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Abstract BACKGROUND Some patients experience long-term declines in quality of life following meningioma resection, but associated factors are not well understood. OBJECTIVE To investigate whether long-term declines in quality of life (specifically impaired adaptive functioning) after meningioma resection are associated with specific personality disturbances that often develop with lesions in ventromedial prefrontal cortex (vmPFC). METHODS  We studied 38 patients who underwent resection of meningioma, 18 of whom had vmPFC lesions and 20 with lesions elsewhere (non-vmPFC). A total of 30 personality characteristics were rated by spouse or family, and a neuropsychologist blindly rated adaptive functioning an average of 3.8 yr postresection. Relevant personality disturbance was defined by a priori process: the presence of “conjoint personality disturbance” required specific disturbances in at least 2 of 4 types of disturbance: executive disorders, disturbed social behavior, emotional dysregulation, and hypoemotionality. RESULTS Fourteen patients had impaired adaptive functioning: 12 had vmPFC lesions and 2 had non-vmPFC lesions. Fourteen patients had conjoint personality disturbance, and 12 of them had impaired adaptive functioning. By contrast, among the 24 patients who did not have conjoint personality disturbance, only 2 had impaired adaptive functioning. Mediation analysis showed that the association between vmPFC lesions and impaired adaptive functioning was mediated by the negative impact of acquired personality disturbance on adaptive functioning. CONCLUSION Anterior skull base meningiomas plus resection surgery may result in specific personality disturbances that are highly associated with impaired adaptive functioning at long-term follow-up. These patients may benefit from early counseling regarding potential personality changes and their implications for adaptive functioning.

The behavioral syndrome resulting from damage to the ventromedial prefrontal (VM) region presents major challenges for clinical assessment and management, stemming from the absence of reliable neurologic or psychometric markers, coupled with often debilitating impairments of decision-making and behavior regulation. Damage to this region disrupts neural circuitry critical for emotion, which in turn may contribute to impairments in real-world competencies. Here we present findings from patients with focal lesions in the VM region acquired either in childhood or adulthood, and show that there is a relationship between emotional dysfunction and impairments in real-world behavioral competencies. Emotion was rated by participants' relatives on dimensions including frustration tolerance, lability, anxiety, and blunted affect. Real-world competencies were rated by the relatives on dimensions including judgment, planning, and initiation, and were evaluated by clinician ratings in areas including social, financial, and occupational function. VM damage resulted in severe disruption of emotion, and this emotional dysfunction accounted for a significant portion of impaired real-world competencies. The long-term impairments associated with childhood-onset lesions were at least as severe as those resulting from adult-onset damage. Greater focus on the contribution of emotional dysfunction to the real-world competencies of patients with damage in the VM region may sharpen their neuropsychological assessment and facilitate rehabilitation efforts. (JINS, 2006, 12, 224–235.)

Demographically adjusted norms generally enhance accuracy of inferences based on neuropsychological assessment. However, we hypothesized that demographic corrections diminish predictive accuracy for real-world activities with absolute cognitive demands. Driving ability was assessed with a 45-minute drive along a standardized on-road route in participants aged 65+ (24 healthy elderly, 26 probable Alzheimer’s disease, 33 Parkinson’s disease). Neuropsychological measures included: Trail-Making A and B, Complex Figure, Benton Visual Retention, and Block Design tests. A multiple regression model with raw neuropsychological scores was significantly predictive of driving errors (R2 = .199, p = .005); a model with demographically adjusted scores was not (R2 = .113, p = .107). Raw scores were more highly correlated with driving errors than were adjusted scores for each neuropsychological measure, and among healthy elderly and Parkinson’s patients. When predicting real-world activities that depend on absolute levels of cognitive abilities regardless of demographic considerations, predictive accuracy is diminished by demographic corrections. (JINS, 2010, 16, 679–686.)

Patients with amyotrophic lateral sclerosis (ALS) often show deficits on neuropsychological tests that tap functions related to the integrity of the prefrontal lobes. Various aspects of personality are also known to be mediated by prefrontal regions, particularly ventromedial prefrontal cortex (vmPFC). Other than apathy, personality changes have not been widely reported in patients with ALS, although clinical observations indicate such changes might be relatively common. Here, we report on a middle-aged woman with bulbar onset ALS (diagnosed 06/2011, examined in Spring, 2012) whose neuropsychological exam did not reveal cognitive deficits. She performed normally on tests of executive functioning. Self-report measures of mood and personality were unremarkable. However, significant personality changes subsequent to disease onset were reported by her husband and two daughters, and these changes were quantified with the Iowa Scales of Personality Change. Results show that personality disturbance may manifest in the absence of notable cognitive changes in ALS, and careful assessment of personality may be important for documenting early neurobehavioral changes in some ALS patients. Findings also show that patients with ALS may not have good insight into personality changes, underscoring the importance of acquiring collateral information. More generally, the results provide further evidence that ALS may compromise the integrity of ventromedial prefrontal regions. (JINS, 2014, 20, 1–8)

The problems that some community-dwelling elderly persons develop in real-world decision-making may have disastrous consequences for their health and financial well-being. Investigations across the adult life span have identified personality as an important individual differences variable that is related to decision-making ability. The aim of this study was to investigate the relationship between personality characteristics, as rated by an informant, and complex decision-making performance among elderly persons. It was hypothesized that deficits in decision-making would be associated with personality characteristics reflecting weak executive functioning (Lack of Planning, Poor Judgment, Lack of Persistence, Perseveration, Lack of Initiative, Impulsivity, and Indecisiveness). Fifty-eight elderly persons participated. Their health and cognitive status were deemed intact via comprehensive neuropsychological evaluation. The Iowa Scales of Personality, completed by an informant, was used to assess personality characteristics, and the Iowa Gambling Task, completed by the participant, was used to assess complex decision-making abilities. Longstanding disturbances in executive personality characteristics were found to be associated with poor decision-making, and these disturbances remained predictive of poor decision-making even after taking into consideration demographic, neuropsychological, and mood factors. Acquired personality disturbances did not add significantly to prediction after longstanding disturbances were taken into account. Disturbances in other dimensions of personality were not significantly associated with poor decision-making. Our study suggests that attentiveness to the personality correlates of difficulties with aspects of executive functioning over the adult years could enhance the ability to identify older individuals at risk for problems with real-world decision-making.

This chapter is designed to assist the clinician faced with the issues to consider the broad range of capacities that may be of concern, the many cognitive and noncognitive factors that may compromise capacity, and assessment of capacity. After reviewing more basic issues regarding capacity, it focuses on factors that can make determination of capacity a particularly complex endeavor. Regarding diagnostic considerations in the assessment of capacity to live alone, dementia is obviously an especially impairing problem for many aging individuals. The chapter presents a case study of Peter. The story of Peter, based on an amalgam of actual individuals seen in the clinic, illustrates that questions of competency can be extraordinarily challenging. Early legal consideration of competency developed when the presumption that adults have the cognitive capacities necessary to make reasonable decisions regarding wills and disposition of their property, that is, “sound mind” or “testamentary capacity”, was called into question.

We investigated whether Persian Gulf War veterans (GWVs) were more likely than Persian Gulf War-era veterans deployed elsewhere (GEVs) to have noncredible neuropsychological examinations. A total of 301 GWVs and 99 GEVs underwent neuropsychological testing. The credibility of 173 examinations showing impairment was evaluated based on test performances, clinical background, psychometric measures, and other self-report data. All 11 examinations judged less than fully credible by one neuropsychologist, plus 19 examinations judged impaired but credible, were then evaluated independently by two more neuropsychologists. Noncredibility was judged with excellent reliability (93% agreement). Seven examinations were judged noncredible. Rates of noncredibility did not differ between GWVs (1%) and GEVs (4%). The pattern of associations of noncredible examinations with cognitive, psychological, and clinical variables generally indicated defective neuropsychological scores, with no coherent pattern, and personality disorder. Findings supported the validity of noncredibility judgments and suggested that noncredible examinations are not a significant problem in neuropsychological investigations of GWVs.

The present study investigated the specificity of poor long-term outcomes of depression to DSM-III unstable personality disorders (PDs) as opposed to PD in general. Ninety-two depressives whose personality had been assessed during hospitalization were followed up after four years. Sixty-four were evaluated with the Structured Interview for DSM-III Personality Disorders during their hospitalization, 75 completed the Eysenck Personality Inventory (EPI) six months after discharge. Unstable PD was unrelated to composite indices of course and outcome. Early age of onset and more prior hospitalizations were related to worse outcomes, the severity of the index episode and melancholic subtyping were not. A post hoc decision was made to split the sample into patients age 18 to 25 and patients 26 and older. Unstable PD was unrelated to prognosis among young depressives, but analyses of older patients revealed many of the expected relationships. Among older depressives, unstable PD predicted worse course and outcome, more medically serious suicide attempts, and more manipulative suicidal behavior. Poor prognosis and suicidal behavior were related specifically to unstable PD rather than to PD in general. Together, unstable PD and age of onset accounted for almost one-quarter of older depressives' outcome variance. Information about prior hospitalizations did not improve prediction. The presence of non-unstable PDs was not related to any follow-up measures. High EPI-neuroticism scores were weakly related to poor prognosis. Low EPI-extraversion scores were strongly related to poor outcomes, and EPI-E usurped EPI-N's predictive power. Neither age of onset nor prior hospitalizations contributed to prediction after consideration of EPI scales. EPI scales were unrelated to prognosis among young depressives, but were predictive for older depressives, suggesting that the effect of age on the predictiveness of unstable PD was not an artifact of diagnosis. It appears that unstable PDs, specifically, have negative implications for older depressives. A patient's age group should be considered when examining the implications of an unstable PD, and possibly personality disturbances in general, for prognosis. Examination of data reported in an earlier study suggests the age effect is not limited to the Iowa sample.

Sixty-nine depressed inpatients assessed for DSM-III personality disorders (PDs) were followed up after 4 years. Patients with unstable PDs (USPD; borderline, narcissistic, histrionic, and antisocial PDs) were compared with all other depressives. Considering patients of all ages, USPD was unrelated to course and weakly related to suicidal behavior. In post hoc analyses, patients were divided into \"younger\" (aged 18--25) and \"older\" (over 25). USPD but not other PDs predicted more episodes of depression, more manipulative suicidal behavior, and more medically serious suicide attempts among older depressives. USPD was unrelated to prognosis among younger depressives. This may be because many young USPDs will reach higher levels of adaptive functioning over several years, whereas USPDs still requiring hospitalization beyond their mid-20s tend to have more intractable character pathology with poorer long-term prognosis.

  Are you angry? I'm angry. If you're not angry, you should be. I don't really care which side of the gun control issue you are on. We won't forget the governor's signing of the bill closing all our senior arcades. You, being the governor who promised jobs, put all the people who work in them out of work and the owners in debt. Credit: [Ed Rubin], Boynton Beach; [Meyer Zaremba], Delray Beach; [Linda Ribner], Lauderhill; [Harriet Barrash], Boynton Beach; [Joseph L. Mombrea], Tamarac; [Allen Whetsell], governor, Florida Kiwanis, Sanford