Emotional responding in amyotrophic lateral sclerosis

Clinician Perspectives Highlight the Need for Early Dyadic Coping Skills for People Living With Amyotrophic Lateral Sclerosis

CONTEXT

A diagnosis of ALS can be challenging, and many people find ways to adapt. At the same time, emotional distress can arise early after an ALS diagnosis even when high quality multidisciplinary care is provided. When emotional distress occurs, it can become chronic over time, and can affect both the person living with ALS and their care-partner (together called a dyad).

OBJECTIVES

We set out to understand ALS multidisciplinary clinicians' perception of the challenges experienced by people with ALS and care-partners who experience emotional distress after diagnosis and potential benefits of a coping skills program to help these patients and their care-partners, Resilient Together-ALS (RT-ALS).

METHODS

We conducted semi-structured focus groups and individual interviews with 17 clinicians at the Sean M. Healey & AMG Center for ALS at MGH (N = 2 focus groups and five interviews) to elicit feedback on four domains: 1) Psychosocial Needs of ALS Dyads seen in the clinic; 2) Clinic Flow and Referral System to RT-ALS; 3) Clinic Partnership Approach in Support of RT-ALS; 4) RT-ALS Program Content and Manual Format. We conducted rapid data analyses for a time-efficient hybrid inductive-deductive thematic approach.

RESULTS

Clinicians noted that dyadic distress (distress experienced by both patient and their care-partner individually and as a unit), though not universal, is often present early after diagnosis. The response to the proposed program content (dyadic and individual coping skills) and structure (6 weekly virtual sessions delivered within about 2 months after diagnosis) was positive. Multidisciplinary clinicians emphasized the importance of a skills-based program for dyads experiencing elevated early emotional distress for which referral can be easily integrated within clinic flow so as not to not increase provider and dyad burden.

CONCLUSION

RT-ALS program content and structure is acceptable to clinicians. It is imperative to next seek further input from dyads about whether this type of program would be of interest and if yes, to pilot and refine the program for feasibility testing and then efficacy.

Pallidal functional connectivity changes are associated with disgust recognition in pure motor amyotrophic lateral sclerosis

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In cognitively normal ALS, we detected early difficulties in recognizing disgust.

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Pallidum functional connectivity (FC) alterations occur in pure-motor ALS patients.

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Reduced left pallidum-temporal FC is linked to altered disgust recognition.

In the present study, we aimed to investigate the resting-state functional connectivity (RS-FC) of the globus pallidus (GP) in patients with amyotrophic lateral sclerosis (ALS) compared to healthy controls, and the relationship between RS-FC changes and disgust recognition. Twenty-six pure-motor ALS patients and 52 healthy controls underwent RS functional MRI and a neuropsychological assessment including the Comprehensive Affect Testing System. A seed-based RS-FC analysis was performed between the left and right GP and the rest of the brain and compared between groups. Correlations between RS-FC significant changes and subjects’ performance in recognizing disgust were tested. Compared to controls, patients were significantly less able to recognize disgust. In ALS compared to controls, the seed-based analysis showed: reduced RS-FC between bilateral GP and bilateral middle and superior frontal and middle cingulate gyri, and increased RS-FC between bilateral GP and bilateral postcentral, supramarginal and superior temporal gyri and Rolandic operculum. Decreased RS-FC was further observed between left GP and left middle and inferior temporal gyri and bilateral caudate; and increased RS-FC was also shown between right GP and left lingual and fusiform gyri. In patients and controls, lower performance in recognizing disgust correlated with reduced RS-FC between left GP and left middle and inferior temporal gyri. In pure-motor ALS patients, we demonstrated altered RS-FC between GP and the rest of the brain. The reduced left pallidum-temporo-striatal RS-FC may have a role in the lower ability of patients in recognizing disgust.

Measuring social cognition in frontotemporal lobar degeneration: a clinical approach

Alterations in social cognition, a broad term indicating our ability to understand others and adapt our behavior accordingly, have been the focus of growing attention in the past years. Some neurological conditions, such as those belonging to the frontotemporal lobar degeneration (FTLD) spectrum, are associated to varying degrees with social cognition deficits, encompassing problems with theory of mind (ToM), empathy, perception of social stimuli, and social behavior. In this review, we outline a clinical framework for the evaluation of social cognition and discuss its role in the assessment of patients affected by a range of FTLD conditions.

Social cognition in the FTLD spectrum: evidence from MRI

Over the past few years, there has been great interest in social cognition, a wide term referring to the human ability of understanding others' emotions, thoughts, and intentions, to empathize with them and to behave accordingly. While there is no agreement on the classification of social cognitive processes, they can broadly be categorized as consisting of theory of mind, empathy, social perception, and social behavior. The study of social cognition and its relative deficits is increasingly assuming clinical relevance. However, the clinical and neuroanatomical correlates of social cognitive alterations in neurodegenerative conditions, such as those belonging to the frontotemporal lobar (FTLD) spectrum, are not fully established. In this review, we describe the current understanding of social cognition impairments in different FTLD conditions with respect to MRI.

Emotional Processing and Experience in Amyotrophic Lateral Sclerosis: A Systematic and Critical Review

Even though increasing literature describes changes in emotional processing in Amyotrophic Lateral Sclerosis (ALS), efforts to summarize relevant findings are lacking in the field. A systematic literature review was performed to provide a critical and up-to-date account of emotional abilities in ALS. References were identified by searches of PubMed, Web of Science and Scopus (1980–2021, English literature), with the following key terms: (“Amyotrophic Lateral Sclerosis” or “Primary Lateral Sclerosis” or “Motor Neuron”) and “Emotion*” and (“Processing” or “Attribution” or “Elaboration” or “Perception” or “Recognition”). Studies concerning only caregivers, pseudobulbar affect, and social cognition were excluded. Forty-one articles were included, all concerning ALS, and seven topics were identified: Emotion recognition, Emotional responsiveness, Emotional reactivity, Faces approachability rating, Valence rating, Memory for emotional materials and Alexithymia. The majority of these aspects have only been sparsely addressed. The evidence confirms altered emotional processing in ALS. The most consistent findings regard the recognition of facial expressions for negative emotions, but also alterations in the subjective responsiveness to emotional stimuli (arousal, valence and approachability), in psychophysiological and cerebral reactivity and in emotional memory, together with alexithymia traits, were reported. According to this evidence, emotional abilities should be included in the clinical assessment and therapeutic interventions.

Brain Computer Interfaces for Assisted Communication in Paralysis and Quality of Life

The rapid evolution of Brain-Computer Interface (BCI) technology and the exponential growth of BCI literature during the past 20 years is a consequence of increasing computational power and the achievements of statistical learning theory and machine learning since the 1960s. Despite this rapid scientific progress, the range of successful clinical and societal applications remained limited, with some notable exceptions in the rehabilitation of chronic stroke and first steps towards BCI-based assisted verbal communication in paralysis. In this contribution, we focus on the effects of noninvasive and invasive BCI-based verbal communication on the quality of life (QoL) of patients with amyotrophic lateral sclerosis (ALS) in the locked-in state (LIS) and the completely locked-in state (CLIS). Despite a substantial lack of replicated scientific data, this paper complements the existing methodological knowledge and focuses future investigators' attention on (1) Social determinants of QoL and (2) Brain reorganization and behavior. While it is not documented in controlled studies that the good QoL in these patients is a consequence of BCI-based neurorehabilitation, the proposed determinants of QoL might become the theoretical background needed to develop clinically more useful BCI systems and to evaluate the effects of BCI-based communication on QoL for advanced ALS patients and other forms of severe paralysis.

Impaired recognition of disgust in amyotrophic lateral sclerosis is related to basal ganglia involvement

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Altered ability to correctly recognize disgust in pure motor ALS patients.

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Potential role of the left pallidum in the altered processing of disgust.

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Disgust as one of the first emotion that ALS patients fail to recognize.

In the present study we investigated emotion recognition in pure motor amyotrophic lateral sclerosis (ALS) patients and its relationship with the integrity of basal ganglia, hippocampus and amygdala. Twenty ALS patients without either cognitive or behavioural impairment, and 52 matched healthy controls performed a neuropsychological assessment including the Comprehensive Affect Testing System (CATS) investigating emotion recognition. All participants underwent also a 3T brain MRI. Volumes of basal ganglia, hippocampus and amygdala bilaterally were measured using FIRST in FSL. Sociodemographic, cognitive and MRI data were compared between groups. In ALS patients, correlations between CATS significant findings, brain volumes, cognition, mood and behaviour were explored. ALS patients showed altered performances at the CATS total score and, among the investigated emotions, patients were significantly less able to recognize disgust compared with controls. No brain volumetric differences were observed between groups. In ALS patients, a lower performance in disgust recognition was related with a reduced volume of the left pallidum and a lower performance on the Edinburgh Cognitive and Behavioural ALS Screen. Cognitively/behaviourally unimpaired ALS patients showed impaired disgust recognition, which was associated with pallidum volume. The association with cognitive alterations may suggest impaired disgust recognition as an early marker of cognitive decline.

Longitudinal Study of Cognitive and Emotional Alterations in Amyotrophic Lateral Sclerosis: Clinical and Imaging Data

Objectives: Extra-motor manifestations occur in 50% of patients with amyotrophic lateral sclerosis (ALS). These mainly concern cognition, emotional processing and behavior. Depression and anxiety are less frequent. Little is known about how these manifestations change as the disease progresses. Similarly, although cortical thinning has been well-documented at disease onset, there are scant data about cortical thinning over time and how this correlates with extra-motor manifestations. The present study therefore assessed cognitive, emotional and psychological state and cortical thinning in a group of patients with ALS at baseline and after a follow-up period.

Methods: We assessed executive functions, facial emotion recognition, depressive and anxious symptoms, and cortical thinning in 43 patients with ALS at baseline, comparing them with 28 healthy controls, and 21 of them 9 months later. We looked for links among the extra-motor manifestations and correlations with cortical thickness.

Results: At baseline, patients had poor executive function and recognition of complex emotions from the eyes, and more anxious and depressive symptoms than controls. At follow-up, only inhibition abilities had worsened. Cortical thinning was observed in bilateral pre-central regions and other parts of the cerebral cortex at baseline. Over time, it worsened in motor and extra-motor areas. Executive functions correlated with thinning in the middle and inferior frontal gyrus and orbitofrontal cortex.

Conclusions: During follow-up, there was little deterioration in extra-motor manifestations and psychological state, despite continuing cortical thinning. Patients with affective Theory of Mind (ToM) changes seemed less depressed than the others. Impaired mental flexibility was subtended by prefrontal regions with cortical thinning.

Unraveling Moral Reasoning in Amyotrophic Lateral Sclerosis: How Emotional Detachment Modifies Moral Judgment

In the last decade, scientific literature provided solid evidence of cognitive deficits in amyotrophic lateral sclerosis (ALS) patients and their effects on end-life choices. However, moral cognition and judgment are still poorly investigated in this population. Here we aimed at evaluating both socio-cognitive and socio-affective components of moral reasoning in a sample of 28 ALS patients. Patients underwent clinical and neuropsychological evaluation including basic cognitive and social cognition measures. Additionally, we administered an experimental task including moral dilemmas, with instrumental and incidental conditions. Patients’ performances were compared with a control group [healthy control (HC)], including 36 age-, gender-, and education-matched healthy subjects. Despite that the judgment pattern was comparable in ALS and HC, patients resulted less prone to carry out a moral transgression compared to HC. Additionally, ALS patients displayed higher levels of moral permissibility and lower emotional arousal, with similar levels of engagement in both instrumental and incidental conditions. Our findings expanded the current literature about cognitive deficits in ALS, showing that in judging moral actions, patients may present non-utilitarian choices and emotion flattening. Such a decision-making profile may have relevant implications in applying moral principles in real-life situations and for the judgment of end-of-life treatments and care in clinical settings.

Understanding the role of social cognition in neurodegenerative Disease: A scoping review on an overlooked problem

Social cognition (SC) is the set of socio-cognitive processes that guide automatic and voluntary behaviors by modulating behavioral responses, it includes both cognitive (Theory of the mind - ToM) and affective aspects (Empathy). SC also includes representations of internal somatic states, self-knowledge, perception of others, communication with others and interpersonal motivations. SC is relevant in daily life and reflects the neural complexity of social processing. The purpose of this scoping review is to evaluate the role of SC in neurological disorders, also considering the pathophysiological mechanisms underlying SC and potential assessment tools. The included studies were carried out between 2010 and 2019 and were found on PubMed, Scopus, Cochrane, and Web of Sciences databases, using the combined terms "social cognition"; "dementia"; "multiple sclerosis"; "parkinson", "amyotrophic lateral sclerosis", "neurodegenerative disease". Our review has shown that different SC domains are affected by several neurological conditions, with regards to dementia and amyotrophic lateral sclerosis. Further studies are needed to investigate the association between cognitive and social deficits, for a better management of patients with neurological disorders.

Deficits in Emotion Recognition as Markers of Frontal Behavioral Dysfunction in Amyotrophic Lateral Sclerosis

OBJECTIVE

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with prominent motor symptoms. Patients with ALS may also manifest frontal behavior symptoms and cognitive decline, including impairment in facial emotion recognition. The authors aimed to investigate whether deficits in emotion recognition were associated with frontal behavior symptoms in ALS.

METHODS

Participants were patients with probable or definite sporadic ALS (N=21; male:female ratio, 11:10; median age, 62 years; median disease duration, 3 years) and age-matched and education-matched healthy control subjects (N=25; male:female ratio, 14:11; median age, 61 years). The Facial Emotion Recognition Test (FERT) was administered to all participants. Patients with ALS were assessed using the Cambridge Behavior Inventory-Revised and were classified into two groups according to the presence of frontal behavioral symptoms: ALS with no behavioral symptom (ALSns; N=9) and ALS with at least one behavioral symptom (ALSbs; N=12).

RESULTS

Apathy and mood symptoms were the most frequent neuropsychiatric symptoms in the patient group. Patients with ALS performed worse than control subjects in the recognition of sadness (p<0.004). There were no differences between control subjects and patients in the ALSns group in all FERT scores, but the ALSbs group had lower performance than control subjects in sadness (p<0.003).

CONCLUSIONS

Emotion recognition deficit may be a marker of frontal behavior in ALS.

Cognitive, Emotional and Psychological Manifestations in Amyotrophic Lateral Sclerosis at Baseline and Overtime: A Review

It is now well recognized that, in addition to motor impairment, amyotrophic lateral sclerosis (ALS) may cause extra-motor clinical signs and symptoms. These can include the alteration of certain cognitive functions, impaired social cognition, and changes in the perception and processing of emotions. Where these extra-motor manifestations occur in ALS, they usually do so from disease onset. In about 10% of cases, the cognitive and behavioral changes meet the diagnostic criteria for frontotemporal dementia. The timecourse of behavioral and cognitive involvement in ALS is unclear. Whereas longitudinal studies have failed to show cognitive decline over time, some cross-sectional studies have demonstrated poorer cognitive performances in the advanced stages of the disease. Neuroimaging studies show that in ALS, extra-motor signs and symptoms are associated with specific brain lesions, but little is known about how they change over time. Finally, patients with ALS appear less depressed than might be expected, given the prognosis. Moreover, many patients achieve satisfactory psychosocial adjustment throughout the course of the disease, regardless of their degree of motor disability. There are scant longitudinal data on extra-motor impairment in ALS, and to our knowledge, no systematic review on this subject has yet been published. Even so, a better understanding of patients' clinical trajectory is essential if they are to be provided with tailored care and given the best possible support. We therefore undertook to review the evidence for extra-motor changes and their time course in ALS, in both the cognitive, emotional and psychological domains, with a view to identifying mechanisms that may help these patients cope with their disease.

[Genetics of Amyotrophic Lateral Sclerosis]

Genetics of Amyotrophic Lateral Sclerosis Abstract. In recent years, the knowledge of gene mutation that can lead to amyotrophic lateral sclerosis (ALS), frontotemporal dementia, or a FTD-ALS complex has been drastically improvedwith the help of next-generation sequencing (NGS), so that many new genes and their molecular genetic mechanisms and symptoms of the patients could be described. For example it was found that in the same family with the same gene mutation patients with ALS, FTD or another neurodegenerative disease can be found. The knowledge about the genes does not only contribute to the understanding of these diseases, but should help develop new therapeutic possibilities.

The Complex Interplay Between Depression/Anxiety and Executive Functioning: Insights From the ECAS in a Large ALS Population

Introduction: The observed association between depressive symptoms and cognitive performances has not been previously clarified in patients with amyotrophic lateral sclerosis (pALS). In fact, the use of cognitive measures often not accommodating for motor disability has led to heterogeneous and not conclusive findings about this issue. The aim of the present study was to evaluate the relationship between cognitive and depressive/anxiety symptoms by means of the recently developed Edinburgh Cognitive and Behavioral ALS Screen (ECAS), a brief assessment specifically designed for pALS. Methods: Sample included 168 pALS (114 males, 54 females); they were administered two standard cognitive screening tools (FAB; MoCA) and the ECAS, assessing different cognitive domains, including ALS-specific (executive functions, verbal fluency, and language tests) and ALS non-specific subtests (memory and visuospatial tests). Two psychological questionnaires for depression and anxiety (BDI; STAI/Y) were also administered to patients. Pearson's correlation coefficient was used to assess the degree of association between cognitive and psychological measures. Results: Depression assessment negatively correlated with the ECAS, more significantly with regard to the executive functions subdomain. In particular, Sentence Completion and Social Cognition subscores were negatively associated with depression levels measured by BDI total score and Somatic-Performance symptoms subscore. Conversely, no significant correlations were observed between depression level and cognitive functions as measured by traditional screening tools for frontal abilities (FAB) and global cognition (MoCA) assessment. Finally, no significant correlations were observed between state/trait anxiety and the ECAS. Discussion and conclusion: This represents the first study focusing on the relationship between cognitive and psychological components in pALS by means of the ECAS, the current gold standard for ALS cognitive-behavioral assessment. If confirmed by further investigations, the observed association between depression and executive functions suggests the need for a careful screening and treatment of depression, to avoid overestimation of cognitive involvement and possibly improve cognitive performances in ALS.

Resting state fMRI correlates of Theory of Mind impairment in amyotrophic lateral sclerosis

Theory of Mind (ToM), the ability to recognize thoughts and emotions of another, may be one of the cognitive domains affected in amyotrophic lateral sclerosis (ALS), a neurodegenerative disease now recognized as a multi-system disorder. The present study aimed to identify early dysfunctions of brain resting state functional magnetic resonance imaging (RS-fMRI) networks in a group of ALS patients longitudinally explored for impairment of "cognitive" and "affective" ToM subcomponents. RS-fMRI connectivity was investigated in a group of 21 patients with ALS (i.e., 9 with bulbar-onset or ALS-B and 12 with limb-onset or ALS-L) in early stages of disease and 15 healthy controls (HCs). The same subjects were assessed, at baseline and after six months, for neuropsychological performances, including cognitive and affective ToM and multi-domain cognitive functions. The RS-fMRI study showed a decreased connectivity in frontotemporal areas within the main cognitive resting state networks, including the default mode (DMN), the right and left fronto-parietal (R-, L-FPN), and the salience (SLN) networks, in the entire ALS group. As exploratory results, comparing the ALS-B subgroup to the ALS-L one, we revealed a widespread decrease of RS-fMRI signals in the left middle frontal gyrus for L-FPN and SLN and in the left superior frontal gyrus for SLN. At baseline, no ToM or other cognitive abnormalities were reported in the entire group of ALS patients compared to HCs, although, after six months, the ALS-B subset exhibited a significant impairment of both affective and cognitive ToM subcomponents, whereas the ALS-L group showed significant impairment of the cognitive subcomponent alone. Our findings provide original evidence of the deficit of both ToM subcomponents during the ALS course, supporting the hypothesis of a biologically more aggressive character of ALS-B. Moreover, early RS-fMRI abnormalities in cognitive networks may underlie and precede the clinical appearance of ToM alterations in ALS.

Cognitive-constructivist Approach in Medical Settings: The Use of Personal Meaning Questionnaire for Neurological Patients' Personality Investigation

Objective: The cognitive-constructivist psychotherapy approach considers the self as a continuous regulation process between present and past experience, in which attributions of meaning is characterized by the use of internal rules. In this conception, everyone would be driven by a specific inner coherence called Personal Meaning Organization (PMO). Such approach has never been applied to neurological patients by means of ad hoc developed tools. We performed an explorative study aimed to characterize personality styles in different neurological conditions within the theoretical framework of cognitive-constructivist model.

Materials and Methods: Three groups of neurological patients (Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Primary Headache) and a sample of healthy participants, each composed by 15 participants, for a total of 60 participants, were recruited. The Personal Meaning Questionnaire (PMQ), an Italian questionnaire assessing PMOs construct, and other clinical tools for psychological and quality of life assessment were administered to all subjects.

Results: The main finding concerned the detection, across all clinical conditions, of a higher prevalence of phobic personality style, with Amyotrophic Lateral Sclerosis showing a relevant prevalence of such PMO with respect to all other neurological conditions and controls. However, with respect to controls, in all clinical conditions, PMQ highlighted a tendency, even if not statistically significant, to codify experience by means of specific cognitive and emotional patterns.

Conclusion: Our findings represent the first contribution towards understanding the personality profiles of patients affected by neurological conditions according to cognitive-constructivist theory.

Perception of Emotional Facial Expressions in Amyotrophic Lateral Sclerosis (ALS) at Behavioural and Brain Metabolic Level

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) primarily impairs motor abilities but also affects cognition and emotional processing. We hypothesise that subjective ratings of emotional stimuli depicting social interactions and facial expressions is changed in ALS. It was found that recognition of negative emotions and ability to mentalize other's intentions is reduced.

METHODS

Processing of emotions in faces was investigated. A behavioural test of Ekman faces expressing six basic emotions was presented to 30 ALS patients and 29 age-, gender and education matched healthy controls. Additionally, a subgroup of 15 ALS patients that were able to lie supine in the scanner and 14 matched healthy controls viewed the Ekman faces during functional magnetic resonance imaging (fMRI). Affective state and a number of daily social contacts were measured.

RESULTS

ALS patients recognized disgust and fear less accurately than healthy controls. In fMRI, reduced brain activity was seen in areas involved in processing of negative emotions replicating our previous results. During processing of sad faces, increased brain activity was seen in areas associated with social emotions in right inferior frontal gyrus and reduced activity in hippocampus bilaterally. No differences in brain activity were seen for any of the other emotional expressions. Inferior frontal gyrus activity for sad faces was associated with increased amount of social contacts of ALS patients.

CONCLUSION

ALS patients showed decreased brain and behavioural responses in processing of disgust and fear and an altered brain response pattern for sadness. The negative consequences of neurodegenerative processes in the course of ALS might be counteracted by positive emotional activity and positive social interactions.

The frontotemporal dementia-motor neuron disease continuum

Early reports of cognitive and behavioural deficits in motor neuron disease might have been overlooked initially, but the concept of a frontotemporal dementia-motor neuron disease continuum has emerged during the past decade. Frontotemporal dementia-motor neuron disease is now recognised as an important dementia syndrome, which presents substantial challenges for diagnosis and management. Frontotemporal dementia, motor neuron disease, and frontotemporal dementia-motor neuron disease are characterised by overlapping patterns of TAR DNA binding protein (TDP-43) pathology, while the chromosome 9 open reading frame 72 (C9orf72) repeat expansion is common across the disease spectrum. Indeed, the C9orf72 repeat expansion provides important clues to disease pathogenesis and suggests potential therapeutic targets. Variable diagnostic criteria identify motor, cognitive, and behavioural deficits, but further refinement is needed to define the clinical syndromes encountered in frontotemporal dementia-motor neuron disease.

Microstructural Correlates of Emotional Attribution Impairment in Non-Demented Patients with Amyotrophic Lateral Sclerosis

Impairments in the ability to recognize and attribute emotional states to others have been described in amyotrophic lateral sclerosis patients and linked to the dysfunction of key nodes of the emotional empathy network. Microstructural correlates of such disorders are still unexplored. We investigated the white-matter substrates of emotional attribution deficits in a sample of amyotrophic lateral sclerosis patients without cognitive decline. Thirteen individuals with either probable or definite amyotrophic lateral sclerosis and 14 healthy controls were enrolled in a Diffusion Tensor Imaging study and administered the Story-based Empathy Task, assessing the ability to attribute mental states to others (i.e., Intention and Emotion attribution conditions). As already reported, a significant global reduction of empathic skills, mainly driven by a failure in Emotion Attribution condition, was found in amyotrophic lateral sclerosis patients compared to healthy subjects. The severity of this deficit was significantly correlated with fractional anisotropy along the forceps minor, genu of corpus callosum, right uncinate and inferior fronto-occipital fasciculi. The involvement of frontal commissural fiber tracts and right ventral associative fronto-limbic pathways is the microstructural hallmark of the impairment of high-order processing of socio-emotional stimuli in amyotrophic lateral sclerosis. These results support the notion of the neurofunctional and neuroanatomical continuum between amyotrophic lateral sclerosis and frontotemporal dementia.

Impaired Perception of Emotional Expression in Amyotrophic Lateral Sclerosis

Background and Purpose

The increasing recognition that deficits in social emotions occur in amyotrophic lateral sclerosis (ALS) is helping to explain the spectrum of neuropsychological dysfunctions, thus supporting the view of ALS as a multisystem disorder involving neuropsychological deficits as well as motor deficits. The aim of this study was to characterize the emotion perception abilities of Korean patients with ALS based on the recognition of facial expressions.

Methods

Twenty-four patients with ALS and 24 age- and sex-matched healthy controls completed neuropsychological tests and facial emotion recognition tasks [ChaeLee Korean Facial Expressions of Emotions (ChaeLee-E)]. The ChaeLee-E test includes facial expressions for seven emotions: happiness, sadness, anger, disgust, fear, surprise, and neutral.

Results

The ability to perceive facial emotions was significantly worse among ALS patients performed than among healthy controls [65.2±18.0% vs. 77.1±6.6% (mean±SD), p=0.009]. Eight of the 24 patients (33%) scored below the 5th percentile score of controls for recognizing facial emotions.

Conclusions

Emotion perception deficits occur in Korean ALS patients, particularly regarding facial expressions of emotion. These findings expand the spectrum of cognitive and behavioral dysfunction associated with ALS into emotion processing dysfunction.

Additional resources and the default mode network: Evidence of increased connectivity and decreased white matter integrity in amyotrophic lateral sclerosis

In amyotrophic lateral sclerosis (ALS), cognition is affected. Cortical atrophy in frontal and temporal areas has been associated with the cognitive profile of patients. Additionally, reduced metabolic turnover and regional cerebral blood flow in frontal areas indicative of reduced neural activity have been reported for ALS. We hypothesize that functional connectivity in non-task associated functional default mode network (DMN) is associated with cognitive profile and white matter integrity. This study focused on specific cognitive tasks known to be impaired in ALS such as verbal fluency and attention, and the relationship with functional connectivity in the DMN and white matter integrity. Nine patients and 11 controls were measured with an extensive neuropsychological battery. Resting-state functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) data were acquired. Results showed that ALS patients performed significantly worse in attention and verbal fluency task. Patients showed increased functional connectivity in parahippocampal and parietal areas of the non-task associated DMN compared to controls. The more pronounced the cognitive deficits, the stronger the increase in functional connectivity in those areas. White matter integrity was reduced in frontal areas in the patients. In conclusion, increased connectivity in the DMN in parahippocampal and parietal areas might represent recruitment of accessory brain regions to compensate for dysfunctional frontal networks.

Depression and disease progression in amyotrophic lateral sclerosis: A comprehensive meta-regression analysis

Depression in people with amyotrophic lateral sclerosis, a fatal and progressive neurodegenerative disorder, is a serious issue with important clinical consequences. However, physical impairment may confound the diagnosis when using generic questionnaires. We conducted a comprehensive review of literature. Mean scores from depression questionnaires were meta-regressed on study-level mean time since onset of symptoms. Data from 103 studies (3190 subjects) indicate that the Beck Depression Inventory and, to a lesser degree, the Hospital Anxiety and Depression Scale are influenced by the time since symptom onset, strongly related to physical impairment. Our results suggest that widely used depression scales overestimate depression due to confounding with physical symptoms.

Psychophysiological correlates of coping and quality of life in patients with ALS

OBJECTIVE

Self-regulation models of coping suggest that patients with chronic diseases reporting low quality of life (QoL), an indicator of failed coping efforts, should show facilitated access to disease related words. Here we investigated whether a reduced N400 amplitude within an incongruent, i.e. unpredictable disease-related context would be a correlate of this facilitated access.

METHODS

ERPs were recorded in N=18 patients with amyotrophic lateral sclerosis (ALS) and N=20 age-matched healthy controls during reading of sentences, ending either with congruent or incongruent words. Incongruent and congruent words were disease related or disease unrelated. Mean N400 amplitudes were analyzed with mixed models.

RESULTS

Generally, incongruent words elicited a more negative N400 amplitude than congruent words in all groups and conditions, i.e. an N400 effect. In patients with high QoL this N400 effect did not differ between disease related and unrelated words. In patients with low QoL, however, the N400 effect was significantly smaller for disease related than for disease unrelated words. In healthy controls N400 amplitudes showed no such interaction between congruence, disease relatedness and QoL. Results remained stable when controlling for disease severity, duration and depression.

CONCLUSION

The N400 indicates increased accessibility to disease related information in ALS patients with low QoL. The increased access may imply a constantly activated disease related context which is linked to low QoL.

SIGNIFICANCE

N400 modulation by disease related information may serve as a psychophysiological correlate of coping and the patient's QoL.

Processing and memory for emotional and neutral material in amyotrophic lateral sclerosis

Several studies have reported changes in emotional memory and processing in people with ALS (pwALS). In this study, we sought to analyse differences in emotional processing and memory between pwALS and healthy controls and to investigate the relationship between emotional memory and self-reported depression. Nineteen pwALS and 19 healthy controls were assessed on measures of emotional processing, emotional memory, verbal memory and depression. Although pwALS and controls did not differ significantly on measures of emotional memory, a subgroup of patients performed poorly on an emotional recognition task. With regard to emotional processing, pwALS gave significantly stronger ratings of emotional valence to positive words than to negative words. Higher ratings of emotional words were associated with better recall in controls but not pwALS. Self-reported depression and emotional processing or memory variables were not associated in either group. In conclusion, the results from this small study suggest that a subgroup of pwALS may show weakened 'emotional enhancement', although in the current sample this may reflect general memory impairment rather than specific changes in emotional memory. Nonetheless, different patterns of processing of emotionally-salient material by pwALS may have care and management-related implications.

Prone to excitement: adolescent females with Non-suicidal self-injury (NSSI) show altered cortical pattern to emotional and NSS-related material

Emotion-regulation difficulties have been identified as one of the core components in Non-suicidal self-injury (NSSI), a behaviour often beginning in adolescence. This pilot study evaluated differences in emotion processing between 18 female adolescents with and without NSSI by using verbal responses and functional magnetic resonance imaging (fMRI). Responses to pictures taken from the International Affective Picture System and slides with reference to NSSI were recorded both by verbal rating of valence and arousal and by fMRI. The NSSI group rated pictures with self-injurious reference as significantly more arousing than controls. For emotional pictures, the NSSI group showed a significantly stronger brain response in the amygdala, hippocampus and anterior cingulate cortex bilaterally. Depression explained differences between groups in the limbic area. Furthermore, the NSSI group also showed increased activity in the middle orbitofrontal cortex, and inferior and middle frontal cortex when viewing NSSI picture material. Participants with NSSI showed decreased activity in correlation to arousal in the occipital cortex and to valence in inferior frontal cortex when watching emotional pictures. The fMRI data support the notion that individuals with NSSI show an altered neural pattern for emotional and NSSI pictures. Behavioural data highlight proneness to excitement regarding NSSI topics. This fMRI study provides evidence for emotion-regulation deficits in the developing brain of adolescents with NSSI.

The use of P300-based BCIs in amyotrophic lateral sclerosis: from augmentative and alternative communication to cognitive assessment

The use of augmentative and alternative communication (AAC) tools in patients with amyotrophic lateral sclerosis (ALS), as effective means to compensate for the progressive loss of verbal and gestural communication, has been deeply investigated in the recent literature. The development of advanced AAC systems, such as eye-tracking (ET) and brain-computer interface (BCI) devices, allowed to bypass the important motor difficulties present in ALS patients. In particular, BCIs could be used in moderate to severe stages of the disease, since they do not require preserved ocular-motor ability, which is necessary for ET applications. Furthermore, some studies have proved the reliability of BCIs, regardless of the severity of the disease and the level of physical decline. However, the use of BCI in ALS patients still shows some limitations, related to both technical and neuropsychological issues. In particular, a range of cognitive deficits in most ALS patients have been observed. At the moment, no effective verbal-motor free measures are available for the evaluation of ALS patients' cognitive integrity; BCIs could offer a new possibility to administer cognitive tasks without the need of verbal or motor responses, as highlighted by preliminary studies in this field. In this review, we outline the essential features of BCIs systems, considering advantages and challenges of these tools with regard to ALS patients and the main applications developed in this field. We then outline the main findings with regard to cognitive deficits observed in ALS and some preliminary attempts to evaluate them by means of BCIs. The definition of specific cognitive profiles could help to draw flexible approaches tailored on patients' needs. It could improve BCIs efficacy and reduce patients' efforts. Finally, we handle the open question, represented by the use of BCIs with totally locked in patients, who seem unable to reliably learn to use such tool.

Social cognition in amyotrophic lateral sclerosis

SUMMARY There is an overlap between amyotrophic lateral sclerosis and frontotemporal dementia. Approximately 15% of amyotrophic lateral sclerosis patients suffer from frontotemporal dementia characterized by behavioral change while a further third experience subtle executive dysfunction (typically letter fluency deficits) and corresponding prefrontal changes. Behavior change appears prevalent with apathy being the most prominent feature. Reports of social and emotional cognition deficits are increasing. Deficits have been described on theory of mind tasks including interpretation of stories and cartoons, faux pas detection and in the judgment of preference based on direction of eye-gaze. Impairments in emotional face and prosody perception and emotional enhancement of memory have been reported, and decision making (with and without risk) appears affected. The role of executive dysfunction in this social cognition deficit remains unresolved and more direct evidence of oribitofrontal involvement has yet to be found. Implications for healthcare provision are discussed with deterioration of social interaction with carers predicted.

Right hemisphere dysfunction and emotional processing in ALS: an fMRI study

Emotional processing may be abnormal in amyotrophic lateral sclerosis (ALS). Our aim was to explore functional anatomical correlates in the processing of aversive information in ALS patients. We examined the performance of nine non-demented ALS patients and 10 healthy controls on two functional MRI (fMRI) tasks, consisting of an emotional attribution task and a memory recognition task of unpleasant versus neutral stimuli. During the emotional decision task, subjects were asked to select one of three unpleasant or neutral words. During the memory task, subjects were asked to recognize words presented during the previous task. Controls showed, as expected, greater activation in the right middle frontal gyrus during selection of unpleasant than neutral words, and a greater activation mainly in right-sided cerebral areas during the emotional recognition task. Conversely, patients showed a general increase in activation of the left hemisphere, and reduced activation in right hemisphere in both emotional tasks. Such findings may suggest extra-motor neurodegeneration involving key circuits of emotions, mostly negative, commonly involved in FTD.

MRI-based functional neuroimaging in ALS: an update

With non-invasive functional imaging techniques, neuroscience has reached a new era of connecting anatomy and function. Although other techniques bear the advantage of either higher temporal or spatial resolution, functional magnetic resonance imaging (fMRI) is the most widely used non-invasive brain imaging technique. fMRI provides an acceptable balance between low patient load and high information capacity with good spatial resolution, making it ideal for clinical research in patients with physical restrictions like those with ALS. Most fMRI studies have provided evidence of a spatial shift of function in motor and extramotor areas in ALS patients. Furthermore, MRI-based functional imaging has supported the clinical findings of frontal cortical involvement not only in patients with ALS/dementia complex but also in patients with ALS and sub-clinical cognitive impairment. Functional MRI will identify the preserved but non-executable functions in ALS patients in the end stage and will set the direction for a new way of thinking on the functional capacities of these patients which will have a major impact on our way of thinking about end-of-life decisions.

Frontotemporal dementia and motor neurone disease: overlapping clinic-pathological disorders

Advances in genetics and pathology have supported the idea of a continuum between frontotemporal dementia (FTD) and motor neurone disease (MND), which is strengthened by the discovery of the trans-activating responsive (Tar) sequence DNA binding protein (TDP-43) as a key component in the underlying pathology of FTD, FTD-MND and sporadic and familial MND patients. MND is a multisystem disorder associated with cognitive and behavioural changes which in some instances reaches the criteria for FTD, while a proportion of patients with FTD develop frank MND. We review the overlap between FTD and MND, emphasizing areas of controversy and uncertainty.

Hope in palliative care: from narcissism to self-transcendence in amyotrophic lateral sclerosis

INTRODUCTION

The concept of hope in palliative care is an important and neglected area of research. Amyotrophic lateral sclerosis (ALS), a progressive degenerative motor neuron disease, offers an excellent opportunity to study this construct as the illness is virtually always fatal. Our research explored the meaning of hope in individuals with ALS.

PATIENTS AND METHODS

Sixteen patients (13 males and 3 females; mean age, 54) were interviewed during routine clinic visits to the Forbes Norris MDA/ALS Research Center at California Pacific Medical Center, San Francisco. The Forced Vital Capacity (FVC) Scale and the ALS Functional Rating Scale-Revised (ALSFRS-R) and a Hope Scale were administered. Themes of hope were identified and categorized.

RESULTS

Hope categories included: (1) hope for a cure, (2) social support, (3) search for information, (4) spiritual beliefs, (5) limiting the impact, (6) adapting to changing capacities, (7) living in the moment, and (8) self-transcendence. The relationship between hope and the FVC value and individual as well as overall ALSFRS-R ratings were examined, and none were significant.

DISCUSSION

Individuals varied in their capacity to cope with their illness unrelated to their physical ability. Themes ranged from a primary focus on the self to one of heightened concern for others, on continuum from narcissism to altruism. Respondents cited using a number of categories of hope (mean=5).

CONCLUSION

Patients draw upon a variety of mechanisms to sustain hope when facing chronic disease, including hope for a cure, support from others, seeking information, spiritual beliefs, limiting the impact, adapting to changing capacities, living in the moment, and transcending the self. The palliative care team can play an important role by promoting discussions regarding hopefulness and its many forms in individuals with ALS.

Brain-computer interface systems: progress and prospects

Brain-computer interface (BCI) systems support communication through direct measures of neural activity without muscle activity. BCIs may provide the best and sometimes the only communication option for users disabled by the most severe neuromuscular disorders and may eventually become useful to less severely disabled and/or healthy individuals across a wide range of applications. This review discusses the structure and functions of BCI systems, clarifies terminology and addresses practical applications. Progress and opportunities in the field are also identified and explicated.

Neurodevelopmental and neurodegenerative diseases - is there a pathophysiological link? Attention-deficit/hyperactivity disorder and amyotrophic lateral sclerosis as examples

Attention-deficit/hyperactivity disorder (ADHD), the most common neurobehavioural disorder and amyotrophic lateral sclerosis (ALS), the most common adult motoneuron disease, may be two distinct entities on first sight. This paper aims to highlight parallels concerning clinical features and neurobiology. The presence of increased physical and psychological activity and largely non-progressive frontal dysfunction associated with impaired executive control and decreased attention are characteristic clinical features of both, ADHD and ALS. At the neurobiological level, there is evidence for hyperactivity in the glutamatergic system and a - potentially related - dopaminergic hypoactivity in ADHD and ALS. The clinical features of ALS resembling ADHD are particularly characteristic for the premorbid stage of the patient. Therefore, we hypothesize that clinical features of ADHD may be a risk factor for the development of ALS. This hypothesis is currently of unknown pathogenetic, but of potential future therapeutic relevance. Our hypothesis of a link between ADHD and ALS could also be considered as an example how research on neurodevelopmental diseases might influence the understanding and possibly the prevention and treatment of neurodegenerative diseases.

Prevalence of depression in a 12-month consecutive sample of patients with ALS

There is an impression both in clinical practice and in research literature that patients with amyotrophic lateral sclerosis (ALS) possess 'heroic stoicism with a low frequency of depression'. Reliance on specific interview methods may have contributed to differing estimates of mood disorder in people with ALS. The objective of the current study was to compare prevalence rates of depression and anxiety in ALS using different assessment tools. The Beck Depression Inventory (BDI), The Hospital Anxiety and Depression Scale (HADS) and the Spielberger State-Trait Anxiety Inventory (STAI) were sent to a 12-month consecutive sample of 190 patients with ALS attending a tertiary referral clinic in the UK. Data were collected from 104 patients with ALS. Using BDI scores, 44% were categorized as not depressed, 37% were mild-moderately depressed, 13% were moderately-severely depressed, and 6% were severely depressed. In contrast, the HADS depression subscale identified 75% as not depressed, 13% were in the borderline range, and 13% were categorized as meeting 'caseness' for depression. Twenty-five percent of the patients were using antidepressant medication. The estimated prevalence of mood disorder amongst patients with ALS may vary significantly depending on the measure used.

Cognition and amyotrophic lateral sclerosis (ALS)

Amyotrophic lateral sclerosis (ALS) is classically described as a pure motor disease; however, there is growing evidence of a range of cognitive impairment. Cognitive abnormalities include deficiencies in frontal executive skills, varying from mild deficits to meeting criteria for diagnosis of frontotemporal dementia (FTD). Cognitive impairment occurs in sporadic and familial forms of ALS. Patients may present with cognitive deficits before, after, or at the onset of motor neuron disease. Structural and functional imaging studies have shown extramotor cortical degeneration corresponding to levels of frontal executive impairment on neuropsychologic testing. In addition, ALS and a subset of FTD patients display common pathological findings on immunohistochemistry staining. It is believed that these disorders represent a continuum between motor and nonmotor cortical degeneration. The purpose of this article is to review the literature on cognitive deficits in ALS. Identifying changes in cognition is critical for physicians and caregivers of ALS patients, as cognitive decline may interfere with patient compliance. Diagnosis and treatment of cognitive symptoms in ALS patients may improve quality of life.

Brain responses to emotional stimuli in patients with amyotrophic lateral sclerosis (ALS)

Amyotrophic lateral sclerosis (ALS), a progressive motor neuron disease, affects movement and communication abilities and emotional processing. Subjective ratings of emotional stimuli depicting social interactions and facial expressions differed significantly between ALS patients and healthy controls in a previous study with a reduction of negative emotional valence (pleasantness) and lower subjective arousal (excitement) in ALS patients. In the present study, sixty similar emotional slides were presented to 13 ALS patients, 15 matched healthy controls and six tetraplegic patients. Subjective reports of valence and arousal as well as brain responses to the affective pictures using functional magnetic resonance imaging (fMRI) were measured. The picture series was presented twice with a 6-months interval to investigate effects of disease progression. ALS patients presented an increased brain response in the right supramarginal area and a reduced brain response in extrastriate visual areas at both measurements compared with healthy controls. Within the ALS patients' group a reduction of brain responses in the anterior insula at the follow-up was correlated with the subjective arousal. The reduced response in the anterior insula is tentatively interpreted as indicating reduced arousal during the course of the disease at the neural and behavioural level. The reduction of activity in extrastriate visual areas might be similarly interpreted. The increased brain response in the right supramarginal area of ALS patients might represent an altered sensitivity to social-emotional cues.

Cortical Plasticity in Amyotrophic Lateral Sclerosis: Motor Imagery and Function

Background. Cortical networks underlying motor imagery are functionally close to motor performance networks and can be activated by patients with severe motor disabilities. Objective. The aim of the study was to examine the longitudinal effect of progressive motoneuron degeneration on cortical representation of motor imagery and function in amyotrophic lateral sclerosis. Methods. The authors studied 14 amyotrophic lateral sclerosis patients and 15 healthy controls and a subgroup of 11 patients and 14 controls after 6 months with a grip force paradigm comprising imagery and execution tasks using functional magnetic resonance imaging. Results. Motor imagery activated similar neural networks as motor execution in amyotrophic lateral sclerosis patients and healthy subjects in the primary motor (BA 4), premotor, and supplementary motor (BA 6) cortex. Amyotrophic lateral sclerosis patients presented a stronger response within premotor and primary motor areas for imagery and execution compared to controls. After 6 months, these differences persisted with additional activity in the precentral gyrus in patients as well as in a frontoparietal network for motor imagery, in which activity increased with impairment. Conclusion. The findings suggest an ongoing compensatory process within the higher order motor-processing system of amyotrophic lateral sclerosis patients, probably to overcome loss of function in primary motor and motor imagery-specific networks. The increased activity in precentral and frontoparietal networks in motor imagery might be used to control brain-computer interfaces to drive communication and limb prosthetic devices in patients with loss of motor control such as severely disabled amyotrophic lateral sclerosis patients in a locked-in-like state.

Brain-computer interfaces: communication and restoration of movement in paralysis

The review describes the status of brain-computer or brain-machine interface research. We focus on non-invasive brain-computer interfaces (BCIs) and their clinical utility for direct brain communication in paralysis and motor restoration in stroke. A large gap between the promises of invasive animal and human BCI preparations and the clinical reality characterizes the literature: while intact monkeys learn to execute more or less complex upper limb movements with spike patterns from motor brain regions alone without concomitant peripheral motor activity usually after extensive training, clinical applications in human diseases such as amyotrophic lateral sclerosis and paralysis from stroke or spinal cord lesions show only limited success, with the exception of verbal communication in paralysed and locked-in patients. BCIs based on electroencephalographic potentials or oscillations are ready to undergo large clinical studies and commercial production as an adjunct or a major assisted communication device for paralysed and locked-in patients. However, attempts to train completely locked-in patients with BCI communication after entering the complete locked-in state with no remaining eye movement failed. We propose that a lack of contingencies between goal directed thoughts and intentions may be at the heart of this problem. Experiments with chronically curarized rats support our hypothesis; operant conditioning and voluntary control of autonomic physiological functions turned out to be impossible in this preparation. In addition to assisted communication, BCIs consisting of operant learning of EEG slow cortical potentials and sensorimotor rhythm were demonstrated to be successful in drug resistant focal epilepsy and attention deficit disorder. First studies of non-invasive BCIs using sensorimotor rhythm of the EEG and MEG in restoration of paralysed hand movements in chronic stroke and single cases of high spinal cord lesions show some promise, but need extensive evaluation in well-controlled experiments. Invasive BMIs based on neuronal spike patterns, local field potentials or electrocorticogram may constitute the strategy of choice in severe cases of stroke and spinal cord paralysis. Future directions of BCI research should include the regulation of brain metabolism and blood flow and electrical and magnetic stimulation of the human brain (invasive and non-invasive). A series of studies using BOLD response regulation with functional magnetic resonance imaging (fMRI) and near infrared spectroscopy demonstrated a tight correlation between voluntary changes in brain metabolism and behaviour.

Breaking the silence: brain-computer interfaces (BCI) for communication and motor control

Brain-computer interfaces (BCI) allow control of computers or external devices with regulation of brain activity alone. Invasive BCIs, almost exclusively investigated in animal models using implanted electrodes in brain tissue, and noninvasive BCIs using electrophysiological recordings in humans are described. Clinical applications were reserved with few exceptions for the noninvasive approach: communication with the completely paralyzed and locked-in syndrome with slow cortical potentials, sensorimotor rhythm and P300, and restoration of movement and cortical reorganization in high spinal cord lesions and chronic stroke. It was demonstrated that noninvasive EEG-based BCIs allow brain-derived communication in paralyzed and locked-in patients but not in completely locked-in patients. At present no firm conclusion about the clinical utility of BCI for the control of voluntary movement can be made. Invasive multielectrode BCIs in otherwise healthy animals allowed execution of reaching, grasping, and force variations based on spike patterns and extracellular field potentials. The newly developed fMRI-BCIs and NIRS-BCIs, like EEG BCIs, offer promise for the learned regulation of emotional disorders and also disorders of young children.

Amygdala size in amyotrophic lateral sclerosis without dementia: an in vivo study using MRI volumetry

Background

Evidence for extra-motor involvement in non-demented patients with amyotrophic lateral sclerosis (ALS) has been provided by multiple studies, in particular neuropathological studies have demonstrated neuronal loss in the amygdala. The aim of this study was to investigate possible alterations of amygdala volumes in vivo.

Methods

Twenty-two moderately disabled patients with definite ALS without cognitive or behavioural deficits and 22 age-matched healthy controls were included. Amygdala and total brain volumes were measured by region-of-interest-based volumetry in 3-D MRI.

Results

A trend was observed with reduced amygdala size in the ALS group, since mean absolute and brain size-corrected amygdala volumes were 6.9% and 7.6% lower in the patient group compared to those in normal controls (P = 0.086 and P = 0.110), respectively.

Conclusion

Volumetrically identifiable alterations of the amygdala can be mapped in vivo and may be associated with psychopathological findings in later stages of ALS.