Neuropsychological and neurophysiological evaluation of cognitive deficits related to the severity of traumatic brain injury.

OBJECTIVES: Cognitive impairment is a common permanent sequela of traumatic brain injury (TBI). Its objectivization is based on neuropsychological and neurophysiological assessment. Neuropsychological evaluation requires a test battery, whereas for neurophysiological assessment the most significant is application of P300 Event-Related Potentials (ERPs). The aim of the study was to determine whether it is possible to differentiate between degrees of severity of TBI on the basis of neuropsychological and neurophysiological parameters. PATIENTS AND METHODS: A total of 90 patients with closed TBI were evaluated at least one year after trauma. Subjects were classified into three groups according to severity of TBI: mild, moderate and severe. In all subjects the Intelligence Test, the Wisconsin Card Sorting Test (WCST) and P300 ERPs were performed. RESULTS: General intelligence measures did not prove sensitivity enough to differentiate levels of severity of TBI, whereas the number of achieved categories on the WCST significantly discerned patients with mild and moderate TBI from patients with severe TBI. Perseverative errors significantly separated patients with mild TBI from patients with moderate and severe TBI. Non-perseverative errors significantly differentiated only patients with mild TBI from patients with severe TBI. Finally, P300 latency (EPLAT) significantly differentiated patients with mild TBI from patients with moderate and severe TBI. The results show that the applied test battery can discriminate between different levels of severity of TBI and emphasize the importance of P300 ERP in the evaluation of patients with brain injury. CONCLUSIONS: Our findings indicate that the WCST and ERP P300 latency have a significant role in the assessment of cognitive deficit related to TBI.

Forensic aspect of late subjective complaints after traumatic brain injury.

BACKGROUND: The subjective complaints in patients with TBI (Traumatic Brain Injury) may persist for years. The most frequent complaints are headache, dizziness, drowsiness, mood disturbances, and memory and concentration disturbances. It is assumed that these complaints are caused by injury itself on one hand and psychological, emotional and motivation factors on the other. AIM: Evaluation of late posttraumatic complaints in patients with TBI more than a year after the trauma, and establishing their correlations to the severity of TBI and involvement in the lawsuits for financial compensation (litigation). MATERIALS AND METHODS: Ninety patients with the diagnosis of TBI were divided, according to the severity of the injury, in two groups: mild and with moderate-to-severe. The second classification criterion was litigation. A subjective complaints scale has been designed for the purpose of this research taking into consideration both anamnesis and hetero-anamnesis data. RESULTS: Cognitive disturbance, aggressiveness and sleep disturbance are more frequently reported by the subgroup of moderate-to-severe TBI patients, and they have not been related to the litigation. Posttraumatic headache (PTH) turned out to be a distinctive complaint regarding both classification criteria. Vegetative disturbances are significantly related to litigation, but not to the degree of injury. CONCLUSIONS: Predictive complaints reflecting the severity of TBI are memory deficit, concentration problems, and aggressiveness and sleep disturbance. Vegetative disturbances are predictive in relation to compensation claims. PTH is important from the forensic point of view for the patients with moderate to severe TBI.

Role of sexual abuse in development of conversion disorder: case report.

Described case report speaks in favour of the relation between childhood sexual abuse with the development of conversion disorder. Following Salmonella poisoning, adolescent, at the age of 16, develops series of severe somatic symptoms. Results of diagnostic procedures excluded organic foundation of the symptoms; diagnosis of conversion disorder is established. Soon, patient's problems stop abruptly and spontaneously, and the aetiology of the mental disorder remains unexplained. Six years later, adolescent reveals for the first time data about the childhood sexual abuse during the forensic evaluation (within the court process related to the request for compensation for the complications which occurred following the Salmonella infection). During the forensic evaluation, we had insight into the previous medical history, while an interview, psychological and psychiatric exploration was conducted with the examinee. Data about the sexual abuse retrospectively explain the dynamics of the development of conversion disorder. The described case indicates that sexual abuse of children and adolescents frequently remains unrecognized, which has sequels for treatment and prevention of subsequent consequences for mental health. It is important to emphasize the significance of examining history of abuse during the diagnostic of certain mental disorders. Forensic implications of the case have not been discussed in details for the needs of this report.

Persistent hepatic venous plexus in a patient with Sturge-Weber syndrome.

A patient with extensive facial and intracranial features of Sturge-Weber syndrome was found to have a persistent primitive hepatic venous plexus, characterized by three additional vessels arising from the inferior vena cava, circulating between liver segments, which formed a common trunk in the supra-hepatic region that flowed into the right atrium. To the best of our knowledge, this hepatic finding has not been previously described in association with Sturge-Weber syndrome.

[Occurrence, causes and clinical characteristics of status epilepsy in adults]. / Ucestalost, uzroci i klinicke karakteristike epilepticnog statusa kod odraslih.

INTRODUCTION: Status epilepticus, particularly grand mal, is one of the gravest and most dramatic conditions in neurology requiring immediate attention. Status epilepticus can occur in epileptic patients, often with higher mortality rates in symptomatic than idiopathic, but also as an initial symptom of a number of neurological and systemic diseases. No data are available on the exact incidence rates of status epilepticus. According to some assessments, 10% of patients have at least one status epilepticus in their lifetime (3,6). The prognosis mostly depends on the main cause, time in which seizures are stopped and age of patients. Latest data available in literature suggest the mortality rate of 2-8%. MATERIALS AND METHODS: We analyzed frequency of hospital admissions, causes and clinical characteristics of status epilepticus in adults. The study was retrospective, based on case histories of epileptic patients from the Intensive Care Unit of the Neurology Clinic in Novi Sad in 1990, 1993 and 1995. Special emphasis was placed on differences in studied parameters between cases confirmed earlier and those with status epilepticus occurring as an initial symptom of some other illness or condition. RESULTS: Number of hospital admissions rose slightly in the interval observed in comparison with total admissions (0.68% in 1990, 1.24% in 1993, and 1.73% in 1995) (Tabs 1 and 2). During 1993, status epilepticus was more frequent in cases confirmed earlier (69%) compared with the years 1990 (56%) and 1995 (43%) (Graf.1). Epileptic patients were younger on the average than nonepileptic ones (Tab. 3). Status epilepticus occurred more often in male patients (Tab. 4). Irregular treatment was the prevailing cause in epileptic patients (Tab 5). Symptomatic status epilepticus was reported higher in 1990 and 1995, and stroke was definitely the predominant cause (Tab 6). Convulsive grand mal status prevailed in all patients (Graf 2). Focal status was a more frequent finding in nonepileptic patients (Graf 3). Every third in 16 patients died in 1993 and every fifth in 23 in 1995 probably due to the acute destructive brain damage rather than the status itself. No deaths occurred in 1990. DISCUSSION: According to research carried out by other authors, half of grand mal status cases occurred in confirmed epileptics (4). In our study the grand mal status was reported in 70.4% cases of epilepsy. Primary cause was abrupt withdrawal of antiepileptic treatment, infections, alcohol abuse and use of convulsive drugs. This is compatible with our results which confirm that grand mal status either primary or with secondary generalization prevail in both groups of patients (7,8,9). In terms of causes of status epilepticus in nonepileptic patients, literature data mainly suggest cerebral trauma, frontal brain tumors, cerebral arteriosclerosis or other vascular disorders and anaphylaxis (4). Our results point to stroke as the major cause of status epilepticus in nonepileptic patients, similar with data presented by Towne (10). There is no data in literature concerning the relation between sex of patients and occurrence of status. In our study status epilepticus occurred more frequently in male patients. CONCLUSION: The grand mal status was the major clinical type of status in all patients and was primarily caused by discontinued or irregular antiepileptic treatment in patients with confirmed epilepsy, and by stroke in nonepileptic patients.

[Subjective syndrome after head injury]. / Subjektivni sindrom nakon povreda glave.

UNLABELLED: DEFINITION AND CLASSIFICATION PROBLEMS: Post-traumatic or post-commotion syndrome is one of the most controversial entities in studying consequences of craniocerebral trauma. Part of this problem arises from impossibility of adequate translation of the term brain concussion. Post-concussion syndrome is a broader concept than post-commotion and includes, if not a whole, than part of the post-contusion syndrome. There are also some other terms in the literature: post-traumatic syndrome, post head injury syndrome, post head injury syndrome or symptoms and the old term post-traumatic encephalopathy. Terminological imprecisions have not been solved yet, but the notion itself is determined by relative standard symptoms often associated with closed craniocerebral trauma, but without precise connection with the severity of the trauma. In the classification of mental disorders and behavior disorders, this syndrome is coded as FO7.2. ETIOLOGY: In regard to the etiology of this syndrome some authors speak in favor of psychogenic and some of organic etiology, while Levin considers symptoms of post-commotion syndrome to start as organic and persist as psychic. Wechsler classified subjective disorders after head injuries into 4 categories: simulation, traumatic hysteria, traumatic encephalopathy and traumatic neurosis. The author does not deal with the origin of symptoms, whereas the classification itself suggests priority of psychic to organic factors (11). Those who speak in favor of organic etiology, think that axon damage and neuron damage are organic substrate in mild brain injuries, while fibrous degenerations of the cerebral hemisphere and brain stem are the organic base in severe traumas. On the other hand, many scientists primarily point to psychic moments, especially to importance of aggravation and simulation as well as compensation or rental neurosis in persistent post-traumatic syndrome. Most scientists agree that personality characteristics influence the development of post-traumatic syndrome and can predispose aggravation and simulation, whereas these symptoms more often occur in neurotic persons. The latest investigations reveal that classification in regard to etiologic factors--organic and psychogenic--is an anachronism. Long and Novac state that 80% of persons with cerebral trauma spontaneously speak about symptoms of the post-traumatic syndrome, while by targeted evaluation the percentage rises to 90%, so that they think that universality of symptoms points to their common origin. CONCLUSION: If the post-traumatic syndrome is though of as a line with organic dementia at one end and traumatic neuroses at the other, then this syndrome can be placed at different positions. Some authors put it close to the neurotic syndrome or regard it to be the neurotic syndrome itself, while others, mostly due to homogenity of the clinical picture, believe that this syndrome has an organic cause.

[Evaluation of cognitive deficits after craniocerebral injury]. / Mogucnosti procene kognitivnog deficita nakon kraniocerebralne traume.

The study included 90 persons, one year after experiencing closed craniocerebral trauma. The purpose was to determine, by neuropsychological and neurophysiological methods, the presence of cognitive deficit as a result of cerebral trauma. It is possible to objectivize the organically conditioned cognitive deficit in case of a significant number of patients, and also, by the application of certain methodology, to grade the intensity of existing changes. When compared with other examined parameters, the presence of cognitive deficit was more often in patients of older ages and in those with more serious craniocerebral trauma. A special attention was made to the sensitivity of the used instruments for the verification of cognitive deficit. Among them, Wisconsin test and the method of cognitive evoked potential P-300 appeared to be the most reliable ones.

[Mechanisms of epileptogenesis and antiepileptic drugs]. / Mehanizmi epileptogeneze i antiepilepticki lekovi.

Contemporary data about the mechanisms of epileptogenesis are reviewed. The role of the neuronal membrane and synapsis in the neurons changed by epilepsy is particularly pointed out. The concept of "the paroxysmal depolarizational shift" is defined. Role of some neurotransmitters in the mechanisms of epileptogenesis and their classifications into excitatory and inhibitory ones are also presented. It is pointed to a great variety of receptors for neurotransmitters as well as the role of calcium ions in mechanisms of epileptogenesis. A review of "classical" and new antiepileptic drugs is created and possible mechanisms of their effect are stated. The same antiepileptic medicaments are listed in a special table depending on the type of epilepsy in which they have effect. It is certain that during the last two decades electrophysiologic, biochemic and pharmacologic researchers have significantly improved the knowledge of the main occurrences responsible for epileptogenesis. However, a lot of facts are still doubtful.

[A manic syndrome after cerebral trauma: case report]. / Manicni sindrom nakon cerebralne traume: prikaz slucaja.

This case report describes a 17-year-old female patient in whom a clinical picture of manic syndrome developed four days after craniocerebral trauma. The diagnostic procedure comprised neuropsychological, neurophysiological and neuroanatomical examination. The diagnosis revealed discrete organicity on the level of psychic functions, whereas magnetic resonance imaging revealed changes of the right hemisphere. One case cannot reveal the etiology of affective disorders after cerebral injuries, but gathered results point to the possibility of causal connection between craniocerebral trauma and manic syndrome.

[Sociodemographic and epidemiologic characteristics of hospitalized alcoholics in Vojvodina]. / Sociodemografske i epidemioloske karakteristike hospitalizovanih alkoholicara u Vojvodini.

Using the Register of hospitalized alcoholics in Vojvodina we analyzed data on sociodemographic and epidemiologic characteristics of the alcoholic disease. This retrospective study, using longitudinal and anamnestic data during a three-year period (1991-1993) deals with all patients treated for Alcohol Dependency Syndrome (according to the International classification of diseases, IX revision) treated at neuropsychiatric institutions in Vojvodina and living on this territory. The sample consisted of 4783 examinees. The gathered results indicate that there is a decrease in number of patients treated for alcoholic disease, that is in incidence, prevalence and risk of morbidity in regard to the population of the examined territory. As this decrease is associated with a decreased number of registered psychiatric, neurologic, and somatic complications of the alcoholic disease, the authors may conclude that the intensity of actual social pathology and social disorders, which are characteristic for the above mentioned period resulting in the decrease of production and consumption of alcohol, decreases alcoholism and its complications.

[Psychological study of rape victims]. / Psiholoska eksploracija zrtava silovanja.

This paper covers a study of rape victims, according to the records of Clinic for Gynekology and Obstetrics in Novi Sad, in terms of the late psychological and psychiatric consequences. Several methods were used: special questionnaire, Minnesota Multiphasic Personality Inventory for estimating personality and selfdescriptive scale of depression, Beck Depression Inventory. Results emphasize that the group with the highest rape risk consists of female persons aged from 22 to 30 years, single, without children and with lower education level. Psychological and psychiatric and analysis shows pathological personality of victims in most cases. All victims tested, expressed intensive or mild degree of depression. Analysis of offense situation points to significant degree of victimization.

[Cognitive deficits in alcoholics--significance of cognitive evoked potentials (P-300)]. / Kognitivni deficit kod alkoholicara--znacaj metode kognitivnog evociranog potencijala (P-300).

Method of event related potential has proved to be very useful in estimation of higher nerve functions damage, especially P-300 component as a precise indicator of cognitive and perceptual functioning. According to data available in literature, significant degree of correlation exists between evoked potential parameters (amplitude and latency) and deficit of psychic functions. The sample consisted of 37 patients (male and female) who had signs or alcohol-induced organic mental disorder (according to ICD-10). "Oddball" paradigm of P-300 was used. The results were compared with control group of 20 healthy persons. The results emphasized lower amplitude and prolonged latencies in the group of alcoholics. These findings were more significant in female subsample and may suggest that females are more vulnerable to alcohol than males. Our findings lead to the conclusion that method of event related potential (P-300) may help in estimating organic deficit in alcoholic patients.

[Modern psychosomatic aspects of dermatology]. / Savremeni psihosomatski aspekti u dermatologiji.

Concerning their origin most diseases are multifactorial and that goes for skin diseases too. Emphasizing just one must not exclude further research and other aspects of etiopathogenetic mechanisms. It has been known for along time that psychological factors have a certain influence on the start, aggravation and maintenance on skin changes and that cosmetic defects of this kind disturb the psychological peace of the sick person and his capacity of establishing satisfactory social relations. Psychosomatic approach in dermatology cannot be reduced to investigation of specific etiology in the field of psyche without physical or social spheres. It unites all of them and in that way the old question what cause and what the consequence is has no importance, because there is no time or distance limit among them. They act simultaneously, holistically.

[Homicide and sexual psychopathology]. / Ubistvo i seksualna psihopatologija.

Using data of forensic-psychiatric archive of the Institute for Neurology, Psychiatry and Mental Health in Novi Sad, 61 homicides were processed; in all cases victims and the murderers were of different sexes and were not blood kinships. By psychopathological analysis of the sample it was not possible to determine a unique profile of "sexual homicide". Considering the personality of the murderer, the degree of victimization and the importance of alcohol as a constelative factor, three categories of homicide connected with sexual life in the broadest sense were established and any degree of generalization in the practice of forensic-psychiatric theory and practice is impossible.

[Attempted suicide as a reflection of adolescent crisis]. / Pokusaj samoubistva kao odraz krize u adolescenciji.

Adolescence is a transitory period in the process of maturation of an individual and, as such, is often accompanied by conduct disorders and different crisis manifestations. These crises often result in suicide attempts which have all the characteristics of an "appeal function". In our group of 200 suicide attempts, we compared the group of adolescent to the group of adult suicide attempts. The comparison was based on a series of different sociodemographic and psychopathological characteristics (e.g. sex, presence of "broken home", method of attempt, family history of psychiatric illness, current psychiatric diagnosis). The results show statistically significant differences between the two groups in relation to some of the characteristics. The paper attempts to explain those differences. Overall results also show that adolescents may be considered as suicide risk group which demands our full attention, particularly from the preventive point of view.

[Analysis of the relation between socioeconomic factors and suicidal behavior]. / Analiza povezanosti socijalno-ekonomskih faktora i suicidalnosti.

The paper explores case histories of 128 patients hospitalized for suicide attempts at the Institute of Neurology, Psychiatry and Mental health in Novi Sad for a period of two years. The analysis of relevant suicidological data was carried out with the aim of determining the significance which SOCIOECONOMIC factors play in gene-rating suicidal behavior. Under the item "occupation/employment" most frequent were "workers" 21.88 per cent, followed by unemployed persons--17.19 per cent, while those on social welfare constituted 16.4 per cent. Financial poverty as the motive for suicide attempt is most often encountered among unemployed ones and those on social welfare. In the total sample, this poverty was registered in 19 cases (14.84 per cent). It is interesting that this motive is more often present in younger persons, where mean age for those on social welfare is 28 and for the unemployed ones is 29 years. The diagnosis most often found in these groups is "Adjustment Disorder with Depressed Mood (309.00)", no psychotic episodes were found. With respect to alcohol dependence, it is much less present among those on social welfare than in the rest of the sample. Therefore, financial poverty is not negligible factor of suicide risk. This finding directly confirms that financial poverty as suicide generator has so far not been researched sufficiently or is evidently on the rise, at least in our society.

[The effect of stress and personality structure on the onset and severity of the clinical picture of psoriasis]. / Uticaj stresa i strukture licnosti na pocetak i tezinu klinicke slike psorijaze.

On a sample of 38 psoriatic patients we tried to determine the relationship between neurotic disorders (operationalized MMPI) and the number and hazardous effects of stressful events on the one hand and the severity of the clinical picture and the time of the onset of psoriasis on the other. In our sample neurotic disorders are much commoner than in the general population indicating that they might represent one of the most significant factor of etiology, complications and prevention. The last hypothesis is based on the results showing that neurotic psoriatics develop psoriasis significantly later than non-neurotics. We haven't attained a profile of a typical neurotic person because neurotic disorders are manifested through different symptoms. The average number of stressful events was found significantly higher in more severe forms of psoriasis compared to the milder forms. Finally, a remark has been made about benefits of a multidisciplinary approach to the study of psoriasis and the inclusion of psychotherapy in the treatment of psoriatic patients.

[Evaluation of the level of suicidal tendencies in women with unwanted pregnancies]. / Procena stepena suicidalnosti zena sa nezeljenom trudnocom.

The study was conducted on 250 pregnant women who registered at the Clinic for Gynecology and Obstetrics of the Medical Faculty in Novi Sad with the intention of terminating their pregnancy. The specimen was divided into three groups on the base of pregnancy duration and the legal possibilities of its termination. The examined women were polled through a specially constructed questionnaire and the PSPI scale for the evaluation of the level of suicide capability and depressive state. It was determined that a high score in both scales existed only in those women where there was no possibility of legal termination for the existing pregnancy. The level of existing suicide capability and depressive state had shown to be statistically significant in relation to the other two groups of examined women. Out of the list of examined control variables, only the impossibility of pregnancy termination was high in correlation with the level of both suicide capability and state of depression in the bounds of the risk group, which gives this parameter the meaning of a suicidogenic factor in the conditions of our investigation.

[Characteristics of sexual offenders in our data]. / Karakteristike pocinitelja seksualnih delikata u nasem materijalu.

By analyzing two groups of sexual delinquents: those which have committed rape, attempted rape or committed rape with murder (the first group) and the commiters of indecent acts (the second group), it was established that the named groups are substantially different in relation to some of the studied parameters. In the first group of delinquents, there is considerably less of those who are married (35.48%), in relation to the second group (73.68%). Indecent acts are most often committed in the apartment of the sexual offender (63.16%), while this is the case in 22.58% of the offences from the first group. The victims of indecent acts were only minors. In both groups the most frequent psychiatric diagnosis was psychopathy. Alcoholic state at the time of committing the offence was considerably greater in the first group (87.10%), in relation to the other one (47.37%). There were no important differences relating earlier criminal offences, as well as the psychiatric estimates of accountability between the groups.

[Analysis of the causes of suicide attempts in women]. / Analiza uzroka pokusaja samoubistva zena.

In suicidological literature and practice there is a repeated confirmation of the presence of the appeal function as an unconscious motive in the suicide attempt. In the basis of the appeal is the attempt of the suicidant to restore disturbed relations with surroundings, and according to this, in this case, the suicide attempt is directed more to life than death. In the researched material an analysis was conducted of the cause of death in 319 women with the aim to evident the possible presence of unwanted pregnancy and to give light to the causes and motives of the act of suicide.