[Burnout in doctors]. / Wenn aus Liebe zum Arztberuf Leiden wird. Ausgebrannt zwischen Wunsch und Wirklichkeit.

According to the international ICD classification, burnout is not a defined disease. Signs of burnout are frequently associated with psychiatric symptoms. Many doctors experience a reality shock at the beginning of their professional careers due to the great discrepancy between expectations and reality. Frustration and overwork eventually develop into exhaustion, often substance misuse and resignation. Especially doctors usually resort to medical help only in the final stage of burnout when clear psychiatric symptoms are recognizable. Hence, it is all the more important to heed the early warning signs and to counteract increasing stress.

Effects of tryptophan depletion in drug-free depressed patients who responded to total sleep deprivation.

BACKGROUND: There is some evidence that sleep deprivation (SD) might exert its antidepressant properties by involving serotonergic mechanisms. We investigated the effects of short-term tryptophan depletion (TD) on depressed patients who responded to a single night of total SD. METHODS: Drug-free depressed inpatients (n = 30) were randomly assigned to either TD or sham depletion. Tryptophan depletion was induced by a 24-hour low-tryptophan diet (day 1) followed the next morning by ingestion of a tryptophan-free amino acid mixture (day 2). During sham depletion, the diet and the amino acid beverage were supplemented with tryptophan. Sleep deprivation was performed from day 1 until day 2. Only SD responders received the amino acid beverage the morning after SD. Behavioral ratings and total and free plasma tryptophan levels were obtained before and after the test sessions. RESULTS: Twenty-two of 30 patients showed a favorable outcome after SD. As predicted, TD significantly lowered total and free plasma tryptophan levels, whereas both levels increased during sham depletion. No acute effects on mood were observed during the day after SD in either treatment group. Unexpectedly, TD, but not control testing, prevented the depressive relapse after the recovery night in most of the patients. CONCLUSIONS: Tryptophan depletion did not reverse the antidepressant effects of SD, but it prevented the relapse beyond a night of recovery sleep. These findings suggest that SD does not act via a single monoamine-related mechanism, but they allow the assumption that TD may induce neurochemical alterations that transiently improve depression.

Single photon emission computerized tomography assessment of cerebral dopamine D2 receptor blockade in depression before and after sleep deprivation--preliminary results.

The antidepressant properties of total sleep deprivation (TSD) have been well established. There is some evidence that TSD may improve depression by altering central dopamine (DA) function. We therefore studied five depressed TSD responders and five TSD nonresponders after sleep and after TSD and five controls after sleep with IBZM single photon emission computerized tomography (SPECT). Responders showed a significant decrease (Wilcoxon--test p < 0.05) of relative basal ganglia D2 receptor occupancy after TSD compared to nonresponders (change score responders versus nonresponders p < 0.05, U-test). The data are interpreted as a sign of an enhanced DA release in responders. The results confirm previous hypotheses of dopaminergic involvement in the therapeutic action of TSD and indirectly support a dopamine hypotheses of depression.

Duration of lithium treatment and brain lithium concentration in patients with unipolar and schizoaffective disorder--a study with magnetic resonance spectroscopy.

Twenty psychiatric patients on lithium medication were examined with 7-Li-magnetic resonance spectroscopy of the brain. Patients on long-term lithium treatment (> 6 months) were compared with a short-term group who had been taking lithium for between 4 and 8 weeks. Patients met DSM-III-R criteria for either recurrent unipolar depressive disorder (DSM-III-R 296.3x) or schizoaffective disorder, depressive type (DSM-III-R 295.70). The brain:serum lithium ratio was 0.76 +/- 0.26; there was no significant difference between short-term and long-term treatment. In the group of long-term treatment patients there was a positive correlation between lithium dose per day and brain lithium concentration (R = .72, p < .01), and between lithium plasma concentration and brain lithium concentration (R = .65, p < .05). In the short-term group, however, there was no significant correlation for these parameters. No differences between unipolar and schizoaffective disorder were found.

Rapid tryptophan depletion in drug-free depressed patients with seasonal affective disorder.

OBJECTIVE: Brain serotonin systems might be involved in the pathophysiology of seasonal affective disorder. The authors tested whether tryptophan depletion alters the mood of depressed patients with seasonal affective disorder. METHOD: Eleven drug-free depressed patients with seasonal affective disorder underwent tryptophan depletion in a placebo-controlled, double-blind crossover study. Tryptophan depletion was induced by a 24-hour low-tryptophan diet and by ingestion of a tryptophan-free amino acid beverage. During control testing the diet and the beverage were supplemented with tryptophan. Behavioral ratings and plasma total and free tryptophan levels were obtained before the diet started and several times after administration of the beverages. RESULTS: The diet and the tryptophan-free amino acid drink reduced plasma total and free tryptophan levels by 79.0% and 87.5%, respectively. Both levels increased during control testing. No significant behavioral changes were induced by tryptophan depletion or control testing. CONCLUSIONS: The failure of tryptophan depletion to exacerbate the depressive syndrome suggests that dysfunctional serotonergic activity does not play a primary, direct role in the pathogenesis of winter depression.

Spontaneous slow and fast MEG activity in male schizophrenics treated with clozapine.

RATIONALE: The atypical neuroleptic clozapine induces specific electroencephalogram changes, which have not been investigated using the technique of magnetoencephalography (MEG). OBJECTIVE: The present study investigated whether spontaneous magnetoencephalographic (MEG) activity in patients treated with clozapine differs from that in patients treated with haloperidol and untreated control subjects. METHODS: A 2 x 37 channel biomagnetic system was used to record spontaneous magnetic activity for the frequency ranges (2-6 Hz), (7.5-12 Hz), (12.5-30 Hz) in schizophrenic patients and controls in two trials within 3 weeks. After data acquisition, the processed data were digitally filtered and the spatial distribution of dipoles was determined by a 3-D convolution with a Gaussian envelope. The dipole localisation was calculated by the dipole density plot and the principal component analysis. The target parameters were absolute dipole values and the dipole localisations. The relationship between absolute dipole values, dipole localisations and psychopathological findings (documented by the use of the PANSS, BPRS-scale) during a 3 week period with constant doses of clozapine and haloperidol was investigated using correlation analysis. RESULTS: Our results lend strong support to the assumption of a significant elevation of absolute dipole values [dipole density maximum (Dmax), dipole number (Dtotal), absolute and relative dipole density] in the fast frequency range (12.5-30 Hz) over the left hemisphere, especially in the temporoparietal region by clozapine. In this area, we found a dipole concentration effect only in patients treated with the atypical neuroleptic, whereas the dipole distribution in patients treated with haloperidol and healthy controls was concentrated in the central region. With regard to the absolute dipole values in the frequency ranges 2-6 Hz (delta, theta) and 7.5-12 Hz (alpha), we found no statistically significant differences between the groups investigated. In the slow frequency range (2-6 Hz) no difference was found between the clozapine and haloperidol group for the dipole localisation, which predominated in the temporoparietal region, in contrast to the central dipole distribution in control subjects. CONCLUSIONS: The results of an increase in beta activity under clozapine demonstrate a smaller reduction in activity in terms of unspecific sensory and motor paradigms in comparison with typical neuroleptics. The temporoparietal concentration of dipoles, in particular over the left half of the brain, might illustrate either their special role in the disease process, or the effects of the medication. The latter possibility was supported by the differing dipole distribution in the clozapine group with a left temporoparietal centre in both frequency ranges, and a deviating central dipole localisation in the fast activity range in the haloperidol group.

Dose-dependent stereoselective activation of the trigeminal sensory system by nicotine in man.

RATIONALE: Nicotine applied to the nasal cavity can evoke 'odorous' sensations in the concentration range near the detection threshold by the activation of the olfactory sensory system and at higher concentrations 'burning' and 'stinging' sensations by the dose-dependent recruitment of C- and Adelta-fibers of the trigeminal sensory system. Neuronal nicotinic acetylcholine receptor (nAchR) subunits are expressed in trigeminal primary afferents and could constitute the receptors involved in nicotine perception. OBJECTIVE: In the present study, we dose-dependently investigated the stereoselective effects of R(+)- and S(-)-nicotine on the trigeminal and olfactory sensory system in man. METHODS: Trigeminal detection thresholds for the 'burning' and 'stinging' sensations and the olfactory detection threshold for the 'odorous' sensation were determined. In order to quantify trigeminal activation, we recorded summated electrical responses from the respiratory nasal mucosa during stimulation with R(+)-and S(-)-nicotine vapor (40, 80, 120, 160 ng/ml; stimulus duration: 250 ms). In addition, subjects rated the intensity of 'odorous', 'burning' and 'stinging' sensations. For chemical stimulation with nicotine enantiomers, a vapor-dilution olfactometer (constant flow rate: 140 ml/s, humidity: 80%, temperature: 37 degrees C, stimulus duration 250 ms) was employed. RESULTS: We found significant stereoselective differences for the trigeminal but not for the olfactory system, i.e. higher summated responses, higher trigeminal intensity estimates, and lower trigeminal detection thresholds for S(-)- compared to R(+)-nicotine. CONCLUSION: Our results clearly demonstrate the different stereoselective activation of the trigeminal sensory system by R(+)-and S(-)-nicotine, indicating the presence of specific stereoselective receptors on trigeminal nociceptive Adelta- and C-fibers.

Unusual features in a case diagnosed as subacute sclerosing panencephalitis (SSPE).

SSPE is characterised by progressive mental deterioration, myoclonic and similar motor disorders and final severe comatose states, increase of immunoglobuline G in the CSF, strongly elevated antibody titers to measles virus in serum and CSF and typical periodic K-complexes in the EEG. The disease appears commonly in childhood and has a fatal course. Cases with atypical signs have occasionally been reported. The case described in this paper shows a number of uncommon features: late onset, partial remission and stationary course, increased antibody titers to measles virus but relatively low in comparison to others, dissociation of cytoplasmic and nuclear fluorescent antibodies against SSPE brain tissue and an initial increase of antibodies against rubella virus. The patient was treated with isoprinosine. Improvement was observed before the start of this therapy and stabilized while treatment was being continued.

Effects of sleep deprivation on the limbic system and the frontal lobes in affective disorders: a study with Tc-99m-HMPAO SPECT.

We studied 10 patients with melancholia before and after sleep deprivation and 8 controls with Tc-99m-hexamethylpropylenamineoxime (HMPAO) single photon emission computed tomography (SPECT). All depressed subjects showed relative hypoperfusion in the left anterolateral prefrontal cortex under both conditions. Only responders showed relative hyperperfusion in parts of the limbic system and a reduction of blood flow in these regions after sleep deprivation.

Increased limbic blood flow and total sleep deprivation in major depression with melancholia.

Single photon emission computed tomography (SPECT) with technetium-99m-d,l-hexamethyl-propylene amine oxime (99Tcm-HMPAO) was carried out in 20 melancholic patients before and after total sleep deprivation. Findings in 11 responders to total sleep deprivation (defined by > or = 40% improvement on the Hamilton Rating Scale for Depression) were compared with findings in nine nonresponders. On the basis of a semiquantitative evaluation of SPECT findings, responders showed relative hyperperfusion before sleep deprivation in the right anterior cingulate cortex and in the right and left fronto-orbital cortex and basal cingulate gyrus. Responders who showed > or = 50% improvement also showed hippocampal overactivation before sleep deprivation. It is possible that limbic overactivation may characterize depressed responders to total sleep deprivation as a distinct subtype. Another possibility is that the pattern of limbic hyperactivation reflects the increased number of bipolar patients in the responder group, with response to total sleep deprivation being only a covariate of this bipolar-unipolar distinction.

Effects of glucocorticoids on plasma catecholamines in depression.

To explore corticosteroid-catecholamine interactions in depression, plasma dopamine, norepinephrine, and epinephrine concentrations were studied both before and after dexamethasone in 16 patients during depression and after recovery, and in 28 healthy controls. Dexamethasone had a significant suppressive effect on plasma epinephrine levels in depressed patients and controls, while dopamine and norepinephrine levels were not significantly affected following dexamethasone administration. Levels of norepinephrine, epinephrine, and cortisol were positively correlated, while dopamine showed no correlation with cortisol values. These findings point to differentiated interrelations between certain catecholamines and glucocorticoids which possibly are affected during depressive illness.

Harman and norharman plasma levels in weaned alcoholics: correlations with depression and tobacco smoking.

Based on the hypothesis that ß-carbolines are involved in the pathogenesis of alcohol-related mood disturbance, harman and norharman levels were assayed in the blood plasma of alcoholics and correlated to the Hamilton Depression (HAM-D) scores after 3 and 5 weeks post-admission. Tobacco smoking was co-evaluated since it is known to influence ß-carboline levels. After a 3-week period, plasma harman but not norharman was increased in depressed alcoholics and positively related to the HAM-D sum-score (r = 0.47; p < 0.04) and to tobacco smoking (r = 0.56; p < 0.02). Since no correlation between depression and smoking was found, these data could account for the higher incidence of depressive symptoms in withdrawn alcoholics with increased harman levels. The partial correlations support this hypothesis.

Neuropsychological results of craniopharyngioma surgery in adults: a prospective study.

BACKGROUND: The optimal management of craniopharyngiomas is a topic of ongoing debate. Supporters of limited surgery for craniopharyngiomas claim that more radical approaches are afflicted with adverse neuropsychological sequelae. Since prospective studies on this issue have not yet been performed, we assessed neuropsychological functioning in adults before and after craniopharyngioma surgery. METHODS: Thirteen adults with an age range of 17-76 years (mean, 45 years) were included in the study. Surgery included a transcranial procedure in 10 patients. The bifrontal interhemispheric approach predominated (n = 7). Neuropsychological evaluation was performed before and 3 months after surgery. The test battery was adjusted to evaluate function related to structures in the operative trajectory and at the tumor site. RESULTS: A complete tumor removal was accomplished in eight patients and subtotal removal in three patients. IQ scores for verbal intelligence were in the normal range and not affected by surgery (mean IQ score preoperative: 106.8; postoperative 107.4). In 12 of 13 patients, immediate recall, delayed recall and recognition memory were not impaired after surgery. Postoperative results for abstract thinking were in the normal or above-normal range. Cognitive speed was impaired in three patients preoperatively and in two patients postoperatively. Overall results were significantly better after surgery. Word fluency was not affected by surgery. Quality of life for the category "sleep" was impaired preoperatively, and this improved after surgery. Otherwise, quality of life was normal both before and after surgery. CONCLUSIONS: Neuropsychological performance and quality of life are generally not impaired after surgical removal of craniopharyngiomas. The findings support the attitude that the initial therapy of craniopharyngiomas should be an attempt at total removal.

[Sabbatai Zwi--a false Jewish Messiah. Case report on religious psychopathology]. / Sabbatai Zwi--ein falscher jüdischer Messias. Ein kasuistischer Beitrag zur Religionspsychopathologie.

The life of the Jewish heretical Messiah Sabbatai Zwi (1626-1676) presents several features suggesting a psychotic affective disorder. Particular political and socio-cultural conditions enabled him to arouse a state of rebellion in a large part of the Jewish population. This study investigates relations between the individual psychosis of Sabbatai Zwi and the reaction of the public. In addition relations between psycho-pathological and mystical-demonological terminology are considered.

[Patient education, medication and physical therapy. Balm for "cardiac neurosis"]. / Aufklärende Gespräche, Medikation und Physiotherapie. Balsam für die "Herzneurose".

In the management of psychogenic chest pain, the family doctor has a key role to play. His main task is to exclude physical or organic causes and identify the underlying psychogenesis--admittedly without wishing to establish a definitive (ICD-10) diagnosis. For this purpose, empathic reassurance of the patient is of major importance. Wherever possible, hospitalization of the patient for a diagnostic clarification should be avoided. Therapeutic options comprise suitable physiotherapy, psychohygienic measures, and appropriate pharmacotherapy. Major goals of such an approach are the establishment of a trusting relationship, and improving the patient's sleep patterns, physical fitness and emotional status. In the event of long-term persistence of the condition or a severe course, referral to a specialist is indicated.

[Messy house syndrome]. / Sammeln und Horten: ein Messie kann nicht anders. Die Wohnung als Müllhalde.

The messy house syndrome (Diogenes syndrome) is present when, owing to a disordering of the personality structure, a person is unable to keep order, for example, in the household or his finances. Such persons are also referred to as "messies". Useless objects are hoarded in such quantities that the apartment can no longer be lived in. In many cases, the disorder is due to an underlying mental problem such as dementia, schizophrenia, ADHS or obsessive-compulsive disorders. The Prader-Willi syndrome is also associated with an unusual compulsion to hoard things or food. In the first instance, treatment is aimed at the underlying condition (neuroleptic agents, SSRI). New studies appear to suggest that the particular concomitant cognitive and emotional disturbances associated with hoarding respond to cognitive behavioral therapy.