Pharmacotherapy of disruptive behaviors associated with brain disease.

Disordered behavior resulting from central nervous system dysfunction is a common clinical problem for practitioners and for patients. Setting aside the problem of overtly aggressive, violent behavior, this article addresses the problem of disordered or disruptive behavior associated with neuropsychiatric conditions.

Bilateral sinusoidal ECT following poor response to five unilateral brief-pulse ECTs.

Of 31 depressed patients, 12 failed to respond to five unilateral brief-pulse ECTs. Eight of the 12 responded fully to bilateral sinusoidal ECT. In some patients, therapeutic outcome may be a function of the type of stimulus used.

Volitional disability and physician attitudes toward noncompliance.

We develop the concept of a volitional disability as an aid in understanding those patients who behave in ways that are harmful to themselves in spite of their desire to do otherwise. Using this concept enables us to describe their behavior as intentional but 'involuntary'. We demonstrate the clinical reality of such behavior by giving clinical examples of the behavior of those with phobic, compulsive, and addictive disorders. We then attempt to show how some kinds of self-harming behavior of noncompliant patients are similar to phobic and compulsive behavior. We propose use of the concept of volitional disability to make it easier for physicians to work with these noncompliant patients and thus to improve their ability to provide better care for them.

KIE: Noncompliant patients may elicit negative feelings in their physicians which interfere with good patient care. The authors identify a subclass of these patients whom they characterize as having a volitional disability. Such patients behave in ways that are harmful to themselves in spite of their desire to do otherwise; their behavior can thus be described as intentional but 'unvoluntary'. After developing the theoretical concept of volitional disability, the authors apply it to clinical examples of phobic, compulsive, and addictive disorders, as well as to some forms of noncompliant patient behavior.

Psychosocial and cognitive function after commissurotomy for intractable seizures.

Cerebral commissurotomy appears to be an effective treatment for persons with severe epilepsy that has not responded to pharmacological treatment. Psychosocial and neuropsychological evaluation of eight patients who have received this surgical treatment suggests that patients who have an uncomplicated operative and postoperative course do not experience functionally significant intellectual, emotional, or social impairment. Limiting the operation to extraventricular division of the corpus callosum may significantly reduce postoperative morbidity. The authors suggest ethical guidelines which they believe should be carefully followed when epileptic patients are being considered for this type of surgery.

ECT and special problems of informed consent.

The authors examine the question of whether severely depressed patients can validly consent to ECT, indeed whether anyone should be asked to consent to a treatment that some have held is disabling and beyond the range of rational choice. They suggest some clarification in the use of the terms "competent" and "rational." The authors present examples of cases where ECT may appropriately be used with and without a patient's consent. They conclude that except in cases in which patients may die without ECT, physicians will not err morally by respecting patients' informed decisions about treatment.

On the safety of long-term treatment with lithium.

Thirteen patients with bipolar affective illness who had received lithium therapy for 1-5 years were tested retrospectively for evidence of cortical dysfunction. Data on patients younger than 55 show no abnormalities on the Halstead-Reitan Neuropsychological Battery and suggest that chronic lithium therapy is relatively safe. Significantly elevated Halstead Impairment indexes were observed among elderly patients, but these data are difficult to interpret.

Multiple sclerosis--presenting as depressive illness.

A diagnostic dilemma exists when clinicians face patients with atypical recurrent symptoms involving both physical and psychologic elements. Multiple sclerosis (MS) represents such a dilemma. Few authors address themselves to the significance of depressive illness as the initial presentation in MS. Three patients hospitalized solely due to recurrent emotional disorders are described. Depressive symptoms predominated. In each case no precipitant for depression was identified, no previous neurologic diagnosis was entertained by clinician or patient, and multiple prior psychotherapeutic interventions were unsuccessful. The episodic nature of the symptoms and poor response to usually effective treatments created a high index of suspicion for central nervous system disease. A diagnosis of MS was made based on subtle neurologic signs, spinal fluid gamma globulin elevations, and abnormalities in neuropsychological testing. Treatment involved integrated psychiatric and medical measures.