Clinical Neuropsychology

Theoretical Foundations for Practitioners

Mark E. Maruish, James A. Moses

• Publisher: Psychology Press
• Year: 2013
• ISBN:
  9781134777495
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

With the emergence of clinical neuropsychology as one of the fastest growing specialties in psychology comes the need for current and future practitioners to stay abreast of the most recent research. A number of professional journals more than adequately meet this need. But, there is also a need to stay up to date on the current thinking about important problems. Drawing upon the expertise of leaders in the field, the editors' intent in this book was to provide the practitioner with a source for discussions of topics that are vital to their ongoing development as clinical neuropsychologists but that generally are not addressed in the literature to any great degree.

1

The Establishment of Clinical Neuropsychology as a Psychological Specialty

Manfred J. Meier

University of Minnesota Medical School

Clinical neuropsychology has evolved as a specialized area of knowledge and practice with extensive intra- as well as interdisciplinary foundations. Considered from the perspective of the sociology of the professions, the specialty is characterized by activities in a number of scientific and professional domains. These domains can be seen as having laid the foundation for the practice of clinical neuropsychology, whose specialized mission encompasses roles that address psychological or behavioral manifestations of neurological, neuropathological, pathophysiological, and neurochemical changes in brain disease and the full range of aberrations in the central nervous system that may arise during development. The evolution of this mission has followed the characteristic course of scientifically based professional role functioning, insofar as the foundations in knowledge and practice have been derived not only from the discipline of psychology, but also from the various related disciplines within the traditional professions of medicine, education, and law.

Historically, three primary developmental domains appear to have provided the basis for this area of specialized knowledge and practice: basic experimental research in physiological and cognitive psychology, the development of quantitative and qualitative neuropsychological principles and procedures for clinical practice, and the syndromal analysis of the behavioral consequences of central nervous system lesions (Meier, 1992). The growth of the specialty has also been influenced by the introduction of formalized procedures for accrediting educational programs and individual competencies. The developmental process, based on a considerable expansion of interdisciplinary knowledge and practices during the past half-century, appears to be following a productive course. This is evidenced by the parallel development of participating organizations, publication of numerous books and journals, and the continued expansion of role applications beyond traditional neurological, neuropsychiatrie, and rehabilitation settings into the forensic, educational, and vocational contexts.

Historical Antecedents

The historical foundations of this specialty are already sufficient to warrant a detailed historical account of its evolution. Such an account is beyond the scope of this chapter, which is designed to provide a general perspective by means of a review of major contributors in each of the three aforementioned converging lines of knowledge and practice. Even such a brief overview is insufficient to identify all major contributors so that the individuals identified here by no means constitute an exhaustive list. Although incomplete, such identifications may help to guide interested graduate students and practitioners in the field into the literature and to aid in formulation of career objectives. Extensive introductions to the prescientific, as well as the early scientific, literature of historical significance are available and should be read by the serious student or practitioner (Luria, 1966; Meyer, 1961). A review of modern clinical neuropsychology in general historical perspective, but not a detailed history, is also available (Meier, 1992). This section summarizes the developments within each of the three major developmental domains identified in the first paragraphs of this chapter.

Developments in Physiological, Comparative, and Cognitive Psychology

Karl Lashley (1929) was an extremely influential individual during his time. Publication of Brain Mechanisms and Intelligence resulted in the attribution of his intellectual leadership by many individuals who themselves subsequently became major figures in this domain. The doctrine of strict localization of function was widely held at that time; therefore, Lashley’s finding that the behavioral consequences of experimentally induced brain lesions in rats were a direct function of the amount, rather than the location, of the tissue removed provided the basis for an opposing doctrine that incorporated mass-action principles into a theory of brain function. This work clearly forced an understanding of the nervous system as a functionally dynamic and resilient system, as opposed to a static and discretely differentiated “switchboard” conceptualization.

Although primarily an experimental psychologist. Lashley was known to rotate in clinical settings, such as at St. Elizabeth’s Hospital in Washington, DC, and at laboratories engaged in the experimental analysis of higher cognitive functioning in primates, such as the Yerkes Primate Laboratory. Many physiological and comparative psychologists worked directly with Lashley, including Donald O. Hebb (1949), who subsequently engaged in interdisciplinary clinical research with Wilder Penfield at McGill University, where they set in motion a major series of research activities relating to the effects of removal of prefrontal or anterior/mesiotemporal tissue on intractable focal seizure disorders and, by extension, on higher cognitive and memory functioning. Hebb attempted to integrate the existing literature toward achieving an empirically based foundation for the regional localization doctrine that sought to formulate a rapprochement between the localizationistic and mass-action doctrines in the analysis of the behavioral consequences of cerebral lesions and ablations. His characterizations of cell assemblies and their functional relationships were similar to such concepts as the pluripotentiality of function and dynamic systems and subsystems as formulated by A. R. Luria (1966), the Russian psychologist and neurologist who is more widely acknowledged as having attempted to synthesize elements of strict localization and mass-action doctrine toward a general theory of higher cortical functioning. It was clear that the available empirical bases for formulating theoretical concepts were already sufficiently extensive to force consideration of more dynamic theories of higher cortical functioning.

Although Hebb’s behavior–cognition integration was a major step toward a comprehensive theory of higher cortical functioning, there was an expanding experimental research literature that related to the effects of circumscribed cortical ablations on learning and problem-solving behavior which was expanding the empirical foundation for the analysis of brain–behavior relationships. One of the more noteworthy investigators in this area was Harry F. Harlow at the University of Wisconsin, who developed one of the first regional primate laboratories after World War II. Interestingly, Harlow is known primarily for his experimental studies of infant–maternal relationships in primates. However, the earlier work of his group is noteworthy for having provided perhaps the first experimental demonstration of a double dissociation of the effects of focal anterior and focal posterior cerebral lesions. The major experimental paradigm for isolating the effects of prefrontal regions was the delayed reaction, as described by Carlyle Jacobsen (1936). Visual-discrimination learning paradigms were introduced to isolate the effects of temporoparietal lesions. By demonstrating that solution of the oddity problem was affected by lesions in either the anterior or posterior association cortex (Harlow, Davis, Settlage, & Meyer, 1952), the double dissociation between delayed reaction and visual-discrimination deficits (as a function of the cephalocaudal location of the lesion) was set into even more dramatic relief. The nonspecificity of effect, therefore, and the higher position of the oddity problem function in the hierarchical organization of function in the cerebral hemispheres also were characteristic of the formation of learning sets.

It is perhaps unfortunate that Harlow abandoned this line of research in favor of the work on maternal surrogate-infant relationships for which he is most widely known. Harlow’s research direction, however, was pursued in substantially greater depth by other physiological psychologists in subsequent decades. Among these, Mortimer Mishkin is known for having refined the experimental ablation approach, both methodologically and conceptually, thereby adding substantially to our knowledge of the regional localization of function in the prefrontal and inferotemporal cortex. Although Mishkin did not work directly with Harlow, there were relatively few physiological psychologists at that time and they were in ready communication with each other by means of the Journal of Comparative and Physiological Psychology. Mishkin worked with many on the Eastern seaboard, including Rosvold, Hebb, Sperry, Pribram, and Milner. Pribram is perhaps best known for his highly sophisticated theoretical formulations, but he was also a substantive empirical researcher as well as a neurosurgeon who was able to foster the development of neurosurgical skills among physiological psychologists at that time. He collaborated with Mishkin, who was helped on his career course to ultimately gain major professional recognition, including the Scientific Contribution Award from the American Psychological Association (APA; Mishkin & Pribram, 1954; Pribram, 1986).

The role of the temporal lobe in human learning and memory is now relatively well established. Mishkin and his associates have been able to introduce relatively refined experimental paradigms for studying the interaction between the amygdala and hippocampus in recognition memory and the independence of those structures in associative learning in primates. They have now identified separate pathways for object representation and for spatial vision connecting the occipital and inferotemporal cortices. They are exploring further the cognitive effects of interruptions in relationships between the cortex and the basal ganglia on stimulus-response learning. They are also elucidating the relationship between the cortex and the limbic system and their role in the mediation of stimulus-stimulus processing and learning (Mishkin, 1982; Mishkin & Petri, 1984; Mishkin & Ungerleider, 1983). Although this work may not have direct implications for comparable behavioral and cognitive processes in humans, it shows that where experimental analysis of behavior is feasible and the corresponding anatomical control can be achieved experimentally, theoretical refinements of potential significance for our understanding of human brain function can be achieved.

Hebb, of course, is well known for his positive influence on many students and colleagues in the late 1940s and 1950s. Among these, Brenda Milner at McGill University is perhaps the most notable. Her academic background was in experimental and comparative psychology after receiving the ScD degree at Cambridge. She had also worked with Oliver Zangwill at Cambridge as a graduate student, where she participated in construction of psychological tests and in radar research during World War II. She obtained the PhD in psychology at McGill, where she also participated in prepublication debates over Hebb’s monumental 1949 volume. Her seminal article on the temporal lobes (Milner, 1954) was based on her PhD dissertation and her early work with Hebb and Penfield. A long series of important studies of the effects of prefrontal, anterotemporal, and mesiotemporal removals on learning and memory and on intractable focal (partial complex) seizures followed (Milner, 1964; Milner & Teuber, 1968). These carefully described studies reported perseveration and impairment in abstract reasoning and categorical thinking, as measured by the Wisconsin Card Sorting Test, as a consequence of prefrontal ablations. Dissociated from such deficits in the ability to shift set for the acquisition of a new sorting principle (conceptual flexibility), she also expanded on her earlier work implicating the anterior/mesiotemporal region in learning and recent memory functioning. Her findings about the effects of focal temporal lobe lesions have expanded remarkably on accounts of the neuroanatomical basis of mnestic deficits in Wernicke-Korsakoff Syndrome (Talland, 1966).

Milner (1967) has also been engaged in the study of cerebral dominance and the use of brief cognitive and memory testing procedures during specialized invasive procedures, such as the Wada Test. Her interlaboratory relationships with the group at the Massachusetts Institute of Technology (MIT) and the late Hans-Lukas Teuber has led to much collaborative work. In turn, she has also extended her interests by means of collaboration with Roger Sperry and his colleagues at the California Institute of Technology (Milner, Taylor, & Sperry, 1968). Among her many well-known students are Suzanne Corkin, Doreen Kimura, and Donald Taylor.

At the other end of what became known as the “MIT-McGill Axis” was the laboratory developed by Hans-Lukas Teuber, initially at New York’s Bellevue Hospital and later at MIT. Teuber completed a doctoral degree in experimental psychology at Harvard University after he immigrated to the United States. While in the U.S. Navy, Teuber was assigned to the San Diego Naval Hospital, where he became associated with Morris Bender. Bender was among the few behavioral neurologists in this country who was interested in higher cortical functioning, especially the higher sensory processes, including visual perception, stereognosis, and tactile discrimination. These functions are now assessed routinely on a qualitative basis in a comprehensive neurological examination.

Teuber is remembered as a superb teacher and integrator of current knowledge, who had extraordinary extemporaneous speaking skills when he conveyed his rich theoretical conceptualizations that were based on a wide range of animal and human research in both clinical and experimental contexts. He had access to premorbid baseline data from group tests given in the military and, by means of contract research, was able to study the behavioral effects of penetrating missile wounds in veterans of World War II and Korea (Teuber, 1962, 1964, 1966). An engaging personality as well as the consummate communicator, he attracted large numbers of both students and colleagues.

Teuber’s laboratory became engaged in numerous studies of visual field defects, somatosensory functioning, developmental complications of early brain lesions, problem-solving behavior, and many aspects of higher cognitive functioning, including studies of the conditional reaction (Weinstein, 1985). The works of his group on tactile sensitivity, two-point discrimination, point localization, pattern discrimination, roughness discrimination, spatial orientation, and body image are widely cited. His closest students and colleagues were Sidney Weinstein, Josephine Semmes, Mortimer Mishkin, Lila Ghent, and Stanley Battersby. The psychological component of cognitive neuroscience was initiated largely through his laboratory.

Following his untimely death, his influence continues at MIT, where Suzanne Corkin and her associates now represent that group on the McGill-MIT Axis. Activities of those two groups are well represented in the knowledge base for clinical neuropsychology as it relates to the effects of selected ablations and lesions on higher cortical functions in man. These more basic lines of neuropsychological research are being extended remarkably through the Society for Neuroscience and through the expansion of the neurosciences beyond the study of primary sensory and motor processes into the areas of sensory perception, attention, and problem-solving ability, as well as learning and memory. Such expansion has led to the Journal of Cognitive Neuroscience, edited by Michael Gazzaniga, Sperry’s protegé, and published by MIT Press. The basic work conveyed through this journal includes frequent reference to clinical phenomena as a basis for conceptualizations that lead to specific experiments and theoretical formulations. A British journal, Cognitive Neuropsychology, expands on the neurobehavioral studies reported in cognitive neuroscience through an even more deliberate emphasis on clinical phenomena, such as the neurobehavioral syndromes, as a point of departure for the conduct of cognitive research.

Disciplinary boundaries in neuroscience are decidedly permeable, as can be inferred from the composition of the teams that report research results in these journals. The studies often require some integration of behavioral, neurophysiological, and neurochemical data so that cognitive neuroscience clearly has become an interdisciplinary venture. The recent body of knowledge in each area has already become so elaborate as to elude comprehensive knowledge on the part of the individual (scientist or practitioner), even within a particular discipline on a given subject. This will necessarily prompt permeability of disciplinary boundaries even more and require an increasingly interdisciplinary team approach to research.

Team approaches have long been acknowledged to be essential in basic, as well as more clinical, research. Such an approach is exemplified by the work of Roger Sperry and his group. Sperry received a master’s degree in psychology at Oberlin and a PhD in zoology at the University of Chicago. He has been a major contributor to basic neurobehavioral research and the first Nobel Laureate with linkages to psychology. Sperry was also associated with Lashley while at the Yerkes Laboratories, where he began to study the selective growth of neural connections after the placement of highly circumscribed lesions. While studying with Paul Weiss, a neurophysiologist at the University of Chicago, Sperry (1958) wrote his doctoral dissertation on the reorganization of function following the surgical interchange of nerves and muscles in the frog. This work prompted modification of the neurological and neuropsychological concepts of central nervous system plasticity and the functional interchangeability of neural connections.

The work for which Sperry received the Nobel Prize involved the experimental analysis of the organization of lateralized cerebral functions using the corpus callosotomy paradigm, also known as the split-brain preparation (Sperry, Gazzaniga, & Bogen, 1969). This paradigm established the foundation for the multitude of related studies that followed and that have essentially confirmed many of the hypotheses derived from the clinical and experimental studies of the effects of focal lesions in either cerebral hemisphere. This research paradigm permitted the isolation of each cerebral hemisphere under controlled cognitive processing conditions to yield further experimental evidence that only the dominant cerebral hemisphere has access to word knowledge in confrontation naming, and that the nondominant cerebral hemisphere has a relative advantage for processing figurai or nonverbal stimuli.

Development of Quantitative and Qualitative Neuropsychological Assessment Procedures

While physiological/experimental and cognitive neuropsychological research was being generated on the east coast, and to some extent on the west, a number of investigators, pr...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Foreword
• Preface
• 1. The Establishment of Clinical Neuropsychology as a Psychological Specialty
• 2. Interdisciplinary Relationships: Behavioral Neurology
• 3. Component Process Analysis in Experimental and Clinical Neuropsychology
• 4. Forensic Neuropsychology
• 5. Personality Assessment of Brain-Impaired Patients
• 6. Computerized Neuropsychological Assessment
• 7. Neuroimaging: Interface with Clinical Neuropsychology
• 8. Cognitive Retraining in a Milieu-Oriented Outpatient Rehabilitation Program
• 9. The Role of Self-Regulation Therapy with the Brain-Injured Patient
• 10. The Etiology of Mental Illness
• 11. The Interface Between Standard Psychiatric and Neuropsychological Diagnosis
• 12. Development of Neuropsychological Measures
• 13. Problems in Neuropsychological Research Methodology
• Author Index
• Subject Index