Relationship between neuroleptic extrapyramidal syndromes and patients' all-cause mortality.

INTRODUCTION: It is important to understand factors contributing to a neuroleptic-related increased mortality risk. The objective of this study was to test whether the occurrence of neuroleptic-induced extrapyramidal syndromes (EPS) including tardive dyskinesia (TD) is associated with an increased patients' all-cause mortality. METHODS: In 1995, a sample of 200 patients on neuroleptics was assessed with regard to the presence of Parkinson syndrome, akathisia, and TD. By 2003-2004, i.e., during the following 8-9 year period, 63 patients had died. Patients who had died were compared with 120 patients known to be still alive with regard to several socio-demographic variables and the presence of EPS at the first examination. RESULTS: At the basic assessment, there were no significant differences between patients later still alive and deceased patients with regard to TD. The deceased patients were more frequently women, older, suffered more frequently from an organic disorder, had higher average scores for Parkinson syndrome and less frequently akathisia. Multivariate analysis confirmed age as the only factor contributing to the group difference. Repeating the meta-analysis by Ballesteros et al. (2000) after inclusion of our data, TD remains a weak but a significant predictor of death (OR=1.4). DISCUSSION: Neuroleptic-induced EPS of parkinsonism, akathisia, and TD did not contribute to the patients' all-cause mortality in this study. The association between TD and mortality merits further attention.

Two types of classification for male opioid dependence: identification of an opioid addict with depressive features.

OBJECTIVE: There are similarities between alcoholics and opioid addicts and an overlap between both diagnostic groups. We tested the hypothesis that the type I and II classification, well established in male alcoholism, could also be relevant in a population of male opioid addicts. METHODS: A sample of 100 hospitalized adult opioid dependent men were studied with the help of an extended semi-structured clinical interview, considering four classification criteria sets devised by Cloninger et al. (1981, 1982), von Knorring et al. (1985, 1987), Buydens-Branchey et al. (1989) and Babor et al. (1992). RESULTS: The two types of classification could be confirmed with all four criteria sets. In at least three of four analyses, 52 patients were allocated to the same larger cluster C1, and 25 patients to a smaller cluster C2. These two groups were compared with each other with the help of the stepwise discriminant analysis. Seven variables were identified which excellently discriminate between the groups: The C2 patient is younger, has a history of therapy because of depression and a history of severe suicide attempts, also abuses benzodiazepines and becomes violent while intoxicated. His father suffers from alcoholism and received treatment because of depression. The C1 patient lacks these characteristics. CONCLUSIONS: The hypothesis was confirmed, showing that the two types of classification for male opioid addicts is feasible. A depressive type of male opioid dependent patient was identified. Early identification of patients of this type is clinically important.

Repetition of serotonin syndrome after reexposure to SSRI--a case report.

We describe here the occurrence of a serotonin syndrome (SS) in a 64-year-old depressed female patient with alcoholic hepatic cirrhosis after treatment with SSRIs. Two weeks after the increase of the dosage of sertraline, the patient developed a full-blown SS, which resolved completely after the discontinuation of the drug. The therapy with citalopram led again to development of milder SS, this time immediately after the increase of the dosage. Our case illustrates the variability of the clinical presentation and the temporal evolution of SS in a patient with preexisting medical illness affecting hepatic metabolism. Reexposure of patients with a history of SS to another serotoninergic drug should be avoided; if necessary, it must be carried out with the utmost caution.

Correlates of coping styles in psychotic illness.

BACKGROUND: Both integration and sealing over have been identified as global, clinically distinct coping styles with the psychotic illness and integration was found to be associated with a better outcome. We studied a series of potential correlates of these coping styles. SAMPLING AND METHODS: A total of 75 psychiatric patients in a recovery phase after a psychotic episode were studied. All patients filled out the Frankfurt Self-Concept Inventory and the Parental Bonding Instrument; the Integration/Sealing over Scale and the Positive and Negative Syndrome Scale were completed by an investigator for all patients during a semistructured interview. Besides, some sociodemographic and clinical data were collected. RESULTS: A relationship was found between the integrative coping style and absence of negative symptoms, housing with partner or alone indicating more social competence and a diagnosis of psychotic illness other than (paranoid) schizophrenia. CONCLUSIONS: As only 25% of the variance were explained, other--still unknown--factors are also of importance.

Comparison of four groups of substance-abusing in-patients with different psychiatric comorbidity.

OBJECTIVE: Comparisons of different groups of dual patients are rare, yet potential differences could have therapeutic implications. In this study, four groups of psychiatric in-patients with substance use disorder were compared to each other: patients with no psychiatric comorbidity, patients with comorbid schizophrenia and patients with affective and personality disorder. METHOD: Apart from sociodemographic, therapy-related variables and a detailed survey of their substance use, all subjects were assessed with BPRS and SCL-90-R. RESULTS: No differences were found in the patients' demography, psychosocial adjustment and substance consumption career. Significant differences were found in regard to some therapy variables reflecting adherence to treatment and global outcome and to the level of psychopathology. CONCLUSION: Both substance use and comorbid psychiatric disorder have a variable impact on distinct areas of patients' general condition and functioning. The group with comorbid affective disorder appeared to be the most difficult to treat and the therapeutic approach to this disorder deserves reconsideration.

[Burnout in psychiatric physicians. Results of an empirical study]. / Burnout bei psychiatrisch tätigen Arztinnen und Arzten. Resultate einer empirischen Untersuchung.

OBJECTIVE: The study aimed at assessing burnout in psychiatrists and psychiatric residents, all of them working in the Canton of Zurich, Switzerland, and at identifying some of its correlates. METHODS: Potentially burnout- related demographic, work, leisure activities, and personality (Munich Personality Test) variables were studied in three subgroups of 307 probands--psychiatric residents, psychiatrists working as staff members or in leading positions in psychiatric institutions, and psychiatrists working in private practice--the degree of burnout having been assessed with the Tedium Measure (TM). RESULTS: The mean TM score of all probands of 2.9 (SD = 0.7) was on a low level, high TM scores (> 3.5) were indicated by 57 (18%) participants. Significantly higher TM scores were indicated by psychiatric residents, who also scored higher with regard to neuroticism and lower with regard to frustration tolerance on MPT. CONCLUSIONS: Neuroticism alone explained a substantial proportion of the total TM variance in individual groups. Work-related variables turned out to be of a small importance only, whereas no influence could be demonstrated for different leisure activities.

Antecedents of opioid dependence and personality disorder: attention-deficit/hyperactivity disorder and conduct disorder.

Both attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) were explored as possible antecedents of opioid dependence and personality disorder. One hundred adult opioid-dependent, treatment-seeking male inpatients were explored; an extended clinical semistructured interview to collect sociodemographic, drug use related, and clinical data and the Structured Clinical Interview for DSM-IV personality disorders SCID-II were carried out. Four groups of patients, namely ADHD alone (4 patients), ADHD + CD (7 patients), CD alone (47 patients) and no ADHD/no CD (42 patients) were identified and compared with each other. The results indicate that ADHD alone does not predispose to the development of opioid dependence in male inpatients. Childhood ADHD may nevertheless be found more frequently in male opioid addicts due to its comorbidity with CD, which was identified in more than half of our sample. Patients with ADHD history seemed to go through the drug abuse career earlier and to develop more frequently histrionic and obsessive-compulsive personality disorder. Over half of the CD patients developed borderline and/or antisocial personality disorder; both ADHD and CD predispose significantly to the PD development. Early substance use preventive measures are necessary in children and adolescents suffering from CD and from ADHD comorbid with CD.

Follow-up study of hysterical psychosis, reactive/psychogenic psychosis, and schizophrenia.

The present study was undertaken to learn more about the longer-term course of nonaffective functional psychoses, including hysterical psychosis. A group of 48 female patients diagnosed with hysterical psychosis, nonhysterical reactive/psychogenic psychosis, and schizophrenia at their first admission were reassessed after an average follow-up period of 11.6 years. Seventy-five percent were receiving outpatient treatment; less than half were on neuroleptics, and only 35% were rehospitalized. The patients suffered from a few, mostly unspecific, symptoms and were relatively well adjusted socially. No differences were found between original diagnostic categories regarding all variables studied. Hysterical psychosis does not appear to be a special clinical entity, distinguishable from other reactive/psychogenic psychoses in the short term and from other nonaffective functional psychoses in the longer term. The symptomatology and clinical presentation of nonaffective functional psychoses at first admission do not allow any prognostic longer-term forecast, and the initial differences between individual psychoses tend to disappear over time.

A comparative study on schizophrenic patients with dual diagnosis.

As indicated in the literature, substance abuse is a significant yet complex variable in schizophrenic disorder. We evaluated hospital charts of 86 schizophrenic patients with comorbid substance use disorder and of 56 patients suffering from schizophrenia-only. We surmised that among the former group there will be a substantial proportion of patients abusing opiates and that there will be differences between schizophrenic patients abusing different drugs. Both hypotheses could be confirmed. Among our dual patients, 18 patients with alcohol, 18 patients with cannabis, and 50 patients with "hard drugs" (opiates, cocaine) use disorder were identified and several significant differences were found between the individual groups of patients in respect to basic sociodemographic and clinical variables; in particular, schizophrenic patients with alcohol use disorder (and patients suffering from schizophrenia-only) were older and better socially adjusted than schizophrenic patients with "illegal" drug use disorder. The particularities of schizophrenic patients suffering from different kinds of substance use disorder should be considered when creating individualized therapeutic programs.

[Identity measurement with the Frankfurt self concept scales and their relationship to parental bonding]. / Identitätserfassung mit Frankfurter Selbstkonzeptskalen und deren Beziehung zum Parental Bonding.

Psychiatric inpatients and nonpatients were compared using the Frankfurt Self-Concept Scales (FSKN). Firstly, we tried to validate FSKN as a measure of identity using the DSM-III-R identity rating as an external criterion. Then the FSKN ratings of patients and nonpatients were compared. Lastly, we correlated individual FSKN ratings with certain demographic variables, clinical diagnoses, and the two dimensions of the Parental Bonding Instrument (PBI). All FSKN scores of patients with identity disorders differentiated significantly from those without identity disorder, thus confirming FSKN validity. The most significant differences were found in practically all FSKN results comparing patients with nonpatients of both sexes, always in favor of nonpatients. Male patients presented better self-concepts than female patients, whereas practically no significant relationships were found between FSKN scales and sex in nonpatients or between FSKN, vocational category, and diagnosis. Also, the relationship between the scales and age appears to be slight, showing positive in patients and negative in nonpatients. Many significant correlations were found between FSKN scales and PBI dimensions which were negative between the scales and PBI "control" and positive between the scales and PBI "care", both especially in men with regard to their relationship with the father.

Criminality in female inpatients with substance use disorders.

Three groups of female inpatients were compared with each other with regard to criminal behavior: 51 patients with alcohol dependence, 39 patients with drug (mostly opioid) dependence and 488 patients not fulfilling DSM-IV criteria for substance dependence. 45% of the alcohol-dependent patients, 74% of the drug-dependent patients and 15% of the psychiatric comparison group had a criminal record compared to only 2% of the female reference general population. Comparing criminal with noncriminal patients in both groups with substance dependence, patients with a criminal record were significantly younger than patients without a criminal record; however, otherwise only very few differences appeared. In contrast, alcohol-dependent and drug-dependent female patients with a criminal record appear to represent two quite different populations.

Comparison of assessment of personality disorder by patients and informants.

The present study evaluated the pathology of personality disorder in a group of 8 nonpatient volunteers and 32 psychiatric in- and outpatients, most of them suffering from substance abuse disorder. The patient self-reports were compared with the reports by 2 informants for each proband. All probands and informants completed the Structured Interview for DSM-III-R Axis II Personality Questionnaire. Patient self-reports and informant reports yielded the same number of diagnoses. The diagnostic agreement between the three sets of data was generally poor; however, the concordance was slightly better between both groups of informants than between patients and informants: Median kappa were 0.13 for patients versus parents, 0.14 for patients versus brothers/sisters and 0.29 for parents versus brothers/sisters. Patient and informant evaluations represent two different assessment approaches of the personality, and a complete agreement is not to be expected.

Prevalence of extrapyramidal syndromes in psychiatric inpatients and the relationship of clozapine treatment to tardive dyskinesia.

In 200 inpatients on regular neuroleptics, point prevalence of extrapyramidal syndromes, including Parkinson syndrome, akathisia and tardive dyskinesia (TD), was studied and found to be 20, 11 and 22%, respectively. A total of 46 patients have currently, and for a longer time, (average about 3years, median over 1year) been treated with clozapine, and 127 with typical neuroleptics (NLs). Comparing both groups, higher TD scores were found in the clozapine sample. Investigating the influence of a set of seven clinical variables on the TD score with the help of multiple regression analysis, the influence of the treatment modality disappeared, whereas the age proved to be the only significant variable. Studying the role of past clozapine therapy in patients currently on typical NLs and comparing 10 matched pairs of chronic patients with and without TD in whom a complete life-time cumulative dose of NLs was identified, a relationship between TD and length of current typical NL therapy and life-time typical NL dosage could be demonstrated. On the whole, long-term relatively extensive use of clozapine has not markedly reduced the prevalence of extrapyramidal syndromes in our psychiatric inpatient population. In particular, we failed to demonstrate a beneficial effect of clozapine on prevalence of TD. There are certainly patients who suffer from TD in spite of a long-term intensive clozapine treatment.

[Child sexual abuse, false-memory syndrome and Huntington chorea]. / Sexueller Kindesmissbrauch, False-memory-Syndrom und Chorea Huntington.

We report on a female inpatient who at the age of 47 years presented depressive and anxiety symptoms and alcohol abuse and who suffered from cognitive, personality, and discrete movement disturbances later on. In the course of the long-term psychotherapy which was supported by the technique of creative drawings previously forgotten memories of a very severe sexual abuse in childhood emerged. The recovery of these memories was followed by an intensification of the anxiety which lead to several psychiatric rehospitalizations. During the last hospital stay the diagnosis of Huntington's chorea was verified explaining well the rich psychopathology of the patient. The recollections of sexual abuse were for the most part qualified as a false memory syndrome. In addition to other factors the chorea-inherent cognitive impairment will have contributed to the occurrence of false memory syndrome. The new diagnosis dictated a change of the therapeutic procedure which, at least in the medium-term, proved to be successful.

Identity disturbance in personality disorders.

We explored identity disturbance and some of its correlates and antecedents in patients with personality disorder (PD) pathology. A group of inpatients who all were diagnosed as PD on self-reports were divided as those with (28 patients) and without (62 patients) identity disturbance on the basis of the DSM-III-R borderline PD identity item criterion. The division of the patients was tested and found to be valid. Both groups were compared with each other. Seventy-five percent of patients with and 34% of patients without identity disturbance received the definite interview diagnosis of PD. The syndrome of identity disturbance was encountered in basically all PD types. In contrast, half of all patients with PD presented no identity disturbance. Identity disturbance did not predispose to specific axis I disorders and suicidal behavior, and it was not correlated convincingly with childhood traumatic experiences and parental bonding scores. The results neither support the DSM conceptualization of identity disturbance as an exclusive characteristic of borderline PD, nor the Kernberg's concept of identity disturbance as an essential of borderline personality organization which should be found in almost all PD types.

Possible antecedents of DSM-III-R personality disorders.

In order to extend our knowledge of the effects of environmental influences upon personality disorder (PD) pathology, childhood traumatic events and parental bonding were studied in 90 PD in-patients of both sexes. Childhood traumatic experiences (primarily physical and/or sexual abuse) and parental bonding dimensions were correlated with PD pathology depending on PD type and cluster. Important differences were found between the sexes. The quality of the paternal relationship (high control, low care) was significantly associated with PD pathology in men, whereas childhood traumatic experiences and the quality of maternal parenting were associated with PD pathology in women. The study of traumatic events such as childhood abuse has recently been the focus of considerable attention. More emphasis in empirical research needs to be given to parental relationships, especially in the case of men.

Criminal and violent behavior in schizophrenic patients: an overview.

An overview of the most important older and newer results regarding the relationship between violent and criminal behavior on the one hand and schizophrenic illness on the other hand is presented. Four different methods are available to study this relationship: (i) study of the prevalence of mental illness in criminal/violent populations; (ii) study of criminality/violence rate in samples of psychiatric patients; (iii) study of criminality/violence in community samples comparing mental patients with non-patient community residents; and (iv) study of criminality/violence in birth cohorts prospectively. All these methods have been used; but samples composed of schizophrenic patients exclusively were only exceptionally studied. The results indicate that there is a modest but significant relationship between schizophrenia and violence and crime which persists even after controlling for demographic and socio-economic variables. The probability of schizophrenic patients to be criminal or violent depends on the acuity of their illness and is increased by their use of psychoactive substances. Generally, however, violent and criminal acts directly attributable to mental illness account only for a very small proportion of such acts in the society.

Use of potentially abusive psychotropic substances in psychiatric inpatients.

A series of 417 consecutively admitted psychiatric inpatients were studied with regard to their use of potentially abusive psychotropic substances in the last 3 months preceding admission. In all patients face-to-face interviews were performed; in 354 of them urine specimens could also be tested. Alcohol and benzodiazepines belonged to the most frequently used substances followed by cannabis, opiates and cocaine. Barbiturates, hallucinogens and amphetamine derivatives were only exceptionally reported. The most important finding of the study is that every fifth patient regularly used "hard" drugs (opiates and/or cocaine), every fourth patient illegal drugs and every third patient alcohol. Substances were found in 54% of all urine specimens; methadone, opiates and cocaine were hardly found alone. For the latter substances excellent agreement was found between interview reports and urine exams. Excluding patients diagnosed as substance-use disorders, there were no statistically significant differences between schizophrenic, affective, neurotic/stress/somatoform and other disorders with regard to the use of "hard" drugs and illegal drugs. Regular substance use correlated with much worse psychosocial adjustment. Substance use has to be explored and considered in every individual psychiatric inpatient.

Criminal behavior in males with affective disorders.

Prevalence of criminal behavior in a population of 261 male inpatients with affective disorders was studied. The patients were divided into 3 RDC subgroups and compared with the same number of matched subjects drawn from the general population. The full account of conviction records in the criminal register was used as a measure of criminal behavior. Altogether, 42% of patients and 31% of non-patients had a criminal record. A higher criminality rate was found in bipolar patients and in patients suffering from unipolar minor or intermittent depression, whereas no increased criminality rate was found in patients with unipolar major depression.