Cranial nerve clock. Part II: functional MR imaging of brain activation during a declarative memory task

RATIONALE AND OBJECTIVES

The authors performed this study to assess brain activation during encoding and successful recall with a declarative memory paradigm that has previously been demonstrated to be effective for teaching students about the cranial nerves.

MATERIALS AND METHODS

Twenty-four students underwent functional magnetic resonance (MR) imaging during encoding and recall of the name, number, and function of the 12 cranial nerves. The students viewed mnemonic graphic and text slides related to individual nerves, as well as their respective control slides. For the recall paradigm, students were prompted with the numbers 1-12 (test condition) intermixed with the number 14 (control condition). Subjects were tested about their knowledge of cranial nerves outside the MR unit before and after functional MR imaging.

RESULTS

Students learned about the cranial nerves while undergoing functional MR imaging (mean post- vs preparadigm score, 8.1 +/- 3.4 [of a possible 12] vs 0.75 +/- 0.94, bilateral prefrontal cortex, left greater than right; P < 2.0 x 10(-12)) and maintained this knowledge at I week. The encoding and recall paradigms elicited distributed networks of brain activation. Encoding revealed statistically significant activation in the bilateral prefrontal cortex, left greater than right [corrected]; bilateral occipital and parietal associative cortices, parahippocampus region, fusiform gyri, and cerebellum. Successful recall activated the left much more than the right prefrontal, parietal associative, and anterior cingulate cortices; bilateral precuneus and cerebellum; and right more than the left posterior cingulate.

CONCLUSION

A predictable pattern of brain activation at functional MR imaging accompanies the encoding and successful recall of the cranial nerves with this declarative memory paradigm.

Older adult norms for the Southern California Figure-Ground Visual Perception Test

Older adult norms for men are provided for the Southern California Figure-Ground Visual Perception Test (FG; Ayres, 1966), based on the performance of 117 patients from a geriatric medicine and rehabilitation facility ranging in age from 40 to 77 years. Reasons are presented for administering the entire test rather than using the traditional cutoff. When comparing FG performance to norms of younger adults (Bieliauskas, Newberry, & Gerstenberger, 1988), results indicate that figure-ground discrimination is poorer in older individuals. The norms provided here serve to complement the previous study employing FG, and it is hoped that they will encourage its wider use.

A 39-year followup of the Genain quadruplets

The Genains, a unique group of monozygotic female quadruplets, all developed a schizophrenic disorder by age 24. They have been studied since the 1950s, because of the rarity of this occurrence (estimated to be one in 1.5 billion) and because their illnesses varied in severity. The identical inheritance would tend to rule out genetic differences as the cause of the neuropsychological differences; however, we cannot disentangle the effects of early brain injury and harsh punitive treatment as factors accounting for the differences in the severity of their disorders. We conducted neuropsychological examinations of the Genains at age 66, compared their test profiles, and contrasted certain test scores at 66 with those at ages 27 and 51. Test results indicate generally stable (or even improved) performance over time and support the notion that cognitive decline is not a degenerative process in schizophrenia. The Genains remind us of the exquisite interaction among variables that must be understood before additional, satisfactory progress can be made in preventing the development and predicting the course of schizophrenia.

What Persian Gulf War syndrome?

Recent reports of physical and neuropsychological syndromes putatively associated with service in the Persian Gulf War and ostensibly providing evidence for Gulf War Syndrome (GWS) are critically reviewed. Major methodological weaknesses are identified in the studies and it is contended that there is no solid evidence for GWS at this time. Suggestions are given for future investigations of symptoms associated with service during the Gulf War which may accurately lead to a tangible identification of a war-related illness entity.

Through the looking glass: Where is the thought? A reply to Rodriguez-Menendez

In reply to my presidential address, Rodriguez-Menendez questions my comments about poorer performance on the national licensing exam by graduates of Psy.D. programs and professional schools than by Boulder-model Ph.D. programs. He goes on to confirm that their scores are indeed significantly lower, but suggests this is not important. Apart from this apparent confirmation, the remainder of his assertions that Psy.D. programs indeed provide good scientific training appear to be contraindicated by both the model and the performance of graduates of those programs. Finally, the need for standards is again asserted, with a reiteration of the need to ask who benefits from attacks on upholding standards: the patient and profession or the one who is doing the attacking.

American Board of Clinical Neuropsychology special presentation: The American Board of Clinical Neuropsychology (ABCN), 2000 update

This paper updates neuropsychologists on the process of obtaining board certification in clinical neuropsychology through the American Board of Clinical Neuropsychology (ABCN), a specialty board operating under the auspices of the American Board of Professional Psychology (ABPP). At this time, the ABPP and ABCN have certified 406 clinical neuropsychologists, which makes it the largest board-certification organization in clinical neuropsychology. This article details the advantages of board certification through the ABCN and the four steps which must be passed in order to obtain board certification. These steps are: credential review, written examination, work sample, and oral examination.

PPVT-R as an estimate of premorbid intelligence in older adults

The Peabody Picture Vocabulary Test-Revised (PPVT-R) was examined as an estimate of premorbid intelligence in a clinical sample of elderly patients (N = 150) undergoing clinical neuropsychological evaluation. PPVT-R standard scores were compared across grossly cognitively intact, mildly/moderately and severely impaired groups of patients, and compared to a short form of the Wechsler Adult Intelligence Scale-Revised (WAIS-R) and the Barona regression equation. Results indicate that, while the PPVT-R is vulnerable to increasing levels of cognitive impairment among patients with fewer years of education, the PPVT-R is stable across mild to moderate levels of impairment for patients with greater than 12 years of education. In a sub-sample of grossly cognitively intact patients (n = 91), the PPVT-R standard score correlated significantly with estimated WAIS-R FSIQ (r =.61). Compared to the Barona equation, the PPVT-R was less likely to over-estimate WAIS-R FSIQ in the grossly cognitively intact patients. These data suggest the PPVT-R to be a useful estimate of premorbid ability for patients with a greater than high-school education.

A long-term-care setting pilot study evaluating predictors of success in medication self-administration

OBJECTIVE

To determine whether any specific patient variables or a short battery of neuropsychological tests of cognition and memory predict success in medication self-administration.

DESIGN

A prospective, single-blinded design.

SETTING

An extended care center of a university-affiliated VA Medical Center.

PATIENTS

Thirty predominately male, older veteran patients, mean age 70 +/- 4 years with a range of 63 to 79 years.

INTERVENTIONS

Neuropsychological testing [Mini-Mental Status Examination (MMSE), Delayed Word Recall Test (DWRT), Shipley Institute of Living Scale (SILS), Neurobehavioral Cognitive Status Examination (NCSE), Hopkins Verbal Learning Test (HVLT)], twice a week unannounced bedside medication counts and medication administration record inspections, and educational instruction, if needed, by nurses and pharmacists.

MAIN OUTCOME MEASURES

Patient characteristics such as age, number of medications, presence of a disorder that can alter cognitive or memory function, years of education, and results from the above listed neuropsychological tests. The dependent variable was successful or not successful as defined by whether the patient required a re-education intervention.

RESULTS

Fifteen patients required one or more re-education intervention(s) as a result of meeting the criteria for not being successful. The absence of major depression, stroke, or anxiety disorder did tend to predict success (P = 0.0716) in medication self-administration. The other patient specific characteristics did not predict success. Among the neuropsychological tests administered, only the Judgment Subtest of the NCSE tended to predict success (P = 0.098). The MMSE, DWRT, SILS,HVLT tests did not predict successful performance in the self-medication program.

CONCLUSIONS

Although the presence of a diagnosis that could potentially alter cognitive and memory function tended to predict success, no patient characteristics were found that predicted success independently. Among the neuropsychological tests, only the Judgment subtest of the NCSE tended to predict success in medication self-administration. We conclude that the NCSE and characterization of patient-specific factors, including diseases that may affect cognitive and memory function, seem to be the best predictors of success in medication self-administration in a long-term-care setting.

Neuropsychological subgroups of patients with Alzheimer's disease: an examination of the first 10 years of CERAD data

Neuropsychological CERAD data from 960 patients with Alzheimer's disease and 465 controls were subjected to separate yet identical classification procedures. Consistent with past research, three patient subgroups were reliably identified: Subgroup 1 (LAD; n = 312) was characterized by severe naming impairment yet borderline-normal figure-copying skills; Subgroup 2 (RAD; n = 247) displayed average naming ability but moderately-impaired copying performance; Subgroup 3 (GAD; n = 161) evinced profound anomia and constructional dyspraxia. LAD patients were older and less educated than those of the other subgroups. Control subgroups (n = 2) did not resemble the patient subgroups. Initial patterns of performance remained discernible across time for LAD and GAD, but were less consistent for RAD. Members from patient subgroups were present across disease stage.

Mediocrity is no standard: searching for self-respect in Clinical Neuropsychology

While medicine moved from a training based in proprietary schools to university-based education and board specialty examinations during the early part of this century, psychology has seemed to move in the opposite direction during the past 20 years. Clinical Neuropsychology, as a specialty, has established training and practice guidelines, and more recently, produced an integrated model of education and training, not unlike the models developed by medicine and its specialties. Nevertheless, there are pressures within the field of Psychology in general, and Clinical Neuropsychology in particular, to abrogate standards and weaken credentials. These pressures are seen as stemming from prioritizing the interests of the practitioner over the needs of the patient and the profession. The thesis is presented that upholding standards leads to the benefit of the patient and the long-term health of the profession.

Use of the odds ratio to translate neuropsychological test scores into real-world outcomes: from statistical significance to clinical significance

Standard parametric tests generate p values and effect sizes, but often these are difficult to translate into real-world outcomes. In this study, the odds ratio was applied to neuropsychological testing and was compared to parametric approaches. Participants were 26 community-dwelling adults with possible or probable Alzheimer's disease and 25 matched healthy community-dwelling volunteers. Odds ratios were computed to estimate the probability of concurrent diagnosis given neuropsychological performance level. Odds ratios discriminated the groups at magnitudes that could not be discerned from t-test significance tables. These values were compared to sensitivity, specificity, and overall accuracy. Clinical and research applications and implications were addressed.

Unmasking the heterogeneity of Alzheimer's disease: case studies of individuals from distinct neuropsychological subgroups

Case descriptions of patients with probable Alzheimer's disease (AD) who were reliably classified into three neuropsychological subgroups (global [GAD], right-hemisphere [RAD], and left-hemisphere [LAD]) in an earlier cluster analytic study (Fisher et al., 1996) are presented. Concordance between the neuropsychological patterns and clinical histories of randomly selected and hand-selected cases from within each subgroup was high. Longitudinal analysis revealed stable subgroup-specific neuropsychological progression patterns. Results are discussed in terms of future research avenues worth pursuing, in addition to the conceptual shift in research design necessary to uncover both quantitative and qualitative subgroup-specific ability differences.

Crashes and violations among drivers with Alzheimer disease

BACKGROUND

Several small studies have found a high automobile crash rate for drivers with Alzheimer disease (AD) compared with unaffected elderly drivers, prompting the suggestion that the diagnosis of AD mandate cessation of driving.

OBJECTIVES

To compare automobile crash and violation rates of a large number of patients with AD with appropriately matched elderly subjects. To determine if neuropsychological test scores predict these adverse driving events. To determine if intervention by physicians or family members influences driving cessation.

DESIGN

Review of crashes and violations from 1986 to 1993 in police-filed Michigan State driving records of 143 licensed patients with AD and 715 licensed comparison subjects matched 5 to 1 in age (+/- 6 years), sex, and county of residence. We correlated crashes and violations with neuropsychological test scores. A questionnaire-based inquiry on the influence of physician, family, and state interventions on driving cessation was administered.

RESULTS

The crash and violation rates of patients with AD were not significantly different from those of comparison subjects. However, patients with AD probably drove fewer kilometers than did comparison subjects. Neuropsychological test scores did not predict future crashes or violations.

CONCLUSIONS

This study, the largest to our knowledge involving state driving records of patients with AD, does not confirm the previously reported excessive crash rate among drivers with AD relative to an appropriate comparison population. Reduced driving exposure of patients with AD probably kept their crash adverse equal to that of comparison subjects. Intervention by physicians and family members was major factor in reducing driving exposure. These findings affirm that the mere diagnosis of AD does not justify license revocation.

Failed back surgeries and minnesota multiphasic personality inventory (MMPI) profiles

MMPI profiles were evaluated for 105 prospective surgical patients who had previously undergone surgery or other procedures for treatment of back pain. Patients were classified into groups having undergone zero, one, two, three, or four or more previous surgeries. While all groups demonstrated a characteristicsomatogenic profile, none of the MMPI validity or clinical scales significantly differentiated the groups and there was no relationship between increased number of surgeries and MMPI scale characteristics. These results support the nonoptimistic prognostication of thesomatogenic MMPI profile for surgical intervention for back pain but show no clear relationship of MMPI profile characteristics to degree of experience of previously failed surgery.

Cognitive and psychopathological change in degenerative disease in the elderly

Neuropsychological studies of declining cognitive ability and increasing psychopathology in degenerative neurological diseases in the elderly suggest the following: (1) the physiological basis for affective and thought disorder remains elusive; (2) cognitive capacity and primary psychopathology are not clearly related in degenerative disease; rather neuropsychological studies in this area illustrate a dissociation between accessory (secondary) symptoms of psychopathology and cognitive changes; (3) accessory symptoms of thought disorder may be associated with disorders of the basal ganglia; and (4) current nosology of affective and thought disorders is probably not appropriate when dealing with onset of psychopathology in the elderly. There is a need to closely attend to logical inference in neuropsychological data from this group of patients, and to clearly differentiate primary from secondary symptoms of affective and thought disorders.

Characterizing the neuropsychological functioning of persons with human immunodeficiency virus (HIV) infection, Part II. Neuropsychological functioning of persons at different stages of HIV infection

Neuropsychological impairment has been reported to occur in persons at all stages of infection with the human immunodeficiency virus (HIV). However, the findings of studies to characterize the incidence and pattern of impairment have been limited by inconsistent definitions of impairment and the failure to control for confounding variables, such as hematological abnormalities, history of head injury, or substance abuse. In the present study, neuropsychological tests were administered to 141 persons at four stages of HIV infection. Significant differences were found in the percentage of persons who showed impairment at each stage of infection. Further, participants' performance on the tests tended to decline across progressive stages of infection. These findings may help psychiatric nurses identify and manage the changes associated with HIV infection.

Characterizing the neuropsychological functioning of persons with human immunodeficiency virus infection, Part I. Acquired immunodeficiency syndrome dementia complex: a review

The findings of studies that use psychoneuroimmunological frameworks can help nurses evaluate and treat patients' psychological and physical responses to infection with the human immunodeficiency virus (HIV). One response to HIV infection, acquired immunodeficiency syndrome (AIDS) dementia complex (ADC), may occur at any stage of the infection and is particularly distressing to both patients and nurses. In Part I of this series, current research pertinent to ADC is reviewed. In Part II, we describe an approach used to characterize the neuropsychological functioning of persons at different stages of HIV infection.

Distinguishing between depression and dementia in the elderly: a review of neuropsychological findings

Distinguishing between cognitive deficits seen in depression and progressive dementing, diseases is complex and often difficult clinically. We review recent neuropsychological studies comparing normal elderly individuals, depressed patients, and patients with progressive dementias. Findings from these studies suggest that the distinction between depression and dementia is fairly straightforward and facilitated by neuropsychological evaluation. Data from neuroimaging studies of depressed elderly are reviewed and integrated with the neuropsychological findings. A descriptive scheme for categorizing elderly patients is proposed. It is suggested that the label "pseudodementia" be discarded in favor of more thorough description of cognitive deficits associated with various clinical presentations.

Depression type in Parkinson disease

Thirty-three patients with Parkinson Disease were evaluated neurologically and neuropsychologically. Seventy percent without a previous psychiatric diagnosis, were depressed. This depression was not related to the presence of dementia, stage of the disease, a general estimate of memory and attention, years of Parkinsonism, age, or indices of frontal cortex-related functioning. Because the depression did not positively relate to factors suggestive of advancing disease, it is proposed that the depression is reactive to the disease rather than an integral part of it.

Cognitive rehabilitation two and one-half years post right temporal lobectomy

A 45-year old radiologist, who underwent a right temporal lobectomy to remove a tumor, sought treatment for difficulties with attention/scanning, sustained concentration, leisure reading, driving, and self-monitoring in social situations. A neuropsychological evaluation conducted 2.5 years postsurgery revealed impaired visual-spatial memory, inefficiency in general visual scanning, a mild left-sided neglect, and diminished social perception. The patient subsequently underwent a 4-month cognitive retraining program, which was tailored to his specific neuropsychological deficits. At the termination of treatment, improvements were observed on follow-up neuropsychological data, behavioral observations made by the patient's wife, and efficiency on work-related tasks. This case illustrates the ecological validity of cognitive rehabilitation procedures and emphasizes the need to tailor the procedures to specific cognitive deficits revealed on neuropsychological testing.

Stress and personal attitudes in chronic illness

The possible relation of two stressor types (life events and illness experience) to three sets of attitudes (personal life satisfaction, self-assessed coping, and satisfaction with treatment personnel/facilities) was examined within a sample of 97 outpatients having multiple sclerosis. In addition, potential moderators of hypothesized relationships were examined (trait anxiety, age, social class, and knowledge of the disease). When attitudes were regressed on stressors and moderators, both sets of stressors exerted significant influence, though their impacts were mitigated by the moderators. This study's findings support the position that the association of attitudes with stressor exposure in chronic disease populations is contingent on demographic and psychological moderating factors.

Chronic dopaminergic sensitivity after Sydenham's chorea

We studied psychometric performance on the Minnesota Multiphasic Personality Inventory (MMPI) mini-mult and drug-induced choreic reactions in a group of patients with a history of Syndenham's chorea. Action tremor, motor signs, and residual chorea were common. One-half of the patients reported adverse choreic reactions to one or more agents. Patients with adverse reactions to central stimulants and anorectics had statistically significant elevations in the psychotic tetrad of the MMPI. Sydenham's chorea in childhood seems to confer persistent sensitivity to agents that augment central dopaminergic activity, which may be expressed as acute chorea. Central dopaminergic sensitivity may explain earlier reports of psychologic difficulties in survivors of rheumatic chorea.

Stable behaviors associated with high-point D MMPI profiles in a nonpsychiatric population

Examined behaviors associated with high-point D scale scores on the MMPI for 1829 employed males who completed the test twice, 4 years apart. Ratings of being frequently nervous or upset and a decreased percentage of time in bed sleeping emerged as two stable variables that differed between Hi-D and not high-D scorers.

Psychological depression and cancer

Studies are reviewed which relate to five basic content areas of research concerning depression and cancer: significant loss experience, emotional inhibition, hopelessness, psychiatric assessment of depression, and test measurement of depression. Methodological issues within each area are addressed as they relate to the potential validity and generalizability of findings. In general, there is no support for increased loss experience in cancer patients and mild support for increased emotional inhibition and hopelessness in these individuals. Traditional psychiatric assessment approaches are not seen as providing solid evidence for a depression/cancer relationship due to reliability and design issues, while psychometric assessment provides mild support for a prospective relationship between depression and later cancer. Issues relating to approaches to research, means of measurement of depression, design issues, and questions of conceptualization of depression are discussed.

Psychological depression and 17-year risk of death from cancer

Psychological depression, measured in 1957-1958 by the Minnesota Multiphasic Personality Inventory at the baseline examination of 2,020 middle-aged employed men, was associated (p less than 0.001) with a twofold increase in odds of death from cancer during 17 years of follow-up. The association did not vary appreciably in magnitude among the early (1958-1962), middle (1963-1968), and later (1969-1974) years of follow-up, persisted after adjustment for age, cigarette smoking, use of alcohol, family history of cancer, and occupational status, and was apparently not specific to any particular site or type of cancer. This result, predicted in advance on the basis of findings by other investigators, is consistent with the hypothesis that psychological depression is related to impairment of mechanisms for preventing the establishment and spread of malignant cells.

Life events, 17-OHCS measures, and psychological defensiveness in relation to aid-seeking

Professional aid-seeking for medical or psychological reasons was measured in 80 firefighters for a retrospective period of six months and a prospective period of eight weeks. The magnitude of life stress events, 24-hour urine 17-OHCS levels, and MMPI K-Scale scores were compared between those subjects who had sought professional aid and those who had not. The measured values did not differ significantly between groups and were, in fact, well within normal limits for all subjects tested. Analysis suggests that implied relationships between stress and illness are questionable in low-stress, low-maladjustment populations. These data lend support to the concept of a threshold effect for influence of life change on subsequent illness manifestation.