Limbic P3 potentials, seizure localization, and surgical pathology in temporal lobe epilepsy

Limbic P3 event-related potentials were recorded from mesial temporal electrodes implanted for presurgical investigation in 70 patients with intractable focal seizures. In 46 (81%) of 57 patients with unilateral temporal lobe epilepsy, the limbic P3 potential was absent or rudimentary ipsilateral to the seizure focus and a robust P3 potential was always elicited from the nonepileptogenic temporal lobe. Bilateral P3 potentials were recorded in 6 patients (10%) with unilateral temporal lobe epilepsy. In the remaining 5 patients in the group with unilateral temporal lobe epilepsy, results showed P3 bilaterally absent (2 patients), P3 present in a unilateral investigation (1 patient), P3 absent contralateral to the seizure focus (1 patient), and technically unsatisfactory recordings (1 patient). Bilaterally absent P3 potentials were noted in 2 patients with bilateral temporal lobe epilepsy. In 6 patients with technically adequate P3 studies and extratemporal seizures, bilaterally present P3 potentials were noted. Sensitivity and specificity of P3 absence as a predictor of an epileptogenic temporal lobe were 87% and 95%, respectively. Tissue specimens of the hippocampus were available in 22 patients (43%). Thirteen hippocampi showed sclerosis, all of which were associated with unilaterally absent P3 potentials. Nine hippocampi were normal (5 patients with the P3 absent, 4 with P3 present). Sensitivity and specificity of an absent limbic P3 as a function of hippocampal pathological findings were 100% and 44%, respectively. Absent limbic P3 potentials in temporal lobe epilepsy thus indicate structural or functional hippocampal abnormality and may add important information in presurgical evaluation with depth electrodes of patients who have temporal lobe epilepsy.     

Culture and Psychoanalysis

Abstract. This article explores ghosts–-defined as internalizations gone awry and experienced as inchoate absent presences–-that haunt our patients and that can be profoundly disruptive to clinical process. The case of a patient whose traumatic “ghosts” communicated by way of the bodies of both patient and analyst, via a process the author calls “interpsychic-intersomatic” transmission, is presented and linked to theory. How the analyst's personal ghosts became involved with those of the patient, in both facilitating and interfering ways, is also illustrated. Some of the clinical challenges of “laying ghosts to rest as ancestors” (Loewald, 1960/2000b) are explored.     

Refractory grand mal seizures with onset during infancy including severe myoclonic epilepsy in infancy.

In 1978, Dravet proposed a clinical entity called severe myoclonic epilepsy in infancy (SMEI). In the same year, a patient group, which was later called high voltage slow wave-grand mal syndrome (HVSW-GM), is reported in Japan. Both syndromes are very similar, except for seizure manifestation: generalized tonic-clonic convulsions (GTC) with myoclonic and other polymorphic seizures in SMEI vs. GTC only in HVSW-GM. To study the pathophysiology of these refractory epilepsies, the author formulated new clinical diagnostic criteria common to both syndromes as follows: GTC with onset before the age of 1 year as the principal seizure type; an epilepsy entity unclassifiable either as partial or generalized by all the clinical data including EEG findings; mental and motor dysfunction absent prior to seizure onset but appearing later; absence of epileptiform activities on EEG in the initial stage; stubborn refractoriness to conventional antiepileptic medication. Twenty-two patients meeting all of five clinical criteria above mentioned were recruited in the study. Detailed analysis of clinico-electrical features and long-term follow-up of these patients led the author to the conclusion that GTC in combination with seizures of other types will contribute to an unfavorable pathophysiological or prognostic conditions, and, especially when GTC exists in combination with myoclonic seizures, the severity of epilepsy will increase. The author claimed that the three clinical entities, SMEI, HVSW-GM, and their variant form, share certain characteristics in common and may constitute a unique epilepsy syndrome for which a new name of infantile refractory grand mal syndrome (IRGMS) was offered. This is a more basic concept with broader spectrum than SMEI, encompassing not only SMEI but also related borderlands like HVSW-GM. More recently, the author observed that early zonisamide medication within 1 year after seizure onset may improve seizure prognosis in IRGMS, by preventing the development of myoclonic seizures.     

Tourette syndrome, pimozide, and school phobia: the neuroleptic separation anxiety syndrome

The development of school phobia has been reported in some patients with Tourette syndrome treated with haloperidol. The author reports on a patient who developed school phobia on each of three trials with pimozide, a neuroleptic chemically similar to haloperidol, and proposes the term "neuroleptic separation anxiety syndrome." The syndrome is clinically indistinguishable from DSM-III criteria for school phobia (separation anxiety disorder). Tricyclic antidepressants may have a therapeutic or prophylactic effect. It is not known whether this neuroleptic side effect occurs in patients other than those with Tourette syndrome.     

Catatonia, gastric hyperacidity, and fatal aspiration: a preventable syndrome.

Sudden death from aspiration pneumonitis during acute catatonia is a generally recognized but poorly understood occurrence. The author describes a case in which a schizophrenic patient died following aspiration of gastric contents. In view of findings that suggest that the acidity of gastric contents is related to morbidity following aspiration, he recommends that liquid antacid medication be given routinely to catatonic patients.     

Feeding function, blink reflex and MRI in the severely handicapped

Blink reflexes were studied in 41 patients with severe handicaps, and were correlated with feeding problems and other lower brainstem symptoms such as drooling, an absent gag reflex and stridor. Ventrodorsal diameters of the pons and medulla oblongata on sagittal MRI were also studied in 29 of the cases. The patients were divided into three groups: tube feeding (25 cases), oral feeding (13 cases) and mixed feeding (3 cases). In the tube feeding group, all but three cases showed a prolonged or absent R1 component, and all cases showed prolonged or absent R2 and R2' components. These abnormalities were significantly more frequent in the tube than in the oral feeding group. The patients with drooling, stridor or an absent gag reflex more frequently showed prolonged or absent components than the patients without these symptoms. The brainstem size on MRI was not different between the tube and oral feeding group. These results suggest that the blink reflex, particularly its late components, is a useful indicator for evaluating feeding function and other lower brainstem functions.     

Multiple sclerosis masquerading as lithium toxicity

The author presents a case report of a manic-depressive patient who developed dysarthria and ataxia while on lithium maintenance. These symptoms were erroneously attributed to lithium toxicity occurring at therapeutic serum levels. However, the symptoms persisted despite diminution in lithium dosage and a neurological consultation revealed the diagnosis of multiple sclerosis. The author concludes that lithium therapy is effective with manic-depressive patients, that adverse side effects are infrequent and can occur at toxic or therapeutic serum lithium levels, and that the exceptional patient may have a second illness incorrectly attributed to lithium toxicity.     

Clinical guidelines for the use of involuntary outpatient treatment

Successful involuntary psychiatric outpatient treatment requires identifying patients who are suited to such treatment and ensuring that the service system is able to deliver the treatment. Based on his clinical experience, the author has developed ten sequential guidelines that can help clinicians identify patients who are appropriate for involuntary outpatient treatment. The sequential order of the guidelines means that a patient must meet the criteria for each guideline before being evaluated on subsequent guidelines. The guidelines assume that the patient has a chronic mental illness and a history of dangerousness to self or other because of that illness. The author believes that achieving consensus about who should receive involuntary outpatient treatment is an important first step in permitting evaluation of the efficacy of the approach.     

Serve,Smash, and Self-States

The author draws upon the application and integration of systems theory with Interpersonal theory by Levenson in making the argument that development and change depend on the breakdown of the rigid, unidimensional experience of a personification, a breakdown that results in the formation of a fresh, multidimensional experience of how the person is represented inside the mind. The author argues that the “interpersonal field” between patient and analyst, and the process of coming to subjectively know more about the analyst as a person—with his or her own motivations, intentions, thoughts, and feelings—opens pathways leading to an understanding of one's personifications.     

Patients' reactions to the birth of a male analyst's child

After the author informed his patients he planned to be absent for one week, approximately one month hence, nearly all his patients correctly assumed that his wife was pregnant. The birth of the analyst's child revived conflicts concerning younger siblings. Male patients seemed to respond to the reactivation of oedipal conflicts by a transference intensification of their paternal identifications. Female patients reacted more negatively and more dramatically. For them, the birth of the analyst's child signified a defeat of both their positive and negative oedipal wishes. The author compares and contrasts his findings with the literature on the pregnant analyst.     

Blink reflex in patients with Wallenberg’s syndrome

Knowledge of the neural circuits involved in Wallenberg’s syndrome (WS) is incomplete. Study of the blink reflex (BR) in patients with WS can help in reaching a better understanding of the physiopathology underlying clinical symptoms and may help in the prediction of clinical outcome. We evaluated the BR in response to supraorbital nerve electrical stimuli in 20 patients with WS. All patients were studied within the 1st week after onset of symptoms, and 10 of them were also studied repeatedly during a follow-up period of 3–12 months. At the first examination the long latency bilateral responses (R2 and R2c) to stimulation of the supraorbital nerve of the affected side were absent in 11, delayed in 4, and normal in 5 patients. At follow-up, there was a normalization of the BR in all patients who had absent or delayed responses at the first examination except for one patient whose responses remained absent at the 9th month. Late responses elicited on the side of the lesion by stimulation of the non-affected supraorbital nerve were normal in all but one patient. This patient died from cardiorespiratory arrest within the 1st month of the illness. One patient with normal BR responses also died in the acute phase. The BR is abnormal in most patients with acute WS and tends to normalize in a mean period of 7 months. BR pattern is not a predictor of early fatal complications in patients with this syndrome. Received: 18 March 1996 Received in revised form: 18 June 1996 Accepted: 26 June 1996     

Clinical case management: definition, principles, components

The burgeoning field of case management for long-term psychiatric patients has been handicapped by a lack of conceptual models that delineate the diverse activities of case managers. Based on the actual practice of case management, the author outlines a model of clinical case management that moves beyond the view of the case manager as a systems coordinator, service broker, or supportive companion. Using a contemporary biopsychosocial model of mental illness, the clinical case management model integrates the clinical acumen, personal involvement, and environmental interventions needed to address the overall maintenance of the patient's physical and social environment. Clinical case management involves 13 distinct activities, including engagement of the patient, assessment, planning, linkage with resources, consultation with families, collaboration with psychiatrists, patient psychoeducation, and crisis intervention.     

Nonmedical treatment of patients with dementia

This article reviews some nonmedical interventions that psychiatrists and other clinicians in the field of neuroscience can provide to their patients with dementia. The author discusses how clinicians can help patients and their caregivers understand the diagnosis causing the dementia (whether it be Alzheimer's, traumatic brain injury, Parkinson's disease, or vascular dementia) and help them to set realistic expectations of the treatment process for the patient and his or her loved ones. The author also reviews how clinicians can help caregivers modify their interactions with the patients when required to enhance not only the quality of life for the patient but the quality of life for the caregiver as well. Finally, the author reviews how clinicians can take on new initiatives that may help both the patients with dementia and their loved ones/caregivers when the patients are at the end stages of their disease.     

Origin of the widespread N18 in median nerve SEP.

The widespread N18 potential in median nerve SEP was studied in normal subjects and in patients with high cervical, brain-stem and thalamic lesions who had profound disturbances of deep sensation. N18 was well identified in the HSi-CV2 derivation in every normal subject as a broad elevation from the baseline lasting about 20 msec. The cortical N20 was absent in all patients. N18 was absent in a patient with a dorsal column lesion at C1-2 level. The amplitude and configuration of N18 were normal in all other patients with brain-stem and thalamic lesions, including a patient with a lesion at the ponto-medullary junction. The sagittal distribution of N18 was studied in a patient with a thalamic lesion and an oblique distribution with the maximum region between Cz and nasion was demonstrated. The present results indicate that at least the greater part of N18 is generated at the caudal most brain-stem or through branches from this level. Taking previous animal and intraoperative studies into consideration, we think it most probable that the main part of N18 corresponds to the ventro-rostral negative pole of the dipolar potential generated at the cuneate nucleus by the primary afferent depolarization of presynaptic terminals of dorsal column fibers.     

Somatosensory potentials, CSF creatine kinase BB activity, and awakening after cardiac arrest

OBJECTIVE: To examine the utility of somatosensory evoked potential (SEP) peaks and CSF creatine kinase BB isoenzyme activity (CKBB) in predicting nonawakening from coma due to cardiac arrest. BACKGROUND: Accurate predictors of neurologic outcome in patients comatose after cardiac arrest are needed to improve medical decision making. METHODS: A total of 72 comatose patients had bilateral median SEPs, and of these, 52 had CSF and CKBB. Awakening was defined as following commands or having comprehensible speech. Both short (N1) and long (N3) latency SEP peaks were analyzed. Nonparametric analyses were used. RESULTS: For patients who had both tests, CKBB > or = 205 U/L predicted nonawakening with a sensitivity of 49% and a specificity of 100%. Bilateral absence of the N1 peak predicted nonawakening with a sensitivity of 53% and a specificity of 100%. Using CKBB > or = 205 U/L, bilaterally absent SEP N1 peaks, or both predicted nonawakening with a sensitivity of 69% and a specificity of 100%. Using CKBB > or = 205 U/L, bilaterally absent N1 peaks, bilateral N3 > or = 176 msec or absent, or some combination predicted nonawakening with a sensitivity of 78% and a specificity of 100%. CONCLUSION: The combination of an absent N1 peak and elevated CKBB performs better than either alone in predicting nonawakening after cardiac arrest. Prolonged or absent N3 latency may increase sensitivity. These results should be interpreted with caution given the small number of patients and the possibility of a self-fulfilling prophecy.     

Treatment of the borderline patient, relationship management

The author suggests that not the borderline syndrome itself but many of the worst behaviours of borderline patients are essentially iatrogenic. To do no harm should be the primary goal of any therapist encountering a patient exhibiting borderline features. Management of the patient-therapist relationship is paramount and may be in itself the most effective and safe treatment for both crisis situations and longer therapy. A conceptual model borrowing from and bridging self psychology and interpersonal theory is described. This model leads to a reframing or new interpretation of borderline symptoms and therapists' reactions. Realtionship management guidelines and specific interventions are suggested.     

Recent developments in the care, treatment, and rehabilitation of the chronic mentally ill in Norway

As in most other Western nations, the ideology shaping mental health care in Norway has shifted since World War II from a traditional institutional approach to a community-based concept of treatment for the chronic patient. And as in many other countries, communities have been poorly equipped to deal with the influx of deinstitutionalized patients. Few appropriate community alternatives have been developed to care for hospitalized patients, many of whom must remain institutionalized. The author reports on a 1979 census of Norway's mental patients which showed that about half of the mental hospital patients could be expected to remain in the hospital because adequate community facilities did not exist. However, the author says, there is a new interest in Norway in reducing the number of hospital beds and transferring more patients to community programs; one large mental hospital has recently been closed. Legislation focusing on patients' rights and new research on "quality of life" of patients are also pushing mental health care into the community, he says.     

Bilateral deafness, an initial manifestation of meningeal carcinomatosis]

Three cases of bilateral deafness with cytologically-demonstrated meningeal carcinomatosis are reported. The first patient, a 64-year old man, presented with bilateral deafness, gait disturbances, and bilateral facial paresis. The second patient, a 78-year-old man, had bilateral deafness, unsteady gait and fluctuations in consciousness. The last patient, a 69-year-old man, complained of bilateral deafness and severe headache, and presented with right facial paresis and left laterodeviation while walking. All three patients had abnormal cochleo-vestibular findings and brainstem auditory evoked responses (BAER) that suggested peripheral lesions with absent or very delayed I waves. The brain CT scans with an without contrast enhancement were entirely normal, and the diagnosis was established by lumbar puncture. From our own cases and a review of the literature, deafness in meningeal carcinomatosis may start unilaterally but becomes bilateral in less than a week. Vestibular disturbances may not be apparent, but they can be demonstrated in almost all cases. Facial paresis or plegia is also a very frequent finding. The destruction of the eighth and seventh cranial nerves is probably due to direct infiltration by neoplastic cells as well as to ischemia through compression of the nerve supplying vessels. The 3 cases presented here emphasize once again the important fact that meningeal carcinomatosis remains a cytological diagnosis, several lumbar punctures being sometimes necessary, and that cerebrospinal fluid studies cannot yet be supplanted by other diagnostic techniques like contrast-enhanced CT or MRI with gadolinium.     

Neurologically silent brain tumors in psychiatric hospital admissions: three cases and a review

Three cases are described of patients with brain tumors who presented to a psychiatric hospital with disturbances in behavior or thinking. Neurologic signs and symptoms were absent or minimal in all cases, and psychiatric signs and symptoms were intermittent in two cases. The literature is reviewed and it is noted that tumors cannot be localized definitively by their psychiatric presentation. Further, patients with psychiatric symptoms secondary to brain tumors may respond to treatment with psychotropic medications. One of these cases is the fourth patient reported in the English language literature who meets the criteria for secondary mania due to a brain tumor.