Russell R. Monroe

Limbic Ictus and Atypical Psychoses

This paper reviews the data which support the concept of a limbic ictus as an etiological mechanism in many patients with diagnoses of atypical psychoses. Inasmuch as our clinical neurophysiological techniques cannot easily record this limbic ictus, much of these data are circumstantial. Furthermore, lacking reliable biological markers for the major psychoses, supporting animal data rests on the tenuous identification of psychoses in terms of behavioral observation on these animals, whereas our psychiatric diagnostic criteria for psychoses depend largely on the verbal reports of our patients. There is, however, direct empirical support for this concept which is limited to a small cohort whose psychoses were correlated with electrographic data recorded from chronically implanted subcortical electrodes. These data include not only observations of spontaneously appearing ictal or interictal patterns but also observations following electrical stimulation of subcortical structures. The kindling phenomena induced by such electrical stimulation in animals have also been observed in humans. Kindling then offers a theoretical framework within which to view more prolonged behavioral deviations as neurophysiological processes, although it is still not completely clear whether such deviations are correlated with ictal or interictal phenomena. Some drugs such as cocaine and amphetamine reduce seizural thresholds within the limbic system, and hence facilitate kindling. In fact, some of the neuroleptics and tricyclics now utilized in the treatment of not only the major psychoses but also the atypical psychoses also lower seizural thresholds. This may explain why such drugs often exaggerate rather than ameliorate the symptoms of atypical psychoses. Furthermore, this means that drugs which raise seizural thresholds could be an important addition to our therapeutic armamentarium. This has been particularly demonstrated by the use of the anticonvulsant carbamazepine. Animal studies have shown that this drug is particularly effective in blocking the kindling phenomena in the amygdala. It is still not clear whether the therapeutic effectiveness of carbamazepine in treating the atypical psychoses is due to its anticonvulsant properties or some other action on synaptic neurotransmission with the elevation in seizural threshold as an incidental consequence with regard to the drugs effectiveness in the atypical psychoses.

Correlation of rhinencephalic electrograms with behavior

Abstract Six patients with chronically implanted intracranial electrodes were studied under the influence of d-LSD-25, 1-LSD-25, mescaline, and correlations attempted between the electrograms and behavioral observations. An increase in beta activity and a disappearance of alpha characterized in both cortical and subcortical recordings seemed to be associated with anxiety or its derivatives. Paroxysmal activity induced in the hippocampal, amygdaloid, and septal regions seemed to be associated with overt expressions of disturbed psychotic behavior. Spread of such paroxysmal activity until it became generalized in the cortex seemed to interfere with the full expression of the psychotic behavior. Chlorpromazine not only proved an effective blocking agent as far as the behavior was concerned, but also abolished or minimized the appearance of the low amplitude fast activity as well as the paroxysmal subcortical activity. The possible sites of action of LSD-25, mescaline, and chlorpromazine are discussed with reference to the problems of psychomotor epilepsy, episodic psychotic reactions, and schizophrenia.

A COMPARISON OF CORTICAL AND SUBCORTICAL BRAIN WAVES IN NORMAL, BARBITURATE, RESERPINE, AND CHLORPROMAZINE SLEEP

For several years, the authors have been recording cortical and subcortical activity from chronically implanted electrodes in animals and humans in various states of altered awareness.’ These states included naturally occurring phenomena such as sleep, pathological behavior such as schizophrenia and other illnesses, and pharmacologically-induced states of altered awareness.2* The dramatic tranquilizing effects of reserpine and chlorpromazine that have been noted both in published reports and in our own experience immediately led us to investigate the possible electroencephalographic changes which might accompany the use of these drugs4 Clinical observations have indicated that the most dramatic effect of these drugs was the reduction of spontaneous motor activity. Thus they offered a method of controlling maniacal aspects of behavior whether associated with affective or schizophrenic psychosis. In clinical use, we found, as others have reported, that, with rare exception, the psychiatric ideation remained the same.4 Our clinical results have been inconsistent and unpredictable when these drugs were given in an attempt to control chronic tension in psychotic and neurotic patients. One striking observation, however, was that these drugs, unlike the usual barbiturate sedatives, did not produce central depression. The patients were easily aroused, and were at no time ataxic or confused. The subjective complaint of “dopiness” or being “drugged” was absent. Some of our more introspective patients who could report their feelings would describe sensations of weakness, lassitude, or a feeling of paralysis. One patient said, “I was quiet but didn’t sleep.” Scalp EEG’s seemed to support this subjective evaluation. We observed the patients to be relaxed, motionless, with eyes closed and clinically asleep, but without typical sleep changes in the scalp electroencelphalographic record. The changes encountered in these recordings were those of relaxation or drowsiness. Although the patient appeared to be asleep, there was no spindling or slow-wave activity associated with deeper sleep. Additional electroencephalographic evidence of differences in pharmacological action between the barbiturates and these two drugs was the lack of the usual 20 to 30/second spindling activity characteristic of barbiturates. These findings have been reported by We have previously reported that there is often a marked disparity between the cortical and subcortical recordings, as well as equally marked electroencephalographic differences in the various subcortical regions.’, 2 n , The present study was inaugurated in an effort to clarify problems concerning the site of action of these drugs and to compare their effects with those of barbiturate sedatives. ti

The episodic psychoses of Vincent van Gogh

During his adult life Vincent wrote more than 700 letters, mostly to his brother, Theo. Early in this correspondence he said to Theo, “Do you want me to continue writing about everything the way I have lately, telling you the thoughts that come into my mind without being afraid of letting myself go, without keeping back my thoughts or censoring them?” (15, Letter 169). These letters, written before the discovery of psychoanalysis, constitute an act of self-revelation comparable in many ways to that of the modern psychoanalytic patient. The detailed introspective data contained in them provide a unique opportunity for understanding the syndrome of episodic behavioral disorders. They suggest, in particular, how Vincents episodic psychoses both interfered with and augmented his unique creativity. It is proposed that bursts of electrical activity within the limbic system are associated with an inspirational thought (an experience often referred to as a “brainstorm”) or a new perception of the world similar to the psychedelic experience induced by hallucinogens. If more prolonged, the behavior becomes maladaptive and includes self-defeating impulses (dyscontrol action). If still more persistent, there occurs an episodic psychotic reaction accompanied by overwhelming painful emotions, hallucinations, delusions, and confusion with a consequent loss of personal identity. This is a frightening interruption of ones life style or life flow. Vincents letters dramatize all of these stages of limbic “seizural” activity. Such bursts of seizural activity within the limbic system can be induced not only by psychological stress but also metabolic disequilibrium, external toxins, such as alcohol, and pertinent for Vincents situation, a convulsive constituent of absinthe (thujone). Thus, psychological and neurophysiological mechanisms are complementary and not contradictory. It is proposed that for Vincent, Limbic system sensitivity, physical neglect, absinthe abuse, and repeated psychological stress, as well as strength of character, creative temperament, innate artistic ability, and disciplined development of his artistic skills provided a rare combination of coincidences which in part explains why Vincents life was a shambles and his artistic creativity unique.

DSM-III style diagnoses of the episodic disorders.

The episodic disorders can be clearly differentiated from schizophrenia as now rigorously defined in Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition. Because the affective disorder is a more heterogeneous one, the boundaries between this group and episodic disorders is less precise, but this boundary could be clarified with a rigorous definition of the affective disorders comparable to that utilized for schizophrenia. The acute mode of onset and the remitting course are the most useful differentiating features between schizophrenia and the episodic disorder. The presence of toxic or other organic symptoms, including clouding of sensorium, illusions, visual hallucinations, formes frustes of epilepsy, childhood history of minimal brain dysfunction or attentional deficits, and soft neurological signs, aid in differentiating the episodic disorders from manic and depressive episodes. There is a subgroup of episodic disorders that can be differentiated from the epileptoid or organic episodic disorders as well as from the major psychoses by psychodynamic factors alone.

EEG activation with chloralosane.

Abstract In 39 studies on 37 patients with behavioral disorders requiring hospitalization on a psychiatric ward, only 3 patients failed to show electroencephalographic abnormalities after they had received 500 mg. of chloralose plus 1 2 mg. of scopolamine. Six of this group showed EEG abnormalities during baseline recordings with hyperventilation. Only 7 of the 37 had a history of grand mal or psychomotor seizures. In 15 voluntary controls with no evidence of either epilepsy or severe behavior disorder, only 4 were activated. All activated controls had some irregularities in the baseline recording which, although they might not have been considered abnormal were, nevertheless, deviations from the expected pattern. Activation, which, with one exception, started within the first hour and reached a maximum within the second, consisted of theta-delta activity that was often focal at first but tended to generalize later. Occasionally sharp waves or spikes would be seen. The abnormality would be continuous or paroxysmal and was often associated with an increase in symptoms or behavioral abnormalities. In 8 patients with subcortical chronically implanted electrodes, there was no consistent pattern of subcortical activation before involvement of the cortical areas. Like the clinical studies, the activation often occurred focally then became generalized. Only one patient lost consciousness, and although she showed focal rhythmic clonic movements there was no generalized tonic-clonic convulsion. In view of the fact that only 7 of the 34 patients who were activated had a history of seizures, one should be extremely cautious in interpreting scopolamine-chloralose activation as evidence of epilepsy. Whether this procedure will be useful in identifying a specific group of behavior disorders can only be determined by extending activations to much larger series of patients and controls.

An Experiment in Use of Client in Staff Education [with Discussion]

Historically the education of social caseworkers has relied to a large extent upon a kind of apprenticeship training. This is particularly true of the training that the social worker receives on the job after completing his graduate study. An experienced worker, usually called a supervisor, instructs the less experienced social worker in giving aid to the client. The supervisor uses data presented by the caseworker, material collected through interviews with the client. Whether formally organized, as is customary in presentations to the psychiatric consultant, or in the form of chronological reports of a series of interviews, the materials presented to the agency supervisor have been selected by the worker on the basis of his own problems, limited experience, or intellectual bias. Hence it must often be true that the supervisor gets a distorted picture of the problem. Unlike other apprenticeship arrangements, social work education affords the