Clinical and lesion correlates

In the previous chapter, Prevalence and specificity of clinical symptoms, I listed a number of investigators in Table 29.1 who have examined the clinical and lesion correlates of anxiety disorder following stroke. In an effort to reexamine our findings on the clinical and pathological correlates of poststroke anxiety disorder, we recently analyzed data from our largest group of patients which included 396 acute stroke patients. The background characteristics of patients with or without...

Aprosody had a significantly higher frequency of right hemisphere lesions predominantly in the temporoparietal cortex

And the recognition of facial emotion score were significant and independent correlates of aprosody (r for denial 0.3, r for facial emotion 0.4 p < 0.01). There was, however, no significant correlation with Ham-D score. We also examined the relationship between aprosody and the error rate when there was a conflict between the semantic content of the sentence and its emotional intonation. There was a significant group effect, with aprosodic patients showing significantly more deficits when...

Background

Suicide constitutes one of the major public health problems in the USA. Physical illness has been demonstrated to be a significant risk factor for both suicidal ideation and suicide attempts. Mackenzie and Popkin (1987) reported that suicide risk is greater among patients with physical illnesses than among the general population. DeVivo et al. (1993) found that 6.3 of all deaths among patients with spinal cord injury (SCI) were caused by suicide and that persons with SCI were 4.9 times more...

Cognitive impairment and stroke

There are numerous studies which have demonstrated cognitive impairment associated with of specific regions of cerebral infarction (Gazzaniga 2000). Although the focus of this chapter will be on the relationship between depression and cognitive impairment, it is worthwhile to review some of the recent studies which have documented the frequency and severity of cognitive impairment associated with stroke. Perhaps the most well-designed study is the one involving the Framingham cohort (Kase et...

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Non-depressed * p < 0.05 The frequency of vegetative symptoms of depression in patients with depressed mood and without depressed mood following stroke. Symptom frequency is shown over the 2-year follow-up. Morning depression (i.e., diurnal mood variation) and anergia were associated with depression throughout the entire 2-year period. Loss of libido was only seen early in the follow-up while early morning awakening was only seen late in the follow-up. These findings suggest changes over...

Electroconvulsive treatment

Electroconvulsive therapy (ECT) has also been reported to be effective in some cases of poststroke depression. The first study to report a beneficial effect of ECT was Murray et al. (1986) who conducted a retrospective study of 14 cases of post-stroke depression (nine developed depression within 1 year of stroke and five developed depression after 1 year) treated with ECT. All of the patients who developed depression after 1 year and seven of the nine who developed depression before 1 year were...

Frontal lobe lesions

We have also recently examined the relationship between depression and frontal lobe lesions involving either the lateral frontal cortex (n 8) or the medial frontal cortex (n 8) (Paradiso et al. 1999). The groups were composed of three women and five men with traumatic head injuries, and five men with strokes studied within the first 2 months following brain injury. The mean ages of the medial lesion group was 39.5 17 years SD and the lateral lesion group was 44.1 17 years SD. There were no...

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Figure 33.2 Change of Z score from baseline (pretreatment) scores for both Ham-A and Ham-D scales among patients treated with nortriptyline (n 13). At a dose of 50 mg which represents 2-3 weeks of treatment, Ham-A scores had dropped significantly more than Ham-D scores from the baseline values (*p 0.035). This suggests a more rapid response of anxiety symptoms than depressive symptoms to nortriptyline treatment data from Kimura and Robinson (2003) . To our knowledge, this was the first study...

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Figure 31.1 The frequency of GAD with or without depression during the acute hospital period (early-onset) and 3-24 months (late-onset) following stroke. Of 142 patients seen acutely and at follow-up, the number of early- and late-onset cases associated with depression was quite similar. The great majority of GAD cases had associated depression (data from Castillo et al. 1995). significantly different from the frequency of depression among patients who did not develop GAD during the same...

Insular lesions

We have recently examined the relationship between psychopathology and lesions of the insular cortex. The insular cortex is the in-folded cortex surrounding the central fissure beneath the motor and sensory cortex. Seven patients with left insular stroke and six patients with right insular stroke were compared with six patients having left hemisphere non-insular stroke and six patients with right hemisphere non-insular stroke. Patients were studied between 4 and 8 weeks following acute stroke...

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Figure 3.4 The three (a-c) circuits relevant to behavior are shown. Injury to the dorsolateral prefrontal circuit produces executive dysfunction, damage to the orbitofrontal circuit causes disinhibition, and dysfunction of the medial frontal circuit produces apathy. VA ventral anterior nucleus MD medial dorsal nucleus DLC dorsolateral prefrontal cortex PPC posterior parietal cortex STG superior temporal gyrus ITG inferior temporal gyrus ACA anterior cingulate area HC hippocampal cortex EC...

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Figure 18.1 Mean SD impairment scores at the time of initial in-hospital assessment for 91 patients with stroke who were followed up 10 years later for survival status. Patients who died during the 10-year follow-up had significantly fewer STC than patients who survived. Although differences were not significant, patients who died had greater impairment than survivors on the Johns Hopkins functioning inventory (JHFI), MMSE, and SFE. depression depression depression depression *p < 0.05 Figure...

Longitudinal course

Some studies of elderly populations with dementia of depression have shown long-term cognitive deterioration. Alexopoulos (1993) followed up elderly patients with reversible depressive dementia without stroke and found that 33 developed an irreversible dementia about 33 months later. On the basis of this finding the authors proposed that patients who have late onset depression with reversible dementia may include some who have preexisting early stage dementia. Moroney (1996) followed up on...

Longitudinal course of cognitive impairment and depression

In our original 2-year longitudinal study of 103 patients (see Table 8.1 for population characteristics), we found that the mean correlation coefficient between the severity of depression and the MMSE score declined from 0.34 (p < 0.01) during acute hospitalization to 0.18 at 3 months (p NS). By 6-month follow-up, however, the correlation had increased to 0.31 (p < 0.01). At 1- and 2-year follow-up, however, the correlations were not significant. Thus, in our initial follow-up study, the...

Method of diagnosis

For a number of years the generally accepted method for research diagnoses of psychiatric disorders has been to conduct a structured or semi-structured mental status interview to elicit the presence and duration of symptoms of the disorder and apply these to Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria for that disorder. The current DSM-IV TR (American Psychiatric Association 2000) has identified a category of disorders which are judged by...

Movement disorder

Berthier et al. (1996) examined 9 patients with bipolar affective disorder with cerebrovascular lesions. Of the 9 patients with bipolar disorder, 8 had no family history of bipolar disorder in first-degree relatives. One patient had a father who committed suicide during a stress-induced depression. Two patients had a personal history of depressive disorder prior to the onset of stroke and the mean age at onset of mood disorder was 51.2 9 years. In 8 of the 9 cases, the first affective episode...

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Cardiovascular Severe Hospitalization Stroke *p < 0.02 Sertraline (n 70) Placebo (n 68) Figure 23.4 The frequency of adverse medical events among patients treated for 1 year following acute stroke with sertraline or placebo. Cardiovascular events and hospitalization were significantly lower in the sertraline treated patients compared with the placebo group (from Rasmussen et al. 2003, reprinted with permission). The frequency of adverse events was significantly influenced by the presence or...

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CO CO CO S -a J ffi O The frequency of psychological symptoms of depression in patients with depressed mood and without depressed mood following stroke. Symptom frequency is shown over the 2-year follow-up. Most symptoms (i.e., worrying, brooding, loss of interest, hopelessness, social withdrawal, lack of self-confidence, self-depreciation, ideas of reference, and irritability) were more frequent in depressed patients through the 2 years following stroke. Feelings of self-blame...

Pathological laughing and crying

The association of brain injury with uncontrollable episodes of crying, or less frequently laughing, has been recognized as a consequence of brain injury since the 19th century (Wilson 1923 Davison and Kelman 1939). In 1877, Lepine described pseudobulbar palsy as a cranial nerve palsy (i.e., inability to swallow, move the tongue, articulate, forcefully close the eyes) induced by supranuclear lesions (i.e., lesions of the corticobulbar or corticopontine pathway) resulting from bilateral strokes....

Preface

In the second edition of The Clinical Neuropsychiatry of Stroke, I have tried to include all of the recent findings concerning the neuropsychiatric syndromes associated with stroke published since 1998 when the original edition of this text was released. Integrating the substantial amount of literature which has been generated over the past 7 years has been a large task. The number of publications related to the single topic of poststroke depression has more than doubled in the 7 years before...

Prevalence and clinical symptoms

Since the first edition of this text in 1998, the literature on mania following stroke continues to be dominated by anecdotal reports and small series of cases examining risk factors for secondary mania. Secondary mania is generally defined as mania following a precipitating causative event such as head injury, stroke, or drug exposure (Rosenbaum and Barry 1975 Krauthammer and Klerman 1978 Forrest 1982). Cohen and Niska (1980) first reported on lesion location associated with secondary mania...

References

Astrom, M., Adolfsson, R., and Asplund, K. Major depression in stroke patients a 3-year longitudinal study. Stroke (1993) 24 976-982. Benson, D. F. Psychiatric aspects of aphasia. Br J Psychiatr (1973) 123 555-566. Benson, D. F. Aphasia, Alexia, and Agraphia. Churchill Livingstone, New York, 1979. Crosson, B. Subcortical functions in language a working model. Brain and Language (1985) 25 257-292. Dam, H., Pedersen, H. E., and Ahlgren, P. Depression among patients with stroke. Acta Psychiatr...

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Irritable violent (n 15) Matched control (n 34) *p < 0.05 Figure 39.2 Lesion location using either CT imaging or clinical localization in 49 patients with and without self-reported irritable violent outbursts. Patients with angry outbursts were significantly more likely to have had left hemisphere lesions and less likely to have had right hemisphere lesions compared with controls (data from Paradiso et al. 1996). laterality of lesion was assessed by clinical symptomatology although the...

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Normals (n 17) Left stroke (n 8) Right stroke (n 9) *p < 0.03 Figure 21.4 PET measurements of NMSP binding to cortical S2 serotonin receptors in non-injured areas of frontal, temporal and parietal cortex following first ever right or left stroke. Binding was measured by comparing radioactive counts in the region of interest to non-specific binding in the cerebellum and then comparing the stroke hemisphere to an identical area of the opposite hemisphere. Although left hemisphere stroke (n 8)...

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Left anterior Left posterior Right anterior Right posterior * p < 0.05 Figure 11.4 The percent of patients with major depression divided into anterior, posterior, right and left lesion location who had typical (i.e., normal) and reversed occipital brain asymmetry. The expected pattern of major depression associated with acute left anterior brain injury was found only in patients with typical occipital asymmetry. There was a trend for patients with reversed occipital asymmetry to an increased...

Stroke

Behavioral and Emotional Disorders following vascular Brain injury The Clinical Neuropsychiatry of Stroke This fully revised new edition covers the range of neuropsychiatry syndromes associated with stroke, including cognitive, emotional, and behavioral disorders such as depression, anxiety, and psychosis. Since the last edition there has been an explosion of published literature on this topic and the book provides a comprehensive, systematic, and cohesive review of this new...

Table 171 Demographic data

Age (mean SD in years) 58 16 58 12 Socioeconomic status ( Hollingshead class IV or V) 15 15 Marital status ( married) 54 69 Children (mean number) 3 2 Siblings (mean number) 3 3 Education (mean number of years SD) 10 3 9 2 Tobacco use ( > 1 pack day) 38 69 Time since stroke to depression onset (time to follow-up for non-depressed group) ( ) Family history of psychiatric disorders ( ) 0 0 History of alcohol abuse (hospitalized or had 15 15 withdrawal symptoms ) Time since stroke to CT scan,...

Table 372 Diagnostic criteria for apathy3

Lack of motivation relative to the patient's previous level of functioning or the standards of his or her age and culture, as indicated either by subjective account or observation by others. Presence, with lack of motivation, of at least one symptom belonging to at least two of the following three domains Diminished goal-directed behavior - Dependency on others to structure activity Diminished goal-directed cognition - Lack of interest in learning new things or in new experiences - Lack of...

Table 392 Stroke characteristics neurological findings and radiological findings for aggressive and nonaggressive

Stroke type Infarction ( ) Hemorrhage ( ) Location Left hemisphere ( ) Right hemisphere ( ) Brain stem other ( ) Neurological deficit Motor deficit ( ) Sensory deficit ( ) Visual field deficit ( ) Aphasia ( ) Linear brain measurements (mean SD) Lateral ventricle brain ratio Third ventricle brain ratio Bifrontal ratio Bicaudate ratio Stroke lesion measurements (mean SD) Lesion volume ( of total brain volume) Anterior location ( of AP diameter of brain) 34.8 56.5 8.7 (n 22) 81.8 27.3 31.8 9.1 (n...

Table 401 Continued

Have these episodes occurred in excess of feelings of sadness _Rate the frequency with which the episodes have been disproportionate to the emotional 16. Have these episodes of crying occurred with feelings of happiness _Rate the frequency of association between the episode and the paradoxical emotion in the past 2 weeks. The happiness must precede or accompany the crying. 17. Have these episodes occurred with any emotions other than sadness or happiness, such as nervousness, anger, fear,...

The Clinical Neuropsychiatry of Stroke

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, Sao Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 2RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title www.cambridge.org 9780521840071 R. Robinson 2006 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place...

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GAD alone (n 1) *p 0.02 Figure 32.3 Social functioning outcome in patients with MDD or GAD in-hospital. Patients with both MDD and GAD in-hospital had significantly worse social functioning at both short-term (3-6 months) follow-up and long-term (1-2 years) follow-up than patients with these disorders alone or no mood disorder. At both short- and long-term follow-up, there was a significant MDD by GAD by time interaction (p 0.03) indicating that the combination of anxiety and depression was...

Venous system

The venous drainage consists of a superficial system and a deep system. Both of these venous drainage systems enter into a collecting system of large channels called sinuses which in turn drain into the internal jugular veins that leave the skull through the jugular foramina and eventually empty into the superior vena cava. The superficial venous system consists of surface veins that carry blood into the superior saggital sinus, the cavernous sinus, and the transverse and petrosal sinuses. The...

Vertebralbasilar system

The posterior portion of the brain is supplied by the vertebral system. The vertebral arteries arise from the subclavian arteries and ascend through the vertebral canal and the foramen magnum to enter the skull. At the rostral end of the medulla, they unite to form the basilar artery which courses the full length of the pons to the midbrain (Fig. 4.2). Connections between the posterior circulation (i.e., the vertebral-basilar system) and the anterior circulation (i.e., the carotid system) occur...

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Hemisphere hemisphere ganglia ganglia CR (n 9) No CR (n 50) *p < 0.05 Figure 36.3 The lesion locations found on computerized tomographic (CT) scan in 51 patients with or without CRs. The only lesion site which was significantly associated with the existence of CR was the basal ganglia. There was no association found with laterality of lesion (data from Starkstein et al. 1993). without. In addition to the association of CR and more anterior lesions, the CR group also had a higher frequency of...

Mechanism of cognitive impairment

The finding that patients with major depression had significantly lower MMSE scores than non-depressed patients only during the first 6-12 months following stroke and that cognitive impairment occurred primarily in patients with major depression associated with left hemisphere lesions suggested that depression itself may not have played a major role in producing cognitive impairment. If depression produced cognitive impairment, all patients with major depression regardless of whether they had a...

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Depressed (n 79) 1 Non-depressed (n 316) Figure 7.2 The percent of patients hospitalized with acute stroke who acknowledge autonomic (vegetative) symptoms (top panel) depression (see Table 7.1 for list of symptoms). Patients without depressed mood do acknowledge some vegetative and psychological symptoms of depression but significantly fewer than the depressed mood patients (3.6 2.1 SD versus 1.0 1.1, p 0.001 for autonomic symptoms and 4.1 2.8 SD versus 0.9 1.2, p 0.001 for psychological...

Mortality and poststroke depression

Increased mortality is perhaps the ultimate validation of the importance of depression in the prognosis of physical illness. Several studies have been conducted among patients with stroke which have documented increased mortality rates among those with depression or depressive symptoms. Our first study was a 10-year follow-up of survival obtained for 91 of original series of 103 acute stroke patients (Morris et al. 1993a). Data was obtained by contacting patients' living relatives or searching...

Cognitive impairment and depression

The nature of the relationship between cognitive impairment and depression appears to involve a complex interaction between depression, the stroke lesion and cognitive impairment. Although one might understandably view cognitive impairment as a cause of depression, their relationship is clearly a more complex one. In 1989, we hypothesized that major depression following left hemisphere lesions produces through some physiological process a greater degree of cognitive impairment than can be...

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Figure 35.9 Relationship between denial of illness (anosognosia) and diagnosis of major or minor depression, or GAD using DSM-IV diagnostic criteria. Note that depression and GAD were just as common in the denial compared with the non-denial stroke patients (reprinted from Robinson 2004 with permission). From Self-Awareness Deficits in Psychiatric Patients, edited by Bernard D. Beitman and Jyotsna Nair, Copyright 2004 by Bernard D. Beitman and Jyotsna Nair. Used by permission of W.W. Norton...

Table 391 Background characteristics

Age (mean SD in years) Race ( African-American) Gender ( female) Education (mean number of ( Hollingshead IV, V) Martial status ( married) Family psychiatric history ( positive) Personal psychiatric history ( positive) Alcohol abuse ( positive) Time since stroke (mean SD days) History of CVA ( positive) Reprinted with permission, from Paradiso et al. (1996). *Compared to overall group p 0.008. alcohol or to have significantly less education. Since medication is a common cause of behavioral...

Other types of cerebrovascular disease

One of the other causes of cerebrovascular disease is fibromuscular dysplasia, which leads to narrowed arterial segments caused by degeneration of elastic tissue, disruption and loss of the arterial muscular coat, and an increase in fibrous tissue. Inflammatory diseases of the arterial system can also lead to stroke these include meningovascular syphilis, pyogenic or tuberculous meningitis, temporal arteritis, and systemic lupus erythematosus. There are many other less common causes of...

Vascular disease and age of onset

Another risk factor for late-onset mania was identified by Cassidy and Carroll (2002). The records of 366 bipolar patients were reviewed and divided at age 47 based on the bimodal distribution of age at first psychiatric hospitalization. Using that threshold, 23 (6.3 ) were classified as late onset and 343 (93.7 ) as early onset. The vascular risk factors included hypertension, hyperlipidemia, and history of smoking, atrial fibrillation, coronary artery disease, and cerebrovascular accident. In...

Relationship of depression to social functioning

Social functioning has been recognized for many years to play an important role in development of depression associated with stress or negative life events (Brown et al. 1986 Henderson 1990). Furthermore, the effect of social support on psychological distress depends upon the nature of the supportive attachment. Among women in a community sample, for example, inadequate social support from a spouse was found to have a greater emotional impact than lack of support from a non-spousal relationship...

Specificity of anxiety symptoms

In order to examine the frequency of anxiety symptoms and their specificity for anxiety disorder, patients with acute stroke were grouped according to whether they did or did not express anxiety or worry. As I discussed in Chapter 7 entitled, Phenomenology and the specificity of depressive symptoms, among patients with acute stroke, it is not obvious how one should assess the specificity of symptoms used for the diagnosis of anxiety disorder. If one uses the diagnostic criteria to define the...

Diagnosis of anxiety disorders

As with depressive disorders, the gold standard for the diagnosis of anxiety disorders is a structured or semistructured mental status examination which is applied to the diagnostic criteria of DSM-IV or ICD-10. Although cases of phobic disorder, panic disorder, and obsessive compulsive disorder, have been reported following stroke or brain injury (House 1987 Burvill et al. 1995 Max et al. 2002). The majority of investigators have focused on the more chronic disorder of GAD associated with...

Relationship of anxiety to outcome

For many years clinicians have recognized the importance of anxiety disorder as well as depression in patients following stroke (Schwartzman 1976). The spectrum of anxiety disorders includes panic disorder, generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD) and phobic disorders. There have been anecdotal reports of panic disorder (Maricle et al. 1991) and OCD occurring in patients with stroke. These are relatively rare conditions arising from ischemic brain injury. Our...

Aggressive patients had more anterior hemisphere lesions greater depressive and anxiety symptoms but less cognitive

In addition to confirming many of the findings from our first study of aggression in patients with stroke, in our second study, the patients were participating in our treatment study of poststroke depression (see Chapter 23). Response to antide-pressant medication was therefore evaluated in the 23 initially aggressive patients who entered this 12-week treatment trial. Among the active treatment patients, six were treated with fluoxetine titrated from 10 mg day up to 40 mg day. Four were treated...

Applicable diagnostic categories

In Chapter 7, I will discuss the controversy over the specificity of symptoms in patients with medical illness and alternative suggestions for diagnosis. This chapter, however, will be devoted to the methodology and criteria used for diagnosis of poststroke depression or poststroke mania. The diagnostic category mood disorder due to stroke has four subtypes the first is mood disorder due to stroke with depressive features the second is with major depressive-like episode the third is with manic...

Other diagnostic categories

Besides major and minor depression, the other diagnostic category, which may sometimes be applicable to patients with poststroke depression, is adjustment disorder with depressed mood or adjustment disorder with mixed anxiety and depressed mood. These diagnoses using DSM-IV criteria are based on the existence of depressed mood, tearfulness, or feelings of hopelessness with or without nervousness, worry, or jitteriness occurring within 3 months of the onset of an identified source of social...

Prevalence of depressive disorders

The prevalence of poststroke depression has been assessed in a large number of patients who have been examined in various settings throughout the world. Since the first edition of this text, large numbers of patient populations have been added to the literature and pooling of the data has provided prevalence rates based on more than 6000 patients. There are at least three factors which have complicated the determination of prevalence rates. The first is the setting in which patients were...

Carotid system

A schematic coronal view of the brain taken through the temporal and parietal cortex and thalamus. The overlapping regions subserved by anterior and middle cerebral arteries (internal carotid circulation) and posterior cerebral arteries (posterior circulation) are demonstrated. Figure 4.4 The anterior and middle cerebral artery circulation demonstrating the medial course of the anterior cerebral artery along the interhemispheric separation and the lenticulostriate arteries which penetrate the...

Catastrophic reaction

The sudden onset of anxiety, tears, aggressive behavior, swearing, displacement, refusal, denouncement, and compensatory boasting constitute a syndrome referred to by Goldstein (1948) as a catastrophic reaction (CR). Goldstein believed that this syndrome represented a response to the inability of an organism to cope when faced with a serious defect in their physical or cognitive function. These emotional outbursts would generally last only a few seconds and were usually associated with a...

Mechanism of mortality following poststroke depression

Based on the fact that our studies found an association between both major and minor depression with mortality, it appears likely that severity of depression is not as important as the existence of some level of depression. Subsyndromal forms of major depression appear to place patients at risk for mortality just as much as major depression (House et al. 2001). The mechanism by which depression following stroke leads to increased mortality over many years remains a topic of debate. Although...

The relationship between severity of depression and severity of physical impairment

As indicated in Table 13.1, 83 of studies that have examined the relationship between poststroke depression and physical impairment have found that patients with depression are significantly more physically impaired than patients without depression, and furthermore that there is a direct correlation between severity of physical impairment and severity of depressive symptoms (Robinson et al. 1983 Eastwood et al. 1989 Astrom et al. 1993). We have examined our overall acute stroke patient database...

Relationship of aphasia to depression

Aphasia remains one of the most perplexing problems for investigators of neuropsychiatrie disorders following stroke. Since the diagnoses of all neuropsychiatrie disorders requires subjective responses by the patient to verbal or written questions, the existence of even a moderate degree of comprehension deficit may represent a severe obstacle to the diagnoses of numerous neuropsychiatric disorders. This conundrum has led almost all investigators of poststroke neuropsychi-atric disorders to...

Bipolar disorder following stroke

As indicated in the previous chapter, a significant number of patients with secondary mania were also found to have episodes of depression. In contrast, however, other patients with secondary mania did not have episodes of depression within the period of study or prior to the stroke. We examined patients with bipolar disorder and compared them to patients with secondary mania but no evidence of depressive episodes (Starkstein et al. 1991). The most obvious concern in patients with mania but...

Brain organization and cerebral basis of emotion

As described in Chapter 2, as early as the 19th century Hughlings-Jackson (1875) recognized that symptoms associated with brain lesions may produce both loss of normal function as well as emergence of new, sometimes abnormal symptoms. These new symptoms may arise from the effect of injury on distant uninjured brain areas leading to the release of normally inhibited functions or the loss of normally activated functions. Thus, this chapter will review brain anatomy, particularly the limbic...

Mechanism of mania following stroke

Injury to the inferior temporal cortex, orbital frontal cortex, caudate, and thalamus have all been demonstrated to lead to the development of mania in vulnerable patients. These constitute the major elements of the lateral orbital frontal circuit as described by Alexander et al. (1990) and the association of mania with injury to these structures suggests that these right hemisphere regions may play an important role in the mediation of mania following stroke. One of the main factors, however,...

Anosognosia and denial of illness

In 1914, Babinski (1914) reported that some patients with severe hemiplegia appeared to be unaware of their deficit. He called this absence of awareness anosognosia, a term derived from the Greek words gnosis (knowledge), a (without), and noso (disease). The medical literature of the late 19th and 20th centuries reported a variety of failures of awareness of one's own deficits or diseases including Anton's syndrome of cortical blindness (Anton 1896), unawareness of hemianopsia, amnesia,...

Phenomenology and specificity of depressive symptoms

Phenomenology refers to the study of the structure of observable events. In the study of poststroke depression, phenomenology refers to the study of signs and symptoms which constitute the basis for the diagnosis of depression. Since depression occurs in the context of an acute medical illness, one might naturally wonder whether these depressions are like depressions in patients without acute illness or whether the acute medical illness interferes with our ability to diagnose depression using...

Figure 353 Impairment scores on the MMSE and the JHFI as well as severity of depression scores on the Hamilton

No significant differences between these lesion-matched patients in their total PSE score (14.8 16.5 anosognosia versus 8.1 10.4 control). In addition, three of the 6 patients with anosognosia were depressed (two with major depression and one with minor depression) compared with two of the 6 patients without anosognosia (one had major and one had minor depression). Thus, even after controlling for demographic and lesion location variables, depression was no less common in the anosognosic...

Treatment of poststroke anxiety disorder

The first treatment study of generalized anxiety disorder (GAD) following stroke was based on a merged analysis of results from previous treatment studies conducted by our research group (Kimura and Robinson 2003). These previous treatment studies included poststroke depression (Lipsey et al. 1984), pathological laughing and crying (Robinson et al. 1993) and a comparison of nortriptyline and fluoxetine for poststroke depression (Robinson et al. 2000). From the total of 106 patients in these...

Patients with typical and reversed brain asymmetries

The second study was undertaken to assess depression in patients with evidence on CT scan of reversed anatomical organization of the brain (Starkstein et al. 1991). LeMay and Kido (1978) first reported normal brain asymmetries on CT scans. They found that 78 of right-handed males had a greater occipital length in the left hemisphere compared with the right hemisphere and 67 had a greater left than right occipital width. On the other hand, the right frontal length was greater than the left in 70...

Biological markers

In spite of brief periods of enthusiasm about the potential diagnostic utility or etiological insights to be gained from neuroendocrine tests associated with depression, there has been an overall lack of success of neuroendocrine testing in primary depression. Similarly, among patients with poststroke depression, neuroendocrine tests have not been successful in establishing either an alternative method of diagnosing poststroke depression or illuminating neuroendocrine abnormalities which may...

Relationship of depression to bilateral hemisphere brain injury

The role of each cerebral hemisphere in emotion regulation has been a topic of speculation and experimental investigation for many years. Flor-Henry 1979 , for example, suggested a complex model for the organization of mood. He proposed that the neural substrate for both normal and abnormal mood was predominantly in the non-dominant hemisphere but with bilateral regulation. Thus, according to this hypothesis, euphoria results when the dominant hemisphere no longer receives transcallosal neural...

Irritability and aggression

Irritability and aggression are common disorders associated with neuropsychiatric conditions, such as stroke, dementia, traumatic brain injury, and Huntington's disease Burns et al. 1990 Paradiso et al. 1996 Chemerinski et al. 1998 Kim et al. 1999 . These symptoms create a major stress for the families of patients with stroke Brooks et al. 1986 Williams 1994 and lead to a poorer quality oflife for the patient Angeleri et al. 1993 . Aggressive behavior is a common reason for referral to...

Disturbance of prosody

Monrad-Krohn 1947 described prosody as the melodic line of speech produced by variations of pitch, rhythm, and stress of pronunciation. Heilman and Valenstein 1993 divided prosody into two types affective aprosody, described as the loss or defect in expression, repetition, or comprehension of emotionally intoned speech and prepositional aprosody, characterized by a loss of or defect in expression, repetition, or comprehension of sentences with prepositional content such as questions,...

Table 401 Pathological laughter and crying scale

Have you recently experienced sudden episodes of laughter _Rate the frequency of the episodes during the past 2 weeks. 2. Have you recently experienced sudden episodes of crying _Rate the frequency of the episodes during the past 2 weeks. If you have experienced sudden episodes of laughter, please answer the following questions 3-10 otherwise skip to question 11. 3. Have these episodes occurred without any cause in your surroundings _Rate the frequency with which the episodes have occurred...

Apathy

The definition of apathy in the dictionary is described as a lack of feeling or emotion or a lack of interest or concern. In a study of 124 poststroke patients who were examined at either 2, 6, or 12 months following stroke, apathy was reported in 27 of the patients while depression was reported in 61 and irritability in 33 Angelelli et al. 2004 . Apathy has been associated with bilateral paramedian, or interior thalamic infarctions Ghika-Schmid and Bogousslavsky 2000 Krolak-Salmon et al. 2000...