LA ECONOMÍA COLONIAL

Just over half the sample was also administered some of the subtests from the BADS. These included the rule shift, key search and zoo map.

Rule shift – assesses perseveration and mental flexibility i.e. the ability to adjust behaviour to meet demands of a changing situation

Key search – assesses planning ability 44 45 46 47 48 49 50 51 52 53 54 55 56 H igh n eu ro ticis m Lo w n eu ro ticis m H igh in tro ve rs ion Lo w in tro ve rs ion H igh an xie ty Lo w an xie ty

Boston naming test median score Published norms Whole sample median Borderline impaired

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Zoo map – assesses ability to plan independently and follow a pre-formulated plan, while abiding by a set of rules.

A Pearson’s correlation was conducted to investigate whether personality, clinical characteristics or mood was associated with performance on the BADS. This revealed significant correlations between neuroticism and the raw scores on both version one (r = -.540, p = .038) and two (r = - .591, p = .020) of the zoo map. People with high neuroticism scores scored, on average, 5.00 points lower compared with people with drug-refractory JME and less extreme neuroticism scores (Fig. 11.5). No other variables were significantly correlated with the zoo map.

The zoo map is an executive function test with good ecological validity, thus the findings presented above indicate that refractory JME patients with neurotic personalities may experience problems with planning and following rules in their daily lives. This finding warrants further study, but must be taken with caution as unfortunately only a small number (n=15) of individuals in the current sample were administered both the zoo map and the EPQ-BV.

Figure 11.5: Median scores on version one and two of the Zoo Map for drug-refractory JME with high and low neuroticism scores.

0 1 2 3 4 5 6 7 8

Zoo map -Version one Zoo map - Version two

High neuroticism Low neuroticism

135 11.5 Severity of executive dysfunctions

The severity of executive dysfunctions in the current sample was assessed by inspection of the samples z scores (calculated using manual means). The following tests were used to measure six executive and attention domains:

 Working memory, mental control of auditory-visual stimuli and attention span: assessed using the digit span and letter-number sequencing.

 Visual working memory, mental control of visual-spatial stimuli and attention: assessed using the symbol search, digit-symbol coding and spatial span.

 Verbal fluency: assessed using the letter fluency and category fluency,

 The ability to switch between categories: assessed using category switching and category accuracy.

 The ability to inhibit responses to visual-verbal stimuli: assessed using the colour-word interference test (verbal inhibition and inhibition switch)

 Naming ability: assessed using the Boston naming test

In concordance with previous research [154, 155] a z-score of ≤-1 (one or more standard deviations below the manual means) on at least one of the tests within each of the six domains was categorised as dysfunction in relation to that domain. As naming ability was measured by only one test a z-score of ≤-1 on the Boston naming test was categorised as executive dysfunction in relation to naming ability. If two domains were found to meet these criteria the patient was said to have mild executive dysfunction. If three or four domains met the criteria the patient was said to have moderate executive dysfunction. If five or more domains met the criteria the patient was said to have severe executive dysfunction.

Of the 60 refractory patients in the current sample (2 patient was excluded from this analysis due to missing data), 83% demonstrated a degree of executive/attentional dysfunction, which was moderate-severe in 66% of patients (38/58 patients). When a more conservative value of ≤ 2 SD below manual means were applied to each test 45% of the patients presented with a degree of executive dysfunction, and 28% presented with moderate to severe dysfunction. These percentage are lower than that previously reported in a JME sample [154]. However the previous study was conducted in Brazil thus there may be cultural differences. Moreover IQ was found to be significantly correlated with all of the executive function tests, and although Moschettea and

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Valente’s sample had a very similar mean IQ as the current sample (91.5 and 89., respectively) the current sample received on average almost three more years of formal education than their sample (13 years Vs. 10.1 years).

Extreme EPQ-BV scores were found to exacerbate the level of dysfunction in the current sample, and, when the more conservative value of two SD below published norms was applied, people with extreme EPQ-BV scores demonstrated the greatest level of executive dysfunction impairment; 54% presented with dysfunction, and 39% had moderate to severe dysfunction. This degree of dysfunction was not seen in any individual with unremarkable EPQ-BV scores; only one (8.3%) person had moderate dysfunction, and three (25%) had mild dysfunction.

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11.6 SUMMARY OF CHAPTER ELEVEN

The current chapter investigated whether the abnormal personality exhibited by JME patients is related to the neuropsychological impairments previously reported [7, 11- 14, 16].

The refractory JME sample was found to be significantly introverted compared to the healthy means reported by Sato [129]. In addition the females were also found to be significantly neurotic. When patients were split into neurotic Vs non-neurotic and introverted Vs non-introverted significant differences in neuropsychological functioning were found. Both neurotic and introverted patients scored worse across the majority of the battery. Moreover both neurotic and introverted patients were found to perform in the borderline range for letter fluency and the BNT. This suggests the common finding of impaired letter fluency in JME samples may be due to abnormal personality.

Preliminary analysis with the BADS revealed that the current sample scored significantly worse than manual means on the zoo map. Further, when the zoo map was correlated with personality, mood and clinical characteristics it was found that only neuroticism was significantly correlated with zoo map score. Post hoc analyses confirmed that patients with neurotic personalities perform significantly worse than healthy means and non-neurotic patients.

Overall this chapter has highlighted that refractory JME patients experience executive dysfunctions. It was found that 66% of the current sample experienced moderate to severe executive dysfunction. However 54% of patients with extreme personality scores compared to 1 participant of those with normal personality scores were classified as having moderate to severe executive dysfunction. In addition personality was found to be related to executive functions commonly found in JME, and points towards an association between neuroticism and real life planning ability. Abnormal personality is associated with frontal lobe abnormalities, thus the same frontal lobe abnormalities may be the cause of the executive dysfunctions in this subset of JME patients. However, thus far no cause has been found for the consistent impairment in switching between inhibiting a response and not inhibiting a response.

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CHAPTER TWELVE –

SUMMARY OF RESULTS

Overall the current sample performed worse than published norms across the battery. Worse performance was found even when education was controlled for.

Polytherapy was found to be associated with worse performance on neuropsychological test and explained a proportion of the variance. Subjective effect of AEDs was also associated with cognitive performance.

Anxiety was associated with verbal IQ, performance IQ, full scale IQ and letter fluency. Both anxious and non-anxious patients performed significantly worse than manual means, but anxious patients performed significantly worse than non-anxious patients. Depression was found to be associated with category fluency. Both depressed and non- depressed patients scored significantly worse than manual means on category fluency, but depressed patients scored significantly worse than non-depressed patients.

Introverts and neurotic patients perform worse than published norms across the battery and presented with the worse executive dysfunctions. 54% of patients with extreme personality scores compared to 1 participant of those with normal personality scores were classified as having moderate to severe executive dysfunction

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CHAPTER THIRTEEN –

DISCUSSION