[Psychopathological disorders before and after heart surgery]. / Disturbi psicopatologici prima e dopo cardiochirurgia.

The author describes the frequencies and characteristics of psychopathological disorders before and after open heart surgery. In addition to cognitive and anxious-depressive mood disorders in the preoperative time, anxiety and coping are prominent. Postoperatively, different mood and cognitive disorders, psychotic reactions and delirious syndromes may be found. Conditions and causes of psychopathological disorders are discussed with the aid of the literature and present results. Therapeutic possibilities are outlined.

[Central nervous system risk factors in heart surgery]. / Zentralnervöse Risikofaktoren in der Herzchirurgie.

Serious complications involving the central nervous system in the course of cardiac surgical procedures have become rare. Nevertheless, CNS dysfunctions still are observed in a considerable number of patients, exceeding by far the number of those at risk from preoperative neurological hazards. The influence of extracorporeal circulation performance and hypothermia on the physiology of cerebral autoregulation, as well as microembolization events seem to be crucial factors in this context. The resulting regional or global posthypoxic changes in brain metabolism may lead to the manifestation of various neurologic and psychiatric disorders in the postoperative course. These often minor disturbances of CNS function can only be detected regularly and diagnosed correctly in a prospective way by consulting specialists in neurology, psychiatry and psychology, as performed at the Department of Thoracic- and Cardiovascular Surgery of the University Hospital in Hamburg since 1974, and currently in use an international multicenter study. We found postoperative neurological abnormalities in more than 50% of our patients. While irreversible brain damage occurred in only 0.5% of cases, about twothird exhibited transient symptoms that were no longer apparent after 8-10 days postoperatively. Obvious psychopathological symptoms were noted in 10% of cases after surgery, and minor, likewise transient, psychiatric disturbances were seen in up to 50% of patients; 20% suffered from long-lasting psychic problems. The subjective complaints in these cases exceeded the results of objective assessments to a remarkable amount. The discussion focuses on a critical valuation of clinical and supplementary examination techniques and on the potential pathophysiologic mechanisms induced by extracorporal circulation.

'Head and heart'--neurological and psychological reactions to open heart surgery.

Neurological and psychological reactions to open-heart surgery are widely underestimated phenomena and occur in a much higher incidence than one might expect. When analyzed retrospectively, up to 3.8% of patients who underwent cardiac surgery at the Hamburg University Hospital exhibited these reactions, whereas 35%-50% presented with symptoms and signs of perioperative CNS dysfunctions in prospective studies at our department. About the same percentages are detected in prospective studies of the patients' perioperative psychopathology, stating that a great number of cardiac patients exceed the normal range of anxious, tense, and depressive moods in this setting. The consequences of these findings for the patients' quality of life and the impact for the perioperative management of patients undergoing open-heart surgery are discussed. The current prospective studies, preliminary results of which are presented here, are part of an international interdisciplinary study, initiated to bring more light into the complicated relations between ECC-assisted cardiac surgery, anaesthesiology, neurology and psychology.

[The Hamburg Rating Scale for psychiatric disorders following heart operations (HRPD)]. / Die Hamburger Schätzskala für psychische Störungen nach Herzoperationen (HRPD).

A brief psychiatric inventory has been developed from the AMP/AMDP system for the assessment and classification of psychic disturbances after open heart surgery in a random sample of 99 patients operated upon. By means of item analysis in accordance with classic test theory, a list of 36 symptoms (items) was selected. Factor analysis of this brief inventory resulted in eight factors: disorientation, impaired concentration and thinking, paranoid-hallucinatory symptoms, anxiety, sullen inadequacy (restraint depression), hostility, loss of control, giving up. By cluster analysis the sample was divided into six subgroups: "unnoticeable", "rather unnoticeable", "slight psycho-organic symptoms with affective-emotional disturbances", "severe psycho-organic symptoms with loss of control", "hostility with paranoid and hallucinatory and psycho-organic symptoms", "delirious symptoms". Some results agree well with the descriptions of syndromes given by other AMP/AMDP reports. Other divergent results probably reflect the particular situation of the patients after open heart surgery.

[Phenomenology and psychodynamics of patients with so-called "hard" and "soft" methods of suicide. A comparison]. / Zur Phänomenologie und Psychodynamik von Patienten mit sogenannten "harten" and "weichen" Suizidmethoden. Ein Vergleich.

88 patients with "soft" and "hard" methods of suicide attempts are compared and described. The results show several differences between both groups of patients: (1) In the choice of a "soft" method painlessness played a superior role. Patients who had chosen a "hard" method were far less sensitive to pain, or the experience of pain had extensively faded. (2) Men with "hard" methods seemed to be more needy than men with "soft" methods. (3) Men and women of the "hard" group (preponderantly wrist cutters) showed a stronger and earlier beginning of conflict denial than patients of the "soft" group. Therefore, immediate crisis intervention seems to be especially indicated. (4) Attention should be drawn to the countertransfferance reactions of helpers in contact with patients who had employed different methods of suicide attempts.

Open-heart surgery: somatic predictors of postoperative psychopathology.

This study reports on some relationships between somatic conditions and postoperative psychopathological disturbances in 102 subjects from 20 to 65 years of age, undergoing open heart surgery. The overall incidence of postoperative psychiatric complications was 40%. Only two variables showed a significant correlation with the psychiatric criteria we used, independent of the different diagnoses: body weight and preoperative urea-N levels in serum. Some of the somatic predictors reported in the literature could be found to be specific for mitral or aortic valve disease. Predictors for psychiatric complications in patients with aortic valve replacement were: age, preoperative protein and urea-N levels in serum, and daytime sedation. The predictor in mitral valve replacement was the decrease in venous oxygenation (pulmonary artery) under physical strain.

[Phenomenology and psychodynamics of suicide patients in the awakening phase]. / Zur Phänomenologie und Psychodynamik der Aufwachphase von Suicidpatienten.

In the following paper is given a first survey of the phenomenology and psychosomatics of the period of awakening of patients having attempted suicide. The findings of the first period were compared to those elicited one or two days later with the same methods but under different somato-psychic circumsatnces. We found that soon after awakening patients gain some distance from events connected with their suicide. From this observation it is concluded that therapeutic intervention with these patients should begin right during the awakening period.

[Problems in the classification of psychopathological disorders following cardiac surgery with extracorporeal circulation]. / Probleme der Klassifizierung psychopathologischer Auffälligkeiten nach Herzoperationen mit extrakorporaler Zirkulation.

Classifications of postoperative psychopathological disorders after heart surgery according to the literature are very different as the results are dependent upon the accuracy of the observation. The accuracy and choice of classification are important as the base for identifying causal factors. We studied 214 patients using three alternative methods of classification and discuss problems of classification of the postoperative psychopathological dysfunctions.

Open-heart surgery from the psychological point of view and resulting therapeutic considerations.

A total of 168 patients underwent thorough psychological investigation before and after open-heart surgery. The pre-operative psychological status and the psychosocial situation of the patients were studied by means of questionnaires and semi-standardized interviews. The post-operative psychic status was documented daily on the first four post-operative days and once after discharge from the intensive care unit, by means of a slightly modified version of the AMP rating scale. We found significant correlations between psychosocial problems, the patients' ability to cope with their illness, the surgical stress and the environmental stress of the intense care unit, and post-operative psychic disturbances. The results lead to deliberations on therapeutic consequences.

[Some psychological predictors for psychosis after open heart surgery (author's transl)]. / Einige psychologische Prädiktoren für psychische Auffälligkeiten nach Herzoperationen.

In a study of postoperative psychosis after open heart surgery three psychopathological syndromes were identified which had different psychological predictors. Predictors of postoperative emotional disturbances are family problems and the lack of plans for the future, whereas patients with postoperative disorientations seem to have difficulties in their jobs and therefore feel distressed preoperatively. Predictors of the paranoid syndrome after the operation are: a high degree of fear in awaiting the operation and little confidence in the doctors. The social surroundings of these patients are often unstable and although they have no precise plans for the future they object to start working again after operation.

[Brain atrophy in chronic alcoholism. Clinical and computer tomographic study]. / Hirnatrophische Veränderungen bei chronischem Alkoholismus. Eine klinische und computertomographische Studie.

Fifty chronic alcoholics (37 men and 13 women, ages 26--55, mean age 39.9 years) with different clinical syndromes (alcoholic psychosis, alcoholic encephalopathies) were studied by computerized cranial tomography. Cerebral atrophy was detected in 96% of all cases. Combined cortical and subcortical signs were encountered in almost all cases. Cortical atrophy seemed to be detectable more easily by CT than by pneumencephalography. The computerized tomographic findings were studied in their relations to age, sex, duration of abuse, clinical syndromes, frequency of relapse (and seizures, too), etc. Cerebral atrophy was correlated primarily with the subjects' age and the duration, and less with the intensity of alcoholism. The most distinct changes were found in delirium syndromes and, in cases with relapse of psychosis, especially in combination with seizures. Wernicke-Korsakow encephalopathies showed the widest third ventricles when combined with repeated syndromes of withdrawal in their case histories. Computerized tomographic examinations of ten patients during acute psychosis as well as 4 weeks later showed identical findings; transitory changes, e.g., cerebral edema, were not detected. Computerized cranial tomography appears to be extremely useful to study the numerous open questions concerning the pathogenetic role of age, duration, and severity of abuse with cerebral atrophy.

[A clinical and angiographic study of occlusions of the posterior cerebral artery with special reference to the pathogenetic role of oral contraceptives and nicotine-abuse (author's transl)]. / Verschlüsse der A. cerebri posterior unter besonderer Berücksichtigung des Nikotinabusus und der hormonalen Antikonzeptiva. Eine klinische und angiographische Studie.

A series of 13 cases of occlusions of the posterior cerebral artery are presented as verified by angiography. 9 of these were between the age of 20 and 39. The symptoms and clinical courses are compared with the angiographic findings, especially with the collateral circulation. On the basis of our observations and similar cases reported in the literature the factors, disposing to vascular occlusions are discussed in detail particularly the role of oral contraceptives and nicotine-abuse.