Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 5: Examination and Diagnosis of the Psychiatric Patient

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

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.

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 Scale Brief (20-minute) paper-and-pencil measure of multiple-choice vocabulary and open-ended verbal abstraction Auditory–verbal measure of simple span of attention ( digits forward ) and cognitive manipulation of increasingly longer strings of digits ( digits backward ) Visual–spatial measure of ability to reproduce a spatial sequence in forward and reverse order Requires double tracking to add pairs of digits at increasing rates; particularly sensitive to subtle simultaneous processing deficits, especially in head injury 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. 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 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 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

Shipley Scale

A ttention and C oncentration Digit Span

Visual Memory Span

Paced Auditory Serial Addition Test (PASAT)

Digit Vigilance Test

M emory Wechsler Memory Scale III

California Verbal Learning Test II

Fuld Object Memory Evaluation

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