Archives 1992-2013

2009, volume 18, issue 1

World Psychiatry Forum

Early intervention in psychosis: concepts, evidence and future directions

Patrick D. McGorry, Eóin Killackey, Alison Yung
Postępy Psychiatrii i Neurologii 2009; 18 (1): 3-13

The rise of the early intervention paradigm in psychotic disorders represents a maturing of the therapeutic approach in psychiatry, as it embraces practical preventive strategies which are firmly established in mainstream health care. Early intervention means better access and systematic early delivery of existing and incremental improvements in knowledge rather than necessarily requiring dramatic and elusive breakthroughs. A clinical staging model has proven useful and may have wider utility in psychiatry. The earliest clinical stages of psychotic disorder are non-specific and multidimensional and overlap phenotypically with the initial stages of other disorders. This implies that treatment should proceed in a stepwise fashion depending upon safety, response and progression. Withholding treatment until severe and less reversible symptomatic and functional impairment have become entrenched represents a failure of care. While early intervention in psychosis has developed strongly in recent years, many countries have made no progress at all, and others have achieved only sparse coverage. The reform process has been substantially evidence-based, arguably more so than other system reforms in mental health. However, while evidence is necessary, it is insufficient. It is also a by-product as well as a catalyst of reform. In early psychosis, we have also seen the evidence-based paradigm misused to frustrate overdue reform. Mental disorders are the chronic diseases of the young, with their onset and maximum impact in late adolescence and early adult life. A broader focus for early intervention would solve many of the second order issues raised by the early psychosis reform process, such as diagnostic uncertainty despite a clear-cut need for care, stigma and engagement, and should be more effective in mobilizing community support. Early intervention represents a vital and challenging project for early adopters in global psychiatry to consider.

Special article

Extermination of people with mental disorders in the occupied Poland: the beginnings of the Nazi genocide

Grażyna Herczyńska
Postępy Psychiatrii i Neurologii 2009; 18 (1): 25-30

Aim. The Holocaust was preceded by the Nazi programme of euthanasia of the handicapped, including persons with mental disorders. This horrible slaughter, even though incomparable in terms of the number of victims, surpassed other acts of German genocide. However, a purely arithmetical approach leads to an unacceptable, impersonal attitude toward the victims. The paper deals with the extermination of the mentally ill, preceded - with the full sanction of the Nazi law - by a compulsory sterilization of people with physical disabilities, mental disorders, and of those regarded as socially maladjusted.
Review. A closer look at these events allows, at least to some degree, to avoid impersonality, and better understand the fate of victims and intentions of their butchers. An important, specific feature of genocide of the mentally ill was the active participation, and sometimes even initiative of German physicians, scientists and lawyers: while the former were breaking their Hippocratic oath, the latter created a legal system going against all ethical norms. Takeover of mental hospitals by the German administration with the subseąuent murdering of psychiatric inpatients started on the territory of Poland in September 1939, just a few days after the German invasion. All the patients were killed, regardless of their nationality: Poles, Jews, Germans, Lithuanians, Latvians, and Ukrainians. Various methods of killing were used: shooting, gassing, injecting poison, starving to death. The extermination of people with mental disorders was precisely planned, accurately carried out, and, which seems even more important, provided a model for future homicide of otherpopulation groups regarded as unworthy to live or threatening the purity of race according to the German Nazi law. The extermination of the mentally ill in Poland in the years 1939-1945 was the subject of the book edited by Zdzisław Jaroszewski and published in 1993. The issue was continued from a broaderperspective by Tadeusz Nasierowski in his book under the title "Extermination of the mentally ill in the occupied Poland. The beginnings of the Nazi genocide" published in 2008. A critical analysis of this book is the main aim of the paper.

Original article

Sociodemographic and clinical factors in relation to the anticipated and experienced stigma of mental illness

Andrzej Cechnicki, Anna Bielańska
Postępy Psychiatrii i Neurologii 2009; 18 (1): 31-41

Objectives. A number of multi-center studies concerning the subjective experience of stigma amongpersons suffering from mental illness have been conducted in recent years. The presented study explored relationships between sociodemographic and clinical characteristics on the one hand, and anticipated and experienced stigma on the other.
Method. Participants in the study were 202 patients (mean age 40 years) diagnosed with schizophrenia or schizophreniform syndromes (according to the ICD-10 criteria). They came from the Małopolska region, and on the average had 6 previous hospital stays. Using the ąuestionnaire by M. Angermayer the patients expressed their opinions (anticipating stigma) and reported their experiences (experiencing stigma). In the analysis of intergroup differences the Mann-Whitney test was used, while more complex relationships were analyzed by means of stepwise multiple regression.
Results. (1) Older age and large city as the place of residence explain the anticipated stigma to a limited, but significant extent, while intense experiencing of stigma is explained also to a limited, but significant extent by better education, joblessness, and larger number ofprevious hospitalizations. (2) A significant portion of the experienced stigma may be explained by stigma anticipation, and especially by a number of beliefs: that contacts with the mentally ill are stigmatized by negative stereotypes and therefore made more difficult, that access to employment is more difficult to the mentally ill, that partnership with a person suffering from mental disorders is impossible, or that such persons have a more difficult access to goods distributed by institutions. (3) In our study gender turned out to be a factor insignificant in explaining stigma indicators.
Conclusions. (1) A limited, but significant extent of anticipating and experiencing stigma may be explained by sociodemographic and clinical factors. (2) The experience of stigma may be explained to a limited, but significant extent by stigma anticipation. (3) Therapeutic programs should be focused on an improvement of the patients' self-esteem and counteracting their self-stigmatization.

Original article

Social functioning of persons with long-term mental illness participating in community-based social support programs

Paweł Bronowski, Maryla Sawicka, Sylwia Kluczyńska
Postępy Psychiatrii i Neurologii 2009; 18 (1): 43-50

Objectives. Attempts to overcome difficulties encountered in social functioning by persons with mental illness include community-based interventions. The aim of the presented study was to estimate the level of social functioning of persons with mental disorders who participated in a comprehensive rehabilitation and social support system.
Methods. Participants in the study were 103 persons with long-term mental disorders, who attended a community-based rehabili-tation and social support program. The following tools were used in the research: the Social Functioning Scale (SFS, by M. Birchwood, in the Polish adaptation by M. Załuska), and a structured interview developed for the purposes of this study.
Results. A majority of the respondents are doing well in social situations, they can form interpersonal relationships and have relationships outside the home. However, in this group there are also individuals with very poor social functioning, who withdraw from interpersonal relationships. Most of the respondents' leisure time activities are organized by community care centers, and their own activity is limited. The research findings show that despite their young age and a sense of work capability our respondents struggle with joblessness.
Conclusions. Good functioning of our respondents in social situations can be accounted for by their participation in social support programs. Special attention should be paid to the subgroup manifesting severe problems in interpersonal relations. This group reąuires activation and support methods particularly well matched to their needs. Community-based support programs should lay more emphasis on supporting their participants' own activity and avoid doing everything for them as regards leisure time organi-zation. In the sample studied difficulties in overcoming joblessness are evident (despite the participants' young age, accomplished education, and their sense of work capability only 7% of the group decided to attend an Occupational Activation Unit). This suggests a need for more emphasis on launching occupational activation programs tailored to the specificity of persons with long-term mental illness, and on more effective motivating them to get a job.

Original article

Territorial differentiation of involuntary commitment and direct coercion in psychiatric facilities in the year 2006

Wanda Langiewicz, Monika Pasiorowska
Postępy Psychiatrii i Neurologii 2009; 18 (1): 51-58

Objectives. The main aim of the study was to establish territorial differentiation in the freąuency of involuntary commitment and the use of direct coercion. Data collected within the framework of monitoring the Mental Health Act implementation allow to analyze events associated with involuntary admissions and direct coercion use registered in particularprovinces.
Methods. Questionnaires were analyzed including ąuarterly data for the year 2006, including the number of patients admitted without consent, the use of direct coercion, and the location of guardianship courtproceedings. The data were obtained from 46 mental hospitals and 71 psychiatric departments of general or other specialist hospitals (including clinical teaching hospitals).
Results. A considerable territorial differentiation regarding involuntary commitment was found at the province level. The mean rates of involuntary admissions ranged from 4.3 to 15%, with the mean national rate of 8.7%. Admissions on the grounds of Art. 23 predominated nationwide, constituting 75% of all involuntary admission cases, while in particular provinces this rate ranged from 57.2%o (łódzkie) to 92.2%o (kujawsko-pomorskie). A statistically significant positive correlation was noted bettween the rate of involuntary admissions per 10.000popu-lation and the freąuency of involuntary admissions. Moreover, marked differences were found between particular provinces as regards the location of guardianship court proceedings. The percentage of psychiatric and general hospitals in which the guardianship court proceedings takeplace ranged from 20%o (in the zachodniopomorskieprovince) to 100% (in opolskie). The analyzed data show how very differentiated are the rates of involuntary admissions in particularprovinces, but offer no explanatory arguments, suggesting either possible causes of this state of affairs, or some specific characteristics common for a group of provinces that might serve as an explanation.
Conclusions. Higher rates of involuntary admissions calculated in relation to the province population size generally correspond to higher mean percentages of involuntary admissions to all theprovince facilities. Higherpercentages of admissions on the grounds of Art. 23 correspond to lower percentages of admissions on the grounds of Art. 24. The guardianship court proceedings nationwide more often take place on the hospital premises, but distribution of this variable shows a very large territorial differentiation.

Original article

Cognitive impairments in adolescents with eating disorders and schizophrenia

Marta Gadaś, Janina Skalska, Barbara Remberk, Irena Namysłowska, Anna Siewierska, Anna Krempa-Kowalewska
Postępy Psychiatrii i Neurologii 2009; 18 (1): 59-66

Objectives. The problem of cognitive impairment in eating disorders, especially in anorexia nervosa, remains controversial and the research findings are not univocal. Therefore, in the presented study cognitive disorders were investigated in a homogenous group of young female patients suffering from eating disorders, hospitalized in an adolescent psychiatric unit.
Method Executive functions assessed using the Wisconsin Card Sorting Test (WCST) and Digit Span Test in a group of 60 adolescent girls suffering from eating disorders (anorexia or bulimia nervosa) were compared with these of 30 healthy controls and 20 adolescent inpatients with schizophrenia. Moreover, an attempt was made to establish relationships between cognitive impairments and some clinical features of eating disorders, including illness duration, weight loss, BMI at admission and at discharge, as well as the psychopathological picture as assessed by the EDI Test.
Results. As regards cognitive test performance, both patient groups with eating disorders did not differ from the healthy controls, while there were significant differences bettween the schizophrenia group and the remaining groups. Neither in the group with anorexia nor in that with bulimia nervosa any correlation was found bettween clinical characteristics and the WCSTscores. However, in both groups with eating disorders the patients' performance on the digit span forward test was correlated with their BMI at admission, but in a direction opposite to that expected.
Conclusions. The findings confirmed the presence of evident cognitive deficits in schizophrenic patients, but did not reveal any cognitive impairment in patients with eating disorders.

Review

Loneliness as a neglected type of experience of persons with schizophrenia

Anna Bieniarz
Postępy Psychiatrii i Neurologii 2009; 18 (1): 67-73

Objectives. Thepaper is of phenomenological character. An attempt was made to describe experiences of persons suffering from schizo-phrenia, in terms of a sense of loneliness they experience.
Review. Several definitions of loneliness proposed in psychology, philosophy, sociology and theology are cited. A differentiation was made between loneliness, solitude andsocial isolation, sometimes called alienation. An answer was sought to the ąuestion whether loneliness experienced by people with schizophrenia is ąualitatively different from that experienced by persons who do not receive psychiatric treatment. Relationship was analyzed between "emotional blunting", difficulties in social contacts, and a sense of loneliness, as well as associations between loneliness, autism and "susceptibility to injury ". The issue of loneliness at the time of relapse and during remission of troublesome symptoms was discussed. The notion of religious, existential and metaphysical loneliness was presented, as well as the concept of loneliness in interpersonal communication borrowed from the theory by McGraw, as accurately describing experiences of people with schizophrenia. In search for a common denominator for experiencing loneliness by ill and healthy people, the differentiation between emotional and social loneliness proposed by Weiss turned out to be useful. Moreover, a description of loneliness as a symptom manifested in schizophrenia spectrum disorders (schizoidpersonality, schizoaffective disorders) was given.
Conclusions. Feelings of loneliness reported by patients sufferingfrom schizophrenia may be interpreted as an attempt at seeking contact with the social environment, from which they are separated by an elaborated system of hallucinations and delusions.

Review

Idiopathic intracranial hypertension: etiology, clinical symptoms, treatment

Włodzimierz Kuran
Postępy Psychiatrii i Neurologii 2009; 18 (1): 75-78

Objective. The reviewpresents current opinions and knowledge on etiology, pathogenesis, clinical symptoms and treatment of idiopathic intracranial hypertension (IIH), also namedpseudotumor cerebri.
Review. IIH is a polyetiological syndrome of increased intracranialpressure without brain tumors or CNS infections. Persistent head-aches and vision disturbances are the pivotal clinical symptoms.
Conclusions. Since the IIH pathogenesis is unknown, treatment of the condition is mainly symptomatic with diuretics (acetazolamide). In rare cases of rapidly progressingpapilloedema involving a risk of blindness surgical treatment is recommended.

Review

Dimebon: new use of an old drug in the treatment of Alzheimer 's disease

Maciej Banasiak, Tadeusz Pietras
Postępy Psychiatrii i Neurologii 2009; 18 (1): 79-83

Objectives. The aim of this study is to review a potential role of dimebon, the first-generation antihistamine, in the prevention and treatment of Alzheimer's disease (AD).
Review. Alzheimer 's disease causes neuronal damage in the CNS leading to memory and thinking impairments as well as to behavior change. Since the currently used medications can neitherprevent AD nor reverse its conseąuences, there is a great need for new pharmaceu-ticals for AD. One of such drugs is dimebon, an oral medication that in preclinical trials turned out to prevent neuronal cell death in patients with AD and Huntington 's disease. Now it is being tested as a potential treatment for mild and moderate stage Alzheimer 's disease, in phase 3 clinical trial named Connections Study. Dimebon action is different from that of any of the currently approved AD medications - the drug probably stabilizes mitochondrial function, thus preventing neuronal cell death.

Review

The influence of depression and antidepressive treatment on the development and course of ischemic heart disease

Grzegorz Nawarski, Tomasz Pawełczyk, Jolanta Rabe-Jabłońska
Postępy Psychiatrii i Neurologii 2009; 18 (1): 85-92

Objectives. To review the research literature concerning: (1) the effect of depression on the development and course of ischemic heart disease (IHD), (2) probablepathophysiological mechanisms underlying the association between IHD and depression, and (3) most recent studies on the impact of antidepressants on the course of IHD and comorbid depression (including SADHART, CREATE, ENRICHD, CAST, CASH, MIND-IT).
Review. The hitherto conducted retrospective andprospective clinical studies, as well as meta-analyses clearly indicate a high correla-tion between thepresence of depression and the risk for developing IHD in currently healthy persons, and between the incidence and severity of depressive symptoms on one hand and coronary symptoms severity in persons diagnosed with IHD, on the other hand. Among numerous data suggesting probable mechanisms of the association between depression and IHD, the following seem to be most important: hyper-reactivity of the hypothalamic-pituitary-adrenal (HPA) axis with the associated catecholaminergic system activation, platelet dysfunction with the coagulation system activation, the immune system pathological hyperactivity of an inflammatory character, vascular endothelium dysfunction, and increased homocysteine concentrations. The most recent evaluative studies show that appropriate pharmacotherapy and psychotherapy of depression significantly improve the course and prognosis of IHD, among others, by reducing the risk of heart stroke and death. The SSRI medications turned out to be the safest.
Conclusions. (1) Depression increases the risk for IHD development, is freąuently comorbid with IHD, and has a significant effect on its course and prognosis - thus, there is a need for early diagnosis and effective treatment of depression. (2) Appropriate pharmacological treatment and psychotherapy may improve the course of IHD and its prognosis.

Case report

Atypical course of neuroleptic malignant syndrome in a patient with paranoid schizophrenia treated with risperidone: case report

Krzysztof Krysta, Arkadiusz Stęposz, Agnieszka Koźmin, Bogna Migacz, Adam Klasik
Postępy Psychiatrii i Neurologii 2009; 18 (1): 93-95

Objective. To present a case of a patient diagnosed with paranoid schizophrenia, in whom neuroleptic malignant syndrome (NMS) has emerged in the course of risperidone treatment.
Case report. The patient aged 32, diagnosed with paranoid schizophrenia, has been treated for a few years. Following an approximately 1-year risperidone monotherapy he manifested classical NMS symptoms. The episode was isolated and on risperidone treatment discontinu-ation has never recurred. No NMS symptoms were induced during earlier treatment with clozapine or olanzapine in combination with risperidone.
Commentary. A possibility of NMS onset should be taken into account in patients treated with risperidone, even after a long-term treatment with the drug.

Case report

Environmental factors - their relationship to the development, course and treatment of affective bipolar disorders: a case report

Agnieszka Piwowarczyk, Krzysztof Krysta
Postępy Psychiatrii i Neurologii 2009; 18 (1): 97-99

Objective. Factors affecting the course of illness, frequency of symptom exacerbation, and symptom severity in a patient suffering from bipolar affective disorder were analyzed in the paper.
Case report. A case is presented of a 53-year-old patient diagnosed with bipolar affective disorder, with depression and hypomania episodes occurring during the past 7 years. He has been provided with psychiatric treatment, with variable success. In the course of his illness numerous environmental, mostly familial factors have been noted that might affect his condition severity.
Commentary. Long-term development of affective bipolar disorder with salient depressive episodes confirms the advisability of prolonged therapy for patients with chronic psychiatric disorders, aimed at an improvement of their mental state and consequently, their life quality.

Case report

Diagnostic difficulties in patients with mental retardation: two case reports

Radosław Stepańczak, Krzysztof Kucia, Aneta Sikora, Katarzyna Piekarska-Bugiel
Postępy Psychiatrii i Neurologii 2009; 18 (1): 101-106

Objective. The mentally retarded constitute a large proportion of patients treated by the psychiatrist. The specificity of their cognitive functions, problems with verbal communication, as well as neurodevelopmental andpsychosocial characteristics make the process of diagnostic assessment difficult.
Case report. Two patients with drug resistant paranoid schizophrenia are described. A thorough assessment process allowed to change their diagnosis to that of mild mental retardation, with concurrent obsessive-compulsive disorder in one case. A change of the therapeutic strategy resulted in a significant improvement of their condition.
Commentary. On the grounds of the two case reports and a review of the literature the authors analyzed difficulties in psychiatric diagnostics in patients with mental retardation.