[Obsessive-compulsive and related disorders according to ICD-11 and DSM-5 : With brief consideration of the new obsessive-compulsive disorders olfactory reference disorder and hypochondriasis]. / Zwangsspektrumsstörungen nach ICD-11 und DSM-5 : Mit kurzer Betrachtung der neuen Zwangsspektrumsstörungsbilder "olfactory reference disorder" und Hypochondrie.

This article summarizes the current state of research with respect to the new obsessive-compulsive and related disorders (OCRD) grouping according to the International Statistical Classification of Diseases and Related Health Problems (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The ICD-11 grouping of OCRD is based on common clinical features, such as repetitive undesired thoughts and repetitive behavior and is supported by the literature and empirical data from the fields of imaging and genetics. The disorders in this grouping in ICD-11 include obsessive-compulsive disorder, pathological hoarding, body dysmorphic disorder, trichotillomania, excoriation disorder, and as new disorders differing to DSM­5, hypochondriasis, olfactory reference disorder and Tourette syndrome. The aim of the OCRD grouping is an improvement of the diagnostics and appropriate treatment strategies as well as a further stimulation of research. The new disorders olfactory reference disorder and hypochondriasis are presented and discussed.

Hypogyrification in obsessive-compulsive disorder.

BACKGROUND: Previous studies hypothesized that neurodevelopmental risk factors may play a role in the pathogenesis of obsessive-compulsive disorder (OCD). Cortical folding has been shown to be a reliable indicator for normal and altered neurodevelopment, but in OCD it has barely been investigated up to now. The present study investigates whether alterations in gyrification are detectable in OCD and, if so, how these are associated with clinical characteristics. METHOD: We compared the local Gyrification Index (lGI) between 75 OCD patients and 75 matched healthy subjects across the whole brain. In addition, for those regions exhibiting an altered lGI in patients we explored a potential relationship to symptom severity, age of onset, and influence of medication. RESULTS: OCD patients had a significantly decreased lGI in right parietal, precentral but also insula, temporal, pars triangularis and rostral middle frontal regions compared to healthy subjects. A positive association with age of onset was found but no association with symptom severity. There was no effect of co-morbidity or medication. CONCLUSIONS: The reduced gyrification found in OCD confirms previous findings in other psychiatric disorders and suggests that alterations may already occur during early stages of brain development. Our findings support the idea that altered cortical folding might represent a trait characteristic of the disorder although longitudinal studies are needed to clarify the trajectory of this morphological measure in OCD.

[Heterogeneity and comorbidity of obsessive-compulsive disorder]. / Heterogenität und Komorbidität der Zwangsstörung.

Although the DSM-IV-TR suggests that obsessive-compulsive disorder (OCD) is a coherent syndrome, scientific evidence offers a compelling case that OCD is highly heterogeneous and possibly composed of many different subtypes. OCD can display completely distinct symptom patterns thus making it difficult to identify a single "textbook" profile of OCD. The present state of research concerning subtyping is presented. There is a high comorbidity with depression and anxiety disorders, but all together data concerning OCD comorbidity are still not convincing. Currently obsessive-compulsive spectrum disorders (OCS) are described as a set of disorders lying on a continuum from compulsive to impulsive, with the unifying feature being an inability to regulate behaviour as a consequence of defects in inhibition. OCS disorders fall into three major clusters: impulsive disorders, disorders associated with appearance in bodily sensations, and neurological disorders characterized by repetitive behaviour. How these putative OCS disorders overlap with and are independent from obsessive-compulsive disorder itself is thoroughly discussed.

Connectomics-based structural network alterations in obsessive-compulsive disorder.

Given the strong involvement of affect in obsessive-compulsive disorder (OCD) and recent findings, the current cortico-striato-thalamo-cortical (CSTC) model of pathophysiology has repeatedly been questioned regarding the specific role of regions involved in emotion processing such as limbic areas. Employing a connectomics approach enables us to characterize structural connectivity on a whole-brain level, extending beyond the CSTC circuitry. Whole-brain structural networks of 41 patients and 42 matched healthy controls were analyzed based on 83 × 83 connectivity matrices derived from cortical and subcortical parcellation of structural T1-weighted magnetic resonance scans and deterministic fiber tracking based on diffusion tensor imaging data. To assess group differences in structural connectivity, the framework of network-based statistic (NBS) was applied. Graph theoretical measures were calculated to further assess local and global network characteristics. The NBS analysis revealed a single network consistently displaying decreased structural connectivity in patients comprising orbitofrontal, striatal, insula and temporo-limbic areas. In addition, graph theoretical measures indicated local alterations for amygdala and temporal pole while the overall topology of the network was preserved. To the best of our knowledge, this is the first study combining the NBS with graph theoretical measures in OCD. Along with regions commonly described in the CSTC model of pathophysiology, our results indicate an involvement of mainly temporo-limbic regions typically associated with emotion processing supporting their importance for neurobiological alterations in OCD.

Development of diagnostic checklists for use in routine clinical care. A guideline designed to assess DSM-III-R diagnoses.

To enhance diagnostic assessment in routine clinical care, the Munich Diagnostic Checklists have been developed for a systematic criteria-related evaluation of the most common psychiatric disorders according to DSM-III-R. Design, concept, and areas of application of the instrument are described. An initial test-retest study showed that satisfactory to excellent diagnostic agreement can be reached.

Recall and dating of psychiatric symptoms. Test-retest reliability of time-related symptom questions in a standardized psychiatric interview.

The advent of more explicit diagnostic criteria and the growing interest in "lifetime" rates of mental disorders has made imperative an accurate determination of time-related diagnostic criteria. We used data from two independent test-retest studies of the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI) to study the reliability of different time-related questions in these fully standardized diagnostic interviews. With two exceptions (anxiety disorders and alcohol-related questions), the test-retest reliability of most time-related questions in both interviews was judged to be satisfactorily high. Furthermore, the validity of time-related questions in the DIS (age at symptom onset, duration and frequency of illness episodes) was examined by comparing them with detailed "consensus" ratings done independently by different clinicians for 207 former psychiatric inpatients. A surprisingly high concordance was found for former psychotic patients except for those still severely disturbed at the follow-up investigation. Some severe restrictions were also found for nonpsychotic disorders with regard to judgment of the age at onset of phobias, panic attacks, and depression. For a more valid assessment of time-related symptom information, the use of specific memory aids is suggested.

WHO Neuropsychiatric AIDS study, cross-sectional phase I. Study design and psychiatric findings.

BACKGROUND: Most available studies on the psychiatric, neuropsychological, and neurological complications of HIV-1 infection and AIDS have been conducted in Western countries, on samples of well-educated, mostly white, homosexual men. Concerns about generalizability of the results of those investigations prompted the WHO to implement the cross-cultural venture called WHO Neuropsychiatric AIDS study. METHODS: This project aims to assess the prevalence and natural history of HIV-1-associated psychiatric, neuropsychological, and neurological abnormalities in representative subject samples enrolled in the five geographic areas predominantly affected by the HIV-1 epidemic. Assessment is made by a data collection instrument including six modules. The intercenter and intracenter reliability in the use of each module has been formally evaluated. The study consists of a cross-sectional phase and a longitudinal follow-up. RESULTS: The cross-sectional phase was completed in five centers. This paper reports on the results of psychiatric assessment, which revealed a significantly higher prevalence of current mental disorders in symptomatic seropositive persons compared with seronegative controls among intravenous drug users in Bangkok and homosexuals/bisexuals in São Paulo. The mean global score on the Montgomery-Asberg Depression Rating Scale was significantly higher in symptomatic seropositive individuals than in matched seronegative controls in all centers. CONCLUSIONS: These results suggest that the significance of the psychopathological complications of symptomatic HIV-1 infection may have been underestimated by previous studies conducted on self-selected samples of well-educated, middle-class, mostly white, homosexual men.

WHO Neuropsychiatric AIDS study, cross-sectional phase II. Neuropsychological and neurological findings.

BACKGROUND: The neuropsychological and neurological complications of HIV-1 infection and AIDS were explored within the cross-sectional phase of the WHO Neuropsychiatric AIDS Study. Special attention was devoted to the controversial issue of the prevalence and clinical significance of subtle cognitive deficits in asymptomatic seropositive subjects. METHODS: A neuropsychological test battery validated for cross-cultural use, a structured interview for the diagnosis of dementia, a rating scale of functioning in daily living activities, and a neurological module were administered to representative samples of seropositive subjects and to matched seronegative controls living in the five geographic areas predominantly affected by the HIV-1 epidemic. Data are available for five centers. RESULTS: The prevalence of global neuropsychological impairment was significantly increased in asymptomatic seropositive subjects compared with controls in only two centers. A significant effect of education on neuropsychological performance was observed among asymptomatic seropositive individuals. In the two African centers, low-education, but not high-education, asymptomatic seropositive persons had an impaired performance. The frequency of impaired functioning in daily living activities and of neurologic abnormalities was higher in symptomatic, but not in asymptomatic, seropositive subjects compared with controls in all centers. CONCLUSIONS: These data suggest that the risk of subtle cognitive deficits may be increased in asymptomatic stages of HIV-1 infection. However, these deficits are not associated with neurologic changes and do not seem to affect subjects' social functioning.

A risk-benefit assessment of risperidone for the treatment of behavioural and psychological symptoms in dementia.

The importance of behavioural and psychological symptoms in dementia (BPSD) is increasingly being recognised. Symptoms such as verbal and physical aggression, agitation, sleep disturbances and wandering are common, cause great distress to caregivers and are likely to lead to institutionalisation of patients. At present, these symptoms are also more amenable to treatment compared with the progressive intellectual decline caused by dementing illnesses. The care of individuals with BPSD involves a broad range of psychosocial treatments for the patient and his or her family. If pharmacotherapy is deemed necessary to manage BPSD, a careful balance must be struck between the benefits of symptom control and the inherent risks associated with most psychotropic agents in the elderly. Elderly patients in general, and patients with dementia in particular, are more sensitive to medication adverse effects, including anticholinergic effects, orthostatic hypotension, sedation, parkinsonism, tardive dyskinesia and cognitive impairment than younger patients with dementia or individuals without dementia. To date, treatment of symptoms of aggression and psychosis has relied on the empirical use of antidepressants, anxiolytics, typical antipsychotics (neuroleptics) and other agents. Treatment-limiting adverse effects are frequently reported with all of these agents. However, it is the typical antipsychotics and the atypical antipsychotic clozapine that are associated with the greatest risk of adverse effects in the elderly. The present review highlights the issues that limit the use of older psychotropic agents in the elderly, and presents an assessment of the available evidence concerning the efficacy, safety and tolerability of the atypical antipsychotic risperidone, in the treatment of BPSD in elderly patients with dementia. The extensive clinical development programme for risperidone has shown the drug to be effective and well tolerated in many fragile patients. As a result of its efficacy and safety profile, risperidone can be used for the treatment of behavioural and psychological symptoms in patients with dementia. Risperidone therefore represents a significant addition to the armamentarium for BPSD. While efforts continue in the development of treatment for the cognitive decline associated with dementia, treatment is now available for the noncognitive symptoms. By treating the latter, risperidone has the potential to be of substantial benefit to patients with dementia, their carers and the costs of healthcare.

The overlap between depression and anxiety on different levels of psychopathology.

Symptoms, syndromes, and diagnoses (DSM-III-R) for depression and anxiety were assessed and evaluated in 150 psychiatric outpatients. It was hypothesized that the coexistence of depression and anxiety within subjects strongly depends on the psychopathological level determined. The results confirmed this assumption. Overlap proportions for symptoms were almost twice as high as for diagnoses (52% vs. 29%). Intermediary rates were obtained for syndromes. Implications of these results for research on anxious depression, often considered to be qualitatively distinct from pure depression or anxiety disorders, are discussed.

Attentional control of pain perception: the role of hypochondriasis.

The role of hypochondriasis in the attentional control of pain perception was investigated in 28 in-patients (12 women and 16 men) at a hospital for psychosomatic disorders, who had been classified into high- and low-hypochondriacal categories by means of the Illness Attitude Scales (IAS). The two groups did not differ in their basic pain sensitivity based on their heat pain thresholds. Attentional control was manipulated by a mental arithmetic task, resulting in one experimental condition with distraction and one without distraction. In both of the conditions, subjects rated the intensity and the unpleasantness of nonpainful and painful heat stimuli on visual analog scales (VAS). Distraction significantly reduced the perceived intensity and unpleasantness of the stimuli at painful levels but not at nonpainful levels. Contrary to our expectation, the individual level of hypochondriasis did not influence this result. Although distraction seemed to have a strong influence on pain perception, hypochondriasis as a symptom or a trait did not contribute to this effect.

Loudness dependence of auditory evoked potentials in obsessive-compulsive disorder: a pilot study.

In recent years it has been suggested that a serotonergic dysfunction is involved in the pathogenesis of obsessive-compulsive disorder (OCD). The loudness dependence of auditory evoked potentials (AEPs) is one of the best validated indicators of the activity of the serotonin system in humans. To explore the validity of the hypothesis of a serotonergic dysfunction in OCD, the loudness dependence of AEPs of 22 medication-free OCD patients were compared with those of 22 age- and gender-matched healthy subjects. Auditory evoked N1/P2 activity to tones of increasing intensity was studied using dipole source analysis. Contrary to the hypothesis, OCD patients and healthy controls did not differ in their LDAEPs of the tangential dipole in particular, located in the primary auditory cortex and closely related to central serotonergic activity. Furthermore, no significant correlation was found between the severity of obsessive-compulsive or depressive symptoms and the loudness dependence of AEPs. These findings do not support the hypothesis of a serotonergic dysfunction in OCD patients.

Evaluation of two new neuropsychological tests designed to minimize cultural bias in the assessment of HIV-1 seropositive persons: a WHO study.

In the course of the preparatory work for the WHO cross-cultural study on the neuropsychiatric aspects of HIV-I infection, two new neuropsychological tests (the WHO/UCLA Auditory Verbal Learning Test and the Color Trails 1 & 2) were developed. The evaluation of these tests was performed at four sites, two in developed and two in developing countries. The data obtained suggest that the tests are more culture fair than others currently used to assess the same functional domains, that they are sensitive to HIV-1-associated cognitive impairment, and that this sensitivity "holds" across different cultures.

[New stipulations for rehabilitation of mentally ill. Will return to normal life be facilitated?]. / Neue Bestimmungen für die Rehabilitation psychisch Kranker. Wird damit die Rückkehr in den Alltag erleichtert?

Current changes in the laws pertaining to mental disorders are mainly concerned with the redefinition in the Sozialgesetzbuch IX (SGB IX) [Social Law] of the term "disability", and the forthcoming introduction of the International Classification of Functioning, Disability and Health (ICF). Accordingly, the rehabilitation of the mentally disturbed will be based on an integrative bio-psychosocial treatment concept, which--in parallel with curative therapy--right from the beginning envisages measures aimed at reintegration of the patient into daily/occupational life. On the basis of the ICF, all patients with mental disorders of more than 6 months' duration may be classified by the medical services of the health insurance carriers as being in need of rehabilitation. Appropriate care-related structures in psychiatric and psychosomatic areas are to some extent already available.

Cycloid psychoses and schizoaffective psychoses--a comparison of different diagnostic classification systems and criteria.

In current psychopathological research there are at least two major groups of concepts in the field of psychoses with good prognosis: the more traditional concepts of 'bouffée délirante', cycloid psychoses and Kasanin's 'schizoaffectives'--on the other hand the modern idea of 'concurrent schizoaffective psychoses' like the operational criteria of Kendell, Welner, RDC, DSM-IIIR and ICD-10. Reviewing previous studies, 'bouffée délirante' and cycloid psychosis were found to form a homogeneous group which is very well delineated from affective and schizophrenic psychosis--to some extent also from the modern criteria of 'concurrent schizoaffective psychoses'.

Assessing behavioral symptoms of dementia of the Alzheimer type: categorical and quantitative approaches.

Behavioral disturbances are a prevalent and important aspect of dementia of the Alzheimer type, but they have been relatively neglected by researchers. To characterize patients as having dementia, at least two goals should be addressed: first, determining a reliable definition and categorical diagnosis of dementia using such criteria as the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the International Classification of Diseases (ICD)-10; second, establishing a reliable and valid measurement of the severity of cognitive and noncognitive impairment by means of rating scales. DSM-IV and ICD-10 do not provide definitions of behavioral disturbance, whereas more than 100 geriatric rating scales exist that include some measurement of behavioral disturbances of dementia. There is a need for consensus on the term for these noncognitive symptoms. Some authors prefer the subdivisions of (a) psychiatric and noncognitive symptomatology into psychiatric symptoms, or syndromes and behavioral disturbances; and (b) cognitive syndromes. Given the frequency and clinical significance of behavioral and psychiatric disturbances in dementia, a standardized assessment procedure is needed for reliably and comprehensively describing psychiatric phenomena and behavioral disturbances in patients with dementia.

A new systematic method of measurement and diagnosis of "mild cognitive impairment" and dementia according to ICD-10 and DSM-III-R criteria.

Normative data were collected in a study population of 150 randomly selected elderly subjects. Using the SIDAM (Structured Interview for the Diagnosis of Dementia of the Alzheimer Type, multi-infarct dementia, and dementias of other etiology according to DSM-III-R and ICD-10), both the dimensional and the categorical aspects of dementia and "mild cognitive impairment" are considered. With the SIDAM score (SISCO) [range 0 (minimum)-55 (maximum, no cognitive impairment)] and the SIDAM Mini-Mental State Examination (MMSE) (range 0-30), appropriate cutoffs for the category of DSM-III-R and ICD-10 dementia and "mild cognitive impairment" were defined. MMSE scores of 0-22 were found to be indicative of DSM-III-R and ICD-10 dementia. For "mild cognitive impairment," MMSE scores ranged from 23-27 according to a DSM-III-R definition (ICD-10: 23-28). An MMSE score of 22 or less was found to differentiate between DSM-III-R/ICD-10 dementia and "mild cognitive impairment," with a specificity of 92% (ICD-10: 95.6) and a sensitivity of 96% (ICD-10: 96%). With the SIDAM-based DSM-III-R/ICD-10 diagnoses of dementia as the criterion, the SISCO was 97.3% specific (ICD-10: 99%) and 94% sensitive (ICD-10: 94%) in detecting dementia. A SISCO of 0-33 was highly indicative of DSM-III-R and ICD-10 dementia. For "mild cognitive impairment," a SISCO between 34-47 (ICD-10: 34-51) was found. The SISCO covers a broader range of cognitive functions than the MMSE and is more useful in detecting even very mild cognitive decline. Furthermore, the newly defined category of "mild cognitive impairment" could be validated successfully by means of GDS Stages 2-3 and CDR Stage 0.5. These findings confirm the value of the SIDAM as a short diagnostic instrument for measurement and diagnosis of dementia and "mild cognitive impairment."

[Operationalized diagnosis of schizoaffective and cycloid psychoses]. / Zur Frage der operationalisierten Diagnostik schizoaffektiver und zykloider Psychosen.

Case histories of 128 patients suffering from functional psychoses were evaluated. The operational definitions for schizoaffective psychoses (SAP) of Kendell, Welner, Spitzer (RDC) and Feighner were applied. Of the 30 cases of SAP based on ICD 8 (295.7), Kendell's criteria were fulfilled in 97% Welner's in 77%, Spitzer's in 70% and Feighner's in 30%. The highly sensitive criteria of Kendell are best qualified for delineating the schizoaffective (sa) syndroms, but have the disadvantage of not requiring a time limitation when examining the longitudinal course of the illness. In this respect, the Welner criteria which also demonstrate high sensitivity were found to be more appropriate for the disease concept of the ICD 8. When using the schizoaffective criteria, a striking overlap was found with catatonic schizophrenia (Kendell and Welner diagnosed 33% as sa), paranoid schizophrenia (Spitzer 39%, Kendell and Welner 28%) and mania (Kendell and Welner 50% sa diagnoses). Of the SAP only 30% satisfied Perris' criteria for cycloid psychoses. Except for catatonic schizophrenia (47% overlap), the cycloid psychoses could be well distinguished from the other psychoses. cycloid psychoses therefore should not form a subgroup of the SAP. Kendell's criteria were found to be best qualified for the determination of the schizoaffective group. A higher specificity of the disease concept SAP may be achieved if we use time limitations such as Welner's. To avoid placing cycloid psychoses in the SAP category, the Perris criteria should be applied. Because of their high specificity, the criteria of Feighner and Spitzer were found to be inappropriate. In DSM-III the definition of "psychotic disorders not elsewhere classified" is weak. It lacks an operational definition for SAP so that DSM-III was not used for this investigation. In order to obtain a more homogeneous population not only in the schizoaffective group, but also in both of the two major psychoses, we find it legitimate to maintain the schizoaffective group and, at the same time, recognize the exceptional position of cycloid psychoses as separate groups.

[Neuropsychiatric disorders caused by organic solvents]. / Neuro-psychiatrische Störungen durch organische Lösungsmittel.

Since the early seventies numerous reports, especially from the Scandinavian countries, have indicated a growing incidence of organic brain syndromes after chronic exposure to mixtures of organic solvents. Symptomatology varies widely, but from a psychiatric point of view can best be summarized as: dementia syndromes with cognitive and neurological deficits, neurasthenic and neurotic syndromes. Presenting a single case study the authors describe a dementia syndrome after long-term exposure to organic solvents: from certain areas of work a high index of suspicion seems justified.