Archives 1992-2013

2006, volume 15, issue 4

Original article

Unreal visual perceptions - an analysis of233 cases

Stefan Krzymiński, STANLEY N. CAROFF, Grzegorz Rossa
Postępy Psychiatrii i Neurologii 2006; 15 (4): 223-233

Aim. An analysis of 233 cases of unreal visual perceptions reported in the literature (except for 13 cases). Unreal visual perceptions, usually called hallucinations, according to the literature more frequent in females and in the elderly, are associated with visual impairment and brain dysfunction, especially of the visual tract, diencephalon (thalamus), and the brain stem. Prognosis is considered to be uncertain.

Methods. In the analysis of233 cases of visual hallucinations and parahallucinations reported mostly in the English-language publications in the years 1976-2004, the nature of these patients' organic changes and mental disorders, characteristics and type of their visual perceptions, as well as treatment methods and their efficacy were taken into account.

Results. Five groups of unreal visual perceptions can be distinguished: these related to diseases of the central nervous system, the Charles Bonnet syndrome, to mental disorders, and either drug-induced or associated with an ophthalmic surgery. In all the analysed groups females and individuals with some visual impairment predominated. A third of these patients were aged under 65 years. Brain lesions were situated in both hemispheres, thalamus, visual tract. Good results of treatment were attained in almost 80% ofpatients.

Conclusions. Only in some cases visual perceptions could be recognised as hallucinations due to the patients' lack of insight into their unreal nature. In almost half of cases the presence of insight indicated that such perceptions were parahallucinations (hallucinoids), or sensory automatisms. In the group ofpatients without diseases of the central nervous system neuroleptics were substantially more effective than other treatment methods. In the group with diseases of the CNS there was no such relationship.

Original article

Individual traits in patients with different subtypes of anorexia nervosa

Postępy Psychiatrii i Neurologii 2006; 15 (4): 223-233

Background. The aim of the study was to analyse differences in personality traits, both intergroup, i.e. when comparing anorexic patients with healthy controls, and between patient groups with various subtypes of anorexia nervosa.

Methods. The study group included 109 female patients hospitalised for anorexia nervosa of the restrictive type and 39 patients with anorexia of the bulimic type diagnosed by the ICD-10 and DSM-IV criteria. The control group consisted of 100 females, high school or college students, with no history of eating disorders. The TCI questionnaire by Cloninger in a Polish adaptation was used in the study.

Results. Differences at the level ofpersonality dimensions were found both between healthy controls and patients with eating disorders, and between patients with various subtypes of anorexia nervosa.

Conclusions. The differences in personality traits found in the study may be of importance as regards etiopathogenesis of eating disorders.

Original article

Patients ' falls in a neurological rehabilitation ward

Postępy Psychiatrii i Neurologii 2006; 15 (4): 223-233

Background. Neurological patients, especially stroke patients, are at a high risk for falls. The purpose of the study is to estimate the frequency, character and consequences offalls, as well as risk factors for falls in patients during inpatient neurological rehabilitation.

Methods. Participants in the study were 569 consecutive patients of the Neurological Rehabilitation Ward in Warsaw; in that number 65.7% stroke cases and 34.3% patients with other neurological conditions. Their routine medical records and nursing reports concerning falls were analysed.

Results. Out of 49 (8.6% of the sample) patients who suffered falls 39 (79.6%) were stroke cases. The total of 66 falls were recorded corresponding to the incidence rate of 4.23 falls per 1000patient-days (95% CI 3.21-5.25). Most falls (15, i.e. 22.7%o) occurred during transfers or position changing (14, or 21.2%). No injury was sustained in 40 (60%) falls, while 17 (25%) falls caused some and 3 (4.5%) - severe injury (fractures and wounds). Higher incidence offalls was significantly related to the diagnosis of stroke (RR = 2.2 95% CI 1.07-4.47), the presence of hemineglect (RR = 3.9 95% CI 2.09-9.44) and poor performance on the admission Activities of Daily Living (ADL) scores: Rankin >3 (RR = 4.0 95% CI 2.17-9.11) and score <14 on the Barthel Index (RR = 5.1 95% CI 2.39-13.7). As compared to non-fallers, fallers were older (p = .01) and stayed longer in rehabilitation (p = .003).

Conclusion. Stroke survivors were most prone to falls in this study. The problem needs further investigation.

Original article

Forensic psychiatric opinions of substance dependent perpetrators or those acting under the influence of psychoactive substances: experts reports from six psychiatric facilities

ZENON KULKA, Krystyna Tarczyńska, Alfreda Ruzikowska
Postępy Psychiatrii i Neurologii 2006; 15 (4): 223-233

Background. The study was aimed at an analysis of forensic psychiatric opinions issued on the grounds of observation or outpatient examination of substance abusing or substance dependent perpetrators, or those acting under the influence of psychoactive substances. Opinions submitted by expert psychiatrists from six psychiatric facilities were compared with the practice of forensic experts from the Institute of Psychiatry and Neurology.

Methods. Using a questionnaire developedfor the purposes of this study 50 forensic psychiatric opinions based on observation (21 cases) and outpatient examination (29 cases) were analysed. The opinions had been issued in the years 1992-2002 by expert psychiatrists from six randomly selected psychiatric hospitals (in Bolesławiec, Cibórz, Choroszcz, Międzyrzecz, Toruń, Świecie). A number of variables were analysed: the perpetrator 's age, sex, psychiatric diagnosis, type and number of crimes committed, type and number of psychoactive substances ingested, as well as the perpetrator's accountability at the time of committing crime.

Results. Only two opinions concerned women. Drug dependence was diagnosed in 38 perpetrators, drug abuse in 12, and concomitant alcohol dependence in 8 cases. Most of the perpetrators were using more than one psychoactive substance. Stimulants and opiates were the substances used most frequently, followed by cannabinoles and sedatives, while hallucinogens and inhalants were definitely rare. Personality disorders, mostly dissocial personality, were found in 31 cases, while in 2 cases - personality disorders of organic origin. A majority of perpetrators had been under the influence of psychoactive substances tempore criminis, but in 34 cases the experts found no grounds for recognising either inaccountability or highly diminished accountability. In 3 cases the perpetrator 's inaccountability at the time of committing the criminal act was recognised (Article 31 par. 1 of the Penal Code), but a motion was filed for Article 31, par. 3 of the Penal Code. In 3 perpetrators highly diminished accountability was recognised by the experts. The majority of criminal acts were against property (55%), against the Act on Counteracting Drug Dependence (17%), against the family (15%), while only 13% of offences were against life and health.

Conclusions. Irrespective of the psychiatric facility, there was a consensus between the experts that if criminal acts had been committed under the influence ofpsychoactive substances or in the state ofsubstance dependence, there were no grounds for recognising inaccountability, except for psychotic disorders - unless the perpetrator could have foreseen their occurrence. A motion for diminished accountability is justified if the perpetrator suffered from severe symptoms of the withdrawal syndrome or if organic changes were found in his/her central nervous system. When issuing an opinion on a substance dependent person, experts should articulate the necessity for the perpetrator's treatment in an alcohol/drug treatment ward of a penal institution, even if this question has not been asked by the court.

Original article

A preliminary evaluation of reliability of the Mini International Neuropsychiatrie Interview for Children and Adolescents (MINI-Kid) in Polish adaptation

JOANNA MAZUREK, Krzysztof Małyszczak
Postępy Psychiatrii i Neurologii 2006; 15 (4): 223-233

Background. The aim of the study was to evaluate reliability of the Polish adaptation of the MINI-Kid (Mini-International Neuropsychia-tric Interview for Kids) for psychiatric assessment of children and adolescents.

Methods. 34 adolescents (12 boys and 22 girls aged 11-17 years), patients of the Day Psychiatric Centre for Children and Adolescents and of the Mental Health Outpatient Clinic for Children and Adolescents in Wrocław, were examined using the MINI-Kid questionnaire twice, at the interval of30-33 days. They all were examined by the same specialist in child and adolescent psychiatry, who was not their doctor in charge. The test-retest reliability was assessed using the kappa concordance coefficient.

Results. The kappa coefficient of concordance for all anxiety disorders jointly was 0.72, for the oppositional defiant disorder 0.68, adaptation disorders 1.0, ADHD 0.71, and for conduct disorder 0.80.

Conclusions. The concordance coefficients obtained for the MINI-Kid questionnaire are in the range of these reported for similar diagnostic instruments, including the questionnaire MINI for adults.

Original article

Public opinion poll: social perception of mental illness and the mentally ill in the year 2005

BOGNA WCIÓRKA, Jacek Wciórka
Postępy Psychiatrii i Neurologii 2006; 15 (4): 255-267

Objectives. The aim of a number of initiatives undertaken in recent years in Europe and worldwide has been to improve the public image and status of people suffering from mental illness. These inititives included programs of psychiatric care modernization, mental health promotion, empowerment, and patient's rights advocacy, as well as prevention of stigmatization, exclusion and discrimination of people with an experience of such illness. The aim of this study was to find out Polish society's current views of the subject.

Methods. The opinion poll was conducted on a representative random sample of adult residents of Poland (N = 1037) by the Opinon Poll Centre network in June 2005, as a monthly poll on "Current problems and events".

Results. A majority of respondents (60%) note mostly pejorative terms used in their environment to denote the mentally ill, while only a third (34%) - neutral, descriptive terms. Somewhat over a half (58%) of the respondents believe that mentally ill people can recover, while 31% expressed the opposite view. Incomprehensible behaviours are more often considered to be typical symptoms of mental illness than aggressive or belligerent ones (41-45% as compared to 22-25%). Healthy people respond to a direct contact with a mentally ill person most often with compassion (57%), embarrassment (52%), feelings of helplessness (38%), fear (37%), or pity (34%). However, a vast majority of Poles (76%) believe that mental disorders should be kept secret, since they are shameful. Social distance towards the mentally ill was measured in terms of the respondent's objections to their undertaking various social roles. The objections were the stronger the higher were the role demands (i.e. the greater responsibility and confidence were required for a given role, the stronger was our respondents' belief that it should not be entrusted to people who have suffered from mental illness). An opinion predominates that the mentally ill are treated worse than other citizens, above all, as regards the right to employment (83%), respect for personal dignity (67%), property rights (61%), and to a smaller degree - receiving a fair trial (42%). Differences of opinion were more marked regarding inequality in access to social assistance (42%) and health care (34%).

Conclusions. A rather pessimistic and reluctant stereotype of mental illness, with clearly stigmatising and excluding underpinnings, seems to prevail in the public opinion. Incomprehensible and maladaptive behaviours rather than belligerent ones are more often considered to be typical of mental illness, while a sense of helplessness rather than active reluctance is regarded as a typical reaction to the mentally ill. The level ofsocial distance towards the mentally ill suggests a distrust of their ability to assume social responsibilities. The belief in inequality and discriminatory treatment of mentally ill people in many important areas of life is shared by a large proportion of the respondents.

Review article

Social functioning and social disability - practical and methodological aspects

Postępy Psychiatrii i Neurologii 2006; 15 (4): 269-276

Objective. An attempt was made in the paper to review instruments used in psychiatry for the assessment of social functioning with view to their usefulness for general practitioners, clinicians and researchers.

Review. The development of effective therapeutic interventions requires the use of instruments for the assessment of social functioning and disability that would more and more reliably reflect the real-world behaviour and activity of people with mental disorders in their social environment, taking into account their local conditions and individual potential determined, among other things, by their cognitive functions. The review includes characterization of the most recent trends concerning utility of instruments for the measurement ofpsychosocial functioning and disability. The problems of questionnaire construction and characteristics (usefulness, practicality, reliability and validity) are dealt with. The paper presents studies and research projects that provided data concerning the strong and weak points of the reported assessment instruments. Moreover, the paper outlines the direction of changes in the research into functioning and disability from the historical perspective.

Conclusions. The importance of an integrated approach including the assessment of social functioning as an element of examination seems to increase. Task performance and enactment of "real-life" roles are at present regarded as crucial, since they enable to draw inferences about the individual's specific cognitive abilities and his/her personal potential.

Review article

The community-based psychiatric care model and changes in the health system structure in recent years in Poland

Maria Załuska
Postępy Psychiatrii i Neurologii 2006; 15 (4): 285-276

Background. Deinstitutionalization, reduction of hospital admissions and provision of community-based psychiatric services are the commonly accepted postulates ofpsychiatry in the process of reform. In the paper an impact of both the ongoing general health care reform and the system of contracting health care services on the functioning and development of community psychiatry is assessed.

Method. An analysis is presented of changes in the structure of psychiatric care provision in Poland since the year 1970, in terms of deinstitutionalization and development of community-based forms ofpsychiatric services.

Results. In recent years the number ofpsychiatric wards in general hospitals and of day hospitals has increased, and community-based facilities providing social support to the mentally ill are being established within the welfare system. Nevertheless, the community psychiatry model implemented since the 1970s seems to be endangered at present. The index of the total number of psychiatric beds has increased in the years 1999-2003, especially as regards long-term care, which may be a symptom of the so-called transinstitutionalization.

Conclusions. There is a need for the development of integrated community-based psychiatric care forms that would co-ordinate health care and welfare services provision. An assessment of the total number of people with mental disorders admitted to inpatient facilities providing long-term care, both in the health care and welfare structures, is indicated.

Review article

The CREB transcriptional factor contribution to the mechanism of the antidepressant effect

Tadeusz Pietras, Piotr Gałecki, Janusz Szemraj
Postępy Psychiatrii i Neurologii 2006; 15 (4): 287-276

Objectives. The aim of the article is to review the current literature on the CREB factor role in the mechanism underlying the action of antidepressants.

Review. The antidepressant effect due to an increased direct receptor serotonin and noradrenergic transmission seems to be doubtful. While catecholamine reuptake inhibition can be seen immediately on drug administration, the antidepressant effect related to serotoninergic transmission occurs sometimes with a few week delay. Nowadays, the mechanism underlying the antidepressant action is often associated with an increased protein expression of some transcriptional factors, including CREB (cyclic AMP-responsive element binding). The CREB factor regulates the expression ofgenes connected with synaptic and neuronal plasticity, trophic factors for neurons (e.g. the BDNF - brain-derived neurotrophic factor), and proteins of membrane receptors. The CREB transcriptional factor phosphorylation responsible for delayed effects of the mediator influence on a receptor (connected with adenylane cyclase), is linked to gene expression regulation. All the examined antidepressants were shown to increase mRNA expression in hippocampal cells for the CREB factor, BDNF proteins, and for the oncogene Trk product. The reported research findings confirm an increased expression and phosphorylation of the CREB protein in animal brains after administration of various antidepressants.

Conclusions. In the authors' opinion the action of antidepressants may be associated with gene expression regulation, since an anti-depressant effect of these drugs can be seen only after a few weeks of treatment.

Review article

Cognitive dysfunctions in systemic lupus erythematosus: relationship to selected clinical characteristics

Postępy Psychiatrii i Neurologii 2006; 15 (4): 295-276

Background. The article presents research findings concerning the relationship between cognitive dysfunctions in patients with systemic lupus erythematosus (SLE) and: their disease activity level, concomitant neurological and/or psychiatric (N/P) symptoms, results of neuroimaging scanning, selected immunological indicators, and steroid treatment.

Review. Cognitive dysfunctions in SLE patients are irrespective of either the disease activity level or steroid treatment administered in these cases, but they are often associated with increased levels of anticardiolipin antibodies. Concomitant neurological and/or psychiatric symptoms seem to be another factor contributing to the presence of cognitive dysfunctions, although no evidence has been found to suggest that cognitive deficits in SLE are associated with mood disorders. It should be noted that cognitive dysfunctions occur also in patients who have never manifested any N/P symptoms. Cognitive deficits seem to be associated with changes in magnetic resonance imaging (MRI), magnetization transfer imaging (MTI) and positron emission tomography (PET) scans. However, conclusions from studies seeking a correlation between cognitive dysfunctions and cerebral blood flow abnormalities measured using the single photon emission tomography (SPECT) are discrepant.

Conclusions. Cognitive dysfunctions are a frequent manifestation in SLE, seen both in patients with N/P symptoms and in those without such symptoms. The dysfunctions in the latter group are regarded as a symptom of subclinical impairment of the central nervous system. Due to discrepancy of research results this problem remains under investigation in many studies.

Review article

Eating disorders and the experience of sexual abuse in childhood - a review of research literature

Marta Makara-Studzińska, JOLANTA ŻOGA, Anna Grzywa
Postępy Psychiatrii i Neurologii 2006; 15 (4): 297-276

Background. A review is presented of research on the relationship between sexual abuse in childhood and eating disorders (anorexia nervosa and bulimia nervosa) in later life.

Review. In a majority of reviewed studies such a relationship was found. Eating disorder severity was associated with experiencing also other kinds of violence in the same period. The need for distress reduction and attempts at regaining control over own body are regarded as a psychopathological mechanism underlying eating disorders.

Conclusions. The problem should be taken into account in clinical practice.

Review article

The effect of antiepileptic medication on cognitive functions

Postępy Psychiatrii i Neurologii 2006; 15 (4): 307-276

Background. The literature is reviewed concerning the effect of antiepileptic drugs on cognitive functions in healthy volunteers and in patients treated for epilepsy or mental disorders.

Review. Antiepileptic drugs of "older generation " affect cognitive functioning efficacy. This adverse effect is most pronounced in case of barbiturates and benzodiazepines administration, and less marked for phenytoin. On the other hand, probably no clinically significant changes in cognitive functions ensuefrom monotherapy with standard dosage of carbamazepine and valproates. "New generation " antiepileptic drugs have a differentiated effect on cognitive functions. Research on the use ofgabapentine, oxcarbazepine, vigabatrine, and tiagabine does not indicate any negative effects of these drugs on cognitive functions. As regards lamotrigine, an improvement in cognitive tests performance was even observed. Only the administration of topomirate was followed by a deterioration in some subjects' test performance.

Conclusions. The effect of antiepileptic drugs on cognitive functions is differentiated. An evident cognitive impairment is associated with some "older generation " pharmaceuticals. As far as "new generation " drugs are concerned, adverse effects were seen in some persons receiving topomirate. It should be noted that rather few studies reported in the literature deal with these problems. Moreover, methodological difficulties may affect credibility of the research findings.

Review article

Understanding of the action ofpsychotropic drugs by psychoanalytically-oriented researchers in the early years of contemporary pharmacotherapy

Sławomir Murawiec
Postępy Psychiatrii i Neurologii 2006; 15 (4): 309-276

Background. The paper is aimed at a search for and analysis of alternative to those presently predominating ways of thinking about pharmacotherapy of mental disorders.

Review. Reviewed publications are concerned with the beginnings of pharmacotherapy in clinical practice, mostly in the treatment of schizophrenia. The papers published in the years 1955-1961 by psychoanalytically-oriented authors from a Canadian center deal with the following pharmaceuticals: reserpine, levomepromazine, trifluoperazine, and azacyclonol .

Conclusions. The authors differentiate between a non-individualised pharmacological action of a medicine and its individual therapeutic effect in the context of the patient 's global situation. On the grounds of observation an attempt was also made to answer the question whether administration of a medicine results in a change in the natural course of the disease. A two-stage action of pharmacotherapy was assumed. According to the authors' way of thinking, the biological effect of any drug is only an introduction to the final therapy outcome. The latter depends on "fitting " the drug action into a configuration of the patient 's personal, familial and social determinants. Moreover, transference- and countertransference-related factors and their the importance for the therapy outcome were commented upon. Sometimes it is the patient-doctor relationship or the doctor's intrapsychic characteristics that determine the pharmacotherapy outcome.

Case report

Organic delusional disorder in a young man ssuffering from acute leukaemia in childhood - a case report

Postępy Psychiatrii i Neurologii 2006; 15 (4): 315-317

Aim. The aim of the article was to draw attention to the problem of psychiatric complications of intensive chemo- and radiotherapy administered in childhood. At present most children suffering from acute leukaemia are successfully treated. However, intensive chemo- and radiotherapy are known to affect young patients' mental state.

Case report. A case is reported of a man in remission of leukaemia for the past 15 years. His current personal and social functioning is severely affected by his cognitive impairment and delusional syndrome.

Conclusions. At the time when acute lymphoblastic leukaemia can be successfully treated, new treatment regimens should be introduced taking into account delayed complications of chemo- and radiotherapy in childhood.

Case report

The life of a stammering doctor

Irena Krupka-Matuszczyk, Małgorzata Janas-Kozik, KASPER CZECH, MACIEJ MATUSZCZYK
Postępy Psychiatrii i Neurologii 2006; 15 (4): 319-320

Objective. The aim of the paper is an analysis of the medical history of a patient in a specific familial and professional situation.

Case report. A 33-year-old man, medical doctor, the only child of parents - physicians. The onset of his stammering was at the age of 15. He was unsuccessfully treated by his parents by a variety of methods. His stammer abated after treatment with paroxetine, a set of vitamins and microelements, cognitive-behavioral therapy, and separation from the parents.

Commentary. The paper reports the patient 's coping with his speech disorder present since the age of 15, as well as the treatment used.