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ZusammenfassungKatastrophenpsychiatrie meint die psychiatrisch-psychologische Betreuung von Opfern, deren Angehörigen und den Helfern im Rahmen von Naturkatastrophen und durch Menschen verursachte Katastrophen (Krieg oder Terroranschlag). Diese Betreuung basiert auf dem Diagnose- und Behandlungskonzept der Posttraumatischen Belastungsstörung – Post-traumatic Stress Disorder (PTSD) und der Akuten Stress Reaktion – Acute Stress Disorder (ASD). Während die PTSD eine gut validierte und mit effektiven Behandlungskonzepten ausgestattete Diagnose ist, fehlen diese Voraussetzungen bisher bei der ASD. Konsequenzen für das Konzept der Katastrophenpsychiatrie, Therapie und Prävention von Betroffenen und Helfern werden dargelegt.

Der Einfuhrung operationalisierter Diagnostik von Personlichkeitsstorungen in DSM-III, DSM-III-R und ICD-10 folgte eine erhebliche wissenschaftliche Beschaftigung mit dieser wichtigen Diagnosekategorie, speziell eine sprunghafte Entwicklung von zahlreichen Untersuchungsinstrumenten zur Erfassung von Personlichkeitsstorungen. Die Reliabilitat der in DSM-III, DSM-III-R und ICD-10 beschriebenen Diagnosekategorien konnte erst mit der Einfuhrung von Selbstbeurteilungsfragebogen, Checklisten und strukturierten Interviews deutlich verbessert werden. Im Gegensatz zu Reliabilitat muβ allerdings die Validitat dieser Diagnosekategorien von Personlichkeitsstorungen als unzureichend bezeichnet werden. Neuere Ansatze favorisieren daher eine dimensionale Klassifikation von Personlichkeitsstorungen gegenuber der herkommlichen kategorialen Klassifikation.

Gender differences in prevalence rates of suicide attempts and suicidal thoughts as well as in risk factors for suicide attempts such as traumatic events and mental disorders were investigated in a random sample of 3021 adolescents aged 14-24 years.The M-CIDI (Composite International Diagnostic Interview) was used to survey suicidal behaviour, DSM-IV lifetime diagnoses and traumatic events.The female suicide attempters showed suicidal thoughts and suicide attempts significantly more often, and suicide attempts at a much younger age than the males. Furthermore, the females experienced sexual abuse much more often, and suffered significantly more often from anxiety disorders. The male suicide attempters showed higher rates of alcohol disorders and financial problems.A higher rate of anxiety in female suicide attempters results probably as a consequence of sexual abuse, which in turn makes them more vulnerable than males for attempting suicide between the age of 14-17.

Studies in psychiatric patients described an association between lower serum cholesterol concentrations, suicidality, depression, impulsivity, and aggression which is not entirely attributable to depression-related malnutrition and weight-loss. Several lines of evidence suggest that a serotonergic deficit in the prefrontal cortex may predispose vulnerable subjects to impulsive, autoaggressive, and suicidal behaviour in stressful life-events. In-vitro studies, animal experiments, and human in-vivo studies support the hypothesis that cholesterol reduction may contribute to the serotonergic abnormalities which have been postulated in suicidal subjects. Recently it was hypothesized that decreased consumption of polyunsaturated fatty acids, especially omega-3 fatty acids, may be a risk factor for depression and suicide. Data from human studies in healthy volunteers suggest that increasing the dietary intake of omega-3 fatty acids may increase central serotonergic activity and reduce impulsive and aggressive behaviours. Earlier epidemiological studies showed an association between low cholesterol concentrations and increased suicide risk. Recent epidemiological studies with greater samples and longer follow-up periods, however, even showed a positive correlation between cholesterol concentrations and suicide risk after controlling for potential confounding variables. Large trials of statins (simvastatin, lovastatin, pravastatin) did not show an increase of suicide mortality.

Studies in postmortem brain tissue from suicide victims show a presynaptic serotonergic deficit resulting in compensatory upregulation of postsynaptic 5-HT2 receptors in the prefrontal cortex. Reduced levels of cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid, the major serotonin metabolite, are associated with violent suicide attempts independent of psychiatric diagnosis and predict future suicide attempts and suicide completion, consistent with the notion of a biochemical trait. Neuroendocrine challenge tests, platelet studies and a polymorphism in the gene for tryptophan hydroxylase, the rate-limiting enzyme in the biosynthesis of serotonin, suggest that serotonergic activity may be reduced. This serotonergic abnormality might be related to the vulnerability or diathesis for suicidal behaviour by predisposing individuals to impulsive and autoaggressive behaviour. The hypothesis of hyperactivity of the hypothalamic pituitary adrenal axis (HPA) is supported by the postmortem findings of increased CSF corticotropin releasing hormone (CRH) concentrations and reduced CRH receptor binding sites in the frontal cortex of suicide victims (interpreted as downregulation following CRH hypersecretion) and dexamethasone nonsuppression in suicide attempters. Animal studies and in vitro experiments indicate that the HPA system modulates serotonergic activity. It is hypothesized that the serotonergic alterations potentially result from dysregulation of the HPA system. Data from epidemiological and clinical studies demonstrate that low levels of cholesterol are associated with increased suicide risk. In neuronal membranes cholesterol modulates presynaptic and postsynaptic serotonergic neurotransmission. In monkeys dietary cholesterol lowering inhibits central serotonergic activity and predisposes the animals to impulsive and aggressive behaviour. It is speculated that dysregulation of the HPA system and disordered cholesterol metabolism could enhance the serotonergic deficit, thus contributing to a neurobiological vulnerability or diathesis for impulsive and autoaggressive behaviour.

Transsexualism as a phenomenon clearly contrasts the common understandings of sexuality. This can lead to conflicts for the transsexual himself as well as for those being confronted. Medical care and legislative offer some assistance for patients, which has been proofed as suitable and helpful. These strategies have not been developed by a theoretical approach but pragmatically and can still be further improved. To be able to receive a higher acceptance of this phenomenon in society and to achieve concrete improvement of the patient's personal situation the challenge still exists to understand mechanisms underlying the transsexual experience.

The concept of a posttraumatic stress disorder (PTSD) has become important for psychiatric diagnosis and research, particularly following US-american studies on Vietnam war veterans. Recently, studies on traindrivers involved in suicide accidents have shown symptoms of anxiety and depression in more than 30% of concerned drivers and typical symptoms of a PTSD in 15%. Here, we present the case of a traindriver who was involved in 6 suicide accidents within 17 years of traindriving (the average is 2 suicide accidents). Following the 3rd accident, the driver developed increasingly symptoms like anxiety, sleep disturbances, flashbacks and irritability. Following the 6th accident, he has been unable to work. A former expert opinion saw no relationship between the symptoms of the driver and the suicide accidents. Therefore, further information about the concept of a PTSD seems necessary to ensure early psychotherapeutic and pharmacological treatment of patients with such a disorder.

The general definition of personality disorders (PD) has found agreement in many classification systems and has remained relatively stable over many decades. However, a closer look at the history of the classification of various PD reveals that there are changes from generation to generation: a continuous variation in our cultural norms means that some types are 'renormalised' from time to time and that others are added. On the other hand, a comparison of the descriptions and classifications of PD by Schneider, the DSM and ICD systems shows substantial agreement on many types of PD.

This article reviews recent research results on posttraumatic stress disorder (PTSD). Epidemiological studies show that PTSD is a common disorder within the normal population with a high degree of chronic courses. Degree of severity as well as dissociative symptoms during the traumatic event seem to have an impact on course and outcome of PTSD. A genetic disposition, familial psychopathology and premorbid personality traits as background variables seem to have an influence on the development of PTSD whereas coping strategies, as well as social support, modify the course of the disease. The investigation of biological parameters refers to the hypothalamic-pituitary-adrenal-axis system, provocation studies, psychophysiological studies, and studies of the endogenous opiate system. In regard to therapy studies only those with a randomised allocation to two different therapies as well as with a control group without therapy or a waiting list group are considered, using the DSM-III or DSM-III-R diagnostic criteria for PtSD. Five pharmacological studies could show a positive effect by antidepressants. Six behaviour therapy studies (two systematic desensitisation and four flioding) produced an improvement of PTSD symptomatology. The pathogenetic models discussed here are memory imprinting, kindling, dysregulation of the opioid neuromodulation, classical conditioning and disturbed cognitive schemas, which reflect as single models only a facet of the pathogenesis.

Suicidality under extreme life circumstances is a poorly researched area. However, suicidal behaviour could be better understood by looking at extreme conditions such as the life of internees in German concentration camps. Former inmates of different German concentration camps reported on a low suicide rate in contrast to a high rate of suicide ideas. Reasons for such a low suicide rate are discussed.

Comorbidity refers to the joint occurrence of two illnesses. Its use originated in general medicine and medical epidemiology (Feinstein 1970). Applied to mental disorders, the term refers to the joint occurrence of two or more mental disorders and/or with medical conditions. Comorbidity can take place during an episode of illness for the individual; within the lifetime of an individual; and among members of larger groups, such as patients, the general population, and families (Klerman 1990).

Beginning with the eighties, a paradigm-change concerning anxiety disorders has taken place in considerable parts of psychiatry. Anxiety disorders are no longer regarded as consequences of conflicts and ineffective defences or as concomitants of other psychiatric disorders but rather as disorders of their own. This resulted in a modified outlook on anxiety disorders focusing on the acute panic attack (Panic disorder) instead of focusing on chronic anxiety (Anxiety neurosis). This paper reviews recent empirical studies concerning classification, pathogenesis, and therapy of anxiety disorders, i.e. after introduction of the concept of Panic disorder. Epidemiological studies could demonstrate that in western countries anxiety disorders account for the most frequent psychiatric disorders with prevalence rates of 2.0% to 4.7%. Panic disorders show prevalence rates of 0.4% to 1.1%. Results of recent follow-up studies indicate a favorable course for outpatients and an unfavorable course for inpatients with anxiety disorders. Family studies reported on positive familial loading for Panic disorder but not for Agoraphobia and Generalized anxiety disorder. A twin study found higher concordance rates for panic attacks and Agoraphobias in monozygotic twins than in dizygotic twins. Pharmacological provocation studies with lactate infusion, CO2-inhalation, and administration of Caffeine, Yohimbine, Isoproterenol showed a higher vulnerability of patients with Panic Disorder as compared to healthy controls. However, all studies display methodological short-comings and could be interpreted differently as to the concept of a biologically determined vulnerability. Provocation studies using inverse Benzodiazepine-agonists dealt only with healthy probands. Whereas life events play a rather unimportant role für the pathogenesis of anxiety disorders, recent studies point to the influence of cognitive processes and personality variables for the pathogenesis of anxiety disorders. Concerning treatment of anxiety disorders and especially of panic disorders, pharmacological studies as well as studies of behavioural therapy indicate very good results for acute treatment and good results for behavioural therapy with respect to one to four year follow-up studies. Recently, combined drug and psychotherapy gains growing interest. Conclusions are drawn with respect to the usefulness of the new classification, i.e. after the introduction of Panic disorder as a diagnostic category, and references are given for further research strategies.

Angst und Depression sind neben Suchterkrankungen wahrscheinlich die haufigsten psychischen Storungen uberhaupt (Myers et al. 1984, Wittchen et al. 1987) und neigen zu einem hohen Prozentsatz zur Chronifizierung (Murphy et al. 1986, Wittchen et al. 1987).

To our knowledge, up to now, only five studies (Walton 1958; Paykel and Dienelt 1971; Crook et al. 1975; Sonneck et al. 1976; Slater and Depue 1981) have been concerned with the question of differences between depressives with and without a suicide attempt in their past history.

First a number of aspects are mentioned that should be given special attention in the treatment of sex offenders. This is followed by a review of those treatment studies in which therapy was primarily either psychoanalytic or behavioral and which included a relatively large number of patients. Since the authors of the present study found that either a given treatment approach was indicated for a very limited group of patients only or the long-term outcome was poor, they developed an integrative approach for inpatient treatment of sex offenders. This approach includes behavior therapy, psychoanalytically oriented therapy and social therapy. The procedures are described briefly and the role of each is in the overall therapeutic concept pointed out.

The present study aims to explore the possible association between certain psychopathological characteristics and suicide inclination. Hostility and depression are important factors associated with suicide attempts. Suicide attempters (SA) are usually depressed; difficulty in regulating and expressing hostility is another characteristic common to suicide attempters (Weissman et al. 1973). Paykel and Dienelt (1971) and Weissman et al. (1973) compared depressed patients who had attempted suicide with those who had not and found that overtly expressed hostility was the most important distinguishing feature of the attempters. Whereas depressed SA and nonsuicide attempters (NSA) were equally depressed in the study of Weissman et al. (1973), van Praag and Plutchik (1985) found a significant postsuicidal decrease in depression compared with the level in the week prior to the suicide attempt. Such a drop in depression could not be found by the authors in patients who were also depressed but not suicidal.

The article reports on a ward with 12 beds which has been set up for emergency cases in psychiatry or for immediate intervention in case of a crisis experienced by a patient. In the theoretical part of this article, it is explained that crisis situations are present in most of the psychiatric emergency patients. The article then goes briefly into the fundamentals of therapeutic strategy in such patients: A therapy which helps to uncover hidden conflicts, the pros and cons of therapy focussed on conflict and on supportive measures; as well as a therapy which supports and promotes the ego. This is followed by a comparison of the ward with corresponding facilities in Germany and abroad and a description of their structure, their patients and their function within a psychiatric care system. The concluding part of the article is devoted to a description of the authors' initial experiences and impressions gained during their work with the ward patients, quoting several examples.

The article surveys empirical studies on the relation between alcohol addiction and depression. For a better understanding and interpretation of the results of these empirical since the end of the 'sixties, the author presents first of all a brief historical abstract of the development of classification of depressive disorders and of the definition of alcoholism. In this article, the author restricts his comments to studies conducted since the end of the 'sixties, as self-rating scales or observers-rating scales or standardised interviews have been employed from that time for characterising the pattern of signs and symptoms and for diagnosis, and now widely used diagnostic schemas also became available (ICD-8, Feighner's criteria, DSM-II). For further clarification studies on genetic studies in the patients' families and on the premorbid personality of alcoholics and depressives are utilised for assessment. The results of these empirical studies are interpreted from the "diagnostic viewpoint" of the 'eighties (i.e. from the viewpoint of ICD-9 and DSM III). Suggestions for further research approach are given. The survey shows that depressive moods appear with greater frequency in patients with alcohol abuse or alcoholism who are under inpatient or outpatient treatment. However, such depressions are usually not very intensive; they will mostly subside towards the end of the treatment course. "Primary depression" and "secondary depression" are seen with an incidence rate far beyond the value expected if two diseases would merely coincide at random, in patient populations whenever alcoholism is involved. On the other hand, no increased prevalence rate for alcoholism was seen in first-degree relations of patients with "major depression" and "Bipolar I disorder", compared with a random sample of a healthy population and first-degree relations of such a random sample. To date we can say that a considerably increased incidence of alcohol abuse, but not of alcohol addiction, is definitely present in clinical populations of patients with bipolar disorders. However, because of the lack of studies which differentiate by means of operationalised criteria between manias and hypomanias and between alcohol addiction and alcohol abuse, it has not been clarified to the present time whether alcohol abuse found in these studies is mainly linked to manic/hypomanic or depressive phases, or whether the alcohol abuse is independent of these phases.(ABSTRACT TRUNCATED AT 400 WORDS)

In diesem ersten Abschnitt werden die Patientengruppen mit den Diagnosen endogene Depression, Angstneurose, Phobie und depressive Neurose anhand klinischer und biosozialer Merkmale charakterisiert. Damit soll dem Leser einerseits ein Uberblick uber den klinischen und psychosozialen Ausgangszustand der Patienten vor und wahrend der Indexbehandlung in den Jahren 1973–1975 gegeben und andererseits die Grundlage fur die im Prognosekapital dargestellten Pradiktoranalysen gelegt werden. Wahrend die Indexbehandlung in diesem ersten Abschnitt vergleichend uber alle Untersuchungsgruppen hinweg dargestellt wird, werden in den Folgekapiteln der klinische Verlauf und der Outcome fur jede Gruppe getrennt abgehandelt. Sofern sich zwischen den Gruppen der Patienten mit Angstneurose und Phobie keine bedeutsamen Unterschiede in den Untersuchungsvariablen ergeben, werden beide Gruppen zusammen abgehandelt. Obwohl wir von allen 126 Patienten die Ergebnisse zum Zeitpunkt der Indexuntersuchung zur Verfugung hatten, wird im Ergebnisteil — mit Ausnahme der Darstellung der Suizide — nur uber die Befunde der 1981 nachuntersuchten 101 Patienten berichtet.

The possibility of characterizing subgroups of depressive disorders by biological markers was studied by means of the dexamethasone suppression test (DST), the 24-hr urinary free cortisol (UFC), the growth hormone response to the insulin tolerance test (ITT), and polygraphic sleep recordings. Forty-five hospitalized patients suffering from a moderate to severe nonpsychotic major depressive disorder were clinically subdivided into three groups: endogenous (n = 20), neurotic (n = 19), and "ambiguous" (n = 6). These clinical diagnoses were supplemented by operational diagnostic tools, namely, the Research Diagnostic Criteria (RDC) and the Newcastle Scale. The different diagnostic procedures exhibited a high degree of correspondence. Whereas the results of the ITT were normal in almost all patients, 20% of all patients were dexamethasone nonsuppressors and more than half of the patients showed a shortened REM latency. Both markers did not reveal any specificity for the endogenous subtype. A significant influence of weight loss on the DST and the excretion of UFC was evident.

Neurotic Depression was among the most commonly used psychiatric diagnoses until the introduction of DSM-III. Because of multiple criteria and meanings and the lack of diagnostic stability on follow-up, Neurotic Depression was not included as a category in DSM-III and will be omitted in ICD-10. This article reviews recent research on the validity of Neurotic Depression and its relationship to other types of depressive disorders. Empirical studies do not support the validity of this diagnosis. There is no unitary clinical description or phenomenological discrimination from other disorders, and limited supporting family study, laboratory investigation, or specific treatment response. Revised criteria for Neurotic Depression, derived from three recently conducted studies, need to be validated in prospective studies. Pending new research findings, the decision to omit Neurotic Depression from the classification of depressive disorders in DSM-III, DSM-III-R and in the draft of ICD-10 remains scientifically justified.

An unselected series of 100 psychiatric inpatient admissions were interviewed at admission by a psychiatrist using the German version of the PSE (Present State Examination), with a second psychiatrist as an observer. The diagnostic agreement between the two project psychiatrists was considerably higher than the agreement between clinicians and CATEGO, a computerised diagnostic system based on PSE data. The disagreements are discussed.

On 7 January 1981 a special ward for crisis intervention and emergency psychiatric cases went on stream at the Max Planck Institute of Psychiatry in Munich. The article reports on the development of this ward between 1981 and 1985. First of all, a brief outline of the structure of the ward is given explaining indications and contraindications for acceptance and the treatment concept. This is followed by statistical evaluation of 1981 to 1985 data in respect of number of admissions and readmissions, duration of stay, percentage distribution of the referring institutions, age distribution, distribution of diagnosis, rates of attempted and committed suicides and onward referral to other institutions for further treatment. Finally, the article reviews changes in the basis concept of therapy and in the style of communication and behaviour within the therapeutic team, besides commenting on unfavourable conditions.

Recently developed psychoanalytic theories on the pathogenesis and psychodynamics of sexual perversions are described and their effects on treatment technique discussed. Then a proposal based on these theories its put forth for a comprehensive treatment plan for sex offenders, among person with sexual perversions an especially difficult group to treat. Special emphasis is placed on the problems and possibilities associated with such a psychoanalytically oriented approach, and the author then argues that during the initial phase of treatment two approaches, both psychoanalytically oriented therapy and behavior therapy, should be used parallel to each other.