Archives 1992-2013

2009, volume 18, issue 3

World Psychiatry Forum

What is 'functional impairment”'? Disentangling disability from clinical significance

Bedirhan Üstün, Cillie Kennedy
Postępy Psychiatrii i Neurologii 2009; 18 (3): 217-221

The formulation of disability (or "functional impairment") is currently not operationalized in either the ICD or the DSM. In the DSM system, making a diagnosis depends on a conjoint assessment of symptoms and functioning, whereas the ICD keeps the disability construct separate from the diagnosis of mental disorders. We need an internationally agreed conceptualization between ICD and DSM in terms of better operationalization of disease and disability components. No functioning or disability should appear as part of the threshold of the diagnosis in either system.

Original paper

Evaluation of forensic psychiatrie opinions in involuntary admission cases

Stanisław Dąbrowski, Włodzimierz Adam Brodniak, Wanda Langiewicz, Stefan Welbel
Postępy Psychiatrii i Neurologii 2009; 18 (3): 235-242

Objectives. The paper presents results of an evaluation offorensic psychiatric opinions in cases of involuntary hospitalization, either emergency or upon petition for involuntary admission, by the type of diagnosis.
Method. In the study forensicpsychiatric opinions and court files were analyzed for their ąuality using two ąuestionnaires: "Assessm ent offorensic psychiatric opinions" and "Assessment of guardianship court files", considering the mode of involuntary admission. The total of 560 cases were analyzed, in that number 436 were emergency, and 124 non-emergency hospitalizations, the latter by judicial decision upon a petition for involuntary admission. Moreover, an attempt was made to distinguish specific characteristics of cases with delusional and affective psychoses.
Results. Among emergency admissionspersons diagnosed with schizophrenic disordersprevailed (53.2%), in a largeproportion (25.5%) incapable of expressing their consent to admission to a mental hospital. The majority (66.3%) did not consent to their admission to a mental hospital or a psychiatric ward at a general hospital, while 8.2% expressed at admission their consent to hospitalization and treatment. Major irregularities included: a lack of personal examination (11% of the opinions), inadeąuately justified or lacking socialprereąu isites (31% and 37% of cases, respectively). Insufficient or lacking medical justification was noted in 18 and 9% of the opinions analyzed, respectively, while in 73% of cases it was evaluated as good or satisfactory. As regards patients petitioned for involuntary admission, appeals from the judicial decision and an attorney 's participation in the proceedings were noted in only about 1% of cases. In a considerable number of cases the participants (43%) and forensic experts (35%) were absent from the court hearing. The majority (74%) of the proceedings were completed within 12 weeks. The freąuency of returned files, discontinuance of the proceedings, and less often - of dismissing the motion was not higher than 25%. The majority (75%) of proceedings ended with a judicial decision about involuntary hospitalization. A large proportion (45%) of certificates enclosed to petitions had been issued without a personal examination and with no detailed justification for the need for psychiatric inpatient treatment. On the other hand, a majority of expert opinions had been based on a personal assessment, usually performed at the patient's home, or - less often - in an outpatient clinic or hospital (21% and 11%, respectively). Among diagnoses schizophrenic psychoses and paranoid syndromesprevailed (17% and 26% of cases). Medical justification was well-grounded in 41% of cases, satisfactory in 26% and inadeąuate in 14% of cases. In 21% of the opinions there was no justification for the need for treatment.
Conclusions. In emergency admissions social prereąuisites to justify the case were often missing or inadeąuate. Every 9th opinion had been issued with no previous personal assessment. As regards cases petitioned for involuntary admission, a large proportion of the participants (patients) and forensic experts did not participate in the court hearing; returned files and attorney's participation in the proceedings were noted infreąuently. A large number of certificates had been issued without a personal assessment and with no detailed justification for the need for treatment in a mental hospital. Medical justifications were generally well-grounded, irrespective of the mode of proceedings.

Original paper

Severity of depressive symptoms in adolescents after attempted suicide

Marta Makara-Studzińska, Anna Koślak
Postępy Psychiatrii i Neurologii 2009; 18 (3): 243-246

Objectives. The aims of the study were: to assess severity of depressive symptoms and their relation to attempting suicide by young people; to collect information on modes of suicide, circumstances of the suicidal act, motives for suicide, affective states immediately preceding and following the attempt, instrumental function of suicide, and attitudes towards suicide.
Method. Participants in the study were 99 suicide attempters compared to 301 controls. Psychological interview and the Beck Depression Inventory (BDI, for the assessment of depressive symptomatology severity) were used.
Results. Adolescent suicide attempters scored significantly higher on the BDI than did the controls, which suggests mood disorders in the former. Girls as compared to boys more often attempted suicide at home. The predominating affective state preceding the suicide attempt was emotional arousal (in girls) and depressed mood (in boys). Direct motivation for attempting suicide in a majority of partici-pants involved interpersonal conflicts.
Conclusions. Adolescent suicide attempters are definitely in need for psychological and psychiatric care.

Original paper

Eye Movement Desensitization and Reprocessing effectiveness in outpatient psychotherapy for posttraumatic stress disorder

Jacek Pasternak
Postępy Psychiatrii i Neurologii 2009; 18 (3): 247-254

Objectives. The psychological study was aimed at evaluation of the Eye Movement Desensitization and Reprocessing (EMDR), hypo-thesized to be effective in PTSD treatment.
Method. Participants in the study were 60 outpatients (16 men and 44 women) aged 18-55, diagnosed with posttraumatic stress disorder (PTSD). They were treated with psychotherapy at the Outpatient Mental Health Clinic in Rzeszów. The patients were randomly divided into two eąuinumerous groups: "immediate", starting treatment directly after the initial diagnostic assessment, and "delayed", receiving the same treatment after one month delay. In the pre-and post-treatment assessment a PTSD ąuestionnaire by Pasternak was used (in the "delayed" group an additional assessment was made 1 month after the initial one, i.e. directlypreceding therapy).
Results. In a vast majority of patients a statistically significant reduction in PTSD symptoms severity was noted. Three subgroups differ-ing in treatment outcome (as measured by the Pasternak PTSD Scale scores) were identified, whose therapy was: successful (n = 37), moder-ately effective (n = 14), or unsuccessful (n = 9).
Conclusions. The findings suggest that Eye Movement Desensitization and Reprocessing turned out to be an effective techniąue in the treatment for PTSD, both in the whole sample under study, and in the subgroups ("immediate" and "delayed").

Original paper

Cognitive deficits and depressive disorders in cerebral stroke patients

Katarzyna Nowakowska, Grażyna Adamiak, Karolina Jabłkowska, Aleksandra Lewandowska, Agnieszka Stetkiewicz, Alina Borkowska
Postępy Psychiatrii i Neurologii 2009; 18 (3): 255-262

Objectives. The goal of the study was firstly, to assess selected cognitive functions and depressive symptoms severity in patients with cerebral stroke, and secondly, to investigate relationships between cognitive disorders and depressed mood.
Method. The study involved 52patients (28 men and 23 women, aged 47-84, mean age: 60.0±9.9years) assessed not earlier than at 3 months after cerebral stroke. Three subgroups of patients differing in the stroke site were identified (14patients with dominant hemispheric stroke, 26 with a non-dominant hemisphere stroke, 12 with bihemisphericalpost-stroke impairment), and compared with 30 healthy controls matched for sex, age and education. Clinical diagnosis was based on the ICD-10. Severity of dementia was assessed using the Mini Mental State Examination. In the neuropsychological evaluation the Trail Making Test A-B, the Stroop Test A-B, the Clock-Drawing Test, and the Wisconsin Card Sorting Test were used. Depression severity was assessed with the Beck Depression Inventory.
Results. Stroke patients as compared to healthy controls scored significantly lower on the neuropsychological tests measuring various aspects of cognitive function. Cognitive impairment was most marked in the subgroup with bihemispheric stroke, while deficits of verbal and visuospatial working memory were more freąuent in patients with left-hemispheric stroke. Executive dysfunction severity was similar in patients with either right or left hemisphere damage. No relationship was found in the sample under study between cognitive function impairments and depressive symptoms severity.
Conclusions. 1. A significant impairment of working memory and executive functions was found in stroke patients. Impairments of verbal and visuospatial working memory were more marked in patients with left hemispheric stroke. 2. Severe depressive symptoms were found in over a half of the sample under study. 3. Depressed mood severity in stroke patients was higher than that in the group of healthy controls and was not correlated with the level of cognitive dysfunctions.

Original paper

Risk factor patterns and 30-day outcome in male and female patients with first ever ischemic stroke - analysis of 4802 patients collected in the Lausanne Stroke Registry

Małgorzata Wiszniewska
Postępy Psychiatrii i Neurologii 2009; 18 (3): 263-268

Objectives. Stroke has been for a long time one of the major health problems in both sexes. In women increased stroke-related mortality rates were noted in recent years. The aim of the study was to investigate gender differences in the prevalence of risk factors and in 30-day outcome of first ever ischemic stroke (IS) in various age groups.
Method. Data of4802patients with first ever IS (2898 males, 1904females) collected in the Lausanne Stroke Registry (LSR) in the years 1979-2000 were analyzed. The mean age of men was 63.2, and of women - 64.1 years; the difference was not significant.
Results. The prevalence of stroke risk factors was found to be significantly higher in men than in women (p<0.0002) in all the age groups under 80. In both genders below the age of 55 smoking was the most common risk factor (more freąuent in men, p < 0.0002). In those aged over 55 it was replaced by arterial hypertension, more freąuent in women in the age group over 65 (p<0.006). Irrespective of age, the prevalence of nicotinism was higher in men, and tended to decrease with age. Migraine turned out to be a significant risk factor only inyoung women (19.6%). Theprevalence of atrial fibrillation tended to increase with age in both genders, more markedly in women. The 30-day case fatality rate was higher in women than in men (44.1% vs. 41.4%, respectively; p<0.05). This difference was most pronounced in the 66-80 age group (with mortality rate of 47.7% for women and 42.3% for men, p < 0.03).
Conclusions. The prevalence of risk factors among patients with first ever IS was found to depend on sex and age. The most common risk factor in persons aged under 55 years was smoking (more freąuent in men), and in age groups over 55 - hypertension (more freąuent in women). The relatively higher freąuency of poor outcome (early fatality of stroke) in women reąuires further research. Moreover, more emphasis should be placed on stroke prevention and on stroke management in women.


Clinical consequences of the metabolic syndrome

Adam Wysokiński, Agata Orzechowska, Monika Talarowska, Wojciech Gruszczyński
Postępy Psychiatrii i Neurologii 2009; 18 (3): 269-275

Objectives. The authors present an overview of the literature and summarize crucial findings concerning clinical consequences of dis-orders included in the metabolic syndrome, i.e. central obesity, lipid disorders, diabetes and hypertension.
Views. The metabolic syndrome is not only a side effect of antipsychotic treatment that requires additional therapy, but also a set of significant risk factors involving many health-detrimental and life-threatening complications. The presence of these complications is associated with health impairment and quality of life deterioration in persons receiving psychiatric pharmacotherapy. Moreover, the necessary treatment of these complications results in additional expenses.
Conclusions. Psychiatrists knowledgeable about consequences of the metabolic syndrome should be able to prevent more effectively its many dangerous complications. This should lead to an improvement of the patients' quality of life, their better compliance and adherence.


Premenstrual syndrome and premenstrual dysphoric disorder: diagnosis and treatment

Gabriela Bodzak-Opolska
Postępy Psychiatrii i Neurologii 2009; 18 (3): 277-285

Objective. The aim of the paper is to outline risk factors, clinical picture, and treatment of the premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), especially in the context of depressive symptoms.
Views. PMS/PMDD affect over 60% women of reproductive age. The importance of these conditions, disturbing and destabilizing active life, is underestimated. Hypotheses concerning PMS and PMDD pathomechanisms are discrepant, leading to very different treatment approaches. Research findings suggest that a considerable individualization of treatment is needed. The relatively best investigated method of pharmacological treatment, registered in some countries, involves SSRIs. However, due to a low efficacy of antidepressants in general, other treatments are introduced, including hormones, diet supplements, physical exercise, herbal drugs, and lifestyle modification.
Concłusion. Inconsistent conceptualization ofpathomechanisms underpinning PMS and PMDD results in diverse treatment approaches.


Patient classification methods in nursing staff planning in psychiatrie facilities

Marta Cebulak, Anna Ksykiewicz-Dorota
Postępy Psychiatrii i Neurologii 2009; 18 (3): 285-291

Objectives. The aim of thepaper is to presentpatient classification (PCS) methods used in nursing staff planning in psychiatric units.
Views. The use of PCS methods allows to provide nursing care appropriately to patients' needs, and ensures proper staff management. The methods assume that care reąuirements are variable and depend on the illness specificity, the patient 's condition, age and self-care capability. The approach provides for a variable number of nursing staff in different organizational units, and within the same facility on day and night shifts. If PCM methods are to be applied in other settings than those for which they have been originally designed, particular elements of the method including criteria and categories of care, direct nursing time and auxiliary time standards have to be adjusted to the organizational conditions and health care level in the target country. In the domestic healthcare system PCS methods were adjusted to the needs of patients receiving non-invasive or surgical treatment, but not to those of persons with mental disorders.
Concłusions. Since a more effective management of health care facilities is needed, managers should use appropriate staff planning methods so that the number of staff was consistent with the actual care needs. The PCS methods are appropriate to the purpose. However, their application reąuires that they should be adapted to organizational conditions and the current state of the national healthcare system, including psychiatry.


Application of Dorothea Orem 's theory on nursing care to the assessment of nursing care needs of patients hospitalized in psychiatrie units

Marta Cebulak, Anna Ksykiewicz-Dorota
Postępy Psychiatrii i Neurologii 2009; 18 (3): 293-298

Objectives. To present the application of the theory of nursing care by Orem to the patient classification system in psychiatric facilities.
Views. The assessment of nursing care needs and staffing reąuirements constitutes an essential organizational problem in the nursing subsystem management. Medical care planning and delivery is facilitated by methods of planning staffing reąuirements known under a common heading of the Patient Classification Systems (PCS). An assumption is made in the PCS that staffing should be variable, appropriate to the real patient needs, and not allocated to particular units once and for all. The PCS application in psychiatry reąuires adaptation of the methods to the specificity of mental health careprovision, where basic care reąuirements encompass psychosocial and behavioralproblems and must be compatible with practice standards in particular settings. The application of a chosen theory of nursing care to a patient classification system provides a scientific rationale for professional practice and reflects the value of the theory.
Conclusions. Planning and delivery of nursing care in accordance with patient needs as well as adeąuate staffing estimation reąuire the application of PCS methods. Patient classification methods used in psychiatry must not only account for the specificity of care for this type ofpatients, but also be compatible with practice standards in the particular settings. Application of a nursing care theory provides grounds for good practice and management of the nursing profession.

Case report

Hyperthermia in the course of electroconvulsive therapy: a case report

Dorota Bzinkowska, Anna Z. Antosik, Łukasz Święcicki
Postępy Psychiatrii i Neurologii 2009; 18 (3): 299-302

Objective. To present a case of atypical symptoms occurrence in the course of electroconvulsive therapy (ECT).
Case report. ECT of a 26-year-old male patient diagnosed with major depression is presented. In a series offourteen ECTs an improve-ment of his affective state was attained. Delayed seizure activity, extended seizure duration, as well as his mental and physical symptoms manifested during and after some ECTs were different from those known to the authors and described in literature.
Commentary. An analysis of the patient 's somatic condition, medical treatment used, and the type of seizure in response to ECT revealed no cause of the observed atypical symptoms.

Case report

An extraordinary improvement of neurological condition following zolpidem administration to a patient with ischemic cerebellar stroke, secondary hydrocephalus and brain stem damage: a case report

Grażyna Adamiak, Agnieszka Stetkiewicz, Aleksandra Lewandowska, Alina Borkowska
Postępy Psychiatrii i Neurologii 2009; 18 (3): 303-306

Objectives. Zolpidem, a sedative drug used for insomnia, has been reported in the literature to produce beneficial neurological effects in patients with brain dysfunctions of various origin. The paper presents a case of such effects.
Case report. The medical history and process of zolpidem treatment of a 34-year-old woman with ischemic cerebellar stroke resulting in a brain steam damage and secondary hydrocephalus are presented.
Commentary. The patient's medical history shows that zolpidem may be an effective drug restoring some functions of the brain after ischemic damage to the cerebral tissue.

Case report

Detention - and what's next?

Alfreda Ruzikowska, Krystyna Tarczyńska, Anna Walczyna-Leśko
Postępy Psychiatrii i Neurologii 2009; 18 (3): 307-310

Objectives. To present a proposal how to reduce waiting times forplacement in detention units.
Case reports. Several cases are presented where the provision of outpatient care as a form of safety measure would effectively solve clinical, legal and organizational problems associated with these patients' detention.
Commentary. According to the presented proposal, outpatient care should be provided under court supervision to patients released from detention and to those who due to such care would not reąuire detention at psychiatric units representing various levels of safety measures. Court-supervised outpatient care would reąuire a modification of legal regulations on detention under Articles 93 and 94 of the penal code.