|Year : 2016 | Volume
| Issue : 1 | Page : 20-24
Course of development of neuropsychology in northern india: past, present, and possible future
Ashima Nehra1, Dwarka Pershad2, Sakshi Chopra1
1 Department of Clinical Neuropsychology, All Institute of Medical Sciences, New Delhi, India
2 Department of Neurology, PGIMER, Chandigarh, India
|Date of Web Publication||10-May-2016|
Department of Clinical Neuropsychology, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Nehra A, Pershad D, Chopra S. Course of development of neuropsychology in northern india: past, present, and possible future. J Mental Health Hum Behav 2016;21:20-4
|How to cite this URL:|
Nehra A, Pershad D, Chopra S. Course of development of neuropsychology in northern india: past, present, and possible future. J Mental Health Hum Behav [serial online] 2016 [cited 2020 Feb 16];21:20-4. Available from: http://www.jmhhb.org/text.asp?2016/21/1/20/182087
Neuropsychology refers to the study of brain behavior. Each psychological functioning such as cognitive, conative, and affective mediates through central nervous system and brain. The processes included in responding to a stimulus are a reception, perception, consolidation, and execution. Therefore, impairment of any of these processes may mark difficulty in the responses.
In general, in the clinical sense, organic brain pathology refers to the pathological condition arising from structural, toxic and/or metabolic defects of the brain and manifesting in the form of impairment of orientation, memory, comprehension, calculation, learning capacity, and judgment. There may also be disturbances of mood, lowering of ethical standards and exaggeration or emergence of personality traits and diminished capacity for independent decision. Thus, following changes may associate with brain pathology:
- Decline in intelligence; more in fluid intelligence
- Disturbance in memory; more in new learning, old memory may follow Ribot's law
- Decline in ethical standards; more so lifting social/libidinal inhibition
- Changes in personality traits
- Alogia, poor logic and disturbance in connection of stream of thought
- Acalculia, difficulty in simple addition and subtraction.
In general, a decline in cognitive capacity poses as a bigger handicap for a person with brain pathology. His earning and decision-making capacities declines and personal activities of daily living impairs, depending upon the nature and degree of brain pathology.
| Brain-Behavior Assessment in Neuropsychology|| |
The use of the term will largely depend upon the purpose for which one is concerned, and the discipline one is professing. As an applied psychologist, largely, and brain-behavior researches are concerned with psychiatric disorders including diagnosis, management, and training for rehabilitation. Following three, terms are more popular in behavioral sciences.
- Neuropsychological test batteries
- Cognitive assessment
- Cognitive Psychiatry.
Neuropsychological test batteries are based on the assumption that the brain has differential functions, and different structures of the brain are responsible for different functions. Morgan  has probably rightly stated “we find it natural to say that people are different in the measurement of personality, intelligence, or some other aspects of the behavior, but we often seem to assume that the brains are standard product tinned out on an assembly line so that they look like as much alike as new cars.” The fact is that brains vary a lot in their size, shape, and function. These test batteries ignore the brain mechanism such as adaptability, equipotentiality, and compensatory. These batteries are time-consuming and good for theoretical research purpose than for practical purposes. Central Institute of Psychiatry, Ranchi and Ranchi Institute of Neuro Psychiatry and Allied Sciences, Ranchi are working on Luria-Nebraska Neuropsychological Batteries now for the last About 25 years and encouraging doctoral research work on this tool. There is also work going on for developing an Indian Aphasia Battery, which is one of the colloquial Hindi tool for the differential diagnosis of aphasia.
Cognitive assessments are based on practical aspects of behavior, including the validated concept of intelligence, memory attention, and concentration PGI Battery of Brain Dysfunction uses this concept. Authors reviewed the literature from 1974 to 1988 and revised it in 2007 to find out what psychological parameters are assessed to describe cognitive dysfunctions in various conditions such as head injury cases, epilepsy, cannabis abuse, gases inhalation, and long-term use of lithium. These studies have used intelligence tests, memory tests, perceptuomotor function tests, and NIMHANS battery.,
Cognitive psychiatry is another term mentioned by Dalal and Sivakumar  who said that cognitive researches had huge potentials in India and can help us to unravel mysteries of the human mind. They presented web-based review accessed through Google scholars and PubMed search from 1980 onward tracing beginning of cognitive psychiatry in India. Authors based on their review concluded that cognitive abilities are assessed in wide varieties of psychiatric diagnostic disorders. The first study in India was on the effect of electroconvulsive therapy on intelligence and memory in schizophrenic patients.
To sketch the history of assessment of brain-behavior researches it will not be out of place to remember the name of Fechner  who published voluminous treaties on “Psychophysics.” Two point's threshold experiments in experimental psychology are still popular in psychological experiments. The systematic studies on behavior in India, however, could not be thought of until the program was integrated in the university departments. Even the departments of psychology alone cannot demonstrate the utility of brain-behavior researches without clinical psychology with practicum. Therefore, it is important to trace the history of psychology and clinical psychology in India.
Why do we need a neuropsychological test battery for clinical use?
All comprehensive neuropsychological test batteries developed abroad or in India are focusing on the localization of the lesion. This is probably a concept from Luria-Nebraska  or Halstead–Reitan Test Batteries  that were developed before the invent of radio diagnostic procedures such as:
- Computerized axial tomography
- Magnetic resonance imaging
- Positron emission tomography etc.
At that time, psychological procedures were considered a noninvasive (nontraumatic) procedure of getting an idea about the site of brain lesion. Neuropsychological procedures had a significant role in the assessment of neurological and psychiatric cases.
Now the scenario has changed. The cognitive test batteries are more useful in assessing cognitive deficit or deterioration in psychological functioning for compensation in the roadside accident cases, to understand the course of chronic mental illnesses, and to study the outcome for rehabilitation/cognitive training.
| Approaches for Assessment of Brain Pathology|| |
There are two main approaches: As described in [Table 1]
- Multifactorial approach
- Unitary approach.
Need for assessment
Scientific advancement, psycho-social, political, and cultural development may make the advent of the past only a matter of historical significance not of practical utility in the present era. This philosophy may also be applied with regard to the assessment of the brain pathology through psychological tests. There was a time when a suggestion for brain pathology was required from the psychological testing procedures. Now psychological testing is not required for the evidence of brain pathology rather testing is required for cognitive/brain dysfunction. Neuropsychological testing has now become an important ancillary procedure to neurological diagnostic evaluations. They rarely consider the results of such psychological testing sufficient to make diagnosis, but their role has increased in the understanding of the patients for total management for providing rehabilitatory measures. Cognitive dysfunction is currently used for the following purposes:
- Extent and nature of cognitive dysfunction for planning cognitive training
- For planning home based training for the patient and counseling for the family
- Helping family members to develop insight into the illness, prognosis, and outcome
- Collecting evidence for suggesting costly investigation
- To evaluate the effect of therapeutic processes
- To assist judiciary to decide quantum of compensation after roadside accident or trauma
- To evaluate extend of dysfunction for certification of disability for state benefits.
Misconception of brain-behavior
Some of the misconceptions about brain behavior are that all brain pathologies can be quantified, or are demonstrable on the available clinical investigation, or brain pathology can cause fall in behaviors, and also, most importantly, the assumption of normalcy in intelligence/memory/behavior/ethical standard premorbidly.
| Development of Psychology in India|| |
In India, history of development of psychology is about 100 years old and development of clinical psychology is about 50 years old, as under:
- 1906: Calcutta University introduced experimental psychology in philosophy
- 1916: Calcutta University established Department of Psychology
- 1925: Indian Psychological Association was formed
- 1947: Indian Psychiatric Society became independent
- 1956: Two years post-MA in clinical psychology started at NIMHANS, Bangalore
- 1962: Post-MA course started at CIP, Kanke; Ranchi
- 1968: Indian Association of Clinical Psychology (IACP) formed
- 1974: Indian Journal of Clinical Psychology started from Chandigarh
- 1993: Rehabilitation Council of India (RCI)-Act promulgated
- 1995: RCI started monitoring standard and objectivity in clinical psychology.
| History of Development of Cognitive/neuropsychological Tests|| |
The test batteries which are most widely used in India are presented below in their chronological order of development:
- PGI Battery of Brain Dysfunction 
- All India Institute of Medical Sciences (AIIMS) comprehensive neuropsychological battery in Hindi-adult Form 
- NIMHANS Neuropsychology Battery 
- NIMHANS neuropsychological battery for children.
These batteries were developed working with psychiatric and neurological patients in India.
The development of the tools took more than a decade in each case. The funds were made available from different funding agencies in India for the development and conduct of standardization process. Each of the battery has used the name of the institute where these were developed and standardized. Except for PGI Battery, other two are a time-consuming process, and there are no shortcuts.
There are other batteries which are coming up from India, which would be beneficial in terms of newer population norms, robust than the previous ones, and also, which would be culture and education free.
| Testing Procedures Developed in India|| |
A number of psychological tests batteries have been developed/standardized in India using the concept of dysfunction. A few of them are based on the well-established concept of higher brain functions such as functioning intelligence, estimation of past intelligence, memory functioning, and perceptual acuity. Others are based on neurological examinations and follows the evaluation of the functioning of hemisphere and lobes., Some of the significant test batteries published during the last about two decades in India are given below:
PGI Battery of brain dysfunction 
This battery includes five tests, i.e. Bhatia's Short Scale, Verbal Adult Intelligence Scale, PGI Memory Scale, Bender Visual Motor Gestalt Test and Nahor Benson Test of Perceptual Acuity. Norms are developed for 20–50 years age group; following factorial sampling design of 2*3*5 (two levels of sex, three levels of education and five levels of age). It gives global rating of cognitive dysfunction based on 19 test variables and estimates well-accepted/validated psychological concepts of (a) intelligence, (b) memory, and (c) gestalt formation or perceptual acuity. It provides a profile of current cognitive functioning of the subject.
All India Institute of Medical Sciences comprehensive neuropsychological battery in Hindi (adult form)
This comprehensive tests battery is largely based on Luria-Nebraska Neuropsychological Battery and potentially useful for both diagnosis and rehabilitation. It consists of 13 basic scales-Motor Scale, Tactile Scale, Visual Scale, Receptive Speech Scale, Expressive Speech Scale, Reading Scale, Writing Scale, Arithmetic Scale, Memory Scale, Intellectual Processes Scale, Left Hemisphere Scale, Right Hemisphere Scale, Pathognomonic Scale, and Total Score Scale. It consists of 160 items. It is claimed that it is an ideal psychological instrument for clinical and research settings facilitating identification, lateralization, and localization of brain lesions, in the subjects from 15 to 80 years of age.
A Comprehensive Neuro-Psychological Battery was also developed for children between the ages 8–14 by the same author.
NIMHANS neuropsychology battery 
There are 19 tests in all, which measures 15 functions, in seven neuropsychological domains such as Speed, Attention, Executive functions, Comprehension, Verbal learning and memory, Visuospatial construction, and Visual learning and memory. The subtests used in the battery include, (a) finger tapping test (b) digit symbol substitution (c) color trails (d) digit vigilance (e) triads test (f) controlled oral word test (g) association test (h) animal names test (i) design fluency test (j) n back test (verbal and visual) (k) self-ordered pointing test (l) tower of London Test (m) Wisconsin Card Sorting Test (n) Stroop Test (o) Token Test (p) Auditory Verbal Learning Test (q) Passages Test (r) Complex Figure Test and (s) Design Learning Test. Normative data has been established for adults in the age range of 16–65 years following a factorial sampling design.
NIMHANS neuropsychology battery for children 
This battery is for the children in the age range of 5–15 years. There are a total of 28 areas which are covered in the battery which includes intelligence, motor speed, motor coordination, attention, expressive speech, verbal fluency, design fluency, working memory, visuospatial working memory, planning, set shifting, motivation, behavior change, visuoperceptual ability, visuoconceptual ability, visual recognition, apraxia, somatosensory perception, reading, writing, calculation, verbal comprehension, verbal learning, visual learning, and memory.
Measurement of organic brain dysfunction ,,
This test battery is not published and the material required is not available. This battery was published as a research article. Thus, it is not in use.
| Tests of Unitary Functions|| |
There are a number of other simple, internationally well-known and popular tests, widely used in India for research purposes and a quick clinical impression. These tests are assessing the unitary function of the brain and gives impression about the specific lesions in the brain or the parietooccipital region in general. Tests that are frequently used in India for the diagnostic profile of organic brain dysfunctions include-Wechsler's Intelligence Scale (both verbal and performance tests), PGI Memory Scale, Wechsler's Memory Scale, etc. Other tests of unitary functions include Bender Visual Motor Gestalt Test, Benton Visual Retention Test, Nahor and Benson Test of Organicity, Stroop Color and Word Test, Trail Making Test, Wisconsin Card Sorting Test, N-Back Tests, Tower of London, digit symbol substitution, complex figure test, etc.
No one can answer as to which method/test needs to be preferred in clinical practice. It all depends upon the purpose in hand and the time available to the clinician for the evaluation. One thing is sure that before using any of the assessment tests/tools, one should have undergone some training under supervision to have workable confidence.
| Current Status of Education in Neuropsychology/clinical Psychology in North India|| |
In North India, pioneering research and medical institutes like PGIMER Chandigarh, AIIMS, and Institute of Human Behaviour and Allied Sciences (IHBAS) are doing a lot of work in the field of clinical psychology, and Neuropsychology. M. Phil is not taught in PGI Chandigarh and AIIMS, but PhD is offered in Clinical Neuropsychology in AIIMS. Other institutions offer PhD in Clinical psychology.
In PGIMER Chandigarh, Clinical Psychology was started by two stalwarts in the field - Dr. S.K. Verma and Dr. Dwarka Pershad. They both had Diplomas in Medical and Social Psychology from Ranchi and completed their PhD's in clinical psychology. They both rose to faculty positions and developed many psychological tests which got national and international recognition. PGI Neuroticism Scale, PGI Memory Scale, PGI Battery of Brain Dysfunction, Personality Trial Inventory, PGI Health Questionnaire, Quality of Life Scale, etc., to name a few of the tests and batteries developed by them. Later, the Late Dr. Anil Malhotra joined the department after completing his DM and SP and PhD from NIMHANS, Bangalore. These three stalwarts trained a number of research scientists under their careful supervision. They were Dr. D.K. Menon (Later become Director NIMH, Secunderabad), Dr. Manju Mehta (Ex-President IACP), Dr. Adarsh Kohli, Dr. Karobi Das, Dr. Ritu Nehra and Dr. Ashima Nehra. All these scientists have contributed in the field of Clinical Psychology and Neuropsychology by developing many new tests and actively participating in therapeutic work.
AIIMS is aggressively pursuing work on cognitive assessment and development of neuropsychological test batteries. The main purpose is to provide a quick and usable instrument to the clinician for clinical and research purposes. Neuropsychology has to be a super specialty of Clinical Psychology and hence, the training and education also have to be specialized. Clinical Neuropsychology is an interdisciplinary field which is a part of neurology, psychiatry, neurosurgery and other related medical fields. As it is interlinked, working with these professionals in a bio-psycho-social model is essential. However, it is quite unique and distinct from all these fields in its assessments. For example, the neuropsychological evaluation diagnoses dementia and its stage (which cannot be done by a Neurologist). It can only be done through detailed neuropsychological assessment of the patient, to also rule out dementia mimics. PhD in Clinical Neuropsychology has been initiated since 2013, with an integrated academic program. Since there is no recognition of Clinical Neuropsychology in India yet and even RCI does not give any certification to Neuropsychologists. Hence, the present academic program in Clinical Neuropsychology at AIIMS is prepared on the basis of International Standards.
IHBAS, which was established in 1993, has regular M. Phil and PhD programs in the field of clinical psychology. Other institutes like Institute of Mental Health and Hospital, Agra and Government Medical College and Hospital, Chandigarh also have M. Phil programs to train clinical psychologists, but none of them have a specialized training program for Clinical Neuropsychology. Currently, this super-specialization which is taught at the M. Phil level by just a 3 month posting in neuropsychology is being taught only by NIMHANS, Bangalore, and AIIMS, New Delhi at the doctoral level.
| What Could Be the Reason for Slow Growth of Clinical Psychology/neuropsychology in India?|| |
Notwithstanding any of the noble intensions, lack of knowledge of how professional courses are run or ought to have run, seem to be the most important reason for failure of these endeavors. The fee structure, student strength, the university policies/priorities, distance/location etc., did not appear all that relevant in the casual analysis of this sort of debacle. The heads of these courses meant no ill when they floated these professional courses in their respective institutes/universities. What they did not care for or pay attention to, however, is the building up of the most crucial infrastructure to impart hands-on clinical experience. Most of the university professors having no relevant clinical degrees themselves failed to appreciate the importance and requirement of a vast variety of clinical material essential for a generic training in professional applied psychology, in whatever discipline. Curriculum transactions were weighted more toward theory/classroom teaching than problem-oriented, solution-focused hands-on training. For these reasons, the courses run at the university departments without real-life practical experience and/or training are not recognized by the RCI as sufficient professional qualification for licensing/registering. However, institutes in Northern India such as AIIMS, New Delhi, Postgraduate Institute (PGIMER) Chandigarh, which are actively involved in clinical and research in the area of Clinical and Neuropsychology, which includes teaching of postgraduate students of clinical/applied psychology, ongoing researches in different fields of psychology, and undertaking a doctoral thesis. However, unfortunately, these institutes do not have RCI recognition till date.
| Future Directions|| |
Clinical psychology and Neuropsychology are areas which have a lot of scope in India. While Clinical psychology has grown a lot overall over the country, Neuropsychology is still at its crossroads. Because of gaps in the education and clinical setups, there is an urgent need to finalize guidelines for the upcoming students and specialists in this field so that there is a fixed format for imparting education which includes theoretical and practical training. There should be a trained faculty at all the institutes offering M. Phil or PhDs in Neurosciences. The governing bodies should take into account the availability of trained professionals for providing education and training. It should also keep a check on the accredited institution to ensure that they are following the laid guidelines for academic curriculum and training to be provided, and they are also maintaining the prerequisite resources to carry out the course. This would also help in bridging the gap between inconsistencies of the present education setup where there are still no clear-cut directions for students whether M. Phil should be done before PhD if there is a specialization in Clinical Neuropsychology. Even RCI does not recognize this specialty, so a body needs to be formed which would be a National body for registering all Clinical Neuropsychologists. There is also a need for all institutions who give education and training in Clinical Neuropsychology, to follow an integrated training program in accordance to a gold standard formed by professionals in this area.
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