Neurorehabilitation and cognitive-behaviour therapy of anxiety disorders after brain injury: An overview and a case illustration of obsessive-compulsive disorder

Survivors of acquired and traumatic brain injuries may often experience anxiety states. Psychological reactions to neurological trauma may be caused by a complex interaction of a host of factors. We explore how anxiety states may be understood in terms of a biopsychosocial formulation of such factors. We also review the current evidence for the presence of specific anxiety disorders after brain injury. We then describe how cognitive-behaviour therapy (CBT), a treatment of choice for many anxiety disorders, may be integrated with cognitive rehabilitation (CR), for the management of anxiety disorders in brain injury. We illustrate how CBT and CR may be delivered with a case of a survivor of traumatic brain injury (TBI) who had developed obsessive compulsive disorder and health anxiety. We show how CBT plus CR allows a biopsychosocial formulation to be developed of the survivor's concerns for guiding a goal-based intervention. The survivor made significant gains from intervention in terms of goals achieved and changes on clinical measures. We argue that large-scale research is needed for developing an evidence base for managing emotional disorders in brain injury.     

A constant perfusion slice chamber for stable recording during the addition of drugs

A new design for a brain slice chamber is described. This chamber has the following features: slices are maintained in a stable condition for long-term (3-4 h) intracellular recording; drugs may be injected into the flowing perfusion medium in known concentrations without disturbing intracellular penetration; a wide range of concentrations may be used to test a single cell, highly repeatable results may be obtained; only minute amounts are required of substances to be tested, and the apparatus is easy to use and clean since all parts are removable. The chamber may also be easily modified to allow for the requirements of different experiments. The chamber has been used successfully to test the effects of Ang II, carbachol, insulin and gonadotropin releasing hormone.     

Neurorehabilitation and cognitive-behaviour therapy of anxiety disorders after brain injury: An overview and a case illustration of obsessive-compulsive disorder

Survivors of acquired and traumatic brain injuries may often experience anxiety states. Psychological reactions to neurological trauma may be caused by a complex interaction of a host of factors. We explore how anxiety states may be understood in terms of a biopsychosocial formulation of such factors. We also review the current evidence for the presence of specific anxiety disorders after brain injury. We then describe how cognitive-behaviour therapy (CBT), a treatment of choice for many anxiety disorders, may be integrated with cognitive rehabilitation (CR), for the management of anxiety disorders in brain injury. We illustrate how CBT and CR may be delivered with a case of a survivor of traumatic brain injury (TBI) who had developed obsessive compulsive disorder and health anxiety. We show how CBT plus CR allows a biopsychosocial formulation to be developed of the survivor's concerns for guiding a goal-based intervention. The survivor made significant gains from intervention in terms of goals achieved and changes on clinical measures. We argue that large-scale research is needed for developing an evidence base for managing emotional disorders in brain injury.     

The geriatric depression scale: Rater-administered or self-administered?

A need exists for a simple screening instrument for depression in the elderly which may be applicable in mild to moderate dementia. The GDS is a simple 30-item instrument whose role in screening for depression in dementia is controversial. This may relate to problems with its use as a self-administered questionnaire with unclear guidelines as to which subjects may be aided by the rater. We assessed the GDS as a staff-administered and a self-administered instrument in 100 elderly medical patients. There was a significant difference between the mean scores for each mode of presentation. This may account in part for the discrepancies between published studies on the GDS in dementia. In the absence of strict guidelines for the original mixed mode of application, the GDS should be considered as a staff-administered questionnaire exclusively.     

Presenting psychiatric and cognitive disorders in adult neurolipidoses

Neurolipidoses may present as psychiatric illness or dementia which may be isolated for a long time without neurological manifestations. Thus the relation with a metabolic disease may be difficult to establish. In this survey, we wish to present our clinical and biological experience in relation with lysosomal or peroxisomal disorders giving rise to neurolipidoses, a review of the literature, as well as the elements which allow to present a diagnostic strategy. We report mainly on metachromatic leukodystrophy, GM2 gangliosidosis, Fabry's disease, Niemann-Pick type C, Kufs disease, adrenoleukodystrophy, cerebro-tendinous xanthomatosis. Psychiatric symptoms may overshadow subtle signs of cognitive and motor dysfunction. Careful and persistent neurodiagnostic evaluation must be performed even in cases when CT and MRI scans are considered normal. Resistance to psychotropic drugs may be an element of orientation. The biological diagnosis is mainly biochemical. Although most of the genes involved have been cloned, many of the mutations are private, except for metachromatic leukodystrophy for which specific mutations may be related to adult cases and either with predominantly motor or predominantly cognitive and psychiatric manifestations. This review discusses also other metabolic diseases which may present as isolated or predominant cognitive and psychiatric manifestations.     

Evolutionary concepts of affective disorders

Mood may be considered the module of the human mind, which has evolved to tune the activity ofthe organism to the specific environmental conditions in a better way. In some cases depression may be adaptive, for example in aborting the activity associated with too many obstacles. At the same time hypomania may be related to the capability of mobilising the organism to gain many resources in a short period of time. Severe mood disorders may be related to the genetic variants, eg. of the serotonin transporter or brain-derived neurotrophic factor, which in several situations may give some evolutionary advantage. Affective temperaments, observed in the relatives of patients with affective disorders may be associated with some benefits in the social life. The relationship between early adversities and adult depression may be related to the phenomenon of the stress axis programming, which has deep evolutionary roots. Some infectious factors may cause behaviours similar to the affective symptoms, which may increase their reproductive success. The evolutionary perspective, which is complementary to the current etiopathogenic theories may help in understanding, why genes and traits which     

Reminiscence and life review in the elderly

Reminiscence in skilled hands may be a useful adjunct when caring for older individuals. The individual may benefit psychologically from a feeling of increased self-esteem and control. Staff must clearly establish a modality in which to utilize reminiscence; goals must be set. Problems that may result from uncovering certain memories must be carefully dealt with and may even require the assistance of a skilled psychotherapist. Additional research is necessary to improve our understanding of this potentially useful interactional tool.     

Is there a neural basis for borderline splitting?

It is proposed here that borderline splitting and borderline pathology may have a neural basis. For the infant who splits its emotional and cognitive constitution of its mother during separation-individuation, the "good mother"--"bad mother" engram may be lateralized in the brain in a different way than for an infant who does not use this defense. The infant may be developmentally vulnerable to the effects of splitting during separation-individuation (18 to 36 months) because interhemispheric communication necessary for mental unity is not possible at this time, since neurons connecting left and right hemispheres are not totally myelinated and because the infant has not yet fully acquired language, a prerequisite for an integrated psychological reality. Two separate, unintegrated--and alternating--mental systems may come into being. Later, as myelination is completed, the infant's split emotional and cognitive constitutions of mother and of self may create a neural "template" for splitting all further experience and behavior through the two separate, alternating mental systems. The possibility that emotional trauma occurring later than separation-individuation, and involving other issues, may be the occasion for splitting is considered, as well as the possibility that a congenital abnormality in brain structure or function may be a primary factor in borderline pathology. Ways to test the hypothesis that borderline splitting has a neural basis are suggested.     

Palatability of liquid major tranquillizers

Those with mental disorder in later life may reject medication for various reasons. In the case of liquid medication this may be due not to mental disturbance or swallowing difficulty but to unpalatability of the medication. Thirty volunteers blind-tasted four major tranquillizer liquid medications and a palcebo. Not one of the active preparations was thought to be pleasant, each being associated with bad immediate or delayed taste. Undesirable taste may be a valid cause for rejection by patients of any age. As liquid medication is prescribed more frequently for elderly than for younger patients, palatability should be considered.     

Manic disorder in the aged: a review of the literature

Very little has been written about mania in the elderly population. Most authors of the 1960s and 1970s situate the age of onset of affective disorders well before the geriatric period. In the 1980 some authors reached quite different conclusions about the age of onset. One study calculated an increased frequency of manic psychosis with advanced age. However, it seems difficult to compare these studies. A few cases of primary mania in the elderly have been published and it is important that more of these cases be reported. Mania diagnosis in this group of patients is not easy to make: past history may be difficult to assess, false first diagnosis may still occur in some cases, the course and the presentation of the illness may be less typical, there may be a picture of pseudodementia, confusion, depressed mood, etc. Mania may be secondary to physical illness (organic affective syndrome). Moreover, a frank manic picture may be mistaken for dementia (or for organic brain syndrome) even if it is indeed a primary affective illness.     

Actin in the nervous system

Since synaptic plasticity is an important property of the brain, it is timely to try to understand the possible mechanisms underlying this phenomenon. The role of the cytoplasm for neuronal functions has until now been largely overlooked, the main emphases being on the plasma membrane for fast electrical events and on cytoplasmic organelles for the slower metabolic processes. However, recent studies on the cytoplasm of non-muscle cells have stressed the importance of contractile proteins, like actin, on maintaining the cell shape and a number of vital cellular functions which may be related to the phase transitions in the cytoplasm. The necessary versatility is conferred on the actin networks by actin-associated proteins and by the free cytosolic calcium. In the nervous system, in addition to actin and myosin, a number of actin regulatory proteins was recently isolated, and they were shown to have properties similar to those of other non-muscle cells. Consequently, actin networks in neurons like those in non-muscle cells may be capable of contraction and phase transitions. The phase transitions have a rapid onset, and they may be quickly terminated or they may last over extended periods of time. In this way actin networks may gain control over the state of the cytoplasm and hence over the function of the neuron. Actin may be therefore uniquely suited to regulate various plastic reactions. The cytoplasm of growth cones and dendritic spines contains solely actin networks and is devoid of microtubules and neurofilaments. Since both these structures contain myosin and since growth cones are endowed with a considerable motility, dendritic spines also may have a likewise property. The necessary regulation of the levels of free cytosolic calcium may be provided by the spine apparatus in addition to calcium pumps in the plasma membrane and calcium regulatory proteins in the spine cytoplasm. Various types of stimulation which change the level of free cytosolic calcium may induce contraction of the spine actin network which may be responsible for the morphometric changes observed following different experimental interventions and pathological conditions. Although most of the conclusions in this review are rather speculative they may provide directions for future research in the spine and synaptic plasticity.     

Neuroimaging-based biomarkers for treatment selection in major depressive disorder

The use of neuroimaging approaches to identify likely treatment outcomes in patients with major depressive disorder is developing rapidly. Emerging work suggests that resting state pretreatment metabolic activity in the fronto-insular cortex may distinguish between patients likely to respond to psychotherapy or medication and may function as a treatment-selection biomarker. In contrast, high metabolic activity in the subgenual anterior cingulate cortex may be predictive of poor outcomes to both medication and psychotherapy, suggesting that nonstandard treatments may be pursued earlier in the treatment course. Although these findings will require replication before clinical adoption, they provide preliminary support for the concept that brain states can be measured and applied to the selection of a specific treatment most likely to be beneficial for an individual patient.     

A mnemonic for Parkinson disease patients considering DBS: a tool to improve perceived outcome of surgery

Patients considering deep brain stimulation (DBS) for Parkinson disease (PD) may be exposed to videotapes, media coverage, or literature which show dramatic improvements in PD symptoms after surgical intervention. Based on this information, patients may seek a medical center with expertise in DBS for an evaluation and assessment of their candidacy for surgery. If patients receive a device, they may be disappointed or despondent following surgery because of a failure to achieve a preconceived and unrealistic outcome. In order to address the important issue of patient misconception of potential outcome, we have introduced a simple mnemonic device. The device may be taught and then reviewed with patients and families both before and after surgery. Use of this mnemonic device may allow the patient and family the time necessary to alter the perception of perceived benefit. This education can help to ensure that outcome meets or exceeds expectation, and as a result they become a more satisfied and easy-to-manage DBS patient.     

Commentary: Physical approaches for the treatment of epilepsy: Electrical and magnetic stimulation and cooling

Physical approaches for the treatment of epilepsy currently under study or development include electrical or magnetic brain stimulators and cooling devices, each of which may be implanted or applied externally. Some devices may stimulate peripheral structures, whereas others may be implanted directly into the brain. Stimulation may be delivered chronically, intermittently, or in response to either manual activation or computer-based detection of events of interest. Physical approaches may therefore ultimately be appropriate for seizure prophylaxis by causing a modification of the underlying substrate, presumably with a reduction in the intrinsic excitability of cerebral structures, or for seizure termination, by interfering with the spontaneous discharge of pathological neuronal networks. Clinical trials of device-based therapies are difficult due to ethical issues surrounding device implantation, problems with blinding, potential carryover effects that may occur in crossover designs if substrate modification occurs, and subject heterogeneity. Unresolved issues in the development of physical treatments include optimization of stimulation parameters, identification of the optimal volume of brain to be stimulated, development of adequate power supplies to stimulate the necessary areas, and a determination that stimulation itself does not promote epileptogenesis or adverse long-term effects on normal brain function.     

Restraint procedures and dementia sufferers with psychological trauma

Restraint is an extreme response to an emergency situation in which there is imminent harm to self or others. Although some restrained patients become calm, others may become even more behaviorally disorganized. In some of these latter cases, the restrained patients may be victims of violence for whom the restraint procedure acts as a symbolic reminder of the past victimization. Elderly dementia sufferers may also be among these victims of violence. This paper provides a brief review of psychological trauma, research findings on psychological trauma in the elderly, and an approach to modifying restraint procedures that may be needed for dementia sufferers with a past history of victimization to minimize the disquiet associated with the needed restraint.     

Insomnia in central neurologic diseases--occurrence and management

The objective of this review is to highlight the impact of insomnia in central neurological disorders by providing information on its prevalence and give recommendations for diagnosis and treatment.Insomnia in neurological disorders is a frequent, but underestimated symptom. Its occurrence may be a direct consequence of the disease itself or may be secondary to pain, depression, other sleep disorders or the effects of medications. Insomnia can have a significant impact on the patient’s cognitive and physical function and may be associated with psychological distress and depression. Diagnosis of insomnia is primarily based on medical history and validated questionnaires. Actigraphy is a helpful diagnostic tool for assessing the circadian sleep–wake rhythm. For differential diagnosis and to measure the duration of sleep full polysomnography may be recommended.Prior to initiating treatment the cause of insomnia must be clearly identified. First line treatment aims at the underlying neurologic disease. The few high quality treatment studies show that short term treatment with hypnotics may be recommended in most disorders after having ruled out high risk for adverse effects. Sedating antidepressants may be an effective treatment for insomnia in stroke and Parkinson’s disease (PD) patients. Melatonin and light treatment can stabilize the sleep–wake circadian rhythm and shorten sleep latency in dementias and PD. Cognitive behavioral therapy (CBT) can be effective in treating insomnia symptoms associated with most of the central neurological diseases.The prevalence and treatment of insomnia in neurological diseases still need to be studied in larger patient groups with randomized clinical trials to a) better understand their impact and causal relationship and b) to develop and improve specific evidence-based treatment strategies.     

The molecular neurobiology of depression.

Depression is a condition with a complex biologic pattern in etiology. Environmental stressors modulate subsequent vulnerability to depression. In particular, early adversity seems to induce heightened reactivity to stress through several possible mechanisms, both biologic and psychologic. This increased reactivity results in an enhancement of biologic stress-response mechanisms, especially the HPA axis. Regulators of this system, particularly signal transduction pathways involving PKA and PKC, may be important in the regulation of key genes in this system including genes for GR, BDNF, and trk-b. This system potentially is vulnerable to ROS and therefore, indirectly, to the effects of cytokines. Finally, some of these effects may be controlled by chemical modification of DNA, specifically, methylation of promoters or other gene regions. This modification is a mechanism by which long-term biologic change can be induced by environmental stressors. The brain is homeostatic, and it is possible that alterations at multiple points in this system may induce dysregulation and, as a result, vulnerability to stress. Therefore, a person may be vulnerable to depression, which may be a final common "pathway" for this family of conditions. Individuals may very considerably with regard to the locus of the problem, however. For example, functional variants in a set of genes might predispose some people to depression; others may have epigenetic imprinting; and yet different causes may be at work in others. Although this mix is complicated, it can be unraveled. Doing so could lead to the development of novel interventions that could target specific points of vulnerability, allowing an improved matching of patient to treatment based on differential abnormalities at the cellular level.     

Sleep disturbance as the hallmark of posttraumatic stress disorder

The reexperiencing of a traumatic event in the form of repetitive dreams, memories, or flashbacks is one of the cardinal manifestations of posttraumatic stress disorder (PTSD). The dream disturbance associated with PTSD may be relatively specific for this disorder, and dysfunctional REM sleep mechanisms may be involved in the pathogenesis of the posttraumatic anxiety dream. Furthermore, the results of neurophysiological studies in animals suggest that CNS processes generating REM sleep may participate in the control of the classical startle response, which may be akin to the startle behavior commonly described in PTSD patients. Speculating that PTSD may be fundamentally a disorder of REM sleep mechanisms, the authors suggest several strategies for future research.     

Violent patients in the emergency setting.

Violent or threatening behavior is a common reason for presentation to the ED. Patients with aggressive behavior must first be assessed for the possibility of comorbid medical conditions. Acute withdrawal from alcohol or sedatives needs to be ruled out. Short-term sedation with lorazepam is a safe and effective choice for managing patients with acute agitation. The use of typical neuroleptics may lead to side effects, such as akathisia, which may in turn precipitate additional agitation. This may be obviated with the introduction of IM preparations of atypical antipsychotics.