Diagnostic functional MRI: illustrated clinical applications and decision-making.

Functional magnetic resonance imaging (fMRI) has become a popular research tool, yet its use for diagnostic purposes and actual treatment planning has remained less widespread. The literature yields rather sparse evidence-based data on clinical fMRI applications and accordant decision-making. Notwithstanding, blood oxygenation level dependent (BOLD)- and arterial spin labeling (ASL)-fMRI can be judiciously combined with perfusion measurements, electroencephalographic (EEG) recordings, diffusion-weighted imaging (DWI), and fiber tractographies to assist clinical decisions. In this article we provide an overview of clinical fMRI applications based on illustrative examples. Assessment of cochlear implant candidates by fMRI is covered in some detail, and distinct reference is made to particular challenges imposed by brain tumors, other space-occupying lesions, cortical dysplasias, seizure disorders, and vascular malformations. Specific strategies, merits, and pitfalls of analyzing and interpreting diagnostic fMRI studies in individual patients are highlighted.

Differences in quality of life and course of illness between cycloid and schizophrenic psychoses - a comparative study.

OBJECTIVE: Cycloid psychoses represent a nosological entity not adequately recognised by contemporary psychiatry. They present with full recoveries after each psychotic episode and, thus, have a favourable prognosis. METHOD: To verify this clinical observation course, outcome and quality of life (QoL, measured by the German version of the Lancashire Quality of Life Profile) of 33 patients with cycloid psychosis and 44 schizophrenics were compared after a mean time of 13 years since first hospitalisation. For comparison of objective and subjective QoL measures, 48 healthy controls were included. RESULTS: Concerning the course of their disease, schizophrenics were hospitalised significantly longer and received higher neuroleptic doses than patients with cycloid psychosis. The latter displayed significantly better scores in the CGI, GAF, Strauss-Carpenter-Outcome and PANSS scales. In global QoL measures, cycloid psychotic patients were more satisfied with their QoL than schizophrenic patients, and did not differ significantly from healthy controls. CONCLUSION: Cycloid psychoses seem to exhibit a better prognosis than schizophrenia regarding course, outcome, objective, and subjective aspects of QoL. Thus, they appear to present a useful concept deserving more clinical and scientific attention.

Susceptibility to neuroleptic-induced parkinsonism--age and increased substantia nigra echogenicity as putative risk factors.

OBJECTIVE: Patients treated by neuroleptics often develop neuroleptic-induced parkinsonism (NIP) to a varying extent. The reasons for this are discussed controversially in the literature. Previous transcranial sonography (TCS) findings of the substantia nigra (SN) in patients with idiopathic Parkinson's disease suggest a correlation of echogenicity with nigrostriatal dysfunction. METHOD: One hundred psychiatric patients receiving neuroleptics were included. They underwent clinical examination for NIP (Simpson and Angus-scale) and, independently, TCS of the SN. History of smoking habits and medication were taken from the patient's chart. RESULTS: We found a significant positive association of the prevalence of NIP with age (P < 0.01) and the echogenic area of the SN (P < 0.05). Neither type nor dosage of the neuroleptics was found to have any significant impact on the occurrence of NIP. Smokers displayed lower prevalence of NIP (P < 0.05) and lower EPS scores (P < 0.01). CONCLUSIONS: These findings suggest that age and increased size of SN echogenicity are possible risk factors for NIP. In contrast, smoking seems to have a certain protecting effect.

Perspectives of eating disorders from the Charité Hospital in Berlin.

Eating disorders have attracted steadily expanding clinical and scientific attention since second half of the 19(th) century and, particularly, after the core descriptions of anorexia nervosa had been delivered by Gull and Lasègue. In this review, we attempt to illustrate perspectives on eating disorders that have emerged since then from the work at the Charité Hospital in Berlin. It is shown that the professional fate of care for eating disorders has been tied closely to the maturation of the specialty of child and adolescent psychiatry and psychotherapy in the 20(th) century. From the early beginnings of Theodor Ziehen (1862-1950) heading the Psychiatric and Neurological University Clinic of the Charité Hospital in Berlin and being devoted to child psychiatry and psychology, the issue of eating disorders has been pursued at the Charité throughout the vicissitudes of time. After a ward for children suffering from mental illnesses was instituted by Karl Bonhoeffer (1868-1948) in 1921, child and adolescent psychiatry and psychotherapy has constituted itself first in terms of a division and finally as a separate department at the Charité Hospital. Over the years, quite a remarkable body of work on eating disorders has accumulated in this institution. It is emphasised that the value of contributions inherited appears not just of historical interest. The past has addressed psychotherapeutic, anthropological, biological, psychometric, neuropsychological, and transcultural aspects which continue to yield insights into the nature of eating disorders. Tasks and prospects ahead are based upon this background, and some of these are outlined briefly.

Shall the anthropometry of physique cast new light on the diagnoses and treatment of eating disorders?

Body weight is crucial to eating disorders. Beyond gender, age, and height it is determined by anthropometric features of physique, i. e. somatotypes. We investigated their impact on the anthropometric and metabolic assessment of nutritional status, psychometrics, and other clinical aspects of eating disorders. In 133 eating disordered girls (ICD-10 & DSM-IV criteria) of well-recorded catamneses, various somatometric measures (n = 133), serum leptin (n = 30), plasma tryptophan (n = 108), and psychometric scales (n = 119; EDI-64 & EAT-40) were examined, preferably on repeated occasions of their treatment and in comparison to 41 healthy controls. Somatotyping was performed by gender- and age-specific quintiles of Strömgren's Metrik Index (MI) derived from 6995 volunteers constituting the anthropometric reference.Somatotypes represent a significant factor for assessing nutritional status. Exhibiting higher EDI-64 bulimia ratings at admission, more prevalent self-induced vomiting and purgative substance abuse as well as prolonged refractory illnesses with more previous inpatient treatment trials but later admissions, heavier somatotypes were significantly underrepresented in our total clinical sample but more prevalent among bulimic eating disorders (p < 0.05). Neglecting the anthropometry of physique biases against the detection and treatment of eating disorders in heavier somatotypes at weights below general average. Henceforth, this shall be avoided by somatotyping according to frame indices.

Karl Kleist (1879-1960)- a pioneer of neuropsychiatry.

Karl Kleist (1879-1960) was instrumental in pioneering German neuropsychiatry and neuropsychology, including the description of frontal, constructional, limb-kinetic (innervatory) and psychomotor apraxias, frontal akinesia and aspontaneity, as well as object and form blindness. Besides isolating episodic twilight states, involutional paranoia and symptomatic (especially influenza) psychoses, he was particularly involved in applying Wernicke's syndromatic and Kraepelin's prognostic and aetiological principles to classify "neurogenous" psychoses by refuting the assumption of mixed entities whenever possible. Thus, has phasophrenias denoted manic-depressive illness, unipolar affective disorders and marginal, i.e., atypical psychoses. The rather benign cycloid psychoses form the most prominent examples of the latter. Schizophrenias, on the other hand, were limited to poor long-term catamnestic outcomes. Kleist conceptualized the core group of schizophrenic illness as psychic system diseases-hence the origin of the term "systematic schizophrenias" within the Wernicke-Kleist-Leonhard School. Kleist was mainly influenced by Wernicke and his psychic reflex arc, but Ernst Mach's empiriocriticism, Theodor Meynert's cerebral connectionism, and associationism also shaped his outlook. Kleist's localization of cerebral functions by lesion analyses was indeed the best available at the time and continues to reveal insights to the interested reader. From his Frankfurt School, which may have been the last of a completely unified neuropsychiatry, came sound representatives of psychiatry, neurology and neurosurgery. His technical mastery and achievements seem indisputable, but his balancing acts during the Third Reich may today be questioned. Despite joining the National Socialist German Workers' Party (NSDAP) and the local Court of Genealogical Health (Erbgesundheitsgericht), Kleist was, however, one of the few German physicians who continued to treat Jewish patients, to employ Jewish colleagues and to voice evident criticism of the policies of "eugenics" and "euthanasia". This paper attempts to illuminate Kleist's biography and life's work in the relevant historical context.

The concept of hebephrenia over the course of time with particular reference to the Wernicke-Kleist-Leonhard School.

The concept of hebephrenia has undergone more changes than almost any other diagnostic category in clinical psychiatry. In the present article we want to outline these changes from Hecker's first description of hebephrenia to contemporary concepts mainly based on Bleuler's viewpoints. Due to rather heterogeneous and vaguely defined symptomatology, hebephrenia lost relevance as a diagnostic category in today's classification systems. As an alternative approach, Kleist and Leonhard see hebephrenias as forming distinct clinical entities with insidious beginning and a chronically progressive course leading to specific and stable residual syndromes, mainly featured by disturbed affectivity and, thus, initiative. As known up to now, hebephrenias within Leonhard's classification show poor prognosis, little response to treatment and low heredity. This concept of hebephrenia seems to be more appropriate to demarcate a homogeneous subtype which can be the subject of further promising research to clarify aetiology and nosology of schizophrenic spectrum psychoses.