[Pedophilia. Prevalence, etiology, and diagnostics]. / Pädophilie. Prävalenz, Ätiologie und Diagnostik.

Pedophilia is a disorder of sexual preference that increases the risk for committing sexual offenses against children. Consequently, pedophilia is not only relevant in psychiatric therapy and prognostics, but also greatly influences the public attitude towards criminality. Public opinion seems to equate pedophilia with child sexual abuse and vice versa which leads to stigmatization of patients and may impede treatment. The present paper provides information on recent studies on the potential origins of the disorder and introduces new diagnostic methods. Moreover, the article presents estimates on the prevalence of pedophilic sexual interest.

[Forensic-psychiatric assessment of pedophilia]. / Forensisch-psychiatrische Begutachtung bei Pädophilie.

The present paper illustrates the approach of a forensic psychiatric expert witness regarding the assessment of pedophilia. In a first step it is inevitable to differentiate if the defendant is suffering from pedophilia or if the alleged crime might have been committed because of other motivations (antisociality, sexual activity as redirection, impulsivity). A sound diagnostic assessment is indispendable for this task. In a second step the level of severity needs to be gauged in order to clarify whether the requirement of the entry criteria of §§ 20, 21 of the German penal code are fulfilled. In a third step, significant impairments of self-control mechanisms need to be elucidated. The present article reviews indicators of such impairments regarding pedophilia. With respect to a mandatory treatment order (§ 63 German penal code) or preventive detention (§ 66 German penal code) the legal prognosis of the defendant needs to be considered. The present paper gives an overview of the current state of risk assessment research and discusses the transfer to an individual prognosis critically.

[Forensic psychiatry and behavioural analysis]. / Forensische Psychiatrie und operative Fallanalyse.

UNLABELLED: A case report shows that a patient could make a progress in his therapy with the help of professional behavioural analysis after a 14-year period of stagnating forensic therapy. The method of behavioural analysis represents a criminalistic tool to reconstruct and to analyse an offence on the basis of objective data. Nowadays this method is also used successfully in individual cases in the field of forensic psychiatry. The article shows and discusses the methodology and the current use of behavioural analysis in forensic psychiatry. CONCLUSION: professional behavioural analysis of offences of certain forensic patients provides an additional benefit for their therapy and their risk assessment. This kind of approach should be intensified by increasing cooperation with behavioural analysis units and by further training for forensic therapists.

Affect regulation in borderline personality disorder: experimental findings from psychophysiology and functional neuroimaging.

BACKGROUND: Intense and rapidly changing mood states are a major feature of borderline personality disorder (BPD), which is thought to arise from affective vulnerability. OBJECTIVE: There have been only a few studies investigating affective processing in BPD, and particularly neither psychophysiological nor neurofunctional correlates of abnormal emotional processing have been identified so far. METHODS: Studies are reported using psychophysiological or functional neuroimaging methodology. RESULTS: The psychophysiological study did not indicate a general emotional hyperresponsiveness in BPD. Low autonomic arousal seemed to reflect dissociative states in borderline subjects experiencing intense emotions. In the functional magnetic resonance imaging study enhanced amygdala activation was found in BPD, and it is suggested to reflect the intense and slowly subsiding emotions commonly observed in response to even low-level stressors. CONCLUSIONS: Implications for psychotherapy are discussed.

Emotion in criminal offenders with psychopathy and borderline personality disorder.

BACKGROUND: Criminal offenders with a diagnosis of psychopathy or borderline personality disorder (BPD) share an impulsive nature but tend to differ in their style of emotional response. This study aims to use multiple psychophysiologic measures to compare emotional responses to unpleasant and pleasant stimuli. METHODS: Twenty-five psychopaths as defined by the Hare Psychopathy Checklist and 18 subjects with BPD from 2 high-security forensic treatment facilities were included in the study along with 24 control subjects. Electrodermal response was used as an indicator of emotional arousal, modulation of the startle reflex as a measure of valence, and electromyographic activity of the corrugator muscle as an index of emotional expression. RESULTS: Compared with controls, psychopaths were characterized by decreased electrodermal responsiveness, less facial expression, and the absence of affective startle modulation. A higher percentage of psychopaths showed no startle reflex. Subjects with BPD showed a response pattern very similar to that of controls, ie, they showed comparable autonomic arousal, and their startle responses were strongest to unpleasant slides and weakest to pleasant slides. However, corrugator electromyographic activity in subjects with BPD demonstrated little facial modulation when they viewed either pleasant or unpleasant slides. CONCLUSIONS: The results support the theory that psychopaths are characterized by a pronounced lack of fear in response to aversive events. Furthermore, the results suggest a general deficit in processing affective information, regardless of whether stimuli are negative or positive. Emotional hyporesponsiveness was specific to psychopaths, since results for offenders with BPD indicate a widely adequate processing of emotional stimuli.

Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization.

BACKGROUND: Based on findings of stress-induced neural disturbances in animals and smaller hippocampal volumes in humans with posttraumatic stress disorder), we hypothesized that patients with borderline personality disorders (BPD), who often are victims of early traumatization, have smaller volumes of the hippocampus and the amygdala. We assumed that volumes of these brain regions are negatively correlated with traumatic experiences and with neuropsychological deficits. METHODS: We studied 21 female patients with BPD and a similar group of healthy controls. We performed clinical assessments, a modified version of the Childhood Trauma Questionnaire, and magnetic resonance imaging volumetric measurements of the hippocampus, amygdala, temporal lobes, and prosencephalon. Neuropsychological testing included scales on which disturbances in BPD were previously reported. RESULTS: The patients with BPD had nearly 16% smaller volumes of the hippocampus (P<.001) and 8% smaller volumes of the amygdala (P<.05) than the healthy controls. The results for both hemispheres were nearly identical and were controlled for the volume of the prosencephalon and for head tilts. The volumes of the hippocampus were negatively correlated with the extent and the duration of self-reported early traumatization only when BPD and control subjects were considered together. Levels of neuropsychological functioning were associated with the severity of depression but not with the volumes of the hippocampus. CONCLUSION: In female patients with BPD, we found reduction of the volumes of the hippocampus (and perhaps of the amygdala), but the association of volume reduction and traumatic experiences remains unclear. Arch Gen Psychiatry. 2000;57:1115-1122.

[Impulse control and affect regulation in personality disorders]. / Impulskontrolle und Affektregulation bei Persönlichkeitsstörungen.

In borderline and antisocial personality disorder there is a close interaction between affect dysregulation and impulse control disorder. Different approaches are presented that focus on affective responses to experimental stimuli in these personality disorders. Results suggest that in borderline personality disorder intense emotional responses occur in the context of specific stressors, in particular fear of being abandoned. Evidence for a general emotional hyperreactivity was not found; on the contrary, female borderline subjects rather showed reduced emotional arousal. Regarding the psychopathic subtype of antisocial personality disorder, results provided strong support for the theory of emotional detachment, which may predispose to violence through a lack of feeling of fear or also of compassion which could counteract violent impulses. Consequences for psychotherapy in BPD are considered.

[Positive and negative symptoms in chronic schizophrenic patients under maintenance therapy with flupenthixol decanoate for a twelve month perioid]. / Positiv- und Negativsymptomatik bei chronisch schizophrenen Patienten unter Erhaltungstherapie mit Flupentixol-Decanoat im 12-Monats-Verlauf.

62 chronic schizophrenics, who after a psychotic exacerbation were stabilized again, were randomized on 3 different maintenance dosages of flupentixol-decanoate and observed for 12 months. 15 (24.2%) patients had a relapse independently of the dose. 34 of the 47 patients without relapse had complete documentations of the follow-up. After 3 to 6 months there was an obvious and constant clinical improvement as assessed by various test inventories. The BPRS-scores for psychopathology, negative and positive symptoms improved significantly between 14 to 18%. There was also significant reduction of negative symptoms assessed by SANS (22%) as well in the severity of illness (CGI) and an amelioration of psychosocial functioning (GAS, Strauss-Carpenter). At the end of trial 26.4% of the patients had mild involuntary movements (AIMS), 23.5% were on antiparkinson-medication. It is concluded that there could be an indication for flupentixol-decanoate in the long term maintenance therapy especially of chronic schizophrenics with negative symptoms and problems of compliance under oral medication.

[Total illness costs of schizophrenia and monetary evaluation of prevention of recurrence exemplified by a standard depot neuroleptic (flupenthixol decanoate)]. / Gesamtkrankenkosten der Schizophrenie und monetäre Bewertung einer Rezidivprophylaxe am Beispiel eines Standard-Depot-Neuroleptikums (Flupentixoldecanoat).

Treatment of patients suffering from schizophrenia is very expensive. However, by consistently and methodically performed medical prophylaxis the disease can be controlled sufficiently well. Regular prophylactic treatment compared to repeated treatment of acute episodes has both medical advantages and reduces cost by reducing the rate of hospitalisation. Prophylactic treatment with Flupentixoldecanoat can save up to 68% of costs.

Fluoxetine treatment and single psychotropic comedication: is there an increase in adverse event rates?

After the market launch of fluoxetine (Flx) in Germany in 1990 several series of drug utilization observation studies were carried out under naturalistic conditions (approximately 19,000 patients). This paper focuses on 3158 patients from neuropsychiatric practices comparing adverse event rates plus additional variables in patient groups treated with Flx monotherapy (n=1571) versus those receiving comedication with a single psychotropic (n=737), or those subgroups receiving a single antidepressant (n=222) or antipsychotic drug (n=128). Compared to the monotherapy group, both the comedicated group as a whole and the antidepressant subgroup did not show significant changes in adverse event rates. The subgroup with antipsychotic comedication revealed somewhat higher adverse event rates; the pattern of adverse events, however, was largely comparable, and extrapyramidal symptoms were reported for only a few isolated cases. Thus, these findings suggest that--under naturalistic conditions--comedication of Flx with psychotropic drugs (a commonly used treatment strategy for various reasons) is feasible and does not generally increase patient risk.

[Radiology and geriatrics: limits between normal values and pathology exemplified by conventional thoracic roentgen image, cerebral CT and MRI and pelvic-leg angiography]. / Radiologie und Geriatrie: Grenzen zwischen Norm und Pathologie am Beispiel des konventionellen Röntgenthorax, der zerebralen CT und MRT sowie der Becken-Bein-Angiographie.

Radiological examinations and intervention in the elderly are a matter of routine but require special consideration by technical and medical staff because of specific problems caused by the morbidity of the patient. Aging and degenerative processes of the organism have to be included in the interpretation of the findings. Discriminating pathological from age-related alterations is occasionally difficult. This paper demonstrates senile pulmonary emphysema, physiological brain atrophy and arterial angiosclerosis as typical examples for age involution. Age-related changes are compared with similar pathological findings. Clinical symptoms of the patient are decisive for the interpretation and classification of images as well as the subsequent therapeutical procedure.

Lithium versus carbamazepine in the maintenance treatment of bipolar disorders--a randomised study.

In a randomised multicentre study, the prophylactic efficacy of lithium and carbamazepine was compared in 144 patients with bipolar disorder (74 vs. 70 patients; observation period: 2.5 years; lithium serum level: 0.63 +/- 0.12 mmol/l, carbamazepine dose: 621 +/- 186 mg/day). Hospitalisations, recurrences, need of psychotropic comedication and adverse effects prompting discontinuation were defined as treatment failures. Survival analyses regarding hospitalisations and recurrences showed no statistically significant differences between both drugs. Results were distinctly in favour of lithium, considering recurrences combined with comedication (P = 0.041) and/or adverse effects (P = 0.007). Whereas adverse effects prompting discontinuation were more frequent under carbamazepine (9 vs. 4, ns), lithium patients reported more often slight/moderate side effects (61% vs. 21% after 2.5 years; P = 0.0006). In completers, recurrences occurred in 28% (lithium) vs. 47% (carbamazepine) of the patients (P = 0.06). Lithium seems to be superior to carbamazepine in maintenance treatment of bipolar disorder, in particular when applying broader outcome criteria including psychotropic comedication and severe side effects.

Antidepressant drug use: differences between psychiatrists and general practitioners. Results from a drug utilization observation study with fluoxetine.

Between 1990 and 1993, a series of drug utilization observation studies with fluoxetine (Flx) were conducted in Germany in several waves. 3,158 patients treated by psychiatrists/neurologists (PN) and 15,601 patients treated by general practitioners/internists (GPI) were included; data collection at start and end of treatment focussed on diagnoses, symptoms, prescription, comedication, efficacy (CGI, Zung scale), and adverse events. Differences between PN and GPI patients were of major interest. For more than 90% of both the PN and the GPI cases. Fix was used for the indication of "depression", with a dosis of 20 mg/day. More PN patients (47%) than GPI patients (28%) were diagnosed as "endogenous"; GPI patients more often presented with first episodes (36 vs. 24%). "suicidal ideation" was less prominent compared to PN subjects (17 vs. 28%). Psychotropic comedication was regarded as necessary in 39% (PN) and 10% (GPI) of the cases. Early treatment termination because of "remission/major improvement" was observed in 13% (PN) vs. 21% (GPI) and because of "adverse events" in 11% (PN) vs. 3% (GPI) of the patients. At observation end, 53% (PN) vs. 74% (GPI) were rated as "symptom-free/markedly improved" (CGI); self-ratings reflected comparable results, marked improvements over time, but still PN/GPI differences at the end. "Suicidality" related to depression was more pronounced in the PN group at both points in time. 24% (PN) vs. 6% (GPI) of the cases reported "routine" adverse events, while in 2% (PN) and 1% (GPI) "serious" adverse events were observed. (For all the above comparisons p < 0.001 to < 0.0001.) These findings reveal that-under routine conditions handled by PNs and GPIs-Fix shows an efficacy and safety consistent with clinical trial data. The body of data suggests that PN patients present with more severe depression and more suicidality, require more comedication, and end up with a poorer outcome. Differences in the physicians' perception of psychiatric and somatic symptomatology and their treatment routines may also have something to do with the PN/GPI group differences observed.

Guidelines for the implementation of drug utilization observation (DUO) studies in psychopharmacological therapy. The "Phase IV Research" Task-Force of the Association for Neuropsychopharmacology and Pharmacopsychiatry (AGNP).

The task-force on Phase-IV-Research of the Association for Neuropharmacology and Pharmacopsychiatry (AGNP) has developed guidelines for the implementation of scientifically sound drug utilisation observation studies (DUO studies). These guidelines have been adopted by the executive committee as the position of the association. DUO studies are prospective pharmacoepidemiological studies, by which prescription, illness, and patient data of individual patients are collected without interference with the routine course of treatment. They can answer questions on the interaction of treatment modalities with positive and negative treatment outcome. Scientific standards require that there is a study protocol which describes the epidemiological, statistical, procedural, and quality assurance methodology and states who is responsible for what. As such studies can violate data protection regulations or can be used for sales instead of scientific purposes, consultation of an ethics committee is recommended.

Lithium vs carbamazepine in the maintenance treatment of schizoaffective disorder: a randomised study.

In a randomised multicentre study, the prophylactic efficacy of lithium and carbamazepine was compared in schizoaffective disorder. A total of 90 ICD-9 schizoaffective patients were included in the maintenance phase (2.5 years). They were also diagnosed according to RDC and DSM-III-R and classified into subgroups. Mean serum levels were 0.58 +/- 0.12 mmol/l for lithium and 6.4 +/- 1.5 micrograms/ml for carbamazepine (mean dose 643 +/- 179 mg/d). Outcome criteria were hospitalisation, recurrence, concomitant psychotropic medication and adverse effects leading to discontinuation. There were more non-completers under carbamazepine than under lithium (p = 0.02). Survival analyses demonstrated no significant differences between lithium and carbamazepine in treatment outcome. Patient's ratings of side effects (p = 0.003) and treatment satisfaction (p = 0.02) favoured carbamazepine. Following the RDC criteria, patients of the schizodepressive and non-classifiable type did better under carbamazepine (p = 0.055 for recurrence), whereas in the schizomanic patients equipotency of both drugs was found. Applying DSM-III-R, carbamazepine demonstrated a superiority in the patient group with more schizophrenia-like or depressive disorders (p = 0.040 for recurrence), but not in patients fulfilling the DSM-III-R criteria of bipolar disorder. Lithium and carbamazepine seem to be equipotent alternatives in the maintenance treatment of broadly defined schizoaffective disorders. However, in subgroups with depressive or schizophrenia-like features and regarding its long-term tolerability carbamazepine seems to be superior.

Comparative efficacy of lithium and amitriptyline in the maintenance treatment of recurrent unipolar depression: a randomised study.

The present study, including 81 depressive patients, compares the prophylactic efficacy of lithium and amitriptyline in recurrent unipolar depression over a treatment period of 2.5 years in a randomised multicentre design. Hospitalisation, re-emergence of depressive or subdepressive recurrences, unwanted side-effects and need of concomitant psychotropic medication were considered to indicate treatment failures. Average dosage for amitriptyline was 98 +/- 37 mg/day, average lithium blood level was 0.59 +/- 0.12 mmol/l. Survival analyses demonstrated a significant superiority of lithium (P = 0.015) regarding the outcome criteria 'recurrences and/or subclinical recurrences' and non-significantly better results of lithium compared to amitriptyline concerning 'recurrence' (P = 0.059) or 'recurrence and/or concomitant medication' (P = 0.066).

[Trends in drug therapy of obsessive-compulsive disorders]. / Trends in der medikamentösen Therapie bei Zwangsstörungen.

Within different drug treatment strategies in obsessive-compulsive disorder (OCD) namely selective serotonin reuptake inhibitors (SSRI) (e.g. Fluoxetine max. 60 mg/die as well as Clomipramin 200 mg/die) have conveyed consistent benefit. In the case of non-response after an adequate treatment of 10-12 weeks it should be switched on alternative serotonergic antidepressants. If a persistent non-response results a so-called "augmentation treatment" is recommended. The principle of augmentation consists in an increase of activity resulting from combination of serotonin agonists (e.g. Buspiron) with SSRIs. The combination of monoaminoxidase inhibitors (MAOI) with SSRIs--in the literature often described as effective in treatment resistant OCD--is inadvisable and strictly contra-indicated (cave: Serotonin-Syndrome). In some cases monotherapy with MAOI seems effective (Schmauss et al., 1993). For this, it has to be regarded that a restriction period is given (e.g. 5 weeks after a pre-going Fluoxetine treatment). The combination of SSRIs and alternative serotonergic antidepressants with neuroleptics is only effective in cases of "spectrum disorders" and comorbidity (namely Gilles-de-la-Tourette-Syndrom). The use of neuroleptics in OCD should be strictly limited.

The recruitment process for a multicenter study on the long-term prophylactic treatment of affective disorders.

The paper reports on the process of patient recruitment for a controlled clinical multicenter study on the treatment of affective disorders. Two thirds of the patients screened did not participate because prophylactic treatment was either unnecessary or not justified for medical reasons. Further, a number of patients equal to that eventually allocated to the trial refused to participate for personal, idiosyncratic reasons. In spite of this, the patients in the trial were very similar to those not participating with respect to relevant variables such as age, sex, number of and intervals between previous episodes or severity of the present episode.