Objective Cognitive Outcomes and Subjective Emotional Sequelae in Litigating Adults with a Traumatic Brain Injury: The Impact of Performance and Symptom Validity Measures.

OBJECTIVE: This study examined the relative contribution of performance and symptom validity in litigating adults with traumatic brain injury (TBI), as a function of TBI severity, and examined the relationship between self-reported emotional symptoms and cognitive tests scores while controlling for validity test performance. METHOD: Participants underwent neuropsychological assessment between January 2012 and June 2021 in the context of compensation-seeking claims related to a TBI. All participants completed a cognitive test battery, the Personality Assessment Inventory (including symptom validity tests; SVTs), and multiple performance validity tests (PVTs). Data analyses included independent t-tests, one-way ANOVAs, correlation analyses, and hierarchical multiple regression. RESULTS: A total of 370 participants were included. Atypical PVT and SVT performance were associated with poorer cognitive test performance and higher emotional symptom report, irrespective of TBI severity. PVTs and SVTs had an additive effect on cognitive test performance for uncomplicated mTBI, but less so for more severe TBI. The relationship between emotional symptoms and cognitive test performance diminished substantially when validity test performance was controlled, and validity test performance had a substantially larger impact than emotional symptoms on cognitive test performance. CONCLUSION: Validity test performance has a significant impact on the neuropsychological profiles of people with TBI, irrespective of TBI severity, and plays a significant role in the relationship between emotional symptoms and cognitive test performance. Adequate validity testing should be incorporated into every neuropsychological assessment, and associations between emotional symptoms and cognitive outcomes that do not consider validity testing should be interpreted with extreme caution.

The Relationship Between Cognitive Functioning and Symptoms of Depression, Anxiety, and Post-Traumatic Stress Disorder in Adults with a Traumatic Brain Injury: a Meta-Analysis.

A thorough understanding of the relationship between cognitive test performance and symptoms of depression, anxiety, or post-traumatic stress disorder (PTSD) in people with traumatic brain injury (TBI) is important given the high prevalence of these emotional symptoms following injury. It is also important to understand whether these relationships are affected by TBI severity, and the validity of test performance and symptom report. This meta-analysis was conducted to investigate whether these symptoms are associated with cognitive test performance alterations in adults with a TBI. This meta-analysis was prospectively registered on the PROSPERO International Prospective Register of Systematic Reviews website (registration number: CRD42018089194). The electronic databases Medline, PsycINFO, and CINAHL were searched for journal articles published up until May 2020. In total, 61 studies were included, which enabled calculation of pooled effect sizes for the cognitive domains of immediate memory (verbal and visual), recent memory (verbal and visual), attention, executive function, processing speed, and language. Depression had a small, negative relationship with most cognitive domains. These relationships remained, for the most part, when samples with mild TBI (mTBI)-only were analysed separately, but not for samples with more severe TBI (sTBI)-only. A similar pattern of results was found in the anxiety analysis. PTSD had a small, negative relationship with verbal memory, in samples with mTBI-only. No data were available for the PTSD analysis with sTBI samples. Moderator analyses indicated that the relationships between emotional symptoms and cognitive test performance may be impacted to some degree by exclusion of participants with atypical performance on performance validity tests (PVTs) or symptom validity tests (SVTs), however there were small study numbers and changes in effect size were not statistically significant. These findings are useful in synthesising what is currently known about the relationship between cognitive test performance and emotional symptoms in adults with TBI, demonstrating significant, albeit small, relationships between emotional symptoms and cognitive test performance in multiple domains, in non-military samples. Some of these relationships appeared to be mildly impacted by controlling for performance validity or symptom validity, however this was based on the relatively few studies using validity tests. More research including PVTs and SVTs whilst examining the relationship between emotional symptoms and cognitive outcomes is needed.

Interictal Cognitive Deficits in Migraine Sufferers: A Meta-Analysis.

While a significant proportion of the population suffer from migraine, the existing research literature does not provide a clear indication as to whether migraineurs experience objective cognitive deficits outside of acute migraine attacks. This meta-analysis was conducted to investigate which cognitive domains if any were affected by migraine, by synthesising the existing research quantitatively. The meta-analysis was prospectively registered with the PROSPERO International prospective register of systematic reviews (registration no.: CRD42019134138). A search of the electronic databases PubMed, Ovid MEDLINE, and PsycINFO was conducted for journal articles published between January 1980 and January 2020. Seventeen studies met the inclusion criteria, allowing for the calculation of pooled effect sizes between migraineurs (with and without aura) and healthy controls in the several cognitive domains. During the interictal period, migraineurs demonstrated a moderate, negative effect on complex attention immediate and delayed memory, spatial cognition, and executive functioning. This effect was not attributable to migraine history, attack frequency, or participant age. However, the lack of performance validity testing, and limited data on mood symptomatology and migraine medication use in the included studies may be confounds potentially overestimating the magnitude of effect. Comparison with a clinical control group, which may have accounted for some these extraneous variables, was unable to be conducted. Recommendations for comprehensive future neuropsychological research are provided.

An analysis of distinct navigational domains and topographical disorientation syndromes in ABI: A meta-analysis.

Topographical disorientation is the impairment or inability to successfully navigate in three-dimensional space. Differing topographical disorientation syndromes have been associated with distinct lesion sites in the acquired brain injury (ABI) literature. This meta-analysis attempted to investigate the relationship between lesion location and dysfunctions in specific navigational abilities resulting in topographical disorientation in individuals with ABI, as measured by their performance on experimental and neuropsychological tests. It was expected that focal lesions would be associated with a specific navigational deficit in one ability, with relative sparing of other navigational abilities. Twenty-six papers met the inclusion criteria for the analysis. Results indicated that ABI populations performed worse on all measures of navigation, with moderate to large effect sizes. Dysfunctions in three core navigational skills were consistent with the available lesion studies: a feature/landmark processing unit, a spatial processing unit, and a spatial/feature binding and associative learning unit. A sequential processing model was created to attempt to best represent the transfer of information between these units and the process by which navigational knowledge is generated. The model was then used to assess the validity of existing models of navigation and topographical disorientation.

Performance on neuropsychological assessment and progression to dementia: A meta-analysis.

This meta-analysis examined how performance on various cognitive domains of neuropsychological functioning can contribute to predicting progression to dementia from mild cognitive impairment (MCI) or subjective memory complaints. Studies performed between the years of 1997 and 2018 were identified through a search of the electronic databases Medline and PsycINFO. Data from the articles identified were pooled to determine standardized mean differences, calculated as Hedges g, using a random-effects model. Twenty-four studies were included in the analysis. The majority of studies examined the progression of amnestic mild cognitive impairment (aMCI) to Alzheimer's disease (AD). Nonprogressors performed significantly better than did progressors in the domains of divided attention, executive function, expressive language, immediate recall, processing speed, delayed recall, visuospatial/constructional ability, working memory, and sustained attention. These findings indicate that individuals with MCI or subjective memory complaints who do not progress to dementia, perform better at baseline as compared with individuals that progress to dementia on a range of neuropsychological measures, and lends further support to the contention that neuropsychological assessment can make important contributions to predicting progression to dementia while individuals are still in the MCI or subjective memory complaint stage. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Corticosteroids and Cognition: A Meta-Analysis.

A thorough understanding of the cognitive effects of corticosteroids is essential given their frequency of use. This meta-analysis was conducted to investigate the effects of corticosteroids on the various domains of cognitive functioning, grouped by duration of use. An electronic search of PsycInfo, Medline and Google Scholar was conducted for all journal articles published between January 1990 and May 2018. Twenty six studies were included enabling calculation of standardised mean difference (SMD) using a random effects model for the cognitive domains of divided attention, executive function, expressive language, immediate memory, processing speed, recent memory, sustained attention, very long term memory and working memory. Results revealed that corticosteroids had a modest, negative effect on executive function for acute users, recent memory for short term and chronic users, and very long term memory for acute users. Corticosteroids had a small, significant, positive effect on expressive language for short term users.

Widespread Cognitive Deficits in Alcoholism Persistent Following Prolonged Abstinence: An Updated Meta-analysis of Studies That Used Standardised Neuropsychological Assessment Tools.

OBJECTIVE: This study presents an updated meta-analysis replicating the study of (Stavro, K., Pelletier, J., & Potvin, S. (2013). Widespread and sustained cognitive deficits in alcoholism: A meta-analysis. Addiction Biology, 18, 203-213. doi:10.1111/j.1369-1600.2011.00418.x) regarding the cognitive functioning of alcoholics as a function of time abstinent. METHODS: A total of 34 studies (including a total of 2,786 participants) that met pre-determined inclusion and exclusion criteria were included in the analyses. The alcoholics were categorised into recently detoxified alcoholics (0-31 days sober), alcoholics 32-365 days sober and alcoholics >365 days sober consistent with the previous study. The current study employed more stringent control on the tests included in the analysis to include only those tasks described in contemporary neuropsychological test compendia. Forty-seven percent of the papers surveyed were not include in the previous meta-analysis. RESULTS: The results indicated that there was a diffuse and pervasive pattern of cognitive deficit among recently detoxified alcoholics and that these deficits, particularly with regard to memory functioning, persisted even in longer term abstinent alcoholics. This was inconsistent with the prior meta-analysis which contended that significant cognitive recovery was possible after as little as 1 year. CONCLUSION: The persisting cognitive deficits were noted across a wide range of cognitive functions, supporting the notion of a diffuse rather than a specific compromise of cognition in alcoholism following discontinuation, as measured using standardised neuropsychological tests. Limitations on the finding included the fact that it was a cross-sectional rather than a longitudinal analysis, was subject to heterogeneity of method, had low representation of females in the samples, and had fewer studies of long-term sober samples.

Comparing the effect of the subcategories of atypical antipsychotic medications on cognition in schizophrenia using a meta-analytic approach.

OBJECTIVES: The aim of this study was to compare the two most commonly prescribed classes of atypical antipsychotic medications (i.e., -pines and -dones) with regard to their effects on cognition in patients with schizophrenia. DATA SOURCES: Ovid Technologies web-based software was used to search the Medline and PsycINFO computerized databases to identify articles that met the inclusion criteria. REVIEW METHODS: The search was limited to papers published after 1990, written in English, employing human subjects, using atypical antipsychotics, using a within-subjects design or control group of patients with schizophrenia for comparisons, using participants aged from 18-65, and employing standardized neuropsychological measures. RESULTS: A total of 996 eligible studies were identified, and of these 19 were finally analyzed. Nine domains of cognitive functioning were assessed. The two groups of agents produced equivalent overall effects (-dones = .254 versus -pines = .202). The -pines were found to improve the domains of attention/working memory, executive functioning, fluency, nonverbal memory, processing speed, and verbal memory, each with a significant, small effect size. The -dones were found to improve attention/working memory, executive functioning, motor function, nonverbal memory, processing speed, and verbal memory, each with a significant, small effect size. Failsafe N was robust for all of the domains for the -pines, but only for the verbal memory domain for the -dones, suggesting that the significant findings for the other domains with the -dones are more tenuous. CONCLUSION: The results indicate that the agents were largely equivalent and that there was no clear evidence that the pattern of cognitive effects differed as a result of the agent applied. The effects themselves, while statistically significant, were small, indicating that some or all of the differences may be attributable to practice effects on the instruments employed.

A meta-analysis of the effects of antidepressants on cognitive functioning in depressed and non-depressed samples.

A thorough understanding of the cognitive effects of antidepressant medications is essential given their frequency of use. This meta-analysis was conducted to investigate whether antidepressants differentially affect the various domains of cognitive functioning for depressed and non-depressed participants. An electronic search of PsycInfo, Medline and Google Scholar was conducted for all journal articles published between January 1998 and January 2017. Thirty-three studies were included enabling calculation of Hedges' g using a random effects model for the cognitive domains of divided attention, executive function, expressive language, immediate memory, perceptual motor skills, processing speed, recent memory, sustained attention, visuospatial-constructional skills and working memory. Results revealed that overall, antidepressants have a modest, positive effect on divided attention, executive function, immediate memory, processing speed, recent memory and sustained attention for depressed participants. Selective serotonin reuptake inhibitors (SSRI's) were found to have the greatest positive effect on cognition for depressed participants, as compared to the other classes of antidepressants analysed. Antidepressants did not significantly affect cognitive function in non-depressed participants.

Immediate and Delayed Neuropsychological Effects of Carbon Monoxide Poisoning: A Meta-analysis.

BACKGROUND: Carbon monoxide (CO) poisoning is the leading cause of accidental poisoning worldwide. This study undertook a meta-analysis to examine differences in neuropsychological functioning in patients with CO poisoning as compared to healthy controls, and examined the longer-term neuropsychological effects of CO poisoning. METHODS: Studies performed between the years 1995 and 2016 were identified through a search of the electronic databases Medline and PsycInfo. Data from the papers identified were pooled to determine standard mean differences using a random-effects model. RESULTS: Ten studies were included in the analysis, with healthy controls performing significantly better than CO poisoned participants on the domains of divided attention, immediate memory, and processing speed. No statistically significant differences were found for sustained attention, recent memory, working memory, visuospatial/constructional ability, and expressive language. Performance by participants with CO poisoning for the domains of sustained attention, recent memory, visuospatial/constructional abilities, and working memory significantly improved over time after initial exposure, demonstrating recovery of these functions over time. No statistically significant differences were evident for divided attention or expressive language. CONCLUSIONS: This evidence indicates that healthy controls perform better than do individuals with CO poisoning on a range of neuropsychological domains; however, it also indicates that performance in some domains does improve over time. (JINS, 2018, 24, 405-415).

Examining the beneficial effect of neuropsychological assessment on adult patient outcomes: a systematic review.

OBJECTIVE: Neuropsychological assessment (NPA) addresses important aspects of diagnosis, prognosis, treatment, and rehabilitation planning. This review set out to determine the impact of NPA on the adult patient's outcome, by examining how and whether NPA influences diagnostic decision-making and surgical planning, how NPA can be used to predict patient outcome, and how clients, referrers, and significant others perceive the value of NPA. METHOD: Eligible studies were selected according to pre-defined selection criteria and accessed via the electronic databases Medline and PsycInfo. RESULTS: Eighty-one studies were included, with 14 examining the influence of NPA on diagnosis, 62 in predicting outcomes, and 5 addressing the perceptions of NPA by users. The evidence was generally supportive of the value of NPA for its ability to increase the accuracy of diagnoses, to assist with decisions regarding surgical planning, to predict patient outcomes, and in its clinical benefit as reported by physicians and patients. CONCLUSION: The review demonstrated the benefit of NPA in assisting with diagnosis and prognosis, and showed positive findings with regard to consumer perceptions of NPA. The neuropsychological literature would materially benefit from high-quality randomized control trials of NPA to definitively demonstrate the efficacy of this measure in clinical management.

The Residual Medium and Long-term Cognitive Effects of Benzodiazepine Use: An Updated Meta-analysis.

OBJECTIVE: This study presents an updated meta-analysis of the effects of benzodiazepines on cognitive functioning in long-term, current users of these agents, those who have recently withdrawn and on those who have successfully abstained following withdrawal. The study represents an update of the previous meta-analyses published by our group. METHOD: A comprehensive search of the computerized databases Medline and PsycINFO was undertaken to identify studies that assessed the cognitive effects of benzodiazepines published up to 28 November 2016 (the date of the last update). Nineteen studies (eight studies published since the previous meta-analyses and 11 studies included in the previous studies) were included. RESULTS: The results of the analysis for current users revealed statistically significant, negative effects for the cognitive domains of working memory, processing speed, divided attention, visuoconstruction, recent memory, and expressive language. For those who had withdrawn and successfully abstained following withdrawal, deficits were observed for the domains of recent memory, processing speed, visuoconstruction, divided attention, working memory, and sustained attention. CONCLUSIONS: The results of the study are important in that they corroborate the mounting evidence that a range of neuropsychological functions are impaired as a result of long-term benzodiazepine use, and that these are likely to persist even following withdrawal. The findings highlight the residual neurocognitive compromise associated with long-term benzodiazepine therapy as well as the important clinical implications of these results.

The Cognitive Effects of Obstructive Sleep Apnea: An Updated Meta-analysis.

This meta-analysis set out to ascertain the cognitive function of obstructive sleep apnea (OSA) patients as measured through objective neuropsychological tests. The meta-analysis investigated the cognitive functioning of these patients prior to them receiving any treatment such as continuous positive airway pressure (CPAP). A total of 19 studies met the study inclusion criteria. Results revealed statistically significant negative effect sizes in the cognitive domains of non-verbal memory, concept formation, psychomotor speed, construction, executive functioning, perception, motor control and performance, attention, speed of processing, working and verbal memory, verbal functioning and verbal reasoning. The clinical implication of these results, the possible causal mechanisms of the cognitive impairments and the implication of these for future research were each discussed. Despite a number of important limitations, the analysis highlights the need for clinicians to comprehensively explore complaints about sleep disturbance, particularly OSA, in all clinical assessments to ensure control for this important confounder in order to ensure appropriate attribution of the source of any observed cognitive compromise.

Material-specific retroactive interference effects of the Wechsler Adult Intelligence Scale-Fourth Edition on the Wechsler Memory Scale-Fourth Edition in a nonclinical sample.

INTRODUCTION: This study investigated proactive and retroactive interference effects between the Wechsler Memory Scale-Fourth Edition (WMS-IV) using the flexible approach, and the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV). METHOD: One hundred and eighty nonclinical participants were assigned to a four (visual interference, verbal interference, visual and verbal interference, vs. no interference) by two (retroactive vs. proactive) between-subjects design. The administration order of the tests was counterbalanced (i.e., administration of the WAIS-IV prior to the WMS-IV, and the WAIS-IV administered during the delay interval of the WMS-IV). RESULTS: The WAIS-IV produced significant retroactive interference effects on the WMS-IV; however, no proactive interference effect was observed. The retroactive interference effect was dependent on material specificity. CONCLUSIONS: The results indicate that material presented within the delay of the WMS-IV can have a significant effect on subsequent delayed recall. Clinicians should carefully consider the effects associated with carry-over effects of these tests when using them in combination.

Shame, guilt, and facial emotion processing: initial evidence for a positive relationship between guilt-proneness and facial emotion recognition ability.

Shame and guilt are closely related self-conscious emotions of negative affect that give rise to divergent self-regulatory and motivational behaviours. While guilt-proneness has demonstrated positive relationships with self-report measures of empathy and adaptive interpersonal functioning, shame-proneness tends to be unrelated or inversely related to empathy and is associated with interpersonal difficulties. At present, no research has examined relationships between shame and guilt-proneness with facial emotion recognition ability. Participants (N = 363) completed measures of shame and guilt-proneness along with a facial emotion recognition task which assessed the ability to identify displays of anger, sadness, happiness, fear, disgust, and shame. Guilt-proneness was consistently positively associated with facial emotion recognition ability. In contrast, shame-proneness was unrelated to capacity for facial emotion recognition. Findings provide support for theory arguing that guilt and empathy operate synergistically and may also help explain the inverse relationship between guilt-proneness and propensity for aggressive behaviour.

The acute cognitive effects of zopiclone, zolpidem, zaleplon, and eszopiclone: a systematic review and meta-analysis.

The "z-drugs" zopiclone, zolpidem, eszopiclone, and zaleplon were introduced in the 1980s for the treatment of insomnia, as it was observed that the side effect profile associated with these medications were more benign than those related to the benzodiazepines. This meta-analysis set out to ascertain which domains of cognitive function, if any, were affected by the ingestion of these medications. A total of 20 studies met the study inclusion criteria. Results revealed medium effect sizes for zopiclone and zolpidem on measures of verbal memory. An additional medium effect size was observed for zolpidem on attention. Finally, smaller effect sizes were observed for zolpidem speed of processing and for zopiclone on working memory. It is clear from these data that the use of a single dose of the z-drugs in healthy adults as measured in the morning following the exposure does produce a specific rather than a generalized negative effect on cognitive function. However, there were only enough studies to evaluate the individual cognitive effects of the zolpidem and zopiclone medications; the specific effects of zaleplon and eszopiclone cannot be ascertained because only one study met the inclusion and exclusion criteria for the review.

Is the Boston Naming Test still fit for purpose?

The Boston Naming Test (BNT) (Kaplan, Goodglass, & Weintraub, 1983) is the most commonly used test of confrontation naming in neuropsychology (Rabin, Barr, & Burton, 2005). However, there are significant criticisms of the BNT which suggest that it might not be the assessment measure of choice. These criticisms are that the BNT has poor psychometric properties, is not adequately standardized, and has inadequate norms. It is further suggested that when considered in the context of contemporary conceptualizations of the neuropsychology of naming, the BNT does not adequately capture the processes known to be required for successful naming, and does not sample widely enough from the content domain of "naming". These criticisms suggest that the BNT is flawed as a measure of naming, and are discussed in detail in this review. Other stand-alone visual confrontation naming tasks are reviewed to evaluate whether any might be viable substitutes for the BNT in clinical neuropsychology. The Naming Test from the Neuropsychological Assessment Battery (Stern & White, 2009) was identified as a possible alternative to the BNT, however, neither of these tests was designed with reference to models of the neuropsychology of naming, and development of a new test of naming is indicated.

Impaired decision making on the Balloon Analogue Risk Task as a result of long-term alcohol use.

The Balloon Analogue Risk Task (BART) is an experimental measure of risk taking that has commonly been employed to measure the risk taking behavior of nonclinical populations. Previous research has indicated that the task measures a unique aspect of behavioral disinhibition, but there has not as yet been focus upon the possible impact of other aspects of cognitive processing on performance. The current study investigated the cognitive factors related to performance of the BART in an alcohol-using sample. Seventeen individuals with long-term alcohol use were matched for age and education to a group of 17 nonusing participants. The results indicated that the alcohol-using group pumped the balloons on the BART to a lesser extent than did the nonusing group across all trials on the task. The results indicate that the alcohol-using group made less "optimal" decisions on the BART most notably due to neuropsychological impairment in the domains of immediate memory and executive functioning.

Cognitive and emotional deficits in chronic alcoholics: a role for the cerebellum?

It is now widely accepted that in addition to motor coordination, the cerebellum is also involved in the modulation of cognitive and affective processes. Despite alcoholic cerebellar degeneration (ACD) being the most common form of cerebellar disorder, little systematic investigation of cerebellar-mediated cognitive and affective deficits has occurred in chronic alcoholics. Forty-nine chronic alcoholics and 29 healthy control participants underwent testing of cognitive and affective function, along with measurement of cerebellar ataxia using the International Cooperative Ataxia Rating Scale (Trouillas et al., Journal of the Neurological Sciences 145:205-11, 1997). The alcoholic group demonstrated significantly poorer performance as compared to the control group in a number of domains, including visuospatial and language skills, psychomotor speed, new learning and memory, executive functioning, and emotional regulation and affect processing. There were no differences between the alcoholic and control groups in immediate attention and working memory abilities. Years of heavy drinking and total period of abstinence were found to be the best predictors of cognitive and emotional function in the alcoholic group. After accounting for alcohol chronicity, there was still a relationship between the degree of clinical signs of ACD and some areas of cognitive and emotional functioning, including language, executive functioning, processing speed and affect processing. The results suggest that some of the cognitive and affective deficits observed in chronic alcoholics may be mediated, at least in part, by cerebellar dysfunction. These findings add support to the theory of disruption to bidirectional cerebro-cerebellar circuitry underlying cognitive and affective deficits in chronic alcoholics.

Does the presence of posttraumatic anosmia mean that you will be disinhibited?

Dispute has surrounded the issue of whether the relationship between anosmia and executive dysfunction in traumatic brain injury (TBI) may be artefactual due to poor ascertainment. Three groups matched for age, gender, education, Full Scale IQ, and the Wechsler Working Memory Index and showing adequate symptom validity were compared: 30 anosmic TBIs (TBI-A) matched for posttraumatic amnesia (PTA) and working memory functioning with 36 nonanosmic TBIs (TBI-NA) and 51 controls. The groups performed the FAS test, the Animal Fluency test, the Stroop Neurological Screening Test (SNST), the Wisconsin Card Sorting Test-64 (WCST-64) and the Trail Making Test (TMT-B) as well as tests of emotional functioning and return to work outcome. After adjusting for the covariates (i.e., gender; Wechsler Test of Adult Reading, WTAR; and years of education), a significant effect was found for items successfully completed on the SNST, the FAS task, the Animal Fluency task, and the WCST-64 categories completed. After adjusting for the covariates, a significant difference was found for number of errors on the SNST and for the number and type of errors on TMT-B. The two groups did not differ in terms of their affective functioning (i.e., Beck Depression Inventory or Beck Anxiety Inventory), or in terms of their outcome with regard to return to work. The findings support the notion that the TBI-A group demonstrated considerably weaker performance on executive tasks than did the nonanosmic TBIs. These patients were not, however, more prone to an error-prone pattern of performance, and, if anything, their executive deficit was more likely attributable to a reduced productivity of response.