Biomedical subjects
Publications and source records attributed to J Modestin.
The occurrence of neuroleptic malignant syndrome was examined in a prospective study of 335 neuroleptic-treated inpatients. It was not possible to identify a single unequivocal case of neuroleptic malignant syndrome. It appears to be a very rare condition in patients who are judiciously treated with relatively low doses of neuroleptics. The concept of incomplete forms of neuroleptic malignant syndrome could not be supported.
The majority of schizophrenic patients receive neuroleptics (NL) and a relatively high number of them commit suicide. Is there a relationship between the two variables? Long-term observations failed to demonstrate an interdependence between a large-scale introduction of NL in the therapeutic practice and suicide rates. There is a relationship between depression and suicide and depressive syndroms are frequent in schizophrenic patients. Depressions due to an exclusive use of NL probably do occur, but quite seldom so. Also, possible relationships between other NL side effects (akathisia, dysphoric reaction to NL) and suicidal behavior are not sufficiently supported by the clinical data. Direct comparisons in controlled studies (the own study included) between NL therapy of suicide and control subjects yielded no consistent results. Suicide promoting effect of NL cannot be postulated on the basis of the available data, however, it also cannot be fully excluded in individual cases.
We investigated 64 former psychiatric inpatients who had committed suicide within 1 year after their discharge and compared them with a carefully matched control group of patients who did not commit suicide. One third of the patients in both groups were no longer in treatment at the time of the suicide or, for controls, at the corresponding point in time. At that time, a significantly higher proportion of controls had been receiving psychopharmacotherapy and a significantly higher proportion of them were on lithium.
We studied therapeutic factors influencing suicide during out-patient treatment in severely ill discharged psychiatric in-patients. A subsample of 25 suicide and 27 control patients were all treated by psychiatrists at the time of their suicide or at a corresponding point of time. We were not able to identify any significant psychosocial or clinical pre-discharge differences between the two groups. After discharge, the patients of the control group were treated by psychiatrists with substantially longer professional training-plus-experience, the therapist's experience being the most important therapy factor contributing to the different outcome. On the whole, the contribution of the therapy factors was modest, however, explaining only 26 per cent of the group variance.
OBJECTIVE: There are no reliable data on the prevalence of multiple personality disorder. The objective of the study was to determine whether and, if so, how frequently patients with multiple personality disorder are encountered and diagnosed in Switzerland. METHOD: All qualified Swiss psychiatrists were sent a questionnaire on multiple personality disorder along with the DSM-III description of multiple personality disorder and three case examples. A total of 836 psychiatrists (66%) answered after two mailings, and 770 questionnaires qualified for evaluation. In addition, a random sample of nonresponders were contacted by telephone. RESULTS: Three percent of the psychiatrists indicated that, at the time of the inquiry, they were treating or examining one or more patients who met DSM-III criteria for multiple personality disorder, and 10% indicated that they had seen multiple personality disorder at least once during their professional career. The patients were not equally distributed among the psychiatrists; three colleagues reported that they had seen much higher numbers of patients with multiple personality disorder. The point prevalence of multiple personality disorder among patients seen by psychiatrists in Switzerland amounts to 0.05%-0.1%. CONCLUSIONS: Multiple personality disorder appears to be a disorder that genuinely exists, even though it occurs relatively rarely.
A retrospective analysis of the clinical records of 53 schizophrenic in-patients who committed suicide, and the same number of matched control subjects, was carried out using a larger set of demographic, psychosocial and clinical variables. Univariate analysis of the data indicated an early disturbed psychosocial adjustment, more severe mental illness, unsatisfactory social situation, and more frequent suicidal behaviour in the suicide group. Suicide in schizophrenic in-patients thus appears to be closely connected with a particularly incapacitating form of the illness and its deleterious psychosocial consequences.
Undoubtedly there exist atypical functional psychoses which differ significantly from schizophrenia and manic depressive illness. However, the atypical psychoses are conceptualized in various ways and they represent a quite heterogenous group of disorders. Regarding their main characteristics, they can be classified as 1. schizoaffective psychoses with a predominantly atypical phenomenology, 2. cycloid psychoses with a predominantly atypical course, and 3. psychogenic psychoses with a predominantly atypical etiology. For heuristic and clinical reasons it is recommendable: 1. to separate atypical psychoses from schizophrenia and manic depressive disorder and 2. to handle each of the three depicted forms of atypical psychoses as a different and independent group, regardless of possible overlaps.
The psychodynamic basis of suicidal behavior is investigated from the standpoint of the psychology of drive, ego, object relations, and self. Each of these four perspectives helps us understand the different aspects of suicidal behavior, the psychodynamics of which cannot be formulated in terms of a unique generally valid and all encompassing concept. The high degree of aggressive potential, the ocnophile personality and the pronounced narcissistic vulnerability appear as central conceptions regarding suicidal behavior.
In spite of its frequent use the diagnostic label "borderline disorder" is still not conceptualized in a unified way. The contemporary borderline concepts are presented and discussed, especially borderline disorder as a form of schizophrenia, borderline disorder as a special type of personality disorder in the sense of the DSM-III, borderline disorder in the sense of an encompassing borderline personality organization, and borderline disorder as a form of an affective disorder. Using this concept, it is always necessary to specify its precise meaning.
A total of 37 depressed inpatients were divided according to the endogenous vs. non-endogenous dichotomy, using clinical methods (Research Diagnostic Criteria and Newcastle scale), test-psychological method (Rorschach test), and physiological method (dexamethasone suppression test). With the exception of the two clinical scales no significant diagnostic agreement was found between the methods used. The clinical concept of the endogeneity in the depressive illness resists confirmation by nonclinical methods.
A group of 20 psychiatric inpatients who committed parasuicide during their hospital stay were compared with 58 randomly selected control inpatients and with 34 patients who were admitted following a parasuicide. The findings indicate: (1) The frequency of in-hospital parasuicide amounts to 3.2% of all admissions. (2) Apart from the more frequent past suicidal activity of the in-hospital parasuicide group, no really important differences were identified between these and control patients. The broad definition of parasuicide probably accounts for this result. (3) The patients who committed parasuicide before admission represent a diagnostically different, clinically less severely ill population. The differences between both groups of parasuicide patients support the notion of the heterogeneity of the parasuicide population.
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A total of 49 psychiatric inpatient suicides were compared with 53 former psychiatric inpatients who had committed suicide within one year after their discharge. Significant differences were found in the diagnostic distribution of both groups, especially the predominance of schizophrenics among inpatient suicides, and of alcoholics and drug abusers among suicides of former inpatients. Furthermore, some other important differences between the groups emerged that bore practical implications. In different diagnostic groups suicide occurs for different reasons and based on different psychosocial backgrounds. In the investigation of suicide in psychiatric patients, homogeneity of the population studied in terms of patient status should be strived for.
Using the method of a blind retrospective evaluation of clinical charts, 14 DSM-III pure schizotypal personality disorders (SPD) and 25 schizophrenic patients diagnosed with the help of the ICD-9 and the Flexible System were compared. Some differences emerged between the groups indicating that there may not only be a relationship between clinical samples of SPD (preferably defined by positive symptoms) and schizophrenia but also between SPD and borderline personality disorder. A group of 7 SPD and 17 schizophrenics could be followed up 4 years later. On a blind examination, SPD patients were found to be socially less well adjusted and they tended to be more symptomatic. Compared with a small DSM-III schizophrenia subgroup the differences diminished, SPD still rating higher on social dissatisfaction. A different definition of schizophrenia probably accounts for the greater part of the different results in this and previous studies.
An analysis of the temporal distribution of 115 in-patient suicides that occurred in two Swiss psychiatric hospitals in the years 1977-86 failed to reveal any statistically significant clustering of suicides. Thus, the modelling effect does not generally play a decisive role in psychiatric in-patient suicide.
Using four clinical examples it is demonstrated that the neuroleptic induced side effects occasionally occur due to an interplay of pharmacological and psychological factors. On the one hand, psychic conflicts can in a more or less specific way foster the occurrence of certain side effects; on the other hand, the presence of side effects can enable the patients' psychic problems to become manifest. The clinician should always be on the alert regarding the possible psychosomatic nature of neuroleptic side effects and intervene psychotherapeutically if appropriate.
A patient suffering from manic-depressive illness was treated on a long-term basis with lithium carbonate in consistent dosage. In the course of intercurrent Q-fever he developed lithium intoxication which led to a severe and, as confirmed by a follow-up examination after 5 years, irreversible cerebellar syndrome as well as a discrete organic mental syndrome. The course of the lithium intoxication itself was exceptional in this patient: the cerebellar symptoms appeared very early during the intoxication and were dissociated from any other central nervous system signs or symptoms, especially impairment of consciousness.
On institutional psychotherapy of suicidal patients. Some basic principles of the psychotherapeutic treatment of suicidal patients in the clinical setting are discussed. The importance of a reliable, supporting, and trusting relationship is stressed. The activity and the flexibility of the therapist present essential elements of the psychotherapeutic practice. The most important characteristics of the clinical milieu regarding the treatment of severely suicidal patients are pointed out. Countertransference reactions, frequently reflecting the psychodynamics of the patients, must be controlled. Besides, it is necessary to accentuate therapy differently depending on the diagnosis of the patient.