A study of dementia in adults with Down's syndrome using 99Tc(m)-HMPAO SPET.

Twenty-six people with Down's syndrome (DS) were investigated using 99Tc(m)-hexamethylpropylene amine oxime (99Tc(m)-HMPAO) and single photon emission tomography (SPET). Dementia was diagnosed using a structured carer interview giving a deterioration score and by studying the case notes. Five subjects were clinically demented, 7 showed mild deterioration and 14 no deterioration. Increased deterioration correlated with advancing age (correlation coefficient 0.5425; P<0.02), but there was no significant difference between older (>40 years) and younger (<40 years) patients. Only one of the subjects with dementia had a regional cerebral blood flow (rCBF) abnormality that was of the dementia of Alzheimer type. Three subjects with mild deterioration and three with no deterioration had abnormal SPET scans. There was no association between the SPET abnormality and clinical dementia or with evidence of deterioration.

Positron emission tomography in male violent offenders with schizophrenia.

The FDG PET brain scans from 31 offenders with schizophrenia and schizoaffective disorder from a maximum security mental hospital were compared with those of normal controls (N = 6) in terms of relative FDG uptake in a range of regions covering frontal and temporal regions. The patient sample was divided into those who had a history of repetitive violent offending (RVO, N = 17) and those without a repetitive violent history (NRVO, N = 14) according to the violence rating of their pre-admission convictions. Reduced FDG uptake was noted at both the right and left anterior inferior temporal (R and L AIT) regions in NRVOs but only at LAIT in RVOs. NRVOs had significantly lower FDG uptake at RAIT than RVOs. The findings suggest that metabolic changes at AIT may be related to different patterns of violent offending in patients with schizophrenia.

Psychosis de novo following temporal lobectomy.

A case report of a 61 year-old male with a long history of complex partial seizures is presented. Multiple psychotic symptomatology developed post-operatively. It is argued that these reflect continuing right temporal epileptogenic activity.

The postconcussional syndrome reappraised.

Despite the apparently benign nature of mild head injury, reflected by the short post-traumatic amnesia duration, relative absence of CNS signs and brief hospital stay, a significant number of patients report persistent symptomatology over the weeks or months afterwards. Largely subjective in nature, such symptom clusters are termed the postconcussion syndrome. The discrepancy between the predominantly subjective complaints and negative examination findings has generated uncertainty and debate about the respective causation roles of organic and psychogenic factors. Over the past 30 years evidence for organic brain changes has accumulated through studies of cerebral circulation, neuropsychological deficits, evoked potential recordings and neuroimaging. This paper reviews data from two UK prospective studies of the evolution and course of postconcussional symptomatology using parallel psychosocial, neuropsychiatric, quantitative EEG and brainstem auditory evoked potential recordings. Changes in theta power occurred early with resolution within 10 days. Prolonged brainstem evoked response I-V intervals were seen in between 27% and 46% of patients. Symptom chronicity noted in a minority of people (13%) was associated with a high prevalence of brainstem dysfunction, while the degree of QEEG recovery appeared to relate to the intensity of early symptom reaction to the trauma. Levels of perceived stress at the time of the injury or afterwards were not related to symptom formation, but chronic social difficulties were a feature of the 21% of patients who initially improved but had a late exacerbation of symptoms between 6 weeks and 6 months after the trauma.

The post-concussional state: neurophysiological aspects.

BACKGROUND: Twenty-six young men admitted to an Accident and Emergency Department for observation following a minor closed head injury (post-traumatic amnesia (PTA) less than 12 hours) were investigated within 24 hours of admission (day 0) and followed up at 10 days, 6 weeks and 1 year after the trauma. METHOD: Investigations at day 0 included physical examination, completion of post-concussional symptom and stress-arousal checklists, computerised EEG (CEEG) and auditory brainstem evoked potential (BAEP) recordings. These were repeated at ten days and six weeks. At 12 months follow-up, the Present State Examination (PSE) was carried out and a further post-concussional symptom checklist completed. RESULTS: Post-concussional symptomatology declined progressively from day 0 but half had residual symptoms at 1 year. Seventy-two per cent ran an acute course with recovery by 6 weeks, 8% chronic unremitting course and 20% initially improved but had an exacerbation of symptoms between 6 weeks and 12 months. The CEEG alpha-theta ratios decreased significantly between days 0 and 10, reaching a baseline thereafter. Measures of CEEG recovery from all channels correlated with symptom counts at six weeks; the slower the recovery the greater the symptoms. A relative delay in left temporal recovery was associated with residual psychiatric morbidity (PSE ID scores) at 12 months. Prolonged central brainstem conduction times occurred in 27% of patients at day 0. These correlated positively with PTA and degree of psychiatric morbidity (PSE ID scores) at 12 months. CONCLUSIONS: Symptom chronicity was accompanied by continuing brainstem dysfunction, while the degree of transient cortical dysfunction appeared to have a direct influence in the intensity of early organic symptom reaction to the trauma. Levels of perceived stress at the time of the injury, or afterwards, were not related to symptom formation.

Electroencephalography and single photon emission computed tomography in dementia: a comparative study.

A series of elderly patients with dementia of Alzheimer type (AD), multi-infarct dementia (MID) and functional (non-organic) psychiatric illness (major depressive disorder) were selected according to DSM-III-R criteria and received: a battery of cognitive tests, EEG and Single Photon Emission Computed Tomography (SPECT) using 99mTc HMPAO. The EEG and SPECT scans were examined independently of the clinical data. The former were divided into two abnormal categories, those showing AD type change and vascular change respectively, and a normal group. The SPECT scans were classified as follows: a SPECT rCBF pattern showing bilateral temporoparietal perfusion deficits (AD type); those showing single focal perfusion deficits or multiple areas of low perfusion in the cerebral cortex suggestive of ischaemic change (vascular type SPECT picture); a mixed AD/MID pattern; and those with normal scan findings. There were significant associations between clinical diagnosis, EEG rating and SPECT rCBF pattern, approximately three-quarters of AD and MID patients having the predicted EEG and scan changes. Normal EEG recordings were more common in the MID patients. The two tests agreed in about two-thirds of cases, with no consistent pattern apparent in the cases with divergent findings. Each test misclassified a minority of dementia patients, but in only one patient were both investigations normal. Almost half of the so called 'functionally ill' patients had abnormal rCBF changes, showing mainly vascular changes while one-fifth had abnormal EEGs.

Activation sequence of discrete brain areas during cognitive processes: results from magnetic field tomography.

Magnetic field tomography is a technique for extracting 3-dimensional estimates of current density in the brain, from non-contact, non-invasive measurements of the magnetic field generated by the brain. It allows visualisation of both cortical and subcortical focal activation patterns at millisecond intervals, and the relative time difference between active cortical areas. We have used this technique to study the activation history of discrete brain regions associated with the preparation for, initiation and inhibition of movement, and movement itself in a CNV paradigm. The strongest focal activities are found within well defined cortical regions, namely the auditory (A1), sensorimotor (SM1), medial parietal area (MPA) and anterior supplementary motor area (SMA). For the movement condition, activation history differs for the warning stimulus and the stimulus initiating movement.

Cognitive therapy, analytic psychotherapy and anxiety management training for generalised anxiety disorder.

BACKGROUND: We test the hypotheses that (a) cognitive therapy is of comparable efficacy to psychodynamic psychotherapy, (b) 8-10 sessions of therapy is as effective as 16-20 sessions, and (c) brief therapist training is as effective as intensive training. METHOD: Of 178 out-patients referred to a clinical trial of psychological treatment for generalised anxiety, 110 patients met DSM-III-R criteria for generalised anxiety disorder and were randomly assigned to three different forms of psychotherapy. The main comparison was between cognitive therapy and analytic psychotherapy, delivered by experienced therapists at weekly or fortnightly intervals over six months. A third treatment, anxiety management training, was delivered at fortnightly intervals by registrars in psychiatry after a brief period of training. Eighty patients completed treatment and were assessed before treatment, after treatment, and at six-month follow-up. RESULTS: Cognitive therapy was significantly more effective than analytic psychotherapy, with about 50% of patients considerably better at follow-up. Analytic psychotherapy gave significant improvement but to a lesser degree than cognitive therapy. There was no significant effect for level of contact. Patients receiving anxiety management training showed similar improvements to cognitive therapy after treatment, with rather lower proportions showing clinically significant change. CONCLUSIONS: Cognitive therapy is likely to be more effective than psychodynamic psychotherapy with chronically anxious patients. Significant improvements in symptoms can be achieved by trainee psychiatrists after only brief instruction in behaviourally based anxiety management. However, the superiority of cognitive therapy at follow-up suggests that the greater investment of resources required for this approach is likely to pay off in terms of more sustained improvement. There is no evidence that 16-20 sessions of treatment is more effective, on average, than 8-10 sessions.

Neuroleptic medication for dystonia. Reciprocal relationship between effects on motor function and mood.

BACKGROUND: The presence of dysphoric symptoms associated with neuroleptic medication is commonly reported. METHOD: Neuroleptic treatment of a segmental dystonia resulted in a disabling depressive illness, which when treated with antidepressants led to the return of the involuntary movements. RESULTS: The use of several different antidepressants and neuroleptics confirmed the association between drugs and symptoms. Genetic studies excluded "poor metaboliser status" as a reason for the patient's sensitivity to these drugs. CONCLUSIONS: The case illustrates a delicate imbalance between dose of neuroleptic medication and depressive symptoms. We should be aware of the possibility of mood changes in patients treated with neuroleptics for a variety of conditions.

Neurophysiology and SPECT cerebral blood flow patterns in dementia.

A series of elderly patients with dementia of Alzheimer type (AD), multi-infarct dementia (MID) and functional (non-organic) psychiatric illness (major depressive disorder) were selected by DSM III-R criteria and had the following investigations: a battery of cognitive tests, EEG with power and coherence spectral analyses of T4-T6, T3-T5, P4-O2, P3-O1 channels, visual evoked potential (flash and pattern reversal) and P300 recordings as well as single photon emission tomography (SPECT) using 99mTc HMPAO. Three subsets of patients were chosen on clinical and SPECT criteria. These were as follows: patients with a clinical diagnosis of AD and a SPECT rCBF pattern showing bilateral temporo-parietal perfusion deficits (AD type), patients with a clinical diagnosis of MID and a SPECT rCBF pattern showing single focal perfusion deficits or multiple areas of low perfusion in the cerebral cortex suggestive of ischaemic change (MID type SPECT picture) and functionally ill patients with normal rCBF (controls). The AD type group differed from the MID rCBF group in having significantly less alpha and more delta 2 (2- < 4 Hz) power. The latter had significantly lower alpha power than the controls. The 2 dementia groups with abnormal rCBF patterns did not differ in terms of coherence spectra or P300 latencies, but both had lower within and between hemisphere alpha coherence values and longer P300 latencies than the "controls" with normal rCBF. There were no group differences in the flash VEP P2-pattern reversal P100 latency difference values.

Electroencephalography, computed tomography and violence ratings of male patients in a maximum-security mental hospital.

A retrospective study of brain investigations of 372 male patients in a maximum-security mental hospital patients is described. All computed tomography (CT) scan and electroencephalography (EEG) reports were collected and rated blind; patients were subsequently divided into 3 groups according to the violence rating of their pre-admission offending behaviour. The 3 groups were similar in their mean age, psychiatric diagnosis, Wechsler Adult Intelligence Scale score and proportions of patients investigated with EEG and CT. In the most violent group, 20% had focal temporal electrical abnormalities on EEG (slowing and/or sharp waves) and 41% had structural abnormalities localised to temporal lobe on CT (dilated temporal horn and/or reduced size of temporal lobe). The corresponding figures for the least violent group are 2.4% and 6.7% respectively. These results suggest that high violence rating scores are associated with temporal lobe abnormalities on CT and abnormal temporal electrical discharges on EEG.

Petechial haemorrhage following a partial seizure with secondary generalization: atypical presentation and differential diagnosis.

A case is reported of a patient who had a respiratory arrest on a high dependency ward in a High Security Hospital with an unusual presentation. The patient had head and upper abdominal petechial haemorrhages with extensive conjunctival haemorrhaging. A considered antecedent for this potentially life-threatening presentation was strangulation. Analysis of all the available clinical information supports the hypothesis that he had a single tonic-clonic seizure with a focal-motor onset. This constitutes an unusual consequence of a partial seizure with secondary generalization.

Clinical electroencephalography in a psychiatric service.

An audit of the use of clinical electroencephalography in a psychiatric service was carried out by examining the referrals for an EEG from the service over one year (11% of all referrals), comparing them with matched patient controls, rating the EEGs blindly and estimating the clinical value of the investigation for each patient; 37% were abnormal, 19% anomalous and 44% normal. The following two clusters of symptoms and signs were associated with EEG referral--the patients with "organic" mental state phenomena and/or CNS signs; EEG usually abnormal and the patients with behavioural changes that raise the suspicion of an organic process but, taken alone, are not compelling evidence of such (for example, impulsive behaviour, acute and atypical psychoses, perceptual or behavioural phenomena of the type associated with temporal lobe epilepsy in the absence of frank complex partial seizures); EEG usually normal or anomalous. Ninety-two percent of EEGs were judged to be of clinical value; 53% positive and 39% negative. Eight percent of referrals made no contribution to the clinical evaluation.

EEG power spectra and cognitive change in geriatric psychiatry: a longitudinal study.

Elderly patients with senile dementia of the Alzheimer type (SDAT), multi-infarct dementia (MID) and functional psychiatric illness, along with elderly control subjects, were studied longitudinally at 6 monthly intervals over a 2 year period, with cognitive testing and EEG power spectral analyses being carried out on each occasion. There was no significant change in the EEG power over time although a significant regression effect was noted for cognitive performance in the SDAT group. A number of between-group differences were apparent. The SDAT patients had more delta and theta power and less alpha power than those with MID and the latter group had a higher percentage of delta and theta power than the functional patients. The functional patients and normal subjects were differentiated from each other by a number of EEG power variables. The implications of these findings with respect to differential diagnosis in geriatric psychiatry are discussed.

Estimates of brain activity using magnetic field tomography in a GO/NOGO avoidance paradigm.

This paper presents the first estimates of three dimensional evolution of activity in the brain associated with a GO/NOGO avoidance (CNV) paradigm. These estimates are continuous probabilistic solutions (Ioannides et al. 1990) to the biomagnetic inverse problem, obtained from averaged multichannel magnetoencephalographic (MEG) recordings (Vieth et al. 1991). The emphasis here is placed on the comparison of the activity associated with the GO and NOGO conditions; estimates of activity are shown for the onset of warning stimulus (S1), the early response half a second after S1, the late response lasting for over one second before S2 (the time between S1 and S2 is 3.5 seconds) and the onset of the imperative stimulus (S2). We find responses in regions of the brain implicated with hearing the stimulus, task engagement and motor output. Differences in the images corresponding to GO and NOGO conditions are significant because they reflect differences in brain function when a motor response is required or must be inhibited.

Epileptic seizures in elderly patients with dementia.

All inpatients aged greater than 55 years with dementia in the Dundee Psychiatric Service were surveyed for seizure occurrence by interviewing staff and reviewing records. Of 208 patients, 19 (9.1%) were recorded as having seizures. The seizures were major in 92% and occurred at a rate of approximately 2.3 seizures per patient per year. Patients with epilepsy were significantly younger than a control group of dementia inpatients and were significantly more cognitively impaired on the survey Clifton Assessment Procedure for the Elderly (CAPE), but not on the Mini Mental State Examination. Of 111 reported accidents, only 5 appeared to be associated with epilepsy. Although epileptic seizures are relatively common in patients with severe dementia, they rarely caused severe problems.