Anterograde amnesia is always coupled with a disturbance of past or remote memory (retrograde amnesia). The latter disorder is usually severe in degree, although not complete, and covers a period that antedates the onset of the illness by up to several years. A few isolated events and information from the past are retained, but these are related without regard for the intervals that separated them or for their proper temporal sequence. Usually the patient “telescopes” events into a brief period of time; sometimes the opposite occurs. This aspect of the memory disorder becomes prominent as the initial confusional stage of the illness subsides.
It is probably true that memories of the recent past are more severely impaired than those of the remote past (the rule of Ribot); language, computation, knowledge acquired in school, and all habitual actions are preserved. This is not to say that all remote memories are intact. As discussed in Chap. 20, these are not as readily tested as more recent memories, making the two difficult to compare. It is our impression that there are gaps and inaccuracies in memories of the distant past in practically all cases of the Korsakoff amnesic state, and serious impairments in many.
The cognitive impairment of the Korsakoff patient is not exclusively one of memory loss. Psychologic testing discloses that certain cognitive and perceptual functions that depend little or not at all on retentive memory are also impaired. As a rule, the Korsakoff patient has no insight into his illness and is characteristically apathetic and inert, lacking in spontaneity and initiative, and indifferent to everything and everybody around him. However, the patient has a relatively normal capacity to reason with data immediately before him.
Confabulation had in the past been considered to be a specific feature of Korsakoff psychosis, but the validity of this view depends largely on how one defines confabulation, and there is no uniformity of opinion on this point. The observations of Victor and his colleagues (1959) do not support the oft-repeated statement that the Korsakoff patient fills the gaps in his memory with confabulation. In the sense that gaps in memory exist and that whatever the patient supplies in place of the correct answers fills these gaps, the statement is incontrovertible. It is hardly explanatory, however. The implication that confabulation is a deliberate attempt to hide the memory defect, out of embarrassment or for other reasons, is incorrect. In fact, the opposite seems to pertain: As the patient improves and becomes more aware of a defect in memory, the tendency to confabulate diminishes. Furthermore, confabulation can be associated with both phases of the Wernicke-
Korsakoff syndrome: The initial one in which profound general confusion dominates the disease, and the convalescent phase in which the patient recalls fragments of past experience in a distorted fashion. Events that were separated by long intervals are juxtaposed or related out of sequence, so that the narrative has an implausible or fictional aspect. In the chronic state of the disease, confabulation is usually absent. These and other aspects of confabulation are discussed fully in the monograph by Victor and colleagues (1959).
Other clinical abnormalities Approximately 15 percent of patients show signs of alcohol withdrawal—that is, hallucinations and other disorders of perception, confusion, agitation, tremor, and overactivity of autonomic nervous system function. These symptoms are evanescent in nature and usually mild.