1. A Brief Overview of Memory:
Classification
And Neurcognitive Testing
Craig Goodman, Ph.D.
Lev HaSharon Mental
Health Center, Israel

2. Objectives:
1. Review functional
classification of memory
2. Review evaluation of
memory and
Neuroconitive Testing
3. Cognitive Inpairments in
Schizophrenia
Memory

3. Defining “Information Processing”
Also called “Cognition” or “Neurocognition
Ability to recognize and process information
in order to carry out complex tasks
adequately
Broad Term- Encompassing memory,
attention, sequencing/planning, General
Intelligence, visuo-motor skills
Brain Structures mainly involved -frontal,
temporal, basal ganglia

4. Types of Information Processing
Deficits
GLOBAL DEFICITS
General Intelligence
Measured by IQ Tests-IQ does not decline with
age
Leads to Global Assumptions
Deficit fails to prevent the individuals ability to
acquire, retain or relearn new skills

5. Specific Deficits
MEMORY
Short Term/Working Memory
Verbal- Acquisition of verbal material
Visual- same for visual material
Poorer verbal and spatial memory
Frontal lobes main modulator of WM-may be
related to reduced blood flow to this area
working memory capacity underlies general
intelligence

6. What is Working Memory?
Active Memory Approach - Modern Perspective
- working memory is not static, is not a place
- working memory is information that is activated in
long-term memory
- incoming information is “repackaged”
- connections are made between incoming
information and other information already storedActive
Processes

7. Long term Memory
Ability to hold information over longer time
period-hrs,days,years
Problems seen specifically with recalling
previous events
Memory deficits present in first episode and un
medicated individuals

8. From: Tasman, Psychiatry, 1st ed.

10. Executive Function
Ability to plan and carry out goal
directed behavior
Solving puzzles main
neuropsychological assessment tool
Performance does not improve after
explicit instructions

11. Attention
One of the oldest documented
problems dating back to Kraeplin 1919
Often difficulties remaining vigilant
and not getting distracted
-Dopamine theory
(performance on Neurocognitive
Tests)

12. 17
Working Memory: Baddeley’s Model
The Central Executive
(Supervisory Attentional System )
(central pool of limited resources)
Visual-Spatial “Scratch Pad”
Control and decision processes - allocates
between sensory representations
Reasoning, language comprehension
Transfer information to long-term memory
via rehearsal, recodingRecency effects
Articulatory Rehearsal Loop
(“short-term buffer”)
Recycling items for immediate recall
Articulatory processes
Inner Ear / Inner Voice
Visual imagery tasks
Executive’s resources are drained if
imagery task is difficult

14. Brain areas involved in WM?

15. Perception
and memory
Sensory inputs
Arousal
Selective
attention
Working
Memory
Association
cortex
Hippocampus
Consolidation
Storage
Thalamus

16. Emotional
encoding
Cingulate
Emotional
experience
Amygdala
Emotion
expressionEndocrine Autonomic
Hypothalamus
Sensory inputs
Arousal
Selective
attention
Working
Memory
Hippocampus
Consolidation
Storage
Association
cortex
Thalamus

17. 9
What is the capacity of Working Memory?
Digit Span Test: (Verbal Working Memory)
5 7 9
7 1 8 3
8 3 4 6 9
0 2 5 1 9 8
0 2 5 3 2 8 1
8 3 1 2 7 9 0 4

18. What is the capacity of working memory?
Digit Span Test Results:
Amount recalled = memory span
People on average can recall “7 plus-or-minus 2” items

19. VisuospatialScratch Pad: Summary
• Evidence shows that there is a distinct visual subcomponent to
working memory.
- dual tasks
- neuroimaging studies show different sites in brain activated for
verbal versus spatial tasks
• Functions to allow us to maintain and manipulate visual and
spatial images.
- planning and executing spatial tasks
- tracking objects in our environment

20. Central Executive:Evidence Continued
3. Damage in prefrontal cortex
- neuroimaging studies show prefrontal cortex is active with tasks that
make heavy use of central executive.
- people with prefrontal cortex damage are unable to plan and inhibit
their impulses.

21. Malfunction of the WM system can be
logically perceived to cause impairment of:
• goal oriented behavior
• disorganized cognition - cognitive
organization
• failure of self-monitoring and other
manifestations cognitive dysfunction.

22. Examination of Memory
Short-term: 3 object registration and 3-minute recall.
-warn the patient, have them repeat the words
-attend them in the delay to prevent rehearsal
-if dysphasic, hide 3 objects
Long-term: Name the last 5 PMs or Presidents
-personal history is helpful for specific areas
-present objects and ask what they are used for
2. Test immediate, short-, and long-term memory.
3. Be aware of other localizing findings.
eg. personality change in Huntington’s, sensory
extinction incortical disorder, primitive reflexes, etc.

23. Examination of Memory
BRIEF MEMORY TEST
1. MMSE and MSE
2. 5-7 forward digits
3. 3 minute 3 object recall
4. 5 Prime-Ministers
5. Neurocognitive exam to
localize other findings

24. Example of Typical Cognitive Battery
•Digit Span Test
•Digit Symbol Test
•Rey-Osterrieth Complex Figure Test
•Trail Making Tests
•Rey Auditory Verbal Memory Test
•Beck Depression Inventory
•Finger Tapping

25. Digit Span - Derived from the
Wechsler Adult Intelligence Scales
(Verbal Subtest)
Purpose:
to evaluate ability to repeat digits
forward and backward
measure of attentiveness
immediate recall
working memory capacity

26. Digit Symbol Test - Derived from the
Wechsler Adult Intelligence Scales
(Performance Subtest)
Purpose: visual-motor task - measures subjects
ability to match symbols with numbers according
to a code, assesses speed and visual perception.

27. Digit Symbol Test

28. Rey-Osterrieth Complex Figure Test
Purpose: permits assessment of several
cognitive processes including;
Visuospatial Abilities Memory
Planning, Organizational and
Constructional Skills (executive function)
Problem-Solving
Strategies
Perceptual Visuomotor Skills

29. Rey-Osterrieth Complex Figure

30. Trail Making Tests - Form A and Form B
Purpose: Tests of speed for attention, sequencing, mental
flexibility, visual search, and motor function, and
executive function
Form A
Screens for impairment in attentional (“focused mental processing
speed”), visuo-spatial sequencing, rapid visual search processes/visuo-
motor scanning factor (visuomotor speed ), numeric sequencing and
Identifies frontal lobe dysfunction.
Form B
Higher difficulty level of contextual and procedural memory, cognitive
demands include visual scanning, visual-motor coordination and visual-
spatial ability adequate enough to understand on an on-going basis the
alternating pattern of numbers and letters. Test screens for an inability to
execute and modify a plan of action dysfunction of dopaminergic function
in the frontal lobes, and focal frontal lesions

31. Trail Making Form A

32. Trail Making Form A

33. Trail Making Form B

34. Trail Making Form B

35. Rey Auditory Verbal Memory Test
Purpose: immediate and delayed recall,
learning rate, recognition, interference,
and primacy
and recency effects.
Total Learning (Trials 1-5) Score = (Norm = 46)*
Interference (Trials 6 and & 7) Score = 3 (Norm = 14)*
Delayed Recall (Trial 8) Score = 2 (Norm = 9)*
Recognition (Trial 9) Score = 3 (Norm = 13)*
Screens for impairment of learning, susceptibility to
interference, impairment of memory and recall – may
suggest prefrontal dysfunction.
(Norms: Ages 60-69) *

36. Rey Auditory Verbal Memory Test

37. Rey Auditory Verbal Memory Test

38. Beck Depression Inventory
Purpose: to assess depression
Finger Tapping
Purpose: evaluates visual-motor coordination and
dexterity
Performance in visuo-motoric coordination possibly
indicative of damage to frontal-parietal cortical
pathways.

39. Schizophrenia
Are Characterized by:
 Related Neurocognitive Impairments
 Neuroanatomical and Neurochemical
Abnormalities

40. Cognitive
Working memory
Selective attention
Positive symptoms
Hallucinations
Delusions
Loose associations
Negative symptoms
Avolition
anhedonia
anergia
asociality
alogia
Symptoms of
schizophrenia

41. History and Current Views
Kraepelin’s Views
Emil Kraepelin , a German psychiatrist who
believed defining feature of madness was a
deterioration over time.
He called condition, Dementia Praecox
(premature dementia), citing that it
primarily affected the young, and aged them
before their time.
By the 20th century, this became the
prevailing theory of madness.
“Dementia praecox” (premature deterioration)
- Early onset
- Deterioration
- Poor prognosis

42. Neurocognitive Symptoms
 Poor attention
 Memory impairment
 Poor working memory
 “Executive functions”
 Poor visuo-motor coordination
 Impaired perception of emotion

43. It has been established in the literature that:
• Insight into illness and attitudes towards
medications among schizophrenia patients are
important determinants of clinical outcomes
(Amador et al., 1994).
• Noncompliance and poor medication
adherence in schizophrenia patients is common
and negatively impacts outcomes (Awad, 1993).
• Studies have reported non-adherence rates
ranging from 26% (Drake et al. 1989) to as high
as 73% (Razali and Yahya, 1995), using various
measures of adherence.

44. Findings Continued:
Several studies have reported that a poor level
of insight was a strong predictor of poor
medication adherence (Amador et al., 1994;
Awad, 1993).
• Several reports have correlated schizophrenia
patients’ early subjective response to anti-
psychotics with a less favorable outcome of
treatment (Awad, 1993).
• Few studies examine relationships between
attitudes towards their medications and
cognitive impairment, and present conflicting
data (Jeste et al., 2003).

45. Goodman C, Knoll G, Isakov V, Silver H. Insight Into Illness in
Schizophrenia. Comprehensive Psychiatry. 2005 Volume 46, Issue 4,
(July-August ):284-290.
Goodman C, Knoll G, Isakov V, Silver H. Negative attitude towards
medication is associated with working memory impairment in
schizophrenia patients. Int Clin Psychopharmacol. 2005 Mar;20(2):93-
96.
Both patient groups were impaired in cognitive
performance, consistent with widely reported
cognitive dysfunction in schizophrenia
Schizophrenia patients with positive attitudes towards medication
performed significantly better than those with negative attitudes on
tests of:
• verbal and visual working memory
(digit span forwards and backwards)
•inhibition
•overall mental status (Mini Mental State Exam)
There were no differences in age, education, hospitalizations, or clinical symptoms between
the groups.

46. 0
5
10
15
20
25
30
Digit Span
Forward
Digit Span
Backward
Mini Mental
State Exam
Object
Memory-
Delay
Penn
Inhibition
Test
Differences in Neurocognitive Performance among
Schizophrenia Patients with and without Negative Drug
Attitudes
Positive Attitude Negative Attitude

47. In agreement with our findings:
Jeste et al. (2003) reported that cognitive functions,
especially working memory and attention measured
by the Digit Span Task, were the strongest patient-
related predictors of the ability to manage
medications.
Likewise, our finding that patients with positive drug
attitudes performed better on the MMSE was
consistent with Patterson et al. (2002) who reported
that better medication management was related to
enhanced cognitive performance on the MMSE
Discussion

48. This suggests that:
• Negative drug attitude may be related to
impaired online storage of information and hence
poorer ability to learn and subsequently store
information relevant to drug treatment.
• This finding is consistent with the postulated
central role of working memory dysfunction in
impairment of goal oriented behavior,
disorganized cognition, failure of self-monitoring
and other phenotypic manifestations of
schizophrenia (Silver et al., 2003).

49. What does all this mean?
Working memory impairment may influence:
 retention of relevant information
 limit the ability to learn
 influence knowledge about the effects or
benefit of medication, as well as other
illness features, and the patient’s subjective
attitude towards treatment.

50. Conclusion
Neurocognitive impairments are
diverse and greatly effect a person’s
daily functioning. It is important to
properly diagnose any cognitive
impairments to better understand and
effectively treat patients. This calls
for an awareness and knowledge of
cognitive disorders and appropriate
testing/screening.