Pharmacological treatment for schizoaffective disorder : A comparison with schizophrenia and bipolar disorder.

BACKGROUND: Bipolar disorder and schizophrenia are severe mental illnesses, each with a prevalence of approximately 1-2% in the general population. There is considerable controversy about differentiating schizophrenia from schizoaffective or bipolar disorder owing to many similarities in psychopathology, progression, and biological factors. The aim of this study was to identify similarities and differences in the pharmacological treatment of these disorders by comparing the prescription patterns. METHOD: In this retrospective, explorative study we analyzed the prescribed medication of 300 patients with bipolar, schizophrenic, or schizoaffective disorders from data obtained from ten German adult psychiatric clinics of the LWL ("Landschaftsverband Westfalen-Lippe") psychiatric network. RESULTS: Only 21.8% of patients analyzed were consistently compliant in taking their medication before hospitalization. Polypharmacy was applied in 75.6% of cases, whereby 2.27 psychopharmacological agents were prescribed at discharge. Briefly, we observed greater similarity between prescription patterns associated with bipolar and schizoaffective disorders than with schizophrenia prescription patterns. CONCLUSION: Polypharmacy tends to be more the rule than the exception, especially when patients present with affective psychotic features. Bipolar and schizoaffective disorders cannot be differentiated according to their prescription patterns.

[Expert testimony in post-traumatic stress disorder with pain as the main symptom]. / Begutachtung bei Posttraumatischer Belastungsstörung mit Leitsymptom Schmerz.

Post-traumatic stress disorder (PTSD) is one of the most relevant disorders of patients with chronic pain, but is often underdiagnosed. This also applies to expert testimony. Further complicating the assessment are the different definitions of PTSD in ICD-10 and DSM-IV; the new DSM-5 has added a further definition. The present review aims to provide guidance for making a valid diagnosis. This forms the basis for a differentiated expert testimony in the different fields of law (e.g., criminal law, statutory or private accident insurance or social security benefits), in which different requirements must be taken into consideration by the expert. The recognition of malingering is described at length, which plays a major role in PTSD expert testimony in all fields of law.

[Psychological disorders after severe occupational accidents]. / Psychische Störungen nach schweren Arbeitsunfällen.

After severe accidents, a significant number of victims develop post-traumatic stress disorder (PTSD) and other psychiatric disorders, which lead to considerable impairment in work and daily life. Few studies exist which deal with the psychological consequences of industrial accidents. The Department of Psychiatry and Psychotherapy (University of Freiburg) in cooperation with the Department of Trauma Surgery (University of Freiburg) have therefore carried out a prospective study on the subject. 56 victims of an industrial accident were assessed immediately after the accident, and again six months later, using different instruments, e.g. structured clinical interviews (e.g. ADIS). The prevalence rates of psychiatric disorders in the follow-up assessment after six months were 12% PTSD, 11% subsyndromal PTSD (not all criteria of PTSD fulfilled) and 11% other psychiatric disorders. The patients with PTSD and subsyndromal PTSD were compared with the patients with other psychiatric disorders. The accidents of patients with PTSD/subsyndromal PTSD were more serious, and their injuries more severe. In addition, these patients reported that they had thought much more about their work before the accident and believed that their work was much more dangerous than that of patients with other psychiatric disorders. As early as the first day after the accident the patients with PTSD/subsyndromal PTSD were afraid of developing physical and work-related problems as a consequence of the accident. They also reported more symptoms of PTSD and depression and anxiety symptoms. Patients with PTSD/subsyndromal PTSD reported more limitations in daily life and that they were unfit for work for a longer period. After their return to work, they had more problems and were less resistant to stress.

Evaluation of the German version of the PTSD Symptom Scale (PSS).

The psychometric properties of the PTSD Symptom Scale (PSS) were evaluated in a clinical sample of severely injured in-patients after a traffic accident (n = 123). The PSS contains 17 items which were derived from the DSM-III-R criteria of posttraumatic stress disorder (PTSD). The results indicate that the PSS has satisfactory reliability and validity (internal and external). The results are in correspondence with the results of Foa et al. using a sample of rape and non-sexual-assault patients.

The concept of "sense of coherence" and the development of posttraumatic stress disorder in traffic accident victims.

According to the "sense of coherence" concept, those subjects who can give meaning to a traumatic event can comprehend what has happened and have a sense of manageability of the sequelae, are able to cope better with the traumatic event itself. In the present study, this concept was applied to traffic accident victims. Severely injured traffic accident victims were assessed a few days after the accident and at 6-month follow-up. At follow-up, patients filled in the 29-item version of the Sense of Coherence (SOC) self-rating scale. The results show that the SOC total score correlated negatively with the development of: (i) posttraumatic psychopathology; (ii) psychological disorders (i.e., posttraumatic stress disorder after the accident); and (iii) anxious cognitions. The personality trait of neuroticism correlated negatively and extraversion and frustration tolerance correlated positively with SOC total score. Previous hypotheses are supported by our findings.

Prediction of posttraumatic stress disorder by immediate reactions to trauma: a prospective study in road traffic accident victims.

Road traffic accidents often cause serious physical and psychological sequelae. Specialists of various medical faculties are involved in the treatment of accident victims. Little is known about the factors which might predict psychiatric disorders, e.g. Posttraumatic Stress Disorder (PTSD) after accidents and how psychological problems influence physical treatment. In a prospective study 179 unselected, consecutively admitted road traffic accident victims were assessed a few days after the accident for psychiatric diagnoses, severity of injury and psychopathology. All were inpatients and had to be treated for bone fractures. At 6-months follow-up assessment 152 (85%) of the patients were interviewed again. Of the patients, 18.4% fulfilled the criteria for Posttraumatic Stress Disorder (DSM-III-R) within 6 months after the accident. Patients who developed PTSD were injured more severely and showed more symptoms of anxiety, depression and PTSD a few days after the accident than patients with no psychiatric diagnosis. Patients with PTSD stayed significantly longer in the hospital than the other patients. Multiple regression analysis revealed that the length of hospitalization was due mainly to a diversity of factors such as severity of injury, severity of accident, premorbid personality and psychopathology. Posttraumatic stress disorder is common after road traffic accidents. Patients with PTSD at follow-up can be identified by findings from early assessment. Untreated psychological sequelae such as PTSD cause longer hospitalization and therefore more costs than in non-PTSD patients.

Interleukin-6-(IL-6) plasma levels in depression and schizophrenia: comparison between the acute state and after remission.

The concentration of cytokines such as Interleukin-6 (IL-6) has been reported to be elevated in depressed and schizophrenic patients and, in healthy persons, upon stress. Interleukin-6 plasma levels were determined in depressed (n = 12) and schizophrenic (n = 32) patients during the acute state of illness and after remission at approximately 8 weeks after admission and were compared with healthy controls (n = 12). Patients were diagnosed according to DSM-III-R by the Structured Clinical Interview (SCID). Severity of illness was assessed for depression by the Montgomery Asberg Depression Rating Scale (MADRS) and for schizophrenia by the Brief Psychiatric Rating Scale (BPRS). Interleukin-6 plasma concentrations were elevated during the acute state either of depression or of schizophrenia if compared to controls. After remission, IL-6 concentrations in depressed and in schizophrenic patients had decreased and did not differ significantly from controls. We hypothesize that the elevated IL-6 levels during the acute state of depression or schizophrenia may reflect an unspecific stress response.

[Treatment of panic disorders and agoraphobia. Psychotherapy, psychopharmacotherapy and their combination]. / Die Behandlung von Panikstörungen und Agoraphobien. Psychotherapie, Psychopharmakotherapie und deren Kombination.

During the last two decades substantial progress has been achieved in the development and evaluation of effective treatment approaches to panic disorder and agoraphobia. Many clinical research studies in this area were begun after the definition of operationalized diagnostic criteria for panic disorder and agoraphobia in the DSM-III in 1980. Different concepts concerning the etiology, pathogenesis and maintaining factors of these disorders are still controversial. At the beginning of this controversy, psychopharmacological treatment was believed to suppress spontaneous panic attacks while behavioral treatment mainly focused on anticipatory fears and avoidance behavior. Meanwhile both treatment approaches have proved their effectiveness in reducing panic attacks and agoraphobia. Therefore, it was hypothesized that a combination of both individual treatments could enhance therapeutic efficacy. The few studies examining this question did not allow clear conclusions because of methodological shortcomings. In the short run, there seems to be a trend for better results with combined treatment. In the long run, however, combined therapy has not been observed to be superior to cognitive-behavioral therapy without any psychopharmacological support. In practice, adverse side effects restrict the application of psychopharmacological approaches. On the other hand, qualified cognitive-behavioral therapists are not always available, or patients are referred to them by general practitioners and psychiatrists after a delay. Criteria for the application of behavioral therapy, psychopharmacological therapy and their combination are proposed and discussed.

[Panic disorder and vertigo. On the psychopathologic differentiation between neurologic and psychiatric disease]. / Panikstörung und Schwindel. Zur psychopathologischen Differenzierung zwischen neurologischer und psychiatrischer Erkrankung.

Seventy-six in- and outpatients seeking help for complaints of dizziness in a neurological clinic were assessed by the Structured Clinical Interview for DSM III (SCID). Neurological assessment included electrophysiological and otological examination. We established criteria to differentiate between dizziness as a symptom of panic disorder and dizziness as a symptom of neurological illness. Criteria for dizziness as a symptom of panic disorder are: adverse life events before the onset of dizziness, current comorbidity with depression, a high number of vegetative symptoms typical for panic attacks, a specific cluster of symptoms and little evidence of a neurological illness. We conclude that patients with complaints of dizziness often suffer from anxiety disorders. Thus we describe a vestibular subtype and contribute to the classification of panic disorder.

[Panic attacks and avoidance behavior]. / Panikattacken und Vermeidungsverhalten.

In a crossectional investigation based on a group of 122 patients with panic attacks, compiled from a variety of hospitals and therapy institutions, 97 patients were found to be suffering from panic disorder as a relevant medical problem. The disease, however, is often identified in an unsatisfactory manner. Avoidance behaviour (extensive or limited) associated with a severe form of panic disorder, was evident in more than one-half of the group (60%). In these patients the incidence of panic attacks is higher, anxiety is more marked, and there are more often additional anxiety disorders (generalised anxiety, sociophobia). These results underline the importance of early recognition and specific treatment of panic disorder to prevent development of avoidance behaviour.

[Chronic paranoid-hallucinatory psychosis as the initial manifestation of an HIV infection?]. / Chronifizierte paranoid-halluzinatorische Psychose als Erstmanifestation einer HIV-Infektion?

In a 36-year-old patient an acute onset of psychosis occurred, probably due to HIV infection. For one year HIV-infection with reduced T4/T8 ratio had been known without clinical manifestation (stage IV B of the CDC-classification). He developed chronic delusional hallucinations, which persisted for more than one year in spite of adequate psychoactive drug therapy. So far AIDS-related dementia has not become evident. Focal lesions caused by opportunistic infections or tumour were excluded by computed tomography and magnetic resonance imaging. The latter revealed several small lesions and the brain scan showed a nonhomogeneous pattern of cerebral blood flow. CSF-examination disclosed a mild lymphocytosis and raised protein concentration. A classification as an organic, HIV-induced delusional hallucination seems to be justified.

Computerized brain tomography measures compared with spontaneous and suppressed plasma cortisol levels in major depression.

We determined brain density and ventricular measurements with computerized tomography (CT) in 33 depressed patients and compared the results with basal plasma cortisol and its suppressibility by dexamethasone. Mean plasma cortisol was positively related to elevated ventricular brain ratio (VBR). No association could be found between dexamethasone suppression test (DST) status and VBR or any other CT parameter. Elevated plasma cortisol levels and increased VBRs were positively correlated with total scores on the Brief Psychiatric Rating Scale, the Global Assessment Scale and the Bech-Rafaelsen Melancholia Scale, but they were not significantly correlated with total score on the Hamilton Anxiety Scale.