Category: Neuropsychological Assessment



What you see – descriptive psychopathology vs. what the patient tells you – phenomenology.

At first look you might say: objective vs. subjective. E.g.: appearance, behavior, speech, affect –  all accessible to an external (objective) observer vs. thought content and mood as (subjectively) reported by the subject. Now, these distinctions are not always as neatly clear-cut as one would like. As one can observe (as opposed to experience) his own process, i.e. one’s own thought content or process are the object of examination, an objective process. Or one can note someone’s else report of his internal experience, a report inherently filtered thorough the examiner’s preconceptions and predisposition, i.e. a subjective process. When it comes to a mental status examination the boundaries between objective:subjective are often times blurred.

The take home point: a comprehensive mental state exam necessarily includes an objective and a subjective examination of the external and internal attributes of one’s mental state.

For the objective component the examiner will aim to describe one’s mental state external manifestations (speech, behavior, affect) and ask the patient to describe his mental state internal manifestations (sensations, emotions, thoughts). Examples of questions aimed at internal experiences descriptions: “Please describe what you are feeling at this time.” “Describe your anxiety in terms of severity: mild, moderate, severe. Also frequency: you experience it once in a blue moon, weekly, a few times a week, daily, multiple times a day, all the time.” In other words the goal of the objective component of the examination is to quantitatively describe its objects regardless of their internal:external mental allegiance.

For the subjective component the examiner will aim to put himself in the patient shoes i.e. attempt to feel what the patient experiences. With regards to external manifestations of one’s mental state the examiner should carefully note his own feelings. E.g. an unaccounted for but palpable sadness in the room warrants a search for depressive symptoms even when the patient emphatically denies feeling depressed. With regards to internal manifestations the examiner should ask about the qualities of emotions, sensory experiences, or thoughts, “Describe your depression.” “What does hearing the voices feel like?” are good examples of how to inquire about the phenomenology of one’s internal experiences.

In summary:

A thorough mental status examination uses objective and subjective complementary approaches to assess external as well as internal attributes of one’s mental status exam.

The objective approach strives to produce quantitative data while the subjective approach aims to produce subjective data, regardless of the data’s provenance (external vs. internal).

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When you have questions.

Sounds obvious but I’ve seen neuropsych ordered because “it would be nice to get some neuropsych done…” Just like that. The more specific your question, the more helpful NP testing is. Not helpful to make a diagnosis for most of the major Axis I disorders, i.e. psychotic, mood and anxiety disorders. Helpful in quantifying cognitive deficits, including memory/dementias, attention/AD(H)D but the diagnosis is made on clinical grounds (i.e. NP provides additional info but it is not a deal breaker).

A list of usual NP applications:

1) Diagnosis clarification (see above)
2) Identification of patient’s strengths/weaknesses
3) Competency/disability
4) Research: baseline data or monitoring
5) Vocational planning
6) Patient care/planning

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