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Diagnoses are made for identifying rather homogeneous groups of patients being thereby relevant for research and for therapy. Therefore diagnostic manuals, like the DSM-IV and the ICD-10 are subjected to changing knowledge derived from research on one hand and to changes of clinical necessities. The diagnosis of substance related disorders, published for DSM-IV in 1994 and for the ICD-10 in 1992, has proven of value for epidemiological research and economic validation. In spite of these advantages the concept has prove to be too broad and rather unspecific for research, specific therapeutic strategies and for defining an illness course. During the last 20 years research has yielded many criteria of interest, which never entered DSM IV or ICD-10, remaining therefore on the level of single items, which are nowadays additionally assigned to all patients (like e. g. early versus late onset) or on the level of typologies (like e. g. Lesch's typology) demanding different treatments. To give an example: acamprosate has lasting relapse preventing effects in Lesch types I and II, while naltrexone is effective in types III and IV. For rendering an expertise in Germany, the referring literature recommends to utilize Lesch's typology additionally to the ICD-10 diagnosis, especially when prognosis or therapeutic strategies are demanded. Since 1999 different expert groups strive for including new criteria into DSM IV and ICD-10. The revised manuals should include easily assignable items for severity of different arrays (time illness onset, co-morbidity, withdrawal symptoms, bridge symptoms and neurological sequela). Different therapy stages (e. g. withdrawal or relapse prevention) need a different weighting of individual symptoms (e. g. degree of intoxication, severity of withdrawal is needed for acute treatment, while an assignment of co-morbidity and personality factors is necessary for relapse prevention). This quantifier is rendered by Lesch's typology, which is available in the form of a computer programme, based on a decision tree (see also www.ausam.at - Typology according to Lesch). Non substance related disorders should enter other diagnostic categories, like e. g. impulse control disorders. A revised diagnostic classification suggests presently offered therapeutic strategies to follow up with necessary modifications. A tailor made therapy according to subgroups can result in better long term performance of therapies offered to persons suffering form substance related disorders., ((c) Georg Thieme Verlag KG Stuttgart-New York.)

The efficacy of flupentixol and risperidone were compared in a randomized double-blind study in 153 chronic schizophrenic patients. Flupentixol showed to be not inferior to risperidone concerning schizophrenic negative symptoms at week 8, 16 and 24. Positive symptoms and general psychopathology improved comparably, too. There was a trend in favor of flupentixol concerning the improvement of depressive symptoms and a trend in favor of risperidone concerning the improvement of preexisting parkinsonian symptoms. The study data justify to regard flupentixol as a "partial atypical" antipsychotic.

The efficacy of flupentixol and risperidone were compared in a randomized double-blind study in 153 chronic schizophrenic patients. Flupentixol showed to be not inferior to risperidone concerning schizophrenic negative symptoms at week 8, 16 and 24. Positive symptoms and general psychopathology improved comparably, too. There was a trend in favor of flupentixol concerning the improvement of depressive symptoms and a trend in favor of risperidone concerning the improvement of preexisting parkinsonian symptoms. The study data justify to regard flupentixol as a "partial atypical" antipsychotic.

The long term course of alcohol dependence often includes one or several relapses, which can be divided into low (< 5 standard drinks = lapse, slip) and high intake of alcohol with loss of control (relapse). The biological etiology of relapse is derived from different phenomena such as alcohol craving, psychosocial reasons, development of withdrawal symptoms, different primary psychiatric diseases and "addiction memory". Moreover, the metabolism of alcohol itself substantially contributes to alcohol dependence. For about 100 years different definitions for subgroups of alcohol dependence have been described, of which the Lesch typology is internationally acknowledged, especially for medical treatment. This typology differentiates between four types of alcohol dependent patients in which prevention and treatment of relapse should be specific to the primary psychiatric disease of the patient and to alcohol related disabilities. The aim is a long term improvement of sobriety rates of alcohol dependent patients as well as quality of life and life expectancy.

Even though alcohol dependence is not often found in the elderly, alcohol consumption and alcohol abuse are both common. As the elderly also often take medication on a regular basis, this group is at particularly high risk for problems resulting from the concurrent use of these substances. Physical changes as a result of the aging process (e.g. reduction of body water, decrease of hepatic blood flow) and alcohol related diseases can influence the pharmacokinetics and pharmacodynamics of both ethanol as well as other drugs. Alcohol dehydrogenase (ADH), acetaldehydede hydrogenase (ALDH) and cytochrome P450 2E1 are the enzymes responsible for the metabolism of ethanol. These enzymes are also the sites of direct pharmacological interaction between ethanol and other drugs, however, altered effects of medication can also be caused by ethanol adding to or reducing the drug's effect. Although some of these effects result from heavy use of alcohol, others can also occur with moderate use. Interactions have most frequently been described for analgetics, psychopharmacologically active drugs, antihistamines, anticoagulants antihypertensive drugs and antibiotics.

Cocaine abuse as a risk factor for acute cerebrovascular events has received too little attention, in particular in young patients. Cocaine hydrochloride causes mainly intracerebral and subarachnoidal bleeding, while crack (freebase) causes intracranial hemorrhage and ischemic infarctions with equal frequency. Although no specific antidote is known, an attempt should be made to detect the substance or its metabolites in the urine so as to provide optimal management, and encourage the patient to seek expert counselling.

72% of a collective of chronic alcoholics (DSM-III-R, ICD 9), who were admitted under the influence of alcohol in order to undergo alcohol withdrawal, showed a serum methanol concentration (SMC) above 10 mg/l. This level is usually considered to be the one for the detection of regular alcohol consumption. The SMC values were considerably higher in cases where alcoholic beverages with a higher methanol content were consumed rather than the ones lower in methanol. In the majority of patients a decrease of the methanol concentration could only be detected once an individually varying limit concentration of ethanol (0-0.62 g/kg) was reached. There were, however, a few exceptions where the elimination of methanol independent from the ethanol concentration could be seen. Contrasting the general collective, these 'ethanol independent' methanol eliminators showed a much higher serum level of ethanol and methanol at the time of admission. As a sign of addiction, all patients showed increased beta 60 values for ethanol and preferred high proof beverages, which at the same time have high methanol contents.

The role of drug abuse as a risk factor for cerebrovascular events has been underestimated, particularly in patients with juvenile stroke. The drug most often associated with acute cerebrovascular events is cocaine. After cocaine hydrochloride abuse intracerebral hemorrhages or subarachnoid hemorrhages--predominantly caused by ruptured aneurysms or arteriovenous malformations--are by far the most frequently observed cerebrovascular complications, whereas on abuse with the alkaloidal form ("crack") intracranial hemorrhages and ischemic strokes are encountered with equal frequency. In most cases, the time interval between drug abuse and the cerebrovascular event is less than 3 hours. Several pathophysiological mechanisms are discussed as serving as triggers for the cerebrovascular event, either alone or in combination. No specific antidote to cocaine is known. Nevertheless drug screening (urine analysis) should be performed immediately to allow optimal management of patients with drug-associated acute cerebrovascular events, especially in cases with juvenile stroke.

Concrete cross-sectional studies of the organic brain syndrome, carried out periodically, attempt to establish for the parameters evaluation of substrate damage--and different noopsychopathological rating-scales for the measurement of brain capacity impairment. Beyond the level of the purely correlative-statistical point of view of the relationship between parameter and score changes, demanding for a quantitative model which could provide not only a description, but also an explanation for such a relationship. The fact that there can only be a question here of a "quantitative causality" embracing non-specificity of toxic substances and relative to acute and chronic diffuse organic brain syndromes. It results, that quantitative causality meets the requirements of an exponential function model and that one can validate such models through correlative-statistical methods. This has already been carried out by Ball and Taylor.

Alcoholism is usually understood as ethanolism. There is some evidence that its oxidation product acetaldehyde may condense with endogenous amines to form tetrahydroisoquinoline (TIQ) and - tetrahydro-beta-carboline (THBC) alkaloids which ultimately might be responsible for addiction. In most animal experiments pure ethanol solutions were fed, but chronic alcoholics prefer normal alcoholic beverages, and it is widely ignored that all these beverages without exception also contain methanol. Its metabolite formaldehyde is a much more potent reaction partner for TIQ and THBC formation than acetaldehyde. As our findings in chronic alcoholics proved that these persons in contrast to healthy subjects are able to oxidize methanol despite high ethanol levels, there must be a continuous leakage of formaldehyde. And it seems possible that methanol plays a more significant role in the pathophysiology and possibly the etiology of chronic alcoholism than ethanol.

This paper presents a literature review as well as a study in 13 patients suffering from delusion of infestation. Symptoms found in MMPI are related to clinical experience. Our results suggest the distinction of three different groups of these patients: 1. Patients with predominantly hypochondric traits, with a distinct conviction to suffer from a severe, physical illness that is often looked at as incurable (hypochondriacal delusion of parasitosis). 2. Patients with paranoid symptoms and without hypochondric apprehensions. These patients usually hopelessly fight against their parasites, that impair their sphere of existence. Physical illness is denied. ("delusion of infestation"). 3. Patients with signs of both, hypochondrical as well as paranoid delusions ("hypochondriacal delusion of infestation").

Arterial hypertension is the most important risk factor in all types of stroke. The significance of alcohol in the pathogenesis of stroke is less well defined. Chronic alcoholism leads to an elevation of blood pressure. Thus, the association between alcohol and stroke might be the blood pressure effect of alcohol. However, some studies have shown a significant influence of alcohol on the incidence of stroke--especially of intracerebral haemorrhage and subarachnoid haemorrhage--even after adjustment for blood pressure. Many possible pathomechanisms are discussed. Alcohol inhibits aggregation of thrombocytes, and chronic alcohol abuse may induce thrombocytopenia, which could lead to a haemorrhagic stroke. Alcohol withdrawal leads to rebound thrombocytosis. Acute alcohol ingestion induces a decrease in fibrinolytic activity and an increase in factor VIII activity, which enhances the thrombotic potential. Additionally, alcohol increases plasma osmolarity, erythrocyte aggregability, haematocrit and blood viscosity, and decreases deformability of erythrocytes. The effects of alcohol on cerebral blood flow are still under debate; there is a deterioration in autoregulation of cerebral blood flow anyway. In animal studies alcohol induced dose-dependent vasospasm of the cerebral blood vessels, which could be a possible pathomechanism in ischaemic, as well as in haemorrhagic stroke. Chronic alcoholism is the most common cause of secondary non-ischaemic cardiomyopathy, which can lead to cerebral embolism via rhythm disorders or intracardiac thrombus formation.(ABSTRACT TRUNCATED AT 250 WORDS)

In 34 patients suffering from delusional parasitosis the relevance of an accurate differential diagnosis with respect to pharmacological treatment was investigated. Under a psychopharmacological therapy of the delusion's additional psychiatric symptomatology in 17 patients (50%) a full remission and in other 5 patients an improvement of the delusional symptoms was observed. The unexpected high recovery-rate is explained by the fact that all of the patients with additional depression showed a reduction also of the delusional symptomatology after a treatment with antidepressants. In contrast to that, patients with organic brain syndromes underlying the delusions had a significant worse outcome, which seems to be caused by the considerable lack of effective psychopharmacological treatment of such states. The results indicate that an accurate psychiatric differential diagnosis is of great importance for the psychopharmacological therapy of patients suffering from delusional parasitosis. In this context the Viennese decision-tree for delusional syndromes is discussed.

We report on the establishment and organization of a residential home, located in a small, fairly industrialized community without institutional background (nearest psychiatric treatment facilities more than 100 km away). Following a description of the structure of the populace, a report on the difficulties encountered in the attempt to integrate the inmates of the communal house into the local social frame, is provided. It is shown that a two year period was needed, before adequate communication between local population and home residents could be established and a satisfactory relationship realized. After a detailed account covering the rehabilitation methods employed, the special problems connected with legal and social re-integration are discussed (i.e.: transportation facilities to and from the communal home and the pace of employment). We conclude our review by a report on the results obtained and attempt to provide a number of suitable suggestions on possible improvements, for discussion and comment.

Patients resistant to therapy with lithium or lithium plus tricyclic antidepressants were included in our study. They had shown no curtailment of depression, no lessening of the depth of depression nor any improvement in the manic symptoms. Therapeutic medication with lithium, lithium plus tricyclics, neuroleptics and/or tranquilizer had been tried out for at last three years and the episodes of the manic-depressive illness were documented over this period. The diagnosis in the case of these patients was manic-depressive illness, type bipolar I or II. We report one case covering three years of treatment showing the following trend: Psychopathology did not change after quitting anciliary medication and tricyclic antidepressants while lithium intake was continued. A low-dose MAO inhibitor (tranylcypromine 13.7 mg/die) in addition to lithium led to shortened and less pronounced depressive and manic episodes and more prolonged normorhythmic periods. This trend emerged with even greater clarity during the course of the study.

All long-term patients with the diagnosis "paraphrenia systematica" out of one region were included in this study. 53 patients were treated in an in-patient psychiatric unit between 1979 and 1981 and were available in this study. Parenteral Fluphenacin-Decanoate (25-75 mg monthly) was given. Before, during and after Fluphenacin (each schedule lasting for at least 20 weeks) psychopathological and social evaluations were done. We used quantitative scales: NGI (Nurses Global Impressions) and BPRS (Brief psychiatric Rating Scale). Good Socialization showed a striking correlation to parenteral Fluphenacin-treatment. Differences in the present state psychopathology were not able to explain the social difference. During parenteral treatment 49 patients switched from badly socialized (NGI: more than 12 points) to well socialized (NGI less than 7 points). 18 patients stopped parenteral neuroleptic treatment for various reasons. 13 Patients out of this group had to be readmitted to the psychiatric hospital, while those staying on their parenteral neuroleptic drug-treatment stayed well socialized.

In this study 444 chronic alcoholic patients, hospitalized at the beginning of this study, were followed up for 4 to 7 years (31). During this time 101 patients died (23.2%), with whom severeness of disease as well as the extent of social depravation could be identified as factors influencing mortality. Beginning in January of 1982 we investigated mortality of the population of a village with a similar socio-cultural background (working situation, rural population, wine-growing area). As it was possible to cooperate with the local general practitioner, who has been living and working in this village since 1946, knowing all the troubles and sorrows, we could get data of each person having died. We collected data on each dead of this village until we had 101 definitely not alcohol addicted cases as control group. For getting this number of cases we had to investigate data of 116 dead, because 15 of them met the diagnostic criteria for chronic alcoholism. Sociodemographic data, social development, diseases and causes of death were recorded in all groups of investigation. In the group of formerly hospitalized chronic alcoholic patients we found a preponderance of men as well as a significantly shorter life-time (alcoholic group: 50 +/- 9.8 years, control group 73.9 +/- 12.5 years). Besides alcohol misuse other factors influencing mortality could be elaborated (e. g. stressing or discriminating working situation, incontinuous and/or unsatisfying partnership, additional criminal acts etc.) separating the chronic alcoholic group (with former hospitalisation) from the control group in a significant way. Concerning the disease leading to death, chronic alcoholic patients more frequently had suffered from liver damage (with break of oesophagus blood vessels) as well as from auto-destructive behaviour patterns (like suicide, masked accidents) compared to the non-alcoholic group. This control group died significantly more frequent because of cardio-vascular diseases, often accompanied by cerebral deficits.

13 cases of politoxicomania that had undergone stationary treatment and, at the time of observation, were in rehabilitation, comprised the case load of this study. They were compared with 10 test persons in good state of health. In order to obtain circadine hormone profiles for melatonine, cortisol, human growth hormones (HGH) and thyroid stimulating hormones (TSH), blood samples were taken every hour from 6 pm until 7 am the following morning. The test cycle commenced with obtainment of a biochemical blood profile and a drug-oriented urine analysis. The cases were assorted into three therapy groups: Group 1: complete abstinence. Group 2: no hard drug intake. Group 3: acute relapse after a prolonged period of abstinence. This categorization (i.e. abstinence, soft or hard drug intake) was clearly mirrored by significant differences in the hormone profiles: the group of "abstinents" showed remarkably higher melatonine and cortisole levels than the acute relapsive cases. HGH and TSH profiles showed partly pathological levels which appeared unrelated, however, to the incidence of abstinence, or the manner of drug intake. Compared to the healthy control group, the test cases showed an increase of liver enzymes (Gamma-GT, SGOT, SGPT and LDH) but there was no marked difference between the 3 user categories themselves. The pathological neuroendocrine findings identified in test patients after a long period of abstinence are indicative of changes possibly based on genetic disposition rather than on abusive habits. The issue of self-inflicted damage, therefore, becomes a questionable one.