The impact of insight in a first-episode mania with psychosis population on outcome at 18 months.

BACKGROUND: To explore whether poor initial insight during a first episode of mania with psychotic features was predictive of poor psychosocial and clinical outcomes at 18 months. METHODS: Secondary analysis was performed on data collected during an 8-week RCT comparing the efficacy of olanzapine versus chlorpromazine as an adjunct to lithium, and at 18-month follow-up. 74 participants were divided into three groups (no insight, partial insight, and full insight) according to the insight item from the Young Mania Rating Scale (YMRS). Differences between these three groups were examined at baseline and at 18 months on measures of symptoms (YMRS, HAMD-21, and CGI-S), and social and occupational functioning (SOFAS). Baseline differences between the three groups were determined using general linear models and chi-squared analyses. Group differences from baseline to 18-month follow-up were determined using repeated measures general linear models. RESULTS: At baseline there were significant differences between the three insight groups in terms of mania and functioning, but at 18 months all groups had improved significantly in terms of psychopathology, mania, depression and social and occupational functioning. There were no significant differences between the three groups at study completion with respect to these domains. LIMITATIONS: The study was limited by the lack of availability of a more detailed rating scale for insight, and it did not account for the duration of untreated psychosis (DUI). CONCLUSIONS: Poor initial insight during a first episode of mania with psychotic features does not predict poor clinical and psychosocial outcome at 18 months.

Changes in singing performance and fMRI activation following right temporal lobe surgery.

INTRODUCTION: This study arose in the context of having to estimate risk to the musical abilities of a trained singer (patient A.M.) recommended for right anterior temporal lobectomy (RATL) to ameliorate medically intractable seizures. To date there has been no systematic investigation of reorganisation of musical functions in the presence of epileptogenic lesions, although it is well established that RATL can impair pitch processing in nonmusicians. METHODS: Using fMRI, we compared the network activated by covert singing with lyrics in A.M. before and after surgery, while taking language activation and singing expertise into consideration. Before surgery, A.M. showed lower pitch accuracy of singing relative to individuals of similar experience (experts), thus we compared her to 12 healthy controls matched for singing pitch accuracy. RESULTS: We found atypical organisation of A.M.'s singing network before surgery in the presence of a malformation of cortical development, including partial activation of the singing network of pitch-matched controls, and diffuse activation along the midline spreading laterally into association cortex, typical of generalised cortical hyperexcitability in intractable epilepsy. After tailored RATL, A.M. showed striking behavioural and neuroimaging changes, including significant improvement in pitch accuracy of singing relative to controls (p = .026) and the subjective experience of being a more technically proficient singer. This was accompanied by a significant reduction in cortical activation (p < .05, corrected), with a more focal, expert-like pattern of singing activation emerging, including decreased involvement of frontal language regions. These changes were largely specific to singing, with A.M. showing language activation and performance similar to controls. CONCLUSIONS: This case provides evidence for selective disruption of the singing network that reorganised after successful resection of an epileptogenic lesion and likely occurred through decoupling of the singing and language networks.

Feasibility of neurobehavioral screening following diagnosis of pediatric cancer.

BACKGROUND: Neurobehavioral deficits will affect up to 50% of pediatric cancer survivors treated with central nervous system (CNS)-directed therapies. Guidelines suggest assessment of neurobehavioral skills at diagnosis be extended from patients with brain tumors to include all patients requiring CNS-directed therapies. However, comprehensive neuropsychological assessment at diagnosis is difficult to implement and resource intensive. A screening assessment targeted at the neurobehavioral domains known to be impacted by cancer treatments may be more feasible. This study aimed to assess the feasibility of implementing baseline neurobehavioral screening following childhood cancer diagnosis. PROCEDURE: A consecutive sample of 59 recently diagnosed patients requiring CNS-directed therapies, and 49 healthy controls were assessed using a targeted neurobehavioral screen, which included measures of developmental, cognitive, academic, behavioral, and psychosocial functioning. Feasibility was assessed using a formal feasibility framework, with criteria of brevity, simplicity, relevance, acceptability, and value. Neurobehavioral assessment was compared to standard care to determine the quality of information acquired from the screen. RESULTS: Mean time from diagnosis to assessment was 5.17 weeks. Assessments were completed within 1 hour for 87% of patients. Participant and researcher evaluation indicated the screen was acceptable across a range of criteria, with no differences between clinical and control groups. Compared to standard medical record documentation, the screen provided significant additional information on developmental and neurobehavioral status of patients at diagnosis. CONCLUSION: A brief neurobehavioral screen in the early period following cancer diagnosis is feasible and provides valuable baseline data for children at risk of neurobehavioral late-effects of cancer treatments.

Non-expert clinicians' detection of autistic traits among attenders of a youth mental health service.

AIMS: The aims of this study were to determine the point prevalence of autism spectrum disorders and to estimate the prevalence of autistic traits in a youth mental health service. METHODS: Following three educational sessions on autism spectrum disorders, treating clinicians were interviewed to determine whether the clients on their caseloads had (i) a confirmed prior diagnosis of autism spectrum disorder; (ii) were felt to exhibit autistic traits; or (iii) were not felt to exhibit autistic traits. RESULTS: Information on autism spectrum disorder status was obtained for 476 patients. Of the included patients, 3.4% (n = 16) had a confirmed diagnosis of autism spectrum disorder and 7.8% (n = 37) were reported by treating clinicians to exhibit autistic traits. CONCLUSIONS: The rate of autism spectrum disorder was higher in this population than that in community samples with twice as many again being identified as having autistic traits by their treating clinicians. This has implications for correct diagnosis and appropriate management in these settings.

Finding your voice: a singing lesson from functional imaging.

Vocal singing (singing with lyrics) shares features common to music and language but it is not clear to what extent they use the same brain systems, particularly at the higher cortical level, and how this varies with expertise. Twenty-six participants of varying singing ability performed two functional imaging tasks. The first examined covert generative language using orthographic lexical retrieval while the second required covert vocal singing of a well-known song. The neural networks subserving covert vocal singing and language were found to be proximally located, and their extent of cortical overlap varied with singing expertise. Nonexpert singers showed greater engagement of their language network during vocal singing, likely accounting for their less tuneful performance. In contrast, expert singers showed a more unilateral pattern of activation associated with reduced engagement of the right frontal lobe. The findings indicate that singing expertise promotes independence from the language network with decoupling producing more tuneful performance. This means that the age-old singing practice of 'finding your singing voice' may be neurologically mediated by changing how strongly singing is coupled to the language system.