Neuropsychology

Neuropsychological Assessment of Neuropsychiatric Disorders

Neuropsychological Assessment of Neuropsychiatric Disorders, 2nd edition

Igor Grant, Kenneth M. Adams, editors

New York: Oxford University Press; 1996. 654 pp. with index

ISBN 0-19-509073-X

The remarkable increase in the number of textbooks in neuropsychology is a reflection of the growing importance of the discipline, both in science and in applied health care. In this large field of contenders for readership, this volume is a welcome contribution to the literature. The well-written and comprehensive first edition has been extensively revised and now includes such timely topics as the psycho-social consequences of neuropsychological impairment. The editors, Igor Grant and Kenneth Adams, both highly thought-of opinion leaders in their respective fields of neuropsychiatry and neuropsychology, have pooled their areas of expertise to ensure that this text is a comprehensive as well as a scholarly summary of the current knowledge. The contributing authors are a refreshing mix of well-known names and more junior academics, a combination explicitly acknowledged as an attempt to “keep the treatment of topics fresh.”

The volume is organized into sections. Section 1 reviews methods of comprehensive neuropsychological assessment. The lead-off chapter discusses the Halstead Reitan Battery in a comprehensive but slightly cumbersome way. While useful, the material on the historical context could be reduced. The next chapter, on the analytical approach to neuropsychological assessment, provides conceptual background to theory-based clinical decision trees, while the Boston process and the Iowa-Benton school provide a very practically oriented review of these approaches to neuropsychological assessment. Computers in memory adds an interesting, frequently neglected component to this review. The chapter on cognitive screening methods rounds out the first section and provides a much-needed review of this area, but could have taken a slightly more practical angle, rather than concentrating extensively on conceptual considerations.

The second section, on neuropsychiatric disorders, constitutes the bulk of the book. The reader is led through all major areas of this cluster of disorders, starting with the important issues of demographic influences on test performance to the neuropsychology of dementia and to drug abuse and schizophrenia. While all of these chapters provide important background information, they tend to overlap thematicalry. In particular, the overview of dementia

includes appropriately significant background on various dementing disorders in the context of memory dysfunction, which is again reviewed thematically in the chapters on Huntington’s and Parkinson’s disease. Interestingly, while these diseases, along with epilepsy, Tourette’s syndrome and hypoxia, are given separate chapters, the disease accounting for more than 50% of all dementia cases — Alzheimer’s disease — did not did rate a separate chapter. An important contribution is made by the chapter on the neuropsychology of memory dysfunction, which provides the reader with a careful review of memory systems and the often-confusing taxonomy in this context. The third section, on the psychosocial consequences of neuropsychological impairment, introduces an important and very timely topic; namely, the noncognitive issues in traumatic brain injury, including the controversial issue of malingering. The book deserves praise for tackling the difficult topic of quality of life, both in the context of head injury and of systemic illness. Both chapters raise important and often-neglected issues; they will sensitize the reader to the significance of these topics. This important volume will serve both advanced students and clinicians alike for many years to come.

Human Brain Anatomy in Computerized Images

Human Brain Anatomy in Computerized Images

H Damasio

New York: Oxford University Press; 1995. 303 p

This is a very good textbook which is primarily an atlas of normal human brain anatomy, as seen in T1-weighted magnetic resonance images. As such, it is unique in that it provides exquisite detail of the telencephalon and cerebellum of the human brain. In particular, it identifies and localizes the major gyri and sulci of the cerebral cortex in an accurate and unambiguous fashion. The author is a well-known professor of neurology with special interests in human neuroanatomy and neuroimaging. This textbook will probably have an enthusiastic albeit limited audience and will be especially useful for those involved in clinical neurosciences, including neuroradiologists, neurosurgeons, neurologists, and neuropsychologists. It will undoubtedly be a valuable reference text aiding in the exquisite localization of pathological processes.

An introductory chapter elaborates on the Brainvox 3D technique, which allows reconstruction of the brain in 3 dimensions in such detail that all major sulci and gyri can be identified with the same degree of precision that would be attainable on the autopsy table. Moreover, once identified, these sulci and gyri can be color-traced and the outline of the tracer transferred automatically to the original 2-dimensional images, ensuring their proper location. This allows for accurate sulci and gyri localization on the 2-dimensional images independent of the angle of inclination, which often varies greatly in the axial and coronal planes. The 2nd and 3rd chapters are devoted to 2 different normal brains viewed externally from the lateral and mesial surfaces, the superior and inferior surfaces, and from both the left and right sides. Brain A in chapter 2 is of dolichocephalic configuration, brain B in chapter 3 is brachycephalic in type. A brief descriptive outline precedes both chapters. Chapter 4 is devoted to 24 additional normal brains depicted in the lateral mesial surfaces and from the right and left. The purpose of this chapter is to highlight the marked variation present in areas such as the central sulcus, the superior temporal sulcus, and the calcarine fissure. Chapters 5 and 6 return to the original brains A and B. In these chapters, the brains are depicted in 2 dimensions in 5 different angles of inclination relative to the inferior orbitomeatal line (coronal images being perpendicular to their corresponding axial). Additional parasagittal images are obtained parallel to the hemispheric fissure starting from the left and moving to the right. Chapter 6 also depicts 2-dimensional images, but these are of the dolichocephalic type brain B and include only 2 axial and coronal incidences relative to the infraorbitomeatal line and the corresponding perpendicular coronal counterpart. Finally, chapter 7 includes some focal infarcts that are then localized in both 2- and 3-dimensional images to reinforce the usefulness of the presented gyri and sulci anatomical details.

The images are of good quality and are well labeled by arrows and abbreviations; a complete table of abbreviations of all the relevant sulci, gyri, and midline structures is also included. Additionally, chapters 3 and 5 include color tracing to identify individual gyri, sulci, and lobar subdivisions. This is especially effective in transposing these images from 3 to 2 dimensions.

In summary, I can recommend this textbook as a reference for those departments involved in clinical neuroimaging or as an anatomical atlas for those interested in the detailed topographic anatomy of the brain as related to clinical imaging.

Neuropsychological Assessment

Neuropsychological Assessment. Third Edition

MD Lezak

New York NY: Oxford University Press; 1995. 1026 p

This is a 3rd edition of a comprehensive text on neuropsychological assessment. The 1 st edition, published in 1976, was a landmark text that provided for the 1 st time a thorough and practical overview of this complex and rich discipline. A 2nd edition in 1983 reflected the explosive growth of this field. The number of practicing clinicians has increased steeply, as has the number of scholarly discourses on relevant neuropsychological topics. Both 1st and 2nd editions served more than 2 generations of students well, establishing this text as an integral part of neuropsychological training throughout North America. For practicing clinicians these volumes served as a valuable source of information on a case-by-case basis, and represented an important reference for nonspecialist clinicians.

This 3rd edition is once again a landmark text. Its sheer volume, having increased significantly in size since the 1st edition, speaks to the author’s attempt to make this book as complete as possible. However, as she notes in the preface, the overwhelming volume of new publications makes it impossible to be complete, thus, she decided in favor of “completion” (of the book) rather than “completeness.”

The text, divided into 2 parts: 1) “Theory and Practice of Neuropsychological Assessment,” and 2) “A Compendium of Tests and Assessment Techniques,” provides a self-contained rendition of a particular topic in each chapter. Part 1 begins with an introduction to clinical practice in this field. Early on, case examples provide a practical approach, a theme evident throughout the book. Basic concepts dealing with terminology, and basic tools including brain imaging and elementary background knowledge provide a logical introduction to the “Behavioral Geography” of the brain. An overview of neuroanatomy provides the novice reader with some of the most essential tools to understand subsequent concepts. As the author notes, this introduction is by necessity very superficial, and students should be cautioned that this is not a substitute for detailed instruction in neuroanatomy and physiology, a prerequisite for all clinician students of this discipline. The “Rationale of Deficit Measurement,” followed by “The Neuropsychological Examination,” and ‘The Neuropsychological Examination: Interpretation” introduce the fundamental framework of neuropsychological examination and provide background knowledge for the principles of clinical assessment in this context. The rich case illustrations, with frequent figures, again facilitate both comprehension and retention of these complex and sometimes dry materials. “Neuropathology for Neuropsychologists” and “Neurobehavioral Variables and Diagnostic Issues” conclude Part 1. While well written, these 2 chapters are in relative terms the weakest of the book. In an attempt to retain as practical an orientation as possible, while providing extensive theoretical background, the author has not succeeded altogether with respect to the latter. However, it is this reviewer’s opinion that if one were to err, it would be best to err in the direction of practicality, and the chapters in question are stronger with respect to practical applications as opposed to theoretical background.

Part 2, “A Compendium of Tests and Assessment Techniques,” contains the greatest strengths of this volume. Written authoritatively and with a clear view to practical application, the 12 chapters of this part of the book provide a wealth of information on measurement, interpretation, and diagnostic issues on all currently known aspects of higher cortical function. The neuropsychological domains from “Orientation and Attention,” “Perception,” “Memory (divided in 2 parts),” “Verbal Functions and Language Skills,” “Construction,” “Concept Formation and Reasoning” to “Executive Function and Motor Performance” are comprehensively examined, and the reader is provided with the appropriate information in a relevant and concise fashion. Dr Lezak has succeeded in providing practical information in a comprehensive manner, without sacrificing scholarly completeness. Once again, the many case examples make it easy for the reader to follow these materials and to retain the most salient points.

Chapters on “Batteries of Brain Damage,” “Observational Methods, Rating Scales, and Inventories,” “Tests of Personal Adjustments,” and “Testing for Functional Complaints” round out Part 2. The inclusion, particularly, of the latter 2 chapters speaks to the author’s appreciation of the relative importance of functional factors in neuropsychological assessment. While recognizing that this is an exceedingly complex area, a further edition of the book may wish to deal in more depth with concepts such as “Chronic Pain Syndrome,” “Minimal Head Injury,” and “Medication Effects on Neuropsychological Function,” issues increasingly important to the practicing clinician.

As a whole, this volume makes a very important contribution to the literature. Dr Lezak has succeeded admirably in updating the earlier 2 editions of this volume, and has provided the field with an incisive, comprehensive, and well-written state-of-the-art compendium. This book is of critical importance to students in clinical neurosciences and is useful for practicing neuropsychologists. It also provides an excellent reference source on neurobehavioral questions for the related specialist disciplines of psychiatry, neurology and neurosurgery. Undoubtedly, this book will make an important contribution for years to come.

Contributions to Neuropsychological Assessment

Contributions to Neuropsychological Assessment. 2nd ed

AL Benton, AB Sivan, K deS Hamsher, NR Varney, O Spreen

New York NY: Oxford University Press; 1994. 159 p

As with the first edition of this book, specific test instruments receive comprehensive attention; more so than in any other textbooks discussing neuropsychological assessment procedures. The authors should be applauded for their excellent review and thorough analysis of topics from selective domains.

This clinical manual is divided into 2 major sections: “Tests of Orientation and Learning”, and “Perceptual and Motor Tests”, with each chapter devoted to a particular test. One of the most distinctive features of this book is the consistent outline followed by the authors across all chapters. Each chapter begins with a brief background relating the historical events or clinical observations that led to the development of the assessment procedure discussed. This account is followed by a description of the test itself, including alternate forms, if extant, administration guidelines, scoring criteria, interpretation, and normative observations. The subsequent sections describe the performance of patient groups with different brain diseases, as well as performances of psychiatric patients, normal children of various age groups, brain-damaged children, and/or normal elderly persons, whenever available. The specific implication of aphasic disturbances is highlighted by comparing the performances of aphasic and nonaphasic subjects in selective tests. Most chapters close with a commentary or discussion of unanswered questions and areas that need further investigations, critical observations, and a review of pertinent clinical studies.

Dr Benton and his colleagues have explored the problem of neuropsychological assessment in a methodological and insightful manner. They should be commended for the clarity of the text and the judicious discussion of different tests. Abigail B Sivan, assistant professor of psychiatry and psychology at Rush University, has undertaken the primary responsibility for changes incorporated in this new edition of Contributions to Neuropsychological Assessment. More specifically, this second edition depicts additional normative data on the performances of populations such as those of children and elderly individuals. Findings of clinical and experimental studies, generated since the 1st edition more than 10 years ago, are summarized and include results of cross-national and ethnic studies. The book also attempts to clarify the relationships of the tests to other measures in reporting the outcomes of factor-analytic studies.

The brevity of the book and the consistency of the framework across all chapters facilitate rapid consultation. This will undoubtedly enhance its use and make it a favorite among professionals constricted by time limitations.

On the whole, the authors have provided a concise and relatively encompassing expose of important neuropsychological functions which are often insufficiently imparted. The book should prove useful to clinical neuropsychologists, psychometrists, and researchers in the field of neuropsychological assessment and related issues.

Advances in Neurology: Epilepsy and the Functional Anatomy of the Frontal Lobe

Advances in Neurology: Epilepsy and the Functional Anatomy of the Frontal Lobe. Volume 66

HH Jasper, S Riggio, PS Goldman-Rakic, editors

New York NY: Raven Press; 1995. 400 p

Frontal lobe epilepsy has proven to be much more difficult to diagnose and treat, both pharmacologically and surgically, than the more common temporal lobe epilepsy. This volume represents the proceedings of a multidisciplinary symposium designed to bring together clinicians and basic scientists to elaborate current concepts in frontal lobe function and pathology, especially as they pertain to frontal lobe epilepsy. The book complements a previous work by the same publisher, entitled Frontal Lobe Seizures and Epilepsies. The editors state that the present volume is intended to emphasize “recent experimental work on the developing functional neuroanatomy of the prefrontal cortex in relation to working memory, cognitive behavior, and the physiopathology of frontal lobe seizures and their neurosurgical treatment.”

The first 7 chapters provide a comprehensive overview of animal and human studies which have contributed to our insight into developmental, anatomical, functional, cognitive, and neuropsychological aspects of the frontal lobes. A chapter on “Frontal Degenerative Dementia and Neuroimaging” is somewhat removed from the main emphasis of this collection but nevertheless offers an up-to-date synthesis of the clinical and radiological features of this form of increasingly recognized dementia. One of the highlights of this section is the chapter by Brenda Milner summarizing the ground-breaking work, largely under her direction, on the neuropsychology of the frontal lobes, carried out at the Montreal Neurological Institute over half a century. Herbert Jasper, who also worked in Montreal, provides a historical survey of prefrontal lobotomy, a chapter which should be of interest to psychiatrists.

Frontal lobe complex partial seizures have been notoriously difficult to diagnose and treat. Because they often manifest bizarre motor and vocal features, their seizures are relatively short-lived, and they have minimal surface EEG manifestations both ictally and interictally, patients who present with these types of seizures are often incorrectly labelled as having psychogenic pseudoseizures. The rest of this book is devoted to clinical phenomenology, EEG features, neuroimaging studies, and surgical therapy of frontal lobe seizures. A variety of techniques for localization of foci or investigation of function such as computerized-evoked potential analysis, PET scanning, MRI, depth electrode recordings, and electrical stimulation is covered. Several centres from the US, Canada, and Europe have contributed their experience and expertise to this volume. One of the most useful features of this book is the inclusion of the often revealing and less formal discussions that followed each presentation.

This is a well-organized, up-to-date account of all aspects of frontal lobe function and their relevance to frontal lobe epilepsy. Because of the importance of the frontal lobe in human behavior, cognitive ftinction and memory, and also because of the overlap between epilepsy and psychiatric illness, psychiatrists should find this work useful. It will also serve as a reference for neurologists and neurosurgeons, especially those working in the field of epilepsy.

Screening for Brain Impairment: A Manual for Mental Health Practice

Screening for Brain Impairment: A Manual for Mental Health Practice. 2nd ed

RA Berg, M Franzen and D Wedding

New York: Springer Publishing Co; 1994, 201 pages

Screening for Brain Impairment is an introduction to neuropsychology intended for, in the words of the authors, “general clinicians”. It is a well-written summary of existing material on the subject and is presented in a very accessible way. The authors are experienced neuropsychologists who have published a number of papers and books on this topic.

The first half of the book presents an introduction to neuroanatomy, neuropathology and neurological examinations. This part is apparently intended for a readership with no previous exposure to neurology (i.e., neuroanatomy, neuropathology or clinical examination). It would be appropriate and useful for the social worker who has no experience with brain-impaired patients. However, it is introductory and over-simplistic for other healthcare professionals such as nurses, speech therapists, physicians, occupational- and physiotherapists.

The second half of the book is of much broader interest to the general clinician, and focusses specifically on neuropsychology, its assessment and approaches. These chapters contain a wealth of information related to neuropsychological assessment, its appropriate application and implications. This information is likely to facilitate more effective interaction between the healthcare team and the neuropsychologist. It will also guide the general clinician in conducting a preliminary neuropsychological assessment of the patient.

However, a word of caution is in order. At various points in this book, the authors suggest referring a patient for Anther examination to a neuropsychologist or a neurologist if an undiagnosed neurological disorder is suspected. In my opinion, equating a neuropsychologist with a neurologist is potentially dangerous. Typically, the neuropsychologist has no access to inpatient beds; to neuroimaging diagnostics; to invasive diagnostic procedures (e.g., spinal tap); and to emergency neurosurgical consultation. Valuable time may be lost in a neuropsychological assessment, thereby missing a window of opportunity to diagnose and treat a potentially treatable neurological condition such as subdural hematoma or meningitis.

In summary, this book is a well-written introduction to neuropsychology. Parts of it are oversimplistic for most general clinicians; other parts provide valuable information for people wishing to learn more about assessment devices and concepts of neuropsychology.

Seminars in Basic Neurosciences

Seminars in Basic Neurosciences

Gethin Morgan and Stuart Butler

College Seminars Series (Royal College of Psychiatrists), London: Gaskell, 328 p., 1993.

The following remarks fall into two parts: first, a review of the book listed above; second, some comments on the place of the neurosciences in current psychiatry.

The title (with “Basic Neurosciences” placed in a prominent box on the cover) might suggest that this book is a rival to such a text as that by Kandel et al (1991) on “Principles of Neural Sciences”. This small volume, however, has a different purpose, namely, that of instructing clinical trainees in psychiatry to those aspects of neuroscience which may be of value to the practising clinician (and in meeting examination demands). In fact, it incorporates far more than the basic neurosciences as conventionally understood for it includes, in addition, a concise course in clinical neurology. Perhaps a future addition might reflect this in the title. Two important features should be noted at the outset. First, it is written by “contributors…experienced as teachers of clinical trainees.” Second, “there are many figures, diagrams, tables and boxes to make the information accessible and more easily absorbed”.

The contents of the book fall into nine chapters with short reference lists. They will now be considered seriatim; (the figures in parentheses indicate the page lengths of each).

“Functional neuroanatomy” (41) Butler: This chapter provides, in brief form, a standard account of relevant neuroanatomy. It includes an excellent diagram (Figure 1.14) on the limbic system and its connections.

“Neurophysiology” (28) Logan: This chapter is a concise account of synaptic transmission and, thereafter, reflex phenomena in the sensory and motor sphere. Diagrams are less plentiful but usually useful (for example, Figure 2.5 as opposed to Figure 2.4) (One wonders if the busy clinician will ever have recourse to the complex connections of the cerebellum portrayed in Figure 2.4 – unless it is a particularly slow day).

“Neurochemistry and neuropharmacology” (40) Nutt: This chapter is one of the best chapters in the book. Written by the Director of the Psychopharmacology Unit in the School of Medical Sciences at Bristol University, it deals succinctly with receptors and the mechanisms by which the ever-increasing numbers of psychotropic drugs are presumed to work. While the diagrams are excellent, the tables are outstanding. Figures 3.6 and 3.8 together with Tables 3.1,3.2 and 3.6 are superb summaries of current knowledge and Dr. Nutt deserves our gratitude and congratulations. The book is worth buying for these alone.

“Neurological examination and neurological syndromes” (38) Barrett: This chapter gives a remarkably complete account of clinical neurology as well as the neurological examination. Here summarized information given in “boxes” varies in utility from good 4.3 (classification of epileptic seizures), 4.5 (causes of dementia) to poor 4.4 (causes of epilepsy), 4.6 (causes of delirium). Simply listing seventeen or thirteen items in a “box” without any attempt at organization is daunting, not helpful. Nonetheless, to cover so well a wide area in such a small space does credit to the author.

“Neuropsychology” (34) Hallett: This is another excellent chapter. In Hallett’s own words, “neuropsychology offers a robust system for the measurement and quantification of cognitive function, emotional state and behavioural repertoire…” and is a “complementary system of analysis to psychiatry.” The chapter goes on to detail what psychology can and cannot do in this area. As an even-handed exposition in a small space I doubt if this chapter could be bettered. The appendices are admirable summaries of relevant tests.

“Neuropathology” (34) Luthert: This chapter provides the pathological complement to Barrett’s chapter. After discussing techniques and basic pathological processes, the writer then surveys most of the common neurological diseases. Most relevant to psychiatry is the excellent and concise account (in six paragraphs and one table) of the changes in Alzheimer’s disease. The “boxes” in this chapter are outstandingly good, for example, 6.2 (time course of events following focal occlusion of a cerebral vessel) and 6.3 (routes of infection.)

“Neuroendocrinology” (25) Gilbey and Macrae: This chapter provides a good survey of the field and here excellent diagrams are a feature (Figures 7.1, 7.3, 7.4 and 7.7). This section is particularly valuable since it collects together in one place information which is much less accessible to most of us than the content of many other chapters of this volume. Table 7.4 and 7.5 (psychiatric manifestations of endocrine disorder and endocrine manifestations of psychiatric disorders) are very helpful.

“Clinical neurophysiology” (SS) Hilary Morgan: This chapter deals successively with techniques of recording the EEG, its normal appearance and the changes occurring in metabolic and toxic states and following treatment (including ECT). After an account of changes in the various neurological disorders, there is then a special section devoted to epilepsy. The facts are encapsulated in the “mother of all tables” 8.1 which runs over four pages. Pages 281 to 283 contain important summaries on violence, epilepsy and the EEG; the EEG and episodic behavioural changes and schizophrenia and affective disorders. There is a short account of sleep and the EEG (now a subspecialty of psychiatry with its own testing examination) and the chapter concludes with mapping (including power spectral analysis) event-related potentials and evoked potentials. Instead of boxes there are numerous illustrations of the EEG in various conditions.

“Neuroradiology” (12) Bradshaw and Lewis: After discussing the various techniques in this chapter (plain radiography, angiography, CT, MRI, PET and SPECT), the authors survey successively the spine, congenital lesions, vascular disease, trauma, neoplasia and finally degenerative, metabolic and toxic disorders. There is an introductory and minatory warning against the temptation to scan large numbers of psychiatric patients in the hope of “finding something”. But there are replicable findings, for example, the ventricular changes in schizophrenia and changes in rCBF and glucose metabolism in dementia which deserve discussion. This could with profit replace the account of radiology of the spine. And the use of PET and SPECT to study a wide variety of neuroreceptors is surely of interest (Daniel et al). There are missed opportunities here.

“Appendix and index” The former contains a map of cutaneous innervation and a table of reflexes. There is an excellent index compiled by Linda English.

At first sight, the chapters appear uneven but to a degree this reflects the subject matter. It is easier to be enthusiastic about the latest findings in the brains of patients suffering from Alzheimer’s disease than to get excited over the corticothalamic tracts which haven’t changed much in the last few centuries. But this would be a very unfair reflection on the authors who have produced remarkably good summaries of their areas which, despite brevity, are readable, thanks in large part to the lavish use of boxes and diagrams which contribute to the success of this enterprise.

One could always argue with the editors about allocation of space to the different subjects. Thus, in considering diagnosis, many would put neuropsychology first followed by radiology, endocrinology and the EEG last; yet the pages allotted are 34, 12, 25 and 55 respectively. But the editors are presumably tuned to local needs and the requirements of examinations. (And the pages on the EEG are inflated by numberous multichannel illustrations).

In sum, this excellent volume provides in one place an extremely useful, concise and up-to-date compendium of clinical neuroscience and neurology. If the trainees absorb the contents then they will be well-equipped to deal with the increasing pace of change due to new research findings which, judiciously and selectively, they may wish to incorporate into their clinical practice.

If we accept the view that mental activity is based on brain activity then a knowledge of the basic neurosciences becomes essential. It is true that a few still hold to the dualist view, notably Sir John Eccles and the late Sir Karl Poppers, but most in the field are less defeatist and believe that eventually most mental activity will correlate with neuronal events. There are indeed notable successes to date which are recounted in the volume by Kandel et al (1991) already cited. Kandel’s work on anxiety and the synapse is a classical example of the progress being made.

Nonetheless, to the practising clinician the different neurosciences have varying relevance. Can we not, then, leave some to the specialist? While it is customary to defer to individual experts in, say, radiology or endocrinology, it is still essential, in this reviewer’s opinion, that the clinician have enough general knowledge not only to know what the different disciplines can provide but also to be able to interpret oneself in relation to any individual patient and at times overide the expert.

Some would even go further and deny the need for medical training. Thus, psychologists in the US have sought admission privileges and the right to prescribe drugs. Without full medical training including the neurosciences such a course is fraught with hazard. But if clinicians themselves do not use their medical skills then it becomes more difficult to answer the pressures of competitive professions. However, there is an increasing shift from consultation-liaison psychiatry to medical psychiatry defined by Stoudemire and Fogel (1987) as “a medical specialist who assumes primary responsibility for the diagnosis and treatment of psychiatric disorders within the medically ill population.” They go on to list the reasons for its growing importance as follows: “(1) the increasing prevalence of chronic disease and the aging of the population, (2) advances in neurodiagnostic techniques and psychopharmacology, permitting more rational biological therapy of psychiatric disorders in the medically ill, (3) the development and implementation of brief, focused dynamic psychotherapy techniques appropriate for the medical setting, (4) the development of specialized medical-psychiatric inpatient units, (5) increasing time pressures on other medical specialists, leaving the psychiatrist as the only medical specialist with the time, knowledge, and skills to develop a comprehensive understanding of the emotional dimensions of medical patients’ illnesses, and (6) increased competitive pressures from non-medical psychotherapists, causing psychiatrists to emphasize their medical training and skills.” The role of the basic neurosciences in the above needs no emphasis.

If, indeed, psychiatrists do not pay attention to these areas then psychiatry as a discipline will diminish and may vanish. Our patients will be the big losers. That dire consequences are already upon us is exemplified in a recent editorial by Robin Eastwood (1994). He notes that both by competition from other specialties and by default psychiatry is losing its place in dementia research in Canada. This displacement is occurring elsewhere too and he quotes a Lancet editorial which “says that dementia, especially basic research, is now indeed the domain of neurologists and that even schizophrenia is not exclusive to psychiatry anymore.” If, in fact, psychiatry has decided to concentrate on the “functional” psychoses, he concludes “how sad that the magnificent start given by Kraepelin and Alzheimer at the beginning of the century, at the Ludwig-Maximilians-Universitat in Munich, has come to this in Canada.”

This reviewer hopes the volume edited by Morgan and Butler will help stop the rot.

Handbook of Clinical Trials: The Neuro-Behavioural Approach

Handbook of Clinical Trials: The Neuro-Behavioural Approach

Erich Mohr, Pirn Brouwers

Amsterdam: Swets and Zeitlinger, 386 pp., 1991

This book offers an in-depth discussion of the neuropsychological and neurobehavioral components of clinical trials, which are applicable to disorders encountered in children, young adults and elderly subjects. Mood disorders, schizophrenia and degenerative dementias are targeted specifically.

A specific review of the book’s content reveals an introduction to the broad topic of neuropsychological assessment in drug trials, followed by chapters on screening patients and inclusion criteria, design issues, statistical considerations, neuropsychological test instruments, a brief discussion on normative and reliability considerations, criteria for choice of neuropsychological tests, assessment of effective variables, assessments in pediatric and adolescent patients, approach to patients with schizophrenia and mood disorders, a very detailed discussion of the diabetes control and complications trial methodology and an overview of dementing disorders. The last section of the book describes practical applications in clinical trials using cognitive enhancers, including design considerations standardization and implementation, computerized memory testing in patients with age associated memory impairment, some comments on clinical trials of cognitive rehabilitation, the significance of negative clinical trials, comments on the multi-disciplinary approach to neuroepidemiological surveys and finally a theoretical topological analysis of drug-induced changes in cognitions. The latter is more theoretical than practical since we do not yet have drugs that have been demonstrated to positively alter cognition in a safe and clinically significant way.

This book will prove extremely useful to clinicians from neurology, psychology, psychiatry and rehabilitation who are facing the challenge of clinical trials with subjects suffering from neurobehavioral disorders, with particular emphasis on cognitive enhancers for dementia or age-associated cognitive impairment.

Clock Drawing: A Neuropsychological Analysis

Clock Drawing: A Neuropsychological Analysis

M. Freedman, L. Leach, E. Kaplan, G Winocur, K. I. Shulman and D. C. Delis

Oxford: Oxford University Press, 1994.

“The clock is not merely a means of keeping track of the hours, but of synchronizing the actions of men” (Mumford, quoted in Landis 1983). Measurement of time by means of a sundial goes back at least to ancient Rome, and an elaborate astronomical clock powered by a water wheel was built in China in 979 A.D. (Landis 1983). Clocks showing the time in hours and minutes on a clock face had their origin in Europe in the Middle Ages and have been universally used ever since. The development of the digital clock has raised the question of the future usefulness of the classical clock face (Clarfield and Bergman 1990) but it is generally assumed that familiarity with it is culture free.

This familiarity has encouraged neurologists, neuropsychologists and psychiatrists to evaluate cerebral and cognitive function by using the ability to draw a clock face as a specific test. Localized lesions in the brain have been shown to produce similar deficits in clock drawing, and the progressive deterioration seen in different forms of dementia is accompanied by increasing difficulties in carrying out this task. However, different investigators have used methodologies showing great variation in the instructions given to the subject and in the rating assigned to the drawing.

The present volume attempts to correct the resulting confusion by allowing for these differences and developing a scoring system that is not tied to any one particular approach. By and large the authors have succeeded in meeting this goal.

In the introduction they give an excellent short overview of the history of the test with a full discussion of previous work. They discuss the cerebral processes involved in drawing a clock face, and critically review different sets of instructions used by various workers.

In Chapter 2 they discuss the results of a questionnaire to find out how widely the test was used by different workers, their specific methodologies and how useful they found the test. “Results of this survey indicate[d] that a clock drawing task is frequently used throughout the world in the assessment of cognitive deficits in brain injured patients” (p 11).

In order to develop normative data they tested 348 normal volunteers stratified according to age in ten-year cohorts between 20 and 90 years, and the instructions included both free-drawn and pre-drawn conditions. A comprehensive listing of various attributes of clock drawing is provided. It includes assessment of both contour and size of the circle, presence and position of the numbers, and position and size of the hands. This listing is an excellent reference for evaluating patient-specific deficits from a clinical perspective. However, the acceptance in the normative population of three subjects from the oldest age group who drew the contours too small to accommodate all the numbers is open to criticism. In a recent study (Reichenfeld et al 1991) this finding would have been considered sufficient to justify a diagnosis of minor cognitive deficit.

To provide norms based on age may also be misleading because individuals with undetected deficits could be included in the norming process. A more appropriate stratification would be based on specific physical disorders that can interfere with carrying out the clock drawing task. Conditions such as arthritis, tremor, visual deficits, and fatigue could provide the basis for a classification system on which the norms are developed, and patients would then be compared to the norms established for the major medical conditions.

Furthermore, to be considered from a research perspective, the different attributes would need to be weighted so that they could be combined to provide some general measure of well-being. While the authors have provided a complete and comprehensive listing of the different attributes involved in clock drawing, a research agenda to develop such an index should be considered. It is only after such an index is developed that its various clinometric properties of reliability, validity and responsiveness to change can be assessed. It could then be used as a primary outcome measure in intervention studies.

Chapter 3 discusses the clock drawings produced by patients with dementia and relates the extent of the deficits to the severity of the illness. It gives examples of qualitative changes over time. In Chapter 4 the authors report the results of assessing the clock drawings of 25 healthy occupants of a seniors’ residence and conclude that this test could be used as a screening instrument to detect the earliest changes of incipient dementia. The final chapter returns full circle to the earliest use of the clock drawing test (Critchley 1953) to identify focal brain damage from a variety of causes.

This book is beautifully produced. It is full of excellent examples of clock drawings illustrating the points made in the text. Although the scoring system needs to be developed further to be useful in epidemiological and outcome studies, it is detailed and comprehensive and is appropriate for a full qualitative analysis of clock drawing by patients with a variety of neurolgical and psychiatric disorders.

The bibliography is complete and up-to-date. The book is reasonably priced and can be highly recommended to both clinicians and researchers interested in the elderly, and in patients with specific neurological disorders, focal brain lesions, and different forms of dementia.

Neurobiology of Learning, Emotion, and Affect

Neurobiology of Learning, Emotion, and Affect

John Madden IV

New York, NY: Raven Press, 368 pp, 1991

This book comes at a time of progress and exciting new discoveries in the field of research involving the neural basis of learning, emotion and affect. The study of learning and memory has flourished for many years within the neuroscientific community. Although long neglected by all but a handful of neuroscientists, emotion and affect have begun to attract attention. A clear summary of the status of this recent work is therefore particularly welcomed.

The book is divided into three parts. The first part is devoted to recent advances in the research of the neural mechanisms of fear conditioning, in both invertebrates and vertebrates. Most exteroceptive stimuli we encounter in our life are affectively “neutral”. However, they can take on emotional properties and elicit emotional reactions, such as defence or approach responses, through association with other stimuli or events that are affectively charged. It is possible to study experimentally the ways in which the brain forms such associations through the use of Pavlovian conditioning techniques, whereby a “neutral” stimulus, the conditioned, or conditional stimulus (CS), is paired with a biologically significant (affectively charged) stimulus, the unconditional or unconditioned stimulus (US).

Pavlovian conditioning procedures have been used to study the biology of learning in many species. Whether or not it is reasonable to speak of Pavlovian conditioning as a process of emotional learning is debatable for invertebrates, many vertebrates, and even many mammalian species, if emotion is restricted to subjective, experiential factors. However, if by emotion we also mean the neural mechanisms by which stimuli are evaluated for their significance (LeDoux 1990), it is possible to view all animals as engaging in a form of emotional processing. What is different about humans and possibly higher primates is that the emotional processing of stimulus significance becomes represented as conscious content. This view is advantageous in that it places emotional processes on a continuum and allows for studies of emotion throughout the animal kingdom.

In the Aplysia model, described in detail by Hawkins, the cellular mechanisms and neural loci responsible for associative learning are, without a doubt, understood more than in any other animal model. Are the same basic mechanisms discovered in this simple model in operation also in more complex organisms? Hawkins believes that classical conditioning in Aplysia, Hermissenda, cat and rabbit involve the same neural mechanisms. In Aplysia, the US plays a modulatory role in stimulating the facilitator neurons. The convergence of this input with the appropriate CS input (the one that was paired with the US) increases presynaptic facilitation and produces classical conditioning. A similar mechanism is acting in vertebrate models as well, Hawkins suggests. The aminergic and cholinergic systems in the vertebrate nervous system can behave like the facilitator neurons of Aplysia. One challenge for the future is to test this simple and attractive theory.

Another elegant invertebrate model is Drosophila melanogaster. An advantage of this model is the possibility of using genetic tools. In recent years, the isolation of mutations that affect an aversive conditioning task in the fruit fly has considerably increased our understanding of the molecular mechanisms of learning and memory. Tim Tully reminds us that with Drosophila research, we probably have the only evidence that short-term and long-term memory are indeed two genetically distinct processes.

Our understanding of the molecular and underlying elementary neural mechanisms which make learning possible in an individual is far less developed in vertebrate models. In recent years, however, simple vertebrate model systems have been worked out, and important neural structures and pathways essential in learning have been shown. It now appears that different types of learning are mediated by different but, in some cases, overlapping neural circuits.

One promising vertebrate model is the conditioned fear-potentiated startle paradigm. In this behavioral model, the conditioned stimulus (usually a light) is paired with a shock and startle response elicited by a noise burst in either the presence or absence of the light. If the startle response is greater when elicited in the presence of the light, the fear-potentiated startle has occurred.

The role of the amygdala in this reflex has been demonstrated by Davis and collaborators; in this book they review the current state of affairs. The amygdala is the centerpiece of the neural pathway involved in fear-potentiated startle, as well as in other fear conditioning situations (Kapp et al 1990; LeDoux 1990). Davis and collaborators show that the activation of the amygdala from the visual conditioned stimulus pathway triggers the startle reflex pathway. The central nucleus of the amygdala carries this out through its connection with the nucleus reticularis pontis caudalis (a nucleus in the startle circuit). Davis and colleagues believe that the visual input comes to the amygdala through cortical pathways. However, findings from our laboratory suggest that visual fear conditioning can be mediated by subcortical visual inputs to the amygdala (LeDoux 1990).

There is a general consensus about the involvement of the amygdala in mediating the acquisition of autonomic responses in the aversive classical conditioning. These responses are defined as “non-specific” and include heart rate, generalized motor activity (freezing, startle response) and skin resistance. They all develop rapidly after a few trials, sometimes requiring just a single contingent pairing. “Specific” responses, on the other hand, are discrete, skeletal muscle responses elicited by specific aversive stimuli. They are much slower to develop and are more specifically adaptive for the organism.

Steinmetz and Thompson describe how the cerebellum, in particular the interpositus nucleus, is an important site for the acquisition of these discrete, specific responses. Using a multi-technique approach (recording, stimulation, lesion studies) they developed a detailed anatomical map of the circuitry involved in the adaptation to aversive events for these behavioral responses. According to Steinmetz and Thompson, the cerebellum plays an “informational” role in the learning of the organism. It is activated in conjunction with the aversive system that involves higher brain regions (the amygdala, for example). These two systems in the brain are distinct, but they interact in the adaptive learning phase. The US pathway activates both systems. And while the cerebellum appears to play an important role in learning the specific response, recent studies also suggest that the amygdala is involved in the early phases of learning. The final attempts to relate these ideas to the popular Rescorla-Wagner learning theory.

Part II of the book deals with experimental situations in which the animal is allowed little or no control over the aversive stimulation How do the subjects cope with stressful events when species-specific defense responses are not helpful? What kind of behavioral and biochemical changes will stressful events elicit? Results from these experimental studies are particularly valuable for their clinical implications. Weiss, using an uncontrollable shock paradigm, suggests in fact that stressed animals show symptoms closely corresponding to those developed by depressed individuals. Moreover, the author proposes that stressful events (for example, uncontrollable shock) elicit both anxiety and behavioral depression. In his analysis, Weiss shows how the locus coeruleus seems to be a key structure in the neurochemical unbalance produced by the uncontrollable shock.

Cognitive deficits may also occur as part of the response to stress. Animals that are exposed to shocks that they cannot avoid or escape later fail to escape shock in a situation in which escape is possible. They also fall well behind control animals (that were allowed to escape or avoid shock in the first phase of the experiment) in Y-maze or water-maze learning tests. Some researchers have explained these results in terms of a simple motoric impairment: the shocked animals learn a coping response in the new situation, but they cannot perform it. Maier rejects this hypothesis; his work suggests that inescapable shock gives rise to learning deficits that cannot be explained by a motor activity deficit.

However, the impairment is not the result of associational learning between the first phase of the experiment and later test situations, as it was suggested in the early explanations of this phenomenon. What is impaired in these subjects, according to Maier, is the capacity to attend the salient external cues; the deficit is then a cognitive one, not an associative one (the learned helplessness hypothesis). Whether this cognitive deficit will be connected to some neural loci or biochemical systems will have to be determined in future studies.

More complex issues of depression and human affect disorders, which involve multiple interactions between emotional and cognitive systems operating at conscious and unconscious levels, are difficult to probe with vertebrates too distant from us in the evolutionary ladder and in social habits. Suomi describes a primate model of affective disorders, the separation model. Humans share over 90% of non-replicated DNA material with higher primates. In addition, the behavior of these animals is characterized by advanced and dynamic social interactions among members of the same species. Rhesus monkeys, in particular, have been studied extensively in the wild and in laboratory settings. Stressful events caused by social relationships among individuals closely resemble human social life. Separation from an attachment object, such as a mother or a loved conspecific, produces profound behavioral and physiological effects, both in the wild and in the laboratory. The evidence of individual differences in these animals makes this model particularly interesting. Not all subjects respond to the same social separation in the same manner. There is also consistency in this behavior in individuals. The same monkeys “at risk” are more readily aroused by and behaviorally fearful of other stressful events. Having individuated the groups “at risk” in the rhesus monkeys population, it may be possible to forecast or even prevent the affective disorder. The “separation/risk” model in monkeys, as Suomi defines it, seems to be extremely promising for improving our understanding of the psychobiology of human affective disorders.

There is evidence from this primate model that the noradrenergic system is involved in mediating depressive states. Matthysse reaches the same conclusion in his analysis of mood disorders. In particular, the locus coeruleus, an important source of forebrain noradrenalin, is advanced as a candidate for depression, as Weiss also proposed for the helplessness model. According to Matthysse, this nucleus becomes activated by excited unhappy memories, which are the result of early loss or other traumatic events. Cerebral activation is then reduced by the increased firing of the locus coeruleus. At this point, physostigmine, the cholinergic agent, enters the circuit to produce the physiological symptoms of depression. In Matthysse’s view, while the memories are the primary cause of noradrenergic changes, the biogenic amines are only the effectors in this theory. Matthysse points out that human studies suggest that decreased cerebral activation is produced by physiostigmine in normal subjects (for example, the subjects feel “apathy, slowness of speech and movement”). Physiostigmine physiological symptoms closely resemble those of depression. In his fascinating theory, however, Matthysse does not tell us where these memories may be stored in the brain or why, at a certain point, they overflow to reach the locus coeruleus. Also, it will be interesting to try to define the role of anxiety in this context. Under identical conditions of stress some people respond only with anxiety; do they have the capacity to deal with the unhappy memories activation in a different way? Interesting questions arise from this theory that only future experiments can elucidate.

Control over stressors is a critical factor that influences biological functions which regulate adaptive and maladaptive behaviors. Bandura states that the ability to control stress effects is the principal factor that makes a person cope with stress events. It is the ability to control the stress effects that prevents the release of stress-related hormones or the impairment of the immune system. With the support of human quasi-experimental studies, Bandura describes the effect of being able to gain control over the stressful situation. For instance, catecholamine levels in phobic patients dropped after allowing them to acquire controlling efficacy. Pain tolerance was increased in normal subjects when there was self-efficacy, even in those subjects to whom naloxone was administered to block opioid activation. Self-efficacy mechanisms play an essential role in the individual’s well-being. Bandura’s theory proposes an entire psychological approach to deal with stressful events that deteriorate our biological systems. This approach provides an intelligent stimulus to operate in the sphere of human maladaptive behaviors with “clean” psychological tools but with an attentive eye on the neurobiological domain.

Part III of the book explores broader issues in the field of emotion and affect and presents two models. Gray describes three systems that control emotional behavior. Each of these systems is associated with a particular area in the brain. One of these systems, the behavioral inhibition system, is thought by Gray to be centered around the hippocampal formation. This system is responsive to stimuli associated with punishment or with the conditioned aversive stimuli and is involved in increasing the level of arousal and increasing attention to the environment to cope with the new situation. Anxiolytic drugs affect the septohippocampal system, and lesions of this system lead to a behavioral syndrome similar to that seen after the administration of anxiolytic drugs. These results are the strong-hold of Gray’s theory. The amygdala, a structure that has long been considered to play a pivital role in fear, including fear learning, is not included in the behavioral inhibition system. It is involved instead in the second system, the fight/flight system, which is responsive to unconditioned punishment and non-reward, that is, to issue commands either for fight or for flight depending on the context and type of punishment received. Gray dismisses fear conditioning studies as irrelevant to the problem of anxiety and relegates them to elicitor of a more species-specific type of defence or attack responses. We do not agree with such a view. Nevertheless, Gray’s model is commendable in its breadth and attempt to synthesize divergent findings into a unified theory of anxiety. The second model uses the opponent-process theory to explain a large set of affective phenomena, taken from everyday life and experimental settings. This model states that it is possible to produce acquired motives by non-associative mechanisms alone. The mechanism is repetition, not conditioning (association). Solomon believes that his approach can explain food intake, drug addiction and related phenomena that Pavlovian conditioning is not able to explain. An important question that the author raises is whether or not the opponent-process states are predictable. He is convinced that they are and analyzes the process of food intake and obesity following the logic of opponent-process theory.

Neurobiology of Learning, Emotion, and Affect is a well organized, multi-disciplinary book. It presents a range of approaches and contributions. The literature on behavioral neuroscience, in general, has increased tremendously in the last few years. Moreover, there is a growing interest in research on emotion, which has been somewhat neglected in the age of cognition. This book will help bring research on emotion into the limelight. The book will be very useful as an introduction to research on the biology of emotion and learning and will also be useful as reference point for future research.