Brain, Vol. 124, No. 10, 2121,
October 2001
© 2001 Oxford University Press
Book reviews |
THE CLINICAL NEUROPYSCHIATRY OF STROKE: COGNITIVE, BEHAVIOURAL AND EMOTIONAL DISORDERS FOLLOWING VASCULAR BRAIN INJURY.
By Robert G. Robinson. 1998. Cambridge: Cambridge University Press. Price £60. Pp. 491. ISBN 0-52144-234-6.
Professor of Liaison Pyschiatry, Leeds, UK
Neuropsychiatrists are interested in stroke because of what it might tell us about the neural basis of mental disorder. The stroke lesion is (apparently) neatly localized, and onset is sudden so that it is relatively easy to characterize the course of associated mental abnormality. In this book, Dr Robinson concentrates on his own research in stroke-related psychopathology. His main studies have been in the nature of depression associated with stroke, and his thesis (broadly) is this. Depression is a specific complication of stroke, and it has two different manifestations. The more interesting is the so-called major depressive syndrome—it comes early and persists; it is strongly associated with lesion location; it affects social and intellectual function and it is associated with worse outcomes, including increased mortality. Fortunately it responds to antidepressant medication.
Minor depression, a depressive syndrome with fewer symptoms than its major cousin, has a different profile, and it is generally less exciting in what it tells us about the brain. Other disorders are of some interest, and particularly there is the intriguing idea that mania is a mirror image of major depression, at least as far as lesion location goes.
Undoubtedly the best known part of all this is Robinson's lesion location theory, and particularly his claim that major depression is strongly associated with lesions located in the anterior parts of the left hemisphere. On the face of it, this is a surprising hypothesis. Mood is generally thought to be modulated by slow regulatory signalling in monoaminergic pathways that are diffusely distributed throughout the brain. While the association between frontal damage and mood disturbance is well known, more specific links between lesion location and mood disturbance would not be what one might expect. And yet this is what Robinson and his colleagues have found, and found repeatedly. The theory is at the core of this book, where it serves as a prototype for a far-reaching system that attempts to locate mental disorders in the brain. Thus, the book takes the form of a series of chapters reviewing research (mainly Robinson's) in stroke-related psychiatric disorders, and culminates in a table that lists 12 psychiatric syndromes and the lesion locations with which each is associated.
The most striking initial impression created by reading through the whole work is how thin the evidence is. Many of the studies involve small numbers, with multiple subgroup analyses on samples whose sizes rarely get out of single figures. Chance, bias and confounding—the researcher's unwanted but unavoidable fellow travellers—don't attract much of the author's attention, even if they are ever-present in the reader's mind. The citation of work by other people is extraordinarily partial.
This isn't a systematic review and it certainly isn't the neuropsychiatry of stroke. It does not provide a complete or even balanced view of psychiatric research. It tells a story. And the story is a curiously old-fashioned one about the link between cerebral and mental disorder. The picture that emerges is not of the brain as a dynamic highly networked organ, nor of mental disorder as having interesting psychological elements. Instead the overriding image is of a collection of bolted-together brain modules, each likely to produce (purely by biochemical and physiological disruption) a specific psychiatric disorder if it is damaged. This approach has been accurately described as naive localizationism, and the result reads like a phrenology for the 20th century. The primary research of others, and recent systematic reviews, tell a different story and, no doubt, more will follow.
Don't buy this book, but don't reject a neuropsychiatry of stroke either. There are important consequences to depression in any serious physical disease, and stroke offers a number of disturbances of emotionality that are well worthy of more research. Simply be cautious of claims that we already know many of the answers.
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