An Interview with Elkhonon Goldberg
BOL Editor: It’s a pleasure to welcome you here at Behavior OnLine for a discussion of clinical neuropsychology. In keeping with the forum’s title I’ll begin by asking you what is distinctive about 21st century neuropsychology?
ELKHONON GOLDBERG: It’s my distinct pleasure to be interviewed on BOL. Neuropsychology wears two hats as a discipline. One hat is scientific, the other one clinical. Neuropsychology is making great strides in both capacities. As a science, it is becoming increasingly intertwined with the state-of-the-art neuroimaging technologies, such as functional magnetic resonance imaging (fMRI), magnetoencephalography (MEG) and others. This union of neuropsychology and neuroimaging has resulted in a new level of understanding of the brain mechanisms of mental processes. As a clinical discipline, neuropsychology is central to the diagnosis and treatment of a number of disorders, whose cognitive dimension was underappreciated in the past (e.g. schizophrenia and affective disorders); whose recognized prevalence is on the rise due to an increasing life expectancy (e.g. Alzheimer’s disease and other dementias), better survival rate (e.g. traumatic brain injury), or more accurate diagnosis (e.g. ADHD, autism, dyslexias, and other neurodevelopmental disorders).
BOL: So the 21st century offers vastly improved pictures. And those pictures result in an expanded role for clinical neuropsychology in the new century. Let’s focus first on the role of neuropsychology in diagnoses and treatment of disorders that were previously outside the scope of the neuropsychology. I refer to schizophrenia and to affective disorders. At this stage what seems to be different in the images of the brains of people who suffer from those two disorders?
GOLDBERG: Both schizophrenia and affective disorders are complex diseases, so my response cannot be reduced to a soundbite. Nonetheless, certain features stand out. Frontal lobes are particularly affected in schizophrenia, and to some extent in affective disorders. There is some evidence – but less consistent – that the left hemisphere is particularly affected in schizophrenia.
BOL: So much for my effort to coax you into a bit of speculation. I hope you will forgive me for trying. Let’s turn to treatment. What is the role of the clinical neuropsychologist in the treatment of schizophrenia? Or in the future, what role can you envision the clinical neuropsychologist playing in treating these disorders?
GOLDBERG: Traditionally, the diagnosis and treatment of schizophrenia focused on psychosis and other “positive” symptoms. But recently there has been a greater appreciation of cognitive impairment in schizophrenia, particularly the executive deficit. In fact, already Kraepelin pointed this out indirectly in his classic description of “Dementia Praecox”, but it was thoroughly forgotten until recently. So, with the renewed interest in schizophrenic cognition, neuropsychology plays an increasingly important role in characterizing patients diagnostically. Furthermore, believe it or not, cognitive rehabilitation of schizophrenic patients is growing in prominence.
BOL: I am aware that cognitive rehabilitation is being widely employed in the treatment of schizophrenic patients — and with evident success. It is my impression that effort was well underway prior to recent advances in brain imaging. Has the clearer picture we now have of the brain shaped the nature of those interventions in a particular way?
GOLDBERG: Correct. Cognitive rehabilitation in schizophrenia has been around for approximately three decades and it is growing in prominence. It is not necessarily linked to neuroimaging, but it is a new and expanding arena for neuropsychological applications in psychiatry. As I said earlier cognitive impairment in schizophrenia may take many forms, but it usually dominated by the executive defiicit, and the symptomatology is often difficult to distinguish from other etiologies.
This is not surprising given the extensive evidence pointing to both physiological, biochemical and even structural abnormalities iin the frontal lobes of schizophrenic patients. About a quarter of a century ago, when the evidence of frontal lobe dysfunction in schizophrenia began to accumulate, I conducted a little study eliciting in patient with chronic schizophrenia the kind of symptomatology – mostly motor perseveration – which has been traditionally associated with traumatic brain injury, frontal tumors, aneurisms of the anterior communicating artery and so on. And then I showed these samples to various neuropsychologists urging them to guess the underlying etiology. Nobody was able to correctly diagnose the patients, but today we increasingly appreciate the degree of frontal lobe dysfunction in schizophrenia. So much of therapeutic effort in schizophrenia is directed at the frontal lobes and executive functions.
BOL: That little study is very interesting. Though the skeptic in me wonders if the observed motor perseveration could be the result of anti-psychotic medication rather the disorder?
GOLDBERG: Very interesting indeed… That was my concern also and I published a paper about the possibility of iatrogenic effects of neuroleptics on cognition. If there is tardive dyskinesia, then why not “tardive dysmentia’? The paper was published in Schizophrenia Bulletin, an NIH publication, in 1985, I think, and a few psychopharmacologist friends stopped being my friends as a result. But even if neuroleptics may contribute to “frontal-lobe” like effects, this cannot be the whole story. First, already Kraepelin pointed them out, decades before the discovery of neuroleptics. Second, I was able to examine a sample of never-medicated schizophrenics, and they had similar symptoms.
BOL: That’s a very satisfying answer.
Returning to clinical matters, I wonder what your take is on interventions to prevent cognitive decline in the elderly and to foster maximum performance at any age. How much of this is being done? And with what efficacy?
GOLDBERG: This is a very exciting and rapidly developing field. At the risk of sounding immodest, I have been one of its earliest proponents and wrote about cognitive enhancement in aging in my two books: The Executive Brain and The Wisdom Paradox. Both have been translated into many languages. Even as recently as 10-15 years ago, cognitive enhancement through structured cognitive exercise in aging was viewed as a far-fetched “new age” fantasy. But it has gained legitimacy since, research papers have been published in serious scientific and professional journals, and it is rapidly becoming part of the mainstream.
BOL: I think this would be a good time for us to pause to allow others to join in on the topics we have touched on, or on other topics.