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017 - Chapter 15 - Cognitive Disorders 0001

017 - Chapter 15 - Cognitive Disorders 0001



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Published by Joseph Eulo

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Published by: Joseph Eulo on Feb 08, 2009
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Cognitive Disorders
Diagnostic IssuesClinical Signs of Brain DamageDiffuse versus Focal DamageThe Neuropsychology/PsychopathologyInteractionDementia from HIV-l InfectionVascular Dementia
Clinical PresentationTreatment and Outcome
The Clinical PictureTreatments and Outcomes
Alzheimer's Disease
Can Dietary Supplements Enhance BrainFunctioning?
he brain is an astonishing organ.Weighing around 3 pounds, it is the most complex structure inthe known universe (Thompson,
It is also the only organ capable of studying and readingabout itself. It is involved in every aspect of our lives from eating and sleeping to falling in love.The brain makes decisions, and it contains all the memories that make us who we are.Whetherwe are physically ill or mentally disturbed, the brain is involved.Because it is so important, the brain is protected in an enclosed space and covered by a thickouter membrane called the "dura mater" (literally, "hard mother"in Latin). For further protection, the brain is encased by the skull.The skull is so strong that, if it were placed on the ground andweight were applied very slowly, it could support as much as
tons (Rolak,
Theseanatomical facts alone indicate just how precious the brain is.But the brain cannot be protected entirely. Sometimes there is internal damage that occurs early.When structural defects in the brain are present before birth or occur at an early age, mental retar-dation may result (see Chapter
In other cases, what was a normally developed brain can sufferfrom internal changes that can lead to destruction of brain tissue.Depending on the nature and siteof the damage, this can result in a movement disorder such as Parkinson's disease or in cognitiveconfusion, referred to as dementia.This dementia could be caused.by Alzheimer's disease or by a stroke (so named in
because this cerebrovascular event occurs so suddenly that it was likenedto"a stroke of God's hand"). The brain can also be damaged by external influences. A wide variety of injuries and toxicsubstances may result in the death of neurons or their connections. The brain can be damagedby trauma from traffic accidents or from the repeated blows to the head that can occur in boxingor football.In short, even though it is highly protected, the brain is vulnerable to damage from many sources.When the brain is damaged or brain functioning is in some way compromised,cognitive changes result.Although there may be other signs and symptoms(such as mood orpersonality changes), changes in cognitive functioning are the most obvious signs of adamaged brain. In thischapter we will discuss three major types of cognitive disorders that are recognizedin DSM-IV-TR:delirium, dementia, and amnestic syndrome.Why are cognitive disorders discussed at all in a textbook on abnormal psychology? There areseveral reasons. First, as their inclusion in the DSM indicates, these disorders are regarded as psy-chopathological conditions. Second, as you will see from the
case study 
that follows,some braindisorders cause symptoms that look remarkably like other abnormal psychology disorders.For example, the American composer George Gershwin died at age 39 because doctors failed to rec- ognize that what they were diagnosing as "hysteria" was really the result of a brain tumor (jablon- ski, 1987).Third, brain damage can cause changes in behavior, mood,and personality.You will recognize this more clearly later when we describe the case of Phineas Gage(who surviveda metal bar being blown through his head). Understanding what brain areas are involved when behavior, mood, and personality change after brain damage may helpresearchers better understand the biological underpinnings of manyproblems in abnormal psychology.Fourth,many people who suffer from brain disorders(for example, people who are diagnosed as having Alzheimer's disease) react to the news of their diagnosis with depres- sion or anxiety. Prospective studies also suggestthat depressive symp-toms may herald the onset of disorders such as Alzheimer's disease (AD) by several years (Devanand et al.,
Wilson et al.,
andthat episodes of depression double the risk for AD even
years later(Speck et al.,
Finally, cognitive disorders of the type we describein this chapter take a heavy toll on family members who, for many patients, must shoulder the burden of care. Again,depression and anx- iety in relatives of the patients themselves are not uncommon.
ase studies are descriptionso f  one specific case.Case studies can bea useful source of informationand can help researchers generatehypotheses.Because of their  highl yselective nature, however  , they cannot be used to draw anyscientific conclusions.
Ahighly successful businessman,age 45,with no previ- oushistoryofpsychiatric disorderbegan to act differ- entlyfrom his usual self.Heseemed driven at work.His working hours gradually increased,until finally he was sleeping only
to3hours a night;the restof the time he worked.He became irritable and began to engage in uncharacteristic sprees of spending beyond his means. Although he felt extremely productive and claimed hewasdoing the work of five men,the man's boss felt otherwise.Hewasworriedabout the quality of that work, having observed several recent examples of poor busi- ness decisions. Finally,when the man complained of headaches,his boss insisted that he seek help.(Adapted fromJamieson
Wells, 1979.)
Clinicians always needto be alert to the possibility that brain impairment itself may be directly responsiblefor the clinical phenomena observed. Failure to do socould result in serious diagnostic errors, as when a clini- cian falsely attributes a mood change to psychological causes and fails to consider a neuropsychological originsuch as a brain tumor (Purisch
Sbordone, 1997; Wein- berger, 1984). The case you have just read concerns a manwho, on first glance, looks as if he mightbe havingan episode of mania. In fact, however, he is suffering fromfour tumorous masses in his brain. Clues that the patient has a brain disorder rather than a mood disorder comefrom the fact that he is experiencing headaches atthe same time as a major change in behavior.The fact that he has nopriorhistory of psychopathology is also another clue (see Taylor, 2000).
Prior to the revision of DSM -IV in 1994,most of the dis- orders to be considered in this section were called organic mentaldisorders. This term was designedto convey that there was some kind of identifiable pathologythat was causing the problem (e.g., a brain tumor,stroke,drug intoxication, or thelike). Recognizing this, such disorders were typically treated by neurologists. In contrast, functional mental disorders were brain disorders thatwere considered not to have an organic basis. Suchdisor- ders were treated by psychiatrists. Bythe time DSM-IV was published, however, it was apparent that it was wrong toassume that psychiatric disorders had no organic (or bio- logical) component. Consider,for example, howimpor- tantproblems inbrainneuroanatomy and neurochemistry areto our understanding of schizophrenia (see Chapter 14). Theterms
were thereforedropped.What wastheorganic mental disorders section of  the DSMhas been renamed. It is now called "Delirium, Dementia, andAmnestic and other Cognitive Disorders" (see APA, 2000).
Diagnostic Issues
The DSM -IV-TR presentsthediagnostic coding of various neuropsychological disorders in different and somewhat inconsistent ways. Much depends on whatis causing the cognitive problem. For cognitive disorders that have an underlying medical problem as their cause, both the cogni- tive problemand the medical cause are listed on Axis I. Sometimes the qualifyingphrase "Due to [a specified gen- eral medicalcondition]" is used. Then,in addition, the medicalconditionthat is causing the cognitive problem is listed again on Axis III. Many of the common neuropsy- chologicaldisorders are handled in this manner.For exam- ple, cognitive impairment associated with HIV disease might have the following DSM-IV-TR diagnostic code: Axis I: Dementia due to HIV diseaseAxis III: HIVdiseaseThe diagnosis fordementia caused by Alzheimer's dis- ease is managedin a similar way, with Alzheimer's disease being designatedon Axis III. AxisI: Dementia of the Alzheimer's type Axis III: Alzheimer's diseaseOn the otherhand, pathological brain changes that arerelated to the toxic effects of abusing certain substances,such as long-term, excessive alcohol consumption (seeChapter 12),are handled alittle differently. In these cases, a specific etiologic notation is included in the Axis I diag-nosis, as in "Substance-Induced Persisting Amnestic Dis-order" (a circumscribed and characteristic type of memory impairment). No diagnosis is given on Axis III.Axis I: Alcohol-induced persisting amnestic disorderAxis III: None
Clinical Signs of Brain Damage
With possible minor exceptions, cell bodies and neuralpathways in the braindo not appear to have the power of  regeneration, which means that their destruction is per-manent.When brain injury occurs in an older child or adult,there is a loss in established functioning.This loss-this deprivation of already acquired and customaryskills-can be painfully obvious to the victim, adding an of ten pronounced psychological burden to the physicalburden of having the lesion.In other cases the impairment may extend to the capacity for realistic self-appraisal (acondition called "anosognosia"), leaving these patients

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