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developed quite substantial-ly. It was pleasing, therefore, to present a united front at a recent meeting with Discovery Health at which the issue of coding and tariffs were discussed. The first of – hopefully – many such meetings, it was evident that medical schemes require Clinical Psychology to speak with one voice on matters pertaining to Clinical Psychol-ogy’s “slice of the pie”. Lastly, on the news front, I wish to extend a very heart-felt thank you to the staff at Healthman for all the work that they do – often behind the scenes – to keep the CPF in the field of vision of the various stakeholders in the health industry.

And so, after a year in which

Mind Matters, the CPF and

the profession have

undergone many changes

and seen many develop-

ments, both good and not-so

-good, it is with a sense of

accomplishment that those

of us at Mind Matters, the

Exco of the CPF and

HealthMan wish all our

members a peaceful holiday

season and a prosperous

2015.

Neil Amoore Editor

Well, it seems like forever since Mind Matters hit your Inbox and the fault lies squarely with yours truly. I think you will agree that the aim of getting more contribu-tions from members of our community has been achieved in this edition of the newsletter, but it has not been without its hiccups! So, apologies to all our readers. We have taken some time to get the new system on its feet but the structure is there for a smoother-running operation in 2015. In this issue, though, we have chosen to put the focus on the role of the Clinical Psychologist in the field of neuropsychology and neuro-science. Contributions from Professor Eddie Wolff and Gerhard Grundling, along with feedback from the recent meeting of the aeromedical association gathering should be interesting reading. As an attendee at the recent SA Clinical Neuropsychology Association conference I was struck by how many Clinical Psychologists work in this field, and that it is one in in which the Clinical Psycholo-gist is uniquely situated to

provide direct support and expertise. Furthermore, it is one that needs greater attention from the profession. Of concern is the growing threat to the profession of Clinical Psychology, none more so than the upcoming legal action being undertaken by ReLPAG. Gerhard Grundling poses some vital questions regarding the action in his Chairman’s Report, and it needs a concerted effort to meet this threat. In preparing for the above, readers will want to pop over to the South African Society of Psychiatrists (SASOP) web-site and have a look at the position statement they have released with regards to the issue of ethical boundaries - http://www.sasop.co.za/C_DC_PState_024.asp. In accordance with that, the CPF are currently working on a position statement of our own and have consulted with the necessary legal minds to have a look at it. Reading through Linda Blokland’s feedback report from the recent PsySSA Congress readers will note that the relationship between the Clinical chapter of PsySSA and the CPF has

I N S I D E T H I S

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Chairman’s

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Aeromedical

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4

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P A G E 2

Qua Vadis Clinical Psychology Over the last two years it has become evident that the “identity crisis” within clinical psychology and the broader field of psychology is causing major confusion and is having a huge impact on the profession of psychology and on clinical psychology specifically. This identity crisis can be divided into: 1. An identity crisis from the

external market – meaning that it is difficult for non-psychologists and the public at large to distinguish between the different disciplines within psychology due to a lack of clear communication in this regard from the profession of psychology and the Professional Board for Psychology. Medical schemes, other professionals and the public at large form part of this external market.

1. An identity crisis from the

internal market – this relates to the profession of psy-chology and represents the problems with boundaries, lack of building the identity of the various disciplines in psychology and from clinical psychology an acceptance of the present state of affairs and there for leading to little protection of the profession of clinical psychology.

You would have received the documentation regarding the Relpag (Recognition of Life Long Learning In Psychology Action Group) legal action by this time. This action is a clear example of the identity crisis that exists within psychology. It presents a case to

get the legal system to sanction boundary violation and boundary crossing. In this matter it pertains specifically to get sanction to infringe on the profession of clinical psychology. The concern is that the profession of clinical psychology working primarily in the field of mental healthcare is under attack. It begs the question: Why is the boundary violation within psychology primarily one of other disciplines within psychology wanting to infringe on our profession? This is rarely the other way around. It seems that the attack on clinical psychology also comes largely from educational psychology. In contrast there seems to be a better understanding for example between clinical and counselling psychology and less infringement on each other’s disciplines. If the court grants Relpag their request to sanction crossing the boundary into clinical psychology, by effectively removing the scopes of practice regulations as it stands what would this mean?

This will have serious conse-quences not only for the profession of psychology but also for other professions. It could be that this would alter the landscape of formal training and professional registration within South Africa, leading to experience being accepted as the standard for allowing someone to practice a profession. Would there be any well defined and acceptable levels of so called lifelong learning and experience? This will clearly pose a major threat to the medical professions and may allow boundary crossing and violation to freely take place. How will the public then be protected?

M I N D M A T T E R S

Ch

airp

erso

n’s

Rep

ort

P A G E 3 V O L U M E 1 , I S S U E 1

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your product or service, the key

to a successful newsletter is mak-

ing it useful to your readers.

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to your newsletter is to develop

and write your own articles, or

include a calendar of upcoming

events or a special offer that pro-

motes a new product.

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find “filler” articles by accessing

the World Wide Web. You can

write about a variety of topics but

try to keep your articles short.

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your newsletter can also be used

for your Web site. Microsoft Pub-

lisher offers a simple way to con-

vert your newsletter to a Web

publication. So, when you’re fin-

ished writing your newsletter,

convert it to a Web site and post

it.

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to your newsletter.

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yourself if the picture supports or

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How would this deepen the identity crisis in psychology and widen it to other professions in South Africa? How would this impact on recognition of professional standards in South Africa by people from other countries? Does this mean a free for all situations? Would there be any need for formal training and registration under such conditions? The list of questions is endless. My question is: Are you prepared to

accept this and have your profession

redefined by others and merely sit

and watch this drama unfold around

you?

Clinical Psychology is at a turning point in South Africa. You have worked hard and had to endure one of the most stringent selection processes at university level to become what you are: a clinical psy-chologist. This might not be the case anymore during the course of 2015. Putting bread on your table may be a very different affair if the court grants Relpag it’s wish. This does not need to be the case, let us stand up for what is rightfully ours. Let us operationalise the scope of practice of clinical psychology. It has been promulgated and we have the right to demand that this should be adhered to. This will mean that we all must strongly identify with our profes-sion and that we need to become far more assertive in this regard. Quo Vadis? Gerhard Grundling

DURING July 2014, the Southern African Aerospace Medical Association’s (SAAsMA) biennial conference took place and special attention was paid to the need for Clinical Psychologists in this field of expertise. This is due to the fact that it would appear that the main cause of aircraft accidents appear to be of a psychological nature. Special attention was paid to Aeromedical Psychology. Aero-medical Psychology has been defined as having “to do with the ap-plication of clinical knowledge in order to determine the ability of an aviator who has suffered physical or psychological illness, injury or distress, to return to flying duties." Trevor Reynolds, on the executive of SAAsMA’s psychology chapter, gave an interesting talk on Aeromedical vs Aviation Psy-chology and the intimate relationship that exists between psycholo-gy and flight. Aeromedical examiners expressed the need for more knowledge regarding Psychological disorders and symptoms. This highlighted a more holistic approach towards Aeromedical and Aviation Psychology. The South African Civil Aviation Authority is the only regulator that has permanent representation of Clinical Psychologists on its aeromedical committee, which is unparalleled anywhere else in the world. Johan Erasmus discussed Crew Resource Management (CRM) which was introduced into the aviation field in order to reduce the human error factor. Furthermore, Capt. Carlos Porges discussed the role of Neuro-psychology in aviation and how factors such as high conscientious-ness, low neuroticism and moderate agreeableness make a pilot more competent. The mood disorder protocol (now amended) and how it applies to pilots, is of particular interest to Clinical Psychologists. The previous protocol did not take into consideration new therapeutic interventions for depression, which reduce the risk of sudden incapacitation. The fact that Clinical Psychologists, alongside Psychiatrists, are the only mental health professionals able to diagnose and treat conditions such as depression makes their role pivotal in the field. The amended protocol states that individuals requiring pharma-

cotherapy may apply, or re-apply, for a licence to fly or undertake

air traffic control work. For example, applicants currently taking

SSRI's must be symptom free for 4 weeks before application and

submit both a psychiatrist's and a psychologist's report as well as

submit follow-up reports.

Clinical Psychologists interested in the field met with Trevor

Reynolds and Johan Erasmus at the end of the day and it was

agreed that another meeting would take place in order to discuss

the role of Clinical Psychologists and how they could add value to

the exciting new field of Aviation Psychology.

Aeromedical Psychology and the Clinical Psychologist

by Debbie Hargraves

continued …..

P A G E 4

M I N D M A T T E R S

Flying the CPF flag at the 2014 PsySSA Congress

by LINDA BLOKLAND THE 2014 congress of PsySSA was extremely well

attended with approximately 800 attendees and a

high student presence was noted, which is encoura-

ging that our future professionals are taking their

discipline seriously.

Personal impressions, from events that I attended

and from reports from colleagues, was that the

standard of the presentations were high. I also felt

that the mix of activities was well distributed among

formal presentations, interactive events, and debates.

It was difficult at times to choose what to attend as

the programme presented an array of interesting

items.

Some of the more interesting items included the

controversial debate ‘Twenty years of democracy in

South Africa: Is there something to celebrate?’ and

‘What has Psychology’s contribution been in

shaping this young democracy?’ facilitated

by Eusebius McKaiser. A lively discussion and

diverse responses from the audience followed,

showing that professionals were comfortable in

positioning themselves in various spots on the

continuum of opinion on this matter!

The structure this year was interesting in that all key

note addresses were held on the first day and the two

subsequent days rolled out with the individual

presentations. There were many delectable topics to

choose from.

Prof. Anthony Pillay led a debate on the two major

classification systems presently used in South Africa,

the DSM and the ICD. This also proved to be enlight-

ening and gave some food for thought about this

issue, as medical aids continue to use both for

different reasons, while professionals have their own

preferences when it comes to the two systems of

classification.

Prof. Saths Cooper, in his role as president of the

International Congress of Psychology, chaired a

debate on ‘The role of Psychology in strengthening

democracy in our respective countries and beyond’,

with leading figures in the field of psychology from

various African countries and Europe as the

panellists.

On a lighter note, I heard the party was amazing. It

was with great regret that I could not attend it!

On Thursday evening the AGMs of the chapters were

held. The CPF was invited to attend the Clinical

Division - considered by PsySSA as the "flagship"

chapter, I was told. I represented the CPF at this

meeting and was warmly welcomed.

The chair, Brian Fafudi, introduced the CPF to the

chapter, and announced the collaboration that we are

embarking on together on specific projects such as

coding and the joint position statement on the role of

Clinical Psychologists in the mental health care field.

The position of Clinical Psychology and its Scope of

Practice has been overtly supported by the South

African Society of Psychiatrists (SASOP).

A number of the participants of the Clinical Chapter

showed interest in the CPF and I took a number of

questions from the floor. A concern was expressed

that the CPF and the chapter should not act to further

divide an already fragmented discipline and so the

joint collaboration with PsySSA on important

professional matters was welcomed.

As always it was emphasised that membership needs

to rise in order for the CPF to fulfil its objectives.

By Prof Eddie Wolff TH

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THE ADVENT OF NEUROPSYCHOLOGICAL EVALUATION Science and especially Medical science, often reinvents itself. This necessity allows medical science to not only improve efficiency in the diagnosis and treatment of disease but also to broaden perspectives on health and disease. Developments in psychological science, especially in the last three decades, has allowed it not only to align itself more closely to medical science, but allowed it to contribute significantly to the under-standing and treatment of disease. The most significant of the developments in psychological science has been the exponential increase in the understanding of brain-behaviour relationships as well as the accuracy, validity and reliability of psychological assessment instruments. Psychological assessment now provides data with the description, explanation and prediction of behaviour at a level that equates with the best of medical science. The advent of psychological science’s ability to describe, explain and predict the nature and behavioural consequences of brain dysfunction and damage has proven it to an invaluable ally to neurology in the diagnosis, differential diagnosis, under-standing and treatment of neurological disorders. These disorders not only include the traditional disorders such as stroke, brain trauma, multiple sclerosis, dementing disorders and learning disabilities, but also the autoimmune deficiency syndromes (i.e. HIV-AIDS), multiple chemi-cal sensitivities, chronic fatigue syndrome, exposure to neurotoxins, and develop-mental disorders associated with neuro-toxicity transmitted by mothers during pregnancy.

With the “neuroscientific revolution” in psychiatry, diseases such as schizophrenia and autism, previously viewed from a perspective of “mental disorder” can now be assessed as neurobehavioral disorders with greater diagnostic and treatment accuracy. It is in these fields of endeavour that clinical neuropsychology and neuro-psychological assessment has the differential diagnostic, explanatory and predictive capability to be of marked value to neurological science. This improvement in the understanding, description, diagnosis and treatment of diseases in the psychiatric and other medical domains has in many instances lead to a “reconceptualization” of these diseases.¹ Reconceptualization of an illness occurs when an illness that has been observed for some time is found to have a different cause from what was previously accepted. The clinical phenomenology remains the same, but the conditions thought to produce the illness are often remarkably changed. Autism is probably the clearest example; where even as recent as the publication of the DSM IV (radically changed in the DSM V) the disease was described mostly in the original (psychoanalytic) terminology as initially provided by Leo Kanner. In this case autism has been completely reconceptual-ised as a neurobiological disorder produced by abnormal brain function and is probably genetically based. Thus we have the same disorder with an entirely changed basis. However, the nature of the brain dysfunction is not entirely accessible to neurological observation and neuro-imaging data, and the added information provided by neuropsychological assess-ment often leads to a conclusive diagnosis, affording quicker and more efficient management of the disease.²

M I N D M A T T E R S

P A G E 5

P A G E 6

M I N D M A T T E R S

continued …..

Another important reconceptualization is in the areas of dementia of the elderly. Until recently these dementias were considered to be produced by vascular disease, and that Alzheimer’s disease, a primarily neurodegenerative disorder, was a relatively rare condition. This view has been reversed and is now thought that Alzheimer’s disease is relatively common, and that vascular dementia is relatively rare. Although neuro-imaging-based differential diagnosis could be accurate, neuropsychological assessment could provide the data necessary to more clearly define the disease and lead to improved diagnostic accuracy and appropriate management. How can this be achieved by neuropsychological assessment? NEUROPSHYCHOLOGICAL EVALUATION AND NEUROLOGICAL DIAGNOSIS Neuropsychological evaluation typically provide data about a person’s neurocognitive and neuro-behavioural functioning that is QUANTIFIED and essential for: Diagnosis (e.g. mild cognitive impairment) Identification of the underlying neuro-

anatomical and neurophysiological processes for the findings.

Treatment planning and management.

Thus, the Neuropsychological report typically will: 1. Characterize cognitive and behavioural deficits

and strengths. These strengths and weaknesses would in-

clude, inter alia: Motor speed and coordination

- Attention, concentration and tracking - Speed of information processing - Visuoperceptual and visuoconstructurial

abilities Memory functions including:

- Verbal memory, consisting of: immediate ver-bal memory, delayed verbal memory, verbal recognition memory, verbal learning curve

- Visual memory, consisting of: immediate visu-al memory, delayed visual memory

- Working memory Speech and language functioning Exectutive functions, including:

- Cognitive flexibility - Planning, foresight and self monitoring - Abstract reasoning

General intellectual ability and premorbid intelligence

Adaptive behaviour, mood and personality factors.

2. Relate deficits to functional neuroanatomy,

neurophysiology and neural circuits;

3. Provide diagnostic considerations of the observed deficits.

The conclusion as to the presence or absence of neuropsychlogical deficits are based on measure-ment which requires comparison standards, such as: Comparison to specific (age, gender, occupa-

tion and educational status) population standards, or

Individual comparison standards (such as education, occupation and/or previous indicators of cognitive ability or reserve) wherein the degree of decline within the person could be established.

The “comparison standard” enhances the scientific accuracy of not only the assessment of deficits, but also the scientific accuracy of the diagnostic conceptualization of the disease. The diagnostic conceptualization of a specific neurological disease can be considered to constitute the following: Functional and proximal clustering of the

neuroanatomical substrate of the disease. Functional clustering of changes in the neuro-

anatomical substrate and its associated chemical functions

Functional clustering of the neuroanatomical substrate, changes in the neuroanatomical substrate and its associated chemical functions with the behavioural expression as symptoms.³

M I N D M A T T E R S

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E Neuropsychological evaluation includes the functional capacity to evaluate the above clusters not only clinically, but also statistically. In addition neuropsychological evaluation extends the “comparison standard” to not only include the clustering diagnostic conceptualization of a disease, but to also include estimations of premorbid functioning. Neuropsychological evaluation estimate premorbid ability by means of qualifying demographic variables (age, education level, occupational history) as well as performance at the time of the evaluation (current performance) on var-ious neuropsychological functions thought to be relatively resistant to effects of brain dysfunction and/or aging. By developing an individual comparison standard, the presence of neurocognitive or neurobehavioral deficits can be appreciated at the individual rather than the group level. If, for instance, a person shows neurocognitive functionality at the 25th percentile, has a 10th grade education, and is estimated to be functioning in the normal range (16th to the 84th percentile), no negative change would be inferred. However, if the person’s ability was estimated to be at the 90th percentile, a decline in neurocognitive function would be inferred from a neurocognitive functionality at the 25th percentile. In this way patterns of relative levels of neurocognitive deficit in a single individual could be inferred and a diagnostic model developed. SCIENTIFIC AND FUNCTIONAL VALUE Because the users of the neuropsychological evaluation is answerable to patients and ultimately responsible to provide scientifically accurate and valid diagnoses, treatment and management, the input of the neuropsychological opinion has to be of similar scientific and functional rigour. In addition to contributing essential information of cognitive and/or behavioural dysfunction that is required to make an accurate and scientific diagnosis, the neuropsychological evaluation has to provide necessary and sufficient information for the clinician as to:

Which treatment(s) would be the most effective Which management strategies would yield the

most efficacious outcomes Provide follow-up information with regard to

maintaining or change treatment regimens. Therefore the neuropsychological evaluation would provide evidence of the presence/absence of brain dysfunction, the degree of impairment, and relate this description to the patient’s functioning (i.e. the individual’s level of adjustment and how the individual’s needs for care and/or treatment /rehabilitation /educational programming may be affected). The evaluation conversely will also indicate how the neurocognitive and emotional functioning is likely to affect their ability to adhere to the treatment, interact with their physical and social environment, affect their treatment plan as well as their ability to make decisions, etc. Thus, while a diagnosis might be known, e.g. Parkinson’s dementia, the functional outcomes do not always depend on the neuroanatomical substrates but vary markedly from patient to patient depending on prior history, environmental conditions, cognitive reserve and the like. The neuropsychological evaluation must therefore also provide a rigorous scientific prediction as to the nature and intensity of management strategies that may be followed to adequately manage the patient. Examples of these are diagnostic, differential diagnostic and treatment/ rehabilitation considerations of: Arousal disorders in the disoriented, stuperous,

agitated or somnolent patient Attention and concentration disorders in the

distractible patient Aphasic disorders Memory disorders Visuospatial/ visuoconstructive skills and motor

praxis Frontal lobe/ executive functioning Dementias and mild cognitive impairment as well

as general cognitive aging Episodic neurological symptoms Epilepsy and seizures

P A G E 7

continued …..

P A G E 8

M I N D M A T T E R S

continued ….. Psychogenic nonepileptic seizures Movement disorders Multiple sclerosis and other demyelinating

disorders Moderate and severe traumatic brain injury Mild traumatic brain injury Sport-related concussion Post-concussion syndrome Paediatric traumatic brain injury Brain tumours Neurotoxicity Cognitive decline in childhood or young

adulthood Of interest is that neuropsychological evaluation could also provide diagnostic and differential diagnostic considerations in disorders not always the core focus of neurology, but for which neuro-logical consultation is often requested: Neuro-oncology Multiple systems atrophy, orthostatic hypoten-

sion and autonomic dysfunction and cognition Cardiovascular disease and neurocognitive

functioning The effects of respiratory disorders on

neurocognitive and brain functioning Cognitive dysfunction during migraine and

cluster headaches Rheumatologic conditions such as Sjögrens

syndrome, fibromyalgia and chronic fatigue syndrome

Neurocognitive and affective neuro-psychological aspects of cognition and depression in multiple sclerosis, Guillian-Barré syndrome and HIV-I infections

Neuropsychological functioning in endocrine diseases such as Type 1 and Type 2 Diabetes as well as endocrine disease associated with gonadotropic hormones and corticosteroids

Metabolic diseases such as encephalopathy, and encephalopathy associated with toxic disorders as well as mitochondrial disorder.

In the latter group of conditions the neurological consult can often be complemented by a neuro-psychological evaluation. Other more specific examples, but not exhaustively so, show that the neuropsychological

evaluation can provide, in addition to general neurocognitive information, the following: Neuropsychological evaluations can predict

cognitive outcomes from temporal lobectomy.⁴ Neuropsychological evaluation can contribute

significantly to identifying the laterality of seizure focus.⁵

It can, similarly predict quite accurately the likelihood that a patient will be seizure free following temporal lobectomy.⁵

Neuropsychological data can provide unique predictive value to distinguish patients with relapsing remitting multiple sclerosis from patients with secondary progressive multiple sclerosis.⁶

In fact, neuropsychological evaluation results have provided predictive value beyond other neuroimaging and clinical variables to identify those individuals at risk for cognitive decline over time, as well as disease progression, across a variety of medical conditions such as epilepsy, multiple sclerosis, Parkinson’s disease and mild cognitive impairment.⁷

Neuropsychological evaluation could also provide specific information on what treatment-, neurorehabilative- and/or edu-cational programmes be suggested for the patient not referred for comprehensive neuro-logical rehabilitation, but definitely in need of complementary management.

The abundance of “brain training” programs especially on the internet, attest to that. Recent analyses of these programs by the NIH in the USA show that most of them have no impact beyond that of placebo. It is therefore necessary that the neuropsychological evaluation also provide the clinician with relevant information as to the best possible neurocognitive rehabilitation programmes. CONCLUSION It is clear, from the above, that psychological science has progressed from providing “cognitive testing” services to providing a far more comprehensive service to neurology. In fact, it is fast changing from a “nice to have but not totally necessary” to an essential part of the comprehen-sive neurological practice.

P A G E 9

REFERENCES Amstrong CL and Morrow L (Eds): Handbook of Medical Neuropsycholo-gy: Applications of Cognitive Neuro-cience. Springer, New York, 2012 Schoenberg M and Scott JG (Eds): The little Black Book of Neuropsychology: A Syndrome-Based Approach. Springer, New York, 2011

Seidenberg M, Pulsipher and Hermann B: Cognitive progression in epilepsy. Neuropsychology Review, 17(4), 445-454, 2007

Lineweaver TT, Morris HH, Naugle SR,

Najm IM, Diehl B and Bingham W: Evalu-ating the contributions of state-of-the-art assessment techniques to predicting memory outcome after unilateral tem-poral lobectomy. Epilepsia 47(11), 1895-1903, 2006

Drane DL, Lee GP, Cech H, Huthwaite JS and Ojemann GA et.al: Structured cueing on a semantic fluency task differentiates patients with temporal versus frontal lobe seizure onset. Epilepsy and Behavior, 9, 339-344, 2006

Chelune GJ, Evidence-based practice and research in clinical neuro-psychology. The clinical Neuro-psychologist, 24, 454-467, 2010

Fleisher AS, Sun S, Taylor C, Ward CP, Gamst AC, Petersen RC, et.al: Volumetric MRI versus clinical predictors of Alzheimer’s disease in mild cognitive impairment. Neurology, 70, 191-199, 2008 This article was originally published in the recent edition of Neuron SA, and is reproduced with the kind permission of Professor Wolff.

continued …..

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