Claudia Mehler-Wex

The psychopathological and psychosocial outcome of early-onset schizophrenia: preliminary data of a 13-year follow-up.

BackgroundRelatively little is known about the long-term psychopathological and psychosocial outcome of early-onset schizophrenia. The existing literature describes more severe courses of illness in these patients compared with adult-onset schizophrenia. This article reports preliminary data of a study exploring the outcome of early-onset schizophrenia 13.4 years (mean) after first admission. Predictors for interindividual outcomes were investigated.MethodsWe retrospectively assessed 27 former patients (mean age at first admission 15.5 years, SD = 2.0) that were consecutively admitted to the Department of Child and Adolescent Psychiatry at the University of Wuerzburg between 1990 and 2000. A multidimensional approach was chosen to assess the outcome consisting of a mail survey including different questions about psychopathological symptoms, psychosocial parameters, and standardized self-reports (ESI and ADS).ResultsConcerning the psychopathological outcome, 22.2% reported having acute schizophrenic symptoms. Almost one third (30.8%) described symptoms of depression and 37.0% reported having tried to commit suicide or seriously thought about it. 77.8% of the former patients were still in outpatient treatment. Compared to the general population, the number of patients without a school graduation was relatively high (18.5%). Almost half of participants still live with their parents (48.1%) or in assisted or semi-assisted living conditions (33.3%). Only 18.5% were working in the open market.ConclusionSchizophrenia with an early onset has an unfavourable prognosis. Our retrospective study of the psychopathological and psychosocial outcome concludes with a generally poor rating.

Serum protein profiling and proteomics in autistic spectrum disorder using magnetic bead-assisted mass spectrometry

The pathophysiology of autistic spectrum disorder (ASD) is not fully understood and there are no diagnostic or predictive biomarkers. Proteomic profiling has been used in the past for biomarker research in several non-psychiatric and psychiatric disorders and could provide new insights, potentially presenting a useful tool for generating such biomarkers in autism. Serum protein pre-fractionation with C8-magnetic beads and protein profiling by matrix-assisted laser desorption/ionisation-time of flight-mass spectrometry (MALDI-ToF-MS) were used to identify possible differences in protein profiles in patients and controls. Serum was obtained from 16 patients (aged 8–18) and age-matched controls. Three peaks in the MALDI-ToF-MS significantly differentiated the ASD sample from the control group. Sub-grouping the ASD patients into children with and without comorbid Attention Deficit and Hyperactivity Disorder, ADHD (ASD/ADHD+ patients, nxa0=xa09; ASD/ADHD− patients, nxa0=xa07), one peak distinguished the ASD/ADHD+ patients from controls and ASD/ADHD− patients. Our results suggest that altered protein levels in peripheral blood of patients with ASD might represent useful biomarkers for this devastating psychiatric disorder.

Drug monitoring in child and adolescent psychiatry for improved efficacy and safety of psychopharmacotherapy

Most psychotropic drugs used in the treatment of children and adolescents are applied off label with a direct risk of under- or overdosing and a delayed risk of long-term side effects. The selection of doses in paediatric psychiatric patients requires a consideration of pharmacokinetic parameters and the development of central nervous system, and warrants specific studies in children and adolescents. Because these are lacking for most of the psychotropic drugs applied in the Child and Adolescent and Psychiatry, therapeutic drug monitoring (TDM) is a valid tool to optimise pharmacotherapy and to enable to adjust the dosage of drugs according to the characteristics of the individual patient. Multi-centre TDM studies enable the identification of age- and development-dependent therapeutic ranges of blood concentrations and facilitate a highly qualified standardized documentation in the child and adolescent health care system. In addition, they will provide data for future research on psychopharmacological treatment in children and adolescents, as a baseline for example for clinically relevant interactions with various co-medications. Therefore, a German-Austrian-Swiss Competence Network on Therapeutic Drug Monitoring in Child and Adolescent Psychiatry was founded [1] introducing a comprehensive internet data base for the collection of demographic, safety and efficacy data as well as blood concentrations of psychotropic drugs in children and adolescents.

Expression analyses of the mitochondrial complex I 75-kDa subunit in early onset schizophrenia and autism spectrum disorder: increased levels as a potential biomarker for early onset schizophrenia

Searching for a peripheral biological marker for schizophrenia, we previously reported on elevated mitochondrial complex I 75-kDa subunit mRNA-blood concentrations in early onset schizophrenia (EOS). The aim of this study was to further evaluate the utility of this gene as a potential marker for schizophrenia. Both—schizophrenia and autism—are suggested to be neuronal maldevelopmental disorders with reports of mitochondrial dysfunction and increased oxidative stress. Therefore we have investigated the expression levels of mitochondrial complex I 75-kDa subunit mRNA in whole blood of children with autistic spectrum disorder (ASD) and a group of adolescent acute first-episode EOS patients in comparison to matched controls. We have found that compared to the respective controls only the group of EOS patients—and not the ASD group—showed a significantly altered expression of the complex I 75-kDa subunit mRNA. Although further studies are necessary to test for the specificity of this marker, our findings point to the potential use of the mitochondrial complex I as a biomarker for schizophrenia.

Depression in Children and Adolescents

INTRODUCTIONnPrevalence rates for depression in children and adolescents are estimated up to 8.9%. Symptoms in this age group are different from those of depression in adults. Both neurobiological and psychosocial factors are involved in its development.nnnMETHODSnSelective literature review.nnnRESULTSnOf note are both the high rate of spontaneous remissions in childhood (33%), and the high rate of depressions continuing into adulthood (80%). In addition far fewer evidence based treatments are available than for adults. Fluoxetine is currently the only medication licensed for use in children and adolescents for this indication. Tri- and tetracyclic antidepressants have not been shown in meta-analyses to be effective in children and adolescents. Most antidepressants lead to age related side effects, including attention deficit and in particular behavioral toxicity, which has to be taken seriously wherever there is a suicide risk.nnnDISCUSSIONnThe treatment of depression in childhood and adolescence should be based on multimodal interventions including psychotherapy, including cognitive behavioral therapy, which has proven effectiveness, psychosocial interventions and medications in severe cases. Patients with severe depression, especially suicidal minors, should be treated in patients units.

Bone mineral density in partially recovered early onset anorexic patients - a follow-up investigation

Background and aimsThere still is a lack of prospective studies on bone mineral development in patients with a history of early onset Anorexia nervosa (AN). Therefore we assessed associations between bone mass accrual and clinical outcomes in a former clinical sample. In addition to an expected influence of regular physical activity and hormone replacement therapy, we explored correlations with nutritionally dependent hormones.Methods3-9 years (mean 5.2 ± 1.7) after hospital discharge, we re-investigated 52 female subjects with a history of early onset AN. By means of a standardized approach, we evaluated the general outcome of AN. Moreover, bone mineral content (BMC) and bone mineral density (BMD) as well as lean and fat mass were measured by dual-energy x-ray absorptiometry (DXA). In a substudy, we measured the serum concentrations of leptin and insulin-like growth factor-I (IGF-I).ResultsThe general outcome of anorexia nervosa was good in 50% of the subjects (BMI ≥ 17.5 kg/m2, resumption of menses). Clinical improvement was correlated with BMC and BMD accrual (χ2 = 5.62/χ2 = 6.65, p = 0.06 / p = 0.036). The duration of amenorrhea had a negative correlation with BMD (r = -.362; p < 0.01), but not with BMC. Regular physical activity tended to show a positive effect on bone recovery, but the effect of hormone replacement therapy was not significant. Using age-related standards, the post-discharge sample for the substudy presented IGF-I levels below the 5th percentile. IGF-I serum concentrations corresponded to the general outcome of AN. By contrast, leptin serum concentrations showed great variability. They correlated with BMC and current body composition parameters.ConclusionsOur results from the main study indicate a certain adaptability of bone mineral accrual which is dependent on a speedy and ongoing recovery. While leptin levels in the substudy tended to respond immediately to current nutritional status, IGF-I serum concentrations corresponded to the individuals age and general outcome of AN.

Bedarf für eine eigenständige Adoleszentenpsychiatrie und -psychotherapie

Adoleszenz bezeichnet den Übergang zwischen Pubertät und Erwachsenenleben mit vie− len basalen Entwicklungsaufgaben hinsichtlich einer stabilen Identitätsbildung, Verselbstständi− gung und Gestalten eines eigenen sozialen Rau− mes jenseits der Herkunftsfamilie. Diese Aufga− ben sind in der Regel nicht mit der formalen Voll− jährigkeit des 18. Geburtstags abgeschlossen, sondern benötigen oft bis etwa Mitte 20. Jugendliche und junge Erwachsene, die früh psy− chiatrisch ersterkranken bzw. klinisch behand− lungsbedürftige Symptome zeigen und in biogra− fische Sackgassen geraten, haben oft die üblichen Entwicklungsschritte gesunder Gleichaltriger nicht oder nur unzureichend vollziehen können. Sie sind auch bei formaler Volljährigkeit was per− sönliche Reife und Selbstständigkeit angeht oft um Jahre verzögert und eigentlich psychisch 1jünger“ und können auf weniger Kompetenzen zurückgreifen. Dies ist auch dadurch bedingt, dass häufig jahrelanger sozialer Rückzug und Iso− lation nur wenig altersspezifische Erfahrungen und Reibungsphasen ermöglicht haben. Insbesondere ist hier an Jugendliche mit juveni− len Psychosen, Angst− und Zwangserkrankungen, Essstörungen sowie beginnenden Persönlich− keitsstörungen zu denken. Depressive Syndrome treten in dieser Altersgruppe meist sekundär auf. Oft haben die Patienten keinen Schulabschluss, keine Berufsausbildung oder Arbeit sowie kein tragendes Netz gefestigter sozialer Beziehungen. Hinsichtlich Impulskontrolle, emotionaler Regu− lation und dem Bilden von Handlungsentwürfen entsprechen diese Patienten oft 13 ± 16−jährigen Jugendlichen, können nicht an Strukturen der Er− wachsenenpsychiatrie anknüpfen und diese sinnvoll nutzen. Die gängige Praxis, Patienten mit ihrem 18. Ge− burtstag in erwachsenenpsychiatrischen Abtei− lungen zu behandeln, ja teilweise in diese zu ver− legen, wird der Situation inhaltlich und im Hin− blick auf einen optimalen Behandlungserfolg oft nicht gerecht. Anstatt zur notwendigen Verselbstständigung und Progression kommt es oft zu eher regressi− ven Entwicklungen. Einerseits wird der Patient/ die Patientin leicht zum versorgten Nesthäkchen durch teilweise wesentlich ältere Mitpatienten und übernimmt ungünstige, dysfunktionale Ver− haltensweisen oft chronisch kranker Erwachse− ner mit sekundärer Identitätsbildung durch die Krankheit. Oder aber der Jugendliche geht in Ver− einsamung und Widerstand und produziert eine Menge pädagogischer Probleme, denen erwach− senenpsychiatrische Behandlungsteams oft über− fordert gegenüberstehen. Immer wieder wenden sich bei diesem Klientel erwachsenenpsychiatri− sche Kliniken an uns mit der Bitte um Verlegung der Jugendlichen oder jungen Erwachsenen, da ein spezifisches adoleszenzpsychiatrisches und therapeutisch−pädagogisches Setting erforder− lich ist. In den letzten Jahren ist zu der Problematik der Reifungsverzögerung durch frühe Erkrankung noch ein weiteres pädagogisch−psychosoziales Problemfeld hinzugetreten. Die Kinder− und Ju− gendpsychiatrie unterscheidet über− und unter− sozialisierte Jugendliche. Übersozialisierte Ju− gendliche zeigen eine hohe Anpassungsbereit− schaft und −fähigkeit im Sinne der sozialen Er− wünschtheit, oft um den Preis eines weitgehen− den Verzichts auf individuelle Entwicklung. Im Gegensatz dazu sind wir in den letzten Jahren auch in der Psychiatrie mit einem immer größer werdenden Anteil sogenannter untersozialisier− ter Jugendlicher konfrontiert, dies interessanter− weise unabhängig von der sozialen Schichtzuge− hörigkeit. Wichtige soziale Fähigkeiten für das Gestalten förderlicher Beziehungen und Über− nahme von Aufgaben und Arbeiten in der Ge− meinschaft sind kaum oder nur rudimentär ent− wickelt. Dazu gehören Fähigkeiten wie Empathie, Respekt und Verbindlichkeit, Entwicklung und Pro

Psychopharmakotherapie bei Kindern und Jugendlichen

Die Psychopharmakotherapie im Kindes- und Jugendalter ist immer eingebettet in ein multimodales Behandlungskonzept. Prinzipiell ist nach Art der Storung, Schweregrad, personlichen Ressourcen und Indikation psychotherapeutischer Masnahmen abzuwagen, ob eine medikamentose Behandlung erforderlich ist. Die Behandlung orientiert sich an den Leitlinien der Deutschen Gesellschaf fur Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik (2007). Bei vielen psychiatrischen Erkrankungen stehen psychoedukative, psychotherapeutische und familienbezogene Ansatze im Vordergrund, of begleitet von sozialpsychiatrischen, umfeldbezogenen Masnahmen (z. B. Erziehungshilfen, Eltern-Kind-Trainings, Kooperation mit Jugendamtern und Erziehungsberatungsstellen) sowie schulischer und berufsperspektivischer Beratung.

Aggressive and Autoaggressive Behavior, Impulse Control Disorder, and Conduct Disorder

Aggressive behavior can occur alone or as an accompanying symptom or consequence of various psychiatric disorders as classified in the International Classification of Diseases, 10th revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Aggression can be directed against oneself (self-injury, suicidal thoughts, and acts) or against others. Aggressive behavior can be the symptom of the different kinds of disruptive behavior (e.g., oppositional defiant disorder, conduct disorder, antisocial personality disorder), of emotional dysregulation (e.g., borderline personality disorder), of disturbance of impulse control (attention deficit/hyperactivity disorder, ADHD), of cognitive deficiency (e.g., co-occurring with intellectual disabilities, pervasive developmental disorders, with psychosis or bipolar disorder), and of trauma or stress (e.g., post-traumatic stress disorder, adjustment disorders), and the aggressive behavior may be drug-induced. Thus each kind of behavioral and psychopharmacological treatment of the symptoms of aggression depends on the associated individual conditions of the aggression. Various subtypes will benefit differently from pharmacotherapy.