Cognitive functioning and adjudicative competence: defendants referred for neuropsychological evaluation in a psychiatric inpatient setting.

OBJECTIVE: A paucity of peer-reviewed research exists regarding the relation between cognitive functioning and adjudicative competence, despite increasing awareness of cognitive deficits associated with serious mental illness. This retrospective study sought to add to and expand upon existing research by considering performance validity and court determinations of competence, when available. METHOD: We compared demographic and cognitive variables of a group of defendants with presumed valid testing admitted to an inpatient psychiatric facility for evaluation of adjudicative competence and referred for neuropsychological evaluation (n = 45) and compared individuals determined by the evaluator and/or the court to be competent (n = 30) and incompetent (n = 15). RESULTS: Defendants who were incompetent were more likely to be diagnosed with a cognitive disorder, with a medium effect size. There was a difference in tests of immediate and delayed memory as measured by the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), with medium to large effects, and high delayed memory scores were helpful in ruling out incompetence (Negative predictive power = 85.71%). CONCLUSIONS: These results provide support for the relationship between cognitive functioning and trial competence, particularly at high and low levels of performance.

Impulsivity in bipolar disorder: relationships with neurocognitive dysfunction and substance use history.

OBJECTIVES: Impulsivity is a core feature in bipolar disorder. Although mood symptoms exacerbate impulsivity, self-reports of impulsivity are elevated, even during euthymia. Neurocognitive processes linked to impulsivity (e.g., attention, inhibition) are also impaired in patients with bipolar disorder, and a high frequency of comorbidities associated with impulsivity, such as substance use disorders, further highlights the clinical relevance of this dimension of the illness. Our objective was to assess the relationship between impulsivity and cognition in bipolar disorder. METHODS: We evaluated impulsivity in 98 patients with bipolar disorder and its relationship with symptoms, cognition, and substance use history. We assessed self-reports of trait impulsivity [Barrett Impulsiveness Scale (BIS)] and impulsive behaviors on the Iowa Gambling Task (IGT). A comprehensive clinical and neurocognitive battery was also completed. Patients were compared with 95 healthy controls. RESULTS: Patients with bipolar disorder had higher scores versus healthy controls on all BIS scales. Performance on the IGT was significantly impaired and patients showed a tendency toward more erratic choices. Depressive symptoms were positively correlated with trait impulsivity and with an increased tendency to attend more readily to losses versus gains on the IGT. We found no significant associations between impulsivity and neurocognition in the full bipolar sample; however, when sub-grouped based on substance abuse history, significant relationships were revealed only in subjects without a substance abuse history. CONCLUSIONS: Our data support prior reports of increased trait impulsivity and impairment on behavioral tasks of impulsiveness in bipolar disorder and suggest a differential relationship between these illness features that is dependent upon history of substance abuse.

Emotion processing bias and age of seizure onset among epilepsy patients with depressive symptoms.

The current study examined whether mood-congruent biases in emotion processing extend to epilepsy patients with depressive symptoms and the potentially moderating effects of age of seizure onset on these biases. In addition, we examined associations between depression (Beck Depression Inventory - 2nd Edition; BDI-II) and quality of life (Quality of Life in Epilepsy - 10-item questionnaire; QOLIE-10). Data from 101 epilepsy patients were analyzed, including 61 females and 40 males. Measures included the Comprehensive Affect Testing System - Abbreviated (CATS-A), from which indices of mood-congruent bias were derived. A significant interaction between BDI-II raw scores and age of seizure onset was found for mood-congruent bias scores in the facial affect modality (ß=-0.24, p<.03). Beck Depression Inventory - 2nd Edition raw scores were significantly and positively correlated with quality of life (QOLIE-10; r=.69, p<.01). Results of the current study show that epilepsy patients with an early age of seizure onset may be most at risk for mood-congruent biases when experiencing depressive symptoms and that such symptoms have real-world implications for quality of life for persons living with epilepsy.

Emotional bias in unaffected siblings of patients with bipolar I disorder.

BACKGROUND: Bipolar disorder (BPD) research has identified a number of neurocognitive deficits as potential vulnerability markers; however, very few studies have focused on patterns of performance on affective processing tasks (e.g. affective Go/No-Go tasks) which may be more closely tied to the pathophysiology of the illness. We previously reported that stable BPD patients demonstrate a response bias toward negative affective stimuli as compared with healthy controls and schizophrenia patients. The goal of the current study was to expand upon these prior findings to investigate these patterns in the unaffected siblings of BPD patients. METHODS: An affective Go/No-Go test was used to evaluate inhibitory response to negatively-valenced, positively-valenced, and neutral stimuli in 20 unaffected siblings of bipolar I patients versus 20 healthy controls. Accuracy (d') and response bias (beta) served as dependent variables in a series of repeated measures ANCOVAs. RESULTS: We found a non-significant main effect for group when comparing accuracy performance (d') on the affective Go/No-Go of unaffected siblings versus healthy controls. However, very similar to the pattern that we previously reported in stable BPD patients, unaffected siblings showed a response bias (beta) toward negatively-valenced stimuli versus healthy controls [F=3.81; p=0.03]. LIMITATIONS: Small sample size. CONCLUSIONS: The current results extend our recent work which suggested that stable bipolar patients attend more readily to negative target stimuli than do schizophrenic or healthy subjects. These data, indicating that unaffected siblings also demonstrate an affective processing bias, implicate this task as a potential endophenotype in BPD.

Emotional recognition in depressed epilepsy patients.

The current study examined the relationship between emotional recognition and depression using the Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2), in a population with epilepsy. Participants were a mixture of surgical candidates in addition to those receiving neuropsychological testing as part of a comprehensive evaluation. Results suggested that patients with epilepsy reporting increased levels of depression (Scale D) performed better than those patients reporting low levels of depression on an index of simple facial recognition, and depression was associated with poor prosody discrimination. Further, it is notable that more than half of the present sample had significantly elevated Scale D scores. The potential effects of a mood-congruent bias and implications for social functioning in depressed patients with epilepsy are discussed.

Age and diffusion tensor anisotropy in adolescent and adult patients with schizophrenia.

Findings of white matter pathology as indicated by diffusion tensor anisotropy values in schizophrenia are well established, but the differences in this measure between the onset of the disease and the chronic state are not well known. To investigate the differences between these states in the progression of the disease of schizophrenia we acquired 1.5 T diffusion tensor anisotropy images on 35 adult patients with schizophrenia and schizoaffective disorder, 23 adolescents having their first psychotic episode, and age and sex matched controls (33 adults and 15 adolescents). Regions of interest in major cortical white matter tracts chosen as salient to the prefrontal executive deficit in schizophrenia were assessed using stereotaxic coordinates from the Talairach and Tournoux atlas. Regions of each tract along anterior-posterior and/or inferior-superior directions in both hemispheres were evaluated in multiway ANOVA. Tracts between the frontal lobe and other brain regions, but not temporal, occipital and interhemispheric tracts, showed a differential aging pattern in normals and patients indicating that the white matter pathology in these regions is not stable between the onset and the chronic state in schizophrenia. This suggests that tracts involved in the connectivity of the temporal lobe white matter deficits were already well in place in adolescent patients, while frontal lobe pathology continues to develop from adolescence to adulthood.

FDG-PET in never-previously medicated psychotic adolescents treated with olanzapine or haloperidol.

We acquired Positron emission tomography with 18-F-deoxyglucose (FDG-PET) and anatomical MRI in 30 never-previously medicated psychotic adolescents (ages 13-20). (FDG-PET) was obtained at baseline and after 8-9 weeks of a randomized double-blind trial of either olanzapine or haloperidol. Neuropsychological tests of executive function were also obtained. Patients carried out the serial verbal learning task, a modification of the California Verbal Learning Test, during the uptake of the FDG. PET scans were coregistered with spoiled gradient MRI (TR=24, TE=5, flip angle 40 degrees, slice thickness 1.2 mm, field of view 230 mm) for accurate anatomical identification of regions of interest traced on the MRI. Twenty-two of the thirty patients completed the second PET and clinical evaluation. Individuals treated with olanzapine increased relative metabolic rates in the frontal lobe more than the occipital lobe while patients treated with haloperidol failed to increase frontal metabolic rates and did not show an anteroposterior gradient in medication response. Haloperidol increased striatal metabolic rate more than olanzapine. Both drugs increased thalamic metabolic rates and this increase was significantly larger in younger (age 13-15) than older (16-21) patients.

Diffusion tensor anisotropy in adolescents and adults.

We acquired diffusion tensor images on 33 normal adults aged 22-64 and 15 adolescents aged 14-21. We assessed relative anisotropy in stereotaxically located regions of interest in the internal capsule, corpus callosum, anterior thalamic radiations, frontal anterior fasciculus, fronto-occipital fasciculus, temporal lobe white matter, cingulum bundle, frontal inferior longitudinal fasciculus, frontal superior longitudinal fasciculus, and optic radiations. All of these structures except the optic radiations, corpus callosum, and frontal inferior longitudinal fasciculus exhibited differences in anisotropy between adolescents and adults. Areas with anisotropy increasing with age included the anterior limb of the internal capsule, superior levels of the frontal superior longitudinal fasciculus and the inferior portion of the temporal white matter. Areas with anisotropy decreasing with age included the posterior limb of the internal capsule, anterior thalamic radiations, fronto-occipital fasciculus, anterior portion of the frontal anterior fasciculus, inferior portion of the frontal superior longitudinal fasciculus, cingulum bundle and superior portion of the temporal axis. Sex differences were found in the majority of areas but were most marked in the cingulum bundle and internal capsule. These results suggest continuing white matter development between adolescence and adulthood.

Thalamus size and outcome in schizophrenia.

The size of the thalamus was assessed in 106 patients with schizophrenia and 42 normal controls using high-resolution magnetic resonance imaging. The thalamus was traced at five axial levels proportionately spaced from dorsal to ventral directions. Patients with schizophrenia had significantly smaller thalamic areas at more ventral levels. Thalamic size was positively associated with frontal lobe and temporal lobe size. The effects were most marked in the patients with poorer clinical outcome (i.e., "Kraepelinian" patients). These findings are consistent with post-mortem and MRI measurement suggesting reduction in volume of the pulvinar, which occupies a large proportion of the ventral thalamus and which has prominent connections to the temporal lobe.

Fluoxetine increases relative metabolic rate in prefrontal cortex in impulsive aggression.

RATIONALE: Impulsive aggressive personality disordered patients have been shown to have decreased relative glucose metabolism in orbito-frontal cortex and anterior cingulate gyrus compared with normal subjects. In addition, patients with impulsive aggression have an attenuation of symptoms with selective serotonin reuptake inhibitor (SSRI) treatment. OBJECTIVES: The goals of the present study were to attempt to replicate the finding of improvement in impulsive aggression in borderline personality disorder with SSRIs and to investigate the specific cortical areas modified by medication, which might underlie the observed clinical improvement using (18)FDG-PET. METHODS: Ten impulsive aggressive patients with borderline personality disorder were imaged with (18)F-deoxyglucose positron emission tomography at baseline and after receiving fluoxetine at 20 mg/day for 12 weeks. Anatomical MRIs were coregistered to PET and relative metabolic rates were obtained in 39 Brodmann areas. RESULTS: Brodmann areas 11 and 12 in the orbito-frontal cortex showed significant increases in relative metabolic rate. Significant clinical improvement was also observed as assessed by the Overt Aggression Scale-Modified. CONCLUSIONS: These changes are consistent with a normalizing effect of fluoxetine on prefrontal cortex metabolism in impulsive aggressive disorder.