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Memory Disorders in Psychiatric Practice
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Book description

Memory complaints are a frequent feature of psychiatric disorder, even in the absence of organic disease. In this practical reference for the clinician, first published in 2000, German Berrios and John Hodges lead an international team of eminent psychiatrists, behavioural neurologists and clinical psychologists to focus on the psychiatric and organic aspects of memory disorders from the perspective of the multidisciplinary memory clinic. These disorders include organic syndromes such as the dementias, the amnesic syndrome and transient amnestic states, and also psychiatric aspects of memory disorders in the functional psychoses. Among the specific topics reviewed are the paramnesias, conditions such as déjà vu, flashbulb and flashback memories, and the problems of recovered, false and feigned memories. Throwing light on established conditions, and also introducing two new syndromes, this book makes a major contribution to the understanding and clinical management of memory disorders in psychiatry, neuropsychology and other disciplines.

Reviews

‘This is a book which … approaches memory as a clinical subject with a breadth and comprehensiveness unlikely to be found elsewhere. It is to be strongly recommended, not least for those already engaged or planning to set up memory clinics and to psychiatrists with a desire to learn more about higher mental function .’

Source: Journal of Neurolology, Neurosurgery and Psychiatry

‘This book offers the reader a collection of very well-integrated, written and referenced overviews, several of which throw new light on established as well as less established disturbances of memory. It is highly recommended as a fascinating textbook for the memory interested student of psychiatry, neurology or clinical psychology and as a practical reference volume for the clinician.’

Source: Acta Psychiatric Scandinavian

… this is a solid book.’

Source: Addiction Biology

‘… concise up-to-date evidence-based explanations of the basis of primary, secondary, long-term memory and meta-memory.’

Source: International Journal of Geriatric Psychiatry

‘… I was impressed by Greene and Hodges who take the reader clearly through the clinical process of making a diagnosis of dementia. And insight in dementia is covered in some considerable and interesting detail.’

John Morton Source: Applied Cognitive Psychology

‘… the book is replete with valuable information and resources … the editors have provided a fitting companion for the clinician looking for a memory aid.’

Source: Journal of Clinical Psychiatry

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Contents


Page 1 of 2


  • 1 - Historical aspects of memory and its disorders
    pp 3-33
  • View abstract

    Summary

    This chapter deals with the conceptual history of memory complaints and disorders relatable to psychiatric practice, particularly with the contribution of nineteenth-century alienists. In pre-nineteenth century classical writers identified two aspects of memory: 'conservation' and 'retrieval'. During the early nineteenth century, French philosophy of mind is best represented in the work of LaromiguiŠre and Royer-Collard who believed that memories had first to be entertained in consciousness. The term amnesia is already present in the medical language of the early nineteenth century. Jules Falret (1865), a well-known alienist, his work on amnesia offers one of the best accounts of the disorder available at the division of the century. The chapter suggests that the psychiatric practice we have now is a result of an interaction between the models of memory impairment developed out of clinical observation and the experimental tradition started with Ebbinghaus.
  • 2 - Mood and memory
    pp 34-46
  • View abstract

    Summary

    Mood disordered individuals who present at the clinic invariably complain of day-to-day problems with basic cognitive processes, particularly memory and concentration. This chapter focuses on memory and depression and the effects of other mood states such as anxiety, and of positive emotions, such as happiness. In the memory and depression literature two clear research themes can be identified. The first is concerned with the effects of depressed mood on general memory performance. The second focuses on the effects of depressed mood on memory for emotional material which is either positive or negative in its hedonic tone. There are clear general memory deficits associated with depression. The association is stronger for self-reports of memory difficulties but remains substantial even on objective memory tests with stronger effects being found in younger depressed subjects and in inpatients relative to outpatients.
  • 3 - The concept of metamemory: cognitive, developmental, and clinical issues
    pp 47-57
  • View abstract

    Summary

    This chapter provides an overview of an elaborated concept of metamemory and a brief review of literature pertaining to the assessment of it. This elaborated view of metamemory is especially useful when considering developmental issues and clinical concerns (e.g. how memory disorders are developed, supported and remedied). A theoretically coherent elaborated concept of metamemory includes at least four components: declarative knowledge of memory functioning, awareness (or monitoring) of current memory processes, beliefs about memory skills and change, and memory-related affect. The brief review of the Metamemory in Adulthood instrument and literature demonstrates that it is possible to obtain indicators of multiple dimensions of metamemory simultaneously. Important issues of current and future research include: the extent to which dimensions of metamemory interact in determining memory performance, impairment, or decline; and the extent to which dimensions of metamemory may serve as early indicators of progressive memory decline, associated with organic diseases.
  • 4 - The neuropsychology of memory
    pp 58-74
  • View abstract

    Summary

    This chapter discusses short-term or working memory; declarative or explicit memory with a focus on whether the distinction between semantic and episodic memory is valid; priming or item-specific implicit memory (ISIM); and skills, habits and conditioning. It explains on what brain regions and kinds of memory process they depend. The chapter suggests a new way of organizing thinking about some of the memory processes. Just as ISIM is a form of unaware memory, skills and conditioning do not depend on aware memory although they may be incidentally accompanied by it. It is less clear to what extent ISIM and explicit memory depend on non-overlapping memory systems. There is some evidence that short-term memory, explicit memory, skill memory and classical conditioning depend on partially non-overlapping regions of the brain. Retrieval of a memory representation is not sufficient because it might have arisen from imagination and/or have remained in ISIM.
  • 5 - Psychopharmacology of memory
    pp 75-98
  • View abstract

    Summary

    The study of the neurochemical modulation of memory has dominated the cognitive psychopharmacological literature, in both humans and animals, in recent years. This chapter concentrates on drug treatments for dementia, since it has been the driving force behind the search for cognitive enhancers. From the results of studies in both animals and humans, the cholinergic system has been the neurotransitter system most traditionally associated with the processes of memory and learning. Evidence of 'subcortical' dementia is noted in patients with Parkinson's disease (PD), where the principal lesion appears to be in the substantia nigra, leading to degeneration of the nigrostriatal dopamine system. The cholinergic hypothesis of Alzheimer's disease (AD) is one of the most enduring and resilient theories of cognitive psychopharmacology. There is accumulating evidence that the serotonergic system is compromised in patients with DAT.
  • 6 - The multidisciplinary memory clinic approach
    pp 101-121
  • View abstract

    Summary

    This chapter describes the origins, principles and organization of the Cambridge Memory Clinic (CMC). The main objective of CMC was to assess patients complaining of memory impairment and patients whose memory is considered as impaired by others, even when the patient has no awareness of deficit. Clinical neuropsychology is concerned with the evaluation of cognitive function in patients with known or suspected neurological disease. It is often used as a tool for monitoring a change in function, to provide guidelines for rehabilitation and it plays a major role in the differential diagnosis between neurological and psychiatric disorders. The assessment of general intellectual skills gives information regarding the integrity of cortical functioning as a whole and this in itself can be of diagnostic significance. Knowledge of occupational and educational background can give an idea of an individual's optimal or premorbid level of ability.
  • 7 - The dementias
    pp 122-163
  • View abstract

    Summary

    This chapter addresses the clinical process of making a diagnosis of dementia, and decisions made about whether the patient appears to have a cortical or subcortical dementia. The mini-mental state examination (MMSE) is a useful instrument for grading established dementia but is insensitive for detecting the early stages of dementia of Alzheimer's type (DAT). Having established that the patient has a genuine dementia, the next step is to determine the cause. As memory impairment is a virtually universal feature of the dementias and is in many instances the earliest and most salient feature, a contemporary cognitive model of memory is reviewed briefly. Alzheimer's accounts for approximately two-thirds of all cases of dementia. A wide range of basal ganglia and white matter diseases may result in a pattern of subcortical dementia. Huntington's disease is the commonest genetic disorder to cause dementia.
  • 8 - The amnesic syndrome
    pp 164-186
  • View abstract

    Summary

    Patients with the amnesic syndrome have an unclouded sensorium and appear alert, able to concentrate and are cooperative. Perceptual and intellectual skills are preserved. Amnesic patients do not score differently from normals on tasks that require the immediate reproduction of a sequence of stimuli not exceeding the capacity of the short-term (working) memory store (memory span). Amnesia does not affect equally memories acquired after and before the onset of disease (anterograde and retrograde amnesia, respectively). The study of amnesia has been of paramount importance to the identification of the cerebral structures that mediate memory. The amnesic syndrome, although rare in clinical practice, remains extremely important theoretically for understanding the organisation and neural basis of memory. There is still debate as to whether the amnesic syndrome represents a unitary entity, but there is clear variability in the extent of remote memory loss depending upon the site of pathology.
  • 9 - Transient global amnesia and transient epileptic amnesia
    pp 187-203
  • View abstract

    Summary

    This chapter reviews and contrasts the clinical and neuropsychological features of transient global amnesia (TGA) and transient epileptic amnesia (TEA). It discusses their pathophysiology and outlines an approach to the management of patients with transient amnesia. Attacks of TGA follow a wide variety of stresses, including strenuous exertion, sexual intercourse, immersion in water, pain and emotive events. Neuropsychological testing during attacks has confirmed that amnesia is much the most striking deficit in TGA, and is often the only impairment. In principle, the patchy impairment of remote memory which affects a high proportion of patients with TEA must have one of three explanations: failure to encode episodes into long-term memory, failure to consolidate and maintain such memories or failure to retrieve memories which have been successfully stored. TGA is a common and clearly defined clinical syndrome the aetiology of which remains obscure. Patients with TEA often benefit from anti-convulsant medication.
  • 10 - Insight into memory deficits
    pp 204-233
  • View abstract

    Summary

    This chapter concentrates on the issue of insight and memory function. Both awareness of memory dysfunction and awareness of memory function have been studied in relation to focal brain disease and generalized brain disease (dementias). With respect to 'normal' or non-ill subjects, self-reports of memory function have been treated mainly in experimental psychology where, rather than 'insight' or 'awareness', somewhat different frameworks are used. With respect to stage of the dementia, most studies suggest that insight is preserved early in the disease and diminishes with progression of the disease. In line with 'neurological' research, where associations have been described between 'anosognosia' and frontal lobe pathology attempts have been made to examine the role of the frontal lobe in the relationship between loss of insight and dementia. The different conceptualizations of insight influence the way in which the 'clinical' phenomena of insight/awareness and anosognosia are perceived and measured.
  • 11 - Memory in functional psychosis
    pp 234-267
  • View abstract

    Summary

    The biological approach to functional psychosis began to gain ground and went on to become the dominant explanatory paradigm. In schizophrenia, studies of memory now rival, and may even have overtaken, the other main area of neuropsychological investigation, frontal or executive function. In affective psychosis, the long-standing observation that memory may be affected in depression has gone from being automatically considered secondary to motivational or other factors, to a phenomenon deserving recognition and investigation in its own right. Both schizophrenia and manic-depressive psychosis are associated with memory deficits as part of a wider pattern of cognitive impairments, which can occasionally become severe. The features of the impairment in both disorders, plus other circumstantial evidence, suggest that it is 'biological' in nature, but not 'neurological', that is, that it has different underlying causes than those normally encountered in neurology.
  • 12 - Depressive pseudodementia
    pp 268-290
  • View abstract

    Summary

    The memory lapses often recorded in elderly depressed patients with depressive pseudodementia reflect true cognitive difficulties. Sometimes associated with soft signs, and sometimes contrasted with cognitive impediments seen in patients whose 'subcortical' disease (e.g. progressive supranuclear palsy) primarily affects frontostriatal systems,this reversible dementia is thought to compromise memory primarily by disrupting accessory behaviours (e.g. attention) that are necessary to engage/maintain mnestic activity. Directly relevant to the question of pseudodementia is the research seeking to plot normal cognitive ageing in terms of functional competence, neuropsychological performance, neuroradiological correlates, etc. and how 'non-harbiger' conditions of age-related cognitive decline (DSM4) or age-associated memory impairment (AAMI) differ from dementia. It is still unclear how profiles on cognitive diagnostics can be shown to reliably distinguish between reversible and irreversible patients, and whether such profiles can be used to avoid misclassifying other depressed patients in preclinical stages of Alzheimer's disease (AD).
  • 13 - Practical management of memory problems
    pp 291-310
  • View abstract

    Summary

    There are probably five main approaches to the management of organic memory impairment. The first is to try to restore lost functioning. A second approach to memory rehabilitation and management is to encourage anatomical reorganization. A third approach is to bypass or avoid problems through restructuring or modifying the environment. A fourth approach is to find an alternative means to the final goal, that is, if you cannot do something one way try to do it another way. This approach is analogous to Luria's principle of functional adaptation or to Zangwill's principle of compensation. The final approach to the management and rehabilitation of memory problems is to help people to use their residual, albeit damaged skills, more effectively. This can be done through the use of mnemonics, through rehearsal and study techniques and maybe through the use of games and exercises.
  • 14 - Paramnesias and delusions of memory
    pp 313-337
  • View abstract

    Summary

    With respect to mechanisms underlying paramnesias, Kraepelin was less clear. He mentioned 'alterations of consciousness' which occurred with varying severity and caused a reduced capacity to differentiate between reality and fantasy. During the nineteenth century, the generic term paramnesia was used to refer to a group of clinical phenomena amongst which déjà vu, confabulations, and delusions and hallucinations of memory remain the more salient. These phenomena had been known since earlier but it was only after the work of Sander that they began to be considered as 'memory' disorders. In Kraepelin's taxonomy the paramnesias are included as 'qualitative' disorders of memory affecting either recognition or recollection. Déjà vu remains a curiosity seen in some forms of epilepsy and occasionally in the normal affected by fatigue. Delusions of memory are occasionally mentioned in the literature but hallucinations of memory have disappeared altogether.
  • 15 - Déjà vu and jamais vu
    pp 338-347
  • View abstract

    Summary

    This chapter discusses two types of paramnesia: déjà vu and jamais vu with a focus on their clinical features. The cause of déjà vu has been associated with anxiety, dissociative mechanisms, mood and personality disorders, schizophrenia and organic brain syndromes. In non-psychopathological conditions, predisposing factors include emotional trauma, exhaustion, psychomimetic drugs, fatigue, severe stress, hyperventilation syndrome and illness. As to psychopathogenesis, many authors have viewed déjà vu experiences primarily as a disturbance of memory. Psychoanalytically oriented authors regard the jamais vu experience as a defence mechanism 'by which an event is torn out of the context of experience, removed from consciousness, and rigidly warded off'. Both déjà vu and jamais vu were considered as memory disorders but currently other hypotheses are being entertained, for example, these states are considered in DSM IV as being related to dissociation.
  • 16 - Confabulations
    pp 348-368
  • View abstract

    Summary

    With regard to the analysis of confabulations, it would seem that confusion has arisen from mixing up levels of inquiry: phenomenology, neurobiology, disease associations, aetiological speculation and even pragmatics. At a most general level, 'confabulations' should be considered as sharing a conceptual space with delusions, mythomania, 'pseudologia fantastica' and 'pathological lying'. Two phenomena are conventionally included under the name 'confabulation'. The first type concerns 'untrue' utterances of subjects with memory impairment; often provoked or elicited by the interviewer, these confabulations are accompanied by little conviction and are believed by most clinicians to be caused by the (conscious or unconscious) need to 'cover up' for some memory deficit. Researchers wanting to escape the 'intentionality' dilemma have made use of additional factors such as presence of frontal lobe pathology, dysexecutive syndrome, difficulty with the temporal dating of memories leading to an inability temporally to string out memory data, etc.
  • 17 - Flashbulb and flashback memories
    pp 369-383
  • View abstract

    Summary

    This chapter suggests that 'vivid personal memories' should be studied against the wider canvas of other repetitive phenomena of the imagination such as drug flashbacks, palinopsia, palinacusis, tinnitus, and the post-traumatic memories, and the vivid memories of subjects suffering conditions include phobias, panic attacks, obsessional disorder, phantom-limb phenomena, and depressive melancholia. The creation of a flashbulb memory depends on high level of 'surprise', a high level of 'consequentiality', and high level of 'arousal'. Flashbulb memories seem more accurate and stable than ordinary memories. Flashbacks are triggered by fatigue and certain moods states; and also by environmental cues assumedly related to the original situation suggesting the operation of a context-dependent retrieval mechanism. Victims of trauma often report 'anxious dreams' in which the traumatic event is relived in vivid multisensory images accompanied by the same intense emotions as those of the original event.
  • 18 - Functional memory complaints: hypochondria and disorganization
    pp 384-399
  • View abstract

    Summary

    This chapter reviews the clinical features of memory complaints in subjects with no objective memory deficits, and reports in the said group the existence of two syndromes. It suggests a model to explain the 'functional cognitive disorganization' syndrome, and proposes a new way (echoing model) to understand complaints (including memory ones). Research into the concept of memory complaint is beset with conceptual difficulties. In a medical context, 'complaint' refers to utterances conveying negative personal assessments with regard to the functioning and efficacy of a bodily or mental function. The two syndromes are called 'mnestic hypochondria' (seen predominantly in bright, well-educated, obsessional males, with high-achievement motivation, no attentional deficit and marked anxiety) and the 'functional cognitive disorganization' syndrome (seen predominantly in females with low education and intelligence, low anxiety, and chronically dependent upon relevant others for the organization of their cognitive environment).
  • 19 - Dissociative amnesia: re-remembering traumatic memories
    pp 400-431
  • View abstract

    Summary

    The amnesia phenomenon in patients with dissociative disorders currently represents one of the most intriguing areas in the study of psychiatric disorders and memory processes. Dissociative amnesia intersects with the study of normal and traumatic memory, childhood sexual abuse, and suggestibility. Dissociative amnesia is rarely the single symptom; in the majority of cases the amnesia symptom is embedded in, and co-occurs with, other dissociative phenomena. Hypnosis may well be used to access the memory that otherwise is unavailable to consciousness. Psychotherapy can include art therapy, dance and movement therapy, and journaling and creative writing therapies. In diagnosing dissociative amnesia it is most important to differentiate dissociative from non-dissociative amnesia. Assessment should focus on excluding organic causes, substance abuse, head trauma, or epilepsy. Most important information assessing dissociative amnesia is derived from the patient's history for there is a strong relation to psychological trauma.
  • 20 - Recovered and false memories
    pp 432-442
  • View abstract

    Summary

    The issue of selective forgetting of childhood sexual abuse has produced very complicated and sometimes confusing arguments. Essentially, they revolve around the question of whether or not trauma can be forgotten and later remembered. Early advocates of the concept of selective forgetting took the extreme view that all instances of recovered memories have historical truth. The challenge to the notion of selective forgetting is consistent with evidence from patients suffering from Post-traumatic Stress Disorder (PTSD). In these cases, memories for trauma intrude into consciousness and are remembered unintentionally. The individual would prefer not to remember details of the trauma; yet, thoughts and memories of the trauma cannot be controlled. Many people's lives have been profoundly affected by the phenomena of recovered memories: parents who have been falsely accused; retractors (people who recover memories and later retract their accounts), and people who recover memories of genuine childhood sexual abuse.
  • 21 - The Ganser syndrome
    pp 443-455
  • View abstract

    Summary

    This chapter discusses the Ganser syndrome and gives a brief account on its clinical features. A significant number of clinicians in Europe continued accepting Ganser's basic postulates that the patients showed significant memory disorder and 'answers towards the question' within the framework of traumatic or reactive hysteria. In elderly patients, Ganser type symptoms may be indicative of the onset of dementia. Ganser syndrome raises the question of the interaction between concepts, ideology and clinical observation. The clinician must be aware that a misdiagnosed case of Ganser-type hysteria may result in lawsuits, unnecessary surgical interventions, inappropriate use of minor and major tranquillizers, and social consequences that may be destabilizing for the patient and family. Positive results in the organic investigation should lead to a firm diagnosis and disconfirmation of Ganser syndrome. Persistent negative results and dramatic improvement should tend to confirm the diagnosis.
  • 22 - Malingering and feigned memory disorders
    pp 456-478
  • View abstract

    Summary

    This chapter reviews historical observations concerning malingering. It discusses the techniques currently used to detect malingering of memory deficits. The essential feature of malingering is that symptoms are intentionally produced, indicating malingerers must have self-awareness of the falseness of their symptoms. A number of techniques have been developed with the specific goal of helping the clinician to determine if an examinee is not exerting maximum effort on a task. Among those used to detect feigned memory disorders are Rey's 15-Item Memory Test, Rey's Word Recognition List, and various versions of symptom validity tests. Individuals instructed to simulate memory impairment on standardized memory tests often perform worse than patients with known brain dysfunction, particularly on recognition tasks. Use of such data from established clinical tests provides the additional benefits of diagnostically relevant information without the time and expense of administering procedures specifically designed to detect malingering.
  • 23 - Legal aspects of memory disorders
    pp 479-496
  • View abstract

    Summary

    This chapter discusses the relevance of memory disorders in legal issues. The law of evidence has always been concerned with processes of human perception and memory. Mentally disordered witnesses, suspects and victims are vulnerable in different ways to giving unreliable testimony. Four reasons are put forward for voluntary false confessions: first, a pathological need to be infamous; secondly, a need to relieve guilt about matters unrelated to the confessed crime; thirdly, an inability to distinguish between fantasy and reality, as may be found in people with impaired 'reality monitoring' associated usually with severe mental illness; and, fourthly, an attempt to protect the real culprit. A defendant's right to testify on his own behalf may at times involve the use of hypnotically refreshed memory. Clinical reports prepared for legal proceedings need to be written with meticulous care in order to be credible and effective.

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