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Involuntary hospitalizations of patients with mental disorders in Vrapce Psychiatric Hospital: five years of implementation of the first Croatian law on protection of persons with mental disorders.

AIM: To analyze data on the practice of involuntary hospitalizations of patients with mental disorders in Vrapce Psychiatric Hospital from January 1, 1998, when the Law on Protection of Persons with Mental Disorders came into power, to December 31, 2002; with particular reference to the changes and supplements to the Law on December 1999. METHOD: The data on patient's sex, age, and diagnosis were collected from the medical records. Patients were diagnosed according to ICD-10 criteria. When a patient had two or more diagnoses, he or she was placed in category of the primary diagnosis. Results were statistically analyzed by descriptive statistics and chi-square test. Statistical significance was set to p<0.01. RESULTS: The rate of involuntarily hospitalized patients increased by significantly from 1998 to 1999 (from 30.8% to 39.6%; p<0.01, chi square test). This rate decreased to 5.6% in 2000 (p<0.01), and continued to decrease in 2002 (3.5%). There was no difference between involuntarily hospitalized patients regarding sex in 1998 (p=0.302) and 1999 (p=0.136). Men were significantly more often involuntarily hospitalized than women in 2000, 2001, and 2002 (p<0.01). Schizophrenia and other psychotic disorders were the most common diagnoses among involuntarily hospitalized patients in each of the observed years. CONCLUSION: Changes and supplements to the Law on Protection of Persons with Mental Disorders from December 1999, which abolished the necessity for a written consent for hospitalization and the necessity for prescribed procedure of hospitalized persons who were mentally incompetent to consent for hospitalization, led to significant decrease in the number of involuntary hospitalizations.

Chi-Square Distribution↗

[Evaluation of sympathetic skin response in patients with attention deficit/hyperactivity disorder presenting with comorbid disorders].

We studied sympathetic skin response (SSR) to visual emotional stimuli in two children with attention deficit/hyperactivity disorder (AD/HD) and nine healthy controls, and correlated them with comorbid disorders. They were diagnosed as having conduct disorder at administration. Two years after interventions of medical care, counseling and education, they were improving in behavior, one with oppositional defiant disorder (ODD) and another without ODD at this study. SSR were evoked in the patient without ODD (a 10-year-old boy), but not in the patient with ODD (a 12-year-old boy). These findings indicate failure of a patient with both AD/HD and ODD to respond autonomically to social stimuli, and suggest association between emotional signal and empathy.

Attention Deficit Disorder with Hyperactivity↗

Suicide risk factors in depressive disorders and in panic disorder.

Suicide has been associated traditionally with major depression, alcoholism, and schizophrenia and in the past several years with alcoholism and comorbid depression. More recently, however, panic disorder has been linked with suicide attempts, and the importance of severe anxiety symptoms (panic attacks, psychic anxiety, and agitation) as possible predictors of suicide risk in patients with major affective disorder has been studied. The author discusses data sets from three such studies: (1) the Clinical Studies of the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression, (2) a study on 17-hydroxycorticosteroid concentrations in inpatients with major affective disorder, and (3) a study on inpatient suicides. The author concludes by suggesting that anxiety, which is readily treatable, may in fact be one of the most clinically important symptoms in depressive disorders.

17-Hydroxycorticosteroids↗

[Intensive Naikan therapy for generalized anxiety disorder and panic disorder: clinical outcomes and background].

OBJECT: Intensive Naikan therapy (INT) is used to treat irrational recognition, and to develop awareness of others and self-reflection. Several reports have also shown that INT is effective for treating anxiety disorders. The purpose of the present systematic study was to investigate the factors contributing to the efficacy and clinical outcomes of INT by assessing the background, psychological evolution, and treatment required after such therapy. METHOD: Twenty-eight anxiety disorder inpatients at Tottori University Hospital, 15 with general anxiety disorders (GAD) and 13 with panic disorders (PD), were treated with INT. Age, sex, duration of the present anxiety episode, and diagnosis were investigated. The Tokyo University Egogram (TEG), Yatabe-Guilford personality inventory (YG test) and Rosenzweig picture frustration (PF) study were conducted before and after INT to investigate psychological changes. The long-term efficacy of INT for PD and GAD was assessed with Global Assessment of Functioning (GAF). Whether the patients achieved awareness of others, awareness of egocentricity, feelings of love, and self reflection after INT were investigated. RESULTS: 1) All patients showed improved GAF; the average GAF score increased from 51 +/- 8 (before Naikan therapy) to 83.2 +/- 15 (after therapy). The clinical outcomes of INT were as follows: 17 patients showed extremely effective results (60.7%), 6 were effective (21.4%), 3 were slightly effective (10.7%), and 2 were unchanged (7.1%). Overall, 23 patients (82.1%) showed remarkable improvements as a result of INT (improved group) and 5 showed no remarkable improvements (not improved group). 2) The improved group included significantly more patients with obsessive tendencies or nervous personalities such as a premorbid personality. In addition, significantly more of the patients in this group underwent daily INT and improved more rapidly in the short-term. 3) According to the STAI (state trait anxiety inventory), both state-(S-anxiety), and trait-anxiety (T-anxiety) significantly decreased after INT. The PD group showed significantly reduced S and T-anxiety, but the GAD group only showed significantly reduced T-anxiety. The adult (A) and free child (FC) TEG scales significantly increased, and according to YG, nervousness (N) and depression (D) significantly decreased while general activity (G) and social extraversion (S) significantly increased. Furthermore, according to the PF study, extraggression (E -A) after INT significantly decreased and imaggression (I-A) significantly increased. In the improved group, significantly more patients became more aware of their partners (Naikan) and achieved an objective outlook, awareness of egocentricity, feelings of love and self-reflection after INT. CONCLUSIONS: Our results suggest that INT for PD and GAD is extremely effective, and a very important form of psychotherapy. Attainment of self-reflection caused psychological changes that motivated the patients to continue Naikan therapy daily. We consider this a key factor in maintaining the efficacy of INT.

Adolescent↗

[Depression in the course of bipolar disorder and recurrent depressive disorder in the elderly: diagnostic difficulties].

UNLABELLED: Misdiagnosis of bipolar disorder in depressive patients is a common clinical problem estimated to be evident in up to 40% of patients. Elderly patients might be especially vulnerable to that sort of diagnostic error. AIM: To estimate the rate of misdiagnosis in the elderly (60yrs+) hospitalized due to depression and to establish clinical correlates that might improve diagnosis. METHOD: A retrospective analysis of medical records of all the patients hospitalized in the University based Psychogeriatric Ward and suffering from a depressive episode due to bipolar disorder or recurrent depressive disorder. RESULTS: The rate of misdiagnosis was 54% in bipolar and 9% in recurrent depressive disorder. Bipolar patients were mainly misdiagnosed as having recurrent depression. A severe episode was more common in bipolar subjects (particularly in women) while recurrent depressive subjects tend to suffer from less severe but more protracted episodes. Somatic symptoms of depression were more prevalent among recurrent depressive subjects while psychotic features, particularly delusions, and, to the lesser extent, hallucinations, were more common in patients suffering from bipolar depression. CONCLUSIONS: Bipolar depression is very often misdiagnosed in the hospitalized elderly. There are several features that might help the clinician to distinguish it from recurrent depression. Long history of illness, high number of previous episodes, severe episodes and the presence of psychotic symptoms are typical for bipolar elderly while a protracted current episode and the presence of somatic symptoms of depression might indicate the diagnosis of recurrent depression.

Aged↗

Eating disorder symptoms in affective disorder.

Patients with Major Affective Disorder (MAD), Secondary Depression, Panic Disorder, and bulimia with and without MAD, were given the Eating Disorder Inventory, the Beck Depression Inventory, and the General Behavior Inventory at presentation. It was found that patients with MAD have a triad of eating disorder symptoms: a disturbance in interoceptive awareness, the sense of ineffectiveness, and a tendency toward bulimia. The data supported the concept that the sense of ineffectiveness is secondary to major depression. A disturbance in interoceptive awareness exists independently in bulimia nervosa and in MAD providing a common diathesis from which bulimia may arise given family and social pressure. Bulimics with MAD do not respond to treatment as readily as those without MAD. It is recomended that these two groups be treated separately.

Adult↗

Further evidence for an association between affective disorders and anxiety disorders: review and case reports.

The relationship between anxiety and affective disorders continues to be debated in the literature. The authors report a case of identical twins concordant for attention deficit disorder and somnambulism but discordant for major depression and agoraphobia with panic attacks. The authors discuss the implications of this "finding in nature." Results from neuroendocrinological, family, and twin studies are also reviewed that either lend support or question the existence of a relationship between anxiety disorders and affective disorders.

Adult↗

Benzodiazepines for the treatment of panic disorder and generalized anxiety disorder: clinical issues and future directions.

For several decades, benzodiazepines have shown their effectiveness in the treatment of various manifestations of anxiety. Recent diagnostic systems have divided these manifestations of anxiety into categories and separate pathologies, such as generalized anxiety disorder and panic disorder. Researchers have studied the use and efficacy of benzodiazepine receptor agonists in patients with these distinct diagnostic categories. Clinical studies on generalized anxiety disorder and panic disorder usually suggest equivalent efficacy among benzodiazepine agonists, although truly comparative studies with two or three drugs are scarce. Further work is needed on the differences in side-effects, pharmacokinetics and discontinuation reactions for benzodiazepines. Concerns about benzodiazepine dependency--justified or not--and about discontinuation reactions have motivated the search for newer benzodiazepines without these problems. This paper reviews the efficacy and comparative studies of benzodiazepines that are currently available and discusses recent developments in research on newer benzodiazepines molecules.

Anti-Anxiety Agents↗

Epidemiology of psychiatric disorders in Edmonton. Antisocial personality disorders.

3258 randomly selected adult household residents of Edmonton, Canada, were interviewed by trained lay interviewers using the Diagnostic Interview Schedule (DIS). 104 subjects fulfilled DSM-III antisocial personality disorder (ASP) criteria. Lifetime prevalence rates were found to be significantly higher in males and in the younger adult age groups. The age of onset (i.e. age at which conduct disorder symptoms first appeared) was found to be under 10 years in the majority of cases, with females lagging just slightly behind males. Symptom patterns and frequencies were examined and the relative risks for these symptoms were calculated. Comorbidity, calculated using full DSM-III severity criteria, but without exclusion criteria, revealed an increased prevalence of nearly every other psychiatric disorder in those with antisocial personality disorder, with 90.4% having at least one other lifetime psychiatric diagnosis.

Adolescent↗

Panic disorder in Singapore: clinical features and comparisons with generalised anxiety disorder.

Fifty-eight outpatients with panic disorder (PD) were examined to determine their clinical features in comparison with a cohort of 52 patients with generalised anxiety disorder (GAD). Both groups were of comparable age, sex, educational level, marital status and ethnicity. PD patients were more likely to complain of palpitations, breathlessness, chest pain, numbness, choking sensations and especially fear of dying. GAD patients tended to complain of feeling tense, insomnia, headaches, weakness, restlessness and muscle aches. PD patients had greater comorbidity especially with agoraphobia and depression. Contrary to other reports, there were more males than females in both groups but alcohol dependence and suicide attempts were relatively rare. PD symptoms seemed more distressing, caused more social and occupational disruption, led to more requests for medical investigations and earlier psychiatric consultations. These factors seemed to suggest that panic disorder is a more severe illness than generalised anxiety disorder.

Adult↗

An epidemiological study of disorders in late childhood and adolescence--II. Persistence of disorders.

The persistence and new onset of psychiatric disorder were studied in a sample of 734 children from the general population. Diagnoses for six of the more prevalent disorders were generated from maternal and child interviews when the children were ages 9-18 and again 2 1/2 years later. Analyses demonstrated substantial levels of diagnostic persistence over the 2 1/2 year period for all diagnoses except major depression. With few exceptions persistence was roughly equivalent for age and gender subgroups. It is concluded that disorders assessed by structured interview of non-clinical samples of children cannot be dismissed as transitory.

Adolescent↗

Selective cognitive deficits in obsessive-compulsive disorder compared to panic disorder with agoraphobia.

OBJECTIVE: Visual-spatial and executive functions deficits have been reported in obsessive-compulsive disorder (OCD). We investigated their specificity comparing cognitive function in OCD, panic disorder with agoraphobia (PD/A) and controls by a comprehensive neuropsychological battery. METHOD: Fifty-five subjects (25 OCD, 15 PD/A, 15 controls) without current depressive episode underwent structured clinical interview for DSM-IV, Yale-Brown Obsessive Compulsive Scale, Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale. Neuropsychological battery assessed: executive functions, visual discrimination, spatial memory and learning, verbal memory, general intellectual functioning. RESULTS: OCD showed controlled fluency, visual-spatial construction, learning and memory deficits; PD/A spatial learning impairment. OCD was discriminated from PD/A and controls by three tests scores, predicting group membership for 76.4% of the cases. CONCLUSION: Visual-constructive and controlled fluency deficits seem specific in OCD, while the spatial learning deficit, shared with PD patients, may not be disorder-specific, but anxiety-related. Results support the proposed ventral frontal-striatal circuit involvement in OCD.

Adolescent↗

Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: dissociative disorders.

Children who have experienced severe maltreatment may use dissociation as a strategy to cope with the ongoing trauma of their maltreatment. Although dissociation may help children cope with maltreatment, it can become maladaptive if it is used in other contexts. This article explores the symptoms of dissociate disorders and the ways that maladaptive dissociation can develop in maltreated children. Strategies for distinguishing dissociative disorders from other disorders in children are reviewed and treatment strategies for children and adolescents with maladaptive dissociation, and their families, are explored.

Adolescent↗

Phenotypic Impact of Rare Potentially Damaging Copy Number Variation in Obsessive-Compulsive Disorder and Chronic Tic Disorders.

BACKGROUND: Recent studies report an important-and previously underestimated-role of rare variation in risk of obsessive-compulsive disorder (OCD) and chronic tic disorders (CTD). Using data from a large epidemiological study, we evaluate the distribution of potentially damaging copy number variation (pdCNV) in OCD and CTD, examining associations between pdCNV and the phenotypes of probands, including a consideration of early- vs. late-diagnoses. METHOD: The Obsessive-Compulsive Inventory-Revised (OCI-R) questionnaire was used to ascertain psychometric profiles of OCD probands. CNV were identified genome-wide using chromosomal microarray data. RESULTS: For 993 OCD cases, 86 (9%) were identified as pdCNV carriers. The most frequent pdCNV found was at the 16p13.11 region. There was no significant association between pdCNV and the OCI-R total score. However, pdCNV was associated with Obsessing and Checking subscores. There was no significant difference in pdCNV frequency between early- vs. late-diagnosed OCD probands. Of the 217 CTD cases, 18 (8%) were identified as pdCNV carriers. CTD probands with pdCNV were significantly more likely to have co-occurring autism spectrum disorder (ASD). CONCLUSIONS: pdCNV represents part of the risk architecture for OCD and CTD. If replicated, our findings suggest pdCNV impact some OCD symptoms. Genes within the 16p13.11 region are potential OCD risk genes.

Humans↗

Affective disorder subtyped by psychomotor symptoms, monoamine oxidase, melatonin and cortisol: identification of patients with latent bipolar disorder.

A multivariate approach using pattern recognition method was applied on a multivariable data set from patients with affective disorders comprising biological and clinical variables. The depressed patients were rated according to 23 items of the comprehensive psychopathological rating scale (CPRS). Variables of importance were selected and clusters of patients were found by combining monoamine oxidase, melatonin and post-dexamethasone cortisol with symptoms of psychomotor retardation and agitation. Patients were distributed with high scores of agitation in the extreme of one direction and with high scores of retardation in the opposite direction. By using the combined clinical and biological variables, a diagnostic subcategory with latent bipolar disorder was identified. Two clusters of unipolar patients, one with low melatonin and low psychomotor retardation scores, and one with high melatonin and high psychomotor retardation scores, were found. Identification of a patient group with latent bipolar disorder may have potential therapeutic value since bipolar patients should be taken care of by a specialist in psychiatry, avoid tricyclic antidepressant therapy and may be candidates for lithium treatment.

Adult↗

A Markov model for predicting levels of psychiatric service use in borderline and antisocial personality disorders and bipolar type II affective disorder.

This study examines the relationship between borderline personality disorder (BPD) and the use of psychiatric services in a naturalistic follow-up comparison with antisocial personality disorder and bipolar type II affective disorder. In the first follow-up series, borderline psychopathology was associated with higher levels of psychiatric service use (emergency, daycare, and inpatient). Markov analyses indicated that the transition between levels of psychiatric service use followed a stationary, second order process (i.e. the immediate past and current service use, predicted use on the next follow-up, and the relationship did not depend on the point in time examined in the follow-up series). Further, the transition probabilities generated from this model did not depend significantly on diagnosis. Predictions from the Markov model about the cumulative probability that subjects would use the highest level of psychiatric services were tested on a second series of follow-ups on the same subjects 20 months later. The model-based predictions (starting from the observed levels in the first two follow-ups of the second series) clustered into three groups, of high, middle, and low predicted probabilities. The subject group with the lowest predicted likelihood had a cumulative probability of 0.19 for using emergency, daycare, or inpatient hospitalization by 22 months of follow-up, whereas the group with the highest likelihood (containing a disproportionate number of BPD subjects) had a cumulative observed probability of 0.80. The Markov model generated from this second series supported the stationarity of the transition process. BPD subjects began using high levels of psychiatric services, but their transition from one level to another over time followed a process similar to that of non-BPD subjects.

Antisocial Personality Disorder↗

Symptom correlates of posttraumatic stress disorder in clients with borderline personality disorder.

Limited research has examined the clinical and functional impact of concurrent posttraumatic stress disorder (PTSD) in people with borderline personality disorder (BPD). Such information is particularly lacking for BPD clients with the most disabling symptoms: those who meet criteria for severe and persistent mental illness. We evaluated individuals with severe mental illness to assess whether PTSD in individuals with BPD was associated with more severe symptoms and impaired functioning than BPD alone and replicated these findings in an independent sample. In both the studies, the clients with PTSD and BPD reported significantly higher levels of general distress, physical illness, anxiety, and depression than those with BPD alone. Because individuals with both of these disorders are likely to require more intensive clinical services to reduce distress and improve functioning, work is needed to develop and evaluate interventions designed to address these comorbid conditions.

Adult↗

Comorbid posttraumatic stress disorder is associated with suicidality in male veterans with schizophrenia or schizoaffective disorder.

The purpose of this study was to determine if patients with schizophrenia or schizoaffective disorders and comorbid posttraumatic stress disorder (PTSD) are at higher risk for suicidality than patients without comorbid PTSD. Participants were 165 male veterans with primary diagnoses of schizophrenia or schizoaffective disorder. Those with comorbid PTSD reported higher rates of suicidal ideation and suicidal behaviors compared to those without comorbid PTSD. These findings suggest that patients with comorbid PTSD are at higher risk for suicidality. Enhanced screening and targeted interventions may be warranted to address comorbid PTSD and increased suicide risk in this population.

Adult↗