Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 5: Examination and Diagnosis of the Psychiatric Patient

R eferences Aggarwal NK, Zhang XY, Stefanovics E, Chen da C, Xiu MH, Xu K, Rosenheck RA. Rater evaluations for psychiatric instruments and cultural differences: The positive and negative syndrome scale in China and the United States. J Nerv Ment Dis. 2012;200(9):814. Blacker D. Psychiatric rating scales. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9 th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:1032. Gearing RE, Townsend L, Elkins J, El-Bassel N, Osterberg L. Strategies to Predict, Measure, and Improve Psychosocial Treatment Adherence. Harv Rev Psychiatry. 2014;22:31–45. Gibbons RD, Weiss DJ, Pilkonis PA, Frank E, Moore T, Kim JB, Kupfer DJ. Devel- opment of a computerized adaptive test for depression. Arch Gen Psychiatry. 2012;69(11):1104. Leentjens AFG, Dujardin K, Marsh L, Richard IH, Starkstein SE, Martinez- Martin P. Anxiety rating scales in Parkinson’s disease: A validation study of the Hamilton anxiety rating scale, the Beck anxiety inventory, and the hospital anxiety and depression scale. Mov Disord. 2011;26:407. McDowell I, Newell C. Measuring Health: A Guide to Rating Scales and Ques- tionnaires. NewYork: Oxford University Press; 2006. Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin GA, Greenhill L, Shen S, Mann JJ. The Columbia–Suicide Sever- ity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266. Purgato M, Barbui C. Dichotomizing rating scale scores in psychiatry: A bad idea? Epidemiol Psychiatric Sci. 2013;22(1):17–19. Rush J, First MB, Blacker D, eds. Handbook of Psychiatric Measures. 2 nd ed. Washington, DC: American Psychiatric Press; 2007. Tolin DF, Frost RO, Steketee G. A brief interview for assessing compulsive hoard- ing: The Hoarding Rating Scale-Interview. Psychiatry Rev. 2010;178:147. Wilson KCM, Green B, Mottram P. Overview of rating scales in old age psychia- try. In: Abou-Saleh MT, Katona C, Kumar A, eds. Principles and Practice of Geriatric Psychiatry. 3 rd ed. Hoboken, NJ: Wiley; 2011. Clinical neuropsychology is a specialty in psychology that examines the relationship between behavior and brain function- ing in the realms of cognitive, motor, sensory, and emotional functioning. The clinical neuropsychologist integrates the medi- cal and psychosocial history with the reported complaints and the pattern of performance on neuropsychological procedures in order to determine whether results are consistent with a particu- lar area of brain damage or a particular diagnosis. Neuroanatomical Correlates The early history of neuropsychology was driven in large part by the goal of linking behavioral deficits to specific neuroana- tomical areas of dysfunction or damage. Although this early assessment method helped to validate neuropsychological tests that are commonly used today, the localizing function of neuro- psychological assessment is now considered less important in light of recent advances in neuroimaging techniques. Increasing knowledge in the neurosciences has also led to a more sophis- ticated view of brain–behavior relationships, in which complex cognitive, perceptual, and motor activities are controlled by neural circuits rather than single structures within the brain. An understanding of these brain–behavior relationships is par- ticularly helpful when evaluating patients with focal damage. It is crucial to ensure that the neuropsychological evaluation ▲▲ 5.4 Clinical Neuropsychology and Intellectual Assessment of Adults

adequately assesses relevant behavior that is likely to be associ- ated with that area and its interconnecting pathways.

Hemispheric Dominance and Intrahemispheric Localization

Many functions are mediated by both the right and left hemi- spheres. However, important qualitative differences between the two hemispheres can be demonstrated in the presence of lateralized brain injury. Various cognitive skills that have been linked to the left or right hemisphere in right-handed individuals are listed in Table 5.4-1. Although language is the most obvi- ous function that is largely controlled by the left hemisphere, especially among right-handed individuals, the left hemisphere is also generally considered to be dominant for limb praxis (i.e., performing complex movements, such as brushing teeth, to command, or imitation), and it has been associated with the cluster of deficits identified as Gerstmann syndrome (i.e., fin- ger agnosia, dyscalculia, dysgraphia, and right–left disorienta- tion). In contrast, the right hemisphere is thought to play a more important role in controlling visuospatial abilities and hemis- patial attention, which are associated with the clinical presenta- tions of constructional apraxia and neglect, respectively. Although lateralized deficits such as these are typically char- acterized in terms of damage to the right or left hemisphere, it is important to keep in mind that the patient’s performance can also be characterized in terms of preserved brain functions. In other words, it is the remaining intact brain tissue that drives many behavioral responses following injury to the brain and not only the absence of critical brain tissue. Language Disorders.  Appreciation for the special role of the left hemisphere in the control of language functions in most right-handed individuals has been validated in many studies. These include the results of sodium amytal testing in epilepsy surgery patients, as well as the incidence of aphasia following unilateral stroke to the left versus right hemisphere. Although it is rare for right-handed individuals to be right hemisphere dominant for language, it does occur in about 1 percent of the cases. Hemi- spheric dominance for language in left-handed individuals is less predictable. About two-thirds of left-handed individuals are actu- ally left hemisphere dominant for language, while about 20 per- cent each are right hemisphere dominant or bilaterally dominant. Table 5.4-1 Selected Neuropsychological Deficits Associated with Left or Right Hemisphere Damage

Left Hemisphere

Right Hemisphere

Aphasia

Visuospatial deficits

Right–left disorientation

Impaired visual perception

Finger agnosia

Neglect

Dysgraphia (aphasic)

Dysgraphia (spatial, neglect)

Dyscalculia (number alexia) Constructional apraxia (details)

Dyscalculia (spatial) Constructional apraxia (Gestalt)

Limb apraxia

Dressing apraxia Anosognosia

(From Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry . 9 th ed. Philadelphia: Lippincott Williams & Wilkins; 2009, with permission.)