Hemodynamic correlates of emotion regulation in frontal lobe epilepsy patients and healthy participants.

The ability to regulate emotions is indispensable for maintaining psychological health. It heavily relies on frontal lobe functions which are disrupted in frontal lobe epilepsy. Accordingly, emotional dysregulation and use of maladaptive emotion regulation strategies have been reported in frontal lobe epilepsy patients. Therefore, it is of clinical and scientific interest to investigate emotion regulation in frontal lobe epilepsy. We studied neural correlates of upregulating and downregulating emotions toward aversive pictures through reappraisal in 18 frontal lobe epilepsy patients and 17 healthy controls using functional magnetic resonance imaging. Patients tended to report more difficulties with impulse control than controls. On the neural level, patients had diminished activity during upregulation in distributed left-sided regions, including ventrolateral and dorsomedial prefrontal cortex, angular gyrus and anterior temporal gyrus. Patients also showed less activity than controls in the left precuneus for upregulation compared to downregulation. Unlike controls, they displayed no task-related activity changes in the left amygdala, whereas the right amygdala showed task-related modulations in both groups. Upregulation-related activity changes in the left inferior frontal gyrus, insula, orbitofrontal cortex, anterior and posterior cingulate cortex, and precuneus were correlated with questionnaire data on habitual emotion regulation. Our results show that structural or functional impairments in the frontal lobes disrupt neural mechanisms underlying emotion regulation through reappraisal throughout the brain, including posterior regions involved in semantic control. Findings on the amygdala as a major target of emotion regulation are in line with the view that specifically the left amygdala is connected with semantic processing networks.

Outcome of CBT-based multimodal psychotherapy in patients with psychogenic nonepileptic seizures: A prospective naturalistic study.

PURPOSE: Psychotherapy is recommended in patients with psychogenic nonepileptic seizures (PNES). To date, however, a limited number of studies have attempted to assess the long-term effectiveness of psychotherapy in patients with PNES. Here, we report the short and six-month follow-up seizure and psychopathological outcomes in patients with PNES who have undergone a combination of cognitive-behavioral individual and group therapy. METHODS: In this prospective, naturalistic study, 80 patients with PNES underwent cognitive behavioral psychotherapy in an inpatient setting (mean duration: 64.5 days) and were evaluated prior to treatment (T1) and at its end (T2). Six months after treatment, 55 patients participated in the follow-up assessment (T3). Psychopathology questionnaires and PNES ratings were used at T1, T2, and T3 to determine outcomes. RESULTS: At T2, 23% of the patients were free from PNES for ≥2 weeks. At T3, 21.8% were seizure-free for ≥1 month and 10.9% for ≥3 months. Only two patients who were free from PNES at T2 remained free from PNES until T3. Ten further patients achieved seizure freedom during the follow-up period and were free from seizures for ≥1 month at T3. Nevertheless, a subjective improvement of the seizure situation was reported by 74.1% of the patients. Patients' psychopathology scores decreased from T1 to T2 and remained stable after discharge (except for a slight increase of depression score from T2 to T3). Those patients who were PNES-free at T3 had less severe psychopathology, experienced less traumatic events, and PNES were prolonged prior to treatment than those who did not become seizure-free. SIGNIFICANCE: Inpatient psychotherapy led to PNES freedom in a minority of patients. Pretreatment psychopathology was the key factor affecting six-month follow-up seizure outcomes. Expectations should be formed in accordance with these perspectives, i.e., seizure freedom is difficult to achieve in many patients, but psychotherapy may be useful to treat underlying psychopathology. As our results stem from a specific patient sample (i.e., patients with chronic and refractory PNES) treated in a very specific setting, the generalizability of our findings is limited.

Postepileptic seizure PTSD: A very rare psychiatric condition in patients with epilepsy.

PURPOSE: It has been shown that relatives of patients with epilepsy could experience a seizure as a traumatic event followed by a posttraumatic stress disorder (PTSD). In one questionnaire study, 51% of the patients with epilepsy were reported to have a PTSD caused by a traumatic seizure, termed postepileptic seizure PTSD by the authors. However, it remained unclear whether these patients had further psychiatric comorbidities and if certain seizure features may foster the development of the proposed epilepsy-specific PTSD. METHODS: We conducted a structured clinical interview assessing psychiatric disorders in 120 patients with difficult-to-treat epilepsies. We also used a modified version of the Posttraumatic Stress Diagnostic Scale conducted as an interview to assess the number of patients who fulfilled the criteria for a PTSD caused by an epileptic seizure. We additionally compared certain features of traumatic versus nontraumatic seizures. RESULTS: Fifty of the 120 patients identified a seizure that fulfilled the criteria for a traumatic event, whereas 28 patients identified a worst seizure not meeting the trauma definition. Six patients fulfilled all PTSD criteria caused by a traumatic seizure. However, three of these patients also had a regular PTSD, and in two further patients, the results of the clinical interview suggested that the PTSD-like symptoms could be better explained by an adjustment disorder. We could not identify seizure characteristics differentiating traumatic from nontraumatic seizures. CONCLUSION: Our results showed that it is recommendable to conceptualize an epileptic seizure as being potentially traumatic in nature when assessing PTSD in patients with epilepsy, although we could not identify specific characteristics that could differentiate between traumatic and nontraumatic seizures. However, while using interview-based psychiatric assessment, we found a very low rate of a postepileptic seizure PTSD. It is worth conducting a comprehensive psychiatric diagnostic interview to differentiate PTSD-like symptoms from other comorbidities, such as epilepsy-related adjustment disorder.

Psychiatric disorders and trauma history in patients with pure PNES and patients with PNES and coexisting epilepsy.

Several studies found high prevalence rates of psychiatric disorders in patients with pure psychogenic nonepileptic seizures (PNES). Traumatic experiences were also reported to be elevated in patients with PNES and were discussed as a crucial risk factor for the development of PNES. Much less is known about psychiatric comorbidities and specifically, about trauma history in patients with PNES and coexisting epilepsy. Here, we aimed at directly comparing psychiatric disorders and traumatic life experiences in patients with pure PNES and in patients with PNES and coexisting epilepsy. We assessed the presence of current axes I and II disorders in 109 patients with either pure PNES (n = 67) or with PNES + epilepsy (n = 42) by using structured clinical interviews. We also compared the trauma histories by using the posttraumatic diagnostic scale (PDS) as an interview and the extent of physical, sexual, and emotional childhood maltreatment measured with the Childhood Trauma Questionnaire (CTQ). Patients of both groups had very high rates of psychiatric disorders: 79.1% of the patients with pure PNES and 76.2% of the patients with PNES + epilepsy had at least one psychiatric disorder. The frequencies of psychiatric disorders did not differ between groups. However, there was a trend towards higher rates of posttraumatic stress disorder (PTSD) in patients with PNES (32.9%) compared with patients with PNES + epilepsy (16.7%). In both groups, the proportion of patients who recalled traumatic events in the PDS was high (72.6% in the patients with pure PNES, 64.3% in the patients with PNES + epilepsy) and did not differ significantly between groups. The age at first traumatization, the types of trauma events experienced, the number of patients with single traumatization, and those with repeated traumatic experiences also did not differ between groups. We found high frequencies of childhood maltreatment in both groups. Our findings show that patients with PNES and patients with PNES and coexisting epilepsy could neither be differentiated by the amount of psychiatric additional disorders nor by the nature and extent of trauma and maltreatment experiences. Our results suggest that patients with PNES + epilepsy rather resemble patients with pure PNES than patients with epilepsy in respect to psychopathological characteristics and adverse life experiences. Trauma and maltreatment history are therefore assumed to be predisposing factors to PNES in both patients with pure PNES and patients with PNES and coexisting epilepsy.

Partial resection of presurgical fMRI activation is associated with a postsurgical loss of language function after frontal lobe epilepsy surgery.

We describe five patients with frontal lobe epilepsy who underwent electrocortical stimulation (ES) for language localization and language functional magnetic resonance imaging (fMRI) prior to epilepsy surgery. Six months after surgery, three patients suffered from a drop of verbal fluency. In all of them, frontal areas with presurgical language fMRI activity were resected. Our results suggest that resection in regions of areas with presurgical fMRI activation is not without risk for a postsurgical loss of function, even when ES results were negative for language function in these areas. Using fMRI activations might be specifically helpful to plan the resection when ES delivered inconclusive results.

Validation of rapid suicidality screening in epilepsy using the NDDIE.

OBJECTIVE: Standard mortality ratio for suicide in patients with epilepsy is three times higher than in the general population, and such a risk remains high even after adjusting for clinical and socioeconomic factors. It is thus important to have suitable screening instruments and to implement care pathways for suicide prevention in every epilepsy center. The aim of this study is to validate the use of the Neurological Disorder Depression Inventory for Epilepsy (NDDIE) as a suicidality-screening instrument. METHODS: The study sample included adult patients with epilepsy assessed with the Mini International Neuropsychiatric Interview (MINI) and the NDDIE. A high suicidality risk according to the Suicidality Module of the MINI was considered the gold standard. Receiver operating characteristic analyses for NDDIE total and individual item scores were computed and subsequently compared using a nonparametric approach. The best possible cutoff was identified with the highest Youden index (J). Likelihood ratios were then computed, and specificity, sensitivity, positive, and negative predictive values calculated. RESULTS: The study sample consisted of 380 adult patients with epilepsy: 46.3% male; mean age was 39.4 ± 14.6; 76.7% had a diagnosis of focal epilepsy; mean age at onset of the epilepsy was 23.3 ± 17.5. According to the MINI, 74 patients (19.5%) fulfilled criteria for a major depressive episode and 19 (5%) presented a high suicidality risk. A score >2 (J = 0.751) for item 4 "I'd be better off dead" of the NDDIE displayed excellent psychometric properties with a good to excellent validity (area under the curve [AUC] 0.906; 95% confidence interval [CI] 0.820-0.992; p < 0.001), sensitivity 84.21% (95% CI 60.4-96.6), specificity 90.86% (95% CI 87.4-93.6), likelihood ratio+ 9.21 (95% CI 6.3-13.5), likelihood ratio- 0.17 (95% CI 0.06-0.50). SIGNIFICANCE: Item 4 of the NDDIE has shown to be an excellent suicidality screening instrument allowing the development of further care pathways for suicide prevention in epilepsy centers.

Lesion side matters - an fMRI study on the association between neural correlates of watching dynamic fearful faces and their evaluation in patients with temporal lobe epilepsy.

Most studies assessing facial affect recognition in patients with TLE reported emotional disturbances in patients with TLE. Results from the few fMRI studies assessing neural correlates of affective face processing in patients with TLE are divergent. Some, but not all, found asymmetrical mesiotemporal activations, i.e., stronger activations within the hemisphere contralateral to seizure onset. Little is known about the association between neural correlates of affect processing and subjective evaluation of the stimuli presented. Therefore, we investigated the neural correlates of processing dynamic fearful faces in 37 patients with mesial temporal lobe epilepsy (TLE; 18 with left-sided TLE (lTLE), 19 with right-sided TLE (rTLE)) and 20 healthy subjects. We additionally assessed individual ratings of the fear intensity and arousal perception of the fMRI stimuli and correlated these data with the activations induced by the fearful face paradigm and activation lateralization within the mesiotemporal structures (in terms of individual lateralization indices, LIs). In healthy subjects, whole-brain analysis showed bilateral activations within a widespread network of mesial and lateral temporal, occipital, and frontal areas. The patient groups activated different parts of this network. In patients with lTLE, we found predominantly right-sided activations within the mesial and lateral temporal cortices and the superior frontal gyrus. In patients with rTLE, we observed bilateral activations in the posterior regions of the lateral temporal lobe and within the occipital cortex. Mesiotemporal region-of-interest analysis showed bilateral symmetric activations associated with watching fearful faces in healthy subjects. According to the region of interest and LI analyses, in the patients with lTLE, mesiotemporal activations were lateralized to the right hemisphere. In the patients with rTLE, we found left-sided mesiotemporal activations. In patients with lTLE, fear ratings were comparable to those of healthy subjects and were correlated with relatively stronger activations in the right compared to the left amygdala. Patients with rTLE showed significantly reduced fear ratings compared to healthy subjects, and we did not find associations with amygdala lateralization. Although we found stronger activations within the contralateral mesial temporal lobe in the majority of all patients, our results suggest that only in the event of left-sided mesiotemporal damage is the right mesial temporal lobe able to preserve intact facial fear recognition. In the event of right-sided mesiotemporal damage, fear recognition is disturbed. This underlines the hypothesis that the right amygdala is biologically predisposed to processing fear, and its function cannot be fully compensated in the event of right-sided mesiotemporal damage.

Distinguishing between patients with pure psychogenic nonepileptic seizures and those with comorbid epilepsy by means of clinical data.

Patients with psychogenic nonepileptic seizures (PNESs) often have additional epileptic seizures (ESs). Distinguishing between those with ESs and those without ESs is difficult but mandatory. We hypothesize that these two patient groups differ in clinical data, which might be useful for establishing diagnosis. All patients with PNESs (n=114) from the Bethel Epilepsy Centre treated between 1/11/2010 and 1/11/2011 were included. Thirty-six percent had additional epilepsy. In contrast, 84 of the 114 patients with PNESs took antiepileptic drugs (AEDs) (AED treatment: patients with PNESs=44/73, patients with PNESs+ESs=40/41), most of them (65.5%) as polytherapy. Significant differences between both groups were as follows: patients with PNESs were older at disease onset, had a shorter duration from onset to inpatient visit, were less frequently on AEDs, were less frequently on antiepileptic polytherapy, and had a normal EEG compared with patients with PNESs+ESs. Multivariate stepwise logistic regression revealed age at seizure onset, number of AEDs, and difference between number of AEDs and psychiatric drugs as significant predictors of patients with ESs in PNESs (Nagelkerke's r2=0.59). Therefore, clinical data proved to be useful in the diagnostic process.

MRI evidence for material-specific encoding deficits and mesial-temporal alterations in presurgical frontal lobe epilepsy patients.

OBJECTIVE: Neuroimaging studies reveal frontal lobe (FL) contributions to memory encoding. Accordingly, memory impairments are documented in frontal lobe epilepsy (FLE). Still, little is known about the structural or functional correlates of such impairments. Particularly, material specificity of functional changes in cerebral activity during memory encoding in FLE is unclear. METHODS: We compared 24 FLE patients (15 right-sided) undergoing presurgical evaluation with 30 healthy controls on a memory fMRI-paradigm of learning scenes, faces, and words followed by an out-of-scanner recognition task as well as regarding their mesial temporal lobe (mTL) volumes. We also addressed effects of FLE lateralization and performance level (normal vs. low). RESULTS: FLE patients had poorer memory performance and larger left hippocampal volumes than controls. Volume increase seemed, however, irrelevant or even dysfunctional for memory performance. Further, functional changes in FLE patients were right-sided for scenes and faces and bilateral for words. In detail, during face encoding, FLE patients had, regardless of their performance level, decreased mTL activation, while during scene and word encoding only low performing FLE patients had decreased mTL along with decreased FL activation. Intact verbal memory performance was associated with higher right frontal activation in FLE patients but not in controls. SIGNIFICANCE: Pharmacoresistant FLE has a distinct functional and structural impact on the mTL. Effects vary with the encoded material and patients' performance levels. Thus, in addition to the direct effect of the FL, memory impairment in FLE is presumably to a large part due to functional mTL changes triggered by disrupted FL networks. PLAIN LANGUAGE SUMMARY: Frontal lobe epilepsy (FLE) patients may suffer from memory impairment. Therefore, we asked patients to perform a memory task while their brain was scanned by MRI in order to investigate possible changes in brain activation during learning. FLE patients showed changes in brain activation during learning and also structural changes in the mesial temporal lobe, which is a brain region especially relevant for learning but not the origin of the seizures in FLE. We conclude that FLE leads to widespread changes that contribute to FLE patients' memory impairment.

Informing patients about the impact of provocation methods increases the rate of psychogenic nonepileptic seizures during EEG recording.

Observation of psychogenic nonepileptic seizures (PNESs) during video-EEG represents the diagnostic gold standard for PNESs. Different provocative techniques have been used to increase PNES frequency during EEG. These techniques include placebo administration, suggestion strategies, or both. In order to avoid the appearance of deception, we investigated the following hypothesis: If patients with PNESs were informed about the possible reduction of seizure threshold caused by hyperventilation and photic stimulation prior to EEG without any other suggestive strategies, PNESs would occur more frequently. In total, 34 inpatients with a diagnosis of PNESs, who had been informed prior to EEG about the increased seizure risk during hyperventilation and photic stimulation (study group), and 80 "noninformed" patients (control group) were enrolled. Psychogenic nonepileptic seizures occurred significantly more often in the study group compared to controls (38% vs. 10.0%, p=0.001). Our results imply that simply providing correct and explicit information about provocation techniques substantially increased the PNES rate.

Atypical language lateralisation associated with right fronto-temporal grey matter increases--a combined fMRI and VBM study in left-sided mesial temporal lobe epilepsy patients.

By combining language functional magnetic resonance imaging and voxel-based morphometry in patients with left-sided mesial temporal lobe epilepsy and hippocampal sclerosis, we studied whether atypical language dominance is associated with temporal and/or extratemporal cortical changes. Using verbal fluency functional magnetic resonance imaging for language lateralisation, we identified 20 patients with left-sided mesial temporal lobe epilepsy with hippocampal sclerosis and atypical language lateralisation. These patients were compared with a group of 20 matched left-sided mesial temporal lobe epilepsy patients who had typical language lateralisation. Using T1-weighted 3D images of all patients and voxel-based morphometry, we compared grey matter volumes between the groups of patients. We also correlated grey matter volumes with the degree of atypical language activation. Patients with atypical language lateralisation had increases of grey matter volumes, mainly within right-sided temporo-lateral cortex (x=59, y=-16, z=-1, T=6.36, p<.001 corrected), and less significantly within frontal brain regions compared to patients with typical language lateralisation. The degree of atypical fronto-temporal language activation (measured by lateralisation indices and relative functional magnetic resonance imaging activity) was correlated with right-sided temporal and frontal grey matter volumes. Patients with atypical language lateralisation did not differ in terms of language performance from patients with typical language dominance. Atypical language lateralisation in patients with left-sided mesial temporal lobe epilepsy was associated with increased grey matter volume within the non-epileptic right temporal and frontal lobe. Grey matter increases associated with atypical language might represent morphological changes underlying functional reorganisation of the language network. This hard-wired reorganised atypical language network seems to be suitable to support language functions.

Unilateral autoscopic phenomena as a lateralizing sign in focal epilepsy.

Positive autoscopic phenomena - autoscopy, heautoscopy and out-of-body experience - may occur in a variety of diseases and also in physiological conditions. They are a rare but probably underreported phenomenon in focal epilepsies. Here, we investigate whether ictal lateralized autoscopic phenomena give lateralizing information about the underlying epileptic focus. We present the cases of seven patients from our center who experienced ictal lateralized autoscopic phenomena and analyzed their focus lateralization and localization of the underlying brain lesion. In addition, we reviewed seven cases published in German and English language literature. In the total group of 14 patients with ictal lateralized autoscopic phenomena, 12 (85.7%) of them had a well-defined epileptic focus contralateral to the side of the autoscopic appearance. Therefore, the data point to an association between ictal lateralized autoscopy and contralateral epileptic focus.

Structural and functional plasticity of the hippocampal formation in professional dancers and slackliners.

The acquisition of special skills can induce plastic changes in the human hippocampus, a finding demonstrated in expert navigators (Maguire et al. (2000) Proc Natl Acad Sci USA 97:4,398-403). Conversely, patients with acquired chronic bilateral vestibular loss develop atrophy of the hippocampus, which is associated with impaired spatial memory (Brandt et al. (2005) Brain 128:2,732-741). This suggests that spatial memory relies on vestibular input. In this study 21 professional dancers and slackliners were examined to assess whether balance training with extensive vestibulo-visual stimulation is associated with altered hippocampal formation volumes or spatial memory. Gray matter voxel-based morphometry showed smaller volumes in the anterior hippocampal formation and in parts of the parieto-insular vestibular cortex of the trained subjects but larger volumes in the posterior hippocampal formation and the lingual and fusiform gyri bilaterally. The local volumes in the right anterior hippocampal formation correlated negatively and those in the right posterior hippocampal formation positively with the amount of time spent training ballet/ice dancing or slacklining at the time of the study. There were no differences in general memory or in spatial memory as assessed by the virtual Morris water task. Trained subjects performed significantly better on a hippocampal formation-dependent task of nonspatial memory (transverse patterning). The smaller anterior hippocampal formation volumes of the trained subjects may be the result of a long-term suppression of destabilizing vestibular input. This is supported by the associated volume loss in the parieto-insular vestibular cortex. The larger volumes in the posterior hippocampal formation of the trained subjects might result from their increased utilization of visual cues for balance. This is supported by the concomitant larger volumes in visual areas like the lingual and fusiform gyri. Our findings indicate that there is a spatial separation of vestibular and visual processes in the human hippocampus.

Whole-brain functional correlates of memory formation in mesial temporal lobe epilepsy.

The mesial temporal lobe is a key region for episodic memory. Accordingly, memory impairment is frequent in patients with mesial temporal lobe epilepsy. However, the functional relevance of potentially epilepsy-induced reorganisation for memory formation is still not entirely clear. Therefore, we investigated whole-brain functional correlates of verbal and non-verbal memory encoding and subsequent memory formation in 56 (25 right sided) mesial temporal lobe epilepsy patients and 21 controls. We applied an fMRI task of learning scenes, faces, and words followed by an out-of-scanner recognition test. During encoding of faces and scenes left and right mesial temporal lobe epilepsy patients had consistently reduced activation in the epileptogenic mesial temporal lobe compared with controls. Activation increases in patients were apparent in extra-temporal regions, partly associated with subsequent memory formation (left frontal regions and basal ganglia), and patients had less deactivation in regions often linked to the default mode and auditory networks. The more specific subsequent memory contrast indicated only marginal group differences. Correlating patients' encoding activation with memory performance both within the paradigm and with independent clinical measures demonstrated predominantly increased contralateral mesio-temporal activation supporting intact memory performance. In left temporal lobe epilepsy patients, left frontal activation was also correlated with better verbal memory performance. Taken together, our findings hint towards minor extra-temporal plasticity in mesial temporal lobe epilepsy patients, which is in line with pre-surgical impairment and post-surgical memory decline in many patients. Further, data underscore the importance of particularly the contralateral mesial temporal lobe itself, to maintain intact memory performance.

Assessing fitness to drive in older adults: Validation and extension of an economical screening tool.

OBJECTIVES: Due to demographic change, the number of older drivers with impaired driving skills will increase in the next decades. The current study aimed at the validation and extension of the screening tool Safety Advice For Elderly drivers (SAFE) that allows a cost-efficient assessment of driving-related risk factors in older drivers. METHOD: Seventy-four older drivers aged ≥65 years (M = 77 years) recruited from the general population were included in this prospective observational study. Receiver operating characteristic curve (ROC) and hierarchical logistic regression analyses were utilized to examine whether the SAFE and further evidence-based driving-related factors may allow the differentiation between fit and unfit older drivers assessed in standardized on-road driving assessments. RESULTS: ROC analyses revealed significant diagnostic accuracy of the number of SAFE risk factors in differentiating between fit and unfit older drivers (AUC = 0.71). A stepwise logistic regression model revealed that adding further evidence-based risk factors into the SAFE clearly improved diagnostic accuracy (AUC = 0.85). DISCUSSION: The current study shows that the risk assessed by the SAFE predicts on-road driving fitness in older adults. However, the results also suggest a need for a modification of the SAFE by the inclusion of additional evidence-based risk factors. With sensitivity and specificity scores of about 90 % and 75 %, this modified version may be more suitable for clinical use.

Alterations of decision making and underlying neural correlates after resection of a mediofrontal cortical dysplasia: A single case study.

We investigated the impact of a congenital prefrontal lesion and its resection on decision making under risk and under ambiguity in a patient with right mediofrontal cortical dysplasia. Both kinds of decision making are normally associated with the medial prefrontal cortex. We additionally studied pre- and postsurgical fMRI activations when processing information relevant for risky decision making. Results indicate selective impairments of ambiguous decision making pre- and postsurgically. Decision making under risk was intact. In contrast to healthy subjects the patient exhibited no activation within the dysplastic anterior cingulate cortex but left-sided orbitofrontal activation on the fMRI task suggesting early reorganization processes.

Categorization abilities for emotional and nonemotional stimuli in patients with alcohol-related Korsakoff syndrome.

OBJECTIVE: To investigate whether patients with alcohol-related Korsakoff syndrome (KR) have emotion-specific or general deficits in multicategoric classification performance. BACKGROUND: Earlier studies have shown reduced performance in classifying stimuli according to their emotional valence in patients with KS. However, it is unclear whether such classification deficits are of emotion-specific nature or whether they can also occur when nonemotional classifications are demanded. METHOD: In this study, we examined 35 patients with alcoholic KS and 35 healthy participants with the Emotional Picture Task (EPT) to assess valence classification performance, the Semantic Classification Task (SCT) to assess nonemotional categorizations, and an extensive neuropsychologic test battery. RESULTS: KS patients exhibited lower classification performance in both tasks compared with the healthy participants. EPT and SCT performance were related to each other. EPT and SCT performance correlated with general knowledge and EPT performance in addition with executive functions. CONCLUSIONS: Our results indicate a common underlying mechanism of the patients' reductions in emotional and nonemotional classification performance. These deficits are most probably based on problems in retrieving object and category knowledge and, partially, on executive functioning.

Avoidance Behavior Is an Independent Indicator of Poorer On-road Driving Skills in Older Adults.

OBJECTIVES: The aim of the current work was to investigate the relationship between avoidance of specific driving situations and on-road driving skills in older drivers considering factors found to be related to both avoidance behavior and driving skills. METHOD: Seventy-two older drivers (M = 76 years) from the general population were included in this study. Self-reported avoidance behavior, driving practice, perceived driving difficulties, driving-related cognitive functions, as well as medical conditions were assessed within two sessions. Standardized on-road assessments served for assessing on-road driving skills in a third session. RESULTS: Self-reported avoidance behavior was associated with reduced driving skills (r = -.41), and this relationship remained significant beyond the influence of cognitive skills, self-reported health, driving practice, and perceived driving difficulties. Specifically, avoidance of driving in bad weather, poor visibility and complicated parking was found to be associated with reduced driving skills. DISCUSSION: This study suggest that avoidance behavior is an independent indicator of impaired driving skills in older drivers. Our results argue against the assumption that avoidance behavior may be a reasonable strategy for safe traffic participation. Longitudinal studies are urgently needed to get more evidence on safety aspects of avoidance behavior.

Decision making in patients with temporal lobe epilepsy.

The mesiotemporal lobe is involved in decision making processes because bilateral amygdala damage can cause impairments in decision making that is mainly based on the processing of emotional feedback. In addition to executive functions, previous studies have suggested the involvement of feedback processing in decision making under risk when explicit information about consequences and their probabilities is provided. In the current study, we investigated whether unilateral mesiotemporal damage, comprising of the hippocampus and/or the amygdala, results in alterations of both kinds of decision making. For this purpose, we preoperatively examined 20 patients with refractory unilateral mesiotemporal lobe epilepsy (TLE) and a comparison group (CG) of 20 healthy volunteers with the Iowa Gambling Task to assess decision making based on feedback processing, the Game of Dice Task to assess decision making under risk, and with a neuropsychological test battery. Results indicate that TLE patients performed normally in decision making under risk, but can exhibit disturbances in decision making on the Iowa Gambling Task. A subgroup analysis revealed that those patients with a preference for the disadvantageous alternatives performed worse on executive subcomponents and had seizure onset at an earlier age in comparison to the patient subgroup without disadvantageous decision making. Furthermore, disadvantageous decision making can emerge in patients with selective hippocampal sclerosis not extended to the amygdala. Thus, our results demonstrate for the first time that presurgical patients with TLE can have selective reductions in decision making and that these deficits can result from hippocampal lesions without structural amygdala abnormalities.

Do amnesic patients with Korsakoff's syndrome use feedback when making decisions under risky conditions? An experimental investigation with the Game of Dice Task with and without feedback.

We investigated the role of feedback processing in decision making under risk conditions in 50 patients with amnesia in the course of alcoholic Korsakoff's syndrome (KS). Half of the patients were administered the Game of Dice Task (GDT) and the remaining 25 patients were examined with a modified version of the GDT in which no feedback was provided. Patients' results in the GDT and in the modified version were compared with that of 50 healthy subjects of whom 25 subjects performed the original GDT and 25 performed the modified version. While performance on the original GDT was superior to performance on the modified GDT in healthy subjects, KS patients performed similarly on both the GDT with and GDT without feedback. Performance on both task versions was correlated with categorization and set-shifting. The findings indicate that amnesic patients do not profit from receiving feedback for their decisions in explicit risk conditions.