Differential contribution of chronic binge alcohol and antiretroviral therapy to metabolic dysregulation in SIV-infected male macaques

The incidence of alcohol use disorder (AUD) is higher among people living with HIV (PLWH). The advent and continued development of antiretroviral therapy (ART) has significantly reduced mortality, shifting the course of HIV infection to a chronic illness. However, this is associated with an increased incidence of comorbid conditions, including type 2 diabetes mellitus, insulin resistance, and cardiovascular complications. Using a nonhuman primate model of simian immunodeficiency virus (SIV) infection, previous studies have demonstrated that chronic binge alcohol (CBA) administration decreases whole body insulin responsiveness, irrespective of ART administration. The objective of the current study was to determine the effects of CBA and ART on insulin-sensitive peripheral tissues before the development of overt clinical symptoms of SIV disease. Our results show that CBA reduced omental adipocyte cell size, increased collagen expression, and decreased the in vitro differentiation potential of adipose-derived stem cells. In contrast, it did not alter skeletal muscle or omental or hepatic expression of insulin signaling proteins. However, ART significantly decreased skeletal muscle expression of phosphatase and tensin homolog, total mechanistic target of rapamycin, and ribosomal protein S6. In addition, ART increased hepatic phosphorylation of AMP-activated protein kinase α and increased gene expression of key enzymes required for gluconeogenesis and fatty acid synthesis. These findings suggest that CBA and ART differentially promote adverse metabolic effects in an organ-specific manner that may underlie insulin resistance associated with alcohol, SIV, and ART. Whether this is translated in PLWH with AUD remains to be determined.

Decreased myoblast differentiation in chronic binge alcohol-administered simian immunodeficiency virus-infected male macaques: role of decreased miR-206

Skeletal muscle stem cells play a critical role in regeneration of myofibers. We previously demonstrated that chronic binge alcohol (CBA) markedly attenuates myoblast differentiation potential and myogenic gene expression. Muscle-specific microRNAs (miRs) are implicated in regulation of myogenic genes. The aim of this study was to determine whether myoblasts isolated from asymptomatic CBA-administered simian immunodeficiency virus (SIV)-infected macaques treated with antiretroviral therapy (ART) showed similar impairments and, if so, to elucidate potential underlying mechanisms. Myoblasts were isolated from muscle at 11 mo after SIV infection from CBA/SIV macaques and from time-matched sucrose (SUC)-treated SIV-infected (SUC/SIV) animals and age-matched controls. Myoblast differentiation and myogenic gene expression were significantly decreased in myoblasts from SUC/SIV and CBA/SIV animals compared with controls. SIV and CBA decreased muscle-specific miR-206 in plasma and muscle and SIV decreased miR-206 expression in myoblasts, with no statistically significant changes in other muscle-specific miRs. These findings were associated with a significant increase in histone deacetylase 4 (HDAC4) and decrease in myogenic enhancer factor 2C (MEF2C) expression in CBA/SIV muscle. Transfection with miR-206 inhibitor decreased myotube differentiation, increased expression of HDAC4, and decreased MEF2C, suggesting a critical role of miR-206 in myogenesis. Moreover, HDAC4 was confirmed to be a direct miR-206 target. These results support a mechanistic role for decreased miR-206 in suppression of myoblast differentiation resulting from chronic alcohol and SIV infection. The parallel changes in skeletal muscle and circulating levels of miR-206 warrant studies to establish the possible use of plasma miR-206 as an indicator of impaired muscle function.

Chronic binge alcohol administration accentuates expression of pro-fibrotic and inflammatory genes in the skeletal muscle of simian immunodeficiency virus-infected macaques

BACKGROUND

Chronic binge alcohol (CBA) administration exacerbates skeletal muscle (SKM) wasting at the terminal stage of simian immunodeficiency virus (SIV) infection in rhesus macaques. This is associated with a pro-inflammatory and oxidative milieu which we have previously shown to be associated with a disrupted balance between anabolic and catabolic mechanisms. In this study, we attempted to characterize the SKM gene expression signature in CBA-administered SIV-infected macaques, using the same animals from the previous study.

METHODS

Administration of intragastric alcohol or sucrose to male rhesus macaques began 3 months prior to SIV infection and continued throughout the duration of study. Gene transcriptomes of SKM excised at necropsy (~10 months post-SIV) from healthy na\xEFve control (Control), sucrose-administered, SIV-infected (SUC-SIV), and CBA-administered, SIV-infected (CBA-SIV) macaques were evaluated in microarray data sets. The Protein Analysis Through Evolutionary Relationships classification tool was used to filter differentially regulated genes based on their predicted function into select biological processes relevant to SKM wasting which were inflammation, extracellular matrix (ECM) remodeling, and metabolism.

RESULTS

In total, 1,124 genes were differentially regulated between SUC-SIV and Controls, 2,022 genes were differentially expressed between the CBA-SIV and Controls, and 836 genes were differentially expressed between CBA-SIV and SUC-SIV animals. The relevance of altered gene expression was reflected in the up-regulation of pro-inflammatory CCL-2, CCL-8, CX3CL1, SELE, HP, and TNFRS10A mRNA expression. In addition, ECM remodeling was reflected in the up-regulation of TIMP-1, MMP 2, and MMP 9 mRNA expression and transforming growth factor-beta 1 protein expression. In addition, hydroxyproline content and picrosirius staining reflected increased collagen deposition in the CBA-SIV muscle tissue.

CONCLUSIONS

The results of the study demonstrate SKM inflammation as an important underlying mechanism for muscle wasting. In addition, the study provides evidence of SKM fibrotic transformation as a factor in CBA-induced accentuation of SIV-associated muscle wasting.

Chronic binge alcohol consumption alters myogenic gene expression and reduces in vitro myogenic differentiation potential of myoblasts from rhesus macaques

Chronic alcohol abuse is associated with skeletal muscle myopathy. Previously, we demonstrated that chronic binge alcohol (CBA) consumption by rhesus macaques accentuates skeletal muscle wasting at end-stage of simian immunodeficiency virus (SIV) infection. A proinflammatory, prooxidative milieu and enhanced ubiquitin proteasome activity were identified as possible mechanisms leading to loss of skeletal muscle. The possibility that impaired regenerative capacity, as reflected by the ability of myoblasts derived from satellite cell (SCs) to differentiate into myotubes has not been examined. We hypothesized that the inflammation and oxidative stress in skeletal muscle from CBA animals impair the differentiation capacity of myoblasts to form new myofibers in in vitro assays. We isolated primary myoblasts from the quadriceps femoris of rhesus macaques that were administered CBA or isocaloric sucrose (SUC) for 19 mo. Proliferation and differentiation potential of cultured myoblasts were examined in vitro. Myoblasts from the CBA group had significantly reduced PAX7, MYOD1, MYOG, MYF5, and MEF2C expression. This was associated with decreased myotube formation as evidenced by Jenner-Giemsa staining and myonuclei fusion index. No significant difference in the proliferative ability, cell cycle distribution, or autophagy was detected between myoblasts isolated from CBA and SUC groups. Together, these results reflect marked dysregulation of myoblast myogenic gene expression and myotube formation, which we interpret as evidence of impaired skeletal muscle regenerative capacity in CBA-administered macaques. The contribution of this mechanism to alcoholic myopathy warrants further investigation.

IL-21 and IL-10 have redundant roles but differential capacities at different stages of Plasma Cell generation from human Germinal Center B cells

The GC is the anatomical site where antigen-activated B cells differentiate into PC, producing high-affinity antibodies in physiological and pathological states. PC differentiation is regulated by multiple factors within the GC microenvironment, including cytokines. IL-21, a recently identified type I cytokine produced by GC-Th cells, promotes differentiation of human B cells into ISC. In this study, we investigated in detail the functional role of IL-21 in the course of GC-B cell differentiation into terminally differentiated PC compared with that of IL-10, a well-known PC differentiation factor. IL-21 had a greater capacity to initiate PC differentiation from CD77(+) centroblasts than IL-10 by strongly inducing PC transcription factors through activation of STAT3; however, IL-10 was more potent than IL-21 in generating CD138(+) PC from CD20(-)CD38(++) plasmablasts in the terminal stage of GC-B cell differentiation. This differential effect of IL-21 and IL-10 was reflected in receptor expression on B cell subsets emerging in the course of differentiation. Our studies have revealed that IL-21 is a critical decision-maker for driving initial PC differentiation at the stage of CD77(+) centroblasts, yet IL-10 is more effective in producing IgG by generating terminally differentiated CD138(+) PC at the later stage of PC differentiation in the GC.

Strukturdynamik und Vulnerabilitätsmodelle

This paper links Janzarik's structural-dynamic coherence model with Zubin and Springs' vulnerability model and shows that Janzarik's model enables reduction of the multiple and partially speculative single factors of the vulnerability model to a functionally interpretable and coherent theory. We will then review the internal logic of the structural-dynamic coherence model concerning the explanatory power of pathogenetic models of schizophrenia and show that Janzarik is confirmed by the literature in the assumption that primary hypodynamism is present in the run-up to the schizophrenic prodrome and first manifestations. Structural dynamic derailment as a core phenomenon in psychotic disorders is also accepted and confirmed by the literature. On the other hand, the 'einheitspsychose', or unitary psychosis, basis of the structural dynamic model is controversial. In this context the author discusses his own Vienna school's Axes model, which suggests a variety of further determinants of the pathoplastic formation of the idiopathic psychosyndrome above and beyond Janzarik's model. Finally we discuss further questions which may arise out of the structural dynamic model.

[New concepts of schizophrenic sub-syndromes - consequences for treatment]

Etiopathogenetic research gives rise to the suspicion that the classifications on hand pool heterogeneous disturbances under the heading of schizophrenia. This has drawn increasing attention to the necessity of identifying schizophrenic subsyndromes. Investigations using factor analysis revealed convincingly three major groups of schizophrenic symptoms: 1. a "negative factor", 2. a "psychoticism factor", comprising delusions and hallucinations and 3. a "disorganization syndrome" whose cardinal item is formal thought disorder. These studies have not yet furnished final results, but already opened insights enabling the conceptualization of syndrom-oriented therapies. The observation that the psychoticism symptomatology occurs in the frame of a "dynamic instability", based on a thymopsychic hyperreactivity, is in this regard especially important. In schizophrenic patients this hyperreactivity may be caused by secondary biological compensation mechanisms - such as perhaps an "up-regulation" of postsynaptic dopamine receptors. "Classic" neuroleptics can only correct the dynamic instability and thus eliminate psychoticism symptoms and reduce the accentuation of disorganization symptoms. They have, however, no influence upon negative symptomatology and can moreover aggravate "secondary" negative symptoms and especially impede cognitive functions. New "atypical" neuroleptics do not produce these side effects. They seem to have a reducing influence on negative symptoms and to improve cognitive functions. In each neuroleptic therapy a stepwise drug withdrawal should make clear whether or not a continous treatment is necessary. In the first case the needed efficacious dosis must be identified. The patients must learn to recognize relapse prodromes and to prevent the appearance of acute episodes through appropriate modifications of the medication. This strategy requires the combination with adequate psychotherapeutic methods enabling the patient to master persistent negative and disorganization symptoms in the best possible way.

Dose variation due to differences in applicator placement used for intracavitary brachytherapy of cervical cancer

The prognosis for women with early stage cancers of the cervix is excellent. The cervix and proximal vagina are relatively radioresistant structures; dose limiting critical structures for radiation treatment in this area are tissues such as the bladder and rectum. The high dose rate gradient of brachytherapy allows high doses to the tumor volume, while doses to the neighboring structures are lower. Intracavitary treatment of cervical cancer is performed by insertion of tandem and ovoid applicators. Correct tandem and ovoid placement is verified and documented with orthogonal radiographs. If placement of the tandem and ovoid is not acceptable, the packing is removed, and the tandem or ovoid is repositioned or exchanged as necessary. To examine the difference in dose to specific reference points when tandem or ovoid placement was changed by the physician, three patients' initial insertion radiographs were compared to those that were accepted to treat. Points of comparison selected for the patients on each of the insertions were: point A (L and R), external iliac nodes (L and R), bladder, and rectum. Each of the placement changes for the three patients resulted in differences in distance, and therefore, differences in dose. Changes as high as 823 cGy resulted from the adjustment of only one component. In the cases examined, repositioning improved dose distribution to the cervix, and lowered the dose to adjacent critical structures.

[French translation of the Frankfurt Complaint Questionnaire (Frankfurter Beschwerde-Fragebogen, FBF, Süllwold, 1986)]

Observable behaviors play the predominant role in the clinical assessment of schizophrenia, while only secondary emphasis is placed on exclusively subjective complaints. Huber employed the phenomenological approach to obtain subjective symptoms that he named "basic symptoms". Subjective symptoms constitute an important component of the schizophrenic symptomatology. They may play a predominant role during the prodromal or early phases of the disease, they may be useful in elucidating cognitive and perceptual disturbances in schizophrenia. In the last decade, the assessment of patients' subjective experiences has acquired significance with the development of several instruments for their specific evaluation. The Frankfurt Complaint Questionnaire (FCQ, Süllwold, 1986) is the instrument most widely used in Europe for assessing subjective experiences. It covers a wide range of complaints of cognitive deficits that Süllwold compiled from the complaints of schizophrenic patients. We present the French translation of the FCQ. The availability of the FCQ in French could be an important step in promoting the study of subjective experiences in research and clinical activities.

Conceptualization of schizophrenia: the symptom-oriented approach

E. Bleuler proposed to establish the diagnosis of schizophrenia on the basis of fundamental symptoms which he presumed to be particularly linked with the primary deficiency. K. Schneider, on the other hand, based his diagnosis on the presence of symptoms recognizable without difficulty. Modern classifications include both Bleuler's fundamental and Schneider's first-rank symptoms in their diagnostic criteria. This may lead to erroneous attributions in view of the possibility that most first-rank and some of the symptoms Bleuler suspected to be fundamental may be unspecific reactions to different basic disturbances. It can therefore be expected that research on symptoms is better suited for aetiopathogenetic investigations than research based on diagnoses. Strategies to select those symptoms on which research should focus are described and recent findings of symptom-oriented studies are discussed.

The rehabilitation of schizophrenic patients in Austria

The foundation of a rehabilitation center for schizophrenics annexed to the Psychiatric University Clinic of Vienna in 1963 initiated a systematic readaptation strategy for these patients all over Austria. The main task of these rehabilitation units is to evaluate the working and social capacities after acute illness episodes, to motivate the patient to accept professional activities and living conditions adapted to their health state through reinforcement of special competences, to replace inadequate attribution and coping styles by appropriate behavior patterns and to enhance compliance for necessary drug treatment. During the rehabilitation period the families are systematically prepared to live with the patients. In accordance with the obtained level of rehabilitation the patients are then either reintegrated into their family and/or normal professional conditions or placed in special settings (homes, sheltered workshops). A long-term followup is assured.

[Suggestion and hypnosis in hysteria]

Suggestive influences allow to resolve ambiguities. Normally they are only accepted if they correspond with the knowledge and believes of the subject. Under hypnosis or under the impact of serious psychic perturbations one may take up reality constructions which are not in conformity with these criteria. The restriction of consciousness and the ignoring of certain functions permitting this are the common basis of hypnosis and hysteria. But suggestions do not cause the later; they may only shape the symptomatology. Hypnosis can create a terrain facilitating the resolution of the problems underlying hysteria but it does not represent the treatment of hysteria.

[Diagnostic criteria and European nosology]

The elaboration of a-theoretical comprehensive classifications has become a main concern of American psychiatry. European psychiatrists are frequently reluctant to join this consensus-based endeavour. Their nosological approaches have largely been guided by the theoretical distinction between genuine mental diseases and quantitative psychic deviations: Jasper' warning that the dismemberment of the latter leads astray incited them to concentrate mainly on the classification of the former. Thus, European psychiatrists developed several concepts of functional psychoses which differ in regard to the subdivision of these disorders and their delimitation from mere quantitative deviations. The American classifications have partially abandoned or distorted traditional european views. In order to examine the reliance of their concepts the European schools should more systematically provide operational diagnostic criteria and submit them to polydiagnostic validation-studies.

A multicenter double-blind study of three different doses of the new cAMP-phosphodiesterase inhibitor rolipram in patients with major depressive disorder

A multicenter randomized 4-week interindividual double-blind study was carried out in 58 hospitalized patients with major depressive disorder (DSM III 296.23, 296.22, 296.33, 296.32, 296.53 and 296.52) to test the dose-effect relationship of three different doses of the new cAMP-phosphodiesterase inhibitor rolipram: 3 x 0.25 mg, 3 x 0.50 mg and 3 x 1.00 mg rolipram/day. With respect to the desired effect, the 3 x 0.50 mg dosage stood out from the others in almost all relevant parameters. With respect to the response rate, the efficacy of the 3 x 0.25 mg dosage was about the same as that reported in the literature for placebo. The inferior performance of the 3 x 1.00 mg dosage compared to the 3 x 0.50 mg dosage might indicate a reverse U-shaped dose-effect relationship. There was good tolerance to all three dosages. There were no findings that might cast doubt on the safety of the dosages tested.

[Development of the manic-depressive concept in German language psychiatry]

German language psychiatry has had and still has much difficulty in getting rid of the dichotomy of endogenous psychosis as set by Kraepelin. The concept which makes a distinction between schizophrenic psychosis and manic-depressive psychosis grants the former a predominant position by applying Jasper's hierarchic rule: the presence of symptoms regarded as schizophrenic indubitably attributes the disorder to schizophrenia. Such classification, however, does not necessarily imply that schizophrenia and cyclothymia (word proposed by K. Schneider for manic-depressive psychosis) represent separate nosological entities. It is admitted that it is possible for each group to include diseases whose hereditary transmission is not necessarily due to the same genetic predisposition. Thus, German language psychiatry has well accepted the possibility that bipolar manic-depressive psychosis and unipolar depressions represent separate etiologies. For most German-speaking psychiatrists, however, the distinction between endogenous and psychogenic depressions still remains a current assumption. The distinction between these two types of depression is generally made with reference to an "endogenous item profile" or to a depressive endogenomorphous axial syndrome. Only a few authors have accepted the model of continuity between these two types of depression proposed by the London school. The Hamburg school gave a new dimension to the conceptualization of manic-depressive psychosis by drawing attention on the existence of "rapidly alternating mixed states" which are much more common than the stable mixed conditions described by Kraepelin. On the basis of this concept and by questioning the validity of Jaspers' hierarchic rule, the Vienna school has considerably extended the limits of affectives psychosis to the detriment of the wide concept of schizophrenia described by K. Schneider.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evolution of diagnostic criteria for schizophrenia]

Many operational diagnostic criteria for schizophrenia, which are rooted to various degrees in the concepts of Kraepelin, E. Bleuler and K. Schneider, have been developed during the last two decades. They often incorporate prognostic factors to which Langfeldt in particular had drawn attention. These recent criteria vary considerably according to the attitude taken with regard to Jasper's hierarchical principle, which accords a diagnostic superiority to schizophrenic symptoms over affective symptomatology. Attribution to schizophrenia is very different depending upon whether the systems uphold, reject or reverse this principle. One should distinguish between classifications based upon a consensus of experts or experienced clinicians on the one hand and diagnostic research criteria destined to test etiopathogenetic hypotheses on the other. The important principles of attribution of DSM III and DSM III-R are outlined as well as their shortcomings, the latter leading to the conclusion that one should not restrict oneself to employ solely the American classification, but utilize it along with other classifications, such as the French empirical criteria or the Vienna research criteria, in order to see more clearly whether the very broad definitions of schizophrenia do not camoufly particular etiopathogenetic entities which ought to be identified.

Predicting course and outcome in delusional psychoses

Eighty-four of 90 patients with delusional syndromes of different nosological attribution underwent a 7-year follow-up. From 179 items covering the whole spectrum of psychiatric description of index examination, 20 were found to be statistically significant in predicting different aspects of course and outcome by stepwise discriminant analysis. Course and outcome were defined by 6 criteria (course of illness, course of delusion, development of deficiency, length of inpatient care, adequate activity and social adjustment) encompassing separate (but only partly independent) aspects of a disorder. In contrast to the literature, clinical and psychopathological variables have major prognostic weight for different psychopathological as well as psychosocial aspects of outcome. Ten of the 20 significant items cover psychopathology, 4 pre-index course, 3 precipating events, 2 data from childhood, and 1 premorbid personality. Our results stress the importance of sensitive data collection and a clear separation of different outcome variables.

Temporal stability of diagnostic criteria for functional psychoses. Results from the Vienna follow-up study

200 first admissions with functional psychoses were interviewed with PSE and rated simultaneously according to different diagnostic criteria (ICD-9, RDC, DSM-III, St. Louis, Taylor, Vienna Research Criteria). At follow-up 7 years later 186 patients could be traced and a course diagnosis was applied to each patient. Temporal stability of diagnostic criteria was calculated for ICD-9, RDC and DSM-III by stability coefficient and kappa values and was used as a criterion for validity. Schizophrenia and affective disorder display considerable stability over time, no matter whether one uses ICD-9, RDC or DSM-III. The data for schizoaffective disorder are less impressive, the stability coefficient is much higher for schizoaffective bipolar than for schizoaffective depressive patients.

Methodological aspects of follow-up studies on psychotic patients in a polydiagnostic perspective

Polydiagnostic follow-up studies should explore whether certain definitions of a given disorder permit better prediction of the illness course than others and whether this good predictive validity is related to specific etiopathogenetic conditions. In order to carry out such studies successfully they should be based on broadly defined samples and comprise provisions for additional validation such as genetic data, neuropsychological testing etc. After an assessment at baseline and at discharge from hospital, the follow-up assessments should comprise five steps: (1) Identification of successful and unsuccessful diagnostic systems; (2) identification of features determining successful attribution; (3) analysis of successful systems; (4) analysis of unsuccessful systems, and (5) analysis of cases which have changed diagnostic attribution. The conclusions drawn from these analyses are intended to refine classification in psychiatry.

Clinical and epidemiological aspects of dementia in the elderly

Dementia of the Alzheimer's type (DAT) is the most significant disease of the aging brain. Descriptive epidemiology of DAT found a constant doubling of prevalence rates every 5 years. Analytic epidemiology so far failed to reliably detect risk factors for DAT other than age. This might depend on the difficulties encountered in the clinical diagnosis and differential diagnosis of dementia in the elderly, which are discussed with special reference to 1) the definition of dementia, to 2) the grading of severity of dementia, to 3) the differentiation between dementia and depression, and to 4) the differentiation between multi-infarct dementia and DAT.

Neurotic, stress-related and somatoform disorders (section F4) and physiological dysfunction associated with mental or behavioural factors (section F5): results of the ICD-10 field trial

The results of the ICD-10 field trial in German-speaking countries relevant to sections F4 (neurotic, stress-related and somatoform disorders) and F5 (physiological dysfunction associated with mental or behavioural factors) show a comparatively low level of acceptance. Interrater-reliability in various diagnostic categories is not always adequate. In particular the allocation of some of the "old" diagnostic entities of ICD-9 to various sections of ICD-10, and in part unsatisfactory classificatory distinctions gave rise to certain problems.

[Treatment of negative symptoms in schizophrenia with neuroleptics]

Different concepts of negative symptoms in schizophrenia are reviewed. The beneficial effects of neuroleptics are discussed. The results of a pharmacokinetic and pharmacodynamic study with Amisulpride in healthy volunteers are reported. Preliminary findings of a study with Amisulpride in schizophrenic patients with predominately negative symptoms are presented. The utility of various rating scales for documenting the clinical state of these patients during therapy, and correlations of negative symptoms with psychometric and psychophysiological data are discussed. Finally, therapeutic consequences suggested by different hypothesized etiological factors causing negative symptoms are considered.

Delusional theme, sex and age

In a retrospective study of 865 delusional syndromes, connections were investigated between delusional themes and the sex of patients, and the ages in which these themes extensively occurred. According to previous reports, the results of this investigation indicated that differences exist between the ages of manifestation regarding the themes of hypochondria, persecution, love and jealously. Furthermore, differences could be observed between males and females in relation to the frequency of choice of particular themes, as well as the age of occurrence. Based on psychological studies concerned with the content's dependence on motives we conclude that the age distribution of delusional themes corresponds to the main existential concerns in different life periods.

Emotion, affect and mood: a terminological introduction

It is difficult to establish clear distinctions between emotion, affect and mood, because they belong to the same physiological dimension which may be conceived as 'background' activity'; for the purposes of research definitions should be as precise as possible. After a review of the most commonly used and sometimes contradictory definitions of these and related terms, a modified version of Janzarik's model of the 'structural-dynamic coherency' is proposed as a frame of reference for improvement in defining different 'dynamic states'. The clear distinction between emotional resonance, mood and drive for the description of pathological modifications of the background activity is discussed.

Psychopathological concepts of dysphoria

Dysphoric conditions are increasingly postulated as representing independent mood disorders. However, despite much effort at clarification, their psychopathological definitions remain unclear and variable. This paper reviews some examples of these divergent definitions, most of which are based on quality of mood, as well as responsiveness to external stimuli. The paper then introduces a strategy in possible solution of the above-mentioned definition problems. Setting out from restriction of the term dysphoria to conditions of a morose, tense and irritated mood, as suggested by Snaith and Taylor, we support the opinion that dysphoria should be accepted as a third possibility of mood swing, as a psychopathological disturbance which can be well distinguished from stable and unstable mixed states.

Delusional psychoses: genetic findings as a critical variable for the validation of diagnostic criteria

77 patients with delusional psychoses, regardless of their nosological attribution (except severe organicity), and their first-degree relatives were diagnosed with the Research Diagnostic Criteria (RDC) and the Vienna Research Criteria (VRC). The diagnostic procedure was performed blindly in the relatives. Both criteria were sufficiently capable of identifying a schizophrenic and affective subgroup of patients characterized by the appearance of homotypical secondary cases. Apart from a small RDC schizoaffective group differing in genetic pattern, there exists another large group of nonschizophrenic, nonaffective delusional disorders lacking a genetic link to the above-mentioned diagnoses. In respect to the development of the diagnostic criteria, the results of this study call for the formulation of a narrow definition of schizophrenia (as in the VRC) which is based on thought disorder and affective blunting with the exception of so-called productive symptomatology (delusions, hallucinations); separate criteria for schizoaffective disorders (as in RDC), and a broad and nonrestrictive definition for nonschizophrenic delusional disorders.

Approaches to the assessment of schizophrenia in Europe

All definitions of schizophrenia rely more or less on Kraepelin's hypothesis, Bleuler's theory or Schneider's pragmatic criteria. After a discussion on how these assumptions are referred to in classical and operational diagnostic systems in Europe, the results of a survey of 1983 literature are presented to show what kinds of assessments European workers currently employ. Lastly, guidelines are presented to enable psychopharmacological research to make the best use of the diagnostic systems to suit its purposes: essentially, which system or systems (the polydiagnostic approach for example) one should choose depends upon the symptoms the medication to be tested is supposed to treat, keeping in mind that patient sampling varies according to the system in question.

Alcohol and depression

The relationship of alcohol and depression has always been a subject of clinical and scientific interest. Though many studies have been carried out to clarify the mode of this relationship it still remains in its complexity an area for further research. The two basic ideas of a possible connection are on one hand symptomatic alcoholism with a preexisting depression and on the other hand alcoholism leading to a symptomatic depression. There is in literature a great variability of results with regard to this problem which will be discussed in view of the results of an own study on 444 chronic alcoholic patients.

First-rank symptoms and Bleuler's basic symptoms. New results in applying the polydiagnostic approach

By comparing six different operational diagnostic systems (International Classification of Diseases, Diagnostic and Statistical Manual; 3rd ed., Research Diagnostic Criteria, St. Louis criteria, Taylor criteria and Vienna Research Criteria), the data presented in this paper illustrate how attribution to various categories of functional psychoses varies according to the applied algorithms. Bleuler's basic symptoms are obviously considered by all of the compared systems to be more significant for attribution to schizophrenia than first-rank symptoms.

'Paranoid psychoses'. New aspects of classification and prognosis coming from the Vienna Research Group

After a presentation of the traditional principles of diagnosis and a precise definition of terms, the Vienna approach to the classification of delusional conditions is introduced. This approach is multiaxial: the first axis consists of a classification of delusional syndromes based on a cross-sectional description of their structural and constituting elements; on the second axis, the relationship between the delusional world and the real one is described; the third axis is for the recording of delusional contents; the fourth axis serves for an attempt at etiological attribution. The Vienna approach differs principally from the usual systems of classification in that it is purely syndromatological and thus it avoids giving an a priori nosological meaning to the various symptoms making up the delusion (for example, certain delusional themes, certain forms of hallucinations). A definitive nosological diagnosis is only possible when an organic cause is clearly evident, otherwise the suffix '-morphic' (endogenomorphic-schizophrenic, endogenomorphic-cyclothymic, and organomorphic axial syndromes) is added to denote the close resemblance of clinical states to certain disorders whose nosological homogeneity should not be taken for granted. Next, the results of our own catamnestic study on a patient population selected solely on syndromatological grounds are presented. It is shown that no prognostic significance can be attributed to the delusional pictures classified according to their description (paranoic syndromes, systematic and unsystematized paraphrenia); on the other hand, such significance certainly falls to one of the axial syndromes formulated on axis 4 (the endogenomorphic-cyclothymic axial syndrome). Nevertheless, a relatively large portion of the patients eluded attribution to one of the axial syndromes, even after a course of several years. Aside from the possibility that a number of them could be so classified after further cross-sectional evaluation, one may suspect that this group contains patients whose delusional formation stems from a psychogenic etiology; or it may be that these patients represent a third illness entity, distinct from the other two groups of endogenous psychoses.

Course and outcome of delusional psychoses

The authors reinvestigated 84 out of a sample of 90 patients with delusional psychoses after an interval of 6-9 years. The results of the follow-up showed a pattern of episodic versus chronic course which compares to follow-up studies on classically diagnosed schizophrenias. The authors found evidence for their hypothesis concerning the nosological heterogeneity of this group of psychoses and propose a syndromatological classification apart from the delusional symptomatology itself. What they call background symptomatology was divided into axial syndromes. The authors feel that this results in subgroups that are more homogeneous for course and outcome than the usual classification systems.

Heterogeneity of delusional syndromes: diagnostic criteria and course prognosis

In addition to genetic findings and treatment response, the course prognosis is also meant to be a possible validating criterion for diagnosis and diagnostic systems. In our study we used the polydiagnostic approach (i.e. the simultaneous application of various criteria for diagnosing a given disorder to one and the same population) to test the ability of several diagnostic systems to create homogeneous groups regarding the course (episodic/chronic). We applied Schneider's FRS, ICD-9, DSM-III, Spitzer's RDC and the Vienna Research Criteria to 90 patients with the diagnosis of delusional syndrome (aside from any nosological classification), who underwent 6-9 years of follow-up. At the index examination, schizophrenia was most frequently diagnosed with Schneider's FRS, which apparently encompasses a very heterogeneous group of patients regarding psychopathology and course. Diagnostic systems which allowed the diagnosis of affective disorders despite the presence of mood-incongruent delusional symptomatology (DSM-III, RDC, Vienna Criteria) or offered the diagnosis of schizoaffective disorder (DSM-III, RDC) succeeded in separating subgroups with an episodic course on a statistically significant level. In ICD-9 this significance appeared only after exclusion of the schizoaffective cases from the group of schizophrenias. Our data thus uphold the old rule of thumb that affective symptomatology apparently has a very high prognostic value regarding the course of the illness and is in this respect superior to productive symptomatology (such as delusions and hallucinations), still taken to be pathognomonic for schizophrenia by some of the diagnostic criteria under study. This aspect warrants further investigation and should be taken into account in the development and improvement of diagnostic manuals (e.g. ICD-10, DSM-IV).

[Semiology and nosology]

While distinguishing three successive steps in the making of a diagnosis, the authors point out the premises of modern semiology. They refer to the work of K. Schneider (pragmatic approach), Jaspers, Bleuler and Janzarik (approach based on theoretical concepts), Kasanin and finally Langfeldt (empirical approach). Current approaches of semiology try to define diagnostic criteria. In that line of thinking, the school of Vienna, while establishing the insufficiency of all systems, proposes the adoption of a polydiagnostic approach that would eventually define consistent semiologies that refer with certainty to real nosological entities.

Approaches to an exact definition of schizo-affective psychoses for research purposes

The perplexity psychiatry is faced with when approaching the problem of 'schizo-affective disorders' is the result of two characteristic features of human psychology: The first consists in the tendency to pick up quickly attractively formulated terms and to prefer them to others designating the same facts. The second psychological trend referred to concerns the use of a well-sounding term in a definition which deviates from the original one. The nosological implications of the existence of the 'cases in between' (K. Schneider), attributable neither to schizophrenia nor to cyclothymia, are briefly reviewed. It is suggested to speak of schizo-affective disorders only if the criteria for both disorders manifest simultaneously. Applying the Vienna Research Criteria we found that 'schizo-affective' disorders occur rarely as compared to other frequently used less restrictive diagnostic instruments.