Archives 1992-2013

2010, volume 19, issue 2

World Psychiatry Forum

Are psychiatrists an endangered species? Observations on internal and external challenges to the profession

Heinz Katschnig
Postępy Psychiatrii i Neurologii 2010; 19(2): 89-114

Based on recently voiced concerns about a crisis in psychiatry, six challenges to our profession are identified and discussed. As we approach the revisions of ICD-10 and DSM-IV, the validity of psychiatry's diagnostic definitions and classification systems is increasingly questioned also from inside psychiatry. In addition, confidence in the results of therapeutic intervention studies is waning. A further challenge is the existence of de facto subgroups with opposing ideologies, a situation which is responsible for an unclear role profile of the psychiatrist. Challenges from outside include mounting patient and carer criticism, intrusion of other professions into psychiatry's traditional field of competence, and psychiatry's low status within medicine and in society in general. Studies suggest that the decline of the recruitment into psychiatry, as it is observed in many countries, might be related to problems arising from these challenges. It is unclear whether psychiatry will survive as a unitary medical discipline or whether those segments which are more rewarding, both financially and in status, will break away, leaving the unattractive tasks to carry out by what remains of psychiatry. The demise of the generalist and the rise of the specialist in modern society may contribute to this development. Attempts are underway by professional bodies to define the profile of a "general psychiatrist". Such discussions should be complemented by an analysis of the incentives which contribute to the centrifugal tendencies in psychiatry.

Original article

Assessment of selected psychological factors in patients with irritable bowel syndrome or gastroesopheagal reflux disease

Agata Orzechowska, Agnieszka Harasiuk, Monika Talarowska, Krzysztof Zboralski, Jan Chojnacki, Antoni Florkowski
Postępy Psychiatrii i Neurologii 2010; 19(2): 115–119

Objectives. To assess the levels of experienced stress, state and trait anxiety, as well as emotional control determinants among patients treated either for irritable bowel syndrome (IBS) or gastroesophageal reflux disease (GERD) as compared to healthy controls.
Method. Three groups of 30 persons each were compared: two groups of patients diagnosed with IBS or GERD, and a group of healthy controls. Self-report psychological tests and questionnaires were used, including the Perceived Stress Scale by S. Cohen, the Emotional Control Questionnaire by J. Brzeziński, and the State-Trait Anxiety Inventory by Spielberger.
Results. Both groups of patients with gastrointestinal diseases differed significantly from the healthy controls in terms of the analyzed psychological variables. In the IBS group as compared to the GERD patients significantly higher levels of experienced stress, anxiety both as a current state and a personality trait, as well as detrimental aspects of emotional control were found.
Conclusions. IBS patients as compared both to GERD patients and to healthy controls displayed the highest intensity of the variables under study. Women as compared to men were less able to control external expressions of their experienced emotions.

Original article

Decoding of emotion in patients with depression

Joanna Sawicka, Stanisława Steuden, Marian Ledwoch
Postępy Psychiatrii i Neurologii 2010, 19(2): 121–126

Objectives. The aim of the study was to explore emotion decoding skills in patients with depression.
Method. Participants in the study (N=56) were 28 inpatients with depression and 28 healthy controls. The Scale for Emotion Decoding Skills by Kulikowska & Steuden, the Beck Depression Inventory, the Mehrabian & Epstein Emotional Empathy Scale, and the Patient's Biographic Inventory by Płużek were used.
Results. No significant quantitative differences were found between depressive inpatients and healthy controls regarding their choice of terms to describe positive, negative and neutral photographs. The patients tended to overrate the emotional saturation of some positive photos, or perceived them as neutral. Healthy controls somewhat more often selected positive and neutral terms referring to self-worth, associated with positive or negative social contacts. As compared to those with a low severity of depression, patients with high depression levels significantly more often selected either positive or negative terms referring to a negative social context, their own helplessness and powerlessness, self-accusation, and guilt feelings.
Conclusions. A considerable similarity between persons suffering from depression and healthy individuals was found as regards emotion decoding. However, marked differences in decoding of emotion were noted between those with a high or low depression severity.

Original article

Anosognosia, unilateral neglect and depression among patients with right hemisphere stroke

Marta Witkowska, Dariusz Wieczorek, Daria Biechowska, Krzysztof Jodzio
Postępy Psychiatrii i Neurologii 2010, 19(2): 127–132

Objectives. Many patients in neurology wards are not aware of their condition, even if they have no generalized cognitive impairments. They often do not realize they have neurological deficits resulting from brain damage, which considerably impedes their treatment and effective rehabilitation. The main aim of the study was to assess comorbidity of anosognosia, unilateral neglect and/or depression in patients with stroke of the right cerebral hemisphere.
Method. The study sample consisted only of right-hemisphere stroke patients, selected on the grounds of CT scans and medical history data. An interview with the patient was followed by an assessment performed in the same stable order using the Beck Depression Inventory, a standardized interview for anosognosia, the Line Bisection task, and the letter "e" deletion test.
Results. A total of 37 right-handed patients after cerebral stroke (30 men, 7 women) participated in the study. In 16 patients (43.2%) anosognosia-type disorders were noted, while over 50% of the sample had symptoms of moderate depression. Unilateral neglect symptoms were diagnosed in 43.2% of the patients. However, no statistically significant relationship was found between the observed disorders.
Conclusions. Although anosognosia was often concurrent with depression and/or hemineglect, in some patients it had a selective, or isolated form. The most frequent cause of anosognosia was stroke situated in deep structures of the right cerebral hemisphere.

Review article

Evaluation of ECT effectiveness in depressive disorders

Tomasz Zyss, Andrzej Zięba, Dominika Dudek, Robert T. Hese
Postępy Psychiatrii i Neurologii 2010; 19(2): 133–142

Background. Electroconvulsive therapy (ECT) is the only treatment method used in psychiatry before the era of modern psychopharmacology that managed to survive till present. This was possible since ECT is both safe and highly effective. Although the range of its applicability has been considerably reduced, in most cases when applied ECT is more effective than standard pharmacotherapy. The paper presents an overview of clinical studies on ECT effectiveness in the treatment of depressive disorders, at present the main recommendation for the use of this technique.
Views. A vast majority of clinical studies corroborate ECT efficacy in the treatment of depressive disorders. This pertains both to older studies using sham stimulation (active placebo), and in more recent controlled trials where ECT efficacy was compared to that of reference antidepressants. ECT is considered to be more effective than antidepressants (60-85% vs. 60-65%, respectively), particularly in severe depressive syndromes, including these with psychotic features. The effect of stimulation parameters on ECT effectiveness, and the place of ECT in refractory disorders were outlined.
Conclusions. ECT as a stable element in the management of severe depressive syndromes should be included in the treatment plan at a specific stage of the therapeutic ladder. Effectiveness of ECT outweighs inconveniences associated with this method, side effects, and ethical objections.

Review article

Potential antidepressive mechanisms of the endocannabinoid system action

Piotr Wierzbiński, Waldemar Kryszkowski, Sławomir Szubert, Antoni Florkowski, Piotr Gałecki
Postępy Psychiatrii i Neurologii 2010; 19(2): 143–150

Background. The endocannabinoid system (CB) is of special interest not only because of its involvement in the organism's energy regulation and digestive processes, but also due to its effect on the individual's psychological well-being. The aim of the paper was to describe and partially explain the mechanisms underpinning the endocannabinoid system action in the CNS.
Views. The endocannabinoid system is an intricate network of connections between neurons that affects serotonergic, noradrenergic and dopaminergic neurotransmission, as well as the hypothalamic-pituitary-adrenal axis. The system modifies GABA release. The pleiotropic effects of endocannabinoids instigate research into new substances that would have a selective effect on the endocannabinoid system.
Conclusions. Antidepressive and anxiolytic effects of endocannabinoids have been reported. A more thorough research on endocannabinoids and on new CB receptor ligands may lead to the development of drugs with a different mechanism of action that might be effective in the treatment of mood and anxiety disorders.

Review article

Causes and psychopathological characteristics of suicides attempted and committed by psychiatric inpatients

Sławomir Szubert, Piotr Wierzbiński, Małgorzata Szpilewska, Antoni Florkowski, Marta Strombek-Milczarek
Postępy Psychiatrii i Neurologii 2010; 19(2): 151–155

Background. The presented review deals with the problem of suicide among the mentally ill. Suicidal behaviors in this group are often an object of interest, but opinions on this subject seem contradictory in many cases.
Views. Suicide attempters' personality traits and symptoms of their mental disorders, especially those meeting the criteria for psychosis, have been investigated most often. Mental illness is commonly regarded as a significant risk factor for suicidal acts. Numerous studies indicate that suicide rates among persons treated for mental disorders are higher than these in the general population.
Conclusions. Due to the importance of this problem further research into the causes and determinants of suicide attempts among psychiatric inpatients is needed to prevent such behaviors more effectively.

Review article

Interactions between the cholinergic system and amyloid in the pathogenesis and treatment of Alzheimer’s disease: do cholinesterase inhibitors affect the natural course of the disease?

Tomasz Sobów
Postępy Psychiatrii i Neurologii 2010; 19(2): 157–164

Objectives. To present available research evidence suggesting a possibility of cholinergic modulation of β-APP metabolism and its theoretical implications for Alzheimer's disease treatment.
Views. Leading hypotheses concerning Alzheimer's disease (AD) consider dysfunction of β-APP metabolism as the basic pathogenic mechanism (the amyloid cascade hypothesis), and a cholinergic neurotransmission disorder as a neurochemical background for clinically observed cognitive and behavioral pathology (the cholinergic hypothesis). Molecular and clinical studies support the idea that β-APP metabolism products interact with the cholinergic system in a quite complicated manner. Beta-amyloid may be particularly toxic to cholinergic neurons, and may lead to a deficiency of acetylcholine biosynthesis. On the other hand, cholinergic dysfunction may lead to an overproduction and cerebral deposition of amyloid β.
Conclusions. Cholinesterase inhibitors facilitating neurotransmission within the cholinergic synapse may produce a more than symptomatic effect, possibly via modulation of β-APP metabolism. Although data obtained in recent years support the view about a possible effect of cholinesterase inhibitors on the natural course of AD, they are not conclusive yet.

Case report

Primary polydipsia in a patient with paranoid schizophrenia: case report

Piotr Antoni Woźniak, Małgorzata Olędzka-Oręziak, Magdalena Wiktorowicz, Anna Batijewska, Maria Gałecka-Wolska, Beata Lipska, Marcin Czarnocki, Kazimierz Andrzej Wardyn
Postępy Psychiatrii i Neurologii 2010, 19(2): 165–172

Objective. We report a case of chronic psychogenic polydipsia with intermittent moderate hyponatremia and comorbid type 2 diabetes in a 52-year-old male patient diagnosed with schizophrenia.
Case report. The patient with a 37-year history of schizophrenia was admitted with signs of psychotic exacerbation including severe auditory hallucinations and dysphoria. His symptoms were increasing over the past 2 weeks in the psychiatric residential facility where he stayed during the past 2 years. He had also a history of drinking bouts. After admission his psychotic symptoms significantly ameliorated, but between 2 and 3 week from admission he developed severe and increasing polydipsia with moderate hyponatraemia (125-130 mmol/l). The latter condition became the target of first-line treatment. Despite fluid restriction behavioral treatment methods turned out to be unsuccessful. All the relevant blood and urine tests were performed. Problems of differential diagnosis are discussed. Besides, the course and management of the patient's symptoms are outlined.
Commentary. A number of pathogenic hypotheses of polydipsia are explored in the analysis of the presented case.

Case report

Effectiveness of continuation/maintenance ECT in drug-refractory depression with psychotic features – case report

Wojciech Merk, Krzysztof Kucia, Magdalena Marszałek, Małgorzata Przytuła, Karolina Drzyzga
Postępy Psychiatrii i Neurologii 2010, 19(2): 173–176

Objective. The presented case illustrates the timing of maintenance electroconvulsive therapy (ECT).
Case. In a 79-year-old female patient ECT was administered for the treatment of a severe drug-refractory depressive episode with psychotic features in the course of recurrent major depression. The procedure was performed using bi-temporally localized electrodes, with simultaneous EEG and EKG monitoring. After a basic series of eight ECT procedures the patient's functioning improved, but she still required an intense maintenance treatment including ECT.
Commentary. Maintenance ECT is a very effective and well-tolerated method. Although attempts are made to produce recommendations determining the frequency and duration of ECT treatment, it is the patient's current clinical status that should always decide what treatment intensity is needed.