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Opiate addiction is common among offenders, and many opiate-dependent lawbreakers are treated in the correctional system according to § 64 STGB. While substitution treatment in prisons has become common practice, substitution treatment in forensic hospitals in the traditionally abstinence-oriented prison system is controversial and also varies from region to region. Basic data on this are lacking so far. The problem is discussed against the background of a current expert opinion case. Current figures from a large forensic hospital in Munich-East show that almost 30% of the patients are treated with substitutes (n=186). The problem of substitution treatment in the prison system is discussed., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: In Europe, there have been several addiction-expert rankings of harms related to the use of psychotropic substances in the last 15 years. Among them, only one expert ranking took into account the potential benefits of these drugs. Non-Opioidergic Analgesics (NOAs), such as gabapentinoids and NSAIDs, which have been increasingly the subject of abuse / misuse reports, have not been considered in such expert rankings. Likewise, there is currently no multi-substance comparison as to whether the valuation rank of the harmfulness of an illegal drug may change along with an imagined change in legal status in Germany., Objectives and Methods: Using a questionnaire, 101 experienced addiction physicians (first cohort) evaluated 33 psychoactive substances including analgesics with regard to their health and social harms as well as potential usefulness for the consumer and their environment / society ('others'). In addition, this cohort investigated whether the harmfulness assessment of an illegal substance changes if it would be legalized. In order to obtain the average overall harmfulness (overall risk) of a substance, the percentage contribution of each dimension to the overall harmfulness was determined in a second survey (second cohort, 36 experienced addiction medicine experts). Finally, the average benefit and overall risk ratings of each substance were related to each other., Results: Prescription psychoactive substances such as analgesics, NOAs (including gabapentinoids) and opioidergic maintenance medications to treat opiate dependence were judged to have a favorable benefit-harm profile. Cannabis and ketamine were placed in the midfield of both, the harm and benefit rankings. Together with most illicit narcotic drugs, alcohol and nicotine, have been ranked among the most harmful and least useful substances, whereby alcohol was judged on average to be more harmful but also more useful than nicotine. In the event of potential legalization, the overall harm of the traditional illegal drugs methamphetamine, heroin, cocaine and cannabis was estimated to be reduced. This was mainly due to a more favorable valuation of the harm to others under these virtual conditions., Conclusion: Prescription substances including opioidergic and non-opioidergic analgesics as well as opioid maintenance therapy medications (methadone and buprenorphine) were assigned a favorable benefit-harm profile. Alcohol, nicotine and traditional illicit drugs (with the exception of cannabis and ketamine) were determined to have an unfavorable profile. The overall harm of traditional illicit drugs was assessed to decrease along with legalization, mainly by decreasing the harm to others in this virtual event., Competing Interests: Prof. Dr. med. Scherbaum erhielt Honorare für verschiedene Aktivitäten (z. B. Mitgliedschaft im Beirat, Vorträge, Manuskripte) von AbbVie, Camurus, Hexal, Janssen-Cilag, MSD, Medice, Mundipharma, Reckitt-Benckiser/Indivior und Sanofi-Aventis. In den letzten drei Jahren hat er an klinischen Studien teilgenommen, die von der Pharmaindustrie finanziert wurden.Dr. med. Thomas Alberti erhielt Honorare (z. B. Mitgliedschaft im Beirat) und / oder Ausbildungsstipendien von Janssen-Cilag, Medice und Otsuka-Lundbeck.Prof. Dr. med. Norbert Wodarz erhielt Honorare für (nicht produktbezogene) Vorträge (Janssen-Cilag, Mundipharma und Reckitt-Benckiser/Indivior). Er erhielt öffentliche Mittel (BayStMGP) zur Bewertung von „Naloxon zum Mitnehmen“.Prof. Dr. med. Thomas Hillemacher hat Honorare für verschiedene Aktivitäten (z. B. Mitgliedschaft im Beirat, Vorträge) von Janssen-Cilag, Amomed, Shire, Takeda, Servier erhalten.Prof. Dr. med. Michael Soyka arbeitet seit drei Jahren als Berater oder hält Vorträge für Ammomed, Indivior, Camurus.Prof. Dr. med. Jens Reimer erhielt Honorare für die Teilnahme an Beiräten, Beratungen und Vorträgen von AbbVie, Amomed, Camurus, Gilead, Indivior und Sanofi-Aventis.Prof. Dr. med. Jens Kuhn erhielt Honorare von Bayer, Janssen, Lundbeck, Neuraxpharm, Otsuka Pharma, Schwabe und Servier für Vorträge auf Konferenzen und für die Reisen dorthin. Von der Medtronic GmbH hat er finanzielle Unterstützungen für Investigator-initiierte Studien erhalten. Die übrigen Autoren gaben an, keine Interessenskonflikte bezüglich dieser Studie zu haben., (Thieme. All rights reserved.)

Background: This study tested whether it is possible to diagnose complex posttraumatic stress disorder (CPTSD) according to the beta version of ICD-11 by means of the Trauma Symptom Inventory 2 (TSI-2). Currently, there is no established measurement for this., Methods: An algorithm for the TSI-2 was developed. This was tested in a sample of 100 psychiatric patients, who had experienced aversive and/or traumatic events. The frequency of CPTSD and differences regarding gender, age and traumatic events will be reported., Results: On the basis of this TSI-2 algorithm, 5% of the sample were estimated to suffer from CPTSD. A trend towards more women being affected was observed, and younger patients were more affected than older ones. Traumatized individuals reported more mental health problems than non-traumatized ones., Conclusion: Tentatively, these results indicate that it may be possible to use a combination of certain scales of the TSI-2 to diagnose CPTSD in line with its current definition by the ICD-11., Competing Interests: Es liegen keine Interessenkonflikte vor., (© Georg Thieme Verlag KG Stuttgart · New York.)

Long-term prescriptions of benzodiazepines are made mainly to elderly and female patients. Withdrawal treatments should be carried out gradually over a period of several weeks. Sleep and depressive disorders during benzodiazepine withdrawal can best be treated with sedating antidepressants. The few studies on this subject suggest psychoeducation, motivational strategies and cognitive behavioural therapy as having some efficacy., Competing Interests: Der Autor gibt an, dass keine Interessenkonflikte vorliegen., (© Georg Thieme Verlag KG Stuttgart · New York.)

Subject: Compared to other illicit drugs Methamphetamine (MethA) is used more frequently by women than by men. Assuming the biopsychosocial etiology model, the dependency is based on several factors in which women and men differ significantly. Systematic gender-differentiated knowledge is missing until today., Method: Based on a database research (PUBMED) the review examines biological, social and psychological as well as therapeutic aspects in MethA-dependent women., Results: MethA-induced cognitive disturbance appear to have severer manifestations in women than in men. MethA-addicted women's lifestyle is often characterized by active and passive (sexualized) violence. They show an increased risk behavior; i. e. unprotected sexual intercourse with several partners. Their psychological comorbidities seem to be more pronounced and especially affect anxiety disorders and depressive syndromes., Conclusion and Clinical Relevance: In women, abuse and dependence of MethA are determined by psychological as well as social factors. However, further research is needed to improve prevention, counseling and therapy., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Stress increases the risk of developing and maintaining alcohol addiction. Mechanism for reacting to, and coping with, stress in persons with alcohol addiction are an important factor enabling them to maintain abstinence in everyday life. Also of Relevance for abstinence, and in particular craving for alcohol, is the severity of the dependence. Numerous studies have focused on the duration of abstinence, but not on the severity of the disease., Objective: This study investigates if, in addition to abstinence duration, also the severity of the alcohol addiction influences stress responsiveness and ability to cope with stress. Another objective is to ascertain in which patients such an influence can be found. The results can shed light on the complex bidirectional relationship between alcoholism and stress, but are also potentially useful in treating patients with this disease., Methods: In a cross-sectional design, 64 alcohol-dependent patients and 30 healthy controls were examined. The alcoholics sample was divided in two groups according to a duration of abstinence of seven days and, 70 days. Each group was further divided in a subgroup of individuals with mild to moderate alcohol addiction and in a subgroup of patients with severe alcohol addiction (A7-severe and A70-severe). Using the Trierer Social Stress Test (TSST), all participants were subjected to acute stress. Parameters measured were salivary cortisol, skin conductance -response, heart rate, addiction-related variables (addiction severity, duration of alcohol abuse, drinking quantity, craving, liver enzymes, family history of alcoholism, number of therapies, smoking), psychopathological variables (anxiety, depression, live events, personality disorders), acute and long-term stress coping, and level of strain on everyday life., Results: In patients with severe addiction, the reaction to stress is weaker and slightly retarded, but also of a longer duration than that patients with mild and moderate addiction and of healthy controls. This is independent of the length of abstinence (7 days and 70 days). In severely ill patients, strategies for coping with acute stress differed from those of the other groups in that they consisted in stronger flight and avoidance responses, a stronger need for social support, and a more intense mental preoccupation. Increased levels of social tension, lack of social recognition, and isolation indicated chronic stress. Patients with severe alcohol addiction also showed a more pronounced familial predisposition, stronger craving, increased anxiety, a longer history of alcohol abuse, and a higher frequency of incisive life events than patients with mild to moderate alcohol addiction., Conclusions: The results indicate that a more differentiated evaluation of stress responsiveness and stress coping in persons with an alcohol addiction not only length of abstinence, but also severity of disease have to be taken into account. Further research is necessary to adjust treatment accordingly., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives This study investigates the assessment of change of depressive symptoms and severity of depression with the "Health of the Nation Outcome Scales" (HoNOS) in an inpatient setting. Method Participants were 132 adults diagnosed with depressive disorder (F32: n=102; F33: n=30). Bivariate correlations were used to determine the correlation of the HoNOS with self-reported (BDI) and observer-rated depressive symptoms (HAMD). The predictive validity of the HoNOS was analysed with linear regression models. Results The HoNOS differentiated significantly between patients with moderate versus severe depression at baseline (p<0,05). It correlated with the HAMD change score (r=0,25, p<0,008), but not with the BDI change score (r=0,19, p>0,008).The HoNOS was not a significant predictor of observer-rated depression at discharge (β=0,03, p>0,05). Conclusion As the HoNOS only partially seems to assess the change and severity of depressive symptoms, it should only be used in combination with depression-specific instruments., Competing Interests: Interessenkonflikt: Dr. Barbara Hochstrasser, M.P.H. war in 2015 und 2016 Mitglied des Advisory Boards für die antidepressive Substanz Vortiotexine der Firma Lundbeck AG.2015 erhielt das Schweizer Expertennetzwerk für Burnout (SEB), welches Dr. Hochstrasser präsidiert, Sponsoring Beiträge für ein durch das SEB organisierte Symposium von den Firmen Lundbeck, Medisuisse, Schwabe Pharma, Mepha. Die anderen Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

The study aimed to validate the German version of the revised Trauma Symptom Inventory (TSI-2) by John Briere. TSI-2 assesses complex posttraumatic stress symptoms. In order to validate it, further instruments were applied, namely the Adverse Childhood Experience Scale, the CIDI list, the revised Impact of Event-Scale, the interview for complex posttraumatic stress disorder, the revised symptom checklist 90, the dissociative experiences scale, the inventory for interpersonal problems, and the self-efficacy questionnaire. The participants were N=100 traumatized psychiatric in-patients of a psychiatric hospital localized in the German-speaking part of Switzerland. The sample consisted of N=42 women. The study design was longitudinal with 2 assessments. The second assessment took place 4 weeks after the first, in order to investigate retest reliability. Here, N=17 patients participated, of whom N=8 were women. Regarding the results, on average, 3.5 aversive or traumatic experiences during childhood were reported, and 2,1 during adulthood. The diagnosis of (classical) PTSD was estimated at 33%. The results indicate that TSI-2 is both reliable and valid with respect to different criteria: Most scales and subscales of the TSI-2 showed acceptable to very good internal consistencies (α from 0.73 to 0.95) as well as good discriminatory power, and an acceptable retest reliability. Results also indicate good divergent and convergent construct validity as well as good criterion validity. It was not possible to replicate the 4-factor-model presented by the original author of the TSI-2. Instead, in line with the study that validated the German translation of the first version of the TSI-1, a 2-factor-model was found. There were gender differences regarding the TSI-2 scales with higher posttraumatic stress symptoms in women. In conclusion, there is evidence that indicates that the German translation of the TSI-2 is a reliable and valid instrument for the assessment of complex posttraumatic stress symptoms., (© Georg Thieme Verlag KG Stuttgart · New York.)

Following a short overview on the epidemiology and clinical correlates of amphetamine abuse and dependence, with special emphasis on metamphetamine ("crystal"), current treatment concepts and recent results of therapy research are discussed. The efficacy of two inpatient treatment models for methamphetamine dependence are currently studied in a study funded by the German Ministry of health. The study concept is given and possible implications are discussed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aims: We have analysed the MAOA-uVNTR polymorphism in the promoter region of the X-chromosomal monoamine oxidase A (MAOA) gene. The first aim was to examine the association between the MAOA genotype and the alcoholic phenotype. In the second part of the paper we have analysed the association of the MAOA genotype with impulsive and aggressive behaviour. Genotypes with 3 or 5-repeat alleles (MAOA-L-genotype) were reported to be associated with impulsive and aggressive traits., Methods: The MAOA genotype was determined in 371 male alcohol-dependent subjects and 236 male controls all of German descent. Behavioural and personality traits were evaluated using the self-report questionnaires Barratt Impulsiveness Scale (BIS), Buss Durkee Hostility Inventory (BDHI), Temperament and Character Inventory (TCI) and NEO-Five Factor Inventory (NEO-FFI). A median split in BIS, Buss Durkee Physical Assault, Buss Durkee Irritability, TCI and NEO-FFI was conducted., Results: No association could be detected between the MAOA genotype and the alcoholic phenotype. Based on the results of the BIS questionnaire, we were able to make out an association between the MAOA-L genotype and higher levels of impulsivity (p = 0.043). Furthermore - without reaching statistical significance - we detected a very slight association between the MAOA-L genotype and higher scores in the BDHI subcategory physical aggression (p = 0.058)., Conclusion: Taken together, these findings suggest that the MAOA-L genotype is to some extent associated with impulsive and antisocial personality traits in alcoholic men. Further studies on that question are needed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Pharmacological "cognitive enhancement" (CE) and "pharmacological neuroenhancement" (PN) are different terms to describe the use of diverse substances by healthy individuals aiming at an increase of individual cognitive skills. Targets of CE are an increase of vigilance, attention, concentration, memory and motivation. Substances used for pharmacological CE can be divided into two categories: stimulants and non-stimulants. The sub-group of methylxanthines like caffeine as well as the sub-group of amphetamines like prescription and illicit amphetamine as well as methylphenidate and modafinil belongs to the group of stimulants; antidementives, antidepressants, phytopharmaceutical products like Ginkgo biloba etc. belong to the group of non-stimulants. Prevalence rates depend on the (type of) study and (group of) substances used for CE. And they range from a 1 % lifetime prevalence rate up to 20 % one-year prevalence rate. This review presents stimulant and non-stimulant substances, their limited clinical effects on cognitive skills as well as their prevalence rates and the aspect of misuse and addiction of the above-mentioned substances which belongs to their respective category., (© Georg Thieme Verlag KG Stuttgart · New York.)

The new edition of the DSM, which was published in May of 2013, has brought the following changes in the now called category "substance-related and addictive disorders". The terms dependency and misuse or abuse will be replaced by the terminus "substance use disorder". There is a moderate substance use disorder, if two or three criterias are fulfilled for a period of 12 months. To speak of a severe substance use disorder, it has to be four or more criteria for the duration of 12 months. Furthermore, pathological gambling will be a part of the DSM-5 as a non-substance use disorder, but rather an addictive disorder. It is possible, that internet addiction will be a part of a revised version in DSM-5 for addictive disorders. The now changed criteria will have consequences on diagnosis, therapy and research concerning substance-related and addictive disorders. The leading diagnosis standards DSM-5 and ICD-10 or the following ICD-11 will continue to drift further apart from each other., (© Georg Thieme Verlag KG Stuttgart · New York.)

This study examines the relationship between (alcohol specific) self-efficacy expectancies and abstinence from alcohol measured at 3 follow-ups (t1 = 6, t2 = 12 and t3 = 24 months after treatment) in 3 groups of patients with different severity levels of their alcohol dependency. N = 169 patients were included (n = 65 outpatient treatment, n = 51 inpatient short-term and n = 53 inpatient long-term treatment). Self-efficacy was measured using the Alcohol Abstinence Self-Efficacy Scale (AASE). Treatment outcome was defined as complete abstinence from alcohol at time of follow-ups. The AASE differentiates reliably between abstinent and non-abstinent patients in each treatment group at the 3 follow-ups. Abstinent patients had significant higher scores in both of the two subscales confidence and temptation. The strongest relationship between AASE and treatment outcome could be found for subjects in short-term inpatient treatment. The impact of the results for clinical practice is discussed.

Aim: To study the prediction potential of demographic and psychopathological variables in the patient allocation context., Method: This was a follow-up study of alcohol-dependent patients (n = 242) who were treated in an outpatient (n = 75), inpatient short-term (n = 88), or inpatient long-term (n = 79) setting between 2003 and 2004. Demographic and psychopathological variables were measured by psychiatric basic documentation and the European Addiction Severity Index (EuropASI) . Abstinence two years after discharge from treatment was the primary outcome criterion., Results: Significant predictors of outcome were a higher secondary school qualification, a finished professional training, later onset of alcohol dependence, less number of treatments for physical illness as well as no history of suicide attempts. Both satisfaction with the family background and being employed were predictors with allocation potential., (Georg Thieme Verlag KG Stuttgart * New York.)

Methylphenidate is increasingly used in adults with attention deficit/hyperactivity syndrome (ADHS). We report two cases of amphetamine misuse in patients with suspected ADH syndrome. In both cases the diagnoses had not been made in childhood. The interrelationship between substance use and adult ADHS is discussed.

Introduction: Evidence-based treatment description is used for knowledge aggregation and knowledge evaluation, for definition of recommendations and encouraging process quality in medicine. Starting with a detailed assessment of therapy studies, the following treatments were specified as effective treatments according to their evidence basing: "training of soft skills", "motivational enhancement therapy", "couple/family therapy", "cognitive behavioural treatment" and "relapse prevention". We examined the analogy of both treatment elements used in inpatient rehabilitation of alcohol dependents and the published knowledge concerning the effectiveness of therapy elements., Methods: The examination based on a representative sample of 5540 alcohol dependent patients completed inpatient alcohol rehabilitation in a clinic for drug addiction in 2004. The analyses based on the realized treatment units., Results: The highest utilisation rate resulted for the treatments "information/schooling" with 93.3 %. The utilisation rate of "cognitive behavioural treatment" was 85.4 %, and of "soft skill training" 79.1 %. Low utilisation rates resulted for "relapse prevention" with 29.6 %, "nutrient schooling" (28.9 %), "non-smoker training" (17.3 %), "motivational enhancement therapy" (14.8 %), and the therapy element "groups of mental comorbidity" (11.2 %). 39.5 % of the patients received services from the therapy element "psychoanalytic therapy". On the average, patients took part in 18 treatment offers (SD = 6.8). This were treatment offers of 9 (SD = 2.1) from a total of 14 evidence based treatment categories, on the average., Discussion: While the scientifically based therapy realization of some treatments, e. g. "soft skill training" and "cognitive behavioural treatment", was at a high level, the low level of utilisation for "relapse prevention" and "motivational enhancement therapy" is surprising on account of their proven effectiveness. Further calculations are to analyze combinations of treatments, the inclusion of demographic variance and to analyse the variance due to different treatment providers.

Aim: To study the validity of the EuropASI in the patient allocation context and to measure the alcohol severity changes with treatment., Method: The examination based on three groups of alcohol-dependent patients (n = 242): outpatients (n = 75), inpatients in a short-term treatment (n = 88), and inpatients in a long-term treatment (n = 79). Treatments took place in two clinics. The European Addiction Severity Index (EuropASI)-Composite Scores were calculated for severity assessment of alcohol dependence. These scores are qualified for change measurement and scientific utilization. Assessments took place on admission and at discharge from the treatment unit. Analyses included the outset values comparison and the examination of both time as well as group effects., Results: Mean age of patients was 45.3 years (SD = 8.6) and 26,4 % of the participants were females (n = 64). The three groups differed significantly in their completion of professional training, employment status, marital status, onset of alcohol dependence, daily alcohol intake in the past half year, previous detoxifications, previous rehabilitations, and at least one attempted suicide. Adjusted for these variables, the 3 groups differed in the alcohol domain at t0, and t0-t1-improvements resulted for the whole sample in the alcohol domain and the domain 'employment satisfaction'., Discussion: The severity ratings by means of EuropASI-Composite Scores illustrated the assumption that the severity level gives information about the treatment needs: the more severe disorder the larger the treatment needs. Furthermore, a t0-t1-decrease of the Composite Scores was shown for the whole sample in the domains 'alcohol use' and 'employment satisfaction'. This points to a reduction of the addiction severity level due to treatment. In spite of some limitations regarding the Composite Scores, the EuropASI seems to be useful for patient allocation.

Based on American studies lifetime prevalence of 'Pathological Gambling' (ICD-10, F 63.0) in Germany can be estimated at 0.5 %. That means about 400,000 gamblers requiring treatment. Epidemiological studies showed that only a little proportion is actually seeking treatment. Reliable knowledge about treatment prevalence does not exist for Germany. The study at hand using secondary data was performed to validate the estimation of the 'Deutsche Suchthilfestatistik' regarding inpatient and outpatient treatment prevalence in 'Pathological Gambling' with data from service providers (cost unit). The analysis proves the estimation of the German Addiction Statistics ('Deutsche Suchthilfestatistik') that the inpatient treatment prevalence has considerably risen. In spite of the consideration that treatment of pathological gambling is not limited to specialized hospitals there is still a considerable gap between estimated prevalence and treatment prevalence.

Background: Up to now, controlled drinking as an alternative to abstinence for alcohol-dependents has been discussed controversially. In the present study we examined in a sample of alcohol-dependent patients whether or not controlled drinking is possible during a three years period following treatment., Methods: 103 consecutively recruited alcohol-dependent participants (ICD-10) which took part in an abstinence-orientated outpatient treatment were re-interviewed 6, 12, 24, 36 months following treatment (follow-up ratio ca. 90 %)., Results: Analysis revealed that 43 % of patients were abstinent during total follow-up period and 12 % of patients were classified as improved at follow-up using the classification proposed by Feuerlein and Küfner. Of these patients, no patient at all was able to practise self-controlled drinking alcohol during the entire follow-up period., Conclusions: Only four patients had a drinking pattern similar to controlled drinking during a maximum period of 24 months. Though the primary aim of the evaluated outpatient clinic was to achieve abstinence and not controlled drinking, controlled drinking in alcohol-dependent patients nevertheless seems to be a rare phenomenon, which cannot be recommended. Moreover, recent animal models for alcoholism indicate alcoholism being an irreversible pattern.

Unlabelled: There are various publications on the impact of the experience of violence and abuse during childhood as it relates to future substance abuse. This study aims to examine how childhood abuse differentiated by type and severity, impacts on future potential for substance abuse. Particular attention is paid to specific psychological symptoms and degree of addiction., Methods: 100 patients being treated for substance abuse completed a questionnaire where they were questioned about a childhood history of sexual, physical and emotional abuse, neglect and family violence. Psychopathology and severity of addiction were assessed using the EuropASI and SCL-90., Results: The results demonstrated that the respondents had been exposed to multiple risk factors in their childhood. The subjects were differentiated into groups according to type of abuse. The type and severity of psychological symptoms were measured by the SCL-90-R. The type and severity of psychosocial and environmental problems were measured by the EuropASI. It was shown that patients with a history of abuse had a significantly higher incidence of symptomatology, particularly of co-morbid psychological conditions. When differentiating victims of abuse by sex, women showed a significantly stronger impairment in 2 categories. These were insecurity in social contact and phobic fear. For all other variables of impairment, there were no differences between men and women. The severity of the various types of abuse was then correlated to the course of the disease. A strong correlation was found between severe forms of abuse where victims were involved in sexual abuse or family violence and future severe psychological symptoms.

Introduction: Suicidal behavior is common in alcohol-dependent subjects. In terms of methods used, violent and non-violent suicide attempts can be distinguished. To confirm the validity of this distinction from a clinical point of view a sample of inpatient alcohol-dependent subjects is explored., Methods: Subjects with a diagnosis of alcohol dependence according to DSM-IV and ICD-10 who took part in an inpatient withdrawal treatment program were included. Characteristics of alcohol dependence and suicidal behavior as well as lifetime diagnosis of other psychiatric disorders were assessed using the SSAGA. Clinical syndromes, personality and temperament were obtained by MMPI-2, TCI and NEO-FFI., Results: Of the 182 included patients, alcoholics with a history of suicide attempts reported more depressive pathology and a personality profile characterized by emotional instability, psychopathy and decreased self-control., Discussion: Distinguishing alcohol dependent suicide attempters according to methods used, no significant differences between violent and non-violent methods could be found. Therefore the clinical validity of this distinction could not be confirmed.

Treatment approaches which are used in the context of inpatient alcoholism treatment are frequently neither theoretically justified nor empirically examined. In view of the enormous method variety the necessity exists for the development of treatment guidelines in order to offer indicators of promising treatment achievement for practitioners and pension funds. In a first step, it must be examined which treatments are effective, which are ineffective and which are possibly even counter-productive. This article aims to give a comprehensive review of randomized-controlled studies/meta-analysis on the efficacy of different treatment approaches. This article reporting the literature review is part of a larger programme to develop clinical practice guidelines for rehabilitation which is supported in form, content and finance by the German Pension Institute for Salaried Employees (Bundesversicherungsanstalt für Angestellte, BfA). Summing up, treatment is effective compared to no treatment. Cognitive behavioural therapy included in a multimodal treatment program is effective. There are a number of treatment protocols for which controlled research has consistently found positive results like social skills training, community reinforcement approaches, behaviour contracting, motivation-enhancing treatment, and family/marital therapy. There is also a number of commonly used treatment approaches that brought neither a positive result or were counter productive like relapse prevention, non-behavioural marital therapy, and insight psychotherapy, confrontational counseling, education, relaxation training, and milieu therapy. Support for matching to a specific treatment is weak, but interventions against alcohol problems should be differentiated according to the severity of the alcohol problem. Since treatment evaluation is mainly accomplished in the US and supplying structures with respect to the US and Germany are substantially different, a generalized transmission of US-American research results on Germany is to be evaluated carefully. Randomized-controlled studies are needed in Germany.

Drug analytics in oral fluid can be of relevance for various clinical and forensic questions, for example when testing for driving ability. To date few studies have been conducted concerning validity of different methods. The reliability of drug analytics in oral fluid was studied using cedia test and emit test (for cannabinoids). CUT-offs for different substances were defined after evaluation of ROC curves following various prestudies. 97 saliva and 103 urins probes from 31 opioid dependent patients were tested. Only for methadone, the results in oral fluid were comparable to those in urine. For most other drugs including opioids and barbiturates, results were less favourable. For cannabinoids and benzodiazepines, results were unsatisfactory. To date drug testing in oral fluid does not seem to be as accurate as urine analytics. Urine testing using immunoassays or gas chromatography is still the most reliable non-invasive test method. Drug testing in oral fluid may be of relevance as an additional method in substitution treatment and as an experimental tool in epidemiological road surveys.

This study analyzed the Alcoholics Anonymous participation and the impact on the abstinence rate of 103 alcohol dependent patients (ICD-10) during the 24 months after their discharge from high-structured out-patient treatment. The treatment retention amounted to n = 74 (72 %), 18 of the 25 dropouts took place because of alcohol relapse. At 6-, 12- and 24-months-follow-up 87 - 95 % of the patients were successfully located and re-interviewed. Analyses revealed that 64 % of the patients were abstinent at the 6-months-follow-up evaluation, 56 % at the total 12-months-follow-up evaluation. 49 % of the patients remained abstinent until the 24-months-follow-up evaluation, 14 % were improved and 37 % relapsed. 56 patients (55 %) participated in selfhelp-groups the first six months following treatment, two years later 45 patients (44 %) still attended a group. 53 - 56 % participated on a weekly basis. Patients who participated regularly on a weekly basis in self-help-groups fared the best on 2-year outcome. Patients who infrequently at all participated or not had the poorest outcome (relapse). After controlling for confounding variables (sex, treatment drop-out, relapse during treatment) these results were still statistical significant. Results indicate the predictive value of AA attendance for relapse prevention after controlling for confounding variables. The value of self-help-groups in the network of alcoholism treatment is discussed.

Objective: Impulsive traits are key characteristics in a number of psychiatric disorders and are part of the normal behavior spectrum. The BIS-5 is an instrument developed to assess impulsivity. The aim of this study is to evaluate the BIS-5 in two German psychiatric inpatient samples and healthy controls proving the originally proposed four-factor structure as well as convergent and discriminate validity., Methods: 159 alcohol-dependent subjects and 77 suicidal inpatients were recruited in an University psychiatric hospital. 182 healthy subjects were recruited from town community. BIS-5 items were translated and back-translated. Principal component analysis with oblique rotation was conducted in the whole group. Furthermore, the discriminate and convergent validity of the BIS-5 was evaluated by correlation with other instruments measuring impulsive traits and comparing sample subgroups., Results: A two-factor solution could be identified in this German sample. Alcohol-dependent individuals showed significantly higher factor 1 values compared to suicidal patients. The group of suicidal patients had higher scores in factor 2 compared to controls. Factor 1 correlated most significantly with extraversion-related personality traits while factor 2 showed significant relationships with irritability and neuroticism., Conclusions: A two-factor solution may be more appropriate in using the BIS-5 scale in German samples. These two factors might reflect different aspects of impulsive behavior and might be useful to characterize impulsive behavior in psychiatric and non-psychiatric samples.

Personality disorders (PS) frequently exist as comorbid disorder in alcoholism. However, the impact of comorbid personality disorder on the treatment and course of alcoholism still remains unclear. On that background, the present study on the efficacy of an intensive out-patient therapy for alcohol-dependents investigated the influence of comorbid personality disorder on the relapse and dropout rate during the treatment phase in 102 patients. Personality disorders were assessed with the SCID-II (DSM-IV). On a descriptive level results indicate that comorbidity with negativistic personality disorder and Cluster B PS may adversely affect the course of treatment. Statistical analyses, however, revealed that the observed differences in the type or number of personality disorders between patients with or without relapse resp. between patients with or without dropout failed to reach statistical significance. Thus, we conclude that the relevance of comorbid personality disorder on the course of alcoholism may be overestimated. The present results indicate that patients with comorbid personality disorder can be successfully integrated into a high-structured outpatient therapy.

A number of preclinical and clinical findings suggest that the glutamate system, especially NMDA-receptors has a major function in neuropsychiatric disorders related to chronic alcoholism. Other findings suggest, that glutamatergic mechanisms may also play a role for the addictive process itself including craving and addiction memory. A number of genetic and molecular-biological findings and more recent neuropharmacological studies point in this direction. NMDA-modulators and antagonists have been found to be possible or even clinically effective so called anti-craving-drugs. A better understanding of the glutamatergic mechanisms in alcohol dependence may therefore also be of relevance for the development of new anti-craving-drugs and therapy-research.

This study tested the feasibility of outpatient abstinence treatment among alcohol dependent subjects on welfare. Patients had a long history of alcohol dependence and prolonged unemployment. Over a period of six months a total of 250 patients were approached by the social welfare office and asked to participate in the program. The program involved detoxification and a three month combined alcohol treatment and personal job training. Of the 250 persons approached 96 patients (about 40 %) appeared for the initial examination, 19 patients (13 %) finished detoxification and a total of 5 patients completed the program. The majority of a group of patients considered to be highly therapy resistant did not complete the program. Still it was important to demonstrate that a subgroup of patients did successfully complete this program. We consider this pilot project a successful starting point for further development of treatment approaches targeted more specifically at this group of patients.

In a retrospective study we evaluated the patient files of all schizophrenic patients (ICD-criteria) admitted to the psychiatric hospital of the university of Munich between 1990 - 1995 (N = 2093). Relevant sociodemographic, clinical and psychopathological data as assessed by means of the AMDP protocol were studied. 292 (14 %) of patients fullfilled the criterion aggression on admission. While there were few differences concerning many sociodemographic variables including, male schizophrenics were rated significantly more often to be aggressive than female schizophrenics. With respect to schizophrenic subtype disorganized patients were most likely to be aggressive. Psychopathological symptoms significantly associated with aggression were e.p. delusional ideas and disorganized thinking. Possible risk factors for aggression in schizophrenia and clinical implications are discussed.

Psychiatric examination of accused for the International Tribunal is a new and challenging task for expert medical witness and forensic psychiatry. After a brief description of a case report relevant aspects of psychiatric evaluation of persons responsible for war crimes are outlined and possible implications for forensic research are discussed.

Chronical alcoholics are a challenge in therapy, especially if they have an adverse course of illness and treatment as well as multiple resulting somatical and neurological diseases. In German treatment of alcoholics the term 'chronisch mehrfach geschädigte Alkoholkranke' (chronically multiple affected alcoholics) has been established, describing patients with severe somatical and psychological disorders as well as social, professional, financial or legal problems. Permanent or even temporary abstinence is hard to achieve for these patients. They are usually found in psychiatric hospitals rather than in addiction wards, but also in social services or even prisons. Rehabilitation is possible in mental state hospitals that accept patients with dual diagnosis, sometimes even in special wards. Psychiatric co-morbidity in alcoholics is often underestimated. This is most important for psychotic illness, as well as other psychic diseases. A special problem is posed by delinquent patients that often have to be treated while in a penal institution. Some of the follow-up studies done on that have shown relatively good results in patients in penal institutions, but further studies are needed. As of yet, recent treatment options in pharmacotherapy to prevent alcoholic relapse are not sufficiently used. Anti-dipsotropics or so-called anti-craving-agents like acamprosate and naltrexone are primarily given to increase the rate of abstinence but could successfully be used in a harm reduction strategy (less drinking, shorter relapses).

The aim of this review article is to evaluate the treatment of cocaine-withdrawal, cocaine-intoxication and long-term relapse prevention of cocaine-addicts. Some 25% of police recognized first time drug users in Germany consume cocaine. However, there is an increasing number of cocaine-abusers and -addicts in the USA. The withdrawal of cocaine can be divided into three phases dominated mainly by psychiatric symptoms. Life-threatening condition can occur in cocaine-intoxication mainly in combination with other drug-use. A high risk of relapse is seen in follow-up trials of cocaine-addicts. Intensive craving, high cocaine- and substance-abuse is reported regularly in cocaine-addicts after detoxification therapy. Recommendations in the treatment of cocaine-intoxication, withdrawal and long-term relapse prevention are made. The use of antidepressives, anticonvulsants, dopaminergic and serotonergic medications as well as behavioural, psychoanalytical and combined therapies and their efficacy in clinical and trails is evaluated. A short review of new experimental therapies in the treatment of cocaine-dependence is shown.

Unlabelled: Sexual or physical abuse of children are discussed as possible causes or risk-factors for psychiatric disorders like posttraumatic stress disorder, alcohol and drug addiction. The aim of this study was to identify possible differences between sexually or physically abused and non-abused patients with polytoxic drug abuse., Method: 100 patients with polytoxic drug abuse were interviewed during their therapy about a history of sexual abuse prior to the age of sixteen. Using different questionnaires we tried to find possible differences between drug users being sexually abused or not and risk factors for later drug addiction., Results: 70% of the female and 56% of the male drug users had been sexually abused as children, 40% of the male and 50% of the female participants had a history of severe sexual abuse with sexual intercourse. In over 50% friends or relatives were the perpetrators committed the crime, in no case the parents had. More than 40% showed also a history of physical abuse. Significantly more drug users than alcohol abusers had a sexual trauma. Especially severe sexual abuse was associated with abuse of hard illegal drugs. Furthermore, we could find significantly more symptoms such as autoaggressive and suicidal behaviour, social isolation, reduced emotional binding to others, tendency to be persistently victimized, prostitution and violence against others in the group of sexually abused. Many of these symptoms are not only characteristic of addiction, but can be found also in other psychiatric diseases such as borderline and eating disorder. In conclusion, we could not find a significant correlation between sexual abuse and later drug addiction. 80% of the drug users themselves did not relate the fact of being sexually abused as child to later drug abuse. However, there seems to be a positive correlation between sexual abuse and a more severe addiction to illegal drugs as well as higher rates of symptoms with a negative course of the disease. For this group of patients with an unfavourable prognosis special therapeutic concepts are needed.

We present the concept and first catamnestic results of a model project "outpatient alcohol detoxification" which was initiated in 1998. To date 48 patients (18 female, 29 male, mean age 44.5 years, mean duration of alcohol dependence 10.2 years) entered treatment, 43 (92%) patients could be successfully detoxified. In only 21 (44%) patients a medication was necessary. To avoid drugs with abuse potential, doxepine (34%) and clonidine (19%) were predominantly used. No severe medical complications were observed. A follow-up examination after 6 months showed that 26 (55%) patients were abstinent and still in outpatient treatment. Further implications of this project are discussed.

The article is preceded by an introduction to world-wide communication networks. Some important basic features are explained. The major impact is on temporary and future aspects of the Internet for psychiatry. A variety of advantages in World Wide Web telemedicine for patients, clients, psychotherapists, clinicians and scientists are extensively demonstrated. Useful and established possibilities are discussed. Finally, the risks of this kind of communication are shown and listed.

For 150,000 drug addicts 5,200 therapy slots are available in Germany. Until the late 80's detoxification treatment was only given a subordinate role in treating drug addicts. Due to the threat of the infectious disease AIDS and the increasing number of drug deaths new concepts were explored: In 1991 the first qualified detoxification ward for drug addicts was opened in a general hospital under the auspices of the Federal German model project "compact therapy for comprehensive drug treatment". Subsequently more than ten detoxification wards specifically for drug addicts were established in Bavaria alone, primarily in psychiatric county hospitals. Drug addicts are accepted into these qualified detoxification wards without preparation and precondition. Data of 1656 drug addicts were analysed who were treated between 1991 and 1996 at the ward described below: More than 70% come directly from the scene and 33% were accepted for the first time to inpatient detoxification treatment. Most of them are diagnosed with addictions to at least two substances (three substances 44%, two substances 24%). Many suffer from additional diseases: In 1079 out of 1656 a positive hepatitis-C serology was found, 22% had previously tried to commit suicide, 37% had to be treated in intensive-care because of life-threatening intoxication. Nevertheless, 58% of the drug addicts are transferred into continuing therapy after detoxification treatment or they continue to work in permanent employment. During detoxification treatment no patient died. Acceptance, additional diseases which can be diagnosed and treated best in a general hospital, and the high prevalence of addicted persons (at least 17-24%) in internal medical or surgical wards suggest that establishing qualified wards with special settings for addicts in general hospital is useful.

In Germany the per capita consumption of alcohol has tripled since World War II with a slight decrease in recent years. The number of alcoholics has been estimated between 2.5 mill. and 10 mill. Epidemiological studies suggest a 6-month prevalence rate of 3.1% (USA 2.9%): 10.4% in males, 0.8% in females; Life-time prevalence estimates range up to 13%. More recent findings also suggest that alcoholism in adolescents is an increasing problem. The resources for treatment of alcoholism are limited: Only 1% of all alcoholics are treated in special addiction rehabilitation programmes, whereas the majority of patients are treated by their physician, in a general hospital or not at all. Approximately 30,000 patients are treated in special clinical rehabilitation programmes per year. Socioeconomic consequences of alcoholism have not been evaluated in detail; some cast models are discussed. In recent years both day-hospital and outpatient rehabilitation programmes for alcoholics have been established but few catamnestic studies have been conducted so far. The possible benefit of new antidipsotropic agents (so-called anticraving drugs) must also be examined in greater detail. Catamnestic findings and the outcome of treatment studies are discussed.

In ICD-10 or DSM IV, the Wernicke-Korsakow Syndrome (WKS) is mentioned among the criteria for the alcohol amnestic disorder. Rarely seen in clinical practice, the Wernicke-Korsakow Syndrome is important in differential diagnosis of amnestic syndromes, because life-threatening conditions can occur. A specific treatment is available for the acute form of Wernicke encephalopathy, in many cases a Wernicke encephalopathy shows a progression to the Korsakow-Syndrome, which is the chronic form of this disease. The aim of this article is to review recent developments in clinical, etiological and pathophysiological research of WKS. The role of thiamin-dependent enzymes like transketolase and the importance of the NMDA (N-Methyl-D-Aspartate) System is discussed. New trends in diagnostics are shown, as are differential diagnosis and epidemiology. Finally, the rarely investigated drug therapy of the Korsakow syndrome with clonidine and fluvoxamine is reviewed.

We report on catamnestic and clinical results of a 18-24 month follow-up study of 65 alcohol-dependent patients who in 1992-1994 took part in an 8-month outpatient treatment programme. The psychotherapeutic concept of this treatment facility is described. 51 of the 65 patients who had participated in the programme could be subsequently personally interviewed, 7 patients refused to take part, 6 could not be reached and 1 had died. 40 of the 51 patients had properly completed the outpatient treatment. Assuming that all patients who could not be interviewed or refused, were relapsers the abstinence rate was found to be 48% (n = 31). Although selective factors may contribute to this result, the clinical findings so far seem to indicate that outpatient treatment for alcoholics is a promising new therapeutic approach in the treatment of alcoholism. Further studies are needed to assess the possible benefits and the indications for this outpatient treatment in greater detail.

Jealousy as a psychopathological symptom has long been neglected by psychiatric research. Despite the obvious difficulty to prove or exclude the infidelity of a spouse, delusional jealousy can clearly be considered as pathological, but the evaluation and classification of non-psychotic jealousy remains a challenge. Typical psychopathological symptoms which usually accompany pathological jealousy and the prevalence of delusional jealousy in different psychiatric disorders are described. In delusional jealousy neuroleptic treatment is necessary. Positive results have been reported especially with pimozide. For non-psychotic jealousy various forms of psychotherapy have been advocated to improve self-esteem or to treat other psychological disorders. Other possible interventions are alcohol therapy or family counselling. Many studies show that jealousy is a frequent motive in homicide with the spouse being nearly exclusively the victim. Finally some forensic aspects of jealousy are discussed.

While schizophrenia-like psychosis is known to occur with chronic alcoholism the nosological differentiation of schizophrenia-like psychosis in patients with drug abuse remains difficult. An increased risk for the development of such psychoses has been discussed for various substances, e.g. cannabis. On the one hand this is supported by clinical and epidemiological studies but a final agreement has not been reached. On the other hand high prevalence estimates for substance abuse in schizophrenics have been reported in the angloamerican literature. Prevalence estimates for drug abuse and dependence range between 7-65% and a comparatively distinct abuse pattern in schizophrenics has been discerned: Apart from alcohol schizophrenics tend to abuse cannabis and psychostimulants including cocaine and hallucinogenes, whereas narcotics are abused only infrequently. Whether these recent figures for substance abuse and dependence are due to a real increase (32) or to improved diagnostic instruments and differences in the classification of psychiatric disorders or to selected samples (3, 122) is still a matter of controversy. In comparison with other schizophrenics dual diagnosis schizophrenics show more positive (psychotic) and less negative symptoms. In this review some clinical and neuro-biological problems concerning the concept of drug-induced psychosis and basic principles of pharmacotherapy and psychotherapy in schizophrenic patients with substance abuse are discussed.

The scientific discussion on the interrelationship of "alcoholism and psychosis" has been dominated by nosological problems for years. Alcohol hallucinosis, a comparatively rare psychosis in chronic alcoholism, can mimic the symptomatology of paranoid schizophrenia. The clinical features (vivid acoustic hallucinations and fear) are often inconclusive, as, unlike other organic psychoses, alcohol hallucinosis does not entail clouding of sensorium and disorientation. On the one hand follow-up studies suggest that alcohol hallucinosis in some cases can take a chronic schizophrenia-like course. Especially in these cases differential diagnosis between both conditions can be difficult. On the other hand a number of recent clinical studies suggest high prevalence rates for substance and esp. alcohol abuse and dependence in schizophrenics. Different approaches account for limitations in comparing the results. In most of the studies prevalence estimates for alcohol abuse and dependence range from 12-43%. In some highly selected clinical populations even higher prevalence estimates have been reported. Epidemiological studies such as the "Epidemiological Catchment Area Study" equally are in support of an appr. 4-fold increased risk for alcoholism in schizophrenics. Schizophrenics with alcohol abuse differ from non-abusing schizophrenics in a variety of clinical symptoms and features. With respect to psychopathological symptomatology schizophrenics with an additional alcohol abuse or dependence show more "positive", psychotic and less "negative" symptoms. Some findings suggest that in comparison with other schizophrenics, dual diagnosis schizophrenics may be superior in terms of a better premorbid functioning. However, during course of illness higher (re-) hospitalization rates and higher rates of suicide attempts have been reported; likewise, aggressivity and delinquency have been encountered. In this review clinical and diagnostic questions concerning the interrelationship between alcoholism and schizophrenic psychosis are discussed and some principles of psychopharmacotherapy in dual diagnosis schizophrenics are outlined.

In connection with the efforts to improve the prophylaxis against relapse in schizophrenic patients, the topic of non-compliance to therapy with neuroleptics is gaining interest in scientific research. The importance of this problem has been underestimated in the past. Starting with a review of the current state of research, the article provides an overview of the various determinants of compliance. The conclusions made are discussed in terms of optimizing therapy possibilities. Central to this point are less psychopharmacological options but more process- related aspects of the doctor/patient relationship. Fully informed consent of the patient is aimed at; providing him with detailed information on the purposes and the side-effects of neuroleptic therapy is discussed in terms of its consequences regarding compliant behaviour.