Psychosis, neurosis and epilepsy. Developmental and gender-related effects and their aetiological contribution

An immunoreactive theory of selective male affliction

Males are selectively afflicted with the neurodevelopmental and psychiatric disorders of childhood, a broad and virtually ubiquitous phenomenon that has not received proper attention in the biological study of sex differences. The previous literature has alluded to psychosocial differences, genetic factors and elements pertaining to male “complexity” and relative immaturity, but these are not deemed an adequate explanation for selective male affliction. The structure of sex differences in neurodevelopmental disorders is hypothesized to contain these elements: (1) Males are more frequently afflicted, females more severely; (2) disorders arising in females are largely mediated by the genotype; in males, by a genotype by environment interaction; (3) complications of pregnancy and delivery occur more frequently with male births; such complications are decisive and influence subsequent development. We hypothesize that there is something about the male fetus that evokes an inhospitable uterine environment. This “evocative principle” is hypothesized to relate to the relative antigenicity of the male fetus, which may induce a state of maternal immunoreactivity, leading either directly or indirectly to fetal damage. The immunoreactive theory (IMRT) thus constructed is borrowed from studies of sex ratios and is the only explanation consistent with negative parity effects in the occurrence of pregnancy complications and certain neurodevelopmental disorders. Although the theory is necessarily speculative, it is heuristic and hypotheses derived from it are proposed; some are confirmed in the existing literature and by the authors' research.

Neural responses associated with positive and negative emotion processing in patients with left versus right temporal lobe epilepsy

Studies on emotion processing in patients with temporal lobe epilepsy have dealt mainly with the processing of negative emotions. To further understand the neural basis of emotional disorders in temporal lobe epilepsy, we studied patterns of brain activation induced by implicit processing of negative and positive emotions perceived through facial expressions and emotionally salient stimuli in candidates for surgical treatment of intractable epilepsy. Using functional MRI, we compared, in patients with mesial temporal lobe epilepsy and healthy subjects, the patterns of brain activation elicited by the implicit processing of fearful, sad, and happy faces and pleasant and unpleasant scenes. The results revealed different patterns of activation in patients with left and right mesial temporal lobe epilepsy, compared with healthy subjects, suggesting that the left and right mesial temporal regions are involved differently in emotion processing, which could be related to different contributions in emotional arousal.

Psychiatric disorders in candidates for surgery for epilepsy

OBJECTIVE

To provide a descriptive analysis of the prevalence and pattern of psychiatric morbidity among 300 consecutive epileptic patients refractive to treatment and admitted during a six year period for evaluation of their candidature for surgery.

METHODS

Patients underwent detailed observation of their seizure and standardised psychiatric assessment. Patients were considered to be refractory to treatment if they continued to manifest seizures with an average frequency of at least once every month even with polytherapy using up to three different anti-convulsants for a period of at least two years. Of the 300 patients, 231 had a temporal lobe focus, 43 had a non-temporal lobe focus, and 26 patients had a generalised and multifocal seizure onset.

RESULTS AND CONCLUSIONS

With the DSM-III-R criteria 142 (47.3%) patients emerged as psychiatric cases. A principal axis I diagnosis was made in 88 (29.3%), and an axis II diagnosis (personality disorder) in another 54 (18.0%) patients. The most common axis I diagnosis was anxiety disorders (10.7%). A schizophrenia-like psychosis was seen in 13 (4.3%). Most patients with personality disorders showed dependent and avoidant personality traits. There was a significantly higher psychotic subscore on the present state examination in the temporal than with the non-temporal group of patients. These findings were not significant when compared with patients with a generalised and multifocal seizure disorder. There were no significant findings between the different seizure focus groups on the neurotic subscores. The findings with regard to laterality of seizure focus and the neurotic or psychotic subscores were not significant.

Comparative pharmacodynamic studies with the novel serotonin uptake-enhancing tianeptine and -inhibiting fluvoxamine utilizing EEG mapping and psychometry

In a double-blind, placebo-controlled study, the encephalotropic and psychotropic effects of tianeptine (TIA)--a new tricyclic antidepressant, enhancing serotonin reuptake--were investigated as compared with the serotonin reuptake inhibiting antidepressant, fluvoxamine (FLU), utilizing EEG mapping, psychometric and psychophysiological measures. 16 healthy volunteers (8 males, 8 females) aged 21-35 (man 27) years received randomized and at weekly intervals single oral doses of placebo, 12.5 and 25 mg TIA and 50 mg FLU. EEG recordings, psychometric and psychophysiological tests and evaluation of pulse, blood pressure and side effects were carried out at 0, 2, 4, 6 and 8 hours; blood sampling, in addition, at hour 1. TIA plasma levels rose fast to peaks at 1-2 hours and declined rapidly as well, while the MC5 metabolite peaked in the 4th hour and declined more slowly. EEG mapping demonstrated that both TIA and FLU induced significant changes in brain function between the 1st and 8th hour, which, however, differed in their time course. 12.5 mg TIA exhibited, as compared with placebo, slight activating properties in the EEG (decrease of delta and theta, increase of alpha and beta, acceleration of the centroid), parallelled by thymopsychic improvement (mood elevation). 25 mg TIA showed EEG activation up to the 4th hour, later EEG sedation, accompanied by an initial thymopsychic improvement and differential changes thereafter (improved mood, decreased vigility), with the noopsyche improving at all times (attention, Pauli test). 50 mg FLU induced initially sedation and thereafter activation, accompanied by thymopsychic deterioration and subsequent improvement, the latter also being observed in the noopsyche (attention, memory). In pupillary and skin conductance measures, generally a slight activation occurred after placebo, which was attenuated by 25 mg TIA. Correlation maps between plasma levels and EEG changes demonstrated: the higher the TIA plasma levels, the more absolute and relative beta power, the less alpha power and the faster the centroid of the total power spectrum, reflecting CNS-activation. Topographically, the correlations were mostly seen over both fronto-temporal regions. In the latter, dominant frequency signalled desactivation in the right and activation in the left hemiphere after both antidepressants which, thereby induced changes in brain function opposite to those observed in depression. Both drugs were well tolerated.

Cerebral hemispheric asymmetry revisited: effects of handedness, gender and schizophrenia measured by radius of gyration in magnetic resonance images

Abnormal patterns of cerebral hemispheric asymmetry have been inconsistently reported in association with schizophrenia. Radius of gyration (Rg) is a measure of the mean dispersion of points in a radially organized structure about that structure's centre of gravity. We developed computerized methods for estimating Rg of the magnetic resonance image (MRI) boundary between cortex and subcortex, and applied these methods to measurement of cerebral hemispheric asymmetry in 37 schizophrenics (SZs) and 30 controls (CONs). In right-handed CONs, Rg of right brain boundaries was significantly greater than Rg of left brain boundaries; in left-handed CONs, Rg of left brain boundaries was significantly greater than Rg of right brain boundaries. In right-handed males (both SZ and CON) there were significant differences in Rg between hemispheres; whereas in females (both SZ and CON), there were no such differences. Right-handed male SZs (N = 26) were distinguished by reversal of the right-handed male CON pattern of interhemispheric difference in Rg, and by global reduction in Rg of right brain boundaries. These was no evidence for significant abnormality of Rg in right-handed female SZs (N = 7). There findings suggest an important interactive effect of gender and schizophrenia on lateralized cerebral structure.

Comments on neuropsychological evaluation of epilepsy surgery: are the tests sensitive enough?

Epileptic lesions often affect two of the most important functions in human behavior, memory and emotion. While cognitive functions, e.g, speech and memory, are normally carefully studied, emotional and psychosocial aspects of behavior are often overlooked in the pre- and postoperative evaluation of epilepsy patients. In my comment, I will address the need for methodological and theoretical refinement, especially regarding measurements of emotional and psychosocial aspects. In evaluating memory functions, a functionalistic approach is suggested; that is, in contrast to the entity view, studies should focus on the interaction between task demands and the available cognitive capabilities of the rememberer. We should develop a broad set of tests and demonstrate dissociations between different tasks that tap different capabilities and different memory systems: we should look for patterns of results rather than single scores.

Emotional behavior as an agenda in neuropsychological evaluation

In an effort to objectify neuropsychologic evaluations, consideration of a patient's emotional behavior has often been neglected. An extensive literature review is undertaken in an effort to document lateralized emotional behaviors commonly found in brain injury populations. This evidence is contrasted with the psychiatric symptoms and lateralized neuropsychologic impairments seen in major depression and schizophrenia. A theoretical model is then proposed that attempts to integrate these "functional" vs. "organic" symptoms based upon reciprocal inhibition of lateralized emotional functioning in brain injury and psychiatric disorders. This opponent process model not only seems to account for some of the discrepant findings in the literature, but additionally provides a cogent and useful marker to neurophychologically differentiate "neuronal" vs. "metabolic" disorders. The model further suggests new ways of envisioning treatment and recovery from both psychiatric illness and brain injury.

Epilepsy, language, and behavior: clinical models in childhood

The complex relationship between epilepsy, language, and behavior is not well understood. Neurologic disorders such as Landau-Kleffner syndrome, electrical status epilepticus during slow-wave sleep, infantile spasms, Lennox-Gastaut syndrome, tuberous sclerosis, autism, and developmental language disorders are useful clinical models in the investigation of this complex relationship. These disorders are reviewed in terms of their contribution to our present knowledge of the relationship between epilepsy, language, and behavior. Present management issues and directions for future research are discussed.

Differentiating neuropathology from psychopathology with longitudinal and retrospective data: report of a case

This case study report of diagnostic psychological testing considers the implications of a 53-point verbal-performance IQ differential, with the benefit of neuropsychological and neuroradiologic imaging studies, a 6-month follow-up Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) evaluation, and retrospective examination of early school records and test findings. The approach highlights the limitations of cross-sectional clinical studies in differential diagnosis, particularly when both psychodynamic and neuropsychological factors are at issue. This report demonstrates how an early acquired neurodevelopmentally based deficit can alter or restructure the appearance of adult cognitive-perceptual functions. Further, early neurodevelopmental impairment is considered from the standpoint of its influence on compromised autonomous ego functions.

Lateral asymmetries in auditory acuity distinguish hallucinating from nonhallucinating schizophrenic patients

Bilateral absolute auditory thresholds for frequencies ranging from 250 to 8000 Hz were examined on two occasions in schizophrenic patients and normal control subjects. Patients were classified as hallucinators and nonhallucinators on the basis of symptom ratings on both occasions. Previous evidence of better right than left ear acuity in schizophrenia was replicated but was found to characterize nonhallucinating patients only. Hallucinators showed no lateral asymmetry and inferior right ear acuity as compared with that in nonhallucinators. The results were reliable on retest. Brief Psychiatric Rating Scale scores of positive and negative symptoms in some cases differentiated hallucinators from nonhallucinators. The relationship of verbal hallucinations and right ear-left temporal lobe functions is discussed, together with complexities in cerebral laterality-syndrome relationships.

Pharmacodynamics of venlafaxine evaluated by EEG brain mapping, psychometry and psychophysiology

1. In a double-blind, placebo-controlled study the effects of venlafaxine--a novel nontricyclic compound inhibiting neuronal uptake of serotonin, noradrenaline and to a lesser extent dopamine--were investigated utilizing EEG brain mapping, psychometric and psychophysiological measures. 2. Sixteen healthy volunteers (eight males, eight females) aged 21-36 years received randomized and at weekly intervals single oral doses of placebo, 12.5 mg, 25 mg and 50 mg venlafaxine. EEG recordings, psychometric and psychophysiological tests, and evaluation of pulse, blood pressure and side-effects were carried out at 0, 2, 4, 6, and 8 h. 3. EEG brain mapping demonstrated that venlafaxine exerted a significant action on human brain function as compared with placebo at all three doses, characterized mostly by attenuation of absolute power, increase of relative delta/theta and beta, and decrease of alpha power, as well as by an acceleration of the total centroid fronto-temporally and by its slowing centrally and parietally. These findings are similar to antidepressants such as imipramine. Topographically, drug-induced alterations were most pronounced over both fronto-temporal and the right temporal to temporo-occipital regions. 4. Psychometric and psychophysiological investigations demonstrated significant dose-dependent psychotropic properties of the drug. Multivariate statistics exhibited an improvement of both the noopsyche (e.g. attention, concentration, attention variability, memory, fine motor activity, reaction time performance) and thymopsyche (e.g. drive, wakefulness)) but also significant psychophysiological activation (e.g. in c.f.f., pupillary and skin conductance measures). 5. Time-efficiency calculations showed significant central effects from the 2nd hour onwards, with increasing differences between placebo and treatment up to the 8th hour. Nausea was the most frequent complaint and appeared dose dependent.

Emotivity, personality, and task-dependent EEG asymmetry

In order to verify if task-dependent EEG asymmetry is related to emotivity or personality traits, the relationship between EEGraphic (EEG mapping) asymmetry, personality aspects, and emotional-affective state in 12 healthy volunteers was evaluated by means of standardized methods (SAD and CPI). Our subjects show an EEG asymmetry which is currently attributed in the literature to anxiety. In our subject the absence of anxiety and the presence of hyperthymic characteristics suggests that the different individual trends observed in various studies which have used methods similar to ours, could, at least partly, depend on interference on these variables.

Evoked potentials and psychopathy

All previous studies which have assessed evoked potentials (EPs) in psychopathic populations are critically reviewed. Three main themes emerge from this review. Firstly early EP studies suggest a dysfunctional arousal system at a brainstem or parietal cortex level in psychopaths. Secondly, middle-latency EP studies suggest that psychopaths show larger visual EP amplitudes, particularly at high intensity levels, indicating cortical augmenting. Thirdly, psychopaths are characterised by enhanced P3 EPs to task-relevant events. An extended sensation-seeking model of psychopathy is proposed which attempts to incorporate these electrophysiological findings into an information-processing framework. It is argued that under certain circumstances psychopaths are characterised by information-processing proficiencies and that they are clearly differentiated from schizophrenics at a psychophysiological level in terms of P3. It is concluded that current 'processing deficit' conceptions of antisociality are overly restrictive and ignore performance superiorities which may have important implications for our understanding of psychopathy.

Gender and schizophrenia: implications for understanding the heterogeneity of the illness

This study begins to test the hypothesis that schizophrenic men and women may be at risk for experiencing different subtypes of the illness. Given past research, hypotheses predict that schizophrenic men will have an earlier age of onset, poorer premorbid history, lower family morbid risk, and poorer course. Data consist of 332 schizophrenic patients diagnosed according to DSM-III and 713 of their first-degree relatives from the double-blind Iowa 500 and non-500 family studies. Survival analysis was used to estimate age of onset, and Strömgren's abridged method for age correction was used to estimate family morbidity risks. Findings support our hypotheses and suggest that men may be at risk for experiencing a more severe form of schizophrenia.

Electrodermally differentiated subgroups of anxiety patients and controls. II: Relationships with auditory, somatosensory and pain thresholds, agoraphobic fear, depression and cerebral laterality

Patients diagnosed (DSM III) with anxiety disorders (agoraphobia, panic syndrome, generalised anxiety syndrome) were classified along with controls as electrodermally stabile or labile on the basis of non-specific electrodermal activity and rate of habituation to tones. While patients showed more evidence of psychopathology than controls on scales of anxiety, neuroticism, depression and agoraphobic fear, patient labiles scored higher than stabiles on agoraphobic fear and were differentiated by higher scores of Beck depression. They were also more sensitive to pain, whereas patient stabiles were less sensitive at absolute somatosensory threshold. Amongst controls agoraphobic fear was associated with lability and stabiles scored higher on autonomy in locus of control. Lateral asymmetries in auditory thresholds were consistent with reciprocal hemispheric influences on electrodermal reactivity and habituation, modifiable by anxiety. Interrelationships between fear, depression, sensitivity to somatosensory stimulation, pain, and superior vigilance performance in patient labiles were consistent with elevated right hemisphere function.

An animal analogue of forced unilateral nostril breathing: relevance for physiology and pharmacology

Since forced unilateral nostril breathing activates the contralateral brain hemisphere, an animal analogue of this technique could be provided by methylmethacrylate gluing large plastic pellets in either the right or left nostrils in a group of rats. A large number of physiological, pharmacological, and immunological parameters may be differentially affected.

Gender differences in age at onset of schizophrenia. An overview

We present the results of a review of the literature concerning gender differences in age at the onset of schizophrenia. In view of the very consistent finding that the first admission to hospital for schizophrenia occurs on average earlier in men than in women we examined the question whether this is due to the fact that the psychosis manifests itself earlier in men or that the period between first manifestation and admission to hospital is shorter than in women. By means of a metaanalytic approach we then looked for evidence for the existence of local or temporal variations in the degree of gender difference. Lastly, we dealt with the question whether gender differences in age of onset can be observed in other functional psychoses.

Auditory evoked potentials and total sleep deprivation in depressed patients

Cortical auditory evoked potentials (latencies N1 and P2, N1-P2 amplitude, and amplitude/stimulus intensity function) were studied before and after 1 night's total sleep deprivation in 20 drug-free depressed inpatients. Responders to sleep deprivation showed an augmenting pattern on the non-dominant hemisphere and a reducing pattern on the dominant hemisphere. The interhemispheric difference in auditory cortex was also apparent in the group of patients who failed to respond to sleep deprivation, but with values pointing in the opposite direction. The augmenting pattern shown by responders in the nondominant hemisphere may be a predictor of therapeutic response to sleep deprivation and to subsequent treatment with drugs influencing serotonergic pathways.

Influence of sex on age at onset of schizophrenia

The age at onset of schizophrenia was investigated in 2,417 inpatients (1,433 males and 984 females) meeting the DSM-III criteria for schizophrenia. About 80% of the patients became schizophrenic before the age of 30. The mean age at onset of the male patients was slightly earlier than that of the female patients. There was a higher cumulative percentage of the male patients who became affected at each age quinquennium. More men than women became schizophrenic before the age of 30.

Gender and the expression of schizophrenia

The expression of schizophrenia was examined in 169 DSM-III diagnosed schizophrenics. Restricted maximum likelihood factor analysis was used to test the invariance of the hypothesized symptom model across gender. Findings indicated that schizophrenic women not only expressed more impulsivity and affective symptomatology than did men, but their psychotic symptoms covaried consistently with the expression of impulsivity, anger and other affective symptomatology. Men's expression of schizophrenia covaried positively with withdrawal/isolation and an inability to function, suggesting a possible negative symptom pattern. Gender differences were not attributable to misclassification, differences in diagnostic subtypes, nor to selection. Results are discussed in light of their implications for understanding the heterogeneity of schizophrenia.

Mediational factors underlying cognitive changes and laterality in affective illness

Affective illness has been associated with lateralized right hemisphere deficits and global cognitive dysfunction. However, there has been very little exploration of information-processing strategies that may underlie cognitive changes in this population. Twenty euthymic, drug-free, bipolar patients and 20 controls were given a series of tasks to assess lateralized impairment of the cerebral hemispheres and sequential (analytic) versus simultaneous (gestalt) information-processing strategies. There were no differences between patients and controls in tests sensitive to right or left hemisphere impairment or in total errors on a face recognition task. However, patients tended to rely on individual facial features for recognition whereas controls were able to synthesize multiple elements of the faces. Moreover, on a task that required holistic synthesis of multiple stimulus elements (Street Gestalt Completion Test), patients made significantly more errors than controls. Implications for information-processing changes in bipolar affective illness are discussed.

Strength of handedness as an indicant of delinquent's behavior

In a sample of incarcerated male delinquents (N = 254), dichotomous and continuous measures of handedness were compared in concurrent prediction of delinquent behavior and correlation with past delinquency. The continuous measures proved to be more sensitive indicants of scores on a rating scale of conduct disorder than was the simple dichotomy of left- vs. right-handed. This superiority of continuous measures was not seen on other indicants of delinquency, where sinistrality did not relate to delinquency. Sinistrality was related to the ratings of conduct disorder. No differences on measures of delinquency appeared when strongly and weakly lateralized groups of right- and left-handers were compared.

Interictal behavioral features of patients with epilepsy

Three questions are dealt with in this paper. (1) Do patients with epilepsy differ behaviorally from normal control groups and from persons with other medical and neurological conditions with respect to emotional adjustment, and if so, in what ways? (2) Are patients with temporal lobe epilepsy different emotionally or behaviorally from patients with other types of epilepsy? (3) To what degree does underlying brain dysfunction create a substrate for abnormal and maladaptive behavior? A review of the literature reveals the following. Persons with epilepsy demonstrate more emotional and psychiatric problems than normal individuals and more difficulties than other patient groups having nonneurological disorders, but have about the same incidence of these problems as persons with other neurological disorders. Increased emotional and psychiatric problems are not found among patients with temporal lobe epilepsy in comparison to patients with other types of epilepsy, although there are some behavioral peculiarities which appear in a small proportion of these patients. There is a mild tendency for impairment on neuropsychological tests to be associated with emotional and psychiatric problems in epilepsy.

Male and female mania

A total of 74 manic or hypomanic episodes were scrutinized in 31 probands (18 women and 13 men), followed over the years by the author on an outpatient basis. These turned out to herald bipolar affective illness in some 70 percent of males and almost 40% of females. Unipolar mania occurred twice as often in men, as it did in women (38.4% vs. 22.2%). Men tended to be younger (only 30% aged 45 or older), than women (almost a half in the menopausal age bracket). One third of all female probands (and over 46% of those under age 45) manifested their manic episodes in connection with childbirth (gestational mania). As a paradoxical, acute grief reaction ("funeral mania"), the syndrome under scrutiny, occurred in about 1/7 of the men, and more than 1/4 of the women. Significant medico-surgical problems were found to accompany or precede female mania twice as often, compared to male cases (61.1% vs. 30.7%); and clinical confusion or other indices of "organicity" were present in 2/3 of the women, and less than a half (46.1%) of the men. Over half the male probands demonstrated either an inverted sexual attraction, or hypogonadism; and four out of 13 males were aged 45 or older. The above findings are tentatively related to gender differential in cerebral hemispheric specialization.