Pharmacological treatment of chronic cognitive deficit: A review

Impaired cognitive function occurs in disorders which have been described by such terms as acute or chronic brain failure, delirium, confusion, acute or chronic organic brain syndrome, and dementia.¹ This article will consider the pharmacological treatments for those mental disorders caused by a recognized biological process which affects brain function, excluding the schizophrenias, manic-depressive disorders, and other so-called “functional” psychoses.Over 50% of chronic brain disorder in the elderly results from senile Alzheimer dementia, while multiinfarct dementia is responsible for about 20%. In a further 20% these two diseases occur together.^2–5 Other causes include other structural changes, toxic effects on the brain, metabolic disorders, abnormalities of cerebral blood flow, and epileptic disorders.^6–9Drugs may be prescribed in an attempt to improve various cognitive functions or to modify secondary psychiatric disorders, such as mood change or behavioral disturbances. Pharmacological agents may act directly on the brain,^10–12 or may produce their cerebral effects as a result of an extracerebral action such as an improvement of cardiac function.     

Delirium updated

The new classification of organic mental disorders in Diagnostic and Statistical Manual of Mental Disorders, 3 ed (DSM-III)¹ features delirium as one of the seven organic brain syndromes. Acute failure of integrated cerebral functioning, due to a wide range of possible noxious factors, is manifested at the behavioral level by the syndrome of delirium.² Although well described by numerous writers since antiquity, delirium is still often misdiagnosed, and confusion about its essential features persists. For example, a recent report on lithium toxicity describes a patient as distractible, fully disoriented, and visually hallucinated, but curiously concludes that, “Despite the similarity of this illness to an acute delirium with occasional lucid intervals, the patient had no clouding of consciousness.“³ To counteract such diagnostic and related errors, an update of the diagnosis, pathogenesis, and management of delirium is presented, which supplements a previous extensive review.⁴     

Change of diagnosis in schizophrenia and first-rank symptoms: An eight-year follow-up

Fifty-seven patients diagnosed as schizophrenic at the inception hospital admission, because they had Schneider's first-rank symptoms, were investigated 8 years for change of diagnosis. The average duration of their psychiatric contact after the admission was 5 years. During this period 88% still had a diagnosis of schizophrenia, but seven patients had been given other diagnoses. Change of diagnosis was significantly associated with “voices discussing” when it was the only first-rank symptom. The question of whether “voices discussing” should be included in the canon of Schneiderian first-rank symptoms is discussed.     

Independent learning: a self-instructional videotape approach in psychiatry 1

In response to the increased need to train well-rounded general practitioners within a limited time schedule, the teaching staff developed a self-instructional videotape programme devoted to suicide assessment. This tape, if successful, was to serve as a pilot for a full series of 18 tapes devoted to the assessment and treatment of normally stable patients suffering acute situational stress. In order to avoid the passivity induced by most educational tapes and films, a self-instructional format was adapted to the videotape medium and extensively tested. Students in the experimental group scored significantly higher on three of four measures of effectiveness than did the control group. Students and teachers both strongly supported the production of tapes using a similar format.     

Treatment of writer''s cramp by progression from paintbrush in supinated hand

A case of writer's cramp was treated by training the patient in muscle relaxation and then have him draw circles of decreasing diameter with a paintbrush held between the index and middle fingers of his supinated hand. Later he was asked to draw spirals and straight lines. He was then asked to hold a brush like a pen and write large block letters. The sequence was repeated with a normally held soft lead pencil and finally a pen was introduced. At the conclusion of therapy the patient could write comfortably and legibly for up to $\text{1}\text{2}$ hr without hand muscle tension. The improvement was maintained at a 6-month follow-up.     

Development of brief measures of psychosocial adjustment to medical illness applied to cancer patients

The interrater reliability and validity of brief interview rated measures of psychosocial adjustment were examined in four sequential studies. A total of 25 videotaped interviews with cancer patients were rated by 105 social workers, nurses, physicians, and specialists in psychosocial oncology. The Rating of Psychosocial Function (RPF), Coping Adequacy Rating (CAR), and Global Adjustment to Illness Scale (GAIS) were used by various rating groups with an indication of interrater agreement. Agreement on ratings was not influenced by the length of interview (15 vs. 30 minutes) but appeared to be affected by the structure of the interview and profession of the raters. All three instruments showed a measure of matching with clinical impressions in addition to demonstrating a measure of both convergent and divergent construct validation. The GAIS was chosen as most adequately reflecting their clinical impression by a majority of raters. With a degree of training, any of the three instruments could be used to assess psychosocial adjustment with some measure of confidence in the validity of the rating.     

Medical students' attitude towards psychiatry: a ten-year comparison†

Medical students' interest in and attitudes toward psychiatry, both as a field of education and as a medical specialty, have been explored by a number of investigators. The present study compares two series of investigations completed at the McGill University teaching hospitals over a ten year span and involving third year medical students in 1968–69 (n=59) and in 1978–79 (n=168). The findings of these two studies are evaluated in two parts: (1) comparison of attitudes toward psychiatry before and after clinical training in 1978–79. (2) comparison of the results obtained in 1969 with those in 1979. The results of the comparison showed that students currently put more emphasis on the clinical aspects of psychiatric training and less on the theoretical and research aspects of psychiatry. Thirty-two percent of students in 1979 found psychotherapy to be the most useful treatment modality as compared with only 10 percent in 1969. Findings reflecting the usefulness of organic therapies in psychiatry remained fairly consistent, but behaviour therapy was found to be less useful by students in 1979 than in 1969. In the 1969 survey, 2 per cent of the third year students indicated an interest in psychiatry as a future career as compared with 3.3 per cent in 1979. The implications of these findings are discussed in relation to the psychiatric training programmes in medical schools.