Archives 1992-2013

2010, volume 19, issue 1

World Psychiatry Forum

Salient components of a comprehensive service for eating disorders

Katharine A. Halmi
Postępy Psychiatrii i Neurologii 2010; 19(1): 5–24

Eating disorders are challenging and difficult to treat, because of the necessity of a multidisciplinary treatment team for effective outcomes and the high mortality rate of anorexia nervosa. An adequate initial assessment and evaluation requires a psychiatric assessment, a medical history and medical examination, a social history and an interview of family members or collateral informants. A comprehensive eating disorder treatment team includes a psychiatrist coordinating the treatment and appropriate medical physician specialists, nutritionists, and psychotherapists. An adequate outpatient eating disorder clinic needs to provide individual psychotherapy with cognitive behavioral techniques specific for anorexia nervosa and bulimia nervosa, family therapy, pharmacological treatment and the resources to obtain appropriate laboratory tests. Eating disorder patients requiring inpatient care are best treated in a specialized eating disorder inpatient unit. A cognitive behavioral framework is most useful for the overall unit milieu. Medical management and nutritional rehabilitation are the primary goals for inpatient treatment. Various group therapies can cover common core eating disorder psychopathology problems and dialectical behavior therapy groups can be useful for managing emotional dysregulation. Residential, partial hospitalization and day treatment programs are useful for transitioning patients from an inpatient program or for patients needing some monitoring. In these programs, at least one structured meal is advisable as well as nutritional counseling, group therapy or individual counseling sessions. Group therapies usually address issues such as social skills training, social anxiety, body image distortion or maturity fears. Unfortunately there is s paucity of evidence based randomized control trials to recommend the salient components for a comprehensive service for eating disorders. Experienced eating disorder clinicians have come to the conclusion that a multidisciplinary team approach provides the most effective treatment.

Original article

Quality of life in patients with schizophrenia – 7 to 12 years after their first hospitalization

Andrzej Cechnicki, Miquel Valdez, Łukasz Cichocki, Aneta Kalisz, Hubert Kaszyński
Postępy Psychiatrii i Neurologii 2010; 19(1): 25–30

Objectives. Relatively little research has been done on the quality of life (QoL) of community-living people diagnosed with schizophrenia. The aim of this study was to assess changes in the quality of life in a group of patients with a relatively long duration of the illness, receiving systematic outpatient care.
Methods. Participants were 64 patients diagnosed with schizophrenia by the DSM-IV criteria and treated for many years under a special outpatient care program in Cracow. Subjective and objective indicators of their QoL measured at seven (K7) and twelve (K12) years after their first hospitalization using a Polish adaptation of the Lehman Quality of Life Interview were compared.
Results. Subjective QoL indicators turned out to be relatively stable over the period under study – a significant change (improvement) was found only as regards self-estimated social relations (p<0,01). At the same time a decrease was noted in objective QoL indicators in the following spheres: social relations (p=0,01), financial situation (p=0,01), health (p=0,01), and religion (p=0,01).
Conclusions. In persons suffering from schizophrenia an increase in subjective satisfaction with extrafamilial relationships was noted in the period between 7 and 12 years from their first hospitalization, with a simultaneous decrease in objective QoL indicators in this sphere, as well as in these regarding their financial situation, health and religion.

Original article

Diagnosing dementia with Lewy bodies in clinical practice

Stefan Krzymiński, Grzegorz Rossa, Mirosława Kordacka
Postępy Psychiatrii i Neurologii 2010, 19(1): 31–38

Objective. An attempt was made to identify cases of dementia with Lewy bodies (DLB) on the grounds of medical records of psychogeriatric patients primarily diagnosed with other dementias. DLB is considered to be the second most common type of degenerative dementia after Alzheimer's disease (AD). Even though current clinical diagnostic criteria for DLB characterized by a considerable sensitivity and specificity seem to be relatively simple, DLB is seldom diagnosed in everyday clinical practice.
Method. The clinical diagnostic criteria for DLB were applied to data obtained from medical records of patients who had been diagnosed with some other type of dementia, mostly AD or vascular dementia (VaD). Using this approach 22 cases of probable or possible DLB were identified, with cognitive deficits accompanied by symptoms considered to be axial for DLB, i.e. fluctuations in cognitive functioning, parkinsonism, and visual hallucinations. The patients were compared with 22 cases of probable AD.
Results. The group identified as DLB cases differed from AD patients in a number of ways. Some of the differences achieved the level of statistical significance. Namely, AD patients performed significantly better on the task of copying a line drawing of overlapping pentagons, while the DLB group had significantly more symptoms supporting their diagnosis. Fluctuations turned out to be the most frequent axial symptom of DLB, occurring however significantly more often only as compared to visual hallucinations. Fluctuations were diagnosed using the Fluctuations Composite Scale [Ferman et al. 2004], and on the grounds of the MMSE scores variability.
Conclusions. It is feasible to diagnose DLB in everyday psychogeriatric practice. It is important not only to identify the symptoms considered to be axial for DLB, but also to establish that the patient with a relatively high level of cognitive functions is incapable of adequate copying the picture of pentagons.

Review article

Genetic and psychosocial aspects of impulsiveness

Andrzej Jakubczyk, Marcin Wojnar
Postępy Psychiatrii i Neurologii 2010; 19(1): 39–45

Objectives. Impulsiveness as a heritable characteristic being both a symptom of many mental disorders and a personality trait of healthy individuals meets the criteria for an endophenotype. The article presents a review of the research literature on genetic and environmental determinants of impulsivity.
Background. Genetic factors are responsible for about 45% of variation in impulsiveness levels in twins, while the remaining variation is accounted for by demographic and psychosocial factors including age, education and economic situation that modify and shape the level of impulsiveness since early childhood. Genetic research findings to date indicate that functional polymorphisms in the dopaminergic and serotonergic system genes are crucial to the regulation of impulsivity. Genetic variants responsible for high activity of D2 and D4 receptors as well as low activity of the dopamine transporter and COMT have been found to be associated with lower levels of impulsiveness. As regards the effect on the serotonergic system activity, the most important role is ascribed to TPH2, MAOA, 5HTR2A and SLC6A4 genes. Genetic analyses confirm the hypothesis that low serotonin activity may lead to increased levels of impulsiveness.
Conclusions. The level of impulsivity is a result of specific interactions between genetic and environmental factors.

Review article

Ganser’s syndrome

Waldemar Kryszkowski, Monika Talarowska, Kinga Bobińska, Antoni Florkowski, Piotr Gałecki
Postępy Psychiatrii i Neurologii 2010; 19(1): 47–51

Objective. The paper presents past and present classifications, forensic-psychiatric meaning of the Ganser's syndrome. Data from the ProQuest, ScienceDirect, PubMed databases (keyword "Ganser syndrome") and from available publications on the subject were taken into account.
Background. The syndrome was described for the fi rst time in 1898 by Sigbert Josef Maria Ganser. An analysis of earlier psychiatric classifications and current publications shows considerable changes over time in the approach to this syndrome. At present it is included among dissociative or conversion disorders (both in the ICD-10 and DSM-IV). Moreover, some authors classify the Ganser syndrome as prison psychosis, because it is most common among the accused and detained.
Conclusions. The Ganser syndrome is an important but still underestimated problem in psychiatry. Questions concerning Ganser's syndrome are especially important in the provision of forensic-psychiatric expert opinions, where this condition has to be differentiated from malingering and fake disorders. Despite established diagnostic criteria for the syndrome, many authors point out subjectivity in the evaluation of particular symptoms of Ganser's syndrome, which may frequently result in false-positive diagnoses and make comparisons across studies difficult.

Review article

Molecular analysis of neuroplasticity of the brain of alcoholics – a genomic and neuropsychological perspective

Mariusz Panczyk, Paweł Krukow
Postępy Psychiatrii i Neurologii 2010; 19(1): 53–60

Objective. The paper presents a review of research on molecular analysis of selected brain structures in alcohol abusers, with particular emphasis on specific characteristics of neuroplasticity mechanisms subject to pathological changes resulting from alcohol intoxication.
Review. The mesocorticolimbic system constitutes the main pathway in the reward system targeted by most medications presently used in alcohol dependence treatment. Neuroadaptive changes induced in that cerebral area by alcohol use provide a substrate for the development of alcohol tolerance and dependence. During the past decade attempts have been made by a few research teams to describe changes in expression of several thousand genes in autopsy studies using alcohol-dependent persons' brain tissue, in order to identify alcohol-sensitive gene groups. Research findings reported by different authors have in common, first and foremost, the description of changes in the gene panel responsible for oxidative stress, as well as biochemical pathways responsible for energy provision. Moreover, in tissues acquired from the nucleus accumbens and ventral tegmental areas changes were found in expression of genes responsible for neurotransmission (i.e. neurotransmitters, transporters, and synaptic receptors) and for transduction of intercellular signals.
Conclusions. Expression changes found in cortical areas of the brain are associated with pathologic processes caused by a long-term exposure of nervous tissue to the impact of alcohol and its metabolites. Moreover, the body of changes described in the mesocorticolimbic dopaminergic pathway at the molecular level are related to the neuroplastic efficacy of the cerebral neurochemical system. Therefore, it seems that the traditional neuropsychiatric and neuropsychological views on the determinants of nervous tissue degeneration in the alcoholic brain should be re-examined.

Review article

Kynurenic acid – a neuroprotective substance in diseases of the central nervous system

Danuta Turzyńska, Janusz Szyndler, Piotr Maciejak, Alicja Sobolewska, Adam Płaźnik
Postępy Psychiatrii i Neurologii 2010; 19(1): 61–72

Objectives. The aims of the paper are to describe kynurenic acid, a neuroactive metabolite of tryptophan, and to outline its potential neuroprotective role in some pathological processes occurring in the CNS.
Background. Kynurenic acid (KYNA) is the only known endogenous antagonist of ionotropic receptors for excitatory aminoacids (EAA) in the mammalian brain. KYNA has a weak affinity for ionotropic EAA receptors, and a high affinity for the glycine site of the NMDA receptor complex. Moreover, kynurenic acid non-competitively blocks α7 nicotinic acetylocholine (nACh) receptors. It is suggested that KYNA is involved in the pathophysiology of some brain disorders including epilepsy, Alzheimer's disease, Down syndrome, Parkinson's disease, Huntington's disease.
Conclusion. In view of significant differences between ill and healthy people in kynurenic acid brain concentration it is conceivable that KYNA may play an important role in various CNS pathologies.

Case report

Electroconvulsive therapy in mother and daughter in the course of two different psychiatric diseases

Karolina Drzyzga, Krzysztof Kucia, Wojciech Merk, Małgorzata Przytuła, Magdalena Mostowska-Grzesik
Postępy Psychiatrii i Neurologii 2010, 19(1): 73–75

Objective. The authors present beneficial effects of electroconvulsive therapy (ECT) in two family members: a mother suffering from drug-resistant recurrent depression and her daughter with drug-resistant paranoid schizophrenia.
Case. The 64-year-old mother was diagnosed with recurrent depression 9 years earlier and had a history of 6 severe psychotic episodes. Since her psychopharmacotherapy proved unsuccessful, she was receiving maintenance ECT during the past 5 years. Her 31-year-old daughter has been suffering from paranoid schizophrenia for a year. Although her therapy with olanzapine was initially promising, ECT turned out to be the only effective treatment during her subsequent hospitalization.
Comments. The mother and her daughter suffer from two different psychiatric disorders. However, they share some common elements: psychotic symptoms, drug-resistance, a good tolerance to and high efficacy of electroconvulsive therapy.

Case report

Problems with the mental state examination of the individual from different cultural area on example of psychiatric consultation of woman from Afghanistan

Andrzej Klemens Radzikowski, Marzena Pawlus
Postępy Psychiatrii i Neurologii 2010, 19(1): 77–80

Objective. Presentation of difficulties which are encountered by consulting psychiatrist who is diagnosing a patient from different cultural circle.
Case report. About 60 years old Afghan woman who was treated from multiorgan injuries as a result of military operations. She had psychiatric consultation because of changes in her behaviour during hospitalization.
Commentary. It is required to analyze observed symptom complex in patient's sociocultural context in order to diagnose appropriately and to apply proper treatment. It is necessary to take into account professed religious principles, accepted behaviour patterns, social position of examined individual as well as nutritional habits and applied stimulants. The help of cultural adviser may turn out necessary.