Facial emotion discrimination: II. Behavioral findings in depression.

The facial discrimination tasks described in part I (Erwin et al., 1992) were administered to a sample of 14 patients with depression and 14 normal controls matched for sex (12 women, 2 men) and balanced for age and sociodemographic characteristics. Patients performed more poorly on measures of sensitivity for happy discrimination and specificity for sad discrimination, and had a higher negative bias across tasks. Severity of negative affect was correlated with poorer performance for patients. The results suggest that depression is associated with an impaired ability to recognize facial displays of emotion.

An interdisciplinary perspective on the agitated brain injured patient.

The Special Interest Group on Brain Injury of the American Academy of Physical Medicine and Rehabilitation is developing a practice parameter for the agitated patient following traumatic brain injury (TBI). The eventual goal of the project is to create an interdisciplinary practice guideline for classifying and treating these patients using a common nosology, based on contributions from the literatures of neurosurgery, psychology, psychiatry and rehabilitation medicine. It is envisioned that a uniform classification system would ultimately promote interdisciplinary research and serve to advance our understanding and treatment of this patient population. In the acute post-injury period, many TBI patients can be characterized by confusion, agitation, post-traumatic amnesia and delirium. In various acute care settings, psychiatrists, psychologists or rehabilitation medicine physicians (physiatrists) are asked to evaluate and treat this population of patients. Each of these disciplines employ specialty-based diagnostic criteria and rating instruments, with little or no consensus across disciplines concerning the appropriateness of these tools. This article reviews the classification and rating systems utilized within the fields of neurosurgery, rehabilitation medicine, psychology and psychiatry, to describe patients displaying agitated behaviors. The authors review the literature establishing the definitions, measurement and possible neuroanatomic and neurophysiologic substrate for delirium and brain-injury agitation, with its characteristic cognitive and behavioral manifestations. Pharmacologic treatment is briefly reviewed to emphasize the significantly different viewpoints from the fields of rehabilitation medicine and psychiatry. The authors explore support from the literature for an interdisciplinary definition for agitation following TBI which includes criteria for delirium, post-traumatic amnesia, and associated behavioral excesses such as disinhibition, aggression, or emotional lability. Wide acceptance of this definition by medical and research professionals may potentially lead to a greater understanding of this clinical state and its neuropathogenesis through promotion of intra- and inter-disciplinary research.

Transient postictal psychosis associated with a course of ECT.

Postictal psychoses, defined as episodic, time-limited psychiatric disturbances of diverse phenomenology, temporally related to a seizure or cluster of seizures, have been well described in patients with focal and generalized epilepsies. Although similar disturbances have been reported in patients undergoing electroconvulsive therapy (ECT), the syndrome of ECT-associated postictal psychosis has not been well described. We review the literature defining the syndrome of postictal psychosis (PIP) associated with the epilepsies, as well as reports of confusional and manic disturbances meeting accepted criteria for PIP, which have been reported to occur as complications of ECT. In addition, we report a case of delusional and hallucinatory psychosis associated with a course of ECT, also having the characteristics of a PIP. We conclude that time-limited psychiatric disturbances, phenomenologically (and possibly pathophysiologically) similar to the PIP of epilepsy can occasionally occur as complications of ECT, and that they may have confusional, manic, delusional, or hallucinatory symptoms. The implications of these occurrences for the use and continuation of ECT are discussed.

ECT in the treatment of patients with neurological and somatic disease.

OBJECTIVE: An evaluation of the safety and efficacy of electroconvulsive therapy (ECT), for the treatment of patients with severe medical and neurological illness, was undertaken. METHOD: The English-language literature reporting the use of ECT in patients with neurological and somatic disease was reviewed. This review included reports describing ECT used for the treatment of affective disturbances and catatonia in patients with concurrent neurological or somatic disease, as well as reports dealing with the efficacy of ECT for the treatment of certain neurological conditions for which it has been reported to have some benefit independent of its psychiatric effect. CONCLUSIONS: ECT is safe and effective for the treatment of affective and catatonic disorders in patients with most neurological and medical diseases, including elderly and debilitated patients with multiple illnesses, if the specific medical risks are carefully evaluated in each case, and appropriate modifications of technique are used to reduce the risk of potential complications. Apart from its use in psychiatry, ECT has been reported to have therapeutic effects in Parkinson's disease, neuroleptic malignant syndrome, aggressive behavioral disorders following brain injury, certain forms of epilepsy, and some forms of delirium due to toxic or metabolic encephalopathies. The potential for ECT to play an active role in the clinical management of patients with these disorders, many of whom are presently refractory to maximal medical treatment, should be evaluated by systematic studies.

The expression of bipolar affective disorders in brain injured patients.

OBJECTIVE: A prospective study was designed to investigate the varied presentations of major affective disorders in patients with organic brain disease. METHOD: Patients admitted to our neuropsychiatry service, with affective and behavioral disturbances, and known neurological disorders, were classified, on phenomenological grounds, into the following groups: 1) elated mania; 2) irritable mania; 3) affective lability with periods of irritability, but without other symptoms pathognomonic for mania; and 4) intermittent psychosis with absent or ambiguous mood changes. RESULTS: A majority of patients in all four groups responded to pharmacotherapy with anti-cycling agents. CONCLUSIONS: It is proposed that these groups represent different expressions of mania in brain injured persons, and that these expressions range through a spectrum of phenomenology, included elated mania, irritable mania, episodic psychosis and explosive organic personality disorder. The DSM-III-R classification of these disorders, and approaches to their clinical management, are discussed.

Ultra-rapid cycling bipolar affective disorder following a closed-head injury.

A young adult with no prior history of affective disease suffered the onset of a rapid cycling bipolar illness, marginally responsive to psychotropic medications, following a mild closed-head injury, and persisting after the cognitive effects of the injury had resolved. A concurrence of findings on the neurological examination, neurobehavioural examination, SPECT scan, EEG and neuropsychological test battery suggested the presence of a diffuse cerebral injury with a predominance of left frontotemporal findings. This case demonstrates that a severe and disabling mood disorder may follow a mild head injury, and that its course may be independent of cognitive impairment and recovery.

Psychiatric aspects of temporal lobe epilepsy before and after anterior temporal lobectomy.

OBJECTIVES: Psychopathology has been reported to be prevalent both before and after surgical treatment for medically intractable temporal lobe epilepsy. Individual patients were evaluated prospectively to assess the effect of anterior temporal lobectomy (ATL) on prevalence and severity of psychiatric disease. METHODS: Psychiatric status was assessed in a consecutive series of epilepsy patients before and 6 months after ATL using a structured psychiatric interview, psychiatric rating scales, and self report mood measures. RESULTS: A DSM-III-R axis I diagnosis was present in 65% of patients before and after surgery. The most common diagnoses were depression, anxiety, and organic mood/personality disorders. There was a trend for major psychiatric diagnoses to be more common in patients with right compared to left temporal lobe seizure focus, both before and after surgery. The apparent stability in the overall rate of psychiatric dysfunction concealed onset of new psychiatric problems in 31% of patients in the months shortly after surgery, and resolution of psychiatric diagnoses in 15% of patients. In the group as a whole, the severity of psychiatric symptoms was lower at 6 months postsurgery than before temporal lobectomy. CONCLUSIONS: The overall prevalence of psychiatric dysfunction was comparably high before and after ATL, but individual changes in psychiatric status and changes in severity of symptoms occurred in many patients in the 6 months after surgery.

Treatment of organic bipolar mood disorders in Parkinson's disease.

Two patients with long-standing idiopathic Parkinson's disease (PD), without individual or family histories of affective disorders, developed bipolar mood disorders. Both were treated with lithium and clozapine, and one responded favorably. These may be the first reported cases in which mania was treated with clozapine in PD patients.