A friendly critique of neuropsychology: facing the challenges of our future

Archives of Clinical Neuropsychology 18 (2003) 847–864 A friendly critique of neuropsychology: facing the challenges of our future夽 Ronald M. Ruff a,b,c,∗ a St. Mary’s Medical Center, 450 Stanyan Street, San Francisco, CA 94117, USA b University of California, San Francisco, CA 94143, USA c Stanford University, Stanford, CA 94305, USA Accepted 1 July 2003 Abstract Neuropsychology emerged as a discipline in the 1940s when prior to performing a craniotomy, neurosurgeons based their localization on EEGs, X-rays and neuropsychological test results. This practice ended in the mid 1970s when computerized tomography became available. As the neuropsychologists’ role in localizing has become miniscule, the referral questions have shifted to obtaining quantitative descriptions of the patient’s cognitive status. The current paper explores future directions for neuropsychology on the basis of asking the following question: Are we meeting the needs of the patients? The answer is clear: Patients’ needs are not met by merely diagnosing cognitive deficits. There is a growing need to advance services that maintain cognitive health, since modern societies place increasing value on highly educated and skilled work forces. Thus, the time has come for neuropsychologists to identify as caretakers for cognitive health. Just as we expect from the disciplines responsible for physical and emotional health, we must provide a combination of diagnostic and treatment services for cognitive health. © 2003 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved. Keywords: Neuropsychological testing; History of neuropsychology; Cognitive treatment 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 夽 This article summarizes the presidential address held in San Francisco, 2001. Tel.: +1-415-771-7833; fax: +1-415-922-5849. E-mail address: (R.M. Ruff). ∗ 0887-6177/$ – see front matter © 2003 National Academy of Neuropsychology. doi:10.1016/j.acn.2003.07.002 848 R.M. Ruff / Archives of Clinical Neuropsychology 18 (2003) 847–864 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. 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 (e.g., Squire, 1987; Stuss & Knight, 2002; Van Zomeren & Brouwer, 1994). 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. Why have we stagnated as a diagnostic discipline? In part the answer is based on the reality that far too many of us are riding the litigation gravy train. This explains why casual conversations between neuropsychologists often focus on war stories about litigation cases. Rarely do my colleagues share stories that promote exciting new treatments. With patients I am finding it progressively more difficult when I have so little to offer in form of efficacious treatments after testing them for hours and hours. Therefore, what I do not love about my discipline is that we are merely stumbling forward without a vision for our future. 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). 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 R.M. Ruff / Archives of Clinical Neuropsychology 18 (2003) 847–864 849 Fig. 1. Assessment according to localization paradigm. double dissociation principle to support the multiple dissociation paradigm, which has led to profile analysis of multiple test scores (Behaviors A to Z) that are distinctly associated with specific brain regions (1 to n). As a graduate student at the University of Zurich in the early 1970s, I recall working with neurosurgeons who provided us with feedback following the surgery on the accuracy of our localization. At that time decisions of where to perform craniotomies were solely based on EEGs, X-rays, and neuropsychological results. Further, I recall that we took turns to cover Saturdays in our neuropsychological laboratory, because neuropsychological results were needed for emergency surgeries on weekends. However, these practices dropped off dramatically in the mid 1970s, once we received our first CT scanner. Now, 30 years later, it would be considered malpractice for a neurosurgeon to evacuate a tumor based on EEGs, X-rays and neuro (...truncated)