Executive attention and personality variables in patients with frontal lobe damage

Comparisons of electrophysiological markers of impaired executive attention after traumatic brain injury and in healthy aging

Executive attention impairments are a persistent and debilitating consequence of traumatic brain injury (TBI). To make headway towards treating and predicting outcomes following heterogeneous TBI, cognitive impairment specific pathophysiology first needs to be characterized. In a prospective observational study, we measured EEG during the attention network test aimed at detecting alerting, orienting, executive attention and processing speed. The sample (N = 110) of subjects aged 18-86 included those with and without traumatic brain injury: n = 27, complicated mild TBI; n = 5, moderate TBI; n = 10, severe TBI; n = 63, non-brain-injured controls. Subjects with TBI had impairments in processing speed and executive attention. Electrophysiological markers of executive attention processing in the midline frontal regions reveal that, as a group, those with TBI and elderly non-brain-injured controls have reduced responses. We also note that those with TBI and elderly controls have responses that are similar for both low and high-demand trials. In subjects with moderate-severe TBI, reductions in frontal cortical activation and performance profiles are both similar to that of controls who are ∼4 to 7 years older. Our specific observations of frontal response reductions in subjects with TBI and in older adults is consistent with the suggested role of the anterior forebrain mesocircuit as underlying cognitive impairments. Our results provide novel correlative data linking specific pathophysiological mechanisms underlying domain-specific cognitive deficits following TBI and with normal aging. Collectively, our findings provide biomarkers that may serve to track therapeutic interventions and guide development of targeted therapeutics following brain injuries.

Deficits in visuospatial attentional cueing following mild traumatic brain injury

Visual attentional deficits are frequently reported in patients with mild traumatic brain injury (TBI). In the present study, the ability to orient visual attention (i.e., the use of endogenous and exogenous visual cues) was investigated using a modified Posner visual search task, in which the participant was required to search for a target shape (radial frequency patterns) amongst distractor shapes. Participants were required to determine whether a target radial frequency pattern was present or absent from an array of distractors. Attention to the target location was cued using central or peripheral cueing procedures to investigate endogenous or exogenous attention allocation. Predictability was not manipulated between central and peripheral cues. Search difficulty was varied by systematically changing the radial frequency difference between target and distractors (and thereby shape difference), and cues could be valid or invalid in that they correctly or incorrectly indicated the position of the target shape. Both target discriminability (i.e., identifying the presence or absence of the target) and reaction times were measured. Thirteen patients with chronic mild TBI and 21 age-, sex-, and IQ -matched healthy controls participated in the study. For control participants, both discrimination accuracy and reaction times improved with visual search efficiency, and they were sensitive to the type of cue, with performance worst for cue invalid conditions than valid conditions. However, the results for TBI patients were strikingly different; we find that discrimination accuracy slightly improved with visual search difficulty (compared to controls), but not reaction times, and TBI patients were largely insensitive to the type of visual cue, and did not show a selective deficit for central or peripheral cues, suggesting an impairment in both endogenous and exogenous visual attention. In conclusion, patients with mild TBI exhibit a poor ability to orient visual attention.

Longitudinal alterations in gamma-aminobutyric acid (GABAA) receptor availability over ∼ 1 year following traumatic brain injury

Longitudinal alterations of gamma-aminobutyric acid (GABA_A) receptor availability following traumatic brain injury have remained uncharacterized and may reflect changes in neuronal structure and function linked to cognitive recovery. We measured GABA_A receptor availability using the tracer [11C]flumazenil in nine adults with traumatic brain injury (3–6 months after injury, subacute scan) and in 20 non-brain-injured individuals. A subset of subjects with traumatic brain injury (n = 7) were scanned at a second chronic time-point, 7–13 months after their first scan; controls (n = 9) were scanned for a second time, 5–11 months after the first scan. After accounting for atrophy in subjects with traumatic brain injury, we find broad decreases in GABA_A receptor availability predominantly within the frontal lobes, striatum, and posterior-medial thalami; focal reductions were most pronounced in the right insula and anterior cingulate cortex (p < 0.05). Greater relative increase, compared to controls, in global GABA_A receptor availability appeared between subacute and chronic scans. At chronic scan (>1 year post-injury), we find increased pallidal receptor availability compared to controls. Conversely, receptor availability remained depressed across the frontal cortices. Longitudinal improvement in executive attention correlated with increases in receptor availability across bilateral fronto-parietal cortical regions and the anterior-lateral aspects of the thalami. The specific observations of persistent bi-frontal lobe reductions and bilateral pallidal elevation are consistent with the anterior forebrain mesocircuit hypothesis for recovery of consciousness following a wide range of brain injuries; our results provide novel correlative data in support of specific cellular mechanisms underlying persistent cognitive deficits. Collectively, these measurements support the use of [11C]flumazenil to track recovery of large-scale network function following brain injuries and measure response to therapeutics.

Altered Attention Network in Paratroopers Exposed to Repetitive Subconcussion: Evidence Based on Behavioral and Event-Related Potential Results

Cognitive impairment caused by repetitive subconcussion has received increasing attention in recent years. Although the dysfunction of attention has been confirmed by neuropsychological research using scales, there is no event-related potentials (ERPs) research. The Attention Network Test (ANT) has been widely used to evaluate the three separate components of attention processing (alerting, orienting, and executive control). Twenty-seven paratroopers exposed to repetitive subconcussion (subconcussion group) and 25 matched healthy control participants (HCs group) were enrolled, and all of them performed the ANT test while continuous scalp electroencephalography data were recorded. On the behavioral performance level, the subconcussion group showed a slower task response, with an especially significant slower reaction time in alerting. Concerning ERP results, reduction amplitudes of cue-N1 in the alerting network were observed, indicating that this group was less able to make efficient use of cues and maintain an alerting state for incoming information. For the orienting network, no difference in N1 amplitude was observed between the two groups. Moreover, there was a reduced P3 amplitude in the executive control network in the subconcussion group compared with the HCs group, suggesting a dysfunction of attentional resource allocation and inhibition control in the former group. This study is, to our knowledge, the first analysis of the altered attention network caused by repetitive subconcussion from the perspectives of behavioral and neuropsychology levels. These preliminary results revealed the possible damage of the alerting and executive control networks and provided a reference for further research on subconcussion cognitive impairment.

Visuospatial Attention Allocation as an Indicator of Cognitive Deficit in Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Traumatic Brain Injury (TBI) is defined by changes in brain function resulting from external forces acting on the brain and is typically characterized by a host of physiological and functional changes such as cognitive deficits including attention problems. In the present study, we focused on the effect of TBI on the ability to allocate attention in vision (i.e., the use of endogenous and exogenous visual cues) by systematically reviewing previous literature on the topic. We conducted quantitative synthesis of 16 selected studies of visual attention following TBI, calculating 80 effect size estimates. The combined effect size was large (g = 0.79, p < 0.0001) with medium heterogeneity (I² = 68.39%). Subgroup analyses revealed an increase in deficit with moderate-to-severe and severe TBI as compared to mild TBI [F_{(2, 76)} = 24.14, p < 0.0001]. Task type was another key source of variability and subgroup analyses indicated that higher order attention processes were severely affected by TBI [F_{(2, 77)} = 5.66, p = 0.0051). Meta-regression analyses revealed significant improvement in visual attention deficit with time [p(mild) = 0.031, p(moderate-to-severe) = 0.002, p(severe) < 0.0001]. Taken together, these results demonstrate that visual attention is affected by TBI and that regular assessment of visual attention, using a systematic attention allocation task, may provide a useful clinical measure of cognitive impairment and change after TBI.

Effectiveness of a neuropsychological treatment for confabulations after brain injury: A clinical trial with theoretical implications

Confabulators consistently generate false memories without intention to deceive and with great feelings of rightness. However, to our knowledge, there is currently no known effective treatment for them. In order to fill this gap, our aim was to design a neuropsychological treatment based on current theoretical models and test it experimentally in 20 confabulators sequentially allocated to two groups: an experimental and a control group. The experimental group received nine sessions of treatment for three weeks (three sessions per week). The sessions consisted of some brief material that participants had to learn and recall at both immediate and delayed time points. After this, patients were given feedback about their performance (errors and correct responses). Pre- and post-treatment measurements were recorded. Confabulators in the control group were included in a waiting list for three weeks, performed the pre- and post- measurements without treatment, and only then received the treatment, after which a post-treatment measurement was recorded. This applied to only half of the participants; the other half quit the study prematurely. Results showed a significant decrease in confabulations and a significant increase in correct responses in the experimental group; by contrast, patients in the control group did not improve during the waiting list period. Only control group patients who subsequently received the treatment after serving as controls improved. The effects of the treatment were generalized to patients' everyday lives, as reported by relatives, and persisted over time. This treatment seems to be effective and easy to implement and consequently of clinical interest. Moreover, it also has theoretical implications regarding the processes related to the genesis and/or maintenance of confabulations. In particular, results point to a deficit in early stages of memory retrieval with the preservation of later strategic monitoring processes. Specifically, some of the processes involved may include selective attention or early conflict detection deficits. Future research should test these hypotheses.

Executive attention deficits after traumatic brain injury reflect impaired recruitment of resources

Deficits in attention are a common and devastating consequence of traumatic brain injury (TBI), leading to functional impairments, rehabilitation barriers, and long-term disability. While such deficits are well documented, little is known about their underlying pathophysiology hindering development of effective and targeted interventions. Here we evaluate the integrity of brain systems specific to attentional functions using quantitative assessments of electroencephalography recorded during performance of the Attention Network Test (ANT), a behavioral paradigm that separates alerting, orienting, and executive components of attention. We studied 13 patients, at least 6 months post-TBI with cognitive impairments, and 24 control subjects. Based on performance on the ANT, TBI subjects showed selective impairment in executive attention. In TBI subjects, principal component analysis combined with spectral analysis of the EEG after target appearance extracted a pattern of increased frontal midline theta power (2.5–7.5 Hz) and suppression of frontal beta power (12.5–22.5 Hz). Individual expression of this pattern correlated (r = − 0.67, p < 0.001) with executive attention impairment. The grading of this pattern of spatiotemporal dynamics with executive attention deficits reflects impaired recruitment of anterior forebrain resources following TBI; specifically, deafferentation and variable disfacilitation of medial frontal neuronal populations is proposed as the basis of our findings.

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Electrophysiological correlate of impaired executive attention after Traumatic Brain Injury is derived.

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Theta increases in medial frontal and beta suppression in frontal regions is linked to behavioral performance.

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Individual-specific pathophysiology allows for tracking of recovery/interventions and studies of function-structure.

Men and women with fibromyalgia: Relation between attentional function and clinical symptoms

OBJECTIVES

This study was the first to explore whether individuals with fibromyalgia (FM) have different cognitive alterations (i.e., in alertness, orienting, and executive control) depending on their sex. We also analysed possible gender differences in the relationships between cognitive functioning and some of the main symptoms of FM.

DESIGN

Cross-sectional study.

METHODS

Two clinical groups with FM (n = 58 women and n = 20 men) and two healthy control groups (n = 21 women and n = 27 men) aged between 30 and 60 years old participated in this study. Pain intensity, sleep disturbance, depression, anxiety, pain catastrophizing, and daily functioning were evaluated with self-report measures. Attentional function was assessed with the ANT-I task (Attentional Network Test-Interactions).

RESULTS

Mixed ANOVAs showed impairment in vigilance and executive control in both male and female patients with FM compared with controls. Control men were faster than control women, but FM eliminated sex differences. In addition, attention deficit was associated with worse daily functioning in women but not in men with FM. Emotional distress and sleep disruption seemed to contribute differently to these cognitive alterations in both sexes.

CONCLUSIONS

Therapy strategies aimed at reducing emotional distress and sleep disruption are likely to improve cognitive function by enhancing vigilance. Therapies aimed at reducing emotional distress seem to improve attentional function more in women than in men; those aimed at improving sleep quality are likely to reduce a vigilance/alertness deficit in women and executive problems in men.

Behavioural ratings of self-regulatory mechanisms and driving behaviour after an acquired brain injury

OBJECTIVE

To explore whether measurements of self-regulatory mechanisms and cognition predict driving behaviour after an acquired brain injury (ABI).

DESIGN

Consecutive follow-up study.

PARTICIPANTS

At baseline participants included 77 persons with stroke and 32 persons with a traumatic brain injury (TBI), all of whom completed a multidisciplinary driving assessment (MDA). A follow-up cohort of 34 persons that succeeded the MDA was included. Baseline measurements: Neuropsychological tests and measurements of self-regulatory mechanisms (BRIEF-A and UPPS Impulsive Behaviour Scale), driving behaviour (DBQ) and pre-injury driving characteristics (mileage, compensatory driving strategies and accident rates). Follow-up measurements: Post-injury driving characteristics were collected by mailed questionnaires from the participants who succeeded the MDA.

METHODS

A MDA, which included a medical examination, neuropsychological testing and an on-road driving test, was considered in the decision for or against granting a driver's license. Self-regulatory mechanisms and driving behaviour were examined for research purposes only.

RESULTS

At baseline, self-regulatory mechanisms were significantly associated to aberrant driving behaviour, but not with neuropsychological data or with the outcome of the on-road driving test. Aspects of self-regulation were associated to driving behaviour at follow-up.

CONCLUSION

It is recommended that self-regulatory measurements should regularly be considered in the driving assessments after ABI.

Detaching from the negative by reappraisal: the role of right superior frontal gyrus (BA9/32)

The ability to reappraise the emotional impact of events is related to long-term mental health. Self-focused reappraisal (REAPPself), i.e., reducing the personal relevance of the negative events, has been previously associated with neural activity in regions near right medial prefrontal cortex, but rarely investigated among brain-damaged individuals. Thus, we aimed to examine the REAPPself ability of brain-damaged patients and healthy controls considering structural atrophies and gray matter intensities, respectively. Twenty patients with well-defined cortex lesions due to an acquired circumscribed tumor or cyst and 23 healthy controls performed a REAPPself task, in which they had to either observe negative stimuli or decrease emotional responding by REAPPself. Next, they rated the impact of negative arousal and valence. REAPPself ability scores were calculated by subtracting the negative picture ratings after applying REAPPself from the ratings of the observing condition. The scores of the patients were included in a voxel-based lesion-symptom mapping (VLSM) analysis to identify deficit related areas (ROI). Then, a ROI group-wise comparison was performed. Additionally, a whole-brain voxel-based-morphometry (VBM) analysis was run, in which healthy participant's REAPPself ability scores were correlated with gray matter intensities. Results showed that (1) regions in the right superior frontal gyrus (SFG), comprising the right dorsolateral prefrontal cortex (BA9) and the right dorsal anterior cingulate cortex (BA32), were associated with patient's impaired down-regulation of arousal, (2) a lesion in the depicted ROI occasioned significant REAPPself impairments, (3) REAPPself ability of controls was linked with increased gray matter intensities in the ROI regions. Our findings show for the first time that the neural integrity and the structural volume of right SFG regions (BA9/32) might be indispensable for REAPPself. Implications for neurofeedback research are discussed.