Applied neuropsychology

What is neuropsychology

The study of the brain and how changes can affect emotions, behaviour and cognition

Who do neuropsychologists work with

• People with an acquired brain injury eg trauma, stroke and tumour

• People with a degenerative neurological condition eg dementia (Alzheimer) neurodegenerative (multiple sclerosis, hungtingtons, parkinsons)

• People with a functional neurological disorder

• The families, carers or organisations supporting the person with a neurological condition or symptoms

Neurological conditions and distress 

• There is a wide range of neurological conditions, but some shared or common difficulties 

• Severity can vary wildly from a ‘prolonged disorder of consciousness’ to a return to (or maintenance of) previous work

• Activities with little or no ‘visible’ ongoing functional or psychosocial change 

• Distress is common and may result from biological/physical/social and psychological changes 

Literature supporting neurological conditions and distress 

• Pyschosocial and behavioural difficulties are common following an acquired brain injury, remaining prevalent at least a decade later (Thomsen, 1984)

• Frequent difficulties include self isolation, emotional lability, apathy, aggressive behaviour, reduced social awareness and reduced empathy 

• Some of these are common when there are communication difficulties (indicating a role of frustation) (Alderman et al 2003)

• Neurodegenerative conditions become even more complex when cognitive systems interact with/cause these 

• Difficulties from these conditions include depression, anxiety and aggression

• Craufurd et al 2011, referring to huntingtons disease 

Possible biological changes as a result of neurological disease

• Physical changes in the brain, damage to the emotion centres, amygdala

• Hormone imbalances, damage to the hypothalamus and pituitary gland

• Pain, sensory disruption and nerve damage

• Changes in mobility

• Changes to awareness, seizures

• Reduced energy and/or increased fatigue or sleepiness

Possible social changes as a result of neurological disease

• Losing or changing roles and responsibilities, eg work and family roles

• Financial implications

• Lessened ability to understand and cope with social interaction, can make a person want to avoid others

• Others might not understand how it feels, their reaction can make things feel more difficult

Possible psychological changes 

• Shock, potential sudden change in self identity, expectations and personal narrative

• Frustation, anger and denial, feelings of injustice, ‘i dont deserve this’, this cant be happening to me

• Low mood, depression, realising loss, changes in abilities, lifestyle and roles and relationships

• Anxiety, noticing changes in thinking skills, personality and how others are reacting to us

• Low motivation, ‘there’s no point’ ‘nothing i do will change anything’ ‘its all over’

What is the ‘change curve’ with people with multiple sclerosis

• Since MS does not have a current cure, individuals are supported as much as possible with the process of adjustment

• In a small scale study, 36 participants newly diagnosed with MS found evidence corroborating with the Kubler ross 5 stages of grief model (Maniscalo et al, 2019)

• First 6 months of diagnosis, high anxiety decreasing towards the end of the first year

• From end of first year, depressive symptoms began to increase, peaking at the 20th month

What is a transdiagnostic approach

Focuses on common psychological processes across multiple disorders rather than treating each diagnosis separately

How are these difficulties transdiagnostic

• Difficulties typically experienced by people with physical health and neurological conditions

• Therapy can be helpful working through loss and changes in function

• Transdiagnostic approaches are common eg ACT but conditions have quite specific experiences and difficulties

‘Typical’ ageing

• Older adults experience increasing cognitive deterioration after age 50

• Changes in cognition affect wellbeing, work and daily living

• Numerical ability as well as verbal ability and memory deteriorate as we age

Difficulties in ageing

• Memory, worsened ability to memorise and retrieve information, including remembering info about people, appointments and daily tasks

• Attention, difficulty concentrating on important information, filtering out distractions and multitasking, all affect daily tasks

• Speed of processing, becoming slower to understand information, complete tasks or participate in conversations, affects safety while driving and working

• Executive function, struggling with complex cognitive abilities such as problem solving, planning and responding flexibly to changing situations. Can cause difficulties with home management and relationships

Shame and stigma in cognitive ageing 

• People with visible physical signs of ageing and illness experience distress linked to shame and perceived stigma

• Having cognitive difficulties evident to others may cause similar problems 

• Participants in informal participant engagement groups report embarrassment at symptoms like forgetfulness

• This is consistent with findings that people with dementia experience shame and avoid potentially embarrassing situations 

• Mental health symptom prevalence in older adults reaches an estimated 32-37%

• Current approaches to older adult mental wellbeing are inadequate and new models are required 

Functional neurological issues

• Physical difficulties eg weakness, paralysis, tremors or spasms which can interfere with walking, driving and daily activities

• Numbness or tingling of pain

• Seizures, blackout, fainting

• People often get this diagnosis when other options have been exhausted, there is sometimes no obvious physical cause so clinicians diagnose as ‘functional neurological disease’

• Has huge impacts on self image and relationships with healthcare professionals

Possible contributing factors to neurological disease (Cope et al, 2017)

• Previous experience of trauma

• Emotion regulation difficulties

• Expression of psychological distress as physical symptoms

• Low mood or anxiety

• Stressful life events

• Experiencing epilepsy or having a family member with epilepsy

Stigma around people with neurological difficulties 

• Stigma can affect diagnosis, treatments and research

• Symptoms can be misunderstood, invalidated or dismissed

• Surveys document frustration experienced by providers and distressing healthcare interactions experienced by people with these difficulties 

• The need to investigate further, was necessary, prevalence and context of stigma and it’s impact on people with functional neurological difficulties and healthcare providers (MacDuffie et al, 2020)

What is huntingtons disease

• Life limiting neurological disease about 100 in 100,000 people

• Caused by a CAG expansion on the HTT gene

• Dominant gene, inherited from an affected parent, its not possible to be a carrier

• Mutant hungingtin causes symptoms

• People with HD may have a wide range of mental health difficulties and communication may get in the way

• People with HD report fewer symptoms than their carers do about and overestimate their abilities (Simpson et al, 2016)

HD onset

• Motor symptoms, start around 30-50 years old

• Include ‘chorea’ a movement disorder, rigidity and bradykinesia slowness of movement, these are used diagnostically

• Effects on Independence for the affected person and those around them

• However cognitive, behavioural and emotional changes predate physical changes by at least 15 years

Cognitive changes in HD

• Memory

• Orientation

• Speed of processing

• Executive function, inhibition, putting the brakes on, cognitive flexibility, switching tack, working memory and loss, multitasking

Family and context in HD

• HD is entirely genetically determined but if the gene continues then it is possible to develop HD

• However mental health symptoms are very common in HD compared to other populations without a neurological diagnosis 

What else can cause distress in HD

• Changes in narratives and expectations

• Grief and loss

• Worries for relatives

• Financial stressors

• Affects relatives without HD as much as people with HD

Heritable component of living with HD

• Children of affected parents have a 50% risk of inheriting the disease themselves

• Predictive genetic testing is available from 18 years onwards although the vast majority dont undertake it

• Multiple family members can be affected, high burden on families with inter generational trauma, grief and loss

Mental health difficulties (Maltby et al 2021)

• Factor anaylsis was used to examine mental health difficulties in 4 groups

• Manifest, HD after onset of motor symptoms

• Premanifest, HD before onset of motor symptoms

• Genotype negative, people once at risk but have tested negative 

• Family controls, from HD affected families but have never been at genetic risk

Findings of mental health difficulties (Maltby et al 2021)

• Four factors that were consistent across groups

• Anxiety, dread and inability to relax

• Depression, not enjoying life and not looking forward to the future 

• Outward irritability, loss of temper

• Self harm, suicidal ideation

• There was no difference of the severity of symptoms between groups for anxiety

• For depression and outward irritability, the manifest group only differed from the genotype negative group consistently.

• Only scattered differences of severity of symptoms from the premanifest and family controls

• The exception was self harm, where the manifest group differed consistently from all other groups

What support does a neuropsychologist offer

• Provides therapeutic support to an individual around adjustment, emotional management and managing changes

• Supporting relatives or others close to the individual, emotionally and/or practically (adjustment, relationships and coping with symptoms)

• Co working with carers and others in the interdisciplinary team to change how they interact with a person eg supporting with behavioural management

• Modelling positive engagement or strategies to help the person cope differently to reduce risk and to enhance quality of life

What is acceptance and commitment therapy

• Grows out of similiar understandings about interrelations between thoughts, feelings, physical sensations and behaviour

• Focuses less on what is ‘wrong’ in the individual and more on adjusting to difficult situations and promoting valued living and enjoyment of life

• Over 700 randomized controlled trials of ACT efficacy, including specific trials in neurological conditions such as acquired brain injury

Cognitive defusion in ACT hexaflex

• The ability to step back from thoughts, emotions and sensations, to see them as stories told by our minds

• Stories can be compelling but we don’t have to accept them

• Sometimes they are not helpful or accurate but it is important that we can choose 

Acceptance in ACT hexaflex

• The ability to make space for distressing thoughts, images, emotions and sensations

• Accepting that they cannot be rid of, pain is part of life

• Concept of ‘clean’ and ‘dirty’ pain

Key points for therapeutic work in ACT

• Focusing on specific stimuli such as the breath, the physical self and the inner experience of thoughts, sensations and emotions

• Noticing what is going on rather than spending all of our time worrying about the future

• Remembering that values are not goals, values remain whereas goals can be completed or ticked off

• This is helpful for people who have experienced a major change in life

Insight into HD study (Gunn, Maltby and Dale, 2020)

• Evaluated differences in psychological symptom reporting with and
  without an informant present

• Four groups (n = 7914):

• Manifest HD – after onset of motor symptoms

• Premanifest HD – before onset of motor symptoms

• Genotype negative” people – once at risk, but have tested negative

• Family controls – from HD-affected families, but have never been at genetic risk

Insight into HD findings (Gunn, Maltby and Dale, 2020)

• Individuals with HD may underestimate their apathy levels, having an informant present to provide extra information did push scores up compared to self rated scores

• For affect (anxiety, low mood and suicidal thoughts) it made no difference if the person with HD came alone or with an informant

• Scores were higher for manifest, premanifest and genotype negative groups when an informant was present

• Fits with a relevant past finding: irritability self-ratings diverge most before cognitive changes (Chatterjee et al., 2005)

What is the CBT ‘hot cross bun’

• Thoughts

• Behaviours,

• Feelings,

• Bodily sensations

• The hot cross bun model illustrates the relationship between these factors

• Helps individuals to develop self awareness by showing how these elements influence one another

What is the ACT hexaflex

• 6 core processes of ACT which focus on one core concept of psychological flexibility

• Psychological flexibility is the ability to adapt to challenging situations while staying true to their value

• Following core processes:

• Acceptance

• Defusion

• Committed action

• Self as context

• Contact with the present moment

• Values

Self as context in ACT hexaflex

• Learning to see oneself as a container of experiences and not the experience themselves

• We can witness emotional reactions and our distress and remain distinct from them

Finding values in ACT hexaflex

• Underlying guide to life, helping us to make choices that are right

• eg being a hard worker or taking care of people we love

Committed action in ACT hexaflex

• Once an individual has identified their values, they can start finding ways to change their behaviour

• Finding ways to explore new options

• Finding ways to live in line with those values and lead a richer, fuller meaningful life