Further evidence for dementia of the prefrontal type in schizophrenia? A controlled study of teaching the Wisconsin Card Sorting Test.

Recent physiological and cognitive studies of schizophrenia have implicated dysfunction of prefrontal cortex as a possible explanation for some of the disabling intellectual and social aspects of the disorder. To investigate the potential reversibility of cognitive deficits and the role of state variables, eg, attention and motivation, three groups of patients with schizophrenia were administered the Wisconsin Card Sorting Test on six consecutive occasions. Two of the groups received incremental information on how to do the test, including explicit card-by-card instruction. The third group served as a control. Regardless of the degree of instruction, patients who could not do the test could not learn it. The deficit did not appear generalized, as patients were able to learn word lists on the Selective Reminding memory test and were not globally demented on the Mini-Mental State Examination. These data suggest that prefrontal-type cognitive deficits in schizophrenia may be more profound than is generally appreciated.

Maintenance of training effects on the Wisconsin Card Sorting Test by patients with schizophrenia or affective disorders.

The authors used the Wisconsin Card Sorting Test to study 50 hospitalized psychiatric patients: 28 with schizophrenia, 17 with affective disorders, and five with schizoaffective disorder. The schizophrenic patients performed significantly more poorly than the patients with affective disorders. Both groups of patients improved when given additional instructions. The schizophrenic patients maintained their improvement when retested approximately 6 weeks later. The results suggest that factors other than frontal cortex dysfunction are involved in schizophrenic patients' performance on the Wisconsin Card Sorting Test.

Improved delayed visual reproduction test performance in multiple sclerosis patients receiving interferon beta-1b.

We assessed neuropsychological function longitudinally in 30 MS patients who participated in the pivotal trial of interferon beta-1b (IFN-beta-1b). Nine patients received high-dose IFN-beta-1b (8.0 million units), eight low-dose IFN-beta-1b (1.6 MIU), and 13 placebo. There was significant improvement in Wechsler Memory Scale Visual Reproduction-Delayed Recall scores between years 2 and 4 of the trial in MS subjects receiving high-dose IFN-beta-1b. Motoric performance, MRI lesion area, and depression rating scores did not correlate with this finding. Comparison of MRI at baseline and at years 2 and 4 revealed significant changes over time for the total cohort (p < 0.02). Mean lesion area in the high-dose group did not change over time, whereas the low-dose and placebo groups had increases in total lesion area of 28 and 36%, respectively, at year 4. Expanded disability status scale scores did not change significantly between years 2 and 4 of the trial, nor did they correlate with MRI lesion area at any assessment point. We conclude that high-dose IFN-beta-1b improves delayed visual reproduction test performance in MS patients, a finding unlikely to be explained by practice effects or brain lesion area.

Attention and mental processing speed in hemodialysis patients.

It has remained unclear whether well-dialyzed patients with end-stage renal disease (ESRD) show persisting neurocognitive deficits, especially in tasks that depend on sustained attention or psychomotor speed. We administered a battery of six attentional measures to 10 stable hemodialysis (HD) patients (age, 61+/-16 years; education, 12.4+/-3.8 years; Kt/V, 1.35+/-0.07) and 10 matched controls with normal renal function (age, 62+/-10 years; education, 11.6+/-1.0 years; estimated creatinine clearance, 92+/-25 mL/min). Results of the Trailmaking Test, Paced Auditory Serial Addition Test, Stroop Test, Digit Span, Continuous Performance Test (CPT), and Gordon Diagnostic System did not differ between groups. We conclude it is unlikely that well-dialyzed patients with ESRD manifest significant uremic neurocognitive deficits in the functional spheres related to sustained attention or mental processing speed.

Charles Bonnet syndrome: an early marker for dementia?

OBJECTIVE: To clarify the neuropsychological function in patients with Charles Bonnet Syndrome. DESIGN: Control group comparison study. SETTING: University of Chicago Hospitals. PARTICIPANTS: The neuropsychological function of 15 older adults with presenting complaints of visual hallucinations who met criteria for Charles Bonnet Syndrome (CBS) were compared with 11 demographically matched controls to determine if there was any evidence of functional brain impairment. CBS patients were screened for focal brain lesions and epileptic disturbance via MRI and EEG and also received pattern visual evoked potentials and ophthalmological examinations. MEASUREMENTS: Scores from the Wechsler Adult Intelligence Scale-Revised, Mattis Dementia Rating Scale, Wechsler Memory Scale, and the Auditory Verbal Learning Test were compared. RESULTS: Significant differences were found between the two groups on the neuropsychological measures. Moreover, 14 of 14 subjects had ocular abnormalities and six of eight had abnormal age-corrected pattern visual evoked potentials indicative of dysfunction in the visual system. CONCLUSIONS: The results of the study indicate that patients diagnosed with Charles Bonnet Syndrome evidence neuropsychological changes commonly associated with the early stages of dementia. Therefore, in patients with impaired vision, the appearance of cognitive deficits, albeit subtle, occur with the onset of visual hallucinations. We propose that isolated visual hallucinations in the older adult may be an indication of the early stages of dementia.

Recall memory deficit in schizophrenia. A possible manifestation of prefrontal dysfunction.

Patients with schizophrenia have memory deficits when compared to other neuropsychiatric and normal samples, but the mechanism by which the deficits arise is obscure. In the present study, 13 older, less educated normal subjects, and 31 inpatients with schizophrenia were administered the Selective Reminding test. In addition, the schizophrenic patients received the Mini Mental State Exam and the Brief Psychiatric Rating Scale. While normal subjects performed at a higher level on various measures of recall, a significant effect of repeated trials was present for each group for each measure, indicating that both groups learned. Normal subjects also outperformed the patients on a test of recognition memory. However, the patients exhibited a significantly greater disparity between recognition and recall than did the normal subjects, suggesting they were better able to acquire new information than to retrieve it ('forgetting to remember'). Moreover, anergia, a factor measure on the Brief Psychiatric Rating Scale, correlated significantly with recall, but not recognition memory, in the patient group. The data are suggestive of prefrontal-type cognitive and behavioral deficits in schizophrenia.

Electrical injury through the eyes of professional electricians.

This paper presents the first results of an attitudinal survey that was conducted among professional electricians in order to explore their knowledge and beliefs related to occupational electrical injury. Four hundred eighty-one out of 1200 questionnaires were returned and analyzed. The presented statistical and qualitative data reflect electricians' personal experiences with electrical injury, their communication patterns around electrical trauma, their understanding of possible electrical injury sequelae, their safety beliefs and attitudes towards occupational dangers, and the reasons for their occupational choice. We expect that the results of this study will enhance our understanding of the psychological profile, environment, and culture of electrical workers. The collected data may also help to identify those at risk for poor outcome after electrical injury and determine a new set of risk factors to be taken into account by medical professionals, social workers, and union/utility training officers.

Life after electrical injury. Risk factors for psychiatric sequelae.

Long-term cognitive and emotional deficits have been commonly reported in electrical injury (EI) survivors. However, it remains undetermined what factors may lead to the development of such effects in some patients and not in others. In this study, we hypothesized that certain elements of subjective EI experience may predict specific psychiatric sequelae. A group of 73 post-acute EI patients were included in this retrospective study. Statistical associations were examined between major psychiatric diagnoses (posttraumatic stress disorder and major depression) and such EI descriptors as having experienced "no-let-go" or having been knocked away on contact, as well as loss of consciousness or altered states of consciousness at the scene of the accident (including amnesia for the event). The study results will help physicians determine which patients may be at increased risk of developing psychiatric symptoms and address these issues as part of their total rehabilitation plan.

MMPI-2 patterns in electrical injury: a controlled investigation.

The psychological consequences of electrical injury (EI) are many. Depression, posttraumatic stress disorder, anxiety, and somatic preoccupation are often concomitant with this type of injury (Kelley, Pliskin, Meyer, & Lee, 1994). The present study utilized the MMPI-2 as a tool for characterizing profiles of psychological distress in EI. We examined MMPI-2 profiles in 79 EI patients and their relationship to both injury parameters (i.e., time since injury, LOC, voltage), and extra-diagnostic factors, such as litigation status. EI patient profiles were also compared to individuals with mild traumatic brain injury (TBI), and chronic pain sufferers (CP). Results indicated that in EI, clinical elevations (T > or = 65) were found on the Hs and Hy scales, and approached clinical levels on the D scale. The injury parameter of time since injury was predictive of a distinctive profile, with individuals in the post acute phase experiencing more distress. Compared to other clinical groups, MMPI-2 scores on the Hs and Hy scales were significantly higher within the EI cohort as compared with their CP peers, with higher scores on the Pd scale for CP than EI. No statistically significant differences emerged between the EI and TBI groups. However, TBI patients showed significant elevations on Hy and D compared to CP, and EI patients endorsed more somatic symptoms than CP patients. Implications of these findings and future directions will be discussed.

Neurocognitive function in chronic hemodialysis patients.

We administered a comprehensive neuropsychological test battery, including measures of intelligence, immediate and delayed memory, attention and mental processing speed, language abilities, complex problem solving, motor skills, and depression, to 16 well-dialyzed (Kt/Vurea = 1.46 +/- 0.24) patients with end-stage renal disease (ESRD) and 12 age- and education-matched medical controls. We observed no clear neuropsychological deficits in these ESRD patients who had low average intelligence and limited educational achievement, and hypothesize that previously observed apparent deficits resulted either from very low dialysis delivery or comparison with poorly-matched historical controls. There were significant deficits in language ability and intelligence in ESRD patients with higher than median scores on the Beck Depression Inventory compared with less-depressed ESRD patients. However, this effect of depression did not result in differences between dialysis and non-ESRD patient groups.

Relationship between confabulation and measures of memory and executive function.

Confabulation has traditionally been attributed to a combination of memory impairment and executive dysfunction, but recent models propose that confabulation can result from executive dysfunction alone. One hundred and ten patients with diverse neurologic and psychiatric diagnoses were subdivided into high-, low-, and non-confabulator groups based upon the ratio of confabulations to total responses produced during story recall. Consistent with the combined deficit model, high-confabulators performed significantly worse than the low- and non-confabulators on measures of memory and measures of executive function that assess sustained attention, mental tracking, and set-shifting ability. However, there were no differences between groups on measures of problem-solving, concept formation, and verbal fluency, suggesting a dissociation in executive functions that contribute to confabulation.

Performance of schizophrenic patients on putative neuropsychological tests of frontal lobe function.

Though individual tests thought to assess frontal lobe function have been administered to patients with schizophrenia for many years, approaches in which a number of tests thought to tap a single function or brain region have rarely been used. Such an approach might define a critical test or a common dysfunctional cognitive process. In the present study four putative neuropsychological tests of frontal lobe integrity, namely, the Wisconsin Card Sorting Test, the Category Test, Trail Making B, and verbal fluency, were administered to 28 patients with schizophrenia. Seventy-five percent performed abnormally on at least one test. However, relationships among the test results were difficult to characterize, either by correlation or factor analysis. A hierarchical arrangement in which "higher order" tests proscribe performance on "lower order" tests did not appear to be present. Regarding sensitivity, Trails B, the only timed test, was most frequently impaired and verbal fluency was least frequently impaired. The results suggest that the tests assess somewhat different aspects of frontal lobe function, and that no single frontal lobe test is uniquely sensitive to cognitive impairment in schizophrenia.

Neuropsychological symptom presentation after electrical injury.

OBJECTIVE: This study explored the relationship of neuropsychological complaints to accident- and injury-related characteristics, affective state, and work status in a group of electrical injury (EI) patients. METHODS: Sixty-three EI patients and 22 electricians with no history of electrical shock completed the Neuropsychological Symptom Checklist and the Beck Depression Inventory as part of an extensive neuropsychological evaluation. RESULTS: The EI group endorsed significantly more physical, cognitive, and emotional symptoms than did the controls. Symptom complaints were not related to injury parameters or litigation status. Only the time interval between injury and assessment accounted for differences in symptom presentation, with patients in the postacute stages of recovery showing the most cognitive and emotional complaints. CONCLUSION: The neuropsychological syndrome of electrical injury survival includes physical, cognitive, and emotional complaints. Considering that most electrically injured patients are treated within the acute medical setting, greater attention needs to be directed early in the course of treatment toward addressing neuropsychologic and psychiatric issues.

Assessing depressive symptoms in multiple sclerosis: is it necessary to omit items from the original Beck Depression Inventory?

Overlap between depression scale item content and medical symptoms may exaggerate depression estimates for patients with multiple sclerosis (MS). We reconsider Mohr and co-workers' (1997) recommendation to omit Beck Depression Inventory (BDI) items assessing work ability (item 15), fatigue (17), and health concerns (20) for MS patients. Subjects were medical patients with either MS (n = 105) or a medical disorder for which the BDI is empirically supported [diabetes mellitus (DM), n = 71; chronic pain (CP), n = 80], psychiatric patients with depressive disorder (MDD; n = 37), and healthy controls (HC; n = 80). Relative scores for the eight "somatic" BDI items were analyzed by multivariate analysis of variance with demographic variables and BDI total as covariates. The only significant difference was MS > HC (item 15). On raw scores, MS patients exceeded HCs on items 15 and 21 (sexual disinterest), but this was attributable to the low HC item endorsement. There were no other differences on somatic items or item-total correlations. Scale consistency was good across groups, regardless of item omission. Somatic items were unassociated with major MS parameters. We thus encourage continued application of the full BDI for assessing depressive symptoms in patients with MS.