We investigated the use of deep brain stimulation (DBS) of the ventral capsule/ventral striatum (... more We investigated the use of deep brain stimulation (DBS) of the ventral capsule/ventral striatum (VC/VS) for treatment refractory depression.
Social support is associated with better response to treatment. Treatments focused on relationshi... more Social support is associated with better response to treatment. Treatments focused on relationships, such as marital and family therapy, are directed in part at promoting this support. However, the strength of the relationship between support and abstinence is modest, as is the demonstrated incremental effectiveness of treatments focused on relationships. Treatment-matching research needs to determine under what set of conditions treatments focused on relationships will enhance abstinence. The primary aim of this study was to determine whether the relationship between alcohol involvement and alcohol-specific social support is moderated by a person's social investment. The second aim was to determine the set of circumstances under which extended individually focused cognitive behavioral (CB) treatment and a relationship enhancement (RE) of brief cognitive behavioral treatments would improve outcomes. Patients were randomly assigned to individual or relationship-enhanced outpatien...
Persons displaying Antisocial Personality Disorder (ASP) may be at risk for neuropsychological im... more Persons displaying Antisocial Personality Disorder (ASP) may be at risk for neuropsychological impairment due to a number of developmental and later life experiences to which they are prone. Thirty substance abusers meeting research criteria for ASP were compared to a demographically matched non-ASP cohort on neuropsychological test performance. The ASP subjects were found to have a higher prevalence of neuropsychological deficit. The groups were then compared on factors which might lead to brain impairment. Presence of ASP was associated with earlier and heavier past drinking patterns, more negative health and behavioral effects of alcohol abuse, and greater abuse of other drugs in addition to alcohol. The ASP alcoholics also reported a high prevalence of serious head injury (58%). although they did not differ from non-ASP alcoholics in this regard. Implications for the neuropsychology of alcoholism and for treatment are discussed.
Eight patients with intracranial cysts presenting with primary psychiatric diagnoses were studied... more Eight patients with intracranial cysts presenting with primary psychiatric diagnoses were studied. The cysts were visible on computed tomography (CT) and magnetic resonance imaging (MRI), and they produced neurologic, electroencephalographic (EEG), and neuropsychologic abnormalities. Descriptions of psychiatric manifestations associated with intracranial cysts are rare, and their potential neuropsychiatric significance has been minimized. This study demonstrates that intracranial cysts can cause neuropsychiatric symptoms, that surgical intervention may resolve the psychiatric manifestations in selected cases, and, in cases not warranting surgery, that psychopharmacological therapy to treat the behavioral manifestations is indicated. These cases mandate consideration of intracranial cysts in the diagnostic and therapeutic formulation of atypical neuropsychiatric disorders.
... Stroke, 288 Sergio E. Starkstein and Robert G. Robinson 16. Dementia of the Frontal Lobe Type... more ... Stroke, 288 Sergio E. Starkstein and Robert G. Robinson 16. Dementia of the Frontal Lobe Type, 304 David Neary and Julie S. Snowden 17. The Contribution of Frontal Lobe Lesions to the Neurobehavioral Outcome of Closed Head Injury, 318 Harvey S. Levin, Felicia C ...
The authors describe methods for conducting a thorough assessment of functions subserved by the f... more The authors describe methods for conducting a thorough assessment of functions subserved by the frontal lobes, employing both bedside and psychometric methods of assessing frontal subsystems. Qualitative or process aspects of frontal behavior observable from formal testing, interview, and social behavior are noted. It is argued that the skilled clinician must be guided by a knowledge of frontal lobe subsystems and their roles in determining specific types of abnormal behavior. The clinician will then be alert to changes in incidental behaviors that indicate frontal impairment, and bedside maneuvers can be designed to discriminate dysfunction. Given the complexity of the behaviors involved and the profound effects of maturation and aging on frontal functions, neuropsychological assessment can provide an invaluable tool for testing these functions.
The Mini-Mental State Exam is a brief screening instrument commonly used in evaluating geriatric ... more The Mini-Mental State Exam is a brief screening instrument commonly used in evaluating geriatric patients for the presence of cognitive impairment. An investigation of the instrument's ability to detect varying levels and types of cognitive impairment in psychogeriatric patients was conducted. Results revealed significant limitations in the instrument's ability to detect dementia, as well as other cognitive impairments. These limitations suggest that certain types of cognitive impairment may be overlooked if the MMS is relied upon as a definitive screening tool. (C) Lippincott-Raven Publishers.
Contemporary research has shown that delusions are often the product of identifiable neurologic d... more Contemporary research has shown that delusions are often the product of identifiable neurologic disease, particularly when the delusions have a specific theme or are confined to one topic--monosymptomatic or content-specific delusions. Although these delusions are considered rare, some of them can be found at high rates in certain populations and settings. The literature on several classes of content-specific delusions (misidentification, sexual, and somatic) is critically reviewed. The review demonstrates that when adequate diagnostic workups are conducted, a high proportion of such delusions are found to have a neurologic basis. Lesions of the frontal lobes and the right hemisphere are shown to be critical to the development and persistence of many content-specific delusions.
Review of the recent literature on Capgras syndrome reveals primary and secondary subtypes of the... more Review of the recent literature on Capgras syndrome reveals primary and secondary subtypes of the disorder having distinctly different neurodiagnostic findings, clinical presentations, and response to psychotropic medications. Primary cases tended to have negative neurodiagnostic work-ups, positive psychiatric histories (usually of paranoid schizophrenia), and gradual onset before age 40. Paranoia and violence were common in these primary cases, but neuroleptic response was good. In contrast, the secondary Capgras cases had positive neurodiagnostic findings (usually indicating right frontotemporal dysfunction), negative psychiatric histories, and sudden onset after age 40. There was a relative absence of paranoia and violence and more variable response to neuroleptics in the secondary cases. Two cases epitomizing the primary and secondary types are described, and a neuropsychological model for the disorder is presented. (C) Lippincott-Raven Publishers.
Data from 30 elderly inpatients with major depression were analyzed to explore the relationship b... more Data from 30 elderly inpatients with major depression were analyzed to explore the relationship between subcortical hyperintensities (SH) on MRI and activities of daily living (ADLs). A comparison of subjects based on a median split of the severity of SH revealed that subjects with greater SH performed worse on both instrumental and physical ADLs. A hierarchical multiple regression revealed that age, depression severity, neuropsychological test performance, and SH variables accounted for a total of 53% of the variance in ADL functioning. Severity of SH accounted for an additional 18% of the variance over and above the other three variables. Results suggest that severity of subcortical disease measured by MRI improves prediction of functional impairment in elderly individuals.
This study examined the effects of modafinil on apathetic symptomatology, performance of activiti... more This study examined the effects of modafinil on apathetic symptomatology, performance of activities of daily living (ADLs), and caregiver burden in individuals with Alzheimer's disease (AD). 23 participants with a diagnosis of mild-to-moderate probable AD according to National Institute of Neurologic and Communicative Disorder and Stroke-Alzheimer's Disease and Related Disorders criteria were randomized into the experimental (modafinil 200 mg daily) or control (placebo) groups. All participants were also receiving stable doses of a cholinesterase inhibitor medication. Participants completed assessments at baseline and after 8 weeks of treatment. Outcome measures included family report measures of apathy, ADL performance, and caregiver burden, as well as direct assessment of ADL performance. The study was conducted at a private psychiatric hospital in Rhode Island from September 2005 until September 2007. Both the experimental and control groups showed reductions in apathy on...
Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists, Jan 11, 2015
The Trail Making Test Part B (TMT-B) is widely used in clinical and research settings as a measur... more The Trail Making Test Part B (TMT-B) is widely used in clinical and research settings as a measure of executive function. Standard administration allows a maximal time score (i.e., floor score) of 300 s. This practice potentially masks performance variability among cognitively impaired individuals who cannot complete the task. For example, performances that are nearly complete receive the same 300-s score as a performance of only a few moves. Such performance differences may have utility in research and clinical settings. To address this, we propose a new TMT-B efficiency metric designed to capture clinically relevant performance variability below the standard administration floor. Our metric takes into account time, correct moves, and errors of commission and omission. We demonstrate that the metric has concurrent validity, permits statistical analysis of performances that fall below the test floor, and captures clinically relevant performance variability missed by alternative meth...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
The purpose of this study was to examine the extent to which executive cognitive dysfunction and ... more The purpose of this study was to examine the extent to which executive cognitive dysfunction and frontally-mediated behavioral disturbances are associated with functional impairment in patients with mild-to-moderate Alzheimer disease (AD). Patients with AD (N=45) completed the Mattis Dementia Rating Scale, and patients' caregivers completed the Frontal Systems Behavioral Inventory and a modified form of the Lawton and Brody Activities of Daily Living (ADLs) Questionnaire. Multiple-regression analyses revealed that executive cognitive dysfunction and apathy scores accounted for 44% of the variance in instrumental activities of daily living; executive cognitive dysfunction alone explained 17% of the variance in instrumental ADLs, and apathy scores explained an additional 27%. Executive dysfunction and frontal-behavioral impairment explained 28% of the variance in basic ADLs (BADLs), and, after accounting for executive dysfunction, apathy was the only symptom found to explain addit...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2001
The authors examined whether scores on two recently developed measures of behavioral disturbance,... more The authors examined whether scores on two recently developed measures of behavioral disturbance, the Frontal Lobe Personality Scale (FLOPS) and the Neuropsychiatric Inventory (NPI), are associated with functional impairments in patients with dementia. Caregivers of 30 dementia patients were administered the FLOPS Family Form, the NPI, and an Activities of Daily Living (ADL) scale. Findings indicated a relationship between behavioral changes and functional limitations in patients with dementia. Moreover, the FLOPS, an instrument designed to specifically measure behaviors subserved by frontal lobe systems, was more strongly related to failures in instrumental ADLs than was the NPI. The authors conclude that behavioral measures add information over and above that available from cognitive tests in determining ADL functioning.
Neuropsychiatry, neuropsychology, and behavioral neurology, 2000
The goal of this investigation was to describe the neuropsychological and magnetic resonance imag... more The goal of this investigation was to describe the neuropsychological and magnetic resonance imaging (MRI) findings in a patient with an extramedullary plasmacytoma that extensively infiltrated the cerebral dura, especially over the frontal region. Extramedullary plasmacytomas are rare tumors that have been reported to involve the dura matter in only a small number of cases. In most of the reported occurrences, the dura plasmacytomas were successfully treated with a combination of surgery and irradiation, without prominent cognitive sequelae. MRI of the brain and neuropsychological tests were conducted approximately 13 months after the patient underwent radiotherapy. In addition, measures of frontal lobe personality characteristics were obtained before and after radiotherapy. MRI findings revealed extensive enhancement around the anterior frontal lobes and prominent involvement of the anterior longitudinal fissure. Results from neuropsychological testing indicated mild to moderately...
The Journal of neuropsychiatry and clinical neurosciences, 1998
Neuropsychiatric research seeks to improve the lives of patients with brain-based behavioral dist... more Neuropsychiatric research seeks to improve the lives of patients with brain-based behavioral disturbances. There has been dramatic progress in diagnosis and treatment of neuropsychiatric disorders, and progress in neuroscience and biotechnology promises further success. Paradoxically, recent trends threaten to erode this progress. In this environment, neuropsychiatric clinician-scientists must advocate for the importance of research. This position statement defines neuropsychiatric research, describes current challenges to the neuropsychiatric clinician-scientist, summarizes research opportunities, describes how future neuropsychiatric clinician-investigators should be trained, and makes recommendations for promoting neuropsychiatric research.
We investigated the use of deep brain stimulation (DBS) of the ventral capsule/ventral striatum (... more We investigated the use of deep brain stimulation (DBS) of the ventral capsule/ventral striatum (VC/VS) for treatment refractory depression.
Social support is associated with better response to treatment. Treatments focused on relationshi... more Social support is associated with better response to treatment. Treatments focused on relationships, such as marital and family therapy, are directed in part at promoting this support. However, the strength of the relationship between support and abstinence is modest, as is the demonstrated incremental effectiveness of treatments focused on relationships. Treatment-matching research needs to determine under what set of conditions treatments focused on relationships will enhance abstinence. The primary aim of this study was to determine whether the relationship between alcohol involvement and alcohol-specific social support is moderated by a person's social investment. The second aim was to determine the set of circumstances under which extended individually focused cognitive behavioral (CB) treatment and a relationship enhancement (RE) of brief cognitive behavioral treatments would improve outcomes. Patients were randomly assigned to individual or relationship-enhanced outpatien...
Persons displaying Antisocial Personality Disorder (ASP) may be at risk for neuropsychological im... more Persons displaying Antisocial Personality Disorder (ASP) may be at risk for neuropsychological impairment due to a number of developmental and later life experiences to which they are prone. Thirty substance abusers meeting research criteria for ASP were compared to a demographically matched non-ASP cohort on neuropsychological test performance. The ASP subjects were found to have a higher prevalence of neuropsychological deficit. The groups were then compared on factors which might lead to brain impairment. Presence of ASP was associated with earlier and heavier past drinking patterns, more negative health and behavioral effects of alcohol abuse, and greater abuse of other drugs in addition to alcohol. The ASP alcoholics also reported a high prevalence of serious head injury (58%). although they did not differ from non-ASP alcoholics in this regard. Implications for the neuropsychology of alcoholism and for treatment are discussed.
Eight patients with intracranial cysts presenting with primary psychiatric diagnoses were studied... more Eight patients with intracranial cysts presenting with primary psychiatric diagnoses were studied. The cysts were visible on computed tomography (CT) and magnetic resonance imaging (MRI), and they produced neurologic, electroencephalographic (EEG), and neuropsychologic abnormalities. Descriptions of psychiatric manifestations associated with intracranial cysts are rare, and their potential neuropsychiatric significance has been minimized. This study demonstrates that intracranial cysts can cause neuropsychiatric symptoms, that surgical intervention may resolve the psychiatric manifestations in selected cases, and, in cases not warranting surgery, that psychopharmacological therapy to treat the behavioral manifestations is indicated. These cases mandate consideration of intracranial cysts in the diagnostic and therapeutic formulation of atypical neuropsychiatric disorders.
... Stroke, 288 Sergio E. Starkstein and Robert G. Robinson 16. Dementia of the Frontal Lobe Type... more ... Stroke, 288 Sergio E. Starkstein and Robert G. Robinson 16. Dementia of the Frontal Lobe Type, 304 David Neary and Julie S. Snowden 17. The Contribution of Frontal Lobe Lesions to the Neurobehavioral Outcome of Closed Head Injury, 318 Harvey S. Levin, Felicia C ...
The authors describe methods for conducting a thorough assessment of functions subserved by the f... more The authors describe methods for conducting a thorough assessment of functions subserved by the frontal lobes, employing both bedside and psychometric methods of assessing frontal subsystems. Qualitative or process aspects of frontal behavior observable from formal testing, interview, and social behavior are noted. It is argued that the skilled clinician must be guided by a knowledge of frontal lobe subsystems and their roles in determining specific types of abnormal behavior. The clinician will then be alert to changes in incidental behaviors that indicate frontal impairment, and bedside maneuvers can be designed to discriminate dysfunction. Given the complexity of the behaviors involved and the profound effects of maturation and aging on frontal functions, neuropsychological assessment can provide an invaluable tool for testing these functions.
The Mini-Mental State Exam is a brief screening instrument commonly used in evaluating geriatric ... more The Mini-Mental State Exam is a brief screening instrument commonly used in evaluating geriatric patients for the presence of cognitive impairment. An investigation of the instrument's ability to detect varying levels and types of cognitive impairment in psychogeriatric patients was conducted. Results revealed significant limitations in the instrument's ability to detect dementia, as well as other cognitive impairments. These limitations suggest that certain types of cognitive impairment may be overlooked if the MMS is relied upon as a definitive screening tool. (C) Lippincott-Raven Publishers.
Contemporary research has shown that delusions are often the product of identifiable neurologic d... more Contemporary research has shown that delusions are often the product of identifiable neurologic disease, particularly when the delusions have a specific theme or are confined to one topic--monosymptomatic or content-specific delusions. Although these delusions are considered rare, some of them can be found at high rates in certain populations and settings. The literature on several classes of content-specific delusions (misidentification, sexual, and somatic) is critically reviewed. The review demonstrates that when adequate diagnostic workups are conducted, a high proportion of such delusions are found to have a neurologic basis. Lesions of the frontal lobes and the right hemisphere are shown to be critical to the development and persistence of many content-specific delusions.
Review of the recent literature on Capgras syndrome reveals primary and secondary subtypes of the... more Review of the recent literature on Capgras syndrome reveals primary and secondary subtypes of the disorder having distinctly different neurodiagnostic findings, clinical presentations, and response to psychotropic medications. Primary cases tended to have negative neurodiagnostic work-ups, positive psychiatric histories (usually of paranoid schizophrenia), and gradual onset before age 40. Paranoia and violence were common in these primary cases, but neuroleptic response was good. In contrast, the secondary Capgras cases had positive neurodiagnostic findings (usually indicating right frontotemporal dysfunction), negative psychiatric histories, and sudden onset after age 40. There was a relative absence of paranoia and violence and more variable response to neuroleptics in the secondary cases. Two cases epitomizing the primary and secondary types are described, and a neuropsychological model for the disorder is presented. (C) Lippincott-Raven Publishers.
Data from 30 elderly inpatients with major depression were analyzed to explore the relationship b... more Data from 30 elderly inpatients with major depression were analyzed to explore the relationship between subcortical hyperintensities (SH) on MRI and activities of daily living (ADLs). A comparison of subjects based on a median split of the severity of SH revealed that subjects with greater SH performed worse on both instrumental and physical ADLs. A hierarchical multiple regression revealed that age, depression severity, neuropsychological test performance, and SH variables accounted for a total of 53% of the variance in ADL functioning. Severity of SH accounted for an additional 18% of the variance over and above the other three variables. Results suggest that severity of subcortical disease measured by MRI improves prediction of functional impairment in elderly individuals.
This study examined the effects of modafinil on apathetic symptomatology, performance of activiti... more This study examined the effects of modafinil on apathetic symptomatology, performance of activities of daily living (ADLs), and caregiver burden in individuals with Alzheimer's disease (AD). 23 participants with a diagnosis of mild-to-moderate probable AD according to National Institute of Neurologic and Communicative Disorder and Stroke-Alzheimer's Disease and Related Disorders criteria were randomized into the experimental (modafinil 200 mg daily) or control (placebo) groups. All participants were also receiving stable doses of a cholinesterase inhibitor medication. Participants completed assessments at baseline and after 8 weeks of treatment. Outcome measures included family report measures of apathy, ADL performance, and caregiver burden, as well as direct assessment of ADL performance. The study was conducted at a private psychiatric hospital in Rhode Island from September 2005 until September 2007. Both the experimental and control groups showed reductions in apathy on...
Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists, Jan 11, 2015
The Trail Making Test Part B (TMT-B) is widely used in clinical and research settings as a measur... more The Trail Making Test Part B (TMT-B) is widely used in clinical and research settings as a measure of executive function. Standard administration allows a maximal time score (i.e., floor score) of 300 s. This practice potentially masks performance variability among cognitively impaired individuals who cannot complete the task. For example, performances that are nearly complete receive the same 300-s score as a performance of only a few moves. Such performance differences may have utility in research and clinical settings. To address this, we propose a new TMT-B efficiency metric designed to capture clinically relevant performance variability below the standard administration floor. Our metric takes into account time, correct moves, and errors of commission and omission. We demonstrate that the metric has concurrent validity, permits statistical analysis of performances that fall below the test floor, and captures clinically relevant performance variability missed by alternative meth...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
The purpose of this study was to examine the extent to which executive cognitive dysfunction and ... more The purpose of this study was to examine the extent to which executive cognitive dysfunction and frontally-mediated behavioral disturbances are associated with functional impairment in patients with mild-to-moderate Alzheimer disease (AD). Patients with AD (N=45) completed the Mattis Dementia Rating Scale, and patients' caregivers completed the Frontal Systems Behavioral Inventory and a modified form of the Lawton and Brody Activities of Daily Living (ADLs) Questionnaire. Multiple-regression analyses revealed that executive cognitive dysfunction and apathy scores accounted for 44% of the variance in instrumental activities of daily living; executive cognitive dysfunction alone explained 17% of the variance in instrumental ADLs, and apathy scores explained an additional 27%. Executive dysfunction and frontal-behavioral impairment explained 28% of the variance in basic ADLs (BADLs), and, after accounting for executive dysfunction, apathy was the only symptom found to explain addit...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2001
The authors examined whether scores on two recently developed measures of behavioral disturbance,... more The authors examined whether scores on two recently developed measures of behavioral disturbance, the Frontal Lobe Personality Scale (FLOPS) and the Neuropsychiatric Inventory (NPI), are associated with functional impairments in patients with dementia. Caregivers of 30 dementia patients were administered the FLOPS Family Form, the NPI, and an Activities of Daily Living (ADL) scale. Findings indicated a relationship between behavioral changes and functional limitations in patients with dementia. Moreover, the FLOPS, an instrument designed to specifically measure behaviors subserved by frontal lobe systems, was more strongly related to failures in instrumental ADLs than was the NPI. The authors conclude that behavioral measures add information over and above that available from cognitive tests in determining ADL functioning.
Neuropsychiatry, neuropsychology, and behavioral neurology, 2000
The goal of this investigation was to describe the neuropsychological and magnetic resonance imag... more The goal of this investigation was to describe the neuropsychological and magnetic resonance imaging (MRI) findings in a patient with an extramedullary plasmacytoma that extensively infiltrated the cerebral dura, especially over the frontal region. Extramedullary plasmacytomas are rare tumors that have been reported to involve the dura matter in only a small number of cases. In most of the reported occurrences, the dura plasmacytomas were successfully treated with a combination of surgery and irradiation, without prominent cognitive sequelae. MRI of the brain and neuropsychological tests were conducted approximately 13 months after the patient underwent radiotherapy. In addition, measures of frontal lobe personality characteristics were obtained before and after radiotherapy. MRI findings revealed extensive enhancement around the anterior frontal lobes and prominent involvement of the anterior longitudinal fissure. Results from neuropsychological testing indicated mild to moderately...
The Journal of neuropsychiatry and clinical neurosciences, 1998
Neuropsychiatric research seeks to improve the lives of patients with brain-based behavioral dist... more Neuropsychiatric research seeks to improve the lives of patients with brain-based behavioral disturbances. There has been dramatic progress in diagnosis and treatment of neuropsychiatric disorders, and progress in neuroscience and biotechnology promises further success. Paradoxically, recent trends threaten to erode this progress. In this environment, neuropsychiatric clinician-scientists must advocate for the importance of research. This position statement defines neuropsychiatric research, describes current challenges to the neuropsychiatric clinician-scientist, summarizes research opportunities, describes how future neuropsychiatric clinician-investigators should be trained, and makes recommendations for promoting neuropsychiatric research.
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Papers by Paul Malloy