2009, volume 18, issue 4
Postępy Psychiatrii i Neurologii 2009; 18 (4): 315-318
The problem of care delivery to the ageing is outlined against a wide historical and social background. Controversies concerning institu-tionalization of such care a contemporary tendencies to take over tasks of the state by local communities and their civic activities are discussed. The author reports facts that confirm development of thisprocess both in Germany and in Poland, and emphasizes its significance for mentalhealth experts'professionalroles (Eds.).
Postępy Psychiatrii i Neurologii 2009; 18 (4): 319-322
Internet based on information packaging using the so-called networkprotocols has evolved from a computer science achievement into a social phenomenon over the past decade. As a new form of communicating it creates new milieus in a natural way, releases hidden potentials, liberates forces capable of changing the world. On the example of the forum for persons suffering from schizophrenia (http://schizofrenia.evot.org) the paper describes possibilities of integrating various environments by means of Internet forums.
Iwona Koszewska, Ludmiła Boguszewska
Postępy Psychiatrii i Neurologii 2009; 18 (4): 323-331
Objectives. To check whether registered prevalence rates of selected mental disorders among residents of the Tatra county differ from corresponding registered prevalence rates for the general population of Poland.
Method. The following variables were analyzed: prevalence of mental disorders registered in the outpatient and inpatient psychiatric facilities, with the emphasis on affective and alcohol-related disorders (including alcohol psychoses), suicide rate.
Results. While the registered prevalence rates of mood and alcohol-related disorders were lower than these for the whole Polish population, a rapid increase in prevalence rates of alcohol-related disorders in the period under study was much higher in the Tatra county. The increasing rates of alcohol-related disorders were accompanied by a decrease in mood disorders prevalence, which was rising in the general Polish population at that time. Hospital admission rates for alcohol psychoses in the years 2003-2005 and 2007 were higher than the respective average rates for Poland. Suicide rates were almost twice as high (and almost thrice as high in the year 2003) in the Tatra county than the average Polish rate. Suicide was committed more often by men, and in recent years by rural area residents of the county.
Conclusions. The prevalence and dynamics of mental disorders in the Tatra county differ from the tendencies observed generally in Poland. Significantly higher suicide rates may suggest a more widespread depressive disorders, even though there was no increase in the registered prevalence of affective disorders. At the same time, the rapid increase in alcohol-related disorders prevalence and more frequent diagnosing of alcohol psychoses in recent years may indicate depression masked by alcohol. Thus, perhaps action aimed at an improvement of psychiatric care delivery to patients with depressive disorders in the Tatra county should be considered.
Tomasz Sobów, Radosław Magierski, Iwona Kłoszewska
Postępy Psychiatrii i Neurologii 2009; 18 (4): 333-337
Objective. To establish whether augmentation of ongoing clozapine treatment with risperidone is efficacious in patients unresponsive or partially responsive to clozapine alone.
Method. A meta-analysis of randomized, placebo-controlled clinical trials.
Results. In the presented meta-analysis of randomized, placebo-controlled trials risperidone augmentation of ongoing clozapine treatment in patients with refractory schizophrenia was not not found to be an effective method as assessed either by the odds ratio of patients showing an at least 20% improvement on clinical scales, or by the effect size calculated from continuous measures of psychopathology. The treatment outcome seems to be independent of the trial duration. Further independent clinical trials are needed to confirm the suggestion that the best response can possibly be obtained using moderate (4-4.5 mg/day) doses of risperidone.
Conclusions. Risperidone augmentation of clozapine in the treatment of patients unresponsive orpartially responsive to clozapine alone cannot be recommended as a standard clinical procedure.
Bożena Roczniak, Jacek Wciórka
Postępy Psychiatrii i Neurologii 2009; 18 (4): 339-347
Objectives. To assess and compare selected neuropsychological functions in a group of patients with schizophrenia, their healthy first-order relatives, and unrelated healthy controls.
Method. Participants in the study (n = 94) were: 34 patients diagnosed with schizophrenic psychosis (18 men, 16 women), 30 of their healthy first-order relatives (8 men and 22 women), and 30 healthy controls from the general population (13 men, 17 women). The patients were assessed during remission (none or minimalpsychotic symptoms). Their mean length of illness was differentiated (about 13±8years). Cognitive functions were assessed using a number of tests of attention and memory selected from the Vienna Test System (VTS, Schuhfried), more or less associated with the working memory function: the Visual Pursuit Test (LVT), the Corsi Block Tapping Test (CORSI), and the Stroop Interference Test (STROOP). Differences in the test performances were assessed using analysis of variance and post hoc tests of least significant difference (LSD).
Results. On all the tests of neuropsychological functions patients with schizophrenia had the lowest mean scores, while the best performance was noted in unrelated healthy controls. Healthy first-order relatives' performance scores were between these of the other two groups. Analysis of variance showed significant differences between the three groups in almost all the indicators under study. Between-group post hoc testing mostly confirmed significance of the differences between the three comparedgroups. However, there were also some interesting exceptions: in the CORSI test of visual short-term memory span neither the performance time nor the number of memorized items significantly differed the patients and their healthy relatives. Besides, in all parts of the STROOP Interference Test there were no significant differences in the number of erroneous responses between the patients' healthy relatives and healthy unrelated controls. Test scores were moderately correlated with length of illness (negatively) and with years of education (positively). Both these variables were intercorrelated (r = -0.38).
Conclusions. (1) As regards neuropsychological indicators under study, patients with schizophrenia performed poorest, while healthy controls showed the best performance. (2) Relatives of schizophrenic patients usually had intermediate scores - however, they did not differsignificantly from thepatients in the yisual short-term memory capacity, and theirperformance on color-word interference tasks did not differ from that of healthy controls. (3) The findings can be interpreted as not at variance with a hypothesis about endophenotypical character of the analyzed neuropsychological dysfunctions of attention and memory (and probably related working memory disturbances), regarded as a risk factor for schizophrenic psychosis. Such an interpretation should be treated with caution, especially due to the limited representativeness of the groups under study, as well as to the effect of education level and age.
Andrzej Jakubczyk, Marcin Wojnar
Postępy Psychiatrii i Neurologii 2009; 18 (4): 349-356
Objectives: Although impulsiveness (or impulsivity) is considered to be an important symptom of many psychiatric disorders, it lacks a univocal and commonly accepted definition. The article presents different theories and models of impulsivity.
Background Attempts at producing a consistent and universal definition of impulsivity, as well as difficulties resulting from complexity of the phenomenon are described. The concepts ofbehavioural and cognitive, functional and dysfunctional impulsivity are outlined. Mor eover, psychiatric disorders associated with high levels of impulsivity and the idea of transient, state-related impulsiveness are discussed. The issue of impulsivity as a stablepersonality trait is analyzed in terms of variouspsychological models, and methods to measure impulsiveness are brieflypresented.
Conclusions. The failure to produce a univocal definition of impulsiveness along with the fact that elements of this phenomenon are present in so many areas ofpsychopathology may be explained by heterogeneity and complexity of the construct.
Andrzej Jakubczyk, Marcin Wojnar
Postępy Psychiatrii i Neurologii 2009; 18 (4): 357-365
Objectives. Impulsiveness characterized by complexity of its clinical pattern seems to be a multidimensional construct not only in the aspect of symptomatology. The article presents research findings showing the influence of different brain areas and of particular neurotransmitter systems on the level of impulsivity.
Background. Cerebral areas associated with impulsiveness level are situated in the prefrontal cortex, limbic system and striatum. These brain regions have been found to play an important role in mediating different (cognitive and motor) aspects of impulsiveness. As far as neurotransmitters are concerned, there is growing evidence that impulsivity is affected by a number of interrelated systems described in the article. The serotonin system seems to be the most important, since it modifies impulsiveness level through involvement in dopaminergic, glutamatergic and GABAergic neurotransmission. Norepinephrine neurotransmission is considered to be responsible for state-related impulsivity increase. In pharmacological treatment of impulsive behaviour mood stabilizers and antidepressants, especially serotonin reuptake inhibitors, may be useful.
Conclusions. The treatment of impulsiveness remains a problem yet to be solved, mainly due to the fact thatparticular neurotransmitters may influence impulsivity in different ways, depending on the cerebral area involved, receptor type, and the actual level of impulsivity.
Postępy Psychiatrii i Neurologii 2009; 18 (4): 367-375
Objectives. The aim of thepaper is to discuss the role of two neurosteroids: dehydroepiandosterone (DHEA) and pregnenolone in schizophrenia, in the light of experimental and clinical studies.
Background Neurosteroids are precursors or metabolites of steroid hormones that regulate the nervous system excitability. Since neurosteroids modulate a number of receptors implicated in pathophysiology of schizophrenia, investigation of the physiology and patho-physiology of neurosteroid metabolism in the CNS seems to be important for our better understanding of thepathomechanism of schizophrenia. Among neuroactive steroids the followingplay a major role in the pathophysiology of psychotic symptoms:progesterone, dehydroepiandosterone (DHEA), pregnenolone sulfate (PREGS), and dehydroepiandosterone sulfate (DHEAS). All the four substances modulate NMDA receptors positively and GABA-A receptors-negatively. In patients with schizophrenia elevated plasma levels of circulating DHEA, DHEAS, testosterone, cortisol, progesterone, and estradiol can be seen, although clinical significance of these findings remains unclear. DHEA, DHEAS, progesterone or its derivative, allopregnenolone, manifest clinical anxiolytic, antidepressant, and antipsychotic action.
Conclusions. Studies conducted so far allow to conclude that in the course of schizophrenia a disturbance of neurosteroid balance occurs. Moreover, a positive response to neuroleptic treatment was shown to be related to changes in plasma levels of a number of neurosteroids. Finding out whether this is a random effect or whether some neurosteroids perhaps mediate the positive response to antipsychotic treatment would be a significant development in psychopharmacotherapy of schizophrenia.
Postępy Psychiatrii i Neurologii 2009; 18 (4): 377-386
Objectives. To discuss the role of clinical diagnosis in the process of stigmatization ofpersons with mental disorders.
Background. The sigma of mental illness is not only a source of subjectively experienced suffering for persons receiving psychiatric treatment, their families and friends, but also has some important implications for public health. The course of the process of stigmatization of the mentally ill is outlined in thepaper, and the role of psychiatric diagnosis in thisprocess is discussed, with an emphasis on the relation-ship between the diagnosis and two key elements of stigma: labeling and stereotyping. To illustrate the stigmatizing effect of psychiatric labels the diagnosis of schizophrenia was used, since both the concept and the name have been more and more sharply criticized in recentyears.
Conclusions. Psychiatric diagnosis is inevitably associated with social conseąuences and may reinforce the stigma of mental illness. Thus, the process of diagnosing should not be for psychiatrists a routine procedure lacking reflection, also on ethical aspects. The use ofpsychiatric diagnostic labels in clinicalpractice reąuires due critical attitude, caution, and sensitivity to theirpotentially discrediting character.
Emilia J. Sitek, Emilia J. Sitek, Jarosław Sławek, Dariusz Wieczorek
Postępy Psychiatrii i Neurologii 2009; 18 (4): 387-391
Objectives. The aim of the article was to review studies on cognitive function in myasthenia gravis.
Background. Myasthenia gravis (MG) is a neuromuscular disorder affecting the peripheral nervous system. Attempts were made to obtain neuropsychological evidence that the central nervous system (CNS) is implicated in MG as well. However, neuropsychological findings concerning cognitive function in MG are inconsistent. The discrepancies may be due to differences in methodological approaches used in particular studies, different patient selection criteria, assessment methods, and types of comparative groups (healthy controls vs. patients). Possible cognitive impairments were interpretedas due to cholinergic neurotransmission deficits in the CNS, respiratory insufficiency, or increased fatiguability.
Conclusions. Results of neuropsychological studies conducted to date have provided no evidence for cognitive dysfunction in MG due to the CNS involvement.
Piotr Wierzbiński, Sławomir Szubert, Antoni Florkowski, Piotr Gałecki
Postępy Psychiatrii i Neurologii 2009; 18 (4): 393-398
Objectives. Electroconvulsive therapy (ECT) is a non-pharmacological method of psychiatric treatment. Advances in pharmacotherapy and development of new drugs have reduced the indications for ECT. Nevertheless, the method shows a very high efficacy in the treatment of affective disorders mainly.
Background. The mechanism underlying action of ECT has not been fully explained yet. A number of hypotheses relate the therapeutic effect of ECT to neurotransmission alterations. In the article an attempt was made to draw attention to and summarize the knowledge about possible influence of ECT on oxidative systems of the human organism.
Conclusions. The findings reported in the literature on the effect of ECT on oxidative stress parameters in humans are rather scarce. No conclusive evidence has been provided by many relevant studies conducted so far. Thus, there is a growing need for further research to investigate the multidirectional mechanism of action of ECT.
Agnieszka Wlazło, Renata Wojtyńska, Jerzy Leszek
Postępy Psychiatrii i Neurologii 2009; 18 (4): 399-402
Objectives. To describe a diagnostically challenging case of a 53-year-old female patient with depression symptoms and complex cogni-tive dysfunction.
Case report. Despite antidepressant treatment administered to the patient for three years, she displayed mood disorders and a gradual cognitive deterioration. A detailed diagnostic examination including neuropsychological assessment indicated that her symptoms wereprobably due to a vascular dementing process, and that the mood disorders were of reactive character. Antidepressants were replaced with apro-cognitive treatment and supplemented with psycho-corrective interventions appropriate to the patient 's individual needs, which provided good results.
Commentary. The case suggests that in patients resistant to treatment, presenting with a complex clinical picture and mixed etiology, diagnostic and therapeutic cooperation of a multi-specialist team is needed.
Anna Pilszyk, Ewa Waszkiewicz
Postępy Psychiatrii i Neurologii 2009; 18 (4): 403-406
Objectives. Firstly, to present diagnostic difficulties of importance to expert forensic psychiatrists who are to issue a forensic psychiatric opinion determining the suspect's accountability andcapability toparticipate in theproceedings. Secondly, to draw attention to apossibility of using the phenomenon of pedophilia to solve one's personalproblems.
Case reports. Two cases are described of men suspected of committing a pedophile deed.
Commentary. On the grounds of an analysis of the reported cases a number of doubts are discussed concerning the diagnosis of pedophilia and the motivation of perpetrators suspected of pedophile deeds.
Postępy Psychiatrii i Neurologii 2009; 18 (4): 407-411
Objectives. The aim of the paper is to acąuaint psychiatrists and psychologists with major changes, particularly those concerning opinions about a lack of sufficient grounds to continue detention, in view of modifications introduced in Chapter XIII of the Executive Penal Code (EPC).
Notes. The objectives of detention order providing for the perpetrator 's placement in a closed secure institution are: to prevent "his/her repetitive behaviors life- or health-threatening to others, or causing damage to objects of a considerable value", and to submit the perpetrator to appropriate treatment, therapeutic interventions or rehabilitation, as well as resocialization. The above-listed interventions are aimed at an "improvement of his/her health and conduct in a degree enabling him/her to return to life in the community and continue treatment in non-institutional conditions". After the amendment the tasks and objectives of institutions enforcing detention orders remained the same, but the mode of informing the court about the treatment outcome has changed. The former information or notification by the detaining institution director was replaced by periodical forensicpsychiatric opinions about treatment effects and their conseąuences for continuation of the detention. Forensic experts predict in their opinion whether there is a high probability of recurrence of a deed of a considerable social harmfulness related to the perpetrator 's mental disorder, mental retardation or psychoactive substance dependence, or whether such prediction would be groundless.
Conclusions. Changes introduced by the Executive Penal Code amendment of2003 were aimed at a reinforcement of the judicial body control over the detention order enforcement, including, among others, the reąuest for periodical forensic psychiatric opinions. In addition to these formal reąuirements, any expert opinion stating that further mental hospital detention of the perpetrator serving detention is not necessary should includepsychiatric assessment to justify such an opinion of psychiatry experts.
Letter to the Editor
Stefan Krzymiński, Ewelina Piotrowska, Małgorzata Czekaj
Postępy Psychiatrii i Neurologii 2009; 18 (4): 413
Postępy Psychiatrii i Neurologii 2009; 18 (4): 415
Postępy Psychiatrii i Neurologii 2009; 18 (4): 415-416