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Abstract Background The criterion for dementia implicit in DSM-IV is widely used in research but not fully operationalised. The 10/66 Dementia Research Group sought to do this using assessments from their one phase dementia diagnostic research interview, and to validate the resulting algorithm in a population-based study in Cuba. Methods The criterion was operationalised as a computerised algorithm, applying clinical principles, based upon the 10/66 cognitive tests, clinical interview and informant reports; the Community Screening Instrument for Dementia, the CERAD 10 word list learning and animal naming tests, the Geriatric Mental State, and the History and Aetiology Schedule – Dementia Diagnosis and Subtype. This was validated in Cuba against a local clinician DSM-IV diagnosis and the 10/66 dementia diagnosis (originally calibrated probabilistically against clinician DSM-IV diagnoses in the 10/66 pilot study). Results The DSM-IV sub-criteria were plausibly distributed among clinically diagnosed dementia cases and controls. The clinician diagnoses agreed better with 10/66 dementia diagnosis than with the more conservative computerized DSM-IV algorithm. The DSM-IV algorithm was particularly likely to miss less severe dementia cases. Those with a 10/66 dementia diagnosis who did not meet the DSM-IV criterion were less cognitively and functionally impaired compared with the DSMIV confirmed cases, but still grossly impaired compared with those free of dementia. Conclusion The DSM-IV criterion, strictly applied, defines a narrow category of unambiguous dementia characterized by marked impairment. It may be specific but incompletely sensitive to clinically relevant cases. The 10/66 dementia diagnosis defines a broader category that may be more sensitive, identifying genuine cases beyond those defined by our DSM-IV algorithm, with relevance to the estimation of the population burden of this disorder.

Abstract Background Latin America, China and India are experiencing unprecedentedly rapid demographic ageing with an increasing number of people with dementia. The 10/66 Dementia Research Group's title refers to the 66% of people with dementia that live in developing countries and the less than one tenth of population-based research carried out in those settings. This paper describes the protocols for the 10/66 population-based and intervention studies that aim to redress this imbalance. Methods/design Cross-sectional comprehensive one phase surveys have been conducted of all residents aged 65 and over of geographically defined catchment areas in ten low and middle income countries (India, China, Nigeria, Cuba, Dominican Republic, Brazil, Venezuela, Mexico, Peru and Argentina), with a sample size of between 1000 and 3000 (generally 2000). Each of the studies uses the same core minimum data set with cross-culturally validated assessments (dementia diagnosis and subtypes, mental disorders, physical health, anthropometry, demographics, extensive non communicable disease risk factor questionnaires, disability/functioning, health service utilisation, care arrangements and caregiver strain). Nested within the population based studies is a randomised controlled trial of a caregiver intervention for people with dementia and their families (ISRCTN41039907; ISRCTN41062011; ISRCTN95135433; ISRCTN66355402; ISRCTN93378627; ISRCTN94921815). A follow up of 2.5 to 3.5 years will be conducted in 7 countries (China, Cuba, Dominican Republic, Venezuela, Mexico, Peru and Argentina) to assess risk factors for incident dementia, stroke and all cause and cause-specific mortality; verbal autopsy will be used to identify causes of death. Discussion The 10/66 DRG baseline population-based studies are nearly complete. The incidence phase will be completed in 2009. All investigators are committed to establish an anonymised file sharing archive with monitored public access. Our aim is to create an evidence base to empower advocacy, raise awareness about dementia, and ensure that the health and social care needs of older people are anticipated and met.

Background: The criterion for dementia implicit in DSM-IV is widely used in research but not fully operationalised. The 10/66 Dementia Research Group sought to do this using assessments from their one phase dementia diagnostic research interview, and to validate the resulting algorithm in a population-based study in Cuba.Methods: The criterion was operationalised as a computerised algorithm, applying clinical principles, based upon the 10/66 cognitive tests, clinical interview and informant reports; the Community Screening Instrument for Dementia, the CERAD 10 word list learning and animal naming tests, the Geriatric Mental State, and the History and Aetiology Schedule - Dementia Diagnosis and Subtype. This was validated in Cuba against a local clinician DSM-IV diagnosis and the 10/66 dementia diagnosis (originally calibrated probabilistically against clinician DSM-IV diagnoses in the 10/66 pilot study).Results: The DSM-IV sub-criteria were plausibly distributed among clinically diagnosed dementia cases and controls. The clinician diagnoses agreed better with 10/66 dementia diagnosis than with the more conservative computerized DSM-IV algorithm. The DSM-IV algorithm was particularly likely to miss less severe dementia cases. Those with a 10/66 dementia diagnosis who did not meet the DSM-IV criterion were less cognitively and functionally impaired compared with the DSMIV confirmed cases, but still grossly impaired compared with those free of dementia.Conclusion: The DSM-IV criterion, strictly applied, defines a narrow category of unambiguous dementia characterized by marked impairment. It may be specific but incompletely sensitive to clinically relevant cases. The 10/66 dementia diagnosis defines a broader category that may be more sensitive, identifying genuine cases beyond those defined by our DSM-IV algorithm, with relevance to the estimation of the population burden of this disorder. [ABSTRACT FROM AUTHOR]

Electroencephalographic abnormalities in the absence of any other major laboratory or imaging findings are a frequently encountered phenomenon in many psychiatric disorders. In some cases, clear-cut interictal epileptiform EEG abnormalities in patients with classic primary psychiatric disorders lead to referrals to epilepsy departments for diagnostic evaluation. Although video/EEG telemetry in these cases generally proves that there is no direct temporal link between the EEG pathologies and psychiatric symptoms, and therefore the psychiatric syndrome cannot be regarded as epilepsy, the relevance of the EEG abnormalities remains open to discussion. In this article we put forward the model of a paraepileptic pathomechanism, which might explain the pathogenetic role of such EEG pathologies, at least in subgroups of such patients. We propose that ictal or nonictal epileptic neurophysiological activity can lead to local area neuronal network inhibition (LANI). In this model clinical symptoms are related not to the excitatory epileptiform abnormalities themselves, but to the extent, site, and dynamics of the resulting local neuronal network inhibition. The LANI hypothesis is capable of explaining the complex relationship between EEG abnormalities and clinical symptoms in different neuropsychiatric syndromes and can be verified and falsified in empirical research., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Disturbances in cognitive function, particularly memory, are a common complaint of patients with epilepsy. Factors contributing to cognitive dysfunction are the type of epilepsy, type and frequency of seizures, anti-epileptic drugs and the location of underlying brain lesions. Whilst a great deal of attention has been paid to permanent cognitive impairment, the nature and underlying mechanisms of ictal and peri-ictal cognitive changes are poorly understood. In-depth investigation of seizure related cognitive dysfunction is of great clinical relevance, as these changes are potentially reversible and treatable, thus reducing the cumulative effect of frequent seizures. Greater knowledge of peri-ictal and ictal cognitive dysfunction would improve seizure prediction, localization of seizure focus and assessment of treatment effectiveness, greatly reducing distress and disability. This paper will review current understanding of peri-ictal and ictal cognitive dysfunction and discuss future directions for research.

To properly address the psychosocial health of people with epilepsy, service and resource allocation, standards of care, and research should reflect the differing needs of patients presenting at different care levels and in different parts of the world. Ideally, people with epilepsy should have access, according to need, to adequately trained primary care physicians and nurse practitioners; to dedicated secondary care epilepsy clinics staffed by trained multidisciplinary teams; and to tertiary level dedicated staff, able to offer a range of psychosocial interventions and supported by comprehensive assessment tools for psychosocial screening, diagnosis, and management. Established protocols linking the various tiers of care would be important, as would a dedicated, nationally applicable online EMR system. In developing countries, best practice needs to be tailored to be realistic and achievable, and some potentially useful models are already available.

Background: Studies have suggested that the prevalence of dementia is lower in developing than in developed regions. We investigated the prevalence and severity of dementia in sites in low-income and middle-income countries according to two definitions of dementia diagnosis., Methods: We undertook one-phase cross-sectional surveys of all residents aged 65 years and older (n=14 960) in 11 sites in seven low-income and middle-income countries (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Dementia diagnosis was made according to the culturally and educationally sensitive 10/66 dementia diagnostic algorithm, which had been prevalidated in 25 Latin American, Asian, and African centres; and by computerised application of the dementia criterion from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). We also compared prevalence of DSM-IV dementia in each of the study sites with that from estimates in European studies., Findings: The prevalence of DSM-IV dementia varied widely, from 0.3% (95% CI 0.1-0.5) in rural India to 6.3% (5.0-7.7) in Cuba. After standardisation for age and sex, DSM-IV prevalence in urban Latin American sites was four-fifths of that in Europe (standardised morbidity ratio 80 [95% CI 70-91]), but in China the prevalence was only half (56 [32-91] in rural China), and in India and rural Latin America a quarter or less of the European prevalence (18 [5-34] in rural India). 10/66 dementia prevalence was higher than that of DSM-IV dementia, and more consistent across sites, varying between 5.6% (95% CI 4.2-7.0) in rural China and 11.7% (10.3-13.1) in the Dominican Republic. The validity of the 847 of 1345 cases of 10/66 dementia not confirmed by DSM-IV was supported by high levels of associated disability (mean WHO Disability Assessment Schedule II score 33.7 [SD 28.6])., Interpretation: As compared with the 10/66 dementia algorithm, the DSM-IV dementia criterion might underestimate dementia prevalence, especially in regions with low awareness of this emerging public-health problem.

We assessed 228 people with epilepsy (PWE) in the residential care setting using the Neuropsychiatric Inventory (NPI) and Brief Psychiatric Rating Scale (BPRS) as caregiver- and observer-rated instruments. There was a significant burden of psychopathology, about half of all subjects surveyed scoring positive on either or both instruments. Psychopathology as measured by the NPI and BPRS was significantly greater in cognitively impaired subjects than in those with intact cognitive function. The NPI was found to be a valid caregiver-rated measure of psychopathology in PWE, with a principal components analysis yielding a reliable and interpretable four-factor solution, psychosis, interictal dysphoric disorder, depression, and anxiety being identified. Mental health service needs were found to be considerable in this population, with a significant hidden burden of psychiatric comorbidity. As this population has ongoing service needs through the life span, further research is necessary.

The classification of psychiatric disorders in epilepsy has evolved considerably from the first attempts in the 19th century. A dedicated subcommission of the ILAE Commission on Psychobiology of Epilepsy (now the Commission on Neuropsychiatric Aspects) has developed this classification proposal. The aim of this proposal is to separate disorders comorbid with epilepsy and those that reflect ongoing epileptiform activity from epilepsy-specific disorders, and to attempt to subclassify the epilepsy-specific disorders alone. Further, the classification of epilepsy-specific psychiatric disorders has largely followed their relationship to the ictus, with factors such as relationship to antiepileptic drug (AED) change being coded as additional information. Finally, this proposal presents a clinical and descriptive system of classification rather than an etiological classification on the grounds that there is currently inadequate information for the latter approach to be employed globally.

1) Depression is a common and important accompaniment of epilepsy. 2) Depression in epilepsy is phenomenologically different from the usual forms of depression and it is essential that treating physicians assess for these varied forms as well. 3) Depression in epilepsy may be managed more effectively if the relationship to the ictus is better understood. 4) Other factors such as stressful life events, related or unrelated to epilepsy, may contribute to the depressive symptoms. 5) Antiepileptic drugs, particularly GABAergic agents such as vigabatrin, tiagabine, topiramate and phenobarbitone are depressogenic in nature. 6) The newer antidepressants, SSRIs such as sertraline, citalopram and paroxetine do not lower seizure threshold and can be safely used to treat depression in epileptic individuals. Fluoxetine may be avoided because of its longer half-life.

Epilepsy and behavior have a complex, often intriguing relationship. We report here the interesting case of Mrs. A, who presented with depression and developed seizures and an ictal psychosis precipitated by use of a selective serotonin reuptake inhibitor. She subsequently presented with forced normalization characterized by affective somatoform and hysterical manifestations.

The evaluation of behavioral disturbances in epilepsy is an area fraught with complexity. On the one hand, there are no instruments that have been developed specifically for the assessment of behavioral disturbances in epilepsy. On the other hand, the phenomenology and pathophysiology of behavioral disturbances in epilepsy are unique and defy conventional descriptions in the psychiatric literature. The vast majority of studies have used instruments that have not been validated for this purpose. Studies with a psychiatric orientation generally tend to employ unvalidated semistructured or structured tools except for the Structured Clinical Interview for DSM, which has been validated for epilepsy. Studies with a neurological orientation generally use screening questionnaires and interpret the results of these as diagnostic. Neither approach is valid and both generally fail to measure potential confounders, such as seizure frequency, seizure severity, temporality of seizure occurrence in relation to time of assessment, life events, disablement, quality of life, and other socioeconomic indicators. Furthermore, instruments are generally employed using cutoff scores that may not be valid for epilepsy populations; the emphasis is often on symptom severity rather than symptom multiplicity (or load), which may also have an impact on the patient's outcome. In addition, instruments that have a basis in psychiatric criteria as opposed to symptomatology have inherent pitfalls at the interface between epilepsy and behavior. These and other issues in evaluating behavioral disturbances in people with epilepsy are reviewed and some solutions for the future are proposed.

Background and Purpose: Stroke prevalence data among mixed Asian populations are lacking. Prevalence rates of stroke were studied among Singaporeans aged > or =50 years of Chinese, Malay, and Indian origin., Methods: Study participants were selected by disproportionate stratified random sampling by race. Trained interviewers performed face-to-face interviews with subjects using the World Health Organization screening protocol for neurological diseases. Data were also collected on a self-report of stroke. Subjects suspected to have had a stroke underwent a clinical evaluation to diagnose or exclude stroke. Case notes review was performed for those who were unable to come for clinical evaluation., Results: The study involved 14 906 participants: 6734 men, 8172 women, age range 52 to 106 years, Chinese:Malay:Indian ratio 3:1:1. Participation rate was 66.9%. Six hundred and six were diagnosed to have a stroke, yielding a crude prevalence rate of 4.05% (95% CI, 3.75 to 4.38) and a World Health Organization world population age-gender-standardized rate of 3.65% (95% CI, 3.36 to 3.96). Prevalence rates rose with age (P<0.001 for trend) and were higher among men compared with women, 4.53% (95% CI, 4.05 to 5.07) versus 2.91% (95% CI, 2.57 to 3.29), P<0.01. Age and gender-standardized rates among Chinese, Malays, and Indians were 3.76% (95% CI, 3.38 to 4.17), 3.32 (95% CI, 2.72 to 4.07), and 3.62% (95% CI, 2.95 to 4.44), respectively, P>0.2. Prevalence was highest among Chinese men at 4.78% (95% CI, 4.14 to 5.50) and lowest among Malay women at 2.81% (95% CI, 2.08 to 3.81), P=0.01., Conclusions: There is no difference in stroke prevalence among Chinese, Malay, and Indian Singaporeans. Prevalence is highest among Chinese men and lowest among Malay women. The reasons for these differences warrant further investigation.

Objective: To assess the relationship between the behavioural triad of hyper-religiosity, hypergraphia and hyposexuality in epilepsy, and volumes of the mesial temporal structures., Method: Magnetic resonance images were obtained from 33 patients with refractory epilepsy and mesial temporal structure volumes assessed. Amygdala and hippocampal volumes were then compared in high and low scorers on the religiosity, writing, and sexuality sub-scales of the Neurobehavioural Inventory., Results: Patients with high ratings on the religiosity scale had significantly smaller right hippocampi. Religiosity scores rated by both patient and carer showed a significant negative correlation with right hippocampal volumes in this group. There were no other differences in amygdala or hippocampal volumes between these groups, or between high and low scorers on the writing and sexuality sub-scales., Conclusions: These findings suggest that right hippocampal volumes are negatively correlated with religiosity in patients with refractory epilepsy.

Many people with epilepsy suffer from comorbid depression. Despite this, there have been few studies addressing the treatment of depression in this population, and the literature on psychiatric management techniques in patients with epilepsy is composed largely of opinions rather than evidence from randomized, controlled trials or other systematic investigations. Antidepressant drugs, including tricyclics and selective serotonin reuptake inhibitors, can be used to treat patients with epilepsy and comorbid depression. Nonpharmacological treatment options include vagus nerve stimulation, transcranial magnetic stimulation, and psychological therapies including cognitive-behavioral therapy, individual or group psychotherapy, patient support groups, family therapy, and counseling. Another important area that remains largely uninvestigated is psychiatric research in patients with epilepsy in non-Western cultures (with the exception of Japan). Factors such as problems with access to and acceptability of therapies in many developing nations have further implications for the treatment of psychiatric disorders in epilepsy.

We used quantitative magnetic resonance imaging (MRI) to examine the mesial temporal structures in subjects with refractory partial epilepsy and comorbid anxiety and found preservation with a right-sided preponderance. The findings indicate a role for this brain region in the genesis of anxiety.

Bilateral symmetrical hippocampal atrophy (BHA) has been implicated as a possible causal element in various neuropsychiatric disorders, in particular depressive disorder and schizophrenia. To test the hypothesis that bilateral symmetrical severe volume loss of the hippocampi is of causal relevance to these psychiatric syndromes rather than an epiphenomenon we assessed the psychopathology in a group of patients with temporal lobe epilepsy (TLE) and very severe bilateral symmetrical hippocampal atrophy and compared it with that of a patient control group. Patients with TLE and hippocampal volumes smaller than three standard deviations below the mean of a control population were identified and compared with a matched patient population with normal hippocampal volumes. Psychopathology was assessed by blinded trained psychiatrists using the Present State Examination and Neurobehavioral Inventory. The prevalence of psychiatric syndromes was high in both patient groups; however, there was no significant difference between the two groups. With use of the more specific Neurobehavioral Inventory a psychopathological pattern reminiscent of the Geschwind syndrome emerged when patients with BHA were characterized by caregivers. While BHA does not result in an increased prevalence of specific psychiatric syndromes, specific symptoms that characterize the Geschwind syndrome like hypergraphia and hyposexuality might be pathogenically related to hippocampal atrophy.

Purpose: To review transcultural perspectives in the neuropsychiatry of epilepsy., Methods: Systematic literature searches of standard databases, cross-referencing, chapters, and opinion leader articles., Results: Articles from the Indian subcontinent, Africa, and Japan were identified and are reviewed herein. The spectrum of psychopathology in epilepsy is rather similar across cultures. However, psychopathology specific to epilepsy, the interictal behavioural syndrome of Geschwind, for example, has not been well studied outside the Western world., Discussion: There is a need for well-designed epidemiological studies of neuropsychiatric disorders in epilepsy. These should use harmonised protocols and outcome measures. Special attention should be paid to the impact of aetiology on psychiatric co-morbidity and disablement.

Purpose: To identify research priorities in epilepsy for developing nations., Methods: A panel discussion with audience participation at the Indo-U.K. Workshop on Epilepsy. This included short presentations by panelists, the presentation of a research proposal, and debate on research priorities., Results: The need to focus on primary-care populations; to use a multi-centre random block design; to incorporate rural areas and a service component; to study incidence, natural history, and aetiology; to focus on problems, such as cysticercosis, and to adopt a comprehensive public health-centred approach in doing so; to study disorders of local interest, such as hot water epilepsy; to pilot both pharmacological and nonpharmacological interventions; to incorporate comprehensive measures of cognition, behaviour, and psychosocial outcome in all studies; and to examine the role of novel diagnostic tools (imaging for example) and therapy (surgery for example) on cost were all outlined as priority areas., Discussion: There is a felt need for greater and better-quality research output from the developing world. The development of uniform research protocols, the twinning of developed and developing nations for research, and training of developing nations' personnel are likely to increase research output in the years that come.

Abulia is the relatively uncommon yet debilitating lack of spontaneous, goal-directed behaviour that is seen predominantly with lesions of the basal ganglia and the frontal lobes. We sought to confirm the existence of abulia as an entity recognized by clinicians, to generate a set of items characteristic of the condition, and to see how clinicians differentiate between overlapping disorders. The Delphi technique was used to survey consultant neurologists and psychiatrists at three hospitals in London. The study consisted of two phases: semi- structured interviews of a small group of neurologists and psychiatrists, followed by a survey of a larger group of consultants using postal questionnaires. Both neurologists and psychiatrists recognized abulia to be a distinct clinical entity but its status as a syndrome was unclear. Features such as difficulty in initiating and sustaining spontaneous movements and reduction in emotional responsiveness, spontaneous speech, and social interaction were identified as being characteristic of abulia. The information generated by this study may help to develop a working classification for disorders of diminished drive and motivation, and instruments for clinical assessment and decision making., (Copyright 2002 Movement Disorder Society)

In 1953, Landolt described a group of patients with poorly controlled epilepsy who had psychotic episodes associated with remission of their seizures and disappearance of epileptiform activity on their EEGs. He called this phenomenon "forced normalization." Since then, neurologists and psychiatrists have been intrigued by this phenomenon, and although it has been also reported by others, its existence continues to be the source of much debate. In this article, we review the clinical characteristics and potential pathogenic mechanisms of forced normalization and illustrate the complexities inherent in reaching this diagnosis, as well as its differential diagnosis in two representative cases.

To study the nature of personality and psychopathology in nonepileptic attack disorder (NEAD) and epilepsy, we prospectively assessed 45 consecutive attendees to a specialist assessment unit for epilepsy. Patients with NEAD were more likely to report clinically significant symptoms of anxiety, worry, disordered eating, and somatoform disorder. An ICD-10 diagnosis of anxiety or phobic disorder was significantly more common in NEAD patients. Together DSM-IV personality Clusters A and C were more common in epilepsy than NEAD. Hierarchical logistic regression with diagnosis as the target variable found anxiety, eating, and worry but not somatoform symptoms were reliably associated with NEAD. Together the Present State Examination (PSE) eating, PSE worrying/tension, PSE expansive mood, past psychiatric history, and gender variables allowed for correct classification of more than 88% of all cases. Personality and psychopathology variables seem to be valid clinical predictors of epilepsy and NEAD, and should be examined in epidemiological studies.

In recent years there has been considerable research interest at the interface between epilepsy and psychiatry. Topics of interest include the epidemiology of psychiatric co-morbidity in epilepsy; clinical syndromes at this interface and their classification; the relationship between cognitive dysfunction and psychiatric co-morbidity; biological mechanisms that mediate such co-morbidity, especially with developments in imaging and genetic research; the association between temporal lobe surgery, vagus nerve stimulation, and other non-pharmacological treatments, and the development of such co-morbidity; the contribution of anticonvulsant drugs towards the development of psychiatric co-morbidity; quality of life and other psychosocial issues; and non-epileptic attack disorder. In this review, papers on these psychiatric issues in epilepsy, with a focus on those published in the past year (October 1999 to October 2000) are critically evaluated, and some important current issues at this interface are considered in detail.

Purpose: The occurrence of psychiatric symptoms after temporal lobectomy is well documented. The aim of the present study was to identify preoperative factors that predict postoperative psychiatric outcome., Methods: We studied the case notes of 121 patients (from an initial sample of 167) who underwent temporal lobectomy at the National Hospital of Neurology and Neurosurgery, Queen Square, London, between 1988 and 1997. Data concerning gender, laterality of lesion, pathology, seizure outcome, psychiatric history, psychiatric outcome, resection volume, telemetry, and MRI scans were systematically collected. Factors that predict the occurrence of postoperative psychiatric symptomatology were investigated using correlational, chi(2), and logistic regression techniques., Results: Poor postoperative psychiatric outcome in general was positively associated with preoperative bilateral independent spike discharges at telemetry. The size of surgical resection was positively correlated with the occurrence of postoperative emotional lability. The laterality of the epileptogenic lesion was not associated with a poor psychiatric outcome. Developmental lesions were associated with a good psychiatric outcome at a marginally significant level. Patients with a preoperative psychiatric history and de novo psychiatric symptomatology had a poorer surgical outcome in terms of seizure frequency, also at a marginally significant level. A significant correlation was found between a past psychiatric history and seizure outcome., Conclusions: We identified a high frequency of psychiatric symptoms both before and after temporal lobectomy, demonstrating that it is not a benign procedure from the point of view of psychopathology. Our results show that there are certain predictive factors that may help identify patients most at risk for postoperative psychiatric disorders.

A case of fixation-off sensitivity (FOS) in an asymptomatic adult is presented and studied as a model for continuous epileptiform discharges. Video-electroencephalographic (EEG) revealed continuous bilateral occipital spike wave discharges during elimination of central vision, which were shown to be associated with transitory cognitive impairment demonstrated by neuropsychological testing. Functional MRI showed activation of parieto-occipital and frontal brain areas during the fixation-off discharges. This localization was confirmed with 64-channel EEG source analysis. The applied methods provided additional information on the pathophysiology of epileptiform discharges.

This article deals with disorders of mood and the interaction between mood and cognitive function. The various ways in which environmental toxins can lead to disorders of mood are presented, and discussions regarding the neurobiology of mood are presented.

The phenomenon of forced normalization and its clinical counterpart, alternative psychoses, is discussed. The historical origins are briefly noted before the clinical presentation, and some associated clinical findings are given. The main part of the article is devoted to the literature on chemical and electrical kindling, in an attempt to provide some heuristic model to understand the antithetical relationship between seizures and behavior disorders. We conclude that the use of the kindling model may provide further insights into these phenomena, particularly taking into account such key neurotransmitters as glutamate, dopamine, and GABA.

About 70% of noncardiac chest pain (NCCP) patients have mental disorders as reported from Western countries. The phenomenon of somatization is considered to be aetiologically important in the genesis of NCCP. Though somatization is generally considered as more prevalent among non-Western cultures, systematic studies of mental disorder among NCCP patients are rare from developing countries. Based on treadmill test, 54 male inpatients in a cardiology general ward in India were divided into a group having ischaemic heart disease (IHD) and another group of NCCP. A psychiatric interview was conducted blindly on these subjects with the help of a structured interview schedule, and DSM-III-R diagnosis was made. Sixty-eight percent in the NCCP group and 27% in the IHD group had a mental disorder. The total number of subjects with a mental disorder, including panic disorder and major depression, were significantly more in the NCCP group. Mental disorders appears to be equally common among NCCP patients in developing countries also and detailed psychiatric assessment is warranted in patients with chest pain of non-IHD origin.