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Insight is any sudden comprehension, realization, or problem solution that involves a reorganization of the elements of a person’s mental representation of a stimulus, situation, or event to yield a nonobvious or nondominant interpretation. Insight is sudden, but it is preceded by substantial unconscious processing. In a clinical context, ‘insight’ refers to a conscious knowledge of health conditions and the capability to identify or judge the presence or severity of disease or symptoms. Altered insight cuts across different brain disorders including multiple forms of dementia, traumatic brain injury (TBI) and schizophrenia, among others. Reduced insight is commonly observed in Alzheimer's disease (AD) and is especially prominent in frontotemporal dementia (FTD). Altered insight into disease or specific symptoms is a important clinical feature of FTD. FTD is the second commonest cause of young onset dementia. Our understanding of FTD and its related syndromes has advanced significantly in recent years. In this presentation I will discuss insight in FTD and associated syndromes. The neurological basis of insight is an exciting new area of research with connections to fundamental cognitive processes.

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The term Vascular Cognitive Impairment (VCI) was introduced to emphasise the important contribution of vascular pathology to any severity of cognitive impairment, ranging from subjective cognitive decline and mild cognitive impairment (MCI) to dementia. Although vascular pathology and Alzheimer’s Disease (AD) is common in elderly individuals with and without cognitive impairment or dementia, pure vascular dementia (VaD) or AD is uncommon. Indeed, most patients with VaD or AD also have other types of pathology, the most common of which is a combination of AD and cerebrovascular disease (CeVD).

Several different VCI criteria have been proposed. The more recent VASCOG, DSM-5 and VICCCS criteria may have greater sensitivity, modest concurrent validity and better predictive validity than older criteria such as the NINDS-AIREN and DSM-4 criteria for VaD. Importantly, diagnoses for vascular MCI can now be made which may be useful for clinical and research purposes which include establishing cognitive trajectories, prognostic biomarkers and better understanding of the underlying mechanisms.

Vermiglio (2014) proposed several criteria for a clinical entity : 1) The clinical entity must possess an unambiguous definition; 2) It must represent a homogeneous patient group; 3) It must represent a perceived limitation for the patient and 4) It must facilitate diagnosis and intervention This presentation will discuss ways in which VCI fulfils these criteria.

Refining the concept of VCI enables a better understanding of pathophysiology and aids in treatment efforts which is currently mainly through prevention by treating vascular diseases and other risk factors until the advent of disease-modifying treatments.

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It was Landolt working in the Swiss Epilepsy Centre who first described the phenomenon of Forced Normalization in 1953. He observed that in patients with intractable epilepsy exposed to the then new drug, ethosuximide, the seizures became controlled, but there emerged a range of psychiatric symptoms. The EEG at this time was relatively or completely normal, leading Landolt to comment on the "paradoxical nature" of the relationship between seizures and behaviour. Tellenbach, described this phenomenon as "the alternative psychosis of epilepsy". Wolf in his extensive review described how Forced Normalization was reported with every anti-epileptic drug developed, the condition being reviewed extensively in the eponymous book edited by Trimble & Schmitz. Forced Normalization has been described in the last two decades with novel AEDs, levetiracetam, lacosamide; however, the risk of alternative psychosis and forced normalization seems to be particularly low with the new anticonvulsants oxcarbazepine, eslicarbazepine, gabapentin and pregabalin.

Despite many years of research, Forced Normalization remains a controversial entity in neuropsychiatry. Many case series and reports point to its presence as a phenomenon in clinical practice when a new AED is introduced in patient management and seizures cease. Yet, very little by way of prospective research or clinical trial attention as been paid to this condition, which indeed could help one distinguish, perhaps, strong from weak AEDs. In this talk we will examine the myth and reality of Forced Normalization in epilepsy, the contemporary relevance of the phenomenon in drug development and clinical practice, and indeed its future application.