Domain-specific relationships of subjective and objective cognition in epilepsy.

OBJECTIVE: Many people with epilepsy report subjective cognitive impairment (SCI), i.e., problems with memory, attention, or executive functions, reducing quality of life. Nevertheless, overlap with objective cognitive impairment (OCI) is often weak. One reason may be a domain-specific mismatch between subjective reports and objective tests. We aimed to evaluate relations between SCI and OCI of corresponding domains and to assess whether these differ between persons who over- or underestimate their performance. METHODS: In this prospective, cross-sectional sample of 104 adult inpatients with epilepsy, we performed multiple regression analyses predicting SCI in the domains attention, memory, and executive functions. We tested relationships with measures of psychomotor speed, short-term memory, verbal learning, verbal delayed recall, and word fluency while controlling for age, sex, seizure frequency, structural lesions, mono- versus polytherapy and adverse events of antiseizure medication (ASM), depressive and anxiety symptoms, level of education, and employment status. Furthermore, we tested whether these relationships differed between realistic raters and over- and underestimators. RESULTS: We found domain-specific relations for attention and executive functions for the full sample, explaining a small proportion of variance of SCI (general dominance index = .03 and .004), whereas ASM adverse events and psychological variables were more important predictors. When dividing the sample according to the concordance of SCI and OCI, we found high frequencies of both over- (23%-46%) and underestimation (31%-35%) depending on the domain. The explanatory power of OCI for SCI was stronger within the subgroups compared to the full sample, suggesting nonlinear relationships and different underlying mechanisms for realistic raters, underestimators, and overestimators. SIGNIFICANCE: Domain-specific SCI and OCI are related, and both should be assessed with standardized instruments. These relationships differ between over- and underestimators as well as realistic raters. Based on the concordance of self-ratings and objective measures, tailored counseling and treatment should be offered.

Subjective cognition is linked to everyday functioning in epilepsy.

OBJECTIVE: Many people with epilepsy (PWE) suffer from reduced everyday functioning such as unemployment, relationship difficulties, or lifestyle limitations. To identify whether subjective cognitive impairment (SCI) is a potential source of these impairments, associations with restrictions of daily life (RDL) and reduced daily activities (DA) were examined. METHODS: In a prospective cross-sectional sample of 316 adult in-patients with epilepsy, multiple regression analyses were calculated predicting RDL and DA. The relationships between these two measures and SCI were controlled for age, sex, seizure frequency, presence of structural lesions, epilepsy duration, mono- vs polytherapy and adverse events of antiseizure medication (ASM), level of depressive and anxiety symptoms, education, and employment. We also checked for an interaction between depressive symptoms and SCI, to evaluate whether patients with more depressive symptoms are more vulnerable for unfavorable associations between SCI and RDL or DA, respectively. General dominance indices (GDIs) were calculated to compare predictors. RESULTS: Substantial SCI was present in 46% of our sample. SCI was independently associated with RDL and DA. Comparison of relative predictor importance revealed that SCI accounted for 23% of the total variance of RDL (GDISCI  = 0.12, R RDL 2  = 50%) and 24% of the total variance of DA (GDISCI  = 0.08, R DA 2  = 32%). SCI was among the two most important predictors in both models. PWE with more depressive symptoms had stronger associations between SCI and RDL or DA, respectively. SIGNIFICANCE: Subjective cognitive impairment represents a frequent concern in PWE and may have detrimental consequences for their everyday life. PWE with depressive symptoms may be at greater risk of unfavorable relationships between SCI and everyday functioning. Exchange and collaboration between professionals offering psychotherapeutic, neuropsychological, and psychosocial interventions are crucial to address the patients' individual needs.

Psycho-socio-clinical profiles and quality of life in seizure disorders: A cross-sectional registry study.

OBJECTIVE: This prospective study aimed at comparing quality of life (QoL) and psycho-socio-clinical profiles between patients with epilepsy, psychogenic nonepileptic seizures (PNES), and syncope. We also intended to identify predictors of QoL in these three seizure disorders. METHODS: A total of 245 inpatients (epilepsy n = 182, PNES n = 50, syncope n = 13) from a tertiary epilepsy clinic were included. Information on QoL as well as on psychological, sociodemographic, and clinical profiles was retrieved using questionnaires and medical records. Group comparisons on QoL and psycho-socio-clinical profiles were performed via analyses of variance, chi-square tests, and related post hoc tests. Predictors of QoL in epilepsy and PNES were determined using general linear modeling, which was not possible for syncope due to a small sample size. RESULTS: Patients with epilepsy, PNES, and syncope reported levels of QoL impairment that did not differ significantly between groups (p = 0.266). However, there were significant group differences regarding sex distribution (p < 0.001), seizure disorder duration (p = 0.004), seizure frequency (p = 0.019), current treatment with antiseizure medications (ASM) (p < 0.001), number of current ASM (p < 0.001), and adverse ASM events (p = 0.019). More depressive symptoms (p = 0.001), more adverse ASM events (p = 0.036), and unemployment (p = 0.046) (in this order) independently predicted a diminished QoL in epilepsy. For PNES, more depressive symptoms were the only independent predictor of lower QoL (p = 0.029). CONCLUSIONS: Patients with epilepsy, PNES, and syncope experience similarly diminished QoL and show a general psycho-socio-clinical burden with a specific pattern for each seizure disorder diagnosis. Although clinical aspects play an undisputed role for QoL in epilepsy, the psychosocial aspects and consequences are equally, or for PNES probably even more, meaningful. A comprehensive approach to research and treatment of seizure disorders seems mandatory to increase QoL for these patients. More research on QoL in syncope is needed.

Perceived epilepsy-related stigma is linked to the socioeconomic status of the residence.

Purpose: Epilepsy is one of the most common neurological disorders with high costs for the healthcare systems and great suffering for patients. Beyond seizures, psychosocial comorbidities can have detrimental effects on the well-being of people with epilepsy. One source of social stress and reduced quality of life is epilepsy-related stigma that often occurs, e.g., due to public misconceptions or myths. Stigma has individual biological, psychological and social correlates. Moreover, environmental factors like living in remote areas are associated with stigma. However, little is known about the link between the social structure of the residence and stigma in epilepsy. Thus, we investigated the association between the structural socioeconomic status (SES) and perceived stigma in an urban epilepsy population. Methods: This prospective, cross-sectional study examined 226 adult in-patients with epilepsy from Berlin. Multiple regression analyses were performed to check the relationship between structural SES and stigma controlling for individual-level demographic, clinical, psychological and social factors. Continuous social indices (SI) of the districts and neighborhoods ("SI district" and "SI neighborhood") of Berlin were used to measure different levels of structural SES. Non-linear relationships are tested by grouping the SI in quartiles. Results: Both indicators of structural SES were independently linked to stigma (p = 0.002). For "SI district", we identified a non-linear relationship with patients from the most deprived quartile feeling less stigmatized compared to those in the second (p < 0.001) or least deprived quartile (p = 0.009). Furthermore, more restrictions of daily life (p < 0.001), unfavorable income (p = 0.009) and seizure freedom in the past 6 months (p = 0.05) were related to increased stigma. A lower "SI neighborhood" was associated with higher stigma (p = 0.002). Conclusion: Strategies to reduce epilepsy-related stigma need to consider the sociostructural living environment on different regional levels. Unfavorable relations with the immediate living environment may be directly targeted in patient-centered interventions. Non-linear associations with the structural SES of broader regional levels should be considered in public education programs. Further research is needed to examine possible underlying mechanisms and gain insight into the generalizability of our findings to other populations.

Assessment of dementia in a clinical sample of persons with intellectual disability.

BACKGROUND: Assessment of age-associated disorders has become increasingly important. METHODS: In a clinical setting, people with intellectual disability with and without dementia were assessed retrospectively using the Neuropsychological Test Battery (NTB) and the Dementia Questionnaire for People with Learning Disabilities (DLD) at two different times to analyse neuropsychological changes and diagnostic validity. One group (n = 44) was assessed with both instruments, while the DLD was applied in 71 patients. RESULTS: In the NTB (n = 44), only patients with dementia (n = 26) showed a decline in the NTB total score and three subscales. Receiver operating characteristic analysis revealed a diagnostic sensitivity of .67, a specificity of .81, and an area under the curve (AUC) of .767. In the DLD group (n = 71), only those with dementia displayed a decrease in the cognitive and social scale; diagnostic sensitivity and specificity values were low (.61/.63) and the AUC was .704. CONCLUSIONS: Neuropsychological assessment was sensitive to detect cognitive changes over time. Sensitivity values of both instruments suggest a reassessment at a later time point.

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.

Cortisol modulates men's affiliative responses to acute social stress.

The dominant characterization of the physiological and behavioral human stress reaction is the fight-or-flight response. On the other hand, it has been suggested that social affiliation during stressful times ("tend-and-befriend") also represents a common adaptive response to stress, particularly for women. In the current study, we investigate the extent to which men may also show affiliative responses following acute stress. In addition, we examine a potential neuroendocrine modulator of the hypothesized affiliative response. Eighty male students (forty dyads) were recruited to undergo either the Trier Social Stress Test for Groups (TSST-G) or a non-stressful control situation. Subsequently, participants completed a dyadic interaction task and were then asked to report their feelings of psychological closeness to their interaction partner. Although participants assigned to the stress condition did not differ overall on psychological closeness from participants assigned to the control condition, participants with high cortisol responses to the stressor showed significantly higher ratings of psychological closeness to their interaction partner than participants with low cortisol responses. Our findings suggest that men may form closer temporary bonds following stressful situations that are accompanied by a significant cortisol response. We suggest that the traditional characterization of the male stress response in terms of "fight-or-flight" may be incomplete, and that social affiliation may in fact represent a common, adaptive response to stress in men.