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Introduction: Apathy is common in neurocognitive disorders (NCD) but NCD-specific diagnostic criteria are needed., Methods: The International Society for CNS Clinical Trials Methodology Apathy Work Group convened an expert group and sought input from academia, health-care, industry, and regulatory bodies. A modified Delphi methodology was followed, and included an extensive literature review, two surveys, and two meetings at international conferences, culminating in a consensus meeting in 2019., Results: The final criteria reached consensus with more than 80% agreement on all parts and included: limited to people with NCD; symptoms persistent or frequently recurrent over at least 4 weeks, a change from the patient's usual behavior, and including one of the following: diminished initiative, diminished interest, or diminished emotional expression/responsiveness; causing significant functional impairment and not exclusively explained by other etiologies., Discussion: These criteria provide a framework for defining apathy as a unique clinical construct in NCD for diagnosis and further research., (© 2021 The Authors. Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Clinicians should use a systematic approach to evaluating patients presenting with a concern for cognitive impairment. This approach includes interviewing a knowledgeable informant and performing a thorough mental status examination in order to determine the presence of functional impairments and the domains of cognition that are impaired. The results of this interview and examination determine the next steps of the diagnostic work-up. The pattern of cognitive impairment shapes the differential diagnosis. Treatment should address symptoms, and environmental, psychological, and behavioral interventions are essential., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Delayed neurocognitive recovery (DNR) is common in elderly patients after major noncardiac surgery. This study was designed to investigate the best statistical rule in diagnosing DNR with the Montreal cognitive assessment (MoCA) in elderly surgical patients.This was a cohort study. One hundred seventy-five elderly (60 years or over) patients who were scheduled to undergo major noncardiac surgery were enrolled. A battery of neuropsychological tests and the MoCA were employed to test cognitive function at the day before and on fifth day after surgery. Fifty-three age- and education-matched nonsurgical control subjects completed cognitive assessment with the same instruments at the same time interval. The definition of the international study of postoperative cognitive dysfunction (ISPOCD 1) was adopted as the standard reference for diagnosing DNR. With the MoCA, the following rules were used to diagnose DNR: the cut-off point of ≤26; the 1 standard deviation decline from baseline; the 2 scores decline from baseline; and the Z score of ≥1.96. The sensitivity and specificity as well as the area under receiver operating characteristic curve for the above rules in diagnosis of DNR were calculated.The incidence of DNR was 13.1% (23/175) according to the ISPOCD1 definition. When compared with the standard reference, the 2 scores rule showed the best combination of sensitivity (82.6%, 95% confidence interval [CI] 67.1%-98.1%) and specificity (82.2%, 95% CI 76.2%-88.3%); it also had the largest area under receiver operating characteristic curve (0.824, 95% CI 0.728-0.921, P < .001). The cut-off point rule showed high sensitivity (95.7%) and low specificity (37.5%), whereas the 1 standard deviation and the Z score rules showed low sensitivity (47.8% and 21.7%, respectively) and high specificity (93.4% and 97.3%, respectively).Compared with the ISPOCD1 definition, the 2 scores rule with MoCA had the best combination of sensitivity and specificity to diagnose DNR.

Introduction: The value of the P300 cognitive event-related potential in the diagnosis of Alzheimer subtype neurocognitive disorders is still incipient. Recent studies suggest that combining it with neuropsychological tests by cognitive domains would allow an objective and early characterisation of the cognitive impairment in its initial stages., Aims: To characterise the electrophysiological patterns in the P300 potential that obtain a discriminatory value for the diagnosis and classification of the neurocognitive disorders with a possible Alzheimer-type aetiology., Subjects and Methods: This study examines 39 patients classified, according to the DSM-5, with possible Alzheimer-type minor and major neurocognitive disorders, aged between 50 and 85 years, and 53 control subjects with normal cognitive functions. The P300 potential is registered in the auditory mode, oddball paradigm and centroparietal recording., Results: P300 latency is significantly prolonged in subjects with neurocognitive disorder; there are significant differences in the mean values and confidence intervals between healthy controls and patients. No significant differences are obtained in P300 latency between groups with minor and major neurocognitive disorder. The mean amplitude value decreases in neurocognitive disorder, and the P300 amplitude logarithm of the control groups and those with minor and major neurocognitive disorder reaches significantly different mean values and confidence intervals., Conclusions: The parameters quantified in the P300 potential can be used as complementary biomarkers to classify the presence and level of cognitive dysfunction with a possible Alzheimer-type aetiology.

Introduction: We investigated multi-domain baseline neurocognition of primary brain tumor patients prior to radiotherapy (RT), including clinical predictors of function and association between pre-RT and post-RT impairment on a prospective trial., Methods: A multi-domain neuropsychological battery (memory, executive functioning, language, attention, processing) was performed on 37 patients, pre-RT and 3-(n = 21), 6-(n = 22) and 12-(n = 14) months post-RT. Impairment rate was the proportion of patients with standardized T-scores ≤ 1.5 standard deviations below normative means. Per-patient impairment across all domains was calculated using a global deficit score (GDS; higher value indicates more impairment). Associations between baseline GDS and clinical variables were tested. Global GDS impairment rate at each time point was the fraction of patients with GDS scores > 0.5., Results: Statistically significant baseline neurocognitive impairments were identified on 4 memory (all p ≤ 0.03) and 2 out of 3 (p = 0.01, p = 0.027) executive functioning tests. Per-patient baseline GDS was significantly associated with tumor volume (p = 0.048), tumor type (p = 0.043), seizure history (p = 0.007), and use of anti-epileptics (p = 0.009). The percentage of patients with the same impairment status at 3-, 6-, and 12-months as at baseline were 88%, 85%, and 85% respectively., Conclusions: Memory and executive functioning impairment were the most common cognitive deficits prior to RT. Patients with larger tumors, more aggressive histology, and use of anti-epileptics had higher baseline GDS values. GDS is a promising tool to encompass multi-domain neurocognitive function, and baseline GDS can identify those at risk of cognitive impairment.

Background: Neurocognitive impairment remains a common complication of human immunodeficiency virus (HIV) despite effective antiretroviral therapy (ART). We previously reported improved neurocognitive functioning with ART initiation in 7 resource-limited countries for HIV+ participants from the AIDS Clinical Trials Group (ACTG) 5199 International Neurological Study (INS). Here, we apply normative data from the International Neurocognitive Normative Study (INNS) to INS to provide previously unknown rates of neurocognitive impairment., Methods: The A5199 INS assessed neurocognitive and neurological performance within a randomized clinical trial with 3 arms containing World Health Organization first-line recommended ART regimens (ACTG 5175; PEARLS). The ACTG 5271 INNS collected normative comparison data on 2400 high-risk HIV-negative participants from 10 voluntary counseling and testing sites aligned with INS. Normative comparison data were used to create impairment ratings for HIV+ participants in INS; associations were estimated using generalized estimating equations., Results: Among 860 HIV+ adults enrolled in ACTG 5199, 55% had no neurocognitive impairment at baseline. Mild neurocognitive impairment was found in 25%, moderate in 17%, and severe in 3% of participants. With the initiation of ART, the estimated odds of impairment were reduced 12% (95% confidence interval, 9%, 14%) for every 24 weeks (P < .0001) on ART. Mild impairment dropped slightly and then remained at about 18% out to week 168., Conclusions: Almost half of HIV+ participants had neurocognitive impairment at baseline before ART, based on local norms. With ART initiation, there were significant overall reductions in neurocognitive impairment over time, especially in those with moderate and severe impairments., Clinical Trials Registration: NCT00096824., (© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Polyglutamine expansions in the transcriptional co-repressor Atrophin-1, encoded by ATN1, cause the neurodegenerative condition dentatorubral-pallidoluysian atrophy (DRPLA) via a proposed novel toxic gain of function. We present detailed phenotypic information on eight unrelated individuals who have de novo missense and insertion variants within a conserved 16-amino-acid "HX repeat" motif of ATN1. Each of the affected individuals has severe cognitive impairment and hypotonia, a recognizable facial gestalt, and variable congenital anomalies. However, they lack the progressive symptoms typical of DRPLA neurodegeneration. To distinguish this subset of affected individuals from the DRPLA diagnosis, we suggest using the term CHEDDA (congenital hypotonia, epilepsy, developmental delay, digit abnormalities) to classify the condition. CHEDDA-related variants alter the particular structural features of the HX repeat motif, suggesting that CHEDDA results from perturbation of the structural and functional integrity of the HX repeat. We found several non-homologous human genes containing similar motifs of eight to 10 HX repeat sequences, including RERE, where disruptive variants in this motif have also been linked to a separate condition that causes neurocognitive and congenital anomalies. These findings suggest that perturbation of the HX motif might explain other Mendelian human conditions., (Copyright © 2019 American Society of Human Genetics. Published by Elsevier Inc. All rights reserved.)

HIV-associated neurocognitive disorders (HAND) commonly feature verbal episodic memory impairment historically characterized by a retrieval deficit, consistent with a classic "subcortical" presentation; however, there are hints of a subtle shift toward a more "cortical" memory profile characterized by a primary encoding deficit. The current study evaluated this possibility by comparing the pattern of HAND-associated verbal episodic memory deficits to those of traditional "subcortical" (i.e., Huntington's disease; HD) versus "cortical" (i.e., left temporal lobe epilepsy with mesial temporal sclerosis; L-MTLE) profiles. Seventy-seven individuals with HAND, 47 individuals with HD, 21 individuals with L-MTLE, and 45 healthy participants were administered the California Verbal Learning Test - 2 nd Edition (CVLT-II). CVLT-II profiles were classified as reflecting a primary encoding deficit, retrieval deficit, or a normal profile. Among participants with a deficit profile, the HAND group showed the highest rates of retrieval versus encoding profiles (71% vs. 29%), followed by HD (59% vs. 41%), L-MTLE (46% vs. 54%), and healthy (50% vs. 50%) groups. While significant profile heterogeneity was observed across clinical groups, findings suggest that HIV-associated verbal episodic memory impairments are most consistent with a traditional "subcortical," retrieval deficit profile, consistent with the primary frontostriatal neuropathogenesis of HIV disease.

The section 06 (Mental, Behavioural or Neurodevelopmental Disorders) of the current version Beta Draft (Mortality and Morbidity Statistics, 16.12.2017) of the ICD 11 (International Statistical Classification of Diseases and Related Health Problems) replaces the F0-section of the ICD-10. Several changes, particularly with regard to the classification of neurodegenerative disorders have been introduced. It can be considered a progress that the concept of "organic" syndromes has been dropped and that the section focusses on acquired conditions with cognition as the main area of symptoms. Regarding dementia, the 06 section still uses a syndromal approach of for example dementia due to Alzheimer disease (AD). The development of biomarkers and the molecular concept of AD is not incorporated, yet. In section 08 (Diseases of the Nervous System) Alzheimer disease without reference to symptoms can be classified, however, this section also misses reference to biomarkers, which leaves uncertainty of how the diagnosis should be made.In section 06 the condition of minor neurocognitive disorder was originally only defined as a syndrome without reference to a disease. This has been modified and it is now possible to classify the condition in association with a disease (e. g. AD), however, also without reference to biomarkers.The syndromal approach of section 06 is of value, since in many parts of the world, there is no access to AD biomarkers and all current therapies are tested and in some cases approved for Alzheimer dementia rather than AD as a molecular condition. The lack of any reference to AD biomarkers within ICD-11 so far, however, is a highly relevant limitation with the development of treatments, which target specific components of pathology (e. g. anti-amyloid treatment)., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: HIV-associated neurocognitive disorder (HAND) remains an important and yet potentially underdiagnosed manifestation despite the fact that the modern combination antiretroviral therapy (cART) has achieved effective viral suppression and greatly reduced the incidence of life-threatening events. Although HIV neurotoxicity is thought to play a central role, the potential of viral genetic signature as diagnostic and/or prognostic biomarker has yet to be fully explored., Results: Using a manually curated sequence metadataset (80 specimens, 2349 sequences), we demonstrated that only three genetic features are sufficient to predict HAND status regardless of sampling tissues; the accuracy reached 100 and 94% in the hold-out testing subdataset and the entire dataset, respectively. The three genetic features stratified HAND into four distinct clusters. Extrapolating the classification to the 1619 specimens registered in the Los Alamos HIV Sequence Database, the global HAND prevalence was estimated to be 46%, with significant regional variations (30-71%). The R package HANDPrediction was implemented to ensure public availability of key codes., Conclusions: Our analysis revealed three amino acid positions in gp120 glycoprotein, providing the basis of the development of novel cART regimens specifically optimized for HAND-associated quasispecies. Moreover, the classifier can readily be translated into a diagnostic biomarker, warranting prospective validation.

Background: There is little information on the application and impact of revised criteria for diagnosing dementia and mild cognitive impairment (MCI), now termed major and mild neurocognitive disorders (NCDs) in the DSM-5. We evaluate a psychometric algorithm for diagnosing DSM-5 NCDs in a community-dwelling sample, and characterize the neuropsychological and functional profile of expert-diagnosed DSM-5 NCDs relative to DSM-IV dementia and International Working Group criteria for MCI., Methods: A population-based sample of 1644 adults aged 72-78 years was assessed. Algorithmic diagnostic criteria used detailed neuropsychological data, medical history, longitudinal cognitive performance, and informant interview. Those meeting all criteria for at least one diagnosis had data reviewed by a neurologist (expert diagnosis) who achieved consensus with a psychiatrist for complex cases., Results: The algorithm accurately classified DSM-5 major NCD (area under the curve (AUC) = 0.95, 95% confidence interval (CI) 0.92-0.97), DSM-IV dementia (AUC = 0.91, 95% CI 0.85-0.97), DSM-5 mild NCD (AUC = 0.75, 95% CI 0.70-0.80), and MCI (AUC = 0.76, 95% CI 0.72-0.81) when compared to expert diagnosis. Expert diagnosis of dementia using DSM-5 criteria overlapped with 90% of DSM-IV dementia cases, but resulted in a 127% increase in diagnosis relative to DSM-IV. Additional cases had less severe memory, language impairment, and instrumental activities of daily living (IADL) impairments compared to cases meeting DSM-IV criteria for dementia. DSM-5 mild NCD overlapped with 83% of MCI cases and resulted in a 19% increase in diagnosis. These additional cases had a subtly different neurocognitive profile to MCI cases, including poorer social cognition., Conclusion: DSM-5 NCD criteria can be operationalized in a psychometric algorithm in a population setting. Expert diagnosis using DSM-5 NCD criteria captured most cases with DSM-IV dementia and MCI in our sample, but included many additional cases suggesting that DSM-5 criteria are broader in their categorization.

The author considers an important issue of clinical psychiatry - mental or exogenous organic disorders. An analysis of publications of 9 Russian psychiatric journals for the period 2011-2015 and program reports of the XV and XVI Russian psychiatric congresses shows that very small attention is given to this pathology. According to the author's opinion, many aspects of this problem are unexplored or controversial. Some different interpretations of the term 'exogenous organic' makes it uninformative. There are not clear ideas about the structure of the clinical exogenous-organic disorders; their prevalence in different populations is not well studied; their combination with other mental illnesses requires further studies. One of the causes of it is a lack of attention of specialists to this pathology because it has not been included in the ICD-10. The solution of this problem is the creation of a national classification of mental disorders, which would include exogenous-organic mental disorders and, at the same time, would be integrated with the new version of ICD.

When the early trials of Ginkgo biloba extract EGb 761(®) were conducted, different terms were used to denote ageing-associated neurocognitive disorders. With the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a taxonomy covering dementia and pre-dementia stages of such disorders became available. DSM-5 diagnostic criteria for neurocognitive disorders (NCDs) were applied to patients with any type of ageing-associated cognitive impairment, including dementia, enrolled in randomized controlled clinical trials of EGb 761(®), taking into account the reported inclusion and exclusion criteria and patient characteristics at baseline. For 23 of 31 trials (74 %), the inclusion diagnoses could be classified as NCD in accordance with DSM-5. Thirteen trials enrolled patients with major NCD, four trials enrolled patients with mild NCD and six trials enrolled patients with NCD, who could not be classified unambiguously as having mild or major NCD. Although various terms were formerly used for neurocognitive disorders, the patients enrolled in the majority of clinical trials with EGb 761(®) could be classified retrospectively using modern DSM-5 diagnostic criteria.

Background: It is evident from the dsm-iv-tr that alcohol-related impairment is extremely difficult to classify accurately. As a result, cognitive deficits can easily be overlooked. The dsm-5, however, incorporates a new category, namely 'neurocognitive disorders', which may lead to significant improvements in clinical practice., Aim: To compare the classification of alcohol-related cognitive dysfunction in dsm-iv-tr and dsm-5 and to discuss the clinical relevance of the revised classification in the dsm-5., Method: We compare the chapters of the dsm-iv-tr and the dsm-5 concerning alcohol-related cognitive impairment and describe the changes that have been made., Results: The dsm-5 puts greater emphasis on alcohol-related neurocognitive impairment. Not only does dsm-5 distinguish between the degree of severity (major or minor neurocognitive disorder), it also distinguishes between the type of impairment (non-amnestic-type versus confabulating-amnestic type). It also makes a distinction between the durations of impairment (behavioural and/or persistent disorders)., Conclusion: The dsm-5 gives a clearer description of alcohol-related neurocognitive dysfunction than does dsm-iv-tr and it stresses the essential role of neuropsychological assessment in the classification, diagnosis, and treatment of neurocognitive disorders.

A disease concept should be broad enough to provide social protection for all subjects suffering from this malady but at the same time it needs to be narrow enough to avoid pathologization of behavior that is merely socially undesirable. From a medical perspective a"disease" is present if functions are impaired that are relevant for individual survival. In the field of psychiatry and psychotherapy, such medically relevant functions include the ability to be alert and fully oriented, to ascribe one's own intentions to oneself and to modulate affects according to the situation. Beyond such medically relevant symptoms of a disease, any clinically relevant dysfunction should also be harmful for the individual if a mental malady is to be diagnosed. One such harmful consequence of a disease can be that the person feels ill and suffers from this state, another negative consequence for the individual can be due to an impairment of activities of daily living and social participation. These harmful consequences of a disease are usually discussed under the heading of the"illness experience" and the"sickness aspect" of any disorder. Beyond mental maladies characterized by disease symptoms that are accompanied either by an illness experience or impaired activities of daily living and social participation (sickness), there are many states of human suffering which can be objectified and classified but do not constitute a disease in the medical sense and should more aptly be named a disorder.

Background: The article defends an interpretation of mental illness as mental dysfunction. It develops a concept in line with the naturalistic viewpoint in the philosophy of medicine., Methods: The concept of mental function is scrutinized. Functions are regarded as effects of traits that enable an organism to live independently. The significance of this theoretical perspective for the psychiatric practice is discussed. Finally, the developed conceptualization is compared to the current edition of the diagnostic and statistical manual of mental disorders (DSM)., Results and Discussion: It is emphasized that the theoretical conceptualization of mental disorder determines what may justifiably and in a scientifically valid way be deemed a disease entity. Nevertheless, the practical perspective needs an additional element of individual well-being as not every mental dysfunction involves impairment in this respect. It is claimed that the DSM takes a perspective similar to the one defended in this article.

The DSM-5 introduces major modifications in the category of mental disorders due to brain lesions compared to the previous DSM versions, which are reviewed in this paper. The description of the category Major neurocognitive disorder, as a substitute for dementia, seems to fit better for patients and families, and more adapted to many neurodegenerative cognitive disorders for which memory impairment is not predominant. Similarly, the introduction of the category of Mild neurocognitive disorder appears to be an improvement although some difficulty still remains for distinguishing mild cognitive disorder from normal aging. The addition of new etiological categories such as fronto-temporal NCD or NCD with Lewy bodies should also to be considered as a significant improvement. Despite these advances, to circumscribe the mental disorders due to brain lesions to cognitive deficits and biological mechanisms remains highly questionable, and does not provide an adequate care for the patients and families if not complemented by a psychological and environmental approach.

Current diagnostic systems for mental disorders were established before the tools of neuroscience were available, and although they have improved the reliability of psychiatric classification, progress toward the discovery of disease etiologies and novel approaches to treatment and prevention may benefit from alternative conceptualizations of mental disorders. The Research Domain Criteria (RDoC) initiative is the centerpiece of NIMH's effort to achieve its strategic goal of developing new methods to classify mental disorders for research purposes. The RDoC matrix provides a research framework that encourages investigators to reorient their research perspective by taking a dimensional approach to the study of the genetic, neural, and behavioral features of mental disorders, RDoCs integrative approach includes cognition along with social processes, arousal/regulatory systems, and negative and positive valence systems as the major domains, because these neurobehavioral systems have all evolved to serve the motivational and adaptive needs of the organism. With its focus on neural circuits informed by the growing evidence of the neurodevelopmental nature of many disorders and its capacity to capture the patterns of co-occurrence of behaviors and symptoms, the RDoC approach holds promise to advance our understanding of the nature of mental disorders.

Neuropsychiatric symptoms (NPS) in dementia, previously denominated as behavioural and psychological symptoms of dementia, are often more distressing, impairing, and costly than cognitive symptoms, representing a major health burden for older adults. These symptoms are common features of Alzheimer's disease (AD), and are one of the major risk factors for institutionalization. There is a high prevalence of neuropsychiatric disturbances in patients with AD, including depression, anxiety, apathy, psychosis, aggression, and agitation. At present, the role of the apolipoprotein E (APOE) genotypes in the development of NPS or neuropsychiatric syndromes/endophenotypes in AD patients is unclear. In this article, we summarized the findings of the studies of NPS and neuropsychiatric syndromes in AD in relation to APOE genotypes, with special attention to the possible underlying mechanisms. While some studies failed to find a significant association between the APOE polymorphism and NPS in late-onset AD, other studies reported a significant association between the APOE ɛ4 allele and an increase in agitation/aggression, hallucinations, delusions, and late-life depression or anxiety. However, current cumulative evidence coming from the few existing longitudinal studies shows no association of APOE genotypes with NPS as a whole in AD. Some negative studies that focused on the distribution of APOE genotypes between AD patients with or without NPS further emphasized the importance of sub-grouping NPS in distinct neuropsychiatric syndromes. Explanations for the variable findings in the existing studies included differences in patient populations, differences in the assessment of neuropsychiatric symptomatology, possible lack of statistical power to detect associations in the negative studies, and small sample sizes generating false positives that cannot be consistently replicated. Finally, many reviewed studies were cross-sectional, whereas it would be of paramount importance to evaluate the risk for incident NPS in relation to the APOE genotype in prospectively followed cohorts of AD patients. In fact, identifying predisposing genetic risk factors may allow us to understand the pathophysiological features of neuropsychiatric syndromes or symptoms in AD, so optimizing possible therapeutic options., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Stigma associated with mental illness has been shown to have devastating effects on the lives of people with psychiatric disorders, their families, and those who care for them. In the current article, the relationship between diagnostic labels and stigma is examined in the context of the forthcoming DSM-V. Three types of negative outcomes are reviewed in detail - public stigma, self-stigma, and label avoidance. The article illustrates how a clinical diagnosis may exacerbate these forms of stigma through socio-cognitive processes of groupness, homogeneity, and stability. Initial draft revisions recently proposed by the DSM-V work groups are presented, and their possible future implications for stigma associated with mental illness are discussed.

Objective: To review the problems posed for doctors by the failure of existing taxonomies to provide a satisfactory method for deriving diagnoses in cases of physical/psychiatric comorbidity, and of relating diagnoses on multiple axes., Method: Review of existing taxonomies and key criticisms. The author was guided in selection by his experience as a member of the working parties involved in the creation of the American Psychiatric Association's DSM-IV., Results: The attempts of the two major taxonomies, the ICD-10 and the American Psychiatric Association's DSM-IV, to address the problem by use of glossaries and multiple axes are described, and found wanting. Novel approaches, including McHugh and Slavey's perspectives of disease, dimensions, behaviour and life story, are described and evaluated. The problem of developing valid and reliable measures of physical/psychiatric comorbidity is addressed, including a discussion of genetic factors, neurobiological variables, target markers and other pathophysiological indicators. Finally, the concept of depression as a systemic illness involving brain, mind and body is raised and the implications of this discussed., Conclusions: Taxonomies require major revision in order to provide a useful basis for communication and research about one of the most frequent presentations in the community, physical/psychiatric comorbidity.

Objective: There is no universally accepted consensus for organic psychiatric disorders (OPDs) between the two major classifications, ICD-10 and DSM-IV. The aim was to compare the coverage of these systems with the Lindqvist & Malmgren (LM) classification system for organic psychiatry., Method: Organic psychiatric disorders were diagnosed according to ICD-10, DSM-IV, and the LM system in 119 patients 12 months after surgery as a result of aneurysmal subarachnoid hemorrhage., Results: Among 35 patients with astheno-emotional (AE) disorder (LM system), 83% (95% CI: 67-92%) had mild cognitive disorder (MCD) according to ICD-10 clinical descriptions and diagnostic guidelines (CDDG), 49% (95% CI: 33-64%) had MCD according to ICD-10 diagnostic criteria for research (DCR), and 34% (95% CI: 21-51%) had mild neurocognitive disorder according to DSM-IV. The coverage for other OPDs did not differ between the systems., Conclusion: The coverage for AE disorder (LM system) was significantly higher than the corresponding diagnoses of the ICD-10 and DSM-IV systems. Modifications of the latter systems are suggested.

Purpose: To evaluate further the relevance of designating psychotic episodes as either postictal or interictal, we compared several biologic variables between epilepsy patients with and without psychosis., Methods: The study subjects comprised 282 patients with psychosis (36 with postictal psychosis, 224 with interictal psychosis, and 22 with both postictal and interictal psychoses, i.e., bimodal psychosis), and 658 epilepsy patients without psychosis. The clinical characteristics of these patients were reviewed retrospectively by experienced neuropsychiatrists. Factors predicting the development of each type of psychosis were determined by serial multivariate logistic regression analyses., Results: Factors that were comparable between postictal and interictal psychoses were intellectual function, family history of psychosis, epilepsy type, and the presence of complex partial seizures. In contrast, age at the onset of epilepsy and at the onset of psychosis and the presence of generalized tonic-clonic seizures differed for the three types of psychosis. Patients with bimodal psychosis showed characteristics associated with both postictal and interictal psychoses., Conclusions: This study documented conditions, including both general factors and epilepsy-related factors, common to epilepsy patients with psychosis, regardless of chronologic distinctions. Certain epileptic processes appear to have equal influence on postictal and interictal psychoses. However, some differences between postictal and interictal psychoses suggest that these chronologic descriptors are valid. Our findings confirmed that psychosis associated with epilepsy should not be defined as a single, simple condition but rather as a complex condition with several possible subcategories.

Background: Delirium is a common neuropsychiatric syndrome characterized by disturbance of attention and consciousness developing over a short period of time. Symptoms tend to fluctuate during the course of the day. Delirium is by definition a direct physiological consequence of a general medical condition and is probably the most common presenting symptom of disease in old age., Material and Methods: Literature review based on search on PubMed and Medline up to 31 December 2001 and a summary of several doctoral theses and our own clinical experience., Results and Interpretation: Several recent intervention studies have clearly shown that delirium can be prevented and treated. Successful intervention programmes have been multifactorial and interdisciplinary, including assessment and treatment of underlying causes as well as prevention and treatment of factors endangering cerebral metabolism. In particular, cerebral hypoxemia caused by i.e. sleep-apnoea syndrome, anaemia, hypotension, pulmonary diseases, and heart failure is often easily prevented and treated. Excellent nursing care seems to be a prerequisite for successful prevention and treatment of delirium. Acceptable scientific evidence for pharmacological treatment is still lacking; it is sometimes necessary but should be used with caution. If sedation is acceptable, clomethiazole is the drug of choice but if the delirium is complicated by frightening hallucinations and agitation, haloperidol or risperidone can be used but only for short periods. Cholinesterase inhibitors are probably a better choice, though randomised treatment studies are still lacking.

The official diagnostic classification systems have been increasingly employed in the last few years, and this is true of both ICD-10 and DSM-IV. We will propose a few principles which should be considered when revisions are attempted. Our existing classifications should be simplified, but new syndromes incorporated where they have pathological justification. Links to other specialist diagnostic classifications should be made (e.g. in epilepsy, sleep disorders, dementias) wherever possible. A broader range of 'Neuropsychiatric Disorders' should be incorporated, including alcohol-related organic disorders, head injury, sleep disorders, if possible including the 'psychogenic syndromes'. Progressive, degenerative disorders need to be clearly distinguished from non-progressive syndromes, and some gradation of severity needs to be built into the classificatory system. Finally, the definitions need to be concise and accurate., (Copyright 2002 S. Karger AG, Basel)

Objective: This study examined whether criminals with organic brain syndrome could be divided into two distinct types. The authors proposed that early starters (onset of criminal activity by age 18) would display a persistent, long-lasting pattern of deviance that was largely independent of their brain disorder, whereas late starters (onset at age 19 or after) would exhibit deviant behaviors that began late in life and were more directly related to their brain disorder., Method: Subjects were 1,130 male criminal offenders drawn from a birth cohort of all individuals born between January 1, 1944, and December 31, 1947, in Denmark. The main study group included all men with both a history of criminal arrest and a hospitalization for organic brain syndrome (N=565). In addition, for a subset of analyses, the authors examined a randomly selected, same-size comparison group of men with a history of criminal arrest who were not hospitalized for organic brain syndrome. Data were available on all arrests and all psychiatric hospitalizations for individuals in this cohort through the age of 44., Results: Among those with organic brain syndrome, early starters were significantly more likely than late starters to 1) be arrested before the onset of organic brain syndrome, 2) show a higher rate of offending before but not after the onset of organic brain syndrome, 3) be both recidivists and violent recidivists, and 4) have a diagnosis of antisocial personality disorder., Conclusions: Male criminals with organic brain syndrome can be meaningfully divided into two distinct types on the basis of age at first arrest. Early starters show a more global, persistent, and stable pattern of offending than late starters. These results have implications for treatment and risk assessment.

Objective: This study investigated the association between Mini-Mental State Examination (MMSE) scores and diagnosis, computerized tomographic scans or electroencephalogram findings in geropsychiatric inpatients (age > or = 65)., Method: We analyzed the MMSE records of patients sixty-five and older who had been hospitalized in our psychiatric ward during a nine-year period. Case data were collected by review of chart records., Results: In these patients, MMSE scores were significantly different among the seven diagnostic groups included. Demented patients had the lowest MMSE scores. Patients who had abnormal findings on computerized tomographic scans or electroencephalogram had lower MMSE than patients with normal findings., Conclusion: Our findings suggest that the MMSE is a useful screening instrument for organicity in the geropsychiatric inpatients. However, because of the lower average MMSE score in geropsychiatric inpatients, the optimal cut-offpoint of MMSE for dementia should be lower than those used in other populations.

All research on schizophrenia depends on selecting the correct phenotype to define the sample to be studied. Definition of the phenotype is complicated by the fact that there are no objective markers for the disorder. Further, the symptoms are diverse, leading some to propose that the disorder is heterogeneous and not a single disorder or syndrome. This article explores an alternative possibility. It proposes that schizophrenia may be a single disorder linked by a common pathophysiology (a neurodevelopmental mechanism), which leads to a misconnection syndrome of neural circuitry. Evidence for disruption in a specific circuit is explored: the cortical-thalamic-cerebellar-cortical circuit (CCTCC). It is suggested that a disruption in this circuit leads to an impairment in synchrony, or the smooth coordination of mental processes. When synchrony is impaired, the patient suffers from a cognitive dysmetria, and the impairment in this basic cognitive process defines the phenotype of schizophrenia and produces its diversity of symptoms.

Objective: Reduplicative paramnesia (RP) is thought to be related to other delusional misidentification syndromes (DMS) such as Capgras syndrome. DMS are thought to occur when brain lesions disrupt cortical functioning. This study tests this hypothesis and tries to understand whether focal lesions are as important in the etiology of RP as they are in other types of DMS., Method: The computed tomography (CT) scans of 10 consecutive psychiatric inpatients with RP and another principal psychiatric diagnosis were compared with those of control patients without RP matched for age, sex, and principal psychiatric diagnosis. The scans were assessed blindly by a neuroradiologist using a previously published rating scale for the presence of lesions in 11 discrete anatomic areas. The differences between the 2 groups were examined statistically using log-linear analysis., Results: Statistical analysis revealed that index patient cortical atrophy, cortical fissure enlargement, and deep brain atrophy distinguished the 2 groups significantly (P < 0.05)., Conclusions: Bilateral anterior cortical, brain stem, and cerebellar vermis atrophy and dysfunction may be important in the pathogenesis of RP in particular and of DMS in general.

The presence of stable personal disharmony in the form of a reduced organic mental syndrome served as a criterion for diagnosis of personality changes after traumatic head injuries. The patients were divided into a group with prevalence of personality changes (81 patients) and a group with predominance of pronounced organic mental syndrome (141 patients). Personality disorders prevailed in the patients who had got mild and moderate traumas at the age of 13-25 years, with less number of additional pathogenic factors of exogenic organic spectrum in anamnesis. 3 variants of the course of personality disorders were recognized: with a tendency toward reduction of emotional and drive pathology; with a tendency to intensification of intellectual and mnestic disorders and transformation into large-scale organic mental syndrome; with a tendency toward an increase of pathological traits of personality in conditions of growing influence of the environmental and psychogenic factors.

It remains unclear how impaired insight and neurocognitive impairment are related to one another in schizophrenia. In order to examine this relationship, subjects with schizophrenia or schizoaffective disorder were classified as having 'impaired' (n=38) or 'unimpaired' (n=43) insight based on their insight rating on the Positive and Negative Syndrome Scale (PANSS). Their performance on neuropsychological tests of global function, executive function, memory and vigilance was then compared. Multivariate analyses followed by Scheffe tests indicated that subjects with impaired insight performed less well on the Wisconsin Card Sorting Test, demonstrating poorer abstract flexibility and heightened perseveration. No differences were found between the groups with regard to global cognitive function, memory or vigilance. This suggests that insight is closely linked to deficits in executive function, and that it may be associated with the compromise of frontal lobe function.

Since the publication of "The Myth of Mental Illness" in 1960, there has been an ongoing debate about Thomas Szasz's ideas concerning mental illness. In this paper, Szasz's views are summarized, as are the views of Szasz's critics. Specifically, the following areas are addressed: Szasz's definition of disease, his notions regarding the unconscious and rationality, his beliefs regarding culpability, his proposed differences between psychiatry and other branches of medicine, the uses of the term "mental illness," and the possibility of implicating physical lesions in some mental illnesses. With this discussion as a backdrop, the importance of these issues to mental health practitioners is addressed.

This report describes a computer program for applying a new statistical method for determining levels of agreement, or reliability, when multiple examiners evaluate a single subject. The statistics that are performed include the following: an overall level of agreement, expressed as a percentage, that takes into account all possible levels of partial agreement; the same statistical approach for deriving a separate level of agreement of every examiner with every other examiner; and tests of the extent to which a giver examiner's rating (say a symptom score of three on a five-category ordinal rating scale) deviates from the group or overall average rating. These deviation scores are interpreted as standard Z statistics. Finally, both statistical and clinical criteria are provided to evaluate levels of interexaminer agreement.

A new method is introduced for assessing levels of interexaminer agreement when multiple ratings are made on a single subject, with an application in psychiatric research. It is designed to provide an overall level of interexaminer agreement and separate indices of agreement for each examiner. These indices are based on biostatistical and clinical criteria to determine whether the ratings of any given examiner are appreciably higher or lower than the group average, or a consensus diagnosis. A number of examples, from ongoing psychiatric research, are provided to illustrate conditions favoring the application of the new methodology. Finally, the necessary software for performing the analyses is available to clinical investigators with interest in this area of assessment.

As part of a multicenter project to study noncognitive behavioral disturbances in dementia, the authors developed a comprehensive caregiver-rated questionnaire for these behaviors. The authors determined the reliability of caregiver ratings and compared caregiver ratings with clinician ratings using standard instruments. Caregivers showed good test/retest reliability for ratings of all types of patient behavioral disturbance. Caregiver interrater reliability was highest for depression and lowest for psychosis. The correlation between caregiver reports and professional assessments was highest for agitation, intermediate for psychosis, and lowest for depression. The match between caregiver and clinician assessments of patient behaviors appears to vary significantly by the type of behavior assessed.

The Category Test, a major part of the Halstead-Reitan Neuropsychological Battery, was first described in a 1943 article by Halstead and Settlage. This paper reviews the development of the test, the psychometric properties of the instrument, available administration and scoring methods, discusses various interpretative strategies, and the empirical support for the test's clinical validity. Recent developments are then reviewed, as well as what the authors see as the future potential for this instrument.

The BNI Screen for Higher Cerebral Functions (BNIS) was administered to 41 patients with known cerebral dysfunction. 22 psychiatric patients (some of whom were psychotic) without documented brain lesions, and 22 medical inpatients without neurological or psychiatric diagnoses. Patients with cerebral dysfunction scored significantly lower than the medical and psychiatric patients (p < 0.05). Utilizing the recommended cutoff score of 47, 40 of the 41 brain-dysfunctional patients were correctly classified as impaired, but only seven of the medical and five of the psychiatric patients were correctly classified. Using age-based T-scores, 36 of the 41 brain-dysfunctional patients (87.8%) were correctly classified. Specificity improved slightly, but these numbers were still low (55%), primarily because psychotic patients performed like neurological patients (100%). This study provides further empirical validation of this screening instrument in identifying patients with brain disorders.

Recent studies have shown that patients with schizophrenia who have an adolescent-symptom onset (before age 21) have a worse clinical course and greater frequency of cerebral abnormalities than those with an adult-onset (after age 25). However, little is known about the neuropsychological functioning of these groups. A comprehensive neuropsychological examination was administered to groups of patients with schizophrenia with either an adolescent- or adult symptom-onset and a healthy control group. The adolescent-onset group performed worse than the adult-onset and control groups, particularly on measures of memory and executive function. The adult-onset group also performed worse than the controls, but to a lesser extent than did the adolescent-onset group. Results are discussed with reference to hypotheses that adolescent-onset schizophrenia represents a distinct neurodevelopmental disease entity.

For the first time, the present study assessed the achievable predictive value of early self-experienced neuropsychological deficits for the fater development of schizophrenia. Ninety-six patients with DSM-III-R diagnoses mainly of the formerly neurotic or personality disordered field, of whom 81% had shown such basic disorders at the time of the index examination and therefore were classified as persons at high risk of developing schizophrenia, were re-examined for schizophrenia. After an average follow-up period of about 8 years, more than half of the re-examined sample had developed a schizophrenic disorder according to DSM-III-R. The outcome of schizophrenia versus no schizophrenia was predicted correctly in 77% of cases by the presence or absence of self-experienced disturbances of perception, thought, speech or action.

This paper evaluates the role of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of psychiatric disorders according to the "International Classification of Diseases" (ICD-10). Indications for CT/MRI can be derived from ICD-10 for the identification or exclusion of defined cerebral lesions resp. for the etiology in organic disorders. Due to the lack of specific morphological findings, CT/MRI do not contribute to the classification of all other diagnoses. CT/ MRI can only exclude causal organic factors. However, ICD-10 provides only few guidelines for ruling out cerebral pathology (e.g. tumors in bulimic anorexia). Therefore, recommendations for routine CT/MRI-investigations for the exclusion of organic disorders are required and might be developed by the quality assurance. Application of CT or MRI: CT plays an important role in diagnostic imaging in routine as well as in emergency situations (haemorraghe, hamatoma, infaction, head injury, tumour, vascular malformation). MRI on the other hand, is more sensitive in the diagnosis of inflammatory diseases, skull base lesions, degenerative changes of the white matter and in the imaging of hydrocephalus and epilepsy.

Paroxysmal-like disorders (PLD) were observed in 11 patients with manic-depressive psychosis and in 34 ones with shift-like progredient schizophrenia. 8 variations of the fits were described by the author earlier and included the states from vegetative fits to complex psychotic ones with manifestations of Kandinsky-Clérambault syndrome. Clinical pattern of endogenous psychoses was characterized by considerable presence of affective disorders (both hypomanic and depressive), moreover depressive disturbances were observed more frequently. Debut of PLD was mentioned either before depressions' or in their structure: The appearance of psychotic symptoms in structure of affective phases does not change the character of paroxysmal-like states. It was supposed that endogenous diseases with PLD are the special variant of psychoses.

Despite their extensive use in psychiatric and medical settings, brief mental status examinations have significant limitations that are easily overlooked in the pressure-cooker environments within which they are commonly used. Although undoubtedly of value as quick screening devices, the sheer brevity of these instruments all but guarantees limited validity. Brief examinations perform best with grossly impaired cases, alerting clinicians to the fact that something is badly amiss in patients who are significantly confused, disoriented, aphasic, or otherwise severely impaired. Very poor scores are accordingly frequently useful. Moderate or even perfect scores, however, will frequently be misleading, because patients with compromised brains often obtain them (Nelson et al. 1986). One such case follows.

The presentation of Ms. E. by Hawkins and Cooper provides an excellent discussion of the diverse ways in which clinicians and clinical researchers are currently conceptualizing neurocognitive deficits within severe psychiatric disorders. The thorough neuropsychological evaluation of this patient provided a wealth of information that was completely missed by the Mini-Mental State Exam (MMSE; Folstein et al. 1975). As Hawkins and Cooper point out, the tendency of some clinicians to discount the role of neuropsychological deficiency in the face of adequate MMSE scores and evident psychiatric symptoms is not justified by the relevant clinical research literature. Furthermore, recent developments in scientific conceptions of the role of neurocognitive deficits in the more severe psychiatric disorders, such as schizophrenia, schizoaffective disorder, and bipolar mood disorder, deserve more attention in clinical practice.

Neuropsychological dysfunctions after traumatic brain injury are classified into a taxonomy to plan a comprehensive examination, and organize and report findings for diagnosis and treatment: consciousness, information processing, sensorimotor, neurophysiological, cerebral personality disorders, intelligence, memory, language, stress, psychodynamic, identity and weltanschauung, adaptation, complex adaptive functions, and development of children. Wide-range sampling enhances the detection of acute and late-developing dysfunctions, and diagnosis of complex syndromes. Historical, personality, and injury data are components of the assessment. Issues discussed include underestimation of brain injury, malingering, interaction of symptoms, symptom persistence, and noncerebral lesional contributors to impairment after mild head injury.