[On the 200th birthday of psychiatry]. / Die Psychiatrie hat 200. Geburtstag. Ein Grund zum Feiern?

Two hundred years ago the term "psychiatry" (first named "psychiatery") was introduced by Johann Christian Reil in the city of Halle, Germany. With the word's composition Reil demonstrated that psychic disorders belong to the medical domain, which he justified in a long paper explaining why psychiatry must be one of the three major branches of medicine (the others being surgery and pharmacy). Further he emphasized that psychosomatics and medical psychology are part of the comprehensive new discipline psychiatry. He described psychotherapy as an essential treatment for mental and somatic diseases and having equivalence with pharmacological and surgical methods. Johann Christian Reil launched an antistigma campaign and a crusade towards humanization of psychiatric asylums. Two hundred years later psychiatry is well established as a medical discipline and has become self-confident through its self-determination, in spite of certain setbacks and some objectives that have not yet been achieved.

[Mixed affective disorders]. / Gemischt-affektive Störungen.

The Kraepelin concept of "mixed states" has experienced a renaissance over the last two decades. This has been caused by clinical as well as theoretically relevant factors. Of particular clinical relevance is the fact that more than 40% of all patients with bipolar disorders show at least one mixed affective episode during the course of their illness. However, the correct assessment and the precise classification of the symptoms are very important. A diagnosis according to the tight criteria of ICD-10 or DSM-IV, or perhaps based on the moderate Pisa or Cincinnati criteria, is recommended, whereas the use of broader definitions cannot be advised. Mixed schizoaffective episodes are under-diagnosed in comparison to pure affective mixed episodes, although both are defined by ICD-10 as well as by DSM-IV, and the frequency of occurrence is almost the same. Mixed schizoaffective episodes appear to be one of the most severe forms of bipolar disorders. Their clinical relevance is mainly caused by their unfavourable prognosis and difficulty in treatment. Atypical neuroleptics combined with anticonvulsives have proved to be more effective than any other psychopharmacological substances. The occurrence of mixed depressive and manic symptoms during one and the same episode is theoretically important, especially in the sense of their nosological and etiological differentiation.

The role of collagen-derived proteolytic fragments in angiogenesis.

Basement membrane molecules and fragments derived from them are regulators of biological activities such as cell growth, differentiation and migration. This review describes proteolytically derived fragments from the non-collagenous (NC1) domain at the C-terminus of the basement membrane collagens type IV, XV and XVIII, which have been implicated as regulators of angiogenesis. Endostatin is an endogenous collagen XVIII/NC1 derivative, inhibiting endothelial cell proliferation and migration in vitro and tumor-growth in vivo. A homologous NC1 domain fragment of type XV collagen has anti-angiogenic activity as well. Furthermore, NC1 domain fragments of the most abundant basement membrane collagen, type IV collagen, have been shown to inhibit induced vessel growth.

Adult onset of Tourette's syndrome: a case report.

A 45-year-old man fulfilled all DSM-III criteria for the diagnosis of Gilles de la Tourette's syndrome except for early onset of the disease. He first developed tics at age 35 and coprolalia at age 40.

Electroencephalogram alterations during treatment with olanzapine.

RATIONALE: Olanzapine is similar in structure and pharmacology to clozapine. An increased incidence of electroencephalogram (EEG) abnormalities and seizures has been associated with clozapine but not with olanzapine, although isolated cases of seizures under olanzapine have been observed in high-risk patients. OBJECTIVE: To evaluate the frequency of epileptic and non-epileptiform EEG abnormalities during treatment with olanzapine. METHODS: Using a rating scale of demonstrated reliability, 43 EEGs of patients receiving 10-25 mg/day olanzapine in routine treatment were blindly rated and compared with EEG registrations from the same 43 patients with a different medication. RESULTS: There was no difference in epileptiform activity between the conditions with and without olanzapine. However, EEG slowing was significantly more frequent with olanzapine than under the other condition. This difference could not be attributed to concomitant medication. CONCLUSIONS: Although epileptiform activity did not increase under olanzapine, unspecific EEG abnormalities may be more frequent than with use of other neuroleptics. Careful surveillance of patients with risk factors for seizures is advisable. Further studies addressing the frequency and clinical relevance of EEG changes under olanzapine are necessary.

Prognostic value of initial subtype in schizophrenic disorders.

The prognostic value of the subtype diagnosis at the initial episode was investigated in 148 narrowly defined schizophrenic patients. Every initial episode was classified according to multiple criteria: DSM-III-R, ICD-10, the positive/negative dichotomy, and Schneider's first rank symptoms. Patients were followed up on average 23 years later (range 10-50 years). Different aspects of long-term outcome were evaluated (global functioning, social adjustment, negative social consequences). In 93% of the patients persisting alterations were found at the end of the observation time. The influence of the predominant clinical features at the initial episode on various aspects of long-term outcome was found to differ depending on which of the four diagnostic systems was used. The highest power for discrimination was found for the subtypes of DSM-III-R, while the presence of first rank symptoms had no prognostic value. It was found that patients with an initial paranoid or positive episode had a significantly better long-term outcome than patients initially having a disorganised/hebephrenic or catatonic episode. The frequency of negative social consequences was not influenced by the initial subtype, with the exception of permanent hospitalisation.

Validity of the negative/positive dichotomy for schizophrenic disorders under long-term conditions.

A total of 148 patients fulfilling the DSM-III symptomatological criteria of schizophrenia were classified according to Andreasen's criteria of positive, negative and mixed symptomatology. After excluding cases of permanent hospitalisation and patients with monoepisodic course the remaining 100 patients had a total of 458 episodes. Of these episodes, 213 were identified as positive, 134 as negative and 111 as mixed. During the course of illness the proportion of negative episodes increased and the proportion of positive episodes decreased. The great majority of the patients (76%) had a bimorphous course, i.e. one showing both types of schizophrenic symptomatology, positive and negative. Only 6% of the patients had only negative episodes, and only 18% had only positive episodes. The shift from one type of episode to another is dependent on the length of illness. Stability was not greater later during the course of illness than at the beginning.

The relation of "acute and transient psychotic disorder" (ICD-10 F23) to bipolar schizoaffective disorder.

The aim of this work is to investigate differences between acute and transient psychotic disorders (ATPD; F23 of ICD-10) and bipolar schizoaffective disorders (BSAD). In a controlled prospective and longitudinal study, we compared all inpatients with ATPD treated at Halle university hospital during a 5-year period with matched controls with BSAD. Sociobiographical data were collected using a semi-structured interview. Follow-up investigations were performed at a mean of 2.2-3.3 years after the index episode or 8.2-16.1 years after the first episode by means of standardized instruments. ATPD differs significantly from BSAD on various relevant levels, such as gender (more female), age at onset (older), development of the full symptomatology (more rapid), duration of the symptomatology (shorter), acuteness of onset (more acute), preceding stressful life-events (more frequent) and long-term prognosis (better). It is concluded that ATPD and BSAD are different nosological entities.

Clinical genetics of familial keloids.

BACKGROUND: Keloids are proliferative fibrous growths that result from an excessive tissue response to skin trauma. Most keloids occur sporadically, but some cases are familial. However, the genetics of keloid formation have only rarely been documented, and the mode of inheritance is not known. OBJECTIVE: To elucidate the clinical genetic characteristics of keloid wound-healing disorder. OBSERVATIONS: We studied the clinical and genetic characteristics of 14 pedigrees with familial keloids. The ethnicity of these families is mostly African American (n = 10), but also white (n = 1), Japanese (n = 2), and African Caribbean (n = 1). The pedigrees account for 341 family members, of whom 96 displayed keloids. Of the affected family members, 36 are male and 60 are female. The age of onset varies from early childhood to late adulthood. There is variable expression of keloids within the same families: some affected members have only minor earlobe keloids, whereas others have very severe keloids affecting large areas of the body. In the described pedigrees, 7 individuals are obligate unaffected carriers, revealing nonpenetrance in about 6.8% of keloid gene carriers. Syndromes associated with keloids, namely Rubinstein-Taybi and Goeminne syndrome, were not found in these families. Additionally, linkage to the gene loci of these syndromes and X-chromosomal linkage were excluded. CONCLUSIONS: The pattern of inheritance observed in these families is consistent with an autosomal dominant mode with incomplete clinical penetrance and variable expression. This is the most comprehensive collection of keloid families described to date, and it allows for the first time the elucidation of the clinical genetic characteristics of the familial form of this wound-healing disorder.

Origin and development of concepts of bipolar mixed states.

This paper reviews the historical origins of the contemporaneous resurgence of interest in mixed states. This is a classical concept whose origins can be traced back to ancient times. In more modern times, already in the pre-Kraepelinian era we can find descriptions and classifications of "mixed states". For example, in his classification of mental disorders described "mixtures of exaltations and depression", and he distinguished among "mixed mood disorders", "mixed mental disorders", and "mixed volition disorders". Subsequently, (the father of empirical and biological psychiatric research in Germany) described the "mid-forms". Half a century later we encounter the crucial role of Emil Kraepelin and the development and systemization of his views between 1899 and 1913--leading to the characterization of such conditions as "depressive-anxious mania", "excited depression", and "stuporous mania". The remainder of this article focuses on the essential points of the first book on mixed states in the psychiatric literature: On The Mixed States of Manic-Depressive Insanity by. For much of the present 20th century nothing new emerges, followed by a contemporary renaissance of mixed states, particularly in the United States. The paper concludes with proposal of mixed states as temperament intruding into an episode of opposite polarity.

Expanding the group of bipolar disorders.

The concept of bipolar disorder is an ongoing process. Its roots can be found in the work of the ancient Greek physician Aretaeus of Cappadocia, who assumed that melancholia and mania are two forms of one and the same disease; he actually believed that mania was a more severe form of melancholia. Falret [Bull. Acad. Natl. Med., Paris (1851)] and Baillarger [Ann. Méd-psychol. 6 (1854) 369] from France are the fathers of the modern understanding of bipolar disorders. But the definitive distinction of bipolar from unipolar disorders occurred in 1966 by Jules Angst and Carlo Perris in Europe, and later supported by Winokur and colleagues in the United States. Schizoaffective disorders should also be dichotomized into unipolar and bipolar forms. Another extension of the group of bipolar disorders is the contemporaneous rebirth of cyclothymia, originally described in the work of Kahlbaum (1882) and Hecker (1898) [Z. Prakt. Arzte 7 (1898) 6]; the main importance of cyclothymia today is its relevance for what Akiskal [Clin. Neuropharm. 15(1) (1992) 632] considers the realm of the 'soft bipolar spectrum.' A further interesting development is the renewed research in the field of 'mixed states' which originated in the classic Handbook of Kraepelin a century ago (1899).

Bipolarity from ancient to modern times: conception, birth and rebirth.

We review the history of bipolar disorders from the classical Greek period to DSM-IV. Perhaps the first person who described mania and melancholia as two different phenomenological states of one and the same disease was the Greek physician of the 1st century AD, Aretaeus of Cappadocia. The modern concept of bipolar disorders was born in France, with the publications of and. Emil Kraepelin, however, in 1899, unified all types of affective disorders in 'manic-depressive insanity'; in spite of some opposition, Kraepelin's unitary concept was adopted worldwide. In the 1960s, however, the rebirth of bipolar disorders took place through the publications of Jules Angst, Carlo Perris, and George Winokur, who independently showed that there exist clinical, familial and course characteristics validating the distinction between unipolar and bipolar disorders; in addition, they verified several of the corresponding opinions of the Wernicke-Kleist-Leonhard school. The concept of unipolar and bipolar disorders has further advanced in the last three decades: landmark developments include the renaissance of Kraepelin's mixed states and of Kahlbaum's and Hecker's cyclothymia and related affective temperaments, the concept of soft bipolar spectrum (Akiskal), and the distinction of schizoaffective disorders into unipolar and bipolar forms.

Dysthymia and cyclothymia: historical origins and contemporary development.

The aim of this article is to review and put in their historical context today's data, methodologies and concepts concerning subaffective disorders. The historic roots of dysthymic and cyclothymic disorders--part of the subaffective spectrum--are essentially Greek, but the first use of the word 'dysthymia' in psychiatry was by C.F. Flemming in 1844. E. Hecker introduced the term 'cyclothymia' in 1877. K.L. Kahlbaum (1882) further developed the concepts of hyperthymia, cyclothymia and dysthymia--with possible subthreshold symptomatology--in 1882. After Kraepelin's rubric of 'manic-depressive insanity', the term 'dysthymia' was widely forgotten, and 'cyclothymia' became ill defined. Nowadays the latter term is used in three, partially contradictory, senses: (1) a synonym for bipolar disorder (K. Schneider), (2) a temperament (E. Kretschmer) and (3) a subaffective disorder (DSM-IV, ICD-10). A renaissance of subaffective disorders began with the development of DSM-III. Therapeutically important research has focused on dysthymic disorder and its relationship to major depressive disorder, while cyclothymic disorder is relatively neglected; nonetheless, operationalized as a subaffective dimension or temperament, cyclothymia appears to be a likely precursor or ingredient of the construct of bipolar II disorder.

Affective symptoms at index hospitalization in childhood and depressive symptoms in adulthood: a "catch-up" study.

PURPOSE: To analyze whether affective symptoms during psychiatric treatment in childhood or adolescence could predict the later development of depressive symptoms. METHOD: We used a "catch-up" design. A cohort of former child and adolescent psychiatric patients was assessed in adulthood with standardized instruments according to the criteria of ICD-10 (SCAN) and dimensional values for depression (both self-reported and observer-rated). Initial affective symptoms had been extracted from clinical records according to a standardized system (AMDP). RESULTS: We assessed 164 former patients. Twelve percent of these fulfilled diagnostic criteria of an affective disorder (F3) according to ICD-10. In univariate analyses of variance the depression scores were significantly related to affective symptoms during childhood treatment, even if the presence of an affective disorder at catch-up was considered as an independent covariate variable. Nevertheless, the latter variable explained a large part of the variance of depression scores, while initial affective symptoms explained no more than 6%. CONCLUSION: Affective symptoms in childhood and adolescence may predict the later development of subthreshold depressive symptomatology.

Personality disorders in offenders: categorical versus dimensional approaches.

The present study focused on the consequences of cut-off scores in personality disorder diagnoses for their association with criminal behavior. Using ICD-10 personality disorder criteria eliminating offence-related symptoms, we studied the distributions of categorically diagnosed personality disorders and of dimensional personality disorder scores in a group of offenders and a noncriminal control group. Whereas the dimensional scores of the offender group differed significantly from those of the control group for all personality disorders under study, the frequency of categorical diagnoses differed significantly for two personality for two personality disorders only. Moreover, prediction of group membership (offenders vs. nonoffenders) from personality disorder scores was substantially more precise than prediction from categorical diagnoses. It is concluded that a dimensional approach to personality disorder diagnosis is not only superior theoretically but also yields more precise information about the specific associations with criminal behavior.

The relationship between five-factor personality measurements and ICD-10 personality disorder dimensions: results from a sample of 229 subjects.

This article examines the relationship between the five-factor model (FFM) and dimensional ICD-10 personality disorders. In a follow-up study of a child and adolescent psychiatric cohort, former patients and controls were assessed with NEO-FFI and the IPDE interview (CD-10 personality disorder). Full data were available for 229 subjects (149 former patients, 80 controls). Multiple regression analysis showed that the five factors of the FFM as independent variables explained between 5% (schizoid personality disorder) and 32% (anxious personality disorder) of the variance of ICD-10 dimensional personality disorder scores. For the two types of emotionally unstable personality disorder dimension (impulsive and borderline), for anxious (avoidant) personality disorder dimension and for the total score of any personality disorder dimension, FFM explained between 17% and 32% of the variance with almost identical results for the former patient group and the control group. High neuroticism was a feature of paranoid, emotionally unstable, histrionic, anankastic, anxious (avoidant), and dependent personality disorder dimensions, whereas low agreeableness was found in dissocial, emotionally unstable and histrionic personality disorder dimensions. Low extraversion was found in schizoid, anxious (avoidant) and dependent personality disorder dimensions, whereas histrionic PD dimension correlated with high extraversion. We find that the FFM is valuable for the further understanding not only of DSM-IV but also of ICD-10 personality disorder dimensions. The differences between ICD-10 and DSM-IV in this respect seem to be small.

What becomes of children hospitalized for enuresis? Results of a catch-up study.

BACKGROUND: . The purpose of this study was to reassess former child and adolescent psychiatric patients with nocturnal enuresis as young adults and to compare them with former patients without enuretic symptoms and with a comparison group from the general population. METHOD: We used a 'catch-up' design. From a former child and adolescent psychiatric patient cohort we identified all subjects with documented enuretic symptoms in childhood and compared them with two groups matched for gender and age - non-enuretic patients and a comparison group from the general population. Subjects were assessed as adults with standardized instruments according to the criteria of ICD-10 (SCAN, IPDE) and dimensional values for depression, satisfaction with life, global functioning and personality (NEO-FFI). RESULTS: We assessed 55 former patients with nocturnal enuresis (recruitment rate 68%) after a mean interval of 13.1 years. At catch-up the former enuretic patients had a lower frequency of personality disorders (ICD-10), lower mean depression values, higher global functioning and a lower rate of psychiatric treatment after the age of 18 years than did former non-enuretic patients. Former enuretic patients did not differ significantly from the comparison group from the general population concerning any of the outcome variables, although there was a non-significant trend for former enuretic patients to more often fulfill criteria for a psychiatric ICD-10 diagnosis at catch-up. There were no differences concerning personality among the three groups at catch-up. CONCLUSION: Although it may constitute a mild vulnerability factor for further development, nocturnal enuresis had a good long-term outcome in a cohort of treated subjects.

[Habitual shoplifting in multi-infarct syndrome]. / Habitueller Ladendiebstahl bei Multiinfarktsyndrom.

The authors report on a 59-year-old male who repeatedly had been apprehended for shoplifting. The behavior only started after he had suffered multiple ischemic strokes. The deviant behavior is explained as a consequence of frontal lobe lesions leading to behavioral disinhibition. Criminal responsibility had to be denied.

[Homicides--the sociodemographic background of the offender and the behavioral symptoms]. / Tötungsdelikte--soziodemographischer Hintergrund der Täter und tatspezifische Merkmale.

The authors examined 261 forensic-psychiatric reports to determine whether persons convicted of criminal homicide differed from persons convicted of other crimes with regard to personal biography, sociodemographic milieu, and character traits. Both groups were found to come from similarly disadvantaged social backgrounds. Murderers could not be distinguished on the basis of biographical data alone. The parameters found to be distinctive of murderers were: site of the crime, criminal-victim relationship, motive for the act, intoxication at the time of the crime, and the perpetrator's opinion regarding the purpose and intent of the homicide. The present findings confirm some of the results obtained by other authors on this topic.

Brief and acute psychoses: the development of concepts.

This paper reviews the conceptual history of brief and acute psychoses. As psychotic disorders of usually dramatic symptomatology but nevertheless with a usually benign course, brief and acute psychoses have the air of a paradox. Thus, they have posed specific problems in regard to nosology, diagnostics and aetiology. Despite a strong convergence of the descriptive elements, the historical concepts of brief and acute psychoses have yielded different answers to the questions raised. Kahlbaum and Kraepelin set the stage on which brief and acute psychoses appeared "atypical". The concept of "bouffée délirante" used degeneration theory as a background for nosological and aetiological allocation. Similarly, the concepts of cycloid psychoses, reactive (psychogenic) psychoses, emotional psychoses and atypical psychoses have provided diverging but interrelated ways to delineate brief and acute psychoses, to determine their nosological status and to explain the coexistence of severe disorder and favourable prognosis. Modern classifications, namely the acute and transient psychotic disorder of ICD-10 and the brief psychotic disorder of DSM-IV, reflect the varied history of the concept.