[Fredy Quadfasel (1902-1981) : Neuropsychiatrist, politically persecuted NS opponent and his impact in American exile]. / Fredy Quadfasel (1902-1981) : Neuropsychiater, politisch verfolgter NS­Gegner und sein Wirken im US­amerikanischen Exil.

The physician and psychologist Dr. Fredy Quadfasel, born in East Prussia, was trained in neuropsychiatry by Kurt Goldstein in Frankfurt/Main and by Karl Bonhoeffer at the Charité in Berlin. After he was detained by the Gestapo due to political opposition, he was probably denounced for offending the so-called Malicious Practices Act (Heimtückegesetz) from March 1933, and imprisoned for 2-3 months. In 1934/35 he emigrated to the USA via England and Canada, where he initially ran a neuropsychiatry office in New York. Very soon he was able to take on an academic post and became an instructor in neurology. After medical military service in 1944-1947 at the Cushing General Hospital in Framingham near Boston, he was appointed head of the neurological department. Later he moved on to the Boston Veterans Administration Hospital. His academic positions included being an instructor in neurology at Harvard Medical School and associate professor at the Boston University School of Medicine. He had a considerable impact on neurology, especially on the locally emerging discipline of neuropsychology represented by Harold Goodglass and Norman Geschwind. Despite a lack of personal records of Quadfasel, a chequered reconstruction of his life and work was possible due to many archival documents with which it was possible to trace the career of a highly esteemed neurologist in Germany and the USA.

Leo Kanner: his years in Berlin, 1906-24. The roots of autistic disorder.

By providing the first description of infantile autism Leo Kanner (1894-1981) has substantially influenced the field of child and adolescent psychiatry. The classification of the disorder seems to be evolving with progress in clinical and diagnostic research, epidemiology and genetics. In the current classification systems of ICD-10 and DSM-IV, Kanner's name is merely mentioned, in contrast to other specified pervasive developmental disorders. This article draws attention to Kanner's early scientific career at Berlin's Charité University Hospital which ended in 1924 with Kanner's emigration to the United States. The study is based on original documents such as the files of Kanner's doctoral thesis on electrocardiography and cardiophonography found at the archives of Humboldt University of Berlin, and his unpublished autobiography, located at the library of the American Psychiatric Association in Washington, DC.

The outcome of adolescent eating disorders: findings from an international collaborative study.

Within the International Collaborative Outcome Study of Eating Disorders in Adolescence (ICOSEDA) we studied the clinical features, treatment, and outcome in consecutive cohorts of adolescent patients at five sites in former West Berlin and East Berlin, Zurich, Sofia and Bucharest. A total of N = 242 patients were followed up after a mean interval of 6.4 years in young adulthood. Using semi-structured interviews it was found that on average the patients were in either inpatient or outpatient treatment for 30% of the entire period between first admission and follow-up. Across the five sites 70% recovered from the eating disorder and a similar rate showed good or fair psychosocial functioning and no other psychiatric disorder. However, the combination of these three criteria showed that at follow-up only every second former patient was a mentally healthy and psychosocially well functioning person. The univariate and joint consideration of a large list of predictors lead to the conclusion that individual prognosis of the course of adolescent eating disorders is a hazardous undertaking.

Karl Bonhoeffer and the concept of symptomatic psychoses.

With the description and classification of Symptomatic psychoses in 1908, Karl Bonhoeffer laid the foundation for a categorization into exogenous and endogenous psychoses. This opened new pathogenic and psychopathologic horizons in connection with the aetiology of psychoses, as was particularly exemplified by Bonhoeffer in the 'catatonic psychoses'. Later, his concept of Symptomatic psychoses was further developed. Especially the symptom of an impaired consciousness as a diagnostic criterion in delirium underwent a critical discussion. However, Bonhoeffer's basic positions have not even now lost their significance. They find their representation in a modified form in all of the recent classification systems ICD-10 and DSM-IV. The study of pathogenic, clinic-psychopathologic, classificatory and therapeutic perspectives in detail, following Bonhoeffer's example, remains an important task for neuropsychiatry in the present as well as the future.

Body image and self-esteem in adolescent ballet dancers.

Body-image disturbances and low self-esteem have been implicated in the pathogenesis of eating disorders. This study investigated self-perception of body and personality among adolescent ballet dancers in a cross-sectional survey. Two questionnaires assessing "my body right now" and "my personality right now," using semantic differentials were completed by 90 ballet school students and 156 controls. Adolescent female dancers (ages 13 to 17 years) scored higher than age-matched controls and 11- to 12-yr. old peers on Undesirability and Sensitivity for personality and Unattractiveness for body. For both subscales of personality, differences were also found between male and female dancers; female ballet students scored higher. Within the control group a difference could be found only for Sensitivity on which girls scored higher than boys. Male dancers did not differ from controls except for a lower score on the Body mass measure. Adolescent female dancers showed a distinct answering profile for 7 of 16 semantic differentials in each questionnaire implicating less favorable body image and self-esteem. Interventions focused particularly on enhancing self-esteem may be useful in the prevention of psychopathology in adolescent ballet dancers.

[Autism in children. Speech, behavior and motor activity point to diagnosis]. / Autismus bei Kindern. Sprache, Verhalten und Motorik verraten die Diagnose.

Austistic disorders characteristically involve specific impairments of social skills, of the language and of stereotyped body movements. L Kanner and H. Asperger were the first to describe these psychopathologic features, which still form the core of the diagnostic criteria of contemporary psychiatric classification systems, ICD-10 and DSM-IV, in the category pervasive developmental disorders. Useful diagnostic tools have been developed to establish the clinical diagnosis. The results of research point to a predominantly genetic pathogenesis involving a complex interaction of multiple genes. While no causal treatments are available for these heterogenic disorders, there are many therapeutic concepts. Although some treatments may achieve significant improvements, autistic disorders usually mean a lifelong individual impairment.

Mathematics and the brain: uncharted territory?

The prevalence of disorders of arithmetic skills in children of circa 6 % calls for intensive consideration of the subject by health care providers and researchers. The necessity of interdisciplinary cooperation is evident. The current classifications by the ICD-10 (Specific disorder of arithmetic skills) and DSM-IV (Mathematics disorder) represent different viewpoints. A developmental dyscalculia is exclusively diagnosed according to clinical presentation. Arithmetic and its disorders are brain functions, determined and influenced by the (cerebral) human development. With modem neuroimaging techniques, a connectionistic model of distinct arithmetic functions has been specified. The results of single case descriptions of arithmetic disorders correspond well in that context with the concept of parallel cortico-subcortical and subcortico-cortical neuronal circuits. In comparison with dyslexia, there is intense need for research in the field of arithmetic disorders. Only through analysis and understanding of the complex cerebral connections in arithmetic can improved diagnostic as well as multidimensionally therapeutic approaches to arithmetic disorders be achieved, possibly opening new ways of academic and social integration of the affected individuals.

Are there specific disabilities of number processing in adolescent patients with Anorexia nervosa? Evidence from clinical and neuropsychological data when compared to morphometric measures from magnetic resonance imaging.

The cerebral effect of the loss of body weight in Anorexia nervosa (A.n.)--the so-called 'pseudoatrophy'-- is well known and confirmed by several neuroimaging studies. Another subject of intensive research has been whether A.n. leads to specific cognitive impairments, especially of intelligence. However, there are no previous studies on the relations between the cerebral changes, intelligence performance, and disorders of number processing in adolescent patients with A.n. We examined n = 18 inpatients with A.n. (means at admission: age 14.5 years, SD 1.59; BMI 14.9, SD 1.36), diagnosed according to ICD-10 criteria at three different timepoints: at admission to treatment (T1), with 50 % restoration of their normal weight (T2), and with normal weight (T3). At each timepoint, a cerebral MRI scan was obtained. Based on the MRI we determined the volume of the external and internal cerebrospinal fluid cavities, fissures of Sylvius, the surface of mesencephalon and pons, and surface and length of the Corpus callosum. At T1 and T3, a neuropsychological examination was conducted including tests of the general fluid ability and general cristallized ability of intelligence (CFT-20), as well as tests of vocabulary and number processing. The same instruments were given to a group of matched controls (means: age 15.8 years, SD 1.57; BMI 20.5, SD 2.3) at one timepoint. We could show a significant volume difference of the lateral ventricles and the fissure of Sylvius between patients at T, and controls, which abaded with the patient's weight restoration. But a significant surface deficit of the mesencephalon, and less pronounced in the pons, persisted to T3 in patients when compared to controls, suggesting a selectivity of the cerebral changes in A.n. The neuropsychological examinations revealed significant changes in test performance for both the general intelligence test and number processing. At T1 the number processing performance was significantly lower in patients when compared to controls. However, when the patients had restored their normal body weight, we found 2.02 % with a 'severe disorder of arithmetic skills' and 4.45 % with a 'functional disorder of arithmetic skills'. This combined prevalence of 6.47 % of patients with a subnormal arithmetic performance is analogous to that in the normal population.

Neuropsychological differentiation of subnormal arithmetic abilities in children.

For the neuropsychological diagnosis of a Specific disorder of arithmetic skills the standard is defined worldwide by the diagnostic guidelines of the two major classification systems of psychiatric disorders, the ICD- 10 and the DSM-IV, both of which use the discrepancy criterion as the key feature of the diagnosis. It becomes clear that following such guidelines can only mean an extensive diagnostic assessment of patients with subnormal arithmetic abilities, including the social and previous medical history followed by the exclusion of a present disorder or disability, often necessitating laboratory, neuroimaging and neurophysiological tests. In the neuropsychological diagnosis of a Specific disorder of arithmetical skills we found a stepwise approach including previously obtained test results to be most practical and economical. The assessment instruments such as intelligence tests, neuropsychological test batteries, academic achievement tests, specific neuropsychological tests, test batteries for arithmetic abilities or error analysis are discussed. An overview of case studies in the literature is given; however, the overwhelming majority of case reports on patients with arithmetic disabilities are casuistics of adult patients with an acquired loss of arithmetic abilities. The importance of a differentiated neuropsychological diagnosis is demonstrated by four of our own cases: of borderline deficient intelligence, a combined disorder of academic skills, congenital brain dysfunction, and a specific disorder of arithmetic skills. Especially the new quality in assessing arithmetic abilities with the NUCALC battery is demonstrated; diagnostic and therapeutic consequences are discussed.

The specific disorder of arithmetic skills. Prevalence studies in a rural and an urban population sample and their clinico-neuropsychological validation.

There is an often noted lack of research in the field of disorders of arithmetic skills. The present study assessed the prevalence in both an urban and a rural population sample of German schoolchildren, using standardized academic achievement tests. Eight school classes of third graders in each area were examined (n = 181,182; respectively). We found that 6.6 % (n = 12) of the rural and 6.59 % (n = 12) of the urban school children performed significantly worse in arithmetic than in their spelling tests. Since the diagnostic criteria for the Specific disorder of arithmetical skills and their significance are widely discussed, we attempted in a second step of the study to validate the diagnosis of the Specific disorder of arithmetical skills from a neuropsychological and medical viewpoint. For the validation we assessed clinical data, imaging and neurophysiologic studies as well as a neuropsychological test battery. Nine and five of the children, respectively, were available for this further evaluation. Although the majority of these probands (n = 10) had distinct arithmetic deficits, only three of them met the full diagnostic criteria of the ICD-10 for a Specific disorder of arithmetic skills. In a last step, we compared the data of both studies. Our data strongly support a thorough cliniconeurological, neuropsychological and academic assessment of students with a suspected Specific disorder of arithmetic skills. The current diagnostic criteria should be reconsidered and possibly modified towards a more psychopathologic definition. We stress the need that the condition becomes better known among all professions concerned with the care of children, as difficulties with acquiring arithmetic skills should be detected and approached appropriately as early as possible. The imperative demand of future empiric research is emphasized.

[Anorexia nervosa--the triad of metric index, BMI age-specific percentile curve and goal weight]. / Anorexia nervosa--Die Trias von Metrik-Index, BMI-Altersperzentilenkurve und Zielgewicht.

Cross sectional and longitudinal data from the Berlin Anorexia Study on the inpatient treatment of n = 133 adolescent females with the principal axis I diagnosis of an eating disorder (n = 104 anorexia nervosa, n = 19 bulimia nervosa, n = 10 eating disorders not otherwise specified; according to ICD-10 and DSM-IV criteria) indicate a significant shift in the frequency distribution of somatometrically assessed types of body shape among patients as categorized by the Metric Index, towards the leptomorphic phenotype (p < 0.050, chi 2/Fisher's). Three explanatory models are discussed. Diagnostic and therapeutic implications, particularly of the determination of target weight in anorexia nervosa based on the individual's type of body shape, are emphasized, and an operational algorithm is proposed which uses the Metric Index and sex-specific BMI age percentiles adjusted for type of body shape.

[Anorexia nervosa and "anorexia athletica"]. / Anorexia nervosa und "Anorexia athletica"?

Available evidence supports the assumption that stressors in vulnerable adolescence potentially lead to restrictive dieting and imbalances of serotonergic metabolic particularly in females. In conjunction with idealized body images and developmentally characteristic bodily perceptions prone to distortion pathogenetic mechanisms of eating disorders are released. The entities of eating disorders are dimensionally viewed as points of continua a functions and categorized according to ICD-10 or DSM-IV, respectively. Data of our studies on grammar school students, ballet dancers and anorexia nervosa patients emphasize the necessity to differentiate different types of body shape by using the metric index. Facing this background a distinction of "anorexia athletica" appears unreasonable.

Adolescent ballet school students: their quest for body weight change.

Body mass index (BMI) and body type of female and male adolescent ballet dancers (n = 90) and school students (n = 156) were determined. Participants were asked for the body weight she or he would prefer, and ballet students were administered the Eating Attitudes Test-40 (EAT-40). Results between age groups and with reference values were compared. Both in dancers and controls, girls wanted to lose more body weight than boys, with female ballet dancers more than female controls. The desire for reducing body weight was expressed by female ballet dancers of all BMI percentiles and body types, with the highest difference between real and desired body weight in 11-, 13-, and 16-year-olds. In the other groups, a quest for lower body weight was expressed only by adolescents of higher BMI and pyknomorphic and/or mesomorphic body type. Female ballet dancers of all age groups sought to reach body weights below the 5th percentile or below 82% of normal body weight. Desired body weight change was influenced by BMI and body type and correlated positively with EAT-40 score.

The Eating Attitudes Test: comparative analysis of female and male students at the Public Ballet School of Berlin.

Differentiated examination of eating attitudes and behaviours of female and male German ballet school students with particular reference to their age and analysis of common points with and differences from female Anorexia nervosa (A.n.) patients. The Eating Attitudes Test (EAT-40) was used. Male and female adolescent students of a ballet school and a high school as well as anorectic patients participated in this study. EAT totals exhibited by female and male ballet school students were higher with significance than those recorded from high school students. EAT totals > 30 were reached by 21.6% of female ballet school students but by no male ballet school student at all. In the context of certain EAT items, a number of differences are described between female ballet school students, on the one hand, and female A.n. patients, on the other. No case was identifiable which would satisfy ICD-10 criteria for Anorexia nervosa. Attitudes and behaviours of adolescent female and male ballet dancers toward eating and their own body should be judged with due consideration of their specific living conditions.

[Eating before of an unselected student population of the 7th to 10th grade in a Berlin school]. / Untersuchungen zum Essverhalten in einer unselektierten Schülerpopulation der 7. bis 10. Klasse einer Berliner Schule.

In 1990 a study of 32 girls and 44 boys in Grades 7 to 10 in a former "East Berlin" school in the borough of Prenzlauer Berg was carried out in continuation of an "East-West Berlin Study on Eating Disorders in Adolescents" which we had initiated in the mid-eighties. The Eating Attitudes Test (EAT), Eating Disorder Inventory (EDI), State of Comfort Scale (SCS) were used in a one-step study design together with complementary clinical and sociodemographic data, including body weight, height and BMI. On the whole, all students were well aware of their own body measurements and had definite ideas about their ideal body weight. Boys were less sure about their real weight, while girls showed some insecurity in defining their ideal weight. Regardless of weight parameters, girls were more strongly preoccupied with issues specific to eating disorders, such as dissatisfaction with their own body, the quest for a slim figure and diet. They were more severely affected by perceptions of insufficiency. 44% of all girls and 4% of the boys said they had problems with their body weight. These students' intensive preoccupation with issues specific to eating disorders was dependent on their actual body weight. They exhibited more clearly pronounced psychological characteristics of eating disorders. Eating-related and psychological characteristics of eating disorders were significantly more pronounced in girls with irregular menstruation. The correlation between irregular menstruation and individually perceived weight problems was significant. These results are discussed in greater detail with due consideration of the need for understanding the specific dynamics of eating attitudes in the general population.

Mortality and sudden death in anorexia nervosa.

OBJECTIVE: Mortality rates of anorexia nervosa (AN) are generally assumed to rise with increasingly protracted follow-up periods. Reports are highly variable, with rates ranging between 5 and 20%. A rate of 5.9% resulted from very recent meta-analyses. Causes of death of AN patients ranged from suicide to sudden death. METHOD: Findings so far published on clinical course, follow-up, outcome, prognosis, mortality, and sudden death in AN cases were systematically analyzed with the view to checking on divergent definitions of mortality rate, crude mortality rate, mortality death rate, and methodological problems of recording which may be causes of variability of data and evaluations. The same variability applied to descriptions of causes of death in AN. While suicide data usually are precise, most of all deaths resulted from inadequately defined complications of eating disorder, and in some cases the cause of death, including sudden death, is reported as unknown. RESULTS: The crude mortality rate due to all causes of death of AN patients was found to be 5.9% by means of linear regression in a meta-analysis. However, no absolute, precise data were given on causes of death, including sudden death in AN. Reference is made to the great variety of somatic alterations as well as to the role played by cardiac arrhythmia and acute circulatory failure in the context of sudden death. DISCUSSION: Any AN death should be fully reported for proper elucidation of the causes. Neuroanatomic, neuropathological, and neurohistological studies should be conducted, primarily into the right brain hemisphere for accurate determination of etiological relationships between cerebral function, brain alterations, and AN. An account is given in this paper of preliminary results obtained from a quantitative-neurohistological investigation of the brain of a female AN patient aged 13.5 years who died a sudden death.

Anorexia nervosa and sudden death in childhood: clinical data and results obtained from quantitative neurohistological investigations of cortical neurons.

A crude rate of mortality of 5.9% has been quoted for Anorexia nervosa (AN) in recent studies. There are different causes of death ranging from suicide to sudden death. Autopsy data are extremely rare about brain alterations in deceased AN patients. Reported in this study is a female patient, aged 13.5 years, who died of acute AN. Quantitative neurohistological investigation post mortem was performed on her brain. Results were compared with data obtained from a girl of the same age with no contributory neuropsychiatric findings. In the cortex of the anorexia case beside typical pyramidal neurons, a slim neuron type with one extremely long basal dendritic field was found to occur more frequently than normal. In the neurons of the AN case, the ramification pattern of single basal dendritic fields was found to be reduced and changes in the spine morphology, as well as reduction in spine density, were observed. However, a simultaneous lengthening of the terminal dendrites of higher order gave some evidence for repair mechanisms and neuronal plasticity. The AN-specific implications of these findings are discussed. The conclusion is that all AN deaths should be reported together with descriptions of causes and cerebral alterations.