LETTERS
TO
THE
Am
EDITOR
2. Wells CE: Transient ictal psychosis. Arch Gen Psychiatry 32:1201-1203, 1975 3. Glaser GH: The epilepsies, in Textbook of Medicine. Edited by Beeson PB, McDermott W. Philadelphia, WB Saunders Co, 1975, p 731
J Psychiatry
135:7,
July
1978
It would thus be of interest to learn the reasons for Dr. Wells’ exclusion of CSF examination in his suggestions, as well as his inclusion of B12 and folate levels. REFERENCES
STEWART
M.D.
SHEVITZ, Nashville,
1. Marsden
Tenn.
tients Dr.
and
Ward
SIR: chosis
test.
Associates
2. Freemon tellectual
Reply
Dr. Shevitz’s point is well may be a source of false
Past
and
tives.
present
taken. Transient positives with
have
Such
mal testing
improvements
appeared
may
not give
but
still
respond
may
PATRICK
SIR: (January
Guidelines
for
abnormal
EEGs
under
to intravenous
nor-
guidelines
for the evaluation
in the treatment 1975
of aggression.
NICHOLAS G. WARD, DAVID B. ROWLETT, BURKE, M.B., CH.B.,
I
M.D. M.D. PH.D.
Disease:
An Overview” E. Wells, M.D. suggested of the demented patient before ,
are a
scan as a screening procedure in his basic diagnostic battery and does not suggest examination of the cerebrospinal fluid (CSF). There seem to be both diagnostic and logistic considerations in this regard. There are some diagnoses that can be made by CT scan even with a negative CSF exam (e.g. normal pressure hy,
in which
the CSF will give
CNS infection, early metastatic disease, multiple sclerosis). In two series quoted, Marsden and Harrison (I) and Freemon (2) both examined CSF as part of their protocols. In the former study, 1 out of 36 cases of identifiable causes of dementia was obtained by CSF exam, and in the latter, 2 out of 60. Additionally, Marsden and Harrison found no vitamin B12 deficiency, and Freemon concluded, Unrewarding tests included vitamin B12 and folate levels.” The CT scan is not readily available in all areas of the country, and its cost, while decreasing in high-availability areas, must remain a consideration for some patients. Similarly, the facilities to do a lumbar puncture may not exist in many psychiatrists’ offices, although enlistment of hospital outpatient facilities (as well as house staff) may be a partial solution. positive
findings
with
a negative
SIR: I am grateful to Dr. Javel for his comments opportunity to explain more fully the reasons for tions.
The
most
important
CT
scan
(e.g.
,
reason puncture useful use this
very
useful,
why
I did
and for the my sugges-
not and
do not ad-
for demented patients is its low information. I did not mean to diagnostic procedure or that it is
but
I reserve
its use
for those
patients whose history or clinical findings suggest that examination of the CSF may be of specific diagnostic or therapeutic value. In only I patient (with syphilis) out of 166 in the
by Dr. Javel did CSF findings provide As Dr. Freemon reported, this patient VDRL and an Argyll Robertson pupil,
either of which would have made examination of the CSF mandatory in that patient. As Dr. Javel notes, CSF examination provides exact diagnostic information only in CSF infections, early metastatic disease, and multiple sclerosis. These disorders rarely present as dementing syndromes per se, and
Wash.
Patients
Brain
are others
Replies
two series mentioned an exact diagnosis. had a positive serum
CT
but there
Wells
vise routine lumbar yield of specifically suggest that I never
amytal.
or instead of neurological consultation; these suggestions welcome but deserve comment. Dr. Wells recommended
drocephalus),
Dr.
not on occasion
Demented
In his article ‘ ‘Chronic 1978 issue) Charles
Calif.
better
Seattle,
Diagnostic
M.D.
JAVEL,
Martinez,
REFERENCE 1. Monroe RR: Anticonvulsants Nerv Ment Dis 160:119-126,
F.
ALAN
in the
to correlate
seizures
CD, Harrison MIG: Outcome of investigation of papresenile dementia. Br Med I 2:249-252, 1972 FR: Evaluation of patients with progressive indeterioration. Arch Neurol 33:658-659, 1976
ictal psythe amytal
second patient with the institution of antipsychotic medication than with the development of therapeutically effective barbiturate levels. However, this is only a clinical observation, and the possibility of status epilepticus in that patient still exists. We have also considered the possibility of limbic system seizures as reported by Monroe (1) as a source offalse posi-
we described
with
even more rarely without other clinical features pointing to the correct diagnosis. Even though the diagnostic yield is low with lumbar puncture in dementia, I would probably accept its routine use were the procedure noninvasive, inexpensive, and attended by no significant morbidity. It is indeed for these reasons that I have suggested determination of B12 and folate levels
routinely in dementia ever, lumbar puncture vasive, physician ity (the
though the yield is low. Hownot meet these criteria. It is in-
expensive (in terms of time and equipment) for both and patient, and attended by considerable morbidpain of the procedure itself and the posttap head-
ache). I realize examination
even does
that some
believe
is unjustified.
the omission I am
ready
of the routine to change
my
mendations if good evidence for such routine use coming. However, studies to date do not, in my support this position. CHARLES
E.
WELLS,
Nashville,
CSF recom-
is forthopinion,
M.D. Tenn.
“
.
870
.
.
Depression
in Chronic
Schizophrenia
SIR: We read with interest ‘ ‘The Assessment of Depression: A Model for Quality Review of Emergency Psychiatry” by Frederic Kass, M.D. , and associates (February 1978 issue). The results of this study come as no surprise to us.
TO
THE
Am
EDITOR
2. Wells CE: Transient ictal psychosis. Arch Gen Psychiatry 32:1201-1203, 1975 3. Glaser GH: The epilepsies, in Textbook of Medicine. Edited by Beeson PB, McDermott W. Philadelphia, WB Saunders Co, 1975, p 731
J Psychiatry
135:7,
July
1978
It would thus be of interest to learn the reasons for Dr. Wells’ exclusion of CSF examination in his suggestions, as well as his inclusion of B12 and folate levels. REFERENCES
STEWART
M.D.
SHEVITZ, Nashville,
1. Marsden
Tenn.
tients Dr.
and
Ward
SIR: chosis
test.
Associates
2. Freemon tellectual
Reply
Dr. Shevitz’s point is well may be a source of false
Past
and
tives.
present
taken. Transient positives with
have
Such
mal testing
improvements
appeared
may
not give
but
still
respond
may
PATRICK
SIR: (January
Guidelines
for
abnormal
EEGs
under
to intravenous
nor-
guidelines
for the evaluation
in the treatment 1975
of aggression.
NICHOLAS G. WARD, DAVID B. ROWLETT, BURKE, M.B., CH.B.,
I
M.D. M.D. PH.D.
Disease:
An Overview” E. Wells, M.D. suggested of the demented patient before ,
are a
scan as a screening procedure in his basic diagnostic battery and does not suggest examination of the cerebrospinal fluid (CSF). There seem to be both diagnostic and logistic considerations in this regard. There are some diagnoses that can be made by CT scan even with a negative CSF exam (e.g. normal pressure hy,
in which
the CSF will give
CNS infection, early metastatic disease, multiple sclerosis). In two series quoted, Marsden and Harrison (I) and Freemon (2) both examined CSF as part of their protocols. In the former study, 1 out of 36 cases of identifiable causes of dementia was obtained by CSF exam, and in the latter, 2 out of 60. Additionally, Marsden and Harrison found no vitamin B12 deficiency, and Freemon concluded, Unrewarding tests included vitamin B12 and folate levels.” The CT scan is not readily available in all areas of the country, and its cost, while decreasing in high-availability areas, must remain a consideration for some patients. Similarly, the facilities to do a lumbar puncture may not exist in many psychiatrists’ offices, although enlistment of hospital outpatient facilities (as well as house staff) may be a partial solution. positive
findings
with
a negative
SIR: I am grateful to Dr. Javel for his comments opportunity to explain more fully the reasons for tions.
The
most
important
CT
scan
(e.g.
,
reason puncture useful use this
very
useful,
why
I did
and for the my sugges-
not and
do not ad-
for demented patients is its low information. I did not mean to diagnostic procedure or that it is
but
I reserve
its use
for those
patients whose history or clinical findings suggest that examination of the CSF may be of specific diagnostic or therapeutic value. In only I patient (with syphilis) out of 166 in the
by Dr. Javel did CSF findings provide As Dr. Freemon reported, this patient VDRL and an Argyll Robertson pupil,
either of which would have made examination of the CSF mandatory in that patient. As Dr. Javel notes, CSF examination provides exact diagnostic information only in CSF infections, early metastatic disease, and multiple sclerosis. These disorders rarely present as dementing syndromes per se, and
Wash.
Patients
Brain
are others
Replies
two series mentioned an exact diagnosis. had a positive serum
CT
but there
Wells
vise routine lumbar yield of specifically suggest that I never
amytal.
or instead of neurological consultation; these suggestions welcome but deserve comment. Dr. Wells recommended
drocephalus),
Dr.
not on occasion
Demented
In his article ‘ ‘Chronic 1978 issue) Charles
Calif.
better
Seattle,
Diagnostic
M.D.
JAVEL,
Martinez,
REFERENCE 1. Monroe RR: Anticonvulsants Nerv Ment Dis 160:119-126,
F.
ALAN
in the
to correlate
seizures
CD, Harrison MIG: Outcome of investigation of papresenile dementia. Br Med I 2:249-252, 1972 FR: Evaluation of patients with progressive indeterioration. Arch Neurol 33:658-659, 1976
ictal psythe amytal
second patient with the institution of antipsychotic medication than with the development of therapeutically effective barbiturate levels. However, this is only a clinical observation, and the possibility of status epilepticus in that patient still exists. We have also considered the possibility of limbic system seizures as reported by Monroe (1) as a source offalse posi-
we described
with
even more rarely without other clinical features pointing to the correct diagnosis. Even though the diagnostic yield is low with lumbar puncture in dementia, I would probably accept its routine use were the procedure noninvasive, inexpensive, and attended by no significant morbidity. It is indeed for these reasons that I have suggested determination of B12 and folate levels
routinely in dementia ever, lumbar puncture vasive, physician ity (the
though the yield is low. Hownot meet these criteria. It is in-
expensive (in terms of time and equipment) for both and patient, and attended by considerable morbidpain of the procedure itself and the posttap head-
ache). I realize examination
even does
that some
believe
is unjustified.
the omission I am
ready
of the routine to change
my
mendations if good evidence for such routine use coming. However, studies to date do not, in my support this position. CHARLES
E.
WELLS,
Nashville,
CSF recom-
is forthopinion,
M.D. Tenn.
“
.
870
.
.
Depression
in Chronic
Schizophrenia
SIR: We read with interest ‘ ‘The Assessment of Depression: A Model for Quality Review of Emergency Psychiatry” by Frederic Kass, M.D. , and associates (February 1978 issue). The results of this study come as no surprise to us.
