[The melancholic-delusional depression as a disturbance of the drive]. / Die melancholisch-wahnhafte Depression als Störung des Antriebs.

Distinguishing between melancholic and non-melancholic depression is still of significant importance in the classification and differentiation of depressive disorders. Melancholy appears to be a psychopathological and biologically based entity which can be described as a disorder of drive and which finds its extreme culmination in depressive delusion. Its pathogenesis ranges from the melancholic predisposed personality, mostly of the Typus melancholicus, over psychomotor inhibition and depersonalization, to depressive delusion. Delusion arises from the fear that the realization of basic human values, such as one's existence for important others or ideals, health and livelihood has become hopeless. A clear understanding of the nature and pathogenesis of melancholic delusional depression not only facilitates the diagnostic process, and the empathic assistance to the patient, but also has direct consequences for an appropriate treatment of this disorder.

Phenomenology of Obsessive-Compulsive Disorder: A Methodologically Structured Overview.

A methodological order is derived from the concept of phenomena and stages of understanding are developed according to Karl Jaspers. The three levels of descriptive, genetic and hermeneutic understanding are applied to the study of obsessive-compulsive disorder. Descriptive understanding essentially reveals a sense of incompleteness and depersonalization that underlies the experience of the nonsense of obsessive thoughts and that obsessive-compulsive symptoms do not come to an end. Genetic understanding shows particularly by reference to the trigger situation that sensitivity, undifferentiated affects, affective hyperarousal and traumatization are important aspects in the development and maintenance of the obsessive-compulsive disorder. Hermeneutic understanding brings to light the fear of death in obsessive-compulsive disorder as its anthropological dimension. The aim of this methodologically structured overview is to focus on the experience of the obsessive-compulsive patient, to keep curiosity and interest alive, so that both research and relationship to the patient is stimulated.

Internet-Delivered Disease Management for Recurrent Depression: A Multicenter Randomized Controlled Trial.

BACKGROUND: Strategies to improve the life of patients suffering from recurrent major depression have a high relevance. This study examined the efficacy of 2 Internet-delivered augmentation strategies that aim to prolong symptom-free intervals. METHODS: Efficacy was tested in a 3-arm, multicenter, open-label, evaluator-blind, randomized controlled trial. Upon discharge from inpatient mental health care, 232 adults with 3 or more major depressive episodes were randomized to 1 of 2 intervention groups (SUMMIT or SUMMIT-PERSON) or to treatment as usual (TAU) alone. Over 12 months, participants in both intervention arms received, in addition to TAU, intense monitoring via e-mail or a smartphone, including signaling of upcoming crises, assistance with personal crisis management, and facilitation of early intervention. SUMMIT-PERSON additionally offered regular expert chats. The primary outcome was 'well weeks', i.e. weeks with at most mild symptoms assessed by the Longitudinal Interval Follow-Up Evaluation, during 24 months after the index treatment. RESULTS: SUMMIT compared to TAU reduced the time with an unwell status (OR 0.48; 95% CI 0.23-0.98) through faster transitions from unwell to well (OR 1.44; 95% CI 0.83-2.50) and slower transitions from well to unwell (OR 0.69; 95% CI 0.44-1.09). Contrary to the hypothesis, SUMMIT-PERSON was not superior to either SUMMIT (OR 0.77; 95% CI 0.38-1.56) or TAU (OR 0.62; 95% CI 0.31-1.24). The efficacy of SUMMIT was strongest 8 months after the intervention. CONCLUSIONS: The fully automated Internet-delivered augmentation strategy SUMMIT has the potential to improve TAU by reducing the lifelong burden of patients with recurrent depression. The fact that the effects wear off suggests a time-unlimited extension.

Coping with delusions in schizophrenia and affective disorder with psychotic symptoms: the relationship between coping strategies and dimensions of delusion.

BACKGROUND: Self-generated coping strategies and the enhancement of coping strategies are effective in the treatment of psychotic symptoms. Evaluating these strategies can be of clinical interest to develop better coping enhancement therapies. Cognitive models consider delusions as multidimensional phenomena. Using a psychometric approach, the relationship between coping and the dimensions of delusion were examined. METHODS: Thirty schizophrenia spectrum patients with delusions and 29 patients with affective disorder with psychotic symptoms were interviewed using the Heidelberg Coping Scales for Delusions and the Heidelberg Profile of Delusional Experience. Analyses of variance were conducted to investigate differences between the groups, and Spearman's rank-based correlations were used to examine the correlations between coping factors and the dimensions of delusion. RESULTS: Schizophrenia spectrum patients used more medical care and symptomatic coping, whereas patients with affective disorder engaged in more depressive coping. In the schizophrenia spectrum sample, the action-oriented, the cognitive, and the emotional dimensions of delusion were related to coping factors. In patients with affective disorder, only the action-oriented dimension was related to coping factors. CONCLUSION: Patients with schizophrenia and affective disorder cope differently with delusions. The dimensions of delusion are related to coping and should be regarded when using cognitive therapy approaches to enhance coping strategies.

Supportive monitoring and disease management through the internet: an internet-delivered intervention strategy for recurrent depression.

Major depression is a highly prevalent, disabling disorder associated with loss of quality of life and large economic burden for the society. Depressive disorders often follow a chronic or recurrent course. The risk of relapses increases with each additional episode. The internet-deliverable intervention strategy SUMMIT (SUpportive Monitoring and Disease Management over the InTernet) for patients with recurrent depression has been developed with the main objectives to prolong symptom-free phases and to shorten symptom-loaden phases. This paper describes the study design of a six-sites, three-arm, randomized clinical trial intended to evaluate the efficacy of this novel strategy compared to treatment as usual (TAU). Two hundred thirty six patients who had been treated for their (at least) third depressive episode in one of the six participating psychiatric centers were randomized into one of three groups: 1) TAU plus a twelve-month SUMMIT program participation with personal support or 2) TAU plus a twelve-month SUMMIT program participation without personal support, or 3) TAU alone. Primary outcome of this study is defined as the number of "well weeks" over 24months after index treatment assessed by blind evaluators based on the Longitudinal Interval Follow-Up Evaluation. If efficacious, the low monetary and nonmonetary expenditures of this automated, yet individualized intervention may open new avenues for providing an acceptable, convenient, and affordable long-term disease management strategy to people with a chronic mental condition such as recurrent depression.

Heidelberg Coping Scales for Delusions: psychometric evaluation of an expert rating instrument.

BACKGROUND: Coping is of substantial relevance in the treatment and course of psychiatric disorders. Standardized instruments to assess coping with psychotic symptoms, particularly delusions, are rare. The aim of this study was to develop and evaluate the psychometric properties of a new instrument to assess coping strategies in the context of delusional experiences: the Heidelberg Coping Scales for Delusions (HCSD). METHODS: Two hundred and twelve inpatients with schizophrenia spectrum disorders and affective disorders currently experiencing delusions were interviewed with the HCSD and other coping assessment instruments. Psychometric properties and factor structure were analyzed. RESULTS: The HCSD showed good inter-rater reliability and convergent validity. Factor analysis yielded an interpretable structure with five factors: resource-oriented coping, medical care, distraction, cognitive coping, and depressive coping. Symptomatic behavior, due to its particular characteristics, was considered apart. CONCLUSION: The HCSD is a reliable and valid instrument for the assessment of coping strategies in patients with delusions. Further research is needed to evaluate coping changes over time and their influence on treatment and clinical outcomes.

Ego disturbances in the sense of Kurt Schneider: historical and phenomenological aspects.

The phenomena which were grouped together by Kurt Schneider to constitute the ego disturbances have always been of particular diagnostic relevance for schizophrenia. The manner in which these symptoms are described and distinguished from other psychopathological symptoms has generally been rather imprecise. The introduction of phenomenological methods into the field of psychiatry led to considerable improvements in symptom descriptions and to a clearer distinction between psychotic and nonpsychotic experience. Continued developments in phenomenology have further incorporated aspects of schizophrenic symptom development and in doing so have brought so-called transitional phenomena and the core schizophrenic syndrome into focus. The ego disturbances accordingly appear to stem from a particular form of depersonalization which is described as a modified sense of mineness and which can be distinguished from the neurotic experience of depersonalization.

Successful treatment of ultradian or ultra-ultra-rapid cycling: a case report.

Only three cases of ultradian or ultra-ultra-rapid cycling are to be found in the literature till now. The case of a 19-year-old patient is added and her successful treatment described. Discontinuation of the antidepressive medication and the introduction of lamotrigine and quetiapine resulted in the very stabilization of mood which was necessary for successful antidepressive treatment with reboxetine.

The concept of psychosis: historical and phenomenological aspects.

The historical development of the concept of psychosis and its increasing differentiation from the neuroses up to the modern classification systems, Diagnostic and Statistical Manual of Mental Disorders and International Statistical Classification of Diseases, is initially presented. In portraying this development, the struggle surrounding the clinical relevance of concepts on the one hand and their reliability and validity on the other are reflected. Thus far, diagnostic reliability has primarily been improved by focusing on externally observable symptoms in connection with expression and behavior. The identification of disease-specific symptoms, however, is principally achieved through the differential description of subjective experience. How this experience is to be explored and assessed remains for the most part unclear. With reference to its founder Karl Jaspers, the phenomenological method is presented as the decisive instrument for the assessment of experience. It is shown that a return to the legacy of phenomenology and a reformulation of the long-standing question concerning the specific symptoms of the schizophrenic psychosis are currently in progress. The revival of historical knowledge and a focus on direct clinical phenomena continue to provide inspiration for further advancement in modern psychiatry.

Phenomenological investigation of despair in depression.

In current psychopathological literature, the concept of despair is almost redundant. At most, the term is applied in a behavioral biological context as a synonym for helplessness and hopelessness. In light of the fact that the subjective experience of despair is neglected, the present paper adopts a phenomenological approach. The selection and hermeneutic investigation of philosophical concepts serve as tools for an initial delineation of the core structure of despair. On the basis of a growing deviation between desire and reality, target and actual status, an alternating development is initiated which increasingly constricts and leads to hopelessness and suicide. This phenomenological core structure is identified from a number of integral characteristics of depression and further developed. Despair, thus, becomes a psychopathological key term through which access can be gained to the subjective experience of the depressive individual and which can provide the basis for promoting understanding and communication as well as developing successful therapeutic interventions.