Associations of individual and structural socioeconomic status with cognition and mental distress in pharmacoresistant focal epilepsy.

OBJECTIVE: Epilepsy is often associated with low socioeconomic status (SES). People with epilepsy (PWE) also suffer from cognitive dysfunction and mental distress. In the general population, these constraints are related to individual and structural SES. However, in PWE, cognitive dysfunction and mental distress have been mainly attributed to biological factors such as brain lesions or pharmacological treatment, whereas comprehensive studies on possible social determinants are missing. Here, we study associations of individual and structural SES with cognition and mental distress in PWE. METHODS: We retrospectively studied 340 adult patients with pharmacoresistant focal epilepsy from Berlin treated at a tertiary epilepsy center. Individual SES (education, employment, and income), structural SES (social index of district and neighborhood), and their interactions were examined. Associations between social variables and verbal learning, psychomotor speed, and mental distress were analyzed with multiple regression analyses, controlling for demographic and medical variables and intelligence. RESULTS: Our sample had lower educational levels and lived more frequently in low SES neighborhoods compared to the general population of Berlin. Thirty percent showed reduced verbal learning, 31% had deficits in psychomotor speed, and 20% revealed significant mental distress. Lower structural SES was related to lower psychomotor speed (ΔR2 = 0.9%) and higher mental distress (ΔR2 = 1.6%). Employment was related to verbal learning (ΔR2 = 0.7%) and psychomotor speed (ΔR2 = 1.2%). Income and education were linked to mental distress (ΔR2 = 5%). Neighborhood and individual SES covered more than half of the explained variance in mental distress. Furthermore, interactions between individual and structural SES were identified. CONCLUSION: We confirm cognitive deficits, significant mental distress, and individual and structural social disadvantage in PWE. Our findings indicate that individual and structural SES are related to cognitive and emotional well-being beyond demographic and medical characteristics. As a clinical implication, individual and structural SES should be considered when interpreting neuropsychological findings.

Are mental distress and cognitive impairment related in temporal lobe epilepsy?

OBJECTIVE: Cognitive impairment and depression often co-exist among patients with epilepsy. However, there is still debate whether depression and cognition are related in patients with temporal lobe epilepsy (TLE). Even if they were related, it is still unclear whether symptoms of depression specifically, or rather symptoms of mental distress in general, have a negative impact on cognition in patients with TLE. In the present study, we examined whether self-rated symptoms of mental distress and of depression are related to different cognitive functions in unilateral TLE. METHODS: We retrospectively studied 162 patients undergoing preoperative evaluation for epilepsy surgery (95 patients with left TLE (LTLE) and 67 patients with right TLE (RTLE)). Severity of mental distress and symptoms of depression were measured with the Symptom Checklist-90-Revised (SCL-90-R) and the Beck Depression Inventory (BDI), respectively. Bivariate correlations were calculated between these two measures and neuropsychological measures of verbal recall, figural learning, psychomotor speed, and phonemic word fluency. Due to multiple testing, a corrected level of p < 0.0063 was regarded as significant, only. RESULTS: Seventeen and 19% of patients reported meaningful mental distress and meaningful symptoms of depression, respectively. Mental distress highly correlated with symptoms of depression (rs = 0.80). We found no significant correlations of either mental distress or symptoms of depression with measures of cognitive function. CONCLUSIONS: In contrast to some former studies with smaller sample sizes, the present study could not detect a relationship of depression with cognitive impairment in patients with unilateral TLE. Likewise, mental distress and cognition were unrelated in our sample of patients. Our results may argue against theoretical models claiming a causal link between depression and cognitive impairment or a common pathogenic mechanism for these conditions in patients with TLE.

The relationship between structural MRI, FDG-PET, and memory in temporal lobe epilepsy: Preliminary results.

Structural and metabolic abnormalities of the temporal lobe are frequently found in temporal lobe epilepsy (TLE). In the present retrospective study, we investigated whether structural abnormalities evident in magnetic resonance imaging (MRI) and hypometabolism evident in [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) independently influence verbal and nonverbal learning and delayed memory in patients with TLE. Sixty-eight patients with refractory unilateral TLE (35 left TLE, 33 right TLE) were divided into three groups: (1) no evidence of pathology in either MRI or FDG-PET studies (MRI-/PET-, n=15), (2) temporal FDG-PET determined hypometabolism with normal MRI findings (MRI-/PET+, n=21), and (3) evidence of temporal abnormalities in both MRI and FDG-PET studies (MRI+/PET+, n=32). A fourth group (MRI+/PET-, n=4) was too small for further statistical analysis and could not be included. Patients with MRI+/PET+ showed worse verbal memory than patients with MRI-/PET- (p<0.01), regardless of side of seizure focus. Verbal memory performance of patients with MRI-/PET+ was located between patients with MRI+/PET+ and MRI-/PET-, although group differences did not achieve statistical significance (ps>0.1). No group differences were found for nonverbal memory (p=0.27). Our results may suggest an interactive negative effect of metabolic and structural temporal lobe abnormalities on verbal memory. Still, our results are preliminary and need further validation by studies involving larger patient groups and up-to date quantitative imaging analysis methods.

Female verbal memory advantage in temporal, but not frontal lobe epilepsy.

Women show better performance than men on a range of episodic memory tasks. Evidence regarding a neuroanatomical localization of this effect remains ambiguous. It has been suggested that anterior temporal lobe structures are responsible for sex differences in verbal memory, yet temporal lobe epilepsy (TLE) and TLE surgery do not affect women's verbal memory advantage. Instead, frontal lobe regions may be relevant for female verbal memory superiority, i.e. by enabling more efficient encoding and retrieval strategies in women. The aim of the present study was to investigate whether women's verbal memory advantage can be found in patients with frontal lobe epilepsy (FLE), and how patients with FLE and those with TLE differ with regard to sex differences in verbal memory. Fifty patients with unilateral FLE (26 women, 24 men) were compared with 183 patients with unilateral TLE (90 women, 93 men) on both verbal learning and delayed memory. We found that women showed better verbal memory than men in the TLE group, but not in the FLE group. In addition, we found that patients with TLE showed worse verbal learning than those with FLE. Our findings support the idea that women's advantage in verbal memory may be related to frontal lobe function.

Sex differences in verbal and nonverbal learning before and after temporal lobe epilepsy surgery.

Women outperform men in a host of episodic memory tasks, yet the neuroanatomical basis for this effect is unclear. It has been suggested that the anterior temporal lobe might be especially relevant for sex differences in memory. In the current study, we investigated whether temporal lobe epilepsy (TLE) has an influence on sex effects in learning and memory and whether women and men with TLE differ in their risk for memory deficits after epilepsy surgery. 177 patients (53 women and 41 men with left TLE, 42 women and 41 men with right TLE) were neuropsychologically tested before and one year after temporal lobe resection. We found that women with TLE had better verbal, but not figural, memory than men with TLE. The female advantage in verbal memory was not affected by temporal lobe resection. The same pattern of results was found in a more homogeneous subsample of 84 patients with only hippocampal sclerosis who were seizure-free after surgery. Our findings challenge the concept that the anterior temporal lobe plays a central role in the verbal memory advantage for women.

Using the yes/no recognition response pattern to detect memory malingering.

BACKGROUND: Detection of feigned neurocognitive deficits is a challenge for neuropsychological assessment. We conducted two studies to examine whether memory malingering is characterized by an elevated proportion of false negatives during yes/no recognition testing and whether this could be a useful measure for assessment. METHODS: Study 1 examined 51 participants claiming compensation due to mental disorders, 51 patients with affective disorders not claiming compensation and 13 patients with established dementia. Claimants were sub-divided into suspected malingerers (n = 11) and non-malingerers (n = 40) according to the Test of Memory Malingering (TOMM). In study 2, non-clinical participants were instructed to either malinger memory deficits due to depression (n = 20), or to perform normally (n = 20). RESULTS: In study 1, suspected malingerers had more false negative responses on the recognition test than all other groups and false negative responding was correlated with Minnesota-Multiphasic Personality Inventory (MMPI) measures of deception. In study 2, using a cut-off score derived from the clinical study, the number of false negative responses on the yes/no recognition test predicted group membership with comparable accuracy as the TOMM, combining both measures yielded the best classification. Upon interview, participants suspected the TOMM more often as a malingering test than the yes/no recognition test. CONCLUSION: Results indicate that many malingers adopt a strategy of exaggerated false negative responding on a yes/no recognition memory test. This differentiates them from both dementia and affective disorder, recommending false negative responses as an efficient and inconspicuous screening measure of memory malingering.

Sex influence on face recognition memory moderated by presentation duration and reencoding.

OBJECTIVE: It has been suggested that women have a better face recognition memory than men. Here we analyzed whether this advantage depends on a better encoding or consolidation of information and if the advantage is visible during short-term memory (STM), only, or whether it also remains evident in long-term memory (LTM). METHOD: We tested short- and long-term face recognition memory in 36 nonclinical participants (19 women). We varied the duration of item presentation (1, 5, and 10 s), the time of testing (immediately after the study phase, 1 hr, and 24 hr later), and the possibility to reencode items (none, immediately after the study phase, after 1 hr). RESULTS: Women showed better overall face recognition memory than men (ηp² = .15, p < .05). We found this advantage, however, only with a longer duration of item presentation (interaction effect Sex × DURATION: ηp² = .16, p < .05). Women's advantage in face recognition was visible mainly if participants had the possibility to reencode faces during former test trials. CONCLUSIONS: Our results suggest women do not have a better face recognition memory than men per se, but may profit more than men from longer durations of presentation during encoding or the possibility for reencoding. Future research on sex differences in face recognition memory should explicate possible causes for the better encoding of face information in women.

Reduction of claustrophobia with short-bore versus open magnetic resonance imaging: a randomized controlled trial.

BACKGROUND: Claustrophobia is a common problem precluding MR imaging. The purpose of the present study was to assess whether a short-bore or an open magnetic resonance (MR) scanner is superior in alleviating claustrophobia. METHODS: Institutional review board approval and patient informed consent were obtained to compare short-bore versus open MR. From June 2008 to August 2009, 174 patients (139 women; mean age = 53.1 [SD 12.8]) with an overall mean score of 2.4 (SD 0.7, range 0 to 4) on the Claustrophobia Questionnaire (CLQ) and a clinical indication for imaging, were randomly assigned to receive evaluation by open or by short-bore MR. The primary outcomes were incomplete MR examinations due to a claustrophobic event. Follow-up was conducted 7 months after MR imaging. The primary analysis was performed according to the intention-to-treat strategy. RESULTS: With 33 claustrophobic events in the short-bore group (39% [95% confidence interval [CI] 28% to 50%) versus 23 in the open scanner group (26% [95% CI 18% to 37%]; P = 0.08) the difference was not significant. Patients with an event were in the examination room for 3.8 min (SD 4.4) in the short-bore and for 8.5 min (SD 7) in the open group (P = 0.004). This was due to an earlier occurrence of events in the short-bore group. The CLQ suffocation subscale was significantly associated with the occurrence of claustrophobic events (P = 0.003). New findings that explained symptoms were found in 69% of MR examinations and led to changes in medical treatment in 47% and surgery in 10% of patients. After 7 months, perceived claustrophobia increased in 32% of patients with events versus in only 11% of patients without events (P = 0.004). CONCLUSIONS: Even recent MR cannot prevent claustrophobia suggesting that further developments to create a more patient-centered MR scanner environment are needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT00715806.

Reduction of claustrophobia during magnetic resonance imaging: methods and design of the "CLAUSTRO" randomized controlled trial.

BACKGROUND: Magnetic resonance (MR) imaging has been described as the most important medical innovation in the last 25 years. Over 80 million MR procedures are now performed each year and on average 2.3% (95% confidence interval: 2.0 to 2.5%) of all patients scheduled for MR imaging suffer from claustrophobia. Thus, prevention of MR imaging by claustrophobia is a common problem and approximately 2,000,000 MR procedures worldwide cannot be completed due to this situation. Patients with claustrophobic anxiety are more likely to be frightened and experience a feeling of confinement or being closed in during MR imaging. In these patients, conscious sedation and additional sequences (after sedation) may be necessary to complete the examinations. Further improvements in MR design appear to be essential to alleviate this situation and broaden the applicability of MR imaging. A more open scanner configuration might help reduce claustrophobic reactions while maintaining image quality and diagnostic accuracy. METHODS/DESIGN: We propose to analyze the rate of claustrophobic reactions, clinical utility, image quality, patient acceptance, and cost-effectiveness of an open MR scanner in a randomized comparison with a recently designed short-bore but closed scanner with 97% noise reduction. The primary aim of this study is thus to determine whether an open MR scanner can reduce claustrophobic reactions, thereby enabling more examinations of claustrophobic patients without incurring the safety issues associated with conscious sedation. In this manuscript we detail the methods and design of the prospective "CLAUSTRO" trial. DISCUSSION: This randomized controlled trial will be the first direct comparison of open vertical and closed short-bore MR systems in regards to claustrophobia and image quality as well as diagnostic utility. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00715806.

Influence of personality on sexual quality of life in epilepsy.

We prospectively investigated the effect of personality on sexual quality of life (SQOL) in 49 epilepsy patients (23 women). Fifteen patients had generalised epilepsy and 34 had focal epilepsy. SQOL was determined using the Derogatis Interview for Sexual Function - Self Report Inventory (DISF-SR) and personality was studied using the NEO five-factor inventory (NEO-FFI). Lower extraversion and female sex were factors associated with decreased SQOL, accounting for 22% of SQOL variance. Our results suggest that particularly introverted women with epilepsy may have an elevated risk of decreased SQOL.

Long-term versus short-term memory deficits for faces in temporal lobe and generalized epilepsy patients.

It is still an open question whether short-term and long-term memory are two anatomically dissociable memory systems working in parallel or whether they are represented by neural circuits within similar cortical areas. Epilepsy may be used as a model to study these memory processes. We hypothesized that a double dissociation of short-term and long-term memory exists in temporal lobe epilepsy (TLE) and idiopathic generalized epilepsy (IGE). Immediate and 24-hour face recognition was tested in 10 TLE patients, 9 IGE patients, and 10 healthy controls. TLE patients' immediate recognition was unimpaired, but their memory scores were reduced as compared to healthy controls after 24 hours. In IGE patients, memory was already reduced during immediate recognition. These results are in line with the idea that short-term memory is a transient trace that requires consolidation supported by the medial temporal lobe to change into a more stable status of long-term memory.

Long-term face memory as a measure of right temporal lobe function in TLE: the Alsterdorfer Faces Test.

There is a shortage of neuropsychological tests to assess right temporal lobe memory function in TLE patients. Although right temporal lobe dominance for face memory is well established, neuropsychological studies on face memory in epilepsy surgery candidates have reported mixed results. These latter studies in TLE patients mostly concentrated on immediate face recognition. There is evidence suggesting that increasing test delays raise the sensitivity of neuropsychological face recognition tests to predict face memory decline after right temporal lobectomy. Long-term face recognition may also help in lateralizing right TLE in preoperative patients with little or no hippocampal sclerosis. In this context, we will introduce the Alsterdorfer Faces Test, a computerized long-term face memory test developed in the clinical context of an epilepsy center.

Enhanced activity during associative encoding in the affected hippocampus in right temporal lobe epilepsy patients.

Mnestic deficits represent the core cognitive impairment of patients with temporal lobe epilepsy (TLE), irrespective of the existence of overt morphological lesions. Compared to controls, patients with symptomatic TLE show altered functional activation patterns in fMRI studies on memory processes. But, so far, such studies have rarely investigated patients with temporal lobe epilepsy of unknown cause. Therefore, in the current study, a small sample of 6 right TLE patients with normal structural MRIs was compared to controls with respect to brain activity during encoding of face-name associations using fMRI. Compared to controls, patients retrieved fewer face-name associations correctly, but showed significantly greater activation of the affected hippocampus for successfully encoded stimuli. Therefore, higher hippocampal activation seems necessary for successful encoding of associations in patients compared to controls. But, this process is not entirely successful since the patients cannot achieve the same performance as controls. In conclusion, the hyperactivation of the hippocampus might represent a compensational but inefficient process.

Sexual quality of life in epilepsy: correlations with sex hormone blood levels.

Seventy-nine consecutive inpatients of an epilepsy center (34 women, 45 men) who had either generalized epilepsy, temporal lobe epilepsy, focal epilepsy of other origin, or no epilepsy completed the Derogatis Interview for Sexual Function-Self-Report Inventory. Quantitative assessments of blood levels were performed for prolactin, total testosterone, sex hormone-binding globulin, estradiol, dehydroepiandrosterone sulfate, luteinizing hormone, and follicle-stimulating hormone. In men, increasing sex hormone-binding globulin levels and duration of epilepsy decreased sexual quality of life. Sex hormone-binding globulin level in men was related to enzyme-inducing antiepileptic drugs and age. In women, we found no associations between blood hormone levels and sexual quality of life. Our results suggest that sexual quality of life is affected by sexual hormone blood levels in men, but not in women with epilepsy. Avoiding enzyme-inducing antiepileptic drugs may lower the risk of raised sex hormone-binding globulin levels and, thus, of lowered sexual quality of life in men with epilepsy.

T2 relaxation time correlates of face recognition deficits in temporal lobe epilepsy.

This study explored structural correlates of immediate and delayed face recognition in 22 nonsurgical patients with nonlesional, unilateral mesial temporal lobe epilepsy (TLE, 10 left/12 right). We measured T2 relaxation time bilaterally in the hippocampus, the amygdala, and the fusiform gyrus. Apart from raised T2 values in the ipsilateral hippocampus, we found increased T2 values in the ipsilateral amygdala. Patients with right TLE exhibited impaired face recognition as a result of a decrease from immediate to delayed recognition. Higher T2 values in the right than left fusiform gyrus or hippocampus were related to worse immediate face recognition, but did not correlate with 24-hour face recognition. These preliminary results indicate that structural changes in the fusiform gyrus and hippocampus may influence immediate face recognition deficits, but have no linear influence on long-term face recognition in TLE. We suggest that long-term face recognition depends on a right hemispheric network encompassing structures outside the temporal lobe.

Remembering versus knowing during face recognition in unilateral temporal lobe epilepsy patients with or without hippocampal sclerosis.

Recognition memory involves knowing an item was learned (familiarity) and remembering contextual details about the prior learning episode (recollection). We tested three competing hypotheses about the role of the hippocampus in recollection and familiarity. It mediates either recollection or familiarity, or serves both processes. We further tested whether the left temporal lobe mediates recollection and the right temporal lobe familiarity (modes of processing view), or whether the two temporal lobes mediate remembering material specifically (material specificity view). We investigated 24-h face recognition using the "remember-know" procedure. We studied 23 left and 24 right temporal lobe epilepsy (LTLE/RTLE) patients with and without hippocampal sclerosis (HS+/HS-) and 31 healthy participants. HS+ patients made fewer know responses than HS- patients or healthy participants. RTLE was related to fewer remember responses than LTLE. Our results suggest the hippocampus has a critical role in familiarity. Further, our findings support the material specificity hypothesis of laterality.

Face memory in MRI-positive and MRI-negative temporal lobe epilepsy.

PURPOSE: Effects of MRI-positive (MRI(+)) as compared to MRI-negative (MRI(-)) temporal lobe epilepsy (TLE) on face memory are not yet known. METHODS: We studied 24 MRI(-) (11 right/13 left) and 20 MRI(+) (13 right/7 left) TLE patients, 12 generalized epilepsy patients, and 12 healthy subjects undergoing diagnostic workup with 24-72-h Video-EEG-monitoring. Twenty faces were shown, and had to be recognized from 40 faces immediately and after a 24-h delay. RESULTS: MRI(+) and MRI(-) right TLE (RTLE) patients showed deficits in face recognition compared to controls or generalized epilepsy, consistent with right temporal lobe dominance for face recognition. MRI(+) RTLE patients had deficits in both immediate and delayed recognition, while MRI(-) RTLE patients showed delayed recognition deficits only. The RTLE groups showed comparable delayed recognition deficits. Separate analyses in which the MRI(+) group included patients with hippocampal sclerosis only, did not alter results. Furthermore, MRI(-) RTLE had a worse delayed recognition than MRI(-) left TLE (LTLE). On the other hand, MRI(+) RTLE did not differ from MRI(+) LTLE in delayed recognition. Combining MRI(-) and MRI(+) TLE groups, we found differences between RTLE and LTLE in delayed, but not immediate face recognition. CONCLUSIONS: Our results suggest that a delayed recognition condition might be superior to immediate recognition tests in detecting face memory deficits in MRI(-) RTLE patients. This might explain why former studies in preoperative patients did not observe an immediate face recognition dominance of the right temporal lobe when combining MRI(-) and MRI(+) TLE patients. Our data further point to an important role of the right mesial temporal region in face recognition in TLE.