Neuropsychological testing and brain mapping have emerged as valuable tools for the diagnosis of neurological disorders. They are also useful in assessing current mental health status. Using them correctly not only improves diagnosis but can also improve treatment outcomes.

Neuropsychological testing explores the relationship between the brain and behavior. It measures mental abilities by using an interview and specific tests.During an interview, an examiner asks questions about:

• Medical and psychological history
• The severity of symptoms and if they have become worse with time
• How the symptoms have affected day-to-day activities

They will also assess mood, attitude, and behavior.

The test scores help determine if the patient has any issues in the brain that may affect mental functions. A neuropsychological test is used to measure cognitive problems after a stroke. Examples of mental functions include the ability to:

• Think
• Read
• Write
• Focus
• Plan
• Understand and memorize things
• Explain an abstract picture

Neuropsychological testing includes standardized tools. This means that the tools are used and scored similarly by all test-takers. Thus, the scores are independent of where a person takes the test or who the examiner is. Testing often uses a set of performance-based questions, also known as a neuropsychological test battery. Using a battery helps provide more detailed information about an individual’s mental function.

“Neuropsychological testing is 90% accurate in differentiating Alzheimer’s dementia from nondementia.”¹

What Tests are Used in Neuropsychological Testing?

More than 60 different forms of tests are used for neuropsychological testing.​​​² The selection of a test depends on the type of information the examiner needs. For instance, to measure a person’s level of attention, they will probably recommend the Trail Making Tests. Likewise, to measure memory, the examiner may use the Wechsler Memory Scale (WMS).Most are “pencil and paper type” tests and do not require any special equipment. The commonly used tests are:

Cognition Test

These tests measure cognition. Cognition includes mental processes involved in thinking, memory, learning, and decision-making. Diseases that affect the brain can cause cognitive problems (cognitive impairment). These include dementia and Alzheimer’s.Examples include recalling a list of words or numbers and drawing a copy of an object.

Verbal Communication Test

These tests measure the ability to use words correctly, understand meanings, and explain written words.

Motor Tests

These tests measure fine and gross motor skills. Walking and running are gross motor skills while threading a needle is a fine motor skill.The examiner may use tests to check if there are hearing and vision problems. They will also check if these problems affect thinking and memory.

Specific Tests Used in Neuropsychological Testing

Below is the list of examples of tests for:

Intelligence

• Wechsler Scales
• Wechsler Adult Intelligence Scale-Revised (WAIS-R)
• Wechsler Adult Intelligence Scale-III (WAIS-III)
• Wechsler Intelligence Scale for Children-IV (WISC-IV)
• Stanford-Binet Intelligence Scale-IV

Academic Achievement

• Wechsler Individual Achievement Test (WIAT)
• Woodcock-Johnson Achievement Test

Language Processing

• Boston Naming Test
• Multilingual Aphasia Examination

Attention/Concentration

• Cancellation Tasks (Letter and symbol)
• Behavior Assessment System for Children (BASC)

Memory

• Wechsler Memory Scale (WMS)
• WMS-III Verbal Memory Index

Speed of Processing

• Simple and Choice Reaction Time
• Symbol Digit Modalities Test – Written and oral

How Long Does Neuropsychological Testing Take?

The duration depends on the type of tests and the questions the examiner asks. Typically, it lasts several hours. However, breaks are allowed. For complex tests, someone may have to visit the test center for several days.

Who Completes Neuropsychological Testing?

A neuropsychologist completes neuropsychological testing. They understand how the structures and functions of the brain affect behavior and thinking.

A neuropsychologist is a licensed psychologist who has a Psy.D. or Ph.D. degree. They have also trained in neuropsychology for two years. In the US,“26% of board-certified psychologists and 9% of licensed psychologists practice clinical neuropsychology.”​​​³ Sometimes, a trained psychometrist may administer some neuropsychological tests. In such cases, they need to do it under the supervision of a neuropsychologist.

For What Conditions is Neuropsychological Testing Used?

Neuropsychological testing is useful in identifying problems with brain function and designing a treatment plan. It is also used to predict the outcomes of treatment.

Aid Diagnosis of Neurological or Mental Disorders

Neurological disorders, such as dementia, cause cognitive impairment. Mental illness, such as depression, can also cause similar issues. Results from neurological testing help determine the exact cause of the problem. To confirm a diagnosis, the doctor will also use information from other tests. These can include brain scans and blood tests.

Differentiate Dementia from Pseudodementia

Dementia causes problems with memory, thinking, behavior, and emotions. The issues are severe enough to affect essential daily activities. It has no cure, and treatment cannot reverse the symptoms. Pseudodementia causes similar symptoms, usually associated with depression. Unlike dementia, pseudodementia is typically reversible.

Differentiate Epilepsy from Nonepileptic Seizures

Epilepsy is a neurological disorder that causes abnormal brain activities. Symptoms include seizures and fainting. Pseudo-seizures produce similar symptoms. However, they are usually caused by an underlying mental illness, such as anxiety or stress.

Determine the Severity of a Stroke or a Traumatic Brain Injury (TBI)

Stroke and TBI cause cognitive impairment of varying severity. Neuropsychological testing helps determine the severity of the condition. Testing also guides the rehabilitation program.

Assist in the Diagnosis of Dyslexia, Autism, and Attention Deficit Hyperactivity Disorder (ADHD)

Neuropsychological testing for a child checks processing speed and attention span. Information from these tests is used to diagnose learning disabilities, autism, or ADHD.

Moreover, neuropsychological tests provide useful information for determining if a person:

• Can live independently or needs assistance
• Is improving with treatments for their neuropsychological disorders
• Has been exposed to toxins that affect the brain
• Is eligible for electroconvulsive therapy (ECT). ECT uses small electric currents to stimulate the brain. Some people with severe depression may need ECT.

When is Neuropsychological Testing Necessary?

The three most common reasons for referral for neuropsychological testing are:​​​⁴ To confirm the diagnosis 0% To plan for rehabilitation approaches 0% To determine the competency for legal procedures 0% Referrals are often necessary for people with a history of:

• Head injury
• Developmental delays
• Problems with learning or concentration
• Exposure to drugs or alcohol while in the womb
• Diseases that affect the brain cells, such as Parkinson’s and Alzheimer’s
• Seizures
• Drug or alcohol addiction
• Strokes
• Dementia
• Mental illness

How Does Neuropsychological Testing Help Doctors?

Neuropsychological testing provides invaluable information for diagnosis when:

• The doctor suspects their patient has a brain disorder, but brain scans show no abnormalities. This is common among people who have a mild head injury or Alzheimer’s.
• The brain disorder seems unrelated to the symptoms a person has.

Moreover, a doctor may recommend the tests to find out if surgery or other treatments have worked as intended.

Is Neuropsychological Testing Covered by Insurance?

Insurance coverage for neuropsychological testing depends on individual plans. To check with an insurer before the test, use the following CPT codes:​​​⁵

• 96132 for neuropsychological testing by a psychologist
• +96133 for neuropsychological testing evaluation services
• 96136 and +96137 for test administration and scoring

How to Prepare for Neuropsychological Testing

You should be able to provide accurate and comprehensive information to the examiner. To prepare for testing, it may be beneficial to:

• Prepare a list of medications with their doses.
• Ask a family member or friend to go with you during the interview.
• Ask a family member or friend to go with you during the interview.
• Take all the reports of previous tests along. These can include brain scans, EEG reports, and results of a neuropsychological test.
• Sleep at least 7 hours the night before the test. Not getting enough sleep can affect memory and attention.
• Avoid drinking alcohol at least 24 hours before the test.
• Consider staying at a local hotel a day before the test date if you live far away from the test center. Driving long hours can cause exhaustion that may interfere with performance.
• Ask the doctor how sleeping pills (if taken) might affect memory and cognition.
• Relax and spend time with loved ones. Stressing too much about the results will only affect performance.

What Does a Neuropsychological Test Report Look Like?

A neuropsychological test report is typically 6-8 pages long. The report contains clear and concise information written in simple language.A report usually has the following sections:

Identifying Information and Referral

This section contains personal information, such as the name, age, date of birth, and ethnicity. Referral questions are clearly mentioned.

Chief Complaints

his section includes the causes of the referral. The complaints may be obtained from the person or his/her friends or family members. A common complaint can be problems with memory and thinking.

History of Present Illness

This section contains detailed information about one or more chief complaints. Examples include:

• When did the illness start?
• Have there been any gradual or abrupt changes in the symptoms?
• Have you received treatment for your problem? If yes, what medications did you take?

Other Medical/Psychiatric History

This section contains information about illnesses other than the chief complaints. Examples include a history of diabetes or depression.

Family History

This section includes information about significant medical and psychiatric disorders in parents or siblings. One should also note a history of addiction in immediate family members.

Social/Education/Vocational History

This section includes information about the level of education and employment status. If a person has served in the military, they should mention the type of discharge.

Mental Status Exam/Behavioral Observations

This section includes information about a person’s:

• Level of alertness
• Orientation
• Gait
• Posture
• Mood
• Speech quality
• Motivation

Table of Test Results

The table has different columns for:

• Names of tests taken
• Scores obtained
• Score descriptors, such as average, superior, or borderline

Summary of Results

The summary consists of brief information about the patient, his/her test scores, behaviors, strengths, and weaknesses.

Diagnostic Impressions and Recommendations

This section contains diagnostic codes and recommendations based on the diagnosis.

What is Brain Mapping?

Brain mapping examines how a diseased brain differs from a healthy brain. It aims to explore a link between brain function/structures and mental health issues.

Neurological diseases, such as Alzheimer’s, affect brain structures and how they work. Likewise, depression can shrink the brain. Structural changes have also been observed in people with long-term anxiety and schizophrenia.

There are two broad types of brain mapping. They are:

Structural Mapping

This studies how one part of the brain is connected to another region. Nerve cells in a part of the brain are stimulated using an electric current or magnetic field. Then, the response of such stimulation in another part is recorded.

Functional Mapping

This “maps” brain regions that have specific functions. Functional mapping aims to locate the areas that give people the ability to see, think, speak, reason, and judge. Scientists call it localization of function.

Who Completes Brain Mapping?

Who completes brain mapping depends on several factors. These include the technique used, the cause requiring imaging, and expected outcomes.A team of health professionals performs brain mapping. Members of the team may include:

• A neuroradiologist/interventional neurologist (a doctor who specializes in using imaging devices)
• A doctor who interprets the results of a brain mapping test
• A board-certified neurofeedback specialist (who checks and prepares brain mapping reports)
• An epileptologist (an expert in seizure treatment)

How Does Brain Mapping Work?

Brain mapping works in four steps:

• Recording activity in key brain regions
• Analyzing the record and comparing it with a database of similar records
• Detecting abnormalities in brain activity
• Recommending training to restore normal brain function

What Tests are Used in Brain Mapping?

Brain mapping uses the following techniques:

How Does Brain Mapping Work?

Computer tomography (CT): This uses X-rays to create detailed images of the brain. The images reveal structural abnormalities.Structural magnetic resonance imaging (MRI): This uses a magnetic field and radio waves to create high-quality images of the brain. MRI gives clearer images than a CT scan does.

Electrical Activity in the Brain

Electroencephalography (EEG): An EEG measures electrical activity in the brain. It uses small plates known as electrodes. The electrodes may be implanted in the brain (invasive) or placed on the scalp (non-invasive). Positron emission tomography (PET): A PET scan reveals images using a radioactive marker (tracer). Functional MRI (fMRI): fMRI detects brain activity by measuring blood flow in specific brain regions.

Newer Tools

High-definition fiber tracking (HDFT): HDFT creates three-dimensional images that show how the brain’s fibers are connected.

Magnetoencephalography (MEG): MEG records brain activity in the form of a magnetic field. The brain’s natural electric currents produce the magnetic field.

What is Brain Mapping Used For?

Brain mapping is a relatively new concept. That’s why its uses are mostly investigational. Scientists are studying if brain mapping tests such as qEEG have clinical use in:

• Post-concussion syndrome (persistent headache and dizziness after a blow to the head)
• Mid-to-moderate head injury
• Alcoholism
• Learning disability
• Schizophrenia
• Depression
• Attention disorders
• Drug abuse

How Does Brain Mapping Help Doctors?

Brain mapping can help doctors or surgeons:​​​⁶

• Diagnose neurological disorders, such as Parkinson’s and Alzheimer’s
• Protect critical brain areas during surgery to remove a tumor
• Identify areas that contribute to seizures
• Detect abnormal electrical activity in the brain of people with autism or ADHD
• Monitor structural changes in the brain of people who have had a stroke or traumatic brain injury

Pharmaco fMRI may help find the best treatment for neurological disorders, such as epilepsy.​​​⁷

What Should a Person Expect on the Day of the Brain Mapping Test?

A non-invasive brain mapping test is done in specialized centers. The entire procedure takes roughly 2 hours.Invasive mapping, such as that used in epilepsy surgery, is done at a hospital. It usually lasts less than an hour.Non-invasive techniques are painless and comfortable. During the test, a person will wear a cap that contains electrodes—the electrodes record activity in dozens of brain regions. A doctor may record two types of readings. One while the patient is closing their eyes and another with their eyes open. Each session lasts about 10 minutes.Then, a doctor compares the brain activity readings with those of other people of the same age. It helps to see if the brain is working normally or has any issues. Next, a neurofeedback specialist checks the information and prepares a brain map report.

What Does a Brain Mapping Report Look Like?

A typical brain mapping report is a 5 to 10-page long document. It contains information about:

• Different brainwaves, such as alpha, beta, theta, delta, and gamma. Many psychiatric and neurological disorders affect brainwaves. These include depression, ADHD, anxiety, autism, addiction, and schizophrenia.
• A person’s cognition, emotions, memory processing, and executive functions. The emotional analysis shows if they are prone to anxiety or obsessive thoughts. Executive analysis reveals their motivation and problem-solving skills.

The last section of the report contains recommendations to restore brain function.

Resources

1. http://www.afp-digital.org/afp/january_15_2019/MobilePagedArticle.action?articleId=1456343#articleId1456343
2. https://emedicine.medscape.com/article/317596-overview#a3
3. https://www.apa.org/monitor/2017/09/datapoint
4. https://www.aafp.org/afp/2010/0901/p495.html
5. https://blog.therapynotes.com/new-cpt-codes-take-effect-january-1-2019
6. https://www.sas.rochester.edu/dsc/assets/pdf/MiniCase_URMC_brainmapping.pdf
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5067101/