Can cognitive and behavioural disorders differentiate frontal variant-frontotemporal dementia from Alzheimer's disease at early stages?

Frontal variant-Frontotemporal dementia (fvFTD) and Alzheimer's disease (AD) patients matched for severity of dementia at the Clinical Dementia Rating (CDR) received neuropsychological testing in order to explore if the dysexecutive disorder might characterise fvFTD at early stage, when AD is dominated by the episodic memory defect. We also determined if the behavioural syndrome was more severe in fvFTD than AD, and if specific patterns of behavioural symptoms could differentiate the two types of dementia, using the Neuropsychiatry Inventory (NPI). AD patients performed worse than fvFTD not only in memory but also in executive tasks. Apathy and eating disorders proved to be more severe or frequent in fvFTD even if the two groups did not differ in the total NPI score. CDR score significantly correlated with the NPI score in fvFTD and with the MMSE in AD. Our data confirm that the memory disorders may differentiate the two types of dementia; however, the dysexecutive syndrome is as severe, and even more severe in AD. The severity of the behavioural syndrome is comparable in the two groups but the nature of the behavioural disorders may vary to some extent. We conclude that AD dementia at early stage is a behavioural-cognitive syndrome, while in fvFTD the behavioural disorders appear when the cognitive deficit is still relatively mild.     

Dementia and suicidal behavior

Behavioral and psychological symptoms of dementia, including depression, might complicate the course of the disorder additionally. Dementia is more frequent in older people and suicide rates are higher in later life than in any other age group. To explore the phenomenology of suicidal behavior in patients with dementia, we searched electronic databases and key journals for original research and review articles on suicide in demented patients using the search terms “suicide, suicidal behavior, dementia, Alzheimer disease, and old age”. Although cognitive impairment could result in a diminishing ability to think flexibly and to solve problems or to cope with conflict, in the early stage of dementia such impairments are absent or mild, and suicidal behavior might be expected, especially following diagnosis. In addition, personality changes based on declining cognitive capacity and the neurochemical imbalances described in late-life depression and in dementia may predispose patients to aggressive or impulsive acts, such as suicide attempt. The literature on suicidal behavior and dementia highlights the need for further research in this area.     

‘Beyond forgetfulness’: How psychoanalytic ideas can help us to understand the experience of patients with dementia

We must cast ourselves forwards to a time when words must fail (Samuel Beckett, Happy days, 1961 Beckett, S. 1961. Happy days, London: Faber & Faber.  [Google Scholar]).

This paper approaches dementia and its care from a psychoanalytic perspective. It recognizes both the psychoanalytic literature on dementia and a biological understanding of neuro‐degenerative processes. Using neuro‐psychoanalysis to synthesize the two views, meeting points are found that may take the theoretical understanding of dementia processes a small step further, introducing the death instinct as one example. The mind and the brain are distinct entities which are also intimately related. A mind/brain model was proposed by Freud in his ‘project’ (1895). It pre‐dated his psychoanalytic work but was abandoned. None the less it runs as a rich vein throughout his work.

Although other causes exist there are two main types of dementia. Alzheimer's and vascular dementia have distinct differences and similarities in their respective clinical presentations. This paper explores the complex deterioration of brain and mind in both diseases and explains these in psychoanalytic terms. Developmental models of the mind are helpful, however dementia patients are adults, and are losing their minds in a non‐linear fashion. Dementia is not infant/child development in reverse order.

Three broad stages of dementia are proposed and psychoanalytic models of patient experience are suggested, as well as potentially offering ameliorating interventions. The first stage of dementia is dominated by anxiety and depression; also repression and denial and behavioural problems that may be akin to hysterical states. These seem to be amenable to analysis and psychoanalytically informed therapy. In the intermediate stages reality principle versus pleasure principle issues are patent, as are shame and humiliation (particularly around sexuality). Art and music therapies informed by psychoanalysis can be helpful as they depend less on words. In the final stages of extreme dependency, projective identification may be the most common method of communication. Understanding this phenomenon can assist sufferers and help carers to cope with unbearable states of mind. Some psychoanalytic ideas are already in use in some enlightened dementia services; there is room for more.     

Emotional reality: A further contribution to dramatology

This paper is a further contribution to dramatology, introduced in this journal in 2009. It focuses on the two basic modes of communication in any dramatic situation: (1) the nonverbal transfer of feelings and emotions, originating in the preverbal period of the love relationship between mother and child, and (2) the interchange of words and thoughts that develops with the acquisition of language. The early nonverbal mode of communication is the basis for proposing to rename Freud's concept of psychic reality “emotional reality.” On this view, emotional reality is seen as the primary fact of psychological life versus thoughts expressed in words as the derivative fact. Developmentally, emotions and ideas become united in complexes combining the emotional coloration of ideas and the ideational content of emotions. From the perspective of methodology, Freud, his followers, and his critics all conflated theories of disorder and theories of treatment. At the beginning of his journey, Freud was dyadic and interpersonal in formulating a unified theory of disorder and a method of treatment. In later years, he formulated monadic and intrapersonal theories of disorder while remaining interpersonal in his method of treatment, contributing to conflicts among the various psychoanalytic schools.     

Pharmacological interventions in autism: theoretical and practical issues

Focused on issues of drug treatment in relation to autism. Pharmacological treatment studies in autism are complicated by various factors including a tremendous range of syndrome expression, a lack of robust animal models of the disorder, and various methodological problems. Theories have tended to follow treatments, and various neurochemical systems have been the focus of study. Neurochemical systems potentially implicated include those involving dopamine, norepinephrine, serotonin, and neuropeptides. The dopaminergic system has been the most extensively studied. Treatments developed are effective relative to certain disabling symptoms but "core" problems (e.g., in social relatedness and communication) appear less responsive to medications. The development of new approaches to assessment, including integration of behavioral and pharmacological approaches, is an important research priority.     

Facilitation of early speech development in a dysphatic child by use of signed Norwegian

Non-vocal language intervention is mostly used to develop communication skills in severely dysfunctional children. In the present study, a 3-year-old dysphatic boy was taught signs to facilitate his speech development. After 6 months of sign instruction, he showed substantial improvement in spoken language, and had gained one year on the Receptive and the Expressive scales of Reynell Developmental Language Scales in half a years time. Behavior problems were markedly reduced. It is concluded that sign instruction may be used with a wider range of subjects than is usual today.     

Prolonged Exposure Therapy and Irritable Bowel Syndrome: A Case Study Examining the Impact of a Trauma-Focused Treatment on a Physical Condition

Previous research has shown that psychological treatments, particularly those employing cognitive techniques, are particularly effective in the treatment of irritable bowel syndrome (IBS). It is presumed that these psychological interventions are effective at ameliorating the IBS by treating an underlying psychological disorder (often an anxiety disorder), which may be contributing to the autonomic reactivity. This case study examined the change in the physical symptoms of IBS for a patient seeking treatment for rape-related PTSD with comorbid conditions of major depression and panic. At posttreatment, the patient no longer met criteria for PTSD, major depression, or panic. In addition, her primary symptom of IBS, diarrhea frequency, was significantly improved. These findings were maintained at 3 and 9 months posttreatment. Implications for the assessment and treatment of IBS patients with PTSD are discussed.     

Fragile X-associated tremor/ataxia syndrome (FXTAS)

Carriers of fragile X mental retardation 1 (FMR1) premutation alleles (55 to 200 CGG repeats) are generally spared the more serious neurodevelopmental problems associated with the full-mutation carriers (>200 repeats) of fragile X syndrome. However, some adult male premutation carriers (55-200 repeats) develop a neurological syndrome involving intention tremor, ataxia, dementia, parkinsonism, and autonomic dysfunction. In excess of one-third of male premutation carriers over 50 years of age develop the fragile X-associated tremor/ataxia syndrome (FXTAS). FXTAS also represents a new form of inclusion disease, with eosinophilic intranuclear inclusions found throughout the brain in both neurons and astrocytes. Because FXTAS appears to be relatively specific to male premutation carriers, who are known to possess elevated levels of FMR1 mRNA, the neuropathology may arise as a consequence of a toxic gain-of-function of the mRNA itself, although this proposal requires additional direct testing. One of the critical needs at present is a better estimate for the prevalence of this disorder, because FXTAS is likely to be underdiagnosed in the adult movement disorders clinics.     

Casuistic contribution to the differential diagnosis of the myoclonic syndrome]

Involuntary muscle twitches, which are accompanied by a more or less pronounced effect of motion and which may last for several hours, are a common guiding symptom of a number of neurological syndromes. This paper reports the case of a 24-year-old male who had been suffering since his sixth year from episodic muscular spasms accompanied by attacks of petit mal. These are regarded as representing a myoclonic-epileptic syndrome. In this connection, a distinction has to be made, by differential diagnosis, between the "true" myoclonic syndrome which is characterized by the absence of complications due to attacks of grand mal or petit mal, Kojewnikoff's epilepsy, and the myoclonic-epileptic dementia form of syndrome.     

BONE MARROW TRANSPLANTATION IN A PATIENT WHO EXPERIENCED TORTURE IN A PRISONER OF WAR CAMP: NARCISSISM AND SURVIVAL

Post-traumatic stress disorder has been described as a syndrome from which an individual may suffer as a result of extraordinary trauma. Torture of prisoners of war in Serbian camps during the war in Croatia is just such a stressful situation that requires mobilization of all defense mechanisms of an individual. The authors present a case study of a former prisoner of war who acquired acute myelogenous leukemia several months after release and was treated with bone marrow transplantation. On release the patient was medically examined, like all prisoners of war, and the findings did not suggest any disease. Because of the situation, the patient was in psychotherapeutic observation and treatment after his illness was diagnosed and throughout the transplantation treatment.     

Prediction of outcome from cognitive-behavioral treatment of irritable bowel syndrome

The presence of a diagnosable Axis I psychiatric disorder predicted significantly (P < 0.001) lower likelihood of significant improvement among 90 irritable bowel syndrome patients given cognitive and behavioral treatments to help the disorder. Other psychological tests, including the MMPI, BDI, STAI, as well as demographic variables, failed to yield significant prediction.     

Family Therapy with a Multiparental/Multispousal Family

This article examines therapy with a Bedouin-Arab family from the Negev, Israel, which consisted of 69 members: a husband, 8 wives, and 60 siblings. The husband, who lived with his youngest wife, paid little attention to his other wives and their children. There was considerable competition, hostility, and jealousy among the wives; no communication between the co-wives or the children of different wives; and a variety of behavioral and psychosocial problems among family members. I describe the varied strategies and systems involved in family therapy. The main strategies were to establish good relationships among the co-wives and to build a coalition among them, including the youngest wife, through group therapy in a medical clinic. A secondary strategy was using the children's problems to get the husband involved in the therapy. With improvement of the children's functioning, and with reduced intra-subfamily hostility, the husband's relationships with his children and wives improved.     

The Longitudinal Impact of a Family-Based Communication Intervention on Observational and Self-Reports of Sexual Communication

Parents can play a vital role in shaping teenagers’ sexual attitudes, behavior, and contraceptive use through communication, however, less is known about how to modify parent–adolescent communication among youth with mental health problems. The impact of a family-based sexual risk prevention intervention on both observational and self-report of parent–adolescent sexual communication was examined at 12 months among adolescents with mental health problems. Of the 721 parent–adolescent dyads recruited for the study, 167 videotapes of sexual discussions between parents and adolescent were coded for the family-based intervention and 191 videotapes for the active comparison. Longitudinal analyses examined differences between conditions (family-based vs. comparison) in self-reported and observed parent–adolescent sexual discussions and also examined the impact of gender on intervention response. More parent I-statements, healthier parent body language, and fewer adolescent Negative Vocalizations were detected for family-based intervention participants 12 months after participating in the brief intervention (11?h of total intervention time) relative to those in the comparison condition. Parents in the family-based intervention also self-reported better sexual communication at 12 months. The current study provides supporting evidence that a relatively brief family-based intervention was successful at addressing parent–adolescent sexual communication among a mental health sample.     

Making Decisions About Life-Sustaining Medical Treatment in Patients With Dementia

The problem of decision-making capacity in patients with dementia, such as those with early stage Alzheimer's, can be vexing, especially when these patients refuse life-sustaining medical treatments. However, these patients should not be presumed to lack decision-making capacity. Instead, an analysis of the patient's decision-making capacity should be made. Patients who have some degree of decision-making capacity may be able to make a choice about life-sustaining medical treatment and may, in many cases, choose to forgo treatment.     

Biofeedback as a treatment for childhood hyperactivity: a critical review of the literature

Hyperactivity is a significant problem for which no causal theories have been unequivocally substantiated and one in which treatment approaches have met with limited success. Recent research in behavioral medicine has brought biofeedback into use as a treatment for disorders that are mediated by physiologic functioning, with hyperactivity as one such disorder. 36 studies are reviewed in which biofeedback was used as a treatment for hyperactivity. This review indicated that biofeedback treatments alone have not been effectively evaluated, and methodological problems with the current studies severely limit generalizations that may be made to hyperactive populations. Biofeedback in conjunction with other techniques appears to have promise for reducing some of the behavioral symptoms of the hyperactivity syndrome. Directions for further research are presented.     

A disturbance of interpreting,of symbolisation and of curiosity in the analyst‐analysand relationship: (The patient without insight)1

The author examines the function of the analyst who may distort the unconscious communication with the patient by means of the expression of his countertransference. He studies a disturbance in curiosity and in symbolisation in a patient with a narcissistic pathology. Both problems were related to this failure in interpreting. The curiosity of the patient, which initially seemed to be non‐existent, was found to be directed towards investigating the mind of the analyst, this being his sole purpose. The disturbance in symbolisation was manifested as a constant verbal acting out, which was expressed as verbal communication empty of meaning. A change in the interpretative attitude enabled a modifi cation in the objective of the curiosity, which became focused on investigating his own inner world, and the emptiness of the verbal communication was replaced by representations. This change in communication allowed the analyst to relate the facts of the psychoanalytic relationship both with the patient's phantasy and with the events in his history. An idealised identifi cation with destructive aspects of the mother towards the father was discovered. This idealisation had been sustained by the analyst by means of his errors in interpreting. The author explores disturbances in symbol formation and in the use of symbols, and he considers the different states of emptiness.     

The syndrome of traumatic grief

Traumatic grief is a common and debilitating syndrome whose clinical presentation is well recognized but whose diagnostic criteria have only recently been delineated. Though it shares features with major depressive disorder, adjustment disorder, and posttraumatic stress disorder, none of these subsume the criteria set for traumatic grief, and the diagnostic overlap is limited in community samples. Furthermore, diagnosis of traumatic grief appears to have prognostic value for clinical course and treatment response among bereaved individuals. In the absence of empirically supported treatments of pathological grief, a new, manualized treatment for traumatic grief symptoms has been developed and is currently undergoing testing in a randomized controlled trial. The conceptual basis for Traumatic Grief Treatment (TGT) is presented, the structure of the treatment is outlined, and the primary clinical strategies employed are described.     

Object interest in autism spectrum disorder: a treatment comparison

A randomized control trial comparing two social communication treatments for children with autism spectrum disorder examined the effect of treatment on object interest. Thirty-two children, 18-60 months, were randomly assigned to the Picture Exchange Communication System (PECS) or Responsive Education and Prelinguistic Milieu Teaching (RPMT) condition. Assessment of object interest was conducted in an unstructured play session with different toys, activities, adult, and location than experienced in treatment. Results indicated children in the RPMT condition showed greater increases in object interest as compared to children in the PECS condition. Because child characteristics such as interest in objects may influence response to interventions using object play as contexts for treatment, it is important to improve our understanding of whether intervention can affect object interest.