Paul Hoff

History and philosophy.

Antipsychiatry is dead ± long live antipsychiatry! Dramatic advances in the neurosciences in the ®nal decade of the twentieth century have led many in psychiatry to believe that the ®nal triumph of the biological model of mental disorder, which was the target of so much antipsychiatric sentiment in the debate about mental illness in the 1960s and 1970s, is just around the corner. This years articles in the history and philosophy of psychiatry show, to the contrary, that the debate between psychiatry and antipsychiatry is far from over.

Wilhelm Griesinger (1817-1868) - sein Psychiatrieverständnis aus historischer und aktueller Perspektive

ZusammenfassungDie Beschäftigung mit Wilhelm Griesingers Werk ist weit über den psychiatriehistorischen Rahmen hinaus von besonderem Interesse für die aktuelle Debatte um das Selbstverständnis unseres Faches. Dies folgt vor allem daraus, dass Griesinger – der wohl am häufigsten verkürzt und undifferenziert rezipierte und kommentierte richtungsweisende psychiatrische Autor des 19. Jahrhunderts – den (auch damals schon) ungeliebten erkenntnistheoretischen Grundfragen des Faches nicht ausgewichen ist, sondern sie ideenreich und in ständigem Bezug zur klinischen und wissenschaftlichen Praxis erörtert hat.SummaryThorough re-analysis of Wilhelm Griesingers scientific work is very interesting not only from the historical point of view, but also with regard to the present-day debate about the role and self-image of psychiatry. In the literature, Griesingers ideas are often reported in a rather undifferentiated and condensed manner. Therefore, it may be overlooked that he did not avoid getting involved with the principal epistemological issues of psychiatry (which were an unpopular topic in his time as well), but discussed them intensively and with a constant look at their relevance for clinical and research purposes.

Theories of delusional disorders. An update and review.

Delusional syndromes can occur in a number of psychiatric, neurological or other disorders. They can also be caused by neurotoxic agents (e.g., heavy metals) as well as substance addiction. There are several hypotheses on the underlying cognitive or emotional processes associated with organic factors of delusional disorders, depending on the patient groups examined and the methods used. The aim of this paper is to provide a comprehensive review and critical assessment of the various, rather heterogeneous theories in this field.

High-Frequency Somatosensory Thalamocortical Oscillations and Psychopathology in Schizophrenia

Human cortical somatosensory evoked potentials (SEPs), which are presumably generated in afferent thalamocortical and early cortical fibers, reveal a burst of superimposed early (N20) high-frequency oscillations (HFOs), around 600 Hz. There is increasing evidence of an imbalance of thalamocortical systems in schizophrenic patients. In order to assess correlations between somatosensory evoked oscillations and symptoms of schizophrenia, we investigated median nerve SEPs in 20 inpatients and their age-matched and gender-matched healthy controls using a multichannel EEG. Dipole source analysis and wavelet transformation were performed before and after application of a 450-Hz high-pass filter. In schizophrenics, the maximum HFOs occurred with a significantly prolonged latency. There was also a higher amplitude (energy) in the low-frequency range of the N20 component compared with the controls. Importantly, amplitudes (energy) of HFOs were inversely correlated with symptoms of formal thought disorder and delusions. Alterations of the thalamocortical somatosensory signal processing in schizophrenia with absence of an early HFO – assumed to be of inhibitory nature – could indicate a dysfunctional thalamic inhibition with increased amplitudes of N20, paralleled by enhanced positive schizophrenic symptoms.

Externe Qualitätssicherung der stationären Behandlung schizophrener Patienten Ergebnisse einer multizentrischen Studie

ZusammenfassungIn einem vom BMG geförderten 2-jährigen Projekt wurde anhand von insgesamt 1042 Behandlungsfällen an 4 psychiatrischen Kliniken unterschiedlicher Struktur in Nordrhein-Westfalen die Voraussetzung für eine externe Qualitätssicherung mit Hilfe der Tracer-Diagnose Schizophrenie geschaffen und durchgeführt. Ziele waren die Evaluation eines Erhebungsinstrumentariums, die Entwicklung von Qualitätsindikatoren und der Aufbau eines Rückmeldesystems zur Optimierung des internen Qualitätsmanagements. Anhand der erhobenen Daten ist es auf wissenschaftlich-statistischer Basis gelungen, Qualitätsindikatoren und eine vergleichende Art der Rückmeldung zu entwickeln, die neben Ergebnisvariablen auch Struktur-, Patienten- und Prozessvariablen beinhaltet. Diese Qualitätsprofile bilden einen wesentlichen Ausgangspunkt für krankheitsspezifische Problemanalysen im Rahmen eines internen Qualitätsmanagements.SummaryDue to legal regulations, external quality assurance is mandatory in Germany. Supported by the German Health Ministry (BMG),we present the results of a multicenter study in four hospitals with different structures on 1042 inpatients with the trace diagnosis of schizophrenia (ICD 10). We defined disease-specific indicators of structure, process, and outcome quality, developed an assessment instrument, and implemented a feedback system for quality comparison. The resulting quality profiles are useful as a starting point for internal quality management.

Kraepelin and degeneration theory

Emil Kraepelin’s contribution to the clinical and scientific field of psychiatry is recognized world-wide. In recent years, however, there have been a number of critical remarks on his acceptance of degeneration theory in particular and on his political opinion in general, which was said to have carried “overtones of proto-fascism” by Michael Shepherd [28]. The present paper discusses the theoretical cornerstones of Kraepelinian psychiatry with regard to their relevance for Kraepelin’s attitude towards degeneration theory. This theory had gained wide influence not only in scientific, but also in philosophical and political circles in the last decades of the nineteenth century. There is no doubt that Kraepelin, on the one hand, accepted and implemented degeneration theory into the debate on etiology and pathogenesis of mental disorders. On the other hand, it is not appropriate to draw a simple and direct line from early versions of degeneration theory to the crimes of psychiatrists and politicians during the rule of national socialism. What we need, is a differentiated view, since this will be the only scientific one. Much research needs to be done here in the future, and such research will surely have a significant impact not only on the historical field, but also on the continuous debate about psychiatry, neuroscience and neurophilosophy.Emil Kraepelin’s contribution to the clinical and scientific field of psychiatry is recognized world-wide. In recent years, however, there have been a number of critical remarks on his acceptance of degeneration theory in particular and on his political opinion in general, which was said to have carried “overtones of proto-fascism” by Michael Shepherd [28]. The present paper discusses the theoretical cornerstones of Kraepelinian psychiatry with regard to their relevance for Kraepelin’s attitude towards degeneration theory. This theory had gained wide influence not only in scientific, but also in philosophical and political circles in the last decades of the nineteenth century. There is no doubt that Kraepelin, on the one hand, accepted and implemented degeneration theory into the debate on etiology and pathogenesis of mental disorders. On the other hand, it is not appropriate to draw a simple and direct line from early versions of degeneration theory to the crimes of psychiatrists and politicians during the rule of national socialism. What we need, is a differentiated view, since this will be the only scientific one. Much research needs to be done here in the future, and such research will surely have a significant impact not only on the historical field, but also on the continuous debate about psychiatry, neuroscience and neurophilosophy.

Depression during an acute episode of schizophrenia or schizophreniform disorder and its impact on treatment response

The aim of the present study was to examine the relevance of depressive symptoms during an acute schizophrenic episode for the prediction of treatment response. Two hundred inpatients who fulfilled DSM-IV criteria for schizophrenia or schizophreniform disorders were assessed at hospital admission and after 6 weeks of inpatient treatment using the Positive and Negative Syndrome Scale (PANSS) and the Hamilton Rating Scale for Depression (HAM-D). Depressive symptoms showed positive correlations with both positive and negative symptoms at admission and after 6 weeks, and decreased during 6 weeks of treatment. Pronounced depressive symptoms (HAM-D score> or =16) were found in 28% of the sample at admission and in 9% after 6 weeks of treatment. Depressive symptoms at admission predicted a greater improvement of positive and negative symptoms over 6 weeks of treatment, but also more, rather than fewer remaining symptoms after 6 weeks. Both results, however, lost statistical significance when analyses were controlled for the influence of positive and negative symptoms at admission. Therefore, the hypothesis that depressive symptoms are predictive of a favorable treatment response was not supported by the present study.

The electrically elicited startle blink reflex in patients with schizophrenia : A threshold study of different reflex components

The electrically elicited blink reflex consists of three components (R1, R2, R3). In humans the excitability of these components is influenced by attentional states. In particular, distraction from the stimulus leads to facilitation of the bilateral R2 and R3. The present study was performed in order to investigate the excitability of the different components of the electrically evoked blink reflex in 13 patients with schizophrenia and 13 normal controls under standard conditions. Therefore, the thresholds of the distinct components were determined without any inhibitory or facilitatory procedure. There was no significant difference in R1 and R2 thresholds between patients and controls. In contrast, the R3 threshold was significantly reduced in schizophrenic patients (R3 threshold = 17.5 mA in normal subjects, 10.5 mA in patients, p = 0.0001). In recent studies the R3 magnitude was found to be highly susceptible to changes in the attentional state of normal subjects. The lower threshold of R3 in patients with schizophrenia might therefore be a neurophysiological marker of attentional dysfunctions in schizophrenia.

Multiaxiales System des Kapitels V (F) der ICD-10 Erste Ergebnisse der multizentrischen Praktikabilitäts- und Reliabilitätsstudie*,**

ZusammenfassungMit der Einführung der operationalisierten psychiatrischen Diagnostik kam der multiaxiale Ansatz zu neuer Beachtung. Der Entwurf des multiaxialen Systems der ICD-10 umfaßt auf Achse I psychiatrische und somatische Diagnosen. Mit der Achse II (disability diagnostic scale, DDS) werden Beeinträchtigungen der psychosozialen Funktionsfähigkeit abgebildet, während auf der Achse III Belastungsfaktoren eingeschätzt werden. Als Teil der internationalen WHO-Anwendungsstudie wurden in 7 deutschsprachigen Zentren die Anwendbarkeit und Interraterreliabilität des Systems untersucht. Weiterhin wurde die Achse II mit der entsprechenden Achse des DSM-III-R (global assessment of functioning scale) verglichen. 45 deutschsprachige Kliniker beurteilten 12 englischsprachige, von der WHO bereitgestellte Fallgeschichten in insgesamt 488 diagnostischen Einschätzungen. Die Diagnosen der Achse I zeigten eine mittlere prozentuale Übereinstimmung von 65,6 % und einen ϰ-Wert von 0,50, der damit in einem mittleren Reliabilitätsbereich liegt. Für die Achse II wurde aufgrund der Skalenqualität als Maß der Interraterreliabilität der Intraclasskoeffizient berechnet, der für diese Achse (0,62) und auch für die GAF-Skala (0,65) in einem mittleren Bereich lag. Zwischen den Subskalen und der Globaleinschätzung der Achse II wurde eine hohe Korrelation gefunden. Auf der Achse III gab es nur eine geringe Übereinstimmung für die benannten Belastungsfaktoren, der ϰ-Wert lag hier im Mittel bei 0,16. In der Diskussion werden Anmerkungen für den Revisionsprozeß des multiaxialen Systems der ICD-10 gemacht.SummaryWith the introduction of operationalized diagnostic systems the multiaxial approach became a more important issue. The proposed multiaxial system of ICD-10 consists of three axes: on axis I psychiatric diagnoses are made according to the ICD-10 Clinical Guidelines or Diagnostic Criteria for Research. Axis II (Disability Diagnostic Scale, DDS) deals with impairment of psychosocial functioning. On axis III environmental/circumstantial and personal lifestyle management factors are rated. As part of the WHO international field trial, applicability and inter-rater reliability of the system were examined in seven German-speaking centers. In addition axis II was compared with the corresponding axis of DSM-III-R (Global Assessment of Functioning Scale). 45 German clinicians rated 12 case histories written in English (provided by WHO) with 488 ratings altogether. Diagnoses on axis I with an average percentage agreement of 65.6 % and a mean ϰ of 0.50 showed a moderate inter-rater reliability. For axis II the intraclass coefficient was 0.62, and that for the corresponding DSM-III axis was 0.65: both these axes thus also had a moderate inter-rater reliability. There was a close correlation between the subscales and the global assessment of axis II there was. Wide variation was found in the psychosocial circumstances on axis III, the mean ϰ value being 0.16. In the discussion proposals for the revision process for the multiaxial ICD-10 system are made.

The concurrent validity and sensitivity of change of the German version of the health of the nation outcome scales in a psychiatric inpatient setting.

Background: The Health of the Nation Outcome Scales (HoNOS) were developed to assess the severity of a mental illness. They are used as outcome measures in different countries, and are meanwhile translated from the original English version into many languages, among others into German (HoNOS-D). We conducted a study in order to estimate the concurrent validity and sensitivity to change using clinical parameters as ICD-10 diagnoses, as well as the Clinical Global Impression Scale (CGI), and the Association for Methodology and Documentation in Psychiatry (AMDP) psychopathology scale, a frequently used psychopathological rating system, in a representative clinical sample. Sampling and Methods: Data on the three instruments (CGI, AMDP, HoNOS-D) were collected at admission and discharge of 100 psychiatric inpatients using a representative clinical sample. Experienced clinicians completed the CGI, AMDP and HoNOS-D. Descriptive and comparative data analyses were performed. We estimated the concurrent validity by calculating correlations between the HoNOS and other scales. Secondly, we examined the differences between HoNOS scores related to diagnoses and demographic parameters. Thirdly we calculated change criteria and outcome effect size for the HoNOS. Results: Even in a small clinical sample (n = 100), the HoNOS-D items are highly correlated with the corresponding AMDP syndromes (p < 0.003). The HoNOS-D score is associated with the CGI score (p < 0.01). Correlations of HoNOS symptoms, behavior and impairment items with AMDP syndromes as well as differences in diagnoses were appropriate and comprehensible as regards clinical content, and change on the HoNOS total score is statistically significant (t = 6.57, d.f. = 89, p < 0.0001). Conclusion: This study is the first to investigate the concurrent validity of HoNOS-D concerning psychopathology using the AMDP rating system in a clinical sample of patients with mental disorders in an inpatient setting. HoNOS-D can be recommended for routinely screening outcomes in inpatient psychiatric settings. Our analysis showed that HoNOS-D covers psychopathology corresponding to the AMDP rating system. A limitation of the study is that the study sample comprised only an inpatient population; there may well be differences compared to an outpatient sample.