Types of authority and two problems of psychiatric wards

This paper concerns the relationship between authority structures and two problems reported in the literature as common to milieu or therapeutic community wards. Psychiatric wards with rational-legal and charismatic authority structures are found more likely to experience mood and morale swings on the part of patients and staff and to spend excessive time and energy changing ward rules.     

Partners in ministering — A psychiatrist and a pastor

Interdisciplinary relationships can complement and effect successful outcomes in therapy. Some essential criteria are suggested as the result of a pastor and psychiatrist working conjointly in a compatible fashion. Stereotypes and traditional roles are barriers which must be worked-through. The working-through process may not be applicable to every professional dyadic relationship, but the conjoint approach might be considered in addition to current modus operandi. Interdisciplinary co-therapists must utilize the same process they are trying to teach their patients—practice what you preach. The authors wish to express their appreciation to the cotherapist and family participants in the Multi-Family Group Therapy and to others who have helped to make this paper possible.     

Electron microscopic structure of the alzheimer's neurofibrillary changes in case of atypical senile dementia

Summary A man aged 70, showed early disorientation, memory defects, delusions and rages at 66, later mental deterioration with muteness and dysphagia. He died of cardiac failure. The postmortem examination revealed macroscopically and light microscopically the neuropathological findings of atypical senile dementia.Moreover, it is the interesting characteristic in the presented case that there are electron microscopically two types of filaments making the neurofibrillary tangles. One showed the so-called paired helical filaments, which were observed in the cerebral cortex. The other showed parallel straight filaments. These straight filaments were found in the bilateral hippocampi.     

Schizophrenia suspecta

Summary We investigated what makes a Schneider-oriented psychiatrist diagnose suspected schizophrenia yet nevertheless stop short of a definitive diagnosis of schizophrenia. We compared the case records of 1208 patients hospitalised for schizophrenia for the first time in their life and all patients with discharge diagnosis suspected schizophrenia (n = 358).We found that the main factors for making the diagnosis of suspected schizophrenia are, as when using Bleuler's concept, intrasymptomatological ones, i.e. type, structure and constellation of symptoms. Hereby the non-committal character of the expression symptoms in the wider sense (Schneider), i.e. disorders of thought, of affect and behaviour, is of particular importance. Psychotic productive symptoms in the form of delusions or hallucinations alone are not always sufficient to confirm the diagnosis of schizophrenia. Even first rank symptoms cannot establish the diagnosis schizophrenia if certain factors reducing their pathognomonic value are present.Elaboration of the computer programme: Dr. rer. nat. E. Godehardt, Cologne University Institute of Medical Documentation and Statistics (Director: Prof. Dr. V. Weidtman)     

Psychiatric consultation for Project Head Start

Psychiatric and/or mental health services for the Project Head Start program need to be adapted to the character of the population group to be dealt with. This requires special knowledge and skills, not only in relation to the psychopathology of the preschool-age child, but also to the subtleties of family pathology and the ways in which a disturbed child of this age is simultaneously causative agent and victim. Because of the socioeconomic characteristics of many of the groups to be served, special adaptation to travel problems and location will need to be made. Also, because of these factors and the limitations of motivation, the standard model of psychotherapy will in most instances not be feasible. Maximum use of the nursery school teachers as therapeutic agents will be necessary. With appropriate and continuing consultation, they should emerge as pivotal educative figures for the whole family.     

Meningiomas with a non-meningotheliomatous component

Summary Seven cases of meningiomas with pseudopsammoma bodies have previously been described in the literature. Two additional cases are presented. Electron microscopy of the cells surrounding the pseudopsammoma bodies reveals an ultrastructure different from that of the meningotheliomatous cells. It is concluded that meningotheliomatous meningiomas with pseudopsammoma bodies are mixed tumours, including a non-meningotheliomatous component, the origin and significance of which is uncertain.     

Mental Hygiene of the Special Schools Teachers in Kerman,Iran

The goal of this research is to identify and study the mental hygiene and its related factors (individual, family, organizational) in the Kerman special schools teachers. 266 teachers of the special schools of the cities of the province Kerman were chosen as the research sample. The necessary data were obtained by questionnaire which its validity and reliability were determined. The statistical analysis of the research findings (by Spearman coefficient test) Man-Whithey and Kruskal wallis tests showed that there was a positive and meaningful relationship between Level of education, service of record the number of the members of teachers family, income, dwelling-place, economic power, acceptance of the teachers job in their family, leadership style, suitable educational possibilities, suitable educational space, job satisfaction with the mental hygiene of the teachers. The results of the research also showed that the Kerman special schools teachers enjoyed a relatively desirable mental hygiene.     

Multicystic encephalomalacia in term infants

The terms multicystic encephalomalacia and subcortical leucomalacia (SCL) are used to describe the presence of areas of necrosis that develop into cystic lesions inside the brain. These lesions are generally due to severe asphyxia and/or hypotension. The designation SCL can also be used to describe the extent and the seat of the lesion in the brain or to distinguish subcortical lesions from periventricular and/or combined ones. In this study we give an account of our experience with eight newborns admitted to our neonatal intensive care unit, who presented clinical-neurological alterations and encephalomalacic lesions whose presence was documented by ultrasonography.     

Extraocular muscles light microscopy and ultrastructural features

Summary Thirty extraocular muscles (EOM) from 20 patients were evaluated by light microscopy (LM), electron microscopy (EM), and enzyme histochemistry (EZH). Twenty-one EOM were obtained from 13 patients with strabismus, 9 EOM from 4 patients undergoing eye surgery for other reasons and from 3 autopsy cases. One m thick sections revealed marked variation in muscle fibre shape and size and in myofibrillar structure; also noted were small, hypertrophied, whorled, and ringbinden fibres. Dense and granular material in the central portion of some fibres and sarcomere disruption in 2–3 m sections was observed. EZH revealed the absence of the classical mosaic pattern usually found in skeletal muscles. ATPase studies were inconsistent and did not correlate with the expected reciprocal activity of NAD-H diaphorase, particularly on the large fibres.Ultrastructural features consisted of vacuoles within myofilament bundles, smearing of Z bands, and nemaline rods. Occasional myelin figures and lipid-like droplets were observed in subsarcolemmal spaces, associated with scattered clusters of glycogen granules. Abnormal mitochondria and subsarcolemmal inclusions of dense and granular material were conspicuous. Leptomeric profiles, Zebra bodies, or striated bodies were noted in 8 EOM's, and an Hirano body was found in 1. The intramuscular nerves contained structures resembling Luse bodies in 7 cases.These observations suggest that EOM from individuals with and without strabismus possess unique structural characteristics suggestive of developmental and morphological disarrangement of contractile elements. Some of these changes might play a role in the pathogenesis of strabismus and in the development of clinical symptoms.These features are significantly different from striated skeletal muscle. Therefore the criteria used in the pathological evaluation and diagnosis of skeletal muscle disorders cannot be unequivocally applied to EOM investigations. These data establish the necessity to determine histological norms, ultrastructural patterns, and develop new enzyme histochemistry criteria for the evaluation of EOM. Only then can an acceptable comparison of EOM and skeletal muscle be made.     

Reliabilität psychiatrischer Diagnosen — eine Voruntersuchung

Zusammenfassung Es wird über eine Pilot-Study zu der Untersuchung Reliabilität psychiatrischer Diagnosen berichtet. Ziel dieser Arbeit war es, Hinweise auf die Beantwortung der folgenden Fragen zu erhalten: — Welche der zehn Diagnosen aus den Bereichen endogene Psychose, Neurose und Persönlichkeitsstörung (Psychopathie) werden übereinstimmend mit charakteristischen Symptomen gut beschrieben? — Welche Symptome, Verlaufskriterien, anamnestische und ätiologische Daten sind zur differentialdiagnostischen Abgrenzung der zehn psychiatrischen Krankheitsbilder geeignet? — Welche der zehn Diagnosen werden nicht oder unzureichend unterschieden? — Bei Erhebungen in drei psychiatrischen Landeskrankenhäusern und zwei psychiatrischen Universitätskliniken beteiligten sich 52 Mediziner und Psychologen, die gebeten wurden, fünf bis zehn diagnostische Stereotype, z. B. die Schizophrenie, an Hand der von uns vorgegebenen Symptomlisten zu charakterisieren. Hinter jedem Symptom war eine 10 cm lange Skala von uncharakteristisch bis sehr charakteristisch, auf der die Einzelentscheidung, z.B. wie charakteristisch sind Halluzinationen bei der Schizophrenie? durch einfache Markierung festgehalten wurde. — Die Auswahl der zur Charakterisierung brauchbaren Symptome erfolgte auf zwei Wegen. Zum einen wurde geprüft, ob die Beurteilungen jedes Items folgenden Kriterien genügten: — 1. Verteilungssymmetrie der Beurteilungen eines Items bei jeder Diagnose. — 2. Der Mittelwert der Beurteilungen eines Items muß mindestens bei einer Diagnose im Bereich sehr charakteristisch liegen. — 3. Der Abstand zwischen höchstem und niedrigstem Mittelwert eines Items bei den Diagnosen muß etwa die Hälfte der theoretisch möglichen Differenz erreichen. — Auf der anderen Seite wurde eine Rangfolge der Items nach deren Eignung zur Abgrenzung der Diagnosen voneinander mit Hilfe einer schrittweisen Diskriminanzanalyse errechnet. Durch die Kombination dieser beiden Auswahlverfahren war eine sinnvolle Selektion möglich; von den ursprünglich 98 Symtomen erwiesen sich nur 52 als ausreichend brauchbar zur Charakterisierung der zehn Diagnosen. — Die Ergebnisse einer Faktorenanalyse zeigten die unterschiedliche Abgrenzbarkeit der ausgewählten Diagnosen. Eine Trennung der drei verschiedenen Depressionsformen ließ sich nicht nachweisen. Von den zehn Diagnosen fanden sich in der Faktorenanalyse nur fünf als Symptomgruppierungen wieder. Es bleibt abzuwarten, ob diese vorläufigen Ergebnisse sich in der Hauptuntersuchung bestätigen lassen.

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Summary This is a preliminary report on a pilot study addressing the following questions: Which of ten diagnoses in the area of endogenous psychosis, neurosis and personality disorder are supported consensually as to characteristic symtoms, and which symptomatic, anamnestic, etiological and clinical-course data fit and support the diagnostic discrimination; conversely, which diagnoses are insufficiently supported? — As a preliminary methodological step, fifty-two psychiatrists and psychologists in three governmental hospitals and two university clinics were asked to characterize from five to ten diagnostic stereotypes by assigning symptoms to a point on a 10-point scale, ranging from uncharacteristic to very characteristic. Characteristic symptoms were then selected by determining, (a) the distribution of the judgment of each item for each diagnosis; (b) those items which were judged very characteristic with regard to a diagnosis and, (c) the range of differences in mean values of each item by diagnosis. At the same time, the items were placed in rank-order by means of a step-wise discriminant function analysis. Of the original 98 symptoms only 52 proved useful for the underpinning of the ten diagnoses. — Factor analyses then demonstrated the discrimination and the limitation of the respective diagnoses. For instance, the three forms of depression could not be differentiated reliably. Of the ten diagnoses, only five proved valid in terms of symptom clusters. It remains to be seen if these preliminary results will be confirmed in the course of this study.

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Résumé Les auteurs présentent une étude pilote destinée à examiner la reliabilité des diagnostics psychiatriques. Le but de ce travail était de répondre aux questions suivantes: — Parmi 10 diagnostics du domaine de la psychose endogène, de la névrose et des troubles de la personnalité (psychopathic), lesquels sont bien décrits, de façon concordante avec les symptômes caractéristiques? — Quels symptômes, critères d'évolution, données anamnestiques et étiologiques, permettent de délimiter le diagnostic différentiel des 10 tableaux cliniques? Lesquels de ces 10 diagnostics ne sont pas différenciés, ou de manière insuffisante? — On a procédé à une enquête auprès de 52 médecins et psychologues de 3 cliniques psychiatriques régionales et de 2 cliniques psychiatriques universitaires; ceux-ci ont été priés de caractériser, à l'aide des listes de symptômes établies par les auteurs, 5 à 10 stéréotypes diagnostiques, par exemple la schizophrénie. Pour chaque symptôme, on disposait d'une échelle de 10 cm de longueur allant de non caractéristique à très caractéristique, sur laquelle chaque décision était reportée par un marquage simple (par exemple: à quel point les hallucinations sont-elles caractéristiques de la schizophrénie?). Le choix des symptômes utilisables pour caractériser les affections a été effectué de deux façons. D'une part, on a examiné si les évaluations de chaque item répondaient aux critères suivants: — 1. La valeur moyenne des évaluations d'un item doit se situer, au moins pour un diagnostic, dans la zone très caractéristique. — 3. La distance entre la valeur moyenne maximale et minimale d'un item doit atteindre environ la moitié de la différence théoriquement possible. D'autre part, on a calculé, au moyen d'une analyse de discrimination pas à pas, un ordre des items selon leur utilité pour délimiter les diagnostics. Grâce à. la combinaison de ces deux procédés de choix, il a été possible d'opérer une sélection raisonnable; parmi les 98 symptômes initiaux, 52 seulement se sont avérés suffisamment adéquats pour caractériser les 10 diagnostics. Les résultats d'une analyse factorielle ont montré la différenciation variable des diagnostics choisis. Il n'a pas été possible de démontrer une séparation entre les 3 différentes formes de dépression. Parmi les 10 diagnostics, 5 seulement se sont retrouvés dans l'analyse factorielle sous forme de groupements de symptômes. Il reste maintenant à voir si ces résultats préliminaires seront confirmés par l'étude principale.

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Die Arbeit ist in Zusammenhang mit dem Aufbau des Sonderforschungsbereichs 116 — psychiatrische Epidemiologie — verfaßt worden.

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Herrn Professor Häfner danken wir für die Mitwirkung bei der Planung und für Anregungen bei der Durchführung und Darstellung des Forschungsprojektes.

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Herr J. Zenker arbeitete an der vorliegenden Untersuchung im Rahmen seiner Dissertation mit, die unter dem Titel Untersuchung über die Zuverlässigkeit verbaler Konzepte von 10 psychiatrischen Diagnosen vorliegt.     

Clinical Evaluation of Attention-Deficit Hyperactivity Disorder by Objective Quantitative Measures

This study assessed the diagnostic potential of the actigraph, the Continuous Performance Test, and the Matching Familiar Figures Test in diagnosing attention-deficit hyperactivity disorder (ADHD). Twenty boys previously diagnosed with ADHD and 52 controls were examined. By these measures the boys with ADHD were differentiated from the controls with sensitivity and specificity above 75%. We were able to classify ADHD into eight subtypes by combining the scores of the actigraph and the CPT: hyperactive-impulsive, hyperactive-inattentive, impulsive-inattentive, hyperactive, impulsive, inattentive, mixed, and unspecified type. These classifications may be useful in diagnosing ADHD.     

School Violence Reduction: A Model Jamaican Secondary School Program

Violence in United States' schools is epidemic. Solutions are rare. Community mental health centers are now being challenged to become part of the solution. The Montego Bay Secondary School project presents an example of how violence reduction can be achieved using almost no physical resources and the special effect, called the Bruno Effect, created by one Jamaican police officer with the consultation of a psychodynamically-led training and intervention team. The Bruno Effect resulted in a dramatic reduction in the number of physical attacks from an observed 5 fights per day (3 out of the 5 involved knives and cutting) to 1 per week. The violence rate returned immediately to its former level as soon as Bruno left the school. The dramatic violence reduction appears related to establishing an adult protective shield. Results stem from the unique personality of the adult protector, as well as a combination of the special role of the police and the outside intervention team.     

Focal mucoid degeneration of peripheral nerve

Summary Focal mucoid degeneration was found in a N. suralis biopsy of a 8 year old child, diagnosed clinically and electrophysiologically as progressive muscular atrophy Charcot-Marie-Tooth.     

Quality of life in multiple sclerosis: The disability and impact profile (DIP)

Seventy-three Dutch and Flemish patients with definite multiple sclerosis (MS) were assessed by means of the Disability and Impact Profile (DIP), which is a 2 × 39 item, self-administered questionnaire with parallel questions aboutdisabilities and their importance for orimpact on the patient, resulting in a profile of weighted scores. It was designed as a tool for clinical assessment of quality of life (QoL) domains in MS patients. Group data showed more than 50% loss on weighted scores for walk, clean home, work and worry about deterioration. In individual patients a median of 7 (range 0–23) major disruptions of quality of life (MD-QoL: loss on weighted score more than 50%) was found. Prevalence of MD-QoL in more than 10% of the patients was found for as many as 31 disabilities and > 50% for 3 (clean home, work and worry about deterioration). Results in the MS group were compared with available data from 25 patients with rheumatoid arthritis (RA) and 25 patients with a spinal cord lesion (SCI). Weighted scores of read, memory and concentration were significantly lower in the MS group than in the RA and SCI groups. Significantly lower weighted scores in both the MS and RA groups compared with the SCI group were found for worry about deterioration, physical endurance, clean home, work, see and write. In conclusion, major disruptions in many domains of QoL were found in MS patients. Weighted score profiles for MS were in accordance with clinical manifestations. Unlike Kurtzke's Extended Disability Status Scale, DIP assesses a wide range of potentially MS-affected human activities, and also takes into account the subjective perception of disabilities.     

Cerebral hemodynamics and “re-build-up” phenomenon on electroencephalogram in children with moyamoya disease

Re-build-up phenomenon, induced by hyperventilation, is a characteristic finding on electroencephalogram (EEG) in children with moyamoya disease, and suggests close correlation with cerebral ischemic attack. Its mechanism, however, remains obscure. In this study, we examined the relationship between the cerebral hemodynamics and this phenomenon before and after vascular reconstructive surgery. Regional cerebral blood flow and its reactivity to acetazolamide were analyzed using the xenon-133 inhalation method and single photon emission computed tomography in six children with moyamoya disease. These results were compared with the EEG. Regional vasoreactivity to acetazolamide was significantly lower in re-build-up-positive regions than in re-build-up-negative regions. Postoperative studies revealed a significant improvement of reactivity in the regions where the re-build-up phenomenon disappeared after surgery. These results suggest that the re-build-up phenomenon represents a focal reduction of the cerebral perfusion reserve in moyamoya disease.     

Kritische Anmerkungen über die Gedankeneingebung

Zusammenfassung Gedankeneingebung ist eines der Symptome ersten Ranges im Sinne von Kurt Schneider. Schon früher hatte Karl Jaspers eine feinere Trennung vollzogen: Er unterschied zwischen der Gedankeneingebung in einem engeren Sinne und gemachten Gedanken. Indessen haben die meisten deutschen und englischen Autoren die Jasperschen Kriterien dieser Unterscheidung verschmolzen und dadurch den Gebrauch des Terminus ausgeweitet. Auch Kurt Schneider und Weitbrecht sprachen von Gedankeneingebung, gemachten Gedanken und Gedankenbeeinflussung, als ob diese Phänomene identisch seien. Demgegenüber bietet die Jaspersche Differenzierung eine Trennschärfe bei der Erfassung psychopathologischer Symptome, auf die nicht verzichtet werden sollte. Logischerweise und aus praktischen Gründen läßt sich diese Differenzierung auf alle gemachten oder Beeinflussungserlebnisse ausdehnen, so daß man vier Aspekte solcher Phänomene unterscheiden kann. Einige differential-diagnostische Überlegungen hinsichtlich der Gedankeneingebung werden abschließend kurz besprochen.Professor H. -H. Meyer zum 65. Geburtstag herzlich zugeeignet.     

Electroconvulsive therapy in Parkinson's syndrome with “on-off” phenomenon

Summary During long-term treatment with L-dopa in Parkinson's syndrome on-off phenomenon develops in many cases, often entailing considerable therapeutic problems. Decreased sensitivity in postsynaptic striatal dopamine (DA) receptors has been shown to occur in parkinsonian patients during long-term treatment with L-dopa. This has been suggested as one possible mechanism for development of the on-off phenomenon. In contrast to L-dopa treatment electroconvulsions have been shown to increase sensitivity in the DA receptors, when administered to animals.The antiparkinsonian effect of electroconvulsive therapy (ECT) was investigated in five parkinsonian patients with on-off phenomenon, with or without concomitant signs of mental depression. ECT was administered according to praxis in treatment of mental depression. Drug therapy, including L-dopa, was maintained on previously adjusted doses during and after ECT.A marked improvement in the parkinsonian symptoms as well as in the on-off phenomenon occurred in three of the patients, persisting for several months. The other two patients showed only slight and transient improvement.It thus seems that ECT may be useful as a supplementary treatment in parkinsonian patients with on-off phenomenon. The antiparkinsonian effect of ECT is probably mediated by increased sensitivity in postsynaptic DA structures.     

Changes in electroretinogram and serum potassium during l-DOPA treatment in parkinsonism

Summary The relationship of l-DOPA plasma level, parameters of ERG and severity of extrapyramidal symptoms after a single dose of l-DOPA was investigated in 11 patients suffering from parkinsonism of idiopathic or arteriosclerotic origin.After a drug-free night, each patient received his/her usual morning dose of l-DOPA. In the subsequent 3 h, the ERG recordings, blood levels and clinical ratings of extrapyramidal symptoms significantly dropped after a delay of 60 min in relation to the occurrence of the peak plasma l-DOPA level.The initial b wave amplitudes as well as initial serum potassium values were abnormally high. There was a statistically significant correlation between the decrease of b wave amplitude (b) and the potassium normalization index (i.e. the ratio between the observed decrease of serum potassium and the pretreatment difference from the middle normal potassium value).A definite interpretation of the data cannot be provided until more knowledge about the origin of b wave of ERG is available. It can be concluded tentatively that dopaminergic processes influence electrophysiological reactivity of the retina.     

An approach to the measurement of suitability for psychotherapy

Summary As a first step toward the measurement of the complex variable, suitability for psychotherapy, this essay defines this variable by a set of criteria. These criteria may be applied to content analysis of transcribed interviews; and they allow a differentiation of patients into easy and difficult candidates for psychotherapy. In the difficult group, patients: (1) cannot describe feelings; (2) they exhibit relationships in which the object is essential but is not overvalued; (3) they tend to use nonspecific pronouns; (4) they make bizarre interpretations of sensations; and (5) they display circumstantiality in their accounts of past experiences.The relation of these criteria to a primitivity of character structure, and in turn to the problem of psychosomatic illness, is discussed. Some implications in the development of human emotional states are briefly suggested.From the department of psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina.     

An Operationalized Multisymptomatic Model of Neuroses (OMMON): Toward a reintegration of diagnosis and treatment in behaviour therapy

Summary Experimental results from a sample of 216 patients with four different symptom-neuroses show that 65% to 90% of these patients have different combinations of multiple symptomatology.With a background of these data, we present an Operationalized Multisymptomatic Model of Neuroses (OMMON), based on self-rating assessment of these patients on 4 symptom scales. Individual ratings on each scale are dichotomized into (+) or (-) results with regard to defined cut-off points and the model is derived from their 16 mathematically possible combinations. Subsequent analysis of these data (from a single test application) with our Varying Cut-Off Point Assessment (VACOPA) leads to hypotheses regarding causal symptom interactions and prediction of symptom changes over time, easily evaluated by repeated test application.In treatment research the model seems suitable to: (a) build more homogeneous diagnostic groups; (b) operationalize varying degrees of neurotic disturbance, from normal via client to patient—independently of existing illness theories; (c) support prognoses of individual developments within and without treatment; (d) specify treatment aims and optimal sequences of interventions; (e) monitor predicted outcome; (f) reconsider earlier apparently contradictory outcome studies; (g) evaluate theoretical concepts regarding neurotic symptom formations in neuroses, psychoses, and psychosomatic disturbances.For treatment purposes, OMMON should only be used together with clinical hypotheses; its prognostic potential can be increased by additional application of our Operationalized Multivariate Model of Motivation (OMMOM).All three diagnostic approaches may be used for mutual evaluation.Different sections of this paper have been presented to:1. International Congress of Behaviour Therapy, Trondheim/Norway, 19.–22. 8. 19812. The 1st European Conference on Psychotherapy Research, Trier/Federal Republic of Germany, 18.–20. 9. 19813. 2. Kongreß für Klinische Psychologie und Psychotherapie, Berlin, 14.–19. 2. 1982We wish to thank the patients and the Allgemeines Krankenhaus Ochsenzoll for their cooperation, and Profs. F. Kanfer and R. Liberman for valuable comments on a first draft (May 1981) of this paper.