Long-Term Cognitive and Psychological Functioning in Post-Electroconvulsive Therapy Patients.

OBJECTIVE: Electroconvulsive therapy (ECT) is associated with positive outcomes for treatment-resistant mood disorders in the short term. However, there is limited research on long-term cognitive or psychological changes beyond 1 year after -ECT. This study evaluated long-term outcomes in cognitive functioning, psychiatric symptoms, and quality of life for individuals who had undergone ECT. METHODS: Eligible participants (N = 294) who completed a brief pre-ECT neuropsychological assessment within the last 14 years were recruited for a follow-up evaluation; a limited sample agreed to follow-up testing (n = 34). At follow-up, participants were administered cognitive measures (Repeatable Battery for the Assessment of Neuropsychological Status [RBANS], Wide Range Achievement Test-4 Word Reading, Trail Making Test, Wechsler Adult Intelligence Scale-Fourth Edition Letter Number Sequence and Digit Span, and Controlled Oral Word Association Test), along with emotional functioning measures (Beck Depression Inventory-Second Edition [BDI-II] and Beck Anxiety Inventory) and the World Health Organization Quality of Life-BREF quality of life measure. Follow-up-testing occurred on average (SD) 6.01 (3.5) years after last ECT treatment. RESULTS: At follow-up, a paired t test showed a large and robust reduction in mean BDI-II score. Scores in cognitive domains remained largely unchanged. A trend was observed for a mean reduction in RBANS visual spatial scores. Lower BDI-II scores were significantly associated with higher RBANS scores and improved quality of life. CONCLUSIONS: For some ECT patients, memory, cognitive functioning, and decreases in depressive symptoms can remain intact and stable even several years after ECT. However, the selective sampling at follow-up makes these results difficult to generalize to all post-ECT patients. Future research should examine what variables may predict stable cognitive functioning and a decline in psychiatric symptoms after ECT.

Temporal lobe asymmetry in FDG-PET uptake predicts neuropsychological and seizure outcomes after temporal lobectomy.

OBJECTIVE: The objective of this study was to determine whether preoperative [18F]fludeoxyglucose (FDG)-positron emission tomography (PET) asymmetry in temporal lobe metabolism predicts neuropsychological and seizure outcomes after temporal lobectomy (TL). METHODS: An archival sample of 47 adults with unilateral temporal lobe epilepsy who underwent TL of their language-dominant (29 left, 1 right) or nondominant (17 right) hemisphere were administered neuropsychological measures pre- and postoperatively. Post-TL seizure outcomes were measured at 1year. Regional FDG uptake values were defined by an automated technique, and a quantitative asymmetry index (AI) was calculated to represent the relative difference in the FDG uptake in the epileptic relative to the nonepileptic temporal lobe for four regions of interest: medial anterior temporal (MAT), lateral anterior temporal (LAT), medial posterior temporal (MPT), and lateral posterior temporal (LPT) cortices. RESULTS: In language-dominant TL, naming outcomes were predicted by FDG uptake asymmetry in the MAT (r=-0.38) and LPT (r=-0.45) regions. For all patients, visual search and motor speed outcomes were predicted by FDG uptake asymmetry in all temporal regions (MPT, r=0.42; MAT, r=0.34; LPT, r=0.47; LAT, r=0.51). Seizure outcomes were predicted by FDG uptake asymmetry in the MAT (r=0.36) and MPT (r=0.30) regions. In all of these significant associations, greater hypometabolism in regions of the epileptic temporal lobe was associated with better postoperative outcomes. CONCLUSIONS: Our results support the conclusion that FDG uptake asymmetry is a useful clinical tool in assessing risk for cognitive changes in patients being considered for TL.

Blood-Brain Barrier Permeability Is Associated With Cognitive Functioning in Normal Aging and Neurodegenerative Diseases.

BACKGROUND: The purpose of this study was to investigate the relationship between blood-brain barrier (BBB) permeability and cognitive functioning in healthy older adults and individuals with neurodegenerative diseases. METHODS AND RESULTS: A total of 124 participants with Alzheimer disease, cerebrovascular disease, or a mix Alzheimer's and cerebrovascular diseases and 55 controlparticipants underwent magnetic resonance imaging and neuropsychological testing. BBB permeability was measured with dynamic contrast-enhanced magnetic resonance imaging and white matter injury was measured using a quantitative diffusion-tensor imaging marker of white matter injury. Structural equation modeling was used to examine the relationships between BBB permeability, vascular risk burden, white matter injury, and cognitive functioning. Vascular risk burden predicted BBB permeability (r=0.24, P<0.05) and white matter injury (r=0.38, P<0.001). BBB permeability predicted increased white matter injury (r=0.34, P<0.001) and increased white matter injury predicted lower cognitive functioning (r=-0.51, P<0.001). CONCLUSIONS: The study provides empirical support for a vascular contribution to white matter injury and cognitive impairment, directly or indirectly via BBB permeability. This highlights the importance of targeting modifiable vascular risk factors to help mitigate future cognitive decline.

Examination of the relationship between symptom and performance validity measures across referral subtypes.

INTRODUCTION: The extent to which performance validity (PVT) and symptom validity (SVT) tests measure separate constructs is unclear. Prior research using the Minnesota Multiphasic Personality Inventory (MMPI-2 & RF) suggested that PVTs and SVTs are separate but related constructs. However, the relationship between Personality Assessment Inventory (PAI) SVTs and PVTs has not been explored. This study aimed to replicate previous MMPI research using the PAI, exploring the relationship between PVTs and overreporting SVTs across three subsamples, neurodevelopmental (attention deficit-hyperactivity disorder (ADHD)/learning disorder), psychiatric, and mild traumatic brain injury (mTBI). METHODS: Participants included 561 consecutive referrals who completed the Test of Memory Malingering (TOMM) and the PAI. Three subgroups were created based on referral question. The relationship between PAI SVTs and the PVT was evaluated through multiple regression analysis. RESULTS: The results demonstrated the relationship between PAI symptom overreporting SVTs, including Negative Impression Management (NIM), Malingering Index (MAL), and Cognitive Bias Scale (CBS), and PVTs varied by referral subgroup. Specifically, overreporting on CBS but not NIM and MAL significantly predicted poorer PVT performance in the full sample and the mTBI sample. In contrast, none of the overreporting SVTs significantly predicted PVT performance in the ADHD/learning disorder sample but conversely, all SVTs predicted PVT performance in the psychiatric sample. CONCLUSIONS: The results partially replicated prior research comparing SVTs and PVTs and suggested that constructs measured by SVTs and PVTs vary depending upon population. The results support the necessity of both PVTs and SVTs in clinical neuropsychological practice.

Validation of the Personality Assessment Inventory (PAI) scale of scales in a mixed clinical sample.

Objective: This exploratory study examined the classification accuracy of three derived scales aimed at detecting cognitive response bias in neuropsychological samples. The derived scales are composed of existing scales from the Personality Assessment Inventory (PAI). A mixed clinical sample of consecutive outpatients referred for neuropsychological assessment at a large Midwestern academic medical center was utilized. Participants and Methods: Participants included 332 patients who completed study's embedded and free-standing performance validity tests (PVTs) and the PAI. PASS and FAIL groups were created based on PVT performance to evaluate the classification accuracy of the derived scales. Three new scales, Cognitive Bias Scale of Scales 1-3, (CB-SOS1-3) were derived by combining existing scales by either summing the scales together and dividing by the total number of scales summed, or by logistically deriving a variable from the contributions of several scales. Results: All of the newly derived scales significantly differentiated between PASS and FAIL groups. All of the derived SOS scales demonstrated acceptable classification accuracy (i.e. CB-SOS1 AUC = 0.72; CB-SOS2 AUC = 0.73; CB-SOS3 AUC = 0.75). Conclusions: This exploratory study demonstrates that attending to scale-level PAI data may be a promising area of research in improving prediction of PVT failure.

Replication and cross-validation of the personality assessment inventory (PAI) cognitive bias scale (CBS) in a mixed clinical sample.

Objective: This study is a cross-validation of the Cognitive Bias Scale (CBS) from the Personality Assessment Inventory (PAI), a ten-item scale designed to assess symptom endorsement associated with performance validity test failure in neuropsychological samples. The study utilized a mixed neuropsychological sample of consecutively referred patients at a large academic medical center in the Midwest. Participants and Methods: Participants were 332 patients who completed embedded and free-standing performance validity tests (PVTs) and the PAI. Pass and fail groups were created based on PVT performance to evaluate classification accuracy of the CBS. Results: The results were generally consistent with the initial study for overall classification accuracy, sensitivity, and cut-off score. Consistent with the validation study, CBS had better classification accuracy than the original PAI validity scales and a comparable effect size to that obtained in the original validation publication; however, the Somatic Complaints scale (SOM) and the Conversion subscale (SOM-C) also demonstrated good classification accuracy. The CBS had incremental predictive ability compared to existing PAI scales. Conclusions: The results supported the CBS, but further research is needed on specific populations. Findings from this present study also suggest the relationship between conversion tendencies and PVT failure may be stronger in some geographic locations or population types (forensic versus clinical patients).

Classification accuracy of individual and combined executive functioning embedded performance validity measures in mild traumatic brain injury.

The development of more sophisticated performance validity measures is important due to concerns with coaching as well as providing clinicians with a greater variety of options when assessing performance validity. Examinees with noncredible performance may find it more difficult to elude detection by PVTs derived from arithmetical summation or logistic regression. The present study evaluated the classification accuracy of several executive functioning (EF) variables as PVTs both individually and when combined into derived variables. The current study evaluated a simple mathematic summation of embedded PVT scores and a logistic regression-based formula based on embedded PVTs from executive function measures. A total of 155 consecutive patients completed neuropsychological evaluation after sustaining a mild traumatic brain injury (MTBI) were studied and were placed into a PVT-PASS (N = 95, mean age = 44.9, SD = 12.55, mean education = 13.45, SD = 2.23, 38% male, 97% Caucasian) or PVT-FAIL group (N = 60, mean age = 44.1, SD = 15.47, mean education = 13.05, SD = 2.58, 55% male, 92% Caucasian). Trail Making Test B, Wisconsin Card Sorting Test, and Stroop Color Word Test were summed and also used in logistic regression to predict whether patients had credible performance. Both the mathematical summation and the logistic regression methods achieved excellent classification accuracy (summation AUC = .79; logistic regression AUC = .82) with higher sensitivity than individual PVTs.

The construction and the initial validation of the Cognitive Bias Scale for the Personality Assessment Inventory.

Objective: This study describes the derivation and initial validation evidence of a novel Personality Assessment Inventory (PAI) scale designed to be sensitive to cognitive response bias, as defined by poor performance on performance validity tests (PVTs), in the context of neuropsychological assessment. The Cognitive Bias Scale (CBS) is a ten-item scale that was designed to discriminate between neuropsychological patients who passed or failed PVTs. Method: In a sample of 306 consecutive mixed neuropsychological outpatients, the CBS was derived by initially selecting items that significantly discriminated participants who passed and failed two or more PVTs, with further item refinement utilizing Item Response Theory methods. Results: Initial validation evidence suggests the CBS outperforms existing PAI symptom validity tests in predicting failure on two or more PVTs. The CBS showed good ability to discriminate between valid and invalid performance validity (Cohen's d = -0.96), with good classification accuracy (area under the curve = 0.72). Conclusions: Study results suggest the CBS may be useful in detecting cognitive response bias in a mixed neuropsychological outpatient sample; however, cross-validation will be necessary to further establish its utility.

Exploring the sensitivity of the Personality Assessment Inventory symptom validity tests in detecting response bias in a mixed neuropsychological outpatient sample.

OBJECTIVE: Few studies have evaluated the symptom validity tests (SVTs) within the Personality Assessment Inventory (PAI) in a neuropsychological assessment context. Accordingly, the present study explored the accuracy of PAI SVTs in identifying exaggerated cognitive dysfunction in a mixed sample of outpatients referred for neuropsychological assessment. METHOD: Participants who failed two or more Performance Validity Tests (PVTs) were classified as having exaggerated cognitive dysfunction (n = 49). Their responses on PAI SVTs were compared to examinees who did not fail PVTs (n = 257). RESULTS: Multivariate analysis of variance indicated the Negative Impression Management (NIM) scale most strongly discriminated between those with exaggerated cognitive dysfunction from honest responders (Cohen's d = .58). Nonetheless, its classification accuracy was low (area under the curve [AUC] = .65). A k-means cluster analysis and a subsequent multinomial logistic regression indicated evidence for two distinct groups of exaggerators. In particular, one group seemed to exaggerate symptoms, whereas another presented in a defensive manner, implying that individuals with positive and NIM biases on the PAI were apt to display invalid performance on PVTs. CONCLUSIONS: Findings indicated that exaggerated cognitive dysfunction tends to be present when NIM is very high and that evidence exists for a defensive response style on the PAI in the context of PVT failure.

Derivation of a Cross-Domain Embedded Performance Validity Measure in Traumatic Brain Injury.

OBJECTIVE: Performance validity assessment is increasingly considered standard practice in neuropsychological evaluations. The current study extended research on logistically derived performance validity tests (PVTs) by utilizing neuropsychological measures from multiple cognitive domains instead of from a single measure or a single cognitive domain. METHOD: A logistic-derived PVT was calculated using several measures from multiple cognitive domains, including verbal memory (California Verbal Learning Test-II Trial 5, Total Hits, and False Positives), attention (Brief Test of Attention Total score), and language (Boston Naming Test T-score, and Animal Fluency T-score). Due to its cross-domain nature, the cross-domain logistic-derived embedded PVT was hypothesized to have excellent classification accuracy for non-credible performance. Participants included 224 patients who completed all measures and were moderate to severe traumatic brain injury (STBI) patients (N = 66), possible mild TBI (MTBI-FAIL) patients who failed at least 2 independent PVTs (N = 67), and possible mild TBI patients who passed all PVTs (MTBI-PASS; N = 91). Logistic regression and ROC analyses were conducted on the MTBI-FAIL group and the STBI group. RESULTS: Multivariate analysis of variance indicated that the MTBI-FAIL group was significantly lower on all measures than the MTBI-PASS and the STBI groups. Using logistic regression, CVLT Total Hits, BTA, and the CVLT False Positives best differentiated between the MTBI-FAIL and STBI groups. The logistically derived PVT had excellent classification accuracy (area under the curve [AUC] = .84), with sensitivity at .54 when specificity was set at .90, higher than any individual variable. CONCLUSIONS: Findings support the use of this logistical-derived variable as an embedded PVT and support further research with this type of methodology.