Behavioral neurology / monograph PDF
Preview Behavioral neurology / monograph
BEHAVIORAL NEUROLOGY This page intentionally left blank BEHAVIORAL NEUROLOGY Fourth Edition JONATHAN H. PINCUS, M.D. Chief of Neurology Veterans Administration Medical Center Washington, D.C. Professor of Neurology Georgetown University School of Medicine GARY J. TUCKER, M.D. Professor Emeritus Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine OXFORD UNIVERSITY PRESS 2003 OXFORD UNIVERSITY PRESS Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Sao Paulo Shanghai Taipei Tokyo Toronto Copyright © 1974, 1978, 1985, 2003 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 http://www.oup-usa.org Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Pincus, Jonathan H., 1935- Behavioral neurology / Jonathan H. Pincus, Gary J. Tucker.—4th ed. p. cm. Includes bibliographical references and index. ISBN 0-19-513781-7 (cloth)—ISBN 0-19-513782-5 (pbk.) 1. Neuropsychiatry. I. Tucker, Gary J., 1934- II. Title. [DNLM: 1. Nervous System Diseases. 2. Mental Disorders. WL 140 P647b 2003] RC341 .P56 2003 616.89—dc21 2002018383 9 8 7 6 5 4 3 21 Printed in the United States of America on acid-free paper "It ought to be generally known that the source of our pleasure, merriment, laughter, and amusement, as of our grief, pain, anxiety, and tears, is none other than the brain. It is specially the organ which enables us to think, see, and hear, and to distinguish the ugly and the beautiful, the bad and the good, pleasant and unpleasant. Sometimes we judge according to the perceptions of expediency. It is the brain too which is the seat of madness and delirium, of the fears and frights which assail us, often by night, but sometimes even by day; it is there where lies the cause of insomnia and sleep-walking, of thoughts that will not come, forgotten duties, and eccentricities. All such things result from an unhealthy condition of the brain." Hippocrates This page intentionally left blank PREFACE Psychiatry and neurology have undergone revolutionary changes since the last edition of this book was published in 1985. There are now many new medica- tions, discussed here, for the control of epilepsy, depression, mania, schizophre- nia, obsessive-compulsive disorder, anxiety, and movement disorders. The dis- covery that the selective serotonin reuptake inhibitors (SSRIs) could control not only depression but also the symptoms of obsessive-compulsive disorder, phobia, and panic disorder has brought hope and relief to the sufferers from these con- ditions and their families and, perhaps even more importantly, has brought these illnesses into the realm of neuroscience. No one could argue today, as they did in the past, that these conditions are purely "psychological neuroses," disorders of the mind not the brain. New, atypical antipsychotic drugs have provided relief for many of the symp- toms of schizophrenia. These drugs have a much lower rate of extra pyramidal side effects than the neuroleptics available in 1985, especially with regard to the risk of tardive movement disorders. We discuss these and their presumed mech- anism of action. The expanded understanding of Parkinson's disease, its etiology and treat- ment, has provided a paradigm for the understanding of the role of catechola- mines and indoleamines in depression. It has also highlighted a flaw in the amine hypothesis of depression. The changes wrought by dopamine replacement ther- vii viii PREFACE apy in Parkinson's are realized within minutes. The antidepressant drugs induce changes in brain amines within minutes, too, but the onset of their antidepressant effect is delayed for 2 to 3 weeks. The amine hypothesis and alternate hypoth- eses for depression are presented. The physiological effects of psychological stress on the brain may be mediated through steroids that damage and even kill neurons in the hippocampus and elsewhere. Our understanding of reparative brain mechanisms is expanding and may ap- ply to the recovery of brain cells from stress. The old idea that new neurons do not form during postnatal life has been challenged. There is strong and growing evidence that neurogenesis occurs in the adult human brain, especially in the hippocampus. Adult mice provided with enriched environmental living condi- tions grew 60 percent more granule cells in the dentate gyrus of the hippocampus than genetically identical controls and outperformed the controls in learning. There has been an astounding increase of our appreciation of the many links between the brain and behavior. With the introduction of DSM-IV, the diagnostic criteria for psychiatric dis- ease have sharpened. Clinical studies have become more focused and DSM-IV has broadened our understanding of mental illness. The new insights provided by DSM-IV are contrasted with some older ideas. The newest categorization of epilepsy has abolished many imprecise, confus- ing terms that were in use a generation ago, such as petit mal, psychomotor, minor, focal, and grand mal. The new terminology is used in this edition. Many clinical studies have clarified the relationship of pseudoseizures to true epilepsy. It has proven very difficult to distinguish pseudoseizures from the behavioral abnormalities that are the manifestations of complex partial seizures that arise from the frontal and occipital lobes. We review these features and summarize the criteria that differentiate them. There is increasing appreciation of the frequency with which dissociation occurs. It is the operative feature in many conversion reactions, including pseu- doseizures. This insight has only recently emerged. As residents, we were taught that dissociation was rare. It is not rare. The role of child abuse, physical, sexual, or both, and the resulting dissociative defenses have been implicated in the development of many personality disorders (antisocial, borderline, hysterical, paranoid, multiple) and mood disorders. From the days of Freud until recently, the role of abuse in causing subsequent cognitive and behavioral abnormalities has been ignored, but now we know that abuse is an important factor in many of them. The focus of current approaches to this subject is turning toward un- derstanding the brain mechanisms that are altered by abuse. The concept that abuse changes the brain has brought this experiential factor within the purview of neurology. The role of abuse in affecting the organization and the function of the brain is a new addition to this book. Abuse, like any environmental factor that is remembered, changes the brain. Preface ix One of the important themes of the first three editions of this book was that mental illnesses were the clinical manifestations of brain disease, most of it inherited. In this edition we emphasize that the environment changes the brain, sometimes permanently. Experience and heredity, together, shape the lasting connections in the brain that determine behavior and thought. Violence provides an example of a symptom that results from the interplay of experience, neuro- logical disorders, and hereditary mental illness. The role of the frontal lobes of the brain in modulating behavior and thought has achieved a new currency. Dysfunction of the executive capacities that are mediated through the frontal lobes is important in most of the psychiatric dis- eases, many movement and gait disorders, and some odd disorders that are located on the border between neurology and psychiatry, such as Tourette's syndrome. Violence and attention-deficit hyperactivity disorder are two symp- tomatic conditions that were not especially linked to frontal lobe disease in the past but are now thought to result largely from the loss of frontal control mechanisms. Chronic dementias in the past were pretty much identified as "Alzheimer's," but now many other dementias of clinical significance have been delineated. A sterile argument that regarded the diagnosis of Pick's disease as uncertain if rare inclusions called Pick bodies were not seen in the frontal and temporal cortex at autopsy has been sidestepped. The diagnosis of frontotemporal atrophy (read Pick's disease) is now common as tests that assess the executive and frontal- cortical functions are more widely used. Lewy body dementia, a "new" condi- tion, has bridged a gap between Alzheimer's and Parkinson's diseases. The importance of badly made proteins to the dementias is now emerging. The abnormal proteins that seem to play a role in Parkinson's disease, Lewy body dementia, Alzheimer's disease, fronto temporal atrophy, Huntington's dis- ease, and Creutzfeld-Jakob disease are variants of normal neuronal proteins, sometimes only a single amino acid different from the normal cellular constit- uent. The role of vascular dementia caused by small vessel disease in the sym- tomatology of Alzheimer's disease was not appreciated before the famous Nun's study. We have updated our discussion of the pathogenesis of Alzheimer's dis- ease and the other dementias. The tools to investigate brain disorders have advanced dramatically. It is now possible to see the brain at work in health and disease! Position emission to- mography (PET), single photon emission computed tomography (SPECT), func- tional magnetic resonance (MR), and nuclear magnetic resonance (NMR) ad- vances that were not available in 1985 for the investigation of brain disorders have become new research tools. Some (PET and SPECT) utilize radioactive isotopes. Though each technique is developing diagnostic niches in the fields of epilepsy, dementia, and vascular disease as the result of clinical research, none is easy to arrange. Positron emission tomography is expensive and is only done
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