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In row (a), left and right whole-brain threedimensional images are overlaid with all regions in which significant volume deficits in patients with schizophrenia were reported. For example, is any association with brain damage fortuitous or due to the unmasking of a genetic liability to the disorder, or more directly related by way of a causal influence of the brain lesion on the development of the schizophrenia Harrison (1999) estimated from a thorough review of the neuropathology literature that up to 50% of brains from patients with schizophrenia contain non-specific focal degenerative abnormalities, such as small infarcts and white matter changes. He took these to be mostly if not always coincidental, since they were variable in distribution and nature, and reported as unrelated to the clinical picture occurring well after the onset of symptoms in some cases. Nevertheless, the conclusion emerges that lesions, particularly of the temporal lobes and diencephalon, appear to carry a small but definite risk of increasing the likelihood that a schizophrenia-like illness will develop. This hazard appears to exceed what would be expected in view of the known genetic propensities in the populations concerned. It has not yet been clarified whether such schizophrenias are identical in every respect with the naturally occurring idiopathic disorder, in particular with regard to the course followed. Phenomenologically, however, they appear to be indistinguishable from schizophrenias occurring in the absence of brain disease (Table 2. Irrespective of such nosological refinements, the striking fact appears to be that psychotic illnesses with the major features of schizophrenia may coexist with cerebral lesions and may be generated in some fashion by them. The acute and chronic organic reactions described in Chapter 1 are by no means the exclusive hallmarks of mental disorder occasioned by cerebral dysfunction. The corollary implication is that while in the great majority of schizophrenias no clearcut brain lesion will be revealed by routine investigation, in some patients there may be identifiable pathology that warrants careful appraisal. The evidence incriminating the temporal lobes and diencephalon has come from diverse forms of cerebral pathology. That concerning head injuries is described in Chapter 4 (Psychoses), that for cerebral tumours in Chapter 5 (Temporal lobe tumours) and that for epilepsy in Chapter 6 (Postictal disorders). While far from satisfactory or entirely conclusive, for the reasons discussed above, the sum total of evidence begins to look impressive. Bowman and Lewis (1980) reinforced this association in their analysis of the site of major pathology in a large variety of cerebral disorders liable to show aspects of schizophrenic symptomatology. It remains puzzling that frontal lesions are not more often incriminated, with the exception of occasional disorders such as metachromatic leucodystrophy (Chapter 14). Occasional anecdotal reports of schizophrenia following frontal damage are therefore of interest. He then sustained a head injury leading to a left frontal haematoma that necessitated a left frontal lobectomy. A spike-discharging focus was detected 3 years after the injury when he developed epileptic seizures. The authors suggest that the transformation from bipolar affective disorder to schizophrenia, in a patient genetically predisposed to the former, was due to the unusual combination of damage to the left frontal lobe and an excitatory lesion in the left temporal lobe (Pang & Lewis 1996). A boy sustained a blow to the head in the left frontal parietal region after being knocked from his bicycle by a car at the age of 14 years. There was no fracture, but he was unconscious for 3 or 4 hours and had a lowered level of consciousness for 2 weeks. At the age of 16 he presented to psychiatric services following a suicide attempt. He had elaborate delusions of persecution, inappropriate affect and auditory hallucinations. There was a family history of psychosis in a maternal cousin but no history of obstetric or perinatal complications. In some other surveys, confined to younger people, even higher levels of abnormalities have been reported. Apart from possible evidence of demyelination, infarction, trauma, focal atrophy and white matter hyperintensities (see Chapter 3, White matter hyperintensities), developmental anomalies such as cerebellar ectopia, cavum septum pellucidum, pineal cysts and hamartomas were seen. Taking these findings together with numerous case reports, it is very likely that such abnormalities are more common in schizophrenia but only account for a small minority of cases. This may be taken as general evidence consistent with the view that disruption in neurodevelopment is a key aspect if not an essential part of the disorder. These included three cases of syphilis, two of sarcoidosis, and one each of carcinoma of the lung, autoimmune multisystem disease, cerebral cysticercosis and thyroid disease. Statements on the aetiological relevance to schizophrenia requires a ratio to be calculated of the true rate of the abnormality in question in a representative sample of patients against that in the general population. It turns out that of 1000 people, including some elderly, who had volunteered to be controls in Neuropathology A detailed knowledge of the microscopic pathology in the brains of people with schizophrenia is beyond the scope of this book.

Thus if a person is holding a picture of her mother and says, "She is so kind," the holding of the picture is a peripheral cue that "She" is the mother. The system of nerves which collect information from and control the functioning of the body and which lie outside the brain and spinal cord. The continuation of a lower level of language performance after a developmental stage has been finished, as in the continuation of baby talk by schoolage children. The inability to discontinue a behavior pattern when it is not successful, which is often characteristic of an inability to learn. A prolonged state in which there is minimal brain function, which usually includes maintenance of breathing but in which the person shows no responsiveness to stimuli or voluntary motion. Only a very small minority of persons regain normal function after entering a persistent vegetative state, and these are usually children. Constructs are used by the individual to anticipate events and to formulate plans of action for the anticipated events. Personal construct therapy in which a person changes her/his behavior by changing her/his ideas or understanding of some parts of the world was derived from this theory. The dynamic organization within the individual of common traits, behavior patterns, values, interests, plans and motives, selfunderstanding and worldview, abilities, and emotional patterns that determine characteristic behavior and thought. All the systems within the individual that develop and interact to create the unique and shared characteristics of the person. Some psychologists believe that human behaviors represent manifestations of underlying psychological attributes or traits. It is further believed that individuals differ in the extent to which they possess these attributes and, consequently, in the degree to which they engage in trait-relevant behaviors. Personality assessment is the enterprise of measuring individuals and quantifying their differential standing on these psychological characteristics. As such, they cannot be measured directly with electrical or mechanical instruments. The more of a trait that a person possesses, the more trait-relevant behaviors he or she is likely to display. Consider a psychological attribute common to many theories of personality: extroversion. Personality traits are generally conceived of as forming normally distributed dimensions. Thus, for any particular trait, such as extroversion, humans are thought to vary along a continuum, ranging from low levels of the trait to high levels, with most people falling somewhere in the middle of the dimension. The task of personality assessment is to identify those people who are, for example, more extroverted and those who are less extroverted. One way in which to assess degree of extroversion in a person might be to observe how talkative and friendly he or she is among a group of people. But there are two problems with this behavior sampling approach to personality assessment. The first is that the method is very resource intensive, requiring substantial time and effort to obtain individual difference scores on the traits of interest. Contemporary methods of personality assessment generally rely on questionnaires, 371 personality assessment inventories, checklists, and so on. A personality questionnaire comprises one or more personality scales, each of which is designed to quantify differences among people on a personality trait or construct. The rationale behind the personality questionnaire is that people can be trusted to describe their characteristic behaviors accurately. Typical personality scales have items that represent statements describing specific behaviors, behaviors that are considered to be exemplars of personality traits. To illustrate, an extroversion measure might contain the item "I am usually the life of a party. Alternatively, the response could take the form of choosing a number from a 5-point scale, where smaller numbers mean stronger disagreement with the statement and larger numbers mean stronger agreement. For example, an extroversion scale might instruct the respondent to rate the degree to which the term outgoing is characteristic of him or her. This means that a person endorsing the item as false (or disagree) would be measured to be higher on the trait. An example of a reverse-keyed extroversion item would be "I prefer spending time alone rather than in a large group.

Polymorphonuclear cells may number thousands per cubic millimetre, and the protein is raised. Bacterial meningitis can result in damage to both cortical and subcortical areas and neurological outcomes are obviously dependent on the degree and location of injury. Those with pneumococcal infection had higher rates of significant disability than those infected with Haemophilus or N. Impairments have been shown to persist into adolescence, 7 years after early meningitis. Thirty-two per cent had cognitive impairment, with those who had survived pneumococcal infection performing poorly on memory tasks and psychomotor speed compared with those who had been treated for meningococcal meningitis. Cognitive slowness was stable over time after acute infection, and male sex and cranial nerve involvement were predictors of poor 450 Chapter 7 cognitive outcomes. The prevalence of cognitive disturbance was similar for both pneumococcal and meningococcal infection. In another study, over 70% of adult survivors had neurological and mental symptoms at 3 years after acute infection, with poorer outcomes in those infected by Strep. There were again reductions in psychomotor speed as well as concentration, visuoconstructive capacity and visual memory and generally lower psychometric performance scores compared with verbal subscales. Interestingly, Beck Depression Inventory scores in this group were significantly higher than in the controls and did not correlate with neuropsychological test results. Similarly, increased risk of cognitive slowness or cognitive disorder has been corroborated in other studies and many report that Strep. In adults, mild but prolonged depression is common during convalescence, no doubt partly as a reaction to the stress of the illness. A period of fatigue and inefficiency may precede full recovery, and loss of libido may last for several months. Pai (1945) investigated 51 adults after meningococcal meningitis, all of whom were seen in a neuropsychiatric unit. Sixteen patients showed intellectual deterioration or organic change of personality, and these were the ones who had had severe meningitis with marked delirium. Disorders of gait and hysterical paresis had often set in after complete recovery and could be related to external stress. Evidence of premorbid instability could often be discerned, but not in every case. Other symptoms such as headache, blackouts and temporary loss of memory were occasionally hard to apportion to psychogenic or physiogenic causes. Viral meningitis is by far the most common aetiology, with the enteroviruses (including poliomyelitis, coxsackievirus and echovirus) being most frequently incriminated in some 80% of cases (Rotbart et al. In their study of the causes of aseptic meningitis and encephalitis in an adult population, Kupila et al. Nonviral causes must also be considered, including the early stages of tuberculous meningitis, brain abscess, neurosyphilis, leptospirosis and particularly incomplete treatment of bacterial meningitis. There are a number of non-infectious causes to consider as well: iatrogenic (including post vaccination and medication-related cases), collagen vascular disorders, sarcoid and neoplastic disease (Kumar 2005). Viral meningitis occurs across the lifespan but is particularly common in younger children. The incidence in those aged over 16 in the large 1966 birth cohort from Finland was 7. Epidemics are commoner in the summer and autumn when the circulation of enteroviruses among the population reaches a peak. Positive identification of a viral cause has an impact on antibiotic prescribing and length of hospital stay (Ramers et al. Enduring sequelae are distinctly rare, except for the paralysis that follows poliomyelitis and some infections with coxsackievirus type A7. On the other hand, minor temporary debilities are fairly common during convalescence. No major differences could be found with regard to mental symptoms, occupation, school performance or social adjustment.

More openly expressed delusions often originate in sensory falsifications and poverty of grasp. They are usually highly charged with emotion, changeable and unsystematised, and paranoid in content. Cognitive dysfunction is also shown in difficulty with simple mental tests and obvious inability to concentrate or sustain mental effort. In many cases outward behaviour is little disturbed beyond obvious lethargy and failure of cognitive function. In these cases progress usually follows a torpid apathetic course until consciousness is fully regained. As the confusional state improves, confabulations may come to dominate the mental state, almost always accompanied by lack of insight into the injury and its effects, and disorientation. Confabulation is often associated with misinterpretation of surroundings and misidentification of people. It is not unusual for patients to believe that staff or other patients on the ward are familiar to them, for example that their doctor is well known to them or that other patients are old friends. A bizarre state of double orientation may be maintained, or there may be reduplicative paramnesia with reduplications of place. Patients may believe they are still at work, even when they have not worked for many years before the injury. Alternatively, they may believe they are somewhere with emotional significance for them (see case study below). Such confabulatory delusional disorientation is particularly common in those with a history of alcohol dependence. At the time of the interview 6 months after the injury, in July, he had been an inpatient at the Maudsley Hospital in Camberwell in south London, England, for about 3 months. For a period he had developed persecutory delusions, believing staff were plotting to kill him. About 2 weeks before the interview he had developed the belief that he was in hospital in Italy, and would occasionally speak to staff in Italian. Well I have tried over a dozen times to buy maps in order to ascertain this thoroughly for myself exactly where we are. Because all the police there are English the police will sell me these or pass me on to the Italian equivalent of the Automobile Association. But I have now heard on I suppose half a dozen times the sirens going as only an English one goes. From what I understand I would say that it is nowhere near as modern as its true English equivalent. But let me say that I have been very impressed with what I have seen here and I would suggest that the British National Health Service would be well advised to send foraging and investigative teams to Italy proper, including this building, to ask questions and to observe them carrying out their duties. Weston and Whitlock (1971) describe an example in which delusions apparently stemmed from a vivid hallucinatory experience occurring as part of the early post-traumatic delirium. The patient related an episode in which he believed he saw his parents being shot by Chinese communists. Thereafter when his family visited him he believed them to be impostors who had assumed their exact appearance in order to trick him. The profound memory disturbance from which the patient was suffering at the time had prevented him from realising that the head injury had occurred, or from reintegrating his vivid fantasy into normal daily experience. These early psychotic states with confabulations, delusions and hallucinations are almost certainly a result of the generalised disturbance of brain function. They usually Post-traumatic agitation During the post-traumatic delirium some patients pass through an excitable and overactive phase with florid disturbance of behaviour that can pose serious problems of management. Sometimes this is attributable to the abnormal experiences and delusional misinterpretations of a posttraumatic delirium, but sometimes it proves to foreshadow enduring changes of temperament and behaviour occasioned by the injury. The patient may be abusive, aggressive, sexually disinhibited and markedly uncooperative. This phase of agitated behaviour occurs in about 10% of patients with severe brain injury (Brooke et al.

Of particular interest was the finding that the thought-disordered group, even those with preserved cognitive functioning, showed most impairment at the level of semantics in their expressive speech. This was in contrast to high levels of visual confrontation naming and ability to comprehend complex material, for example `. Attempts to recount fairy tales elicited disorganised and tangential speech that lacked a global semantic structure, presumably because of the open-ended, unconstrained nature of these tasks. In line with the main locus of impairment as being at the semantic level, Rodriguez-Ferrera et al. They were less sensitive to linguistic (syntactic, semantic and pragmatic) violations because they were apparently unable to use linguistic context to form an overall semantic representation needed to process speech online. Reduced or slowed speech may reflect depressed mood and psychomotor retardation generally, as well as part of the negative schizophrenia syndrome. Parkinsonism, either idiopathic or secondary to antipsychotic medication, may cause a similar clinical picture. Again, one might argue whether poverty of speech is truly a language disorder or a higher-level problem of initiation and planning. The verbal fluency test may be used to quantify reduced speech in terms of a psychometric deficit. The patient can be asked to generate as many words as possible in a minute beginning with a given letter (F, A or S). This can be contrasted with semantic fluency in which the patient is asked to produce as many words as possible from a given category. Conversion disorders It is only on rare occasions that difficulty arises in distinguishing between psychogenic and organic disturbances of language function. A very rare example of dyslexia and dysgraphia of psychogenic origin has been described by Master and Lishman (1984). Executive (frontal lobe) syndromes Certain clinical features have long been associated with damage to the frontal lobes. These are not unique to frontal lobe pathology, but they are seen more regularly and perhaps more strikingly than after damage to other cortical structures. Clinical picture Evidence about this syndrome has come from studies of patients with various types of brain pathology. Evidence has also accumulated from studies of patients after surgical excisions of frontal lobe lesions and, in the past, from patients who had extensive frontal leucotomies. The consensus of evidence suggests that lesions of the convex lateral surface (dorsolateral cortex) are especially prone to mental slowing and a lack of spontaneity, whereas lesions to the orbital undersurface of the brain (ventromedial pathology) are liable to have adverse effects on personality and social behaviour. The most striking changes are often in terms of behaviour, social awareness, habitual mood, volition, and psychomotor activities. These include a lack of initiative and spontaneity, usually coupled with a general diminution of motor activity. Responses are sluggish, tasks are left unfinished, and new initiatives rarely undertaken. In consequence, the capacity to function independently in daily life can be profoundly affected. Yet when vigorously urged, or constrained by a structured situation, the patient may function quite well. Hebb (1949) described how cognition and intellect can be apparently unaffected despite huge frontal lesions, and the patient may achieve virtually normal performance in situations in which the examiner provides the impetus, such as in many formal tests of intelligence. How far the impairment of initiative represents a true loss of interest, or an apparent loss due to impaired volition, is often hard to discern, but this apathy and inertia may closely mimic depression. They are restless and hyperactive rather than sluggish, but again are likely to display a lack of purposive goal-directed behaviour. There may be rather empty high spirits, accompanied by a boisterous over-familiarity in manner. Such changes are rarely sustained, however, and when left to themselves these patients become inert and apathetic. Outbursts of irritability are also common and a childlike petulance may also be seen. The euphoria is sometimes elaborated into a tendency to joke or pun, to make facetious remarks or to indulge in pranks. Typically, the patient is less concerned with the consequences of his acts than formerly. In interpersonal relationships, there is a lack of the normal adult tact and restraints, and a diminished appreciation of the impact of behaviour on others.