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With Disproportionate Enlargement of There Are Few Reported Letters to the Editor 295 Prevalence (%) ofanxiety, depressive, and psychotic disorders by dementia severity Ataxic type of Creutzfeldt-Jakob disease with of J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.62.3.295 on 1 March 1997. Downloaded from Demented disproportionate enlargement the fourth ventricle: a serial CT study Non-demented Questionable Mild Moderate/severe Disorders (n = 786) (n = 58) (n = 84) (n = 38) There are few reported neuroimaging stud- ies on the ataxic of Anxiety 3-2 (25) 5-2 (3) 3-6 (3) 0 (0) type Creutzfeldt-Jakob Depressive 5-5 (43) 12-1 (7) 20-2 (17) 21-1 (8) disease. In our patient MRI and serial CT Psychotic 0-3 (2) 3-4 (2) 10-7 (9) 5-3 (2) disclosed a progressive enlargement of the fourth ventricles as a Actual numbers of patients are given in parentheses. major finding. A 64 year old woman developed progres- sive gait unsteadiness in June 1994; she was then evaluated in another hospital where were combined. The prevalence of anxiety We thank all the participants in the study popula- examination and CT scan tion and the members of the Kungsholmen Project neurological (the disorders was 3-2% in the non-demented was unavailable to us) were reported as nor- and 3-3% in the combined Study Group for their collaboration. This study demented group. was supported by grants from the Swedish Society mal. She had no history of neurosurgery or Psychotic (F = 21-1, df 1,962, P < 0-001) for Medical Research and the Swedish Medical ocular surgery or family history of neurologi- and depressive (F = 11-3, df 3,962, Research Council. cal disease. Examination in September 1994 P < 0-001) disorders were more common in YVONNE FORSELL showed gait ataxia and gaze nystagmus with- demented than in non-demented persons, BENGT WINBLAD out dysarthria. Routine laboratory investiga- whereas anxiety disorders showed no differ- Stockholm Gerontology Research Centre and tions and tumour markers were normal or ence. No persons with moderate or severe Department of Geriatric Medicine, Karolinska Institute, Stockholm, Sweden negative. Analysis of CSF including IgG dementia were diagnosed as having an anxi- content was normal; oligoclonal bands were ety disorder. Mean MMSE score in those Correspondence to: Dr Y Forsell, Stockholm not detected. Brain CT (figure, A, B) was with a diagnosed anxiety disorder was 25-2 Gerontology Research Center, Olivecronasv 4, S-113 82 Stockholm, Sweden. normal for the patient's age. An EEG (SD 3-1), with a range from 19 to 30. In showed slowing of background activity. As those without a diagnosed anxiety disorder there was no evidence of systemic cancer or the mean MMSE score was 25-5 (SD 4-5), other known aetiologies of cerebellar degen- with a range from 0 to 30. Notable was that eration, a diagnosis of idiopathic late onset of the 71 persons an with MMSE score 1 Lindesay J. Phobic disorders in the elderly. Br cerebellar ataxia was made. Two months < 18, none had an anxiety disorder. JPsychiatry 1991;159:531-41. later there was rapid intellectual decline with Having a history of psychiatric disorders 2 Reiger DA, Boyd JH, Burke JD Jr, Rae DS, Myers JK, Kramer M, et al. One-month complex hallucinations, emotional changes, (OR = 9-8, 95% CI 9-0-10-6) and impaired prevalence of mental disorders in the United disorientation, and confusion leading to a activities of daily living (OR = 3 0, 95% CI States based on five epidemiologic catch- vegetative state within a few weeks. Multi- ment area sites. Arch Gen 2-0-4-1) were found to correlate with having Psychiatry focal axial and appendicular myoclonus was an anxiety disorder. The other 1988;45:977-86. potentially 3 Bland RC, Newman SC, Orn H. Prevalence of now present. Serial waking-sleep EEG associated variables including marital status, psychiatric disorders in the elderly in showed progressive slowing of background sex, institutionalisation, educational level, Edmonton. Acta Psychiatr Scand Suppl activity with occasional periodic complexes. somatic disorders (cardiac, cardiovascular, 1988;338:57-63. 4 Copeland JRM, Dewey ME, Wood N, Serle Serial CT (figure, C-F) showed progressive musculosceletal, or malignant), visual and R, Davidson IA, McWilliam C. Range of men- cerebellar and brain atrophy with pro- hearing problems, or dementia were not tal illness among the elderly in the commu- nounced enlargement of the fourth ventricle. found to correlate. No substantial differ- nity: prevalence in Liverpool using the Transverse GMS-AGECAT package. Br Jf Psychiatry diameters of the fourth ventricle ences were found if demented patients were 1987;40:1167-73. at first, second, and third examination were excluded from the analysis. 5 Rogers MP, White K, Warshaw MG, Yonkers 1-3, 1-9, and 2-5 cm (normal value 1-44 (SD The results indicate that anxiety disorders KA, Rodriguez-Villa F, Chang G, Keller 0-22)).' The brainstem ratio was normal in were diagnosed in 3-2% of this population of MB. Prevalence of medical illness in patients with anxiety disorders. International Journal all three CT studies (for the last 0-19 (con- very elderly adults, and the prevalence was of Psychiatric Medicine 1994;24:83-96. trol value 0-22 (004)).' An MRI study in equally distributed in non-demented and 6 Surtees PG. In the shadow of adversity: the November 1994 corroborated the CT find- demented groups. This finding is in agree- evolution and resolution of anxiety and depressive disorders. Br ings and neither brainstem atrophy nor ment with the _J Psychiatry 1995; prevalence rate reported in 166:583-94. abnormal signal of white matter or basal the ECA, Edmonton studies, and the Guy's 7 Wands K, Merskey H, Hashinsky VC, Fisman ganglia were noted. Two specific proteins http://jnnp.bmj.com/ age concern survey.2"' Moreover, the pre- M, Fox H, Bonifero M. A questionnaire p131 and p130 were identified by gel elec- sent study found that in those persons who investigation of anxiety and depression in trophoresis of CSF and CSF neuron-specific early dementia. _J Am Geriatr Soc 1990;38: were moderate or severely demented, anxi- 535-8. enolase was significantly increased at ety disorders were not present. In fact a 8 Fratiglioni L, Grut M, Forsell Y, Viitanen M, 240 ng/ml (upper limit of normal 50 ng/l; T MMSE score of at least 18 seemed to be Grafstrom M, Holmen K, et al. Prevalence of Weber, University of Gottingen, Germany, critical for the presence of an anxiety disor- Alzheimer's disease and other dementias in an elderly urban population. Neurology personal communication). The patient died der. This might have been a reflection of the 1991;41:1886-92. in February 1995. fact that those participants with more severe 9 Asberg M, Montgomery S, Perris C, Schalling Necropsy, restricted to the nervous sys- cognitive dysfunction lacked the appropriate D, Sedvall G. A comprehensive psy- chopathological rating scale (CPRS). Acta tem, was performed six hours after death. on October 2, 2021 by guest. Protected copyright. insight or were unable to accurately respond Psychiatr Scand Suppl 1978;271:5-27. The brain (fixed weight 1150 g) was of nor- to questions from the CPRS (masking 10 Katz S, Ford AB, Moskowitz RW, Jackson BA, mal external appearance. On section the Jaffe MW. Studies of hypothesis), despite the exclusion of those illness in the aged. ventricular system, especially the fourth ven- who were unable to provide answers in JAMA 1963;185:914-9. data 11 Folstein MF, Folstein SE, McHugh PR. Mini- tricle, was seen to be enlarged and both the analysis. Another possible explanation for mental state: a practical method for grading cerebral cortex and the cerebellar cortex this finding may be that demented persons the cognitive state of patients for the clini- were thin. Microscopically there was wide- at that level of severity are unable to experi- cian. Psychiatr Res 1975;12: 189-98. 12 American Psychiatric Association. Diagnostic spread spongy degeneration throughout the ence complex integrated emotions due to and statistical manual of mental disorders. 3rd grey matter and basal ganglia, most pro- advanced brain disease (the extinction ed, revised (DSM-III-R). Washington DC: nounced over the frontal and occipital cor- hypothesis). By contrast, the instrument in American Psychiatric Association, 1987. tex, thalamus, and putamen. In the use seemed to be able to diagnose depressive 13 Hughes CP, Berg L, Danzinger WL, Coben LA, Martin RL. A new clinical scale for the cerebellum there was considerable loss of and psychotic disorders, even if the person staging of dementia. Br Psychiatry 1982; granule cells with relative preservation of had reached a more severe level of dementia. 140:566-72. Purkinje cells that often exhibited axonal The hierarchy of the diagnostic system also 14 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th "torpedoes". The white matter was gliotic to might have influenced the fact that the ed. Washington, DC: American Psychiatric some degree but myelin stains demonstrated prevalence of depression exceeded the Press, 1994. no evidence of demyelination. Kuru- prevalence of anxiety disorders. 15 Lindesay J, Briggs C, Murphy E. The Guy's like plaques were not found. Spongy degen- Anxiety disorders were found to correlate age concern survey: prevalence rates of cog- nitive impairnent, depression, and anxiety in eration was also seen in the molecular layer with a of having history psychiatric disorders an urban elderly community. Br Psychiatry and brainstem, but cerebellar peduncles and impaired activities of daily living. This 1989;155:317-29. were not demyelinated and there was no cell supports the statement by Lindesay'6 that 16 Lindesay J.
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