Interdisciplinary clinical assessment of patients with illness attributed to environmental factors.

Patients with health problems attributed to environmental factors such as chemical pollutants and electromagnetic fields often do not present evidence of an environmental aetiology of their symptoms. It has been postulated, that their problems are due to disorders diagnosed by other medical disciplines, especially allergology and psychiatry. Our study was designed to subject these patients to a comprehensive diagnostic program involving several medical disciplines in order to achieve diagnoses appropriate to explain the patients' symptoms. Fifty patients consecutively referred to the department of environmental medicine in the university hospital of Aachen, Germany, were submitted to the following examinations: (i) environmental medicine (history, clinical examination, biological and/or ambient monitoring for environmental agents); (ii) allergological examination (history, clinical examination, skin tests); (iii) psychiatric examination (psychopathological examination, psychometric and neuropsychological testing). In addition, the patients were examined in other hospital departments according to the symptoms presented. The findings were discussed in case conferences attended by the physicians involved in order to achieve individual diagnoses. The numbers of patients to whom diagnoses were given by different medical disciplines are as follows: psychiatry (32 patients), dermatology (4), allergology (2), neurology (2), rheumatology (2), gynaecology (1), haematology (1). The most frequent mental disorders diagnosed by the psychiatrists were somatoform disorders (19), followed by schizophreniform and delusion disorders (7). In spite of extensive diagnostic efforts, patients with health problems attributed to the environment usually do not present sufficient evidence of an environmental aetiology of their symptoms. On the other hand the symptoms often meet the diagnostic criteria of other diseases, especially of mental disorders.

Somatization disorders in non psychiatric settings: A multidimensional diagnostic approach.

Given the diagnostic ambiguity of physically unexplained complaints we wanted to study whether the clinically and symptomatically characterized groups, all of them defined according to DSM-III-R criteria, could be reclassified using selected empirical and theoretical variables of operationally defined parameters. Patients with conversion (N = 75), somatization or undifferentiated somatoform disorders (N = 74) and major depression (N = 70) according to DSM-III-R underwent multidimensional work-up including psychopathological, personality-psychological, illness, behavioral and coping assessment. The clinically characterized groups should be statistically reclassified by discriminant analytic techniques. The existing diagnostic categories according to DSM-III-R could be widely confirmed by the statistical reconstitution of the clinical groups. Conversion, somatization and depressive disorder presented as distinct clinical categories. A classification relying widely on symptoms still seems to be too superficial and does not represent the complexity of these patients. Thus, the modern classification systems with their purely phenomenological criteria should be added with further dimensions.

[Course and prognosis of anorexia nervosa: catamnesis of 41 patients]. / Zu Verlauf und Prognose der Anorexia nervosa: Katamnese von 41 Patienten.

The purpose of the following study was a multidimensional assessment of the course of anorexia nervosa. In our follow-up-study we were able to examine 41 out of 51 patients meeting DMS-111 R criteria for anorexia nervosa in our department at a mean follow-up of 5.3 years. At the first evaluation the patients were characterized by an early age of onset (mean 14.2 years), no or very little previous psychiatric treatment, and restrictive eating habits (72.5%); the mean age was 15.2 years. At the time of follow-up, the physical outcome was unfavourable for 50% of the patients; one patient had died. The psychosocial outcome was less favourable for 60%. Against the background of a neurotic structure, social and sexual disturbances were found although the patient's weight was often normal. Depressive symptoms and a "slimness ideal" were found among a large number of patients, just as much as the fear of gaining weight--which prove to be a reliable indicator for the continuation of an eating disorder. A multidimensional evaluation facilitates an assessment of the determinants of prognosis. Previous psychiatric treatment and low body weight were associated with an unfavourable, mention of problems/disturbances in the family environment with a good somatic outcome. Outpatient treatment indicates a favourable psychosocial outcome.

Intracranial vertebral artery disease in the New England Medical Center Posterior Circulation Registry.

We studied 75 patients with severe intracranial vertebral artery (ICVA) occlusive disease from the New England Medical Center Posterior Circulation Registry to learn the etiologies and locations of the vascular lesions, the location and patterns of related ischemia and infarctions, and the outcomes. All patients had neuroimaging and vascular studies. Thirty-nine percent of patients had bilateral ICVA lesions. Twenty-four percent also had basilar artery disease and 36% had associated extracranial disease. The most common site of lesions was the distal ICVA after the origin of the posterior inferior cerebellar artery (PICA). Twenty-five percent of patients had only proximal intracranial posterior circulation territory infarcts (medullary and PICA cerebellar); 32% had infarcts that involved other intracranial territories in addition to the proximal territory. We found more distal intracranial territory infarcts resulting mainly from embolism from ICVA lesions than reported previously; this occurred in 17% of all patients. The ICVA was a recipient site for emboli in 8% of patients. Thirteen percent of patients died during follow-up. The outcome was favorable in most surviving patients. Three-fourths of them had no deficit or only slight disability. The patients with distal territory infarcts due to emboli from the ICVA had the worst outcome.

Thrombolytic therapy of acute basilar artery occlusion. Variables affecting recanalization and outcome.

BACKGROUND AND PURPOSE: Thrombolysis may reduce mortality after acute basilar artery (BA) occlusion. We intended to find variables affecting recanalization and clinical outcome in patients with BA occlusion undergoing thrombolytic therapy. METHODS: We analyzed in retrospect the clinical and angiographic data of a consecutive series of 51 patients treated with intra-arterial urokinase (n = 44; 0.3 to 1.5 mIU) or intravenous or intra-arterial recombinant tissue plasminogen activator (n = 7; 22 to 100 mg). We identified effective variables by multiple logistic regression analyses and univariate tests. RESULTS: Sites of occlusion were the caudal (n = 23), middle (n = 18), and distal (n = 10) segments of the BA. The pathogenesis was embolism in 35 and local atherothrombosis in 16 patients. Collateral circulation was good in 32 patients and poor or absent in 19 patients. Recanalization was achieved in 26 of 51 (51%) patients and was associated with occlusions of embolic etiology (P = .0025). Mortality was 46% (12/26) in the recanalization group and 92% (23/25) in the nonrecanalization group (P = .0004). Other independent variables affecting mortality were length of BA obstruction (P = .0011), age (P = .0008), and collateral state (P = .0454). After follow-up (median, 32 months), 10 of the 16 survivors were only minimally impaired, with a Barthel Index score of 95 or greater; 5 patients were moderately and 1 severely disabled. CONCLUSIONS: Recanalization of acute BA occlusion reduces mortality significantly. Length of BA obstruction and state of the collaterals are additional independent variables affecting survival. Young patients with monosegmental embolic occlusion of the BA seem to have the best chance to considerably profit from thrombolysis.

[The beginnings of child analysis]. / Aus den Anfängen der Kinderanalyse.

The notions hitherto existing of the beginnings of child analysis have to be rectified. The meaning of childhood neuroses within the scope of scientific theory, i.e. the sexual genesis of the neuroses can no longer be maintained. The approach of distinguishing between the latent period and the Oedipus complex as the two phases of sexual development can nowadays be considered to be refuted. The personality of the first children's analyst--Hermine Hug-Hellmuth--needs to be redescribed. She fell victim to her father-transference and deceased murdered by her nephew with the help of whom she had satisfied her own scientific ambitions.

[Homicides by adolescents and young adults from the viewpoint of the adolescent psychiatry expert]. / Tötungsdelikte Jugendlicher und Heranwachsender aus der Sicht des jugendpsychiatrischen Gutachters.

From 1966 to 1986, the Department of Child and Adolescent Psychiatry of the Psychiatric Hospital of the University of Heidelberg gave expert opinions at the request of criminal courts in 37 cases involving homicide and 8 attempted homicide. Eighteen of the offenders were between 14 and 17 years old ("Jugendliche" under German law), 17 between 18 and 20 ("Heranwachsende") and 2 over 20. The largest group (N = 18) consisted of maladjusted male adolescents who had grown up in disadvantageous surroundings, had limited education and, not infrequently following the example of other members of their families, tended to show aggressive behaviour, intolerance to frustration, emotional instability and uncontrolled drinking. The questions the expert was asked by the court were mainly concerned with: liability for crime (section 3 JGG), applicability of juvenile law to offenders aged 18 to 20 years (section 105 JGG) penal responsibility (section 20 and 21 StBG or section 51, Section 1 and 2 StGB a.F.), and measures under section 63 StGB. The court took the expert's position in 28 of the 33 decisions which we were able to obtain for examination; 2 other proceedings were quashed. The juridical classification of the homicides was attempted or completed first-degree murder in 17 and attempted or completed second-degree murder in 6 cases.

[Adolescent crises in puberty. Diagnosis and therapy (author's transl)]. / Reifungskrisen in der Pubertät. Diagnostik und Therapie.

Psychological disorders which become manifest as adolescent crises must be seen as complex phenomena and treated thoroughly: besides the genetic, biographic and psychosocial background of the youthful individual the cultural and economic aspects play an important role. Nevertheless we must admit that associated causal explanations, e.g. for accelerated or late development are lacking. Focal points for the subsequent symptom complexes of sexual behavior in puberty are: psychosexual prematurity or retardation, masturbation, homosexual relations, pubertal asceticism and premature and frequently changing sexual relations.

[Schizophrenia in childhood (author's transl)]. / Die kindliche Schizophrenie.

After considerable controversies during the last decades there is no longer any doubt about childhood schizophrenia as a disease, although within German-speaking countries its somewhat wider definition like in Anglo-Saxon child- and adolescent psychiatry is not accepted. The relation of early childhood autism to the nosologic entity of schizophrenia still remains speculative. The etiology of childhood schizophrenia is not known, equally not that of the even less frequent manic-depressive disease. Symptoms, course, and prognosis of childhood schizophrenia which developes between preschool age and the begin of puberty are described in detail.