthymic patients of
BPAD, patients performed worse than HCs in the same
cognitive flexibility task.
Fleck et al,2008

DEPRESSION
 MEMORY IMPAIRMENT
Reduced hippocampal volumes observed in major
depression consistent with temporal lobe dysfunction
and contributes to memory impairment.
poorer performances on total, short delayed free recall,
long delayed free recall, and recognition of the CVLT.
These memory problems persists into the euthymic
stage of bipolar illness. T.H.Ha et
al,2014
 ATTENTION DEFICITS
Patients in the depressive stage of illness find it difficult
to maintain the concentration for even short periods.
 VERBAL FLUENCY is a cognitive domain specifically
affected in depressive patients.

 depressed patients have poorer performances on tests for
assessing verbal fluency: ‘category instances’ (semantic
fluency) and ‘controlled oral word association test’ (letter
fluency)
Van der Werf-Eldering et al,2010
 IMPAIRED PROCESSING SPEED AND DECISION MAKING
On Cambridge decision making task , depressed patients
show slower decision making times than HCs.
Clark et al 2005
 PLANNING AND RESPONSE TO NEGATIVE FEED BACK
Depressed patients show an abnormal response to negative
feedback , when informed that they have just failed to solve a
problem they are far more likely to fail the next.
 AFFECTIVE PROCESSING BIAS
bias towards the recall of negative autobiographical material
and lacking details when it comes to recall the positive.

ENDOPHENOTYPES
 The findings of cognitive deficits in relatives of patients
with bipolar disorder are suggestive of pre-existing
developmental or genetic vulnerability.
Ferrier et al,2004; Zalla et al,2004
 Unaffected relatives of patients with bipolar disorder
may have deficits in specific cognitive tasks compared
to HCs.
Bora et al,2009; Ferrier et al.2004; Robinson and Ferrier
2006; Arts et al,2008
 Different authors have given statements in the past
decade with evidence most in the favor of –
-VERBAL WORKING MEMORY
-EXECUTIVE FUNCTIONS

 Whereas according to some, Response inhibition deficit
is the most prominent endophenotype of BPAD
Bora et al 2009, Frangou 2005
 Trait related deficits appear to be present in verbal
memory and sustained attention
Quraishi S 2002

FUNCTIONAL OUTCOME
 30 – 50% of patients with BPAD experience
significant social disability that may be related to
persistent cognitive impairment.
Dickerson et al 2004
 no evidence of dysfunction in verbal fluency
during both the acute state and remission period
of a FEM, and non-verbal memory does not
appear impacted during remission.
 This suggests a finite window for potentially
neuroprotective effects as past literature on
chronic bipolar disorder has identified deficits in
both these domains, highlighting the theoretical
importance of early intervention and treatment
adherence. Daglas et
al 2015

 chronic disorder with a high relapse rate,
significant general disability, personal and social
burden, and psychosocial impairment.
Miziou et al, 2015
 Cognitive impairment has serious consequences
for patients and caregivers, by impacting on the
quality of life .
Sapouna 2013

ILL EFFECT OF MEDICATION ON
COGNITION
 STUDIES FOREMOTION
 lithium has mild but adverse
effects on long-term memory
that involves the acquisition
of new information
Judd, 1995
 medication effects
contributed to psychomotor
slowing in bipolar disorder,
processing speed
impairment.
Bora et al 2009
 an increase in the daily dose
of antipsychotic medication
trended towards poorer
processing speed in FEM
patients
Hellvin et al,2012
 AGAINST THE MOTION
 long-term lithium usage is
unlikely to cause progressive
cognitive decline
David et al 2007
 Strakowski et al, 2008
reported no difference in
response inhibition between
medicated and unmedicated
patients.
 Patients treated with lithium
outperformed patients on
divalproex on several
cognitive tasks
Torres et al,2010

SCOPE OF RESEARCH
 The relationships between neuroimaging and
neurocognitive abnormalities in BPD are worthy
of additional investigation.
 Phenotyping neuropsychiatric disorders.
 Relevance
- may yield important insights into the
development, nature, and course of illness.
- better identification of individuals who may be
prone to greater cognitive impairment or decline
and those who might be more responsive to
specific treatments.
Osuji 2005

 To date there are no longitudinal studies to assess
whether cognitive deficits in BPAD show a
progressive course or their association with the age
of illness onset Ferrier and Thompson,2002
 differences in cognition in the manic state, depressed
state, or euthymic (normal) state have not been
dissected. These areas should be researched further.
Torrent et al 2006
 Patterns of sustained attention and processing speed
impairments differ from schizophrenia. Future work in
this area should differentiate cognitive deficits
associated with disease genotype from impairments
related to other confounding factors.
Daglas et al 2015

summary
 Poor performance on verbal memory, working
memory, processing speed, verbal fluency,
attention and executive function/reasoning and
problem solving.
 cognitive impairment were identified in all phases
of the disorder but mainly during manic episodes.
 Correlates like longer length of illness, younger
age of onset, and higher number of
hospitalizations may contribute to the intensity of
cognitive deficits.
 need for clinical assessment and cognitive tests
dynamically applied in order to be able to
determine the stability or evolution of cognitive
impairment in time.

I. SCHIZOPHRENIA
STUDY SAMPLE ASSESSME
NT
RESULT
NIZAMI ET AL
1992
40 schizophrenic
(DSM III) patients,
30 brain damaged
patients and 30
Luria Nebraska
neuropsychologic
al battery
Schizophrenic
patients perform
better than brain-
damaged but had
poor performance
than in
comparison to
normal controls.
ANANTHNARAYA
N ET AL 1993
24 remitted
schizophrenics, 25
currently ill
neurotic
depressives (ICD-
9)
Computer based
tests for visual
information
processing:
Simple reaction
time, choice
reaction time,
forced choice
Remitted
schizophrenics
performed poorly on
all these measures as
compared to
neurotic depressives.

STUDY SAMPLE ASSESSMENT RESULT
MANDAL ET AL
1999
12 schizophrenics
(DSM-III R) each
with predominantly
positive and
negative
phenomenology;
12 healthy controls
Recognition of
Emotion’ sub-test
of the Penn Facial
Discrimination
Task
Schizophrenic
patients with
negative
symptoms
exhibited a
generalized
emotion-
recognition deficit.
Schizophrenic
patients with
positive symptoms
showed a deficit in
recognition of ‘sad’
emotion.
MISHRA ET AL
2002
60 schizophrenic
patients (ICD-9)
Luria Nebraska
neuropsychologica
l battery
Pattern of
performance in
tests indicated
possibility of
combined cerebral
dysfunction, more

SABHESAN ET
AL 2005
31 schizophrenic
patients (ICD-10)
Executive
functions
assessment
schedule, trail
making test,
Raven’s matrices,
fluency tests
Patients had
varying degrees of
involvement of
different
dimensions of
executive function
tests. Poor
performance on
TMT and ravens
matrices.
DAS ET AL 2005 15 chronic
schizophrenic
patients (DSM-
IIIR) 15 controls
continuous
performance task,
Stroop test, Spatial
task
Positive correlation
between negative
symptoms and
neurocognitive
functions
especially card
sort test.

SHRINIVASAN &
THARA ET AL 2005
100 chronic
schizophrenic
(DSM-IV) patients
and 100 normal
controls
Tests from Wechsler
memory scale,
Wechsler adult
intelligence scale,
San Diego
neuropsychological
test battery,
NIMHANS
Schizophrenic
patients
performed poorly
on all cognitive
tests in
comparison to
normal controls.
Cognitive deficits
were related to
gender,
education, age,
duration of illness,
and presence of
positive and
negative
symptoms.
MALHOTRA ET AL
2006
14 childhood onset
schizophrenia
(COS) patients
(ICD-10 DCR)
Wisconsin card
sorting test
COS patients
have difficulty in
executive
functioning
Deficits similar to
those of adult

KRISHAN DAS ET
AL 2007
25 schizophrenic
(DSM-IV) patients
in remission and 25
normal controls
Tests from PGI
battery of memory
dysfunction,
NIMHANS
neuropsychological
battery, Rey-
Osterrieth complex
figure test, Frontal
Assessment
battery
Patients with
schizophrenia
showed significant
deficits on tests of
attention,
concentration,
verbal and visual
memory and tests
of frontal
lobe/executive
function as
compared to
normal controls. No
relationship was
found between
age, duration of
illness, number of
years of education
and cognitive
function. No
statistically
significant

TRIVEDI ET AL
2008
36 non-affected
first degree full
biological siblings
of schizophrenic
(DSM-IV) patients
and 36 controls
Wisconsin’s Card
Sorting Test,
Spatial Working
Memory Test,
Continuous
Performance Test
Sibling group had
substantial
cognitive deficits as
compared to
control group.
Siblings from
multiples families
(>1 schizophrenic
patient in a family)
performed poorer
as compared to
simple families.
BHATIA ET AL
2009
172 schizophrenic
and schizoaffective
patients (DSM-IV)
and their parents (n
=196) ; 120
controls
TMT Cases as well as
their parents
showed more
cognitive
impairment than
controls on the
TMT

SUMMARY
 Poor cognitive function as compared to HCs and
remitted schizophrenia patients perform poor on
cognitive tasks as compared to active depressive
patients.
 Left hemisphere involvement in the dysfunction
primarily
 Significant deficits on attention, concentration,
verbal and visual memory.
 Cases as well as their parents showed more
cognitive impairment as compared to HCs.

II. BIPOLAR AFFECTIVE
DISORDER
TAJ ET AL 2005 30 bipolar disorder
patients in
remission 30
normal subjects
Digit symbol test,
Trail making test
part A and B,
Verbal fluency test,
Digit span forward
and backward test,
Logical memory
test, Paired
association
learning test,
Visual design
reproduction test
Patients with
bipolar disorder, in
remission, have
neuropsychologica
l impairment in
attention, memory
and executive
functioning
TRIVEDI ET AL
2008
15 euthymic
bipolar 1 patients
15 controls
Wisconsin’s Card
Sorting Test,
Spatial Working
Memory Test,
Continuous
Performance Test
Euthymic bipolar
patients showed
significant deficits
in executive
functions.

STUDY SAMPLE ASSESSMNET RESULT
SAREEN ET AL
2009
25 first degree
non affected full
biological siblings
of bipolar affective
disorder patients
25 controls
Wisconsin’s Card
Sorting Test,
Spatial Working
Memory Test,
Continuous
Performance Test.
The sibling group
performed poorly
on cognitive
domains studied
as compared to
controls.

SUMMARY
 Overall impairment in attention, memory and
executive functioning
 Euthymic bipolar patients showed significant
deficits in executive functions.
 First degree relatives of cases perform poorly
than HCs.

INDIAN STUDIES
COMPARING COGNITION IN
SCHIZOPHRENIA AND
BIPOLAR AFFECTIVE
DISORDER

TRIVEDI ET AL
2006
15 stable
maintained
schizophrenia
(DSM-IV) patients;
15 euthymic
bipolar-1 (DSM-IV)
patients; 15
controls
Stable schizophrenia
patients performed
poorly on all the
neurocognitive
parameters as
compared to both
control and bipolar
euthymic patients.
PRADHAN ET AL
2008
48 euthymic bipolar
(ICD-10) patients;
32 schizophrenia
(ICD-10) patients in
remission; 23
normal controls
Wisconsin’s Card
Sorting Test
(WCST), Trail
making test-B,
Controlled words
association test,
PGI memory scale,
Bhatia battery of
performance tests
of intelligence-
Short scale,
Bender visual
motor Gestalt test,
Trail A test
When compared to
controls, both
bipolar disorder and
schizophrenia
patients were
significantly
impaired on
different tests of
executive function,
memory, IQ and
perceptuomotor
functions.
Schizophrenic
patients
consistently

SUMMARY
 Stable schizophrenia patients performed poorly
on all the neurocognitive parameters as
compared to both control and bipolar euthymic
patients.
 Performance on cognitive tasks impaired in order:
 Active schizophrenia> remmision in
schizophrenia> bipolar affective disorder> healthy
controls

LIMITATIONS OF
NEUROPSYCHOLOGICAL
ASSESSMENT
 Varying Interpretations and Uses
- Responsibility of the administering psychologist .
- Two psychologists may interpret the results
differently and
take different courses of action.
 Uncertainty of Measurements
- a gap between what a test is attempting to
measure and what it actually measures.
- nature of the tests often rely on indirect measures
such as an individual responding to hypothetical
situations.
- Decisions made in a testing situation are not
always the same actions people would take when

 Changing Circumstances
-continual development or refinement of psychological
theories, development of technology and passage of
time, psychological tests only remain relevant for a
time.
-Social or cultural changes can lead to test items
becoming obsolete, or new psychological theories
may replace the founding theories of the tests.
- To remain valid and reliable, psychological tests must
be updated often and norm samples should be kept
current.

 Cultural Bias
- Once translated, the tests are no longer truly
standardized.
Anne et al 2006
- cultural background of psychologist may hamper
the results.
 Labelling and self fulfilling prophesy
- Stigma associated with labels such as Learning
Disabled, ADHD, schizophrenia.
- Can result in a self-fulfilling prophesy
E.g., person labeled as learning disabled is not
expected to learn easily, resulting in lowered
expectations, which in turns results in lesser
opportunities.

A WORD ABOUT FUTURE
 “In no other area of science or technology has so
little change been seen in the last 65 years”
Roger L. Greene,2011
 Breaking free from current best practice might
lead to advances in measurement procedures,
the competing definitions and multiple valuations
of reliability and validity, and identification and
analysis.
 Integration of cognitive science and computer
science is going on and hopefully will lead to
several innovations in testing.

neuropsychological assessment in SMI

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (9)

Semelhante a neuropsychological assessment in SMI

Semelhante a neuropsychological assessment in SMI (20)

Último

Último (20)

neuropsychological assessment in SMI