[Poetry and schizophrenia]. / "Wohl muss Umsonst nicht ehren der Geist Das Schicksal" (Hölderlin). Zur Literatur schizophrener Künstler.

The confrontation of a poet with himself and his world may be obvious in his creations. When a breakdown like a schizophrenic illness occurs in his life he will fight with creative efforts against his injury. As fragment of this struggle poetic expressions result which allow us to understand the inner life of a psychotic disturbed person better. The poems of two Austrian authors of our time can help us as introduction in this field.

Incidence of obsessive-compulsive phenomena in the course of acute schizophrenia and schizoaffective disorder.

Studies examining OC phenomena in schizophrenic and schizoaffective disorders have shown a prevalence of such phenomena in 1 to 60% of schizophrenic or schizoaffective patients. In this prospective study, about 10% of 150 male patients suffering from acute psychotic disorders (fulfilling DSM-IV criteria for Schizophrenia or Schizoaffective Disorder) were found to have OC symptoms. These symptoms showed no correlation to the type and severity of psychosis. As only 19% of the patients with obsessions and compulsions during acute psychosis showed an obsessive-compulsive personality disorder prior to their psychotic episodes, it may be concluded that there is no clear linkage between intrapsychotic OC phenomena and premorbid anancastic personality traits.

Zotepine in the treatment of acute hospitalized schizophrenic episodes.

The atypical antipsychotic zotepine was studied in an open, multicentre uncontrolled, post-marketing surveillance study in 108 schizophrenic patients hospitalized in 12 trial centres in Austria. Within the dosage range of 50-450 mg (mean at the end of the study, 207 +/- 125 mg/day), a significant reduction of positive as well as negative symptoms was noted. There was no increase in extrapyramidal side-effects during the study and a significant decrease in akathisia scores. The medication was well tolerated during the 42-day observation period. Zotepine improved both positive and negative symptoms and was not accompanied by extrapyramidal side-effects, justifying its classification as an atypical antipsychotic.

[Aggressive and suicidal behavior. A cluster analysis study of suicidal and nonclinical subjects]. / Aggressivität und suizidales Verhalten. Eine clusteranalytische Studie an Suizidenten und klinisch unauffälligen Vergleichspersonen.

AIMS: An attempt was made to examine the relationship between different dimensions of aggression and suicidal behavior in clinical and non-clinical subjects. METHOD: A clinical sample of 68 suicide attempters (39 females, 29 males) and a matched sample of 70 non-clinical subjects (38 females, 32 males) were subgrouped by cluster analytic techniques. Classification variables included the scales of the Aggressive Factors Questionnaire (AFQ). Discriminant function analyses were performed on the clusters to determine the quality of group separation and to assess the power of each input variable. External variables such as the amount of hopelessness, suicidal ideation and the number of suicide attempts were used to assess the clinical relevance of the identified clusters. RESULTS: Two subgroups were identified in each sample. Variables that contributed most to group separation were Auto-aggression/Depression and Spontaneous Aggression in the non-clinical sample and Excitability in the clinical sample, respectively. The clusters identified within the non-clinical sample differentiated between ideators and non-ideators. Cluster allocation within the clinical sample was indicative of the number of suicide attempts. CONCLUSIONS: Clusters defined on the basis of different dimensions of aggressiveness turned out to be a classification with significant implications for the assessment of suicidal behavior.

Bulimia nervosa. A treatment concept implying an "integrative painting therapy".

At the Department of Psychiatry, University Hospital Graz, we have been applying a concept for treating bulimia nervosa, using a complementary method involving psychosocial and psychotherapeutic strategy as well as psychotropic medication. Thus we have been able to approach the patients from a holistic view. Painting and drawing as a creative method constitute another salient part of our concept. Between January 1995 and September 1999, 36 in-patients with bulimia were treated in the Psychotherapy Unit of the University Hospital's Department of Psychiatry in Graz; our concept focussed on "Integrative Painting Therapy". The wide variety of treatment methods comprised individual and group therapy, diet counselling and thymoleptics (SSRIs). Teamwork and close links within the team constituted an important part of our work, so that the different types of therapy are process-oriented and thus interrelated. In the initial phase of the symptom-oriented approach patients learn to control and ultimately normalise their eating habits. In the phase of acting out and/or conflict awareness, they try to cope with their disorder on a pictorial level. They gain access to their emotions and become aware of their problems, while their eating habits improve. Self-esteem is eventually stabilised and patients develop a sense of self-responsibility and work on effective strategies to cope with their disorder. This development also manifests itself in their pictorial expressions. "Integrative Painting Therapy" led to a marked improvement of the depressive moods initially prevalent in all patients. It also slightly elevated their Body Mass Index. Moreover, control capacity increased significantly, irregularities in eating habits were reduced and craving for food subsided.

The development of agoraphobia in panic disorder: a predictable process?

BACKGROUND: Panic attacks are conceptualized to be the central feature of both panic disorder without (PDU) and with agoraphobia (PDA). As a sizeable percentage of panic patients do not develop avoidance behavior, other factors than 'panic attacks', in general, must influence the different courses of the disorder. METHOD: We studied 84 outpatients suffering from PDU or PDA concerning different factors which were hypothesized to influence the development of agoraphobia. RESULTS: 'Earlier age of onset', 'fear of losing control' and 'chills or hot flushes' turned out to correlate statistically significantly with PDA, while 'chest pain or discomfort' occurred more often in PDU. LIMITATIONS: The present study used retrospective data. CONCLUSIONS: The results of this study suggest that the development of agoraphobia in panic disorder is influenced by specific variables and is not a purely coincidental process.

[Central nervous system control of micturition in patients with bladder dysfunctions in comparison with healthy control probands. An electrophysiological study]. / Zentralnervöse Kontrolle der Miktion bei Patienten mit Blasenfunktionsstörung im Vergleich zu gesunden Kontrollpersonen. Eine elektrophysiologische Studie.

PURPOSE: The pontine micturition center plays a central role in regulating the micturition reflex, but the precise neural mechanisms are unclear. The cerebral cortex is involved in coordinating micturition but there is little knowledge on specific evolutionary higher brain regions. The present study aimed to investigate whether cortical activation during micturition can be demonstrated by EEG power spectra patterns and to explore whether specific cortical regions involved in the interaction of inhibition and release during the micturition reflex can be discerned. We also aimed to test whether intravesical electrostimulation (IVES) therapy in patients with micturition disorders has an effect on patterns of cortical activity. METHODS: The healthy control group was divided into those who were able to void when requested (6 women, 12 men) and those who were not (8 women, 10 men). These subgroups were compared separately with the 14 patients before and after IVES for voiding dysfunction. Following IVES all patients were able to void spontaneously. Mean age of the patients and healthy volunteers was 52 and 30 years, respectively. At the beginning of the study all subjects had a bladder volume of approximately 250 mL as measured by sonography. The EEG was obtained at rest and during the attempt to void. In the patients' group EEG was obtained before IVES treatment and at the day of the last stimulation. The measurement period lasted about 6 minutes. At the beginning of the recording the proband was asked to close his/her eyes. During the resting period after 1 minute the patient was asked to open his/her eyes. After 10 seconds he/she was asked to close his/her eyes again. Then, with eyes still closed, the patient was asked to void. During the entire EEG recording the patient was seated in a comfortable, electrically isolated chair in a darkened room and separated from the examiner by a partition. The subject was asked to relax and not move his/her eyes. The EEG was recorded from the 19 standard points (10-20 System) versus an averaged mastoid electrode with a gold-plated cup electrode (Glass). An EOG was recorded simultaneously to register eye artefacts. The amplification chain was calibrated with a 10-Hz 100-microVss sinus signal generated with a biosignal amplifier. The transitional resistances of all EEG channels were less than 5 kOhm and established as soon as possible. EEG and EOG signals were amplified and recorded with a B.E.S.T. Brain Mapping System. The recording frequency was 256 Hz and the resolution of the analog digital conversion was 12 bit. A high pass and a low pass filter were set to 0.53 Hz and 70 Hz, respectively. All recordings were inspected visually before computer analysis. Artefacts were marked and excluded from the further analysis. None of the EEG recordings showed clinical abnormalities. As expected, the EEGs during voiding attempts showed some muscle potentials and slow motion artefacts. For each subject two artefact-free resting segments of about 20 seconds, one from the resting phase and one from the voiding attempt, were defined by hand for automated analysis. Relative power spectra (microV2) were calculated for the defined segments. From the spectra the relative alpha band power (7.5-13.0 Hz) was calculated for each subject for rest and voiding. Group (patients vs. voiding probands vs. probands unable to void) and sex were independent variables. The alpha power of the 17 electrode positions of the 10-20 system (without Fp1 and Fp2) during rest and attempted voiding were repeated measurement variables. The frontopolar electrode was not used because of its susceptibility to artefacts. The number of dependent variables was due to the explorative nature of the study. With interactions of variables with more than two factor levels a Greenhouse-Geisser correction was performed. Interactions were subjected to contrast analysis and Newman-Keuls-Post tests. RESULTS: Significant effects were seen for BEDINGUNG (

Naturalistic course of obsessive compulsive disorder and comorbid depression. Longitudinal results of a prospective follow-up study of 74 actively treated patients.

Seventy-four patients who met DSM-III-R criteria for obsessive compulsive disorder (OCD) were studied in a prospective follow-up study in order to investigate course and prognosis of OCD with or without comorbid depressive symptomatology. Subjects were examined three times: at admission (baseline), 6 months later (follow-up 1) and 12 months after follow-up 1 (follow-up 2). At admission, 51 (72.9%) OCD patients were assessed as depressive by the Hamilton Depression Scale score. Between admission and follow-up 1, all patients received behavior therapy and a serotonin reuptake inhibitor, between follow-up 1 and follow-up 2 they received different kinds of treatment in order to maximize therapeutic effects. A 25% Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score reduction from admission to follow-up 2 and in addition, a total Y-BOCS score of below 16 at follow-up 2 was defined as 'good prognosis course'. The results obtained showed that OCD patients who followed a good prognosis course, showed no significant depressive symptomatology at follow-up 2 (p = 0.001). These results imply that patients with a diagnosis of OCD may present depression at admission and/or follow-up 1; however, if OC symptomatology decreases longitudinally, depressive symptoms disappear too. We may assume that OCD is dominant over depression, and it seems that a comorbid depression does not have any major influence on the prognosis of OCD.

[Explanatory models for chronicity of psychiatric disorders]. / Erklärungsmodelle zur Chronifizierung psychischer Erkrankungen.

Chronic psychic disorders are very frequent. Corresponding to the psychic illness there are several reasons: the diagnosis is not correct; the therapy is insufficient; additional somatic disorders (like addiction) influence the psychic conditions or psychic burdens (conflicts, problems etc.) delay the psychic disorder. Some psychic disturbances show a long development which would allow an earlier therapeutic intervention in order to prevent a later chronic state. Psychosomatic illnesses are characterized by psychoneurotic signs like anxiety or depression, by influences of stressors, by previously acquired abnormal behaviour and by pathophysiological symptoms like overarousal, which support the chronification. The therapeutic efforts should include psychopharmacological methods as well as psychotherapy in the sense of a multidimensional approach.

[Integrative painting therapy. A therapeutic concept for psychiatric inpatients at the University clinic in Graz]. / Die "Integrative Maltherapie". Ein Therapiekonzept für stationäre psychiatrische Patienten an der Universitätsklinik in Graz.

Integrative painting therapy is a therapeutic concept for the treatment of psychiatric patients. It combines medical and therapeutic treatment strategies. The painting group is the main component of this type of therapy. Its focus is to capture psychodynamic processes by means of "inner pictures". The creative process of painting causes these pictures to become visible; the pictures are then worked upon. Interpreted in accordance with specific rules, the pictures reflect the psychopathology of different psychiatric disorders as well as their development throughout the therapeutic process. The pictures also serve as a starting point for group, single or family therapy. The patients quickly gain access to their emotions and become aware of conflicts which form the basis of their psychodynamics. Their progress through therapy becomes apparent and can be documented by means of the pictures. The structured course of the painting sessions provides additional information. The integration of various aspects, e.g. the phenomenology of the pictures, statements of patients about their pictures, or the behaviour of the patients within the group, serve to increase our fund of diagnostic information. Major aspects of this therapeutic concept are the development of teamwork and the establishment of close contact within the team. This makes it possible to apply different concepts within the program, in accordance with the needs of each patient. The integration of different approaches of treatment promotes the development of a therapeutic environment that supports forces of self-healing and growth in specific stages of therapy.

Efficacy of fluoxetine in Austrian patients with obsessive-compulsive disorder.

In an 8-week double-blind placebo-controlled trial we studied the efficacy of fluoxetine (FLX) in 53 Austrian patients with obsessive compulsive disorder (OCD) diagnosed according to DSM-III-R. The dosage of FLX was fixed at either 20, 40, or 60 mg per day. Response was prospectively defined as an at least 25% reduction on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and an improvement on Clinical Global Impression (CGI) rating to at least "much improved" at the endpoint. Patients treated with at least 40 mg FLX per day showed significantly higher response rates than did those receiving either placebo or FLX 20 mg/day. Compulsions were more reduced than obsessions and we also observed a strong placebo effect which is largely attributable to an improvement in the Y-BOCS compulsion subscore.

[Frequency of immunologic disorders in acute schizophrenia]. / Zur Häufigkeit immunologischer Auffälligkeiten bei akuten Schizophrenien.

Immunological examinations in schizophrenic patients have shown that there are many alterations in both arms of the immune system, i.e. cellular and humoral activities. The results are quite heterogeneous, as not even all schizophrenics show these pathological changes. Immunological findings are assumed to be etiopathogenetically related to the disease process or to be an epiphenomenon. The present study supposes that immunological alterations as they can be found during the course of schizophrenia may be an indicator for somatic vulnerability or an epiphenomenon. 60 male inpatients, fulfilling DSM-IV criteria of schizophrenia where examined during their acute phases of psychosis and during their phases of clinical improvement, by means of a serological profile including cellular and humoral parameters. The control group consisted of 42 healthy male volunteers. It was the aim of this study to find out if there were (a) overall differences in the immune profiles between patients and control group and (b) differences between different categories of schizophrenic disorder. During the acute phase nearly half of the schizophrenic patients showed pathologic immunological parameters, whereas none of the controls did. During the phase of clinical improvement the number of patients with normal immunological findings predominated. Furthermore there was a difference between the Paranoid and the Disorganized Subtype, the latter showing more immunological abnormalities. The results of this study give further support to the hypothesis that immunological aberrations should not be seen as closely etiopathogenetically related to schizophrenic disorders, but rather as an epiphenomenon (e.g. as a stress marker) and/or as indicators for somatic vulnerability.

Influence of age on the parasympatholytic property of tricyclic antidepressants.

Clinical evidence indicates that parasympatholytic effects of tricyclic antidepressants increase with age. The aim of the present study was to determine the possible physiological reason for this phenomenon. Subjects included 23 patients (14 female) with major depression, melancholic type, and 23 age- and sex-matched healthy control subjects. Cardiac vagal tone was measured at rest using both spectral analysis and a time domain beat-to-beat method. Results of the spectral and time domain methods for the estimation of vagal tone used in this study were highly correlated in control subjects as well as in medicated depressed subjects. Both patients and control subjects showed an age-related decline in cardiac vagal tone. Tricyclic antidepressants decreased vagal tone significantly by 25-49% depending on age (20-60 years), although the age difference was not significant. The greater effect of tricyclic antidepressants on parasympathetic activity typically seen in older age groups may reflect the fact that predrug levels of vagal tone are already low in older patients. Measurement of vagal tone prior to drug administration may therefore be of prognostic value for anticholinergic side effects.

Irene, a case study of a bulimia nervosa patient: the therapeutic process of integrative painting therapy.

The bulimic symptomatology--supposedly an expression of certain developments in our society--increased immensely. The progress of Integrative Painting Therapy applied to a bulimia nervosa patient, is simultaneously visible and documented. This gives insight into the psychodynamics and psychopathology of this disorder, as well as its development during treatment. The painting group provides a quick access to the patient's emotions and it permits the establishment of a strong therapeutic relationship. Paintings generated within the group reflect a patient's inner experiences and provide a starting-point for the therapeutic process. In her pictures, Irene confronts her bulimia disorder and is finally able to come to terms with her social role as a woman, her growing up and her longing for a healthy family background especially meaning contact with her father. In this spirally evolving process, where painting groups, single and family therapy work together, she was finally able to break free from her bulimic symptoms and find a new access to herself and her family, especially her father.

Problems of differential diagnosis between depressive pseudodementia and Alzheimer's disease.

Today, pseudodementia seems to be a blurred and misleading term. It is more precise to speak about cognitive disorders which can be observed in both depressed and demented patients. Guidelines which can help to differentiate between depression and dementia are proposed for both the history and the course of the disorders. Additional brain imaging can give further indications. Ergopsychometric setting, which obeys directed burden under speed conditions may be helpful. SSRIs may reduce the HPA axis hyperactivity in depressive patients with Alzheimer disease. Therefore this medication can help to improve the state of these patients.

Prevalence, patterns and role of personality disorders in panic disorder patients with and without comorbid (lifetime) major depression.

A total of 84 consecutive out-patients from the Anxiety Disorders Clinic of the Psychiatric University Hospital in Graz with a current panic disorder were diagnosed for Axis I and II disorders using the Structured Clinical Interviews for DSM-III-R. The subjects were divided into two groups: (i) 49 patients who met the criteria for panic disorder with or without agoraphobia and had no history of an affective disorder and (ii) 35 patients who had a (lifetime) comorbidity of a major depressive disorder. There was a statistically significant difference in the prevalence of personality disorders between the two groups, which was due to the higher frequency of narcissistic personality disorder in the comorbid sample. Logistic regression analysis revealed that agoraphobia and/or major depression were associated with personality disorders, thus indicating that the relationship between panic disorder, agoraphobia and major depression is not straightforward, but is strongly influenced by the presence of Axis II disorders. Furthermore, the results of this study provide support for the 'unitary position' concerning the relationship between panic disorder and depression.

Increased heart rate in depressed subjects in spite of unchanged autonomic balance?

A clinical study was conducted to examine the effects of depression on cardiac autonomic control. Cardiac autonomic control was measured in 26 nonmedicated patients (19 females) suffering from Major Depression, melancholic type, and in 26 age- and sex-matched normal controls. We measured heart rate and high frequency heart rate variability (respiratory sinus arrhythmia), pulsewave velocity and blood pressure, during 10 min of supine rest under controlled conditions. Using a log transformed time domain measure of respiratory sinus arrhythmia (logRSA), we found an inverse linear dependence between cardiac vagal tone and age in the healthy subjects as well as the depressed patients. logRSA was 0.22+/-0.25 in the patients and 0.25+/-0.16 in the control group. While this difference was not significant (P > 0.1), the deviations from the regression line were significantly (P < 0.0005) greater in the patients (0.21+/-0.12) than in the control group (0.09+/-0.07), indicating a more heterogeneous vagal tone in the depressed patients. Heart rate was also significantly (P < 0.03) greater in the depressed patients (76.6+/-12.4) than in the control group (69.5+/-6.9). No between-group differences were found in pulsewave velocity or systolic blood pressure, but diastolic blood pressure was lower in depressed patients (73.5+/-8.7 vs. 80.8+/-9.1). We discuss the possibility that the increased heart rate seen in the absence of vagal tone changes may not be due to altered vagal or sympathetic tone, as measured in this study. Other factors, including altered autonomous heart rate, may be responsible for the higher heart rate in the depressed group.

[Value of drug screening in granting leave of absence to prisoners]. / Der Stellenwert des Drogenscreenings bei der Gewährung eines "Haftausgangs".

Permitting prisoners to leave the prison for a certain time is one basic element of rehabilitation. As a rule, the inmate is not allowed to leave the prison before a psychologist or psychiatrist is consulted. A considerable number of criminals have committed crimes under the influence of addictive drugs. Many of them continue to indulge in drug abuse even in prison. Therefore, a special programme was introduced in the prison of Graz-Karlau in Austria. In the course of this programme, inmates who are about to leave prison are made to undergo a urinarlysis with immunological methods. In 1997, positive results were registered in 95 of 678 tested prisoners. Thus, this method is an effective means of determining whether prisoners may be granted a temporary release. Persons with a positive urine test may be refused permission. At the same time, every inmate with a positive test may avail himself of an appropriate treatment programme.