Posts Tagged ‘epilepsy’

Psychiatric Comorbidity in Epilepsy

Psychiatric Comorbidity in Epilepsy: Basic Mechanisms, Diagnosis, and Treatment

H. Mc-Connell, Peter J. Snyder, editors

Washington (DC): American Psychiatric Press; 1998

ISBN 0-88048-853-0 (hardcover)

There is a fascinating and complex interrelation between psychiatric pathology and epilepsy. Historically, epilepsy was known as the “sacred” disease because of its alleged association with astrology, with the divine, and with demoniacal possession. Despite Hippocrates’ assertion that epilepsy “is no more divine nor more sacred than other diseases, but has a natural cause like other diseases,” these misconceptions continued until well into the 19th century, when the neuropathologic origins of epilepsy were identified.

However, the association between epilepsy and psychiatric illness did not cease when it was identified as a neurologic condition. People with epilepsy have an increased prevalence of both affective and schizophreniform disorders. Personality and adjustment disorders are common and seizures may be simulated by conversion states. Epilepsy also has profound socioeconomic implications for the sufferer. It is perhaps therefore the “psychosomatic” illness par excellence.

This book is a compendium of the psychiatric conditions associated with epilepsy. Its 12 chapters cover the historic, physiologic, pathologic, clinical and social aspects of epilepsy. There is an excellent chapter on the changing systems of classification of the epilepsies; the current international classification bears little resemblance to the systems used even 50 years ago. The advent of sophisticated investigative techniques for studying neuronal activity, such as EEG recordings and neuroimaging, has given this system a firm neuroanatomical basis, and has helped to integrate the neuroanatomical changes with the clinical seizure pattern.

There are excellent chapters on the neuropsychological assessment of patients with seizures, and on the mood disorders and psychoses associated with epilepsy. The latter chapter is of particular interest because recent developments have shown that there are lesions in the medial temporal structures of the brain in both epilepsy and schizophrenia. This etiologic overlap may explain not only the increased prevalence of schizophreniform psychoses in patients with epilepsy, but also suggests that there may be a neurophysiologic overlap at the neurotransmitter level between these seemingly disparate conditions.

Perhaps the 2 most useful chapters in the book are those on pharmacology. One reviews the behavioural effects of antiepileptic drugs, the other discusses the treatment of psychiatric disorders in patients with epilepsy. They provide an excellent state-of-the-art summary of the pharmacology of epilepsy and give many practical suggestions about the use of psychotropic agents and their effects on seizure threshold.

The book ends with 2 chapters on the “social” part of biopsychosocial aspect of epilepsy: one on family systems theory and the other, written by a man with epilepsy, entitled “Living with Epilepsy.” The latter is of special interest because the experiences he describes and the problems he raises are not dealt with elsewhere in the book. For example, he describes memory dysfunction, post ictal pain, social rejection and communication difficulties with his neurologists — experiences that are surely not unique to people with epilepsy. It would have rounded out the book if these consumer-driven issues had been dealt with in the clinical sections.

There are weaknesses in the book. The history of epilepsy is long and colourful and it is unfortunate that it is described here in a trite and cliche-ridden way. The chapter on diagnosis and treatment of nonepileptic seizures was superficial and unhelpful. It is puzzling why such seizures should be described in negative language when acceptable terms such as “conversion” or even “hysterical” seizures are available.

On the whole, however, this is a comprehensive, well structured and well referenced book. Each chapter ends with a conclusion that summarizes the main points in that chapter. I was very glad also to see

a uniform and consistent use of the term “people with epilepsy” rather than “epileptic” throughout the book. The word “epileptic” brands the sufferer in a pejorative manner and reinforces the very stigma we try to avoid. If only psychiatrists would similarly use the term “people with schizophrenia” rather than “schizophrenics”!

This book is highly recommended to psychiatrists, neurologists, neuropsychologists and others who see people with epilepsy in their practice.

The Neuropsychiatry of Limbic and Subcortical Disorders

The Neuropsychiatry of Limbic and Subcortical Disorders

Salloway S, Malloy P, Cummings JL, editors

Washington (DC): American Psychiatric Press; 1997. 217 pp with index

ISBN 0-88048-942-1 (cloth)

The limbic system is a topic of considerable interest to both psychiatrists and neurologists. For biologically oriented clinicians, one can barely go a week without encountering some reference to a limbic disorder. The explosion of information about the interconnectedness of various brain regions is forcing both practising clinicians and neuroscientists to grapple with all brain regions, not just a favorite few. Inevitably, one is confronted with the need to understand the function of the limbic system. The definition of the limbic system has steadily broadened over time to include not just the medial circuit of Papez, but structures that are functionally associated with it. In common usage then, the term “limbic system” speaks to a set of cognitive functions; these functions are subserved by a network of cortical and subcortical structures.

In this spirit, The Neuropsychiatry of Limbic and Subcortical Disorders represents a snapshot of the state of knowledge of the limbic system. This book expands on the summer 1997 special issue of The journal of Neuropsychiatry and Clinical Neurosciences on the same topic. Published by the American Psychiatric Press, it is a high-quality book at a reasonable price, with many colour figures and photomicrographs.

This book is not an easy introduction to the anatomy and function of the limbic system. As the editors state in their introduction, “The essays in the volume cover a broad range of basic and clinical material at various levels of difficulty. … Some of the chapters present complex material requiring careful study and perhaps a second reading.” This is not an understatement. The book is divided into 2 sections: Anatomy and Neurochemistry, and Clinical Syndromes. It is the first, more technical section that presents the most difficult material. For neuroscientists familiar with the terminology, these chapters represent an excellent resource. They are good summaries of the anatomical literature with extensive references. Most chapters have 50 to 100 well-selected references, though a few contain up to 300. There is an abundance of photomicrographs, many of which have been previously published and retain an alphabet soup of anatomical abbreviations. This may present a problem, primarily to the student of behaviour wanting to learn more about the neural substrates.

If the anatomy section suffers from over-inclusion of information, then the clinical section suffers from a lack of rigour, and must be taken as hypothetical in many cases. There are interesting ideas here, and the authors have put forth several theories regarding the pathology of syndromes including temporal lobe epilepsy, emotional experience, recovered memory and religious experience.

While many of the chapters focus purely on the anatomical or clinical aspects of the limbic system, a few successfully link anatomy and function. The chapter entitled “Neurobiology of Fear Responses,” by Michael Davis, is a particularly cogent exposition of the role of the amygdala in fear. This chapter, appropriately positioned between the 2 major sections, introduces concepts such as classical conditioning, and outlines the evidence from lesion and excitation studies for the amgydala’s function. It is accessible to both anatomists and behaviourists. The chapter entitled “The Neurobiology of Emotional Experience,” by Kenneth Heilman, lucidly outlines several theories of emotion, ultimately arriving at the modular theory. One version of the modular theory states that emotions are mediated by anatomically distributed modular networks, and it is the relative activation of these modules that gives rise to the variety of human emotion. The location of the modules, of course, overlaps with the limbic system. The chapter entitled “Limbic-Cortical Dysregulation,” by Helen Mayberg, is an excellent exposition of a theory of the functional organization of medial cortical and limbic structures. This theory, based largely on human functional imaging (positron emission tomography and functional magnetic resonance imaging), is quite successful in unifying often contradictory studies regarding cingulate function. Finally, the chapter by Koob and Nestler entitled “The Neurobiology of Drug Addiction” is a good summary of the neural substrates that underlie reward behaviour, and how drugs of abuse affect them.

All of the authors in this book have published extensively in their fields. Consequently, most of the material has appeared in other review articles. Nevertheless, it is convenient to have the information all in one place, together with the colour reproductions.

In a book that juxtaposes both anatomical and syndromic chapters, it becomes painfully obvious that our knowledge of brain wiring is fast outpacing our ability to describe behaviour. A great deal is known about connectivity, neurotransmitters and gene expression, but how can these be related to only a crude description of human experience? Saver and Rabin, in their chapter on religious experience, offer several convincing descriptions that would suggest that the mystical quality of a religious experience is a manifestation of limbic activity, if not outright seizure activity. While quite reductionist, it may even be true, but something is lost in the characterization of the experience. It is no coincidence that virtually every work of fiction is fundamentally concerned with “limbic function.” The conclusions of all classical tragedies are known — it is the human experience that captures our interest. When speaking about the function of the limbic system, one quickly realizes that the putative functions, emotion, memory and motivation, are difficult to describe, let alone quantify — hence, an unlimited supply of literature. Unlike other cognitive functions such as perception, language and motor behaviour, these limbic processes do not lend themselves easily to experimentation.

Are these processes unquantifiable? Perhaps the language is wrong. For example, anxiety is an emotion variously localized to the limbic system. One can go to great lengths using different rating scales to quantify the severity of anxiety, but ultimately one relies upon individual interpretation of crude descriptions. What if an emotion like anxiety were compacted to a measure of probability? For example, “I feel like I’m going to die,” represents the assignment of a non-zero probability to the outcome of death. While the individual may know death is unlikely, it nevertheless creates a situation of uncertainty: “I know I won’t die, but then again, what if I do?” Measures of uncertainty, while not in the usual parlance of emotion, do lend themselves to quantification, and ultimately correlation with neural activity. Perhaps it is time for a shift in the description of limbic behaviour. Only when these phenomena are accurately described will we be able to relate them to brain function and dysfunction.

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.

Basic Neurochemistry: Molecular, Cellular and Medical Aspects

Basic Neurochemistry: Molecular, Cellular and Medical Aspects

GJ Siegel, editor

New York: Raven Press; 1994. 1080 p

This multiauthor volume (80 contributors) is a 5th edition of the book published under the auspices of the American Society for Neurochemistry. The 4th edition was published in 1989 under the same editorship. The book is divided into 6 parts: neuronal membranes, synaptic function, molecular neurobiology, cellular neurochemistry, medical neurochemistry, and behavioral neurochemistry. Each part contains several (from 3 to 14) chapters; there are 50 chapters in total. Each chapter is further divided into sections and has a separate bibliography.

Rapid advances in the field of neurosciences and a virtual explosion of information in areas of molecular biology and genetics during the last several years have presented the editors with the enormous challenge of conveying the material in a comprehensive yet readable manner within a single volume. It appears that they have successfully met this challenge. They have expanded the book by only about 100 pages in adding new chapters on the molecular basis of olfaction and taste, neurotransmitter and growth factor receptor families and 2nd-messenger signaling systems, amino acid and purinergic neurotransmission, neurotransmitter uptake system, and molecular targets of drugs of abuse. Many other chapters have been revised or rewritten to include new information on amine transmitters, eicosanoids and neuronal function, developmental neurobiology, gene expression, aging, cytoskeletal development and plasticity, and cognitive functions. An important new feature of this edition is the introduction of color plates for figures and tables and color subheading summarizing key concepts. The cartoons illustrating important concepts and mechanisms are instructive, and some of them use witty symbols (turtles) to indicate various pathways. They are easy to follow and to read. It is, though, a pity that 2 chapters in the behavioral neurochemistry section do not have any illustrations. All of these features make this volume virtually a new book, more readable and appealing than the last edition.

The 2 parts of the book with most extensive coverage of the subject are synaptic function and medical neurochemistry. I found the part on synaptic function well balanced and coordinated with excellent chapters on neuronal proteins and role of protein phosphorylation in regulation of neuronal function. The receptor classification is up to date (that is, to the book’s publication date). The readers will notice that some classifications have changed and new receptors have been identified since the book has appeared. An example at hand is the 5-HT1c receptor that is now classified as a member of the 5-HT2 receptor family (5-HT2C receptor). In addition, 5-HT2A and 5-HT2B receptors have been identified as distinct receptors. The part on medical neurochemistry includes chapters dealing with bio- and neurochemistry of some muscular disorders, vitamin and nutritional deficiencies, neuropathies, myelin diseases, metabolic disorders, drug abuse, ischemia, epilepsy, basal ganglia disorders, and Alzheimer’s disease. A chapter on brain imaging emphasizes the important role of positron emission tomography in studying brain function. Perhaps other techniques (magnetic resonance imaging [MRI], single photon emission computed tomography [SPECT]) could also have been described, at least briefly.

The behavioral neurochemistry part contains chapters on biological aspects of psychotic disorders, hypotheses of mood and anxiety disorders, as well as chapters on learning and memory. It was slightly disappointing to this reviewer that psychiatric disorders received much less prominent treatment than some neurologic disorders (for example, epilepsy). The chapter on mood disorders is actually confined to biochemical hypotheses without presenting some at least illustrative biochemical and clinical data. In this chapter, all hypotheses are given equal importance, although evidence would indicate otherwise (for example, importance of the serotonergic versus the cholinergic system). One of the important hypotheses of depression and mode of action of antidepressants involving adaptive changes of presynaptic 5-HT1A receptor is not even mentioned, though it is often quoted in other textbooks.

Considering that the volume has so many contributors, the chapters are, on the whole, well balanced, and the style of introducing concepts, supporting evidence, illustrations, and conclusions is remarkably uniform. Credit for this goes undoubtedly to the editors. The quality of print and reproductions is high. This is a book that should be a part of the personal library of any worker in the various fields of neuroscience, clinical medicine, and psychiatry who look not only for factual information but also for a feast of ideas.

Clinical Child Neuropsychiatry

Clinical Child Neuropsychiatry

C Gillberg

New York: Cambridge University Press; 1995. 368 p

This reviewer was privileged to hear a remarkable presentation by Dr Christopher Gillberg, a Swedish child psychiatrist, in Australia in 1992. He was one of the invited plenary speakers at the International Association for the Scientific Study of Mental Deficiency at the Gold Coast Conference in 1992. He spoke clearly and precisely as he related a wealth of personal research about the underlying medical conditions leading to the autistic disorders. During the past 10 years, Dr Gillberg has become a preeminent world authority in the field of mental retardation and psychiatric disorder. This textbook confirms that his writing matches his memorable presentation in Australia. It is an encyclopedic distillation of not only the psychiatric aspects of mental retardation but also the organic factors involved in obsessional disorders, attentional disorders, language disorders, sleep and elimination disorders, and more. Even more surprising is his compilation of the existing knowledge on behavioral and physical phenotypes, which he correlates with genetic findings, a task not previously attempted to this reviewer’s knowledge.

With Gillberg’s inclusion of the psychiatric sequelae of traumatic brain injury in children, epilepsy, cerebral palsy, and brain tumors, along with their neurodevelopmental, neuropsychological, and laboratory workups, directors of child and adolescent psychiatry education, after reading this textbook, will likely have to insist on the inclusion of 6 months to a year of developmental pediatric and pediatric neurology in child psychiatry training in order to allow themselves to be called “Complete Child Psychiatrists”!

Although the Ontario Health Study indicates that the percentage prevalence of emotional and behavioral disorders in children and adolescents is in the double figures, Gillberg, in his chapter on epidemiology, states that up to 10% of children have neuropsychiatric disorders(the bulk of which manifest as attention deficit disorders). The importance of workup and diagnosis by trained clinical child psychiatrists is emphasized by such figures.

In this textbook, we are brought up to date with molecular genetics in diagnosing such conditions as fragile X syndrome, Prader-Willi syndrome, Angelman’s syndrome, neuroflbromatoses, Duchenne muscular dystrophy, and possibly Williams syndrome. Other background factors, such as temperament, prenatal, sociocultural, and familial factors are noted, and an excellent bibliography is provided for more detailed reviews.

A brief but significant chapter on normal development includes not only a practical table of milestones (useful for clinical inventory) but also a clear exposition of Baron-Cohen’s “Theory of Mind” and subsequent development of complex social interaction and empathy.

As would be expected from one of Gillberg’s primary areas of interest, the chapter on autism and “autism spectrum” disorders is excellent. It not only brings us up to date with DSM-IV definitions, but also it supports Lorna Wing’s thesis that there is doubtful specificity of “pure” Kanner autism. Instead, Gillberg proposes that there are a number of conditions that result in disorders of “empathy.” He makes a compelling argument against the current classification of pervasive developmental disorders. This is particularly supported when he lists 17 organic conditions that have been confirmed as producing the autism spectrum. The standardized neuropsychiatric assessment and relevant laboratory workups to detect these 17 conditions are outlined. Of particular importance and interest to child psychiatrists is his detailed review of the current state of knowledge of Asperger’s syndrome, including an outline of the controversy over classification and the long-term outcome for those suffering from this condition.

There is a surprising inclusion of anorexia nervosa in the chapter, which also links obsessive-compulsive disorders with tic disorders and Tourette’s syndrome. He outlines the hypothesis that anorexia nervosa is a final common pathway disorder including psychosocial, neurochemical, and local gastric factors with a minimal relationship to family dysfunction.

Gillberg makes a significant contribution to clinical diagnosis and treatment as well as future research potential by introducing the term “DAMP” disorders. This new umbrella term covering “Deficits in Attention, Motor Control and Perception” is much clearer than the alternative phrase, “Minimal Brain Dysfunction.” It was coined by Gillberg in 1983 and is now accepted by the Nordic consortium of child psychiatry. Given that attentional disorders, motor control disorders, hyperkinetic disorders, perceptual (reading and writing) disorders, and speech and language disorders overlap, this is a much-needed classification that is worthy of considerable scrutiny by the American Psychiatric Association and World Health Organization.

Another new term for this reviewer is “Jactatio capitis.” No, it is not a new paraphilia, but it has implications for those clinicians working with tic disorders and other repetitive rhythmic disorders. (To find out more, the reader is referred to Chapter 9.)

The longest chapter (70 pages) and the one filled with the most “meat” is entitled “Specific Syndromes Not Otherwise Referred To.” Here, Gillberg is at his most-knowledgeable best, compiling the prevalence, sex ratios, behavioral phenotypes, pathogenesis, diagnosis, workup, treatment, and outcome of congenital developmental syndromes. My only criticism of this chapter, and it is rather muted, is that the chapter could have included more pictures of the dysmorphic features of some of the syndromes. I suppose, however, that the knowledgeable reader should have a companion volume such as the Nyhan and Sakatis textbook, Diagnostic Recognition of Genetic Disease, on the shelf.

The psychopharmacology of child neuropsychiatric syndromes is complete, succinct, and up to date and draws heavily on the author’s former working relationship with Magda Campbell.

For his next edition (hopefully because of the importance of this textbook there will be many future editions), this reviewer would like to see expansion in the size of the specific syndrome chapter as well as an expansion on the psychiatric sequelae of and psychosocial intervention with traumatic brain injury, cerebral palsy, and epilepsy.

The textbook gains tremendous consistency from its single authorship. It is a major textbook, more comprehensive, detailed, and current than any other on developmental psychiatry. It, along with Levine and others’ 1983 textbook, Developmental-Behavioural Pediatrics, should be on the shelf of every child psychiatry resident, notwithstanding its price. It has fulfilled Gillberg’s goal of being “the first such compilation on clinical child neuropsychiatry, in which all the infancy, childhood or adolescent onset disorders in which mental, emotional and behavioural problems predominate . . . and for which biological factors . . . play a major . . . role are included.” Congratulations, Dr Gillberg!

Concise Guide to Neuropsychiatry and Behavioral Neurology

Concise Guide to Neuropsychiatry and Behavioral Neurology

JL Cummings and MR Trimble

Washington DC: American Psychiatry Press Inc; 1995.275 p

Psychiatry is heading, willy-nilly, down the subspecialty route. Child, geriatric and forensic psychiatry are already recognized as subspecialties, and others such as psychotherapy and consultation-liaison psychiatry are following closely. Unfortunately, subspecialization is progressing in a disorganized manner, and this leads related subdisciplines such as neuropsychiatry and consultation-liaison psychiatry to evolve in parallel. Often, little effort is made to cohere or even to collaborate.

The authors of this small volume define neuropsychiatry and behavioral neurology as “clinical disciplines devoted to understanding and treating behavioral disturbances associated with brain dysfunction” (p 1). This definition seems restrictive and appears to rule out, by definition, the psychosocial aspects of neurological practice. Therefore, neuropsychiatry, according to these authors, does not follow the biopsychosocial model. The first author is a professor of psychiatry and neurology at the University of California at Los Angeles (UCLA) School of Medicine, and the second is a professor of behavioral neurology at the Institute of Neurology, London, England.

Initial chapters are devoted to assessment, neurobiology and psychiatric syndromes. The rest of the book is devoted to neurological syndromes such as epilepsy, dementia, stroke and head injury. Each chapter is concise, and frequent tables list and summarize relevant points. The text is clear, readable and nonrepetitive. No references are given in the text, but there is a useful reading list at the end of each chapter.

Despite the authors’ restrictive definition, I was surprised by the total absence of any reference to somatoform disorders or to the psychosocial aspects of neurology. Somatoform disorders form at least 14% of a neurologist’s practice (Mai 1995). One would have thought that any clinical textbook that included the word “behavior” in its title would also cover the field of illness behavior. However, one looks in vain in this book for any recognition of the existence of illness behavior, conversion or somatization. Even the brief description of pseudoseizures fails to mention that they may have a conversion basis. The authors do not explain the reasons for this omission, but it is likely the result of their chosen focus on neurological disease.

This approach reminds me of the old story about the drunk who returns home late at night to find he has lost the key to his front door. He then confines his search to the area around the street light, because “that’s where the light is”. The authors of this volume have similarly chosen to ignore the darker areas of neurology which, inspite of themselves, affect the clinical practice of this discipline.

In other respects, the book provides a useful and concise description of the field within die confines set by the authors. It could be of value to residents, psychiatrists and neurologists with an interest in this field. It is expensive for a soft-cover book.

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.

Synopsis of Neuropsychiatry

Synopsis of Neuropsychiatry

SC Yudofsky and RE Hales, editors

Washington DC: American Psychiatric Press; 1994. 641 p

This paperback is a synopsis of the American Psychiatric Press Textbook of Neuropsychiatry, which was first published in 1987 (a second edition has subsequently been published). The Synopsis of Neuropsychiatry is designed to condense most chapters from the second edition, and its content is aimed at medical students and residents in psychiatry and neurology.

The book is divided into 5 sections: the basic principles of neuroscience, neuropsychiatric assessment, neuropsychiatric symptomatologies, neuropsychiatric disorders, and neuropsychiatric treatments.

The section on basic principles of neuroscience includes chapters on cellular and molecular biology of the neuron, and on human electrophysiology. The chapter by Daniel Tranel on functional neuroanatomy from a neuropsychological perspective is particularly well done. These chapters are all well organized and plentiful diagrams add interest and clarity.

The neuropsychiatric assessment section includes chapters on bedside neuropsychiatry, neuropsychological evaluation, electrodiagnostic techniques, brain imaging, and epidemiology and genetics. The chapter on bedside neuropsychiatry by Fred Ovsiew is an excellent summary of the major symptoms and signs of neuropsychiatric disorders. The chapters on electrodiagnostic techniques and brain imaging are also good overviews. I found the chapter on epidemiology and genetics too technical when describing linkage analysis and molecular approaches to the investigation of various neuropsychiatric diseases such as Huntington’s Disease and schizophrenia.

The third section on neuropsychiatric symptomatologies includes chapters on differential diagnosis in neuropsychiatry, neuropsychiatric aspects of pain management, and delirium. Chapters on neuropsychiatric aspects of aphasia and related language impairments, and neuropsychiatric aspects of memory and amnesia are also part of this section. The chapter on differential diagnosis by Richard Strub and Michael Wise has an excellent algorithm on the approach to the patient with memory loss, as well as an informative and concise table on common focal behavioral syndromes and their localization. The chapter on pain management by William Brouse and David Spiegel focusses on neurological mechanisms of pain and neuropharmacology but could be more clinically oriented. Delirium is well covered by Michael Wise and George Brandt. Frank Benson provides a superb chapter on aphasia, which presents a complicated topic clearly and succinctly. The chapter on neuropsychiatric aspects of memory and amnesia by Arthur Shimamura and Felicia Gershberg describes the neural and biochemical mechanisms of memory very well, and outlines some clinical syndromes. However, it would benefit by a section on the differential diagnosis and investigation of the patient with memory disturbance.

The next section has 12 chapters on specific neuropsychiatric disorders: traumatic brain injury, epilepsy, sleep, cerebral vascular disorders, brain tumors, human immunodeficiency virus, endocrine disorders, poisonous and toxic disorders, alcohol-induced organic mental disorders, degenerative dementias associated with motor dysfunction, Alzheimer’s Disease and other dementias, and the neuropsychiatry of schizophrenia. There are particularly comprehensive and clinically focussed chapters on sleep (by Thomas Neylan, Charles Reynolds and David Kupfer), cerebral vascular disorders (by Sergio Starkstein and Robert Robinson), Alzheimer’s Disease (by Jeffrey Cummings), and the neuropsychiatry of schizophrenia by Henry Nasrallah. There is little, in any chapter, written on the neuropsychiatric aspects of multiple sclerosis despite its prevalence. Other missing topics include autistic disorders and mental retardation, neuropsychiatric aspects of street drug abuse, and chronic fatigue syndrome.

The final section on neuropsychiatric treatments includes chapters on psychopharmacological treatment in neuropsychiatry, psychotherapy for neuropsychiatric disorders, cognitive rehabilitation and behavior therapy, stress and coping in family caregivers, and ethical and legal issues in neuropsychiatry. The chapter on psychopharmacology by Steven Dubovsky is comprehensive and well organized. I found the chapter on psychotherapy too long and wordy, although the tables nicely summarize the lengthy discussion in the text. The chapter on cognitive rehabilitation and behavior therapy by Mark Lovell and Christopher Starratt is a well-written overview, and serves as a good introduction to this topic. Stress and coping in family caregivers is covered mostly by discussing theorical models with little attention to clinical issues. Ethical and legal issues in neuropsychiatry are well covered in the chapter by Robert Simon.

Overall, this is a strong textbook which provides a solid overview of neuropsychiatry. The authors are all recognized neuropsychiatry experts. Every chapter is well referenced, which enables the reader to investigate any topic in more depth, if necessary. A strength of almost every chapter is the liberal use of tables, diagrams and figures. Unfortunately, several chapters contain diagrams and figures that require colour to be useful, such as figures of PET and SPECT scans. The reader is referred to The American Psychiatric Press Textbook of Neuropsychiatry, second edition, for full-color figures. This is extremely irritating, and it is unlikely that many readers will have ready access to the larger textbook when reading this chapter, thus losing the benefit of illustrations. I suggest that the publisher consider adding full-color figures even if it increases the cost of the Synopsis of Neuropsychiatry.

This book will be very useful for residents in psychiatry, particularly during a rotation in consultation-liaison psychiatry, and also for neurology residents and neuropsychology interns. Medical students will benefit from this book during their rotations in psychiatry and neurology. It will also be useful to clinical psychiatrists involved in inpatient and consultation-liaison psychiatry, although other textbooks will be necessary if an indepth look into a particular area is desired.

Epilepsy and Quality of Life

Epilepsy and Quality of Life

MR Trimble and WE Dodson, editors

New York: Raven Press; 1994.306 p

This volume affords the opportunity to assess the current state of quality of life (QOL) research in epilepsy. As is the case with most concepts in science, one can trace the evolution of an area of interest from its infancy (early attempts to define the subject domain, followed later by single-variable studies) to maturity (multifactorial experimental designs, links to theory, consensus regarding definition, and randomized controlled trials).

Trimble and Dodson’s book is worthwhile in that it indicates quality of life research in epilepsy has moved past its infancy, but has yet to reach its mature state. The book is the product of a 1993 workshop during which definition and measurement issues regarding QOL in epilepsy were addressed. It contains chapters written by international researchers who are prominent in the field. Researchers and clinicians who deal primarily with epilepsy will find this book useful. Considerable space is devoted to contemplating the dimensions of quality of life in epilepsy, and how QOL is experienced by patients, families, and their associated social systems. Key assessment instruments are reviewed in significant detail, and 4 of the leading measures are actually reproduced in appendices. The book’s effort to provide practical information is helpful. Specific implications of quality of life are also given attention. Examples include Cramer’s chapter on compliance issues, and Hermann’s particularly well-written chapter on cognitive and psychosocial outcomes following epilepsy surgery. It was enlightening to read the 2 chapters written by representatives of the pharmaceutical industry who provide a novel view of advances and problems in the research. Their suggestions cause us to reflect on the directions our work is taking.

The editors are to be commended for trying to balance applied and statistical/experimental issues. They acknowledge the diverse perspectives that QOL research has adopted. The North American approach to QOL seems to be overshadowed by the ESI-55 and Quality of Life in Epilepsy questionnaire (QOLIE) (both described in this book), but it is abundantly clear from other chapters that the European approach is somewhat different (for example, Trimble’s use of repertory grid techniques in the UK). In contrast to these approaches are the epidemiological concepts of risk and standard gamble; several contributing authors appropriately cite the seminal influence of Guyatt and others in this area. This wide diversity reminds us that as much as a consensus regarding definition and measurement of QOL would be desirable, it has not yet been achieved.

This volume is comprehensive and most chapters are clear, well organized, and well written. Two of the strongest are by Johnson and Fallowfield, who discuss theoretical and practical issues pertaining to test construction and human measurement. All who conduct research into QOL must have a grasp of these concepts, and the field will likely not advance further until such is the case. Although progress is apparent in the work contained in these pages, a consensus definition of QOL remains elusive. Coordinated, programmatic research efforts are still the exception. This volume has usefully taken the pulse of QOL research in epilepsy, and should stand as an impetus to advance its level of sophistication and scientific rigor.

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.