Dr Tisha J Ornstein CPsych Department of Psychology Ryerson University Overview Why are neuropsychologists special particular way of thinking eg Phineas Gage research approach Discussion about Attention Deficit Hyperactivity Disorder ADHD and relevance as related to Traumatic ID: 628333
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Slide1
Cognition in psychopathology: can we say one way or another whether certain cognitive processes are unique to a given disorder?
Dr. Tisha J. Ornstein, C.PsychDepartment of PsychologyRyerson UniversitySlide2
Overview
Why are neuropsychologists special – particular way of thinking, e.g., Phineas Gage; research approachDiscussion about Attention Deficit Hyperactivity Disorder (ADHD) and relevance as related to Traumatic Brain injuryLink between ADHD and Obsessive-Compulsive Disorder; research endeavours to be discussed by graduate student: Peter EgetoSlide3
Phineas Gage
Before
the accident, Phineas Gage had been a capable and efficient foreman who was looked on as
a
shrewd, smart business man. Afterwards, he was fitful, grossly profane, impatient and obstinate. His friends said he
was,
“no longer Gage.”
Massive
damage to the frontal lobes can cause dramatic changes in personality while keeping sensation, movement, consciousness and most cognitive faculties intact. Slide4
Neuropsychology: As a Way of Thinking…
Humans have evolved a range of subtle cognitive control mechanisms to regulate more basic cognitive processes in the service of future-oriented goals in an uncertain environment
These mechanisms are known as executive control
Executive control includes anticipation, goal selection, planning, and response inhibition, among other processes.
Executive control depends on a series of partially segregated frontal subcortical loops (e.g., Alexander, Delong, & Strick, 1986; Lichter & Cummings, 2001).
Perturbations of these loops and the resultant effect on executive control are implicated in various neuropsychiatric disorders, such as attention deficit hyperactivity disorder, and obsessive compulsive disorderSlide5
Frontostriatal circuits and Neurocognitive Processes
Neurocognitive processes mediated by the circuits include attention, the inhibition of inappropriate responses, shifting between thoughts or actions, performance monitoring, decision-making, planning
ability,
and using working memory to help guide behavior.
Dysregulation
of frontostriatal circuits likely underlies many of the symptoms related to the disorders of
interest.
Would
it not be wonderful to identify key cognitive mechanisms associated with a disorder? What are some implications? Slide6
Research Approach
Disorders of the frontostriatal system:
Attention deficit
hyperactivity
disorder, Obsessive-compulsive
disorder
Other disorders that are frontal with respect to their cognitive characteristics:
Traumatic Brain injury
Understanding the nature of neuropsychological characteristics associated with various conditions:Consider neuropsychological test battery or neurocognitive measures sensitive to the disorder of interest;Comparative approach Co-morbidities (pain, anxiety, depression)Change and variability (early work) Long-term follow-up (determine impact of injury on development) (future endeavour)Ultimate goal
is to elucidate the mechanisms that underlie abnormal behaviourSlide7
Introduction to Attention Deficit Hyperactivity Disorder (ADHD)
Most common developmental disorderAffects children, youth, and young adults
Costly, impairing and persistent
Phenotypically complex
Cognitive deficitsSlide8
Neurocognitive Deficits
Neurocognitive deficits in ADHD, and more specifically executive deficits, extend to adults, although the research lags behind child/adolescent-focused studies.
DSM-5 states, “Individuals with ADHD may exhibit cognitive problems on tests of attention, executive function, or memory, although these tests are not sufficiently sensitive or specific to serve as diagnostic indices
.” “No biological
marker
is diagnostic for ADHD.” (p. 61).
Even so, certain neuropsychological domains have been proposed as crucial.Slide9
Neurocognitive TestsSlide10
Response
InhibitionMotor Control/
Fluency/Syntax
Self-Regulation
Of Affect/
Motivation/ArousalInternalizationOf SpeechReconstitution
WorkingMemory
Barkley’s Theory of ADHD
Barkley asserts that these deficits manifest in ADHD children through:
Ability to adapt to new information
Ability to predict what will happenAbility to generate responses to future infoADHD = “nearsighted when it comes to time” Slide11
Which tests should we use? Why?
Consider:Why is the subject being referredWhat is/are the presenting issues
How old is the subject; Male or female
Any presenting difficulties, like hearing impairment
What are the cognitive concerns presented in the literature
Neuroanatomical substrates
Test parametersSlide12
Stop-Signal Paradigm
Response inhibition considered a signature deficit of ADHD; recent meta-analysis reported an effect size of .62 for SSRT in ADHD as compared to controls (Lipszyc & Schachar, 2010), and not related to the ‘go’ response. Slide13
Caveat; even so…
Not all children are impaired; however,
Relatives of impaired children on the stop signal reaction time task performed worse than relatives of non-impaired ADHD and healthy control children;
has been replicated.
McAuley and colleagues
(
2014) said that certain of executive control processes, including response inhibition, are markers of genetic risk for ADHD. Looking to evaluate whether certain skills are state-independent. Children were reassessed as adolescents. They compared ADHD children to peers and then ADHD subgroups (persistent, remittent, and partially remittance forms of the disorder) on average five years later. They found that response inhibition distinguished ADHD children from their unaffected peers, but also that the deficit persisted regardless of the course of the disorder. Slide14
Traumatic brain injury (TBI)
Leading cause of death and disability 375 per 100,000 person years500,000 cases / yr. to ER
40% admitted
80% + are mild; 80% receive attention
7% moderate
8% severe30,000 suffer permanent disability
Children, youth and young adults50% < 19 years; 25% < 9 yearsPhenotypically complex Cognitive deficitsSlide15
Pre-injury mental illness
15-40% have pre-injury mental illness ADHD most common (upwards of 25% of TBI cases)
Aggression
Phobia, SAD, ODD, OCD, GAD, LD
Multiple problemsSlide16
Pre-injury predictors of new disorders
Mental illnessInjury severityNumber of previous head injuriesLow pre-injury adaptive functioning SES, psychosocial
adversity, family
functioningSlide17
Post-injury mental illness
Secondary ADHD (S-ADHD: ADHD develops after TBI)Persist, inattentivePersonality change disorder
Labile, aggressive, disinhibited, apathetic, paranoid
Oppositional defiant and conduct disorder
Post-concussive symptoms
Headaches, dizziness, fatigue, irritability, insomnia, loss
of concentration and memory, noise and light sensitivityComorbidityComorbidity predicts severity and increases health care needs. Slide18
Traumatic Brain Injury and Attention Deficit Hyperactivity Disorder
Association between ADHD and TBI:Those with ADHD are at a greater of suffering a TBI due to the nature of deficits – risk-taking behavior, impulse control issues (cf. Adeyemo, 2014)
TBI has been shown to result in
S-ADHD
Perhaps
TBI and/or inhibitory control performance shapes the expression of ADHD, leading to an etiologically distinct form of ADHD.Slide19
274
children6–14 yrs2 years post TBI
SSRTSlide20
6-16 yrs
Injured at ~ 10 yrs
141 at
6 monthsSlide21
126 followed at
12 monthsSlide22
NOTE:
OCD; SCHZ Adults includedSlide23
Obsessive-Compulsive Disorder
Estimated lifetime prevalence of 2 to 3%; approximately 600 000 Canadians will be affected by this illness in their lifetime.
Among adults, men and women are equally affected, but in adolescents boys are more commonly affected.
The disorder begins most often in adolescence or early adulthood; it may begin in childhood.; around one-half to one-third of adult OCD cases have their onset in childhood or adolescence.
It is usually a chronic course that waxes and wanes
.
OCD may be accompanied by depression, eating disorders, or other anxiety disorders. Slide24
Neuropsychology
Few early neuropsychological studies in adults with OCD; results were inconsistent.
More recent neuropsychological studies of executive functions in adults with OCD have reported increased difficulty with switching cognitive set, generating strategies (i.e., executive planning), and response inhibition; memory difficulties are said to be related to problems with strategic learning. Slide25
Few studies have examined executive functioning in children with OCD. Of the handful of published studies, findings are inconsistent.
It is important to study children with OCD for many reasons:
Executive processing plays an important role in children’s learning and problem solving.
Can assess the underlying deficit unbiased by the effects of treatment and the consequences of the disorder itself
.
NeuropsychologySlide26
Research ArticleDEPRESSION AND ANXIETY
NEUROPSYCHOLOGICAL PERFORMANCE IN CHILDHOOD OCD:
A
PRELIMINARY STUDY
Tisha J. Ornstein, Ph.D., C.
Psych, Paul Arnold, M.D. F.R.C.P (C), Katharina Manassis, M.D. F.R.C.P (C), Sandra Mendlowitz, Ph.D., C. Psych, and Russell Schachar, M.D. F.R.C.P (C)Background: Neuropsychological deficits have often been found in studies
of adults with obsessive compulsive disorder (OCD). However, few studies have examined such impairment in children with OCD and of those studies published, the results are mixed. Methods: In the present study, 14 OCD children were compared to 24 healthy developing children of similar age and intellectual ability on a series of neuropsychological tests that assess response inhibition, abstract reasoning and problem solving, planning ability, verbal and nonverbal fluency, working memory, attention and information processing speed, and visual
and verbal memory and learning. Results: No significant differences emerged between the children with OCD and healthy controls for working memory, verbal fluency, attention, information processing speed, concept formation/abstraction, and response inhibition. We observed some deficits and a trend toward performance differences between the groups for psychomotor speed and attention, cognitive flexibility, nonverbal fluency, planning ability, and verbal memory and learning. Results are partially consistent with those found in adults with
OCD. Findings were not related to depressive symptoms or self-report feeling of anxiety. Conclusions: This preliminary survey indicates that OCD children may have deficits for cognitive flexibility and planning ability and differ from adults with OCD in not presenting with poor response inhibition or memory deficits. Larger, multi-site studies are warranted to help delineate the neurocognitive deficits associated with childhood OCD. Slide27
Child Literature
TestsFindings
Beers, 1999
Digit Span, Stroop, WCST, COWA, TOH, Go/No-Go,
CVLT, TMT
Null findings;
participant with OCD did better on some measuresShin, 2008CPT, WCST, TMT-B, RCFTNo differences on CPT, TMT-B, RCFTWooley, 2008Stop Signal Task, Motor Stroop
No differencesOrnstein, 2010Stop Signal, WCST, Spatial Span, n-Back, DKEFS ,TMT, CVLT, RCFTNo deficits, but trends towards deficits
in cognitive flexibility and planning abilityBehar, 1984Money’s Road Map Test of Directional sense, Maze Learning, Rey Word Learning List, RCFTDeficits in mental rotation in space & learning mazesAndres, 2007
RCFT, RAVLT, TMT, WCST, COWA, StroopDeficits in visual memory & visual organization. Slide28
ADHD and OC Behaviours
Background:Collaboration with Sick Kids Hospital (Drs. Schachar &
Crosbie
)
Children with ADHD and OC behaviours
ADHD: 5%
OCD: 1.2%ADHD+OCD: 10-33%
ADHD+OCB: 11.2%Slide29
ADHD and OC Behaviours
Background:ADHD & OCD: common neurobiological abnormalitiesCortico-striatal-thalamic pathwayAnterior cingulate cortex activity: ↓ in ADHD, ↑ in OCD
(
Brem
,
Grünblatt, Dreschler, Riederer &
Walitza, 2014)Inhibition impairmentsBehaviour & thought suppressionInhibition in ADHD+OCB: Arnold et al., 2005Somewhat ↑ inhibition in ADHD+OCB vs ADHDSlide30
ADHD and OC Behaviours
Measures: 3 inhibition tasksCognitive inhibition: Eriksen Flanker Task (distractor suppression)Response inhibition: Go/No-Go (response inhibition) Response inhibition: Stop
Signal Task (ongoing response
inhibition)
‘L’
‘X/O’
‘X’Slide31
ADHD and OC Behaviours
Results:
Task
Variable
ADHD (n=85)
OCB (n=10)
ADHD+OCB (n=14)
Controls (n=68)Post-hocGo/No-GoMCRT
734.9 (165.5)657.6 (165.6)683.54 (129.0)634.6
(121.1)ADHD > HCMCRT SD
253.0 (105.8)178.8 (78.9)231.9 (149.5)
188.8 (80.7)
ADHD > HC
Eriksen
Flanker
MCRT SD
283.9
(
95.1)
240.9
(
68.4)
241.7
(
67.0)
243.8
(
91.1)
ADHD > HC
MIRT SD
298.6
(
140.1)
293.8
(
314.2)
327.3
(
158.9)
228.5
(
125.7)
ADHD > HC
Stop Signal
All
n.s
.Slide32
ADHD and OC Behaviours
Conclusions:ADHD slower and more variableGeneral trend: ADHD > ADHD+OCB > controls > OCBProcessing speed vs variability?No differences on processing speed index (WISC-IV coding & symbol search)
OC symptoms: ↓ inhibition/inattention deficitsSlide33
ADHD and OC Behaviours
Future directions:Other inhibition measures (e.g., Stroop), larger sample, full OCD diagnosesOther studies:EEG and neuropsychogical
testing in OCD
Error related negativity (ERN), N2 (conflict monitoring), P3 (inhibition)Slide34
Current Endeavours
Decision-making in relation to:Inhibition;Quality of life and disabilityComponents of decision-making – Intolerance of uncertainty; reassurance seeking; impulsivity; subjective reporting (Frost Indecisiveness Scale…)Looking at these features in OCD and spectrum-related disordersSlide35
THANK YOU!
Acknowledgement: Ryerson research lab, Hospital for Sick Children, Sunnybrook Health Sciences Centre, and US collaborators.