[Thoughts on Hungarian Forensic Psychiatric Expertise. Interview with professor László Tringer on his 80th birthday].

Professor László Tringer, on the occasion of his 80th birthday, will revive his almost half a century experience in the field of Hungarian forensic psychiatry (since 1970) as an expert witness, as well as the memorable events of his work in this field. The activities of Medical Research Council Justice Committee (MRC JC), the inflation of psychiatric diagnoses and the question of expert objectivity are also discussed.

DO PREVIOUS OFFENCES PREDICT VIOLENT ACTS IN PSYCHIATRIC PATIENTS? A RETROSPECTIVE STUDY IN HUNGARY.

AIM: To investigate the presence of offences in the previous past history of perpetrators of violent acts who have undergone forced medical treatment. METHODS: The documentation of all patients released over a 10-year period from the National Institute of Forensic Psychiatry (IMEI) was reviewed. A comparison was drawn between patients who were convicted of any type of offense before the violent act (patients with previous offences-PPO) and those who were not (patients with no previous offences-PNO). RESULTS: Eighty-six (29%) and 208 (71%) patients formed the PPO and PNO groups, respectively. Prior contact with psychiatric services was significantly higher in the PPO group (p=0.038) and this group was also more likely to offend under the influence of a psychoactive substance (p<0.001). Exceptional brutality and other qualifying factors were more frequent in the PNO group (p=0.019). CONCLUSION: As IMEI is the only forensic institution in Hungary, the picture presented here reflects the situation in the entire country. A recidivism rate of 29% is within the internationally published range.

[How could forensic psychiatry be made more attractive?] / Hogyan lehetne az igazságügyi pszichiátriát vonzóbbá tenni?

INTRODUCTION: Decrease in the number of forensic psychiatric experts recently reached a critical level. Shortage of forensic experts caused difficulties in the health care as well as in the justice system. OBJECTIVE: Surveying of how the field of forensic psychiatry and the forensic psychiatric expert work can be made more attractive. METHOD: We performed an online survey among forensic psychiatric experts and specialists in psychiatry. We complied a questionnaire that beside demographic data contained questions in 4 areas. The first 2 areas of the questionnaire - simplifying the forensic psychiatry training (10 items), decreasing the cost of the forensic psychiatry training (5 items) - consisted of simple tatements. Responders had to indicate on a 10-point Likert scale their level of agreement. In the last 2 areas, participants were asked to describe in unstructured format whether they see any circumstance that makes forensic psychiatry attractive or unattractive. The questionnaire was sent out in electronic form to the forensic psychiatric experts on the mailing list of the Hungarian Forensic Expert Chamber, and all specialists in psychiatry on the mailing list of the Hungarian Medical Chamber. RESULTS: Altogether 171 persons filled in the questionnaire with a mean age of 57.26 ± 11.57 years. There were 122 (71.3%) females among the participants. The following proposals received the highest ratings from the forensic psychiatric experts as well as from the specialists in psychiatry: increasing the number of the training institutes; decreasing the costs of the training; making the Hungarian Forensic Expert Chamber course free of charge; and introducing a stipend to cover the costs of the training. DISCUSSION: Results of the survey indicate that active forensic psychiatric experts and specialists in psychiatry representing a potential professional resource, concur that forensic psychiatry training can be made more attractive mainly with increasing the number of training institutes and decreasing the total costs of the training which is compiled from different constituents. CONCLUSION: Due to the critical lack of necessary professionals, urgent action is needed to make forensic psychiatry more popular and the forensic psychiatry qualification easier to obtain. Orv Hetil. 2023; 164(35): 1373-1380.

[Relationship between schizophrenia and criminal behavior]. / A szkizofrénia és a bünelkövetés kapcsolata.

Referring to the scientific literature the authors analyze the correlation between criminal offense and psychiatric disorders. Frequency of violent behaviour in schizophrenia together with the risk factors are reviewed. The issue of violent offense is separately discussed. Impact of deinstitutionalization on offense is also analyzed. Results regarding the genetic correlations are also reviewed. Finally the question of re-offending is discussed. In summary the importance of this issue in stigmatization and in the development of the mental health care system is highlighted.

Convulsive therapy turns 75.

The Hungarian psychiatrist Laszlo Meduna was the first who induced epileptic fits to influence the course of mental illness. The following account, based on a review of Meduna's recently unearthed files and his writings, traces the beginnings of convulsive therapy.

László Meduna's pilot studies with camphor inductions of seizures: the first 11 patients.

In his autobiography, László Meduna described the first session of convulsive therapy using intramuscular camphor as occurring on January 23, 1934 at Royal National Hungarian Institute of Psychiatric and Neurology at Budapest-Lipótmezo in Hungary. Unearthed records of the patients treated at this institution reveal that Meduna's dose-finding experiments began on January 2, 1934. The symptomatology and history of illness, diagnosis, socio-demographic data, the seizure characteristics, and immediate and long term outcomes of the first 11 patients are described. These first trials elicited seizures in less than half the injections. Seizures of various durations (including missed seizures) and double (tardive) seizures were recorded. Mutism, refusal to eat requiring tube feeding, and other signs of catatonia dominated the psychopathology of 7 of the first 11 patients. Two improved sufficiently to be discharged from the hospital and third patient became fit for occupational therapy. These records exhibit the meticulous systematic nature of the first human trials with induced seizures and the fortuitous nature of the first human trials with induced seizures and the fortuitous nature in patient selection of catatonic patients--an illness that is most responsive to induced seizures.

The beginnings of modern psychiatric treatment in Europe. Lessons from an early account of convulsive therapy.

Convulsive therapy (COT) is a major European contribution to the psychiatric armamentarium and biological psychiatry. COT was introduced in psychiatry by László Meduna, a Hungarian neuropsychiatrist. All subsequent publications about the first patient treated with COT, Zoltán L (ZL), were based on Meduna's papers and autobiography. After 4 years of catatonic stupor, ZL received camphor-induced COT which resulted in full remission and discharge from the institution. The aim of this paper is to reconstruct ZL's case history from the original case notes--partly written by Meduna himself--which were recovered from the archives of the National Institute of Psychiatry and Neurology. The case notes show that ZL repeatedly received COT between 1934 and 1937, first with camphor and then with cardiazol induction. After the first course of COT the catatonic stupor was resolved and the psychotic symptoms subsided. However, the remission lasted for only a few months and was followed by a relapse. Despite repeated courses of COT, ZL never became symptom free again, was never discharged and died in the Institute in 1945. This historical case is discussed from both the diagnostic and therapeutic points of view, and an attempt is made to explain the possible reasons for the discrepancies found between Meduna's account and ZL's case notes.

Károly Schaffer and his school: the birth of biological psychiatry in Hungary, 1890-1940.

In the first third of the twentieth century, neuropathology seemed to offer the key to unlock the causes of psychiatric illness. Among the top centers devoted to the microscopic anatomy of the brain was that of Károly Schaffer in Budapest. Schaffer, a pioneer in the histopathology of Tay-Sachs-Schaffer disease, was also a charismatic teacher, bringing forth a school of investigators in psychopathology. Among them was László Meduna, who originated convulsive therapy. Despite the importance of the Schaffer school, it is almost unknown outside of Hungary, largely the result of the introduction of neurophysiological, neurochemical and molecular genetic methods that distracted attention away from histopathological contributions in psychiatry after the Second World War. The microscopic study of the brain and its diseases seemed increasingly less important. The present biographical account of Károly Schaffer and his school seeks to bring this important story in the early history of biological psychiatry to a wider audience and explain why it has since been forgotten.

[The birth of biological therapy in Hungary: the story of László Meduna's first patient receiving convulsive therapy]. / Biológiai terápia születése Magyarországon: Meduna László "elsô" görcskezelt betegének története.

Convulsive treatment was introduced to psychiatry by László Meduna, a Hungarian neuropsychiatrist. In his autobiography, Meduna gave a detailed description of his first patient who underwent convulsive therapy. According to Meduna's recollections, this patient was L. Zoltán, who after 4 years of fluctuating catatonic stupor received several sessions of camphor-induced convulsive therapy resulting in full remission and discharge from the institution. In this communication, the authors reconstruct L Zoltán's case history from the original case notes, which were recovered from the Archives of the National Institute of Psychiatry and Neurology, Budapest. The case notes show that L. Zoltán received courses of convulsive treatment between 1934 and 1937, first induced with camphor and then with cardiazol. After the first course of treatment the catatonic stupor was resolved and the psychotic symptoms subsided. However, this incomplete remission lasted only for a few months and was followed by a relapse. Despite further courses of convulsive therapy, L. Zoltán never became symptom free again, could never be discharged and died in the institute in 1945. The authors attempt to explain possible reasons for the discrepancies found between Meduna's account and L. Zoltán's case notes.

[Neuropsychiatric symptoms caused by mefloquine (report of several cases)]. / A mefloquin okozta neuropszichiátriai tünetegyüttesek (néhány eset alapján).

INTRODUCTION: The number of Hungarian citizens travelling to countries infected with malaria is increasing year by year. Mefloquine is the most effective medicine in the prophylaxis and treatment of malaria. However, neuropsychiatric side-effects can more often be seen with the use of mefloquine compared to other anti-malaria drugs. AIMS: To assess the neuropsychiatric side-effects with mefloquine prophylaxis; to screen those patients who are possibly affected by the side-effects and to explore factors that forecast the possible side-effects. METHOD: The retrospective analysis of patients, who in the past 2 years, have had mefloquine prophylaxis and then turned up at Semmelweis University, Department of Psychiatry and Psychotherapy and at Szent László Hospital, Outpatient Department of Psychiatry and Addictology because of neuropsychiatric symptoms. RESULTS: Out of the 6 cases presented, whose neuropsychiatric symptoms ranged from slight dizziness, malaise through panic attacks and depression to psychosis, the preceeding psychiatric condition was positive in 4 cases. Even the most serious psychiatric symptoms disappeared within a few days using temporary drug-treatment. In those cases in whom the side-effects were more serious, a positive psychiatric history or a more sensitive personality differing from the average was established. CONCLUSIONS: Because of the low number of cases it is not possible to draw a general conclusion. After analysis of the data the authors assume, that besides the psychiatric history, the premorbid personality can also be a factor that forecasts the possible neuropsychiatric side-effects caused by mefloquine prophylaxis.

Predictors of suicide attempts after violent offences in schizophrenia spectrum disorders.

The aim of this survey was to identify predictors of suicide attempts that immediately followed a violent crime in patients with schizophrenia. Documentations of patients diagnosed with schizophrenia and released in a 10 years period from the National Institute of Forensic Psychiatry were reviewed. Twenty-six out of 223 patients attempted suicide after the violent crime. The young age of the victim, and living in partnership were those factors differentiating suicidal violent offenders from their non-suicidal counterparts.

Anxiety in epilepsy--based on two case reports.

There are a great number of psychopathological symptoms which manifest themselves in 70-75% of epileptic patients but most of them remain unrecognised and untreated. These symptoms may affect the patients' quality of life more negatively than the epileptic seizures themselves. Anxiety is one of the most frequently occurring interictal psychopathological symptom. A number of specialists agree that chronic epilepsy causes the amplification of endogenic seizure suppressing mechanisms which hinder the epileptic seizures and are responsible for the development of interictal psychopathological symptoms. However the physiological effects of the interictal psychopathological conditions (e.g. anxiety) have epileptogenic effect as well. There is a high chance that the conditions of epilepsy and anxiety will mutually create a destructive vicious circle and it will be illustrated by our two case reports. In our experience, before modifying the pharmacotherapy of a patient suffering from chronic epilepsy with increased frequency of seizures, the anxiety level should be defined; and if it is high it should be treated first. From our perspective, the so-called "rational bitherapy" is very effective when a high potential antiepileptic drug is combined with an anxiety reducing method. The latter can be drug related or consists only of psychotherapy. We need more controlled clinical research to prove that inside epilepsy there are risk groups as well as conditions of high risk when the connection between anxiety and epilepsy is more than evident. The described cases seem to indicate that the existence of periictal anxiety can be a risk factor in developing later interictal anxiety.

[Utility of electroshock therapy in epilepsy-associated psychosis]. / Az elektrosokk-kezelés alkalmazhatósága epilepsziához társuló pszichózisban.

Psychiatric disorders which indicate the use of electroconvulsive therapy (ECT) also occur in epileptic patients, but there is a lack of medical authority concerning the use of ECT in epileptic patients. This is surprising because in recent years it has been proved that ECT has an anti-convulsive effect to some degree. A case study of an epileptic patient is presented whose progress has been monitored for several years. Antiepileptic drugs were seemingly able to control his epilepsy but at the same time progressive behavioural disturbance (schizophreniform psychosis) accompanied by agitation and violent behaviour developed. Considering the recurrent psychotic decompensations and the relative ineffectiveness of antipsychotics, the authors decided to administer ECT. As a result they were able to bring about the longest symptom free balanced period in the patient. According to the data based on previous medical studies and the experience they can suppose that ECT is not immediately contraindicated by the presence of epilepsy with active interictal focus if the psychopathological condition makes it necessary. In view of the epileptogenic risk factors of classical neuroleptics, the epileptogenic effects of accompanying psychosis and the probable anticonvulsive potential of ECT in cases of severe psychiatric complications accompanying epilepsy ECT could be used more frequently.

The birth of convulsive therapy revisited: a reappraisal of László Meduna's first cohort of patients.

BACKGROUND: The introduction of convulsive therapy (COT) was undoubtedly one of the milestones in the history of psychiatry. Its originator, László Meduna, has become one of the founding fathers of biological psychiatry. METHODS: In his first major publication on COT, Meduna described the short-term treatment outcome of the first 26 schizophrenia patients who underwent camphor- or cardiazol-induced COT; 10 improved significantly, 3 appeared slightly improved, and 13 were unimproved. The original medical notes of 23 of the 26 patients were recently recovered and the patients re-diagnosed by the authors employing ICD-10 criteria. RESULTS: The diagnosis of schizophrenia was confirmed in 15 cases (all but two of them involving prominent catatonic symptomatology), while 2 cases met diagnostic criteria for schizoaffective disorder, 3 for Bipolar Affective Disorder (BAD) with psychotic features, 1 for psychotic depression, and 1 for Acute and Transient Psychotic Disorder (ATPD). In a final case, the most probable diagnosis was schizophrenia. Scrutiny of the notes revealed that 4 schizophrenia patients evidenced slight improvement on COT and in one case the improvement was only transient. A limitation of this study is that the quality of the original files varied considerably and the re-evaluation was done retrospectively. CONCLUSIONS: A very broad concept of schizophrenia in the 1930s explains the discrepancy between the original and the revised results. In line with the current views on the effectiveness of electroconvulsive therapy, catatonic symptoms, but not the core schizophrenic process, showed some improvement while all ATPD, BAD and depressed patients responded to COT.

The history of Lipótmezö, the site of the first convulsive therapy.

The National Institute of Psychiatry and Neurology, better known as "Lipót," where convulsive therapy was first performed by László Meduna in 1934, is an important site in the history of biological psychiatry. In the first half of the article, the circumstances regarding the foundation of the Institute and its first 60 years are reviewed. Meduna's achievements, the theoretical foundation of convulsive therapy, and its realization as an effective therapy are described. Finally, the latest 70 years of the Institute will be briefly reviewed, with special emphasis on the events of the last few months of 2007 in which the institution has been closed.

Regressive and intensive methods of electroconvulsive therapy: a brief historical note.

In the 1940s, regressive and intensive methods were developed to increase the therapeutic effects of electroconvulsive therapy. The diagnostic indications, methods of application, effectiveness, complications, and mortality of these techniques are briefly discussed here. An attempt is also made to evaluate the risks and benefits of these methods from a historical perspective.

O advento do tratamento psiquiátrico moderno: a terapia convulsiva de László Meduna / Lessons from an early account of convulsive therapy

A terapia convulsiva (TC) constitui uma das principais contribuições européias ao tratamento psiquiátrico moderno e à psiquiatria biológica. A TC foi introduzida na psiquiatria em 1934 por László Meduna, neuropsiquiatra húngaro. As publicações subseqüentes sobre o primeiro paciente tratado com TC, Zoltán L (ZL), baseiam-se nos artigos e na autobiografia de Meduna. De acordo com essas referências, após quatro anos de estupor catatônico, ZL recebeu TC induzida por cânfora que resultou em plena remissão dos sintomas esquizofrênicos, culminando com alta da instituição. Este artigo reconstrói a história do caso de ZL a partir da recente recuperação de anotações - algumas escritas pelo próprio Meduna - dos Arquivos do Instituto Nacional de Psiquiatria e Neurologia (Hungria). Essas anotações mostram que ZL recebeu repetidas sessões de TC entre 1934 e 1937, primeiramente induzidas por cânfora e depois por cardiazol. A primeira série de TC resultou na suspensão do estupor catatônico e na remissão parcial da psicose. Entretanto, a remissão foi breve e, a despeito de repetidas sessões de TC, ZL nunca esteve inteiramente livre de sintomas, nunca teve alta hospitalar e veio a falecer no Instituto em 1945. Na discussão do caso de ZL, tentamos explicar as possíveis razões das discrepâncias entre o relato de Meduna e as notas originais do prontuário médico.

Convulsive therapy (COT) is a major European contribution to the psychiatric armamentarium and biological psychiatry. COT was introduced in psychiatry by László Meduna, a Hungarian neuropsychiatrist. All subsequent publications about the first patient treated with COT, Zoltán L (ZL), were based on Meduna's papers and autobiography. After 4 years of catatonic stupor, ZL received camphor-induced COT which resulted in full remission and discharge from the institution. The aim of this paper is to reconstruct ZL's case history from the original case notes-partly written by Meduna himself-which were recovered from the archives of the National Institute of Psychiatry and Neurology. The case notes show that ZL repeatedly received COT between 1934 and 1937, first with camphor and then with cardiazol induction. After the first course of COT the catatonic stupor was resolved and the psychotic symptoms subsided. However, the remission lasted for only a few months and was followed by a relapse. Despite repeated courses of COT, ZL never became symptom free again, was never discharged and died in the Institute in 1945. This historical case is discussed from both the diagnostic and therapeutic points of view, and an attempt is made to explain the possible reasons for the discrepancies found between Meduna's account and ZL's case notes.