A review of the natural course of bipolar disorders (manic-depressive psychosis) in the pre-drug era: review of studies prior to 1950

A review of the most important original studies describing the natural course of bipolar disorder (manic-depressive psychosis) published in the pre-drug era - before 1950 - is conducted. Discrepancies among studies are detected, most of which are likely explained by methodological differences. However, some conclusions from these old studies remain perfectly valid nowadays: mania is a chronic brain disorder, inherited in most cases, decompensation being more frequent between March and August. It is more common in males, and in some cases, is secondary to other somatic problems. Mixed states are more frequent in the elderly. The review of this type of historical studies is aimed at underscoring the importance that should be attached to the careful study of psychopathology and its recording, both in clinical practice and in psychiatry research.

Formal thought disorder, neuropsychology and insight in schizophrenia

BACKGROUND

Information provided by patients with schizophrenia and their respective carers is used to study the descriptive psychopathology and neuropsychology of formal thought disorder (FTD).

SAMPLING AND METHODS

Relatively intellectually preserved schizophrenia patients (n = 31) exhibiting from no to severe positive FTD completed a self-report scale of FTD, a scale of insight as well as several tests of executive and semantic function. The patients' carers completed another scale of FTD to assess the patients' speech.

RESULTS

FTD as self-reported by patients was significantly associated with the synonyms test performance and severity of the reality distortion dimension. FTD as assessed by a clinician and by the patients' carers was significantly associated with executive test performance and performance in a test of associative semantics. Overall insight was significantly associated with severity of the reality distortion dimension and graded naming test performance, but was not associated with self-reported FTD or severity of FTD as assessed by the clinician or carers.

CONCLUSIONS

The self-reported experience of FTD has different clinical and neuropsychological correlates from those of FTD as assessed by clinicians and carers. The assessment of FTD by patients and carers used along with the clinician's assessment may further the study of this group of symptoms.

Insight and obsessive-compulsive disorder: a conceptual analysis

Analysis of insight in obsessive-compulsive disorders (OCD) raises conceptual problems that need addressing before meaningful empirical work can be undertaken. Insight and OCD are locked within a definitional contradiction relevant both to the nosological boundaries of OCD and the meaning of insight itself. Given that it is a form of self-knowledge, it is proposed here that insight is best conceived as a mental state rather than symptom or symptom-dimension. As an aspect of this mental state, the clinical phenomenon of insight should be understood as independent of any underlying disease albeit influenced by it and by other factors. As the focus of empirical research, the phenomenon of insight is dependent on the concept of insight, the measure by which it is assessed and on the 'object' of insight assessment. Explication of these factors allows for the delineation of specific insight phenomena whose respective usefulness can be determined by empirical research.

Epistemology of mental symptoms

BACKGROUND AND METHODS

Psychiatric diagnosis is dependent on the identification of mental symptoms. On the assumption that they are 'natural kinds', the latter are routinely entered as correlational variables in empirical research. Published work on the philosophy of psychiatry has tended to concentrate on the concept of mental disorder or on individual symptoms but has given less attention to mental symptoms as a class. This paper deals specifically with the epistemology of mental symptoms, that is, with focusing on the nature of mental symptoms as a class of 'objects' and how the clinician gets to know them. In order to do this, mental symptoms can be explored from various perspectives, namely: (i) as types of objects, (ii) as structures, (iii) as definitions, (iv) as pockets of meanings, (v) as comprising constituents, (vi) as attractors in specific dialogical contexts, etc. In this paper, on account of space constraints, we deal only with the former 4 perspectives.

RESULTS AND CONCLUSION

Our analysis shows mental symptoms to be unstable constructs with implications for both correlational research and further theoretical exploration.

'Essay on a classification of different genera of insanity'. 1853

Less well known than some of his contemporaries, Jules Baillarger (1809—90) tends to be celebrated by `who said it first' writers as the man who assisted the `birth of bipolar disorder'. This view is based on the anachronistic claim that Baillarger's `insanity with a double form', Kraepelin's `das manisch-depressive Irresein', Leonhard's concept of Bipolarität and DSM-IV's `Bipolar I and Bipolar II' Disorder somehow constitute an incremental approximation to the same `disease'. Baillarger is important because he was a high profile conceptual interlocutor in the great 19-century debates on hallucinations, hypochondria, language disorders, General Paralysis of the Insane, cretinism and goitre. Classic Text No. 75 is a translation of Baillarger's important 1853 paper on the classification of madness, and it is a good illustration of the popular method of top-to-bottom psychiatric taxonomy. Written before psychiatrists felt the need to conceal the theoretical nature of the exercise behind a farrago of `empirical evidence', it shows how hidden assumptions govern the way in which the boundaries of mental disorders are actually drawn.

Incidence and diagnostic stability of ICD-10 acute and transient psychotic disorders

OBJECTIVE

The 10th Revision of the International Classification of Diseases (ICD-10) introduced a new diagnostic category, F23 acute and transient psychotic disorders (ATPD) to embrace clinical concepts such as the French bouffée délirante, Kleist and Leonhard's cycloid psychoses, and the Scandinavian reactive and schizophreniform psychoses. The relative rarity of these disorders and insufficient follow-up studies with adequate numbers of patients makes ATPD classification as uncertain as their validity. The aim of this study was to evaluate incidence and validity of ATPD in terms of diagnostic stability.

METHOD

A 6-year analysis of readmission patterns of all subjects listed in the Danish psychiatric central register as having been first-ever admitted to hospital or treated in outpatient services with a diagnosis of ATPD from January 1 to December 31, 1996, was conducted.

RESULTS

The incidence of ATPD was 9.6 per 100 000 population, with a higher rate of females than males (9.8 vs 9.4). Incidence rates by age group were higher for males than for females, with a marked reversal of this pattern above 50 years. This contrasted with incidence of schizophrenia that was almost twice as high in males as in females, particularly in the 20-29 year age group. Of 416 cases with a first-admission diagnosis of ATPD, an increasing number tended to change on subsequent admissions, nearly half to another F2 category schizophrenia and related disorders. The overall stability rate reached only 39%.

CONCLUSIONS

Although demographic differences from schizophrenia are topics that deserve further research, poor diagnostic stability argues against attempts to separate ATPD from borderland disorders.

Two new scales of formal thought disorder in schizophrenia

Information provided by patients and respective carers may help to understand formal thought disorder (FTD) in schizophrenia. Two scales, one for patients (FTD-patient) and one for carers (FTD-carer), were constructed to assess pragmatics, cognitive, paralinguistic, and non-verbal aspects of communication. In the first scale the patients themselves assess their verbal communication; in the second scale the carer assesses the speech of the respective patient. Both scales exhibited internal reliability and evidence of good test-retest reliability. Higher total scores on both scales (FTD-patient and FTD-carer) were significantly associated with positive FTD, but not with negative FTD. Principal component analysis of the scales yielded a multidimensional structure. It is suggested that FTD in schizophrenia may be associated with a range of deficits (e.g. pragmatics, lexical activation, working memory, sustained attention). These scales, in conjunction with the clinician's assessment, can provide a more comprehensive picture of FTD in schizophrenia, revealing its dimensions and making it possible to establish associations between symptoms of FTD and neuropsychological, neurophysiologic, and neuroimaging data. In addition, they provide service users' and carers' perspectives for the assessment of communication in schizophrenia.

Confabulation in schizophrenia and its relationship to clinical and neuropsychological features of the disorder

BACKGROUND

A form of confabulation has been documented in schizophrenia and appears to be related to the symptom of thought disorder. It is unclear whether it is associated with the same pattern of neuropsychological deficits as confabulation in neurological patients.

METHOD

Thirty-four patients with chronic schizophrenia, including those with and without thought disorder, and 17 healthy controls were given a fable recall task to elicit confabulation. They were also examined on a range of executive, episodic and semantic memory tests.

RESULTS

Confabulation was seen at a significantly higher rate in the schizophrenic patients than the controls, and predominated in those with thought disorder. Neuropsychologically, it was not a function of general intellectual impairment, and was not clearly related to episodic memory or executive impairment. However, there were indications of an association with semantic memory impairment.

CONCLUSIONS

The findings support the existence of a form of confabulation in schizophrenia that is related to thought disorder and has a different neuropsychological signature to the neurological form of the symptom.

Cotard's syndrome in adolescents and young adults is associated with an increased risk of bipolar disorder

OBJECTIVES

To assess the effect of age at onset on the phenomenology of Cotard's syndrome (CS) as a recent study reported a high rate of occurrence of bipolar disorder (BD) in adolescents and young adults with CS followed up for > or =2 years.

METHODS

We reviewed all cases of CS reported since it was first described. A statistical analysis was carried out to determine the effect of age at onset on CS phenomenology.

RESULTS

We found 138 cases including 21 cases aged 25 years or younger. In these younger CS patients, BD was more frequent, and the risk of associated BD was increased nine times (p < 0.0001). Within the BD sub-group (n = 27), admixture analysis identified two sub-groups with mean ages at onset of 18.7 years [standard deviation (SD) = 3.2] and 50.5 years (SD = 11.7).

CONCLUSIONS

Young people with CS should be monitored carefully for the onset of BD, and families should be educated about this risk. Treatment with mood stabilizers can be helpful for those who develop BD. Within BD associated with CS, early versus late onset should be distinguished.

An analysis of the cognitive deficit of schizophrenia based on the Piaget developmental theory

OBJECTIVE

The objective of the study was to evaluate from the perspective of the Piaget developmental model the cognitive functioning of a sample of patients diagnosed with schizophrenia.

METHOD

Fifty patients with schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and 40 healthy matched controls were evaluated by means of the Longeot Logical Thought Evaluation Scale.

RESULTS

Only 6% of the subjects with schizophrenia reached the "formal period," and 70% remained at the "concrete operations" stage. The corresponding figures for the control sample were 25% and 15%, respectively. These differences were statistically significant. The samples were specifically differentiable on the permutation, probabilities, and pendulum tests of the scale.

CONCLUSIONS

The Longeot Logical Thought Evaluation Scale can discriminate between subjects with schizophrenia and healthy controls.

'The clinico-diagnostic perspective in psychopathology' by K Kahlbaum

Karl Kahlbaum (1828-99) introduced the concept of time into European psychiatric nosology. In 1863 he first expressed the view that disease definition should take into account the course of the disease, the extension to which psychological functions were compromised, the relevance of the period of life when the mental disorder first appeared, and its primary or secondary nature. Via E. Kraepelin these ideas have moulded the way in which mental disorder has been conceived ever since. And yet Kahlbaum never made it into academic psychiatry. For reasons which remain obscure, he did not obtain a university teaching position and had to spend the rest of his life in private psychiatry. Whether the novelty of his ideas irked contemporary psychiatric officialdom needs further study.

'The varieties of effects resulting from such morbific causes as are capable of rendering more vivid the feelings of the mind' by S. Hibbert (1825)

The transformation of the old notion of apparition into the new concept of hallucination started in earnest at the beginning of the 19th century. Apparitions were naturalized on the argument that in no case were they a response to an external stimulus; and were secularized by challenging the very existence of external spirits or forces. Both arguments are clearly stated in the work on 'Apparitions' by Samuel Hibbert (a chapter of which has been included below as Classic Text No. 69). Although the debate on the ontology and meaning of the 'phantasms of the living' has continued to this day, it has had no influence on the medical concept of hallucination. It is likely that the latter has suffered as a result.

The relationship of reactive psychosis and ICD-10 acute and transient psychotic disorders: evidence from a case register-based comparison

BACKGROUND

ICD-10 introduced a new diagnostic category, F23 'acute and transient psychotic disorders' (ATPD), to embrace clinical concepts such as bouffée délirante, cycloid psychosis, psychogenic (reactive) psychosis and schizophreniform psychosis. The purpose of this study was to examine the relationship between the concept of reactive psychosis (RP), equivalent to the ICD-8 298 category of 'other psychoses', and ATPD.

SAMPLING AND METHOD

Since January 1, 1994, ICD-10 has replaced ICD-8 as official classification in Denmark. Patients given an ICD-8 298 diagnosis on their last admission in 1992-1993 were identified from the Danish Psychiatric Central Register, and the ICD-8 diagnoses assigned were compared with their ICD-10 diagnoses when readmitted in 1994-1995.

RESULTS

Diagnosis of RP was recorded in 19.2% of patients with functional psychoses in 1992-1993, whereas ATPD overall prevalence accounted for 8.7% of those with non-organic psychotic and affective disorders in 1994-1995. Thirty-eight per cent of patients with an ICD-8 298 diagnosis were readmitted during the years 1994-1995. Schizophrenia and related disorders (F2) and affective disorders (F3) accounted for three quarters of ICD-10 diagnoses. The most frequently used ATPD subcategories were F23.3 'other acute delusional psychotic disorders', F23.0 'acute polymorphic psychotic disorder without symptoms of schizophrenia' and F23.9 'acute and transient psychotic disorder unspecified'. A significant majority were female and associated acute stress was recorded only in 5.3% of cases.

CONCLUSIONS

ICD-8 298 register diagnosis of RP showed little empirical continuity to ATPD and conformed more to F23.3 acute delusional disorder among ATPD subtypes.

'Mind in general' by Sir Alexander Crichton

The history of the 'philosophies of psychiatry' can be defined as the contextualized study of past theoretical views on the nature, understanding and management of madness and related notions. The application of an hermeneutic apparatus to past psychiatric narratives gives rise to the history of psychiatry; its application to current narrative gives origin to the philosophy of psychiatry. If the latter employs off-the-shelf, ready-made, external philosophies, it follows a centripetal approach; if it starts from the inside of psychiatry and generates its own tools and meta-language, it follows a centrifugal approach. Psychiatry is burdened by intrinsic and extrinsic philosophical problems. The former result from its hybrid nature, i.e., from the fact that psychiatry unsteadily straddles the natural and human sciences. The latter are borrowed from the conceptual frames into which psychiatry has been inscribed since the 19th century. The philosophy of psychiatry may anticipate or follow empirical research. The ante rem mode is based on the idea that empirical research requires conceptual supervision, audit and guidance, for it is always ideology- and theory-laden. The post rem mode is based on the view that science is the only way to 'truth' and hence all that the philosophy of psychiatry can (or should) do is facilitate, interpret, justify, defend or glorify empirical findings. The Classic Text that follows was written by Sir Alexander Crichton at the end of the 18th century, and is a good example of the centripetal mode of philosophy-making.

Approaches to the assessment of awareness: conceptual issues

Recent interest in the empirical exploration of patients' awareness in relation to their clinical states has resulted in a range of approaches taken to evaluate such awareness. These approaches vary in terms of the bases on which awareness is determined and rated, the contents of the measures used, the level of detail and complexity of judgements required, etc. The approaches use different definitions and objects of awareness and hence give rise to different (and on occasions divergent) awareness phenomena. Such differences help to explain both the contradictory nature of published results and the difficulties involved in generalising from them. In practical terms, these differences should encourage the development of management and rehabilitation strategies that are individual to specific phenomena of awareness.

'Madness from the womb'

The word 'nymphomania', the concept of 'madness from the womb' and the belief in the existence of a behaviour consisting in an abnormally high female sexual drive converged during the second half of the seventeenth century to give rise to a new clinical category which, with minor changes, has survived until the present (e.g., in ICD-10). This Classic Text, an excerpt from the work of Lazare Rivière, provides a glimpse into the process whereby medical categories are constructed. According to Rivière (and many others) 'madness from the womb' was a disease which resulted from overheating and putrefaction of accumulated seed (female sperm) in the womb. Like all medical constructs, 'madness from the womb' (and soon nymphomania) included a symptomatology, natural history, aetiology, prognosis and cure. It is also clear that it was rehash of the earlier moral notion of 'satyriasis' (a male category applied to women) and the expression of seventeenth-century changing male attitudes towards, and fears of, female sexuality.

Phthisical insanity by T.S. Clouston

The history of the relationship between tuberculosis and insanity has been neglected. This is surprising, for during the nineteenth century it was subject to an important medical and cultural debate and gave rise to a style of analysis which has been used ever since to study the clinical phenomenon of 'disease-coexistence' (rebaptized 'comorbidity' during the 1970s). Triggered by a perceived increase in the prevalence of tuberculosis and insanity, the debate centered around the meaning and mechanisms of disease-coexistence, techniques which may be used to rule out fortuitous associations, the comparative relevance of epidemiological, congenital, genetic and environmental factors, and the clinical effects that the members of the disease pair may have on each other. The Classic Text reprinted below provides an adequate introduction to the main issues listed above.

On the fantastic apparitions of vision by Johannes Müller

The history of the construction of the concept of hallucination remains biased in the favour of the French contribution. Important to this history are the first 30 years of the nineteenth century for it was then that it was decided that hallucinations were: (1) primary disorders of perception; (2) the same class of phenomena, regardless of the sense of modality in which they occurred; (3) generated by stimulation of brain regions related to perception and hence were mechanical responses with no semantic or informational import; and (4) medical problems. In 1826 Johannes Müller published a book on the fantastic phenomena of vision. Therein her proposed new rules for the description and explanation of hallucinations. Although published after Purkinje's books on an analogous theme, and after Esquirol's entry for the Panckoucke dictionary, Müller's book served as one of the foundations for the new nineteenth-century speculative physiology and physiopathology of hallucinations. This way of conceptualizing these phenomena was to culminate in the irritation model proposed by Tamburini in the 1880s. This paper justifies the choice of Müller's book as a classic text, provides biographical data about its author, and places the book in its historical context.

The Addenbrooke's cognitive examination (ACE) in the differential diagnosis of early dementias versus affective disorder

OBJECTIVE

The authors describe the profile of performance of patients whose cognitive complaint is due to dementia, affective disorder, or combinations thereof on the Addenbrooke's Cognitive Examination (ACE) test battery.

METHODS

Authors tested 90 subjects with dementia (63 Alzheimer disease [AD]; 27 fronto-temporal dementia [FTD]), 60 subjects with "pure" affective disorder (23 major depression [MDD], 37 whose affective symptoms did not meet criteria for major depression [Affective]); 22 patients with symptoms of affective disorder and organic dementia (Mixed); and 127 healthy volunteers (NC).

RESULTS

The total ACE scores for the AD, FTD, and Mixed groups were significantly lower than for the NC group. Likewise, on total score, the AD and FTD groups scored significantly lower than either of the "pure" affective-disorder groups. Within the dementia group, the AD group scored significantly lower than the fronto-temporal group.

CONCLUSIONS

The profile of performance on the ACE of patients with dementia is different from that of patients suffering from affective illness. Mild impairment in the total ACE score, along with a low score on the memory domain tasks and letter fluency (in contrast to normal category fluency), are strongly indicative of an affective, as opposed to organic, pathology. A total score of <88 in suspected dementia patients with affective symptoms appears strongly predictive of an underlying organic disorder.

Excerpt from Medicinische Psychologie oder Physiologie der Seele by Dr Rudolph Hermann Lotze

Hermann Lotze (1817-81) is a neglected figure in the history of psychiatry although it has been claimed that his early views were influential, for example, on the young Griesinger. Trained as a physician, psychologist and philosopher he saw better than many the impending epistemological crisis that was to affect disciplines such as psychology and medical psychology as they were being taken over by the natural sciences. The problem he endeavoured to resolve was double-headed. On the one hand, Lotze believed that the mechanisms proposed by physiology and other relevant natural sciences were essential to the explanation of human behaviour provided that its meaning and context were respected; on the other, he wanted to do away with the mysterious (metaphysical) explanations such as 'vital force' which in his time were still popular in biology. The solutions he eventually offered can understandably be seen as a weak compromise and one which statisfied no one. Materialists à outrance such as Vogt, Büchner, Lange and Ribot though he was too 'metaphysical'; spiritualist philosophers believed that he had surrendered too much to biology. It is likely that Lotze remained, in fact, a metaphysician as can be ascertained by studying his concept of Seele (soul, mind) into which he packed enough furniture to make many believe that he was an idealist thinker. This paper discusses some of these issues and justifies the choice of classic text, namely, Lotze's illuminating Introduction to his book Medicinische Psychologie oder Physiologie der Seele.

Formal thought disorder in schizophrenia: an executive or a semantic deficit?

BACKGROUND

It has been hypothesized that the schizophrenic symptom of formal thought disorder is linked to both executive and semantic dysfunction.

METHOD

Intellectually preserved schizophrenic patients with (n = 15) and without (n = 16) formal thought disorder, plus matched normal controls (n = 17) were administered four executive and four semantic tests. Tests of verbal fluency and comprehension of grammar were also given.

RESULTS

The patients with formal thought disorder were significantly impaired on all four executive tests compared to the patients without the symptom. They were only impaired compared to non-thought-disordered patients on 1 of 4 semantic tests, which probed semantic associations between concepts. Naming performance did not distinguish the two groups, nor did a previously used measure of semantic fluency controlling for phonological fluency.

CONCLUSIONS

The results provide support for a dysexecutive hypothesis of formal thought disorder in schizophrenia, and, in line with other studies, suggest that there may be a restricted 'higher-order' semantic deficit which spares naming.

[The measurement of the depersonalisation-derealisation-syndrome with the German version of the Cambridge Depersonalisation Scale (CDS)]

Self-rating scales have proved to be essential in the study of depersonalisation, which regrettably, is still seldom recognised in clinical practice. In recent studies the Cambridge Depersonalisation Scale (CDS) has emerged as an useful instrument for the study of depersonalisation. Here we report a validation study of the authorised German version of the CDS in a sample of 91 inpatients, 43 of whom had pathological depersonalisation and 48 without pathological depersonalisation. The SCID-D Interview for depersonalisation and derealisation was used as the gold standard and the German version of the Dissociative Experiences Scale was used to test the external validity of the scale. The German version of the CDS was found to have high internal consistency and reliability (alpha = 0,95 and Guttman Split-half = 0,95) and could differentiate patients with pathological depersonalisation from the control group. We therefore conclude that the German version of the CDS can be considered as reliable and valid.

The association between negative and dysexecutive syndromes in schizophrenia: a cross-cultural study

This paper examined the relationship between the ‘negative syndrome’ (NS) and the neuropsychological ‘dysexecutive syndrome’ (DES) in schizophrenia. The study also examined whether any relationship that exists between the NS and the DES holds equally for British and Japanese subjects. We compared 26 Japanese with 17 British schizophrenic patients, divided into ‘mild’ and ‘severe’ NS groups, on the basis of performance on neuropsychological tests, including the ‘Behavioural Assessment of Dysexecutive Syndrome’ (BADS). We found that patients with severe NS showed more everyday executive deficits than those with mild NS. The severity of NS was correlated with executive competence. The association between NS and the BADS performance was closer than that between NS and other conventional executive measures. These findings were not influenced by cultural differences between Japanese and British subjects, and, hence, suggested the existence of culture-neutral neurobehavioural processes.

Of Mania: introduction (Classic text no. 57)

Classic Text no. 57 is meant to illustrate the way in which the old, pre-1800 clinical notion of mania was transformed into its current counterpart. In Classical times, the term 'mania' had been used to refer to three orders of objects: medical (as featured in this introduction and in the Classic text), theological (two Greek deities) (Smith, 1870) and epistemological. In regard to the last, a mania of 'divine'origin is mentioned by Plato in the Phaedrus, as a way to gain full knowledge, i.e., to journey from the sensible world to the ideal or intelligible world.By the end of the nineteenth century, however, the clinical category 'mania' had changed its referent completely: it now named a different symptom-cluster, was inscribed in a novel nosological frame, and was explained by new mechanisms. This metamorphosis took about sixty years to complete, and the extract reprinted below instances the way in which such a process took place within English alienism.

Assessment of insight in psychosis: a re-standardization of a new scale

Over the last decade, a number of tools have been developed to evaluate, in a systematic way, patients' insight into their psychotic illness. Such tools, however, capture different clinical phenomena of insight. So far, there is no indication as to which phenomenon of insight might be the most useful or predictive (e.g. clinically or therapeutically) to assess. This article reports the re-standardization of a revised self-administered insight scale in patients with psychosis, first published in 1992. It is meant to capture views held by individuals suffering from psychosis about changes occurring within themselves and in their environment. The scale was administered to 64 patients with a diagnosis of schizophrenia but with a range of symptoms and in different stages of their illnesses. This new version is simpler to use and score than the original instrument and shows good reliability, internal consistency and concurrent validity. This study forms the preliminary basis for future work examining the phenomenon of insight, its relationship to clinical variables and its predictive validity in terms of patients' behaviours and prognoses.

The insanities of the third age: a conceptual history of paraphrenia

In 1863, Kahlbaum used the term 'paraphrenia' to refer to insanities related to transitional periods life (there were adolescent and senile forms); Kraepelin used paraphrenia to refer to a form of paranoid psychosis with attenuated hallucinatory disturbances; and Leonhard named with it at least seven types of insanities. Since the turn of the 20th century the population hit by 'old age' has grown larger and cases of 'late-onset' insanity seem to be on the increase. Some of these insanities have different clinical features and respond differently to treatment and it is unclear whether this is due to pathoplastic effects, organic factors or social expectation. In the 1950s, the Newcastle school introduced 'late-paraphrenia'. The problem of how to classify the insanities of old age remains parasitical upon beliefs about the insanities affecting people. Historians see science and medicine as examples of social narrative and practice; clinicians see science and medicine as purveyors of absolute truth and as the only way to understand the insanities. This lack of convergence is hampering the understanding and management of elderly people suffering from insanity and must be resolved.

Erotomania: a conceptual history

Four historical convergences are identified in the history of erotomania. According to the first, which lasted from Classical times to the early eighteenth century, erotomania was a 'general disease caused by unrequited love'. According to the second, erotomania was a disease of 'excessive physical love (nymphomania)'; this view remained active well into the nineteenth century. The third convergence focuses on the view that erotomania is a form of 'mental disorder', and this was held throughout the twentieth century. The fourth and current definition (a development of the third stage) sees erotomania as a 'the delusional belief of being loved by someone else'. Differences between Anglo-Saxon and French views cast doubt on the meaning or coherence of the much-abused English eponym 'de Clérambault syndrome'. Erotomania is a construct, a mirror reflecting Western views on spiritual and physical love, sex, and gender inequality and abuse. On account of this, it is unlikely that there will ever be a final, 'scientific' definition rendering erotomania into a 'natural kind' and making it susceptible to brain localization and biological treatment.

Depression and anxiety in memory clinic attenders and their carers: implications for evaluating the effectiveness of cognitive rehabilitation interventions

BACKGROUND

The potential of cognitive rehabilitation (CR) for people who have a diagnosis of Alzheimer's disease (AD) is increasingly being recognised. It has been suggested, however, that interventions targeting memory functioning in AD have negative effects on the well-being of participants and carers in terms of mood and perceived strain. While some 'memory training' studies do report an increase in self-report scores on scales assessing these variables, it is not clear whether the changes are attributable to the intervention. There is some overlap between CR and 'memory training', but CR is a much more individualised approach, and therefore CR intervention studies often adopt within-subjects or single case experimental designs, for which relevant comparison data are required.

METHOD

Participant and carer depression and anxiety, and carer strain, were assessed at initial attendance and again by postal survey 6 months later in a consecutive series of 94 Memory Clinic referrals who received standard treatment but no specialised CR interventions.

RESULTS

At the group level, there were no statistically significant changes in scores at follow up, although the participants scoring above designated cut-points were not necessarily the same individuals at the two time points.

CONCLUSIONS

The study provided useful comparison data for use in evaluating the effects of cognitive rehabilitation interventions on mood and carer strain, showing that in the absence of intervention scores remain generally stable over time. Significant changes observed in intervention studies should be viewed in this context.

The concept of neuropsychiatry: a historical overview

The elusive nature of the social practice called neuropsychiatry is the most important obstacle for writing its history. At different times, and in different countries, the term has been used to name different ideological and professional packages. Choosing any of these as the prototype would, however, bias and regionalize the historical account. One solution is to identify an ideological marker or common denominator. To spin its yarn, this paper has chosen the foundational claim (putatively common to all practitioners of 'neuropsychiatry') that all 'mental disorders are disorders of the brain'. Three among its results are worth noting. One is that the meaning and exercise of 'neuropsychiatry' will continue to depend on social, economic and political factors; this augurs future instability. The second is that each time that the foundational claim has been uttered in history it has meant something different. Further research is needed to clarify whether this is due to the way in which the claim becomes 'inscribed' in different cultural niches; what is clear is that by using the foundational claim as a marker it is not possible to establish a continuity in the progress of neuropsychiatry. The third finding is that users of the foundational claim require the use of a concept of matter and in this paper 'plain' and 'baroque' types of matter have been identified. To explain the origin of mind, those using the plain notion need to resort to external ingredients and their narratives incorporate bits of the real world. Users of the baroque definition do not need such aids. It is not for the historian to judge which of these two definitions is more felicitous and more conducive to the moral and aesthetic edification of psychiatry and her patients.

Psychiatric symptoms in neurologically asymptomatic Huntington's disease gene carriers: a comparison with gene negative at risk subjects

OBJECTIVE

Psychiatric profiles of two at-risk groups [Huntington's disease (HD) gene carriers and non-carriers] were compared by means of a computerized battery and a structured interview.

METHOD

To avoid confounding, only subjects who were free from neurological and cognitive deficits (neurologically asymptomatic) were included in the study. To avoid evaluation biases, all subjects were seen before the genetic testing was undertaken.

RESULTS

Gene carriers had significantly worse recognition memory and scored higher in measures of irritability than controls. The groups also differed in terms of the factor structure of their psychiatric symptoms. None of the subjects qualified for a psychiatric diagnosis at the time of assessment.

CONCLUSION

The groups differed with respect to their profile of psychiatric symptoms. It is hypothesized that these differences are the expression of different mechanisms, i.e. that cognitive deficits relate more to genetic factors and neurotic complaints more to being brought up in a disturbed family background. Issues concerning instrument sensitivity, selection bias and the advantage of seriatim assessments are discussed.

Assessment and measurement in neuropsychiatry: a conceptual history

Since the time the parent discipline of psychiatry became organized as a profession, one of its ludi saeculares (neuropsychiatry) has enjoyed at least 4 vogues. On each, neuropsychiatry has been known to ally itself to a cause: currently it is the big business of neurobiology. This move can be seen as scientific progress or as a side-effect of the (professional rather than scientific) infighting that affected neuromedicine during the late 19(th) century and which led to the construction of the notion of "neurological disease." Alienists responded to this variously: some, like Kahlbaum and Kraepelin accepted the split and returned to the more botanico approach; others, like Ziehen chose psychology; yet others, like Freud, delved in hermeneutics; lastly, there were those, like Meynert, Wernicke, Von Monakow, and Liepmann who sought an accommodation with neurology. Born out of this compromise, neuropsychiatry has remained a blurred activity (whose definitions range from "psychiatry of neurology" to a crusade for the "naturalization of the mind"). Neuropsychiatric assessment is a methodology designed to collect information about patients whose mental symptoms are thought to be caused by brain disease. When it first appeared, it was torn by the debate between "nomothetic versus idiographic" science. For a time, the neuropsychiatry assessment techniques stuck to the old personalized narratives characteristic of 19(th) century "casenotes" (trying to meet its descriptive, explanatory, therapeutic, legal, and ethical obligations). But during the late 19(th) century, measurement and quantification became part of the new rhetoric of science. Soon enough this affected psychology in general and neuropsychology in particular and neuropsychiatric assessment followed suit. It has changed little since except that now and again old tests and markers are replaced by more "reliable" ones and phenomenological data are squeezed out further. Its laudable enthusiasm for objectivity and truth was ab initio justified by 19(th) century Positivism; currently, it seems to be supported by a naïve version of Popperian falsificationism. In the meantime, the scientific worth of the neuropsychiatric assessment remains unclear; indeed, in an age of evidence-based medicine, it is surprising that both its informational and communicational value and its efficiency as a general epistemic tool have not been subjected to any serious empirical testing.

Erotomania revisited: clinical course and treatment

Erotomania is a rare disorder in which an individual has a delusional belief that a person of higher social status falls in love and makes amorous advances towards him/her. Little is known about the background, classification, treatment, or outcome of individuals with this disorder. The purpose of this study was to evaluate current criteria for diagnosing and classifying primary and secondary erotomania in addition to examining course, outcome, and impact on victims of erotomania. Semistructured interviews covering personal and family details in addition to treatment and outcome to date were performed on a series of erotomanic patients identified in a defined area. Evaluation of diagnosis used DSM-IV and other criteria. Fifteen erotomanic subjects (11 female, four male) were identified. Most were isolated, without a partner or full-time occupation. Forty percent had a first-degree relative with a psychiatric history and of those half had a first-degree relative with a mono-delusional disorder. Less than half of the objects of their affection, mainly noncelebrities, were subject to harassment. Subjects with primary erotomania and erotomania secondary to other psychiatric diagnoses were identified using DSM-IV criteria. Ellis and Mellsop's criteria were found to be useful in assessing erotomania but we could not replicate Seeman's fixed and recurrent groups. Treatment and outcome was better than expected particularly for those with primary erotomania and erotomanics with a diagnosis of bipolar affective disorder. In this series, erotomanic symptoms largely occurred in the context of other psychiatric disorders, although subjects with pure erotomanic symptoms were seen. Subjects were less dangerous and engaged in less harassment of victims than the literature suggests. Subjects were often isolated, unemployed, and with few social contacts. Strong family psychiatric histories were seen particularly with regard to mono-delusional disorders raising the possibility of genetic inheritance. An adaptation of Ellis and Mellsop's criteria was suggested for the diagnosis of primary and secondary erotomania. Response to treatment and prognosis was good, particularly for primary erotomania and erotomania secondary to bipolar affective disorder.

Impact of the term schizophrenia on the culture of ideograph: the Japanese experience

The ideographic Chinese writing system (in use in Asian countries that account for about a quarter of the world's population) directly expresses the meaning of schizophrenia as "the disease of disorganized mind." The term directly challenges a deeply ingrained concept of personal autonomy, and this is stigmatizing. Japanese psychiatrists are thus reluctant to tell their patients that they are suffering from schizophrenia, and, as a result, no more than 20 percent of sufferers actually do know about their diagnosis. Because taking medication is based on informed consent and the exercise of the patient's autonomy, such lack of information has important negative effects. It is unlikely that this problem can be resolved by education or information alone, and it may well be the case that in cultures using ideographs, the illness will need to be renamed. This article suggests some alternatives.

The 'object' of insight assessment: relationship to insight 'structure'

Insight is a relational or 'intentional' concept, i.e., it is only understood in terms of its relation to something; and that 'something' is the 'object' of insight. In clinical practice, the 'object' of insight thus generally refers to a particular mental or physical state (e.g., mental illness, neuropsychological deficit) in relation to which insight is being assessed. It is argued in this paper that the 'object' of insight plays a crucial role in shaping or determining the sort of insight that is elicited in clinical practice (i.e., the phenomenon of insight). Three ways in which the 'object' of insight can shape the clinical phenomenon of insight are discussed. One concerns the conceptual background in which the 'object' is embedded and which is likely to impose a similar structure onto the phenomenon of insight. Another is the semantic category to which the 'object' of insight belongs and which will imprint its particular structure on the phenomenon of insight. Yet another concerns the specific nature of the 'object' which itself will shape the insight phenomenon elicited. This carries implications for research on insight, since insight tends to be explored in relation to a variety of 'objects'. Phenomena of insight in relation to different 'objects' are likely to vary in structure, and this, in turn, has consequences for mechanisms underlying insight in each case. Understanding more about the nature and contribution of the 'object' of insight in the insight-'object' relationship will help to delineate separate insight phenomena and achieve consistency in empirical studies on insight.

The phenomenological stability of depersonalization: comparing the old with the new

The view that depersonalization is a stable syndrome became well established during the first half of the 20th century. Current operational definitions restrict depersonalization to the experience of unreality. This is likely to neglect clinical features of potential neurobiological relevance. By using the year 1946 as the dividing line, 200 cases of depersonalization disorder reported in the medical literature since 1898 were divided into two historical groups (1 and 2). The groups were then compared in terms of 18 phenomenological variables with a sample of 45 prospective cases of DSM-IV depersonalization disorder (group 3 or gold standard). Groups 1 and 2 differed in terms of their symptom profile, but the highest frequency that symptoms achieved in either group did not differ from the rates identified in group 3. A core of (invariable) symptoms, including emotional numbing, visual derealization, and altered body experience, was present throughout. These high rates of spontaneous reporting in all three groups may be explained by the fact that they all are accompanied by specific distress. With the exception of heightened self-observation and altered time experiencing, all other symptoms were significantly lower in group 2. The results suggest that the phenomenology of depersonalization has remained stable over the last 100 years. Our study found differences in frequency for some symptoms, but these are likely to have resulted from reporting biases, themselves governed by changing theoretical views. Clinical descriptions became poorer as the present is approached. This cannot be solely explained on the basis of empirical progress, and it is likely that theoretical biases also play a role. Because the neurobiological relevance of the symptoms of depersonalization remains unknown, it makes sense to continue collecting as many symptoms as possible, thereby avoiding both biased selection or premature closure.

Psychiatric symptoms and CAG repeats in neurologically asymptomatic Huntington's disease gene carriers

The putative relationship between the psychiatric profile of a sample of neurologically asymptomatic Huntington's disease gene carriers and CAG repeats was investigated. The psychiatric assessments (by consultant psychiatrist and computerised battery) were undertaken before the genetic testing was carried out. In this way, the informational distortions caused by neurological and cognitive deficits were avoided. The hypothesis that there is a relationship between psychiatric and CAG repeats was tested by seeking direct correlations between psychiatric systems and CAG repeats, and also by correcting the correlation by the number of years above or below the estimated age of onset in Huntington's disease. Scores for irritability and cognitive failures were high in the sample. There was no correlation between any psychiatric variable and CAG repeats. Possible explanations for this lack of correlations are discussed.

Perception, attention, and working memory are disproportionately impaired in dementia with Lewy bodies compared with Alzheimer's disease

OBJECTIVE

To test the hypotheses that visuoperceptual and attentional ability are disproportionately impaired in patients having dementia with Lewy Bodies (DLB) compared with Alzheimer's disease (AD).

METHODS

A comprehensive battery of neuropsychological tasks designed to assess working, episodic, and semantic memory, and visuoperceptual and attentional functions was given to groups of patients with DLB (n=10) and AD (n=9), matched for age, education, and mini mental state examination (MMSE), and to normal controls (n=17).

RESULTS

Both patient groups performed equally poorly on tests of episodic and semantic memory with the exception of immediate and delayed story recall, which was worse in the AD group. Digit span was by contrast spared in AD. The most striking differences were on tests of visuoperceptual/spatial ability and attention. Whereas patients with AD performed normally on several subtests of the visual object and space perception battery, the DLB group showed substantial impairments. In keeping with previous studies, the AD group showed deficits in selective attention and set shifting, but patients with DLB were more impaired on virtually every test of attention with deficits in sustained, selective, and divided attention.

CONCLUSIONS

Patients with DLB have substantially greater impairment of attention, working memory, and visuoperceptual ability than patients with AD matched for overall dementia severity. Semantic memory seems to be equally affected in DLB and AD, unlike episodic memory, which is worse in AD. These findings may have relevance for our understanding of the genesis of visual hallucinations, and the differential diagnosis of AD and DLB.

A brief cognitive test battery to differentiate Alzheimer's disease and frontotemporal dementia

OBJECTIVES

To validate a simple bedside test battery designed to detect mild dementia and differentiate AD from frontotemporal dementia (FTD).

METHODS

Addenbrooke's Cognitive Examination (ACE) is a 100-point test battery that assesses six cognitive domains. Of 210 new patients attending a memory clinic, 139 fulfilled inclusion criteria and comprised dementia (n = 115) and nondementia (n = 24) groups. The composite and the component scores on the ACE for the two groups were compared with those of 127 age- and education-matched controls. Norms and the probability of diagnosing dementia at different prevalence rates were calculated. To evaluate the ACE's ability to differentiate early AD from FTD, scores of the cases diagnosed with dementia with a Clinical Dementia Rating < or = 1 (AD = 56, FTD = 24, others = 20) were compared.

RESULTS

Two cut-off values for the ACE composite score (88 and 83) were of optimal utility depending on the target population. The ACE had high reliability, construct validity, and sensitivity (93%, using 88 as cut-off). Using the lower cut-off of 83, the ACE had a higher sensitivity (82%) and predictive value than the Mini-Mental State Examination for a wide range of dementia prevalence. The ACE differentiated AD from FTD, and the VLOM ratio (derived using component scores: [verbal fluency + language]/[orientation + memory]) of <2.2 for FTD and >3.2 for AD was highly discriminating.

CONCLUSION

The ACE is a brief and reliable bedside instrument for early detection of dementia, and offers a simple objective index to differentiate AD and FTD in mildly demented patients.

Process-outcome analysis in computer-aided treatment of obsessive-compulsive disorder

The study purpose was to examine dose-response relationships between behavior on a computer-delivered treatment program and outcome in obsessive-compulsive disorder (OCD), and to report the use of human-computer interactions (HCIs) as a process measure in psychotherapy research. Thirteen OCD patients completed three 45-minute sessions at weekly intervals on an interactive computer program which provided vicarious exposure and response prevention for OCD. The scenario modeled exposure to dirt for the treatment of a hand-washing ritual. HCIs were recorded and analyzed to provide a detailed description of the behavioral strategies used. The relationship between subject characteristics, process measures, and outcome was examined. Across the three computer treatment sessions, all subjects showed a marked increase in vicarious exposure behavior, that is, enacting a hand-dirtying behavior sequence on the interactive computer program. Some subjects enacted hand-washing, although this decreased across sessions. A higher amount of vicarious hand-dirtying behavior predicted symptom reduction on the Padua Inventory (PI). Higher National Adult Reading Test (NART) scores, an intelligence measure, predicted more enactments of hand-dirtying behavior, but the relationship between hand-dirtying and outcome remained significant after controlling for NART scores. We conclude that HCIs are a novel and objective process measure that may aid in clarifying specific treatment factors. The relationship between hand-dirtying and outcome suggests a likely increased benefit from higher treatment dosages.

Group and case study of the dysexecutive syndrome in alcoholism without amnesia

OBJECTIVES

To test the dysexecutive syndrome (DES) hypothesis of chronic alcoholism by the neuropsychological group and case study approaches.

METHODS

A comprehensive neuropsychological assessment, including the "behavioural assessment of dysexecutive syndrome", a battery of tests recently designed to be "ecologically valid", was administered to 17 patients with chronic alcoholism without amnesia to examine executive functions, intelligence, and memory. In terms of each neuropsychological measure, reciprocal analyses of group means and individual case profiles were conducted: for the first contrasting the alcoholic patients with 17 age matched healthy subjects; and for the second making intersubject and intrasubject comparison of the patients, according to percentile basis impairment indices obtained from the control subjects.

RESULTS

Despite relatively unimpaired memory and intelligence, the patients as a whole had the impairment of a wide range of executive domains, extending to "everyday" problem solving as well as more elementary aspects of executive functions, such as visuospatial performance, mental set shifting, and the inhibition of habitual behaviour. The profile analysis divided individual patients into four groups: the representative DES characterised by a clear dissociation between impaired executive functions and preserved intelligence and memory; the group of a modified dysexecutive pattern in which memory as well as executive functions were impaired with intelligence preserved; the group of general cognitive deterioration; and the group of unimpaired cognitive functioning. About two thirds of the patients were categorised into either the first or the second type of DES.

CONCLUSION

DES characterised by the even more pronounced impairment of executive functions than of intelligence and memory afflicts a considerable proportion of patients with chronic alcoholism. Due to its subtlety, this would be potentially left out, unless appropriate behavioural measures were administered. This condition may prevent patients with alcoholism from achieving full recovery and benefiting from rehabilitation.