[Jan Wier: a heretical physician for the witches: historical truth and myths]. / Jan Wier; een ketterse arts voor de heksen. Historische waarheid en mythevorming.

BACKGROUND: Jan Wier was a remarkable person, well known to many as a leader of the fight against the persecution of witches. In a broader sense, he is regarded as one of the earlier defenders of human rights and as a acute observant of psychiatric disorders. AIM: To investigate whether these and other theories about Jan Wier are correct. METHOD: The biography studied was : "Jan Wier; a heretical physician for the witches" written by Vera Hoorens, professor of social and cultural psychology. RESULTS: Hoorens places the complete works by Wier in the historical context in which they were written. Wier was a particularly influential opponent of the persecution of witches, but this was not his main aim. His ideas were not original, although his books on witches show an early understanding of later psychiatric insight. Nevertheless he did contribute to an improvement in the administration of justice. His ideas on pathological anger were innovative, because when describing this disorder he included causes, effects, prognosis, treatment and prevention. CONCLUSION: On the basis of a thorough study of the complete works of Jan Wier, Hoorens distinguishes the historical truth from the myths that have arisen around this important person.

[Late-life depression and subcortical ischemic white matter lesions]. / Ouderdomsdepressies en subcorticale ischemische hersenschade.

Late-life depression and cerebral ischemic white matter lesions. Interest in cerebrovascular disease as a risk factor for depression in the elderly has grown in the last few years. Some authors recently have proposed the concept of a 'vascular depression'. In this paper, which presents a selective review of the literature, it is argued that 'vascular depression' is not a nosological entity. However, it has been shown that cerebral white matter lesions, identified using Magnetic Resonance Imaging (MRI) and thought to represent ischemic damage, are related to depression in the elderly. In particular, there is a correlation with late-onset depression. Moreover, these white matter lesions in depressed elderly adults are associated with cognitive impairment, and probably also with a relatively poor response to treatment.

A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients.

OBJECTIVES: To develop and test the effect of a nurse-led interdisciplinary intervention program for delirium on the incidence and course (severity and duration) of delirium, cognitive functioning, functional rehabilitation, mortality, and length of stay in older hip-fracture patients. DESIGN: Longitudinal prospective before/after design (sequential design). SETTING: The emergency room and two traumatological units of an academic medical center located in an urban area in Belgium. PARTICIPANTS: 60 patients in an intervention cohort (81.7% females, median age = 82, interquartile range (IQR) = 13) and another 60 patients in a usual care/nonintervention cohort (80% females, median age = 80, IQR = 12). INTERVENTION: (1) Education of nursing staff, (2) systematic cognitive screening, (3) consultative services by a delirium resource nurse, a geriatric nurse specialist, or a psychogeriatrician, and (4) use of a scheduled pain protocol. MEASUREMENTS: All patients were monitored for signs of delirium, as measured by the Confusion Assessment Method (CAM). Severity of delirium was assessed using a variant of the CAM. Cognitive and functional status were measured by the Mini-Mental State Examination (MMSE) (including subscales of memory, linguistic ability, concentration, and psychomotor executive skills) and the Katz Index of activities of daily living (ADLs), respectively. RESULTS: Although there was no significant effect on the incidence of delirium (23.3% in the control vs 20.0% in the intervention cohort; P =.82), duration of delirium was shorter (P =.03) and severity of delirium was less (P =.0049) in the intervention cohort. Further, clinically higher cognitive functioning was observed for the delirious patients in the intervention cohort compared with the nonintervention cohort. Additionally, a trend toward decreased length of stay postoperatively was noted for the delirious patients in the intervention cohort. Despite these positive intervention effects, no effect on ADL rehabilitation was found. Results for risk of mortality were inconclusive. CONCLUSIONS: This study demonstrated the beneficial effects of an intervention program focusing on early recognition and treatment of delirium in older hip-fracture patients and confirms the reversibility of the syndrome in view of the delirium's duration and severity.

Psychiatric complications of drug treatment of Parkinson's disease.

Drug-induced psychiatric conditions are a common and severe problem in the treatment of patients with Parkinson's disease. Psychotic symptoms are the most frequent reason for nursing home placement of patients with Parkinson's disease. The psychotic symptoms seem to present themselves in a continuum where alterations in dreaming patterns often precede visual hallucinations, which often progress into delusional syndromes and, finally, into confusional organic syndromes. When evaluating a patient on dopaminergic treatment, it is important to inquire systematically about abnormal sleep related phenomena, for these are important clues in the early detection of psychotic symptoms. The pathogenesis of the psychotic symptoms is not yet fully understood but complex adaptations of various neurotransmitter systems seem to be involved. In the treatment of these drug-induced psychotic symptoms, the atypical antipsychotic drug clozapine plays an important role. Drug-induced mania, hypersexuality and anxiety, although less frequent than the psychotic symptoms, also occur as a complication of dopaminergic treatment. Depressive symptoms, although common in Parkinson's disease, are less likely to occur as a side effect of the drug treatment.

A randomised, double-blind comparison of the efficacy and safety of citalopram compared to mianserin in elderly, depressed patients with or without mild to moderate dementia.

Depression is the most common psychiatric disorder among the elderly and in old age may interact with emotional and cognitive functioning. Depression in old age has been shown to be associated with degenerative changes in the brain. It is, therefore, important that in this patient population antidepressants with a favourable tolerability profile, such as the selective serotonin reuptake inhibitors (SSRIs), are examined for both antidepressant efficacy and effect on cognitive function and emotional impairment. This randomised, double-blind study compared the efficacy and tolerability of citalopram and mianserin in 336 elderly, depressed patients with or without dementia. Patients received either citalopram 20-40 mg/day or mianserin 30-60 mg/day for 12 weeks. The treatments were equivalent with respect to change in Montgomery-Asberg Depression Rating Scale (MADRS) total score; patients in both treatment groups responded well. Patients with dementia showed a smaller decrease in total MADRS score than patients without dementia. Both treatments were well tolerated with a relatively low incidence of adverse events. Fatigue and somnolence were more frequent with mianserin, while insomnia was more frequent with citalopram. Overall, this study showed that the two treatments were equivalent in efficacy, and that citalopram is an effective, well-tolerated and non-sedative treatment for elderly depressed patients with or without dementia.

Delirium in the hospitalized elderly: nursing assessment and management.

Delirium is a serious health problem with significant negative consequences which is experienced by many hospitalized elderly patients. Because of its clinical impact and potential reversibility, prompt treatment of delirium is essential. Therefore an understanding of delirium, its manifestations, methods of detection, prevention, and treatment in hospitalized elderly patients is needed. This article provides an overview of the diagnostic and therapeutic dilemmas of delirium.

A historical perspective on the care of the aged in medieval times.

Although aging had already been treated among the classical writers of Antiquity, the late Middle Ages and the Renaissance obviously must be regarded as the chief source and inspiration, as well as the starting point of the history of gerontology. Nevertheless, the treatment of aging in medieval medicine remains relatively unexplored, in contrast with other fields such as obstetrics, gynecology, and even pediatrics, where the literature has become prolific. This contribution focuses on some of the most interesting medieval regimina and consilia, dealing with health and its preservation. It especially informs the reader about the most popular pathogenetic theories concerning normal and pathological aging, and also gives an impression of the most vivid clinical descriptions of the pathology of old age by fifteenth century physicians.

[Plato's conceptions of disorders of the soul (Ta peri psuchên nosêmata). Timaeus as the beginning of a dynamic and ethic psychopathology]. / Plato's opvattingen inzake de zielsziekten (Ta peri psuchên nosêmata). De Timaeus als aanzet tot een dynamische en ethische psychopathologie.

This contribution to the study of the evolution of fundamental concepts in psychiatry, and in particular of the interpretative models of mental disease, focuses on Plato's conceptions concerning the "disorders of the soul". Plato's "psychopathological" work suggests the decline of an hereditary conglomeration of interpretative arrangements of the irrational phenomena related to mental disease which, corresponding to the social needs of that time, had been united by the belief in myth and its therapeutic value. These archaic religious conceptions have most certainly been reversed by Plato, especially in his Timaeus, one of the three most influential of his dialogues. In a notable passage in this cosmological dialogue (86b ff.) Plato treats of those diseases of the soul which are caused by things physical, whether this be a "defective bodily constitution" or "faulty education". The diseases of the soul are thus no longer considered having a divine origin. Mental diseases to which man is unwittingly subject by defects in birth or education concern himself and his inner life and they cannot be dismissed with simplistic allegories. According to Plato they originate from a conflict, supported by a secret, hidden, irrational "self" that has its roots in the sôma, the rational "self" being only able to recuperate its total integrity if it manages, through self-discipline and knowledge, to check the somatic impulses, the folly of the body. Also, Plato offers a series of remedies to correct the undue influence of body on soul and soul on body, with a view to instituting a right balance and proportion between them. This, together with a stress on "care of the soul", particularly of the divine and immortal element, implicitly assumes that it is in man's power to apply the necessary remedies to himself and effect some sort of readjustment.

A chromosome 18 genetic linkage study in three large Belgian pedigrees with bipolar disorder.

The contribution of genetic factors to the susceptibility for affective disorders has been firmly established. Recent reports found evidence for a susceptibility locus for affective disorders in 2 regions on chromosome 18. We describe 3 large Belgian pedigrees with multiple patients with affective disorders. Both chromosome 18 regions were investigated in the 3 families, using parametric and nonparametric segregation methods. In the pericentromeric region, all evidence was against a disease gene in our families. Also the data obtained for the distal part of 18q, argue against a genetic susceptibility factor in our sample.

Risk profiles for institutionalization in a cohort of elderly people with dementia or depression.

Seventy-five elderly persons with dementia or depression, served by a nursing outreach assessment and case management service in Belgium, were entered in a risk profiling study. Cluster analysis yielded three clusters, each presenting a different risk profile for institutionalization: (1) High Risk Profile, with subjects of moderately advanced age, highly dependent for activities of daily living (ADL), with severe cognitive impairment, poor communication skills, and behavioral problems; (2) Moderate Risk Profile, with subjects of advanced age, limited ADL-dependency, yet high care demands for Instrumental ADL (IADL), moderate to severe cognitive impairment, adequate communication competency, and some behavioral problems; and (3) Low Risk Profile, consisting of relatively young elderly, partially ADL and IADL-dependent, mild or no cognitive impairment, good communication abilities, and no particular behavioral problems.

Correlations between triplet repeat expansion and clinical features in Huntington's disease.

OBJECTIVE: To investigate possible correlations between the length of the (CAG)n trinucleotide repeat in Hungtington's disease gene IT15 and clinical features (age at onset, symptoms at onset, and mode of progression) in Huntington's disease. DESIGN: In 59 patients with Huntington's disease, the expansion of the (CAG)n trinucleotide repeat was determined and clinical data were obtained retrospectively. SETTING: The Center for Human Genetics, affiliated with a university hospital. PATIENTS: All patients belonged to an initial group of 248 individuals tested in an indirect predictive testing procedure. RESULTS: A good correlation was found between the expansion of the (CAG)n trinucleotide repeat and the age at onset (r = -.71). No correlation was found between the repeat length of the normal allele and the age at onset. No correlations were found between repeat expansion and other clinical features, such as the nature of the symptoms at onset (neurologic, psychiatric/cognitive, or both) and the mode of progression. CONCLUSION: Factors that determine the nature of symptoms at onset and the mode of progression of Huntington's disease seem to be operating independently of the (CAG)n trinucleotide repeat in gene IT15.

[Aretaios concerning the relationship melancholy-mania and psychogenesis: a look backwards on a "forward" look]. / Aretaios omtrent de relatie melancholie-manie en de psychogenese: een terugblik op een "voor"-blik.

This contribution to the study of the evolution of fundamental concepts in psychiatry, and in particular of the history of "atrabilious disease", focuses on Aretaios the Cappadocian, one of the most eminent medical authors of Greek antiquity. A rigorous reading, both philological and psychiatric, of Aretaios' text clearly illustrates his importance as a psychiatric nosologist, especially with regard to the articulation between melancholia and mania, which are nowadays considered to be antinomous mood disorders. Contrary to the assumption of most scholars, Aretaios cannot be considered the "inventor" of "manic-depressive psychosis", but rather a "precursor" of "unitary psychosis", a concept that emerged in German psychiatry in the middle of the 19th century. Het may also be regarded as the first author to focus on "premorbid characteristics" in patients with melancholia and mania. Moreover, he assumed a psychogenetic, not merely organogenetic etiology of these psychiatric disorders and, consequently, the possibility of psychotherapy for these conditions.

Assessing depression in elderly patients.

Late onset depression often appears similar to depression in younger persons. However, it may present a diagnostic challenge to the clinician because of its atypical expression in the aged. For example, it may be characterized by cognitive impairment, neurotic symptoms, prominent anxiety, somatization, and high bodily concern. Since depressive disorders are not always obvious to the observer, they are perhaps the most poorly recognized and therefore untreated psychiatric disturbances in the aged.

The diagnosis of dementia and other "deficitary' psychopathological syndromes in old age: reflections and recommendations of a clinical psychiatrist.

Clinical evaluation and staging of dementia and related disorders has been approached in various ways. Performance of subjects featuring cognitive decline has been scored on established, often lengthy psychometric and neuropsychological tests, by means of behavioural rating, and by means of various combinations of simplified psychometric and behavioural evaluations. Although concerning the assessment of the clinical aspects of cognitive decline in the elderly, broad areas of agreement among experts exist, yet there is no clear consensus on a number of assessment issues. There are, for example, different views concerning the utility of particular assessment instruments. Also are there different perspectives from which the selection of psychological performance tests can be undertaken. This paper may contribute a mite in touching the existing literature on several sore points, by formulating some relevant methodological and semantic remarks that could well form a starting point for vigorous discussion.

[Psychiatric symptoms before and subsequent to acute CVA]. / De psychiatrische verschijnselen bij en na een acuut CVA.

The psychiatrist is very seldom faced with the acute or prolonged care of stroke victims. This may be surprising, since it is generally accepted that much of the disability resulting from strokes is mental rather than physical. Psychological influences may even be paramount in determining what progress is made. This paper aims to give a review of those aspects of symptomatology and therapy of stroke patients that are particularly pertinent to the psychiatrist.

[Psychiatric considerations concerning the competency for making a will]. / Psychiatrische kanttekeningen omtrent de handelingbekwaamheid tot het opmaken van een testament.

Incompetency in terms of one legal function does not necessarily mean incompetency in terms of all. Once a person has been found 'mentally ill' or 'insane', he is not to be considered as incompetent for all legal purposes, including his competency to make a will. Testamentary capacity may be consistent with mental disorder and should be determined on narrow standards applicable to this specific legal function. As yet the standards that have been formulated by most courts emphasize almost exclusively cognitive capacity. As a psychiatrist, the author strongly feels that testamentary capacity must meet 'affective' criteria as well. Under all circumstances one should bear in mind both cognitive and affective criteria, when assessing one's competency at the moment he prepares his will, or when testifying in court concerning the testamentary capacity of a testator, now deceased, at the time he made the provision.

[Comments on the National Hospital Federation's report: assessment of the elderly with mental disorders]. / Commentaar bij 'de observatie van geestelijk gestoorde bejaarden', een rapport van de Nationale Ziekenhuisraad.

This report is discussed from the viewpoint of a Belgian psychiatrist. For Belgium too, it is called important and useful. It may contribute to a more complete and better screening and treatment of the psychogeriatric patient and besides it will stimulate the formulation of national policy recommendations. Minor shortcomings are: the examination of the tractus respiratorius is not mentioned, nor the importance of an orienting neurological examination. The author wonders whether the extramural examination must be stressed that strongly as is preferred in the report.