[Effects of slow-stroke massage as complementary treatment of depressed hospitalized patients]. / Wirkungen einer "Slow Stroke"-Massage als komplementäre Therapie bei stationären depressiven Patienten. Ergebnisse einer kontrollierten Studie (SeSeTra)1.

BACKGROUND AND OBJECTIVE: Among methods of complementary treatment of depression, massage plays an important role, at least in the U.S.A. Although there are some pointers to the antidepressive and anxiolytic action of slow-stroke massage in various randoms studies of patient cohorts, there have been no controlled trials of depressed hospitalized patients. PATIENTS AND METHODS: 32 depressed patients (24 women, 8 men; average 48 years - coveringthe entire spectrum of affective disorders listed in the ICD but without comorbidity in axis 2) with a minimum BRMS score of 16,7 - were included in the study. The randomized cross-over trial involved three massage sessions at set times (M) and sessions in two control groups (C) (relaxation and perception) lasting for 60 min 2-3 days apart. Under the control conditions there was no touching. The effects of depression-specific variables (e.g. mood, drive, abnormal cognition, as well as typical progress variables of the slow-stroke massage (bodily awareness, general state of health, etc.) were measured by both the patients' own assessment and that of an independent observer. RESULTS: Under condition of both M and C, comparison of before and after effects, there was not only the primarily postulated mood-enhancing effect, but also some very marked changes in almost all dimension, the mean improvement ratio under M often being stronger than under C. After Bonferroni correction for multiple tests, the statistical significance there remained the stronger effect of M in four dimensions (global tenseness, restlessness, depressed mood, neck/shoulder tension). The intensive effect of M compared with C was confirmed by both female and male patients regarding the answers to various open questions. CONCLUSIONS: Slow-stroke massage is suitable for adjuvant acute treatment of patients with depression. It is very readily accepted also by very ill patients. In relation to the skin as an organ that aids identity, non-hedonic depressed patients are able to recognize the sensory quality of therapeutic touching as a positive stimulus. In view of the latent period of many weeks and the only moderate efficacy of antidepressants, the described complementary method, which does not require physiotherapeutic training, should be more often applied in both a hospital and general practice setting.

Basic parameters of saccadic eye movements--differences between unmedicated schizophrenia and affective disorder patients.

BACKGROUND: Smooth pursuit eye movement (SPEM) dysfunctions are considered a biological marker for schizophrenia and have been studied widely. In contrast, saccadic eye movements have received less attention, although disturbances have been described previously. Basic neurophysiologic parameters of saccades in schizophrenics, especially in unmedicated patients, have not been studied extensively. METHODS: Saccadic eye movements of 38 unmedicated schizophrenic patients, 32 patients with major depression and 42 non-psychiatric controls were examined using high-resolution infrared oculography. Two large-amplitude saccadic tasks were presented. The groups were compared on peak velocity, reaction time and accuracy. RESULTS: Peak velocity was significantly increased in schizophrenic patients. Depressive patients had a significantly longer reaction time. Both patient groups needed more corrective saccades to reach the target than controls. CONCLUSIONS: Peak velocity distinguishes unmedicated schizophrenic patients from depressive patients and normal controls. This could be explained by deficits of the prefrontal cortex in the inhibitory control of saccades. Our findings suggest that schizophrenia affects not only SPEM but also saccadic eye movements.

Subthreshold symptoms and vulnerability indicators (e.g., eye tracking dysfunction) in schizophrenia.

Subthreshold symptoms in schizophrenia can be prodromal signs of a psychotic relapse. In people without schizophrenia, similar symptoms may indicate the presence of disorders termed schizophrenia spectrum disorders. Subthreshold schizophrenia-like symptoms may indicate a genetically transmitted higher proneness to schizophrenia. Such a higher liability to develop schizophrenia is ascertained on a symptom level. In genetic studies, asymptomatic members of a pedigree are therefore classified as unaffected although they may possess the genes in question. On a biological level, eye tracking dysfunction has been shown to fulfill certain criteria for a vulnerability indicator and therefore promises to offer more information on genetically transmitted proneness to schizophrenia even in people without psychopathological symptoms. Subthreshold symptoms may warrant treatment. The database for prophylactic treatment in populations at high risk, especially those without symptoms, is currently very small.

[Schizophrenia simplex, schizotypal disorder and compulsions. Differential diagnostic considerations]. / Schizophrenia simplex, schizotype Störung und Zwänge. Differentialdiagnostische Uberlegungen.

We report on the case of a man, whose psychopathological symptoms markedly varied during different phases of his illness, causing difficulties in applying common diagnostic criteria for schizophrenia. Depending upon each of the predominant symptoms, this resulted in different diagnoses and therapeutic strategies. We also discuss the importance of obsessions and compulsions in differential diagnosis in this case.

Smooth pursuit eye movements in schizophrenia and affective disorder.

BACKGROUND: Smooth pursuit eye movement (SPEM) dysfunction is considered to be a promising candidate for a biological marker for genetic vulnerability to schizophrenia. There are conflicting findings regarding the question of what is exactly dysfunctional in SPEM dysfunction and what component of eye movements is really specific to schizophrenia. The purpose of the current study was to help to clarify the nature of (SPEM) dysfunction and its specificity to schizophrenia. METHODS: Smooth pursuit eye movements of 43 schizophrenic patients, 34 patients with major depression and 42 normal controls were examined using high resolution infrared oculography. These groups were compared on several indices of oculomotor functioning (gain, different saccadic categories). RESULTS: Schizophrenics had a significantly higher catch-up saccade rate than depressed patients and normals. The percentage of subjects with an abnormally high catch-up saccade rate defined as beyond the mean plus 2 S.D. of the normal control group was significantly higher in schizophrenics (27.9%) than in depressed patients (8.8%) and normal controls (0%). Low gain and higher numbers of intrusive saccades tended to be more prevalent in both patient groups but did not distinguish schizophrenics from depressed patients. CONCLUSIONS: Low gain and high rates of intrusive saccades contribute to SPEM dysfunction in major depression. Abnormally high rates of catch-up saccades seem to be the oculomotor component in smooth pursuit, that is specific to schizophrenia.

Serum concentrations of thyroid hormones in patients with nonseasonal affective disorders during treatment with bright and dim light.

Serum concentrations of thyroxine (T4), triiodothyronine (T3), and thyrotropine were measured in 34 patients with nonseasonal affective disorders before and after 1 week of light treatment. Nineteen of these patients received bright white light (2500 lx) and 15 dim red light (50 lx) for 2 hours daily in the mornings over a 1-week period. Slight but significant reductions in the rating scores for the depressive symptomatology were found for both the bright-and dim-light groups, but there were no significant differences between the two groups. The improvement is thus most likely a placebo effect. Surprisingly, the small changes in the severity of the depressive symptoms in the group as a whole were significantly correlated to the changes in the serum levels of T4 during the weeks of bright- and dim-light treatment, respectively. The more a patient improved, the further his or her T4 level fell and vice versa. The fluctuations in the concentrations of T4 during light treatment were significantly greater in the depressed patients than in a group of 12 healthy controls who also received bright or dim light, whereas the changes in T3 were significantly smaller than those of the healthy controls. The pronounced fluctuations in T4 levels were probably not secondary to changes in mood. Rather, they are likely to reflect changes in tissue (intracellular) metabolism of T4, which may be involved in the mechanisms underlying the fluctuations in mood in these patients.

Structure and feasibility of a standardized stepwise drug treatment regimen (SSTR) for depressed inpatients.

"Standardized stepwise treatment regimes" (SSTR) are one way to rationally guide treatment in cases where the first treatment intervention did not yield satisfactory results. At the Department of Psychiatry of the Free University of Berlin a SSTR has been implemented into routine drug treatment for depressive disorders. The SSTR consists of eight consecutive treatment steps. If there is no sufficient change in the Bech-Rafaelsen Melancholy Scale (< 25% score reduction) in the course of two weeks, treatment has to progress to the next step. This paper describes the overall feasibility and efficacy of the strategy and the progress of the patients within the SSTR. Of those who enter the "antidepressant monotherapy phase" 52% finish treatment successfully at this stage or during the following "lithium augmentation phase". The results of this treatment-monitoring study also show that during consecutive phases of the SSTR a considerable proportion of patients in a university inpatient setting had their treatment modified according to special attitudes and clinical experiences of physicians and patients. The reasons for deviating from the SSTR obviously were more convincing than the rationale for progressing to the next step. SSTR, therefore are an important tool to give complex treatment courses a rational basis, even in patients where clinical case management requires deviations from the outlined sequence of treatment steps.

Differences in semantic information processing in schizophrenics.

Well-established findings in schizophrenics suggest that they have difficulties in interpreting contextual information. We used electrophysiological means to investigate this hypothesis. The N 400 paradigm was used in 29 acute schizophrenic patients and 28 controls. The main findings were a changed topographical distribution of amplitude in the schizophrenic group; that is, a reduced amplitude at the frontal sites and a pronunciation at the occipital sites. We did not find latency differences. When remitted patients (n = 17) were reinvestigated, a negative correlation of the amplitude to the total amount of neuroleptics used was found. These results are discussed in relation to structural and functional findings supporting the hypofrontality hypothesis in schizophrenia.

Clozapine treatment after agranulocytosis induced by classic neuroleptics.

Despite its potentially fatal side effect--agranulocytosis--clozapine has become an important drug in antipsychotic treatment. With this in mind, this report presents the case of a 23-year-old schizophrenic who had suffered from agranulocytosis after simultaneous short-term treatment with butyrophenone and phenothiazine neuroleptics 3 years ago. After nonresponse to two other classic neuroleptics, the administration of high-dose clozapine led to a full recovery without the recurrence of hematologic disorders during 24 months of follow-up examinations. Although patients with a known history of agranulocytosis are usually excluded from treatment with clozapine, we propose that, in very severe or otherwise therapy-resistant cases, clozapine be administered and then white blood cell counts monitored very stringently. Although a single case can prove little, our case provides further evidence for the presumption that noncross-reactivity exists between clozapine and other neuroleptic drugs in the induction of agranulocytosis.

Orthostatic challenge during neuroleptic test dose: a possible predictor of short-term outcome.

Cardiovascular measurements were used as indicators of autonomic arousal during an orthostatic challenge test without medication and after a test dose of 150 mg perazine in 20 acute schizophrenic patients. Unmedicated schizophrenics showed elevated heart rates and elevated systolic and diastolic blood pressure in comparison to healthy volunteers. After a test dose of 150 mg perazine, responders (using BPRS outcome criteria after 23 days) showed a pronounced orthostatic heart rate reaction in comparison to nonresponders. Results are discussed in relation to arousal theories and central dopaminergic activity in schizophrenia.

Lithium effect on smooth pursuit eye movements of healthy volunteers.

Smooth pursuit eye movement (SPEM) dysfunctions in major affective disorder patients have been reported to be associated with lithium treatment. We report that SPEM of 13 healthy volunteers, either taking lithium (n = 7) or placebo (n = 6), were not significantly impaired by lithium. This could point to a pathophysiologic difference between affective disorder patients and a normal population.

Blood serotonin, serum melatonin and light therapy in healthy subjects and in patients with nonseasonal depression.

The 24-h rhythms of blood serotonin and serum melatonin were determined in 39 unmediated inpatients with nonseasonal affective disorder and in 14 healthy men and women after 7 days of morning bright-light (2500 lx) or dim-light (50 lx) treatment. Bright-light treatment led to a more than 50% decrease in the Hamilton Rating Scale for Depression (HRSD) score in 4/19 patients and dim light in 1/17 patients. After light treatment the mesor (the daily mean estimated by cosinor analysis) of patients' and subjects' melatonin levels did not change significantly, nor was there a correlation between phase change and decrease in HRSD score. We observed after bright- and dim-light treatment a consistent increase in blood serotonin in patients and healthy subjects, which differed significantly between healthy subjects and patients. These findings suggest the involvement of serotonergic mechanisms following light therapy.

The vestibulo-ocular response during transient arousal shifts in man.

Horizontal vestibulo-ocular response (VOR) evoked by continuous sinusoidal rotation (0.1 Hz, +/- 90 degrees) was recorded in 20 young and healthy volunteers by DC oculography (EOG). Arousal was assessed by EEG and by reaction time measurement. While alert subject showed the characteristic VOR with vestibular nystagmus, the quick repositioning flicks disappeared during light sleep and changed to largely compensatory smooth eye deviations. This state of reduced arousal was also characterized by EEG attenuation and slow reaction times. Furthermore, we observed brief states with complete extinction of the vestibular response but without significant EEG change. The results demonstrate the high variability of VOR with shifting arousal. The polysynaptic system in the reticular formation which generates the fast phase of the nystagmus beat is far more modifiable than the three-neuronal reflex arc of the slow nystagmus component.

Phototherapy in nonseasonal depression.

Previous reports have shown that bright light exposure may benefit patients with seasonal depression. In the present study, the possible therapeutic effect of bright light in nonseasonal major depressive disorder was examined. Forty-two depressed patients not receiving additional antidepressant medication were exposed to bright white light of 2500 lux or dim red light of 50 lux over one week for two hr daily in the morning. The change in depressive symptoms was assessed by rating scales (Hamilton Depression Rating Scale, CGI) and by self-rating scales (Depression Scale, Complaint List, Visual Analogue Scale). Consistent for all ratings, the decrease in depressive symptoms after bright white light was only slight and not different from dim red-light exposure. Contrary to the findings in seasonal affective disorder, phototherapy administered over one week for two hr daily is not effective in nonseasonal major depressive disorder.

Side-effects of phototherapy in nonseasonal depressive disorder.

The data of the Berlin light therapy study were systematically reinvestigated for side-effects of light therapy as described in the literature. Forty-two patients with major depressive disorder (RDC), who also met the criteria of ICD-9 (296.1 and 296.3), were included. Patients were either given bright white-light treatment (2,500 lux) or dim red-light treatment (50 lux) from 7.20 a.m. to 9.20 a.m. every morning for a period of seven days. The study did not reveal any differences in side-effects between the two treatments. The results are discussed in relation to the two different treatment conditions.

Increased blink rates in schizophrenics. Influences of neuroleptics and psychopathology.

During a standardized visuomotor task, eye blinking, a possible parameter of central dopaminergic activity, was studied in 18 previously medicated and eight drug-naive schizophrenic in-patients in the acute state and during remission. Whereas schizophrenics executed the visuomotor task with the same precision as age- and sex-matched normal control subjects did, the mean blink rate was increased in both schizophrenic groups. During neuroleptic treatment, the mean blink rate was reduced only in the group of drug-naive patients, but not in the previously neuroleptic treated schizophrenics. This varying blinking activity is discussed with respect to the development of neuroleptic tolerance and influence of psychopathology.

Diurnal variations of mood and sleep disturbances during phototherapy in major depressive disorder.

The influence of diurnal variations of mood (DVM) and sleep disturbances on treatment response was investigated in 42 patients with major depressive disorder (not SAD) under the treatment of either bright white light (2,500 lx) or dim red light (50 lx). We found only a slight influence in certain subscales of DVM and no influence of sleep disturbances. These results are discussed under a clinical point of view and with respect to phase shift theories of depressive disorders.

Increased blink rate in drug-naive acute schizophrenic patients.

Eye blinks were investigated during a standardized visuomotor task in 15 drug-naive schizophrenic inpatients (8 men and 7 women) and 15 age- and gender-matched healthy volunteers. Whereas the schizophrenics demonstrated the same precision as normal controls in executing the visuomotor task, their mean blink rate was markedly increased (16.2 +/- 10.8 versus 9.3 +/- 6.4, p less than 0.05). Following neuroleptic treatment, the blink rate decreased, and was no longer statistically distinct from controls. The changes in blink rate correlated significantly with changes in several Brief Psychiatric Rating Scale (BPRS) items: "anxiety" (tau = 0.75; p less than 0.02), "hostility" (tau = 0.78; p less than 0.02), and "unusual thought content" (tau = 0.59, p less than or equal to 0.05), but not with the neuroleptic dose given between the first and second testing. These results underscore the influence of psychopathology on blink rates in schizophrenics.