Age and recovery from brain injury: legal opinions,clinical beliefs and experimental evidence

Despite considerable scientific evidence to the contrary, many medical practitioners maintain that children recover from brain injury better than adults. This belief, which is commonly referred to as the 'Kennard Principle', has important ramifications for personal injury compensation claims in which the amount of financial damages claimed is partly based on medical experts' prognoses for recovery and long-term outcome. The present study investigated whether legal practitioners' beliefs are consistent with those of medical practitioners. Lawyers were asked to estimate their confidence in consultant neurologists' estimates of recovery in four clinically-based but fictitious case studies which differed only in the reported age of the patient. The lawyers showed more confidence in estimates which coincided with the Kennard Principle than those which did not. These results support previous findings in showing widespread belief that 'younger is better' in recovery from brain injury. In consequence, it is likely that financial compensation for children with brain injury is currently being underestimated in litigation, thereby prejudicing the long-term outcome of the child.     

Neural compensation after early lesions: a clinical view of animal experiments

The widely held view, known as Kennard's principle, that lesions in the human central nervous system in the perinatal period are followed by better compensation than equivalent lesions sustained at a later age is under challenge from results of animal experiments. Experiment in rats have demonstrated, contrastingly, that lesions at early stages generally lead to more behavioral impairments than lesions of a similar size and location at adult stages. It also has been demonstrated that early lesions often lead to extensive neural reorganizations. Certain experiments even indicated that the extent of these reorganizations (e.g., after lesions in the motor cortex or the cerebellum) is inversely related to the degree of behavioral compensation. The question arises, why there is a discrepancy between the results in the human, suggesting enhanced functional recovery after lesions at perinatal ages, and those from animal experiments? One explanation is that lesions in animal experiments often are much larger than those occurring in the human. Secondly, the timing of the insult relative to the brain development seems to be critical. For each neural system a specific relation seems to exist between the timing of the insult, the degree of the neuronal reorganization and the behavioral consequences. Results from experimental research have suggested that the recruitment of stem cells in the brain after early lesions in certain regions might play a role in the repair of lesioned areas and also, that stem cells might play a role in the rescue of compromised cells. Ultimately such therapies might help to alleviate the consequences of perinatal brain lesions in the human.     

L'Actualité intempestive de Jacques Lacan

In this study, the author attempts to show how some of Jacques Lacan’s hypotheses qualified as ‘untimely’, ‘not relevant’ to the period during which he gave his seminars, were in fact used to support what he referred to as the ‘psychoanalytical act’ and the ‘current’ concepts developed in the field of psychoanalysis. The author recalls the role that the encounter with psychosis played in Lacanian theory, in fact in the various domains of psychosis, and in the female perception of sexual pleasure, and going even further, in the ‘invention’ of object a, but always with reference to Freudian theory either to use it as a basis for an argument, or in an attempt to deal with these questions over and beyond Freudian concepts, but without excluding them. Jaspers’ calling into question as ‘mirage’ of the ‘relations of comprehension’ used during the period when he developed his hypothesis is, according to the author, on a similar level to this ‘invention’ of object a that Lacan qualified as being ‘completely apart from any question of meaning’. These concepts are used by the author to test the current relevance of Jacques Lacan’s theories to ‘ultra-modern’ subjects/objects, at odds with the Alter-ego, which constitute objects of the market, ‘‘these last looks and these giggly voices’’ and the rise of segregation and racism.     

The 'correlates' in neural correlates of consciousness

In the search for neural correlates of consciousness (NCC), the concept of ‘consciousness’ remains problematic. We suggest that not only the ‘consciousness’ in neural correlates of consciousness is a confused term, but ‘correlates’ is as well. When brain events are found to covary with conscious experience, these brain events can be the neural substrates of the experience, as is often (implicitly) suggested, but they can also be neural prerequisites or neural consequences of the experience. We here disentangle these different sorts of brain processes conceptually. But we also propose a concrete multi-pronged research program that may, in near-future consciousness research, distinguish these brain processes empirically.     

Neuromodulation of multisensory perception: a tDCS study of the sound-induced flash illusion

This study explores whether brain polarization could be effective in modulating multisensory audiovisual interactions in the human brain, as measured by the ‘sound-induced flash illusion’ (Shams et al., 2000). In different sessions, healthy participants performed the task while receiving anodal, cathodal, or sham tDCS (2 mA, 8 min) to the occipital, temporal, or posterior parietal cortices. We found that up- or down-regulating cortical excitability by tDCS can facilitate or reduce audiovisual illusions, depending on the current polarity, the targeted area, and the illusory percept. Specifically, the perceptual ‘fission’ of a single flash, due to multiple beeps, was increased after anodal tDCS of the temporal cortex, and decreased after anodal stimulation of the occipital cortex. A reversal of such effects was induced by cathodal tDCS. Conversely, the perceptual ‘fusion’ of multiple flashes due to a single beep was unaffected by tDCS.This evidence adds novel clues on the cortical substrate of the generation of the sound-flash illusion, and opens new attractive possibilities for modulating multisensory perception in humans: tDCS appears to be an effective tool to modulate the conscious visual experience associated with multisensory interactions, by noninvasively shifting cortical excitability within occipital or temporal areas.     

Marcel Proust : le temps ne fait rien à l'affaire

As the art historian Daniel Arasse emphasised [1], ‘The anchorage of the artistic drive in the sexual drive was known throughout antiquity, before Christian and ‘Humanist’ theories of art would occult and repress that primary reality’. The too copious Proustian activity of association, beyond masking and revealing crude sexual images poetically, those very same which he qualified as ‘inevitable’, and which may have persecuted him all his life, fully marks out the abyss hollowed out by those who dying abandoned he who was a four year old boy for too long, and then the ‘eternal young man’. This absence was at once the painful and ecstatic lifting of their silence on his strange behaviour. The sadism, covered over with heavy but delectable and syrupy contrition, nestling in the heart of the work or in the many letters of condolence in his correspondance, is undoubtedly the erotisation of a grief otherwise inconsolable. The grief of being separated from Mummy, but not necessarily for the reasons we think. In Search of Lost Time will be the research for lost reasons. The famous reminiscences are less likely to deliver to the author the keys of happiness in ‘pure time’ than the reasons for his unhappiness (all-powerful mother, absent father), are less the traces of a lost intimate paradise than those of a break-down in a small, personal world of nothingness. That childhood innocence is never rediscovered and that grief lasts longer than love are two discoveries made in The Research. The reminiscences will only give in fine a specious sentiment of ephemeral eternity; as soon as they stop, the abyss of the unlived will open … of the real time lost. The time of the child's waiting for the Mother , in the mirror of which will be reflected the time spent waiting for death and to be reunited. To stop time in order to find illusory intimate happiness in the Mother-world fusion will have been Marcel Proust's viaticum. To contain the intolerable suffering of absence by negating time and space, and finding the here and now , even for one moment only, but body and soul, and so the lost object in the memory; this will have been his epic. The Research is the story of an allergic adult who scratched passionately at his childhood wounds and adolescent warts, thus reactivating a past which would not pass since it did not take its place. The only real memories which resist infantile amnesia, are those of disagreement with the object, the only restitutive memory and that of absence, the memory of the absence of the body of the child separated from the object, insofar as it is true to say that there is more difficulty renouncing a source of wounding than a source of happiness.     

Children's executive functions: Are they poorer after very early brain insult

Traditionally early brain insult (EBI) has been considered to have better outcome than later injury, consistent with the notion that the young brain is flexible and able to reorganize. Recent research findings question this view, suggesting that EBI might lead to poorer outcome than brain insult at any other age. Exploring this early vulnerability perspective, we investigated whether skills developing later in childhood, for example, executive functions (EF), would be at greater risk of disruption from EBI. The aim of this study was to investigate EF in children sustaining EBI at different developmental stages. We expected that brain insult during gestation and infancy, before the emergence of EF, would lead to global EF deficits. In contrast, we predicted that brain injury in late childhood would have fewer consequences. Using a cross-sectional, retrospective, group design we compared six groups of children (Total N = 164), with a history of brain insult and documented focal brain pathology, aged 10-16 years on a range of measures of EF. Groups were based on age of EBI: (1) Congenital; (2) Peri-natal; (3) Infancy; (4) Preschool; (5) Middle Childhood; and (6) Late Childhood. Children with EBI were at increased risk for impairment across all aspects of EF. Presence of seizures and/or frontal pathology were not predictive of outcome, but age at insult was. Children sustaining EBI before age 3 recorded more global and severe EF deficits, while children with later EBI performed closer to normal expectations. With the exception of attentional control, skills emerging at time of insult were found to be more vulnerable to disruption than those previously established, supporting the ‘early vulnerability’ model for EBI.     

Behavioral assessment of Japanese children with epilepsy using SDQ (strengths and difficulties questionnaire)

The aim of this study was to elucidate the availability of the strengths and difficulties questionnaire (SDQ) as a screening tool for identifying behavioral problems in Japanese children with epilepsy. Methods: Eighty-three 4–16 year-old epileptic patients, followed at Tanabe-Kadobayashi Children’s Clinic, were studied. Children with severe mental or physical disability were excluded. The Japanese version of the SDQ was used, and scores were compared to the Japanese standard. Results: ‘Hyperactivity’ was the SDQ category with the most striking differences from normal: a significant numbers of children had scores above the clinically normal range and only a small proportion were within the normal range (p < 0.0001). The rates of epilepsy patients with scores above normal range were also significantly higher for ‘peer problems’ and ‘conduct problems’ (p < 0.0001 and p < 0.01). The rates of epilepsy patients with scores within the normal range was significantly lower for ‘emotional symptoms’ than in normal controls (p < 0.001). On the other hand, the ‘pro-social behavior’ score did not differ significantly from the Japanese standard. As for clinical factors, patients with symptomatic localization-related epilepsy and focal electroencephalographic abnormalities had significantly higher scores for some SDQ items. Age at epilepsy onset correlated negatively with scores for ‘total difficulties’ and ‘hyperactivity’, suggesting early onset to be a risk factor for poor SDQ scores. Conclusions: These findings confirm that higher rates of psychiatric comorbidity in Japanese children with epilepsy may be diagnosed using SDQ in Japanese children with epilepsy. These problems should be addressed in the early phase of epilepsy management in order to preserve health-related quality of life for affected patients.     

Marguerite Burnat-Provins la visionnaire ou L'œuvre imposée. Sur « Ma ville » : visions du Réel et dialogue avec l'objet a

The writer and painter Marguerite Burnat-Provins (1872-1952) was a French-born artist. Part of her work is now exhibited in the supplementary collections of Primitive Art in Lausanne. In 1919, a first vision led to a long series of drawings, a series which she entitled “My town”. These drawings were “dictated” to her, as were the names and particularities of the characters she depicted, an experience she was unable to avoid. In this manner, Marguerite Burnat-Provins produced nearly three thousand figures which today are scattered far and wide, and as many comments about the identity of the characters that she depicted. The hypothesis developed in this article is that of the establishment of a sort of dialogue throughout her work with the enigmatic part of her personality which continued to influence her; but also its production, and she attempted by representation and in writing to express this enigmatic aspect and at the same time to authenticate it. The work of art “My town”, a series which has been qualified as “hallucinatory”, meets this definition. It can also be viewed as the treatment, essentially by representation, of a subject that acquired all its importance in Marguerite Burnat-Provins’work, the gaze on the characters’faces. The way in which she has treated their gaze does not denote psychosis in spite of the imposed nature of the subject matter that she herself emphasized, and categorizing “My town” as a hallucinatory work is unjustified. The strange series entitled “My town” is both a return to the enigma womanhead and a sublimatory attempt to express this enigma, without recourse to representations of the Real. Marguerite Burnat-Provins is clearly a visionary artist.     

Parental assessment of pain coping in individuals with intellectual and developmental disabilities

Pain coping is thought to be the most significant behavioural contribution to the adjustment to pain. Little is known about how those with intellectual and developmental disabilities (IDD) cope with pain. We describe parental reported coping styles and how coping relates to individual factors. Seventy-seven caregivers of children and adults with IDD reported on coping styles using the Pediatric Pain Coping Inventory (PPCI), pain behaviour using the Non-Communicating Children's Pain Checklist—Revised (NCCPC-R), illness-related interactions using the Illness Behaviour Encouragement Scale (IBES) and past pain experience using the Structured Pain Questionnaire. Scores were compared across mental ages and interactions between pain coping and the other factors were explored. A Multivariate Analysis of Variance (MANOVA) by mental age group (‘≤4 years’, ‘5-11 years’ and ‘≥12 years’) revealed that those in the ‘5-11 years’ mental age group used more coping styles than those in the ‘≤4 years’ mental age group, and those in the ‘≥12 years’ group used more cognitively demanding coping styles than the other two groups (F_(10,130) = 2.68, p = .005). Seeking Social Support (r = .39, p = .001) and Catastrophizing/Helplessness (r = .33, p < .01) coping styles were significantly related to a greater display of pain behaviour. Those with younger mental ages, who Seek Social Support or Catastrophize, also displayed more pain behaviour, which may be an attempt to seek external resources when pain is beyond their ability to deal with independently.     

Who actually read Exner? Returning to the source of the frontal “writing centre” hypothesis

We have translated the most famous text of Sigmund Exner (1846-1926), which relates to the existence of a localised “writing centre” in the brain. We discuss its relevance to modern studies and understanding of writing and agraphia. In Exner’s most famous text, he hypothesised about the eponymous “Exner’s Area”, a discrete area within the brain that was located in the left middle frontal gyrus, which was dedicated to the function of writing. This text in German, included in a book published in 1881 “Untersuchungen über die Lokalisation der Functionen in der Grosshirnrinde des Menschen” (Studies on the localisation of functions in the cerebral cortex of humans), lent itself to passionate debates during the following decades on the possibility of finding a specific writing centre in left middle frontal gyrus. Modern authors still refer back to the evidence cited in this seminal text. However, over the 281 pages of Exner’s book, only a few chapters dealt with agraphia. Only four of the 167 case reports in the book explicitly mention agraphia. Although Exner describes the anatomical details of these lesions (from autopsies), no patient had pure agraphia, and only one case had an isolated lesion of the posterior part of the middle frontal gyrus. The small number of patients, the absence of pure agraphia symptoms, and the variation in the anatomy of these lesions are the main reasons why Exner’s hypothesis of a writing centre in left middle frontal gyrus has been continually debated until now. More than the seminal publication of Sigmund Exner on agraphia, we think that the diffusion of his hypothesis was partly due to the influence that Exner and his family had within the scientific community at the turn of the 20th century.     

Passive toothbrushing-induced seizures: Report of a severely disabled girl

Toothbrushing-induced seizures are rare reflex seizures triggered by the brushing of one’s own teeth. We encountered an 11-year-old girl with severe mental retardation, hypotonic cerebral palsy and epilepsy who presented with toothbrushing-induced seizures. She had had spontaneous brief tonic seizures several times a day since the age of 1 year and 2 months and started presenting with the same type of seizures induced by toothbrushing from the age of 8 years. As she could not brush her teeth by herself due to her disabilities, her mother brushed her teeth daily for her. The interictal EEG showed spike-and-wave complexes in the frontal regions bilaterally. The [Tc-99m]HMPAO-SPECT at the time of the seizure induced by toothbrushing suggested that the seizures originated from the left perisylvian cortex. This is the first report of toothbrushing-induced seizures triggered by the brushing of the patient’s teeth by another person (‘passive toothbrushing’).     

Clinical characteristics and treatment outcome of depression in patients with and without a history of emotional and physical abuse

Clinical features and treatment outcome were compared in depressed outpatients with and without a history of emotional and physical abuse (EPA), including childhood maltreatment. Patients were initially randomized to IPT or SSRI and then augmented with the second treatment if they did not remit with monotherapy. Assessments included the SCID-I, the SCID-II for DSM-IV diagnoses, the HRSD, the QIDS and the Mood Spectrum Self-Report (MOODS-SR). Seventy-eight (25%) patients reported a history of EPA; 60 (76.9%) were women. Patients with a history of EPA did not differ from those without on HRSD scores at baseline, but showed an earlier age at onset of depression and a longer duration of illness. The two groups differed on several mood spectrum factors, namely: ‘depressivemood’ (15.6 ± 4.9 vs. 13.5 ± 5.4; p < 0.004), ‘psychomotorretardation’ (11.7 ± 4.5 vs. 9.6 ± 4.7; p < 0.001), ‘drugandillness-relateddepression’ (1.3 ± 1.3 vs. 0.6 ± 1.0; p < 0.0001), and ‘neurovegetativesymptoms’ (8.3 ± 2.6 vs. 6.9 ± 2.9; p < 0.0001). Patients with EPA had also a significantly longer time to remission (89 vs. 67 days, log-rank test, p = 0.035). The need for augmentation treatment was significantly more frequent among patients with EPA than in those without. The present study suggests that patients with a history of EPA show a subtype of depression characterized by poor treatment response and more severe neurovegetative and psychomotor symptoms.     

Neuroimaging in social anxiety disorder: A systematic review of the literature

Brain imaging techniques allow the in vivo evaluation of the human brain, leading to a better understanding of its anatomical, functional and metabolic substrate. The aim of this current report is to present a systematic and critical review of neuroimaging findings in Social Anxiety Disorder (SAD). A literature review was performed in the PubMed Medline, Scielo and Web of Science databases using the following keywords: ‘MRI’, ‘functional’, ‘tomography’, ‘PET’, ‘SPECT’, ‘spectroscopy’, ‘relaxometry’, ‘tractography’ and ‘voxel’ crossed one by one with the terms ‘social anxiety’ and ‘social phobic’, with no limit of time. We selected 196 articles and 48 of them were included in our review. Most of the included studies have explored the neural response to facial expressions of emotion, symptoms provocation paradigms, and disorder-related abnormalities in dopamine or serotonin neurotransmission. The most coherent finding among the brain imaging techniques reflects increased activity in limbic and paralimbic regions in SAD. The predominance of evidence implicating the amygdala strengthens the notion that it plays a crucial role in the pathophysiology of SAD. The observation of alterations in pre-frontal regions and the reduced activity observed in striatal and parietal areas show that much remains to be investigated within the complexity of SAD. Interesting, follow-up designed studies observed a decrease in perfusion in these same areas after either by pharmacological or psychological treatment. The medial prefrontal cortex provided additional support for a corticolimbic model of SAD pathophysiology, being a promising area to investigation. Furthermore, the dopaminergic and GABAergic hypotheses seem directed related to its physiopathology. The present review indicates that neuroimaging has contributed to a better understanding of the neurobiology of SAD. Although there were several methodological differences among the studies, the global results have often been consistent, reinforcing the evidence of a specific cerebral circuit involved in SAD, formed by limbic and cortical areas.     

Asymmetrical motor behavior in rats with unilateral striatal excitotoxic lesions as revealed by the elevated body swing test

Severe degeneration of basal ganglia neurons, particularly the intrinsic neurons of the striatum, is the major underlying neuropathology implicated in clinical attributes of Huntington's disease (HD). The excitotoxin-lesioned striatum provides a useful model for evaluating behavioral parameters of HD. Animals with unilateral excitotoxic lesions exhibit asymmetrical rotational behavior in response to dopamine agonists, such as apomorphine. However, the observed behavior is a pharmacological reaction, and subject to sensitization effects. A behavioral test using undrugged animals may demonstrate a more natural response of the animals to the lesion effects. Recently, we have developed the ‘drug-free’ elevated body swing test (EBST), and demonstrated that hemiparkinsonian rats exhibited significant biased swing activity. In the present study, we observed that animals with unilateral intrastriatal 3-nitropropionic acid or quinolinic acid lesions displayed a significant biased swing activity with the direction ipsilateral to the lesioned side of the brain. This ipsilateral swing corresponded to the ipsilateral rotational behavior exhibited by the lesioned animals when challenged with apomorphine. The present results demonstrated that the EBST is a sensitive measure for characterizing asymmetrical behavior in animals with striatal lesions.     

Grasping tools: effects of task and apraxia

In patients with apraxia the ability to access tool-use-knowledge and to integrate it into a movement plan is frequently disturbed. The present study investigated potential differences between a ‘transport’- and a ‘use’-task as well as the influence of apraxia on the preceding grasping movement, when the tool is presented with its handle pointing away from the participant. 20 controls, 10 patients with right brain damage (RBD-group) and 17 patients with left brain damage (LBD-group) were tested. 10 LBD-patients were classified as moderately to severely apraxic according to erroneous demonstration of tool-use. Participants were asked to grasp the tool and either to demonstrate its typical ‘use’ or to ‘transport’ it into a container. Functional grasp, which enables comfortable use, was distinguished from non-functional grasp. The results showed that task-content influences the way to grasp an object. Apart from some LBD-patients, nearly all participants produced 100% functional grasps during the ‘use’-task. Additionally inappropriate non-functional grasping has always been followed by apraxic tool-use behaviour. Compared to the ‘use’-task in the ‘transport’-task, functional grasping was significantly reduced in all groups. Our results imply that grasping a tool is specific to a task. Selection of the grasp type seems to be determined by individual weighting of several factors, including knowledge about the function of the object, structural tool characteristics, biomechanical costs of the movement, and previous experience. In general perception and integration of tool-structure plus specific tool-related functional knowledge are necessary for its use and might be processed synchronously. Patients with apraxic tool-use may fail to access any of these information resources.     

The presence of a perseverative iterative style in poor vs. good sleepers

Catastrophizing is present in worriers and poor sleepers. This study investigates whether poor sleepers possess a ‘perseverative iterative style’ which predisposes them to catastrophize any topic, regardless of content or affective valence, a style previously found to occur more commonly in worriers as compared to others. Poor (n = 23) and good sleepers (n = 37) were distinguished using the Pittsburgh Sleep Quality Index (PSQI), from a sample of adults in the general population. Participants were required to catastrophize 2 topics: worries about sleep, and a current personal worry; and to iterate the positive aspects of a hypothetical topic. Poor sleepers catastrophized/iterated more steps to a greater extent than good sleepers to these three interviews, (F(1, 58) = 7.35, p < .05). However, after controlling for anxiety and worry, this effect was reduced to non-significance for the ‘sleep’ and ‘worry’ topics, suggesting that anxiety may mediate some of the association between catastrophizing and sleep. However there was still a tendency for poor sleepers to iterate more steps to the ‘hypothetical’ topic, after controlling for anxiety and worry, which also suggests that poor sleepers possess a cognitive style which may predispose them to continue iterating consecutive steps to open-ended tasks regardless of anxiety and worry. Future research should examine whether the presence of this cognitive style is significant in leading to or maintaining insomnia.     

Phenotype of spontaneous orofacial dyskinesia in neuregulin-1 ‘knockout’ mice

Studies in antipsychotic-naïve patients with schizophrenia indicate a baseline level of spontaneous involuntary movements, particularly orofacial dyskinesia. Neuregulin-1 is associated with risk for schizophrenia and its functional role can be studied in ‘knockout’ mice. We have shown previously that neuregulin-1 ‘knockouts’ evidence disruption in social behaviour. Neuregulin-1 ‘knockouts’ were assessed for four topographies of orofacial movement, both spontaneously and under challenge with the D₁-like dopamine receptor agonist SKF 83959. Neuregulin-1 ‘knockouts’ evidenced an increase in spontaneous incisor chattering, particularly among males. SKF 83959 induced incisor chattering, vertical jaw movements and tongue protrusions; the level of horizontal jaw movements was increased and that of tongue protrusions decreased in neuregulin-1 ‘knockouts’. These findings indicate that the schizophrenia risk gene neuregulin-1 is involved in the regulation of not only social behaviour but also orofacial dyskinesia. Orofacial dyskinesia in neuregulin-1 mutants may indicate some modest genetic relationship between risk for schizophrenia and vulnerability to spontaneous movement disorder.