Search

ResumenEl presente estudio, realizado en colaboración entre los Departamentos de Psiquiatría en universidades suizas y la Organización Mundial de la Salud, tiene dos metas principales: desarrollar métodos de evaluación que se puedan utilizar posteriormente en los centros suizos de una manera estándar, y tomar medidas para la colaboración continuada entre los centros en Suiza y la adquisición de nuevos conocimientos sobre las distinciones entre depresión y deterioro cognitivo. Con este propósito se seleccionaron tres grupos diferentes de pacientes ancianos de ambos sexos durante el periodo de noviembre de 1989 a julio de 1991 para su incorporación al estudio. Los dos primeros grupos incluían a los primeros diez pacientes de ambos sexos con más de 60 años de edad que contactaron consecutivamente con las instituciones participantes y que mostraban depresión con o sin síntomas clínicos significativos de deterioro cognitivo; el grupo de control incluía pacientes que no mostraban depresión o síntomas clínicos significativos de deterioro cognitivo. En la valoración inicial se incluyó un total de 125 pacientes, 69 de los cuales fueron evaluados de nuevo en un seguimiento a los siete meses (como media). Se administraron a cada paciente varios instrumentos calificados por el clínico o de autoinforme para la evaluación de la depresión, el deterioro cognitivo, las discapacidades, el estado físico y el comienzo de los trastornos.El estudio ha mostrado que se pueden utilizar diversos instrumentos para la evaluación fiable de la depresión o el deterioro cognitivo en los ancianos, pero los instrumentos para la evaluación de la depresión diferencian sólo pobremente entre pacientes con deterioro cognitivo o sin él. Debido a la importancia de identificar entre los ancianos tanto a pacientes deprimidos como a pacientes con deterioro cognitivo, es necesario administrar simultáneamente instrumentos de evaluación diferentes dirigidos a grupos de síntomas diferentes

SummaryThe present study, conducted in collaboration between the Departments of Psychiatry in Swiss Universities and the World Health Organization, had two main goals: to develop assessment methods which could subsequently be used in the Swiss centres in a standard manner; and to make arrangements for continuing collaboration between the centres in Switzerland and the acquisition of new knowledge about the distinctions between depression and cognitive impairment. For this aim, three different groups of elderly patients of either sex were selected during the period of November 1989 to July 1991 for inclusion in the study. The first two groups included the first ten patients of either sex over 60 years of age consecutively contacting the participating institutions and showing depression with or without clinically significant symptoms of cognitive impairment; the control group included patients showing no depression or clinically significant symptoms of cognitive impairment. A total of 125 patients were included in the initial evaluation, 69 of which were reassessed at a seven-month follow up (on average). Each patient was administered a number of clinician-rated or self-report instruments for the assessment of depression, cognitive impairment, disabilities, physical status and onset of disorders. The study has shown that a variety of instruments can be used for the reliable assessment of depression or cognitive impairment in the elderly; but the instruments for the assessment of depression differentiate only poorly between patients with or without cognitive impairment. Because of the importance of identifying both depressed and cognitively impaired patients among the elderly, different assessment instruments targeted at the different symptom clusters need to be administered simultaneously.

H.M. van Praag has been suggesting a reappraisal of syndromes in psychiatry for over 20 years. He has tried to define syndromes originating from the same biochemical disorder. He has denoted this concept as 'functional psychopathology'. As an example of such a functional syndrome, he has cited the serotonin-shortage syndrome which unifies various psychiatric symptoms under a new point of view. The treatment of the serotonin-shortage syndrome is best served by psychopharmaca which raise the metabolism of serotonin in the synaptic cleft, e.g. the selective serotonin re-uptake inhibitors. Borrowing F. Freyhan's concept of 'target symptoms', one can now speak of 'functional target syndromes', within the frame of functional psychopathology.

Hippocrates described both melancholy and dysthymia. An episode of mild depression lasting up to 2 years, which does not make patients unfit to work, although the repressive irritative mood disorder does reduce their ability to work. Severe depressive moods can develop from dysthymia. While dysthymia responds to antidepressant treatment similarly to depressive episodes, treatment must be carried out for a considerably longer period. The dosage dose not differ from that for severe depressive episodes. A few examples of cases are presented from the speaker's own cases to illustrate how well they responded to treatment with St.-John's wort.

Sexual problems, especially in the elderly, are to handle as a part of the whole personality. After an informative talk about the knowledge in the field of sexuality, we have to differ between subjective and objective problems of the patient and to find out possibilities to solve real problems and conflicts. This discussion of the problems is in every case the first step to any form of therapy.

Disturbances of impulse control, classified in ICD-10 and/or DSM-IV, have a high risk of comorbidity with other disturbances of the serotonin system. These affective disturbances could be interpreted as symptoms of a related syndrome because they usually respond to antidepressive pharmacotherapy. Selective SSRIs in addition to their antidepressant activity are useful even for impulse control disturbances and for common multimorbid mixed disturbances by their polyvalent serotoninergic activity because they improve at least quality of life in these patients. Results are better in patients with episodically disturbed impulse control than in those constitutionally afflicted.

Spatestens seit G. L. Engel 1977 das biopsychosoziale Modell seelischer Erkrankungen postuliert hat, ist in der Psychiatrie immerhin ein Paradigmawechsel in dem Sinne eingetreten, das partikularistischen Annahmen zur Entstehung und Behandlung von seelischen Erkrankungen die theoretische Basis entzogen wurde. Dies hat sich dann auch In der Empirie bestatigt. Selbstverstandlich ist die Funktion des Gehirns die Basis aller seelischen Krafte und Funktionen und auch der Storungen. Das hat schon Hippokrates gewust, denn bei ihm lesen wir: „Der Mensch sollte wissen, das seine Freuden und Vergnugungen, sein Lachen und sein Gluck, doch auch Kummer, Sorgen, Tranen und Schmerz seinem Gehirn und nur seinem Gehirn entspringen.“ Die Entwicklung der Naturwissenschaften hat im vergangenen Jahrhundert zu dem beruhmten Ausspruch von Griesinger gefuhrt: „Alle Geisteskrankheiten sind Gehirnkrankheiten.“

The classification of psychiatry to date is governed firstly by psychopathological symptoms and syndromes in addition to factors of personal and family history. It succeeded for the first time after discovering the serotonin-shortage syndrome, to correlate the different psychopathological conditions with a biochemical disturbance, as the result of which a new indication orientation based on a functional target syndrom could come about in psychiatry.

One can of course tell the story of psychiatry based purely on medicine history, but if one examines it from the point of view of evolution, one discovers a profound meaning in its development. Considering for instance deep psychiatry, one can ascertain that a development had definitely taken place starting from the biopsychological going on to social and finally to spirituell concepts. This draws psychotherapy and pastoral duties closer to one another again and thus cancels the Freudean concept according to which religious need is the expression of neurotic development.

The medical dialogue constitutes the basis of every doctor-patient relationship and it consists of more parts. The diagnostical dialogue comprises of a symptome-oriented and of a problem-oriented part. In the symptom-oriented part there have to be as many as possible symptoms systematically ascertained to come to a diagnosis, in the problem-oriented part the dialogue must be quite free to enable the patients to realise their problems without them getting the feeling of having been influenced. In the therepeutic part of the dialogue the problem has to take shape and the possibilities of its solution has to be discussed. The decision should be made by the patient.

This paper reports on cooperation between ophthalmologists and psychiatrists as seen from the latter's standpoint, primarily with regard to psychosomatic medicine and work in Balint groups. Ophthalmological experience both in a general Balint group and in a special Balint group mainly for ophthalmologists is described. The "general" part is mainly devoted to a discussion of everyday language associated with eyes and sight, since everyday language usually gives clues to psychophysical relationships. The main advantage of participating in Balint groups is that the practitioner learns to integrate himself, as a diagnostic instrument, with regard to his feelings and experiences. This results in a new relationship between patient and practitioner which could be defined as "relationship diagnostics" and "relationship therapy".

Sigmund Freud’s Meinung, das alles was die Kulturentwicklung fordere gegen den Krieg sei, wurde durch den ersten Weltkrieg von 1914–1918 schwer in Frage gestellt. In seiner entscheidenden Arbeit aus dem Jahre 1920 „Jenseits des Lustprinzips“ formulierte Freud seine Hypothese vom Todestrieb als Gegensatz zur Libido, nachdem er 1915 an seiner Arbeit „Zeitgemases uber Krieg und Tod“ sich erstmals mit den Problemen der Destruktivitat beschaftigt hatte. 18 Jahre spater, 1933, befaste er sich ein zweites Mal mit der Problematik des Todestriebes in seinem Aufsatz „Warum Krieg?“

Ethical problems in psychiatry are many-fold. The questions about preventive seclusion on one hand and ethics in psychiatric research on the other hand deserve particular emphasis. Preventive seclusion has been covered in some reviews; based on the convention on human rights of the WHO, it is applied in a manner that the patient has a guarantee for a decision by judiciary procedure whether his seclusion conforms to law. It is a distinct disadvantage in this context that only treatment of patients that endanger others or themselves is regulated. For many other patients in serious need for treatment the actual situation is problematic when-as is common in this group-insight into their state of illness is lacking. Another important problem is posed to ethical committees responsible for approval of research. An appropriate prerequisite is a broad political spectrum in the electing body for these committees, in order to exclude one-sidedness in any direction.

Pain as a psychophysical experience and in particular its treatment have always been--and are particularly nowadays--an essential problem in medicine. Beyond that pain has a multitude of connections to human existence. The phenomenon of pain appears in almost all areas of art (painting, sculpture, music and poetry), philosophy and the religions. In the arts pain and its expression is often proof of the noblest esthetic-spiritual creativity; in medicine on the other hand it touches only the depth of human existence, then, when severe, chronic pain leads to disintegration of personality. From these propositions emerges that pain is not only sensed but is also a sentiment. Both belong together in an inseparable act of passive acceptance and active creative experience. Whereas the phenomenon of pain has earlier been seen in its alternative respective components such as physical or spiritual, it is in modern times, following the holistic perception of medicine, regarded as complementary. This complementary view is also the basis for the various forms of combined pain-treatment in use today.

In psychiatry there are two major problem areas where ethical questions are of greatest importance. On one hand these are problems arising from commitment to an institution, e.g. forced hospitalisation and forced treatment. Swiss civil law requires in articles 397a to f that such patients may appeal to a judicial court. When this court is a commission comprised of an attorney and of psychiatric and psychotherapeutic specialists, it is of greatest importance that the patient himself be heard by the attorney and not just by a member of the commission and that this attorney also takes into account statements of relatives, as an incompetent patient may say things that are inconsistent with actual facts. As existing or planned hospitalization laws apply mainly to acutely ill patients who are dangerous to themselves or to others, the treatment of chronically ill psychiatric patients cannot be guaranteed. Thus conflicts of conscience arise, since physicians are required to provide medical aid; therefore if such aid is not given or if it is refused, a physician can be sued for inflicting heavy injury. Hence there is an urgent need for judicial measures that guarantee also the treatment of the chronically ill who, like all patients, have a right to be treated. A second problem area is represented by the ethical commissions that decide which scientific investigations may be performed on psychiatric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

While describing mimic and pantomimic aspects in depressive patients, the author points out how these features can often be found clearly reproduced in the paintings of artists. Then paintings of a depressive and suicidal female patient are discussed and compared with paintings of a talented student-nurse from our institution expressing her experiences with depressive patients. Also some examples of literary depiction of experienced depression are discussed. Finally the question is posed whether suicidal individuals can be freed from their ideas and impulses by pictures expressing suicidal ideas.

Diese Tagung findet in einem Raum statt, der Michael Balint gewidmet ist, welcher hier gelebt, gewirkt, gesprochen und gearbeitet hat. Es musten jedoch Jahrzehnte vergehen, bis das erste Wort einer Tagung von einem Kollegen aus Ungarn und Rektor einer ungarischen Universitat gesprochen wurde. Wir haben zwar schon seit langerer Zeit Kollegen aus Ungarn begrust, aber das heute das Eroffnungswort von einem ungarischen Kollegen, Magnifizenz Prof. Janos Szilard, gesprochen wurde, ist meiner Meinung nach ein wirklich schones Erlebnis, das dem Namen Monte Verita Wahrheit verschafft. Wir Asconauten haben allen Grund, da wir uns doch im Sinne von Balint verstehen, zu diesem Ereignis ein herzliches und lautes „Allegra“ zu rufen.

Psychosomatic medicine can be approached from several points of view; one of them is the psychophysiological approach. This contribution places particular emphasis on reticular formation. The reticular formation is fed by specific impulses and enervates the brain to a higher level of activation by very fast unspecific impulses. In a phylogenetic perspective this higher level of activation was the antecedent of fight and flight.

Initially we differentiate a simple psychosocial crisis from a psychiatric crisis; the former is usually a non-pathological phenomenon, which may result in a pathological development. As one critical assumption, we consider suicidal potential. After discussing the phenomena of suicide and attempted suicide, the problem of suicide and family is emphasized in regard to biological-genetic and psychosocial aspects. Finally, we refer to prophylactic-therapeutic interventions for psychosocial crisis and manifest suicidal tendency.