Investigations of the Korsakoff syndrome by researchers from different disciplines have proliferated in recent years, making it apposite to review the various findings.

This review is based on the author's knowledge of reports in the major clinical and neuropsychological journals, supplemented by Medline searches to update particular subtopics.

The Korsakoff syndrome is defined as a disproportionate impairment in memory, relative to other aspects of cognitive function, resulting from a nutritional (thiamine) depletion. The initial manifestations of the disorder are variable, and a persistent memory impairment can result from a non-alcoholic aetiology, although this seems to happen much less commonly than in the past – presumably because of generally higher standards of nutrition. Although there is agreement on the underlying neuropathology, the critical lesion sites for memory disorder have been debated. Recent evidence suggests that the circuit involving the mammillary bodies, the mammillo-thalamic tract and the anterior thalamus, rather than the medial dorsal nucleus of the thalamus, is particularly critical in the formation of new memories. The relationship of these deficits to thiamine depletion remains a topic of current investigation, as does the purported role of neurotransmitter depletions in the cholinergic, glutamate/GABA and catecholamine and serotonergic systems. Neuro-imaging studies have confirmed autopsy findings of more widespread structural and metabolic abnormalities, particularly involving the frontal lobes.

The relationship of these neuropathological, neurochemical, and metabolic abnormalities to cognitive functioning, with particular reference to specific aspects of memory processing, has been considered in some detail. Whereas structural and/or neurochemical abnormalities within the limbic/diencephalic circuits account for anterograde amnesia, some other factor, such as frontal lobe dysfunction, must underlie the severe retrograde memory loss which is characteristically found in this syndrome.

Dysthymia has been reconceptualised in recent years from a personality disorder to a chronic affective disorder. It is incorporated into both the DSM and ICD diagnostic systems. Method. The members of the WPA Dysthymia Working Group combined the results of their manual literature searches with a search using Medline.

Available data are summarised under the headings of classification, epidemiology, validity, comorbidity, course and outcome, pharmacotherapy and psychotherapy. The coexistence of major depressive disorder, constituting ‘double depression’ is of particular importance.

Improved knowledge of this disorder has led to a more positive approach to treatment, in which antidepressants can usefully be complemented by psychosocial measures. A high proportion of cases remain unrecognised in most populations, leading to prolonged morbidity and distress, much of which is now treatable.

Decision analysis is an explicit, quantitative approach to examining difficult decisions about course of action. Its applicability to psychiatry is considered.

An example of how decision analysis could be used in psychiatry is given, criticism of the technique is discussed, and previous attempts to apply it to mental illness problems (from a Medline search from 1966 onwards) are reviewed.

The future for decision analysis in psychiatry lies in teaching, audit and research, rather than clinical work.

It is unclear whether the causative factors of non-psychotic postnatal depression are the same as those of depression at other times.

The course and recurrence of postnatal depression was studied in two groups of primiparous women experiencing an index episode of postnatal depression: those for whom the mood disorder had arisen de novo (n = 34), and those for whom it was a recurrence of previous affective disturbance (n = 21). The mental state of these two groups, together with a psychiatrically well control group (n = 40), was studied for five years.

It was found that those for whom the index episode was a recurrence of depression were at raised risk of further non-postpartum episodes but not postpartum episodes, and that those for whom the index episode had arisen de novo were at raised risk for further episodes of postnatal depression but not for non-postpartum episodes.

These findings suggest a specific nosologic reference for the concept of postnatal depression.

The aim was to investigate the secretion profile of melatonin and seasonal affective disorder before and after treatment with fluoxetine.

A six-week case-controlled study with repeated overnight blood sampling was conducted. Ten patients fulfilling the criteria for major depressive disorder, seasonal type, with a 29-item Hamilton Depression Rating Scale (HDRS) score of at least 20 were compared with ten age- and sex-matched healthy controls in a clinical laboratory. The effects of fluoxetine (20 mg/day) on the HDRS and melatonin concentration were measured.

Fluoxetine significantly reduced melatonin levels in both groups. There was no significant difference in melatonin secretion between the groups.

The effect of fluoxetine differs from tricyclics and fluvoxamine, both of which increase melatonin.

Depression and alcohol dependence are frequently found to co-exist but the relationship between these disorders requires further elucidation. This study tested several hypotheses related to the relevance of whether the diagnosis of depression was made before admission or after detoxification in the current episode for those with alcohol dependence.

The Schedule for Affective Disorders and Schizophrenia (SADS) was administered to obtain Research Diagnostic Criteria (RDC) on 82 randomly selected alcohol dependent in-patients. Alcohol-related (Severity of Alcohol Dependence Questionnaire (SADQ), alcohol consumption and alcohol-related problems), socio-demographic variables and treatment for depression were assessed.

For the episode of drinking which led to admission, a diagnosis of major depression was found in the majority of patients (67%). Once detoxification from alcohol took place, only the minority (13%) met criteria for major depression.

It is suggested that depression is largely associated with the episode of drinking which led to admission in patients who are dependent on alcohol and may be due to the effect of chronic alcohol intoxication. Socio-demographic and alcohol-related characteristics appear to bear little relation to the presence of depression. Clinicians exercise appropriate judgement in not prescribing antidepressant treatments to patients whose depression may remit with abstinence from alcohol.

This study explored the psychopathological state of a sample of ‘late paraphrenic’ patients and the reliability of their diagnosis according to the most widely used systems of classification of mental disorders.

The presence and severity of psychiatric symptoms were assessed with the Present State Examination (PSE), the Scale for the Assessment of Positive Symptoms (SAPS), and the High Royds Evaluation of Negativity (HEN) scale. Patient signs and symptoms were classified according to the PSE9–CATEGO4, DSM–III–R, DSM–IV, and ICD–10 diagnostic systems. Agreement among the 11 most widely used criteria for the diagnosis of schizophrenia was assessed for these patients. These included DSM–III–R, DSM–IV, ICD–10, Schneider, Langfeldt, New Haven Schizophrenia Index, Carpenter, Research Diagnostic Criteria (RDC), Feighner, Taylor & Abrams, and PSE9–CATEGO4. The study assessed 47 patients, including in-patients, out-patients, day-patients, and those in the community. Thirty-three elderly controls were recruited from luncheon clubs in Southwark and Lambeth (London, UK).

Patients showed a wide range of delusional ideas, most frequently involving persecution (83.0%) and reference (31.9%). Eighty-three per cent of patients reported some sort of hallucination, most frequently auditory (78.7%). Formal thought disorder was very rare, only one patient showing mild signs of circumstantial speech. No patients exhibited catatonic symptoms or inappropriate affect. Shallow, withdrawn, or constricted affect was found in only 8.5% of patients. The various systems of classification indicated that most patients displayed typical schizophrenic symptoms, although up to one-third of them did not meet criteria for the diagnosis of schizophrenia. There was poor agreement among the different diagnostic schedules as to whether to classify patients as schizophrenic (0.02 < k < 0.45).

Psychotic states arising in late life are accompanied by various psychiatric symptoms that are not entirely typical of early-onset schizophrenia. The current trend to include ‘late paraphrenia’ into the diagnosis of schizophrenia or delusional disorder has poor empirical and theoretical bases.

This study explored the association between ‘late paraphrenia’ and various risk factors such as female gender, sensory impairment, marital status, positive family history of psychoses, and the presence of abnormal neurological signs. It was hypothesised that patients would show significantly more abnormal neurological signs than controls.

Inclusion criteria for the diagnosis of late paraphrenia were fulfilled by 47 patients, including in-patients, out-patients, day-patients, and those living in the community. Thirty-three age-, sex-, education-, and premorbid IQ-matched elderly controls were recruited from luncheon clubs in Southwark and Lambeth (London, UK). A scale for the assessment of neurological soft and hard signs was developed for this study. The Abnormal Involuntary Movement Scale (AIMS) and the Tardive Dyskinesia Rating Scale (TDRS) were also used.

There was a high female-to-male ratio (42:5), and a fourfold increase in the risk of patients having hearing impairment (odds ratio = 4.15, Clodds = 1.36 to 12.63). There was no difference between the two groups in visual difficulties nor in marital status. Patients were approximately ten times more likely to be living on their own (odds ratio = 10.61; Clodds = 3.59 to 31.33) and 16 times more likely to be considered socially isolated (odds ratio = 16.65; Clodds = 5.39 to 51.40). There was no difference between patients and controls in frequency of schizophrenia-like family history. Patients were more likely than controls to exhibit neurological soft signs (z = 4.70; P < 0.001; Cld = 4.61 to 9.63). The presence of abnormal involuntary and tardive dyskinesia movements was associated with the use of antipsychotic medication.

Women appear to run a greater risk of developing late paraphrenia, especially those who are socially isolated and present with associated hearing impairment. The increased presence of neurological soft signs among patients indicates that brain disease may be a critical factor in the development of psychotic symptoms in late life.

The mental status examination of an extreme case of longevity, J. C., aged 118 years and 9 months, is documented in order to further knowledge regarding profiles of morbidity in the extremely elderly. J. C. is presently considered to have the longest authenticated life-span in the history of the human species.

Neuropsychological tests were improvised taking into account the subject's severe perceptual deficits. The examination was carried out over a six-month period. A CT scan was also conducted.

The subject's performance on tests of verbal memory and language fluency is comparable to that of persons with the same level of education in their eighties and nineties. Frontal lobe functions are relatively spared and there is no evidence of depressive symptomatology or other functional illness. Cognitive functioning was found to slightly improve over a six-month period.

The subject shows no evidence of progressive neurological disease. A high initial level of intellectual ability may have constituted a protective factor.

The literature on the statistical analysis of symptoms of psychoses was limited to positive and negative symptoms in schizophrenia. The present study explored the relationship between positive and negative symptoms as well as affective symptoms in a wider category of psychotic disorders.

The symptoms of 584 psychiatric patients, consecutively admitted to any of the 95 mental hospitals in Japan, were studied. They manifested at least one of the following: (a) delusions, (b) hallucinations, (c) formal thought disorder, (d) catatonic symptoms, or (e) negative (defect) symptoms.

Factor analysis yielded five factors interpretable as (a) manic symptoms, (b) depressive symptoms, (c) negative (defect) symptoms and formal thought disorders, (d) positive (psychotic) symptoms, and (e) catatonic symptoms.

These results suggest that although major symptoms seen among psychotic patients can be categorised into positive, negative, manic, and depressive groups, corresponding to current knowledge of phenomenology, catatonic symptoms constitute a discrete syndrome, while formal thought disorders merge into the negative syndrome.

The effects on memory of an anticholinergic (biperiden) and a dopaminergic (amantadine) anti-Parkinsonian agent were compared.

Twenty-six chronically medicated schizophrenic (DSM–III–R) in-patients received amantadine (200 mg/day) or biperiden (4 mg/day) for two weeks in a double-blind cross-over design.

Biperiden treatment was associated with significantly lower scores on Benton Visual Retention Test (P < 0.003) and the visual subscale of Wechsler Memory Scale (WMS) (P ≤ 0.02), with a trend to poorer scores on WMS total (P = 0.086) and the digit span (P = 0.07) and logical memory (P = 0.06) subscales.

In usual clinical doses, biperiden interferes with memory, particularly visual, more than amantadine.

We used [18F]FDG and PET in patients with obsessive–compulsive disorder (OCD) to evaluate cerebral metabolic involvement before and after treatment with serotonin-specific reuptake inhibitors.

In 11 untreated, drug-free adults, regional cerebral metabolic rate for glucose (rCMRglu) was compared with that of 15 age-matched normal controls.

rCMRglu values were significantly increased in the cingulate cortex, thalamus and pallidum/putamen complex. After treatment a significant improvement in obsessive–compulsive symptoms on the Y-BOC scale (t = 3.59, P < 0.01) was associated with a significant bilateral decrease of metabolism in the whole cingulate cortex (P < 0.001). Clinical and metabolic data were significantly intercorrelated (Kendall's τ = 0.65; P < 0.01).

These findings indicate that OCD is associated with functional hyperactivity of a selected neuronal network and that treatment to reduce symptoms may have a selective neuromodulatory effect on cingulate cortex.

The striking analogies between the ideas of Freud and Friedrich Nietzsche, whose works were published from one to three decades before those of Freud, have been commented upon, but no previous systematic correlation of the ideas of Nietzsche and Freud has been made.

The major works of Nietzsche were read, and each possible analogy to an idea later broached by Freud was correlated by a systematic review of his works. Any references to Nietzsche in Freud's writings and reported conversation were culled.

Concepts of Nietzsche which are similar to those of Freud include (a) the concept of the unconscious mind; (b) the idea that repression pushes unacceptable feelings and thoughts into the unconscious and thus makes the individual emotionally more comfortable and effective; (c) the conception that repressed emotions and instinctual drives later are expressed in disguised ways (for example, hostile feelings and ideas may be expressed as altruistic sentiments and acts); (d) the concept of dreams as complex, symbolic “illusions of illusions” and dreaming itself as a cathartic process which has healthy properties; and (e) the suggestion that the projection of hostile, unconscious feelings onto others, who are then perceived as persecutors of the individual, is the basis of paranoid thinking. Some of Freud's basic terms are identical to those used by Nietzsche.

Freud repeatedly stated that he had never read Nietzsche. Evidence contradicting this are his references to Nietzsche and his quotations and paraphrases of him, in casual conversation and his now published personal correspondence, as well as in his early and later writings.

The aims were to determine the prevalence of the Charles Bonnet syndrome (CBS) in low-vision patients and analyse possible associated ophthalmic and sociodemographic factors.

A semi-structured interview on visual hallucinations was given to 300 adult low-vision patients and 200 elderly general ophthalmic patients. Positive cases were examined with the Geriatric Mental State Schedule and the Mini Mental State Examination. Diagnostic criteria were as follows: complex, persistent, or repetitive visual hallucinations; full or partial retention of insight; no hallucinations in other modalities; and no delusions. Ophthalmic and sociodemographic data were gathered for all patients.

The prevalence of CBS in low-vision patients was 11%. CBS was significantly associated with an age over 64 years and a visual acuity in the best eye of 0.3 or less. No significant associations with ophthalmic diagnoses, patient sex, marital status, or social circumstances were found.

Our findings support association of CBS with sensory deprivation and advanced age.

It has been hypothesised that change in the family environment affects short-term recovery from schizophrenia.

Observation and study of 210 schizophrenic patients who were influenced by family environmental alteration show that the prognosis of schizophrenia caused suddenly by family environmental alteration is better than that of schizophrenia caused by a persistently unfavourable family environment.

Hence, we think sudden family environmental alterations do not cause psychorrhoea, but slow family environmental alteration may cause change in the mental state of patients. The prognosis is worse in the countryside than in the city. From the study group, we conclude that the first cure rate was 28%, and that 26% of patients were able to work. This indicates that there were no typical cases of the core pattern of schizophrenia, and that there was a certain potential for recovery.

In the future, the emphasis of prevention and treatment must be placed on the countryside, and attention should be paid to the improvement of living and working conditions there, to the correct administration of patients, and to the improvement of recovery measures and therapy. We advocate that efforts should be made in the countryside to raise the national educational and cultural level.