LETTERS

Dopamine-Responsive
Dysnomia?
SIR: Recently,
we evaluated
and
treated
a patient
with post-stroke
depression.
Computed
tomography
(CI) revealed
a right subcortical
and a left medial
frontal
cortical
infarct and significant
neuropsychological impairment,
including
dysnomia,
and depressed
mood
were present. Aphasias (including
dysnomia)
classically
improve
within the firstthree to six months
after an infarction.1 Further, aphasic
disorders
are not prominent
in
depressive
pseudodementias.2
Surprisingly,
the patient’s
dysnomia
remitted
with successful
treatment
of
the post-stroke affective disorder,
though
the infarction
had occurred
eight months
earlier.
During
that
eight months
there had been little
change
in the naming
abnormality.
The patient
was a 52-year-old,
right-handed
woman
with insulindependent
diabetes
mellitus
and no
previous
psychiatric
history.
She
suffered
a cerebrovascular
accident
(CVA) six months
prior to evaluation. Upon presentation,
she described
feeling
a loss of interest
in
usual activities,
anergia,
irritability,
impaired
memory
and motivation,
low mood,
anxiety,
and phobia
of
driving
for the last several
months.
She complained
of motor
weakness
in her right hand. A mental
status
examination
revealed
flat and depressed
affect, hypomimia
without
parkinsonian
findings,
word-finding abnormalities,
and anxious
mood without
psychomotor
agitation. Behavior,
speech,
appearance,
intellect,
memory
(immediate,
recent,
and remote),
insight,
judgment, orientation,
fund of knowledge, flow of thought,
thought
content,
spelling,
reverse
spelling,

JOURNAL

OF NEUROPSYCHIATRY

and subtraction
of serial 7s were
otherwise
normal.
Several
months
earlier,
the patient
had had an episode
of abrupt
onset
of “confusion”
and decreased
grip
in the left hand which fully resolved.
There were no difficulties
with speech,
vision, or swallowing.
Family
history
was negative
for depression,
but the patient’s
father
and paternal
grandfather
had had
“senility.”
The neurological
examination
was notable
for 5-15 decreased
right hand grip, slow rapid
alternating
movements,
and poor
tandem
gait without
other contributory motor,
cerebellar,
sensory,
cranial nerve, or reflex changes.
A
diagnosis
of organic
mood disorder,
depressed
type, was made.
Neuropsychological
testing
revealed
significant
dysnomia.
Ihe patient completely
missed
two test
items and exhibited
prolonged
response
time on two other items out
FIGURE

1.

Computed

caudate

tomography
infarctions

scan

of a total of six items. Other abnormal tests included
Trails A and B,
Categories,
and the lactual
Performance lest.
A CT scan revealed
a wedgeshaped
infarction
of the left anterior
cerebral
artery territory
and a small
lucency
in the right caudate.
Cortical language
areas were not involved.
The patient
was begun
on 100 mg
bid bupropion,
an antidepressant
with dopamine
agonist
properties,
which then was increased
to 100 mg
tid. Within
six weeks of treatment,
all depressive
signs and the phobia
remitted.
Repeat
testing
revealed
complete
remission
of the dysnomia, and the word-finding
impairment was now absent
on mental
status exam. Other neuropsychiatric
features
were unchanged.
This report
points
to the variability of features
associated
with poststroke depression
(e.g., phobias).

demonstrating

left anterior

cerebral

and

right

353

LETFERS

Post-stroke
depression
is quite common with left frontal
lesions.3
This
case suggests
that reversible
depressogenic
aphasic
disorders
may
remit with treatment.
Lesion location1 and resolution
time course
were unusual
for dysnomic
disorders. Finally,
this report
supports
the idea that dopamine
agonists
(bupropion
in this case) may ameliorate aphasic
disorders.
Medial
frontal lesion speech
hesitancy4
and
hypokinesia5
(possibly
due to yentrotegmentocortical
dopamine
pathway interruption)
are remediable
with D2 agonists.45
EDWARD
C. LAUTERBACH,
M.D.
I.ELISABETH
SPEARS,
M.S.
MICHAEL
J. PREWETF, PH.D.
Department
Behavioral
Mercer
Macon,

University
Georgia

The authors
mings,

of Psychiatry
Science

and

School

of Medicine

thank

Jeffrey

L. Cum-

and

Barbara

Warren.

M.D.,

References
1.

Kertesz
ders,

2.

A: Aphasia
and Associated
Taxonomy,
Localization,
and

ery. New York, Grune and Stratton,
pp 152-153
Stoudemire
A, Hill C, Gulley LR, et al:
Neuropsychological
and biomedical
sessment
of depression-dementia
dromes.

The

and Clinical
361
3.

4.

Journal

assyn-

University

School

New Haven,

Connecticut

of Medicine,

1989; 1:347-

for aphasia.

Neurology

1988; 38:877-879
Jackson
DM, Ross SB, Hashizume
M: Dopamine-mediated
behaviors
produced
in
naive
mice by bromocriptine
plus SKF
38393.J
Pharm
Pharmacol
1988; 40:221-

223

Neuropsychiatrist-Who
Qualifies
as One?
SIR: Your definition
of neuropsychiatry in the Fall 1989 issue is too restrictive.
In the classical
tradition,

354

Yale

of Neuropsychiatry

Neurosciences

Robinson
RG, Kubos
KL, Starr
LB, et al:
Mood
changes
in stroke
patients:
relationship to lesion
location.
Compr
Psychiatry
1983; 24:555-566
Albert
ML, Bachman
DL, Morgan
A, et at:

Pharmacotherapy
5.

Disor-

Recov1979,

psychiatrist
was a neurologist. It has only been with the overenthusiastic
embrace
of Freud’s
very interesting
theories
by nonmedical
therapists
that psychiatry
has strayed
from the path of treating diseases
of the brain. This trend
must be reversed
if psychiatry
is to
remain
a viable specialty
in the
modern
era of neuroscience.
In my opinion,
psychiatrists
may
not call themselves
neuropsychiatrists unless
they are capable
of performing
a very skillful
neurological
examination
and are able to interpret the data obtained
in light of the
patient’s
history
and complaints.
Likewise,
neurologists
who call
themselves
behavioral
neurologists
but who are not capable
of treating
schizophrenia,
manic depression,
panic disorder,
or obsessive
compulsive disease,
as well as evaluating
dementia
and aphasia,
have no business calling
themselves
neuropsychiatrists.
In this era of third-party
payment
and studies
of efficacy
and utilization, psychiatry
must return
to its
medical
heritage
if it is to remain
part of the medical
profession.
JAMES
R. MERIKANGAS,
M.D.
every

In Reply
The definition
of neuropsychiatry
to
which
you refer was included
in the
editorial,
“When
Patients
Ask...
What is Neuropsychiatry?”1
In this
editorial,
we attempted
to craft a
nontechnical
definition
of neuropsychiatry
for use by patients,
their
family
members,
or the many other
individuals
who may benefit
from
neuropsychiatric
services.
We believe that your letter refers more to
a technical
definition
of how we
neuropsychiatrists
“define
ourselves”
and how we differentiate
our field from other professional

disciplines.

Among

the

important

questions
that your letter raises are:
1) What should
be the knowledge
base and skills of the neuropsychiatrist and behavioral
neurologist?
and 2) What comprise
the diagnostic entities
that define
the boundaries of neuropsychiatry?
For
historical
background
in this area,
we recommend
that you read from
the excellent
text The Bridge Between
Neurology
and Psychiatry,
particularly the chapters
by Sir Denis Hill
and Professor
W. A. Lishman.2’3
Both authors
trace the histories
of
psychiatry
and neurology
and the
interface
of these fields through
the
paradigm
of neuropsychiatry.
Ihey
also add their own personal
conclusions about certain
of the definitional issues that you raise in your
letter.
We believe
that the concept
of
neuropsychiatry
constantly
is evolving and that we presently
are at the
beginning
of a nonparalleled
era of
opportunity
for its growth
and impact. We believe
that newly formed
organizations,
such as the American
Neuropsychiatric

Association

and

the British Neuropsychiatry
Association, as well as, we hope, new scientific journals,
such as The Journal
of Neuropsychiatry
and Clinical Neurosciences, will, through
their leadership, initiatives,
and foci, serve best
to define on an ongoing
basis what
a neuropsychiatrist
is and does.
STUART
YUDOFSKY,
M.D.
ROBERT
E. HALES,
M.D.
References
1. Yudofsky
SC, Hales
RE: When
patients
ask.. .What
is neuropsychiatry?
The Journal of Neuropsychiatry
and Clinical
Neurosciences
1989; 1:362-365
2. Hill D: The bridge
between
neurology
and psychiatry,
in The Bridge Between

Neurology
and Psychiatry,
Vol 3. Edited
by Reynolds
EH, Trimble
MR. New York,
Churchill
Livingstone,
1989, pp 11-23
3. Lishman
WA: Neurologists
and psychiatrists,
in The Bridge
Between
Neurology
and Psychiatry,
Vol 4. Edited
by Reynolds
EH, Trimble
MR. New York,
Churchill
Livingstone,
1989, pp 24-37

VOLUME

2 #{149}
NUMBER

3.

SUMMER

1990