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Background: Abnormalities in the serotonergic (5-HT) system have been implicated in the pathogenesis of suicidal behavior. Studies on peripheral serotonergic parameters as a measure for central serotonergic function in suicidal patients appear to be promising, yet failed to show a clear association with suicidality. The objective of this study was to elucidate the role of serotonergic blood parameters in depressed suicidal patients and to examine their usefulness as a potential biological marker for suicidality. A number of personality traits were assessed in order to provide a basis for a psychobiological model of suicidal behavior., Methods: Depressed patients with a recent suicide attempt (SA; n = 59) were compared to those without history of suicide attempts (NSA; n = 28). 5-HT2A receptor binding in platelets and tryptophan/amino acid ratio in plasma were measured. Acute psychopathology and personality traits as well as characteristics of suicide attempts were assessed., Results: There was no significant difference between SA and NSA in terms of peripheral serotonergic parameters as well as personality traits. However, the whole sample showed associations between certain personality traits and serotonergic platelet parameters. Furthermore, we observed a relation between suicidal ideation, lethality of suicide attempts and peripheral serotonergic markers., Limitations: The number of cases with data on peripheral markers is relatively low. The potential influence of antidepressant medication previous to study inclusion has to be taken into account. The study focussed on depressed patients only., Conclusions: Low serotonergic function is involved in the pathogenesis of suicidality, whereas the use of platelet 5-HT2A receptor activity and tryptophan availability as biological markers for suicidality in depressed patients could not be proven an appropriate tool. Alterations in the serotonergic system are associated with trait aggression and other character dimensions.

After the Tsunami disaster in Southeast Asia, India, Sri Lanka, and Africa, the German government set up a crisis task force that implemented crisis-intervention teams covering Thailand (Phuket and Khao Lak), Sri Lanka, and Sumatra. Two crisis teams were sent to Phuket; the first one on 28 December 2004, and the second one on 3 January 2005, each for an average of 1 week. This intervention was primarily for the benefit of German citizens and their expatriates and relatives caught up in a major catastrophe as well as the German helpers. This article describes the organizational structures of the German crisis intervention, protective factors for the helpers, psychiatric syndromes--often acute traumata, the problems of the identification process for relatives, and crisis intervention itself. Consequences for further crisis intervention after natural disasters are discussed.

Low cholesterol concentrations and cholesterol-lowering therapies have been suggested to be associated with increased suicidality. This article examined the association of cholesterol, triglycerides, and body-mass index (BMI) with suicidal ideation and suicide attempts. Findings are based on a nationally representative community sample of n = 4,181 subjects (18-65 years) examined with a standardized diagnostic interview (CIDI) for (DSM-IV) mental disorders. Controlling for age and gender the study revealed a moderate positive association between cholesterol, triglycerides, BMI, and suicide attempts in subjects with depressive symptoms during the past 12 months (n = 1,205). The results of this study are compatible with two recent epidemiological cohort studies showing a positive association between cholesterol and completed suicide.

This study explores the accuracy of prevalence estimations for suicide attempts. Data came from the Early Developmental Stages of Psychopathology (EDSP) Study, a prospective community study (mean follow-up period was 42 months) of 3,021 respondents aged 14 to 24 years at the outset of the study. Suicide attempters are at least 1.6 times more likely to drop out than subjects with no suicide attempts and suicidal ideas. A total of 8% of all suicide attempters answered in the negative the depression-related gate questions of all surveys. One-third of all baseline suicide attempters did not report their suicide attempt again at the four years later assessment. In particular, 80% of all nonreporters were female, and almost 60% were aged 14-17 at baseline.

This is the first report on proteomic analysis of the cerebrospinal fluid (CSF) in unmedicated suicide attempters and non-attempters with major depressive disorder. Two-dimensional (2D) gel electrophoresis revealed that suicide attempters differed from non-attempters in one protein with an approximate molecular weight of 33 kD and an isoelectric point of 5.2. Proteomic analysis of the CSF is a promising non hypothesis-driven screening method for the detection of new candidate genes in neurobiological suicide research.

Objective: This study evaluated the associations between suicidal ideation and suicide attempts in mothers and various aspects of suicidality in their offspring in a representative community sample., Method: Baseline and 4-year follow-up data were used from the Early Developmental Stages of Psychopathology study, a prospective, longitudinal community study of adolescents and young adults. Results are based on 933 adolescents who completed follow-up and for whom direct diagnostic information for the biological mother was available. Suicidal ideation and suicide attempts were assessed in adolescents and mothers with the Munich-Composite International Diagnostic Interview., Results: Compared to offspring of mothers without suicidality, offspring of mothers reporting suicide attempts showed a remarkably higher risk for suicidal thoughts and suicide attempts and a tendency toward suicide attempts at an earlier age. Associations were comparable for male and female offspring. Transmission of maternal suicidality was roughly stable with control for maternal comorbid psychopathology., Conclusions: The offspring of mothers with suicide attempts are at a markedly increased risk for suicidality themselves and tend to manifest suicide attempts earlier than offspring of mothers without suicidality. Suicidality seems to run in families, independent of depression and other psychopathology.

Several studies have shown that there is a significantly increased risk of suicide related mortality in patients with a positive history of suicide attempts. The SUPLI-Study is the first prospective, randomized, double blind, placebo controlled multi-center trial focusing on the proposed suicide preventive effects of lithium in patients with suicidal behavior but not suffering from bipolar disorder or recurrent major depressive disorder. Patients with a recent history of a suicide attempt are treated with lithium versus placebo during a 12 month period. The hypothesis is that lithium treatment will lead to a 50% reduction of suicidal behavior. The protocol of the study and preliminary results are presented.

The subproject 1.5 "Neurobiology of Suicidal Behavior" is a multicenter study assessing peripheral parameters of the serotonergic, noradrenergic, and dopaminergic transmitter systems. Additionally, stress hormones and the lipid system as well as inhibitory and excitatory amino acids will be investigated. The different parameters are collected in cerebral spinal fluid (CSF), blood, and saliva. Patients with a depressive spectrum disorder with and without a suicide attempt (during the last three weeks) and being medication free for two weeks are included in the study. So far, 103 patients and controls have been recruited. The design and development of this project as well as interconnections with the others subprojects are described. Preliminary results about the stress hormone system and suicidality are presented.

We examined prospectively whether mania and hypomania are associated with an elevated risk for suicidality in a community sample of adolescents and young adults. Baseline and four-year follow-up data were used from the Early-Developmental-Stages-of-Psychopathology (EDSP) Study, a prospective longitudinal study of adolescents and young adults in Munich. Suicidal tendencies (ideation/attempts), mania, and hypomania were assessed using the standardized Munich-Composite-International-Diagnostic-Interview. At baseline, mania/hypomania was associated to a different degree with suicidality (Odds ratios [OR] range from 1.9 to 13.7). In the prospective analyses, the risk for subsequent incident suicidal ideation was increased in the presence of prior mania (38.0% vs. 14.1%; OR = 4.4; 95% CI = 1.4-13.5). No associations could be found between prior mania/hypo-mania and incident suicide attempts. The prospective analyses revealed a remarkable relationship between preexisting mania and increased risk for subsequent suicidal ideation.

Increased plasma arginine vasopressin (AVP) concentrations have been reported in depressed suicide attempters. Plasma AVP is primarily produced by the magnocellular system in response to increased plasma osmolality, and central AVP may be independently regulated. In the present study we investigated cerebrospinal fluid (CSF) and plasma AVP concentrations in depressed patients and controls. Nineteen drug-free depressed psychiatric inpatients (nine suicide attempters) and nine neurological control subjects underwent lumbar puncture and psychiatric evaluation. CSF and plasma concentrations of AVP, serotonin (5-HT), 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid (HVA), and cortisol were assayed. In 15 depressed patients (eight suicide attempters), the combined dexamethasone/corticotropin-releasing hormone (Dex/CRH) test was performed to examine the hypothalamic-pituitary-adrenocortical (HPA) system. There were no differences between depressed subjects and controls in all parameters measured. Suicide attempters did not differ from nonattempters. In depressed patients, plasma AVP correlated positively with cortisol. There was no relationship between CSF AVP and monoamine metabolites in CSF.

Background: According to some reports, patients treated with risperidone may develop akathisia. Restless legs syndrome (RLS), which shares some clinical features with akathisia, is a distinct movement and sleep disorder that may be induced by various drugs that act on the CNS., Methods: We studied a 31-year-old patient suffering from a schizoaffective disorder including auditory hallucinations who developed symptoms typical of the RLS during treatment with risperidone, using polysomnography to objectify sleep disturbances and associated periodic leg movements during sleep (PLMS)., Results: After switching from clozapine to risperidone treatment, the patient complained about dysethesias primarily of the legs, an urge to walk around, and sleep disturbances. The latter could be confirmed by polysomnography, including an abnormal PLMS index. Risperidone was switched to haloperidol. However, RLS symptoms were still present. After switching to quetiapine, RLS symptoms vanished and a second polysomnography test demonstrated better sleep quality and normal PLMS measurements. During the whole treatment period with different neuroleptics, the patient additionally received valproic acid., Conclusions: Symptoms typical of RLS may be induced by risperidone treatment and should be differentiated from akathisia. Although polysomnography is not necessary, it may be helpful confirming the diagnosis.

Epidemiological and clinical studies have described an association between lower serum cholesterol concentrations and increased suicide risk that is not entirely attributable to depression-related malnutrition and weight loss. Recent epidemiological studies with greater samples and longer follow-up periods, however, have even shown a positive correlation between cholesterol concentrations and suicide risk after controlling for potential confounding variables. A meta-analysis of earlier intervention trials suggested that cholesterol lowering could cause or worsen depressive symptoms and increase the risk of suicide. Large trials of statins (simvastatin, lovastatin, and pravastatin) did not show an increase of suicide mortality. The aim of this selective review is to critically discuss the current evidence for a potential link between cholesterol, essential fatty acids, depression, suicide, impulsivity, and aggression. Preclinical data support the hypothesis that cholesterol reduction may contribute to the serotonergic abnormalities that have been postulated in suicidal subjects. Recently, it was hypothesised that a decreased consumption of polyunsaturated fatty acids, especially omega-3 fatty acids, may be a risk factor for depression and suicide. Currently, we do not have sufficient evidence that cholesterol-lowering therapies increase the risk of depression and suicide. Increasing the dietary intake of omega-3 fatty acids may increase central serotonergic activity and reduce impulsive and aggressive behaviours.

Objective: 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., Method: The M-CIDI (Composite International Diagnostic Interview) was used to survey suicidal behaviour, DSM-IV lifetime diagnoses and traumatic events., Results: 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., Conclusion: 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.

Functional and structural abnormalities in the thalamus as well as a generalized phospholipid membrane disorder have been implicated in the pathogenesis of schizophrenic psychosis. To determine whether thalamic neuronal abnormalities and altered membrane-associated metabolites can be detected in schizophrenic patients, we used in vivo proton magnetic resonance spectroscopy (1H-MRS) in 32 acutely-ill, medicated schizophrenic patients and 17 age-matched controls. Thalamic and white matter metabolite concentrations (myo-inositol (mI), choline-containing compounds (Cho), total creatine (Cr) and N-acetylaspartate (NAA)) were estimated and corrected for atrophy (CSF) and gray and white matter contributions (GM, WM) by use of image-based voxel segmentation. Thalamic NAA was significantly reduced in schizophrenic patients, whereas Cho and mI were significantly increased in the parietal white matter. White matter Cr was significantly elevated in patients and correlated positively with the brief psychiatric rating scores (BPRS). Regional metabolite levels were inversely associated with GM and WM content reaching significance for mI and Cr in the thalamus and Cho and NAA in the white matter. Reduced NAA in the left thalamus of schizophrenic patients confirms and extends previous spectroscopic data and agrees well with histologic and imaging findings of reduced neuronal density and volume. Elevated Cho in line with 31P-MRS studies suggests increased myelin degradation thus further supporting a generalized membrane disorder in schizophrenic patients. In addition, we demonstrate the need to correct metabolite concentrations for regional tissue composition in studies employing patients with altered brain morphology.

Several lines of evidence suggest a dysregulation of the adrenocortical (HPA) system with hypersecretion of CRH is associated with suicidal behavior. However, controversial results have emerged from the determination of corticotropin-releasing hormone (CRH) concentrations in the lumbar cerebrospinal fluid (CSF) of suicide attempters probably due to methodological differences. We simultaneously measured CRH concentrations in the CSF and in the plasma of 41 psychiatric in-patients with different diagnoses (affective disorder, schizophrenia, personality disorders, adjustment disorder, substance abuse) and eight neurological control subjects. We also measured plasma cortisol concentrations because data from animal experiments suggest that cortisol may influence CSF CRH concentrations. The major finding was that patients who attempted suicide prior to admission had significantly lower CSF CRH concentrations than psychiatric patients without suicidal behavior. CRH concentrations were significantly higher in the CSF than in plasma in both, psychiatric patients and neurological control subjects. There was no significant difference between suicide attempters and patients with acute suicidal ideations. The latter group showed a trend towards lower CSF CRH concentrations compared with the neurological control subjects. Patients with affective disorder alone as well as patients with multiple diagnoses, but not schizophrenic patients, showed significantly lower CSF CRH concentrations than neurological control subjects. Plasma CRH and plasma cortisol concentrations did not differ among diagnostic groups or between suicide attempters vs. non-attempters. Further studies with more homogeneous samples, drug-free patients and with simultaneous assessment of various parameters of the HPA system are warranted.

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.

The role of comorbidity as a risk for suicide attempts is investigated in a random sample of 3021 young adults aged 14-24 years. The M-CIDI, a fully standardized and modified version of the Composite International Diagnostic Interview, was used for the assessment of various DSM-IV lifetime and 12-month diagnoses as well as suicidal ideation and suicide attempts. Of all suicide attempters, 91% had at least one mental disorder, 79% were comorbid or multimorbid respectively and 45% had four or more diagnoses (only 5% in the total sample reached such high levels of comorbidity). Suicide attempters with more than three diagnoses were 18 times more likely (OR = 18.4) to attempt suicide than subjects with no diagnosis. Regarding specific diagnoses, multivariate comorbidity analyses indicated the highest risk for suicide attempt in those suffering from anxiety disorder (OR = 4.3), particularly posttraumatic stress disorder followed by substance disorder (OR = 2.2) and depressive disorder (OR = 2.1). Comorbidity, especially when anxiety disorders are involved, increases the risk for suicide attempts considerably more than any other individual DSM-IV diagnoses.

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.

Background: Recent observations indicate that a certain pre-morbid personality profile ('autonomic lability', i.e. elevated neuroticism, frequent somatic complaints and increased interpersonal sensitivity) appears to be a valid antecedent of major depression. However, most of these prospective studies used samples drawn from the general population, which limits the power of any observed differences between subjects who developed a depressive disorder during the follow-up period and those who did not., Methods: We investigated the psychometric profile of 54 high-risk probands (aged between 18 years and 45 years) without a current or lifetime diagnosis of any psychiatric disorder, but who had first-degree relatives with an affective disorder according to DSM-III-R criteria. Twenty-two control probands, matched for age and gender and without any personal or family history of psychiatric disorders, served as the reference group., Results: As a group, the high-risk probands scored higher than the controls on scales that assessed neuroticism, rigidity, depressive cognitions, vegetative lability and stress. With an individual-orientated approach (cluster analysis), 30 high-risk probands were identified as conspicuous, characterized by elevated rigidity and increased 'autonomic lability'. The remaining 24 high-risk probands showed a psychometric profile very similar to that of the controls., Conclusions: The present findings in 54 probands at high risk for affective disorders not only strongly underline the assumption that the personality trait 'autonomic lability' is a valid antecedent of at least major depression, but also add the personality trait 'rigidity' as a further and potential candidate for a true vulnerability marker for affective disorders.

Personality disorders (PD) play an important role in clinical psychiatry. The typologies of personality disorders (PDs) found in different classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), are quite congruent. There are many methodological problems with reliability and validity of the diagnosis of PD. However, having a typology seems to be very helpful. Recent psychological autopsy studies reported that about one third of suicide victims met the criteria for a PD. Antisocial PD, borderline PD, narcissistic PD, and depressive PD in particular were often clinically associated with suicidal behavior.

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.

The International Diagnostic Checklists for the assessment of the DSM-III-R and ICD-10 personality disorders (IDCL-P) were compared with a structured interview, the International Personality Disorder Examination (IPDE), using a balanced test-retest design with forty psychiatric inpatients. The results, using pairwise kappa for the calculation of agreement, were as follows: any personality disorder versus no personality disorder 0.52 for DSM-III-R diagnoses and 0.75 for ICD-10 diagnoses. The range for the single personality disorders diagnosed at least five times was from -0.07 to 0.71 for DSM-III-R diagnoses and from 0.38 to 0.68 for ICD-10 diagnoses. Only for DSM-III-R diagnoses do figures exist from three other studies comparing two structured interviews with each other. The results of all four studies suggest that 60% of the variance in personality disorder diagnoses represents variance not attributable to the patients, which is scientifically unacceptable.

The effect of comorbidity on rates of suicidal ideation and suicide attempts from an adult general population of former West Germany is investigated. The assessment instrument is a modified German version of the Diagnostic Interview Schedule (DIS), a fully standardized interview for the assessment of selected DSM-III lifetime diagnoses as well as suicidal ideation and suicide attempts. Of the general population 4.1% (2.2% male and 4.1% female) made suicide attempts during their lifetime. Only 2 of 18 people who attempted suicide did not meet criteria for a DSM-III-R diagnosis. Cases with pure major depression did not have an odds ratio for suicide attempts significantly higher than subjects with no DSM-III diagnosis. However, cases with both a major depression and a lifetime-anxiety-disorder diagnosis showed significantly elevated odds ratios. Therefore, it is suggested that comorbidity of anxiety and depression, and not depression itself, seems to be a risk factor for suicide attempts.

Two instruments for the assessment of the DSM-III-R personality disorders were compared: The Personality Disorders Questionnaire--Revised (PDQ-R) and the Munich Diagnostic Checklist for the assessment of DSM-III-R Personality Disorders (MDCL-P). Using kappa value as a measure of agreement, the diagnostic agreement was less than 0.40 for personality disorder vs. no personality disorder as well as for the specific personality disorders. The PDQ-R diagnosed more frequently personality disorders (58%) than did the MDCL-P (43%).

A systematic assessment of psychiatric diagnoses according to the new classification system ICD-10 can be guided and enhanced by the International Diagnostic Checklists (IDCL). This instrument was developed and evaluated primarily for use in routine clinical care. It consists of 30 separate lists in pocket form, each assigned to a specific disorder and allowing immediate and operationalized diagnostic decisions (without the need of computer assistance). Personality disorders are covered by a separate 12-page booklet (IDCL-P). Examples of the checklists are given together with possible areas of application. First studies have indicated good clinical practicability and satisfactory to excellent diagnostic reliability.

It has been suggested in empirical studies that an attempted suicide has a cathartic effect. However, only one study used a control group of depressives who had not attempted suicide. A replication of these results using more strictly defined patient groups and a more comprehensive assessment of the psychopathology during index treatment was not possible. Major depressives with and without suicide attempts before index admission displayed similar courses of their depressive symptoms and somatic complaints during index treatment. The cathartic effect of a suicide attempt may be restricted to a severe major depression or to a violent suicide attempt.

This 4-6-year prospective follow-up study compared reactive depressives with (n = 48) and without suicide attempts before index admission (n = 24). Both groups showed a favourable course and outcome concerning psychiatric diagnoses (DSM-III), psychopathology, social integration, and social functioning as well as displaying a nearly identical course and outcome. In both groups, two patients committed suicide attempts during the follow-up period. 2 (1) male patients from the group with suicide attempts committed suicide.

This paper reports lifetime and 6-month prevalence rates of alcohol abuse and dependence in West Germany. Assessment instruments are a modified German version of the Diagnostic Interview Schedule (DIS), a fully standardized interview for the assessment of selected DSM-III diagnoses and the Munich Alcoholism Test (MALT). According to the DIS/DSM-III criteria, 13.0% of the adult general population (aged 25-64 years) were found to fulfill the lifetime criteria for alcohol abuse, alcohol dependence, or both; however, only 1.3% of all men and 0.9% of the women interviewed received a current DSM-III diagnosis of alcohol abuse or dependence. There was good consensus between current DSM-III diagnoses with current clinical ICD-diagnoses, but poor concordance with lifetime diagnoses. Symptoms of alcoholism, onset and severity, comorbidity with other DIS/DSM-III disorders as well as some selected risk factors are reported. The results are primarily compared with the results of the US-Epidemiological Catchment Area Program (ECA).

Diagnostic checklists for the assessment of DSM-III-R Axis I diagnoses have proven to be a reliable and feasible instrument in research and routine clinical care. Therefore, a checklist for the assessment of the DSM-III-R Personality Disorders (MDCL-P) has been developed. An English version of the MDCL-P is available. The MDCL-P has been tested for reliability in a test-retest design. The average duration of the interview was 36 min. Of the patients, 48% received a diagnosis of at least one personality disorder. The Kappa value concerning the distinction personality disorder as opposed to no personality disorder was 0.62. The range of Kappa values of specific personality disorders, which were diagnosed at least five times, was from 0.35 to 0.79.

The results of a 5-year follow-up study of 76 patients in a crisis intervention ward who were suffering from an adjustment reaction (brief or prolonged depressive reaction) according to ICD-9 criteria indicate a rather favorable course and outcome using standardized instruments. Only 17% developed a chronic or severe course of primarily depressive symptoms and only 1 (2%) patient committed suicide after discharge, whereas 64% had a very favorable and 18% a favorable course and outcome. This result is reflected in a rather low use of psychiatric and psychotherapeutic outpatient services during the follow-up period.

In 18 patients with a benzodiazepine (BZD) dependency the drug was withdrawn. The dose of BZD was gradually reduced in nine of the patients, while the others were additionally treated with carbamazepine (CBZ) for a further 15 days after BZD discontinuation. Withdrawal symptoms were assessed every third day during the study period. When comparing results in both groups, a clear trend towards less severe withdrawal symptoms could be observed in the group treated with CBZ. Some of the differences were statistically significant on days 9-12 after BZD withdrawal. Fundamental withdrawal symptoms (like hypersensitivity to sensory stimuli, abnormal perception of movement, depersonalisation or derealisation) were also less severe in the group treated with CBZ compared with the group not receiving that treatment. These findings support the results of previous reports indicating a therapeutical effect of CBZ in BZD withdrawal.

Twenty-two inpatients with an acute major depression without an additional lifetime DSM-III axis I diagnosis were compared with 20 inpatients suffering from an acute major depression with a coexistent anxiety disorder. The comparisons focused on social dysfunction, social support, and premorbid personality features. Characteristics of provoking life events and chronic conditions of life during the year before the index admission were analyzed exploratively. Major depressives with an anxiety disorder reported a higher number of abnormal premorbid personality traits such as neuroticism and a tendency towards social isolation; they had fewer confidants and lived alone more frequently than pure major depressives. Furthermore, pure major depressives reported more non-illness-related chronic burdening conditions during the year before the onset of depression than did major depressives with an anxiety disorder. However, there were no differences between the patient groups as to social dysfunction. The results point to fewer personal and social resources of the comorbidity group.

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.

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.

Twenty inpatients suffering from an adjustment disorder with depressed mood according to the DSM-III criteria were compared with 22 inpatients with a (situationally provoked) major depression without an additional DSM-III/axis I diagnosis, with regard to expert- and self-rated symptomatology, social dysfunction and personality features. Furthermore, social support prior to admission was described. Subjects who had developed an adjustment disorder had less severe depressive symptomatology, associated social dysfunction and premorbid rigidity, and they remitted faster. Social support for both groups was similar to that of healthy controls.

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.

Latency of rapid eye movement (REM) sleep was measured in eight healthy volunteers under baseline conditions and after administration of physostigmine. An infusion of 0.5 mg of physostigmine 5 minutes after sleep onset caused a significant shortening of REM latency in comparison with baseline conditions. In 45 patients with major depression, REM latency during baseline nights was significantly shorter than in control subjects. This shortening of the REM latency was found to be similar in endogenous, neurotic, and unclassified depressed patients. In contrast to findings in the controls, the physostigmine infusion provoked no further significant reduction of REM latency in depressed patients, but awakened the majority of patients. The data concerning spontaneous REM latency and REM latency after physostigmine do not allow a differentiation among the endogenous, neurotic, and unclassified depressed subgroups. The results of the cholinergic REM induction test do not conclusively support the hypothesis of a cholinergic hypersensitivity in depression.

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.

Psychopathological status and psychosocial functioning of 40 former inpatients suffering from an anxiety neurosis (ICD 300.0) or phobia (ICD 300.2) were followed up over a period of 6-8 years using standardized instruments. In addition, the course of illness, the utilization of medical services and the periods of work disabilities were assessed. With regard to psychopathology, in more than half of the patients course and outcome could be regarded as chronic and severe; only one third of the patients were free of marked or severe psychopathological symptoms during the 12 months preceding the reexamination. Although on the psychosocial outcome level 67% of the 40 former inpatients showed marked or severe difficulties in most social role areas, especially in the field of personal interaction, the great majority of these patients seemed to have adapted somehow to their life situations. Only 13% could be regarded as severely impaired and in continuous need of supervision and guidance. Coping difficulties with everyday demands and dissatisfaction with their social functioning and their anxiety-related restrictions were most prominent in all anxious patients. In contrast to some other long-term follow-up studies, most of which were carried out on outpatients, the results suggest a rather unfavourable course and outcome of anxiety disorders.

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.