Faculty Bibliography

Impaired memory is a common and often debilitating complaint in patients with epilepsy. Overlapping variables such as seizure control, attentional dysfunction, and mood disorders further complicate diagnosis and management. Direct therapy for memory deficits associated with epilepsy is rarely attempted. The varied pharmacological (AED selection, cholinesterase inhibitors, stimulants, antidepressants, and herbal supplements) and nonpharmacological approaches to cognitive remediation in epilepsy patients are reviewed

OBJECTIVE: To examine the independent contribution of executive versus semantic function to improvement in formal thought disorder after initial stabilization in a first-episode sample. BACKGROUND: Neurocognitive deficits have been suggested to predict treatment response in patients with first-episode schizophrenia. However, studies targeting putative neurocognitive mechanisms to explore improvement in positive psychotic symptoms and especially formal thought disorder are lacking. METHOD: Formal thought disorder symptoms in 81 first-episode patients with schizophrenia or schizoaffective disorder either showed significant improvement (responders > 60% change) or not (nonresponders < 60%) 6 months after initial stabilization of symptoms. These two groups were compared on neuropsychologic (n = 16), clinical (n = 15), and volumetric measures of the frontal and temporal lobes (n = 5) in univariate analyses. The variables that significantly differed between these two groups were used in a forward binary logistic regression analysis. RESULTS: As compared with nonresponders, responders were younger at time of testing, had higher verbal intelligence and reading achievement scores, higher scores on the arithmetic subtest of the Wechsler Adult Intelligence Scale-Revised, and lower number of perseverative responses on the Wisconsin Card Sort Test. Responders also had larger frontal lobe volumes than nonresponders. Only two measures (perseverative responses on the Wisconsin Card Sort Test and age at testing) entered the regression equation. Measures of semantic competency and volumetric measures of the temporal lobes were not associated with formal thought disorder improvement. CONCLUSIONS: Neurocognitive deficits are associated with treatment response in formal thought disorder in first-episode patients with schizophrenia. The improvement in formal thought disorder is more strongly linked to executive than semantic function in this sample, pointing to the salience of frontal systems in treatment response in positive psychotic symptoms.

Neuropsychological (NP) testing is now recognized as an important method for evaluating treatment effects. However, there are limitations to how these tests are currently used in most drug treatment protocols. Changes in cognition are typically defined in statistical terms, with little knowledge as to whether the observed differences are meaningful in any other sense. Methods for assessing changes in test scores need to account for test-retest reliability, practice effects, regression to the mean, and the impact of initial performance. All of these factors may vary according to the individual characteristics of the subject. This article reviews two methods from the NP literature that have attempted to account for these sources of test-retest bias. The reliable change index provides a confidence interval for predicted change by taking into account the test-retest reliability of the measure. Standardized regression-based measures use a more sophisticated statistical approach that enables them to better account for other potential sources of confound. Use of this methodology has been limited to studies of epilepsy surgery and sports-related concussion. These methods have the potential for enhancing the interpretation of NP test data in drug treatment protocols by providing an empirically based definition of clinically meaningful change

PURPOSE: To identify and define clinical and behavioral features of patients with adult-onset idiopathic generalized epilepsy (IGE). METHODS: We reviewed the charts of 313 IGE patients at the NYU Comprehensive Epilepsy Center over the past 5 years to identify patients with adult onset (18 years old or older). We excluded patients with childhood or adolescent symptoms that suggested absence, myoclonic, or tonic-clonic seizures, as well as those with a history of significant head injury or other known causes of localization-related epilepsy. RESULTS: Forty-two (13.4%) patients had a clear onset of IGE in adulthood; average age of onset was early 20s (mean, 23.8 years; range, 18-55 years). Twenty-one patients had adult myoclonic epilepsy (AME, 50%), and three had generalized tonic-clonic seizures on awakening (GTCS-A, 7%). More than two thirds (n=30) are well controlled with current antiepileptic drugs (AEDs), and almost 90% are currently employed (n=37). One third were diagnosed and treated for mental disorders, including depression (n=12), anxiety (n=7), obsessive-compulsive personality disorder (n=2), and postictal psychosis (n=1). CONCLUSIONS: Adult-onset IGE is associated with a good prognosis. An association may exist between psychological disorders, psychotropic medication, and level of seizure control in adults with IGE

Neuropsychology, with its emphasis on standardized and empirically based methods, has made a number of scientific contributions to address growing concerns about concussions resulting from sports injuries. This study employs a test-retest paradigm to determine the immediate effects of concussion in high-school and college athletes. The Standardized Assessment of Concussion (SAC) was administered to 1,313 male athletes prior to the beginning of the competitive season. Reliable change indices and multiple regression models were computed on retest scores obtained from 68 noninjured athletes who were readministered the SAC at either 60 or 120 days following baseline testing. Receiver operating characteristic (ROC) curve analyses were used to test these models with data obtained on 50 athletes tested immediately following concussion. The results indicate that a decline of I point on the SAC at retesting classified injured and noninjured participants with a level of 94% sensitivity and 76% specificity. The RCI and multiple regression models provided comparable levels of group classification, but provided cut-offs that are conservative for use with this population. The results support and extend previous research findings indicating that the SAC is a valid instrument for detecting the immediate effects of mild traumatic brain injury

OBJECTIVE: To familiarize athletic trainers with methodologic issues regarding the development and implementation of neuropsychological tests used in programs for monitoring sport-related cerebral concussion. DATA SOURCES: Knowledge base and MEDLINE and PsychLit searches from 1980-2000 using the terms sports, athletes, concussion, and brain. DATA SYNTHESIS: Neuropsychological testing is a proven method for evaluating symptoms of concussion that results from a variety of different causes. These tests have been shown to be effective in evaluating symptoms of subtle cognitive dysfunction in a number of patient groups. Applying these tests in an athletic population has required some procedural modifications, including the use of brief test batteries, collection of preseason baseline data, and evaluation of subtle postconcussive changes in test scores over time. New methods are now being used for improved evaluation of the reliability and validity of neuropsychological tests in athletes. Proper scientific analysis of the psychometric properties of neuropsychological tests and the ultimate value of their use in the sport setting will require years of detailed study on large numbers of athletes with and without symptoms of concussion. CONCLUSIONS/RECOMMENDATIONS: Athletic trainers and related personnel need to be aware of the training and methodologic issues associated with neuropsychological testing. Knowledge of the scientific properties of these tests, their advantages, and current limitations will ultimately enhance the athletic trainer's ability to use information from neuropsychological testing in an effective manner.

Attentional dysfunction can be found in nearly every form of psychopathology, not just in attention deficit disorder (ADD). Being able to distinguish ADD from other psychiatric conditions is crucial for clinicians working with adolescents and young adults, particularly in the case of psychoses where making the correct diagnosis and beginning treatment promptly is extremely important. In this paper we review the literature on the attentional dysfunction found in schizophrenia and compare it to that found in ADD in an effort to increase our knowledge of etiology and underlying mechanisms. Investigators studying ADD may learn from the study of schizophrenia by realizing that ADD is also a complex disorder of attention that occurs across the developmental spectrum and is characterized by various predispositional, environmental, and maturational factors.

OBJECT: The authors sought to determine the impact of early temporal lobectomy (in patients younger than age 17 years) on intellectual functioning. The efficacy of temporal lobectomy for treating seizures is well established and the procedure is becoming more acceptable as a treatment for children whose seizures are intractable. However, cognitive outcomes of temporal lobectomy in children and adolescents are largely unreported. The present study takes advantage of a unique multicenter collaboration to examine retrospectively intellectual functioning in a large sample of children who underwent temporal lobectomy. METHODS: Intellectual functioning was assessed before and after temporal lobectomy for treatment of medication-resistant seizures in 82 patients at eight centers of epilepsy surgery. All children underwent standard presurgical examinations, including electroencephalography-video monitoring, magnetic resonance (MR) imaging, and neuropsychological testing, at their respective centers. Forty-three children underwent left temporal lobectomy and 39 underwent right temporal lobectomy. For the entire sample, there were no significant declines in intelligence quotient (IQ) following surgery. Children who underwent left temporal lobectomy demonstrated no significant loss in verbal intellectual functioning and improved significantly in nonverbal intellectual functioning. Children who underwent right temporal lobectomy did not demonstrate significant changes in intellectual functioning. Although group scores showed no change in overall IQ values, an analysis of individual changes revealed that approximately 10% of the sample experienced a significant decline and 9% experienced significant improvement in verbal functioning. Significant improvement in nonverbal cognitive function was observed in 16% of the sample and only 2% of the sample showed significant declines. Risk factors for significant decline included older patient age at the time of surgery and the presence of a structural lesion other than mesial temporal sclerosis on MR imaging. CONCLUSIONS: The present study provides preliminary data for establishing the risk of cognitive morbidity posed by temporal lobectomy performed during childhood. With respect to global intellectual functioning, a slight improvement was significantly more likely to occur than a decline. However, there were several patients in whom significant declines did occur. It will be necessary to study further the factors associated with such declines. In addition, further study of more specific cognitive functions, particularly memory, is needed.