ARTERIOSCLEROTIC BRAIN DISORDER

A psychotic disorder caused by hardening of the arteries in the brain; classified by The American Psychiatric Association (1952) as “Chronic Brain Syndrome associated with cerebral arteriosclerosis.”A substantial percentage of psychosis occurring in later life is due to constriction or blocking of the cerebral arteries. This condition reduces the flow of blood which brings nutrition to the brain, resulting in damage to neural tissue and loss of mental functions. The term arteriosclerosis is somewhat loosely used in this connection to cover both the hardening of cerebral arteries and the narrowing of these blood vessels due to the formation of “plaques,” or patches of fatty and calcified material on their inside walls. The latter condition is known specifically as atherosclerosis, and is believed to be more directly reponsi- ble for the reduction of blood circulation than is a simple hardening of the arteries, since the deposits narrow the opening or “lumen” of the blood vessels. Brain circulation may be slowed by these deposits but also by blood clots clinging to the inside walls of the arteries (cerebral thrombosis), or by sloughed-off material carried to a narrow point in the arterial system (embolisms).Blockage of the flow of blood may in some cases cause a rupture of blood vessels and consequent hemorrhage. If small blood vessels are involved, a “small stroke” occurs. A single stroke may lead to temporary mental and physical symptoms, but a series of these strokes may result in cumulative brain damage. If a large blood vessel is blocked or ruptured, a major stroke or “cerebral vascular accident” is suffered, leading not only to a confusional state or coma, but to serious and usuallypermanent loss of brain functions—if the patient survives at all.These disorders are on the increase because of the lengthening span of life. The number of victims in this country is estimated at two million men and women at present. Not infrequently cerebrovascular disease leads to serious mental illness—“psychosis with cerebral arteriosclerosis”—and this disorder ranks second to schizophrenia, constituting about 12 per cent of all first admissions to mental hospitals in 1965. The onset of the psychosis usually occurs after fifty-five years of age, and the age at first admission is about seventy-four years for both sexes, with males slightly outnumbering females.The clinical picture in these psychoses is greatly varied, since the symptoms depend on the nature and extent of brain damage as well as the pre-illness personality and life situation of the patient. Over half of all patients suffer a sudden attack as a result of a cerebral vascular accident, and are brought to the hospital in a state of acute confusion. They continue to show such symptoms as clouding of consciousness, disorientation, incoherence, excitement, and restlessness. About 50 per cent become temporarily paralyzed on one side of the body (hemiplegia). If these patients survive the acute attack, their symptoms usually subside in time but leave some residual mental and physical impairment.Many patients, however, suffer from a series of small strokes instead of a large or apoplectic stroke and develop such physical symptoms as acute indigestion, unsteadiness in walking, aphasia, and changes in handwriting. Accompanying these effects are such psychological symptoms as irritability, intense concern with bodily functions, and general mental deterioration. Additional strokes may bring on periods of delirium, incoherence, paralysis, and convulsions. Their combined effect is to weaken the patient to a point wherehe has to remaing in bed. He usually succumbs within three to five years as a result of pneumonia, heart attack, or another stroke.Where onset is gradual, the initial symptoms are likely to be fatigue, headache, dizziness, memory defect, inability to concentrate, drowsiness late in the day, and reduced mental and physical efficiency. Some patients are subject to syncopal attacks (fainting spells). In most cases there is also a noticeable character change or exaggeration of previous personality tendencies. As the disease slowly progresses these patients may become irritable, jealous, suspicious, and flare up at the slightest provocation, after which they tearfully apologize. They also lose their initiative, neglect their appearance, and have a fixed expression on their faces. As mental deterioration sets in, they lose their power to concentrate, remember names, or do productive work of any kind. As in senile dementia, judgment is increasingly impaired, control of behavior is relaxed, and sexual indiscretions may be attempted, particularly with children. See SYNCOPE.The general physical, mental, and moral decline of the advanced arteriosclerotic patient cannot be distinguished from the deterioration that occurs in senile dementia. Sometimes the two disorders may be present at once. In the less advanced stages, however, differential diagnosis is usually possible. Cerebral arteriosclerosis often sets in earlier in life and develops and runs its course more rapidly, especially when a vascular accident occurs. Intellectual impairment is less marked than in senile dementia. The patient usually has some recognition that he is failing both physically and mentally, and therefore is likely to develop depressive rather than paranoid reactions. Headaches, dizziness, convulsive seizures, and emotional lability are more common in arteriosclerotic patients, and there is usually greater fluctuation in the course of the disease.This fluctuation is probably due to the fact that a series of minor hemorrhages frequently occurs, with relative absence of symptoms between attacks. If the course of the disorder is gradual, the patient may profit from rehabilitation procedures. Tranquilizing drugs are frequently administered to reduce insomnia, restlessness, and confusion. A balanced regimen of physical activity, good nutrition, recreation, and rest will help these patients maintain some sense of well-being as long as possible.Illustrative Case: ARTERIOSCLEROTICBRAIN DISORDER L.A., white male, fifty-seven, admitted on court order for observation. Complained that, “I have weak spells, I’ve had them for four years. I get dizzy, sometimes I think it’s my mind. My family upsets me all the time.”Developmental history is that of individual with sixth-grade education, no serious illnesses or accidents, outgoing social interests; marriage compatible until about four years ago. Farmed all his life.Family history significant in that mother and one sister died of “apoplexy.” Examination upon admission showed neat, well-nourished male of stated age who displayed prominently emotional lability, weeping frequently but quickly shifting to different mood level. Talk coherent and relevant; displayed a defensive attitude with definite paranoid trends. Admitted increased irritability for four years and said he occasionally lost his temper. Was preoccupied with wife’s supposed infidelity and accused children of wanting him “out of the way.” Believed they purposely did things to antagonize and upset him. Hallucinations were not elicited. Orientation was satisfactory, but examination of remote memory was punctuated by such remarks as “I’m gonna guess,” “Now let me see,” and “Well, sir, I can’t tell you.” Recent memory intact.