Depression and Pseudodementia in .NET

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Depression and Pseudodementia
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The essential feature of major or clinical depression is either depressed mood or the loss of interest or pleasure in nearly all activities during a period of at least 2 weeks (APA, 1994). Additional symptoms that may be present include sleep and/ or eating disturbances, psychomotor retardation or agitation, loss of energy, difficulties in thinking or concentration, and suicidal ideation. Typically, intelligence tests are not used as the primary
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assessment tool in diagnosing depression; however, they can be useful to this end. For instance, many individuals with learning disabilities also have major depression (APA, 1994; Culbertson & Edmonds, 1996). Additionally, it can be difficult, particularly in elderly persons, to determine whether cognitive symptoms are due to dementia or to a major depressive episode (APA, 1994). In fact, the literature suggests that the cognitive symptoms associated with depression are the most common type of pseudodementia and the most easily misdiagnosed (Lishman, 1987). Thus, neuropsychological testing and other tests assessing cognitive abilities can be helpful in the differential diagnosis of depression versus other disorders. Although research with the KAIT and depressed patients is limited, an initial study found that a sample of patients with clinical depression (N = 44) did not differ from their matched controls on any subtest of the KAIT (Kaufman & Kaufman, 1993; Grossman, Kaufman, Mednitsky, Scharff, & Dennis, 1994). One significant difference between depressed and nondepressed subjects was found regarding the size of the discrepancy between scores on Auditory Comprehension and Auditory Delayed Recall (tasks of
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TABLE 13.15
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Symptom
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Hypothesized KAIT results for clients with Alzheimer s-type dementia
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Hypothesized Effect on KAIT Relatively poor performance on Auditory Comprehension, Rebus Learning, Auditory Delayed Recall, Rebus Delayed Recall, and Memory for Block Designs Difficulties on the Faces and Places Trouble on Mystery Codes, Logical Steps, Double Meanings Lowered score on Mental Status Exam Because some of the Crystallized subtests require fluid skills (e.g., Double Meanings) or memory (e.g., Faces and Places), a Crystallized IQ > Fluid IQ may not be present
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Impairment in ability to learn new information or forgetting previously learned material
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Difficulty producing names of individuals and objects Problems in planning, shifting mental sets, or performing complex tasks Attention and orientation problems General cognitive impairment
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PART V
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ADDITIONAL MEASURES OF ADOLESCENT AND ADULT IQ
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immediate versus delayed recall). Specifically, the discrepancy between these two subtests was significantly larger for the depressed group than for the control group and the depressed group scored higher on the delayed task than the immediate task. Given that depressed individuals often have difficulties with concentration and problems in encoding and learning, the lower score on the initial Auditory Comprehension task is not surprising. The overall lack of findings in this KAIT study between the depressed and control samples is not consistent with prior research on other cognitive instruments. For example, prior research has shown that depressed patients have problems with memory (Gruzelier, Seymour, Wilson, Jolley, & Hirsch, 1988), planning and sequential abilities (Burgess, 1991), psychomotor tasks (Pernicano, 1986), and cognitive tasks requiring sustained effortful responding (Golinkoff & Sweeney, 1989). Given that the KAIT requires sustained effortful responding in addition to assessing many of the above-mentioned skills, the absence of differences between the depressed and control samples is surprising. However, Kaufman and Kaufman (1997) noted that the conclusions based on prior research regarding depressed patients deficiencies may have been drawn prematurely in part because of weaknesses in experimental design and inappropriate applications of statistics. They further noted that the one area of weakness that may reflect true deficiencies may be psychomotor retardation, which is sometimes reflected in lower Performance IQs than Verbal IQs on Wechsler tests (Kaufman, 1990). Similar findings on the KAIT would not be expected because the KAIT minimizes visual motor speed. However, it should be mentioned that the depressed sample in Grossman et al. (1994) earned their lowest scaled scores on Memory for Block Designs, one of the KAIT subtests requiring the most visual motor coordination and speed. No research to date has been conducted on pseudodementia using the KAIT. However, neuropsychological studies utilizing other cognitive tasks have been conducted. Thus, we can use the
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available research to help us understand and predict KAIT profiles. For these studies, pseudodementia refers to the coexistence of a psychiatric disorder and dementia, with the dementia symptomatology being treatable or reversible (Nixon, 1996). A study of patients with pseudodementia associated with depression (N = 14) versus patients with dementia (N = 28) was conducted by Reynolds et al. (1988). The results showed that those with pseudodementia performed better on Mini Mental Status Exams than those with dementia, whereas the groups did not differ on measures of short-term recall or repetition. In a longitudinal study of patients referred for differential diagnosis of dementia versus pseudodementia (N = 37), the following tests were differentially sensitive to early organic dementia: WAIS-R Block Design (Wechsler, 1981), Temporal Orientation Questionnaire (Benton, Hamsher, Varney, & Spreen, 1983), and Revised Visual Retention Test (RVRT; Benton, 1974). Specifically, patients with pseudodementia performed well on these tests, whereas patients with dementia performed poorly. Another study compared patients with dementia, depression, and controls on a variety of tests assessing memory, language, abstraction, calculation, judgment, praxis, and gnostic functions. In this study, Chaves and Izquierdo (1992) found significant differences among the groups such that the patients with depression showed significantly better memory functioning than the patients with dementia. As can be seen from the above research, profiles differentiating depression or pseudodementia from organic dementia are not consistent and have not yet been identified. However, the research can provide us with information both to increase our understanding of these disorders and to help us predict performance on other cognitive batteries. Given that most patients with depression or pseudodementia do not show significant impairment in orientation, naming, or other tasks associated with mental status exams, it is likely that these patients will perform in the normal range on the KAIT Mental Status Exam. Moreover, if psychomotor retardation is present for the
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KAUFMAN ADOLESCENT AND ADULT INTELLIGENCE TEST (KAIT)
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depressed individual, he or she may do poorly on Memory for Block Designs. Because the memory difficulties in depressed people are suggestive of problems in encoding and learning, as opposed to retention or retrieval of information, we might see poorer performance on the KAIT immediate recall tasks (Rebus Learning, Auditory Comprehension) and better performance on the delayed recall tasks (Rebus Delayed Recall, Auditory Delayed Recall). Certainly, it is important to observe patients behaviors during testing and to attempt to determine if there are any additional factors affecting performance, such as poor concentration or motivation. Moreover, as was mentioned in the previous section on Alzheimer s disease, more research is needed to give evidence of the diagnostic validity of the KAIT for use with these special populations. Until that time, examiners must be cautious in applying these conclusions (summarized in Table 13.16), always integrating test scores with multiple sources of data.
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