[Hallucinogen Persisting Perception Disorder (HPPD) and Flashback Phenomena ­ Differential Diagnosis and Explanation Models]. / Halluzinogen-induzierte Persistierende Wahrnehmungsstörung (HPPD) und Flashback-Phänomene ­ Differenzialdiagnose und Erklärungsmodelle.

OBJECTIVE: The purpose of this article is to provide an overview of the current research on "Hallucinogen Persisting Perception Disorder" (HPPD) and "Flashback" phenomena. The definition and diagnostic features of "Flashback" and HPPD remained often unclear and since the 1960 s interchangeable. METHODS: Relevant literature was identified by means of a computerized MEDLINE search including the years 1994-2014. Finally 75 journal articles out were included in the review. RESULTS: Consistent with the ICD-10 (F16.70) definition "Flashback" is often used to describe brief visual perceptual, mood, and altered states of consciousness effects reminiscent of acute hallucinogen intoxication effects. Many users regard flashback phenomena as benign and even pleasant. HPPD is described in DSM-5 as a visual perceptual disorder, sometimes persisting for months or years causing severe individual distress. The prevalence of flashback and HPPD is unknown. It is considered to be remarkable in view of the relatively few case reports published out of millions of hallucinogen users since the 1960 s and 1970 s. Despite a multitude of etiological and therapeutic approaches the exact pathophysiological mechanisms underlying HPPD remain elusive. At present HPPD appears to be further a DSM-5-genuine but still puzzling disorder. The different consequences including new therapeutic approaches are discussed in clinical context.

[Substance use associated disorders: frequency in patients with schizophrenic and affective psychoses]. / Substanzbezogene Störungen: Häufigkeit bei Patienten mit schizophrenen oder affektiven Störungsbildern.

BACKGROUND: Alcohol and substance use disorders (ASUD) are considered to be among the most frequent comorbidities in schizophrenic and affective psychoses and have a significant negative influence on their course and prognosis. In the present study patients with diagnosis from the ICD-10 category F2 or F3 were examined regarding a substance use disorder in a multicentre cross-section evaluation at nine psychiatric hospitals in Baden-Württemberg. The aim of this study is to discuss the current research on substance use disorders and psychosis comorbidity regarding the theoretical models by means of collected data. METHODS: The examination of 50 consecutive admissions per centre is based on a shortened version of the European Severity Index (Europ ASI). An initial urine drug screening was carried out with all patients after admission. Statistical assessment was based on percentage distributions, mean values, standard deviations and suitable correlation analysis. RESULTS: The representative sample included 448 patients. A proportion of 169 patients (37.7%) had a dual diagnosis F2 and F1 and a proportion of 144 patients (32.1%) had a dual diagnosis F3 and F1; 64 patients (14.3%) had an F2 diagnosis and 71 patients (15.8%) had an F3 diagnosis without ASUD. Apart from lifetime use of alcohol (n = 268) and tobacco (n = 325) hypnotics/tranquilizers (n = 214), cannabis (n = 156), opioids (n = 71), stimulants (n = 96) and hallucinogens (n = 36) were consumed. The most frequent combination and long-term intake consisted of tobacco, alcohol, hypnotics/tranquilizer, cannabis and psychostimulants especially in men with schizophrenic disorders. Regarding motivation before first substance use general psychological adjustment disorders (51%), peer impact (42%) and unspecific affective symptoms were predominant. CONCLUSIONS: Altogether the present study clearly demonstrates that patients suffering from schizophrenia, affective disorders and ASUD have significantly higher rates of more severe substance use disorders in their psychosocial environment and more suicidal behaviour than patients without substance misuse. The high rate in the cross-sectional prevalence of tobacco, alcohol, cannabis and psychostimulant use calls for more effective drug prevention.

[Criteria for culpability of substance dependent patients in various types of crime]. / Kriterien der Schuldfähigkeit Drogenabhängiger bei unter-schiedlichen Delikformen.

When judging whether a person is capable of committing a punishable offense in connection with effects of drugs we have to differentiate between an addict and an occasional consumer of drugs. In last case we can orientate ourselves only by the commonly visible signs of the drug-effect found with such persons. Contrary to this is drug-addiction an illness influencing the total mind of a person to act in a certain way. This leads to a typical behavioral pattern whereby the addict, whilst trying to procure his drug, mostly shows also limitations of his ability to act responsible in accordance with the law section 21 StGB. "Normal" punishable offences of drug-addicts are to be judged by the performance and the behaviour of the person.

[Driving capacity of drug addicts]. / Fahrtüchtigkeit bei Drogenkonsumenten.

When deciding whether a person is fit to drive a vehicle whilst he is in a drug-induced delirious state of mind, we take into consideration the actual condition of the person at the time of driving a vehicle. As a rule, the mere presence of drugs in the urine or serum does not give a positive clue as to the ability to drive a vehicle. Here one has to take into consideration the effects of the respective drug consumed has at whole. In cases of chronic drug abuse or drug-dependence as well as dependence on methadone-substitutes we have two possibilities to judge by: Either we follow the guidelines of the report by the Federal Government on "Illness and Driving", in which case drug-dependence excludes driving on the whole or we orientate ourselves here again by the actual performance of the person at the time of driving, in which case many drug users would be declared fit and able to drive. However as far as the legal aspect of it goes, it would be contradictory to the law as regards to drinking and driving. Naturally the law wil decide in the end which of the two methods are legally applicable.

[Comments on the definition of so-called "new addictions"]. / Bemerkungen zur Definition der sogenannten "Neuen Süchte".

To apply the term "addiction" to non-substantial addiction-like behavior is both problematic and useful. It is problematic because the uncritical application of the term has led to an inflation of addictions. If everything is called addiction the term is losing its predicative power and is getting meaningless. In the field of non-substantial addicted behavior we have been given the chance to study the phenomenon addiction in "pure" form without disturbing influences of any substance. To apply the term "addiction" to non-substantial addicted behavior is possible in principle. Von Gebsattel 1954 and Giese 1962 have already referred to this. However, it requires well-defined criterias. A strictly composition of the term would be recommendable.

[Sequelae of cannabis use--results of a survey of experts on traffic accidents and "echopsychoses" (flash-back)]. / Folgen des Cannabiskonsums--Ergebnisse einer Expertenbefragung zu Strassenverkehrsdelikten und "Echopsychosen" (Flash-Back).

There is a lack of knowledge in the judgement of the effects and the dangerousness of cannabis. Specially in the judgement of the delinquency of traffic the effects must be clarified. Cannabis plays often a fundamental role in road accidents. Obviously flash-backs of consumers of cannabis are observed more often than documented in the literature hitherto. The existing but not published experiences of experts have to be considered extensively to get an idea more complete of the diverse effects of cannabis in traffic offences.

A controlled comparison of clonidine and doxepin in the treatment of the opiate withdrawal syndrome.

Clonidine and doxepin alleviate the symptoms of the opiate withdrawal syndrome. Clonidine was slightly more effective in controlling sweating, hot flushes, palpitations and nausea, and doxepin was slightly more effective in relieving the craving for opiates, lassitude and depression. Adverse effects such as sedation, dry mouth and falls in blood pressure occurred in both groups. There were six cases of collapse during treatment with high doses of doxepin, whereas only one subjective circulatory effect occurred in the clonidine group. At these high doses, doxepin may cause orthostatic hypotension via a peripheral alpha-receptor blockade. Clonidine reduced pulse rate whereas doxepin, with its anticholinergic action and indirectly via its alpha-receptor blocking action, raised it. Several patients in the doxepin group hat fits, as opposed to only one in the clonidine group. It is possible that the use of barbiturates had reduced the convulsive threshold in some of our patients. Overall, clonidine and doxepin were equipotent at adequate individual dose levels, and both were well tolerated. In this trial, serious side-effects occurred less often in the clonidine group.

[Psychopathology and differential diagnosis of so-called Cannabis psychoses]. / Zur Psychopathologie und Differentialdiagnose sogenannter Cannabispsychosen.

From 237 patients examined for drug-induced psychoses, 50 cannabis psychoses were examined according to the criterion "main cause of addiction" and 107 were examined according to the criterion "consumption during the last three months before hospitalization". The cannabis psychoses were compared to the other drug-induced psychoses as well as to a control group consisting of 219 schizophrenic patients. General agreement was found with the other drug-induced psychoses as well as with the group of schizophrenic patients. The variation from the symptomatology of the schizophrenics is generally common to both the cannabis psychoses and the other drug-induced psychoses. Judging by the results of our investigations, it must be concluded that there is no disease "cannabis psychosis" in its own right, just as the disease "drug-induced psychosis" also does not exist in its own right. While there is a certain slight drug-specific psychopathological undertone, it does not entitle us to speak of a syndromatic or indeed a nosological entity. The psychopathological cross section does not permit a differentiation in the individual psychoses groups mentioned, although this has often been attempted in the literature. That there are no relevant psychopathological differences between cannabis psychoses and endogenous schizophrenia could, for one, be based on the fact that we are observing the final stage of one and the same underlying pathological process. In this case both syndromes would in practice be endogenous psychoses, with the cause not being known in one case. The psychopathologic similarity of these two psychoses forms could, however, also be based on the assumption that cannabis psychoses are triggered schizophrenias, so that we could in both cases be dealing with one and the same disease. We see the solution to the problem of diagnosing symptomatic psychoses, and in particular cannabis psychoses, in making a diagnosis that takes the etiology into consideration in addition to the syndrome diagnosis.

[Are there new methods in therapy of drug dependence?]. / Gibt es neue Wege in der Therapie der Drogenabhängigkeit?

The therapy of drug addicts must not be confused with measures to reduce drug problems. Therapy means medical care for the treatment of a disease. In the treatment of drug addiction, we apply pharmacological and psychological therapy but also psychosocial techniques to address the problems of an addict. Actions might contain causal, symptomatic, or palliative therapies according to the measures currently available. The choice of a treatment procedure in the frame of the available alternatives is oriented on the objective findings, the chance for success, and the patient's intentions. The therapy of the drug addiction is divided into the stages of contact, detoxification, weaning, and aftercare. We aim for a patient's living without consuming drugs and the ability to critically and socially deal with the reality. The break with the pleasure/reluctance principle and switching to the performance principle is crucial. We have success rates ranging between 20 and 40% over five years in the currently available treatment-facility. The substitution therapy is also available as an additional choice for a smaller group of addicts where we do without an abstinence. Naturally, this is a substitution with methadone and may only be a measure for prolonging life. The application of heroine has currently no foundation as it has no advantages to the administration of methadone. Therefore, we should focus mainly on abstinence orientated procedures and to keep the methadone substitution ready for a small group resistant to therapy.

[Communicating hydrocephalus. Clinical aspects, diagnosis, pathogenesis]. / Hydrocephalus communicans Klinik, Diagnose, Pathogenese

A description of the clinical symptoms of the communicating hydrocephalus (normal-pressure hydrocephalus = NPH) is given: progressive psycho-organic alterations, ataxia, tetraspastic signs, urinary incontinence, without increased intracranial pressure. Diagnosis can be confirmed by use of pneumencephalography, isotope-cisternography and tomography of the brain by use of a water-solubile contrast fluid. Skull radiographs. EEG, testing of liquor and psychological examinations are of less diagnostic value. The illness is the result of a disturbance of liquor resorption and circulation. In this context there is to differentiate between cases of known (Hydrocephalus communicans obstructivus = HCO) and unknown etiology (Hydrocephalus communicans non obstructivus = HCNO). The group of cases with unknown etiology represents the central part of cases of normal-pressure hydrocephalus (NPH). The prognosis after a ventricular shunt-procedure is here worse than in the group of cases with known etiology. For differential diagnosis presenil dementia, cerebrovascular insufficiency, intracranial tumors and reactive and psychotic depressions are to be considered.

[Problems of toxic psychosis as illustrated on the example of the so-called LSD psychosis]. / Zur Frage der toxischen Psychose am Beispiel der sog. LSD-Psychose

The effects of LSD are characterized by a number of disturbances of perception and experience, which can be observed in the fields of visual, spatial and temporal perception and of affectivity. We also see disturbances of experience, which can otherwise be observed only in psychoses, for example reduction or change of cognitive functions, but also depersonalization and euphoria. In atypical courses of intoxication ("horror-trips") anxiety and excitement are predominant. Atypical courses of intoxication may be interrupted by "talk down" and additional application of tranquilizers. In a certain number of LSD-users in our clinic we saw psychoses. We classify them into flash-backs, exogenic (toxic) psychoses and so-called "endoform psychoses". The latter implies three possible constellations: accidental coincidence of LSD-use and psychosis; pre-existing psychosis with symptomatic use of LSD as an attempt of self-treatment; finally the onset of a psychosis may be triggered by the use of the halluzinogen. From the symptomatological cross-section they cannot reliably be distinguished from real schizophrenia. An independent nosological unit "LSD-psychosis" does not seem to exist.

[Flashback following use of cannabis--a review]. / Flashback nach Cannabiskonsum--eine Ubersicht.

The present study tries to find an answer to the question, whether the consumption of cannabis can cause flashbacks, and, if so, under what circumstances they occur. This is of interest for the treatment, prognosis and also from the legal viewpoint. The definition of a flashback is often unclear. Empirical investigations are often not sufficiently comparable, the supplementary data are very often missing, making the evaluation of the results difficult. Self-diagnosis by the consumer is usually unsuitable for estimating the frequency and phenomenology of flashbacks. Cannabis may trigger flashbacks after consuming hallucinogenes; the probability of the occurrence of a flashback seems to increase with the amount of hallucinogenes a person has consumed. A definite correlation between the amount of hashish consumed and the occurrence of flashback does not exist. Flashbacks have also been reported after consuming cannabis alone. However, data vary regarding the frequency of such flashbacks. According to the available data they occur rarely and require a thorough differential diagnostic evaluation in each individual case. As a rule, the occurrence of a flashback may take place in cases where there is an intake of hallucinogenic drugs in the recent case history.

[Codeine and dihydrocodeine as substitute and alternative drugs]. / Codein und Dihydrocodein als Ausweich- und Ersatzdrogen.

There has been an increasing tendency in West Germany since the beginning of the 60s to abuse codeine and dihydrocodeine-containing drugs as substitutes and alternative drugs. This paper will firstly look at this situation from an epidemiological point of view and summarize the chemical and pharmacological effects, the side effects and toxicology of both kinds of substances. On the basis of own case reports the importance of codeine and dihydrocodeine during the development of an addiction of polydrug addicts and opiate addicts has been revealed, analysed and discussed, also with a view to the legal aspects in connection with the issue of treatment by substitution of drug dependents.

[Delinquency under drug influence (author's transl)]. / Straftaten unter Einfluss von Drogen.

In delinquency, connected with alcohol, the immediate and acute effect of the substance is prominent, whereas in delinquency connected with drugs, one has to deal with chronic effects. The criteria for judging drunken offenders also stand as a model for judging the responsibility of the addicted offender for his crime. We consider: 1. the personality of the offender 2. the way, the amount and the point of time of the last intake of the drug 3. the potential dependence 4. the psychopathological state at the time of offense and at the time of examination 5. the kind of the offense itself. Most cases, which have to be examined, deal with indictable offenses, which were undertaken, in order to get new supply, i.e. "supply-offenes". These cases surmise, that the offender is physically addicted, that he knows about withdrawal symptoms from own experience, and that he committed the crime purely for securing his personal supply. We differentiate between direct "supply-offenses" (i.e. direct stealing by the addict himself) and indirect "supply-offenses" (i.e. mainly trading and commission business). For the latter offenses the state of consciousness and insight at the time of offense does not serve as a suitable criterion for judging the responsibility for the crime, since these offenders usually are not deprived of their drugs and therefore in a stable state of mind. Therefore the inner situation and the motivation for carrying out the crime has to be analysed carefully. For these indirect "supply-offenses" reduced responsibility for the offense has to be considered, whereas for direct "supply-offenses" a total lack of responsibility can be assumed.