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Personal contextual factors play an essential part in the model of the International Classification of Functioning, Disability and Health (ICF). The WHO has not yet classified personal factors for global use although they impact on the functioning of persons positively or negatively. In 2010, the ICF working group of the German Society of Social Medicine and Prevention (DGSMP) presented a proposal for the classification of personal factors into 72 categories previously arranged in 6 chapters. Now a positioning paper has been added in order to stimulate a discussion about the fourth component of the ICF, to contribute towards a broader and common understanding about the nature of personal factors and to incite a dialogue among all those involved in health care as well as those people with or with-out health problems in order to gain a comprehensive perspective about a person's condition., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To date there is a lack of tools to measure participation and the already existing measures are not properly used as yet. In 2005 the IMET (Index zur Messung von Einschränkungen der Teilhabe) was developed and is able to measure the ICF associated construct participation as a generic instrument in chronic diseases. IMET and numerous instruments were applied in our own study and results were compared with results of an unpublished study. In addition, to test IMET for its use in neurorehabilitation the effects of outpatient neurorehabilitation were investigated and compared with results obtained in an inpatient setting., Method: In a multicentric observational study, consecutively treated patients of 6 outpatient neurorehabilitation centres were asked to fill in a questionnaire at three time points (admission and discharge in the course of rehabilitation and at 4 months follow-up). Additionally, clinical experts were asked to rate the patients' status at admission and discharge. The data were compared with results of a sample of inpatients of an unpublished study., Results: The IMET seems to be the to date best instrument to measure participation in a global, ICF-defined and economic way. Especially participation, general health status and capacity in leisure time and daily routine show the biggest improvements. In comparison, the outpatients show improvements in their participation status. Participation-oriented outpatient neurorehabilitation seems to have a considerable impact on participation status in neurological patients through the course of rehabilitation., (© Georg Thieme Verlag KG Stuttgart · New York.)

In 2005, the "Deutsche Gesellschaft für Neurowissenschaftliche Begutachtung" (German Society for Neuroscientific Legal Evaluation) together with other Societies published a guideline for the legal evaluation of patients with closed head injuries. Meanwhile, not only scientific progress in imaging techniques but also in other fields such as neuropsychology has necessitated a revision, which is presented here. In the mean time, the handling of guidelines has been systematised in Germany so that a registration with the Cooperation of German Medical Learned Societies is applied for and publication in the German Guideline Registry is expected., (© Georg Thieme Verlag KG Stuttgart · New York.)

The SGB IX, book 9 of the German social code (Sozialgesetzbuch, SGB), which is the legal basis of rehabilitation in Germany, states "participation and self-determined conduct of life" as the ultimate ambition of rehabilitation. This concept of participation and disability is based on the WHO model expressed in the International Classification of Functioning, Disability and Health (ICF). In this model, participation after the onset of a health problem may not only be infringed by disturbances in body functions and structures and the resulting activity limitations but also by contextual factors such as environmental and personal factors. In an outpatient neurological rehabilitation centre we prospectively rated for 49 patients the influence of these contextual factors as well as of objectively assessed functional/activity limitations on the overall disability. On average, functional/activity limitations were rated as contributing 58.4% (SD=17.2%), personal factors 26.4% (SD=12.7%) and environmental factors 15.1% (SD=11.2%) to the overall disability. The functional/activity limitations closely matched the expected limitations based on the underlying brain lesions. The degree of disability based on contextual factors was not related to activity limitations based on disturbances of body functions and structures. Also, demographic variables such as age, sex or chronicity were not significantly linked to contextual factors. Since contextual factors together contributed 41.6% (SD=17.2%) to the overall disability they have major relevance for the rehabilitation process, because they essentially decide on the extent to which abilities acquired by the rehabilitant during rehabilitation actually be transfered to his everyday life. Therefore, rehabilitation programmes need to include assessment and treatment of contextual factors. It hence is necessary to develop instruments to quantify contextual factors.

Anhedonia, a cardinal sign of depression, is discussed to originate from a transmitter dysbalance in the central dopaminergic reward system. This system involves neuroanatomically many structures of the olfactory system. Hence the question arises whether anhedonia can be quantified when depressive patients judge smells hedonically. Sensory evaluation of olfactory stimuli by 16 depressive patients was compared that of an age-matched control group. In the group comparison, mono- and birhinal sensory thresholds as well as judgment of intensity were not significantly different. For four of the eight smells, the hedonic judgements were found to be identical between the group of depressives and controls, with the remaining smells not significantly different. There were no differences in the consistency of ranking of smells. In a longitudinal (test-retest) assessment there were again no differences in intensity, familiarity, and hedonic quality of the smells. The findings suggest that changes in the dopaminergic transmitter balance during the state of depression causing anhedonia affect neither olfactory perception nor the hedonic judgement of smells. Contrary to the clinical picture, anhedonia thus seems not to arise at the level of sensory perception yet but should be considered a more complex construct of disturbed central processing.

We studied 361 Viennese patients (m = 111, f = 250) admitted to our observation ward after attempted suicide by drug ingestion over a two-year period. Age and sex distribution, social status, time of attempt, motives, and drugs used were documented, as well as the therapeutic management of the cases. The patients were divided into 4 age groups: 57 juveniles, 179 young adults, 80 middle-aged adults and 45 geriatric patients. These groups were compared with each other in manifold respects. Our analysis showed that the geriatric patients who had attempted suicide by drug ingestion differed from those of other groups insofar as there was a lack of exogenous influence with regard to motives and methods. They may represent a separate entity more akin to suicide than to attempted suicide. Vienna data on attempted suicide by drug ingestion did not differ markedly from international data.

We studied 38 geriatric patients admitted to our observation ward after attempted suicide by drug ingestion. Age and sex distribution, social status, time of attempt, drugs and therapeutic procedures were registered and compared to suicide attempts of other age groups (n = 231). Our analysis showed that geriatric attempted suicides differed from those of other age groups by less exogenous influences, in motivation, methods and therapeutic procedures. They may represent an own entity of disease nearer to suicide than to attempted suicide.

We studied 259 patients (m: 204, f: 55) admitted to our observation ward after drinking alcohol with blood levels above 3.9 g/l. Epidemiological data, clinical and laboratory data and therapeutic procedures were registered. Our analysis showed that such high blood levels of ethanol were only tolerated by a definite age-group of chronic alcoholics with mild organic injuries. Elevated mean cell volume and gamma-glutamyl transpeptidase and additionally low BUN may be useful markers for chronic alcohol consumption.

We studied 153 patients admitted to our observation ward after attempted suicide within the last 12 months. The time of attempt, age and sex distribution, social status, kind of suicide attempt and therapeutic procedures were registered. Our analysis showed, that exogenous factors like weather and season (April, November/December) must be considered as important for the time of suicide attempt. Furthermore we noted, that vacations, young age, isolation and unemployment were conducive to suicide attempt. Geriatric attempted suicides differed from those of other age groups in motivation and methods. They may represent on own entity of disease.