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Those who do not understand history are destined to repeat it, so Professor Berrios' reminder of the history of therapeutics is opportune. We often like to think of therapeutic discoveries being made in a logical sequence but so many of them are random. The famous Cambridge experimental psychologist, Frederick Bartlett, described a large part of our memory processes as ‘effort after meaning’, and this is illustrated excellently in this account. We are reminded that the meanings of words and our understanding of therapies almost has to be retranslated every hundred years. It is also chastening to find out how many of our treatments are discovered entirely by chance and on misplaced premises (read the section on ECT and psychosurgery and then look at Chapter 4II for the more recent arguments) and how long it took for ineffective treatments such as insulin coma therapy to be discredited. Readers of Orwell's Animal Farm will be interested to note that Cerletti and Bini's work on the introduction of ECT originated in observations with pigs, which is a logical sequence of sorts. The other illuminating aspect of this chapter is the way we have been almost seduced into the idea that all maladies have a cure, and that ‘treatment resistance’ formalizes the notion that out there is a successful treatment for every illness, and it just needs a clever therapist to find it.
The concept of self is a construct. It is not a ‘natural kind’ sited somewhere in the human brain. The western concept of self emphasizes individualism and autonomy but this view is cultural and no more scientific or truthful or advanced than the syncytial or collective view of self developed in other cultures and which revolves around family or clan rather than individual. Originally meant by St Augustine to be just a metaphorical or virtual space within which theological models of responsibility, guilt and sin could be played out, the self regained importance in the hands of Luther who started its reification as a private cave where god and man would regularly meet to sort out their differences. During the seventeenth century, the metaphors of the Reformation become secularized and built into liberalism and capitalism. The self survived by becoming a conceptual prop for bourgeois notions such as individual ownership, natural rights and democracy.
Wanting to reinforce the political status quo, nineteenth-century science transformed the political self into a psychological entity and proceeded to ‘naturalize it’ (i.e. render it into a natural kind). This additional reification engendered curious inferences. One was the belief that a ‘self’ really existed inside the European mind and brain. This self was characterized as driving, organized, executive and with a capacity for leadership and domination.
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.
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.
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).
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.
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.
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.
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.