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Nash N. Boutros Standard EEG: A Research Roadmap for Neuropsychiatry Standard EEG: A Research Roadmap for Neuropsychiatry Nash N. Boutros Standard EEG: A Research Roadmap for Neuropsychiatry 123 Nash N. Boutros Department of Psychiatry University of Missouri-Kansas City School of Medicine (UMKC) Kansas, MO USA and The Center for Behavioral Medicine University of Missouri-Kansas City School of Medicine (UMKC) Kansas, MO USA ISBN 978-3-319-04443-9 ISBN 978-3-319-04444-6 (eBook) DOI 10.1007/978-3-319-04444-6 Springer Cham Heidelberg New York Dordrecht London Library of Congress Control Number: 2013957811 (cid:2)Springer International Publishing Switzerland 2013 This work is subject to copyright. 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Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Foreword Since the time of Berger, psychiatrists have searched for the clinical significance of the electrical activity of the brain. Thus far they have learned little from the EEG to relate to diagnosis, treatment, or course of illness. There is even the likelihood that the standard EEG as a clinical and research tool in psychiatry might be abandoned in favor of more sensitive electrophysiological and other brain imaging techniques. However, this trend could well be premature as evidenced in the present volume. There is a general agreement that EEG findings do not conform to present-day (DSM-based) diagnostic categories. Almost all the conditions and situations described in this book can display a variety of EEG aberrations, including increased fast activity, sharp waves and spikes, slowing of frequencies, and/or one or more of the controversial waveforms. Or the EEG may be entirely within normal limits although the latter category requires lengthy recordings in waking and sleep to assure that deviations are not missed. There is also the problem of referral bias wherein practitioners limit EEG studies to those patients suspected of brain disorders. Despite these concerns, there are sound data showing significant associations with symptomatology, family history, and other attributes which are described in detail herein. The issue of whether different diagnostic groups that display similar EEG characteristics may have other features in common is largely unknown. This situation resembles a recent genetics study in which certain risk loci were identified with shared effects on five major psychiatric disorders (Serretti and Fabbri 2013). This was particularly remarkable since the syndromes were so different clini- cally—schizophrenia, autistic disorder, bipolar disorder, major depressive disorder, and attention deficit hyperactivity disorder! Could it be that the EEG also is indicative of some type of overlap? Answers to these and other important research issues should still be sought from standard EEG recordings with attention to the painstaking documentation of current knowledge and questions for further investigation that Boutros has pro- vided. Clearly, it is not yet the time to abandon standard EEG recordings in psychiatry! Joyce G. Small v vi Foreword Reference Serretti A, Fabbri C (2013) Shared genetics among major psychiatric disorders. Lancet 381(9875):1339–1341. doi:10.1016/S0140-6736(13)60223-8 Preface The voluminous EEG literature relevant to psychiatry extends back to the mid- 1930s and is spread throughout a large number of journals of different specialties as well as in textbooks and atlases. The psychiatrist interested in exploring this literature faces a tedious task. This volume is designed to serve as a reference source containing both historical and recent references with a special focus on the existing gaps of knowledge regarding EEG deviations in psychiatric populations. This book is not meant to be an exhaustive compendium of this vast literature, but a guide to interested clinical researchers into the many unanswered questions regarding standard EEG deviations in clinical psychiatry. The interested researcher will find this book a good starting point with the most influential literature sum- marized and the issues and questions highlighted. The researcher will then need to further explore the literature particularly the areas not covered in this book. It will become obvious to the reader that much of the literature reviewed in this book is rather old. Many of these old works remain the most current work on the particular topic. This is a testimony to the severe neglect this area of research has experienced in the last few decades as the field of the clinical EEG in psychiatry became an orphan field with minimal interest from both the fields of neurology and psychiatry. Structure and Organization of the Book: every chapter begins by outlining the clinical issues then reviews available literature and concludes by highlighting; (a) currently supportable findings, and (b) open research questions. In some chapters the suggestions regarding the research design that will most likely lead to gen- erating data that can move the field toward resolving unresolved issues are offered. Some references are bolded. This signifies particular significance for the paper or the textbook. Part I of the book handles a number of general topics of relevance to the entire field of psychiatry. This part begins with a historical account of why psychiatry and the standard EEG are currently so far removed from each other. The chapter is focused on the reasons for this current situation and then discusses some of the issues that give the interpretation of the standard EEG in psychiatric settings a special status, and the skills necessary for the adequate and skilled performance of this task. The history chapter at the beginning of the Boutros et al. (2011) goes into more details of the history of EEG in general. This part continues by tackling the issue of the boundaries of the normal EEG and highlights the current lack of well- vii viii Preface defined borders between patients with and without psychiatric problems. The two kinds of abnormalities encountered in the standard EEG (the term sEEG is used throughout the book to denote the visually inspected interpretation of the EEG which is the sole focus of this volume) are discussed in separate chapters. Slowing of the EEG rhythms or the appearance of abnormal slow rhythms occupies one chapter while epileptiform activity occupies another. In the epileptiform chapter, we also provide some data on the value of an animal model of the isolated epileptiform discharge (IED). This part also covers areas related to the effects of psychotropic medications on the sEEG within the context of differentiating gen- eralized slowing of the EEG background or the superimposition of diffusely dis- tributed slower rhythms secondary to the toxic effects of psychotropic medications and diffuse slowing due to other general medical conditions. The book has not attempted to cover the effects of psychotropics on the EEGs that do not render them abnormal. This is the province of the pharmaco-EEG discipline. Part II deals with various adult psychiatric conditions with Part III covering a number of childhood and adolescent psychiatric conditions where increased prevalence of EEG abnormalities have been documented. Part IV deals with the difficult issue of the controversial waveforms. The five chapters included in this part were the most difficult to write and I am deeply indebted to Prof. Frederick Struve for his contribution to the Small Sharp Spike and B-Mitten chapters which he developed while working with me at Yale University. This book drew on a large number of outstanding sources most importantly the ‘‘Electroencephalography: Basic Principles, Clinical Applications and Related Fields’’ edited by Ernest Niedermeyer, Fernando Lopes da Silva particularly the latest two editions in 1987 and 2005. The ‘‘EEG and Evoked Potentials in Psy- chiatry and Behavioral Neurology’’ by Hughes and Wilson (1983) remains an important source of this literature. The Gibbs and Gibbs atlases are also important and essential sources. Throughout the time I was working on this volume, I was repeatedly advised to include sections on the quantified EEG (QEEG). I elected to keep the volume focused on the standard EEG. It is fully predicted that the major expansion in psychiatric electrophysiology will come from the quantification of the signal whether the signal was collected from evoked potential EEG or magnetoenceph- alography (MEG) procedures. The inclusion of the already massive QEEG data in psychiatric conditions would have completely drowned the important points being made in this volume and would have resulted in increasing the cost of production which also was felt to defeat the purpose. Finally, a number of excellent texts devoted to QEEG have been already appeared. I would like to specially mention the ‘‘Handbook of Quantitative electroencephalography and EEG Biofeedback’’ by Thatcher (2012). This volume is being periodically updated in print and online. Finally, the volume also avoids the delving into neurological conditions like dementia and delirium. The reason for that is again to keep the book focused on main stream psychiatric disorders and the fact that these topics are extensively covered in many EEG textbooks. An apparent obvious omission would be the issue of epilepsy and psychiatric symptoms. Again, this topic has been the subject of Preface ix extensive investigations and a number of excellent volumes dedicated to this topic are available. Relative to the many neurological disorders with psychiatric man- ifestations is the skillful use of the standard EEG in conjunction with neuropsy- chological testing. While some early work indicated correlations between the measures, this literature remains limited and work on this interrelationship is now all but abandoned in favor of the more advanced computer-based EEG analysis. Janati (2010) argues against the premature discounting of the standard EEG in the clinical practice of psychiatry. All in all, my hope is that psychiatric electrophysiologists will find many ideas worth pursuing in this book. In fact if the publication of this book results in a single research project, I would be satisfied that I have succeeded in my mission. References Boutros NN, Galderisi S, Pogarell O et al (2011) Handbook of standard EEG in clinical psychiatry. Blackwell, London Hughes JR, Wilson WP (1983) EEG and evoked potentials in psychiatry and behavioral neurology. Butterworths, Boston Janati A (2010) Why the EEG should not be discounted. J Clin Neurophysiol 27(6):484 (letter) Niedermeyer E, Lopes da Silva F (eds) (1987) Electroencephalography: Basic principles, clinical applications and related fields. Urban & Schwarzenberg, Baltimore-Munich Niedermeyer E, Lopes da Silva F (eds) (2005) Electroencephalography: Basic principles, clinical applications and related fields. Urban & Schwarzenberg, Baltimore-Munich Thatcher RW (2012) Handbook of quantitative electroencephalography and EEG biofeedback. Anipublishing Company, St. Petersburg Contents Part I General Issues 1 Philosophical Differences in Standard EEG Interpretation Between Neurology and Psychiatry: A Historical Perspective . . . . 3 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The Renaissance of Electroencephalography in Psychiatry . . . . . . . . 5 The American Psychiatric Electrophysiology Association: History and Mission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The Birth of the APEA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 AMEEGA-APEA Interactions. . . . . . . . . . . . . . . . . . . . . . . . . . 8 APEA-AMEEGA Rapprochement . . . . . . . . . . . . . . . . . . . . . . . 8 The Birth of the EEG and Clinical Neuroscience Society (ECNS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2 What Constitutes a Normal EEG . . . . . . . . . . . . . . . . . . . . . . . . 15 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Discussion and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Supported Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Open Research Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3 Special Electrodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 T1 and T2 Electrodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Sphenoidal Electrodes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Supported Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Open Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 4 Effects of Psychotropic Drugs on the EEG. . . . . . . . . . . . . . . . . . 27 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 First Generation Psychotropic Agents. . . . . . . . . . . . . . . . . . . . . . . 28 Atypical Antipsychotic Medications. . . . . . . . . . . . . . . . . . . . . . . . 29 xi