Psychosomatic disorders and illnesses: a blind spot of medicine / Pszichoszomatikus tünetek és betegségek: a medicina vakfoltja.

Összefoglaló. Bevezetés: A pszichoszomatikus medicina területéhez tartozó betegek ellátása rossz hatásfokú. Ez egyaránt jelentos terhet jelent a betegek és az egészségügy számára. Célkituzés: A pszichoszomatikus tünetek és betegségek megjelenésének és ellátási ajánlásainak vizsgálata az irányadó hivatalos szakmai anyagban. Módszer: Az adatgyujtés idopontjában elérheto 531 Szakmai irányelvbol annak a 134 dokumentumnak a részletesebb elemzése, amelynek témájában pszichoszomatikus tünetek/betegségek gyakoribbak. Ebbol 39 egyértelmuen pszichoszomatikus vonatkozású anyag tartalmi vizsgálata, továbbá a Szakmai Kollégiumok listáján szereplo három pszichiátriai szakterület összes (26) szakmai irányelvének hasonló szempontú értékelése. Eredmények: A megvizsgált irányelvek töredéke tartalmaz csupán a pszichoszomatikus tünetképzésre, illetve kezelésre, megelozésre vonatkozó megállapítást. A releváns témájú irányelvekben szereplo diagnosztikai utalások aránya: direkt 10,25, indirekt forma 23,7, a terápiás ajánlások között direkt 25,64, indirekt forma 15,38%. A megelozésre vonatkozóan alig (5,12%-ban) szerepel említés, a pszichés betegségek egyideju fennállásának esélyére is mindössze 10,25%-ban történik megállapítás. A szorongásos zavarok befolyásáról kevesebb, mint minden harmadik irányelv számol be (30,76%). A pszichiátriai irányelvek között pszichoszomatikus betegségekre vonatkozóan nincs célzott szakmai irányelv. Következtetés: A pszichoszomatikus medicina a hatékony betegellátás követelményeit meghatározó szakmai irányelvekben elégtelen arányban jelenik meg. Okait szemléleti zavarokban, a pszichiátriai szakmai konszenzus és a szakmaközi együttmuködés hiányosságaiban kell keresni. Mind a vonatkozó kutatásokban, mind az irányelvek fejlesztése során erofeszítéseket kell tenni a fentiek miatt kallódó nagy betegpopuláció hatékonyabb ellátása érdekében. A szerzo javaslatot tesz a szükséges konkrét lépésekre. Orv Hetil. 2021; 162(7): 252-261. INTRODUCTION: The care of patients with psychosomatic disorders has bad efficacy. It beards hard both for the patients and the health care providers. OBJECTIVE: Review of presentrecommendations for psychosomatic symptoms and illnesses in the recent Hungarian medical protocols. METHOD: A detailed evaluation of 134 medical protocols from altogether 531 protocols with closer connection with psychosomatic disorders were carried out, their diagnostic and therapeutic recommendations were analyzed. Further review of 39 (of the 134)directly related to psychosomatics was done. Investigation of psychiatric protocols for the same aspects was carried out, as well. RESULTS: Only a small part of the protocols contain recommendations for psychosomatic disorders. Ratios of their presence: diagnostic - direct 10.25, indirect 23.7, therapeutic - direct 25.64, indirect 15.38%. Efforts for prevention are only in 5.12% of the materials and 10.25% of the protocols mention a possible dual nature of the given clinical manifestation. Anxiety disorders occur only in 30.76%. Psychiatric protocol directly aiming psychosomatic problems is lacking. CONCLUSION: Presence of psychosomatic medicine in clinical guidelines defining the conditions of successful care of patients is practically minimal. Possible explanations: confusion in approaches, lack of consensus among the psychiatric institutions, and deficiency of interdisciplinary cooperation. Both in relevant clinical research and in development of medical protocols common additive efforts are necessary for achieving a more successful care of high numbers of patients presently neglected because of the mentioned causes. Author advises some concrete steps for the solution. Orv Hetil. 2021; 162(7): 252-261.

[Decisional collisions between evidence and experience based medicine in care of people with epilepsy]. / A bizonyítékon, illetve tapasztalaton alapuló orvosi szemlélet ütközései az epilepsziás betegek szakellátása során hozott egyes döntésekben.

Background - Based on the literature and his long-term clinical practice the author stresses the main collisions of evidence and experience based medicine in the care of people with epilepsy. Purpose - To see, what are the professional decisions of high responsibility in the epilepsy-care, in whose the relevant clinical research is still lacking or does not give a satisfactory basis. Methods - Following the structure of the Hungarian Guideline the author points the critical situations and decisions. He explains also the causes of the dilemmas: the lack or uncertainty of evidences or the difficulty of scientific investigation of the situation. Results - There are some priorities of experience based medicine in the following areas: definition of epilepsy, classification of seizures, etiology - including genetic background -, role of precipitating and provoking factors. These are able to influence the complex diagnosis. In the pharmacotherapy the choice of the first drug and the optimal algorithm as well as the tasks during the care are also depends on personal experiences sometimes contradictory to the official recommendations. Same can occur in the choice of the non-pharmacological treatments and rehabilitation. Discussion and conclusion - Personal professional experiences (and interests of patients) must be obligatory accessories of evidence based attitude, but for achieving the optimal results, in some situations they replace the official recommendations. Therefore it is very important that the problematic patients do meet experts having necessary experiences and also professional responsibility to help in these decisions.

[28 years in the service of the cooperation of national clinical neurosciences]. / 28 év a hazai klinikai idegtudományok együttmuködésének szolgálatában.

Two leading managers of the scientific journal currently publishing its 71st volume give an overview on the history and content- and form-related development of the journal. Recognizing the constantly decreasing role of paper-based literature products, the value system and the priorities of the journal were established more than 20 years ago: 1) preservation of high standards by achieving and maintaining international registration and annual qualification (i.e. impact factor); 2) enabling publication in Hungarian language for scientists living in Hungary and abroad; 3) displaying an ever broader spectrum of clinical neurosciences in the publications; 4) presentation of cutting-edge findings (related to the etiology, diagnostics, therapy, and care) of the most frequent and most relevant diseases in order to assure and enhance the quality of national clinical practice; 5) providing the possibility for the highest possible standard of scientific publication for Hungarian clinical neuroscientist; and finally 6) maintaining a readily available interaction surface and debate forum for the involved professionals in clinical questions of public interest. With respect to the above aspects, an outline is given of the efforts of the nearly three decades by listing editorial, publication, and other activities introduced throughout the history of the journal. The presumed strengths and weaknesses of the journal are summarized, the opportunities and limitations of the established objectives are highlighted, based on which the editors outline the most important tasks (SWOT analysis).

Reliability and validity of the Hungarian version of the Pittsburgh Sleep Quality Index (PSQI-HUN): comparing psychiatric patients with control subjects.

PURPOSE: The Pittsburgh Sleep Quality Index is used to evaluate subjective sleep quality, and it is commonly used in clinical research. Subjective sleep quality is also an important clinical measure in patients with psychiatric disorders. The aim of the present study was to evaluate the reliability and validity of the Hungarian version of the Pittsburgh Sleep Quality Index (PSQI-HUN) in both clinical and non-clinical samples. METHODS: The original version of PSQI was translated into Hungarian according to standard guidelines. The PSQI-HUN and the Athens Insomnia Scale (AIS) were subsequently administered to 53 psychiatric patients (schizophrenia, recurrent depressive disorder, mixed anxiety, and depressive disorder) and 178 healthy controls. RESULTS: Internal consistency as measured by Cronbach's alpha in the whole sample was 0.79. Pearson's product-moment correlations between component scores and the global scores were high (0.59-0.88) in the PSQI-HUN indicating the homogeneity of the scale. PSQI-HUN global and component scores differed significantly between psychiatric patients and control subjects. In the psychiatric patient subsample, schizophrenics had lower global scores compared to the other two patient groups. The analysis of convergent validity showed significant correlations between the AIS and the global as well as the component scores of the PSQI-HUN (except the component of sleep latency). CONCLUSIONS: The present study concludes that the PSQI-HUN is a reliable, valid, and standardized measure for assessment of the subjective sleep quality in clinical and research settings.

Diagnosis of primary insomnia by actigraphy--improved results by data selection.

STUDY OBJECTIVES: In spite of the useful information provided by actigraphy in sleep medicine it is still not an independent tool either in the clinical diagnosis or in the follow-up. In the frame of a retrospective study, a simple new method of data reduction was applied with the aim of improving the clinical impact of actigraphy for the diagnosis of primary insomnia. METHODS: Actigraphic records with a duration of 1 week produced on 47 subjects who met the inclusion-exclusion criteria. The daily activities during the investigational period were registered by means a self-completed questionnaire. Three parameters (sleep latency, sleep fragmentation and sleep efficiency) and only their three 'worse - as regards insomnia' daily values were analyzed statistically. The study participants comprised 13 healthy controls, 17 healthy 'bad sleepers' and 17 subjects with primary insomnia. RESULTS: The post-hoc tests did not reveal statistically significant difference in the three parameters between the healthy and 'bad sleeper' groups, but these two groups differed statistically from the primary insomnia group. CONCLUSION: The actigraphic analysis of sleep latency, sleep fragmentation and sleep efficacy allows a significant differentiation between subjects with primary insomnia and healthy controls, but not between healthy controls and healthy 'bad sleepers'. Statistical algorithms indicated 'models' for clinically good and bad sleepers. Further studies on large populations are necessary before this method can be introduced in the routine medical care of individuals with primary insomnia.

[Dostoyevsky's epilepsy in the light of recent neurobiological data]. / Dosztojevszkij epilepsziájáról az újabb neurobiológiai adatok tükrében.

BACKGROUND AND PURPOSE: Since the 1960s several theories have developed on the epilepsy of Fyodor Mikhailovich Dostoyevsky. Probably the most exciting and still actual question might be the subject of the "ecstatic aura", he described in his novels based on his own experiences. During this extremely rare seizure onset the patients experience a strong sense of happiness, harmony and wholeness. The symptomatogenic zone of ecstatic seizures were considered to be of temporal lobe origin for a long time. Lately though this theory seems to be questioned based on the results of SPECT and deep brain EEG monitoring techniques in addition to the enrichment of our knowledge concerning the function of the insular cortex. METHODS: Literary and scientific overview on the subject of Dostoyevsky's epilepsy, with special concern to his ecstatic seizures. RESULTS AND CONCLUSION: According to new electrophysiology and imaging techniques ecstatic seizures--including the seizure onset of Dostoyevsky--could rather be connected to the insular cortex.

[Oligoepilepsy: a real entity or the benign form of epileptic disorder?]. / Oligoepilepszia: onálló entitás vagy az epilepsziás készség benignus formája?

BACKGROUND AND PURPOSE: Although oligoepilepsy (OLE) is a used term in many protocols, guidelines and the everyday routine, it is found practically nowhere in the scientific literature. The aim of our study is to investigate and evaluate of the main characteristics of his subcategory of epilepsy. We try to find answer to the basic question of not only theoretical but also great practical importance whether the OLE does really exist, is it an independent entity of epilepsy or only its general benign clinical presentation. METHODS: We considered OLE if the patients had two seizures maximally in the last year of their course. We counted only the two most severe clinical types, the generalized tonic-clonic and the complex partial seizures. We divided the OLE into two subtypes: those patients who had OLE from the beginning of their epilepsy (OLE1) and those in whom the OLE was the result of the treatment (OLE2). We retrospectively analysed the data of 817 "OLE-suspicious" patients taken from our EPIMED database. RESULTS: We found 47 patients met the inclusion criteria (OLE1 = 34, OLE2 = 13). OLE patients did not differ from the general epileptic population according to the age and gender, the type of seizures, the electro-clinical diagnosis and the possible cause of their first seizure. But we found statistically significant differences in two measures. In OLE, far less seizure provoking factors were found in the sporadic seizures. Concerning the social conditions: while the range of employees was equal, the vast majority of OLE patients were able to work at their level of education. CONCLUSION: We found that more than 5% of people with epilepsy can belong to the OLE category. In the majority of OLE patients the seizure frequency is low from the beginning of the disease. The sporadic seizures in OLE are generally not provoked. The chances of OLE patients in the world of job are better for the OLE patients. In our opinion OLE rather seems to be an independent entity among epilepsy. Therefore larger prospective studies are needed to the exact description of OLE and to establish the special standards for the everyday medical practice.

[Theoretical and practical considerations in rational polytherapy for epilepsy]. / A racionális politerápia elvi és gyakorlati lehetoségei epilepsziában.

Author analyses the consideration of rational polytherapy for epilepsy. Among the theoretical aspects he points the different effect of seizure inhibitory drugs on the epilepsy models but didn't find data enough for the basis of any successful combination. Combinations of compounds having different way of action are more promising. Rational polytherapy can serve also the epileptic patients' tailored therapy in the daily routine. There have already been some proved synergisms concerning drug interactions. Based on detailed analysis of side effects a possibility occurs for neutralization of side effects when anticonvulsants with side effects of opposite nature are combined. Considering both the side effect profiles and the different (somatic and psychic) habits of the patients we can create a special list of favourable combinations. Co-morbid states and their treatments play a significant role in the application of rational polytherapy. Combination of anticonvulsants of lower potential but without drug-interactions can be the choice in these cases. The non-epileptic indications of the anticonvulsants can also be utilized in polymorbid patients. Based on the theoretical and practical considerations the author defines the ten-step-cognitive-preparation-process in planning the optimal (poly)therapy. On speculative basis he suggests eight beneficial versions of seizure inhibitory rational polytherapy.

[Living with lost individuality. Special concerns in medical care of severely demented Alzheimer patients]. / Elni az egyéniség elvesztése után. A súlyos Alzheimer-betegek orvosi ellátásának sajátos szempontjai.

While the expected life-time increases dementias will show a pandemic nature. Author analyses the special medical and social concerns of severe states of Alzheimer disease. Having introduced the epidemiologic, diagnostic data and forms of palliative therapies he concentrates on the hitherto unsolved problems of patients and caregivers. He belongs to the experts identifying the Alzheimer diseases as a forced aging process. Accepted the theory of L. Hayflick he evaluates the aging process in frame of an evolution model. He states that for aged human beings having already performed the task of reproduction further conditions of living circumstances and even that of death are no more programmed. This hypothesis may have a very negative content at the first sense. But the author rather considers the uncertainty of aging a positive message. He establishes that the occurrence of degenerative processes connecting the aging must be limited by preventive interventions far more efficient than the present possibilities. Concerning these steps we are still on the level of recommendations for preserving our general health and data of relevant science are quite contradictory. Although criteria of "healthy", "qualified" or "assumable" aging are getting defined, we still do not know exactly how we should live optimally and what should we do for this in different epochs of our life. Somatic and psychological parameters are lacking which would be able to signalize the actual level of the aging process in a given person. We, physicians, also do not have exact opinion on the level of severity of dementias at which the patient already lost his her features of personality and individuality on an irreversible way. We have no idea on the phase when the ratio of joy and suffer falls below the value of 1.0 because we still have no tool for its measure. The author pointed the necessity of acceptance of a new preventive attitude and application of new methods in the medical care of the forced or pathological aging, instead of the present approaches based on the "wait and treat" attitude. Because of the intensive increase of the patient population the identification and care of patients can be efficient with a much more involvement of the basic medical network. Financial background can be improved by new theoretical bases of criteria of the palliative treatments. But the direct professional programs can be planned after solution of the existing moral and social dilemmas.

[Classical neurology: Adieu! Or: the future of Hungarian neurology, fruitful transformation or preprogrammed death?]. / Klasszikus neurológia: Adieu! Avagy: az ideggyógyászat jövoje a termékeny átalakulás vagy programozott halál?

According to our opinion several ideas, trends and aims of the traditional neurology became outworn. (So together with all the romantic beauty and hierarchic relations: Adieu!). The specialisation within the main body of the profession is unavoidable. A new, high quality, cost-benefit sensitive, institutional system should be built up, non essentially on inpatient, but on outpatient basis, supported by a personal and partnership oriented patient/doctor relationship, with multidisciplinatory co-operations and team-work. Education should be also rebuilt accordingly. This analysis of the present situation and recommendations for the future plans was given--since our ages--without any personal interest or attraction. We tried to keep before us only the future of our beloved profession, the preservation of worths, and the exploration of the withdrawing dogmatic views. We invite everybody who is interested in the current questions of our profession to share their opinion with the whole neurological society and take part in open discussion of these important questions.

Actigraphy: a valuable diagnostic tool or a luxury investigation? (Neuropsychiatric aspects).

AIM: Despite of the continuing interest in actigraphy it has a relatively low impact on the everyday medical routine. Accordingly, we set out to review the current state and to recommend relevant further indications for its application, especially in neuropsychiatry. METHOD: We surveyed the areas of its use and then reviewed the literature, with special regard to its advantages and methodological limitations. Adding to the results we enlarged the results with our own personal experience. RESULTS: The limitations of the method may be decreased by methodological manipulations (a simple rational data reduction is recommended). Actigraphy appears to be a useful tool in the diagnosis of illnesses, syndromes or disorders influencing the vigilance level, the motor performance or the energetic balance of the organism. We constructed a list of the most relevant fields of indication of actigraphy in diagnostics, illustrated by anecdotal actigraphic case records. CONCLUSION: Further methodological considerations are needed for the successful evaluation of accelerometry. Targeted basic epidemiological studies in the healthy population and in patient groups should solve various open questions in order to make full use of the advantages of actigraphy in the everyday clinical routine.

[Antiepileptic drugs as mood stabilizers: what did we learn from the epileptology?]. / Hangulatstabilizáló antiepileptikus szerek: mire jók az epilepsziában szerzett tapasztalatok?

Author summarizes the practical aspects of psychiatric application of mood stabilizing antiepileptic drugs. He observes how to transfer experiences taken from the "epileptologic" practice into the psychiatric care of bipolar patients. He shortly demonstrates the relevant information on the mechanisms of action, controversies and possible clinical effects influenced by the seizure inhibiting effect of the concerning molecules. By the opinion of the author the clinical importance of pharmacokinetic parameters are underestimated in the psychiatric practice. Therefore--as an original approach in the literature--he summarizes the detailed clinical indications of serum level measurements of antiepileptic drugs applied in psychiatry as mood stabilizers. The therapeutic experiences in epilepsy added a lot of practices for the most effective dosing, building, tapering and exchange of the mood stabilizer antiepileptics. Drug interactions (appear among the psychotropic drugs or with the commonly used medicines). As in any chronic therapies the main condition of patient's compliance is the lacking or very mild presence of the applied therapy. The paper discusses the most frequently occurring and drug-specific side effects in table forms. Using the term of "relative therapeutic potential" the need of balance between the efficacy (influenced by the choice and dosing) and the tolerance are pointed. Rules of application can change significantly in special populations like in pregnancy, obesity, chronic diseases or in chronic comorbid states and in case of polytherapy. As for the special therapeutic effects, the experiences are not completed even in group of antiepileptics: we have larger and more favorable knowledge on the traditional drugs (carbamazepine and valproate) and on lamotrigine (from the newer generation) but promising but not enough information exists on the newest antiepileptic molecules. Further targeted studies are needed for the identification and positioning of antiepileptic drugs in the palette of mood stabilizing pharmacotherapy and for the definition of evidence based, individually tailored and lifelong applied highly effective combinations of the mood stabilizing pharmacotherapy containing antiepileptic agents.

Are there real unprovoked/unprecipitated seizures?

Resistant epileptic patients often experience seizure precipitating conditions. Their lack or presence is extremely important not only for the diagnosis of epilepsy but also for the most appropriate treatment of the seizures. Unfortunately, there are a lot of uncertainty in their evaluation occurring in the daily routine and the exact definitions for the practice are still lacking. Based on the consonant and contradictory aspects concerning the consideration of the seizure precipitant factors a new hypothesis is suggested: every clinical epileptic manifestation should need a tonic (chronic cerebral cortical epileptic dysfunction) and a phasic (acute epileptogenic noxa) condition simultaneously. Results of a pilot study aimed to evaluate the possible role of precipitants in the manifestation of habitual seizures of patients strengthened the hypothesis. The (34%) total population might be more sensitive to actual phasic epileptogenic changes and 5.5% who are considered as "seizure precipitant responders". The five most frequent precipitants provoked the patients' "habitual" seizures were: unexpected life events (29.6%), changes in drug intake (23.7%), insomnia (20%), meteoropathological effects (17%) and alcohol consumption (9.5%). The paper lists the evidences and practical experiences supporting the hypothesis and mentions some counter arguments. In conclusion, the acceptance of the hypothesis might open new perspectives in the complex antiepileptic therapy especially for the subpopulation most vulnerable of phasic epileptogenic conditions (about 5-6% of the total). Further investigations are recommended to elucidate the remaining theoretical and practical reservations.