No abstract

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 Cotard's 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 (63%) 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 1 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 négations 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 négations refers only to the delusion of being dead has also carried little favour as its likely to waste information.

The relationship between Wilson's disease and epilepsy is explored, both in the literature and in a series of 200 cases of Wilson's disease. Details of 44 literature and 14 personal cases of both disorders are presented. The prevalence on December 1, 1986 of epilepsy in the Cambridge series was 6.2%, ten times higher than that of epilepsy in the general population. Seizures in Wilson's disease occur at any stage of the disease, but often begin shortly after the start of treatment. Prognosis of seizures was comparable with the best quoted figures for idiopathic epilepsy: at 7 years 60% of cases had been seizure-free for at least 5 years, and 75% for at least 2 years. Possible mechanisms of seizures are discussed. Penicillamine-induced pyridoxine deficiency is probably not involved in more than a minority of cases. It is more likely that a direct effect of copper deposition is responsible for most of the seizures.

SynopsisAn historical analysis is made of the word and of the concept of ‘dementia’ before the nineteenth century. With regard to the word, it is shown that it had legal and medical meanings and that, while the former developed during the seventeenth century, the latter did so only during the eighteenth century (earlier than psychiatric historians have suggested). As evidence for the latter point, rare historical material on ‘Démence’ from the first edition of the Encyclopédie Française is presented for the first time in English. It is also shown that the legal meaning was finally enshrined in the ‘Code Napoléon’. With regards to the concept of dementia, it is shown that it took final shape in the work of Willis, Hartley and Cullen in whose view it was made to include terminal states of behavioural incompetence due to severe failure of almost any mental function. During this period, dementia was not yet associated with a particular age group nor was specifically defined in terms of cognitive deficit. The origins of the ‘cognitive’ paradigm of dementia and of the clinical boundaries of the future concept of dementia are briefly outlined.

The eighteenth century witnessed an intense drive to classify diseases as natural kinds. Together with Linné, Macbride, Cullen, Sagar and Vogel, François Boissier de Sauvages, Professor of Medicine at Montpellier, was an important player in this process. In his monumental Nosologie Méthodique, Sauvages based his nosological system on the more botanico view proposed by Thomas Sydenham, namely, that human diseases (including mental ailments) should be classified in the same way as were plants. Classic Text No. 104 is an abridged translation of the Preliminary Discourse to the Nosologie Méthodique.

The current characterisation of dementia as a state of global cognitive failure (DSM-III-R, 1987) cannot differentiate it reliably, in cross-sectional diagnosis, from other states of compromised cognition. This is likely to contribute to both the over- and under-diagnosis of dementia in clinical practice (Marsden & Harrison, 1972; Fleminger, 1975; Ron et al, 1979; Smith & Kiloh, 1981; Garcia et al, 1984; Klein et al, 1985). However, diagnostic discrimination between true dementia and its behavioural phenocopies (e.g. depressive pseudo-dementia, quiet delirium, etc.) can be improved in a number of ways. One such is the longitudinal assessment of symptom-clusters (e.g. those related to memory, personality, and cortical syndromes); another is the inclusion of new symptoms into the definition of dementia. The first of these strategies has been given more attention than the second.

Thirty-five percent of a sample of 100 elderly patients suffering from a degree of cognitive impairment were found to have urinary incontinence. They were significantly older, had lower memory and information scores and were more disorientated, hyperactive, aphasic, apraxic and socially incompetent than their continent counterparts. Their diagnosis was more likely to be a combination of senile and arteriosclerotic dementia (ICD-9); they suffered less often from concomitant functional psychiatric disease and showed a higher mortality rate (at 18 months’ follow-up) than the patients without incontinence.

SynopsisThe concept of ‘stupor’ is subjected to historical analysis. Particular attention is given to the nineteenth-century, during which three evolutionary stages are identified. During the first stage stupor is considered as a simple state of non-responsiveness. The second stage recognizes that some stupors are accompanied by rich subjective experiences and separates them as ‘psychiatric stupors’. During the third stage some of its symptoms are reinterpreted as resulting from an interaction between patient and environment. A number of historical sources are reviewed in an attempt to illustrate the evolution of the concept and its association with cognate behavioural states.