The assessment and treatment of concerns and anxiety in patients undergoing presurgical monitoring for epilepsy.

PURPOSE: This study investigated the impact of a treatment information package on patients being monitored for possible surgical treatment for temporal lobe epilepsy. METHODS: One hundred patients were randomly assigned to either a high- or low-information preparation condition. Levels of anxiety were tested soon after admission by using the Hospital Anxiety and Depression Scale (HADS), The State-Trait Anxiety Inventory (STAI), and a newly devised questionnaire to assess specific concerns and anxieties of epilepsy patients presenting for monitoring and surgery, the Concerns About Epilepsy Monitoring Questionnaire (CAEMQ). Dispositional desire for information was assessed by the Miller Behavioural Style Scale (MBSS) to investigate whether coping disposition affected coping styles in the hospital setting. Patients assigned to the high-information condition were exposed to an intervention package, which included viewing a video depicting two separate interviews with patients who had undergone surgery as well as an information package, which described the various tests that the patient would undergo in the course of the monitoring procedure. Patients assigned to the low-information group were given information that the hospital provided to all patients in their care. All subjects were then retested on anxiety levels a few days later. RESULTS: Those in the high-information group showed a significant decrease in anxiety and depression levels compared with those in the low-information group. CONCLUSIONS: Within the main findings, an effect of dispositional style was found. Identification as either a monitor or blunter on the MBSS showed different coping strategies on arrival in hospital as measured by the CAEMQ, indicating that the level of information given to patients with epilepsy on arrival needs to be mediated by awareness of these two dispositional styles so that they obtain maximal benefit from the information to which patients with epilepsy are exposed.

Predictors of change in the neuropsychological profiles of children with type 1 diabetes 2 years after disease onset.

OBJECTIVE: To identify type 1 diabetes-related predictors of change in the neuropsychological profiles of children over the first 2 years of the illness. RESEARCH DESIGN AND METHODS: Children (n = 116) aged 3-14 years were assessed soon after diagnosis and re-evaluated 2 years later to examine relationships between illness variables, such as age of onset and metabolic control history, and changes in neuropsychological status over the first 2 years of type 1 diabetes. RESULTS: Illness variables were significant predictors of change in neuropsychological test scores within 2 years of onset of type 1 diabetes. Age of onset of type 1 diabetes predicted negative change on Performance Intelligence Quotient, whereas both recurrent severe hypoglycemia and chronic hyperglycemia were associated with reduced memory and learning capacity. CONCLUSIONS: These results suggest that the relationship between metabolic control and neuropsychological risk is nonlinear in that children with either recurrent severe hypoglycemia or chronically elevated blood sugars exhibit negative changes in their neuropsychological profiles. Onset of type 1 diabetes very early in life adds another dimension of risk, particularly affecting the acquisition of visuospatial skills.

Neuropsychological complications of IDDM in children 2 years after disease onset.

OBJECTIVE: To compare the neuropsychological profiles of children with IDDM with a community control group at two time points: 3 months after disease onset and 2 years after the baseline assessment. RESEARCH DESIGN AND METHODS: A total of 123 children (age 3-14 years) with recent IDDM onset were compared with 129 community control subjects, stratified for age and sex, on standardized measures of general intelligence, attention, speed of processing, memory, learning, executive skills, and behavioral adjustment soon after diagnosis and 2 years later. Exclusion criteria were premorbid evidence of central nervous system disease or trauma, or English not spoken in the home. RESULTS: There were no differences between children with IDDM and control subjects on any measure at the initial assessment 3 months after disease onset. Two years later, children with IDDM tended to show a less positive change, relative to control subjects, in their standardized scores on measures of general intelligence, and significantly so on the vocabulary (P < 0.01) and block design (P < 0.05) subtests. Multivariate group differences were also apparent on speed of processing (P < 0.05) and learning (P < 0.01) subtests, reflecting smaller developmental gains in the children with IDDM when compared with control subjects. CONCLUSIONS: The findings are consistent with previous reports, suggesting that IDDM is associated with an increased risk of mild neuropsychological dysfunction. The skills most affected in this cohort were information processing speed, acquisition of new knowledge, and conceptual reasoning abilities. Clinicians and educators should be made aware of the risk of specific neuropsychological deficits in children with IDDM.

Degree of left hippocampal atrophy correlates with severity of neuropsychological deficits.

The relationship between the degree and distribution of hippocampal atrophy measured by volumetric magnetic resonance imaging and severity of memory deficits in 25 patients with temporal lobe epilepsy secondary to mesial temporal sclerosis was assessed. Hippocampal volumes were expressed as a ratio of smaller to larger, normal ratio greater than 0.95. Neuropsychology tests included: subtests of the WAIS-R, Rey Auditory Verbal Learning Task, Rey Figure and the Austin Maze. Degree of left hippocampal atrophy in patients with left temporal lobe epilepsy was associated with severity of verbal memory deficits as measured by RAVLT total recall (P < 0.05), delayed recall (P < 0.001), story recognition (P < 0.001), list recognition (P < 0.001) and final delayed recall (P < 0.001) and recall of the Rey Figure (P < 0.01). There was no association between degree of right hippocampal atrophy and any of the memory tests. Diffuse left hippocampal atrophy was associated with more severe verbal memory deficits than anterior atrophy. We conclude, the association between degree of left hippocampal atrophy and verbal memory provides further evidence of the predominant involvement of the left hippocampus in verbal memory. The finding of a relationship between degree of left hippocampal atrophy and measures of non-verbal function suggests these tests are dependent on verbal memory, or that mesial temporal sclerosis is a bilateral but asymmetrical condition.

Computerised psychoeducation for patients with eating disorders.

OBJECTIVE: To assess a new computer-based method of health education for patients with bulimia and anorexia nervosa. METHOD: Fifty-four patients with DSM-III-R diagnosed eating disorders were allocated randomly to one of two groups, one receiving a computer-presented health education package called DIET, the other experiencing a placebo computer-based program. Each group contained 14 anorexia nervosa patients, four anorexic patients with bulimia and nine bulimic patients. Groups were equivalent in terms of the severity of their eating disorder as measured on the Eating Disorders inventory and their estimated premorbid intelligence according to the National Adult Reading Test. Both groups were assessed before and after intervention on a questionnaire measuring knowledge of eating disorders and a questionnaire measuring attitudes to eating-disordered behaviour. RESULTS: The DIET group members were significantly improved when compared to the placebo group in terms of both their knowledge and attitudes towards their disorder. The patients rated the DIET program as being both easy to use and helpful. CONCLUSION: The DIET program has been found to be a resource-efficient means of health education for patients with eating disorders. Further research is required to assess whether the program has therapeutic effects in terms of behavioural improvement.

Using a memory handbook to improve everyday memory in community-dwelling older adults with memory complaints.

Community-dwelling, nondemented older people (60-70 years) with reported memory complaints were randomly assigned to either a memory-handbook (MHB) group (n = 20) or a placebo group (n = 20). The MHB group members were given a self-contained memory handbook and were individually trained on two of the handbook's sections that related to (a) remembering a person's name and (b) prospective memory, for approximately 30 minutes each. The placebo group was given an instructional pamphlet with a description of three list-learning mnemonics as a placebo treatment. Subjects were tested before and after the intervention. When compared with the placebo group, the MHB group members significantly improved their performance on a face-naming task and a strategies knowledge questionnaire, but not on the prospective memory measures, when compared with the placebo group. In addition, the MHB group showed a significant advantage on an everyday memory diary that was filled out by all subjects following the intervention. Following the study, the placebo group was also given the memory handbook, and both groups were then assessed on their knowledge and use of strategies by questionnaire at a 4-month follow-up. At this time the MHB group appeared to maintain most of its original gains, while the placebo group made some improvement.

Brief report: bradyphrenia in Parkinson's disease, Huntington's disease, and schizophrenia.

The current paper assessed bradyphrenia, or slowed thinking, in patients with Parkinson's disease, Huntington's disease, and schizophrenia using a modified planning measure designed to maximise the demands on cognitive processing. Findings indicated normal performance in schizophrenia but prolonged thinking time in Parkinson's disease and, to a lesser degree, Huntington's disease and a relationship between thinking time and task complexity.

Subcortical dysfunction in schizophrenia: a comparison with Parkinson's disease and Huntington's disease.

Neuropsychological performance in 20 chronic schizophrenic patients was contrasted to 25 Parkinson's disease, 12 Huntington's disease patients and 26 normal controls on measures shown to be sensitive to subcortical dysfunction. Some overlap was observed in the performance of the schizophrenic and basal ganglia groups on tasks of executive and mnestic function, but the general pattern indicated significant differences in performance. Notably, in contrast to the two basal ganglia groups, there was no evidence of slowed thinking, or impaired motor function in schizophrenia, which are considered hallmarks of subcortical grey matter disease. An association was observed between poor performance on the tests of executive function and the severity of negative symptoms. Our findings suggest that schizophrenia is not associated with primary subcortical impairment, but is more likely to reflect frontotemporal dysfunction. We consider that the similarities between this disorder and subcortical degenerative syndromes may be due to a difficulty in generating action in schizophrenia, perhaps arising from dorsolateral prefrontal disconnection.

A brief assessment of executive control dysfunction: discriminant validity and homogeneity of planning, set shift, and fluency measures.

The current study evaluated the discriminant validity and homogeneity of category fluency, Stroop interference, and planning measures of executive dysfunction and introduced a new measure of planning behavior. We compared performance of patients with schizophrenia, Parkinson's disease, and Huntington's disease, which are disorders associated with some impairment of executive function. Findings indicated that all three measures successfully discriminated between patient groups and controls. Correlational analysis suggested a strong association between test scores on these measures, which were only moderately related to performance on nonexecutive function measures. It is concluded that the three tasks are sensitive and relatively homogeneous in their recruitment of executive functions.

Neuropsychological and structural brain changes in anorexia nervosa before and after refeeding.

The neuropsychological performance and Magnetic Resonance Imaging (MRI) brain appearance of a consecutive series of 46 in-patients with anorexia nervosa (AN) was compared with that of 41 normal-weight controls. The groups were matched for sex, age, estimated pre-morbid intelligence and education. AN patients who had gained at least 10% of their body weight were retested and rescanned. Controls were retested after a similar interval. The AN group performed significantly worse than the controls on tasks measuring attention, visuospatial ability and memory. On tasks assessing flexibility and learning, no group differences were evident although an examination of deficits in individuals revealed that more anorexics were impaired on both. Following treatment, the AN group improved relative to the control group only on those tasks assessing attention. Comparison of MRI measures showed a significant proportion of anorexics had enlarged lateral ventricles and dilated sulci on both cortical and cerebellar surfaces, but no dilatation was evident for the third and fourth ventricular measures. Improvements were found after treatment on some of the radiological measures but many differences remained. Relationships between morphological brain changes and cognitive impairments were weak. Lower weight, but not duration of illness, was associated with poorer performance on tasks assessing flexibility/inhibition and memory, and with greater MRI ventricular size.

Cognitive flexibility and complex integration in Parkinson's disease, Huntington's disease, and schizophrenia.

Two new tasks designed to individualize and assess aspects of cognitive flexibility and complex integration were administered to patients with schizophrenia (n = 16), Parkinson's disease (PD; n = 25) and Huntington's disease (HD; n = 12). Findings indicated impaired performance in the schizophrenic and HD groups on components of solution fluency, reactive flexibility and integration. The PD group demonstrated normal performance on all but the solution fluency and reaction time measures. These findings corroborate previous studies suggesting that executive and problem solving disturbances feature in schizophrenia and HD and that these functions may not be as severely affected in medicated PD. Slowed reaction time by both dementia groups is explained with reference to the concept of bradyphrenia.

Dysfluency in Huntington's disease, Parkinson's disease and schizophrenia.

Verbal fluency was compared in Huntington's disease (n=12), Parkinson's disease (n=25) and schizophrenia (n=18) with a series of fluency tasks evaluating the effects on productivity of cuing with subordinate categories and alternation between fluency probes. Findings indicated reduced output in the patient groups across all tasks consistent with a difficulty in intrinsic generation. A significant group interaction was observed with cue provision, but not with alternation. The facilitation of performance with cuing in all groups suggests a common mechanism of disruption in these disorders, most likely reflecting interruption of the prefrontal modulation of retrieval processes. To explain the observed pattern, we propose that the semantic retrieval anomaly in these disorders reflects a difficulty in intrinsic extra-dimensional shift. Verbal productivity was significantly associated with negative dimensions of schizophrenia, such as poverty of speech and flattened affect, a finding that is discussed in terms of the neurocognitive heterogeneity of schizophrenia and theories of cognitive dysfunction in subtypes of this disorder.

Initiation and execution of movement sequences in those suffering from and at-risk of developing Huntington's disease.

Recent research has shown that Huntington's disease (HD) causes problems in the initiation and execution of movement (akinesia, bradykinesia): information which is useful in documenting the functional progression of the disease. The present experiment used a sequential movement task to characterize such impairments. Eighteen patients diagnosed as suffering from HD, and a similar number of matched At-Risk (AR) and Normal control subjects, performed sequential button pressing tasks, under varying amounts of visual advance information. Specific dimensions of motor control were examined (hand, direction). Movement initiation and in particular movement duration were useful indicators of the functional progression of the disease, and also detected anomalies of performance in some AR individuals. Impaired motor programming was indicated by patients' difficulty in initiating movements in the absence of external visual cues, and their problems in utilizing advance information to control movement. Patients had specific deficits in initiating movements with the nonpreferred hand, and directional movement asymmetries were accentuated. The results suggest that HD causes difficulties at three discrete levels: in utilizing advance information, in the initiation and in the spatial representation of movement.

Neuropsychological impairment in anorexia nervosa: before and after refeeding.

Neuropsychological measures were administered to 18 patients with anorexia nervosa shortly after admission to hospital and again after substantial weight gain. These patients were compared with a group of 18 normal weight controls, also tested on two occasions, who were matched for age, sex, and estimated premorbid IQ. At low weight, impairment was evident on tests of attentional-perceptual-motor functions and on tests of visuospatial construction and problem-solving. Learning was less affected. Refeeding resulted in significant improvements in performance.

Visual recognition memory. Neurophysiological evidence for the role of temporal white matter in man.

A novel event-related potential (ERP) elicited by a visuospatial recognition memory task was recorded in 20 patients with temporal lobe epilepsy using depth electrodes sited in the temporal lobes. The ERPs comprised two components, an N400 and a P600, and were similar in morphology to the previously reported ERP to verbal recognition memory tasks. The two ERP components in both verbal and visuospatial tasks were dependent on stimulus type and our data suggest that they do not simply represent delayed P300 ERP responses. In 17/20 patients robust, reliable bilaterally present ERPs were elicited by both verbal and visuospatial memory tasks. N400 amplitude was larger in response to novel stimuli, whereas P600 amplitude was larger to repeated stimuli. P600 amplitude was larger in the right temporal lobe to both visuospatial and verbal stimulus material. N400 and P600 latencies did not vary with task, stimulus type or side of recording. In 3/20 patients, no ERPs were elicited by either memory task. In all 3 cases, unilateral temporal white matter abnormalities were demonstrated by magnetic resonance imaging. Behavioural measures, expressed in the form of standardized accuracy scores, did not differ from those of a normal control group, and hence are unlikely to account for the abnormalities in ERPs. These results are discussed with reference to the primate visual recognition memory pathway and suggest that ERPs to recognition memory tasks are generated by an interaction between the two homologous inferotemporal recognition memory pathways.

Early HIV-related neuropsychological impairment: relationship to stage of viral infection.

Sixty male outpatients with no past neuropsychiatric history were examined for evidence of early HIV-related neuropsychological impairment. Significant cognitive deficit, as measured by the RAVLT and WAIS-R Digit Symbol Substitution tests, and moderate correlation with indices of immune function, were observed in a group of patients with AIDS-Related Complex [ARC]. Patients with asymptomatic HIV-infection demonstrated no significant differences in performance compared to a group of HIV-seronegative controls. No significant group differences in age, education, predicted-IQ or self-rated depression and anxiety were observed. These results support the hypothesis that HIV-related cognitive disturbance occurs within the context of immunosuppression.

Post-ictal recognition memory predicts laterality of temporal lobe seizure focus: comparison with post-operative data.

Standardized verbal and visuo-spatial memory recognition were obtained on 15 patients with unilateral temporal lobe epilepsy (TLE), using a reference group of 43 (12 males, 31 females) subjects with no previous history of neurological disease. Inter-ictal measures on these two tasks failed to differentiate between those patients with left vs right seizure foci. When eight of these patients were tested post-ictally (within 1 hr of seizure), seven showed the expected selective memory impairment when compared to inter-ictal performance. Left TLE patients showed a relative lowering of verbal memory, whereas patients with right TLE showed a relative visuo-spatial memory impairment. A similar result was also found in the patients when a comparison between pre-operative (inter-ictal) and post-operative performance was made, thereby further substantiating the validity of the tasks. This significant association between side of seizure focus and selective impairment of post-ictal memory performance provides evidence of a more direct method of neuropsychological diagnosis in TLE patients prior to surgery.

Management of disruptive behaviour in the brain-damaged patient using selective reinforcement.

Selective reinforcement was used to reduce screaming in a 32-year-old woman with diffuse cerebral dysfunction following a suicide attempt. This paper describes the successful reduction in this disruptive behaviour in a patient with severe communicative disability. Also outlined are some of the organizational and educational problems encountered during the introduction of treatment.