Do specific neurocognitive deficits predict specific domains of community function in schizophrenia?

We examined whether specific neurocognitive deficits predicted specific domains of community outcome in 40 schizophrenic patients. Neuropsychological assessments were conducted before hospital discharge, and measures of functional outcome were obtained 1 to 3.5 years later. A priori hypotheses were generated based upon a recent review by Green (Green MF [1996] What are the functional consequences of neurocognitive deficits in schizophrenia? American Journal of Psychiatry, 153(3):321-330). As hypothesized, verbal memory predicted all measures of community outcome, vigilance predicted social outcomes, and executive functioning predicted work and activities of daily living (ADLs). However, in addition to the predicted relationships, many other associations were found between neuropsychological test scores and adaptive function. Furthermore, both cognitive and functional measures were intercorrelated. If deficits in adaptive functioning are neurocognitively multi-determined, utilizing compensatory strategies to bypass multiple areas of cognitive impairment may be more efficient than cognitive remediation in improving community outcomes.     

Do cognitive deficits in juvenile bipolar disorder persist into adulthood?

This article reviews neuropsychological research in adults with bipolar disorder and compares the findings with emergent data on neuropsychological function in juvenile bipolar disorder. Despite a recent surge of interest in childhood onset bipolar disorder, there remains a scarcity of neuropsychological literature investigating this population. From the study of adult bipolar disorder a substantial body of literature points to the existence of trait deficits in verbal and executive function that are detectable even during euthymia. In the nascent literature on neuropsychology in early onset bipolar, there is growing evidence to suggest that some of the deficits apparent in adults are also discernible in adolescents. Precise knowledge about when, how, and why these deficits appear requires future research of prodromal changes in neurocognition in childhood and adolescent bipolar disorder.     

Do sphenoidal electrodes aid in surgical decision making in drug resistant temporal lobe epilepsy?

ObjectiveThe utility of sphenoidal electrodes (SPh) in analyzing interictal epileptiform discharges (IEDs) and ictal electrography remains controversial, despite its widespread use.MethodsOne hundred and twenty-two consecutive patients with presumed temporal lobe epilepsy (TLE) who underwent presurgical evaluation were prospectively studied. SPh and Silverman’s electrodes were placed, in addition to routine electrodes in 10–20 international system. IEDs and ictal electroencephalography (EEG) were analyzed separately in bipolar and referential montages. The proportion of patients selected for surgery after adjusting for SPh placement based on the earlier ictal onset and IEDs were analyzed.ResultsOf the 8701 IEDs in SPh, only 65% were seen over the scalp bipolar montage; 1392 (16%) IEDs were confined to SPh electrodes, and were not seen at scalp bipolar montage (p < 0.001). Spike amplitudes were highest at SPh (p < 0.001). Of the 592 seizures analyzed, 62 (61%) had simultaneous SPh and scalp onset, while in 26 (25%) SPh onset preceded the scalp.ConclusionsOut of the 35 patients with unilateral mesial temporal sclerosis (MTS) with additional neocortical changes and/or non-lateralized bitemporal IEDs and/or diffuse ictal onset (group 1), 27 were selected for surgery (77%). About 7% was selected for surgery in this group by SPh placement. Also, in patients with bilateral MTS (group 2), 25% (5/20) were chosen for anterior temporal lobectomy, SPh provided an additional benefit in 11% (p < 0.001). Patients with normal magnetic resonance imaging (group 3) and temporal plus epilepsy (group 4) had a lower surgical yield, only 12% and 9.5% could undergo surgery. They were denied surgical candidacy with SPh (p < 0.001).SignificanceOne-third of patients after SPh placement were selected for resective surgery obviating the need for invasive monitoring. The maximum yield was noted in unilateral MTS (associated with additional neocortical features or non-lateralized bilateral temporal interictal IEDs or diffuse ictal onset in scalp EEG) and in bilateral MTS. Those with normal MRI/temporal plus epilepsy could be excluded from direct resective surgery.     

Are there reliable neuropsychological deficits in obsessive-compulsive disorder?

The aim of this study was to confirm in a large clinical sample that subjects with obsessive-compulsive disorder (OCD) have deficits on certain tasks of executive functioning, non-verbal memory, and/or motor speed. Our ultimate goal was to evaluate whether these deficits contribute to functional impairment and could be the target of a novel treatment intervention. Therefore, in a sample of convenience, the clinical characteristics and neuropsychological performance of adults with OCD and matched healthy controls were evaluated; neuropsychological tasks of executive functioning, non-verbal memory, and motor speed that have shown strong effects in prior studies were used. Primary analyses compared subjects with current OCD only (current-OCD, n=30), subjects with current OCD plus a comorbid disorder (comorbid-OCD, n=15), subjects with a history of OCD (n=15), and matched healthy controls (n=35). Secondary analyses examined whether clinical characteristics (e.g., OCD severity or medication status) were associated with neuropsychological performance. We found no significant overall differences in neuropsychological performance among the four groups. In pairwise comparisons, current-OCD subjects differed significantly from healthy controls only on the Benton Visual Retention Test. OCD severity had little effect and medication status had no effect on neuropsychological performance. In sum, contrary to our expectations, we found few differences in neuropsychological performance between OCD subjects and healthy controls. Whether there are reliable neuropsychological deficits in OCD that can be easily identified in a clinical sample and that contribute to functional impairment remains unclear and requires further study.     

Does actigraphy differentiate ADHD subtypes in a clinical research setting?

OBJECTIVE: To compare subtypes of attention-deficit/hyperactivity disorder (ADHD) (predominantly inattentive and combined types) and a comparison group on an objective measure of activity level (actigraphy). METHOD: Actigraphs were worn by 64 children (49 boys, 15 girls) during a full-day clinical diagnostic assessment; 20 subjects had a diagnosis of ADHD predominantly inattentive type, 22 had ADHD combined type, and 22 were non-ADHD controls. Mean actigraph scores were calculated for two 2-hour intervals, comprising, respectively, a psychometric evaluation in the morning and the completion of a speech and language assessment and research measures in the afternoon. RESULTS: There were no significant group differences in activity level in the morning session. During the afternoon session, children with ADHD were significantly more active than controls, but there were no differences between ADHD subtypes. CONCLUSIONS: These data partially support specifications in the DSM-IV regarding hyperactivity in ADHD; however, they also indicate that situational and/or temporal factors may affect the degree to which hyperactivity is expressed. Furthermore, the findings contradict specifications in the DSM-IV that suggest that children with ADHD combined type should be more hyperactive than children with ADHD predominantly inattentive type.     

Informed shared decision making in multiple sclerosis--inevitable or impossible?

Patients and health authorities increasingly claim active roles in health care decision making processes. As immune therapies in MS are partially effective MS is a prototypic condition for a shared decision making process. The treatment of acute relapses and the initiation, change or withdrawal of so called disease-modifying treatments are key decisions in MS management. We developed two decision aids following the phased approach of the framework of increasing evidence for complex interventions for these key decisions. In prestudies we found that 80% of MS patients demand autonomous roles in treatment decisions which contrasts with a poor knowledge of risks. On the other hand MS patients are not disturbed by evidence-based, balanced complex information. MS patients do understand this kind of information and are able to transfer new abilities to other situations. Currently we study the effects of a 4-hour education programme on relapse management versus an information leaflet in controls in 150 MS patients. In a second trial with n=298 MS patients we study the effects of an evidence-based patient information on immunotherapy on decisional role preference and performance in the patient physician encounter. Results in early 2007 will show to which extent patient education with a focus on evidence-based patient information influences participation in the decision making process.     

Assessing cognitive deficits in bipolar disorder: are self-reports valid?

Patients with affective disorders frequently report problems with attention, concentration and memory, although little research has investigated subjective cognitive complaints relative to objective neuropsychological deficits. We compared subjective (self-rated) cognition and objective (clinician-rated) neuropsychological functioning in 37 DSM-IV bipolar outpatients. Subjects completed three standardized self-report inventories: the Cognitive Difficulties Scale (CDS), Cognitive Failures Questionnaire (CFQ), and Patient's Assessment of Own Functioning (PAOF). These were followed by a systematic neuropsychological test battery. More than 75% of our sample of bipolar patients displayed some cognitive deficits, most notably in the domains of verbal learning and memory. In general, patients' self-reports of impairment failed to reliably predict objective neuropsychological deficits. Mood ratings for mania and depression were not significantly correlated with any of the self-report inventories or the objective neuropsychological variables. The findings suggest that most bipolar patients demonstrate objective signs of cognitive impairment, but they are unable to report them accurately, at least using available self-report inventories. Such discrepancies could relate to impaired insight, efforts to conceal deficits, or to subthreshold affective symptoms.     

Executive functions in obsessive-compulsive disorder: state or trait deficits?

OBJECTIVE: Despite the neuropsychology literature providing reliable evidence of impaired executive functions in obsessive-compulsive disorder (OCD), to date it has not been determined whether these deficits are trait-related (independent of symptomatology) or state-dependent (dependent on symptomatology). The current research examines the executive functions in OCD in a comprehensive manner and, for the first time, assesses the stability of these deficits over the developmental course of the disorder. METHOD: Using a cross-sectional design, Study 1 examined the executive functions (set shifting, inhibition, planning, verbal fluency and working memory) in 60 subjects (20 actively Symptomatic OCD, 20 Remitted OCD and 20 Panic Disorder). Using a longitudinal design, Study 2 reassessed a subsample of OCD subjects (participants in Study 1) once they reached remitted status. RESULTS: Study 1 found that the OCD groups exhibited deficits in set shifting and inhibition relative to Panic Disorder controls; however, no deficits were observed in planning, verbal fluency or working memory. There were no differences found between the Symptomatic and Remitted OCD groups on any of the executive function measures. Study 2 found that the identified executive function deficits in individuals were stable over time and remained unchanged despite symptom remittance. CONCLUSION: Current results confirm the presence of specific executive function deficits in OCD, and indicate that these deficits are trait-like in nature.     

Do cognitive measures of response inhibition differentiate between attention deficit/hyperactivity disorder and borderline personality disorder?

This study examined whether cognitive measures of response inhibition derived from the AX-CPT are able to differentiate between adult attention deficit/hyperactivity disorder (ADHD), borderline personality disorder (BPD), and healthy controls (HC). Current DSM-IV-TR symptoms of ADHD and BPD were assessed by structured diagnostic interviews, and parent developmental interviews were used to assess childhood ADHD symptoms. Patients (14 ADHD, 12 BPD, 7 ADHD and BPD, and 37 HC) performed the AX-CPT. Seventy percent of AX-CPT trials were target (AX) trials, creating a bias to respond with a target response to X probes in the nontarget (AY, BX, BY) trials. On BX trials, context, i.e. the non-‘A’ letter, must be used to inhibit this prepotent response tendency. On AY trials context actually causes individuals to false alarm. The effects of ADHD and BPD on AX-CPT outcome were tested using two-way ANOVA. BPD was associated with higher percentage of errors across the task and more errors and slower responses on BX trials, whereas ADHD was associated with slower responses on AY trials. The findings suggest response inhibition problems to be present in both ADHD and BPD, and patients with BPD to be particularly impaired due to poor context processing.     

Should schizophrenia be treated as a neurocognitive disorder?

The search is on for meaningful psychopharmacological and cognitive/behavioral interventions for neurocognitive deficits in schizophrenia. Findings in this area are emerging rapidly, and in the absence of integrating frameworks, they are destined to emerge chaotically. Clear guidelines for testing neurocognitive interventions and interpreting results are critical at this early stage. In this article, we present three models of increasing complexity that attempt to elucidate the role of neurocognitive deficits in schizophrenia in relation to treatment and outcome. Through discussion of the models, we will consider methodological issues and interpretive challenges facing this line of investigation, including direct versus indirect neurocognitive effects of antipsychotic medications, selection of particular neurocognitive constructs for intervention, the importance of construct validity in interpreting cognitive/behavioral studies, and the expected durability of treatment effects. With a growing confidence that some neurocognitive deficits in schizophrenia can be modified, questions that seemed irrelevant only a few years ago are now fundamental. The field will need to reconsider what constitutes a successful intervention, what the relevant outcomes are, and how to define treatment efficacy.     

Excessive Internet gaming and decision making: do excessive World of Warcraft players have problems in decision making under risky conditions?

The dysfunctional behavior of excessive Internet gamers, such as preferring the immediate reward (to play World of Warcraft) despite the negative long-term consequences may be comparable with the dysfunctional behavior in substance abusers or individuals with behavioral addictions, e.g. pathological gambling. In these disorders, general decision-making deficits have been demonstrated. Hence, the aim of the present work was to examine decision-making competences of excessive World of Warcraft players. Nineteen excessive Internet gamers (EIG) and a control group (CG) consisting of 19 non-gamers were compared with respect to decision-making abilities. The Game of Dice Task (GDT) was applied to measure decision-making under risky conditions. Furthermore psychological-psychiatric symptoms were assessed in both groups. The EIG showed a reduced decision-making ability in the GDT. Furthermore the EIG group showed a higher psychological-psychiatric symptomatology in contrast to the CG. The results indicate that the reduced decision-making ability of EIG is comparable with patients with other forms of behavioral addiction (e.g. pathological gambling), impulse control disorders or substance abusers. Thus, these results suggest that excessive Internet gaming may be based on a myopia for the future, meaning that EIG prefer to play World of Warcraft despite the negative long-term consequences in social or work domains of life.     

Do adolescent anorexia nervosa patients have deficits in emotional functioning?

Adult eating disorder patients have been characterised by alexithymia. We investigated whether adolescent eating disorder patients also show deficits in emotional functioning. To measure emotional functioning a questionnaire (the TAS) and an emotion recognition test were administered to 30 eating disorder (ED) adolescent girls and 31 healthy controls (HC), matched for age, education, and social status. Non-emotional, cognitive parallel tasks were administered on the same occasion to find out whether a possible deficit was emotion-specific or of a more general cognitive nature. The ED patients scored higher on the TAS and performed worse on the emotion recognition test, but no differences between the groups were found on the non-emotional cognitive instruments. It was concluded that adolescent eating disorder patients, just like adult eating disorder patients, are characterised by alexithymia and show specific deficits in emotional functioning. The implications of these findings are discussed. Accepted: 21 August 2001     

Does anxiety mitigate the behavioral expression of severe conduct disorder in delinquent youths?

The purpose of this article is to examine the purported attenuating effects of comorbid anxiety on conduct disturbance in a sample of youths exhibiting severe Conduct Disorder (CD). Further, we examined the differential expression of CD and comorbid anxiety in male and female youths. Seventy-nine incarcerated youths between the ages of 12 and 19 were interviewed using the Diagnostic Interview Schedule for Children. Youths were identified who exhibited CD and CD plus an anxiety disorder. In contrast to previous findings with younger, less seriously disturbed male subjects, no overall differences were found between CD anxious and CD nonanxious youths in terms of age of first offense and overall number and severity of delinquent acts. Moreover, no differences were found between males and females, and gender did not moderate the effects of comorbidity anxiety on outcome measures. Findings suggest purported mitigating effects of anxiety on conduct disturbance may be attenuated in severe forms of CD and support the notion that comorbidity across internalizing and externalizing domains of child and adolescent psychopathology may differentially impact clinical presentation of disordered behavior depending on the severity of externalizing behavioral disturbance.     

Do positive emotions predict symptomatic change in bipolar disorder?

Objectives:  Bipolar disorder is associated with positive emotion disturbance, though it is less clear which specific positive emotions are affected.
Methods:  The present study examined differences among distinct positive emotions in recovered bipolar disorder (BD) patients (n = 55) and nonclinical controls (NC) (n = 32) and whether they prospectively predicted symptom severity in patients with BD. At baseline, participants completed self-report measures of several distinct trait positive emotions. Structured assessments of diagnosis and current mood symptoms were obtained for BD participants. At a six-month follow-up, a subset of BD participants' (n = 39) symptoms were reassessed.
Results:  BD participants reported lower joy, compassion, love, awe, and contentment compared to NC participants. BD and NC participants did not differ in pride or amusement. For BD participants, after controlling for baseline symptom severity, joy and amusement predicted increased mania severity, and compassion predicted decreased mania severity at the six-month follow-up. Furthermore, amusement predicted increased depression severity and pride predicted decreased severity of depression. Awe, love, and contentment did not predict symptom severity.
Conclusions:  These results are consistent with a growing literature highlighting the importance of positive emotion in the course of bipolar disorder.     

Do larger studies find smaller effects? The example of studies for the prevention of conduct disorder

Introduction  There is some emerging evidence in medicine that larger clinical trials tend to be associated with smaller effect sizes. Much of the evidence-base currently informing practice in Child Psychiatry relies on relatively small trials. We therefore investigated the relationship between trial size and effect size in research within a key area of child mental health. Method  A recent systematic review of 20 trials of prevention of conduct disorder was subjected to meta-regression, to examine the relationship between study size and effect size, and to explore hypothesised confounding variables. Results  In this sample of studies, reported effect size was inversely related to sample size. This effect is not explained by year of publication, intervention type or quality of methodology in the study. Discussion  Our finding is consistent with other reports in the literature. The origin of this effect is not yet clear. However if replicated it clearly has significant implications for the way trials in child mental health are interpreted. Richard Harrington: Diseased