Richard Abrams

Establishing diagnostic criteria for mania.

There has been general agreement on the symptoms of mania, but the validity of criteria for diagnosing mania have not been studied. The present study evaluates diagnostic criteria for mania by examining their internal construct validity, i.e., whether they are consistent with structure implicit in the concept of diagnostic criteria. Symptom information from 235 patients with varying diagnoses were studied. Elevated, expansive, or irritable mood, hyperactivity, and rapid or pressured speech were found to define a diagnostic classification of mania. Grandiosity and flight of ideas were related to this classification but did not contribute to its definition. Results suggested new diagnostic criteria for mania, with patients being diagnosed manic if they had at least two of the three designated symptoms. Additional information on the presence or absence of grandiosity and/or flight of ideas changed the diagnoses of only seven patients (3 per cent), all of whom had had the lowest certainty of diagnosis based on three symptoms. The entire study was replicated on an independent sample of 182 patients with nearly identical results.

Is Unilateral Electroconvulsive Therapy Really the Treatment of Choice in Endogenous Depression

Although Lancaster et al. were not the first to apply electroconvulsive therapy (ECT) treatment electrodes over the nondominant hemisphere, they gave the method its present name, unilateral ECT (U/ECT), and were the first to systematically compare its cognitive and therapeutic effects with those of conventional bilateral ECT (B/ECT).’ In a random assignment study using blind assessments of depression and orientation, they found that 4 B/ECT reduced depression scores by 71%, compared with 54% for U/ECT (not significant), and that recovery of orientation was significantly faster after U/ECT. These authors recommended that B/ECT be given to involutional depressives, patients who were actively suicidal, depressed patients who failed to show substantial improvement after 6 U/ECT, and catatonic schizophrenics who were “dangerously impulsive.” In general, these original observations were repeated in many later studies: U/ECT induced substantially less cognitive dysfunction than did B/ECT; the two methods frequently appeared therapeutically equivalent when compared objectively; but the subjective clinical and anecdotal impressions of many investigators were that B/ECT was therapeutically more active than U/ECT. By 1975, d’Elia and Raotma could find 29 comparisons of U/ECT and B/ECT which they tabulated for research findings and clinical impressions.’ If one corrects their misidentification of the study of Martin et u I . ~ as showing U/ECT to be “decidedly more effective” (it was equal to B/ECT), and of Strain et al! as showing U/ECT to be “somewhat less effective according to clinical impression” (it was significantly less effective according to objective measures), 15 studies reported the two methods to be equally effective, 13 reported an advantage for B/ECT, and 1 reported an advantage for unilateral ECT (p -= 0.001). These clinical observations took various forms, and were characterized by assertions that B/ECT worked faster; could be given less frequently; worked better in severely disturbed, agitated, manic, catatonic, suicidal, or endogenously depressed patients; resulted in fewer symptoms at the end of the treatment course; required fewer treatments; or produced greater depression scale score reductions.5 For example, the study of Cronin et al., described by d’Elia and Raotma as showing U/ECT “somewhat less effective according to clinical impression,”* actually reported that 6 B/ECT reduced Beck Depression Inventory scores in endogenous depressives by 72% compared to 35% for U/ECT.6 Much smaller differences were found in their patients with reactive depression, confirming the dictum that ECT is not indicated in this disorder.

Brief pulse ECT in melancholia: EEG and clinical effects

In a visual analysis of electroencephalograms (EEGs) obtained in 33 melancholic men before and after six brief pulse right unilateral, left unilateral, or bilateral electroconvulsive therapy (ECT) treatments, the authors were unable to detect the relation between therapeutic outcome and differential hemispheric lateralization of ECT-induced EEG slowing that had been reported previously for sine wave ECT at the same clinical site. These results may be related to differences in neurophysiologic effects between sine wave and brief pulse ECT, and do not support the hypothesis that lateralization of ECT-induced EEG slowing is central to the antidepressant effects of ECT.

Familial and non-familial mania

We compared 34 manics with a positive family history of affective disorder (familial mania) and 84 manics with a negative family history of affective disorder (non-familial mania) for clinical, demographic and historical variables related to abnormal brain function and for cortical functioning measured by neuropsychological and electroencephalographic techniques. Proband and relative research diagnosis, neuropsychological and electroencephalographic interpretations were made blindly and independently of each other. Except for index admission severity of illness being greater in familial manics, we could find no significant differences for any of the variables studied. We conclude that differences in family illness patterns do not identify subgroups of manics and if it exists, heterogeneity, must be sought by studying other biologic correlates of psychopathology.

Rise in Deoxyribonucleic Acid Polymerase Activity in the Absence of Deoxyribonucleic Acid Synthesis in Cultured Kidney Cells

IN the liver cells of the partially hepatectomized rat and in kidney cells cultured directly from the rabbit, the stimuli to cell multiplication are not followed immediately by DNA synthesis. Instead, there is a long presynthetic period (12–18 h in rat liver1, 30 or more hours for the cultured cells2) during which metabolic changes occur that endow the cells with the ability to replicate DNA. In both the liver3 and kidney cells4 a marked increase in DNA polymerase (EC 2.7.7.7) activity occurs, beginning at about the same time as DNA replication. This temporal coincidence could mean that DNA synthesis begins after the rise in level of enzymes involved in its synthesis or, conversely, that initiation of DNA synthesis indirectly stimulates the manufacture of higher levels of enzymes and substrates needed for replication.

Psychopathology in schizophrenics and their families

We present preliminary results of a four-year, prospective family study of schizophrenia in which we are using semi-structured personal interview, personality measures, and blind and independent diagnoses of probands and relatives using operationally defined research criteria to study the first-deeree relatives of five patient groups (N-600): 1) chronic, deteriorated, emotionally blunted schizophrenics (termed core schizophrenics), 2) chronic, but non-blunted patients with a nonaffective positive-symptom psychoses (termed non-core schizophrenics), 3) patients with schizoaffective disorder, 4) patients with classical bipolar or unipolar affective disorder, and 5) psychiatrically and neurologically normal medical/surgical controls.

The pathophysiology of emotional blunting: implications for heterogeneity of schizophrenia

In a series of studies, we examined the clinical, cognitive and biological correlates of emotional blunting (EB). The concept of emotional blunting, considered a core feature of schizophrenia by Kraepelin and Bleuler, closely parallels the current concepts of negative and deficit symptoms in schizophrenia. We found that emotionally blunted schizophrenic patients presented with more severe overall symptomatology, exhibited poor response to treatment, and stayed longer in the hospital than nonblunted schizophrenic patients. When both groups were exhibiting emotional blunting, even patients satisfying the inclusion criteria for research diagnosis of mania fared as poorly as schizophrenic patients. We were, however, unable to replicate the previously reported association between negative symptoms and tardive dyskinesia. The correlation between emotional blunting scores and AIMS scores was only 0.093 (N=29, p=O.32), with emotionally blunted patients having a mean AIMS score of 8.3 (SD-5.3), compared to the mean AIMS score of 6.6 (SD-6.2) (t=0.78, ns) in nonemotionally blunted patients.