[On the 200th birthday of psychiatry]

Two hundred years ago the term "psychiatry" (first named "psychiatery") was introduced by Johann Christian Reil in the city of Halle, Germany. With the word's composition Reil demonstrated that psychic disorders belong to the medical domain, which he justified in a long paper explaining why psychiatry must be one of the three major branches of medicine (the others being surgery and pharmacy). Further he emphasized that psychosomatics and medical psychology are part of the comprehensive new discipline psychiatry. He described psychotherapy as an essential treatment for mental and somatic diseases and having equivalence with pharmacological and surgical methods. Johann Christian Reil launched an antistigma campaign and a crusade towards humanization of psychiatric asylums. Two hundred years later psychiatry is well established as a medical discipline and has become self-confident through its self-determination, in spite of certain setbacks and some objectives that have not yet been achieved.

Zur Abgrenzung von Affekttaten und Impulstaten

In this article we try to differentiate between impulsive crimes and crimes of passion. The former are all impulsively executed and unplanned aggressive acts where we can find no specific preceding events which can be derived from a relevant relationship between offender and victim. Crimes of passion on the other hand are also impulsive and aggressive acts executed in a highly stressful affective state, but they are directed towards another relevant person and characterized by specific preceding events derived from the relationship between offender and victim. Thus they result from a perceived threat to the offender's self-image. We outline features for assessing crimes of passion as well as some indications which could facilitate them. The above mentioned differentiation between impulsive crimes and crimes of passion is relevant in forensic practice. Assessment of the psychological and psychopathological processes and states described in this article allows forensic psychiatric experts to give more reliable and more distinct recommendations to a court regarding the offender's criminal responsibility.

Gemischt-affektive Störungen

The Kraepelin concept of "mixed states" has experienced a renaissance over the last two decades. This has been caused by clinical as well as theoretically relevant factors. Of particular clinical relevance is the fact that more than 40% of all patients with bipolar disorders show at least one mixed affective episode during the course of their illness. However, the correct assessment and the precise classification of the symptoms are very important. A diagnosis according to the tight criteria of ICD-10 or DSM-IV, or perhaps based on the moderate Pisa or Cincinnati criteria, is recommended, whereas the use of broader definitions cannot be advised. Mixed schizoaffective episodes are under-diagnosed in comparison to pure affective mixed episodes, although both are defined by ICD-10 as well as by DSM-IV, and the frequency of occurrence is almost the same. Mixed schizoaffective episodes appear to be one of the most severe forms of bipolar disorders. Their clinical relevance is mainly caused by their unfavourable prognosis and difficulty in treatment. Atypical neuroleptics combined with anticonvulsives have proved to be more effective than any other psychopharmacological substances. The occurrence of mixed depressive and manic symptoms during one and the same episode is theoretically important, especially in the sense of their nosological and etiological differentiation.

[Bipolar affective and schizoaffective disorders of older age -- classification, symptoms and course]

Bipolar affective and schizoaffective disorders of older age are underdiagnosed, although they are of growing importance for psychiatric services. In this review article, we present and discuss results concerning classification, psychopathology, epidemiology, course, prognosis, neuroimaging, family studies and therapy. Bipolar (schizo)affective disorders of older age are a diagnostic heterogeneous group, especially as secondary manias must be separated from "endogenous" bipolar disorders nosologically. Bipolar (schizo)affective disorders of older age show some peculiarities: Gender ratio, age at onset, mortality and comorbidity with neurological disease are amongst them. Nevertheless, in many other aspects bipolar (schizo)affective disorders of older age do not differ from bipolar disorders of younger patients. For the acute and maintenance treatment there is a dearth of controlled studies. Lithium is of great importance. Other substances, as well as psychoeducation and ECT may be used analogously as in younger patients, if age specific factors are taken into account (as for example the danger of falls).

[Anxiety disorders comorbid with unipolar depression. Clinical diagnoses versus standardized diagnostic interview]

Anxiety disorders frequently co-occur with affective disorders. It is well-known that such comorbid anxiety disorders are more frequently diagnosed with standardized interviews than during the "daily routine." In 117 consecutive inpatients with major depression we assessed the frequency of DSM-IV anxiety disorders and compared it to the routine diagnoses of the discharge letters to analyze underlying principles of such diagnostic strategies. According to SCID-I (DSM-IV) 36 patients fulfilled criteria for a comorbid anxiety disorder, while this was only true for 17 patients according to discharge letters. Logistic regression revealed that clinically recognized cases had higher anxiety levels (higher diagnostic threshold). At the same time, in patients with higher depression scores anxiety syndromes tended not to be seen as separate disorders. This strategy is in line with "classic psychopathology," where severe depression (or melancholia) "included" anxiety symptoms. The borderline between depressive disorders and anxiety disorders is not as clear-cut as DSM-IV and ICD-10 try to indicate.

Affective disorders: basic principles regarding clinical course, long-term therapeutic and prophylactic strategies

Affective disorders, mainly depressive and bipolar afflictions are life-long recurrent diseases and require constant treatment and prophylaxis. Both acute and maintenance therapeutic strategies have to be applied to the special subgroups of the depressive and bipolar spectrum. Despite the development of new pharmacological agents and psychotherapeutical settings, the long-term prognosis, especially functional outcome, did not change considerably in comparison to past decades.

The schizoaffective phenomenon: the state of the art

OBJECTIVE

Schizoaffective disorders are well established. Nevertheless, the definition in the International Classification of Diseases (ICD)-10 and the Diagnostic and Statistical Manual (DSM)-IV are insufficient.

METHOD

Critical review of the literature from Kahlbaum (1863) to the 21st century.

RESULTS

Many authors have described people suddenly developing a disorder with both 'schizophrenic' and 'affective' symptoms. In DSM-IV and ICD-10, the schizoaffective disorder is defined as the concurrent occurrence of schizophrenic symptoms with a major affective disorder. However, there is no reason for a chronological distinction regarding the co-existence of schizophrenic and affective symptomatology. Moreover, longitudinal aspects are not included in the definitions.

CONCLUSION

Two types of schizoaffective disorder must be distinguished: the 'concurrent' and the 'sequential' type. The first includes people having only a coincidence of schizophrenic and affective symptoms. The 'sequential' type is defined as the schizoaffective disorder under a longitudinal aspect subsuming disorders with a symptom change between different episodes. Consequences for further research are discussed in detail.

Kategoriale und dimensionale Erfassung von "psychopathy" bei deutschen Straft�tern

The personality construct "psychopathy" is of utmost importance in legal prognosis. In the last 20 years, a multitude of empirical research proved the predictive validity of this concept concerning the degree of dangerousness represented by an offender. In the present study, a representative, nonselected sample of 416 offenders was examined using the Screening Version of the Psychopathy Checklist (PCL:SV). The data were analysed both categorically and dimensionally according to the three-factor model proposed by Cooke and Michie. In comparison to North American Studies the prevalence of high scorers was significantly lower, implicating intercultural differences. Analyses of the effects of gender yielded higher scores on each of the three factors in male offenders. Concerning different age cohorts, it turned out that the arrogant and deceitful interpersonal style and deficient affective experience remained stable, whereas the impulsive and irresponsible behavioral style decreased with increasing age. Therefore, our results point out intercultural differences already shown in the prevalence of "psychopathy" and confirm the effects of gender and age concerning this construct.

[Temperament and affective disorders--historical basis of current discussion]

The history of the temperament concept begins in ancient Greece. The humoral theory remained influential over the centuries. At the beginning of the 20 th century, both Wilhelm Wundt and his pupil Emil Kraepelin formulated new aspects. Wundt described two dimensions: "speed of variability of emotions" and "intensity of emotions". Kraepelin observed four fundamental states (depressive, manic, irritable and cyclothymic), which he linked to manic-depressive illness. Since then different lines of temperament research have evolved: (1) psychiatric-psychopathological theories (e. g. Ewald, Kretschmer and Sheldon), which tend to see temperament as a dilution of full-blown affective disorders; (2) neurobiological theories (e. g. Pavlov, Eysenck and Gray), which understand temperament as determined by underlying neurobiological processes - especially levels of arousal; and (3) developmental theories (e. g. Chess & Thomas, Rothbart and Kagan), which derived their temperament concept from early childhood observations. Recent theories (e. g. those of Cloninger or Akiskal) combine different aspects. After reviewing the historical temperament concepts we present underlying factors which are linked to affective disorders (such as emotional reactivity, cyclicity or trait affectivity). Finally, we illustrate the importance of temperament concepts for research in affective disorders.

Brief and acute psychoses: the development of concepts

This paper reviews the conceptual history of brief and acute psychoses. As psychotic disorders of usually dramatic symptomatology but nevertheless with a usually benign course, brief and acute psychoses have the air of a paradox. Thus, they have posed specific problems in regard to nosology, diagnostics and aetiology. Despite a strong convergence of the descriptive elements, the historical concepts of brief and acute psychoses have yielded different answers to the questions raised. Kahlbaum and Kraepelin set the stage on which brief and acute psychoses appeared "atypical". The concept of "bouffée délirante" used degeneration theory as a background for nosological and aetiological allocation. Similarly, the concepts of cycloid psychoses, reactive (psychogenic) psychoses, emotional psychoses and atypical psychoses have provided diverging but interrelated ways to delineate brief and acute psychoses, to determine their nosological status and to explain the coexistence of severe disorder and favourable prognosis. Modern classifications, namely the acute and transient psychotic disorder of ICD-10 and the brief psychotic disorder of DSM-IV, reflect the varied history of the concept.

Personality features of patients with mixed and pure manic episodes

OBJECTIVE

To test the hypothesis that patients with a mixed manic episode show different personality features than patients with a pure manic episode.

METHOD

Sixteen patients with a mixed manic episode (broad criteria) and 26 patients with a pure manic episode were assessed with diagnostic interviews (SCID I/II) as well as instruments for depression, mania and personality.

RESULTS

Even after controlling for age as well as depression and mania score at assessment, no differences between the two groups emerged concerning either personality features as assessed with the NEO-five-factor inventory (NEO-FFI) or personality disorders.

CONCLUSION

We found no difference between patients with mixed mania and patients with pure mania concerning their personality features. Possible reasons for this are being discussed.

The relation of "acute and transient psychotic disorder" (ICD-10 F23) to bipolar schizoaffective disorder

The aim of this work is to investigate differences between acute and transient psychotic disorders (ATPD; F23 of ICD-10) and bipolar schizoaffective disorders (BSAD). In a controlled prospective and longitudinal study, we compared all inpatients with ATPD treated at Halle university hospital during a 5-year period with matched controls with BSAD. Sociobiographical data were collected using a semi-structured interview. Follow-up investigations were performed at a mean of 2.2-3.3 years after the index episode or 8.2-16.1 years after the first episode by means of standardized instruments. ATPD differs significantly from BSAD on various relevant levels, such as gender (more female), age at onset (older), development of the full symptomatology (more rapid), duration of the symptomatology (shorter), acuteness of onset (more acute), preceding stressful life-events (more frequent) and long-term prognosis (better). It is concluded that ATPD and BSAD are different nosological entities.

The concordance of ICD-10 acute and transient psychosis and DSM-IV brief psychotic disorder

BACKGROUND

ICD-10 acute and transient psychotic disorder (ATPD; F23) and DSM-IV brief psychotic disorder (BPD; 298.8) are related diagnostic concepts, but little is known regarding the concordance of the two definitions.

METHOD

During a 5-year period all in-patients with ATPD were identified; DSM-IV diagnoses were also determined. We systematically evaluated demographic and clinical features and carried out follow-up investigations at an average of 22 years after the index episode using standardized instruments.

RESULTS

Forty-two (4.1%) of 1036 patients treated for psychotic disorders or major affective episode fulfilled the ICD-10 criteria of ATPD. Of these, 61.9% also fulfilled the DSM-IV criteria of brief psychotic disorder; 31.0%, of schizophreniform disorder; 2.4%, of delusional disorder; and 4.8%. of psychotic disorder not otherwise specified. BPD showed significant concordance with the polymorphic subtype of ATPD, and DSM-IV schizophreniform disorder showed significant concordance with the schizophreniform subtype of ATPD. BPD patients had a significantly shorter duration of episode and more acute onset compared with those ATPD patients who did not meet the criteria of BPD (non-BPD). However, the BPD group and the non-BPD group of ATPD were remarkably similar in terms of sociodemography (especially female preponderance), course and outcome, which was rather favourable for both groups.

CONCLUSIONS

DSM-IV BPD is a psychotic disorder with broad concordance with ATPD as defined by ICD-10. However, the DSM-IV time criteria for BPD may be too narrow. The group of acute psychotic disorders with good prognosis extends beyond the borders of BPD and includes a subgroup of DSM-IV schizophreniform disorder.

[Temperament and affective disorders. The TEMPS-A Scale as a convergence of European and US-American concepts]

In temperament research, three traditions can be found: (1) in psychiatry or psychopathology, (2) in neurobiology, and (3) in developmental psychology. After giving an overview, we present results and theories concerning the relation between temperament and affective disorders. Based on Kraepelin's concept of the fundamental states ("Grundszustände"), we describe four types of temperament: hyperthymic (manic), depressive, irritable, and cyclothymic. A fifth anxious temperament is added. Clinical description and scientific implications are described in the light of recent work by Akiskal and the German version of the TEMPS-A scale, a self-report questionnaire for assessing temperament.

Origin and development of concepts of bipolar mixed states

This paper reviews the historical origins of the contemporaneous resurgence of interest in mixed states. This is a classical concept whose origins can be traced back to ancient times. In more modern times, already in the pre-Kraepelinian era we can find descriptions and classifications of "mixed states". For example, in his classification of mental disorders described "mixtures of exaltations and depression", and he distinguished among "mixed mood disorders", "mixed mental disorders", and "mixed volition disorders". Subsequently, (the father of empirical and biological psychiatric research in Germany) described the "mid-forms". Half a century later we encounter the crucial role of Emil Kraepelin and the development and systemization of his views between 1899 and 1913--leading to the characterization of such conditions as "depressive-anxious mania", "excited depression", and "stuporous mania". The remainder of this article focuses on the essential points of the first book on mixed states in the psychiatric literature: On The Mixed States of Manic-Depressive Insanity by. For much of the present 20th century nothing new emerges, followed by a contemporary renaissance of mixed states, particularly in the United States. The paper concludes with proposal of mixed states as temperament intruding into an episode of opposite polarity.

Bipolarity from ancient to modern times: conception, birth and rebirth

We review the history of bipolar disorders from the classical Greek period to DSM-IV. Perhaps the first person who described mania and melancholia as two different phenomenological states of one and the same disease was the Greek physician of the 1st century AD, Aretaeus of Cappadocia. The modern concept of bipolar disorders was born in France, with the publications of and. Emil Kraepelin, however, in 1899, unified all types of affective disorders in 'manic-depressive insanity'; in spite of some opposition, Kraepelin's unitary concept was adopted worldwide. In the 1960s, however, the rebirth of bipolar disorders took place through the publications of Jules Angst, Carlo Perris, and George Winokur, who independently showed that there exist clinical, familial and course characteristics validating the distinction between unipolar and bipolar disorders; in addition, they verified several of the corresponding opinions of the Wernicke-Kleist-Leonhard school. The concept of unipolar and bipolar disorders has further advanced in the last three decades: landmark developments include the renaissance of Kraepelin's mixed states and of Kahlbaum's and Hecker's cyclothymia and related affective temperaments, the concept of soft bipolar spectrum (Akiskal), and the distinction of schizoaffective disorders into unipolar and bipolar forms.

Concordance of acute and transient psychoses and cycloid psychoses

OBJECTIVE

We prospectively investigated a sample of 42 patients with acute and transient psychotic disorder (ATPD) as defined by the 10th revision of the International Classification of Diseases (ICD-10; F23) to determine the clinical and demographic features of this entity and its relationship to cycloid psychoses.

METHODS

During a 5-year period, all in-patients with ATPD were identified. We systematically evaluated demographic and clinical features and carried out follow-up investigations on average 2 years after the index episode, using standardised instruments.

RESULTS

We found 42 cases of ATPD (4.1%) among 1,036 patients treated for psychotic disorders or a major affective episode. There was a marked female preponderance in ATPD (79%). Fifty-five percent of cases concurrently met the criteria of cycloid psychosis according to Perris and Brockington [in Perris C, Struwe G, Jansson B (eds): Biological Psychiatry. Amsterdam, Elsevier, 1981, pp 447-450]. There was no difference in gender distribution between cycloid and non-cycloid ATPD. As expected, abrupt onset and polymorphic features were significantly more common in cycloid than in non- cycloid ATPD. At follow-up, patients with cycloid ATPD showed less persistent alterations and better social functioning.

CONCLUSION

ATPD as defined by ICD-10 is a heterogeneous category. A diagnosis of cycloid psychosis is made in half of the cases of ATPD, and in these cases, the prognosis is more favourable.

Personality disorders in offenders: categorical versus dimensional approaches

The present study focused on the consequences of cut-off scores in personality disorder diagnoses for their association with criminal behavior. Using ICD-10 personality disorder criteria eliminating offence-related symptoms, we studied the distributions of categorically diagnosed personality disorders and of dimensional personality disorder scores in a group of offenders and a noncriminal control group. Whereas the dimensional scores of the offender group differed significantly from those of the control group for all personality disorders under study, the frequency of categorical diagnoses differed significantly for two personality for two personality disorders only. Moreover, prediction of group membership (offenders vs. nonoffenders) from personality disorder scores was substantially more precise than prediction from categorical diagnoses. It is concluded that a dimensional approach to personality disorder diagnosis is not only superior theoretically but also yields more precise information about the specific associations with criminal behavior.

Affective symptoms at index hospitalization in childhood and depressive symptoms in adulthood: a "catch-up" study

PURPOSE

To analyze whether affective symptoms during psychiatric treatment in childhood or adolescence could predict the later development of depressive symptoms.

METHOD

We used a "catch-up" design. A cohort of former child and adolescent psychiatric patients was assessed in adulthood with standardized instruments according to the criteria of ICD-10 (SCAN) and dimensional values for depression (both self-reported and observer-rated). Initial affective symptoms had been extracted from clinical records according to a standardized system (AMDP).

RESULTS

We assessed 164 former patients. Twelve percent of these fulfilled diagnostic criteria of an affective disorder (F3) according to ICD-10. In univariate analyses of variance the depression scores were significantly related to affective symptoms during childhood treatment, even if the presence of an affective disorder at catch-up was considered as an independent covariate variable. Nevertheless, the latter variable explained a large part of the variance of depression scores, while initial affective symptoms explained no more than 6%.

CONCLUSION

Affective symptoms in childhood and adolescence may predict the later development of subthreshold depressive symptomatology.

[Carl Wernicke: his impact past and present]

From April 1904 until his premature death due to an accident in June 1905, Carl Wernicke was head of the Department of Psychiatric and Nervous Diseases at the University of Halle-Wittenberg, Germany. We report on Wernicke's work and activities during this short but influential period in the context of his biography and scientific development. Archive materials reveal some interesting details concerning Wernicke's appointment and his diagnostic practice in Halle. As the most outstanding representative of 19th century neuropsychiatry, Wernicke constantly strove to base his psychiatric doctrine on the brain research of the time. In Breslau, his former place of employment, his scientific working environment had dramatically deteriorated. In Halle, Wernicke found not only a well-functioning clinical institution but also an important neurobiological tradition inaugurated by Eduard Hitzig. He immediately resumed his research programme. Fields of interest included the implementation of his nosological system in clinical practice, the study of aetiological factors of mental diseases and the use of a new method of puncture for the localisation of brain tumours. Wernicke's biological research agenda was interrupted not only by his premature death but also by historical developments. Many aspects of this agenda, however, have been raised anew by today's psychiatry.

What becomes of children hospitalized for enuresis? Results of a catch-up study

BACKGROUND

. The purpose of this study was to reassess former child and adolescent psychiatric patients with nocturnal enuresis as young adults and to compare them with former patients without enuretic symptoms and with a comparison group from the general population.

METHOD

We used a 'catch-up' design. From a former child and adolescent psychiatric patient cohort we identified all subjects with documented enuretic symptoms in childhood and compared them with two groups matched for gender and age - non-enuretic patients and a comparison group from the general population. Subjects were assessed as adults with standardized instruments according to the criteria of ICD-10 (SCAN, IPDE) and dimensional values for depression, satisfaction with life, global functioning and personality (NEO-FFI).

RESULTS

We assessed 55 former patients with nocturnal enuresis (recruitment rate 68%) after a mean interval of 13.1 years. At catch-up the former enuretic patients had a lower frequency of personality disorders (ICD-10), lower mean depression values, higher global functioning and a lower rate of psychiatric treatment after the age of 18 years than did former non-enuretic patients. Former enuretic patients did not differ significantly from the comparison group from the general population concerning any of the outcome variables, although there was a non-significant trend for former enuretic patients to more often fulfill criteria for a psychiatric ICD-10 diagnosis at catch-up. There were no differences concerning personality among the three groups at catch-up.

CONCLUSION

Although it may constitute a mild vulnerability factor for further development, nocturnal enuresis had a good long-term outcome in a cohort of treated subjects.

A catch-up study of former child and adolescent psychiatric inpatients: psychiatric status in adulthood

BACKGROUND

The purpose of this study was to reassess former child and adolescent psychiatric patients as adults with regard to their further development.

METHODS

We used a 'catch-up' design. A former child and adolescent psychiatric patient cohort and controls (matched for sex and age) were assessed as adults with standardized instruments (Schedules for Clinical Assessment in Neuropsychiatry, International Personality Disorder Examination, biography, psychiatric history, Global Assessment Scale, Satisfaction with Life Scale).

RESULTS

We assessed 164 former patients and 80 controls. The mean catch-up period was 13.2 years, and the subjects had a mean age of 24.8 years. Thirty-nine percent of the former patients and 25% of the controls fulfilled criteria for an ICD-10 diagnosis (present state) at catch-up, with a clear excess of personality disorders in the former patient group (13 vs. 3%). Using a survival analysis we estimated that 38% of the former patients and 10% of the controls would undergo psychiatric treatment between the ages of 18 and 31 years.

CONCLUSIONS

Most former child and adolescent psychiatric patients did not come into contact with psychiatric treatment facilities again in their twenties, although they had a higher risk for a psychiatric disorder than controls. Nevertheless, the risk of later developing a personality disorder according to ICD-10 seems to be markedly raised for former child and adolescent psychiatric patients.

Expanding the group of bipolar disorders

The concept of bipolar disorder is an ongoing process. Its roots can be found in the work of the ancient Greek physician Aretaeus of Cappadocia, who assumed that melancholia and mania are two forms of one and the same disease; he actually believed that mania was a more severe form of melancholia. Falret [Bull. Acad. Natl. Med., Paris (1851)] and Baillarger [Ann. Méd-psychol. 6 (1854) 369] from France are the fathers of the modern understanding of bipolar disorders. But the definitive distinction of bipolar from unipolar disorders occurred in 1966 by Jules Angst and Carlo Perris in Europe, and later supported by Winokur and colleagues in the United States. Schizoaffective disorders should also be dichotomized into unipolar and bipolar forms. Another extension of the group of bipolar disorders is the contemporaneous rebirth of cyclothymia, originally described in the work of Kahlbaum (1882) and Hecker (1898) [Z. Prakt. Arzte 7 (1898) 6]; the main importance of cyclothymia today is its relevance for what Akiskal [Clin. Neuropharm. 15(1) (1992) 632] considers the realm of the 'soft bipolar spectrum.' A further interesting development is the renewed research in the field of 'mixed states' which originated in the classic Handbook of Kraepelin a century ago (1899).

[Acute effects of alcohol and chronic alcoholism as causes of violent crime]

To study the influence of alcohol and psychosocial variables on delinquent behavior, we coded data from the psychiatric evaluation of 254 defendants using a standardized score sheet, analyzing correlations between acute intoxication at the time of the crime (ICD 10:F10.0), diagnosis of alcohol dependency according to ICD 10 (F10.2), psycho-biographical variables, criminal history, and parameters relating to the index offence. We found that 64.6% of all defendants studied were intoxicated when committing the crime and 25.6% suffered from alcohol dependency. Alcohol intoxication correlated to occurrence of violent crime, cruelty in committing the index offence, and earlier convictions. Logistic regression, with demographic and psychosocial variables entered as covariables, revealed acute alcohol intoxication but not alcohol dependency as a predictor of violent crime (odds ratio 2.3, P = 0.02). Alcohol intoxication and dependency were also independent predictors of earlier convictions (intoxication, odds ratio 4.4, P = 0.0001; dependency, odds ratio 3.6, P = 0.003). Our findings support the hypothesis that acute alcohol intoxication, not dependency, influences violent crime in a direct manner. However, alcohol dependency predicts criminal recidivism.

[Inpatient treated, mono-symptomatic childhood enuresis--results of follow-up in adulthood]

32 formerly monosyndromatic enuretic patients who had been treated for this condition between 1980 and 1992 were compared with a matched control group from the general population in respect of sociobiography, psychopathological and dimensional factors (depressiveness, satisfaction with life, global functioning). Most of the former patients did not fulfil diagnostic criteria for an ICD-10 diagnosis at follow-up, although there was a 37% vs. 9% difference between former patients and controls in this respect--without a clear diagnostic pattern of such disorders. Furthermore, former patients had slightly higher depression scores and slightly lower global functioning than controls at follow-up. These results confirm that childhood enuresis has a low negative predictive value concerning the development of psychiatric disorders, although it may constitute a vulnerability factor.

[Comorbidity in psychiatric diseases. Theoretical considerations]

During the last 10 years, comorbidity has become an important topic in psychiatric research, leading to a growing number of publications. We discuss the theoretical and historical background of this development and present definitions and models for the phenomenon. Methodological difficulties have to be stated: considering its clinical consequences, we conclude that (1) comorbidity is an inevitable methodological consequence of the diagnostic strategies and continued diversification of DSM-IV and ICD-10, (2) there is little doubt of its relevance in the clinical context, and (3) the diagnostic strategies of DSM-IV and ICD-10 concerning comorbidity are difficult to follow in clinical reality.

Electroencephalogram alterations during treatment with olanzapine

RATIONALE

Olanzapine is similar in structure and pharmacology to clozapine. An increased incidence of electroencephalogram (EEG) abnormalities and seizures has been associated with clozapine but not with olanzapine, although isolated cases of seizures under olanzapine have been observed in high-risk patients.

OBJECTIVE

To evaluate the frequency of epileptic and non-epileptiform EEG abnormalities during treatment with olanzapine.

METHODS

Using a rating scale of demonstrated reliability, 43 EEGs of patients receiving 10-25 mg/day olanzapine in routine treatment were blindly rated and compared with EEG registrations from the same 43 patients with a different medication.

RESULTS

There was no difference in epileptiform activity between the conditions with and without olanzapine. However, EEG slowing was significantly more frequent with olanzapine than under the other condition. This difference could not be attributed to concomitant medication.

CONCLUSIONS

Although epileptiform activity did not increase under olanzapine, unspecific EEG abnormalities may be more frequent than with use of other neuroleptics. Careful surveillance of patients with risk factors for seizures is advisable. Further studies addressing the frequency and clinical relevance of EEG changes under olanzapine are necessary.

[Acute and transient psychotic disorders]

Psychotic disorders with acute onset, a dramatic and polymorphous symptomatology and rapid resolution have been described in different countries and by different psychiatric schools. They have been called cycloid psychosis, bouffée délirante, psychogenic psychosis or good prognosis schizophrenia. ICD-10 has given an operational definition under the name "acute and transient psychotic disorders" (F23). Their nosological status is unclear. The Halle-Study of acute and transient psychotic disorders (ATPD) has investigated in a prospective manner clinical, para-clinical features and course of illness in 42 patients with ATPD and matched controls with positive schizophrenia, bipolar schizoaffective disorders as well as mentally healthy patients with acute surgical conditions. First results of our study show that ATPD amount to 4% of psychotic in-patients, prefer female sex, show short prodromi, marked affective disturbances within the episode and much better outcome as schizophrenic psychoses according to psychopathological, social, psychological and biographical criteria. Though ATPD may still be an inhomogeneous group, their clinical delineation from schizophrenia seems justified.

Violence, criminal behavior, and the EEG: significance of left hemispheric focal abnormalities

The authors studies the relationship of EEG abnormalities and violent criminal behavior in 222 defendants referred for psychiatric evaluation. There was no connection between the number of violent offenses and EEG abnormalities in general. Focal abnormalities, however, especially of the left hemisphere, were related to a significantly higher number of violent offenses. In many cases these abnormalities were accompanied by mental retardation, epilepsy, or earlier brain damage. The findings suggest that impairment of left hemisphere functions may enhance the propensity for violent behavior in a subgroup of offenders.

[Homicides--the sociodemographic background of the offender and the behavioral symptoms]

The authors examined 261 forensic-psychiatric reports to determine whether persons convicted of criminal homicide differed from persons convicted of other crimes with regard to personal biography, sociodemographic milieu, and character traits. Both groups were found to come from similarly disadvantaged social backgrounds. Murderers could not be distinguished on the basis of biographical data alone. The parameters found to be distinctive of murderers were: site of the crime, criminal-victim relationship, motive for the act, intoxication at the time of the crime, and the perpetrator's opinion regarding the purpose and intent of the homicide. The present findings confirm some of the results obtained by other authors on this topic.

[Psychotic symptoms as initial manifestation of a multiple system atrophy]

Multiple system atrophy is a disease characterised clinically by any combination of parkinsonian, pyramidal, autonomic or cerebellar symptoms and signs. This neurological status is often complicated by associated mental disturbances such as deficits in concentration, memory or learning. There are only very few reports in the literature describing cases of multiple system atrophy associated with psychotic symptoms. We report on two cases in which psychotic symptoms were the initial manifestation of multiple system atrophy. In view of the known neuropathologic and biochemical changes in multiple system atrophy the concurrent incidence of paranoid-hallucinatoric symptoms seems not uncommon and should be studied further.

[Dysthymia and cyclothymia--serious consequences of rarely diagnosed disorders]

Dysthymia and cyclothymia are chronic affective disorders with a minimum duration of 2 years. Both ICD-10 and DSM-IV define cyclothymia as a bipolar disorder with low intensity. This disorder is rare and little research has been done on it. Its economic and social consequences vary from case to case. In contrast dysthymias, chronic depressive disorders, are frequent (prevalence 3-6%) and cause considerable distress. They have serious economic and social consequences, which are comparable to those caused by other chronic conditions such as arthritis or diabetes mellitus. Despite widely held conviction a majority of dysthymias improves under consequent pharmaco- and psychotherapy.

[Habitual shoplifting in multi-infarct syndrome]

The authors report on a 59-year-old male who repeatedly had been apprehended for shoplifting. The behavior only started after he had suffered multiple ischemic strokes. The deviant behavior is explained as a consequence of frontal lobe lesions leading to behavioral disinhibition. Criminal responsibility had to be denied.

Acute clozapine overdose: plasma concentration and outcome

Clozapine is a tricyclic dibenzodiazepine derivative that is classified as an "atypical neuroleptic" drug for treatment of psychotic diseases. A 19-year-old schizophrenic female, treated with 400 mg clozapine per day, was admitted to the emergency department after ingestion of 5000 mg (50 x 100 mg tablets) of clozapine. Clozapine plasma level 2.5 hours after ingestion was 3.8 microg/ml (normal range 0.2-0.7 microg/ml) and very high in gastric lavage. Contrary to reported cases with such high plasma concentrations the patient suffered only from somnolence with intermittent periods of agitation and a mild anticholinergic syndrome with sinus tachycardia and slight hypotension. After detoxication with gastric lavage and short-term administration of pyridostigmine she remained stable, and 24 hours after ingestion she was transferred to the psychiatric unit without further sequelae. To prevent late-onset complications she was carefully monitored for five days. The clozapine plasma level 24 hours after the first measurement was normal. This case and others reported in the literature confirm that signs and symptoms after clozapine intoxication are variable and that high plasma levels are not lethal in every case.

Frequency and phenomenology of persisting alterations in affective, schizoaffective and schizophrenic disorders: a comparison

Investigating the long-term outcome of affective, schizoaffective and schizophrenic disorders, a model that integrated the operationally gathered findings with the 'interactional atmosphere' experienced by the clinician was applied. Eight different types of phenomenological constellations of persisting alterations were delineated (depletion syndrome, apathetic-paranoid (respectively apathetic-hallucinatory) syndrome, adynamic deficiency syndrome, chronic psychosis, structural deformation, slight asthenic insufficiency syndrome, chronic subdepressive syndrome, chronic hyperthymic syndrome. Former assumptions that cross-sectionally the persisting alterations in affective disorders are usually indistinguishable from those in schizophrenia could not be confirmed.

Dysthymia and cyclothymia: historical origins and contemporary development

The aim of this article is to review and put in their historical context today's data, methodologies and concepts concerning subaffective disorders. The historic roots of dysthymic and cyclothymic disorders--part of the subaffective spectrum--are essentially Greek, but the first use of the word 'dysthymia' in psychiatry was by C.F. Flemming in 1844. E. Hecker introduced the term 'cyclothymia' in 1877. K.L. Kahlbaum (1882) further developed the concepts of hyperthymia, cyclothymia and dysthymia--with possible subthreshold symptomatology--in 1882. After Kraepelin's rubric of 'manic-depressive insanity', the term 'dysthymia' was widely forgotten, and 'cyclothymia' became ill defined. Nowadays the latter term is used in three, partially contradictory, senses: (1) a synonym for bipolar disorder (K. Schneider), (2) a temperament (E. Kretschmer) and (3) a subaffective disorder (DSM-IV, ICD-10). A renaissance of subaffective disorders began with the development of DSM-III. Therapeutically important research has focused on dysthymic disorder and its relationship to major depressive disorder, while cyclothymic disorder is relatively neglected; nonetheless, operationalized as a subaffective dimension or temperament, cyclothymia appears to be a likely precursor or ingredient of the construct of bipolar II disorder.

[What is cyclothymia?]

The term "cyclothymia" is being used with different meanings. DSM-IV and ICD-10 define "cyclothymia" or "cyclothymic disorder" as a long lasting, subeffective disorder with frequent shifts between hypomanic and (sub)depressive states. In the tradition of Kurt Schneider cyclothymia was understood as a synonym for manic-depressive illness exclusively, while different personality typologies speak of a "cyclothymic" typus. Historically, the term was first used by the German psychiatrist Ewald Hecker in 1877. The definitions of DSM-IV and ICD-10 seem to be satisfactory in respect to reliability, but the nosological position of "cyclothymic disorder" is unclear. We review results concerning clinical symptomatology, comorbidity, biological parameters, personality (including the question of creativity), psycho- and pharmacotherapy as well as clinical course, which leave many questions open. Nevertheless, results in family studies support the idea that at least a fraction of "cyclothymia" is a mild or subclinical form of bipolar disorders. Until further research, which is urgently needed, we suggest that the term "cyclothymia" should be only used according to the guidelines of DSM-IV and ICD-10.

Unilateral hallucinations and other psychotic symptoms due to otosclerosis

We report the case of a 35-year-old man suffering from otosclerosis and unilateral auditory hallucinations as well as other psychotic symptoms that disappeared completely after surgery for otosclerosis. The patient experienced a change of his acoustic sensations: the tinnitus was transformed into music, and 4 months later the music changed into commenting and imperative voices. However, on both occasions the transformation from one form to another occurred during an alcohol withdrawal syndrome characterized mainly by vivid visual hallucinations. Some theoretical considerations on hallucinatory predisposition, development of hallucinations, and psychological factors determining psychotic symptoms will be discussed.