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¿Distinguishing a Neurological from a Psychogenic Basis 872 HASSANYEH ET AL prednisolone was discontinued. Re-prescribing her MCCAWLEY, A. (1965) Cortisone habituation - a clinical note. prednisolone, at a relatively small dose of 3—4mg New England Journal of Medicine, 273, 976. a day, restored her to good mental and cognitive MINDEN,S. L., ORAv, J. & SCHILDKRAUT,J.J. (1988) Hypomanic reactions to AC'FH and prednisone treatment for multiple functioning. A synacthen test revealed partial sup sclerosis. Neurology, 33, 1631—1634. pression of her adrenal cortex. In view of a normal RUTGERS, A. W. F., LINKS, 1. P., COULTRE, R. L., et a! (1988) ESR and dramatic response to a small dose of Behavioural disturbances after effective ACTH - treatment of the dancing eyes syndrome. Developmental Medicine and Child prednisolone, cerebral vasculitis is unlikely. Neurology,30,408-409. This case illustrates the need to consider possible Woutowrrz, 0. M. & RAPAPORT, M. (1989) Long-lasting behavioural adrenocortical deficiency as a cause of psychiatric changes following prednisone withdrawal. Journal of the disorder or cognitive impairment in patients in whom American Medical Association, 261, 1731-1732. long-term corticosteroids have been discontinued. Such a deficiency state may persist for a considerable period of time after discontinuation. •¿F.Hassanyeh, MBBS, FRCPsych, Consultant Psy chiatrist, Department of Psychiatry, Royal Victoria References Infirmary, Newcast!e upon Tyne NEJ 4LP; R. B. BOSTONCOLLABORATIVEDRUGSURVEILLANCEPROGRAMME(1972) Murray, MBChB, Genera! Practitioner, Raby Cross Acute adversereactions to prednisone in relation to dosage. Medical Centre, Newcastle upon Tyne NE6 2FF; H. Clinical Pharmacology and Therapeutics, 22, 155-158. Rodgers, MBChB,MRCP, Medica! Registrar, Royal GLYNNE-JONES, R., VERNON, C. & BELL, G. (1986) Is steroid Victoria Infirmary, Newcastle upon Tyne psychosispreventableby divided doses?Lancet, ii, 1404. GREvES,J. A. (1984) Rapid onset steroid psychosis with very low dosageof predmsolone.Lancet, i, 1119—1120. •¿Correspondence Amnesia in Relation to Fugue States —¿Distinguishinga Neurological from a Psychogenic Basis NARiNDER KAPUR A case of transient amnesia is described in which a patient wanders over some considerable distance, patientreportedmemorylossforfivedays,duringwhich often reports loss of personal identity and may he hadwanderedextensively.Analysisshowedthat he present himself to organisations such as the police did not have selective amnesiafor the publicevents rather than turn up in clinical settings. Since a fugue which had occurredduringthe five days for which he state can also be characteristic of some patients with professedmemoryloss.Thisfindingwas incompatible with our case having a neurologically based global temporal lobe epilepsy (Mayeux et a!, 1979), it is memory disorder during the fugue state. These findings clearly important to document those features which offer support for a distinction between personal and may help distinguish psychogenic and neurological public episodic memory. aetiologies, especially since psychiatric conditions British Journal of Psychiatry (1991), 159, 872—877 such as anxiety and depression may be accompanied by patchy cognitive impairment. Transient amnesic states can present in a variety of In contrast to clinical reports of psychogenic forms, ranging from transient global amnesia to memory loss, there have been few experimental conditions such as transient psychogenic amnesia. studies on cognitive aspects of such a memory While the former condition has been well docu disorder. One exception to this is the case report by mented, our clinical and theoretical understanding Schacter eta! (1982). When admitted to hospital, he of the latter condition remains relatively limited. could not remember his name, his address or any Withintheclassofconditionsknownaspsychogenic other information about himself or his past (although amnesia, those which present with a fugue state there is no evidence of any prolonged fugue state represent a fairly distinct subset. In this state, the preceding this sudden memory loss). His retrograde PSYCHOGENIC AMNESIA 873 amnesia lasted for four days, ending fairly suddenly et al's patient, i.e. normal performance for famous while he was watching a funeral scene on television. faces in the presence of marked loss of memory for He subsequently had almost complete shrinkage of personal past events, we designed a memory task to his retrograde amnesia, and his only memory loss see if an analogous pattern of memory loss would was for the 12-hour period preceding his hospital be found in a patient with a more typical fugue state. admission when he had become aware of a loss of We were able to assess the basis of his memory loss identity. by means of a specially designed public events Schacter et al administered both tests of past amnesia test in which we assessed the patient's ‘¿semantic'memory (identification of famous faces) recognition memory for 20 real or fictitious recent and a test of ‘¿episodic'memory(recall of any past events, some of which had occurred during the personal event in response to a cue word provided critical five-day period of the patient's fugue. If his by the examiner). These tests were carried out during memory loss had a neurological basis, the patient and after the period of amnesia. During both time should show impaired identification of the critical periods, the patient performed well when asked to events. However, if the global memory loss was identify famous faces. However, in the case of the psychogenic in nature, his performance on these autobiographical cued recall task, when assessed critical items should not be selectively impaired. during the amnesic episode he tended to only recall events from the previous few days; after his amnesia Case report had cleared, he retrieved much older episodes, usually ones which had occurred years earlier. Thus, AB, a 33-year-oldright-handedpsychologygraduate who the clinical symptom of an inability to recall personal worked as a computer consultant (born in 1956), first events or information from his past found a close presented to a hospital casualty department on a Saturday parallel in his performance on the cued recall task. in 1989 complaining that he had suffered a severe headache while driving his car the previous Monday, and that his next Schacter et a! pointed to the lack of temporal memory was of waking up in his car on Saturday morning gradient in the functional retrograde amnesia of their at 5.00 a.m. At this time, apart from a stiff neck, there were patient; they contrasted this with the temporal no other signs, and he was admitted to the medical wards. gradient which is usually observed in retrograde On further examination, he described the onset of his amnesia based on cerebral pathology. They also headache as sudden, bilateral frontal and then radiating observed that in their patient ‘¿islands'of intact totheleftsideandtotheocciput.Hereportedhavingsome memory in the period of retrograde amnesia were nausea, but no vomiting. He indicated that his headache those which had a strong positive affective com had persisted since that time, but had become less severe. ponent, rather than those which were related to any To detailed questioning several days after admission, he reported an almost complete memory loss from the time particular temporal sequence. Two points of note of the headache to the point when he awoke in his parked about this patient are —¿thepresence of some long car near the hospital five days later. The two exceptions standing right temporal lobe pathology following a to this were a brief memory of driving later on Monday head injury which the patient suffered in childhood, into the lay-by of a town about 40 miles from the hospital, and the fact that his complaints of back pains getting out of the car and walking for a short distance, and appeared to be genuine, since after his amnesia had then driving off again. He also had a brief memory for a cleared he underwent back surgery to repair a short period late on Friday night, driving on a road leading spinal abnormality which was found on physical to the hospital. His memory was normal for events examination. This highlights the interaction which preceding this five-day period. From indirect evidence (car mileage, cheque book stubs, receipts, etc.) it appeared that may often be present between psychogenic and he had travelledadistanceofaround 1800 milesduring physical factors in patients who present with non the period, and stayed in hotel accommodation for part neurological forms of memory loss. of the time. It also appears that during this time he looked In the present study, we were able to examine a after his needs and his personal hygiene. He did not admit patient who presented with some of the features at any time to having lost his personal identity, nor did he of a fugue state, but who did not show other at any stageapproach bodiessuch as the policeor the distinctive features —¿suchas loss of personal identity Samaritans. When he was visited by his relatives in hospital, or prolonged period of retrograde amnesia. He also there was no evidence of failure to recognise them. showed low-average cognitive scores which could On physical examination, there were no neurological signs. Past medical history was unremarkable (four weeks conceivably have been associated with a mild neuro previously he had a minor riding accident in which he fell logical condition. We therefore sought to design a off his horse, injuring his head and shoulders, but not definitive memory test which would establish the suffering any concussion). A computerised tomography presence or absence of organic amnesia. In view of (CT) scan was carried out, with 4 mm cuts in the area of the pattern of memory loss shown by Schacter the temporal lobes, but this failed to detect any abnormality. 874 KAPUR An electroencephalogram (EEG) examination was also personalities from the 1960sto the 1980swere dead or alive, normal. Cerebrospinal fluid (CSF) was examined to exclude he correctly recognised almost all of the items (44/46).
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