Clinical and neuropsychological correlates of impaired awareness of deficits in Alzheimer disease and Parkinson disease: a comparative study.

OBJECTIVE: To compare patients with Alzheimer disease (AD) and Parkinson disease (PD) with regard to their awareness of cognitive, emotional/social interaction, self-care, and motor-related neurologic deficits. BACKGROUND: Unawareness of deficits, a clinically important symptom, is found in AD. It has been hypothesized to be associated with disruption of frontal-subcortical circuits but has been little studied in other neurodegenerative disorders. Because PD has a different anatomic-pathologic substrate, a comparison of impairment of awareness in AD and PD may shed light on the neural basis of this phenomenon. METHOD: Impairment of awareness was measured as the difference between patient self-report and caregiver ratings of patient abilities on questionnaires tapping cognitive, emotional/social interaction, self-care, and motor function. These "discrepancy scores" were then compared between the two diagnostic groups and examined in relation to selected neuropsychological test data. RESULTS: In general, both AD and PD patients rate themselves as being less impaired than do their caregivers. The two diagnostic groups, AD and PD, differ significantly, however, on awareness discrepancy measures in the cognitive domain. In their ratings of patient cognitive skills, AD caregivers rate patients as significantly more impaired than patients rate themselves, whereas PD caregivers and patients do not differ significantly on these ratings. Impaired awareness in PD but not in AD is associated with poorer overall cognitive function and performance on tests measuring memory, attention, and constructional ability. CONCLUSIONS: Both AD and PD patients display impaired awareness of deficits in multiple domains, including motor-related neurologic function. Parkinson disease patients with comparatively intact cognitive function display relatively preserved awareness of motor and other deficits.

Praxis lateralization: errors in right and left hemisphere stroke.

Whereas the representations of skilled movements in most right handers are stored in the left hemisphere, the right hemisphere's contribution to action planning remains unclear. We investigated error patterns in left (LHD) and right hemisphere damaged (RHD) subjects as well as normal control subjects (C) to determine if specific components of action programs may be processed by the right hemisphere or bilaterally represented. We had these subjects perform gestures to verbal command with the ipsilesional limb. Although the LHD group made significantly more qualitative errors than the C and RHD groups, the RHD subjects produced a number of apraxic errors. Specifically, the LHD group produced a wide range of spatiotemporal and conceptual errors for both transitive and intransitive gestures, while the RHD group made specific spatial and temporal errors primarily when performing transitive gestures. These findings support the postulate that the left hemisphere stores the spatiotemporal and conceptual representations of learned skilled movements, while several specific components of action programs, such as external configuration (limb orientation) and timing, may have bihemispheric representations.

Impact of threat relevance on P3 event-related potentials in combat-related post-traumatic stress disorder.

The purpose of this study was to examine electrophysiological response to trauma-relevant stimuli in combat-related post-traumatic stress disorder (PTSD). Study design incorporated comparison of 10 Vietnam War veterans with PTSD diagnosis to 10 Vietnam War veterans with no mental disorder diagnosis on P3 components in a series of two oddball tasks (trauma-relevant threat, trauma-irrelevant threat) counterbalanced for order. Each task included high probability emotionally neutral distractor words and low probability neutral target words, but differed in the content of low probability threat words. Whereas threat words in the trauma-relevant oddball task pertained directly to combat trauma, threat words in the trauma-irrelevant oddball task were socially threatening words. Results revealed that, in comparison to healthy combat veterans, those diagnosed with PTSD demonstrated: (a) attenuated P3 response to neutral target items at selected electrode sites across both oddball tasks; and (b) increased responsivity to trauma-relevant combat stimuli but not to trauma-irrelevant social-threat stimuli at frontal electrode sites (F3, F4). Results are consistent with resource allocation models of PTSD, which suggest that PTSD is characterized by attentional bias to threat stimuli at the expense of attention to emotionally neutral information.

Contribution of PTSD/POW history to behavioral disturbances in dementia.

As many World War II and Korean Conflict veterans suffering from posttraumatic stress disorder (PTSD) grow older, increasing numbers will be diagnosed with dementia. We retrospectively analyzed patients with dementia, comparing the behavioral disturbances of those with PTSD to those without PTSD. We hypothesized that due to the additive effect of the neurobiological and behavioral changes associated with PTSD and dementia, the dementia with PTSD group would show more agitation and disinhibition than the dementia without PTSD group. Sixteen patients with diagnoses of dementia and PTSD were matched on age and Mini-Mental States Examination (MMSE) scores to 16 patients with dementia without PTSD. Demographic characteristics, co-morbid diagnoses, global Assessment of Functioning (GAF), Cohen-Mansfield Agitation Inventory (CMAI), and paranoid items of Brief Psychiatric Rating Scale (BPRS) and Positive and Negative Syndrome Scale for Schizophrenia (PANSS) were assessed. The patients with diagnoses of dementia with PTSD did not differ significantly in their clinical presentation, hospital course, and condition at discharge from patients with dementia without PTSD. Chi-square analysis showed that significantly more subjects in the PTSD group were prescribed anti-depressants compared to the non-PTSD group. Interestingly, within the PTSD group, the subgroup of patients who were former prisoners of war had a significantly higher mean score for paranoia and significantly less verbal agitation. This pilot study reveals that a diagnosis of PTSD alone is not sufficient to influence behavior in veterans with dementia; however, we also present provocative results that patients with more severe trauma (POW) do have changes in their behavior.

Memory of psychodiagnostic information: biases and effects of expertise.

Problem-solving expertise has been associated with enhanced memory of domain-specific information. This enhanced memory is thought to play an important role in expert decisions. Meanwhile, research on psychodiagnostic decision making has found consistent limitations in experienced clinicians' ability to make optimal decisions. To what extent are these limitations associated with suboptimal memory processes? We compared memories of expert clinicians and novice graduate students for information learned while viewing a videotaped psychodiagnostic interview. Results of 3 tests suggest that expert clinicians exhibit enhanced memory that is flexible, selective, and accurate but with limitations that might contribute to poor decisions. Experts exhibited superior memory of personal criteria and disconfirmatory information. However, a framing manipulation induced performance in experts consistent with suboptimal decision making, and both groups needed exhaustive prompts for optimal memory search. Implications of these findings for expertise models are discussed.

Qualitative block design analysis in posttraumatic stress disorder.

Qualitative and quantitative Block Design performance was examined in Vietnam combat veterans with PTSD diagnoses (n = 23) and Vietnam combat veterans without PTSD or other mental disorders diagnoses (n = 19). Results indicated that PTSD-diagnosed veterans committed more single block rotations than the comparison sample, and that their errors occurred more frequently in right hemispace than errors made by the comparison sample. The two groups did not differ in the number of configural errors made, errors committed in left hemispace, or in quantitative performance measures. Findings are suggestive of relative left hemisphere hypoactivation and are congruent with prior research documenting cerebral asymmetries in emotional disorders.

Head injury as a predictor of psychological outcome in combat veterans.

Although it is recognized that psychosocial variables influence the expression of psychopathology following trauma exposure, physiological variables have received less attention as potential mediators of psychological outcome in trauma victims. The purpose of this study was to examine the relationship of head injury to psychological outcome in 171 combat veterans seeking compensation for service-connected disabilities for mental disorders attributed to etiologies other than head injury. Veterans underwent structured psychiatric diagnostic interview and completed self-report measures of combat exposure, posttraumatic stress disorder (PTSD), depression, and occurrence of head injury. Comparisons between veterans with and without history of head injury indicated that head injury was associated with more severe depression. Regression analysis suggested that head injury predicted depression, but not PTSD, severity.

War zone stress, personal and environmental resources, and PTSD symptoms in Gulf War veterans: a longitudinal perspective.

Cross-sectional research has demonstrated a link between personal and environmental resources and development of emotional distress after war zone service. Less is known about the longitudinal relationship between resources and distress. The authors addressed this issue in a study of 348 Gulf War returnees tested at 2 time points. Resources decreased and posttraumatic stress disorder (PTSD) symptoms increased over time. Time 1 avoidance and family cohesion predicted PTSD symptoms at Time 2. Regression analyses revealed a bidirectional relationship over time between resources and PTSD symptoms. Time 1 resources predicted Time 2 psychopathology after accounting for Time 1 emotional distress. PTSD symptoms at Time 1 also predicted changes in coping and family relationships, even after accounting for Time 1 resources. Findings are consistent with the concept of a loss spiral (Hobfoll, 1989), in which resource factors and emotional sequelae to war stress exert reciprocal effects.

Olfactory identification in combat-related posttraumatic stress disorder.

Recent neuropsychological conceptualizations of posttraumatic stress disorder (PTSD) implicate dysfunction of the fronto-limbic system, a brain system thought to be involved in the mediation of emotion. However, few studies have examined fronto-limbic subregions, such as the orbitofrontal cortex, in PTSD. As a measure of orbitofrontal integrity, olfactory identification was assessed in 26 Vietnam War veterans with PTSD, 25 Vietnam War veterans without mental disorders, and 17 Vietnam-era, non-war-zone veterans without mental disorders. Relative to veterans without PTSD, those diagnosed with PTSD were less proficient in odor identification and verbal learning but not on other cognitive tests sensitive to dorsolateral prefrontal and mesial temporal functioning. Results bolster prior research indicating fronto-limbic dysfunction in PTSD, and suggest involvement of the orbitofrontal region.

Relationship of psychiatric status to Gulf War veterans' health problems.

OBJECTIVE: A growing body of research has shown that there are important links between certain psychiatric disorders and health symptom reporting. Two disorders in particular (posttraumatic stress disorder (PTSD) and major depression) have been the most widely implicated to date, and this association has sometimes been used to explain the occurrence of ill-defined medical problems and increased somatic symptoms in certain groups, most recently Gulf War veterans. METHODS: Structured psychiatric diagnostic interviews were used to examine the presence of major psychiatric (axis I) disorders and their relation to health symptom reporting in a well-characterized, stratified subset of Gulf War veterans and a non-Gulf-deployed veteran comparison group. RESULTS: Rates of most psychiatric disorders were substantially lower than national comorbidity estimates, consistent with prior studies showing heightened physical and emotional well-being among active-duty military personnel. Rates of PTSD and major depression, however, were significantly elevated relative to the veteran comparison group. The diagnosis of PTSD showed a small but significant association with increased health symptom reports. However, nearly two-thirds of Gulf participants reporting moderate to high health symptoms had no axis I psychiatric diagnosis. CONCLUSIONS: Results suggest that rates of psychiatric illness were generally low with the exception of PTSD and major depression. Although PTSD was associated with higher rates of reported health problems, this disorder did not entirely account for symptoms reported by participants. Factors other than psychiatric status may play a role in Gulf War health problems.

Attention and memory dysfunction in posttraumatic stress disorder.

Attention and memory performances were studied in Persian Gulf War veterans with and without posttraumatic stress disorder (PTSD) diagnoses. Veterans diagnosed with PTSD showed relative performance deficiencies on tasks of sustained attention, mental manipulation, initial acquisition of information, and retroactive interference. Their performances were also characterized by errors of commission and intrusion. The tendency toward response disinhibition and intrusion on cognitive tasks was correlated positively with reexperiencing symptoms and negatively with avoidance-numbing symptoms. These cognitive deficit patterns are consistent with models of PTSD that emphasize the role of hyperarousal and implicate dysfunction of frontal-subcortical systems. Results suggest that intrusion of traumatic memories in PTSD may not be limited to trauma-related cognitions but instead reflects a more general pattern of disinhibition.

Health status of Persian Gulf War veterans: self-reported symptoms, environmental exposures and the effect of stress.

BACKGROUND: Most US troops returned home from the Persian Gulf War (PGW) by Spring 1991 and many began reporting increased health symptoms and medical problems soon after. This investigation examines the relationships between several Gulf-service environmental exposures and health symptom reporting, and the role of traumatic psychological stress on the exposure-health symptom relationships. METHODS: Stratified, random samples of two cohorts of PGW veterans, from the New England area (n = 220) and from the New Orleans area (n = 71), were selected from larger cohorts being followed longitudinally since arrival home from the Gulf. A group of PGW-era veterans deployed to Germany (n = 50) served as a comparison group. The study protocol included questionnaires, a neuropsychological test battery, an environmental interview, and psychological diagnostic interviews. This report focuses on self-reported health symptoms and exposures of participants who completed a 52-item health symptom checklist and a checklist of environmental exposures. RESULTS: The prevalence of reported symptoms was greater in both Persian Gulf-deployed cohorts compared to the Germany cohort. Analyses of the body-system symptom scores (BSS), weighted to account for sampling design, and adjusted by age, sex, and education, indicated that Persian Gulf-deployed veterans were more likely to report neurological, pulmonary, gastrointestinal, cardiac, dermatological, musculoskeletal, psychological and neuropsychological system symptoms than Germany veterans. Using a priori hypotheses about the toxicant effects of exposure to specific toxicants, the relationships between self-reported exposures and body-system symptom groupings were examined through multiple regression analyses, controlling for war-zone exposure and post-traumatic stress disorder (PTSD). Self-reported exposures to pesticides, debris from Scuds, chemical and biological warfare (CBW) agents, and smoke from tent heaters each were significantly related to increased reporting of specific predicted BSS groupings. CONCLUSIONS: Veterans deployed to the Persian Gulf have higher self-reported prevalence of health symptoms compared to PGW veterans who were deployed only as far as Germany. Several Gulf-service environmental exposures are associated with increased health symptom reporting involving predicted body-systems, after adjusting for war-zone stressor exposures and PTSD.

Neuropsychological deficits in probands from multiply-affected schizophrenic families.

This study was designed to determine if schizophrenics from families with more than one psychotic relative show more severe neuropsychological deficits than schizophrenics with only one psychotic relative, non-familial schizophrenics, and a group of matched normal controls. Eighty-one schizophrenic-spectrum patients were divided into three groups on the basis of the presence of psychotic disorder among first- and second-degree relatives. The three groups of schizophrenics and the normal controls were compared for differences on a brief neuropsychological testing battery. The four groups showed significant multivariate differences. Patients from multiply-affected families showed significantly greater neuropsychological dysfunction on measures of abstract concept formation, visuomotor-coordination, and attention than patients from families that had only one psychotic relative. Schizophrenics from low-density families showed more severe deficits in fine motor-control than non-familial schizophrenics. These data suggest that abnormalities in those frontal systems that are likely to mediate fine motor control and abstract concept formation may be related to the degree of familial loading for psychotic disorder.

Longitudinal assessment of deficit unawareness in Alzheimer's disease.

Longitudinal progression of impaired deficit awareness across varied functional domains was evaluated in 28 patients diagnosed with probable Alzheimer's disease (AD). Unawareness, as measured by patient-caregiver rating discordance, was first assessed in reference to patient memory, health status, self-care skills, anxiety, depression and irritability. The identical protocol was then repeated an average of 16.4 months later. Results indicated that, compared with caregiver ratings, patients tended to underestimate their deficits across functional domains. Patient-caregiver rating discrepancies were most pronounced in judgment of memory and self-care decline, indicating domain-specific differences in degree of unawareness. However, patient-caregiver rating discrepancies increased on most measures from time 1 to time 2 with no differences in the magnitude of these increases, suggesting a nonspecific longitudinal progression of unawareness. Although unawareness of deficits increased with time, longitudinal change in unawareness was not related to other disease and demographic variables such as age, education, age at onset, or duration of illness.

Awareness of deficit in Alzheimer's disease: relation to caregiver burden.

Patients with Alzheimer's disease (AD) show varying degrees of awareness of their deficits. To examine the impact of this phenomenon upon the distress experienced by family caregivers of AD patients, we analyzed caregiver burden in relation to patient awareness of deficit in three different functional domains. The relationship of burden to selected sociodemographic variables was also explored. Results of multiple regression analyses suggested that caregiver burden was associated with impaired patient awareness of memory deficit independent of disease stage and dementia severity. The findings suggest that impaired awareness may be an important mediator of caregiver burden, a concern in the management of AD.

A preliminary study of the neuropsychological heterogeneity of familial schizophrenia.

This exploratory study describes the heterogeneity of the neuropsychological deficits that characterize familial schizophrenia. Forty-six familial schizophrenics showed significantly more variability in abstraction and problem-solving and motor control than 39 non-familial schizophrenics. Cluster analyses of these two neuropsychological parameters indicate that while the non-familial schizophrenics fall into one homogeneous cluster, the familial schizophrenics fall into three relatively distinct clusters which differ significantly in their morbid risk for schizophrenic-spectrum disorder. These preliminary data suggest that frontal lobe deficits are associated with an increased familial risk for schizophrenia.

Psychopathology in war-zone deployed and nondeployed Operation Desert Storm troops assigned graves registration duties.

Early psychopathology outcomes were compared in troops mobilized for Persian Gulf graves registration duty but differentiated by war-zone deployment. Constructs of interest were Axis I psychiatric disorders, particularly posttraumatic stress disorder (PTSD), negative affect states, and somatic complaints. Psychometric instruments, including the Structured Clinical Interview for DSM-III-R, were administered to troops attending drill exercises. Although similar in personal characteristics and reporting low rates of premorbid psychopathology, groups differed in the prevalence of PTSD diagnoses, anxiety and anger symptoms, and somatic complaints. Current and lifetime PTSD rates of 48% and 65%, respectively, suggest that the psychological aftermath of war-zone participation involving the gruesome task of handling human remains was profound.