Duties of the Neuropsychologist

PETITION TO INTERVENE

Initially, the intervention by the Neuropsychologist may be requested for the purpose of evaluation, assessment and diagnosis of higher psychological functions and affective-behavioural condition, in order to understand the problem with the patient, as well as its cause and implications.

More specifically, the purpose of the assessment may be aimed at the detection and localization of brain lesions, in cases such as low-severity brain disorders, the beginning of degenerative processes, minimal brain dysfunction, etc.

The differential diagnosis may also be an objective of neuropsychological assessment, i.e. discriminating whether changes that the patient presents have an organic base, or conversely are functional, such as the differential diagnosis of depression/dementia.

Moreover, the evaluation process can be directed towards the study and detection of simulation in the judicial proceedings, in which there may doubt over the veracity of the disorder and/or exaggeration of possible symptoms.

In the same judiciary scope, the valuation may go to the completion of forensic neuropsychological appraisals, whose purpose is to objectify and determine, with the highest degree of accuracy, possible difficulties and their implications for the life of the person. That is to say, the consequences associated with neurological disorders, in their bio-psycho-social and labour dimension, are measured.

Regarding the work sphere, the assessment of psychological functions after brain injury is performed in order to consider possible reintegration into the workplace.

Furthermore, with regard to the child population, the study may be directed to more specific issues such as the progress of mental retardation and assessment of special educational needs.

WHAT DOES THE NEUROPSYCHOLOGIST EVALUATE AND ASSESS?

Basically we can divide the field of study of the neuropsychologist into two: higher psychological functions and the effects, emotions and behaviour.

Higher psychological functions are those cognitive abilities that allow us to face, effectively and efficiently, the demands of everyday life to which we are exposed through people throughout our lives, and thus we can distinguish the following:

–       Orientation: this covers 4 dimensions. Personal, in which the most essential and close information to the person is sought (name, age, date of birth, marital status, etc.). Temporal, in which the time parameters are valued (day of the week, day of the month, month and year). Spacial, the degree of knowledge that the person has on your location is looked at (place where they are located, city, etc.). Situational, explores the degree of knowledge that the person has about their present situation (what’s happened, where, and why is the person in the hospital, etc.).

–       Attention: This is the basic mechanism underlying all cognitive processes that enables the person to focus on any proposed activity, without losing the its progress, allowing them to be kept immersed for a period in a given activity (studying, driving, reading a book, watching television, following a conversation, performing a routine domestic or household task, etc.).

–       Hemi-spacial neglect: This is the difficulty to address and respond to stimuli within a hemispacial and hemibody area, contralateral to the lesion.

–       The speed of information processing and execution: The speed with which our brain processes information and can issue a response. Any activity that we carry out requires an adequate speed in order to function effectively. After a brain injury, the brain slows down, needing more time to perform any activity (talking, answering, thinking, writing, etc.).

–       Language: This is the faculty that allows us to communicate with each other, and can be considered as an expressive or comprehensive mode, by allowing us to understand the messages conveyed and in turn allowing us to issue our own messages. That is, it is the basis of personal relationships and social communication. Also, language is a tool for intellectual activity (thinking, memorizing, representing reality, etc.) and for the organization and regulation of mental processes (planning, scheduling, etc.). Language can be impaired in different ways, each forming a characteristic syndrome (aphasia).

–       Reading and writing are special forms of comprehensive and expressive language.  Therefore, people with language impairment (aphasia) will have difficulty expressing or understanding written instructions and messages. We can also assess changes in reading and writing independently and without language impairment (dyslexia and agraphia).

–       Arithmetic skill is the ability to identify and understand numeric values and perform arithmetic operations (money management, accounts and problems.). This can also be affected as part of language disorders, but impairments may also occur independently (acalculia).

–       Memory is one of the most important fields of neuropsychological investigation. The type of problem will vary depending on the brain structures affected. Some people have generalized impairments, others more specific to retaining verbal information (names, text, etc.), as well as impairments in retaining visual information (images, video, physical spaces, etc.), other examples include problems with immediate information (repeating a phone number), or the ability to retain the temporal order of events, etc. Memory is largely what makes us different as people. “We are what our memory is”, from the moment we are born we accumulate experiences and memories, and when they disappear through injury, we erase all of our personal history. Difficulties can be rendered visible in daily life, presenting problems in retaining information managed by the person, directly or indirectly, (what he has done the previous day, who he has called on the phone, conversations, movies, reading newspapers and books, and can even lead to repetition due to having forgotten that the subject has already been mentioned, etc.), as well as prospective memory (what to do tomorrow, what to buy, what food do I have to make today, etc.). Similarly, memory problems may lead to the inability to recognize familiar faces and people (you can mistake the wife and children for strangers), or the immediate area in which we live (become disoriented and lost in a familiar place).

–       Executive functions are evaluated rigorously in neuropsychological investigation, constituting the cognitive capacities involved in the initiation, planning, programming, controlling and regulation of all cognitive processes and behaviour. Allow the proper handling of the information that we receive, which allows us to understand and efficiently integrate with the demands of daily life, acting in a planned and programmed manner, anticipating the consequences of our behaviour (preparing food, household activities, shopping, etc.).

–       The superior visual functions will be needed to handle all the information, in visual form, that we see daily; we distinguish between the following three groups:

–       Visuoperceptual functions:

o    Problems in visual analysis and synthesis (discriminating the differences between similar images, inferring an image from an element).

o    Problems in recognizing objects and pictures (visual agnosia), where the patient does not know what a particular and known object or drawing is.

o    Difficulties in facial recognition (the patient does not recognize faces, even those with whom they are closest).

–       Visuospacial functions:

o    Problems locating a given point in space and tracking it with the eye.

o    Problems appreciating the distance from a given a point in space.

o    Difficulty recognizing the same image or object in a different position.

o    Problems or topographical orientation (people becoming spatially disoriented and may even become lost).

o    Hemi-spacial visual neglect (difficulty responding to stimulation from one side of a spacial area, either the right or the left).

–       Visuoconstructive functions:

o   Problems assembling or joining (doing puzzles, building figures with parts, etc.).

o    Problems copying or drawing.

–       The motor functions are explored through the study of motor skills, handedness, left/right orientation, motor coordination and performing movements and gestures (praxis) with hands (complex) and the mouth and face (orofacial).

–       Perception and reproduction of rhythmic structures consists of the imitation and production of sequences and rhythms, the impairment of which is closely related to disorders such as dyslexia or aphasia.

–       Examination of higher cutaneous and kinesthetic functions is necessary for studying skin, muscle and joint sensations. These are of great importance in examining the brain areas that receive such information, valuing also touch, discrimination and tactile sensitivity.

–       IQ or Intellectual Quotient (IQ), is a means of intelligence scales, by which we can obtain the general intellectual performance of the individual, as a global measure of cognitive functionality.

From an emotional-behavioural point of view, the following problems are treated:

– Apathy, indifference and demotivation.

– Lack of initiative and not completing activities.

– Impulsiveness.

– Lack of awareness of disease and deficits (anosognosia).

– Confabulation (memory gaps that the patient fills with fantasy and that have a behavioural impact).

– Irritability and aggressiveness.

– Inappropriate sexual conduct.

– Disinhibition.

– Depersonalization (feeling of being separated from one’s body and mental processes).

– Derealization (feeling that one’s surroundings are not real and are strange, like a dream).

– Childish and immature attitude.

– Egocentrism.

– Emotional lability (rapid mood changes).

– Difficulty with emotional expression (aprosodia).

– Difficulty controlling and regulating behaviour.

– Deficits in social skills.

– Suspiciousness or paranoid ideation.

– Changes in thought content (delusions, overvalued, obsessive).

– Changes in the course of thought (concretism, stiffness, prolix thought, tirelessness).

– Perceptual changes (hallucinations).

– Mood disorders.

From the psychopathological point of view disorders that may or may not be associated with brain injury are measured:

– Anxiety disorders.

▪ Specific phobias.

▪ Social phobia.

▪ Agoraphobia.

▪ Panic disorder.

▪ Obsessive compulsive disorders.

▪ Post traumatic stress disorder.

▪ Generalized anxiety.

– Sexual dysfunctions.

▪ Hypoactive sexual desire.

▪ Sexual aversion disorder.

▪ Erection disorder in men and arousal disorder in women.

▪ Ejaculation disorder.

▪ Female orgasmic disorder.

▪ Problems and couple therapy.

– Somatoform disorders.

▪ Hypochondria.

▪ Body dysmorphic disorder.

– Mood disorder.

▪ Depression.

▪ Bipolar disorders.

– Factitious disorder (intentional production or feigning of symptoms).

– Personality disorders.

Specifically assessed in the child population:

– Encephalopathy and cerebral palsy.

– Disorders of cognitive function.

▪ Learning disabilities (reading, writing and arithmetic).

▪ Mental deficiency.

– Language disorder.

– Disorders of communication and social interaction.

– Motor conduct disorder.

▪ Laterality problems.

▪ Dysgraphia.

▪ Dyspraxia.

▪ Psychomotor instability.

– Behavioural disorders.

▪ Oppositional, defiant, hostile and aggressive behaviour.

▪ Phobias and fears.

▪ Obsessive behaviours and rituals.

▪ Hysterical behaviour.

▪ Attention deficit disorder with hyperactivity.

– Affective disorders.

▪ Depression.

▪ Anguish and anxiety.

– Bladder/bowel control problems.

RETURNING THE INFORMATION:

Once the assessment has been completed, it is necessary to relay the results by means of two procedures:

–       Making a written report.

–       Verbal information to the family and/or the patient.

SETTING GOALS AND THE DEVELOPMENT OF THE INTERVENTION PROGRAMME

Subsequently, the general objectives are established, and the specific initial targets and intervention programme are drafted:

–       Psychological and neuropsychological objectives.

–       Specific cognitive objectives to be developed during Occupational Therapy.

INTERVENTION 

The next step is intervention, rehabilitation and carrying out the appropriate neuropsychological and psychological treatments, using the wide range of psychotherapeutic techniques and procedures available to adults, adolescents and children.

Establishment of guidelines for the management of the patient by the hospital staff and by the family (behaviour modification programmes, as well as programmes to address aggressiveness, severe memory problems, etc.).

FOLLOW-UP

–          Monitoring of cognitive behavioural progress during the therapeutic process.

–          Restructuring of the initial objectives.

–          Drafting of clinical reports on a quarterly basis.

–          Provision of periodic information to the family.

–          Coordination and supervision of occupational therapy.

DISCHARGE

Drafting of clinical reports on treated patients upon discharge, which reflects, in detail, what the psychological or neuropsychological situation is at the point of discharge, as well as establishing certain guidelines.