Ecological relevance of the Iowa gambling task in patients with Alzheimer's disease and mild cognitive impairment.

BACKGROUND: In spite of their extensive use, the ecological relevance of tasks dedicated to assessing real-world decision-making in a laboratory setting remains unclear. OBJECTIVES: Our study aimed to evaluate the relationship between decision-making and behavioral competency and awareness of limitations. METHODS: A total of 20 patients with Alzheimer's disease (AD), 20 with amnestic mild cognitive impairment (aMCI) and 20 healthy controls (HC) were assessed for decision-making using the Iowa Gambling Task (IGT). Behavioral competency was evaluated by the Patient Competency Rating Scale (PCRS), which requires each participant and a relative to answer the same 30 questions on participant's competency and to rate each item, while awareness of limitations was evaluated by subtracting the self-rated score from the relative-rated score. RESULTS: Using the median-split approach, the proportion of disadvantageous decision-makers was higher in both the MCI and AD groups than in HC (P=0.02 and P=0.03, respectively), with no differences between clinical groups. The percentage of participants with poorer behavioral competency was also higher in the MCI and AD than in the HC (self-rated: P=0.025 and P=0.01, respectively; relative-rated: P=0.008 and P=0.008, respectively), again with no differences between MCI and AD. All groups were comparable in awareness. For all participants, disadvantageous decision-making was associated with both reduced behavioral competency and poor awareness of limitations (OR: 3.47, P=0.03 and OR: 5.4, P=0.004, respectively). CONCLUSION: Our findings support the ecological relevance of the IGT. Behavioral competency integrity and awareness of limitations are both associated with advantageous decision-making profiles.

A multidimensional approach to impulsivity in Parkinson's disease: measurement and structural invariance of the UPPS Impulsive Behaviour Scale.

BACKGROUND: Poor impulse control is a common feature in patients with Parkinson's disease (PD). However, before testing whether patients with PD and controls differ in impulsivity, one must assess whether impulsivity measures are invariant across groups. Consequently, we examined (a) the measurement and structural invariance of a scale assessing changes in four dimensions of impulsivity (urgency, lack of premeditation, lack of perseverance and sensation seeking) among patients with PD and controls; and (b) whether the four impulsivity traits relate differentially to risky decisions by patients. METHOD: Close relatives of 78 patients with idiopathic PD and 96 control participants were given the short Urgency-Premeditation-Perseverance-Sensation seeking Impulsive Behaviour Scale (UPPS), which assesses changes in four dimensions of impulsivity. Participants also completed the Game of Dice Task (GDT), a laboratory measure of risk taking. RESULTS: Multigroup confirmatory factor analyses supported measurement invariance across groups, whereas structural invariance was not confirmed. Patients with PD showed greater variability and higher impulsivity than controls. Furthermore, patients with impulse control disorders (ICDs) demonstrated even greater levels of sensation seeking than patients without ICDs. Finally, lower premeditation and greater perseverance were significantly associated with greater risk taking in patients with PD, and higher agonist dopaminergic doses with less risky choices on the GDT. CONCLUSIONS: The questionnaire appears to function comparably across patients and controls. Thus, group comparisons on the questionnaire can be considered valid. Mean differences between groups on the dimensions of impulsivity may reflect executive impairments and/or abnormal reward processing in patients with PD, which may lead to risky behaviours.

Increased tobacco and alcohol use among women with joint hypermobility: a way to cope with anxiety?

Joint hypermobility (JH) is a common trait of heritable disorders of the connective tissue which has been identified as a risk factor for anxiety states. Anxiety and other negative emotions lead some people to use tobacco and alcohol as a coping strategy. The purpose of this study was to examine JH in relation to the consumption of these psychoactive substances and the associated anxiety and coping strategies. A cross-sectional sample of 305 female college students completed self-administered questionnaires on JH, tobacco and alcohol use, state and trait anxiety, and coping strategies. The prevalence of JH in the final sample (N = 301) was 51.8 %. The percentage of smokers, smokers using tobacco to calm anxiety, at-risk drinkers, tobacco and alcohol users, and the number of standard drinks consumed per week were significantly higher among females with JH than among those without it. The percentage of participants with severe state anxiety was significantly higher in the JH group, as were the emotion-focused coping score. The results of the logistic regression analysis showed that the odds of being assessed with JH were greater in those who consume tobacco and alcohol. This study provides evidence that women with JH report higher levels of state anxiety than non-JH women and use emotion-focused coping (i.e., efforts to regulate affect) more than any other coping strategies to deal with stress. These factors may help explain the increase in tobacco and alcohol use observed in this population.

[The clinic of apathy in schizophrenia: a critical review of the issue]. / L'apathie dans la schizophrénie: une revue clinique et critique de la question.

INTRODUCTION: Today the concept of apathy is subject to many questions. This psychological state is present and predominant in different disorders such as neurodegenerative and psychiatric diseases or neurological acquired disorders. Apathy is a part of the clinical vocabulary, however, we can note that in the literature there remains confusion in its definition, and we can find an amalgam with other clinical symptoms. OBJECTIVES: The aim of this review is to provide a clarification of the concept of apathy in clinical practice in schizophrenia as well as to highlight the gaps that exist. LITERATURE FINDINGS: Apathy belongs to the negative symptoms of schizophrenia. For its understanding, it is necessary to define apathy as a multidimensional syndrome (cognitive, emotional, and behavioral) manifesting as a quantitative reduction of voluntary behaviors directed toward one or several goals. However, at present, we are witnessing a reductionist and simplistic conception of the syndrome of apathy and this especially in the Anglo-Saxon literature. Several authors reduce apathy to its behavioral component, so in other words, to avolition/amotivation. Avolition refers to a loss of self-initiated and spontaneous behaviors. In this definition only observable behavior is taken into account and not the underlying mechanisms (cognitive and emotional). In order to understand the syndrome of apathy, it is necessary to have a holistic and multidimensional outlook. Some authors have proposed diagnostic criteria for apathy by taking into account the different dimensions of apathy. Moreover not only is apathy confused with avolition, but it is also still difficult to distinguish it from depression. Apathy and depression share common clinical signs (i.e. loss of interest), but they also have distinct clinical signs (lack of motivation for apathy, and suicidal ideation for depression). Authors have shown that the presence of one symptom (apathy or depression) does not predict the presence of the other. An apathetic patient does not have to be necessarily in a depressive state and vice versa. However, to our knowledge, there is no data capable of distinguishing depression from apathy in schizophrenia, and knowing what is the part of one and the other when the patient has both symptoms. In addition, we can see that the confusion that persists between those two symptoms also stems from assessment tools. Indeed, some assessment tools such as the Montgomery and Asberg Depression Rating Scale (MARDS) have an apathy subscale. Therefore, this scale does not only evaluate depression. Regarding the assessment of apathy in schizophrenia, there are specific and nonspecific tools. Nonspecific tools define apathy differently. For this reason, authors have proposed to measure apathy by using analytic factors of negative symptoms. In this case, apathy is going to be assessed by the factor "motivation/pleasure" including anhedonia, asociality and avolition. This factor will provide the possibility of a better assessment of apathy. Concerning specific scales (like AES), there are gaps such as a lack of standardization in the execution and the quotation. Furthermore, no scale takes into account the factors causing apathy. CONCLUSION: Knowing the reasons for apathy is necessary because this syndrome is frequent in schizophrenia, and it is found in the different phases of this disease (prodromal, first episode psychosis, and chronic). In addition, apathy has significant functional consequences on the patient's quality of life, as well as on his or her global functioning. Indeed, apathy impacts on his or her social and professional life. Patients with schizophrenia have a loss of autonomy, less employment and social withdrawal. Consequently, interest in its drug or treatment it is obvious. However, drug and non-drug treatments are not specific to apathy and therefore little effective on this syndrome. Implications to stimulate future research are presented.

[Evolution of the concept of apathy: the need for a multifactorial approach in schizophrenia]. / Évolution du concept d'apathie: nécessité d'une approche multifactorielle dans la schizophrénie.

BACKGROUND: Schizophrenia is a chronic and severe mental illness that affects over 1% of the population, characterized by multiple symptom dimensions. One of this class of symptoms, "negative symptoms", have received more attention over the last few years. Negative symptoms, including among others blunted affect, withdrawal or apathy, are particularly important for recovery and are associated with negative functional outcomes, such as inability to get an employment and conduct normal daily living activities. While positive symptoms are usually treated by antipsychotic drugs, negative symptoms are usually persistent, which indicates the need for better treatment. The aim of this article is to highlight recent scientific progress on apathy and to explore current multidimensional approaches of this concept in schizophrenia. Apathy is a symptom frequently encountered in schizophrenia and in many neurological disorders. Therefore, it can be regarded as a transnosographic symptom. LITERATURE FINDINGS: A long time considered as a loss of motivation (psychological concept hard to define), recent descriptive and etiological models have proposed to consider apathy as a multidimensional phenomenon. Marin et al., have proposed a model of apathy in reference to the motivation concept. Marin et al.'s apathy model is composed of three dimensions: firstly, cognitive dimension, secondly, sensory-motor dimension and thirdly, affective dimension. These authors propose to differentiate "apathy syndrome" from "apathy symptom". "Apathy syndrome" resulting from a lack of motivation whereas "apathy symptom" results from cognitive and/or emotional/affective disorders. In addition, Marin et al. propose that apathy syndrome corresponds to the "lack of motivation" not attributable to diminished level of consciousness, cognitive impairment or emotional distress. Following this proposal, Levy and Dubois propose to define apathy as a quantitative reduction of self-generated, voluntary and purposeful behaviors. It is therefore observable and can be quantified. Levy and Dubois have proposed an apathy model considering: firstly, apathy as a syndrome related to reduction in goal-directed behaviors; secondly, anatomically, apathy can be secondary to dysfunctions or lesions of the prefrontal cortex. Since the prefrontal cortex is functionally and anatomically heterogeneous, subtypes of apathy occur in diseases affecting the basal ganglia, because these diseases disrupt associative and limbic pathways from/to the prefrontal cortex; thirdly, from a pathophysiological point of view, apathy may be explained by the impact of lesions or dysfunctions of the basal ganglia, because these lesions or dysfunctions lead to a loss of temporal and spatial focalization, both of which result in a diminished extraction of the relevant signal within the frontal cortex, thereby inhibiting the capacity of the frontal cortex to select, initiate, maintain and shift programs of action.

Joint hypermobility syndrome: problems that require psychological intervention.

Joint hypermobility syndrome (JHS), also known as Ehlers-Danlos III, is an inherited disorder of connective tissue, characterised by an exceptional increase in the joint's mobility and the presence of musculoskeletal and other symptoms. It is a benign syndrome if compared with the other types of Ehlers-Danlos, but it can become disabling particularly because it is a significant source of pain and distress. The purpose of this work is to describe some common problems in JHS that render psychological intervention in their overall management relevant. Chronic pain, associated psychopathological factors such as anxiety, depression and somatosensory amplification, and problems arising from a lack of recognition and knowledge of the syndrome, are frequent among those affected, having a negative impact on their quality of life. We emphasise the relevance of addressing JHS from a biopsychosocial approach.

[Learning potential and cognitive remediation in schizophrenia]. / Potentiel d'apprentissage et revalidation cognitive dans la schizophrénie.

BACKGROUND: Many studies have stressed the importance of neurocognitive deficits in schizophrenia that represent a core feature of the pathology. Cognitive dysfunctions are present in 80% of schizophrenic patients, including deficits in attention, memory, speed processing and executive functioning, with well-known functional consequences on daily life, social functioning and rehabilitation outcome. Recent studies have stressed that cognitive deficits, rather than the positive or negative symptoms of schizophrenia, predict poor performance in basic activities of daily living. If it is possible to reduce psychotic symptoms and to prevent relapses with antipsychotic medication, it is not yet possible to have the same convincing impact on cognitive or functional impairments. Cognitive remediation is a new psychological treatment which has proved its efficacy in reducing cognitive deficits. A growing literature on cognitive rehabilitation suggests possibilities that in schizophrenia, specific techniques are able to enhance an individual's cognitive functioning. LITERATURE FINDINGS: Presently, two distinct and complementary cognitive remediation methods have been developed: the compensatory and the restorative approaches: (A) restorative approaches attempt to improve function by recruiting relatively intact cognitive processes to fill the role of those impaired, or by using prosthetic aids to compensate for the loss of function; (B) in contrast, in the restorative approach cognitive deficits are targeted directly through repeated practice training. However, results concerning cognitive remediation remain inconsistent. It is clear that not all individuals with schizophrenia display cognitive impairment, and even among those who do, the specific pattern of cognitive functioning varies. Moreover, traditional neurocognitive assessment, with a single or static administration of cognitive measures, provides moderately good prediction of skills acquisition in schizophrenia. Among other factors such as motivation, awareness of having a disease and acuteness of symptomatology, some studies have exposed that a cognitive variable, learning potential could mediate in part the effectiveness of cognitive remediation. DISCUSSION: The concept of learning potential is used to explain some of the observed variability in cognitive functioning. Learning potential is the ability to attain and utilize cognitive skills after cognitive training: it is assessed by individual variation in performance across three consecutive administrations of the Wisconsin Card Sorting Test (WCST): a pretest with standard instruction procedures, a training phase with expanded instruction and a post test with only standard instruction. Three learner subtypes can be identified: "learners" who perform poorly at the pretest but improve performance during the post-test, "non-retainers" who perform poorly at pre-test and do not improve at post-testing and "high achievers" who perform well in the initial pretest and maintain their good performance across the other two administrations. The assessment of learning potential could predict, with other psychological measures such as insight and motivation, the most effective neurocognitive rehabilitation program for an individual patient, and could help the clinician to optimize patient outcome through appropriate individual management. CONCLUSION: Indeed, learning potential could represent a good cognitive predictor and indicator for rehabilitation in schizophrenia for clinicians and should be used in cognitive assessment practice. However, the individuals most likely to benefit from cognitive remediation, and whether changes in cognitive function translate into functional improvements, are as yet unclear.

[Lack of insight in schizophrenia: a review]. / La conscience des troubles (insight) dans la schizophrénie : une revue critique Partie II : modèles explicatifs et hypothèses psychopathologiques.

BACKGROUND: Relative to other psychiatric disorders, patients with schizophrenia are often unaware of the consequences of their disease and their need for treatment. These deficits in awareness referred in general in the English literature as "poor insight", have been the focus of many clinical studies over recent years. This phenomenon, which is considered as fundamental in clinical evaluations of schizophrenia, should be understood as a multidimensional process rather than a dichotomic phenomenon, as is presently the case. The links between insight deficits and responses to vocational rehabilitation efforts represent a major interest in research, including those related to medication compliance and clinical outcome. To conduct such studies, various evaluation tools have been developed, enabling the assessment of insight, of its time-course and of its components in psychosis and schizophrenia spectrum disorders. LITERATURE FINDINGS: The Scale to Assess Unawareness of illness in Mental Disorders (SUMD) developed by Amador and Strauss appears to be the most frequently used scale for the evaluation of awareness of the disorder in schizophrenia. Although the model proposed by Amador and Strauss is considered as the privileged model in the multidimensional approach of insight, it corresponds only to a phenomenological analysis of this concept. In the second part of this article, we thus review the current models attempting to explain the lack of insight in schizophrenia. Four current explanatory models of lack of insight will be described as follows: resulting either from adaptation or defence mechanisms to environmental stressors, resulting from cognitive bias of data processing, resulting from neuropsychological functional deficits and resulting from metacognitive deficits. DISCUSSION: Several hypotheses concerning these deficits arise from clinical studies. Although coping, and defence mechanisms to the consequences and stigmatization of the disease were hardly studied, the fact that poor insight does not appear related to the severity of symptomatology or to the emotional state of the patients argue against this hypothesis. Conversely, a considerable body of literature emphasized how unawareness may result from cognitive deficits. Research in neuropsychology and cognitive psychology has provided consistent results concerning the link between deficit in executive functions, frontal lobe dysfunction and poor insight. Recent studies on bias in cognitive information treatment and social cognition theories currently open new prospects.

[Lack of insight in schizophrenia: a review. Part I: theoretical concept, clinical aspects and Amador's model]. / La conscience des troubles (insight) dans la schizophrénie : une revue critique. Partie I : insight et schizophrénie, caractéristiques cliniques de l'insight.

INTRODUCTION: Schizophrenia is the psychiatric disorder in which the awareness of pathology (or insight) is most frequently altered. LITERATURE FINDINGS: A review of the literature shows that between 50 and 80% of patients with schizophrenia do not believe they have a disorder. Studies published on this subject over the two last decades stressed the specificity of this phenomenon in schizophrenic patients, taking into account both its prevalence and its clinical consequences comparatively to other mental disorders. If in bipolar disorders a lack of insight is linked with the intensity and acuteness of symptomatology, there is only a limited relationship between these factors in schizophrenia, thus making lack of insight a trait rather than a state-related symptom. DISCUSSION: Though defined for a very long time as a dichotomic phenomenon, the recent interest on insight in psychosis and the development of assessment tools for its evaluation have made it possible to underline its multifactorial and dynamic characteristics. Although lack of insight related to pathologies may vary across time in bipolar disorders, the results of clinical studies suggest that this phenomenon remains stable in schizophrenia. CONCEPTUAL PROPOSALS: In this review, we will reconsider the evolution of this concept in psychiatry and its definition. The clinical characteristics, which are specifically associated with the lack of insight in schizophrenia will be outlined. We will describe more specifically the model of Amador and Strauss and their assessment tool: the Scale to Assess Unawareness of Mental Disorder (SUMD). This model developed since the 1990s takes into account the time-related evolution of insight, and can be applied both to bipolar and psychotic disorders. ASSESSMENT TOOLS: The SUMD has six general items and four subscales. The general items estimate the three most widely used definitions of insight: awareness of having a mental disorder, awareness of the achieved effects of medication and awareness of the social consequences of having a mental disorder, and include assessment of both current and past-time periods. Four other subscales, each composed of 17 items, assess awareness and attribution of specific current and retrospective symptoms as well as deficits associated with severe mental disorders. Insight, thus, appears as a multidimensional and continuous phenomenon, since patients' awareness may apply only to part of their symptoms and vary over time. In this article, we will review existing scales assessing insight in schizophrenia. The deficiency of available scales validated in French limits the number of scientific publications concerning this important aspect of the clinical evaluation of schizophrenic patients. THERAPEUTICAL ASPECTS: Finally, interventions to improve insight in patients with schizophrenia are presented. Recent studies have shown cognitive behavioural therapy (CBT) to be of benefit in the treatment of poor insight in schizophrenia. CONCLUSION: Evidence suggests that early diagnosis and treatment of schizophrenia leads to better prognosis. An important suggestion from theses studies may be that psychosocial therapy needs to focus on explanations that are in tune with the culture, rather than focus on diagnostic labels.

[Mild cognitive impairments in the elderly: a critical review]. / Les troubles cognitifs légers de la personne âgée: revue critique.

The aging of the population leads to increased awareness of problems associated with age-related degenerative dementias. Given that these dementias are progressive in onset, many clinicians and researchers have proposed criteria that allow for the identification of older subjects manifesting cognitive impairment, but not responding to the criteria for dementia. Our knowledge of subjects with mild cognitive impairment is limited; it is, however, established that they present a high risk of developing dementia in the future. Although it is essential to increase our comprehension of their cognitive and functional decline, the study of subjects presenting mild cognitive impairment is compromised due to the existence of numerous non-converging classifications. The goal of the present article is to conduct a critical review of the different classifications of mild cognitive impairment in the elderly in order to attempt to identify the optimal criteria, allowing for a distinction to be made between subjects with mild cognitive impairment, who remain in a stable state and those whose condition evolves to a dementia. These criteria may enable us to describe a homogenuous group of individuals presenting with different rates of dementia risk factors. We present the classifications most frequently used in clinical and research settings. After listing them according to categorial, clinical or dimensional approaches, we performed a critical analysis for each one. Depending on the diagnostic criteria applied, major variations are revealed for the prevalence of cognitive impairment and the incidence of dementia. They are explained by methodological and theoretical shortcomings that we point out and discuss (e.g., reference group, lack of diagnostic criteria or exclusion criteria, high level of subjectivity). Beyond these criticisms, we discuss the challenges to be met in order to reach the optimal identification criteria. Notably, the impact of mild cognitive impairment on daily living activities should be tested with the use of more specific questionnaires/tasks. The goal of the objective definition of cognitive impairment should be to minimize subjectivity in the diagnosis. It is also suggested that sensitive cognitive measures would be used on all aspects of cognition, while recognizing and taking into account all confounding factors (e.g., age, education level). Given the nature and consequences of mild cognitive impairment, an inter-disciplinary approach is suggested (e.g., neurobiological, psychiatric, and genetic cues). A consensus on optimal diagnostic criteria is essential to propose cognitive and pharmacological treatments for the effective prevention of ementia.

[Management of memory disorders in anxious patients consulting a memory clinic]. / Troubles de mémoire des sujets anxieux dans les consultations de mémoire et prise en charge.

The proportion of patients consulting pluridisciplinary memory clinics who present anxiety disorders varies with recruitment and referral practices but often exceeded 10p.100. Most of these subjects have an anxiety trait or stress-related generalized anxiety, often triggered by diagnosis of Alzheimer's disease in a close friend or relation. The consultant should play special attention to analyzing the complaint in order to disclose difficulties in attention, true "loss of memory" events, and any recent traumatic events. The psychometric examination is generally normal or evidences discrete frontal dysfunction. Other diagnoses should be ruled out: associated depression, iatrogenic effect, alcoholism, anxiety as a sign of a somatic disease. Management may include drugs, usually on a short term regimen. Short-term psychotherapy or group therapy may be helpful.

[Effects of cognitive aging on memory performances]. / Effet du vieillissement cognitif sur les performances mnésiques.

PSYCHOLOGY OF AGING: This article sums up studies on influence of normal aging in memory. Aging is a process involving many dimensions: Psychological, Biological and Social. These elements interact with each other and needed to be considered in the description of human memory aging. COGNITIVE APPROACH OF HUMAN MEMORY: Moreover, researches on human memory have been conducted within the framework of current theoretical views of memory. The present review provides an outline of the cognitive neuropsychology models of memory, its nature, components and organization. CLINICAL APPROACH OF AGING AND MEMORY, CONSEQUENCES: This introduction may help the reader to understand more clearly empirical evidence of age-related differences in memory and attentional functioning. In closing, the human factors psychologists must be take in account while adopting a global approach of the understanding of memory aging. Psychological field provides a complete structure for assessing human being and is helpful before to conclude between normal or pathological memory aging.

[Early diagnosis of Alzheimer disease]. / Le diagnostic précoce de la maladie d'Alzheimer.

On of the major challenges for public health in developed countries for the 21st century is that of aging, and in particular Alzheimer's disease. Progress has been made in the development of symptomatic treatment and prevention and early diagnosis of Alzheimer's disease is becoming mandatory. In the present state of our knowledge, no marker for early diagnosis has been described. However, the combined use of clinical observations (behavioral and neuropsychological features) and complementary information (brain morphology and functional imaging, biological data, neurophysiology explorations) could be helpful for early diagnosis of Alzheimer's disease well before the onset of dementia.

[Methodology of neuropsychological evaluation in memory clinics]. / Méthodologie de l'évaluation neuropsychologique dans les consultations de la mémoire.

Cognitive assessment in memory clinics requires selection of the appropriate tests according to several criteria such as (a) sensitivity and specificity for diagnosis purpose, (b) equivalence of test forms for follow-up purposes, (c) pragmatic aspects (acceptability, duration), (d) theoretical background. Clearly, there is not any single test available that can satisfy all these requirements. Clinical experiences from many groups involved in memory clinics were collected and compared in order to try and identify strategies to improve and, it was hoped, to make uniform various methods for memory assessment. Indeed, early diagnosis, a condition sine qua non for better treatment, should benefit from such uniform and theory-based assessment across French-speaking countries.