Suzan Uysal

Axis I Psychopathology in Individuals with Traumatic Brain Injury

Objectives:To assess the incidence, comorbiclity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TIM) Design:The Structured Clinical Interview for DSM-IV Diagnoses (SC1D) was utilized. Diagnoses were determined for three onset points relative to TBI onset: prc-TBI, post-TUI, and current diagnosis. Contrasts of prevalence rates with communitybased samples, as well as chi-square analysis and analysis of variance were used. Demographics considered in analyses included gender, marital status, severity of injury, and years since TIM onset Setting:Urban, suburban, and rural New York state. Participants: 100 adults with TBI who were between the ages of 18 and 65 years and who were, on average, 8 years post onset at time of interview Main Outcome Measures:SCID Axis I mood diagnoses of major depression, dysthymia, and bipolar disorder; anxiety diagnoses of panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and phobia; and substance use disorders Results:Prior to TBI, a significant percentage of individuals presented with substance use disorders. After TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders (ie, PTSD, OCD, and panic disorder). Comorbidity was high, with 44% of individuals presenting with two or more Axis 1 diagnoses post TBI. Individuals without a pre-TBI Axis I disorder were more likely to develop post-TBI major depression and substance use disorders. Rates of resolution were similar for individuals regardless of previous psychiatric histories. Major depression and substance use disorders were more likely than were anxiety disorders to remit Conclusion:TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated

Central Nervous System Dysfunction after Noncardiac Surgery and Anesthesia in the Elderly

MORE than 50 yr ago, clinicians reported changes in mental function after anesthesia and surgery in the elderly. As these phenomena have been elucidated in subsequent years, they have been categorized into the distinct syndromes of delirium and postoperative cognitive dysfunction (POCD). These phenomena seem to be increasing in prevalence, concomitant with the increase in the number of elderly patients undergoing surgery. In this brief clinical review, we describe the presentation of, course of, risk factors for, and when applicable, management of these syndromes. Delirium and cognitive function after cardiac and neurosurgical procedures are distinct subjects beyond the scope of this review.

Axis II psychopathology in individuals with traumatic brain injury

Primary objectives:To determine the frequency and nature of post-TBI personality disorders (PDs) in a community-based sample of individuals with TBI. Research design:One hundred individuals with TBI were administered a structural clinical interview to determine Axis II psychopathology. Methods of procedures:The Structured Clinical Interview for DSM-IV Personality Disorders, Clinician Version (SCID II) was used to determine 12 Axis II personality disorders. SCID II questions were modified so that symptom onset could be rated as occurring pre-injury vs. post-TBI. Data were analysed using student T-tests, chi-square analysis and one way analyses of variance. Outcomes and results:Pre-TBI PDs were diagnosed in 24% of the sample; antisocial PD and obsessive–compulsive PD were the most common diagnoses. Post-TBI, 66% of the sample met criteria for at least one PD, with PDs independent of TBI severity, age at injury, and time since injury. The most common post-TBI PDs were: borderline, avoidant, paranoid, obsessive–compulsive and narcissistic. Men were more likely to be diagnosed with antisocial PD and narcissistic PD. Individuals with pre- TBI PDs were at greater risk of acquiring additional psychopathology post-TBI. Personalty traits endorsed by more than 30% of the sample post-TBI reflected loss of self-confidence, attempts to cope with cognitive and interpersonal failures and negative affect. Conclusion:These findings argue against a specific TBI personality syndrome, but rather a diversity of personality disorders reflective of the persistent challenges and compensatory coping strategies developed by individuals post-TBI. Prospective need for clinical assessment, pro-active education and focused treatment approaches are discussed.

Undiagnosed Health Issues in Individuals with Traumatic Brain Injury Living in the Community

Objectives:To examine the self-reported prevalence of long-term health issues in individuals with traumatic brain injury (TBI) living in the community Design:A structured health interview. For individuals with TBI, the presence of a specific health-related issue with onset post-TBI and currently a problem at the time of the interview was explored. For individuals without disability, a specific health-related issue was evaluated at time of interview. For each health issue, the proportion of individuals with TBI experiencing post-TBI onset but current symptoms was contrasted with symptom reports of individuals without disability. Chi-square statistical analyses were used to determine significance. For individuals with TBI, logistic regressions were used to model the probability of having a particular health difficulty when four covariates were examined, such as age, gender, time since onset of TBI, and duration of loss of consciousness (LOC) Setting:Urban, suburban, and rural New York State Participants:338 individuals with TBI and 273 individuals without disability between the ages of 18 and 65 years. Individuals with TBI were, on average, 10 years post-onset at the time of interview Main Outcome Measures:Self-reported health issues reflective of neuroendocrine, neurological, immunosuppression, and other health issues Results:Chronic health issues suggestive of ongoing neuroendocrine dysfunctions (ie, changes in hair/skin texture, body temperature changes), neurologic difficulties (ie, headaches, seizures, balance difficulties, spasticity, sleep disturbances, loss of urinary control), and arthritic complaints were significantly more common in individuals with TBI. The prevalence of many of these health-related difficulties was related to duration of LOC but not to time since injury. Age and gender effects were found, with older women with TBI more likely to report thyroid conditions, sleep disturbances, loss of urinary control, and arthritic changes. Women also reported greater frequency of headaches, colds, weight changes, and temperature changes post TBI Conclusion:Health issues reflective of neuroendocrine, neurological, and arthritic difficulties are common long-term health issues for individuals with TBI. Proactive patient education, ongoing health screening with appropriate medical follow-up, and timely interventions for individuals with TBI are indicated. Longitudinal studies are necessary to examine the natural course of post-TBI health difficulties

Left temporal neocortex mediation of verbal memory Evidence from functional mapping with cortical stimulation

We examined the contribution of the temporal neocortex to short-term memory (STM) in 15 patients with left hemisphere language dominance during intraoperative or extraoperative cortical mapping prior to left anterior temporal lobectomy. Recall errors were examined following stimulation during the acquisition, consolidation, and retrieval stages of a verbal STM task. Ten patients showed stimulation-induced recall errors, and five patients showed no significant memory errors. More patients showed errors following stimulation during consolidation than during acquisition or retrieval, possibly because of disrupted transfer of information from the temporal neocortex to the hippocampus. Patients with stimulation-induced recall errors did not differ significantly from patients without memory errors in terms of seizure, demographic, or neuropsychological variables. Patients with resection of sites showing stimulation-induced recall errors had greater postoperative decline in verbal memory than did patients with resection sparing these sites. We suggest that the left temporal neocortex contributes to verbal memory consolidation in patients with chronic epilepsy.

Retrograde cerebral perfusion as a method of neuroprotection during thoracic aortic surgery

Retrograde cerebral perfusion is commonly used as an adjunct to hypothermic circulatory arrest to enhance cerebral protection during thoracic aortic surgery. This review summarizes a large number of studies that demonstrate a spectrum of beneficial, neutral, and detrimental effects of retrograde cerebral perfusion in humans and experimental animal models. It remains unclear whether retrograde cerebral perfusion provides effective cerebral perfusion, metabolic support, washout of embolic material, and improved neurological and neuropsychological outcome.

Retrograde cerebral perfusion during thoracic aortic surgery and late neuropsychological dysfunction

OBJECTIVE Retrograde cerebral perfusion (RCP) is commonly used in thoracic aortic surgery, ostensibly to provide metabolic support, maintain cerebral hypothermia and/or wash out particulate emboli. We tested the hypothesis that RCP would affect neuropsychological outcome in a clinical cohort. METHODS Ninety-four patients undergoing elective thoracic aortic repairs requiring deep hypothermic circulatory arrest consented to participate in this study. These patients underwent preoperative neuropsychological evaluation and comprise the reference group. Fifty-six of these patients also underwent neuropsychological evaluation several weeks postoperatively, 12 of whom (21%) had RCP. The neuropsychological domains tested were attention, processing speed, memory, executive function, and fine motor function. A global assessment of impairment, negative neuropsychological outcome (NNO), was defined as a postoperative decrease in function in two or more neuropsychological domains for patients with at least three domains tested both pre- and postoperatively (n=48). The relationship of three potential predictors (RCP, cerebral ischemia time and patient age) to negative outcomes was analyzed using Wilcoxon two-sample tests, chi(2) tests, Mantel-Haenszel tests and multiple logistic regression. P<0.05 was considered significant. RESULTS Memory dysfunction and NNO had strong associations with RCP. This effect remained significant when controlling separately for age and cerebral ischemia time. CONCLUSIONS The effects of RCP are difficult to distinguish from those of age and prolonged cerebral ischemia time, because complex thoracic aortic repairs are associated with advanced age, prolonged cerebral ischemia and use of RCP. Despite this limitation, these preliminary data indicated that RCP had no beneficial effect (and most likely a negative effect) upon cognitive outcome.

Evidence of a supraspinal opioid analgesic mechanism engaged by lateral hypothalamic electrical stimulation

Brief trains of electrical stimulation were applied to the tails of rats to evaluate pain thresholds in the presence and absence of concurrent brain stimulation. Lateral hypothalamic (LH) stimulation, particularly in the dorsolateral medial forebrain bundle, elevated threshold for eliciting a post-stimulus vocalization response. Thresholds for eliciting a simple vocalization and motor response--both of which are organized at lower levels of the CNS than post-stimulus vocalization--were not significantly affected. This restricted form of analgesia was reduced by the opioid antagonist, naltrexone. Rewarding effects of stimulation in these LH sites, as evaluated in tests of self-stimulation threshold, were not affected by naltrexone. These results suggest that LH stimulation activates an opioid analgesic mechanism that is selectively active at a supraspinal level and diminishes the affective consequences of otherwise noxious stimuli.

The relationship of cognitive, personality, and academic measures to anesthesiology resident clinical performance

UNLABELLED Cognitive skills (including vigilance), personality factors, and standardized academic test performance may be associated with clinical competence in anesthesiology to varying degrees. Sixty-seven anesthesiology residents in training at one center between 1993 and 1995 were administered the modified Vigil (For Thought, Ltd., Nashua, NH), the Paced Auditory Serial Addition Test, the California Personality Inventory, the State-Trait Anxiety Inventory, and five standardized academic performance tests. The clinical performance of anesthesiology residents was rated on a quarterly basis by a clinical competence committee. A growth curve model indicated that there was significant variability in clinical competence at the start of residency and a statistically significant improvement over time, and that the relative ranking of the residents remained stable over the course of training. Of 46 potential variables, 7 were associated (P < 0.10) with poor clinical performance; these were subjected to a multivariate test (Mantel-Haenszel). Cognitive variables predicting poor clinical performance were difficulty performing a rapid mental arithmetic test requiring divided attention and commission errors during complex visual target detection. Personality variables predicting poor clinical performance were introversion and flexibility. A predictive academic variable was poor anesthesia knowledge as measured by using two different tests during the first month of training. There were varying levels of independence among these variables. IMPLICATIONS Early academic test performance and certain cognitive and personality tests were associated with the clinical performance of anesthesiology residents. The predictive value of these findings should be confirmed in a prospective, multicenter study.

Repeated inescapable stress produces a neuroleptic-like effect on the conditioned avoidance response.

This study tests the hypothesis that the dopaminergic system mediates a restitutive response by decreasing its own activity in the face of events like persistent inescapable stress that threaten to interrupt organized mental activity. It is well established that neuroleptic drugs inhibit the conditioned avoidance response (CAR), but not the escape response, probably via a reduction in subcortical dopaminergic activity. We trained rats to perform the CAR and then subjected them to acute and chronic stress to determine whether this would result in inhibition of the CAR. Rats subjected to twice daily tailshock stress for 8 days showed inhibition of the CAR and a reduction in dopamine (DA) utilization in the nucleus accumbens. These findings are compatible with the hypothesis that an endogenous DA-dependent mechanism exists that mimics neuroleptic effects in the face of repeated stress. In humans this response may serve as a protection against psychotic decompensation from chronic endogenous or exogenous insult.