Evaluation of a newly implemented crisis-resolution and home-treatment team in munich – a mixed-methods-analysis

Introduction

Challenged by the lack of collaboration between treatment sectors in psychiatric care in Germany, a legal basis for the implementation of Stationsäquivalente Behandlung (StäB), a programme for crisis resolution and home treatment (CRHT), was formed in 2017. It offers intensive care to patients with severe mental illness in their own living environments, carried out by a team of diverse professionals.

Objectives

The present analysis is the first to evaluate the CRHT-program that has been established in the greater Munich area in 2018.

Methods

Qualitative and quantitative data were collected within the framework of a mixed-methods-analysis. Records of all patients (N=139) included in the CRHT over a thirteen-month period (’18–’19) were examined regarding sociodemographic, clinical parameters, and treatment data. A focus group with StäB-employees (N=8) and individual interviews with patients (N=10) were conducted, then transcribed, and analysed using thematic analysis.

Results

139 patients (74% female) were treated in 164 cases for 38 days on average. Main diagnoses were schizophrenic diseases (43%) and mood disorders (35%), with patients ranging from markedly to severely ill (mean CGI-S: 5.8). 9.4% were in postpartum. Qualitative analysis is still in progress. Preliminary results demonstrate positive responses to individual treatment and environmental integration, whereas frequently changing contacts and the logistical effort were seen critically.

Conclusions

Work is still in progress. We expect StäB to be an adequate alternative to inpatient treatment for women in puerperium and a new opportunity for patients who need intensive treatment but refuse hospitalisation.

The validity of self-rated psychotic symptoms in depressed inpatients

Background

Self-ratings of psychotic experiences might be biased by depressive symptoms.

Method

Data from a large naturalistic multicentre trial on depressed inpatients (n = 488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale.

Results

At discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P<0.001) and with the BDI total score (0.64, P<0.001). Moderate correlations were found for the MADRS (0.34, P<0.001), HAMD (0.37, P<0.001) and AMDP depression score (0.33, P<0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P<0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P<0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P = 0.02).

Conclusions

In depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.

[A review of the update of the German S3-guideline on diagnostics and therapy of bipolar disorders 2019]

Since the first publication of the guideline in 2012, which included critically reviewed evidence up to 2010, several hundred articles with new evidence were published and some topics of the clinical consensus needed to be reconsidered. Therefore, it was urgently necessary to revise the guideline to bring them up to date. In this article important revisions and updates are presented and the chances and limitations of the development of the guidelines and their implementation are discussed.

[Predictors of success of long-term treatment in alcohol dependency]

OBJECTIVE

There is a lack of positive predictors for long-term treatment of subjects with alcohol addiction. We analyzed the relation between motivation and other external variables of access to treatment as well as treatment outcome.

METHOD

434 persons with alcohol addiction, treated in 2004 in the Diakonie-Krankenhaus Harz (DHK), Elbingerode, as part of a long-term therapy, were followed-up one year after treatment. Access variables were defined and examined in relation to outcome variables with multiple linear and logistic regressions.

RESULT

Ways of accessing treatment had no effect on later treatment outcome, while motiva­tion at the start of therapy was relevant: Patients with ambivalent motivation had the most negative outcome.

CONCLUSION

Therapy motivation was the main predictor for the outcome of a long-term anti-addiction treatment. To improve the quality of the treatment system, interventions to strengthen motivation should be promoted.

[Involuntary psychiatric hospital admissions: a comparison between five hospitals in three German federal states]

BACKGROUND

There is considerable variance in involuntary psychiatric hospital admission rates both in Europe and Germany. In a prospective comparison between five hospitals in three German federal states we assessed and analyzed involuntary psychiatric hospital admissions, including the patient's perspective.

MATERIAL AND METHOD

All involuntarily admitted patients were assessed by an independent researcher. Clinical data, patient and psychiatrist views were documented with different instruments including the McArthur admission experience survey.

RESULTS

In this study 104 out of 244 involuntarily admitted patients gave informed consent. We found considerable differences between study centres concerning involuntary admission quotas (3.2-25.8% of all hospital admissions) and involuntary admission rates (16.6-97.6 per year per 100,000 inhabitants). Hospitals in the state of Baden-Württemberg had the lowest involuntary admission rates while they were highest in Bavaria. In Baden-Württemberg involuntarily admitted patients were more likely to suffer from chronic schizophrenia, they were more severely ill and experienced the involuntary hospital admission as more strenuous. There were no differences between centres concerning frequency of dangerous behavior or self-harm.

CONCLUSION

We found a high variance across regions concerning the reasons for, frequencies and legal basis of involuntary hospital admissions. Regional differences of legal frameworks and service organization can explain this only to a limited amount. Transparency, legal certainty and reflection of stakeholder roles are a future necessity. Furthermore, there is a need for stringent compliance with legal regulations and coherent documentation.

[S3 guidelines on diagnostics and therapy of bipolar disorders: development process and essential recommendations]

Bipolar disorders are severe psychiatric disorders with extensive individual and health economic consequences. Starting in 2007 the first German evidence and consensus based guideline for diagnostics and treatment of bipolar disorders was developed which holds the potential of increasing confidence of therapists, patients and relatives in the decision-making process and improving healthcare service experiences of patients and relatives. Apart from recommendations for diagnostics and treatment the guidelines provide those for trialogue action, knowledge transfer and self-help and for strategies for healthcare provision of this complex disorder. In the present article the methodology and essential recommendations are outlined and complemented in specific topics by corresponding articles in this special issue. Due to restrictions of the length of this presentation there is the need to refer to the comprehensive version of the guidelines at several points also regarding a detailed discussion of the limitations.

Relationship between baseline severity of depression and antidepressant treatment outcome

INTRODUCTION

Assessment of depression severity is of key importance, since several clinical guidelines recommend choice of treatment dependent on the depression severity grade. Using different tools to assess baseline severity may result in different outcomes.

METHODS

This paper describes the results of a multicentre, naturalistic study investigating the relationship between depression symptom severity (using 4 different measures of symptom severity) and clinical outcome among patients hospitalised for depression (N=1 014). Moreover, the impact of differences between methods of measuring depression severity has been investigated. Statistical analyses (univariate measurements, logistic regression models) were conducted to detect coherences and differences between the various methods of severity categorisation.

RESULTS

Results revealed different associations between outcome and classification methods. Response or remission rates varied if baseline severity was assessed by different instruments. Moreover, the number of responders increased with higher baseline severity grades of depression, whereas the number of remitters decreased. Additional analyses dependent on outcome criteria using continuous instead of categorical data revealed similar results.

DISCUSSION

Baseline severity may be only one of many other important clinical variables that mediate clinical outcome, but it is surely an important one deserving further research and consideration.

[Predicting improvement in work status of patients with chronic mental illness after vocational and integrative rehabilitation measurements]

PURPOSE

Chronically mentally ill patients often need special rehabilitation to be able to re-enter competitive employment. We know only very little about predicting favourable or unfavourable rehabilitation courses. The present study seeks to examine the relationship between successful rehabilitation -- as defined by a progress in professional ability -- and individual parameters obtained at initiation off-take.

METHOD

Data of 101 subjects who had completed a rehabilitation programme serve as the basis. At the beginning of rehabilitation, sociodemographic, intellectual, psychopathological and quality of life measures were obtained. Each participant was assigned to one of two rehabilitation outcome groups: progress vs. stagnation, determined by the vocational status after programme termination. Both groups were then compared regarding the aforementioned parameters at programme onset to identify substantial predictors for rehabilitation success via regression analysis.

RESULTS

High level of functioning, fewer periods of unemployment, a high level of work-related adaptation, and young age at programme onset were found to be predictive of progress in vocational status.

CONCLUSIONS

Objective parameters have a higher predictive potential regarding vocational reintegration of psychologically ill people compared to subjective criteria. Psychiatric diagnoses as defined by DSM-IV do not reveal relevant connections with subsequent vocational successful reintegration, whereas the initial level of functioning has a definite predictive value.

[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).

Eine Studie über Personen mit Verwahrlosung, Vermüllung oder Horten

PURPOSE

Who develops neglect, lives in filth and squalor or tends to hoard? What happens to people with such tendencies, after heaving been discovered by community mental health services?

MATERIALS AND METHODS

During a two-year observation period it was attempted to study all such persons in the city of Halle/Saale. Life history as well as medical, social and psychiatric variables were assessed. After a mean period of 11 months these persons were re-assessed.

RESULTS

35 persons who lived in squalor and filth or in a neglected condition or who were known to hoard were assessed (60 % male, mean age: 63 years). 17 persons (49 %) suffered from an organic brain disease, 14 (40 %) fulfilled criteria of psychotic illness (mainly schizophrenia). In 9 cases a comorbid physical disorder contributed to the prevailing living conditions. After 11 months, for 21 persons (60 %) no amelioration of neglect, squalor or hoarding was observed, which was especially true for persons suffering from a psychotic illness. The results yielded some evidence that interventions, which aimed at living conditions (such as moving to sheltered accommodation), had positive effects, while this was not true for standard mental health care within community services and hospital treatment.

CONCLUSION

Neglect, living in squalor and hoarding are frequently symptoms of an underlying psychiatric or somatic illness. In this respect the results suggest that "standard care" proved to be of limited effect -- especially for subjects with a psychotic illness.

[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.

Neuropsychologische Diagnostik in der beruflichen Rehabilitation schizophrener Menschen

Until now it is difficult to predict the success of vocational rehabilitation programs for subjects with severe mental illnesses. The growing knowledge about the neuropsychological mechanisms of psychiatric disorders has not been fully integrated into psychiatric rehabilitation research. We reviewed the literature how to use neuropsychological parameters for predicting outcome of vocational rehabilitation programs in subjects with schizophrenia and schizoaffective disorders. Twenty studies were reviewed, which evaluated neuropsychological variables to predict dimensions of rehabilitation success. As a result of this review, we suggest implementing neurocognitive tests, which assess executive functions, working memory, and attention deficits in routine rehabilitation to better plan and coordinate rehabilitation, and to predict rehabilitation outcome.

[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.

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.

[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.

[The concept of hyperthymia]

The article reviews the conceptual history of "hyperthymia". Since K. W. Stark had used this term in the early 19(th) century, it has developed in two different directions: (1) to delineate a psychopathological syndrome and (2) to define a type of personality disorder (psychopathy). As Kurt Schneider's personality disorder (psychopathy) concept was easily understood and highly practicable, it became influential during the 20(th) century. Earlier before, psychiatrists such as E. Mendel, C. Wernicke and C. G. Jung had described entities such as "chronic mania", "hypomania" or "sanguinic degeneration", which were rather similar to each other. We analyze the historical development of such concepts. Emil Kraepelin was highly influential, as he introduced "constitutional excitation" into a broad concept of manic-depressive illness and saw it as a very mild form. After Kraepelin such spectrum concept was first forgotten. Only in recent years these historical considerations were confirmed by empirical observations, although a separate hyperthymic disorder is neither part of DSM-IV nor ICD-10. The concept of a hyperthymic temperament or a hyperthymic personality is a trait-marker and should be differentiated from hypomania as a state-marker. Nowadays, the importance of hyperthymia is not so much one of a disorder requiring treatment; rather the concept has interesting genetic, diagnostic and conceptual consequences.

[Psychiatric care in Sachsen-Anhalt: a survey of institutions and services with the "European Services Mapping Schedule" ESMS]

OBJECTIVE

To describe the availability of outpatient, inpatient and community based psychiatric care in 21 rural districts and 3 cities of Sachsen-Anhalt, one of the federal states of eastern Germany, with rapid changes and developments in psychiatric care over the last ten years.

METHOD

Information about services was obtained from files of the "Committee for Issues of Psychiatric Care in Sachsen-Anhalt", which was established in 1992 with six multiprofessional "visitation groups" to perform inspections of all institutions providing psychiatric service to the community. Reports about these regular visits followed semi-standardized protocols. The ESMS was used to classify 365 institutions visited between 1996 and 1998, and numbers of places per 100 000 inhabitants were used to compare the 24 regions of the state.

RESULTS

The visitation protocols as the main source of information and the ESMS as a classification tool proved to be useful. The interrater-reliability was high, and the validity of the data was supported by other official statistics. Outpatient care was provided by 4 psychiatrists and 3 psychologists in private practice per 100 000 inhabitants, which is low compared to the German mean. 10 secure beds (forensic psychiatry), 48 acute beds, 13 elective beds and 13 day hospital places per 100 000 inhabitants were available for inpatient care, with a marked shortage of beds in the southern and eastern regions of the state. Non-acute non-hospital residential services with indefinite stay and 24 hour support accumulated to 240 places per 100 000, with regional differences ranging from less than 100 to more than 1000. About 80 % among the residents of these institutions were considered as suffering from "mental retardation", suggesting some persisting institutionalism. All other residential services taken together (time-limited or with less than 24 hour support) came to 24 places per 100 000. Sheltered workshop places corresponded to the number of persons in residential homes. Other facilities offering paid work or work-related activities were scarce; some services providing structured activity or social contact were available in urban agglomerations. The data about the frequency of contacts in outpatient and community services are limited.

CONCLUSIONS

Psychiatric care in Germany is fragmentary, as regards providers and funding. Information collected by the "Committee for Issues of Psychiatric Care in Sachsen-Anhalt", taken mainly from visitation protocols, was sufficient to establish a general survey over 24 regions of this federal state. We propose to repeat this approach regularly to monitor developments in the field of social psychiatry for further planning and interventions. Overall, our results show that the aims formulated in the German "Inquiry into Psychiatry" ("Psychiatrie-Enquete") have not been fully accomplished (e.g. the preferential status of outpatient versus in-patient services).

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.

The relationship between five-factor personality measurements and ICD-10 personality disorder dimensions: results from a sample of 229 subjects

This article examines the relationship between the five-factor model (FFM) and dimensional ICD-10 personality disorders. In a follow-up study of a child and adolescent psychiatric cohort, former patients and controls were assessed with NEO-FFI and the IPDE interview (CD-10 personality disorder). Full data were available for 229 subjects (149 former patients, 80 controls). Multiple regression analysis showed that the five factors of the FFM as independent variables explained between 5% (schizoid personality disorder) and 32% (anxious personality disorder) of the variance of ICD-10 dimensional personality disorder scores. For the two types of emotionally unstable personality disorder dimension (impulsive and borderline), for anxious (avoidant) personality disorder dimension and for the total score of any personality disorder dimension, FFM explained between 17% and 32% of the variance with almost identical results for the former patient group and the control group. High neuroticism was a feature of paranoid, emotionally unstable, histrionic, anankastic, anxious (avoidant), and dependent personality disorder dimensions, whereas low agreeableness was found in dissocial, emotionally unstable and histrionic personality disorder dimensions. Low extraversion was found in schizoid, anxious (avoidant) and dependent personality disorder dimensions, whereas histrionic PD dimension correlated with high extraversion. We find that the FFM is valuable for the further understanding not only of DSM-IV but also of ICD-10 personality disorder dimensions. The differences between ICD-10 and DSM-IV in this respect seem to be small.

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.

[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.

[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.

[Compulsive disorder with homicidal impulses and paranoid symptoms in vascular encephalopathy]

We report on the case of a 45-year old man with OCD who had the obsessive impulse to kill his 3-year old son. The patient showed signs of vascular encephalopathy after perinatal brain damage; besides that, he had developed a mild "explanatory" delusional system. Under treatment with SSRI and clozapin he improved remarkably. Presenting this case, we discuss the connection between organic disorders and OCD, and especially its relationship to perinatal brain damage.

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.

[Conrad Ferdinand Meyer reflected in the paradigm change in German psychiatry]

German-speaking psychiatrists had a great interest in the Swiss poet and writer Conrad Ferdinand Meyer (1825-1898)-even after his death. Meyer was hospitalised twice for major depression with psychotic features. For many years of his life he showed a chronic depressive disorder. We would diagnose a dysthymic disorder with comorbid recurrent major depressive disorder with psychotic features according to DSM-IV or ICD-10. After Meyer had lived isolated for many years and had hardly left his house, he reached public recognition and found his "profession" only at the age of 40. Different pathographic publications (amongst others Möbius, Hellpach, Sadger, Lang, Jung) on Meyer in the early 20th century reflect the debate over both Kraepelin's theories and psychoanalysis. In these publications the scientific argument was often more important than Meyer's biography. Two topics play an important role in these discussions: the differences between idiographic and nomothetic method, and the question, where the border between "personality variation" and "illness" lies.

[Delusion of mercury poisoning in multiple sclerosis]

We confirmed the diagnosis of multiple sclerosis in a 54-year-old man. The patient rejected this diagnosis and was completely convinced that all his symptoms resulted from a chronic mercury intoxication. We found evidence that this delusional disorder was an independent illness, and not a "symptomatic psychosis in multiple sclerosis." So far, little notice has been taken in psychiatry of delusions of environmental poisoning, which cause difficulties in applying common criteria of delusion.

[The dysthymia concept: current and historical aspects--an overview]

The article reviews the historical development of the understanding of dysthymia from C. F. Flemming (1844) to DSM-IV and to Akiskal's concepts. Recent results on epidemiology, comorbidity, neurobiology, familial patterns, clinical course, psychological characteristics, psycho- and pharmacotherapy of dysthymia are discussed. Although present concepts of dysthymia have led to results of high scientific and clinical relevance, the classification of chronic depression and their relation to both personality disorders and affective psychoses need further clarification. The development of dysthymia reflects the differences between Anglo-American operational psychiatric systems and the rich tradition of psychopathology in German-speaking psychiatry.

["Masked" or "hidden" schizophrenia: initial diagnosis of a 12 year psychoses based on negative symptoms]

We report th case of a 45-year-old woman who was referred to our hospital for a treatment of analgetic substance abuse. Surprisingly she reported after some time that she had been hearing imperative and commenting voices for 12 years. We discuss the importance of negative symptoms for the diagnosis of schizophrenia.

[Social support by professional personnel during inpatient treatment of cancer patients. "Chronic disease and coping with illness" research project]

We examined 63 in-patients in a medical hospital with a semi-structured and video-taped interview about the professional social support they had received. Patients were quite satisfied with physicians' and nurses' support, still more than one third of them had missed appraisal support from physicians. We found evidence that older, more ill and female patients perceived more professional social support was given. With the help of a hierarchical cluster analysis it was shown that the importance of professional social support depended remarkably on individual factors as identity or partner relation.