Dangerous or merely difficult? The new population of forensic mental hospitals.

BACKGROUND: During recent decades, there has been a substantial increase in admissions to forensic mental hospitals in several European countries. It is not known if reforms implemented in mental health policies and practices are responsible for this development. OBJECTIVE: Our study examined the development of mental health care in Austria and the incidence and prevalence of mentally disordered offenders judged not guilty by reason of insanity (NGRI). METHODS: We analysed data on service provision and data from criminal statistics between 1970 and 2008 from several national sources. RESULTS: During the first decade when reforms to mental health practice were implemented, the incidence and prevalence of offenders judged NGRI remained unchanged, despite a reduction of mental hospital beds by nearly 50% and little outpatient care. Surprisingly, the enormous increase in admissions to forensic inpatient treatment began in Austria only after community mental health services were rolled out across the country in the 1990s. This increase was primarily due to admissions of patients who had committed less severe offences, while rates of those who had committed homicide remained unchanged. CONCLUSION: Our results cannot be explained by details of the reforms such as the downsizing of mental hospitals or a lack of outpatient facilities, nor by changes to criminal sentencing. Rather, the results provide evidence of an increasingly inadequate provision of comprehensive care for "difficult" but not extremely dangerous psychotic patients living in the community. This may result from the attitudes of mental health professionals who have become less inclined to integrate aggressive behaviour into their understanding of psychosis. As a consequence, increasing numbers of "difficult" patients end up in forensic psychiatric institutions. This development, which can be observed in nearly all European countries, raises concerns with regard to efforts to destigmatize both patients and psychiatry.

Homicide and major mental disorders: a 25-year study.

OBJECTIVE: This study was designed to investigate the association between major mental disorders (MMDs) and homicide. METHOD: The rates of exculpations because of MMDs among 1087 Austrian homicide offenders during 1975 and 1999 were compared with the rates of the respective disorders in the general population. RESULTS: MMDs were associated with an increased likelihood of homicide (two-fold in men and six-fold in women). This was exclusively because of schizophrenia (age-adjusted ORs in men 5.85, CI 4.29-8.01; in women 18.38, CI 11.24-31.55) and delusional disorder in men (OR 5.98, CI 1.91-16.51). Comorbid alcohol abuse/dependence (additionally) increased the odds in schizophrenia, major depression and bipolar disorder. CONCLUSION: The increased likelihood of homicide in subjects with MMDs cannot be fully explained by comorbid alcoholism. The results point to the special importance of sufficient treatment for a subgroup of mentally ill individuals being at higher risk of violence.

Being a webcam.

Searching through studies of schizophrenic delusions with a view to the new media, we came across the case of a young woman who integrated the Internet in her delusional system. Analysing the story she told, we recognised a psychotic symptom, which we preliminarily called 'perception broadcast'. Perception broadcast shows a more complex structure than the related first rank symptom 'thought broadcast' described by Kurt Schneider. In our view the existence of a structure like perception broadcast depends on the existence of new technologies, such as the World Wide Web and 'virtual reality', creating new cultural patterns which themselves are associated with collective perceptions of derealisation.

Old wine in new bottles? Stability and plasticity of the contents of schizophrenic delusions.

A number of recent case reports published during the last 20 years described a quick inclusion of new technologies and cultural innovations into schizophrenic delusions which led many of the authors to the conclusion that the 'Zeitgeist' is creating new delusional contents. On the other hand, long-term comparisons and comparative transcultural studies on delusions showed, despite a certain degree of variability, a stability of delusional themes over longer periods of time. Combining anthropological and historical theories of the development of societies with a differentiated psychopathological approach (Klosterkötter's three-stage model of the formation of schizophrenic delusions), we were able to resolve the problem of the ostensibly divergent results: there are only a few themes of extraordinary anthropological importance for the organization of human relationships which can be found in every epoch and in different cultures (persecution, grandiosity, guilt, religion, hypochondria, jealousy, and love). With the exception of persecution and grandiosity, these themes showed a certain variability over time and between cultures. The 'new' themes, referring to the development of modern technology and the rapid changes of 'cultural patterns' turned out to be only the shaping of the basic delusional themes on the 3rd stage of Klosterkötter's phase model (concretization).

Are we witnessing the disappearance of catatonic schizophrenia?

The decrease in the frequency of diagnosed catatonic subtypes among schizophrenic disorders as a whole during the last 50 years has long been regarded as an established fact. Until now the factors responsible for this development have been under discussion. As it is not clear if there is a true decrease or an ostensible one due to other factors such as changed diagnostic habits or neuroleptic treatment, we examined 174 consecutively admitted schizophrenic patients from three different psychiatric institutions diagnosed according to DSM-IV and Leonhard's criteria. It turned out that-depending on the diagnostic system-the rates of diagnosed catatonias were 10.3% (DSM-IV) and 25.3% (Leonhard's criteria). Comparison of the two original Leonhard cohorts (1938 to 1968, 1969 to 1986) with our own (1994 to 1999) shows a decrease in the frequency of catatonias from 35% to 25%, which-albeit statistically significant-is much less pronounced than in studies that used a narrower definition of catatonia. Here, besides sociocultural developments, the use of neuroleptics seems to effect the decrease in the frequency of catatonias in two ways: on one hand, they cause a decrease of hyperkinesia, excitement, or impulsivity; while on the other hand, they themselves produce motor abnormalities like rigidity, effects that favor the attribution of motoric symptoms to neuroleptics.

Guilt and depression: a cross-cultural comparative study.

Although nearly a century has passed since Kraepelin's investigations in Java [Cbl Nervenheilk Psychiatr 1904; 27:468-469], one crucial question regarding guilt in the course of depression has still not been decided: Is there a more or less stable connection independent of culture, or is guilt confined to certain civilisations? This study investigated this issue in 100 Pakistani and 100 Austrian out-patients diagnosed with 'major depression' according to DSM-IV by means of standardised instruments (Schedule for Affective Disorders and Schizophrenia-Life Time Version, Hamilton Rating Scale for Depression, 21-item version). The experiences of guilt were subdivided into ethical feelings (ethical anxiety and feelings of guilt) and delusions of guilt. It turned out that ethical feelings could be found in both cultures regardless of age and sex. They seem to be primarily related to the extent of depressive retardation. However, the distribution of the two subsets of ethical feelings was culture dependent. Delusions of guilt were confined to patients of the Austrian sample. So, our data qualify the exclusivity of the aforementioned two points of view and support the need for a psychopathologically differentiated approach.

The age of onset of schizophrenia and the theory of anticipation.

The clinical phenomenon called anticipation is usually defined as a decrease in age at onset and/or an increase in disease severity in successive generations of afflicted families. The purpose of this study was to examine variables that might influence anticipation in schizophrenia. A total of 380 Austrian patients, born between 1935 and 1964, met criteria for schizophrenia with ICD-8 or ICD-9, SADS-L and DSM-III-R criteria. The inclusion criteria also required medical records of patients to contain information about the year of birth, season of birth, age at onset, accidents or meningoencephalitic diseases during childhood, first- and second-degree relatives afflicted with schizophrenia, sibship size, sib order, education of patient, age of parents, occupation of parents, loss of parents, and place of residence. A Cox multiple-regression analysis showed three factors as having a significant influence on the age of disease onset, including year of birth (which had the largest influence), family history (sporadic cases showed an onset 2 years later than familial cases) and residence (urban dwellers showed psychotic symptoms approximately 1 year sooner than rural ones). A Kaplan-Meier Survival Analysis showed that younger cohorts had onset approximately 10 years earlier in sporadic and familial cases. This cohort effect might be a major source of bias in studies of anticipation.

Sibling orders of schizophrenic patients in Austria and Pakistan.

The influence of siblings on the socialization of the individual has been recognized as a fact by both psychology and sociology. The significance of sibling order for the outbreak of psychiatric diseases on the other hand is still discussed controversially. In our study, we compared the expected values and the positions actually found in the sibling order of 379 (233 males, 146 females) Austrian and 144 (101 males, 43 females) Pakistani patients diagnosed with schizophrenia according to DSM-IV (295). The position in the sibling order had no influence on the outbreak of schizophrenia in Austria; with Austrian schizophrenics, the results found were very near to the expected values. In Pakistan on the other hand, the eldest brothers from families with 2-4 siblings had a significantly higher risk of falling ill. The investigation of the composition of the sibships of schizophrenic patients also showed a high overrepresentation of men in the firstborn position in Pakistan. These facts seem to exercise influences that may either protect against the outbreak or encourage it. The differences found agree well with the fact that in Pakistan, both the gender of a child and the position in the sibling order entail different ways of treatment and different scopes of responsibility. Socialization in Austria on the other hand, at least in the recent decades, has become very uniform for both sexes, regardless of the sibling position.

Inactivation of detergent-solubilized sarcoplasmic reticulum ATPase.

Inactivation of sarcoplasmic ATPase in the solubilized state was studied in the absence and presence of Ca2+, Mg2+ and glycerol. The effects of the detergents octa(ethyleneglycol) mono-n-dodecyl ether (C12E8), 1-O-tetradecylpropanediol-(1,3)-3-phosphorylcholine and myristoylglycerophosphocholine were compared. All three detergents caused a rapid decline of the dinitrophenyl phosphatase activity of the unprotected enzyme. The stabilizing effect of Ca2+ ions was kinetically analysed. It was found that the stability of the solubilized enzyme depends on the Ca2+ concentration in a manner which is best explained by assuming rapid inactivation of Ca2+-free enzyme accompanied by slow inactivation of a calcium-enzyme complex (E1Ca). The apparent affinity constants obtained are in the order of 10(6)M-1, suggesting that high-affinity Ca2+ binding must be involved. No indications of a contribution were found, either of low-affinity Ca2+-binding sites of the conformational state E2 or of the high-affinity calcium complex E1Ca2. If Ca2+ was replaced by Mg2+, which exerts a weaker protection, the apparent affinity constants for Mg2+ are in the range of 1 mM-1. The stoichiometry of the effect of Mg2+ depends on the detergent.

Reaction of fluorescein isothiocyanate with thiol and amino groups of sarcoplasmic ATPase.

Several model compounds containing thiol and/or amino groups (mercaptoethanol, glutathione, cysteine, ethanolamine, glycine) were studied with respect to their reactivity towards fluorescein isothiocyanate (followed spectrophotometrically at 504 and 412 nm), stability of product and long-wave absorption maximum of the fluorescein residue attached. Thiol groups reacted by far more readily than amino groups. A specific effect was observed with cysteine, indicating an intramolecular transfer of the fluorescein residue from SH to NH2. With sarcoplasmic vesicles both types of reactions were observed. The ratio of products, which can be distinguished by their different stabilities and absorption spectra, depended on the absence or presence of detergents. While with native vesicles the NH2 reaction predominated, with vesicles solubilized with sodium dodecylsulfate, octaethyleneglycol mono-n-dodecyl ether or 1-0-tetradecyl-propanediol-(1,3)-3-phosphorylcholine the SH reaction became prevailing. Already 0.35 mg sodium dodecylsulfate per mg protein were sufficient to give rise to dithiourethane formation exclusively. Excess fluorescein isothiocyanate reacted with several thiol groups of dodecylsulfate-solubilized vesicles. In the presence of ATP binding of fluorescein isothiocyanate to native vesicles was significantly reduced. Total blockage of the vesicular SH groups with N-ethyl-maleimide led to preparations that reacted with fluorescein isothiocyanate much more slowly, compared to native vesicles. Octaethyleneglycol mono-n-dodecyl ether or 1-0-tetradecyl-propanediol-(1,3)-3-phosphorylcholine in the assay accelerated the thioureide formation from N-ethylmaleimide modified vesicles, whereas sodium dodecylsulfate prevented it almost completely. Our results support the suggestion that one or several thiol groups in vicinity of the highly reactive lysyl residue might play a role in the fast specific reaction, which is only observed with intact native vesicles.

[Extreme kidney displacement caused by an adrenal pseudocyst]. / Extreme Nierenverlagerung durch eine Nebennieren-Pseudozyste.

Renal displacement is very infrequently associated with a space occupying adrenal disease and sometimes imposes major diagnostic problems. The diagnosis of monstrous, retroperitoneal cysts is of particular difficulty. In a 51-year-old female patient the diagnosis and the association of a cystic formation to the adrenal gland could only be made at surgery, despite the steadily increasing renal displacement. The etiology of adrenal cysts, the diagnostic procedures and the possible concurrence of hypertension are discussed.

Transient activation of the Ca2+-ATPase from sarcoplasmic reticulum during thiol modification by 5,5'-dithiobis(2-nitrobenzoate).

In the reaction of sarcoplasmic reticulum membranes with excess 5,5'-dithiobis(2-nitrobenzoate) (DTNB) some new features were observed: The Ca2+-dependent ATPase activities of increasingly modified preparations were considerably enhanced during the initial stage of thiol blockage. A maximum (130-160% of the control activity) was reached when about 1.5-2 mol thiol groups per 10(5) g vesicular protein had reacted, in the absence of ATP and detergent. At higher extents of modification inactivation occurred. Purified ATPase behaved principally similar to native sarcoplasmic vesicles. In the presence of Mg2+ and ATP the activity maximum (up to 180% of control) was broadened and shifted towards a higher degree of thiol blockage. Concomitantly the modification and inactivation rates were considerably reduced. Glycerol (10-30%, v/v) slightly enhanced the ATPase activity maximum and reduced the rate of inactivation essentially only by decreasing the DTNB modification rate. In the presence of sufficient myristoylglycerophosphocholine for solubilization no activation was observed. The steady state level of phosphoprotein from ATP was raised to about 150% of the control level 10 s after addition of DTNB (about 1/2 thiol blocked), followed by a linear decrease with the number of thiols labeled, while the Ca2+-dependent ATPase activity of preparations modified under equivalent conditions (10(-4) M Ca2+ and 2 X 10(-3) M Mg2+ present) showed a broader maximum corresponding to 1.5 thiols blocked.

Bile salt delipidation, residual phospholipids and reactivation of the Ca2+-ATPase from sarcoplasmic reticulum.

1. Delipidation of the Ca2+-ATPase of sarcoplasmic reticulum membranes by gel chromatography employing ionic detergents (cholate, deoxycholate and mixtures of both) in the presence of glycerol has been studied with respect to residual phospholipids and ATPase activities. 2. The extent of delipidation depends on the detergent chosen and on the ionic strength of the elution buffer. Increasing ionic strength favours a more effective removal of phospholipids, down to about 1 phospholipid molecule per ATPase molecule. 3. The residual ATPase activities of the delipidated preparations are negligibly low. Extensive restoration of the Ca2+-dependent ATPase activity has been achieved by oleic acid, a lysolecithin (myristoylglycerophosphocholine) and a lecithin (dimyristoylglycerophosphocholine). The percentage of reactivation by oleate depends linearly on the amount of residual phospholipids and on the detergent employed. 4. After gel filtration through an Ultrogel or Sepharose column containing 1% cholate in the elution buffer the delipidated ATPase is eluted as a reactivatable high molecular aggregate, whereas 1% deoxycholate favours the formation of completely lipid-free monomeric units which cannot be reactivated, however. A high molecular aggregate is also formed in deoxycholate, the ratio of monomer to polymer depending on the solubilizing and elution conditions. 5. The residual lipids are always composed of a mixture of all different lipid classes present in the native sarcoplasmic vesicles, even at high degrees of delipidation. Specific changes with varying extent of delipidation were not detected.

[Comparative studies of radioisotope uroflowmetry (author's transl)]. / Vergleichende Untersuchungen zur Aussagefähigkeit der Radioisotopenuroflowmetrie.

Radioisotope uroflowmetry allows continuous recording of urinary stream with determination of maximum and mean urine flow rate, duration of voiding and residual urine without urethral catheterisation. By the aid of twenty simulated tests and nine examinated patients the precision of this method was investigated by comparing our results with the findings of simultaneously recorded mictiographic measurement. The flow curves and the maximum flow rate show a high correlation.

Effects of phospholipase A2 and albumin on the calcium-dependent ATPase and the lipid composition of sarcoplasmic membranes.

1. The calcium-dependent ATPase activity of phospholipase-A2-digested sarcoplasmic vesicles decreases concomitantly with the contents of residual lysophospholipids and fatty acids when increasing albumin concentrations are applied. 2. Delipidated albumin preferentially removes unsaturated fatty acids and lysophosphatidylcholine. A complete removal of the phospholipids by albumin does not occur. 3. The membrane-bound lysophospholipids were analysed with respect to type of phospholipid, plasmalogen content and fatty acid chains by means of thin-layer chromatography and gas chromatography. 4. While the fatty acid composition of the lysophospholipids is independent of the degree of delipidation, the composition of the residual free fatty acids is found to change with the albumin concentration. 5. Reactivation of the Ca2+-ATPase by oleate leads to reasonable activities at room temperature as long as a minimum of about 30 lysophospholipid molec-les per ATPase is left. The course of the residual Ca2+-ATPase activity with the degree of delipidation is related to the presence of unsaturated fatty acids. 6. No specific role of either sphingomyelin or the plasmalogens has been found.

[Rare arterial variations during upper abdominal and pancreatic angiography (author's transl)]. / Seltene arterielle Variationen bei der Oberbauch- und Pankreasangiographie.

Selected cases showing rare variations of the arteries of the upper abdomen indicate how difficult the exact identification of individual vessels can be. In the presence of such variations, which usually involve several vessels, it is essential to find and demonstrate all vessels in the upper abdomen. Vessels which are not seen easily must also be specially searched for. In the presence of anomalous vessels, angiography may prevent the surgeon from ligating the incorrect arteries during operation on the pancreas, the liver, stomach, spleen or colon.