Understanding and breaking the intergenerational cycle of abuse in families enrolled in routine mental health services: study protocol for a randomized controlled trial and two non-interventional trials investigating mechanisms of change within the UBICA II consortium.

BACKGROUND: Parents' mental illness (MI) and parental history of early life maltreatment (ELM) are known to be significant risk factors for poor parenting while poor parenting is a crucial mediator of the intergenerational continuity of child maltreatment. Hence, maltreatment prevention programs for families with an MI parent, which pay particular attention to experiences of ELM in the parent, are urgently needed. Parental mentalizing was previously found to mediate successful parenting. Interventions aimed at improving the parental mentalizing capacity reduced maltreatment risk in parents. The aim of the present study is to investigate the effectiveness of a mentalization-based parenting-counseling in acutely mentally ill parents currently treated at a psychiatric hospital. METHODS: Mentalization-based parenting-counseling (MB-PC) vs. enhanced standard clinical care (SCC+) will be administered in a cluster-randomized-controlled trial (RCT). Patients treated at psychiatric hospitals with children between 1.5 and 15 years will be included in the trial. MB-PC will be administered as a 12-h combined individual and group program enriched by social counseling (over a course of 5 weeks) as add-on to standard clinical care, while the control condition will be standard clinical care plus a 90-min psychoeducation workshop on positive parenting. Primary efficacy endpoint is self-reported parenting practices at follow-up. Embedded within the RCT will be two sub-studies investigating social cognition and dyadic synchrony as biobehavioral mechanisms of change. DISCUSSION: The main goal of the present study is to investigate ways to break the intergenerational continuity of maltreatment by assessing the benefits of a prevention program which aims at improving parenting in vulnerable mothers and fathers. MB-PC is a short, low-cost intervention which can be delivered by nurses and social workers and is applicable to MI patients with children with a broad range of diagnoses. If it is shown to be effective, it can be directly implemented into standard psychiatric hospital care thereby providing help to prevent child maltreatment. TRIAL REGISTRATION: German Clinical Trials Register DRKS00017398 . Registered on 5 July 2019.

Oxytocin and social anxiety: Interactions with sex hormones.

Oxytocin has been associated with anxiolytic and stress reducing effects in a number of studies. Less is known about the associations of endogenous oxytocin concentrations and their interaction with other hormones such as sex hormones in relation to self-reported anxiety levels. In this study, endogenous oxytocin and sex hormone levels were analyzed in 99 high (51 women) and 100 low (50 women) socially anxious individuals. Regression analyses showed that women with high oxytocin and estradiol levels reported a lower total Liebowitz Social Anxiety Score (LSAS) as well as a lower score on the subscale LSAS Fear. This association of hormonal interaction with social anxiety scores was significant in the subsample of high socially anxious women. In men there were no significant associations for endogenous hormones with LSAS scores. These findings suggest that in women the link between oxytocin and anxiety might be dependent on basal anxiety levels as well as on individual sex hormone levels.

A mechanism-based group-psychotherapy approach to aggressive behaviour in borderline personality disorder: findings from a cluster-randomised controlled trial.

BACKGROUND: Aggressive behaviour is a prevalent and harmful phenomenon in patients with borderline personality disorder (BPD). However, no short-term, low-cost programme exists that specifically focuses on aggression. AIMS: Attuning therapy modules to pathogenetic mechanisms that underlie reactive aggression in BPD, we composed a 6 week mechanism-based anti-aggression psychotherapy (MAAP) approach for the group setting, which we tested against a non-specific supportive psychotherapy (NSSP). METHOD: A cluster-randomised two-arm parallel-group phase II trial of N = 59 patients with BPD and overt aggressive behaviour was performed (German Registry for Clinical Trials, DRKS00009445). The primary outcome was the externally directed overt aggression score of the Modified Overt Aggression Scale (M-OAS) post-treatment (adjusted for pre-treatment overt aggression). Secondary outcomes were M-OAS irritability, M-OAS response rate and ecological momentary assessment of anger post-treatment and at 6 month follow-up, as well as M-OAS overt aggression score at follow-up. RESULTS: Although no significant difference in M-OAS overt aggression between treatments was found post-treatment (adjusted difference in mean 3.49 (95% CI -5.32 to 12.31, P = 0.22), the MAAP group showed a clinically relevant decrease in aggressive behaviour of 65% on average (versus 33% in the NSSP group), with particularly strong improvement among those with the highest baseline aggression. Most notably, significant differences in reduction in overt aggression between MAAP and NSSP were found at follow-up. CONCLUSIONS: Patients with BPD and aggressive behaviour benefited from a short group psychotherapy, with improvements particularly visible at 6 month follow-up. Further studies are required to show whether these effects are specific to MAAP.

[Innovative psychotherapy research: towards an evidence-based and process-based individualized and modular psychotherapy]. / Innovative Psychotherapieforschung: auf dem Weg zu einer evidenz- und prozessbasierten individualisierten und modularen Psychotherapie.

Psychotherapy has been proven to be effective; however, this statement applies in particular to the "average patient" in randomized controlled trials. As a considerable proportion of patients do not show any benefits despite the constant development of new therapy methods and the mechanisms of action are still too little understood, innovative psychotherapy research has to address both problems. In addition, the idea of personalization that originated in somatic medicine or - from our point of view more appropriately - individualization or person-centering should be taken up. After providing an overview of further developments in psychotherapy beyond disorder-specific methods, this article presents an evidence- and process-based individualized and modular psychotherapy as a visionary goal of psychotherapeutic research: Beyond syndromes and disorders, as many biopsychosocial characteristics as possible and the processes and mechanisms underlying the mental problems should be analyzed and bundled in an individual comprehensive functional analysis. Based on this functional analysis, evidence-based techniques and modules should be selected. The individual response during the course of therapy should be continuously documented, so that feedback helps to determine the further therapeutic procedure. In order to pursue this vision, studies are needed that are oriented towards the individual patient, investigate the central mechanisms of action and generate large translational datasets. These should be analyzed by ideographic analyses and reduce the gap between research and practice, thus contributing to the paradigm of a practice research network, which is now consistently moving to the centre of research.

[Impact of early life maltreatment of women on the mother-child relationship : Data from mother-child dyads from Heidelberg and Berlin]. / Einfluss früher Gewalterfahrungen von Frauen auf die Mutter-Kind-Beziehung : Daten von Heidelberger und Berliner Mutter-Kind-Dyaden.

Early life maltreatment can have severe and long-lasting consequences for the directly affected individual as well as for the next generation. Data from our research including mother-child dyads from Heidelberg and Berlin show that early life maltreatment is associated with behavioral and neural changes including personality traits and attachment style of the affected mothers that negatively affect their relationship with their child. The children of these mothers affected by early life maltreatment have an elevated risk to be maltreated and to develop mental disorders. They also show a heightened cortisol concentration and a reduced inhibition control. It seems to be of importance whether the mother has experienced early life maltreatment but is resilient, meaning that she has not developed a mental disorder (up to the time of examination) or whether in addition to the early life maltreatment she has developed a mental disorder later in life. Children of mothers with early life maltreatment and a lifetime mental disorder seem to be especially exposed to stress and show the greatest impairments and risks. Based on the existing data from our research practical and clinical implications are discussed and one possible intervention in the form of a training of mentalization competencies for parents is presented.

[Borderline personality : Alterations to brain structure and function through psychotherapy]. / Borderline-Persönlichkeitsstörung : Veränderung der Hirnstruktur und -funktion durch Psychotherapie.

BACKGROUND: There are now several scientifically evaluated psychotherapeutic methods for borderline personality disorder (BPD), all of which aim to improve the ability to regulate emotions. In recent years, there have been first studies on the neuronal correlates of the mechanisms of emotion regulation and of changes caused by psychotherapeutic interventions. METHODS: This article reviews the data on functional and structural imaging studies that examine facets of disturbed emotion regulation before and after psychotherapy. RESULTS: Although the overall database is still sparse, clinical improvement in psychotherapy appears to be associated with modulation of brain structure and function. Frontolimbic regulation circuits including the amygdala, insula, anterior cingulate cortex (ACC) and other prefrontal areas appear to be involved in these changes. An important finding is the reduction of initially increased amygdala activity after successful Dialectical Behavior Therapy (DBT). CONCLUSION: The changes shown here most probably reflect an improvement in emotion regulation capacities in BPD and demonstrate the possibility of modulating disturbed emotion regulation processes. Since long-term follow-up data are still missing, the sustainability of the suggestive improvements still has to be proven in further studies.

Oxytocin and Pain Perception: From Animal Models to Human Research.

An accumulating body of evidence suggests that the hypothalamic neuropeptide oxytocin (OT) has a modulatory effect on pain processing. Particularly strong evidence comes from animal models. Here, we review recent advances in animal research on the analgesic effects of OT and discuss possible target sites of OT within descending and ascending pain pathways in the brain. In addition to the spinal cord being a direct target of the neuropeptide, OT has also been shown to modulate the neuronal activity of limbic and cortical brain regions, which play a major role in the cognitive and emotional processing of pain. Human studies investigating the influence of OT on pain perception are less numerous and have revealed less consistent results. The human literature is therefore scanned thoroughly and different approaches to study the effects of OT on pain perception in humans are discussed. Moreover, we also address how OT might alleviate pain by influencing socio-emotional components in humans. We conclude that further investigating specific OT and OT-sensitive circuits, which modulate pain processing especially in primates, will improve our understanding of OT-analgesic effects. In human research, the increased use of neuroimaging and autonomic measures might help to bridge the gap to animal studies.

Performance of International Medical Students In psychosocial medicine.

BACKGROUND: Particularly at the beginning of their studies, international medical students face a number of language-related, social and intercultural challenges. Thus, they perform poorer than their local counterparts in written and oral examinations as well as in Objective Structured Clinical Examinations (OSCEs) in the fields of internal medicine and surgery. It is still unknown how international students perform in an OSCE in the field of psychosocial medicine compared to their local fellow students. METHODS: All students (N = 1033) taking the OSCE in the field of psychosocial medicine and an accompanying written examination in their eighth or ninth semester between 2012 and 2015 were included in the analysis. The OSCE consisted of four different stations, in which students had to perform and manage a patient encounter with simulated patients suffering from 1) post-traumatic stress disorder, 2) schizophrenia, 3) borderline personality disorder and 4) either suicidal tendency or dementia. Students were evaluated by trained lecturers using global checklists assessing specific professional domains, namely building a relationship with the patient, conversational skills, anamnesis, as well as psychopathological findings and decision-making. RESULTS: International medical students scored significantly poorer than their local peers (p < .001; η2 = .042). Within the specific professional domains assessed, they showed poorer scores, with differences in conversational skills showing the highest effect (p < .001; η2 = .053). No differences emerged within the multiple-choice examination (p = .127). CONCLUSION: International students showed poorer results in clinical-practical exams in the field of psychosocial medicine, with conversational skills yielding the poorest scores. However, regarding factual and practical knowledge examined via a multiple-choice test, no differences emerged between international and local students. These findings have decisive implications for relationship building in the doctor-patient relationship.

[Coercive measures in German hospitals for psychiatry and psychotherapy : A pilot study by the DGPPN to evaluate a uniform assessment instrument]. / Zwangsmaßnahmen in deutschen Kliniken für Psychiatrie und Psychotherapie : Eine Pilotstudie der DGPPN zur Erprobung eines einheitlichen Erfassungsinstrumentes.

STUDY OBJECTIVE: A simple instrument to record case-related coercive measures was tested as part of a pilot project of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN). METHODS: To assess coercive measures data were collected for 3 months in 8 German hospitals for psychiatry and psychotherapy. The type of measures used, the main diagnosis and the legal basis for the coercive measures were documented. RESULTS: In the sample studied, coercive measures were applied in 8% of cases. Coercive measures were most commonly used in patients with a schizophrenic disorder. The principle of justifiable necessity according to § 34 of the German Penal Code was used particularly often as the legal basis for justifying the coercive measures. CONCLUSION: Suitable measurement instruments and reliable data that enable the learning of best practices represent the basis for a reduction of coercive measures.

[Guideline-adherent inpatient psychiatric psychotherapeutic treatment of borderline personality disorder : Normative definition of personnel requirements]. / Leitliniengerechte stationäre psychiatrisch-psychotherapeutische Behandlung der Borderline-Persönlichkeitsstörung : Normative Personalbedarfsermittlung.

BACKGROUND: Borderline personality disorders (BPD) are severe mental diseases which place high pressure on the psychiatric healthcare system. Nowadays, well-tested, disorder-specific treatment concepts are available also for inpatient treatment in Germany. These show very good and long-term improvements in the psychopathology as well as posttreatment social participation; however, prerequisites for the implementation of these evidence-based inpatient psychotherapy programs are well-trained treatment teams and appropriate financing of resource expenditure. OBJECTIVE: The aim was to formulate a definition of normative needs for treatment duration and intensity for a guideline-conform, empirically proven and effective inpatient treatment of borderline personality disorder as well as the derived personnel requirements in comparison to the currently available resources within the framework of the Psychiatry Personnel Act (Psych-PV). MATERIAL AND METHODS: The resource requirements were established based on evaluated hospital ward models, the recommendations of the S2 guidelines and the criteria of specialist societies and compared with the personnel stipulations according to the Psych-PV. RESULTS: The results for a normatively established treatment program showed a pronounced deficit in the financing of the evaluated resource requirements, even when the stipulations laid down in the Psych-PV were implemented to 100 %. DISCUSSION: Disorder-specific inpatient treatment programs for borderline personality disorder have been scientifically proven to be highly effective; however, resource analyses show that the personnel requirements necessary for effective implementation of these programs are much higher than those allocated by the funding according to the Pysch-PV. The current underfunding leads to inadequate treatment outcomes with high readmission rates and as a result high direct and indirect costs of illness.

[Guideline-adherent inpatient psychiatric psychotherapeutic treatment of obsessive-compulsive disorder : Normative definition of personnel requirements]. / Leitliniengerechte stationäre psychiatrisch-psychotherapeutische Behandlung der Zwangsstörung : Normative Personalbedarfsermittlung.

BACKGROUND: Guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with obsessive-compulsive disorder (OCD) is an important part of the care available for these patients. It may not be adequately reflected in the current personnel resources available according to the German psychiatry personnel regulation (Psych-PV). OBJECTIVES: The goal of this work was to assess the personnel resources necessary for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD and compare the necessary resources with the resources available according to Psych-PV. METHODS: Based on the German national guidelines for OCD and a meta-analysis on treatment intensity, we formulated a normative weekly treatment plan. Based on this plan we calculated the necessary personnel resources and compared these with the resources available according to Psych-PV category A1 (standard care). RESULTS: The weekly treatment time for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is 23.5 h per week. This corresponds to a weekly personnel requirement of 20.9 h. This requirement is only partly reflected in the Psych-PV (17.3 h, 82.8 %). The coverage of personnel resources by Psych-PV is even lower for psychotherapy provided by psychiatrist and psychologists (38.3 %, i. e. 183 min in the normative plan versus 70 min in Psych-PV). CONCLUSIONS: The current paper shows that the personal resources required for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is not adequately reflected in the German psychiatry personnel regulation (Psych-PV). The actual shortage may be underestimated in our paper.

[Guideline-conform inpatient psychiatric psychotherapeutic treatment of chronic depression: Normative personnel requirements]. / Leitlinienentsprechende stationäre psychiatrisch-psychotherapeutische Behandlung der chronischen Depression : Normative Personalbedarfsermittlung.

BACKGROUND: Chronic depression is a frequent mental disorder representing a significant subjective and economic burden. Effective disorder-specific treatment of chronic depression presupposes sufficient funding of treatment resources. OBJECTIVE: Definition of normative needs of personnel resources for guideline-compliant and evidence-based inpatient treatment of chronic depression based on treatment duration and intensity. The personnel resources determined were compared to the resources provided on the basis of the existing reimbursement system (Psych-PV) in Germany. MATERIAL AND METHODS: Resources determined according to national treatment guidelines and empirical evidence were compared to personnel resources dictated by the German Psych-PV reimbursement algorithm. RESULTS: The current funding algorithm greatly underestimates the resources needed for a guideline-compliant and evidence-based treatment program, even if healthcare providers received 100 % reimbursement of the sum determined by the Psych-PV algorithm. DISCUSSION: The results clearly show that even in the case of a full coverage of the current German reimbursement algorithm, funding allocation for evidence-based inpatient treatment of chronic depression is insufficient. In addition, the difficulties of specific coding of chronic depression in the ICD-10 system generates a major problem in the attempt to measure the current resources needed for sufficient treatment.

[Resource use and financing of guideline-adherent psychotherapeutic inpatient care]. / Aufwand und Finanzierung leitliniengerechter, psychotherapeutischer Behandlung im Krankenhaus.

BACKGROUND: The financing of psychiatric psychotherapeutic care in Germany is determined by the German psychiatric staffing regulations which are unchanged since 1991. Psychotherapy was established after 1991 as an effective and indispensable treatment of mental and behavioral disorders. AIMS AND OBJECTIVES: The aim of this study was to empirically investigate the use of psychiatrists' and psychologists' working time for psychotherapy in guideline-adherent hospital care. A further aim was to compare these results to the resources defined by the German psychiatric staffing regulations and in the new prospective payment system for psychiatry and psychosomatics in Germany. MATERIAL AND METHODS: University hospitals for psychiatry and psychotherapy were asked to retrospectively provide data of patients for which guideline-adherent care was possible. Participating institutions provided both data describing the staff time utilization of psychotherapeutic services provided by psychiatrists and psychologists and patient classifications according to the German psychiatric staffing regulations and the new prospective payment system for psychiatry and psychosomatics. RESULTS: Resources defined by the German psychiatric staffing regulations covered a mean of only 71 min of psychotherapy per patient and week while the actual mean intensity of psychotherapeutic care provided by the participating hospitals was 194 min per patient and week. The associated use of staff time was 102 min per patient and week. Both figures increased during an inpatient episode. The resources defined by the German psychiatric staffing regulations covered only 70 % of medical and psychological personnel. The current configuration of the new prospective payment system for psychiatry and psychosomatics covered only 59 % of staff time. CONCLUSION: The results of this study provide another unambiguous recommendation to adjust the out-dated German psychiatric staffing regulations to the current evidence and S3 guidelines for psychiatric psychotherapeutic hospital care. In particular, more resources are required for the provision of psychotherapeutic care.

[Guideline-adherent psychiatric-psychotherapeutic hospital care: Normative definition of staff required using the example of depression]. / Leitliniengerechte psychiatrisch-psychotherapeutische Krankenhausbehandlung : Normative Personalermittlung am Beispiel Depression.

BACKGROUND: Unipolar depression is of high relevance in German inpatient treatment. An effective psychiatric psychotherapeutic hospital treatment also requires sufficient staff for carrying out psychotherapeutic treatment. AIMS AND OBJECTIVES: The aim of this study was to define the staff requirements for guideline-adherent psychiatric-psychotherapeutic inpatient treatment of depression on the basis of a weekly treatment schedule for a 5-week admission period. A further aim was to compare the staff required with the resources defined by the German psychiatric staffing regulations (Psych-PV). MATERIAL AND METHODS: The weekly schedule was normatively defined on the basis of the current evidence for treatment efficacy and effectiveness. The staff required was calculated on the basis of the weekly schedule. The time for psychotherapy defined by the Psych-PV was calculated using the treatment classification provided by a large nationwide database. RESULTS: Regarding psychotherapy, 280 min per week is regarded as necessary and usually sufficient according to the current evidence. The results showed clearly higher requirements of working time of psychiatrists and psychologists than those defined by the Psych-PV. In particular, the Psych-PV allows only 72 min for psychotherapy per patient and week and only a limited amount of direct patient contact with psychiatrists. CONCLUSION: The figures provided impressively show that the Psych-PV does not allow effective guideline-adherent hospital treatment within a reasonable length of hospital stay. Despite its evidential effectiveness, psychotherapeutic treatment cannot be sufficiently provided under the current financing circumstances.

[Psychotherapeutic work with older patients]. / Psychotherapeutische Arbeit mit älteren Patienten.

Despite the high prevalence of mental illness in Germany, elderly people are significantly under-represented in psychotherapeutic treatment. This is not only due to their own reservations about psychotherapy but also to a greater extent a reflection of the models of old age in our society. Deficit-oriented theories dating back to the origins of psychotherapy in the last century are still widespread leading to fear of contact with consultants and therapists.The specific methods of psychotherapeutic work with older patients are presented. Methodologically, the treatment of elderly patients with depressive disorders has been elaborately worked out. In addition, detailed psychotherapeutic programs have also been developed for anxiety disorders, trauma-related diseases and dementia. Overall, relatively little research has been done in the field of geriatric psychotherapy despite the fact that from the scientific and clinical perspectives, different approaches or methods, such as cognitive-behavioral therapy, interpersonal therapy, psychodynamic therapy, as well as systemic therapy, can be considered effective and may be applied to the entire spectrum of mental disorders in old age.

[Involuntary psychiatric hospital admissions: a comparison between five hospitals in three German federal states]. / Psychiatrische Unterbringungspraxis : Ein Vergleich von fünf Kliniken in drei Bundesländern.

BACKGROUND: There is considerable variance in involuntary psychiatric hospital admission rates both in Europe and Germany. In a prospective comparison between five hospitals in three German federal states we assessed and analyzed involuntary psychiatric hospital admissions, including the patient's perspective. MATERIAL AND METHOD: All involuntarily admitted patients were assessed by an independent researcher. Clinical data, patient and psychiatrist views were documented with different instruments including the McArthur admission experience survey. RESULTS: In this study 104 out of 244 involuntarily admitted patients gave informed consent. We found considerable differences between study centres concerning involuntary admission quotas (3.2-25.8% of all hospital admissions) and involuntary admission rates (16.6-97.6 per year per 100,000 inhabitants). Hospitals in the state of Baden-Württemberg had the lowest involuntary admission rates while they were highest in Bavaria. In Baden-Württemberg involuntarily admitted patients were more likely to suffer from chronic schizophrenia, they were more severely ill and experienced the involuntary hospital admission as more strenuous. There were no differences between centres concerning frequency of dangerous behavior or self-harm. CONCLUSION: We found a high variance across regions concerning the reasons for, frequencies and legal basis of involuntary hospital admissions. Regional differences of legal frameworks and service organization can explain this only to a limited amount. Transparency, legal certainty and reflection of stakeholder roles are a future necessity. Furthermore, there is a need for stringent compliance with legal regulations and coherent documentation.

Intranasal oxytocin increases covert attention to positive social cues.

BACKGROUND: The neuropeptide oxytocin (OT) has positive effects on the processing of emotional stimuli such as facial expressions. To date, research has focused primarily on conditions of overt visual attention. METHOD: We investigated whether a single intranasal dose of OT (24 IU) would modulate the allocation of attentional resources towards positive and negative facial expressions using a dot-probe paradigm in a sample of 69 healthy men. Attentional capacity for these facial cues was limited by presentation time (100 or 500 ms). In addition, we controlled for overt visual attention by recording eye movements using a remote eye tracker. RESULTS: Reaction times (RTs) in the dot-probe paradigm revealed a pronounced shift of attention towards happy facial expressions presented for 100 ms after OT administration, whereas there were no OT-induced effects for longer presentation times (500 ms). The results could not be attributed to modulations of overt visual attention as no substance effects on gazes towards the facial target were observed. CONCLUSIONS: The results suggest that OT increased covert attention to happy faces, thereby supporting the hypothesis that OT modulates early attentional processes that might promote prosocial behavior.

[Contribution of neurobiology to our knowledge of borderline personality disorder]. / Beitrag der Neurobiologie zum Verständnis der Borderline-Persönlichkeitsstörung.

Affect dysregulation and impulsivity are the main topics of neurobiological research in borderline personality disorder. Affect dysregulation subsumes enhanced resting arousal, increased emotional responsiveness as well as deficient emotional regulation and is associated with structural and functional abnormalities in a prefrontal-limbic network, above all orbitofrontal hypoactivity and amygdalar as well as insular hyperactivity. Impulsivity describes a lack of future-oriented problem solving style as well as a decreased threshold for motoric responses and is associated with decreased serotonergic activity in the ventral prefrontal cortex. Future research has to clarify how specific the findings of borderline personality disorder are and how far temperament dimensions, such as neuroticism can explain the neurobiological deviations from the norm.

[Development of antisocial disorders--impact of the autonomic stress system]. / Entwicklungsfaktoren dissozialer Störungen--die Bedeutung des autonomen Stresssystems.

The current selective review emphasizes the heterogeneity of antisocial behaviour in children and adolescents. It focuses on the development of children of the early-starter subtype of conduct disorder who are at high risk for the development of an antisocial personality disorder. Especially the autonomic stress system seems to have an important impact on symptoms and the prognosis of antisocial individuals. While autonomic hypoarousal and a reduced autonomic reagibility seem to be associated with more proactive aggressiveness and a negative outcome, increased autonomic arousal and reagibility might be related to reactive aggressiveness and constitutes possibly a protective trait. Data of the current psychophysiological and neuroendocrinological literature are summarized. Moreover, the impact of comorbid attention deficit hyperactivity disorder and anxiety disorders on dissocial development is illustrated. Particularly early diagnostic assessment of the individual's extent of trait anxiety might help to specify therapeutic opportunities and could thereby improve therapeutic efficiency.

Homocysteine and cognitive function in geriatric depression.

BACKGROUND/OBJECTIVES: Cognitive dysfunction is a common aspect of the spectrum of symptoms of geriatric depression. High homocysteine levels have been linked to cognitive decline in neuropsychiatric disorders. The present study investigated possible associations between cognitive impairment observed in geriatric depression and homocysteine levels. METHODS: The performance of 25 mentally healthy individuals and 40 patients with geriatric depression in terms of language processing, processing speed, concentration and attention was assessed with the Stroop Test and the d2 Test of Attention. Serum homocysteine was determined with an enzyme immunoassay. RESULTS: The performance of depressed patients was significantly worse in language processing (p = 0.001) and processing speed (p < 0.0001). Depressed patients with high levels of homocysteine performed better than patients with homocysteine concentrations