Categoría: Papers con abstracts

OBJECTIVE: Early detection and treatment of Bipolar Disorder (BD) determine a significant relief in the considerable burden this disease implies. In order to adequately plan the strategies to guarantee access to treatment, it is useful to consider data which reflect the everyday vicissitudes the people affected by this pathology have to deal with. People on treatment for BD in centres in Argentina and Chile were surveyed, collecting data on their access to diagnosis and treatment. The centre surveyed in Chile, unlike those in Argentina, operates as a specialized unit. METHODOLOGY: An anonymous assisted survey was carried out; a random sample of people assisted in the participating centres with a diagnosis of BD type I or II, and stabilized for a period no shorter than 12 months, was assessed. RESULTS: 100 people were surveyed in Argentina and 69 in Chile (70% women, age 45.2 +/- 14.7, average schooling 12 years). Seventy one percent began symptoms at adult age (28,43 +/- 13 years), 14% during childhood. Age at first consultation was: 30 +/- 12.5; 85% reported having suffered psychotic symptoms, 46.4% suicide attempts, 71% hospitalisations for BD. Sixty-nine percent reported diagnostic delays longer than a year (median 8 years), 75% reported having received other diagnosis prior to their BD diagnosis (62% unipolar depression, 41% schizophrenia). Forty-one percent reported being unemployed. Delays and diagnostic errors were associated to a significant increase in the functional impact reported. CONCLUSION: Approximately 7 out of 10 people report difficulties in the access to a BD diagnosis. These difficulties magnify the already important impact of the disease.

OBJECTIVES: To determine the rate, types, and correlates of psychiatric disorder (PD) following stroke and orthopedic disorders in children and adolescents. METHOD: Children aged 5 to 19 were assessed. The study used a cross-sectional design that compared 29 stroke subjects with 29 congenital clubfoot or scoliosis subjects. Assessments of psychiatric status; cognitive, adaptive, academic, and family functioning; family psychiatric history; neuroimaging; and neurological status were conducted. The main outcome measure was a current PD not present before the stroke or orthopedic disorder. RESULTS: Poststroke PD occurred significantly more often than postorthopedic diagnosis PD (17/29 [59%] versus 4/29 [14%], p < or =.001). Subjects with ongoing poststroke PD had significantly more impaired intellectual and adaptive functioning, higher intensity family psychiatric history scores, and tended toward higher neurological severity index scores, but they were not different regarding lesion volume or family functioning compared with stroke subjects without PD. Regression analyses showed that neurological severity and family psychiatric history independently contributed significantly to predicting PD. CONCLUSIONS: The data suggest that there are significant biopsychosocial correlates of PD in children with focal neurological lesions. These include a relatively abnormal neurological exam, lower IQ, and increased family psychopathology.

One important challenge in neuropsychiatry is how to diagnose depression in patients with acute brain lesions, since there may be an overlap between symptoms of depression and signs associated with the neurologic disease. The best approach is to assess the presence of depressive symptoms using semi-structured or structured psychiatric interviews such as the Present State Exam, the Structured Clinical Interview for DSM-IV, or the Schedules for Clinical Assessment in Neuropsychiatry. The diagnosis of a depressive syndrome should be made using standardized diagnostic criteria for mood disorders due to neurological disease such as in the DSM-IV or the ICD-10. Depression rating scales, such as the Hamilton Depression Scale and the Center for Epidemiologic Scales for Depression may be used to rate the severity of depression and monitor the progression of antidepressant treatment. Most studies in acute and chronic neurologic disorders demonstrated the specificity of both autonomic and psychological symptoms for the syndrome of depression. The present review article examines important considerations before a diagnosis of depression in neurologic disease, discusses a variety of psychiatric instruments that are used to examine the presence and severity of depression in neurologic disease, examines relevant phenomenological issues, and proposes different diagnostic strategies.

Recent work has suggested an association between the orbitofrontal cortex in humans and practical decision making. The aim of this study was to investigate the profile of cognitive deficits, with particular emphasis on decision-making processes, following damage to different sectors of the human prefrontal cortex. Patients with discrete orbitofrontal (OBF) lesions, dorsolateral (DL) lesions, dorsomedial (DM) lesions and large frontal lesions (Large) were compared with matched controls on three different decision-making tasks: the Iowa Gambling Task and two recently developed tasks that attempt to fractionate some of the cognitive components of the Iowa task. A comprehensive battery including the assessment of recognition memory, working memory, planning ability and attentional set-shifting was also administered. Whilst combined frontal patients were impaired on several of the tasks employed, distinct profiles emerged for each patient group. In contrast to previous data, patients with focal OBF lesions performed at control levels on the three decision-making tasks (and the executive tasks), but showed some evidence of prolonged deliberation. DL patients showed pronounced impairment on working memory, planning, attentional shifting and the Iowa Gambling Task. DM patients were impaired at the Iowa Gambling Task and also at planning. The Large group displayed diffuse impairment, but were the only group to exhibit risky decision making. Methodological differences from previous studies of OBF patient groups are discussed, with particular attention to lesion laterality, lesion size and psychiatric presentation. Ventral and dorsal aspects of prefrontal cortex must interact in the maintenance of rational and ‘non-risky’ decision making.

The cognitive effects of active and sham repetitive transcranial magnetic stimulation (rTMS) were examined in 19 middle-aged and elderly patients with refractory depression. Patients received either active (n = 9) or sham (n = 10) rTMS targeted at the anterior portion of the left middle frontal gyrus. Patients in the active rTMS group improved significantly on a test of cognitive flexibility and conceptual tracking (Trail Making Test-B).

The neuropsychiatric effects of insular damage in humans have not previously been examined. We therefore examined the neuropsychiatric impairment in seven patients with left insular stroke, six patients with right insular stroke, six patients with left hemisphere noninsular stroke, and six patients with right hemisphere noninsular stroke. Between 4 and 8 weeks after acute stroke, patients were administered a neuropsychiatric battery. Patients with right insular lesions had a greater frequency of subjective anergia and underactivity (Fisher’s exact p = .002) as well as tiredness (Fisher’s exact p < .002) compared with patients with non-insular lesions or left insular lesions. Subjective feelings of impaired energy or drive after right insular damage may result from disconnection between the insula and the frontal lobe or the anterior cingulate cortex, structures that have been associated with willed action and motor behavior.

This study was undertaken to identify the clinical and pathoanatomical correlates of irritability in patients with closed head injuries. A consecutive series of 66 patients was assessed in hospital and at 3, 6, 9, and 12-month follow-ups. Patients fulfilling criteria for irritability were divided into 2 groups based on the immediate or delayed onset of their irritability and compared with patients without irritability for background characteristics, impairment variables, and lesion characteristics. There were 12 patients (18.2%) with acute onset irritability and 10 (15.1%) with delayed onset irritability. Acute onset irritability patients had a higher frequency of left cortical lesions. Delayed onset irritability patients showed a strong association with poor social functioning and greater impairment in activities of daily living. The findings suggest that post-brain injury irritability may have different causes and treatment in the acute and chronic stages.

Transcranial Magnetic Stimulation (TMS) is an exciting new technology that along with repetitive TMS (rTMS) offers the potential to explore and understand brain-behavior relationship in a way that builds on recent advances in functional neuroimaging (ie, PET, SPECT, fMRI imaging). rTMS as a relatively noninvasive probe of cortical function provides an opportunity to explore the relationships between regional brain activity and symptomatology across psychiatry illnesses. In this article we briefly review the current thinking regarding the neurobiology of mood and the effects of rTMS on mood in healthy and depressed subjects.

Advances in surgical procedures and new immunosuppressor therapies have improved the outcome of renal grafts. However, these changes have been accompanied by infectious, neoplastic and neurologic complications. The purpose of this study was to determine the incidence of neurologic complications among 542 patients receiving a renal transplant (from living or cadaveric donors) at CEMIC between 1970 and 1996. Neurologic complications occurred in 43 patients (8%) as follows: 8 meningitis (1.5%), 8 acute confusional syndrome (1.5%), 7 encephalitis (1.3%), 7 cerebrovascular accidents (1.3%), 6 convulsions (1.1%), 3 tumors (0.5%), 3 femoral nerve lesion (0.5%), and 1 epidural lipomatosis (0.1%). Etiologic agents most commonly observed in meningitis were: Cryptococcus neoformans, Listeria monocytogenes and Mycobacterium tuberculosis. Major difficulties arose in the diagnosis of encephalitis. Diagnosis of the above complications required clinical astuteness and repeated bacteriologic, serologic and imaging studies.

Clozapine has been shown not only to be effective in ameliorating dopaminomimetic psychosis but to improve parkinsonian symptomatology. Six parkinsonian patients with motor fluctuations under levodopa treatment and severe interdose «off » periods (believed to be mediated by an inhibitory effect of subthreshold levels of levodopa) underwent a trial of clozapine. The effects of this drug on levodopa response were measured by means of an acute levodopa test both before and after receiving clozapine. After 1 month of treatment, clozapine 25 mg/day reduced parkinsonian scores at all stages of the evaluation (pre-levodopa «off, » «on, » and interdose «off «). The effect was consistently more significant for the interdose «off. » Clozapine could be exerting its beneficial effects through the inhibition of an inhibitory effect mediated by low-level dopaminergic stimulation, thus behaving as an apparent anti-parkinsonian drug.