[The Role of Gut Feeling as an Alarm Signal for Identifying Misdiagnoses in the Psychosomatic Consultation]. / Der Stellenwert des Bauchgefühls als Warnsignal für Fehldiagnosen im Psychosomatischen Konsil.

BACKGROUND: A psychosomatic consultation service offers an opportunity to correct misdiagnoses. The doctor's non-analytical, experience-based gut feeling plays an essential role as diagnostic trailblazer. METHODOLOGY: In a case series study, the procedures of 165 psychosomatic consultations and the emotional and cognitive processes occurring in the consultant were recorded. The diagnostic process was analysed with reference to the dual process theory. With gut feeling, a distinction was made between a sense of alarm and a sense of reassurance. As an example, the processes that led to the discovery of misdiagnoses were presented at four consultations. RESULTS: A misdiagnosis was found in 24 consultations (16%). The reason for this was always a sense of alarm, which appeared in 29 of 165 consultations (18%). In 11 consultations (7%) there was a sense of reassurance, which in ten consultations was associated with a confirmation of the diagnosis and only in one case gave way to a sense of alarm and led to a later correction of the diagnosis. CONCLUSIONS: Paying attention to gut feeling and its sense of alarm is an effective method of recognizing misdiagnosis. Training programs should not only promote rational-analytical thinking, but also the doctor's self-critical introspection skills.

[Clozapine in the Treatment of Schizophrenic Psychosis: Patient Characteristics and Antipsychotic Combinations in One Cohort at a Psychiatric Care Hospital]. / Clozapin in der Behandlung schizophrener Psychosen Patientencharakteristika und antipsychotische Kombinationstherapien bei einem Behandlungsjahrgang eines psychiatrischen Versorgungskrankenhauses.

BACKGROUND: In many studies, clozapine has been reported to have superior effectiveness compared to other antipsychotics. So far there is little systematic data on the practice of clozapine prescription and characteristics of patients treated. METHOD: Retrospective evaluation of all 392 treatment courses of inpatients with schizophrenic psychoses during one year. Detailed analysis of the patients treated with clozapine including the dosages and additional psychotropic medication. RESULT: Patients treated with clozapine showed a higher disease severity than patients without clozapine. They received more frequently pharmacological combination therapies, which in some cases significantly contradicted the current guideline recommendations. CONCLUSION: The results underline the pronounced disease severity of patients receiving clozapine treatment and substantiate evidence from the literature on the limited implementation of guidelines in prescribing practice. The study carried out serves as a pilot survey of a multicenter research project on the practice of prescribing clozapine in psychiatric hospitals in different German regions.

[The Intensive Psychiatric Care Unit at a Hospital with Maximum Care - An Analysis of Treatment Variables in the Therapy of Psychiatric and comorbid Somatic Disorders]. / Die psychiatrische Intensivstation an einer Klinik der Supramaximalversorgung ­ Analyse der Behandlungsvariablen aus der Therapie Psychiatrischer und Komorbider Somatischer Erkrankungen.

ZIEL DER STUDIE UND METHODIK: Alle 873 Behandlungsakten einer psychiatrischen Intensivstation aus einem Zeitraum von 5 Jahren gingen in eine Analyse des Patientenkollektivs, des Behandlungsoutcomes und von Prädiktoren für die stationäre Behandlungsdauer ein. ERGEBNISSE UND SCHLUSSFOLGERUNG: Auf der beschriebenen Station wurden sowohl Patienten mit psychiatrischen Notfallsyndromen als auch Patienten mit komorbiden psychischen und somatischen Erkrankungen behandelt. Somatische Zusatzerkrankungen beeinflussen den stationären Behandlungsverlauf psychisch Erkrankter erheblich, z. B. durch eine um durchschnittlich 2,4 Wochen kürzere intensivpsychiatrische stationäre Behandlungsdauer bei häufiger Notwendigkeit (41,3%) einer stationären, z. B. rehabilitativen Anschlussbehandlung. Die Stationsauslastung von 110 % und die durchschnittliche Behandlungsdauer von 63 Tagen deuten auf einen hohen Bedarf an interdisziplinären psychiatrisch-somatischen Behandlungsmöglichkeiten hin. In Zukunft ist ein Zusammenwachsen von Psychiatrie und somatischer Medizin anzustreben. Untersuchungen zu Versorgungssituation und Wirtschaftlichkeit interdisziplinärer Behandlungsangebote stehen aus. BACKGROUND AND METHOD: All 873 medical files of psychiatric inpatients treated over a 5 year period at a psychiatric intensive care unit were analyzed in regard to characteristics of the patient group, outcome and predictors for the length of stay. RESULTS AND CONCLUSIONS: Patients with psychiatric emergency syndromes and patients with comorbid psychiatric and somatic disorders were treated on the described unit. Somatic comorbidities have a considerable effect on the course of treatment for patients with psychiatric disorders. They have to receive stationary treatment for a shorter period (2.4 weeks) but often need further stationary, e. g. rehabilitative treatment. The utilization of this specific unit (110%) and the above average length of stay (63 days) point to an increasing need in inpatient treatment capacities for patients with psychiatric and somatic comorbidities. In future a growing together of somatic medicine and psychiatry in Germany is worthwhile. The evaluation of the treatment situation and aspects of cost effectiveness are yet to come.

The overnight reduction of amyloid ß 1-42 plasma levels is diminished by the extent of sleep fragmentation, sAPP-ß, and APOE ε4 in psychiatrists on call.

INTRODUCTION: In mice there might be an association between sleep deprivation and amyloid ß plasma levels. Hence, we examined whether amyloid plasma levels are associated with sleep duration or fragmentation in 17 psychiatrists on-call. METHODS: Amyloid ß (Aß)42, Aß40, and soluble amyloid precursor protein ß (sAPP-ß) plasma concentrations were measured at the beginning and end of 90 on-call nights, and analyzed using generalized linear models. RESULTS: In on-call nights, a 10.7% reduction of Aß42 was revealed overnight. Every single short sleep interruption diminished this reduction by 5.4%, as well as every pg/mL of sAPP-ß by 1.2%, each copy of APOE ε4 by 10.6%, and each year of professional experience by 3.0%. DISCUSSION: The extent of sleep fragmentation diminishes the physiological overnight reduction of Aß42 but not Aß40 plasma levels in the same direction as the enzyme for Aß42 production, the genetic risk factor for Alzheimer's disease (AD), and on-call experience. Might on-call duty and sleep fragmentation in general alter the risk for AD?

[How do employees of psychiatric hospitals evaluate medical ethical conflicts in coercive measures]. / Wie bewerten Mitarbeiter einer psychiatrischen Klinik medizinethische Konflikte bei Zwangsmaßnahmen.

BACKGROUND: The practice of coercive treatment in psychiatric hospitals raises numerous medical, juridical and ethical questions. Moreover, coercive measures lead to the contradiction of certain medical ethical principles. We examined the attitudes of psychiatric hospital employees towards ethical conflicts in medicine and asked them how they decide for or against coercive measures through the help of a hypothetical case. METHOD: In a questionnaire, 73 psychiatric hospital employees of various professions were asked about their attitudes towards several ethical conflicts in medicine. They were requested to decide for or against the use of coercive measures in the case of a hypothetical patient suffering from schizophrenia. RESULTS: The majority of the respondents agreed that in conflicts between principles of medical ethics the focus of treatment should be on the wellbeing of the patient (89 %) rather than on that of society (11 %). They also favored the principle of autonomy (58 %) over paternalism (42 %). The principle of nonmaleficence appeared to be equally important as beneficence (51 % vs. 49 %). Less invasive coercive measures (assistance through a person in charge) were preferred to more invasive ones (coercive medication), as our case vignette showed. There were no highly significant correlations found between sociodemographic factors (taking work experience and profession into account), judgement about medical ethical conflicts and the decision for or against coercive treatment. Both employees of closed wards with mid-long work experience (6-15 years) as well as nursing staff were more likely to choose coercive treatment. No statistically significant correlation could be determined between the preference of medical ethical principles and decisions about coercive treatment. CONCLUSION: Coercive treatment leads to ethical conflicts in medicine. The impact of such conflicts on the application of coercive measures through employees of psychiatric hospitals should be further explored and examined.

Changes in extra-striatal functional connectivity in patients with schizophrenia in a psychotic episode.

BACKGROUND: In patients with schizophrenia in a psychotic episode, intra-striatal intrinsic connectivity is increased in the putamen but not ventral striatum. Furthermore, multimodal changes have been observed in the anterior insula that interact extensively with the putamen. AIMS: We hypothesised that during psychosis, putamen extra-striatal functional connectivity is altered with both the anterior insula and areas normally connected with the ventral striatum (i.e. altered functional connectivity distinctiveness of putamen and ventral striatum). METHOD: We acquired resting-state functional magnetic resonance images from 21 patients with schizophrenia in a psychotic episode and 42 controls. RESULTS: Patients had decreased functional connectivity: the putamen with right anterior insula and dorsal prefrontal cortex, the ventral striatum with left anterior insula. Decreased functional connectivity between putamen and right anterior insula was specifically associated with patients' hallucinations. Functional connectivity distinctiveness was impaired only for the putamen. CONCLUSIONS: Results indicate aberrant extra-striatal connectivity during psychosis and a relationship between reduced putamen-right anterior insula connectivity and hallucinations. Data suggest that altered intrinsic connectivity links striatal and insular pathophysiology in psychosis.

Aberrant topology of striatum's connectivity is associated with the number of episodes in depression.

In major depressive disorder, depressive episodes reoccur in ∼60% of cases; however, neural mechanisms of depressive relapse are poorly understood. Depressive episodes are characterized by aberrant topology of the brain's intrinsic functional connectivity network, and the number of episodes is one of the most important predictors for depressive relapse. In this study we hypothesized that specific changes of the topology of intrinsic connectivity interact with the course of episodes in recurrent depressive disorder. To address this hypothesis, we investigated which changes of connectivity topology are associated with the number of episodes in patients, independently of current symptoms and disease duration. Fifty subjects were recruited including 25 depressive patients (two to 10 episodes) and 25 gender- and age-matched control subjects. Resting-state functional magnetic resonance imaging, Harvard-Oxford brain atlas, wavelet-transformation of atlas-shaped regional time-series, and their pairwise Pearson's correlation were used to define individual connectivity matrices. Matrices were analysed by graph-based methods, resulting in outcome measures that were used as surrogates of intrinsic network topology. Topological scores were subsequently compared across groups, and, for patients only, related with the number of depressive episodes and current symptoms by partial correlation analysis. Concerning the whole brain connectivity network of patients, small-world topology was preserved but global efficiency was reduced and global betweenness-centrality increased. Aberrant nodal efficiency and centrality of regional connectivity was found in the dorsal striatum, inferior frontal and orbitofrontal cortex as well as in the occipital and somatosensory cortex. Inferior frontal changes were associated with current symptoms, whereas aberrant right putamen network topology was associated with the number of episodes. Results were controlled for effects of total grey matter volume, medication, and total disease duration. This finding provides first evidence that in major depressive disorder aberrant topology of the right putamen's intrinsic connectivity pattern is associated with the course of depressive episodes, independently of current symptoms, medication status and disease duration. Data suggest that the reorganization of striatal connectivity may interact with the course of episodes in depression thereby contributing to depressive relapse risk.

Obstructive Sleep Apnea Among Patients with Mild Cognitive Impairment.

Background: Obstructive sleep apnea (OSA) is associated with cognitive disorders, but little is known about prevalence of co-occurring OSA and mild cognitive impairment (MCI) as well as about co-occurring OSA and Alzheimer's disease (AD). Pathophysiological models integrating OSA, cognitive deficits and neurodegeneration remain speculative. Findings in this area could contribute to the knowledge about pathophysiological processes in cognitive disorders and neurodegenerative processes, be helpful for the diagnosis of cognitive disorders and provide approaches for the treatment of cognitive disorders. Objective: Examining the prevalence of OSA and patterns of cognitive deficits as well as AD biomarker profiles associated with OSA in a cohort of 104 MCI patients. Methods: Assessments used include: respiratory polygraphy, The Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Battery (CERAD NB), Tau, phosphoTau181, amyloid-ß-1-42/1-40, 18F-fluorodeoxyglucose positron emission tomography (F18-FDG-PET). Results: Prevalence of OSA of any severity: 58,7% (Apnea Hypopnea Index (AHI)≥5/h), OSA in a moderate-to-severe extent (AHI≥15/h): 25%. Only 13.1% of MCI patients with OSA reported daytime sleepiness. MCI-OSA patients showed no specific neuropsychological pattern. Presence of OSA was not associated with specific AD biomarker profiles in the whole study group besides a positive association between AD positivity in an AD biomarker sub cohort. Conclusions: OSA is highly prevalent in patients with MCI. It might often remain undiagnosed as only a small number of MCI-OSA patients report daytime sleepiness. OSA could contribute to MCI symptoms and even to AD pathology. Further research is needed to validate these findings and to investigate possible pathophysiological relationships between OSA and MCI as well as between OSA and AD.

[Insomniac symptoms and suicidality-link and management]. / Insomnische Symptome und Suizidalität ­ Zusammenhänge und Management.

BACKGROUND: A link between insomniac symptoms and suicidality has long been suspected and deserves specific attention. OBJECTIVE: We examine the current evidence for this relationship from epidemiology and neurobiology in order to propose a targeted management. MATERIAL AND METHOD: Clinical example and selective Medline-literature research for insomnia symptoms and suicidality. RESULTS: Epidemiological data and statistical analysis show that symptoms of insomnia are independent risk factors for suicidality. Neurobiological factors associated with combined insomnia symptoms and suicidality are: serotonergic dysfunction and circadian rhythm disorder leading to hypofrontality with reduced problem solving capacity and impaired emotional and impulse-control. Social isolation, recurrent rumination, comorbid psychiatric disorders, access to potentially lethal drugs or weapons need urgent evaluation in patients with a combination of suicidality and symptoms of insomnia. CONCLUSION: patients with insomnia and further risk factors for suicide need to be treated resolutely and at an early stage. Modern sleep-promoting antidepressants with low toxicity and antipsychotics must be preferred in the treatment of patients with insomniac sleep disorders and suicidality. Multimodal anti-insomnia and anti-depressive therapy adapted to the circadian rhythm can exert a favorable influence both on depressive-suicidal and insomnia symptoms and their inherent risks.

Environmental risk factors and their impact on the age of onset of schizophrenia: Comparing familial to non-familial schizophrenia.

BACKGROUND AND AIMS: Several risk factors for schizophrenia have yet been identified. The aim of our study was to investigate how certain childhood and adolescent risk factors predict the age of onset of psychosis in patients with and without a familial component (i.e. a relative with schizophrenia or schizoaffective disorder). METHODS: Aside from the age of onset of psychosis, we examined the risk factors for schizophrenia including obstetric complications, birth during winter or spring, behavioral deviances or delayed motor and speech development, exposure to adverse life events and exposure to substance use within a group of 100 patients (45 female, 55 male) with a mean age (± standard deviation) of 35.15 ± 13.21. RESULTS: Birth complications and cannabis abuse are predictors for an earlier onset of schizophrenia in patients with non-familial schizophrenia. No environmental risk factors for an earlier age of onset in familial schizophrenia have been identified. CONCLUSIONS: Certain environmental risk factors for schizophrenia seem to have an impact on the age of onset of psychosis in non-familial schizophrenia, they do not seem to have an impact on familial schizophrenia.

[Dilemma situation: Acute mental illness during pregnancy]. / Dilemmasituation: Akute psychische Erkrankungen in der Schwangerschaft.

Acute mental illness during pregnancy is an emergency medical situation requiring immediate intervention. A variety of medical, pharmacologic, legal, and ethical dilemmas must be resolved to simultaneously ensure the well-being of the mother and unborn child. This article provides an overview of the management of common psychiatric emergency situations in pregnancy.

[Delusional Misidentification Syndrom and Violent Behavior - Risk Assessment and Management]. / Wahnhafte Missidentifikation und gewalttätiges Verhalten ­ Risikoabschätzung und Management.

OBJECTIVE AND METHOD: A case series of three patients with Delusional Misidentification Syndroms (DMS) and violent behavior is presented with respect to the correlation between DMS and violence as well as to the management of such occurrences. RESULTS AND CONCLUSION: DMS could be one of the reasons for violent behavior of patients with psychiatric disorders. In such case violent behavior is not just restricted to intimates and relatives but also turns on non-familiar caregivers. DMS could be a risk factor for violent behavior and should therefore be registered with help of a nuanced psychopathological exploration at the time of clinical admission and in course of treatment. Moreover risk assessment tools and safety measures (e. g. medication, monitoring) could be considered for patients with DMS.

[Nighttime restlessness in elderly patients: differential diagnosis and treatment - Differential diagnosis and therapy]. / Dilemmasituation: Nächtlicher Unruhezustand beim älteren Patienten.

Elderly individuals, particularly those with cognitive impairment, are oftentimes restless during the night, and this increases the distress of relatives, professional carers and themselves. A number of conditions other than dementia need to be considered from nyctophobia and insomnophobia, to pain, specific motor disorders during sleep, parasomnias as REM-sleep behaviour disorder, dipping, hypoglycemia, withdrawal or excessive tea, coffee and alcohol consumption. A clear-cut differential diagnosis between dementia and delirium is not always possible, as dementia is the major risk factor for confusional states decreasing the vulnerability by anticholinergic medication and any other disruptive factor, biological or psychological. Treatment of nocturnal agitation usually requires (1) reassurance and re-orientation; (2a) the discontinuation of anticholinergic substances; (2b) symptomatic psychotropic intervention; and (3) causal treatment of underlying problems. Benzodiazepines should only be used at the lowest necessary dosage for the shortest possible time, particularly in individuals who are already benzodiazepine-dependent. Quetiapine or mirtazapine at low dosages can be employed in patients with psychotic or depressive symptoms. Melatonin and its derivatives hold promise for chronic circadian rhythm disorders. There is no "one fits all" recipe for this notorious problem and each case needs to be examined individually.

[Antipsychotic pharmacotherapy for delirious syndromes - only temporary, symptom-oriented and considering QTc time]. / Antipsychotische Pharmakotherapie bei deliranten Syndromen : Nur zeitlich begrenzt, symptomorientiert und unter Beachtung der QTc-Zeit.

BACKGROUND: QTc prolongation is a common and serious side effect of antipsychotics in the treatment of delirium. Nevertheless, the occurrence of ventricular tachycardia is rarely reported, so that the clinical relevance of a QTc prolongation triggered in this way remains unclear. METHOD: The focus of this review is on the antipsychotic pharmacotherapy of delirium. RESULTS AND CONCLUSIONS: In individual cases, before the prescription of an antipsychotic due to a delirium, a risk-benefit assessment must be made for the patient. For this purpose, patient and substance-specific risk factors for QTc prolongation must be checked and, if possible, reduced. A specific recommendation for an antipsychotic with assured low QTc interference can not be given because all antipsychotics for delirium treatment are potentially QTc-prolonging. Antipsychotic delirium treatment should be monitored, especially in patients with a high risk profile, for QTc prolongation by regular ECG controls.

[Psychiatric Emergencies in Psychiatric Hospitals in Germany]. / Versorgung psychiatrischer Notfälle in psychiatrischen Kliniken in Deutschland.

Objective: Psychiatric hospitals are confronted with high rates of psychiatric emergencies. There are, however, only few investigations that focus on psychiatric emergency care in German psychiatric hospitals, their supply structures and diagnostic and treatment standards. The aim of the survey was a systematic acquisition of the diagnostic and therapeutic approach in treating psychiatric emergencies in German psychiatric hospitals. Methods: We conducted a survey in psychiatric hospitals throughout Germany. The questionnaire consisted of questions concerning the structures of supply and diagnostic and therapeutic standards treating psychiatric emergencies. Results: 42 % of all admissions to German psychiatric hospitals were emergency admissions. More than 60 % of the patients in psychiatric emergency ambulances had to receive inpatient treatment. As standard procedures for medical clearing in psychiatric emergencies physical examination, measurement of heart rate and blood pressure and conducting certain laboratory tests and breath alcohol were named. The most common psychopharmacological agents for emergency situations were diazepam, lorazepam, haloperidol and zuclopenthixol. Conclusion: Diagnosing and treating psychiatric emergencies need more standardisation. More specific data is required to generate diagnostic and therapeutic standards.

More Consistently Altered Connectivity Patterns for Cerebellum and Medial Temporal Lobes than for Amygdala and Striatum in Schizophrenia.

BACKGROUND: Brain architecture can be divided into a cortico-thalamic system and modulatory "subcortical-cerebellar" systems containing key structures such as striatum, medial temporal lobes (MTLs), amygdala, and cerebellum. Subcortical-cerebellar systems are known to be altered in schizophrenia. In particular, intrinsic functional brain connectivity (iFC) between these systems has been consistently demonstrated in patients. While altered connectivity is known for each subcortical-cerebellar system separately, it is unknown whether subcortical-cerebellar systems' connectivity patterns with the cortico-thalamic system are comparably altered across systems, i.e., if separate subcortical-cerebellar systems' connectivity patterns are consistent across patients. METHODS: To investigate this question, 18 patients with schizophrenia (3 unmedicated, 15 medicated with atypical antipsychotics) and 18 healthy controls were assessed by resting-state functional magnetic resonance imaging (fMRI). Independent component analysis of fMRI data revealed cortical intrinsic brain networks (NWs) with time courses representing proxies for cortico-thalamic system activity. Subcortical-cerebellar systems' activity was represented by fMRI-based time courses of selected regions-of-interest (ROIs; i.e., striatum, MTL, amygdala, cerebellum). Correlation analysis among ROI- and NWs-time courses yielded individual connectivity matrices [i.e., connectivity between NW and ROIs (allROIs-NW, separateROI-NW), only NWs (NWs-NWs), and only ROIs (allROIs-allROIs)] as main outcome measures, which were classified by support-vector-machine-based (SVM) leave-one-out cross-validation. Differences in classification accuracy were statistically evaluated for consistency across subjects and systems. RESULTS: Correlation matrices based on allROIs-NWs yielded 91% classification accuracy, which was significantly superior to allROIs-allROIs and NWs-NWs (56 and 74%, respectively). Considering separate subcortical-cerebellar systems, cerebellum-NWs and MTL-NWs reached highest accuracy values with 91 and 85%, respectively, while those of striatum-NW and amygdala-NW were significantly lower with about 65% classification accuracy. CONCLUSION: RESULTS provide initial evidence for differential consistency of altered intrinsic connectivity patterns between subcortical-cerebellar systems and the cortico-thalamic system. Data suggest that differential dysconnectivity patterns between subcortical-cerebellar and cortical systems might reflect different disease states or patient subgroups.

Pharmacotherapy in the treatment of patients with borderline personality disorder: results of a survey among psychiatrists in private practices.

Pharmacotherapy still seems to play a major role in the treatment of patients suffering from borderline personality disorder (BPD). However, little is known about psychiatrists' detailed perspective on indication and significance of medication. A total of 233 psychiatrists in the city of Munich and in Upper Bavaria were asked by questionnaire about their treatment habits in the medical treatment of patients with BPD. One hundred and forty-one psychiatrists answered the questionnaire (60.5%). In total, 94% of BPD patients were treated with psychotropic medication. Psychiatrists predominantly saw an indication to prescribe antidepressants (98%), followed by antipsychotics, mood stabilizers, and benzodiazepines. Citalopram/escitalopram and quetiapine were mentioned most frequently. The results are discussed in conjunction with the international guidelines for the treatment of BPD.