Faculty Bibliography

The role of imaging in the evaluation of neurodegenerative disorders is summarized. The primary role of imaging is to exclude potentially treatable disorders such as meningioma, extracerebral hematoma, Wernicke's disease, and hypothyroidism. Atrophic changes dominate in the hippocampal region on Alzheimer's disease versus the anterior, frontal, and temporal lobes in Pick's disease. Signal hypointensity in the putamen on T2-weighted spin-echo images favors poorly drug-responsive Parkinson's disease whereas putaminal hyperintensity is observed with Creutzfeldt-Jacob, Wilson's, and Leigh's diseases. As our population ages, a thorough understanding of imaging findings in a geriatric population assumes an increasing importance

While many neuropsychological studies have demonstrated age-related performance alterations in tests thought to reflect frontal and temporal lobe function, there is little direct observation and comparison of these hypothesized brain changes in vivo. The cerebral glucose metabolism of frontal, temporal, and cerebellar regions was examined in 40 young (mean = 27.5 +/- 4.9) and 31 elderly (mean = 67.6 +/- 8.8) normal males using PET-FDG. Univariate analysis showed age-related metabolic reductions in all frontal and temporal lobe regions. The reductions ranged from 13%-24% with the greatest changes in the frontal lobes. Multiple regression analyses showed a stronger age relationship with frontal lobe than with temporal lobe metabolism. The dorsal lateral frontal lobe was the region that appears to change most within the frontal lobes. Examination of the temporal lobe showed that age contributed equally to the metabolic variance of both the lateral temporal lobe and hippocampus. These results suggest that age-related metabolic changes exist in both frontal and temporal lobes and that the frontal lobe change is greater

The volume of temporal lobe structures was examined in twenty-seven older (mean age of 69.2 +/- 8.3 years) and ten younger subjects (mean age of 26.1 +/- 4.1 years) using quantitative magnetic resonance imaging (MRI) methods. Multiple regression analysis, using gender, overall atrophy, and head size as covariates, showed unique contributions of age to variance in both medial and lateral temporal lobe volumes. Temporal lobe subregions that showed the strongest unique age-related reductions were the hippocampus, fusiform gyrus, and parahippocampus. These results suggest age-related reductions in temporal lobe subvolumes

Measurements of hippocampal formation atrophy using MRI have been useful in distinguishing demented patients with a diagnosis of probable Alzheimer's disease from cognitively normal controls. To determine whether there is a similar relationship between hippocampal size and dementia in elderly patients suspected of normal pressure hydrocephalus (NPH), the authors obtained mini-mental status examination (MMSE) scores and MRI measurements of hippocampal size and CSF volume on 16 elderly patients whose severe ventriculomegaly and unexplained gait impairment made NPH a probable diagnosis. Hippocampal size correlated strongly with MMSE score (r = 0.75, p < 0.001); no significant MMSE correlation was found for ventricular CSF volume or extra-ventricular/ventricular CSF ratio. It was concluded that hippocampal atrophy is associated with severe cognitive dysfunction in many elderly patients with a diagnosis of NPH. As a hypothesis for further investigation, the detection of such atrophy may help identify cases where the presence of a pathology of Alzheimer's disease complicates the diagnosis of NPH

Although mild progressive memory impairment is commonly associated with normal human aging, it is unclear whether this phenomenon can be explained by specific structural brain changes. In a research sample of 54 medically healthy and cognitively normal elderly persons (ages 55-87, x = 69.0 +/- 7.9), magnetic resonance imaging (MRI) was used to derive head-size-adjusted measurements of the hippocampal formation (HF) (dentate gyrus, hippocampus proper, alveus, fimbria, subiculum), the superior temporal gyrus (STG), and the subarachnoid cerebrospinal fluid (CSF) (to estimate generalized cerebral atrophy). Subjects were administered tests of primary memory (digit span) and tests of secondary memory with immediate and delayed recall components (paragraph, paired associate, list recall; facial recognition). Separate composite scores for the immediate and delayed components were created by combining, with equal weighting, the subtests of each category. The WAIS vocabulary subtest was used as a control measure for language and intelligence. A highly significant correlation (P < 0.001), independent of age, gender, and generalized cerebral atrophy was found between HF size and delayed memory performance. No significant correlations were found between HF size and primary or immediate memory performance. STG size was not significantly correlated with any of the composite memory variables. These results suggest that HF atrophy may play an important independent role in contributing to the memory loss experienced by many aging adults

OBJECTIVE: The primary purpose of this study was to assess whether an interaction between subtle neurological impairment and haloperidol plasma level affects treatment response and, if so, the impact on negative symptoms in particular. METHOD: Forty-three schizophrenic and two schizoaffective inpatients diagnosed according to Research Diagnostic Criteria were given, at the end of a 1-week placebo period, a baseline evaluation consisting of the Brief Psychiatric Rating Scale (BPRS), Scales for the Assessment of Positive and Negative Symptoms, Quantified Neurological Scale, and the Simpson-Angus Scale for extrapyramidal side effects. Subjects were randomly assigned to one of three haloperidol plasma ranges and treated for 6 weeks. At the end point the BPRS, Scales for the Assessment of Positive and Negative Symptoms, and Simpson-Angus Scale were readministered. Multiple linear regressions were used to assess the extent to which the interaction between neurological abnormality and haloperidol plasma level predicted the end-point symptoms once the baseline symptoms, neurological abnormality, and haloperidol plasma level were accounted for. RESULTS: Those patients with higher levels of overall abnormality on the Quantified Neurological Scale at baseline and with frontal dysfunction in particular, had, with increasing haloperidol plasma levels, more severe negative symptoms at end point. Neurological dysfunction was not related to end-point positive symptoms. The effect was specific to end-point negative symptoms and was independent of extrapyramidal side effects. CONCLUSIONS: If confirmed, these findings may indicate that relatively intact frontal function is needed for improvement in negative symptoms and that those patients with schizophrenia who have subtle neurological dysfunction should be treated with lower doses of neuroleptics

Since 1975 in New Jersey, similar legal criteria apply to the discharge of insanity acquittees as those patients who are civilly committed. Based on contact with insanity acquittees (NGRIs) in a regional state hospital, we had the impression that they appeared to be functioning better than the general inpatient population. The purpose of this study was to assess the length of inpatient stay and the level of functioning for the NGRIs and contrast it to a comparison group selected to for variables such as age, ethnicity, Axis I diagnosis, and history of substance abuse, which could impact on our variables of interest. We obtained psychiatrist-rated clinical global impression (CGI) scores and nursing-rated specific level of functioning (SLOF) scores in a group of 62 NGRIs and in a matched group of 62 controls. The NGRIs had significantly better CGI scores, and higher 'personal care skills' and 'social acceptability' SLOF section scores. The social acceptability subscale includes items for aggressiveness towards others, self, and property, all of which were significantly better for the NGRIs. Thus, in our setting, inpatient NGRIs displayed some evidence of better clinical functioning, including less perceived aggressiveness, than the control inpatients. Although the NGRIs has been in the regional state hospital for a shorter period than the controls, the NGRIs had spent an average of over three continuous years in secure facilities before transfer to the regional state hospital. We discuss our findings in view of high rates of paranoid subtypes of psychotic disorders among the NGRI group, and the high prevalence of substance abuse

Involuntary administration of antipsychotic medication to pretrial criminal defendants raises important and controversial questions. These questions arise especially with defendants who have been adjudicated as incompetent to stand trial and who require medication to be restored to trial-competency and return to face their pending criminal charges. This subject has been fiercely debated for decades, but it has received little empirical investigation. We review here the known empirical studies that have looked at the use of involuntary medication for this population of individuals. The following nine conceptual areas are explored: subject selection, definition of 'refusal' and related terms, frequency of refusal, characteristics of refusers, reasons for treatment, reasons for refusal, type and outcome of the review of the refusal, outcome of treatment in the hospital, and outcome of the criminal charges. Relevant findings are reviewed. Methodological limitations call for more research in this area.

The purpose of this study was to assess if a relationship exists between the nature of an individuals criminal charges and the finding of fitness among defendants evaluated at the Forensic Psychiatry Clinic servicing Manhattan. We examined the records of 354 defendants referred to the Forensic Clinic from the New York Criminal and Supreme Courts for a competency to stand trial evaluation. We reviewed their charges in light of the finding of competency. Incompetent defendants were most often accused of misdemeanors rather than felonies and of non-violent rather than violent crimes. Perhaps individuals who are thought to be psychiatrically disturbed get detained by the police on trivial charges so as to get them off the streets. Deinstitutionalization and civil commitment laws are considered as contributing factors and their impact is discussed