Functional Psychoses Is the Concept Disintegrating?

Letters

repetitive yelling, and disruptive behavior. His clinical improvement may be related to the mechanism of actions of these medications. Trazodone, a serotonin reuptake inhibitor, and buspirone, a serotonin agonist, both enhance serotonergic neurotransmission. Though most neurobiological studies have centered on the role of noradrenergic neurotransmittors in PTSD, it has been suggested that irregularities of serotonin transmission may contribute to the pathophysiology of PTSD. 4 This case indicates that the combination of trazodone and buspirone may be a useful pharmacological treatment for PTSD in MID patients. Rita Hargrave, M.D. University of California, Davis Deparunent of Psychiatry Oakland,CA

References I. Freidman MJ: Toward rational pharmacotherapy for posttraumatic stress disorder: an interim repon. Am J Psychiatry 1988; 145:281-285 2. Greenwald BS, Marin DB, Silverman SM: Serotonergic treatment of screaming and banging in dementia. Lancet 1986; 20: 1464-1465

3. Colenda CC: Buspirone in the treatment of agitated dementia (Iener). Lancet 1988; 20: 1169 4. McDougle CJ, Southwick SM, Charney OS, et aI: An open trial of f1uoxetine in the treatment of posttraumatic stress disorder. J Clin Psychopharmacol 1991; 11:325327

imaging (MRI) to those more subtle abnormalities seen in patients with "typical" schizophrenia. 2 In a separate study, patients with multiple sclerosis in whom mania appeared as an initial presentation of psychosis did not show any distinct pattern of white matter lesions on MRI. 3 Nevertheless, the application of modem neuroimaging technology to the study of such patients may provide potentially valuable clues to the nature of "functional" psychoses. Furthermore, such approaches, in tandem with the emergence of cognitive neuropsychiatry,4 represent important advances in the quest for greater conceptual and nosological clarity. Peter F. Buckley, M.D. Case Western Reserve University DepartrnentofPsychiatry Cleveland,OH

References I. Burstein A: Bipolar and pure mania disorders precipitated by head trauma. Psychosomatics 1993; 34: 194-t95 2. Buckley P, Stack JP, O'Ca\\aghan E, et aI: Magnetic resonance imaging of the schizophrenia-like psychoses associated with cerebral trauma: c1inico-pathological correlates. Am J Psychiatry 1993; 150: 146-148 3. Hutchinson M. Stack JP, Buckley P: Bipolar affective disorder prior to the onset of multiple sclerosis. Acta Neurol Scand (in press) 4. David AS: Cognitive neuropsychiatry? Psychol Med 1993; 23:1-5

Functional Psychoses Is the Concept Disintegrating? SIR: I read with interest the report by Burstein on the relevance of cerebral trauma to mania.· Recent refinements in our understanding of the extent and nature of structural brain abnormalities in apparently "functional" psychoses challenge the basic tenets of this concept and focus renewed interest on schizophrenia-like and affective-like organic psychoses. 2,3 We have recently reported on the clinicopathological correlates of cerebral trauma in patients with schizophrenia-like psychoses and note a close similarity in the pattern of lesions on magnetic resonance

462

PSYCHOSOMATICS