CLINICAL NEUROPSYCHOLOGY

Clinical Neuropsychological

Clinical Neuropsychological Case Report

Introduction

When Erin Bigler, PhD presented the Distinguished Neuropsychologist Award at the NAN conference in San Antonio ([Bigler, 2001]), he energetically began his talk outlining the diversity of his clinical and academic work and then, in a spontaneous but genuine moment, he stated: “I love neuropsychology!” This proclamation led me to ask myself what has turned out to be a bittersweet question: Do I love neuropsychology? The complete answer to this question will serve as the focus of this paper. My brief answer, however, is that while I love working with patients, I am often frustrated and even disappointed by what our discipline offers our patients.

Discussion

Clinical Neuropsychology has clearly burgeoned as a diagnostic discipline. Over the past decades there has been an impressive increase in the number of newly published tests ([Lezak, 1995]). Even more impressive is the growing literature that identifies what aspect of cognition is compromised by different neurological disorders . In comparison to these advances, the research and development of treatment modes remains lackluster. In order to create a discipline that benefits patients, we must evolve beyond diagnosis and begin to focus on patient care.

1. Scientific status of neuropsychology

1.1. Challenges

Before we explore appropriate directions for the future of neuropsychology, let us first consider the history of neuropsychology. It has been a century-old quest to associate behavioral maladies with specific brain regions. In the nineteenth century, German and French neurologists meticulously described specific behavioral alterations in patients that according to post-mortem studies were associated with focal lesions. The work of [Broca, 1865] and [Wernicke, 1874] exemplify this approach. Neuropsychology as a discipline began to flourish when, instead of detailed observations, behavior was quantified according to psychometric techniques. Thus, the “Period of Neuropsychological Localization” began about 60-70 years ago. The first generation of neuropsychologists, that included Milner, Luria, Hecaen, Halstead, Zangwill, and Teuber, closely collaborated with neurosurgeons to psychometrically localize brain damage. The rationale for test selection was based on localization (see Fig. 1).

Fig. 1. Assessment according to localization paradigm.

The scientific methodology for neuropsychological localization was solidified by the theory of double dissociation. [Teuber, 1955] asserted that, when damage to a particular brain region causes a specific behavioral deficit, this does not necessarily rule out the possibility that damage to other regions of the brain are not implicated in creating the same deficit. Therefore, an association of Behavior A with Brain Region 1, thus a single association, was deemed insufficient. A double association, however, is achieved if Behavior A (e.g., verbal memory) is associated with Brain Region 1 (left temporal lobe) while Behavior B (visuospatial integration) is associated with Brain Region 2 (right parietal lobe) and the inverse is not true. That is, Behavior A is neither caused by damage to Brain Region 2 nor does Behavior B follow when Brain Region 1 is compromised ( [Weiskrantz, 1991]). Years later, [Pribram, 1971] extended this double dissociation principle to support the multiple dissociation paradigm, which has led to profile analysis of multiple test scores ...