diagnostics on psychoapathology /neuropathology

2. PSYCHOPATHOLOGY
READING

19.  STRICTLY CONFIDENTIAL
 Sunday, March 18, 2012



 PSYCHOLOGICAL REPORT

 Name:
 Sex: male
 Age: 24 years old
 Birthdarte: Mar 14, 1987
 Educational Attainment: First Year Medical Student
 Referred by: DR , PSYCHIATRY
 Reason for referral: Psychological evaluation for diagnostic assessment
 (i.e. routine psychological screening)

 TESTS ADMINISTERED

 Wechsler Social Intelligence Scale
 Hand Test
 Millon’s Test
 Sack’s Sentence Completion Test
 Minnesota Multiphasic Personality Inventory

20. DETERMINATION OF SPECIFIC PERSONALITY DISORDERS
Normal limits: BR of 75 and below
CLINICAL PERSONALITY PATTERNS
1 Schizoid 79 (5.5)
2A Avoidant 80
2B Depressive 107 (1)
3 Dependent 87
04 Histrionic 104 (2)
5 Narcissistic 100 (3)
6A Antisocial 60
6B Sadistic (Aggressive) 61
7 Compulsive 58
8A Negativistic (Passive-Aggressive) 72
8B Masochistic (Self-Defeating) 79 (5.5)
S Schizotypal 66
C Borderline 83 (4)
P Paranoid 63

23. Luria-Nebraska Battery
- Interpretation

24. I. General Comments
- Battery created by Charles Golden based on Lurian
theory and, somewhat, methodology, all measures are
pathognomic signs indicators;
- Upper limit items and all items normal subjects couldn’t
do were dropped, so the battery is not very good for
premorbidly high-functioning people with mild injuries;
- Items chosen on the basis of discriminating normal
controls from people with severebrain damage;
- Three indices were created to take into account age and
education:

25. -Three indices were created to take into account
age and education:
(a) Critical Level (CL)(p. 5 of the scoring booklet) =
68.8 + Age Value - Educ. Value
(b) Predicted Baseline (PB)= Critical Level - 10 (one
standard deviation)
(c) Actual Baseline (AB)= average of the T-scores on
clinical scales (C1-C11)

27. the T-scores of the scales are compared to the Critical
Level (i.e. expected premorbid performance);
-During administration one can repeat instructions and
problems for all scales but C2, C5, and C10;
- C7-C9 are very dependent on education, so they should
not be included while inferring the presence of brain
damage unless there is a suspicion of learning disability;
- If localization data contradicts clinical scales - disregard
it.

29. S1 Pathognomonic
S2 Left hemisphere
S3 Right hemisphere
S4 Profile Elevation
S5 Impairment

31. L1 Right Frontal
L2 Right Sensorimotor
L3 Right Parieto –Occipital
L4 Right Temporal
L5 Left frontal
L6 Left Sensorimotor
L7 Left parietal-occipital
L8 Left Temporal

33. C1 Motor functions
M1 Kinesthesia Based Movement
M2 Drawing Speed
M3 Fine Motor Speed
M4 Spatial Based Movement
M5 Oral Motor Skills
C2 Rhythm Functions
RH1 Rhythm and Pitch Perception

35. C3 Tactile Functions
T1 Simple Tactile Sensation
T2 Stereognosis
C4 Visual Functions
V1 Visual Acuity and Naming
V2 Visual Spatial Organization
C5 Receptive Speech
R1 Phonemic Discrimination
R2 Relational concepts
R3 Concept Recognition
R4 Verbal Spatial Relation

37. C6 Expressive speech
E1 Simple Phonetic Reading
E2 Word Repetition
E3 Reading Polysyllabic Words
C7 Writing
W1 Spelling
W2 Motor Writing Skill
C8 Reading
RE1 Reading Complex Material
RE2 Reading Simple Material

39. C9 Arithmetic
A1 Arithmetic Calculations
A2 Number Reading
C10 Memory
ME1 Verbal Memory
ME2 Visual and Complex Memory
C11 Intellectual Processes
I1 General Verbal Intelligence
I2 Complex Verbal Arithmetic
I3 Simple Verbal Airhtmetic

41. II. Presence of Brain Damage
•If you are using CL calculated from demographic data:
- Clinical Scales Comparisons:
(a) if C1, C2, C3, C4, C5, C6, C10, or C11 > CL there’s >90%
probability of brain damage or psychosis
(b) if any 3 Clinical Scales (C1-C11) > CL there’s >95%
probability of brain damage, esp. If there is a learning
disability;
- Single Indicators of Brain Damage:
(a) if any of C1-S1 > 80T - very high probability of brain
damage
(b) if any of C1-S1 > 70T - strong suspicion of brain damage
(c) C11 and S1 are especially sensitive to brain damage
- Range or Scatter of Clinical Scales (C1-C11) Indicators:
(a) if Range >30 - high probability of brain damage
(b) if Range >20 - strong suspicion of brain damage

42. 2) If there is a premorbid IQ score, calculate CL from it
and use that for comparisons, CL (for WAIS) = 164.8 -
1.09 x FSIQ + .2 x Age, CL (for WAIS-R) = 164.8 - 1.09 x
(FSIQ + 8) + .2 x Age
•if premorbid IQ >120 use CL-10 for Clinical Scales
comparisons and 70T for single indicators comparisons
(b) if premorbid IQ 81-119 use CL for Clinical Scales
comparisons and 80T for single indicators comparisons
(c) if premorbid IQ <80 use CL+10 for Clinical Scales
comparisons and 90T for single indicators comparisons

43. - One can also compare WAIS IQ with Luria-
Nebraska IQ, where
LN VIQ = 158.9 - .47(C11) - .38(C8) - .20(C9),
LN PIQ = 156.9 - .35(C11) - .48(C4) - .26 (C10),
and LN FSIQ = 150.2 - .92(C11):
(a) WAIS IQ or WAIS-R IQ + 8 = LN IQ - low
probability of brain damage
(b) WAIS IQ or WAIS-R IQ + 8 > LN IQ - high
probability of brain damage
(c) WAIS IQ or WAIS-R IQ + 8 < LN IQ - low
probability of brain damage, cultural or
educational issues lowered WAIS IQ

44. 3) If there is no demographic data, one can
calculate the AB and compare Clinical Scale
scores to it.
As before, the results are more certain if only C1,
C2, C3, C4, C5, C6, C10, and C11 are used:
- 1 Clinical Scale >10T > AB - equivocal results,
there might be a subtle injury, a disease like
Multiple Sclerosis, or nothing;
- 2 Clinical Scales >10T > AB - 70% probability of
brain damage;
- 3 Clinical Scales >10T > AB - 90% probability of
brain damage.

45. III. Lateralization of the Lesion
1) Clinical Scales:
- C2 & C4 are right hemisphere indicators, C5 & C6 - left
hemisphere indicators, if there is more than 10T difference between
them - lateralized lesion is likely.
2) Lateralization Scales. S2 contains sensory and motor items from
the right side (left hemisphere) and S3 - from the left side (right
hemisphere), since left hemisphere is dominant for motor functions,
S3 is also elevated by left hemisphere damage. Consequently, use
the following rules:
- S2>CL - left hemisphere definitely involved;
- S3>CL, S2<CL & <60T - likely to be right hemisphere only;
- S2&S3>CL:
(a) if S2 is 10T>S3 - probably only left hemisphere
(b) if S2 is 9-1T>S3 - probably both hemispheres
(c) if S2=S3 - probably diffuse bilateral damage
3) Localization Scales - if two highest scales are from the same
hemisphere (first 4 vs. last 4), lateralization hypothesis is
appropriate.

46. IV. Localization of the Lesion
1) Clinical Scales (relative to each other):
- C1 - anterior (frontal);
- C2 - posterior (temporal, mostly right);
- C3 - posterior (parietal, tactile);
- C4 - posterior (visual, mostly right);
- C5 - posterior (receptive speech, mostly left);
- C6 - anterior (expressive speech, mostly left);
-if >4 scales are >CL than thirtiary areas are more likely to be
affected by brain damage.
2) Localization Scales:
- if one scale is 10T> all others it’s a hit, unless all scales are
elevated;
- if two or more highest scores are in the ajacent areas - it’s
also a hit.

47. V. Course of the Lesion & Prognosis
1) S1 is most sensitive to the process, if S1>CL or >10T
above AB the injury is likely to be acute, progressive, or
severe (if its 20T>CL - very acute, severe, or rapidly
progressing):
- at 6 months past injury, if S1>CL - poor prognosis, if
S1<CL - good prognosis;
- if S1 if near AB - they are compensating, good
prognosis;
- if S1>CL, but the lowest score - they have recovered as
much as they could, don’t expect drastic improvements;
- if S1<CL - stabilized, will not recover further;
-if S1<CL, but is the highest score - posiible subtle brain
injury or a slowly progressing condition, like MS.
2) S4&S5:
- if S4>CL & S5<CL - good prognosis;
- if S4>S5>CL - good prognosis;
- if S4<CL & S5>Cl - bad prognosis.

48. VI. Emotional Issues Differentiation
•S4 - Profile Elevation - is sensitive to
brain impairment in uncompensated state
(depressed, anxious, psychotic, no cog.
rehab.)
2) S5 - Impairment Scale - is supposed to
be a pure indicator of brain damage,
without emotional overlay.

49. VII. Schizophrenia vs. “Organic” Brain Damage
•Schizophrenics with no other brain damage are reliably
elevated on C2, C5, C10, &C11; so, one can subtract 7
points from these scales in order to evaluate brain damage
additional to schizophrenia.
2) A strategy for diagnosing presence of additional brain
damage in schizophrenics (normative sample <45 years,
9-15 years of education):
- >4 Clinical Scales >70T => brain damage;
-give 1 point for each elevation > 70T on C2, C5, C10, &C11;
give 2 points for each elevation >60 for remaining clinical
scales; if the sum is >4 => brain damage;
- S1>65 => brain damage.

50. VIII. Individual Scales & Items
Scales Item Functions Measured / Localization / Notes
s
C1 - Motor Anterior (frontal), movement & mental flexibility
1-4 Simple motor, posterior frontal lobe
5-8 Kinesthetic feedback
9-20 Spatial organization required
21-27 Complex motor (kinetic melodies)
25-27 Apraxia screen
28-35 Oral movements
28-29 Simple
30-31 Kinesthetic feedback
32-33 Complex motor (kinetic melodies)
34-35 Following of verbal directions
36-47 Constructional items (score accuracy & time)
48-51 Speech regulation of motor acts (using internal speech to guide behavior)

51. C2 - Rhythm Right temporal, sensitive to
attention, cannot repeat items
52-54 Compare tones
55-57 Reproduce tones
58-61 Evaluation of acoustic signals
62 Perception/reproduction of
rhythmic pattern
63 Reproduction of series to
verbal command (mental
flexibility involved)

52. C3 - Parietal
Tactile
64- Levels of cutaneous sensation -
73 primary & secondary areas
74- Levels of cutaneous sensation -
79 angular gyrus
80- Muscle/joint sensation, affected by
81 callossal transfer of info
82- Stereognosis (tactile agnosia)
85

53. C4 - Visual Mostly right posterior
86-87 Real & pictured object identification
88 Item identification on the scale from
easy to difficult (telephone & face go
for the gestalt perception - right
posterior)
89 Shading
90-91 Popplereuter items -
simultaneagnosia or visual
perseveration
92-93 Raven’s progressive matrices - IQ
estimate (accuracy & time)
94-96 Spatial orientation / directions
97-98 3-D analysis of pictures
99 Spatial rotation without speech
(sensitive even to minor
impairmerment)

54. C5 - Receptive Speech Left posterior (cannot repeat items, stay
behind to avoid lip reading)
100-107 Comprehension of phonemes
108-116 Comprehension of simple
words/phrases
117-132 Increasingly complex comprehension
items
121-131 Understanding of grammatical &
logical relations, some people solve it
as a visual-spatial task

55. C6 - Expressive Speech Left anterior
133-142 Repetition of sounds/words spoken by
examiner
143-153 Same to written stimuli
154-156 Increasingly complex sentence repetition
157 Confrontational object naming (photograph)
158 Confrontational body part naming (problems
with body schema - parietal)
159 Responsive naming
160-163 Automatic (seriatim) speech
164-169 Spontaneous speech production to
picture/story/topic
170-174 Complex systems of grammatical
expression (frontal if errors are only on
these items)

56. C7 - Writing Education-dependent, not
good neurologically
175-176 Phonetic analysis of words
and copying of increasing
complexity
177 Copying:
abstract/concrete,
verbal/phonemic
knowledge
178-185 Copying of increasing
complexity
186-187 Narrative writing,
differentiate motor/spelling
problems

57. C8 - Reading Education-dependent, not good
neurologically
188-189 Generate sounds from letters
190-191 Name simple letters
192 Read sounds
193 Read simple words
194 Read meaningful letter combos (error if read as
words)
195 Read more complex words
196 Read more complex words, irregular spelling
197 Read simple sentences
198 Read simple sentences with incorrect
(meaning) elements
199-200 Read extended passages (includes memory
component)

58. C9 - Arithmetic Education-dependent, not good neurologically, tests
understanding of basic concepts rather than skills
201-202 Write arabic & roman numbers
203 Write numbers alternating positions
204-205 Write more complex #s (perseveration, like 9000845, frontal)
206-208 Read #s
209 Read #s top to bottom (stressing the system)
210-211 Compare #s - comprehension of # meaning
212-214 Simple arithmetic problems - comprehension of arithmetic
operations
215-217 More complex problems that cannot be done from memory
218-220 More difficult arithmetic algorythms
221-222 Subtraction of serial 7s & 13s from 100

59. C10 - Memory Mostly verbal memory, no
delayed memory (cannot repeat
items)
223-225 List learning, self-monitoring
226 Visual memory with interference
227-230 Sensory trace recall (visual/spatial/
auditory/tactile/verbal) = span of
apprehension
231-232 Verbal memory with interference
(very sensitive items)
233 Visual memory with externally
supplied interference
234 Anecdotal (logical) memory
235 Associative memory (verbal &
visual)

60. C11 - Intellectual Mini-IQ test
Processes
236-237 Understand thematic pictures
238-241 Picture arrangement tasks
242-243 Comprehension of comedy/absurd (very abstract task)
244 Interpretation of story
245 Interpretation of expressions
246-247 Free & multiple choice interpretation of proverbs
248 Concept formation
249-250 Similarities & differences
251-254 Logical relations, categorization
255 Opposites
256 Analogies
257 Categorization
258-269 Arithmetic items in story format

61. S1 - Acuity Elevation indicates that damage is acute,
severe, or rapidly progressing
S2 - Left
Hemisphere
Indicator
S3 - Right
Hemisphere
S4 - Profile Sensitive to brain impairment in
Elevation uncompensated state
S5 - Impairment Supposed to be a pure indicator of brain
Scale damage, without emotional overlay.