[Electroconvulsive therapy in the treatment of severe mania. Case report and a state-of-art review]. / Elektrokonvulsionstherapie in der Behandlung der schweren Manie. Kasuistik und Wissensstand.

Despite newly developed pharmacological possibilities, treatment of acute mania may still be a problem in single patients. Independent of the first choice of medication, i.e. neuroleptics, lithium, carbamazepine or valproate, the average response rate is only approximately 50-70%. Therefore, treating mania often implies a number of monotherapeutic and polypharmaceutic attempts for several months, until a sufficient mood stabilization has been reached. The aim of this case report is to remind that electroconvulsive therapy (ECT) is still in use for treating mania, which has been widely neglected in Germany despite its high success rate, mainly reported from Anglo-Saxon countries. As demonstrated in this report, ECT may be a useful tool for a fast antimanic response in patients which may be either refractory to standard treatment or are medically severely ill, and should, in our opinion, therefore be considered already at an earlier stage of treatment in this group. However, persistence of improvement can usually only be achieved with the overlapping start of drug treatment unless the option of maintenance ECT is given.

Reversible hepatotoxicity of paroxetine in a patient with major depression.

Selective serotonin reuptake inhibitors (SSRIs) are becoming widely used because of their favorable side-effect profile and their safety in overdose. We report about a patient with recurring major depression (DSM-IIIR) who was treated with paroxetine and developed a severe hepatotoxic reaction, which was reversed after withdrawal of the drug. Individual, patient-related causes for this side-effect were not found. To our knowledge, this is the first published case of a probably paroxetine-induced severe hepatotoxicity. Hepatotoxicity should be taken into account as a rare complication that may occur not only with tricyclic antidepressants (TCAs) but also with SSRIs.

[Clinical psychopathology, psychiatric diagnosis and therapy in psychiatry]. / Klinische Psychopathologie, psychiatrische Diagnose und Therapie in der Psychiatrie.

Clinical psychopathology has a diagnostic and therapeutic purpose. On the level of phenomenology one has to deal with four paradoxes. 1. The paradox of gradual transition from normality towards pathology versus the occurrence of symptoms of a new quality, 2. the paradox of nosological nonspecificity of various symptoms versus typical constellations of special symptoms for certain diseases, 3. the paradox of pure and typical symptoms and diseases versus symptoms and diseases which are mixed and non typical. 4. The paradox of the prevalence of psychopathological phenomena versus prevalence of somatic phenomena in one and the same disease. On the level of etiology one must face the fact that there are not only typical endogenous, exogenous (organic) and psychogenic syndromes. Neurotic symptoms may have an endogenous cause. Therefore neuroses may be treated effectively with antidepressants.

[Predictive and rehabilitative perspectives in heart transplantation]. / Prädiktive und rehabilitative Gesichtspunkte bei Herztransplantierten.

27 patients who underwent heart transplantation one to five years ago, were evaluated concerning psychological and social adjustment after heart transplantation. Prior to cardiac transplantation, predictors for good rehabilitation status were absence of psychopathology, clear motivation, good social background, advanced physical debility (being bedridden as opposed to ambulatory), absence of a history of excessive alcohol consumption. Age was not found to be a predictor of outcome. Criteria for good rehabilitation status after cardiac transplantation were absence of psychopathology, good compliance, social reintegration, return to work, psychological well-being, satisfaction with the quality of life and good exercise capacity. The criteria for good rehabilitation correlate positively with the predictors specified and with each other. Psychopathology after cardiac transplantation was related to psychopathology prior to the intervention, motivation, social background, postoperative compliance, social reintegration, return to work, psychological well-being and satisfaction with the quality of life. Compliance was related with the predictors motivation, social background, history of excessive alcohol consumption, psychopathology after transplantation and return to work. Social reintegration was correlated with social background and post-transplantation psychopathology. Return to work was related to motivation, post-transplantation psychopathology and compliance. While physical well-being was not associated with the predictors except motivation, it was related to the rehabilitation factors of post-transplantation psychopathology, social reintegration, and return to work. Satisfaction with the quality of life correlated with only the rehabilitation factors of post-transplantation psychopathology and psychological well-being. Physical exercise capacity was related to psychological well-being after transplantation.

[Heart transplantation: successful treatment of postoperative complications. Case report with 19 months' follow-up]. / Herztransplantation: erfolgreiche Behandlung postoperativer Komplikationen. Fallbeschreibung mit 19monatiger Verlaufskontrolle.

In March, 1981, a 37-year old patient underwent cardiac transplantation, the first to be performed in Germany since 1969. Subsequent to the successful procedure, the patient has now been followed for more than 19 months. The indication for the intervention was established on the basis of endstage coronary artery disease. The operation was performed according to the technique of Lower and Shumway. Immunosuppression, in the early postoperative phase, was carried out with antithymocyte globulin, azathioprine and corticosteroids with administration oriented on the T-lymphocyte and total leukocyte counts as well as analysis of myocardial biopsies. In the late postoperative course, dosage of immunosuppressive agents was based almost exclusively on biopsy findings. Within the course of immunosuppressive therapy for cardiac transplantation, in particular, initial experience was gained with the use of antithymocyte globulin which was given in dosages of up to 12 mg/kg daily. The antithymocyte globulin proved effective for more than six weeks postoperatively. The alterations in immunosuppressive treatment necessitated by two gastrointestinal complications (perforated gastric ulcer, perforation of the small intestine) enabled a comparative analysis of the results of therapy with cyclosporin A given orally, intravascularly and intravenously. The Patient continues to be maintained on a regimen of cyclosporin A and corticosteroids and his general condition is good. For future cardiac transplantations, in the early postoperative course, alternating treatment with antithymocyte globulin, azathioprine and corticosteroids, on the one hand, with cyclosporin A and corticosteroids, on the other hand, would seem meaningful both to minimize adverse reactions as well as to provide effective immunosuppression. The experience rendered would promise to facilitate management of patients after cardiac transplantation.

Psychopatho-ophthalmology, gnostic disorders, and psychosis in cardiac surgery. Visual disturbances after open heart surgery.

The visual disturbances of 45 patients following open heart surgery could be divided into disturbances of (1) visual acuity, (2) visual accuracy, and (3) visual reality testing. The non-hallucinatory phenomena consisted mainly of loss of colour vision, metamorphopsias, visual gnostic disorders and cortical blindness. The hallucinatory phenomena could be divided into the delirium type of hallucinations with clouding of consciousness and the spectator type of hallucinations with a clear sensorium. The causes of the visual symptomatology and cardiac psychoses are seen in microembolization and/or ischemic hypoxia. The basal ganglia and the occipital lobe are areas of predilection for embolic and hypoxic changes. Identical psychoses also occur in cerebral malaria and polycythemia vera which show the same embolic and anoxic neuropathological changes of vascular occlusion as do many patients who die following open heart surgery with extracorporal circulation.

[Choreic syndrome following intramuscular exhibition of a contraceptive preparation (author's transl)]. / Ein choreatisches Syndrom nach intramuskulärer Applikation eines Kontrazeptivums.

PIP: A 32 year old woman with an IQ of 67 was under treatment for a post-partum psychosis characterized by a manic paranoic condition and confused thinking. An injection preparation consisting of medroxyprogesterone acetate was administered as a contraceptive. 2 days later the patient was suffering from a choreatic syndrome involving twitching in the upper extremities. Treatment with 5 mg haloperidol i.v. caused some improvement. Besides a fever, laboratory tests showed no definite results which would indicate the cause of the choreatic disturbance or the manic paranoic condition.^ieng

[Proskynesis and servility as an expression of psychotic behaviour (author's transl)]. / Proskynese und Servilitätssyndrom im Verlauf endogener Psychosen. Zur Frage von Instinktverhalten, Bewusstwerdung und Archetypus in der Psychose und zum Problem atypischer psychotischer Syndrome.

Proskynesis as an expression of submission, reverence and awe is deeply rooted in the religious and sociocultural history of man. It may be traced to the old phylogenetic submissive posture in animals, which is a pattern of behavior belonging to the group of survival instincts. Different forms of proskyneses and servility may emerge as an expression of psychotic behavior in man, reflecting a special stage of "archetypical" (C.G. Jung) consciousness. Archetypical conciousness is understood as a special step in the emergence of the human mind, thought and self-consciousness. The freedom of thinking--as the highest function of the human mind--is lost in every psychotic disorder. Archetypical consciousness with its lower stages of thinking may be typical for one kind of psychotic thinking disorder. Diagnostic problems may arise, if one does not recognize the drive of instinctive behaviour which lies behind the mere forms of human costums and religious rites.

[Diagnosis and differential diagnosis in psychiatry and the question of situation referred prognostic diagnosis]. / Diagnose und Differentialdiagnose in der Psychiatrie und zur Frage der situationsbezogenen prognostischen Diagnose.

To diagnose--in its true meaning--is a search for etiology. The different sides of psychiatric diagnoses in this century do reflect the various attempts of this search. Examples are: Kraepelin's concept of etiological unity (morbus) of a disease, Bonhoeffer's attempt of separating exogenous from endogenous psychoses, K. Schneider's definition of psychiatric illness in terms of medical disease, Kretschmer's and Rümke's multidimensional diagnoses and Essen-Möller's principle of separating (postponing) etiology from psychopathological syndromes. The situationa prognostic diagnosis plays its main role in everyday diagnosing. It presupposes that one can recognize, distinguish and differentiate between different symptoms and diseases. The decision for a specific treatment reveals which etiology one thinks to be the main one. It presupposes that one has constantly to consider the kind, the severity and the course of psychiatric disease, Nosological thinking is necessary. The term etiology has a twofold meaning in Greek. 1. cause = causa and 2. accusation, guilt = culpa. In diagnosing psychiatric illnesses this double aspect plays an important role, though unconsciously and unwillingly. Though somatogenic (metabolic) as well as psychogenic (reactive) etiologies are etiologies in the sense of causa there is a fundamental difference between them. They have a common causa materialis but a different causa efficiens. In the first instance it is the non-personal side (related to pure matter), in the second instance the personal side which makes the difference. Only a person can be responsible. Where responsibility does play a role, there also accusation and guilt play a role.

[Comparison of nondominant unilateral and bilateral electroconvulsive therapy--clinical efficiency and side effects (author's transl)]. / Vergleichende Untersuchung zur unilateralen und bilateralen Elektrokrampf-Therapie. Klinische Wirksamkeit und Nebenwirkungen.

UNLABELLED: In a double-blind study 100 patients were treated either with conventional ECT or with unilateral ECT. The majority suffered from depressive illness, mainly endogenous depression. On average, they were hospitalized 41 days and unsuccessfully treated with antidepressants and other psychoactive drugs before ECT was given as a last treatment resort. ECT efficiency was evaluated by: (1) clinical evaluation, (2) AMP documentation, (3) the Hamilton Rating Scale for Depression, and (4) the von Zerssen Mood Scale. Side effects were evaluated by a test (1) for vigilance (tachistoscopic threshold), (2) for verbal and visual memory, (3) for performance, (4) for concept formation, and (5) the Benton test. RESULTS: There was no difference in clinical efficiency between the two methods. As for side effects, unilateral ECT produced fewer organic brain syndromes and less impairment of verbal memory and performance. Total side effects were significantly less. There was no significant difference between the two methods with regard to vigilance, visual memory, and concept formation. One week after ECT, in both groups there was a significant increase in vigilance and visual memory in comparison to the results before ECT; the unilateral group also showed significant increase in verbal memory and concentration.

[Psychiatric and neurological complications associated with cardiac surgery (author's transl)]. / Zur Frage psychischer und neurologischer Störungen bei Herzoperationen.

The following problems are discussed as the result of an own investigation done with 150 patients after cardiac surgery: 1. the differences in incidence of cerebral complications understood as 2. a probleme of qualitatively different psychopathological and neurological syndromes. 3. Causes and relationship between the clinical stages of heart-disease and neuropsychiatric complications with special regard to the question 4. congenital heart-disease versus aquired heart-disease. 5. The role of extracorporeal circulation. 6. Remarks on the role of microembolism associated with open cardiac surgery. 7. Hereditary factors as the cause for specific psychopathological reactions.