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B. Yugul, M.A., Ph.D.

Associate Professor, The Brody School of Medicine at East Carolina University

While depression is associated with apathy and a tendency to exert insufficient effort as demands increase, manic patients have difficulty in performing effortful tasks as well because of a tendency to respond impulsively and break from response set. Schizophrenia also affects focused attention and performance in effortful tasks (Nuechterlein, Garmezy, Devine, Schulz, & Tamminga, 1989). Damage to frontal and subcortical brain systems tends to affect effortful processing (Cohen, 1993). Following cingulotomy, patients usually show preserved intellectual functioning, yet have reduced capacity for behavioral initiation and spontaneity, seeming more apathetic particularly when the situation is challenging. Similarly, patients with frontal lobe disturbances usually have considerable difficulty as effortful demands increase. In disorders such as multiple sclerosis, problems with attentional effort may correspond with the subjective experience of fatigue, a very common symptom in this neurological disease. Disturbed attentional effort resulting from psychiatric or neurological brain disorders is not volitional, as the patient is not trying to purposely reduce effort for some gain. However, clinical neuropsychologists are often confronted with questions regarding the degree to which certain patients are exerting adequate effort. The concern is that a particular patient may not be motivated to perform well on a task because of some incentive associated with having a cognitive impairment. It is important to distinguish failure to exert effort because of situational incentive from attention impairments on tasks with effortful demands. Often patients who are malingering and not exerting sufficient effort actually fail on tasks with little effortful demand, particularly when the task is assessing a cognitive function that they believe should be impaired. Cross References Attention Automaticity Capacity Fatigue Focused Attention Malingering Sustained Attention E References and Readings Byrne, D. Dissociable executive functions in the dynamic control of behavior: Inhibition, error detection, and correction. The vigilance decrement reflects limitations in effortful attention, not mindlessness. Processing demands, effort, and individual differences in four different vigilance tasks. Co-ordination within and between verbal and visuospatial working memory: Network modulation and anterior frontal recruitment. Future Directions There is now considerable experimental data on factors that influence attentional effort and also disturbances of effortful processing associated with various clinical disorders. However, to date neuropsychological methods have not fully integrated methods for assessing performance in the context of effortful attentional demands systematically in most clinical test batteries. There is also a need for further research on the relationship between the subjective experience of effort and fatigue and objective performance measures of controlled attentional processing. There is thought to be an implicit relationship between controlled processing and these subjective experiences, though they do not necessarily correspond in an exact way for all task or clinical disorders. The characteristics of reduced effort associated with malingering and intentionality has received considerable forensic neuropsychology consideration, but has not been adequately examined relative to the broader existing literature on attention and effort. The issue of dissociating conscious intention and volitional reductions in effort from those related to psychiatric and neurological status remains a major challenge. Functional brain imaging methods will undoubtedly continue to shed light on how the brain is responding under different conditions of effortful attentional demands and 932 E Effort Testing Lawrence, N. Sustained, focused attention under high processing loads: Relevance to vulnerability to schizophrenia. Historical Background Records of electricity-related injuries related to natural phenomena date back to the beginning of recorded history in cultures across the globe. Injury sustained from manmade electrical power is understandably a more recent occurrence, as generated electricity is a relatively modern development. An appreciation of the safety risks of electrical power grew as the technology to harness and apply electricity for commercial and residential use became more common in the middle of the nineteenth century. In 1879, the first fatality attributed to exposure to electrical current was recorded. In 1881, after observing an accidental electrocution, Alfred Southwick developed the electric chair and championed its use as a method of capital punishment. Widespread attention was called to the potential lethality of electricity when Thomas Edison publicly vilified the use of the electric chair in an unsuccessful attempt to sway public opinion away from the use of alternating current in households and businesses and toward his system of direct current. The direct and Electrical Brain Injury E 933 indirect costs to employers are substantial, estimated to be over $15 million per injury. In 2003, an estimated 160 electrocutions related to consumer products were reported.

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Asymptomatic cysts without mass effect may have a lower risk of bleeding if treated (Wilkinson & Winston, 2008; Parsch et al. Currently, treatment in patients with severe developmental delay does not appear to confer a significant functional improvement (Arai et al. These include shunt insertion, open exploration, or endoscopic fenestration (Lena et al. Cyst fenestration consists of opening a window in both the superficial and deep walls of the cyst to allow communication between the cyst and the subarachnoid space. Both microsurgical and endoscopic approaches demonstrate improvement in up to 90% of patients (Karabatsou et al. Endoscopic fenestration is less invasive, and series suggest reduced morbidity (Karabatsou et al. Treatment of an associated subdural hemorrhage or hygroma may lead to resolution of the arachnoid cyst (Parsch et al. Arachnoid cysts of the middle cranial fossa: Experience with 77 patients who were treated with cystoperitoneal shunting. Reports of medical cases selected with a view of illustrating the symptoms and cure of diseases by a reference to morbid anatomy. Endoscopic observation of a slitvalve mechanism in a suprasellar prepontine arachnoid cyst: Case report. Endoscopic treatment of middle fossa arachnoid cysts: a series of forty patients treated in two centres. Asymptomatic massive subdural hematoma in a patient with bitemporal agenesis and bilateral temporal arachnoid cysts. A 245 long been used in labor, construction, and securities regulation, but is gaining popularity in other disputes. A Cross References Mediation References and Readings the Federal Arbitration Act 9 U. This language loop is located in the left hemisphere in approximately 90% of the population. Lesions disrupting the arcuate fasciculus result in conduction aphasia, which is characterized by paraphasic errors in which incorrect words or sounds are substituted and word repetition is impaired, although these individuals generally show reasonably normal speech and comprehension. It is sometimes preferred as a means of settling a matter in order to avoid the expense, delay, and acrimony of litigation. The arbitrator(s) are selected directly by the parties or are chosen in accordance with the terms of the contract in which the parties have agreed to use a court-ordered arbitrator(s) or an arbitrator(s) from the American Arbitration Association. If there is no contract, usually each party chooses an arbitrator and the two arbitrators select a third to comprise the panel. Arbitration has Cross References Superior Longitudinal Fasciculus References and Readings LaPointe, L. Synonyms Numerical reasoning; Quantitative reasoning Arousal A 247 Definition Mathematical reasoning is the mathematical methodology of axiomatic reasoning, logical deduction, and formal inference. A Current Knowledge Research in evolutionary genetics and neuroscience suggests important neurological differences between mathematical capacities that are evolutionary primitive. Empirical data demonstrate that mathematical reasoning and language are functionally and neuroanatomically independent, suggesting (a) there is a common and domain-general syntactic mechanism that underpins both language and mathematics, but that mathematical expressions can gain direct access to this system without translation into a language format, and (b) autonomous, domain-specific syntactic mechanisms exist for language and mathematics (Varley, Klessinger, & Romanowski, Siegal, 2005). Studies on sex differences provide evidence that math reasoning develops from a set of biologically based cognitive capacities that males and females share (Spelke, 2005). Highly selected male and female students show equal abilities to learn mathematics. However, other studies found male advantage in arithmetical reasoning mediated by male advantages in both computational fluency and spatial cognition. From a neuropsychological perspective, arousal refers to the tonic state of cortical activity elicited by subcortical reticular formation that results in increased wakefulness, alertness, muscle tone, and autonomic response.

Axonal damage and loss are thought to produce some of the symptoms of multiple sclerosis, especially in myelin-rich fibers such as the optic nerve. Cross References Multiple Sclerosis Myelin Neuron Dentate Gyrus D 815 References and Readings Compston, A. Denial can be adaptive or maladaptive, depending upon the context and extent to which it is used. In neurological impairments, denial of disability is contrasted with anosognosia and unawareness. Simplified conceptualizations view denial as a psychological process that occurs independently of cognitive impairment, while anosognosia is viewed as a problem of insight that is neurologically and cognitively mediated. More comprehensive conceptualizations consider both denial and impaired selfawareness as ``continuous variables which may interact in a given individual' following brain damage (Prigatano & Klonoff, 1998). One scale used to tease apart and describe the constructs of denial of disability and impaired self-awareness is described by Prigatano and Klonoff (1998). Neural progenitor cells of the subgranular layer enable neurogenesis, a perpetual process believed to support learning and memory, be enhanced by exercise and negatively influenced by stress, depression, and aging. Cross References Hippocampus Cross References Anosognosia Anosodiaphoria Coping Insight, Effects on Rehabilitation References and Readings Scharfman, H. The dentate gyrus: A comprehensive guide to structure, function, and clinical implications: Vol. A gene may also include regulatory elements that determine when expression occurs. Human somatic cells contain 23 pairs of homologous chromosomes and one pair of sex chromosomes. Application in Neuropsychology Twin and adoption studies indicate that most psychiatric disorders, such as schizophrenia and bipolar disorder (Bestelmeyer, Phillips, Crombie, Benson, & St Clair, 2009) are heritable. Neuropsychiatric genetics attempts to understand individual differences in disorder risk by examining differences in genetic risk factors. The ultimate goal of these studies is the development of new drugs to treat the genetic basis of a disorder. For instance, using high-angular resolution diffusion imaging on a sample of young adult twins, Chiang et al. A future goal of the project is to identify genes involved in the myelination of brain circuits in order to preclude diseases such as multiple sclerosis. Gene expression profiling using high throughput methods is an affordable method used to correlate the expression of genes in specific brain regions with specific disorders. For example, microarray studies of bipolar disorder have implicated several genes. The P300 as a possible endophenotype for schizophrenia and bipolar disorder: Evidence from twin and patient studies. Such opinions are scrutinized by the opposing counsel and by the trier of fact. During a deposition, both attorneys and a court recorder are present, but no judge or jury is in attendance. Everything asked and answered during the deposition is transcribed by a court reporter. There are essentially two types of depositions: discovery deposition and trial deposition. A trial deposition and live trial testimony consist of two parts: direct examination and cross-examination. For further details on direct and crossexaminations please see each respective entry. Individuals with depressed skull fracture may develop raccoon eyes, or a battle sign that tips the clinician off about the presence of a skull fracture. Individuals with depressed skull fracture are at the increased risk of developing brain infection, as the brain tissue may be directly exposed to the outside environment.

Diseases

• Phosphoglucomutase deficiency type 1
• Rozin Hertz Goodman syndrome
• Hyperlipoproteinemia type V
• 3-hydroxyacyl-coa dehydrogenase deficiency
• Schereshevskij Turner
• Vitamin D resistant rickets
• Camfak syndrome

In other etiologies such as cerebrovascular disease, they often occur acutely and persist for many months or years. For example, Santiago, Stoker, Beigel, Yost, and Spencer (1987) reported resolution of Capgras following treatment of underlying thyroid disease. Spontaneous resolution of Capgras delusions has also been reported (Ruff & Volpe, 1981). On the other hand, Joseph (1987) described a patient whose chronic psychosis and intermittent psychotic misidentification of the Capgras and intermetamorphosis types were refractory to neuroleptic treatment. Upon administration of a trial of clorazepate, complete remission of psychotic symptoms was achieved for the first time in 19 years, but these recurred when the patient discontinued her clorazepate. The effectiveness of psychological interventions may vary with the type of delusion, and the degree to which neurologic factors are involved. Unfortunately, there has been no systematic treatment follow-up research, and data are limited to uncontrolled case studies. Evaluation Careful clinical interview with both patient and family members will help to elicit evidence of Capgras delusions. In the course of family disputes and initial evaluations, patients may learn to minimize or deny their delusions. The literature is replete with case reports positing a psychodynamic explanation for Capgras, but with no workup to rule out neurologic etiology. Since Capgras is commonly associated with neurologic illness; full workup including neuroimaging and neuropsychological testing is essential. Neuropsychological testing often reveals deficits in frontal/executive and visuospatial functions (Malloy & Richardson, 1994). Delusional misidentification and the role of the right hemisphere in the appreciation of identity. Delusional misidentification of the Capgras and intermetamorphosis types responding to clorazepate. Environmental reduplication associated with right frontal and parietal lobe injury. C 487 Brand Name Tegretol, Carbatrol Class Anticonvulsant C Proposed Mechanism(s) of Action Carbamazepine is a use-dependent blocker of voltagesensitive sodium channels, it interacts with the open channel conformation of voltage-sensitive sodium channels, it interacts at alpha pore-forming subunit of voltage-sensitive sodium channels, and inhibits release of glutamate. Off Label Use Glossopharyngeal neuralgia, bipolar disorder, psychosis, schizophrenia, and personality disorders. Generic Name Carbamazepine 488 C Carbon Monoxide Poisoning Additional Information Drug Interaction Effects. With increased awareness of its potential dangers, the majority of these exposures can be prevented. Natural History, Prognostic Factors, Outcomes Compared to normal oxyhemoglobin. Acute exposure to lower concentrations of carbon monoxide will result in a slowly developing hypoxia that triggers peripheral vasodilation. Paradoxically, when there is a slow increase in carboxyhemoglobin saturation, compensatory changes in respiratory rate may lag. Thus, the symptoms of dizziness, weakness, headache, and nausea will precede fainting. Once unconscious, increased respiration and tachycardia will be followed by convulsions and coma, and death will ensue as the carboxyhemoglobin climbs and remains above 50% saturation. Chronic exposure to low concentrations of carbon monoxide can occur in heavy smokers as well as in individuals whose occupations involve protracted exposure to exhaust fumes. The binding of carbon monoxide to hemoglobin is fully dissociable though these individuals may manifest carboxyhemoglobin saturation at 10%, which is 20-fold higher than normal. Symptoms associated with chronic exposure include headache, fatigue, nausea, difficulty in concentrating, and impaired memory (Kao & Nanagas, 2005). When inhaled into the lungs, it readily competes with oxygen for binding sites on hemoglobin.