[Psychopathological aspects of "raptus melancholicus"]. / Psychopathologische Aspekte des "Raptus melancholicus"

The term "raptus melancholicus" is rarely used in clinical or scientific discussions. There is a lack of data on frequency and attribution to psychiatric disorders. It is found more often in the older literature where authors write of detailed personal experiences with this malicious phenomenon, but the published information is isolated as well. Clinicians and forensic psychiatrists judge raptus melancholicus to represent a risk for suicidal attempts as it appears suddenly and unexpectedly, arising from a state of delayed and inhibited psychomotor motility. This enigma, which sounds quite paradoxical, requires a psychopathological explanation as offered here. The inclusion of forensic aspects suggests that raptus melancholicus is not such a rare entity.

[Acute psychotic productivity in cerebral imaging]. / Akute psychotische Produktivität in der zerebralen Bildgebung1.

Regional cerebral blood flow (rCBF) was analysed in 24 neuroleptically never treated schizophrenics by 99m-Tc-HMPAO-SPECT. Psychopathological symptoms (PANSS) were correlated with rCBF-measures using multidimensional scaling (MDS). Highest degrees of correlation were found for ideas of grandiosity and formal thought disorders compared to different regions of interest (ROIs). An adynamic cluster was defined by basic symptoms which showed signs of deficiency. This cluster was by the highest degree correlated with a cluster defined by rCBF compared to four different clusters of basic symptoms. A fMRI-study was performed in schizophrenic patients with auditive hallucinations in comparison to healthy controls. We offered simple acoustic stimuli perceived as coming from the outside versus inside. For the outside condition, controls activated the medial temporal gyrus on the left side and the rightsided precuneus and postcentral gyrus which represent the auditive source locating and the stimulus processing systems, for inside, they activated the left insula. Hallucinating schizophrenic neither activated the one nor the other system. We discussed the findings as a possible explanation of the schizophrenics' tendency to misinterpret hallucinations as real perceptions.

[Personality disorders and schizophrenic psychoses]. / Persönlichkeitsauffälligkeiten und schizophrene Psychose.

We analysed two aspects of personality abnormality detected before the disorder became diagnostically apparent: potential genetic disposition, assessed using family and adoption studies, and premorbid constitution, which we outlined using retrospective and prospective studies. Current continuum models of the schizophrenic spectrum suggest that genetic disposition and premorbid constitution overlap to some extent, an area which ought to be better defined psychopathologically. In this overview, we determined a group of symptoms-bizarre behaviour, alogia, social withdrawal, and subclinical thought disorders-which are relevant for both schizotypal personality disorders and early schizophrenia. The topic of so-called reactive psychoses is examined to find an interface between personality abnormality and psychosis.

Command hallucinations: who obeys and who resists when?

The impact of auditory command hallucinations on the behaviour of schizophrenic patients sometimes appears to be unpredictable. In order to tackle this problem, the psychopathological characteristics of command hallucinations in 31 schizophrenic patients were assessed using a 24-item questionnaire. Using binary data and relative risk analysis methods, predictors were determined for obeying or resisting command hallucinations. Characteristics of voices and the attitude toward the voices appear equally important for prediction. A set of three psychopathological characteristics comprising a voice known to the patient, emotional involvement during the hallucinations, and seeing the voice as real provides significant predictivity of behaviour following command hallucinations. These results are interesting for clinical and forensic psychiatrists.

[Imperative auditory hallucinations in schizophrenia]. / Imperative akustische Halluzinationen bei Schizophrenie.

Command hallucinations are a subtype of auditory verbal hallucinations in schizophrenia. More likely than any other schizophrenic symptom, they may have an impact on the individual's behavior. In the forensic literature, aspects of dangerous actions induced by psychotic motivation have been discussed. From the psychiatric point of view, the main problem is the unpredictability of behavioral consequences. The present study examines psychopathological details of command hallucinations in 31 hospitalized schizophrenic patients, 10 females and 21 males, using a questionnaire including 24 items. The predictive accuracy of a distinct set of signs was rated concerning compliance vs. resistance of hallucinated commands. The predictors are: identifying the hallucinated voice, being affected by emotions after hallucinations, and misregarding the voice as being real. In the presence of these conditions, behavioral consequences are predicted by a value which was 6.7 times higher than that without any information about predictors. In the absence of these conditions, resistance of command voices is predicted by a value of 7.

[Therapeutic experiences with alcohol-related Korsakoff syndrome]. / Therapeutische Erfahrungen beim alkoholbedingten Korsakow-Syndrom.

Korsakoff's psychosis (Wernicke-Korsakoff-Syndrome) following severe, long-term alcoholism is considered to be widely resistant to treatment. We report two cases with beneficial effects of treatment by a combination of clonidine and fluvoxamine.

Monitoring of olanzapine in serum by liquid chromatography-atmospheric pressure chemical ionization mass spectrometry.

A selective assay of olanzapine with liquid chromatography atmospheric pressure chemical ionization (LC-APCI-MS, positive ions) is described. The drug and internal standard (ethyl derivative of olanzapine) were isolated from serum using a solid-phase extraction procedure (C18 cartridges). The separation was performed on ODS column in acetonitrile-50 mM ammonium formate buffer, pH 3.0 (25:75). After analysis of mass spectra taken in full scan mode, a selected-ion monitoring detection (SIM) was applied with the following ions: m/z 313 and 256 for olanzapine and m/z 327 and 270 for the internal standard for quantitation. The limit of quantitation was 1 microg/l, the absolute recovery was above 80% at concentration level of 10 to 100 microg/l. The method tested linear in the range from 1 to 1000 microg/l and was applied for therapeutic monitoring of olanzapine in the serum of patients receiving (Zyprexa) and in one case of olanzapine overdose. Olanzapine in frozen serum samples and in frozen extracts was stable over at least four weeks. The examinations of urine extracts from patients receiving olanzapine revealed peaks of postulated metabolites (glucuronide and N-desmethylolanzapine).

[Aspects of cerebral connnectivity in schizophrenia. A comparative CBF study on treated schizophrenics before and after medication]. / Aspekte zerebraler Konnektivität bei Schizophrenie. Eine vergleichende rCBF-Studie von nie behandelten Schizophrenen vor und nach Medikation.

INTRODUCTION: The hypothesis of prefrontal-temporolimbic disconnectivity, considered to be relevant to the pathogenesis of schizophrenia, has been tested in 29 drug-naive schizophrenic patients, comparing the active with the remitted state. METHOD: A pre-post-treatment design was applied to 29 drug-naive schizophrenic inpatients, 18 male, mean age 32 years, 11 female, mean age 32 years, mean duration of illness 29 months. Psychopathological symptoms were assessed using PANSS, regional cerebral blood (rCBF) was measured by HMPAO-SPECT. RCBF values were calculated for 21 regions of interest after normalization to cerebellum, and plotted by Euklidean diagrams using the ordinal, nonmetric, multidimensional scaling method. These diagrams represent similarity correlations visualized as spatial distances. High correlation levels as indicated by small Euklidean distances have been interpreted as functional connectivity. RESULTS: In active schizophrenia, functional disconnectivity was observed between prefrontal and temporal cortex. After remission, connectivity was improved between temporolimbic and frontal cortex. CONCLUSION: Comparing active with remitted schizophrenia, a frontotemporal disconnectivity appears. Temporolimbic as well as frontolimbic connections restitute parallel to psychopathological improvement.

Active and remitted schizophrenia: psychopathological and regional cerebral blood flow findings.

Single photon emission computed tomography with technetium-99m-d,l-hexamethylpropyleneamine oxime (99mTc-HMPAO) was used to assess regional cerebral blood flow (rCBF) during both florid and remitted stages of schizophrenia. Forty schizophrenic patients in an active phase of illness (diagnosis by DSM-III-R) were examined in two clinical states (ill vs. improved). At study entry, 24 patients were drug-naive, five were currently drug-free, and 11 were being treated with antipsychotic medication. Twenty medical patients who suffered from non-specific headaches but were free of neurological and psychiatric symptoms served as control subjects. At initial examination during the active phase of illness, cerebral perfusion patterns in the schizophrenic patients were characterized by both hypofrontality and hypotemporality. After remission, hypofrontality was no longer apparent in two of four frontal regions, and hypotemporality disappeared completely. As assessed with the Positive and Negative Syndrome Scale (PANSS), formal thought disorders, hallucinations, and ideas of grandiosity correlated with rCBF in the active phase of illness, but not after remission. In the remitted but not in the florid state, blunted affect, difficulties in abstract thinking, lack of spontaneity, and stereotyped thoughts correlated with rCBF. Correlations of five symptoms with rCBF changed significantly from first to second examination. The present study suggests that correlations between single psychotic symptoms and rCBF differ significantly in florid vs. remitted phases of schizophrenia.

Altered relationships between rCBF in different brain regions of never-treated schizophrenics.

AIM: of this study was to investigate the relations between regional cerebral blood flow (rCBF) of different brain regions in acute schizophrenia and following neuroleptic treatment. METHODS: Twenty-two never-treated, acute schizophrenic patients were examined with HMPAO brain SPECT and assessed psychopathologically, and reexamined following neuroleptic treatment (over 96.8 days) and psychopathological remission, rCBF was determined by region/cerebellar count quotients obtained from 98 irregular regions of interest (ROIs), summed up to 11 ROIs on each hemisphere. In acute schizophrenics, interregional rCBF correlations of each ROI to every other ROI were compared to the interregional correlations following neuroleptic treatment and to those of controls. RESULTS: All significant correlations of rCBF ratios of different brain regions were exclusively positive in controls and patients. In controls, all ROIs of one hemisphere except the mesial temporal ROI correlated significantly to its contralateral ROI. Each hemisphere showed significant frontal-temporal correlations, as well as cortical-subcortical and some cortico-limbic. In contrast, in acute schizophrenics nearly every ROI correlated significantly with every other ROI, without a grouping or relation of the rCBF of certain ROIs as in controls. After neuroleptic treatment and clinical improvement, this diffuse pattern of correlations remained. CONCLUSIONS: These results indicate differences in the neuronal interplay between regions in schizophrenic and healthy subjects. In never-treated schizophrenics, diffuse interregional rCBF correlations can be seen as a sign of change and dysfunction of the systems regulating specificity and diversity of the neuronal functions. Neuroleptic therapy and psychopathologic remission showed no normalizing effect on interregional correlations.

Psychopathological and SPECT findings in never-treated schizophrenia.

A total of 24 never-treated (i.e. drug-naive) actively psychotic schizophrenic patients, operationalized according to DSM-III-R, were examined in a pre-post-treatment design using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) and 99mTc-HMPAO-single photon emission computed tomography (SPECT) to assess regional cerebral blood flow (rCBF). The control subjects were 20 patients free of neurological and psychiatric symptoms. Before treatment there was only a slight hypofrontality, and hypoperfusion was observed in the left temporal superior region. After treatment, hypofrontality was reduced to one region and temporal hypoperfusion disappeared. Formal thought disorders were accompanied by increased rCBF in the bilateral frontal interior and left temporal superior regions. Delusions were associated with hypoperfusion in the anterior cingulate cortex. Negative symptoms showed no linkage to hypofrontality, either before or after treatment. Factor analysis showed delusions and hallucinations loading on different dimensions. The disorganized dimension correlated positively with all regions of interest, whereas these were negatively correlated with reality distortion.

Correlation of positive symptoms exclusively to hyperperfusion or hypoperfusion of cerebral cortex in never-treated schizophrenics.

BACKGROUND: Studies of schizophrenia by single photon emission computed tomography (SPECT) and positron emission tomography (PET) have shown both regional cerebral hyperperfusion and hypoperfusion. The aim of this study was to examine the inter-relations between regional cerebral blood flow (rCBF), psychopathology, and effects of neuroleptic therapy. METHODS: 24 never-treated patients with acute schizophrenia were examined with hexamethylpropyleneamine-oxime brain SPECT and assessed psychopathologically according to the positive and negative syndrome scale; they were studied again after neuroleptic treatment and psychopathological remission. rCBF values that deviated from those of 20 controls by more than 2 SD were regarded as abnormal. FINDINGS: Both hyperperfused and hypoperfused patterns were found among schizophrenia patients during acute illness. The seven positive symptoms on the symptom scale showed different correlations with rCBF: formal thought disorders and grandiosity correlated positively (and strongly) with bifrontal and bitemporal rCBF; delusions, hallucinations, and distrust correlated negatively (and strongly) with cingulate, left thalamic, left frontal, and left temporal rCBF. Stereotyped ideas as a negative symptom correlated negatively (and strongly) with left frontal, cingulate, left temporal, and left parietal rCBF. After neuroleptic treatment (and reduction of positive symptoms), only negative symptoms correlated exclusively with bifrontal, bitemporal, cingulate, basal ganglia, and thalamic hypoperfusion. INTERPRETATION: Different positive symptoms are accompanied by different rCBF values--some related to hyperperfusion, others to hypoperfusion. This finding may help to explain observed inconsistencies of perfusion patterns in drug-naïve schizophrenics.

Regional cerebral blood flow and negative/positive symptoms in 24 drug-naive schizophrenics.

UNLABELLED: SPECT/PET studies in schizophrenia revealed inconsistent changes of regional cerebral blood flow (rCBF). Frontal hyperperfusion as well as hypoperfusion are described. This study was undertaken to investigate the relations between rCBF, psychopathology according to PANSS and effects of neuroleptic therapy. METHODS: Twenty-four drug-naive acute patients with a first manifestation of schizophrenia were examined with 99mTc-HMPAO brain SPECT and assessed according to PANSS. Of these, 22 were controlled again after neuroleptic treatment. Following attenuation correction, region-to-cerebellar count ratios were obtained from 98 irregular regions of interest drawn in all slices (6.25 mm). The ratios were compared to 20 control subjects, and changes lying outside of 2 s.d. were considered abnormal. RESULTS: In different drug-naive patients, hyperperfusion as well as hypoperfused patterns were found. In drug-naive patients, the seven subscores of positive symptoms (pos 1-7) in PANSS showed different correlations to rCBF: Formal thought disorders (pos 2) and grandiosity (pos 5) were positively correlated to bifrontal and bitemporal rCBF (r = +0.59 to +0.70). Delusional ideas (pos 1), hallucinatory behavior (pos 3) and suspiciousness (pos 6) demonstrated a negative correlation to bifrontal, cingulate, left temporal and left thalamic rCBF (r = -0.59 to -0.66). Stereotyped ideas (neg 7) as a negative symptom showed a negative correlation to left frontal, left temporal and left parietal rCBF (r = -0.59 to -0.65). No correlations were found between residual positive symptoms and rCBF after neuroleptic treatment and clinical improvement, but all negative symptoms (neg 1-7) had a negative correlation to bifrontal, bitemporal, cingulate, basal ganglia and thalamic rCBF (r = -0.59 to -0.74). CONCLUSION: Our results illustrate that different positive symptoms are accompanied by different rCBF values: some induce hyperperfusion, others hypoperfusion. After therapy (and reduction of positive symptoms), only negative symptoms correlate exclusively to hypoperfusion. This may be the crucial factor in explaining inconsistencies of past results in perfusion pattern in drug-naive schizophrenic patients.

Phenomenology of simple partial seizures.

Based on a sample of 325 inpatients we present the subjective experiences during simple partial seizures. In a majority of cases, auras comprised composed forms of different symptomatic qualities. We describe rules which seem to govern sequences of aura phenomena. Autonomous and vestibular sensations were shown to have preceding positions related to others, olfactory and gustatory sensations preferred a following position. The tentative explanation of the findings favours the idea of heterogeneity rather than the concept of a focal discharge in a simple partial seizures.

[Physically experienced ego disturbances]. / Uber leiblich erfahrene Ich-Störungen.

The term "schizophrenia" can be translated into "split mind," which usually refers to an abstract and complex theory of split psychic functions. In a different sense, however, being split may mean the bodily experience of a second person existing within the diseased individual who appears doubled. Three cases are presented to illustrate this phenomenon, called "bodily experienced disturbances of the self," and the difference from Schneider terminology is stressed.

18FDG-PET and electroencephalographic findings in a patient suffering from musical hallucinations.

The majority of reports on the phenomenon of musical hallucinations suggests that this abnormality is a complication of a progressive peripheral hearing deficit. The present case report and a review of the international literature would, however, indicate that this syndrome may be the result of a dysfunction of the temporal cortex.

[Multiple personality disorder: old concepts presented as new]. / Störung mit multipler Persönlichkeit: alte Konzeptionen in neuem Gewande.

The rapid increase in numbers of MPD patients in the Anglo-American literature requires discussion of the diagnostic concept. The classification of MPD as Dissociative Disorders by DSM-III-R and ICD-10 follows the traditional conceptualization of hysteria and hypnosis. In the view of the majority of modern authors child abuse appears as a new etiological issue. This theme highly sensitive is critically discussed against the background of older psychopathological concepts of forgetting. A careful analysis of personality traits and motivation in the individual case help to avoid overuse of the new diagnostic label.

[Therapeutic approach to a case of simulated disorder with psychiatric symptoms]. / Therapeutische Begegnung mit einem Fall von vorgetäuschter Störung mit psychischen Symptomen.

The case of a 38-year-old female inpatient with the diagnosis of factitious disorder with psychological symptoms--a presentation rarely reported in the psychiatric literature--is presented with special respect to her personality traits. On the basis of her biographical history a therapeutic approach was possible which tried to understand the symbolic value of the histrionic patient's symptoms. We regarded the manifestation of psychological symptoms as an attempt to express conflicts verbally and as an offer of a more mature form of communication in comparison to the former, autodestructive physical syndromes.

[Musical-verbal hallucinations and their correlation with electroencephalography and PET findings. Case report]. / Musikalisch-sprachliche Halluzinationen und ihre Korrelation mit elektroenzephalographischen und PET-Befunden. Fallbericht.

A case is reported of an organic auditory hallucinosis and depressive episode in a man aged 52. A new finding is the correlation of the musical hallucinosis to a central nervous disorder as shown by pathological sphenoidal EEG and 18FDG-PET-examination and not to acquired peripheral hearing deficit as often reported before.