German E. Berrios

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: Addenbrookes 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 ACEs ability to differentiate early AD from FTD, scores of the cases diagnosed with dementia with a Clinical Dementia Rating < 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.

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 Alzheimers 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.

The Cambridge Neurological Inventory: A clinical instrument for assessment of soft neurological signs in psychiatric patients

A schedule (the Cambridge Neurological Inventory) has been constructed for standardized neurological assessment of psychiatric patients. Normative data and data resulting from its application to a group of patients with schizophrenia are reported. The instrument is comprehensive, reliable, and easy to administer. In conjunction with other forms of clinical assessment, it may be useful for identifying soft neurological signs and other patterns of neurological impairment relevant to neurobiological localization and prognosis in schizophrenia and other psychiatric disorders.

The assessment of insight in clinical psychiatry : a new scale

Difficulties surrounding the meaning of insight in psychiatry have led to neglect of its assessment in clinical practice. A study is described in which an insight scale was constructed and tested in a sample of 43 patients suffering from schizophrenia or depression. The results showed that the insight instrument was able to provide a qualitative and quantitative assessment of insight. Qualitative features brought out by the scale included patients’ perception of changes within themselves and within their environment, their recognition of being ill and their acknowledgment of needing help. Quantitative measurements showed that there was a significant improvement in the level of insight over the period of hospital admission. In addition, scores obtained on the insight scale were inversely correlated with the severity of the patients’ disorder, though these correlations occurred at different times in relation to the different disorders. We thus postulate that other factors (such as intellect, past experience, personality etc.) must be involved in modulating the expression of insight. Although the insight instrument needs refining, we suggest that it may be a useful tool in the further exploration of insight in clinical practice.

Cotard's syndrome : analysis of 100 cases

In 1880, Jules Cotard reported a clinical state he believed was a new type of agitated melancholia. A statistical analysis has been carried out of 100 cases of Cotards syndrome to determine how this clinical concept has fared since its inception. In terms of clinical profile, no difference was found between men and women or between underlying diagnostic categories; age seemed to increase the likelihood of developing délire des négations. Depression was reported in 89% of subjects; the most common nihilistic delusions concerned the body (86%) and existence (69%). Anxiety (65%) and guilt (632) were also common, followed by hypochondriacal delusions (58%) and delusions of immortality (55). An exploratory factor analysis extracted 3 factors: psychotic depression, Cotard type I and Cotard type II. The psychotic depression factor included patients with melancholia and few nihilistic delusions. Cotard type I patients, on the other hand, showed no loadings for depression or other disease and are likely to constitute a pure Cotard syndrome whose nosology may be closer to the delusional than the affective disorders. Type II patients showed anxiety, depression and auditory hallucinations and constitute a mixed group. This new grouping cuts across the more traditional view and may have therapeutic implications. Authors, in general, have considered délire des négutions as a syndrome rather than a new disease and do not seem to support the view that the completeness of the syndrome is a function of presence or severity of depression. The view that délire des négutions refers only to the delusion of being dead has also curried little favour as it is likely to waste information.

Descriptive psychopathology: conceptual and historical aspects

This paper offers a conceptual and historical analysis of descriptive psychopathology. The first section defines it as a cognitive system constituted by terms, assumptions and rules for its application. It traces the conceptual implications of this definition and relates them to clinical practice. The second section contains an up-to-date assessment of current historical work on descriptive psychopathology and offers a new hypothesis to account for its development during the nineteenth century. It is suggested that the work involved in the testing of the hypothesis should be carried out by psychiatrists with historical training and as a separate speciality. It is concluded that the historical calibration of psychiatric symptoms must be considered as an essential stage in the construction of a viable descriptive psychopathology.

Obsessive-compulsive disorder: Its conceptual history in France during the 19th century

Until the 1850s, obsessive-compulsive phenomena were considered to be a variant of the old notion of insanity. Around this time they became a separate disease: first, as a member of the old class of the neuroses; then, briefly, as a variant of the newly formed notion of psychosis; and finally, as a neurosis proper (in the post-1880s sense). These changes reflected theoretical shifts in the definition of the grand psychiatric categories. After 1860, organic causal hypotheses for OCD included dysfunctions of the autonomic nervous system and cortical blood supply. Psychological hypotheses suggested the OCD might result from volitional, intellectual, or emotional impairment, the last of which predominated after 1890. Issues relating OCD to personality types and hereditability were dealt with in terms of the degeneration theory. By the late 1880s, OCD achieved full clinical and nosological definition.

Delusional parasitosis and physical disease

Abstract An historical account is offered of the syndrome of delusional parasitosis. Two explanatory hypotheses developed at the turn of the century are identified and traced to current debates on the etiology of the condition. The clinical and therapeutic aspects of delusional parasitosis are touched upon and four cases with different etiological associations are reported. It is concluded that organic factors must always be kept in mind as it is likely that in some cases pruritus and other tactile disorders (particularly in the elderly) may be elaborated into delusions of infestation.

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 [Huntingtons disease (HD) gene carriers and non‐carriers] were compared by means of a computerized battery and a structured interview.

Insight in clinical psychiatry. A new model.

Recent interest in insight in psychiatry has resulted in studies focusing on correlations between insight and variables such as severity of psychopathology, neuropsychological impairments, and magnetic resonance imaging. However, there has been relatively little exploration of the concept of insight itself as a basis of empirical research. This paper examines the concept of insight, differentiating this from the phenomenon of insight, and proposes that insight is a construct that needs to be considered from the perspective of the patient, of the clinician, and of their interaction. A new hierarchical model of insight construction is described, closely linked to symptom formation, and mechanisms are suggested to explain insight structure in relation to the different ways symptoms arise. The relationship between insight and symptom structure and disease suggests that the phenomenon of insight will vary in relation to different diseases. This in turn suggests that insight assessments should be modified according to the individual disease.