Carmen Uhlmann

Low Risk of Development of Substance Dependence for Barbiturates and Clobazam Prescribed as Antiepileptic Drugs: Results from a Questionnaire Study

There is no systematical research about the topic of dependence on antiepileptic drugs (AED) for patients with epilepsy, despite the fact that barbiturates and benzodiazepines comprise a potential risk of dependence. We hypothesize that there is no psychological substance dependence for patients with epilepsy, possibly because of their outcome expectations. The aim of the study was to examine these patients in terms of substance dependence. One hundred inpatients at the Lake Constance Epilepsy Center were asked about their experiences with AED in terms of dependence in a structured interview. We registered general statements about dependence of AED, markers for substance dependence, and outcome expectations. About 50% of the patients reported withdrawal symptoms and the development of tolerance, but less than 10% noticed loss of control and craving. Withdrawal symptoms and development of tolerance were significantly lower in a group of patients without barbiturates or clobazam versus patients with barbiturates or/and clobazam. There was no significant difference between these two groups in psychological criteria of dependence, that is, loss of control and craving. Outcome expectations of AED were clearly related to the efficacy against seizures, and only to a small amount to psychotropic effects. The study demonstrates that physiological variables of dependence are present more in patients with epilepsy with a permanent intake of barbiturates or clobazam, but psychological variables of dependence are rarely present in epileptic patients, with or without an intake of barbiturates and clobazam. These results confirm our hypothesis that substance dependence is not a major problem in benzodiazepines and barbiturates in patients with epilepsy. Outcome expectations seem to be related mainly to the anticonvulsant and not the psychotropic effect. This might be the reason for the absence of dependence.

Biofeedback treatment in patients with refractory epilepsy: Changes in depression and control orientation

Depression is a common and serious interictal problem in patients with epilepsy. The genesis of depressive disorders is multifactorial. One aetiological aspect focuses on psychosocial factors. It was hypothesized that uncontrollable, unpredictable chronic aversive events (i.e. epileptic seizures) result in cognitive deficits of external control orientation. If this is true, biofeedback training could represent a possible treatment strategy to lower depression, because biofeedback is known to mediate success experiences and control. Measures of depression and locus of control were administered to 20 patients with refractory partial epilepsy before and after biofeedback treatment. The biofeedback consisted of slow cortical potentials or breathing parameters in 10 patients each. A clear relationship occurred between depression and locus of control in the subjects. After biofeedback training control orientation moved towards a more internal locus of control. Also, depression scores were significantly reduced six months after training. Results show that in patients with refractory epilepsy depression is highly correlated with locus of control, in a way that external control orientation relates to high depression scores. Biofeedback is able to improve internal control orientation through personal success mediation.

Successful interventions on an organisational level to reduce violence and coercive interventions in in-patients with adjustment disorders and personality disorders

BackgroundSelf-directed and other violence as well as subsequent coercive interventions occur in a substantial proportion of patients with personality disorders during in-patient treatment. Different strategies may be required to reduce coercive interventions for patients of different diagnostic groups.MethodsWe specialised one of our acute admission wards in the treatment of personality disorders and adjustment disorders (ICD-10 F4 and F6). Patients are not transferred to other acute wards in case of suicidal or violent behaviour. Violent behaviour and coercive interventions such as seclusion or restraint were recorded in the same way as in the rest of the hospital. We recorded the percentage of subjects affected by diagnostic group and average length of an intervention in the year before and after the change in organisational structure.ResultsThe total number of coercive interventions decreased by 85% both among patients with an F4 and those with an F6 primary diagnosis. Violent behaviours decreased by about 50%, the proportion of involuntary committed patients decreased by 70%.ConclusionThe organisational change turned out to be highly effective without any additional cost of personnel or other resources.

Similarities and differences in borderline personality disorder and schizophrenia with voice hearing.

Abstract The aim of the study was to identify psychopathological similarities and differences in borderline personality disorder (BPD) and schizophrenia. We compared 23 female patients with a BPD and 21 female patients with schizophrenia according to auditory verbal hallucinations (AVHs), dissociation, childhood trauma, and additional psychotic symptoms. The character of AVH was similar with regard to commenting voices, location, and foreign voices. Major differences were found in the prevalence of negative symptoms, bizarre delusions, and formal thought disorder. These characteristics were more frequent in schizophrenia and negatively correlated with childhood traumatization. A history of childhood traumatization and dissociative symptoms was significantly more frequent in BPD. AVHs in BPD and schizophrenia are not distinguishable in terms of the historically grown criteria in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision for diagnosing schizophrenia. Other symptoms such as delusions, negative symptoms, formal thought disorder, and dissociative psychopathology could help to differentiate between both groups.

Who is Subjected to Coercive Measures as a Psychiatric Inpatient? A Multi-Level Analysis.

Background: For a reduction in the use of coercive interventions it will be necessary to identify patients at risk. The aim of this study was to explore the impact of basic patient characteristics at admission, history within 24 hours before admission, and living conditions on the risk of experiencing coercive measures, controlling for ward characteristics in a multi-level approach. Methods: Patient characteristics of 3389 patients (1920 women) who had received inpatient treatment in 2007, data relating to coercive measures, and ward characteristics were extracted from the clinical basic documentation. Results: Patients with aggressive behaviour in the 24 hours prior to admission had a three times higher risk of coercive measures compared to non-aggressive patients. Severity of illness increased the risk of coercion markedly. With each level of severity, the risk of coercion was doubled. Voluntariness of stay appeared to be the best protective factor against coercive measures. If a patient stayed voluntarily, this reduced the risk of coercion by more than two thirds. No impact was found for living conditions. Conclusions: To identify patients at risk, it is most important to intensively monitor patients with aggressive behaviour prior to admission and patients with a greater severity of psychopathological symptoms.

Memory deficits and depression in patients with chronic epilepsy

Objective: In this retrospective study, we tested the hypothesis that patients with epilepsy (PWE) with moderate to major depression have more severe memory deficits than PWE with mild depression or no depression. Methods: Hundred and thirty-nine patients with chronic epilepsy were studied with the Self-Rating Depression Scale (SDS) and a neuropsychological-screening battery the day after admission on a specialised ward for PWE. For this study the data from the Memo-test for verbal memory and from the Benton-test for non-verbal memory were taken into account. For testing of the hypothesis of independence of memory deficits and grade of depression we performed a statistical analysis. Results: Eighty-three patients (59.7%) had a pathological score in the SDS, but only 36 (25.9%) scored in the range of a moderate to major depression. When all 83 patients with a pathological score in the SDS were taken into account, these patients did not differ on any cognitive measure from those without pathological score in SDS. The only significant association in our study was found between pathological results in immediate verbal recall and a score in the SDS for moderate to major depression (p = 0.038). Conclusion: Minor depressive symptoms may be a response to chronic illness without any impact on cognitive functioning. Nevertheless, a verbal memory deficit associated with major depression was observed in our study even in the presence of many confounding factors. This may be a hint for an association of severe depressive symptoms with left temporal dysfunction in PWE.

Stationsatmosphäre und Behandlungserfolg nach Eröffnung einer Spezialstation für Patienten mit Persönlichkeitsstörungen und akuten Krisen

Hintergrund: In der aktuellen Diskussion über die psychiatrische Regelversorgung wird die Frage einer spezialisierten versus gemeindenahen Behandlung unterschiedlich bewertet. Untersucht wurde deshalb, ob sich in einem psychiatrischen Krankenhaus der Regelversorgung eine Umstrukturierungsmaßnahme mit Eröffnung einer Spezialstation für Patienten mit akuten Krisen positiv auf Stationsatmosphäre und psychische Symptombelastung auswirkt. Es wurde für diese meist persönlichkeitsgestörten Patienten eine Aufnahmestation mit einem spezifischen therapeutischen Konzept eingerichtet, das sich an die dialektisch-behaviorale Therapie anlehnt. Methoden: Eine unselektierte Gruppe von 63 Patienten des Versorgungsgebietes mit der Haupt- oder Nebendiagnose einer Persönlichkeitsstörung (31 vor, 32 nach Umstrukturierung) wurde in einer quasi-experimentellen Studie evaluiert, mit einem Prä-Post-Treatment-Design mit nichtäquivalenten Gruppen. Erhoben wurden der Verlauf möglicher psychotherapeutischer Wirkfaktoren, vor allem Stationsatmosphäre, mit dem Stationserfahrungsbogen sowie die klinische Symptombelastung einschlieβlich Suizidalität mit einer Kurzform des SCL-90. Ergebnisse: Das Stationsklima verbesserte sich nach der Umstrukturierung hochsignifikant. Im Verlauf der Behandlung verbesserten sich auch Wirkfaktoren wie die einzeltherapeutische Beziehung und die Akzeptanz der Stationsregeln; Faktoren, die sich vor der Umstrukturierung im Verlauf der Behandlung verschlechterten. Die psychische Symptomatik und im Speziellen die Suizidalität verbesserten sich vor und nach der Umstrukturierung gleichermaβen. Bei der Analyse möglicher Wirkmechanismen ergab sich eine signifikante negative Korrelation zwischen der Veränderung der generalisierten Kompetenzerwartung und der Veränderung der Stärke der Symptombelastung. Diskussion: Insgesamt profitierten persönlichkeitsgestörte Patienten wesentlich von der spezialisierten Station. Vor allem das deutlich verbesserte Stationsklima und die verbesserten einzeltherapeutischen Beziehungen kamen dieser Patientengruppe direkt zugute. Ein möglicher Wirkmechanismus zur Verbesserung der psychischen Symptomatik könnte die gesteigerte Selbstwirksamkeit der Patienten sein.

The influence of folate serum levels on depressive mood and mental processing in patients with epilepsy treated with enzyme-inducing anti-epileptic drugs

Background: Folate deficiency is common in patients with epilepsy and also occurs in patients with depression or cognitive deficits. Objective: This study investigates whether low serum folate levels may contribute to depressive mood and difficulties in mental processing in patients with epilepsy treated with anti-epileptic drugs inducing the cytochrome P450. Methods: We analysed the serum folate levels, the score in the Self Rating Depression Scale (SDS) and the results of a bedside test in mental processing in 54 patients with epilepsy. Results: There was a significant negative correlation between the serum folate levels and the score in SDS and significant positive correlations between the score in SDS and the time needed to process an interference task or a letter-reading task. Conclusions: Low serum folate levels may contribute to depressive mood and therefore to difficulties in mental processing. Further studies utilizing total plasma homocysteine as a sensitive measure of functional folate deficiency and more elaborate tests of mental processing are required to elucidate the impact of folate metabolism on depressive mood and cognitive function in patients with epilepsy.

Dissociation in patients with borderline personality disorder in acute inpatient care – A latent profile analysis

PURPOSE Dissociation is a common symptom in Borderline Personality disorder (BPD) and its consideration is important for the therapeutic outcome. The aim of this cross-sectional study was to scrutinize the co-occurrence of BPD symptoms and dissociative experiences. In particular, we were interested in the occurrence of specific symptom clusters characterizing qualitatively different patient groups in a clinical sample of BPD patients. BASIC PROCEDURES We analyzed the data of 103 patients in a specialized acute inpatient care crisis intervention unit. Measures were the Borderline Symptom List (BSL-95), a German adaption of the Dissociative Experience Scale (FDS), and the Symptom Checklist SCL-90-R. We applied a Latent Profile Analysis (LPA) using the subscales of BSL-95 and FDS to investigate the existence of distinct latent classes of symptom profiles. Afterwards, we related the obtained profiles to other clinical and demographic characteristics. MAIN FINDINGS Dissociative experiences of moderate to severe intensity were common among patients with BPD. LPA revealed that a model of three classes fitted the data best: one class was characterized by co-occurrence of severe borderline symptoms and frequent dissociative experiences, one class showed low symptom burden in both measures, and one class showed considerable borderline symptoms but only moderate dissociative experiences. The classes were closely related to the severity of other self-rated psychological problems and showed significantly different occurrences of stress-related comorbid disorders. PRINCIPAL CONCLUSIONS The results underline that dissociation is an important factor in many (but not all) BPD patients. This should be addressed by increased attention to dissociative symptoms in the diagnostic process and the adjustment of treatment plans.

Konzeptionelle und kognitive Umstrukturierung

Objective: In the treatment of patients with alcohol dependence it is next to physical detoxification under protected conditions to promoting abstinence motivation. Further the need of crisis interventions is derived from the clinical practise. To be able to become fairer to all groups of treatment as well as the different demands, the addiction admission station was restructured. Methods: Pre-post-evaluation. Results: It was found that the door was closed up significantly less often after the restructuring. In the residence time structure an increase appeared in the descriptive values with the more than 7-day stays. Conclusions: It is to be able to hold successfully the optional closed door highly significantly more often open.