Diagnostic values of polysomnography in forensic medicine.

A man accused of a first-degree murder of a two-year-old girl claimed that he had not been conscious during the time of the alleged murder. The possibility that he may have committed the crime while "sleepwalking" was raised. The forensic psychiatrist looked to the sleep disorders facility to conduct polysomnographic investigation of the accused in order to investigate the possibility that he had a parasomnia. Overnight sleep recordings with video surveillance carried out for two consecutive nights showed no evidence of parasomnia. On the basis of the full assessment, the final report of the forensic psychiatrist did not support a legal defense of non-insane automatism and "sleepwalking" was withdrawn as a possible defense by the lawyer of the accused.

Manic-depressive and pure manic states after brain lesions.

Although mania is a rare complication of brain lesions, recent reports have emphasized the importance of lesion location and genetic predisposition in these patients. In the present study we compared patients who developed a bipolar affective disorder (i.e., mania and depression) after a brain lesion with patients who only developed mania. Although no significant between-group differences were found on demographic variables, the manic-depressed group showed significantly more impairments on the Mini Mental State Exam than the mania only group. All the bipolar patients had subcortical lesions (mainly right head of the caudate and right thalamus), while patients with unipolar mania had significantly higher frequency of cortical involvement (mainly right orbitofrontal and basotemporal cortices). It is suggested that subcortical and cortical right hemisphere lesions may produce different neurochemical and/or remote metabolic brain changes that may underlie the production of either a bipolar disease or a unipolar mania.

Anosognosia and major depression in 2 patients with cerebrovascular lesions.

We report 2 patients who developed a neglect syndrome, anosognosia, and major depression immediately after a right hemisphere cerebrovascular lesion. These cases demonstrate that neglect, anosognosia, and major depression may coexist in the same patient, and that the presence of anosognosia does not preclude the patient's recognition of emotional impairment.

Mania after brain injury: neuroradiological and metabolic findings.

We present a consecutive series of 8 patients who developed a manic episode after a brain injury. Five patients had cortical lesions (4 with damage to the right basotemporal region, and 1 with bilateral damage to the orbitofrontal area). While the other 3 patients had subcortical lesions (white matter of the right frontal lobe, right anterior limb of the internal capsule, and right head of the caudate), a fluorodeoxyglucose positron emission tomography scan showed hypometabolism in the right lateral basotemporal region in all 3 patients. These findings suggest a major role for the basal region of the right temporal lobe in the modulation of mood.

Relationship between anxiety disorders and depressive disorders in patients with cerebrovascular injury.

The interaction between anxiety disorder and major depressive disorder in patients with cerebrovascular lesions was examined in a controlled, 2 x 2 study design. A consecutive series of 24 patients who met criteria for major depression only were compared with 6 patients who met criteria for both major depression and generalized anxiety disorder, and 45 patients who did not meet criteria for either major depression of generalized anxiety. Among patients with positive computed tomographic scans, the anxious-depressed group (n = 19) showed a significantly higher frequency of cortical lesions, while patients with major depression only (n = 15) had a significantly higher frequency of subcortical (basal ganglia) strokes. No significant between-group differences were found in other variables, such as demographic variables, familial and personal history of psychiatric disorders, and neurologic deficits. These findings suggest that, in this mostly black, low-socioeconomic-status population, cortical vs subcortical lesion location may play an important role in determining whether severe anxiety occurs in patients with post-stroke major depression.