PRINCIPLES OF NEUROLOGY - PART 10 pptx

tion is that in approximately 15 percent of persons, certain personality traits are so inflexible and maladaptive as to cause significant func- tional impairment and subjective distress—in which case they constitute personality disorders. DSM IV recognizes 10 specific patterns of personality disorder, as follows: Paranoid—distrust and suspiciousness such that others’ motives are interpreted as malevolent. Schizoid—detachment from social relationships and a restricted range of emotional expression. Schizotypal—acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. Antisocial—disregard for, and violation of, the rights of others. Borderline—instability in interpersonal relationships, self-image, and affect, and marked impulsivity. Histrionic—excessive emotionality and attention seeking. Narcissistic—grandiosity, need for admiration, and lack of empathy. Avoidant—social inhibition, feeling of inadequacy, and hypersensi- tivity to negative evaluation. Dependent—submissive and clinging behavior related to an excessive need to be taken care of. Obsessive-Compulsive—preoccupation with orderliness, perfection- ism, and control. Personality Disorder Not Otherwise Specified is a category provided for two situations: (1) the features of several different personality disorders are present, but the criteria for any specific one are not met; or (2) the individual’s personality pattern meets the general criteria for a personality disorder, but one that is not included in the above tabulation (e.g., “passive-aggressive,” “inadequate,” “immature”). Antisocial Personality (Sociopathy) This disorder, known long ago as “moral insanity” and later as psycho- pathic personality or constitutional psychopathy, is the best defined of all abnormal personality types and the one most likely to lead to trouble in the family and community. Sociopathy is a chronic state that affects mainly males and, unlike most psychiatric disorders, is fully manifest by the age 12 to 15 years. The most frequent antisocial activities are theft, fire setting, truancy, running away from home, associat- ing with undesirable characters, physical aggression and assault, abuse of drugs and alcohol, precocious and indiscriminate sexual activity, and vandalism. Repeatedly apprehended, the sociopath exhibits no remorse, profits little or not at all from discipline or past experience, and is unable to empathize with family and friends. Restlessness and impulsivity are prominent. School and work performance is erratic and fail- CHAPTER 55 / THE NEUROSES AND PERSONALITY DISORDERS 501 4777 Victor Ch 55 p493-502 6/11/01 2:30 PM Page 501 ure almost invariable. This deviant behavior naturally places the sociopath in trouble with the law, and many such persons end up in reform school or jail. The female sociopath differs only in having a higher incidence of hysterical symptoms. Little is known about the cause. Alcoholism or sociopathy in the father and lack of parental discipline are the most closely related factors but cannot be regarded as causal. It appears that the development of social intelligence and adaptation is delayed. In the classic study of L.N. Robins, more than half of the deviant children lost most of their sociopathic traits in adult life. However, of those who did not become adult sociopaths, the large majority developed other psychiatric illnesses, particularly alcoholism. Psychotherapy has been unsuccessful. For a more detailed discussion of the neuroses and personality types, see Adams, Victor, and Ropper: Principles of Neurology, 6th ed, pp 1507–1529. ADDITIONAL READING Andreasen NC, Black DW: Introductory Textbook of Psychiatry, 2nd ed. Wash- ington, DC, American Psychiatric Association, 1995. Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM IV). Wash- ington, DC, American Psychiatric Association, 1994. Goodwin DW, Guze SB: Psychiatric Diagnosis, 5th ed. New York, Oxford Uni- versity, 1996. Gunderson JG, Phillips KA: Personality disorders, in Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, 6th ed. Baltimore, Williams & Wilkins, 1995, pp 1425–1461. Nemiah JC: Psychoneurotic disorders, in Nicholi AM Jr (ed): The New Harvard Guide to Psychiatry. Cambridge, MA, Belknap, 1988, pp 234–258. Purtell JJ, Robins E, Cohen ME: Observations on clinical aspects of hysteria, JAMA 146:902, 1951. Robins E, Purtell JJ, Cohen ME: Hysteria in men. New Engl J Med 246:677, 1952. Robins LN: Deviant Children Grown Up: A Sociological and Psychiatric Study of Sociopathic Personality. Huntington, NY, Kreiger, 1974. Wheeler EO, White PD, Reed EW, Cohen ME: Neurocirculatory asthenia (anxiety neurosis, effort syndrome, neurasthenia): A twenty-year follow-up of one hundred and seventy-three patients. JAMA 142:878, 1950. 502 PART VI / PSYCHIATRIC DISORDERS 4777 Victor Ch 55 p493-502 6/11/01 2:30 PM Page 502 56 Grief, Reactive Depression, Endogenous Depression, and Manic-Depressive Disease The illnesses llisted in the title have one trait in common—a depressed or dysphoric mood. However, the different settings in which the depressive illness occurs, certain variations in the clinical picture, and the fact that each requires somewhat different management make their separation important. Taken together, they constitute the most frequent of all mental illnesses, accounting, for example, for an estimated 50 percent of psychiatric admissions and 12 percent of all medical admissions to one tertiary referral center. It has been stated that of the adult popula- tion of the United States, 20 percent of women and 10 percent of men will have a depressive illness at least once in their lifetime. There are three main forms of depressive illness with which every physician should be familiar. 1. Grief reaction or other form of reactive or secondary depression in relation to a personal loss or medical disease 2. Dysthymia (chronic mild depression) 3. Endogenous or primary depression (with or without agitation and anxiety) and manic-depressive disease The essential clinical features of depression are also described in Chap. 24. Grief Reaction This, the most common form of depressive reaction, follows the loss of someone who is particularly close and dear to the patient. It is a natural response, to be expected in every thoughtful and sentient person. The grief reaction consists of an intense subjective sensation of mental pain accompanied by a feeling of exhaustion, which alter the usual pattern of behavior. Often there is a preoccupation with the image of the deceased person, a sense of guilt concerning the relationship to the deceased, and sometimes an unwarranted hostility toward friends and relatives. The mood disturbance and the sense of exhaustion and disor- ganization of daily activities are the only ones of these elements for which the authors can vouch. As a rule, the grief reaction begins to abate after 4 to 12 weeks, but there are wide individual variations in its duration and intensity. It tends 503 4777 Victor Ch 56 p503-508 6/11/01 2:30 PM Page 503 Copyright 1998 The McGraw-Hill Companies, Inc. Click Here for Terms of Use. to be prolonged in the elderly. Also, patients who have had a previous depression may remain in mourning for a year or more, and it is then impossible to distinguish between a grief reaction and an endogenous depression. In treating a grief reaction, one attempts to help the patient to a real- istic acceptance of the loss and the changes that may be required as a result of it. A circumscribed course of sedative-hypnotic drugs may be prescribed—flurazepam, 15 to 30 mg at bedtime, or diazepam, 5 mg tid. If the grief reaction is abnormally prolonged or severe, the assistance of a psychiatrist should be sought to determine the correctness of the diagnosis and the proper management. Other Reactive Depressions Often a medical or neurologic disease will be compounded by complaints of undue weakness and fatigue, a loss of interest in and pleasure from the patient’s usual activities (anhedonia), inability to concentrate, or inexplicable pain. The presence of nervousness, irritability, pessimism, poor appetite and sleep may be admitted only on questioning. These should be recognized for what they are—the symptoms of a “masked” depression. Certain diseases, more than others, are known to be associated with reactive depression. These are myocardial infarction, hypothyroidism, pernicious anemia, carcinomas of all types, Parkinson disease, chronic hepatitis, and infectious mononucleosis. Also, there appears to be an increased incidence of depressive reaction with left frontal strokes. A variety of drugs, particularly methyldopa, propranolol, cimetidine, interferon, sedative drugs of any kind, and the phenothiazines, may evoke a depressive reaction. The first step in management is recognition of the depressive symptoms and their separation from the symptoms of the underlying illness. The patient is then assured that such reactive symptoms are to be expected and are medically treatable. Most patients with a reactive depression ultimately recover, even without medical assistance or phar- macologic intervention, but the toll taken by the depression in terms of mental suffering and prolongation of convalescence may be significant, in which case one can safely use tricyclic antidepressants (except during the early convalescence from myocardial infarction) or fluoxetine or other drugs of the same class. Dysthymia An extremely chronic and unremitting but relatively mild depressive illness (“I have been depressed all my life”) is now usually classed as dysthymia. Prevailing opinion is that it responds only to psychotherapy, if at all, and that antidepression drugs are of little use. We believe that 504 PART VI / PSYCHIATRIC DISORDERS 4777 Victor Ch 56 p503-508 6/11/01 2:30 PM Page 504 this generalization does not hold in all cases and that dysthymic patients may respond to antidepressant therapy. Psychologic support—i.e., explanation and reassurance—is helpful but probably does not alleviate the illness. Endogenous Depression and Manic-Depressive Disease These are hereditary diseases that occur in cycles of several months or longer. Current nomenclature recognizes two types of these diseases: unipolar or depressive disorder, in which only endogenous depression occurs, and bipolar disorder, in which mania occurs, often alternating with depression. The occurrence of episodic mania, without depression, is well known but is relatively infrequent. A depressive episode may occur without provocation, but often there is a history of some stressful situation or loss in the preceding months. The patient feels low in spirits, sad, or depressed and expresses feelings of deep pessimism and hopelessness. With this affective disturbance there is a loss of interest in one’s affairs and capacity for enjoyment, a lack of energy, mental and physical fatigue, disturbed sleep (often early-morning wakening), loss of appetite, weight loss, waning of sexual interest, and pain of various types including headache. Agitation and anxiety are present in many patients, especially the elderly. Psy- chomotor retardation characterizes others. Self-deprecation, feelings of worthlessness or guilt, suicidal ideation, and preoccupation with some medical condition (dermatologic, rheumatic, etc.) are common accom- paniments. Excessive complaints of physical deterioration or poor memory may be mistaken by the physician for an occult medical condition or early dementia. A manic attack expresses itself by an elevation of mood and hyper- activity (excessive amount and speed of speech and all of psychomotor activities). With the euphoria, little sleep is required. When the attack is severe, thought may become incoherent. One plan after another is initi- ated and abandoned. Judgment is faulty. The patient lacks insight into his problem and may embark on impractical schemes that jeopardize his social and financial condition. Despite the lively and expansive state, frustration is often tolerated poorly and euphoria is mixed with irritability. Some patients are frankly paranoid and hostile. A special problem is posed by the patient who exhibits both depressive and schizophrenic symptoms—the so-called schizoaffective state. Most such patients prove to have manic-depressive disease. As to etiology of this disease, most neurologists and psychiatrists agree that genetic factors are most important. While stress and other environmental changes may be provocative, studies of families show a high incidence of either unipolar or bipolar disease and a concordance rate of 75 percent in monozygotic twins—clear evidence of a genetic basis. Attempts to investigate the mechanism by measurements of sero- CHAPTER 56 / DEPRESSIVE ILLNESSES 505 4777 Victor Ch 56 p503-508 6/11/01 2:30 PM Page 505 tonin, norepinephrine, corticosteroids, dopamine, or their metabolic products have not yielded consistent results. Depression is now being managed with reasonable success by phar- macotherapy. For unipolar disease, one of the serotoninergic agents or tricyclic antidepressants is the usual first line of therapy. The former agents are now favored because of fewer side effects. If these drugs are unsuccessful, one of the MAO inhibitors is tried. In the patient with a manic attack, a neuroleptic agent (haldol, thorazine, olanzepine) may be necessary in the acute episode and lithium carbonate may afford relief from future attacks. Other drugs, under the direction of an experienced psychiatrist, should be tried in the 20 percent of patients who fail to respond to the program outlined above. Medications may need to be given for several weeks before improvement is apparent and then continued for 6 to 12 months. In using any of these drugs, one should be familiar with all the side effects and cross-reactions with other drugs (Chap. 42). Electroconvulsive therapy (ECT) is reserved for patients who do not respond to or cannot tolerate antidepressant drugs. ECT is most effective in the treatment of agitated depression in middle and late life and can also be used to interrupt a manic episode. The main drawback of ECT is that it causes an impairment of retentive memory, which is usually transient. ECT should not be used in the presence of increased intracranial pressure or severe hypertension. Suicide Manic-depressive psychosis, endogenous unipolar depression, reactive depression (life-threatening disease, catastrophic financial loss), patho- logic grief, and depression in an alcoholic or schizophrenic all carry a significant risk of suicide. One of every five suicidal persons with one of these conditions will commit suicide without having made medical contact. In many of the remaining patients, the presence of a depressive illness and potential for suicide will not be recognized by the physician at the time the patient ends his life. Between 20,000 and 35,000 suicidal deaths are recorded annually, and about 10 times this number attempt suicide. The incidence rises with age. In the evaluation of suicide risk, a previous suicide attempt or a history of suicide in a parent is an important warning. Chronic illness, alcoholism, cancer, heart disease, and progressive, incurable neurologic disease all contribute to the risk. Declared fear of death, devout Catholi- cism, and devotion to family are deterrents. The only rule of thumb is that all depressed patients should be asked about their intentions and all suicide threats should be taken seriously. If there is a suspicion of risk, the family should be warned, a bed should be obtained in a hospital (preferably in a locked psychiatric ward), and a psychiatrist should be consulted. Precautions against suicide should be taken, with the help of 506 PART VI / PSYCHIATRIC DISORDERS 4777 Victor Ch 56 p503-508 6/11/01 2:30 PM Page 506 the nursing staff. If the patient has already attempted suicide, hospital admission is imperative and the patient should be placed under surveil- lance. Anorexia Nervosa and Bulimia Anorexia nervosa (AN) is a disease of unknown cause, the core of which is excessive voluntary weight loss. It occurs almost exclusively in previously healthy adolescent girls and young women. Anorexia in boys and men is usually linked genetically and clinically to an endogenous depression; hence there is no impropriety in appending the description of the anorectic states to this chapter. AN is culturally predicated, being more prevalent in social groups with free access to food and deeply embedded ideas about body habi- tus. Many of the patients are depressed, impatient, and irritable. Often as much as 30 percent of the patient’s body weight will have been lost by the time medical help is sought. Menses cease. To hasten weight loss, the patient may resort to exercise and purging. The cachexia may reach such proportions as to end fatally. For this reason, treatment is mandatory. This is most effectively carried out in the hospital, where food intake can be strictly supervised. Intake is increased gradually to 3500 to 4000 calories per day. Tube feedings are needed if the patient resists. Once weight is gained, the loss of appetite tends gradually to correct itself. Imipramine, 150 mg/day, has been a helpful adjunct in the therapeutic program, even though patients may not exhibit the typical picture of depression. A relationship between depression and AN is suggested by the unusually high incidence of depression in first-degree relatives of patients with AN. Relapse is frequent in early adult life, and the therapeutic program in most cases needs to be continued for 3 to 4 years. Bulimia is an eating disorder characterized by massive binge eating followed by induced vomiting and the use of laxatives. It is probably a variant of AN. The authors are attracted to the view that bulimia, like AN, is a manifestation, peculiar to the female, of a deranged appetite- satiety mechanism in the hypothalamus. At present, proof of this hy- pothesis is lacking. For a more detailed discussion of this topic, see Adams, Victor, and Ropper: Principles of Neurology, 6th ed, pp 1530–1543. ADDITIONAL READING Akiskal HS: Mood disorders: Clinical features, in Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, 6th ed. Baltimore, Williams & Wilkins, 1995, pp 1123–1151. Anderson AE: Practical Comprehensive Treatment of Anorexia Nervosa and Bulimia. Baltimore, Johns Hopkins University, 1985. CHAPTER 56 / DEPRESSIVE ILLNESSES 507 4777 Victor Ch 56 p503-508 6/11/01 2:30 PM Page 507 Cassidy WL, Flanagan NB, Spellman M, Cohen ME: Clinical observations in manic-depressive disease. JAMA 164:1535, 1957. Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM IV). Wash- ington, DC, American Psychiatric Association, 1994. Goodwin DW, Guze SB: Psychiatric Diagnosis, 5th ed. New York, Oxford Uni- versity, 1996. McHugh PR: Food intake and its disorders, in Asbury AK, McKhann GM, McDonald WI (eds): Diseases of the Nervous System, 2nd ed. Philadelphia, Saunders, 1992, pp 529–536. Pirodsky DM, Cohn JS: Clinical Primer of Psychopharmacology: A Practical Guide, 2nd ed. New York, McGraw-Hill, 1992. Robins E: The Final Months: A Study of the Lives of 134 Persons Who Commit- ted Suicide. Oxford, Oxford University, 1981. Starkstein SE, Robinson RG, Price TR: Comparison of cortical and subcortical lesions in the production of poststroke mood disorders. Brain 110:1145, 1987. 508 PART VI / PSYCHIATRIC DISORDERS 4777 Victor Ch 56 p503-508 6/11/01 2:30 PM Page 508 57 The Schizophrenias and Paranoid States Schizophrenia and the depressive illnesses are the two major psychiatric disorders, and together they rank among the most important unsolved medical problems of the twentieth century. The historical events that led to our present view of schizophrenia and the epidemiology of the disease are elaborated in the Principles. Uncertainty of diagnosis, especially of borderline (pseudoneurotic) cases, has thwarted efforts to accumulate vital statistics, since there is no way of proving that a patient is schizophrenic except by the use of clinical criteria. Schizophrenia is defined in DSM IV as an illness that has lasted at least 6 months, that began during adolescence and early adult life, and that consists of delusions, hallucinations, and disordered thought (looseness of associations and tangential thinking) and verbal communication, all of which result in a deterioration from a previous level of functioning. Of diagnostic importance are absence of depression, mania, dementing brain disease, and mental retardation. To these we would add a positive family history of a similar disease. Eccentricity of personality and behavior (a tendency to be solitary and withdrawn socially) is often evident in adolescence and may pre- cede frank psychosis by many years. Then, usually during adolescence and practically always before the age of 40, the patient becomes disturbed and is unable to continue school or work. When first seen, the patient expresses bizarre fears and ideas and suspicions of the motives of family members or of others. Often the patient is hallucinating and deluded—relating fantasies about controlling the thoughts of others or having one’s own thoughts controlled. Notably absent are primary dis- turbances of memory, perception, orientation, etc., which are the iden- tifying features of dementing brain diseases and confusional-delirious states. Such episodes of illness occur repeatedly until the patient finally settles into a condition in which delusions and hallucinations are denied but for unclear reasons continuation of education and effective work are impossible. Unfortunately, suicides or irrational homicides are often unpredictable. Some patients recover but always in such cases there is the question of reliability of diagnosis (see below). The subdivision of schizophrenia into simple, hebephrenic, cata- tonic, and paranoid types is not always helpful. Catatonia, in which the patient lies in a dull stupor—mute, negativistic, and apathetic—is a syndrome more closely related to a retarded form of depression than to 509 4777 Victor Ch 57 p509-513 6/11/01 2:31 PM Page 509 Copyright 1998 The McGraw-Hill Companies, Inc. Click Here for Terms of Use. schizophrenia, and paranoid schizophrenia is considered by many Euro- pean psychiatrists to be a mental illness of diverse origins; some cases are clearly not schizophrenic. Acute psychosis in a previously well-adjusted person (called “brief reactive psychosis”) is probably not a form of schizophrenia. In 75 to 80 percent of such patients admitted to a mental hospital as schizophrenic, the illness is reversible within a few months; often the family history is one not of schizophrenia but of manic-depressive disease, and the patient responds to anti–manic-depressive medication. Thereafter, the mental illness is likely to pursue the course of manic-depressive disease rather than of schizophrenia. Brief illnesses (2 weeks or less) with schizophreniform symptoms often have the characteristics more of a confusional state than of schizophrenia; probably an illness of this type lasting less than 6 months is also unlikely to be schizophrenia (possibly hypomania or some type of metabolic disease). There is still much debate about the existence of a childhood form of schizophrenia, which must be distinguished from autism in high-functioning patients (Asperger syndrome). Even in the group of patients conforming to the diagnostic criteria for schizophrenia, not all patients are alike. Some have suggestive thala- mic–frontal lobe signs such as inattentiveness, difficulty in shifting cognitive attention from one task to another, poor function on continu- ous-performance tasks, and poorly sustained initiative and drive. Also, impairment of smooth ocular pursuit movements, paroxysmal saccadic eye movements, episodic lateral deviation of the eyes, reflex asymme- tries, and slight lowering of IQ are recorded in some. In others, delusions, hallucinations, and a disorder of communication dominate. The symptomatology incriminates different parts of the frontal and tempo- ral lobes, a topography now being verified by blood flow studies. The EEG is abnormal in a nondescript way in many cases. Finally, some patients have slightly enlarged third and lateral ventricles, unrelated to the duration of the illness and medication. Studies of cerebral blood flow have revealed an inability to increase flow to the frontal lobes during demanding psychologic tests. These findings have led to the notion that schizophrenia is a syndrome, not a single disease, and that within the syndrome there is a genetic core disease, which might be called true schizophrenia and other diseases that simulate schizophrenia (i.e., schizophreniform). Search for a consistent neuropathology has been singularly elusive. Crude neuronal destruction and gliosis have not been found. Yet quan- titative studies are beginning to reveal decreased neuronal populations in certain structures such as the cingulate gyri, nucleus accumbens, globus pallidus, and other parts of the limbic system. A new stimulus to anatomic study has come from CT and MR observations of ventricular (particularly third ventricular) enlargement and sulcal widening in chronic schizophrenics. Some MRI studies have 510 PART VI / PSYCHIATRIC DISORDERS 4777 Victor Ch 57 p509-513 6/11/01 2:31 PM Page 510 [...]... Index p51 5-5 51 522 6/11/01 2:31 PM Page 522 INDEX Cerebrovascular disease (Cont.) vertebral artery dissection, 323 Ceroid lipofuscinoses, neuronal, 342t Cervical rib syndrome, 107 108 Cervical spine degenerative disease of, neck and shoulder-arm pain and, 107 108 disc protrusion in, neck and shoulder-arm pain and, 106 107 spondylosis of, with myelopathy, 407–408 Channelopathies, 483–488 of calcium... Locked-in syndrome, 154, 377 Lorazepam (Ativan), 149t for seizures, 152 Low back pain, 100 106 ancillary procedures in, 101 103 conditions causing, 103 106 examination of back and, 101 , 102 Lower half headache, 97t Lower motor neuron disorders, 23–24, 25, 26 bladder and bowel disorders and, 230 dysarthria, 210 Lumbar puncture (LP), 17 headache due to, 90t–91t, 98 Lumbar spine degenerative arthropathy of, ... p51 5-5 51 524 6/11/01 2:31 PM Page 524 INDEX Cranial nerve(s) disorders of, 440–447, 442t of eleventh (accessory) nerve, 446–447 of fifth (trigeminal) nerve, 440–441 of multiple nerves, 444t–445t, 447 of ninth (glossopharyngeal) nerve, 443, 446 of seventh (facial) nerve, 441, 443 of tenth (vagus) nerve, 446 of third, fourth, and sixth nerves, 126, 127, 128 of twelfth (hypoglossal) nerve, 447 testing of, ... pupil, 133t Arm pain See Neck and shoulder-arm pain Arsenic poisoning, 400t Arteriovenous malformations (AVMs), 322–323 Arteritis, cranial (giant-cell), 324 headache due to, 92t–93t, 98–99 Arthritis, of cervical spine, 107 Arthrogryposis, 476 Arthropathy, degenerative, of lumbar spine, low back pain and, 105 106 Articulation (of speech), disorders of, 209– 210 Ascending pain pathways, 63, 65–67, 78–79... degenerative arthropathy of, low back pain and, 105 106 spondylosis of, 408 low back pain and, 105 strain/sprain of, low back pain and, 100 , 103 Lyme disease, 286–287, 398–399 facial palsy and, 443 Lymphomas, cerebral, primary, 273t Lysosomal storage diseases, 340–341, 342t–344t M McArdle disease, 470t rhabdomyolysis with myoglobinuria and, 458 4777 Victor Index p51 5-5 51 6/11/01 2:31 PM Page 535 INDEX Macrocephaly,... myelopathy, 407–408 Channelopathies, 483–488 of calcium channels, 485t, 487–488 of chloride channels, 483, 484t, 486 malignant hyperthermia and, 485t, 488 of sodium channels, 484t–485t, 486–487 Charcot-Marie-Tooth disease, 430 Chemical-induced disorders See Drug- and chemicalinduced disorders Cherry red spot, 341 Cheyne-Stokes breathing, 232 Chiari malformation, 351 Childhood cerebrovascular disease... (Chap 39) An acute onset of confusion, insomnia, mood elevation or depression, and delusional thinking in some combination has been reported with large doses of steroids or ACTH, Cushing disease, and hyperthyroidism Control of the endocrine disease usually restores the patient to normality For a more detailed discussion of this topic, see Adams, Victor, and Ropper: Principles of Neurology, 6th ed, pp... disorders, 37t, 39 Intention tremor, 47t, 48–49 Interhemispheric lesions, 201, 202, 203 Internuclear ophthalmoplegia, 128–129 Intervertebral discs cervical, protrusion of, neck and shoulder-arm pain and, 106 107 herniated, low back pain and, 104 105 , 105 Intracranial hemorrhage, 318–323, 319t arteriovenous malformations, 322–323 cerebellar, 320 intracerebral, primary, 318–320 lobar, 319–320 pontine, 320 putaminal,... phencyclidine) accounts for episodes of paranoid behavior in others Puerperal (Postpartum) and Endocrine Psychoses These are complex problems Postpartum depression of mild degree and short duration is a frequent and well-known phenomenon Severe prolonged depression in this setting differs in no particular way from a monophasic endogenous depression and should be treated as such It is of interest that some patients... or months, but the outlook in general is better than for schizophrenia Careful exclusion of drug psychosis and diseases such as postpartum cerebral venous thrombosis is part of the neurologic investigation In some instances, a frank schizophrenic break can occur in the postpartum period The treatment of this type of syndrome must be undertaken in a psychiatric hospital, and antipsychotic medication is . that of the adult popula- tion of the United States, 20 percent of women and 10 percent of men will have a depressive illness at least once in their lifetime. There are three main forms of depressive. the hypothalamus. At present, proof of this hy- pothesis is lacking. For a more detailed discussion of this topic, see Adams, Victor, and Ropper: Principles of Neurology, 6th ed, pp 1530–1543. ADDITIONAL. illnesses, particularly alcoholism. Psychotherapy has been unsuccessful. For a more detailed discussion of the neuroses and personality types, see Adams, Victor, and Ropper: Principles of Neurology,

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