3.9 Neuropsychological and Psychiatric Examination

Key Point

Many neurologic illnesses are associated with more or less severe disturbances of cognitive and emotional function. The organic neurologic clinical picture is only complete when any psychopathologic abnormalities that may be present have been thoroughly assessed and documented. The goal of the neuropsychological examination is to reveal cognitive deficits (especially aphasia, agnosia, and apraxia) and processing disturbances that imply the presence of a focal brain lesion.

3.9.1 Psychopathologic Findings

The examiner should first determine whether the patient is awake and alert. If not, he or she will be unable to receive and process incoming stimuli in the normal way. The patient may have an impairment of consciousness ranging in severity from drowsiness to coma, as described in ▶ Table 3.10.

Table 3.10 Degrees of impairment of consciousness, and other abnormal states of consciousness

Designation	Features
Normal consciousness	Oriented to place, time, and person (self), answers questions promptly and appropriately, follows commands correctly
Drowsiness	Mostly awake, responds to questions and commands slowly but usually correctly (after repetition if necessary), moves in response to a sufficiently intense stimulus, usually oriented and coherent
Somnolence	Mostly asleep, arousable with a moderately intense stimulus, generally requires repetition of questions or commands but then responds correctly, reacts slowly and after a delay but usually correctly
Stupor	Asleep unless awakened, can only be awakened with a strong (auditory) stimulus or perhaps only with a mechanical stimulus, cannot answer questions or follow commands or does so only after intense repetition, and then only incompletely
Coma	Unconscious, cannot be awakened, does not respond to a verbal or auditory stimulus, may respond to painful stimuli of graded intensities with specific (localizing) self-defense, nonlocalizing withdrawal of a limb, or abnormal flexion or extension responses
Confusion	Inappropriate spontaneous behavior and responses to questions and commands, deficient orientation to place, time, and/or person (self); the confused patient may be fully conscious, less than fully conscious, or agitated (see below)
Agitation	Motor unrest, inappropriate spontaneous behavior, cannot be calmed by verbal persuasion, more or less disoriented, does not follow commands appropriately

In addition to the patient’s level of consciousness and attention, the examiner should assess his or her orientation, concentration, memory, drive, affective state, and cognitive ability. The overall psychopathologic picture is composed of these elements. If mental functioning is disturbed by an underlying neurologic illness (so-called psycho-organic syndrome or organic brain syndrome), the manifestations often progress in a characteristic sequence, regardless of the etiology. At first, short- and long-term memory, concentration, and attention are impaired; the patient is easily fatigued and has difficulty processing new information or performing complex tasks. Later, the patient becomes progressively disoriented, first to time, then to place, and then to person (self). Reactive depression is common at this stage. Ultimately, all spontaneous activity ceases; the patient loses interest, lacks drive, and becomes permanently confused. Disturbances of this type can often be discerned in the patient’s behavior before the formal examination begins, growing increasingly evident to the examiner during history-taking and physical examination. Further details of the patient’s history from the family can often help. The Mini-Mental State Examination ( ▶ Table 3.11, ▶ Fig. 3.36) and the clock test ( ▶ Table 3.12) are widely used to assess cognitive function; the MOCA test is a well-validated alternative (see www.mocatest.org). For acquired dementia, see section ▶ 6.12.

Table 3.11 Mini-Mental State Examination

Parameter	Questions
Name of patient: Date of birth: Date of examination: 1 point for each correct answer
Orientation in time
1.	“What day of the week is it?”
2.	“What is today’s date?”
3.	“What is the current month?”
4.	“What is the current season?”
5.	“What year is it?”
Orientation to place
6.	“Where are we (hospital, old age home, etc.)?”
7.	“On what floor?”
8.	“In what city?”
9.	“In what state (canton, province, etc.)?”
10.	“In what country?”
Retentiveness
	“Please repeat the following words” (to be spoken at one word per second; to be performed only once)
11.	“Lemon”
12.	“Key”
13.	“Ball”
Attention and calculations
14.	“Please count from 100 backward by sevens” (serial-7 test). One point for each correct subtraction, maximum five points
Recent memory
15.	“Which three words did you repeat earlier?” One point for each word correctly recalled
Language, naming
16.	“What is this?” (show a pencil)
17.	“What is this?” (show a watch)
18.	“Please say after me: ‘No ifs, ands, or buts’”
Language comprehension, motor execution
19.	“Take this piece of paper in your hand”
20.	“Fold it down the middle”
21.	“Put it on the ground” (each command to be given only once)
Reading
22.	“Please do what it says on this card” (show card: “Close your eyes”) ( ▶ Fig. 3.36a)
Writing
23.	“Write any sentence” (the patient is given a piece of paper and something to write with)
Drawing
24.	“Please copy this drawing” (overlapping pentagons, ▶ Fig. 3.36b; all 10 edges of the two pentagons must be drawn, and the pentagons must overlap, for the patient to receive one point for this task)
Level of wakefulness:
Total points achieved:
Source: Adapted from Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12(3):189–198.

Table 3.12 The clock test

Task The patient is given a piece of paper with an empty circle drawn on it and is asked to complete the drawing of a clock, including numbers and hands. The time shown should be 10 minutes past 11 o’clock.
Interpretation	Points if correct
Are all 12 numbers present?	1
Is the number “12” at the top?	2
Are two hands of different lengths present?	2
Is the indicated time correct?	2
Note: A score of 5 or below raises the suspicion of dementia.

Fig. 3.36 Forms for the Mini-Mental State Examination. a A written command for the patient to follow (Task 22 in ▶ Table 3.11). b Pentagons to be copied (Task 24 in ▶ Table 3.11). (Reproduced from Mattle H, Mumenthaler M. Neurologie. 13th ed. Stuttgart: Thieme; 2013.)

3.9.2 neuropsychological Examination

The localizing significance of various neuropsychological deficits is shown in ▶ Fig. 3.37. An overview of important neuropsychological terms and syndromes is provided in ▶ Table 3.13.

Table 3.13 Important neuropsychological terms and syndromes

Aphasia	Cortical disturbance of language, usually due to a left-hemispheric lesion
Spatial processing disturbance	Difficulty drawing or copying three-dimensional figures (cube, house, five-pointed star); neglect of the left side of space or the left side of the body (so-called hemispatial neglect); usually due to a right-hemispheric lesion
Apraxia	Disturbance of the goal-directed execution of complex behaviors or behavioral sequences, or of the use of tools: Ideomotor apraxia: individual components of a single action are not put together correctly. Ideational apraxia: individual actions cannot be combined in complex action sequences. More common with left-hemispheric than with right-hemispheric lesions
Agnosia	Disturbance of the ability to recognize and correctly interpret various kinds of sensory stimuli, despite intact sensory function. Visual agnosia: inability to recognize objects visually despite intact vision. Special types: color agnosia, prosopagnosia (inability to recognize faces). The responsible lesion is located in the occipital or occipitotemporal visual cortex Tactile agnosia: objects cannot be recognized by touch with the eyes closed Anosognosia: deficit of self-awareness, i.e., denial or trivialization of one’s own pathologic deficits

Aphasia

Language is a complex process encompassing numerous individual functions ( ▶ Table 3.14).

Table 3.14 Functions that are needed for normal language

Function	Disturbance
Hearing	Hearing impairment, deafness (section ▶ 12.6.1)
Comprehension	Sensory aphasia
Construction of words and thoughts
Construction of speech	Motor aphasia
Phonation and articulation	Hoarseness (section ▶ 12.7), dysarthria (see sections ▶ 3.9.1, ▶ 5.5.5, and ▶ 12.9)

Fig. 3.37 Cognitive deficits that typically result from various focal brain lesions. (Adapted from Schnider A. Verhaltensneurologie. 2nd ed. Stuttgart: Thieme; 2004.)

Cortical disturbances of language are called aphasia and are due to a lesion in the language-dominant hemisphere. The left hemisphere is dominant for language in nearly all right-handers and in most left-handers as well. The clinical varieties of aphasia are:

• Disturbances of language production (motor aphasia or Broca aphasia; ▶ Fig. 3.38 and ▶ Fig. 4.12): the patient’s spontaneous speech is not fluent, even though the “organic prerequisites” for speech production (phonation, breathing, orofacial musculature) are all apparently unimpaired.

• Disturbances of language comprehension (sensory aphasia or Wernicke aphasia; ▶ Fig. 3.38 and ▶ Fig. 4.12): the patient has trouble understanding speech despite intact hearing and auditory processing. The patient’s spontaneous speech is fluent.

• Disturbances of speech repetition. The patient cannot correctly repeat words or sentences spoken by the examiner.

• Nearly all patients with aphasia have difficulty with naming and word-finding.

  

  Fig. 3.38 Brain structures that participate in language function.

The examiner begins to assess the patient’s spontaneous speech while taking the history; if necessary, the patient can be given specific language tasks, for example, “Describe this picture.” Various kinds of abnormality may be noted. The patient’s utterances may be found to be unusually poor in meaning-bearing words and overloaded with connectives and “function words.” Sentences may be faultily constructed (paragrammatism). The flow of speech may be either considerably greater than normal or slow and hesitant (telegraphic speech). Individual words may be deformed in certain characteristic ways (e.g., sound substitutions or phonemic paraphasias, such as “cog” for “dog”), or words may be used in place of other words from the same semantic category (semantic paraphasias, e.g., “table” for “chair”). Some words may be replaced by invented pseudowords (neologisms). Impaired language comprehension may be manifested by the patient’s inability to point out various objects in the room, including parts of his or her own body, when these are named by the examiner. Complex commands are an even more sensitive functional test. The patient can be asked, for example, to place a certain named object in between two other named objects, or to interpret a complicated sentence, such as the following: “Not in the closet, but on top of it, was where he had put his hat. Where was the hat?” Aphasic patients often make mistakes when they repeat spoken sentences or name objects (including parts of the body) that are pointed out to them. Reading and writing may also be impaired, often to a greater extent than spoken language.

The different types of aphasia are classified by the characteristics of the patient’s spontaneous speech, comprehension and repetition of speech, word-finding, and naming ( ▶ Table 3.15). An aphasic patient whose spontaneous speech lacks fluency speaks slowly, with effort, in short sentences containing many meaning-bearing words, with paraphasias and altered melody of speech (dysprosody). An aphasic patient with fluent spontaneous speech speaks at normal speed, effortlessly, and with the normal melody of speech (prosody), but the sentences are of normal length but contain relatively few meaning-bearing words in relation to meaningless filler words and literal and semantic paraphasias.

Table 3.15 The classification and differential diagnosis of aphasia

Type of aphasia	Spontaneous speech	Comprehension	Repetition	Naming, word-finding
Motor aphasia (Broca)	Nonfluent	Normal	Impaired	Impaired
Sensory aphasia (Wernicke)	Fluent	Impaired	Impaired	Impaired
Conduction aphasia	Fluent	Normal	Impaired	Impaired
Global aphasia	Nonfluent	Impaired	Impaired	Impaired
Transcortical motor aphasia	Nonfluent	Normal	Normal	Impaired
Transcortical sensory aphasia	Fluent	Impaired	Normal	Impaired
Anomic aphasia	Fluent	Normal	Normal	Impaired

Dysarthria is not a disturbance of language, but of the mechanical process of speech production (articulation); the content of speech is normal. When the motor apparatus of speech is affected by a central paresis or a muscular coordination disorder, the patient’s speech becomes unclear or slurred, perhaps even unintelligible.

Disturbances of Spatial Processing

Disturbances of spatial processing are usually caused by right-hemispheric lesions. They are manifested, for example, by unusual difficulty in spontaneously drawing or copying three-dimensional figures (cube, house, etc.) ( ▶ Fig. 3.39a). Deficits of this kind are often accompanied by neglect of the left side of space and the left half of the patient’s own body (hemispatial neglect; ▶ Fig. 3.39b,c).

Fig. 3.39 Spatial processing and neglect. a Cube-drawing as a test of spatial processing. This drawing is by a patient with a right parietal lesion. b Drawings of a clock and a woman. The left half of each is missing, indicating severe left hemineglect. The patient had sustained an acute hemorrhage in the right parietal lobe. c Line-dividing test. The patient was a university professor with left-sided neglect due to a tumor (astrocytoma) in the right hemisphere. (Reproduced from Mattle H, Mumenthaler M. Neurologie. 13th ed. Stuttgart: Thieme; 2013.)

Memory and Amnesia

Note

Memory enables us to store and recall information; it makes learning possible. There is a somewhat arbitrary distinction between short- and long-term memory; the latter, in turn, is divided into recent and old memory.

Short-term memory, also called working memory, is that which we are able to keep in mind at any one moment. Its content is rapidly lost unless it is kept active by repetition and transferred to long-term memory.

The examiner gains a first impression of the patient’s short- and long-term memory while taking the history. To test short-term memory, one can ask the patient to repeat sequences of numbers forward and backward or to take mental note of a sequence of 3 to 10 words and repeat them, immediately and a few minutes later.

Old memory can be tested by asking the patient to state autobiographic data that can be checked against other sources, facts about his or her own family, or information about historical dates, political events, or public figures. The findings should be interpreted in the light of the patient’s premorbid level of intelligence and education.

Short-term memory and verbal memory are mainly subserved by the limbic system (section ▶ 5.5.4) and hippocampus. Memory disturbances are called amnesia.

Note

Amnesia is the inability to store or recall conscious memories. Anterograde amnesia is the inability to lay down new memories from the moment of a brain injury onward. Retrograde amnesia is the inability to recall information that was acquired before the brain injury. Persistent amnesia is the main clinical manifestation of dementia (section ▶ 6.12).

Apraxia

Disturbances in the goal-directed execution of complex actions or sequences of actions, or in the use of objects, are known as apraxia. If the individual components of a single action cannot be put together correctly, the patient is suffering from ideomotor apraxia. Different parts of the body can be affected individually. In facial apraxia, for example, the patient may be unable to follow commands to execute certain motor tasks with the face, e.g., drinking through a straw or clicking the tongue. A patient with ideomotor apraxia of the upper limbs may be unable to salute or to mime the action of slapping someone in the face; a patient with ideomotor apraxia of the lower limbs may be unable to kick an imaginary football. In ideational apraxia, individual actions can be performed, but cannot be combined into more complex sequences. A patient might thus be unable to ready a letter for mailing, as this requires several steps: folding the letter, putting it in the envelope, sealing the envelope, and putting a stamp on it. Cortical lesions causing apraxia are usually on the left side.

Agnosia

Agnosia is an inability to recognize and correctly interpret incoming stimuli in a particular sensory modality, even though sensation as such is intact. A patient with visual agnosia, for example, has no visual impairment but cannot recognize objects on sight; the patient can name an object only after feeling or hearing it (e.g., the jangling of a bunch of keys). Special types of visual agnosia include an inability to recognize colors (color agnosia) or faces (prosopagnosia). The responsible lesion is in the visual association cortex, that is, in the occipital or occipitotemporal region, in one or both hemispheres.

Stereognosis is tested by putting a familiar object (key, pair of scissors) in the patient’s hand and asking him or her to palpate and name it (with eyes closed). An inability to do this despite intact sensation is called tactile agnosia. Further special types of agnosia are finger agnosia and autotopagnosia (difficulty recognizing parts of one’s own body).

Anosognosia is the denial or trivialization of one’s own neurologic deficits, for example, hemiplegia or even blindness.

Higher Cognitive Functions

For an individual to thrive in his or her social environment and cope adequately with the demands of everyday life, more is needed than just a properly functioning interaction of the basic neuropsychological functions described earlier. A person’s fund of knowledge, memory, intelligence (i.e., the capacity for abstract thought and problem-solving), personality, and social behavior are all of vital importance, as are his or her mood and motivation. The assessment of these higher cognitive functions requires careful weighing of biographic historical information (particularly useful when derived from persons in the patient’s social environment: family, friends, colleagues), as well as standardized neuropsychological testing. For example, there are specific tests for the patient’s fund of knowledge, logical thinking, and cognitive skills such as difference recognition, category formation, and the interpretation of symbolic information, for example, proverbs. These higher integrative functions are performed by the cerebral cortex in collaboration with other, deeper regions of the brain.