Clinical Applications

In its infancy, neuropsychological testing was used primarily as a means of localizing the site of a lesion in the brain. Developments in the field of neuroimaging have obviated the need to depend exclusively on neuropsychology in this role. In contemporary clinical practice, neuropsychology is primarily devoted to diagnostic formulation, entailing the identification and description of cognitive and behavioral syndromes. Hand in hand with advanced imaging techniques and other diagnostic methodologies, the evolution of a true behavioral neuroscience has been ongoing.

Clinicians often refer patients for neuropsychologi-cal assessment when there is a question about diagnosis. Neuropsychological assessment can be useful in describing the nature of cognitive or behavioral deterioration and can help clarify the pathology underlying such a process. For example, neuropsy-chologists often see elderly individuals who have been referred for the evaluation of a possible neurodegen-erative illness, such as Alzheimer's disease. Through an analysis of a variety of behaviors, neuropsychologists can often clarify the diagnosis and, in so doing, help guide decisions about appropriate treatment and provide information concerning prognosis. It is often difficult to arrive at a definitive diagnosis; in these cases, a neuropsychologist can assist in narrowing the differential diagnosis. Serial follow-up examinations can further clarify the diagnosis by tracking the course of cognitive symptoms across time.

Neuropsychological test data can be useful for establishing a baseline of cognitive functioning against which to calibrate the degree of change in patients with a known history of neurological disease, injury, or developmental abnormality affecting cerebral functions. This involves both tracking decline in the context of illness and also measuring treatment gains. With rich quantitative and qualitative data, neurop sychologists are in a unique position to evaluate the efficacy of treatment interventions (e.g., pharmacotherapy, electroconvulsive therapy, neurosurgery) by establishing a patient's baseline performance and reevaluating following initiation of therapy.

Neuropsychological assessment can delineate the potential impact of brain pathology on venues of reallife functioning, ranging from the most rudimentary human activities (bathing and dressing) to work life and the complexities of intimate relationships. Neuropsychologists can provide an explanatory context for a patient's cognitive, social, or behavioral difficulties. In addition, in the case of progressive disease, neuropsychologists can provide education about how the patient's changing condition will impact day-today functioning differently over time. It is not unusual for an otherwise sensitive spouse to blame an affected husband or wife for a particular behavior, which had been assumed to be under voluntary control. Learning that the behavior is part and parcel of a disease process dramatically alters this attribution and allows both patient and spouse to work together on the problem.

Because of its knowledge base in behavioral neuroscience, neuropsychology has an important role in treatment planning, Neuropsychologists make specific and detailed recommendations for rehabilitation in cases of brain injury, tumor, and stroke and are central to the planning process for patients and families confronting dementing illnesses.

Neuropsychological consultation is frequently critical in cases involving the adjudication of criminal or civil matters. Neuropsychologists with special training and experience in forensics play an important role in the determination of competency in matters ranging from criminal responsibility to guardianship.

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