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Neuropsychological Assessment
NEUROPSYCHOLOGICAL
ASSESSMENT
Fifth Edition

Muriel Deutsch Lezak

Diane B. Howieson
Erin D. Bigler
Daniel Tranel
Oxford University Press, Inc., publishes works that further
Oxford University’s objective of excellence
in research, scholarship, and education.
Oxford New York
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With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
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Copyright © 1976, 1983, 1995, 2004, 2012 by Oxford University Press, Inc.
Published by Oxford University Press, Inc.
198 Madison Avenue, New York, New York 10016
www.oup.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Neuropsychological assessment / Muriel D. Lezak … [et al.]. — 5th ed.
p. cm.
Includes bibliographical references and index.
ISBN 978–0–19–539552–5
1. Neuropsychological tests. I. Lezak, Muriel Deutsch.
RC386.6.N48L49 2012
616.8’0475—dc23
2011022190
Dedicated in gratitude for the loving support from our spouses, John Howieson, Jan Bigler, and
Natalie Denburg; and in memory of Sidney Lezak whose love and encouragement made this work
possible.
Preface

Direct observation of the fully integrated functioning of living human brains will probably always be impossible.
M.D. Lezak, 1983, p. 15

What did we know of possibilities, just a little more than a quarter of a century ago? The “black box” of
classical psychology is no longer impenetrable as creative neuroscientists with ever more revealing
neuroimaging techniques are devising new and powerful ways of finding windows into the black box. In
neuroimaging we can now trace neural pathways, relate cortical areas to aspects of thinking and feeling—
even “see” free association in the “default” state—and are discovering how all this is activated and
integrated in complex, reactive, and interactive neural systems. We may yet uncover the nature of (self-
and other-) consciousness and how synaptic interconnections, the juices that flow from them, and the
myriad other ongoing interactive neural processes get translated into the experience of experiencing. We
can never again say “never” in neuroscience.
Yet, as entrancing and even astonishing as are the findings the new technologies bring to neuroscience,
it is important to be mindful of their roots in human observations. As these technologically enhanced
observations of the brain at work open the way for new insights about brain function and its behavioral
correlates they also confirm, over and over again, the foundational hypotheses of neuropsychology—
hypotheses generated from direct observations by neuropsychologists and neurologists who studied and
compared the behavior of both normal and brain impaired persons. These foundational hypotheses guide
practitioners in the clinical neurosciences today, whether observations come from a clinician’s eyes and
ears or a machine. In the clinic, observations of brain function by technological devices enhance
understanding of behavioral data and sometimes aid in prediction, but cannot substitute for clinical
observations.
When the earliest neuroimaging techniques became available, some thought that neuropsychologists
would no longer be needed as it had become unnecessary to improve the odds of guessing a lesion site, a
once important task for neuropsychologists. Today’s advanced neuroimaging techniques make it possible
to predict with a reasonable degree of accuracy remarkably subtle manifestations, such as the differences
between socially isolated brain injured patients who will have difficulty in social interactions although
actively seeking them, versus those who may be socially skilled but lack incentive to socialize. Yet this
new level of prediction, rather than substituting for human observation and human intervention, only raises
more questions for experienced clinical neuroscientists: e.g., what circumstances exacerbate or alleviate
the problem? what compensatory abilities are available to the patient? is the patient aware of the problem
and, if so, can this awareness be used constructively? is this a problem that affects employability and, if
so, how? and so on. Data generated by new neurotechnologies may help identify potential problem areas:
neuropsychologists can find out how these problems may play out in real life, in human terms, and what
can be done about them.
Thus, in the fifth incarnation of Neuropsychological Assessment, we have tried to provide a wide-
ranging report on neuropsychology as science and as a clinical specialty that is as relevant today as it was
when it first appeared 35 years ago. Certainly what is relevant in 2012 is somewhat different from 1976
as the scope of activities and responsibilities of neuropsychologists has enlarged and the knowledge base
necessary for clinical practice as well as for research has expanded exponentially.
Three major additions distinguish the first and the fifth editions of Neuropsychological Assessment.
Most obvious to the experienced neuropsychologist is the proliferation of tests and the wealth of readily
available substantiating data. Second, a book such as this must provide practically useful information for
neuropsychologists about the generations—yes, generations—of neuroimaging techniques that have
evolved in the past 30 years. Further, especially exciting and satisfying is confirmation of what once was
suspected about the neural organization underlying brain functions thanks to the marriage of sensitive,
focused, clinical observations with sensitive, focused, neuroimaging data. In this edition we convey what
is known about the enormity of interwoven, interactive, and interdependent complexities of neuronal
processing as the brain goes about its business and how this relates to our human strengths and frailties.
What remains the same in 2012 as it was in 1976 is the responsibility of clinicians to treat their
patients as individuals, to value their individuality, and to respect them. Ultimately, our understandings
about human behavior and its neural underpinnings come from thoughtful and respectful observations of
our patients, knowledge of their histories, and information about how they are living their lives.
Muriel Deutsch Lezak
Diane B. Howieson
Erin D. Bigler
Daniel Tranel
Acknowledgments

Once again we want to honor our neuropsychologist friends, colleagues, and mentors who have died in
the past few years. Most of what is written in this text and much of contemporary neuropsychology as
science or clinical profession, relies on their contributions to neuropsychology, whether directly, or
indirectly through their students and colleagues. We are deeply grateful for the insightful, innovative,
integrative, and helpfully practical work of William W. Beatty, Edith F. Kaplan, John C. Marshall, Paul
Satz, Esther Strauss, and Tom Tombaugh. The authors gratefully acknowledge Tracy Abildskov in creating
the various neuroimaging illustrations, Jo Ann Petrie’s editing, and Aubrey Scott’s artwork.
Many of David W Loring’s important contributions to the fourth edition of Neuropsychological
Assessment enrich this edition as well. We miss his hand in this edition but are grateful to have what he
gave us. And thanks, too, to Julia Hannay for some invaluable chapter sections retained from the fourth
edition. Special thanks go to Kenneth Manzell for his aid in preparing the manuscript and illustrations. We
are fortunate to have many colleagues and friends in neuropsychology who—at work or in meetings—
have stimulated our thinking and made available their work, their knowledge, and their expertise. The
ongoing 2nd Wedns. Neuropsychology Case Conference in Portland continues to be an open-door free-
for-all and you are invited.
It has been a pleasure to work with our new editor, Joan Bossert, who has not only been encouraging
and supportive, but has helped us through some technical hoops and taught us about e-publishing. Tracy
O’Hara, Development Editor, has done the heroic task of organizing the production idiosyncrasies of four
writers into a cohesive manuscript while helping with some much needed data acquisition. Book
production has been carefully timed and managed by Sr. Production Editor Susan Lee who makes house
calls. Thanks, OUP team, for making this book possible. Last to get involved but far from least, our
gratitude goes out to Eugenia Cooper Potter, best known as Genia, whose thorough scouring and polishing
of text and references greatly helped bring this book to life.
Contents
List of Figures
List of Tables

I THEORY AND PRACTICE OF NEUROPSYCHOLOGICAL

ASSESSMENT
1. The Practice of Neuropsychological Assessment
Examination purposes
The multipurpose examination
The Validity of Neuropsychological Assessment
What Can We Expect of Neuropsychological Assessment in the 21st Century?

2. Basic Concepts
Examining the Brain
Laboratory Techniques for Assessing Brain Function
Neuropsychology’s Conceptual Evolution
Concerning Terminology
Dimensions of Behavior
Cognitive Functions
Neuropsychology and the Concept of Intelligence: Brain Function Is Too Complex To Be
Communicated in a Single Score
Classes of Cognitive Functions
Receptive Functions
Memory
Expressive Functions
Thinking
Mental Activity Variables
Executive Functions
Personality/Emotionality Variables

3. The Behavioral Geography of the Brain

Brain Pathology and Psychological Function
The Cellular Substrate
 The Structure of the Brain
The Hindbrain
The Midbrain
The Forebrain: Diencephalic Structures
The Forebrain: The Cerebrum
The Limbic System
The Cerebral Cortex and Behavior
Lateral Organization
Longitudinal Organization
Functional Organization of the Posterior Cortex
The Occipital Lobes and Their Disorders
The Posterior Association Cortices and Their Disorders
The Temporal Lobes and Their Disorders
Functional Organization of the Anterior Cortex
Precentral Division
Premotor Division
Prefrontal Division
Clinical Limitations of Functional Localization

4. The Rationale of Deficit Measurement

Comparison Standards for Deficit Measurement
Normative Comparison Standards
Individual Comparison Standards
The Measurement of Deficit
Direct Measurement of Deficit
Indirect Measurement of Deficit
The Best Performance Method
The Deficit Measurement Paradigm

5. The Neuropsychological Examination: Procedures

Conceptual Framework of the Examination
Purposes of the Examination
Examination Questions
Conduct of the Examination
Examination Foundations
Examination Procedures
Procedural Considerations in Neuropsychological Assessment
Testing Issues
Examining Special Populations
Common Assessment Problems with Brain Disorders
Maximizing the Patient’s Performance Level
 Optimal versus Standard Conditions
When Optimal Conditions Are Not Best
Talking to Patients
Constructive Assessment

6. The Neuropsychological Examination: Interpretation

The Nature of Neuropsychological Examination Data
Different Kinds of Examination Data
Quantitative and Qualitative Data
Common Interpretation Errors
Evaluation of Neuropsychological Examination Data
Qualitative Aspects of Examination Behavior
Test Scores
Evaluation Issues
Screening Techniques
Pattern Analysis
Integrated Interpretation

7. Neuropathology for Neuropsychologists

Traumatic Brain Injury
Severity Classifications and Outcome Prediction
Neuropathology of TBI
Penetrating Head Injuries
Closed Head Injuries
Closed Head Injury: Nature, Course, and Outcome
Neuropsychological Assessment of Traumatically Brain Injured Patients
Moderator Variables Affecting Severity of Traumatic Brain Injury
Less Common Sources of Traumatic Brain Injury
Cerebrovascular Disorders
Stroke and Related Disorders
Vascular Disorders
Hypertension
Vascular Dementia (VaD)
Migraine
Epilepsy
Dementing Disorders
Mild Cognitive Impairment
Degenerative Disorders
Cortical Dementias
Alzheimer’s Disease (AD)
Frontotemporal Lobar Degeneration (FTLD)
 Dementia with Lewy Bodies (DLB)
Subcortical Dementias
Movement Disorders
Parkinson’s Disease/Parkinsonism (PD)
Huntington’s Disease (HD)
Progressive Supranuclear Palsy (PSP)
Comparisons of the Progressive Dementias
Other Progressive Disorders of the Central Nervous System Which May Have
Important Neuropsychological Effects
Multiple Sclerosis (MS)
Normal Pressure Hydrocephalus (NPH)
Toxic Conditions
Alcohol-Related Disorders
Street Drugs
Social Drugs
Environmental and Industrial Neurotoxins
Infectious Processes
HIV Infection and AIDS
Herpes Simplex Encephalitis (HSE)
Lyme Disease
Chronic Fatigue Syndrome (CFS)
Brain Tumors
Primary Brain Tumors
Secondary (Metastatic) Brain Tumors
CNS Symptoms Arising from Brain Tumors
CNS Symptoms Arising from Cancer Treatment
Oxygen Deprivation
Acute Oxygen Deprivation
Chronic Oxygen Deprivation
Carbon Monoxide Poisoning
Metabolic and Endocrine Disorders
Diabetes Mellitus (DM)
Hypothyroidism (Myxedema)
Liver Disease
Uremia
Nutritional Deficiencies

8. Neurobehavioral Variables and Diagnostic Issues

Lesion Characteristics
Diffuse and Focal Effects
Site and Size of Focal Lesions
 Depth of Lesion
Distance Effects
Nature of the Lesion
Time
Nonprogressive Brain Disorders
Progressive Brain Diseases
Subject Variables
Age
Sex Differences
Lateral Asymmetry
Patient Characteristics: Race, Culture, and Ethnicity
The Uses of Race/Ethnicity/Culture Designations
The Language of Assessment
Patient Characteristics: Psychosocial Variables
Premorbid Mental Ability
Education
Premorbid Personality and Social Adjustment
Problems of Differential Diagnosis
Emotional Disturbances and Personality Disorders
Psychotic Disturbances
Depression
Malingering

II A COMPENDIUM OF TESTS AND ASSESSMENT TECHNIQUES

9. Orientation and Attention
Orientation
Awareness
Time
Place
Body Orientation
Finger Agnosia
Directional (Right–Left) Orientation
Space
Attention, Processing Speed, and Working Memory
Attentional Capacity
Working Memory/Mental Tracking
Concentration/Focused Attention
Processing Speed
Complex Attention Tests
Divided Attention
 Everyday Attention

10. Perception
Visual Perception
Visual Inattention
Visual Scanning
Color Perception
Visual Recognition
Visual Organization
Visual Interference
Auditory Perception
Auditory Acuity
Auditory Discrimination
Auditory Inattention
Auditory–Verbal Perception
Nonverbal Auditory Reception
Tactile Perception
Tactile Sensation
Tactile Inattention
Tactile Recognition and Discrimination Tests
Olfaction

11. Memory I: Tests

Examining Memory
Verbal Memory
Verbal Automatisms
Supraspan
Words
Story Recall
Visual Memory
Visual Recognition Memory
Visual Recall: Verbal Response
Visual Recall: Design Reproduction
Visual Learning
Hidden Objects
Tactile Memory
Incidental Learning
Prospective Memory
Remote Memory
Recall of Public Events and Famous Persons
Autobiographic Memory
 Forgetting

12. Memory II: Batteries, Paired Memory Tests, and Questionnaires

Memory Batteries
Paired Memory Tests
Memory Questionnaires

13. Verbal Functions and Language Skills

Aphasia
Aphasia Tests and Batteries
Aphasia Screening
Testing for Auditory Comprehension
Verbal Expression
Naming
Vocabulary
Discourse
Verbal Comprehension
Verbal Academic Skills
Reading
Writing
Spelling
Knowledge Acquisition and Retention

14. Construction and Motor Performance

Drawing
Copying
Miscellaneous Copying Tasks
Free Drawing
Assembling and Building
Two-Dimensional Construction
Three-Dimensional Construction
Motor Skills
Examining for Apraxia
Neuropsychological Assessment of Motor Skills and Functions

15. Concept Formation and Reasoning

Concept Formation
Concept Formation Tests in Verbal Formats
Concept Formation Tests in Visual Formats
Symbol Patterns
Sorting
 Sort and Shift
Reasoning
Verbal Reasoning
Reasoning about Visually Presented Material
Mathematical Procedures
Arithmetic Reasoning Problems
Calculations

16. Executive Functions

The Executive Functions
Volition
Planning and Decision Making
Purposive Action
Self-Regulation
Effective Performance
Executive Functions: Wide Range Assessment

17. Neuropsychological Assessment Batteries

Ability and Achievement
Individual Administration
Paper-and-Pencil Administration
Batteries Developed for Neuropsychological Assessment
Batteries for General Use
Batteries Composed of Preexisting Tests
Batteries for Assessing Specific Conditions
HIV+
Schizophrenia
Neurotoxicity
Dementia: Batteries Incorporating Preexisting Tests
Traumatic Brain Injury
Screening Batteries for General Use
Computerized Neuropsychological Assessment Batteries

18. Observational Methods, Rating Scales, and Inventories

The Mental Status Examination
Rating Scales and Inventories
Dementia Evaluation
Mental Status Scales for Dementia Screening and Rating
Mental Status and Observer Rating Scale Combinations
Scales for Rating Observations
 Traumatic Brain Injury
Evaluating Severity
Choosing Outcome Measures
Outcome Evaluation
Evaluation of the Psychosocial Consequences of Head Injury
Epilepsy Patient Evaluations
Quality of Life
Psychiatric Symptoms

19. Tests of Personal Adjustment and Emotional Functioning

Objective Tests of Personality and Emotional Status
Depression Scales and Inventories
Anxiety Scales and Inventories
Inventories and Scales Developed for Psychiatric Conditions
Projective Personality Tests
Rorschach Technique
Storytelling Techniques
Drawing Tasks

20. Testing for Effort, Response Bias, and Malingering

Research Concerns
Examining Response Validity with Established Tests
Multiple Assessments
Test Batteries and Other Multiple Test Sets
Wechsler Scales
Batteries and Test Sets Developed for Neuropsychological Assessment
Memory Tests
Single Tests
Tests with a Significant Motor Component
Special Techniques to Assess Response Validity
Symptom Validity Testing (SVT)
Forced-Choice Tests
Variations on the Forced-Choice Theme
Other Special Examination Techniques
Self-Report Inventories and Questionnaires
Personality and Emotional Status Inventories
Appendix A: Neuroimaging Primer
Appendix B: Test Publishers and Distributors
References
Test Index
Subject Index
List of Figures

The Behavioral Geography of the Brain

FIGURE Schematic of a neuron. Photomicrograph. (See color Figure 3.1)
3.1
FIGURE (a) Axial MRI, coronal MRI, sagittal MRI of anatomical divisions of the brain. (See color Figure 3.2a, b, and c)
3.2
FIGURE Lateral surface anatomy postmortem (left) with MRI of living brain (right)
3.3
FIGURE Ventricle anatomy. (See color Figure 3.4)
3.4
FIGURE Scanning electron micrograph showing an overview of corrosion casts from the occipital cortex
3.5
FIGURE Major blood vessels schematic
3.6
FIGURE Thalamo-cortical topography demonstrated by DTI tractography. (See color Figure 3.7)
3.7
FIGURE Memory and the limbic system
3.8
FIGURE Cut-away showing brain anatomy viewed from a left frontal perspective with the left frontal and parietal lobes removed. (See color
3.9 Figure 3.9)
FIGURE DTI (diffusion tensor imaging) of major tracts. (See color Figure 3.10)
3.10
FIGURE DTI of major tracts through the corpus callosum. (See color Figure 3.11)
3.11
FIGURE Representative commissural DTI ‘streamlines’ showing cortical projections and cortical terminations of corpus callosum projections.
3.12 (See color Figure 3.12)
FIGURE Schematic diagram of visual fields, optic tracts, and the associated brain areas, showing left and right lateralization in humans
3.13
FIGURE Diagram of a “motor homunculus” showing approximately relative sizes of specific regions of the motor cortex
3.14
FIGURE Example of global/local stimuli
3.15
FIGURE Example of spatial dyscalculia by a traumatically injured pediatrician
3.16
FIGURE Attempts of a 51-year-old right hemisphere stroke patient to copy pictured designs with colored blocks
3.17a
FIGURE Attempts of a 31-year-old patient with a surgical lesion of the left visual association area to copy the 3 × 3 pinwheel design
3.17b
FIGURE Overwriting (hypergraphia) by a 48-year-old college-educated retired police investigator suffering right temporal lobe atrophy
3.18
FIGURE Simplification and distortions of four Bender-Gestalt designs by a 45-year-old assembly line worker
3.19
FIGURE The lobe-based divisions of the human brain and their functional anatomy
3.20
FIGURE Brodmann’s cytoarchitectural map of the human brain
3.21
FIGURE Lateral view of the left hemisphere, showing the ventral “what” and dorsal “where” visual pathways in the occipital-temporal and
3.22 occipital-parietal regions
FIGURE (a) This bicycle was drawn by the 51-year-old retired salesman who constructed the block designs of Figure 3.17a
3.23
FIGURE Flower drawing, illustrating left-sided inattention
3.24a
FIGURE Copy of the Taylor Complex Figure (see p. 575), illustrating inattention to the left side of the stimulus
3.24b
FIGURE Writing to copy, illustrating inattention to the left side of the to-be-copied sentences; written by a 69 year-old man
3.24c
FIGURE Example of inattention to the left visual field
3.24d
FIGURE Ventral view of H.M.’s brain ex situ using 3-D MRI reconstruction
3.25
FIGURE The major subdivisions of the human frontal lobes identified on surface 3-D MRI reconstructions of the brain
3.26
The Rationale of Deficit Measurement
FIGURE Calculations test errors (circled) made by a 55-year-old dermatologist with a contre coup
4.1
The Neuropsychological Examination: Procedures
FIGURE An improvised test for lexical agraphia
5.1
FIGURE Copies of the Bender-Gestalt designs drawn on one page by a 56-year-old sawmill worker with phenytoin toxicity
5.2
The Neuropsychological Examination: Interpretation
FIGURE House-Tree-Person drawings of a 48-year-old advertising manager
6.1
FIGURE This bicycle was drawn by a 61-year-old who suffered a stroke involving the right parietal lobe
6.2
FIGURE The relationship of some commonly used test scores to the normal curve and to one another
6.3
Neuropathology for Neuropsychologists
FIGURE This schematic is of a neuron and depicts various neuronal membrane and physiological effects incurred during the initial stage of
7.1 TBI (See color Figure 7.1)
FIGURE Proteins are the building blocks of all tissues including all types of neural cells and in this diagram the Y-axis depicts the degree of
7.2 pathological changes in protein integrity with TBI
FIGURE There are two pathways that lead to a breakdown in the axon from TBI, referred to as axotomy
7.3
FIGURE CT scans depicting the trajectory prior to neurosurgery depicting the trajectory and path of a bullet injury to frontotemporal areas of
7.4 the brain
FIGURE MRI demonstration of the effects of penetrating brain injury
7.5
FIGURE Postmortem section showing the central penetration wound from a bullet which produces a permanent cavity in the brain
7.6
FIGURE Diagram showing impulsive loading from the rear (left) and front (right) with TBI
7.7
FIGURE Mid-sagittal schematic showing the impact dynamics of angular decelerations of the brain as the head hits a fixed object
7.8
FIGURE Wave propagation and contact phenomena following impact to the head
7.9
FIGURE The colorized images represent a 3-D CT recreation of the day-of-injury hemorrhages resulting from a severe TBI (See color
7.10 Figure 7.10)
FIGURE Mid-sagittal MRI with an atrophied corpus callosum and old shear lesion in the isthmus (See color Figure 7.11)
7.11
FIGURE MRI comparisons at different levels of TBI severity in children with a mean age of 13.6
7.12
FIGURE 3-D MRI reconstruction of the brain highlighting the frontal focus of traumatic hemorrhages associated with a severe TBI.(See
7.13 color Figure 7.13)
FIGURE This is a case of mild TBI where conventional imaging (upper left) shows no abnormality but the fractional anisotropy DTI map
7.14 (top, middle image) does (See color Figure 7.14)
FIGURE The brain regions involved in TBI that overlap with PTSD are highlighted in this schematic (See color Figure 7.15)
7.15
FIGURE “The three neurodegenerative diseases classically evoked as subcortical dementia are Huntington’s chorea, Parkinson’s disease, and
7.16 progressive supranuclear palsy
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