[Advance directives and mental disorders: a practice recommendation of the Commission for Ethics and Law of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Patientenverfügungen und psychische Erkrankung ­ eine Praxisempfehlung der Kommission Ethik und Recht der DGPPN.

BACKGROUND: Since the creation of legal requirements for advance directives by the legislator in 2009, special aspects of their application in the treatment of people with mental illnesses have been discussed. GOAL OF THE PAPER: Important questions on dealing with advance directives in everyday life will be answered in a practice-oriented manner. RESULTS: Among other things, this document answers the question of the conditions under which a patient can refuse or consent to hospitalization and treatment in advance, and in particular how to deal with advance directives whose implementation would also affect the rights of third parties. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has addressed these and other questions in the present document and added practical advice on how to formulate advance directives for people with mental illnesses and how to deal with psychiatric advance directives. DISCUSSION: The DGPPN has developed an advance directive for the area of mental health and published it on its website together with detailed explanations. With the help of this advance directive, people can decide on their treatment in phases of incapacity to consent in the context of a mental crisis or illness.

Serial Killings and Attempted Serial Killings in Hospitals, Nursing Homes, and Nursing Care.

BACKGROUND: Serial killing by doctors or nurses is rare. When it occurs, it is generally only detected after multiple homicides by the same perpetrator have escaped detection in the past. The persons at greatest risk are multimorbid elderly patients whose sudden death for natural reasons would not come as a surprise. However, patients' risk of falling victim to homicide is increased only if such vulnerable patients are exposed to perpetrators with certain personality traits. In this situation, homicides can be committed in which little or no evidence of the crime is left behind. In this review, we address the frequency, nature, and circumstances of serial killings and attempted serial killings in hospitals, nursing homes, and nursing care. METHODS: This review is based on publications retrieved by a selective review of the literature in monographs, medical databases, specialty journals, general-interest media, and the Internet. RESULTS: An evaluation of searchable, published case descriptions of serial killings and attempted serial killings in hospitals, nursing homes, and nursing care, mainly from Europe and the English-speaking countries, enables identification of the type of patients at risk, the modes of homicide, and the personality traits of the perpetrators. Multimorbid, care-dependent and nursing-dependent persons are the main victims. The perpetrators (men and women) generally act alone and have often been working in patient care for many years. The most common method of homicide is by drug injection; violent physical homicide is rarer. In many cases, irregularities in drug stocks, erratic behavior of a staff member, and/or a cluster of sudden deaths are indeed noticed, but are too slowly acted upon. CONCLUSION: Irregularities in drug stocks, inexplicably empty drug packages and used syringes, erratic behavior of a staff member before and after a patient's death, or a cluster of unexpected deaths mainly involving elderly, multimorbid patients (detectable from internal mortality statistics) should always lead to further questioning and investigation.

[Free responsibility of the decision for an assisted suicide]. / Zur Freiverantwortlichkeit der Entscheidung für einen assistierten Suizid.

The verdict of the German Federal Constitutional Court on assisted suicide has led to lively debates in the medical world, in the German Federal Parliament and the civil society. In the conception of the German Federal Constitutional Court the determination of free responsibility is of central importance for a protection concept that aims to minimize an uncontrolled assistance to suicide; however, the forensic aspects of this task need to be substantiated. This article comments on this from a psychiatric aspect in order to include the perspective of our discipline in the progression of the discussion.

[Stalking and crimes of passion : Discussion of a case example on ex-partner stalking]. / Stalking und Affektdelikte : Diskussion eines Fallbeispiels zum Expartnerstalking.

Forensic scientists have proposed various evaluation criteria for assessing the criminal responsibility in violent acts against relationship partners under exceptional affective circumstances. Of particular importance, apart from the offender's condition at the time of the offence, are the previous history and the background of the relationship. Although each individual case requires special weighting of the individual aspects, the clinical judgment must always be based on an overall view of the offender and the crime. This article investigates the question of the extent to which empirical findings from stalking research can contribute to the assessment of crimes of passion.

Environmental factors as delusional contents in patients with schizophrenia.

In a series of 50 consecutive cases in the outpatients' unit of Environmental Medicine (UEM) at the University Hospital of Aachen, Germany, five patients with the diagnosis of schizophrenia presented delusions of being poisoned by environmental factors. This case report illustrates the clinical features of the paranoid type of schizophrenic psychoses. Schizophrenia represents an important differential diagnosis in the interdisciplinary diagnosis and management of health problems attributed to environmental factors.

Atypical and typical neuroleptics in acute schizophrenia and related delusional disorders. Drug choice, switching and outcome under naturalistic treatment conditions.

Atypical neuroleptics have improved drug treatment in schizophrenia. However, their use varies greatly between countries and continents. Recent metaanalyses have deemphasized the range and magnitude of their superiority compared to typical neuroleptics. Aims of the present study were to contribute effectiveness data to this discussion. In 725 inpatients with ICD-10 diagnoses F20, 22-25 from four German psychiatric inpatient units acute neuroleptic treatment and outcome were analyzed under naturalistic conditions. Treatment strategies were stratified post hoc to answer the question, which proportion - and which kind - of patients are primarily given atypicals or typicals, for how long, at which rate and when the atypical/typical drugs are switched to typical/atypical drugs, and what the respective outcomes are. As the results demonstrate, atypicals were administered one time during inpatient treatment in nearly 48% of the patients, however as first choice drugs in only 15% of this population. Treatment change occurred in 28% after 5-6 weeks irrespective of the first drug choice. Outcome differences were, if at all, only modest and not systematically biased towards a single strategy. In conclusion, frequency of inpatient treatment with atypical neuroleptics corresponds to pharmaco-epidemiological data in Europe, but is still lower than in the US. Contrary to contemporary guideline recommendations atypical neuroleptics under routine inpatient treatment conditions were scarcely administered as first choice treatment, and acute clinical outcome is comparable to that under treatment with typical neuroleptics. Reasons and implications of these findings considering the methodological limitations are discussed.

Enhanced intensity dependence as a marker of low serotonergic neurotransmission in borderline personality disorder.

Dysfunction of central serotonergic activity has been assumed in patients with borderline personality disorder (BPD) characterized by a prominent impulsive behavioral style. Following the high serotonergic innervation of the primary auditory cortex, there is increasing evidence of the intensity dependence of auditory evoked potentials (AEP), especially the N1/P2 component, indicating serotonergic neurotransmission in animals and humans. 15 females who met the IPDE-criteria for BPD and a group of comparative healthy females (controls) completed extensive personality questionnaires which gave special regard to impulsiveness. We obtained event-related AEP through the application of various loudness stimuli. We examined the relevant N1/P2 amplitude of the tangential dipole of the auditory evoked response using dipole source analysis. The augmentation of the N1/P2 amplitude of tangential dipole source activity with rising stimulus intensity was significantly pronounced in BPD as opposed to controls, accompanied by a reduction in N1 and P2 latencies. The strong loudness dependency of AEP correlated with aspects of impulsiveness. These data imply reduced inhibiting control over cortical sensory processing in BPD. Our findings contribute a further argument to the hypothesis of low serotonergic neurotransmission in BDP and may point to a trait character of impulsiveness in this personality disorder.

Frontal lobe dysfunctions in borderline personality disorder? Neuropsychological findings.

This study aims to determine whether specific neuropsychological performance impairments in borderline patients can be objectified and whether these findings indicate frontal dysfunctions. Twenty-three patients with borderline personality disorder and 23 normal controls were examined using a neuropsychological test battery to assess intelligence, attentiveness, proneness to interference, learning and memory, as well as planning and problem solving. All subjects filled out standardized questionnaires to assess aggressiveness and impulsiveness in the context of these cognitive performance areas. The neuropsychological test results of the borderline patients were comparable to those of the controls. Although there were no indications of frontal dysfunction of cognitive information processing, inverse correlations were found between the severity of borderline-related personality traits regarding impulsiveness and various areas of cognitive performance. Borderline personality patients show no indications of frontal cognitive dysfunction. Further research is needed to clarify the relationship between impulsiveness and cognitive information processing in borderline personality disorder, including a dimensional approach to personality and personality disorder.