Nuevo caso de brote psicótico como presentación de la encefalitis antirreceptor de NMDA. Enfoque de tratamiento desde la neuropsiquiatría / A new case of psychotic break as the presenting symptom of anti-NMDA receptor encephalitis. Treatment from a neuropsychiatric approach

Introducción. La encefalitis límbica generada por anticuerpos antirreceptor de N-metil-D-aspartato (NMDA) es una entidad neurológica aguda y grave, más prevalente en mujeres jóvenes y asociada a un tumor subyacente. La aparición de sintomatología psiquiátrica inicial grave y el curso con alteraciones emocionales y déficit cognitivo grave hacen necesario reflexionar sobre las aportaciones, poco estudiadas hasta el momento, de la neuropsiquiatría al diagnóstico, la evolución y el tratamiento de la enfermedad. Caso clínico. Se presenta el único caso del que se tiene constancia en Navarra, asociado a un teratoma ovárico, atendiendo especialmente a la evaluación, la intervención y la evolución neuropsiquiátrica. Conclusión. La encefalitis antirreceptor de NMDA es una enfermedad que suele cursar con manifestaciones psiquiátricas predominantes en el inicio de la enfermedad, así como con deterioro cognitivo que afecta habitualmente a la memoria y a las funciones ejecutivas. Se demuestra eficaz iniciar un proceso de rehabilitación que incluya estrategias compensatorias del déficit, estimulación cognitiva y tratamiento psicofarmacológico en la fase de recuperación (AU)

Introduction. Limbic encephalitis generated by anti-N-methyl D-aspartate (NMDA) receptor antibodies is a severe acute neurological condition that is more prevalent in young females and is associated with an underlying tumour. The appearance of severe initial psychiatric signs and symptoms and the fact that it is accompanied by emotional disorders and severe cognitive impairment make it necessary to reconsider the contributions of neuropsychiatry to the diagnosis, development and treatment of the disease, since these have received little attention from researchers to date. Case report. We report on what is, to our knowledge, the only case in Navarra, associated with an ovarian teratoma, with special attention paid to its assessment, intervention and neuropsychiatric development. Conclusion. Anti-NMDA receptor encephalitis is a disease that is usually accompanied by predominant psychiatric manifestations at the outset of the illness, together with cognitive deterioration that commonly affects memory and the executive functions. Treatment consisting in beginning a process of rehabilitation that includes compensatory strategies for deficits, cognitive stimulation and psychopharmacological treatment in the recovery phase has proved to be effective (AU)

Propuesta de un modelo de funciones ejecutivas basado en análisis factoriales / Proposed model of executive functions based on factorial analyses

Introducción. Desde que Lezak acuñara el término de funciones ejecutivas como las capacidades mentales esenciales para llevar a cabo una conducta eficaz, creativa y aceptada socialmente, éstas han adquirido progresivo protagonismo en la investigación neuropsicológica. Diversos modelos han sido planteados para explicar su naturaleza, pero no existe consenso respecto a si nos encontramos ante un constructo unitario o un sistema de procesamiento multimodal con componentes independientes, pero interconectados. Para conocer la estructura de este constructo se han utilizado estudios de lesión, neuroimagen y, recientemente, el análisis factorial, que se plantea como una metodología prometedora para ampliar nuestro conocimiento sobre un concepto tan genérico como las funciones ejecutivas. Desarrollo. El propósito de este estudio es realizar una revisión sistemática de modelos factoriales de atención y control ejecutivo en adultos, entre los años 1991-2016, utilizando las bases de datos PubMed, OvidSP y PsycINFO. En total, se revisaron 33 artículos. A partir de la bibliografía, se realiza una propuesta integradora de los procesos ejecutivos. Conclusiones. Aunque no disponemos de un único modelo que pueda explicar la complejidad de las funciones ejecutivas, sí parece existir acuerdo respecto a su multidimensionalidad. En análisis factoriales, actualización, inhibición y alternancia gozan de fuerte evidencia, si bien hay trabajos que plantean factores novedosos. Nuestra propuesta integradora trata de combinar los procesos ejecutivos hallados en la bibliografía con sus correspondientes correlatos neuroanatómicos, defendiendo que la metodología ideal debería utilizar información procedente de estudios de lesión, técnicas de neuroimagen y modelos psicométricos-computacionales (AU)

Introduction. Since Lezak coined the term executive functions to refer to the mental capabilities that are considered essential for performing efficacious, creative and socially acceptable behaviour, they have gradually grown in importance in neuropsychological research. Different models have been proposed to explain their nature, but there is no general agreement as to whether we are dealing with a unitary construct or a multimodal processing system with independent, but interconnected, components. With the aim of gaining a deeper knowledge of the structure of this construct, researchers have conducted lesion, neuroimaging and, more recently, factorial analysis studies, the latter being seen as a promising methodology for expanding our knowledge about such a generic concept as the executive functions. Development. The purpose of this study is to carry out a systematic review of factorial models of attention and executive control in adults, between the years 1991 and 2016, using the PubMed, OvidSP and PsycINFO databases. Altogether, 33 papers were reviewed. Based on the literature, an integrating proposal of the executive functions is put forward. Conclusions. Although we do not have just one single model that can account for the complexity of the executive functions, there does seem to be general agreement on their multidimensionality. In factorial analyses, there is strong evidence of updating, inhibition and alternation, although there are also studies that propose novel factors. Our integrating proposal aims to combine the executive processes found in the literature with their corresponding neuroanatomical correlates, and defends the stance that the ideal methodology should use information from lesion studies, neuroimaging techniques and psychometric-computational models (AU)

Aportaciones de la neuropsicología a la encefalitis por anticuerpos antirreceptoContributions of neuropsychology to anti-NMDA receptor antibody encephalitis: a literature reviewr de NMDA: revisión de la bibliografía / Contributions of neuropsychology to anti-NMDA receptor antibody encephalitis: a literature review

La encefalitis límbica generada por anticuerpos antirreceptor de N-metil-D-aspartato (NMDA) es una entidad neurológica aguda y grave, más prevalente en las mujeres jóvenes y asociada a un tumor subyacente. El curso con déficit cognitivo grave hace necesario reflexionar sobre las aportaciones de la neuropsicología al diagnóstico, evolución y tratamiento de la enfermedad, poco estudiadas hasta el momento. Se revisa la bibliografía precedente, criticando la medición de los síntomas cognitivos (predominantemente mnésicos y ejecutivos) asociados a esta enfermedad. Se proponen instrumentos neuropsicológicos válidos y fiables, y se plantea que las medidas neuropsicológicas pueden servir como pará- metros de seguimiento de estos pacientes que ayuden a monitorizar su funcionalidad en la vida diaria una vez recuperados de la fase aguda, así como convertirse en una base sobre la que articular programas de rehabilitación que favorezcan el logro de la autonomía personal y la reinserción comunitaria de los pacientes. Con todo, se subraya la necesidad de incluir a neuropsicólogos y neuropsiquiatras no sólo en la detección, sino en el tratamiento de los pacientes, en pro de alcanzar la recuperación de la independencia personal y la readaptación a sus entornos naturales (AU)

Limbic encephalitis generated by anti-N-methyl-D-aspartate (NMDA) receptor antibodies is an acute and severe neurological entity, which is more prevalent in young females and is associated to an underlying tumour. Since it leads to severe cognitive impairment, thought needs to be given to the contributions of neuropsychology to the diagnosis, development and treatment of the disease, which have received little attention from researchers to date. A review is conducted of the prior literature, evaluating the measurement of the cognitive symptoms (predominantly mnemonic and executive) associated to this disease. Valid, reliable neuropsychological instruments are proposed, and it is suggested that neuropsychological measures may be used as parameters to follow up these patients which help monitor their functionality in daily living once they have recovered from the acute phase. Similarly they can become a basis on which to assemble rehabilitation programmes that favour the accomplishment of personal autonomy and the patients’ reintegration in the community. Nevertheless, we stress the need to include neuropsychologists and neuropsychiatrists in not only the detection but also the treatment of these patients so as to enable them to recover their personal independence and readapt to their natural settings (AU)

Tempo cognitivo lento: una revisión actualizada / Sluggish cognitive tempo: an updated review

Introducción. El estudio del tempo cognitivo lento (TCL) surgió en gran parte de las investigaciones del trastorno por déficit de atención/hiperactividad (TDAH). Este constructo se define con una gama de síntomas conductuales, como apariencia de somnolencia, soñar despierto, hipoactividad física, pobre iniciativa, letargo y apatía. Desarrollo. Se revisa el constructo de TCL a través de artículos recientemente publicados al respecto sobre características clínicas, síntomas asociados, evaluación, prevalencia, etiología, comorbilidad, perfiles neuropsicológicos y tratamiento. Los trabajos más actuales proponen entender el TCL como un cluster de síntomas distintivo del TDAH. Aunque no hay un consenso claro, los datos son cada vez más consistentes y dotan de gran validez externa al TCL, asociándolo con síntomas internalizantes. Conclusiones. Consideramos necesario anclar los diferentes subtipos de TDAH en modelos conceptuales atencionales. Así, la red de orientación atencional se relacionaría con el TCL, la red de vigilancia o atención sostenida con el TDAH subtipo inatento, y la atención ejecutiva sería la implicada en el TDAH subtipo combinado. La evidencia hasta la fecha, incluyendo esta revisión, apoya la idea de que el TCL es un trastorno de atención diferenciado del TDAH, pero que, como cualquier trastorno dimensional, puede solaparse con él aproximadamente en la mitad de los caso (AU)

Introduction. The study of sluggish cognitive tempo (SCT) arose largely from research carried out on attention deficit hyperactivity disorder (ADHD). This construct is defined by a range of behavioural symptoms such as the appearance of drowsiness, daydreaming, physical hypoactivity, little initiative, lethargy and apathy. Development. The construct of SCT is reviewed by means of recently published papers on its clinical characteristics, associated symptoms, evaluation, prevalence, aetiology, comorbidity, neuropsychological profiles and treatment. The latest studies propose that SCT should be understood as a cluster of symptoms that is distinct from ADHD. Although there is no clear consensus on the matter, the evidence is becoming increasingly more consistent and endows SCT with a high degree of external validity, associating it with internalising symptoms. Conclusions. We believe the different subtypes of ADHD must be grounded in attentional conceptual models. Hence, the attentional guidance network would be related with SCT, the vigilance or sustained attention network would be linked with the inattentive subtype of ADHD, and executive attention would be involved in the combined subtype of ADHD. The evidence obtained to date, including this review, supports the idea that SCT is an attention disorder distinct from ADHD but, like any dimensional disorder, it can overlap with it in around half the cases (AU)

[Sluggish cognitive tempo: an updated review]. / Tempo cognitivo lento: una revision actualizada.

INTRODUCTION: The study of sluggish cognitive tempo (SCT) arose largely from research carried out on attention deficit hyperactivity disorder (ADHD). This construct is defined by a range of behavioural symptoms such as the appearance of drowsiness, daydreaming, physical hypoactivity, little initiative, lethargy and apathy. DEVELOPMENT: The construct of SCT is reviewed by means of recently published papers on its clinical characteristics, associated symptoms, evaluation, prevalence, aetiology, comorbidity, neuropsychological profiles and treatment. The latest studies propose that SCT should be understood as a cluster of symptoms that is distinct from ADHD. Although there is no clear consensus on the matter, the evidence is becoming increasingly more consistent and endows SCT with a high degree of external validity, associating it with internalising symptoms. CONCLUSIONS: We believe the different subtypes of ADHD must be grounded in attentional conceptual models. Hence, the attentional guidance network would be related with SCT, the vigilance or sustained attention network would be linked with the inattentive subtype of ADHD, and executive attention would be involved in the combined subtype of ADHD. The evidence obtained to date, including this review, supports the idea that SCT is an attention disorder distinct from ADHD but, like any dimensional disorder, it can overlap with it in around half the cases.

TITLE: Tempo cognitivo lento: una revision actualizada.Introduccion. El estudio del tempo cognitivo lento (TCL) surgio en gran parte de las investigaciones del trastorno por deficit de atencion/hiperactividad (TDAH). Este constructo se define con una gama de sintomas conductuales, como apariencia de somnolencia, soñar despierto, hipoactividad fisica, pobre iniciativa, letargo y apatia. Desarrollo. Se revisa el constructo de TCL a traves de articulos recientemente publicados al respecto sobre caracteristicas clinicas, sintomas asociados, evaluacion, prevalencia, etiologia, comorbilidad, perfiles neuropsicologicos y tratamiento. Los trabajos mas actuales proponen entender el TCL como un cluster de sintomas distintivo del TDAH. Aunque no hay un consenso claro, los datos son cada vez mas consistentes y dotan de gran validez externa al TCL, asociandolo con sintomas internalizantes. Conclusiones. Consideramos necesario anclar los diferentes subtipos de TDAH en modelos conceptuales atencionales. Asi, la red de orientacion atencional se relacionaria con el TCL, la red de vigilancia o atencion sostenida con el TDAH subtipo inatento, y la atencion ejecutiva seria la implicada en el TDAH subtipo combinado. La evidencia hasta la fecha, incluyendo esta revision, apoya la idea de que el TCL es un trastorno de atencion diferenciado del TDAH, pero que, como cualquier trastorno dimensional, puede solaparse con el aproximadamente en la mitad de los casos.

[Factorial structure of the dysexecutive questionnaire in a sample of the Spanish population with acquired brain injury and memory deficit complaints]. / Estructura factorial del cuestionario disejecutivo en una muestra de población española con daño cerebral adquirido y quejas de déficit de memoria.

INTRODUCTION AND AIMS: The dysexecutive questionnaire (DEX) has been used to study executive deficits in both clinical samples (both psychiatric and neurological) and non-clinical samples, although agreement on its factorial structure is lacking. The aim of this research is to study that structure in the self-administered version in a sample of the Spanish population with acquired brain injury and memory loss complaints, and to compare that solution with those obtained in other studies. PATIENTS AND METHODS: The questionnaire was administered to 119 subjects with acquired brain injury with different aetiologies (traumatic, vascular, tumours, multiple sclerosis, toxic-metabolic and others). RESULTS: The Cronbach's alpha coefficient was 0.88. All the items showed adequate discriminatory power, except item 15. No relation was found between the total score on the DEX and the age, gender and time elapsed since the injury. A negative correlation between total score and level of schooling was confirmed. The total score does not follow a normal distribution. The five-factor solution accounts for a higher percentage of the total variance than those of two, three and four factors (63.76%). CONCLUSIONS: The Spanish version of the DEX is an instrument that is valid for evaluating general dysexecutive symptoms in subjects with acquired brain injury. The five-factor factorial structure (planning, cognitive control, inhibition, social awareness and impulse control) offers a greater wealth of information because it measures more aspects of the dys-executive pathology and therefore appears to be more useful in the clinical setting. It is advisable to use the questionnaire in an early stage of evaluation or screening and to use it as a complement to the proxy-reported version.

Contribución del cerebelo a los procesos cognitivos: avances actuales / Cerebellar contribution to cognitive process: current advances

Introducción. Tradicionalmente, se ha considerado al cerebelo como un sistema neuronal que participaba esencialmente en la coordinación y el control motor. Sin embargo, en las últimas décadas ha cobrado fuerza el concepto del cerebelo como un órgano relacionado con procesos cognitivos de alto nivel, afirmación que viene apoyada por estudios realizados en animales y humanos con lesiones cerebelosas, así como por la contribución de las modernas técnicas de neuroimagen. Desarrollo. Se revisa la contribución del cerebelo en diferentes funciones cognitivas, como la regulación de las funciones motoras, la atención, el lenguaje, las habilidades visuoconstructivas, el aprendizaje, la memoria y las funciones ejecutivas. Los resultados de dicha revisión arrojan como dato más clarificador la influencia del cerebelo en procesos como la atención, la memoria de trabajo (articulación encubierta) y la fluidez verbal, así como el aprendizaje procedimental. Los resultados encontrados en lo que respecta al cerebelo y las funciones ejecutivas no son concluyentes. Conclusiones. Consideramos que es necesario aún sistematizar el cuadro que ha comenzado ya a delinearse. Esto nos llevará a poder responder a la cuestión no sólo de si el cerebelo desempeña algún papel en la cognición humana, sino de cuál es ese papel. Tal vez la base para comprender las funciones cognitivas del cerebelo no se encuentre en que el cerebelo contiene funciones, sino que pone en relación la intención con la acción tanto en el plano cognitivo, emocional como conductual, aunque este papel de ‘interfaz’ se encuentra más próximo a los procesos de output que de procesamiento, y parece claro que se halla más afectado en funciones con un importante componente motor (AU)

Introduction. The cerebellum has traditionally been considered a neuronal system which is an essential part of coordination and motor control. However, in recent decades the idea of the cerebellum as an organ related to high level cognitive processes has gained strength, a claim supported by studies carried out on animals and humans with cerebellar lesions such as the contribution of modern neuroimaging techniques. Development. The contribution of the cerebellum is reviewed in different cognitive functions such as the regulation of motor functions, attention, language, visuoconstructional skills, learning, memory and executive functions. The results of said review produce, as the most clarifying data, the influence of the cerebellum on processes such as attention, working memory (covert articulation) and verbal fluency as well as procedural learning. The results found regarding the cerebellum and the executive functions are not conclusive. Conclusions. We consider it necessary to systematize the table that has already been outlined. This will enable us to answer not only the question of whether the cerebellum plays a role in human cognition but which is its role. Perhaps the basis for understanding the cognitive functions of the cerebellum are not found in the fact that the cerebellum contains functions but that it relates the intention to the action in the emotional as well as the behavioural cognitive plane although the role of ‘interface’ is found closer to the output processes than processing of functions with a motor component (AU)

Relación entre la sustancia blanca y las funciones cognitivas / Relation between white matter and cognitive functions

Introducción. Durante largo tiempo olvidada como contribuyente a la organización de las operaciones cognitivas, la sustancia blanca cerebral es, en la actualidad, objeto de estudio. Estos avances se complementan con las nuevas técnicas de neuroimagen, como el tensor de difusión, que permiten una visualización más detallada de cómo las vías de la sustancia blanca participan en las operaciones cognitivas. Desarrollo. Se revisa la relación de lesiones en la sustancia blanca con diferentes procesos y funciones cognitivas, como el lenguaje, atención, habilidades visuoespaciales y visuoconstructivas, negligencia espacial, velocidad de procesamiento, memoria y funciones ejecutivas. Conclusiones. El foco de atención sobre la sustancia blanca y sus trastornos promete ampliar el conocimiento del cerebro como un órgano extraordinariamente complejo en el que la conectividad y la velocidad de procesamiento proporcionada por la sustancia blanca son aspectos centrales para la cognición, la emoción y la propia consciencia. La sustancia blanca no parece ser el depósito de procesos y funciones cognitivas, sino que su papel se vincularía a dos propiedades necesarias para que un sistema de alta complejidad como el cerebro sea eficaz, como son la velocidad y la conectividad, procesos en los que debemos profundizar y, tal vez, comenzar a dilucidar su papel diferencial en el resultado de los procesos cognitivos (AU)

Introduction. After being largely neglected as a contributor to the organisation of the cognitive operations for many years, the white matter of the brain is now again the object of much research. These advances are complemented with the latestneuroimaging techniques, such as diffusion tensor imaging, which make it possible to obtain a more detailed view of the role played by the pathways of the white matter in the cognitive operations. Development. The study reviews the relation between lesions in the white matter and different cognitive processes and functions such as language, attention, visuospatial and visual-constructional skills, spatial negligence, processing speed, memory and executive functions. Conclusions. Focusing attention on the white matter and its disorders promises to further our knowledge of the brain as an extraordinarily complex organ in which the connectivity and processing speed provided by the white matter are key features in cognition, emotion and consciousness itself. The white matter does not appear to be the deposit for cognitive processes and functions, but rather its role would seem to be linked to two properties that are essential for a highly complex system like the brain to be effective: speed and connectivity. Further studies must be conducted to delve deeper into these processes and perhaps begin to clarify the different roles they play in the outcome of cognitive processes. (AU)

[Relation between white matter and cognitive functions]. / Relación entre la sustancia blanca y las funciones cognitivas.

INTRODUCTION: After being largely neglected as a contributor to the organisation of the cognitive operations for many years, the white matter of the brain is now again the object of much research. These advances are complemented with the latest neuroimaging techniques, such as diffusion tensor imaging, which make it possible to obtain a more detailed view of the role played by the pathways of the white matter in the cognitive operations. DEVELOPMENT: The study reviews the relation between lesions in the white matter and different cognitive processes and functions such as language, attention, visuospatial and visual-constructional skills, spatial negligence, processing speed, memory and executive functions. CONCLUSIONS: Focusing attention on the white matter and its disorders promises to further our knowledge of the brain as an extraordinarily complex organ in which the connectivity and processing speed provided by the white matter are key features in cognition, emotion and consciousness itself. The white matter does not appear to be the deposit for cognitive processes and functions, but rather its role would seem to be linked to two properties that are essential for a highly complex system like the brain to be effective: speed and connectivity. Further studies must be conducted to delve deeper into these processes and perhaps begin to clarify the different roles they play in the outcome of cognitive processes.