Protocol for Cognitive Assessment for CFIDS
Curt A. Sandman PhD and Stephanie Moore PsyD. Originally published in the CFIDS Chronicle, 1992
Two basic questions can be resolved by performing neuropsychological evaluations in CFIDS patients. The first question is "What effects on the brain and behavior are specific and unique to CFIDS?" The second question is "Are there idiosyncratic effects of CFIDS related to patient strengths and weaknesses?" The implications of these questions are quite different, but both are important to answer.
The first question about the specific and unique effects of CFIDS provides basic information about the influence of the disease on the brain and behavior. Until the cause of CFIDS is known and a diagnostic test is available, these effects can serve as markers of the disease to assist in diagnosis. In addition, CFIDS-specific profiles are useful for explaining to patients what to expect and how to compensate for losses. These profiles are guides for research and are clues about which areas of the brain are compromised.
The second question about idiosyncratic effects of CFIDS relates to the interaction between the disease and patient history. Each patient has a unique life history with a special collection of strengths and weaknesses. The influence of CFIDS, as with other neurological and brain disorders, is manifested against this background. Because patients' backgrounds differ, this effect is highly individual.
To answer the first question, a series of tests are needed that are sensitive to the effects of CFIDS (can detect deficits) and can differentiate CFIDS from other diseases (specificity). The development of sensitive and specific test systems has been an elusive goal of neuropsychology. For instance, despite great efforts, no such neuropsychological test system is accepted for Alzheimer's Disease. In addition to requiring extensive effort, the development of such a test system requires serendipity.
Development of the ideal test system demands a large group of well-diagnosed CFIDS patients, groups of healthy subjects matched for age and education with the patients (control group), and at least one other disease group that may share symptoms with the CFIDS group. Tests must be selected that are relevant to the disease, or a large battery of tests can be administered and their diagnostic utility determined empirically. Our approach included all of these components.
We focused on memory because of the initial working case definition of the CDC and included depressed patients as a comparison group because depression was a common complaint of CFIDS patients. Further, there was (is) considerable debate in the literature about the relationship between CFIDS and depression. Our specific and unique effects of CFIDS were confined to the memory tests, but we have described briefly the entire test battery so the context for the conclusions is understood.
A battery of traditional neuropsychological tests were administered only to the CFIDS patients, including mental status examinations (Mini-Mental State Examination; Blessed; Benton; Temporal Orientation Test), Wechsler Adult Intelligent Scale-Revised), Wechsler Memory Scale-Revised, Wisconsin Card Sort Test, Trail-Making Test, Boston Naming Test, and the Visual-Function scale (C4) of the Luria Nebraska Neuropsychological Battery. Comparisons with normative groups were made.
The focused memory tests (Irvine Memory Battery) were administered to all groups with an interactive computer system (Computerized Memory and Interactive Dementia System; C-MIND, Neurocomp, Newport Beach, CA). Two separate studies have been completed with slightly different versions of the C-MIND system. Although the conclusions are identical, the effects were strongest with the latest version of the system. The procedures for the current version are described below.
Semantic Memory Test
The pattern of weak consolidation and vulnerability to interference has been reported in patients with diseases affecting the medial temporal cortex, hippocampus, and structures of the limbic system, including Huntington's Disease and herpes simplex encephalitis. These relationships are particularly interesting because of the recent reports of temporal lobe hypoperfusion as measured with SPECT scans in CFIDS patients by Dr. Ismael Mena. Preliminary comparison of markers from our battery and from the SPECT scans yielded very high associations in six CFIDS patients examined.
As reviewed above, each patient has a unique personal history that adds dimensions to the effects of CFIDS. For instance, a physician who had frontal head trauma from a car accident that occurred in the 1960s, began manifesting frontal symptoms for the first time in the late 1980s, shortly after CFIDS developed. In addition to the classical CFIDS profile, he developed loss of executive functions, impulsivity, and aggression, typically not part of the CFIDS profile. Possibly, the dormant brain injury was exacerbated or "liberated" by CFIDS onset. These symptoms are not detectable without a comprehensive, general battery of test instruments.
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