Hans Schanda

Culture and the prevalence of hallucinations in schizophrenia

OBJECTIVE Besides demographic, clinical, familial, and biographical factors, culture and ethnicity may plausibly influence the manifestation of hallucinations. The purpose of this study was to investigate the influence of culture on the frequency of different kinds of hallucinations in schizophrenia. METHOD Patients with a clinical diagnosis of schizophrenia were diagnosed by means of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Seven independent samples were consecutively recruited in Austria, Lithuania, Poland, Georgia, Ghana, Nigeria, and Pakistan using identical inclusion/exclusion criteria and assessment procedures (N = 1080 patients total). The association of key demographic factors (sex and age), clinical factors (age at onset and duration of illness), and country of origin with hallucinations of different kinds was examined. RESULTS The prevalence of various kinds of hallucinations was substantially different in the samples; however, the rank order of their occurrence was similar. Auditory hallucinations were relatively infrequent in Austria and Georgia and more prevalent in patients with an early age at onset of disease. Visual hallucinations were more frequently reported by the West African patients compared with subjects from the other 5 countries. Cenesthetic hallucinations were most prevalent in Ghana and in patients with a long duration of illness. CONCLUSION We hypothesize that the prevalence of the different kinds of hallucinations in schizophrenia is the result of the interaction of a variety of factors like cultural patterns as well as clinical parameters. According to our study, culture seems to play a decisive role and should be taken into account to a greater extent in considerations concerning the pathogenesis of psychotic symptoms.

Anxiety and hostility in the manifest dreams of schizophrenic patients.

Aside from delusions, hallucinations, and thought disorders, affective disturbances belong to the most prominent symptoms of the schizophrenic process. However, nearly no empirical work has been done on the systematic investigation of the dream affects of patients with schizophrenia. We compared 96 dreams of 19 patients with schizophrenia and an equal number of dreams of 19 healthy controls collected over an 8-week period by means of the Gottschalk-Gleser Analysis Scales. Additionally, central psychopathological syndromes were measured by means of the AMDP-scales each day a patient reported a dream. Although cluster analyses showed general similarities in the organization of dream affects in the two groups, we found differences between patient and control groups in the frequency and intensity of anxious and hostile affects. As in delusions of persecution, patients experience themselves in their dreams more frequently as victims of hostility from outside, which corresponds well with a significantly higher intensity of threat anxieties (death, mutilation). On the other hand, value anxieties (guilt and separation) are found less frequently in the dreams of patients with schizophrenia pointing, together with a less differentiated organization of the dream affects, to the typical affective flattening of residual syndromes.

The treating psychiatrist as expert in the courts: is it necessary or possible to separate the roles of physician and expert?

BACKGROUND Certified medical specialists, including forensic psychiatrists, from the 27 member states of the European Union (EU) may practise in each others countries, but there are professional and legal differences between them. One may lie in whether a patients treating doctor/clinician may give expert evidence about that person in court. AIMS To examine similarities and differences between EU jurisdictions in law and practice in combining or separating such roles and to review the evidence in support of either position. METHODS A psychiatrist with court experience was contacted in each EU country about law, practice and guidance on division of clinician-expert roles. Published literature was searched for an evidence base for practice in the field. Additional material is from discussion at a residential meeting of practising forensic psychiatrists from Austria, Belgium, Denmark, Germany, Hungary, the Netherlands, Switzerland and the UK. RESULTS All acknowledge that a treating clinician can never be an independent expert in that case, but the 22 (of 27) EU countries responding vary in law and practice on whether the dual role may be assumed. There has been almost no research interest in factors relevant to separation of roles. International discussion revealed that ethical and practice issues are not straightforward. CONCLUSIONS On current evidence, either separation or combination of clinical and expert roles in a particular case may be acceptable. Insofar as there are national legal or professional guidelines on this issue, anyone practising in that country must follow them and may safely do so, regardless of practice in their native country. The most important ethical issue lies in clarity for all parties on the nature and extent of roles in the case. This paper has additional material online.

Violence Against Others by Psychiatric Hospital Inpatients with Psychosis

Hospitals are microcosms of society and, as such, have many of society’s strengths and weaknesses. Among the weaknesses is the possibility of violence among individuals or groups or against property. Against this background are conflicting expectations or assumptions: first, that hospitals, as places of healing or asylum, should necessarily be safer than the outside world; and second, that hospitals, as places where damaged and stressed people are grouped and, frequently, undergo unpleasant and restricting procedures, must carry greater potential for violent incidents. Violence in hospitals is no more exclusively the preserve of people with a psychiatric disorder than violence elsewhere in the community. However, as there appears to be a small but significant association between some mental disorders and violence, and as one important reason for admission to a psychiatric hospital is the threat of or actual violence, psychiatric hospitals and units might be expected to be disproportionately affected.

Das Cotard-Syndrom bei schizophrenen Erkrankungen

BACKGROUND The Cotard-Syndrome (CS), the belief of being dead, was described for the first time in 1880. Since then it met the interest not only of psychopathologists but also of philosophers. With a few exceptions, the literature is mainly restricted to case reports of anxious-depressive, demented or paranoid patients. It was the aim of our study to investigate the prevalence and the psychopathological context of the CS. METHODS We analyzed the Austrian data (N = 346) of the International Study of Psychotic Symptoms in Schizophrenia. RESULTS A CS could be diagnosed in three cases (0.87%). In all of them, CS developed on the basis of nihilistic-hypochondriac delusions and a progressive loss of energy. Two patients bridged the logical inconsistencies between obviously being alive and the belief of being dead by visual illusions, the third patient, however, by locating himself in an intermediate region between this world and the afterworld. CONCLUSIONS On the one hand the CS can be considered as a special manifestation of the topic of death in schizophrenic delusions, on the other as a nihilistic delusional identity. Without doubt, this uncommon and bizarre psychotic phenomenon will be an object of interest for general psychopathology as well as for the philosophy of mind also in future.

The traces of violence : Suicide and homicide rates in the former Bloodlands

BACKGROUND Suicide and homicide rates are the ultimate expressions of violence. The rates are globally almost distributed mirror-reverted. Rich, modern democratic countries with a functioning legal system have high suicide and low homicide rates, traditional states with a weak central government high homicide and low suicide rates. Exceptions are some Eastern European countries, in which both, the rates of homicide and suicide are very high. These states are located on the territory of the former Bloodlands (Snyder, Bloodlands: Europa zwischen Hitler und Stalin, 2011), where between 1930 and 1945 14 million people were civilian victims of the Soviets and the National Socialists. We addressed the question of whether these eight countries (Poland, Lithuania, Estonia, Latvia, Moldova, Belarus, Russia and Ukraine) differ from the other European countries of the former East bloc, from the Asian countries of the former USSR and the Western European countries in social, economic and psychosocial factors. METHODS The data used for analyses were taken of various data sets from the WHO, the UN and the CIA. The statistical comparison of the four regions was carried out by nonparametric tests. RESULTS The States on the grounds of the former Bloodlands and the other European countries of the former East bloc are comparable concerning important social and economic parameters such as level of modernization, Democracy-index and Rule of Law-Index. Statistically significant differences were found only in the annual alcohol consumption per capita and the divorce rates. CONCLUSIONS We hypothesize that the high suicide and homicide rates in some Eastern European countries may be the result of the traumatic experience of extreme violence of nearly the entire population between 1930 and 1945. Possible paths of the transgenerational transmission as well as conceivable chains of causality between the trauma in the first generation and suicidal or homicidal behavior in the following generations are presented.

Die Spuren der Gewalt

BACKGROUND Suicide and homicide rates are the ultimate expressions of violence. The rates are globally almost distributed mirror-reverted. Rich, modern democratic countries with a functioning legal system have high suicide and low homicide rates, traditional states with a weak central government high homicide and low suicide rates. Exceptions are some Eastern European countries, in which both, the rates of homicide and suicide are very high. These states are located on the territory of the former Bloodlands (Snyder, Bloodlands: Europa zwischen Hitler und Stalin, 2011), where between 1930 and 1945 14 million people were civilian victims of the Soviets and the National Socialists. We addressed the question of whether these eight countries (Poland, Lithuania, Estonia, Latvia, Moldova, Belarus, Russia and Ukraine) differ from the other European countries of the former East bloc, from the Asian countries of the former USSR and the Western European countries in social, economic and psychosocial factors. METHODS The data used for analyses were taken of various data sets from the WHO, the UN and the CIA. The statistical comparison of the four regions was carried out by nonparametric tests. RESULTS The States on the grounds of the former Bloodlands and the other European countries of the former East bloc are comparable concerning important social and economic parameters such as level of modernization, Democracy-index and Rule of Law-Index. Statistically significant differences were found only in the annual alcohol consumption per capita and the divorce rates. CONCLUSIONS We hypothesize that the high suicide and homicide rates in some Eastern European countries may be the result of the traumatic experience of extreme violence of nearly the entire population between 1930 and 1945. Possible paths of the transgenerational transmission as well as conceivable chains of causality between the trauma in the first generation and suicidal or homicidal behavior in the following generations are presented.