[Joint crisis plans in mental health hospitals-Real practice in an association of psychiatric hospitals]. / Behandlungsvereinbarungen in der Psychiatrie ­ reale Praxis in einem Verbund psychiatrischer Kliniken.

BACKGROUND: Joint crisis plans (JCPs) are offered in many psychiatric hospitals, but patients only rarely make use of them. OBJECTIVE: To assess the rates of JCPs among inpatients of mental health hospitals and to analyze the clinical characteristics of patients who make use of a JCP. MATERIAL AND METHODS: We carried out a retrospective analysis of routine data from the statistical database/basis documentation of the LVR hospital association, which consists of nine psychiatric hospitals. The basis documentation is consistent in the nine hospitals. All admissions between 2016 and 2020 were considered. We recorded the existence of a JCP, age, gender and main diagnosis at release, as well as previous hospital stays, detention under the Mental Health Act of the Federal State of NRW and experiences with compulsory measures (seclusion/restraint) in the previous 24 months before index admission. RESULTS: Out of a total of 117,662 inpatients 467 (0.4%) had completed a JCP. Patients with JCP were more likely to be diagnosed with schizophrenia, bipolar disorder, or emotionally unstable personality disorder. Patients with a JCP had more previous inpatient stays and they had more frequently experienced detentions and compulsory measures. However, 50% of the patients with a JCP had other diagnoses and the vast majority of them had experienced no detention or compulsory measure in the 24 months preceding the first documentation of a JCP. CONCLUSIONS: Overall, the use of JCPs is limited. The targeted group of patients with severe mental illness and previous experience with involuntary placements and compulsory measures make use of the offer of a JCP but so do other patients as well. Additional qualitative analyses are required in order to analyze the content and objectives of JCPs in more detail.

Upscaling e-mental health in Europe: a six-country qualitative analysis and policy recommendations from the eMEN project.

E-mental health (eMH) encompasses the use of digital technologies to deliver, support, or enhance mental health services. Despite the growing evidence for the effectiveness of eMH interventions, the process of implementation of eMH solutions in healthcare remains slow throughout Europe. To address this issue, the e-Mental Health Innovation and Transnational Implementation Platform North-West Europe (eMEN) project was initiated to increase the dissemination and quality of eMH services in Europe. In this project, status analyses regarding eMH in the six participating countries (i.e., Belgium, France, Germany, Ireland, The Netherlands, and the UK) were conducted and eight recommendations for eMH were developed. Expert teams from the six participating countries conducted status analyses regarding the uptake of eMH based on a narrative literature review and stakeholder interviews. Based on these status analyses, the eMEN consortium developed eight policy recommendations to further support the implementation of eMH in Europe. The status analyses showed that the participating countries are in different stages of implementing eMH into mental healthcare. Some barriers to implementing eMH were common among countries (e.g., a limited legal and regulatory framework), while others were country-specific (e.g., fragmented, federal policies). The policy recommendations included fostering awareness, creating strong political commitment, and setting reliable standards related to ethics and data security. The eMEN project has provided the initial recommendations to guide political and regulatory processes regarding eMH. Further research is needed to establish well-tailored implementation strategies and to assess the generalizability of the recommendations beyond the countries involved in the eMEN project.

Identification of risk factors for involuntary psychiatric hospitalization: using environmental socioeconomic data and methods of machine learning to improve prediction.

BACKGROUND: The purpose of this study was to identify factors associated with a high risk of involuntary psychiatric in-patient hospitalization both on the individual level and on the level of mental health services and the socioeconomic environment that patients live in. METHODS: The present study expands on a previous analysis of the health records of 5764 cases admitted as in-patients in the four psychiatric hospitals of the Metropolitan City of Cologne, Germany, in the year 2011 (1773 cases treated under the Mental Health Act and 3991 cases treated voluntarily). Our previous analysis had included medical, sociodemographic and socioeconomic data of every case and used a machine learning-based prediction model employing chi-squared automatic interaction detection (CHAID). Our current analysis attempts to improve the previous one through (1) optimizing the machine learning procedures (use of a different type of decision-tree prediction model (Classification and Regression Trees (CART) and application of hyperparameter tuning (HT)), and (2) the addition of patients' environmental socioeconomic data (ESED) to the data set. RESULTS: Compared to our previous analysis, model fit was improved. Main diagnoses of an organic mental or a psychotic disorder (ICD-10 groups F0 and F2), suicidal behavior upon admission, admission outside of regular service hours and absence of outpatient treatment prior to admission were confirmed as powerful predictors of detention. Particularly high risks were shown for (1) patients with an organic mental disorder, specifically if they were retired, admitted outside of regular service hours and lived in assisted housing, (2) patients with suicidal tendencies upon admission who did not suffer from an affective disorder, specifically if it was unclear whether there had been previous suicide attempts, or if the affected person lived in areas with high unemployment rates, and (3) patients with psychosis, specifically those who lived in densely built areas with a large proportion of small or one-person households. CONCLUSIONS: Certain psychiatric diagnoses and suicidal tendencies are major risk factors for involuntary psychiatric hospitalization. In addition, service-related and environmental socioeconomic factors contribute to the risk for detention. Identifying modifiable risk factors and particularly vulnerable risk groups should help to develop suitable preventive measures.

Psychiatric comorbidity in alcohol use disorders: results from the German S3 guidelines.

Alcohol use disorders (AUD) have a high comorbidity with mental disorders. Vice versa, alcohol consumption plays an important role in affective disorders, anxiety disorders, ADHD, schizophrenic psychosis, and other mental disorders. In developing the current interdisciplinary, evidence-based treatment guideline on screening, diagnostics, and treatment of AUD, available research on comorbid mental diseases in AUD has been compiled to generate recommendations for treatment. The guideline was prepared under the responsibility of the German Association for Psychiatry, Psychotherapy, and Psychosomatics (DGPPN) and the German Association for Addiction Research and Therapy (DG-Sucht). To meet the methodological criteria for the highest quality guidelines ("S3-criteria") as defined by the Association of Scientific Medical Societies in Germany (AWMF), the following criteria were employed: (1) a systematic search, selection, and appraisal of the international literature; (2) a structured process to reach consensus; and (3) inclusion of all relevant representatives of future guideline users. After assessing and grading the available literature, the expert groups generated several recommendations for the screening, diagnosis, and treatment of comorbid mental disorders. These recommendations were subdivided into psycho-, pharmaco-, and combination therapies. These are the first guidelines ever to make specific treatment recommendations for comorbid mental diseases in AUD. The recommendations extend to different treatment approaches including diagnostics and settings to present available effective and state-of-the-art treatment approaches to clinicians. Hitherto, many clinical constellations have not been addressed in research. Therefore, recommendations for future research are specified.

[Mental comorbidities of alcohol-related disorders]. / Psychische Komorbiditäten bei alkoholbedingten Störungen.

BACKGROUND: Alcohol-related disorders have a high comorbidity with mental disorders and vice versa, alcohol consumption plays an important role in affective disorders and schizophrenic psychoses. In developing the current S3 guidelines evidence-based knowledge on the rate and significance of comorbid disorders in alcohol use disorders has been compiled to generate recommendations for treatment. METHODS: In preparation for the guidelines, previous international guidelines and a systematic literature search were taken into consideration. Recommendations for various and specific clinical situations were derived from these sources based on evidence grading. Evidence and recommendations were subdivided into psychotherapy, pharmacotherapy and combination therapy, each having differential efficacies in the treatment of psychiatric symptoms and alcohol consumption behavior. Furthermore, a separate treatment pathway was developed for a stepwise approach to affective disorders for both comorbidities. CONCLUSION: Appearing for the first time in guidelines are specific treatment recommendations for comorbid mental diseases in alcohol use disorders. These recommendations extend to different treatment approaches including diagnostics and settings, affording clinicians more pragmatic relevance.

[Parenteral Antipsychotics in the Treatment of Agitation and Aggression]. / Parenteral applizierte Antipsychotika bei Agitation und Aggression.

This overview presents the current scientific data on intramuscular administration of benperidole, aripiprazole, ziprasidone, and haloperidole and on inhaled loxapine with regard to their efficacy and tolerability as well as their pharmacodynamic and pharmacokinetic properties. In addition, the possible advantages and disadvantages of the different substances are compared when administered to patients who show tension, agitation and aggression.

[A case of Bleuler's disease? 100 years of dementia praecox or group of schizophrenias]. / Ein Fall von Morbus Bleuler? : 100 Jahre "Dementia praecox oder Gruppe der Schizophrenien"

Approximately 100 years ago Eugen Bleuler published the most significant contribution to psychiatry by conceptualizing the term schizophrenia as a diagnostic entity. In modern diagnostic manuals Bleuler's concept is only reflected in subordinated criteria, i.e. the negative symptoms. On the occasion of the anniversary of Bleuler's essential publication, the present work aims to exemplify the differences in diagnostic concepts and it will be illustrated that Bleuler's intention to establish his so-called basic symptom as a guideline for diagnostics has to be considered as failed from a present day viewpoint.

[State-dependent motivational interviewing for people with schizophrenia and substance use: results of a randomised controlled trial]. / Motivationsbehandlung für Patienten mit der Doppeldiagnose Psychose und Sucht : Ergebnisse einer randomisierten Studie.

BACKGROUND: Comorbid substance use disorder in patients with schizophrenia is associated with poor clinical and social outcome and low compliance with integrated outpatient treatment programs. For the first time the present trial compares the efficacy of four sessions of motivational interviewing (MI) and four sessions of supportive therapy (ST). The primary outcome was compliance with integrated outpatient treatment post-intervention. Secondary outcomes were substance use, psychopathology, compliance with medication and stage of change in psychotherapy. METHODS: Sixty inpatients with schizophrenia and substance use disorder were randomised to receive either four sessions of MI or four sessions of ST. Masked assessments took place at baseline, post-treatment and 3- and 6-month follow-ups. RESULTS: The integrated outpatient program was attended by 70.0% of the MI (n=30) and 40.0% of the ST patients (n=30; p=0.020). There were no differences regarding secondary outcome between MI and ST groups. CONCLUSION: The study design allows one for the first time to attribute the findings to the specific effects of MI and thereby emphasizes the effectiveness of this particular treatment approach. In summary, these findings show that the integration of short-term MI for people with both psychosis and substance abuse could significantly improve their chances of attending appropriate outpatient settings and thereby improve their well-being.

[Prevalence of psychosis/substance abuse comorbidity. Clinical-epidemiological findings from different treatment settings in a large German city]. / Prävalenz der Komorbidität Psychose und Sucht Klinisch-epidemiologische Ergebnisse aus verschiedenen Behandlungssettings in einer deutschen Grossstadt.

Comorbid substance use disorders in schizophrenia are of high clinical relevance, because they are common and they are mostly associated with an unfavourable long-term prognosis. Whereas the clinical impression suggests a continuous increase of substance use disorders in patients with schizophrenia over the last 10-20 years, results from epidemiological studies have been inconsistent. The aim of the present investigation was to study the prevalence of substance use disorders within a large sample of patients with schizophrenia in a large German city (Cologne). The prevalence data were examined in different treatment settings (outpatient vs inpatient, university hospital vs mental health hospital). Risk factors for substance use disorders and preferences for specific substances were analysed. The lifetime prevalence of comorbid substance use disorders in the entire sample of 2,337 patients with schizophrenia was 29.4%. However, the data varied substantially depending on the setting of treatment, with the highest comorbidity rates being prevalent in the inpatient sample. Alcohol and cannabis were the most commonly used substances. Commonly recognized risk factors for substance use disorders, such as being male and unmarried and having a low education level, were replicated.

[Dual diagnosis psychosis and substance use disorders in adolescents--part 1]. / Psychose und Sucht bei Jugendlichen und Jungerwachsenen[nl]Teil 1: Prävalenz und Erklärungsmodelle.

Epidemiological studies suggest that 20 % to 50 % of patients with schizophrenia have a lifetime comorbid substance use disorder (SUD). In first-episode psychosis this prevalence is even higher and varies between 20 % and 75 % with cannabis being the most widely used illicit drug. These difficult to treat patients usually have a worse prognosis as compared with non-substance abusing schizophrenic patients. Despite multiple theories proposed such as the self medication hypothesis, common or bidirectional factor models or genetic vulnerability, there is no consensus on the aetiology of increased rates of substance use in people with psychosis which is important to treat these patients. The dually diagnosed population is a heterogeneous group and it is likely that different models may explain comorbidity in different subgroups. The present review part one gives an overview on prevalence and explanation models for dual diagnosis psychosis and substance use with focus in adolescent and young adult populations, the second part reviews the clinical course for both disorders and current psychosocial treatment options.

[Dual diagnosis psychosis and substance use disorders in adolescents--part 2]. / Psychose und Sucht bei Jugendlichen und Jungerwachsenen [nl]Teil 2: Verlauf und Behandlung.

Despite the high prevalence of comorbid substance use disorders (SUD) in young schizophrenic patients and the association of persisting SUD and poor outcome, there are only few randomized controlled psychological treatment studies in this special dual diagnosis group available. According to therapeutic recommendations, efficient treatment models need to integrate traditional psychiatric therapy and therapy of addiction offered in one setting. Short-term interventions have adapted Motivational interviewing (MI) for dual diagnosis, which has been shown to be effective among other substance abuse disorders. However a recent Cochrane review showed that insufficient evidence exists to show that any psychosocial treatment method for dual diagnosis is superior to others. The aim of this review was to assess the current evidence for the efficacy of psychosocial interventions for reducing substance in young patients with psychosis. Five randomized-controlled studies were identified. This review did not find any specific psychosocial intervention that had been replicated and consistently showed clear advantages over comparison condition for substance-related and other psychiatric outcomes.

Prepulse inhibition of the startle reflex and its attentional modulation in the human S-ketamine and N,N-dimethyltryptamine (DMT) models of psychosis.

Patients with schizophrenia exhibit diminished prepulse inhibition (PPI) of the acoustic startle reflex and deficits in the attentional modulation of PPI. Pharmacological challenges with hallucinogens are used as models for psychosis in both humans and animals. Remarkably, in contrast to the findings in schizophrenic patients and in animal hallucinogen models of psychosis, previous studies with healthy volunteers demonstrated increased levels of PPI after administration of low to moderate doses of either the antiglutamatergic hallucinogen ketamine or the serotonergic hallucinogen psilocybin. The aim of the present study was to investigate the influence of moderate and high doses of the serotonergic hallucinogen N,N-dimethyltryptamine (DMT) and the N-methyl-D-aspartate antagonist S-ketamine on PPI and its attentional modulation in humans. Fifteen healthy volunteers were included in a double-blind cross-over study with two doses of DMT and S-ketamine. Effects on PPI and its attentional modulation were investigated. Nine subjects completed both experimental days with the two doses of both drugs. S-ketamine increased PPI in both dosages, whereas DMT had no significant effects on PPI. S-ketamine decreased and DMT tended to decrease startle magnitude. There were no significant effects of either drug on the attentional modulation of PPI. In human experimental hallucinogen psychoses, and even with high, clearly psychotogenic doses of DMT or S-ketamine, healthy subjects failed to exhibit the predicted attenuation of PPI. In contrast, PPI was augmented and the startle magnitude was decreased after S-ketamine. These data point to important differences between human hallucinogen models and both animal hallucinogen models of psychosis and naturally occurring schizophrenia.

Neurotoxicity of methylenedioxyamphetamines (MDMA; ecstasy) in humans: how strong is the evidence for persistent brain damage?

BACKGROUND: The popular dance drug ecstasy (3,4-methylenedioxymethamphetamine: MDMA and some analogues) causes selective and persistent neurotoxic damage of central serotonergic neurones in laboratory animals. Serotonin plays a role in numerous functional systems in the central nervous system (CNS). Consequently, various abnormalities including psychiatric, vegetative, neuroendocrine and cognitive disorders could be expected in humans following MDMA-induced neurotoxic brain damage. AIMS: In recent years, the question of ecstasy-induced neurotoxicity and possible functional sequelae has been addressed in several studies with drug users. The aim of this paper was to review this literature and weigh the strength of the evidence for persistent brain damage in ecstasy users. METHODS: We used Medline to view all available publications on 'ecstasy' or 'MDMA'. All available studies dealing with ecstasy users entered this analysis. FINDINGS AND CONCLUSIONS: Despite large methodological problems the bulk of evidence suggests residual alterations of serotonergic transmission in MDMA users, although at least partial restitution may occur after long-term abstinence. However, functional sequelae may persist even after longer periods of abstinence. To date, the most consistent findings associate subtle cognitive, particularly memory, impairments with heavy ecstasy use. However, the evidence cannot be considered definite and the issues of possible pre-existing traits or the effects of polydrug use are not resolved. RECOMMENDATIONS: Questions about the neurotoxic effects of ecstasy on the brain remain highly topical in light of its popularity among young people. More longitudinal and prospective studies are clearly needed in order to obtain a better understanding of the possible long-term sequelae of ecstasy use in humans.

High intensity dependence of auditory evoked dipole source activity indicates decreased serotonergic activity in abstinent ecstasy (MDMA) users.

Neurotoxic damage of central serotonergic systems has been demonstrated in numerous animal studies after exposure to methylenedioxyamphetamines (ecstasy). A high intensity dependence of auditory evoked potentials and, particularly, of the tangential N1/P2 source activity has been associated with low levels of serotonergic neurotransmission in humans. We performed an auditory evoked potentials study in 28 abstinent recreational ecstasy users and two equally sized groups of cannabis users and nonusers. The ecstasy users exhibited an increase of the amplitude of the tangential N1/P2 source activity with higher stimulus intensities; whereas, both control groups failed to exhibit this feature. These data are in line with the hypothesis that abstinent ecstasy users present with diminished central serotonergic activity. This feature of information processing is probably related to the well-recognized neurotoxic potential of ecstasy. Our data indicate that recreational ecstasy use may cause long-term alterations in the function (and possibly structure) of the human brain.

Neurometabolic effects of psilocybin, 3,4-methylenedioxyethylamphetamine (MDE) and d-methamphetamine in healthy volunteers. A double-blind, placebo-controlled PET study with [18F]FDG.

The neurometabolic effects of the hallucinogen psilocybin (PSI; 0.2 mg/kg), the entactogen 3,4-methylenedioxyethylamphetamine (MDE; 2 mg/kg) and the stimulant d-methamphetamine (METH; 0.2-0.4 mg/kg) and the drugs' interactions with a prefrontal activation task were investigated in a double-blind, placebo-controlled human [F-18]fluorodeoxyglucoseFDG-positron emission tomographicPET study (each group: n = 8). Subjects underwent two scans (control: word repetition; activation word association) within 2-4 weeks. Psilocybin increased rMRGlu in distinct right hemispheric frontotemporal cortical regions, particularly in the anterior cingulate and decreased rMRGlu in the thalamus. Both MDE and METH induced cortical hypometabolism and cerebellar hypermetabolism. In the MDE group, cortical hypometabolism was more pronounced in frontal regions, with the exception of the right anterior cingulate, which tended to be hyperactive. Cognitive activation-related increases in left frontocortical regions were attenuated under all three psychoactive substances, but less so under MDE. Taking into account performance data and subjective reports on task difficulty, these effects may result from different mechanisms across the three groups. Our PSI data are in line with studies on acute schizophrenic patients suggesting frontal overactivity at rest, but diminished capacity to activate prefrontal regions upon cognitive demand. The MDE data support the hypothesis that entactogens constitute a distinct psychoactive substance class, which takes an intermediate position between stimulants and hallucinogens.

Psychopathological, neuroendocrine and autonomic effects of 3,4-methylenedioxyethylamphetamine (MDE), psilocybin and d-methamphetamine in healthy volunteers. Results of an experimental double-blind placebo-controlled study.

The aim of this study was to contribute to the characterization of the entactogen (ecstasy) substance group. The psychopathological, neuroendocrine and autonomic effects of common recreational doses of the entactogen 3,4-methylenedioxyethylamphetamine (MDE), the hallucinogen psilocybin, the stimulant d-methamphetamine and placebo were investigated in a double-blind study with healthy volunteers (n = 32). Psychological effects of the drugs were assessed by means of standardized rating scales, self assessment inventories and free descriptions. The most characteristic effects of MDE were pleasant emotional experiences of relaxation, peacefulness, content and closeness to others. However, significant stimulant and hallucinogen-like effects were also present, although the latter were weaker than the effects of psilocybin. MDE elicited the strongest endocrine and autonomic effects among the three drugs, including robust rises of serum cortisol and prolactin, elevations of blood pressure and heart rate, and a moderate, but significant rise of body temperature. The apparent contrast between psychological and autonomic effects (subjective relaxation versus physical activation) was a unique feature of the MDE state. Our findings are in line with both users' reports and results from previous experimental studies, and support the view that entactogens constitute a distinct psychoactive substance class taking an intermediate position between hallucinogens and stimulants.

[Investigations on the effect of "ecstasy" on cerebral glucose metabolism: an 18-FDG PET study]. / Untersuchungen zum Einfluss von "Ecstasy" auf den zerebralen Glukosemetabolismus: eine 18-FDG-PET-Studie.

PURPOSE: The aim of the present study was to determine the acute effects of the "Ecstasy" analogue MDE (3, 4-methylendioxyethamphetamine) on the cerebral glucose metabolism (rMRGlu) of healthy volunteers. METHOD: In a randomised double-blind trial, 16 healthy volunteers without a history of drug abuse were examined with 18-FDG PET 110-120 minutes after oral administration of 2 mg/kg MDE (n = 8) or placebo (n = 8). Beginning two minutes prior to radiotracer injection, a constant cognitive stimulation was maintained for 32 minutes using a word repetition paradigm in order to ensure constant and comparable mental conditions during cerebral 18-FDG uptake. Individual brain anatomy was represented using T1-weighted 3D flash MRI, followed by manual regionalisation into 108 regions-of-interest and PFT/MRI overlay. Absolute quantification of rMRGlu and comparison of glucose metabolism under MDE versus placebo were performed using Mann-Whitney U-test. RESULTS: Absolute global MRGlu was not significantly changed under MDE versus placebo (MDE: 41.8 +/- 11.1 mumol/min/100 g, placebo: 50.1 +/- 18.1 mumol/min/100 g, p = 0.298). The normalised regional metabolic data showed a significantly decreased rMRGlu in the bilateral frontal cortex: left frontal posterior (-7.1%, p < 0.05) and right prefrontal superior (-4.6%, p < 0.05). On the other hand, rMRGlu was significantly increased in the bilateral cerebellum (right: +10.1%, p < 0.05; left +7.6%, p < 0.05) and in the right putamen (+6.2%, p < 0.05). CONCLUSIONS: The present study revealed acute neurometabolic changes under the "Ecstasy" analogon MDE indicating a fronto-striato-cerebellar dysbalance with parallels to other psychotropic substances and various endogenous psychoses respectively.

Hallucinogenic drug induced states resemble acute endogenous psychoses: results of an empirical study.

Clinical evidence suggests that hallucinogenic drug-induced altered states of consciousness (ASCs) and the incipient, acute stages of endogenous psychoses share many common phenomenological features. The aim of our study was to assess hallucinogen-like phenomena in endogenous psychotic patients using standardised methods. We examined 93 endogenous psychotic patients, 50 healthy controls and a small group of drug induced psychotic patients (n = 7) with two ASC self-assessment scales (questionnaire APZ = Abnormer Psychischer Zustand = Altered State of Consciousness [Dittrich et al, 1985]; and questionnaire OAV = Abbreviation of the three subscales: Oceanic Boundlessness/Angst = Dread of Ego Dissolution/Visionary Restructuralisation [Bodmer 1989]). Patients were examined shortly after remission of their last acute psychotic episode and they answered the questionnaires referring to the early phase of this episode. Differences in the questionnaire scores were significant between psychotic patients and controls. Drug induced patients had numerically higher scores than endogenous psychotic patients, however these differences were only significant for the APZ total score and the undifferentiated items of the APZ, but not for the three APZ subscale and the OAV scores. More than 50% of the endogenous psychotic patients answered 26% of the APZ-and 43% of the OAV-items with "yes". The OAV total score and the OSE (Ozeanische Selbstentgrenzung = oceanic boundlessness) scores of both questionnaires correlated significantly with BPRS Factor 3 (thought disturbance). Our results support the hypothesis that hallucinogen-like experiences represent common phenomena during the acute stages of endogenous psychoses. Remarkably, these phenomena include subjectively pleasant experiences of the OSE dimension. In the routine clinical assessment of endogenous psychotic patients experiences of this dimension may be more easily overlooked than the negative experiences of the AIA dimension (AIA: Angst vor der Ich-Auflösung = dread of ego dissolution).

The electrically elicited R2 blink reflex consists of distinct subcomponents.

In previous studies the later parts of the electrically evoked R2 blink reflex has been found to be more susceptible to the inhibitory effects of repetitive stimulation and prepulses. Consequently, it has been suggested that the R2 reflex may be composed of distinct subcomponents. However, as of yet, no study revealed electromyographical evidence for this hypothesis, probably due to a putative temporal overlap that makes it difficult to clearly separate distinct R2 subcomponents. In the present study we investigated the electrically evoked blink reflex in 26 healthy volunteers by using the paradigm of self-stimulation, which has been found to inhibit the R2 and may thus help to differentiate putative R2 subcomponents. In most of the participants self-stimulation resulted in inhibition of the reflex involving predominantly later sections of R2. In addition, in three subjects it was possible to clearly separate distinct R2 subcomponents. These findings suggest that the electrically elicited R2 blink reflex--like the acoustic blink response--consists of superimposed distinct subcomponents. Based on their differential modulation evoked by habituation, pre-stimulation and self-elicitation it is hypothesized that the early portions of the R2 represent the electrically evoked blink reflex, whereas the later sections belong to the generalized startle reaction in man. However, due to their temporal overlap a differentiation might not be possible in conventional recordings.

[Interdisciplinary concepts of surgical sex transformation in transsexual patients]. / Interdisziplinäre Konzepte zur operativen Geschlechtstransformation bei Transsexuellen.

From the introduction of the law on recognition of transsexuals (TSG) in 1980, over 1400 decisions were made by German regional district judges up to 1990. In over 90% of the cases the desired gender was accepted and attested officially. In the near future, a growing number of requests has to be expected. Generally, transsexual patients desire surgery to achieve a complete sex change. Since the foundation of an interdisciplinary gender dysphoria identity committee at our institution in 1989, we have developed criteria on indications, operative techniques and follow-up, which would overtax a urology department, but which can be managed by an interdisciplinary team. Operative techniques may be regarded as well standardized in male-to-female transsexuals and may be performed by the urologist alone; in female-to-male transsexuals sex transformation remains complex interdisciplinary challenge to urologists and plastic surgeons, mainly due to urethral complications. Continuous psychiatric guidance and endocrinological monitoring of the patients facilitates indications for surgery and perioperative management.