[Transcultural aspects of suicidal behaviour]. / Suizidalität im Kulturvergleich.

Due to increasing immigration in Germany the German Mental Health Care System today has to deal in a growing number with the assessment of the level of psychic functioning and the capability of self control in patients of different ethnic origin. For clinicians this is a challenge, since suicidal behaviour in terms of its frequency, meaning, motives and manner is very much dependent on the cultural context in which it occurs. Moreover, the general attitude of an individual towards suicide is embedded in the culture of origin of the immigrant. Until now there has been only little systematic research on the influence of culture on suicidal behaviour. In this review the traditions of suicidal behaviour in different cultures in their religious and historical dimensions will be reflected. The historical and cultural roots of suicidal behaviour will be put in context to a categorization of the different variants of suicide, such as institutionalized suicide versus individualized suicide. Psychodynamic aspects of suicidal ideation will be highlighted in cross-cultural perspective with a distinction between a. the wish to die, b. the wish to kill and c. the wish to be killed. It will be shown that there can be differentiated between accepted and non-accepted suicide. With respect to epidemiology there will be discussed the impact of culture on the suicide rates across cultures. The influence of culture on the psychopathology of suicidal behaviour will be summed up systematically. These aspects are of high relevance for the understanding and assessment of suicidal crisis in immigrants, since the suicidal patient even today - although subconsciously - is influenced by the deep rooted traditions of suicidal behaviour in his culture of origin.

[Spectrum of neuropsychiatric features associated with velocardiofacial syndrome (Deletion 22q11.2)]. / Das neuropsychiatrische Spektrum des Velokardiofazialen Syndroms (Deletion 22q11.2).

Microdeletion 22q11.2 (22q11DS) is the most frequent chromosomal deletion known in man. Velocardiofacial syndrome is one of numerous clinical syndromes that can be attributed to this micro deletion. There is an increasing recognition of associations with neuropsychiatric disorders. Particularly, schizophrenic psychosis, attention-deficit/hyperactivity disorder (ADHD), intellectual impairment and learning disabilities, seizures and motoric abnormalities have been identified in patients with 22q11DS. Recent studies supported the association of schizophrenia and 22q11DS, but the pathogenetic implications for idiopathic schizophrenia are still controversial. We report on two clinical cases in which psychotic symptoms led to the molecularcytogenetic diagnosis of microdeletion 22q11.2. Additionally, this article gives a systematic review of literature regarding psychiatric disorders, neurologic symptoms and partly corresponding morphological brain abnormalities in 22q11 deletion syndromes.

[Mental disorders associated with multiple sclerosis]. / Psychische Störungen als Begleiterkrankungen der Multiplen Sklerose.

HISTORY: Findings are reported in 4 patients with multiple sclerosis (MS) and various mental disorders which were directly associated with the underlying disease, with disease-related increased vulnerability, were a reactive response or had occurred independently of the MS. CASE 1: A 53-year-old woman with MS for 24 years developed cognitive disorders with markedly impaired quality of life. CASE 2: A 44-year-old man with MS for 8 years had depression and felt suicidal. CASE 3: A 58-year-old woman with MS for 35 years suffered from both depression and symptoms of a compulsive-obsessive disorder. CASE 4: A 19-year-old woman with MS for 2 years was treated by a psychiatrist for the first time when she developed acoustic hallucinations and suicidal ideation during cortisone treatment. DIAGNOSIS, TREATMENT AND COURSE: CASE 1: The progressive mental disorder was classified as manifestation of the chronic progressive MS: it was treatment-refractory. CASE 2: The patient underwent psychotherapy as both an in- and out-patient. His depression was thought to be reactive and improved well under this treatment, despite the deterioration of the MS, requiring him to use a wheel-chair. CASE 3: The compulsive-obsessive symptoms persisted during medication for depression, for which she then received behavioral treatment. CASE 4: The initial symptoms of hallucination and suicidal ideation ceased when cortisone was stopped. A diagnosis of borderline personality was made, based on her continuing symptoms of impaired impulse control, abnormal affect, distorted self-image, a feeling of inner emptiness, agitation with suicidal tendency and factitious injuries. The renewed occurrence of acoustic hallucinations and suicidal tendency occurred independently of cortisone treatment and was interpreted as expression of inflammatory disease activity, but differential diagnosis had to consider the patient s personality disorder, too. CONCLUSION: Mental disorders in patients with MS are manifold and their causes are complex. It is important to recognize these associated diseases and initiate individualized treatment, because they considerably impair the patients quality of life.

Basal ganglia calcification and psychosis in 22q11.2 deletion syndrome.

Intracerebral calcifications are a facultative symptom of hypoparathyreoidism in 22q11.2 deletion syndrome (22qDS). We describe a patient with 22qDS, basal ganglia calcification (BGC) and psychotic symptoms and discuss the etiological connection of BGC with psychiatric symptoms. Future work needs to determine the prevalence of BGC in 22qDS and psychiatric disorders.

Lycanthropy--psychopathological and psychodynamical aspects.

OBJECTIVE: The imagination of being transformed into an animal or being an animal is called lycanthropy. The phenomenon is presented and psychodynamical aspects are discussed. METHOD: A literature review forms the base of this discussion of a psychopathological phenomenon. RESULTS: The lycanthropic symptomatology represents a spectrum of continuity of developmental and culture-dependent normal behaviour via partial forms to the complete picture of lycanthropy. It is observed in different mental disorders. CONCLUSION: Lycanthropy is interpreted by the authors as a delusion in the sense of the self-identity disorder defined by Scharfetter. It is mainly found in affective and schizophrenic disorders but can be a symptom of other psychiatric disorders as well. Psychodynamically this kind of delusion can be interpreted as an attempt to project suppressed affects, especially with aggressive or sexual content, into the figure of an animal. Psychotherapy and/or neuroleptic medication can be effective.

The development of a clinical syndrome of asymptomatic pancreatitis and eosinophilia after treatment with clozapine in schizophrenia: implications for clinical care, recognition and management.

Clozapine, the first atypical antipsychotic, is indicated for the treatment of therapy-resistant schizophrenia. It needs to be monitored closely because of its well-known potential side-effects, especially agranulocytosis. We present a case of a middle-aged woman with chronic schizophrenia, who was treated with clozapine and developed a clinical syndrome of asymptomatic pancreatitis and eosinophilia within the fifth week of treatment. Asymptomatic pancreatitis has rarely been reported up to now and is not recognized as a typical side-effect of clozapine. In our opinion, pancreatic enzymes should be monitored especially in the first 6 weeks of clozapine treatment.

[Erotomania and Frégoli syndrome. A case report]. / Liebeswahn und Frégoli-Syndrom. Eine Kasuistik.

A case report of a female schizophrenic patient is presented who showed a coincidence of erotomania and Frégoli syndrome with some interesting symptom constellations only rarely mentioned in the literature. Organic and psychodynamic factors were found in the etiopathogenesis of this disorder. A combination of psychotherapy and neuroleptic therapy was partly successful.

[Paranoia with late onset. Psychopathology and psychodynamics]. / Paranoia mit spätem Beginn. Psychopathologie und Psychodynamik.

We report on a 70-year-old man who suffered from persecutory delusions during the last 20 years. During first visits, he showed neither cognitive impairment nor Schneiderian first rank symptoms. Inpatient and day clinic treatment as well as further outpatient therapy led to reintegration into social life and trusting relationships between the patient and the therapeutic team, although the persecutory delusions still persisted. During following years, symptoms of cognitive impairment increased gradually and neurological symptoms could be observed. We present a psychodynamic hypothesis regarding the reported psychopathology and discuss alternative diagnoses and pharmacological treatment.

[Unplanned discharge in a psychiatric day clinic - argument for an individualized approach]. / Behandlungsabbruch in der psychiatrischen Tagesklinik - Plädoyer für eine differenzierte Betrachtungsweise.

OBJECTIVE: Drop-outs, respectively unplanned discharges in psychiatric therapy are often explained by so-called lack of insight into the disease or difficult circumstances of admission. We were interested in the question how often drop outs are noticed in a voluntarily day clinic setting where nearly all psychiatric diseases are treated. METHOD: The charts of all patients discharged in 1998 (n = 65) were screened referring to their mode of discharge. RESULTS: 31 patients (47.7 %) regularly ended their treatment. An unplanned discharge was registered with 34 patients (52.3 %). CONCLUSIONS: The statistically relevant term of drop-out does not appear to be the right one to deal with the individual treatment situation and the motivation for the limitation of treatment. A typology of prematurely ended therapies is developed.

[Lycanthropy-zooanthropism--discussion of a psychopathological phenomenon]. / Lykanthropie/Zooanthropismus--Erörterung eines psychopathologischen Phänomens.

The belief to be transformed into an animal is named Lycanthropy. "Zooanthropismus" is the German equivalent. Three case reports raised the question how this phenomenon, in our cases to be transformed into a frog, a bee or a wolf/dog, can be interpreted in a psychopathological and diagnostic regard. Is it pathognomonic for a special disease? With the three case reports and a survey of the literature this paper deals with Lycanthropy trying to put this perhaps neglected topic back into the focus of psychiatric interest and place it in psychopathology.

Social inequality in the utilization of in- and outpatient treatment of non-psychotic/non-organic disorders: a study with health insurance data.

BACKGROUND: This study deals with the utilization of in- and outpatient care due to non-psychotic/non-organic disorders (ICD-9 300-307: neuroses, personality disorders, sexual disturbances, alcohol and substance dependencies, drug abuse and functional disorders). Specifically, it examines whether social gradients to the detriment of individuals from lower social positions appear. This is dealt with both in terms of in- and outpatient treatment. Secondly, it examines whether the likelihood of being treated as an inpatient rather than an outpatient differs between occupational status positions. Finally, the study considers whether the hospital department a given patient is most likely to be assigned to differs between occupational status positions. METHOD: Analyses were performed with records from a statutory health insurance in West Germany. The database consists of 124,917 men and women between 20 and 60 years of age. We included only subjects with employment periods, as otherwise outpatient treatment could not be assessed completely. The data had been recorded between 1987 and 1996. In total, 9129 persons had one of the above mentioned diagnoses, 6115 of them received outpatient treatment and 3014 were inpatients only. RESULTS: The relative risk (RR) for outpatient diagnoses was RR=4.41 for the male unskilled/semi-skilled insured in comparison with men in the highest occupational position, the equivalent RR for women was 2.1. The respective results for inpatient treatment were RR=7.3 for men and RR=2.3 for women. In men, the relative risks were considerably reduced after cases with alcohol- and substance-related diagnoses had been excluded. For the assignment to in- and outpatient treatment, no consistent differences between individuals with different occupational positions emerged. Once diagnosed, higher-status individuals had the longest treatment periods as in- and outpatients. Only a small proportion of diagnosed subjects received medical care in psychiatric wards; this held especially for the group with higher occupational positions. CONCLUSIONS: Social inequalities in the treatment of psychogenic disorders emerged for outpatients as well as for inpatients. Inpatients tended to avoid treatment in psychiatric departments, and it can be concluded that individuals holding higher positions may be more successful in their attempts to avoid stigmatization.

[Psychosocial competence of general practitioners in managing psychiatric patients: initial results of a questionnaire study]. / Psychosoziale Kompetenz von Hausärzten und Versorgung psychisch Kranker: erste Ergebnisse einer Fragebogenstudie.

OBJECTIVE: Given the frequency of patients with psychosocial problems and mental disorders in primary care our study focuses on the relationship between the psychosocial qualifications of general practitioners and their management of these patients. METHOD: A questionnaire was sent to all general practitioners in Hessen asking for sociodemographic and profession-related data as well as their psychosocial competence and their procedure during a regular day in practice. Based on 396 questionnaires we compared five groups of general practitioners with different psychosocial qualifications, proportionate incidence of diagnoses, medical procedures and referrals to specialists and hospitals. RESULTS: The average age of the participants of our study is 45 years, they have been working for 14 years. 163 general practitioners without and 59 with a special interest in psychosocial qualification and 174 psychosocially qualified physicians participated in the study. Of a total of 65 patients seen during the reference day 18 were diagnosed as suffering from mental disorders. Their number increased with greater psychosocial competence of the physicians. Psychosomatic and reactive disorders are the most frequent mental disorders to be seen in primary care with nearly 60%. Verbal therapy is often applied, procedures of the so-called psychosomatic basic care and prescription of psychotropic drugs play only a minor role. Nearly every fourth patient is referred to other specialists, referrals for inpatient treatment occur with 1.3% only. DISCUSSION: Because of the low response rate our study is not representative. Nevertheless the results permit some conclusions concerning the relationship between psychosocial qualification of general practitioners and their management of patients with mental disorders.

[Coping behaviors in Parkinson's disease]. / Krankheitsverarbeitung bei Morbus Parkinson.

In 45 patients with Parkinson's disease, we investigated coping behavior and its correlations to demographic and disease-related data, locus of control, depression, and psychosocial adaptation. Active, problem oriented, and self-reorganizing strategies were predominantly used and regarded as especially helpful by the 27 men and 18 women (age: 56 years; duration of illness: 9 years). While age and sex were not associated with coping, external locus of control correlated positively to "depressive coping" and duration of illness correlated negatively to "distraction and self-affirmation." Coping strategies regarded as maladaptive and a small degree of internal locus of control correlated to unfavourable results for depression and satisfaction.

[Origins of dialogue: phenomenological theories of intersubjectivity in developmental perspectives and as a foundation of psychotherapeutic processes]. / Ursprünge des Dialogs. Phänomenologische Ansätze zur Intersubjektivität in entwicklungsgeschichtlicher Perspektive und als Grundlage psychotherapeutischer Prozesse.

Recognizing the other with his/her psychic peculiarity is an important assumption for psychotherapy. But how is empathy possible? Answers are to be expected by phenomenological-philosophical approaches concerning intersubjectivity and infant research. They are described in a comprehensive way and related to each other in spite of their epistemological differences. As can be seen in the beginning of showing and reading maternal emotions (so-called "social referencing") an infant is able to show intersubjective behaviour from the age of nine months on. Research on the reflected image of the infant and the development of shame shows that consciousness of the ego is not built before the age of one and a half years. These empirically well established results contradict those phenomenological approaches claiming that the other cannot be experienced directly but via cognitive analogies of own emotions (Lipps, Husserl). They better fit an anthropology that states the human being as an innate dialogically structured one and therefore being capable of empathy. Therefore the base for a deeper understanding of the following results of psychotherapy-research is established: 1. Early infant's memories probably do not exist as isolated images but are embedded in interactional structures. 2. Strict therapeutical abstinence may be experienced as a denial of communication and may have a retraumatic effect. 3. Quality of therapeutical relationship is crucial for the success of psychotherapy.

Coping with Parkinson's disease and refractory epilepsy. A comparative study.

Coping strategies and their correlations with demographic and illness related data, depression, locus of control, and psychosocial adaptation were investigated in 45 patients with Parkinson's disease and 40 patients with intractable epilepsy. Three standardized self-report questionnaires were applied: the Freiburg Questionnaire of Coping with Illness (FKV), the von Zerssen Depression Scale (D-S), and the IPC-questionnaire measuring generalized locus of control beliefs. The Social Interview Schedule (SIS), a semi-structured interview, was used to measure psychosocial adaptation. Active, problem-focused and compliance strategies were predominantly used and regarded as most helpful in both groups of patients. Hence, Parkinson and epilepsy patients used similar coping patterns despite the strong dissimilarities of symptoms and illness-associated burdens. The level of depression was not significantly different in both groups and in the range of other chronic somatic diseases. The use of coping patterns, which are regarded as maladaptive, was correlated with distinct depression and a poor psychosocial adaption. In conclusion, no indications for illness-specific coping patterns were found in patients with Parkinson's disease and epilepsy. In both groups, certain coping strategies are associated with good and others with poor psychosocial adjustment. These results indicate the possibility of improving psychosocial adjustment by supporting effective strategies.

[Which patients participate in exercise therapy? An empirical study of a psychiatric clinic]. / Welche Patienten nehmen an der Bewegungstherapie teil? Eine empirische Untersuchung in einer psychiatrischen Klinik.

OBJECTIVE: The aim of our study is to find out in which clinical and sociodemographic parameters patients who take part in kinetic therapy and those, who don't, differ. METHODS: 38 patients of a psychiatric university clinic who regularly took part in movement therapy were compared with 32 patients who did not. RESULTS: The participants had a higher level of education, obtained fewer psychotropic drugs and were assessed as slightly less impaired by their disorder. CONCLUSIONS: Our findings cannot fully explain what determines participation in kinetic therapy. Other factors like the cut-off of five times for assignment, the therapist's influence and the theory of self-efficacy need to be discussed.

Reliability of biographical data, their relations to personality variables and their influence on life-events.

BACKGROUND: First, this study aims to investigate the reliability of biographical and personality data, i.e. analysing the impact of depressive mood on these variables. Second, the influence of early life experience and personality on the reporting of life events was examined. METHODS: Self-reporting questionnaires were administered for a sample of 250 depressive subjects at the beginning, and to assess the influence of depressive mood on the reporting of biographic data at the end of inpatient treatment we used a random sample of 50 subjects out of the 250 patients. RESULTS: Biographical data, unlike personality data, are not significantly influenced by depressive mood and depressive cognition. The number of life-events, and their mean subjective stress, neuroticisms and aim-relatedness are on a direct path strongly influenced by biographical data. That means that the more negatively primary socialisation was reported, the more life-events were communicated, with corresponding increases in the reporting of their subjective stress, and more neuroticism and less aim-relatedness, and vice versa. Neuroticism strongly influences in a positive way, and aim-relatedness negatively influences in a medium way, the number of life-events and their subjective stress. That means the higher neuroticism and the lower aim-relatedness were reported, the more life-events and higher stress were communicated, and vice versa. CONCLUSION: Linear causal processes from mood-independent factors (e.g. biographical factors, vulnerability) may be the beginning of cyclic causal processes, i.e. vicious circles between life-events and mood-dependent factors (e.g. personality variables). LIMITATIONS: According to the design of the investigation there is no differentiation possible between personality and depression. CLINICAL RELEVANCE: To avoid vicious circles between life-events and mood-dependent factors, preventive psychotherapeutic intervention seems to be necessary to avoid the genesis of harmful life-events.

Coping with refractory epilepsy.

We investigated the coping behaviour and its correlation with demographic and illness-related data, depression, locus of control and psychosocial adaptation in 40 patients with intractable epilepsy with primarily or secondarily generalized tonic-clonic seizures. Three standardized self-reporting questionnaires were applied, which are the Freiburg Questionnaire of Coping with Illness (FKV), the von Zerssen Depression Scale (D-S), and the IPC-questionnaire measuring generalized locus of control beliefs; the Social Interview Schedule (SIS), a semi-structured interview, was used to measure the psychosocial adaptation. Active, problem-focused and compliance strategies were predominantly used and regarded as most helpful. Hence, the epileptic patients use similar coping patterns reported in patients with other non life-threatening chronic diseases. The level of depression was moderate and in the range of other chronic somatic diseases. The use of coping patterns, which are regarded as maladaptive, was correlated with distinct depression, a small degree of internal locus of control beliefs and poor psychosocial adaption. These results indicate the possibility to improve psychosocial adjustment by supporting effective strategies.

[Coercive measures in psychiatry. Restraint on psychiatric units of the Hannover Medical University]. / Zwangsmassnahmen in der Psychiatrie. Fixierungen auf den psychiatrischen Stationen der Medizinischen Hochschule Hannover.

Following a short review of some studies from Germany and Switzerland on coercive measures in psychiatry a retrospective investigation of restraints in the two psychiatric departments of the Medical School of Hannover is presented. Frequency, time, diagnoses, reasons and procedures are reported in detail and discussed in comparison with results of other studies.