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Chapter 5: Examination and Diagnosis of the Psychiatric Patient
patients. In addition, the MMSE is likely to underestimate the preva-
lence of cognitive deficits in well-educated older persons with early
Alzheimer’s disease or in younger adults with focal brain injury, but it is
more likely to overestimate the presence of cognitive deficits in persons
with little education. Therefore, cutoff scores should be adjusted for age
and education before concluding that impairment is present. Although
mental status examinations can be very useful in screening for gross
signs of cognitive impairment, they do not provide a sufficient founda-
tion for diagnosing specific etiologies of cognitive impairment, and they
are not interchangeable with neuropsychological testing.
Domains of Formal
Neuropsychological Assessment
The past decade has seen a virtual explosion in the growth of
more sophisticated and better standardized tests and procedures
for neuropsychological evaluation. A list of examples of com-
mon neuropsychological tests and techniques is provided in
Table 5.4-2.
Interview
The clinical interview provides the single best opportunity for
identifying the patient’s concerns and questions, eliciting a
direct description of current complaints from the patient, and
understanding the context of the patient’s history and current
circumstances. Although the patient typically serves as the pri-
mary interview source, it is important to seek corroborating
information for the patient’s account from interviews with care-
givers or family members as well as thorough review of relevant
records, such as medical and mental health treatment, educa-
tional, and employment experiences.
Intellectual Functioning
Assessment of intellectual functioning serves as the cornerstone
of the neuropsychological examination. The Wechsler Intel-
ligence Scales have represented the traditional gold standard
in intellectual assessment for many years, based on carefully
Table 5.4-2
Selected Tests of Neuropsychological Functioning
Area of Function
Comment
I
ntellectual
F
unctioning
Wechsler Intelligence Scales
Age-stratified normative references; appropriate for adults up to age 89, adolescents, and
young children
Shipley Scale
Scale Brief (20-minute) paper-and-pencil measure of multiple-choice vocabulary and
open-ended verbal abstraction
A
ttention
and
C
oncentration
Digit Span
Auditory–verbal measure of simple span of attention (
digits forward
) and cognitive
manipulation of increasingly longer strings of digits (
digits backward
)
Visual Memory Span
Visual–spatial measure of ability to reproduce a spatial sequence in forward and reverse
order
Paced Auditory Serial Addition Test (PASAT)
Requires double tracking to add pairs of digits at increasing rates; particularly sensitive to
subtle simultaneous processing deficits, especially in head injury
Digit Vigilance Test
Timed measure of speed and accuracy in cancelling a specific digit on a page of random
digits; directly examines an individual’s tendency to sacrifice either speed or accuracy
in favor of the other.
M
emory
Wechsler Memory Scale III
Comprehensive set of subtests measuring attention and encoding, retrieval, and recogni-
tion of various types of verbal and visual material with both immediate recall and
delayed retention; excellent age-stratified normative comparisons for adults up to age
89 with intellectual data for direct comparison
California Verbal Learning Test II
Documents encoding, recognition, and both immediate and 30-minute recall; affords
examination of possible learning strategies as well as susceptibility to semantic inter-
ference with alternate and short forms available
Fuld Object Memory Evaluation
Selective reminding format requires patient to identify objects tactually, then assesses
consistency of retrieval and storage as well as ability to benefit from cues; normative
reference group is designed for use with older individuals
Benton Visual Retention Test
Assesses memory for ten geometric designs after 10-second exposures; requires grapho-
motor response
Brief Visuospatial Memory Test—Revised Serial learning approach used to assess recall and recognition memory for an array of six
geometric figures; six alternate forms
L
anguage
Boston Diagnostic Aphasia Examination
Comprehensive assessment of expressive and receptive language functions
Boston Naming Test—Revised
Documents word finding difficulty in a visual confrontation format
Verbal Fluency
Measures ability to fluently generate words within semantic categories (e.g., animals) or
phonetic categories (e.g., words beginning with “S”)
Token Test
Systematically assesses comprehension of complex commands using standard token
stimuli that vary in size, shape, and color
