The Relationship of Psychiatric Symptoms with Performance-Based and Self-Reported Cognitive Function After Ischemic Stroke.

OBJECTIVE: Findings on the relationship of psychiatric symptoms with performance-based and self-reported cognitive function post-stroke are inconclusive. We aimed to (1) study the relation of depression and anxiety to performance-based cognitive function and (2) explore a broader spectrum of psychiatric symptoms and their association with performance-based versus self-reported cognitive function. METHOD: Individuals with supratentorial ischemic stroke performed neuropsychological examination 3 months after stroke. For primary analyses, composite scores for memory and attention/executive function were calculated based on selected neuropsychological tests, and the Hospital Anxiety and Depression Scale (HADS) was used. Psychiatric symptoms and self-reported cognitive function for secondary aims were assessed using the Symptom-Checklist-90 - Revised (SCL-90-R). RESULTS: In a sample of 86 patients [mean (M) age: 64.6 ± 9.2; Mini-Mental State Examination (MMSE), 3-7 days post-stroke: M = 28.4 ± 1.7; National Institutes of Health Stroke Scale (NIHSS) after 3 months: M = 0.7 ± 1.6] depressive symptoms (HADS) were associated with poorer memory performance after controlling for age, sex, and education (p ≤ .01). In a subsample (n = 41; Age: M = 65.7 ± 8.1; MMSE: M = 28.4 ± 1.8; NIHSS: M = 1.0 ± 1.9), symptoms of phobic anxiety (SCL-90-R) were associated with poorer performance-based memory and attention/executive function, and symptoms of anxiety (SCL-90-R) with lower attention/executive function. Higher levels of self-reported cognitive difficulties were associated with higher scores in all psychiatric domains (p ≤ .05). CONCLUSION: Even in relatively well-functioning stroke patients, depressive symptoms are associated with poorer memory. The results also suggest that various psychiatric symptoms are more related to self-reported rather than to performance-based cognitive function. Screening for self-reported cognitive difficulties may not only help to identify patients with cognitive impairment, but also those who need psychological treatment.

Validating the usefulness of the NSI validity-10 with the MMPI-2-RF.

Purpose/Aim of the Study: The Neurobehavioral Symptom Inventory (NSI) is a 22-item self-report measure created to quantify the somatosensory, cognitive, and affective symptoms of Post-concussive Syndrome. Developers of the NSI used a subset of 10 items, the Validty-10, to measure symptom overreporting. We compared the Validity-10 versus the remaining NSI items (i.e., the Remaining-12) for how accurately they detect symptom exaggeration on the Minnesota Multiphasic Personality Inventory Second Edition - Restructured Form (MMPI-2-RF).Materials and Methods: We used a sample of 45 veterans evaluated in a Polytrauma/TBI Clinic of a Midwest VA Healthcare System who completed the NSI and MMPI-2-RF.Results: The Vaidity-10, Remaining-12, and Total Score all strongly correlated with mean of the MMPI-2-RF validity scales (r = .65, .67, and .70, respectively), illustrating equivalency among the various NSI scores. Groups were created based on significant T score elevation on any MMPI-2-RF validity scale (i.e. F-r > 119, or Fp-r, F-s, FBS, or RBS > 99). ROC analyses demonstrated that areas under the curve were equivalent for NSI Total Score (.84), Validity-10 (.81), and Remaining-12 (.81) in detecting overreporting.Conclusions: These findings do not support the notion that the Validity-10 has unique utility as an embedded symptom validity scale and highlights the likelihood that NSI Total Score can also serve this function.

Suspiciously slow: timed digit span as an embedded performance validity measure in a sample of veterans with mTBI.

OBJECTIVE: To explore the utility of Timed Digit Span (TDS) as an embedded performance validity test (PVT) in a sample of veterans with mild traumatic brain injury (mTBI). We hypothesize that TDS will predict PVT failure on an established stand-alone measure (Trial 1 of the Test of Memory Malingering; TOMM). METHODS: TDS was compared to Digit Span accuracy (DS), using TOMM as a criterion measure, in a sample of 99 veterans with mTBI. Correlation and regression were used to characterize associations between PVTs. Logistic regression was utilized to examine the relationship between embedded PVTs and the odds of TOMM failure. Classification accuracy of TDS was examined using receiver operating characteristic (ROC) curves. Predictive power of TDS to estimate TOMM failure was calculated for the current sample and for hypothetical populations with common base rates (BRs). OUTCOMES: TDS significantly predicted failure on the TOMM and added greater incremental predictive value to the model compared to DS accuracy. Estimates of the predictive power of TDS were calculated using observed and hypothetical BRs. Sensitivity to stand-alone PVT, failure was 38% when specificity was set at 90%. CONCLUSION: TDS offers a promising embedded PVT method, given its strong convergence with an established stand-alone PVT.

Streamlining screening of emotional function in Veterans with traumatic brain injury.

OBJECTIVES: This study examined how depression, anxiety, and sleep items from the Neurobehavioral Symptom Inventory (NSI) predict results from longer inventories. METHOD: This was a retrospective review from 484, predominantly male (96.1%) Veterans, mean age 29.7 years, who underwent brief neuropsychological screening during a comprehensive, multidisciplinary evaluation for mild traumatic brain injury (TBI). Participants completed the NSI, insomnia severity index (ISI), and hospital anxiety and depression scale (HADS). RESULTS: OVERALL,: 97.1% who endorsed "severe"/"very severe" anxiety on the NSI had significant anxiety on the HADS; 85% reporting "severe"/"very severe" depression on the NSI, had significant depression on the HADS; and 97.7% reporting "severe"/"very severe" sleep problems on the NSI, had significant sleep difficulties on the ISI. CONCLUSION: Close correspondence between "severe"/"very severe" symptoms on the NSI and lengthier checklists suggests additional checklists may be eliminated and individuals can be referred for mental health treatment. NSI reports of "mild"/"moderate" require further screening.

Population Base Rates and Disease Course of Common Psychiatric and Neurodegenerative Disorders.

Knowledge of population base rates of neurological and psychiatric disorders is fundamental for diagnostic decision making. Consideration of relevant probabilistic information can improve diagnostic efficiency and accuracy. However, such data continue to be misused or underutilized, which can lead to misdiagnoses and negative patient outcomes. The aim of the current review is to create an easily accessible and comprehensive reference of existing age of onset as well as prevalence and incidence data for common neurodegenerative and psychiatric disorders in adults. Relevant epidemiological data were compiled from well-respected and frequently-cited textbooks and scholarly studies. Reviews were collected from PubMed, and publicly-available sources were gathered from Google Scholar. Results are organized and presented in several tables and a figure, which can be used as a diagnostic guide for students and clinicians across healthcare disciplines.

"Top-Down" Mu-Opioid System Function in Humans: Mu-Opioid Receptors in Ventrolateral Prefrontal Cortex Mediate the Relationship Between Hedonic Tone and Executive Function in Major Depressive Disorder.

Cognitive dysfunction and anhedonia, the reduced ability to experience pleasure, are commonly comorbid symptoms that are persistent following successful resolution of negative affect in major depressive disorder (MDD). Little is known about whether they share common etiology. In the present study, the relationship between ventrolateral prefrontal cortex (VLPFC) activity, cognitive dysfunction (i.e., executive dysfunction), and positive emotionality was investigated in conjunction with mu-opioid neurotransmission in a sample of 39 MDD patients. Results suggest that increased endogenous mu-opioid tone in the VLPFC mediates the relationship between increased trait positive emotionality and more efficient executive functioning.

Neuropsychological test validity in Veterans presenting with subjective complaints of 'very severe' cognitive symptoms following mild traumatic brain injury.

OBJECTIVE: This study explored the utility of combining data from measures of performance validity and symptom validity among Veterans undergoing neuropsychological evaluation for mild traumatic brain injury (mTBI). BACKGROUND: Persistent cognitive impairments following mTBI are often reported by returning combat veterans. However, objectively-measured cognitive deficits are not common among individuals with mTBI, raising the question of whether negative impression management influences self-ratings. METHODS: Self-report ratings were obtained for memory, concentration, decision-making, and processing speed/organization using a 5-point scale ranging from 'none' to 'very severe'. Veterans also completed brief neuropsychological testing which included measures of performance validity. RESULTS: Study 1 examined data from 122 participants and demonstrated that veterans reporting a 'very severe' cognitive deficit were over three times as likely to demonstrate poor effort on a validity test than those without a very severe rating. Study 2 replicated these findings in an independent sample of 127 veterans and also demonstrated that both severity of self-report ratings and performance on an embedded measure of effort were predictive of poor effort on a stand-alone performance validity test. CONCLUSION: Veterans with suspected mTBI who report 'very severe' cognitive impairment have a greater likelihood of putting forth sub-optimal effort on objective testing.

PPVT-I administration rules significantly shorten PPVT-III/IV administration.

This study evaluated whether using the Peabody Picture Vocabulary Test-First Edition (PPVT-I) basal and ceiling criteria would result in similar estimates of receptive vocabulary while permitting administration of fewer test items when using the third and fourth editions of the PPVT. Data were retrospectively collected from 119 adult inpatients who completed a neuropsychological screen that included the PPVT-III or PPVT-IV, which were re-scored using PPVT-I criteria. PPVT-III/IV raw scores were not significantly different from PPVT-I raw scores. Although the difference between the PPVT-III/IV and PPVT-I standard scores was statistically significant, the difference was less than 8 points in 95% of cases. On average, 15 fewer items would be administered using the PPVT-I rules, leading to shorter administration time.

Decreased Fronto-Limbic Activation and Disrupted Semantic-Cued List Learning in Major Depressive Disorder.

OBJECTIVES: Individuals with major depressive disorder (MDD) demonstrate poorer learning and memory skills relative to never-depressed comparisons (NDC). Previous studies report decreased volume and disrupted function of frontal lobes and hippocampi in MDD during memory challenge. However, it has been difficult to dissociate contributions of short-term memory and executive functioning to memory difficulties from those that might be attributable to long-term memory deficits. METHODS: Adult males (MDD, n=19; NDC, n=22) and females (MDD, n=23; NDC, n=19) performed the Semantic List Learning Task (SLLT) during functional magnetic resonance imaging. The SLLT Encoding condition consists of 15 lists, each containing 14 words. After each list, a Distractor condition occurs, followed by cued Silent Rehearsal instructions. Post-scan recall and recognition were collected. Groups were compared using block (Encoding-Silent Rehearsal) and event-related (Words Recalled) models. RESULTS: MDD displayed lower recall relative to NDC. NDC displayed greater activation in several temporal, frontal, and parietal regions, for both Encoding-Silent Rehearsal and the Words Recalled analyses. Groups also differed in activation patterns in regions of the Papez circuit in planned analyses. The majority of activation differences were not related to performance, presence of medications, presence of comorbid anxiety disorder, or decreased gray matter volume in MDD. CONCLUSIONS: Adults with MDD exhibit memory difficulties during a task designed to reduce the contribution of individual variability from short-term memory and executive functioning processes, parallel with decreased activation in memory and executive functioning circuits. Ecologically valid long-term memory tasks are imperative for uncovering neural correlates of memory performance deficits in adults with MDD.

Incidental Learning: A Brief, Valid Measure of Memory Based on the WAIS-IV Vocabulary and Similarities Subtests.

OBJECTIVE: We assessed the validity of a brief incidental learning measure based on the Similarities and Vocabulary subtests of the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV). BACKGROUND: Most neuropsychological assessments for memory require intentional learning, but incidental learning occurs without explicit instruction. Incidental memory tests such as the WAIS-III Symbol Digit Coding subtest have existed for many years, but few memory studies have used a semantically processed incidental learning model. METHODS: We conducted a retrospective analysis of 37 veterans with traumatic brain injury, referred for outpatient neuropsychological testing at a Veterans Affairs hospital. As part of their evaluation, the participants completed the incidental learning tasks. We compared their incidental learning performance to their performance on traditional memory measures. RESULTS: Incidental learning scores correlated strongly with scores on the California Verbal Learning Test-Second Edition (CVLT-II) and Brief Visuospatial Memory Test-Revised (BVMT-R). After we conducted a partial correlation that controlled for the effects of age, incidental learning correlated significantly with the CVLT-II Immediate Free Recall, CVLT-II Short-Delay Recall, CVLT-II Long-Delay Recall, and CVLT-II Yes/No Recognition Hits, and with the BVMT-R Delayed Recall and BVMT-R Recognition Discrimination Index. CONCLUSIONS: Our incidental learning procedures derived from subtests of the WAIS-IV Edition are an efficient and valid way of measuring memory. These tasks add minimally to testing time and capitalize on the semantic encoding that is inherent in completing the Similarities and Vocabulary subtests.

Age and gender modulate the neural circuitry supporting facial emotion processing in adults with major depressive disorder.

OBJECTIVES: Emotion processing, supported by frontolimbic circuitry known to be sensitive to the effects of aging, is a relatively understudied cognitive-emotional domain in geriatric depression. Some evidence suggests that the neurophysiological disruption observed in emotion processing among adults with major depressive disorder (MDD) may be modulated by both gender and age. Therefore, the present study investigated the effects of gender and age on the neural circuitry supporting emotion processing in MDD. DESIGN: Cross-sectional comparison of fMRI signal during performance of an emotion processing task. SETTING: Outpatient university setting. PARTICIPANTS: One hundred adults recruited by MDD status, gender, and age. MEASUREMENTS: Participants underwent fMRI while completing the Facial Emotion Perception Test. They viewed photographs of faces and categorized the emotion perceived. Contrast for fMRI was of face perception minus animal identification blocks. RESULTS: Effects of depression were observed in precuneus and effects of age in a number of frontolimbic regions. Three-way interactions were present between MDD status, gender, and age in regions pertinent to emotion processing, including frontal, limbic, and basal ganglia. Young women with MDD and older men with MDD exhibited hyperactivation in these regions compared with their respective same-gender healthy comparison (HC) counterparts. In contrast, older women and younger men with MDD exhibited hypoactivation compared to their respective same-gender HC counterparts. CONCLUSIONS: This the first study to report gender- and age-specific differences in emotion processing circuitry in MDD. Gender-differential mechanisms may underlie cognitive-emotional disruption in older adults with MDD. The present findings have implications for improved probes into the heterogeneity of the MDD syndrome.

Informational literature influences symptom expression following mild head injury: An analog study.

PRIMARY OBJECTIVE: Many Veterans involved in recent OEF/OIF conflicts return with reports of having experienced an mTBI. The Veteran's Affairs (VA) and Department of Defense (DoD) have gone to great lengths to provide information to Veterans regarding possible effects of TBI. Although well intended, this information may possibly have an iatrogenic effect. Conversely, setting positive expectations for recovery from mTBI has been shown to result in decreased symptomatology. RESEARCH DESIGN: One-way ANOVA and Tukey post-hoc analyses were used to determine whether there were significant differences on reported severity and number of PCS symptoms (NSI) among the three experimental groups (recovery focused information; expectation for persistent symptoms; and no information given). METHODS AND PROCEDURES: Undergraduate students, who were told to imagine they had experienced a military-related TBI, reported varying levels of expected symptoms when given either positive or negative information about symptom expectation. MAIN OUTCOMES AND RESULTS: The results indicate that presenting recovery-oriented literature resulted in the lowest report of expected symptoms, whereas presenting no information resulted in the highest report of expected symptoms. CONCLUSIONS: Providing Veterans with information regarding a likely positive trajectory of recovery may result in less symptom persistence during rehabilitation.

Limited usefulness of the Rey Fifteen-Item Test in detection of invalid performance in veterans suspected of mild traumatic brain injury.

OBJECTIVE: This study explored using the FIT as a measure of performance validity among veterans undergoing neuropsychological evaluation for mild traumatic brain injury (mTBI). BACKGROUND: The Rey Fifteen-Item Memory Test (FIT) is a performance validity measure criticized for poor sensitivity. METHODS: Two hundred and fifty-seven veterans completed the FIT and Wechsler Adult Intelligence Scale, Fourth Edition, Digit Span (DS); 109 of whom completed the Test of Memory Malingering (TOMM). FIT cut-offs of <9, <8 and stricter cut-offs were examined using DS and/or TOMM as criterion performance validity measures. RESULTS: Only four participants scored below the standard cut score of 9 on the FIT. Among the 13 veterans failing both criterion tests, only two scored below 9 on the FIT. Regardless of which FIT cut-off was used, the FIT had poor diagnostic accuracy. CONCLUSION: Despite its popularity, the FIT is not supported as an appropriate measure of performance validity in veterans undergoing evaluation for possible mTBI. Therefore, inferences regarding neuropsychological data reliability with adequate statistical certainty require use of other measures of performance validity with greater sensitivity.

The contributions of self-reported injury characteristics and psychiatric symptoms to cognitive functioning in OEF/OIF veterans with mild traumatic brain injury.

Mild traumatic brain injury (mTBI) affects a significant number of combat veterans returning from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Although resolution of mTBI symptoms is expected over time, some individuals continue to report lingering cognitive difficulties. This study examined the contributions of self-reported mTBI injury characteristics (e.g., loss of consciousness, post-traumatic amnesia) and psychiatric symptoms to both subjective and objective cognitive functioning in a sample of 167 OEF/OIF veterans seen in a TBI clinic. Injury characteristics were not associated with performance on neuropsychological tests but were variably related to subjective ratings of cognitive functioning. Psychiatric symptoms were highly prevalent and fully mediated most of the relationships between injury characteristics and cognitive ratings. This indicates that mTBI characteristics such as longer time since injury and loss of consciousness or post-traumatic amnesia can lead to increased perceived cognitive deficits despite having no objective effects on cognitive performance. Psychiatric symptoms were associated with both cognitive ratings and neuropsychological performance, illustrating the important role that psychiatric treatment can potentially play in optimizing functioning. Finally, subjective cognitive ratings were not predictive of neuropsychological performance once psychiatric functioning was statistically controlled, suggesting that neuropsychological assessment provides valuable information that cannot be gleaned from self-report alone.

The influence of sleep and mood on cognitive functioning among veterans being evaluated for mild traumatic brain injury.

OBJECTIVE: Veterans undergoing evaluation for mild traumatic brain injury commonly report insomnia, psychiatric symptoms, and cognitive dysfunction. This study examines the effects of self-reported amount of sleep and subjective sleep quality on neuropsychological test performance. METHOD: 262 veterans were seen for neuropsychological assessment in a Veterans Affairs traumatic brain injury clinic. All participants completed measures of depression, anxiety, and sleep satisfaction, and also estimated the number of hours they slept the night before the assessment. Factor scores of attention/concentration and memory were created using factor analyses. Data were analyzed with linear regression. RESULTS: Depression and anxiety were significantly correlated with sleep satisfaction and predictive of cognitive ability. Both sleep satisfaction and hours slept were significantly correlated with memory, but not attention. After controlling for the effects of depression and anxiety, hours slept but not sleep satisfaction was predictive of memory test performance. CONCLUSIONS: Perceived sleep quality is heavily influenced by psychiatric symptoms; therefore, veterans' report of sleep satisfaction may merely reflect their overall level of distress. Sleep quantity, however, appears to uniquely contribute to memory performance. Thus, assessment of sleep is important and provides clinicians with useful information, especially among individuals with psychiatric comorbidities.

An investigation of impaired scores on the frontal assessment battery in a VA population.

In a population of inpatients, individuals were observed to continually score in the impaired range on the Frontal Assessment Battery (FAB) without exhibiting other signs of frontal-lobe damage. Investigations were undertaken to determine if the subtest structure, demographic factors, or general cognitive functioning may be responsible for patients' poor performance on the FAB overall. Participants were inpatients at the Ann Arbor Veterans Hospital who were administered a standard neuropsychological screening battery. This battery included the FAB, among other tests, as part of regular clinical care. Included in these study analyses were 292 patients with a mean age of 67.27 years (SD = 12.41). Descriptive analyses revealed that 63.7% of patients scored in the impaired range on the FAB based on the criteria set forth by Dubois, Slachevsky, and Litvan ( 2000 ). Analyses of individual subtest performance failed to find any single test that would characterize participants' poor performance overall. Nonetheless, the total FAB score was related to age, general cognitive functioning, and premorbid estimates of intellectual functioning. The internal reliability also was found to be lower than that reported previously. While the FAB may measure frontal-lobe functions, it appears to be influenced by a multitude of other demographic and neuropsychological factors.

Predictors of perceived need for medical care in an inpatient rehabilitation unit: an update.

Limited awareness of illness, or poor insight, has been associated with poor treatment outcomes and prognoses in both psychiatric and medical populations. We examined predictors of insight in a sample of 403 patients in an inpatient rehabilitation unit at a Midwest Veterans Affairs Medical Center. A multiple regression analysis revealed that age, depression, IQ, and a measure of judgment were significant predictors of acknowledgement of illness. Younger age, higher IQ, better judgment, and depression were associated with better insight. By identifying risk factors for poor insight, these findings have significant clinical implications for healthcare providers.

Cognitive function does not worsen during long-term low-dose peginterferon therapy in patients with chronic hepatitis C.

OBJECTIVES: Neuropsychiatric toxicity is a common dose-limiting side effect of interferon therapy. The primary aim of this study was to determine whether patients receiving long-term low-dose peginterferon therapy had a higher incidence of cognitive side effects compared with untreated patients enrolled in the Hepatitis C Antiviral Long-Term treatment against Cirrhosis (HALT-C) Trial. METHODS: A total of 129 patients with chronic hepatitis C and advanced fibrosis completed a battery of 10 neuropsychological tests and the Beck Depression Inventory at pretreatment baseline and at months 12, 24, 36, and 48 while receiving long-term peginterferonalpha2a (90 microg/week) or no therapy during the randomized phase of the HALT-C Trial. Cognitive impairment was defined as a global deficit score (GDS) > or = 1.0. RESULTS: The mean age was 51.2 years, 67% were male, and 42% had cirrhosis. After accounting for baseline GDS scores, the mean GDS scores did not significantly change over time (P=0.46) nor with treatment group (P=0.49). Cognitive function was also not influenced by medication adherence in the 66 patients receiving maintenance peginterferon (P=0.14) after controlling for baseline GDS scores and time. Beck Depression scores did not significantly increase over time (P=0.60), nor did they vary by treatment group (P=0.74). Although 32% of patients experienced objective worsening of their liver disease during follow-up, the frequency and severity of cognitive impairment did not differ in those with and without disease progression (P=0.71). CONCLUSIONS: Measures of cognitive function were neither influenced by low-dose peginterferon treatment nor with objective evidence of liver disease progression in patients with advanced chronic hepatitis C prospectively followed up for 3.5 years.

Contemporary review 2009: cognitive aging.

This article addresses key topics in cognitive aging, intending to provide the reader with a brief overview of the current state of research in this growing, multidisciplinary field. A summary of the physiological changes in the aging brain is provided as well as a review of variables that influence cognitive abilities in older age. Normal aging differentially affects various aspects of cognition, and specific changes within various domains such as attention, executive functioning, and memory are discussed. Various theories have been proposed to account for the cognitive changes that accompany normal aging, and a brief examination of these theories is presented in the context of these domain-specific changes.

Influence of Cognition on Length of Stay and Rehospitalization in Older Veterans Admitted for Post-Acute Care.

OBJECTIVES: Evaluate the relative contribution of cognitive test performance to post-acute care (PAC) length of stay (LOS) and rehospitalization while controlling for key demographic, medical, and functional outcomes. METHODS: Retrospective medical record review of 160 older Veterans, including cognitive test performance (Addenbrooke's Cognitive Examination-Revised [ACE-R]), on admission to a Veterans Administration Hospital Community Living Center (CLC) PAC. RESULTS: Individuals with impaired scores on the ACE-R had a longer LOS (10 median days longer; U = 2,547.00, p = .028). Of those rehospitalized, 71.4% (n = 20) screened positive for cognitive impairment. Key medical factors explained the largest amount of variance in CLC-PAC LOS (29.8%), followed by admission ADL (activities of daily living) dependency (4.6%) and ACE-R total score (3.30%). DISCUSSION: Cognitive screening should be considered on PAC admission, with impairment on ACE-R predicting geriatric rehabilitation outcomes such as risk of increased LOS and rehospitalization.