Einsatz von Bupropion bei älteren Patienten

Die chronische bipolare Depression bei ?lteren Menschen ist eine klinische Herausforderung und erfordert unter Umst?nden, wie der vorliegende Fallbericht zeigt, Behandlungswege, die von Leitlinien nicht unbedingt abgedeckt werden.     

Lithiumtherapie bei älteren Patienten mit bipolarer Erkrankung

psychopraxis. neuropraxis - Die Behandlung psychiatrischer Erkrankungen mit Lithium bei älteren Patienten ist phasenprophylaktisch so wirksam wie in der Allgemeinbevölkerung und besitzt...     

Therapieresistente Depression – eine differenzialdiagnostische Herausforderung

Background

Diagnosis and treatment of major depression is part of daily routine in psychiatric practice. We therefore rely on the latest ICD-10 and the described symptoms. However, is this decision always obvious, and which differential diagnostic considerations should be made, especially for patients with treatment-resistant depression or in elderly patients?

Method

A clinical case report is described, taking into consideration the results of a literature search and national and international guidelines.

Results

Major depression is usually part of daily routine in the psychiatric hospital. It is one of the most common diagnoses; the estimated lifetime prevalence of unipolar major depression is 12?% and continues to increase. But what should be done, if symptoms continue to deteriorate, despite guideline-based treatment? The following case report shows that in this situation further diagnostic procedures are needed and necessary. An 80-year-old man is transferred to a psychiatric ward because of depressive symptoms. Despite adequate treatment, the psychiatric state deteriorates. Finally, the diagnosis of normal pressure hydrocephalus (NPH) is made with the direct consequence of further treatment options. Especially the possible overlap of symptoms for depression, dementia, and NPH are shown, thus, making the differential diagnosis challenging.

Conclusion

In 80?% of cases, NPH remains unrecognized and untreated. Similarities in the symptoms lead to the difficulty of distinguishing NPH from other neurodegenerative disorders and, as in this case report, also from major depression. In case of NPH, early diagnosis and treatment are important because if the disease is too advanced, clinical improvement is unlikely. Therefore, in cases of treatment-resistant major depression it is advisable to perform additional diagnostic tests and to consult with interdisciplinary neurology and neuroradiology teams.     

Mentalisierungsdefizite bei stationären Patienten

Background

Fonagy (2009) considers the improvement of mentalization, understood as an element of structural change, as a global goal of psychotherapeutic treatment. Yet until now there is little knowledge about the mentalizing skills in clinical populations.

Material and methods

We examined the mentalizing skills in 201 patients on admission for complex psychotherapeutic inpatient treatment with the “Reading the mind in the eyes”-Test (RMET). We explored if there are diagnosis-related differences in the RMET and compared our findings to published data on the RMET in clinical and normal populations.

Results

Compared to normal populations our sample scored significantly lower in the RMET, however, no diagnosis-related differences were found.

Conclusions

Although our data are preliminary, psychotherapeutic inpatient treatment should consider the patients reduced mentalizing skills.     

Kasuistik zur Kindeswohlgefährdung bei postpartaler Depression

Postpartum psychiatric disorders adversely affect the relationship between the mother and her baby, frequently in a very serious way. It is common that both objective and subjective aspects of this relationship would be negatively influenced by the maternal pathology. The disturbances that arise from the psychiatric disorders could become a hostile and rejecting quality and could be unfavourable to the long-term development of the child. Obsessional impulses to harm the baby are not rare by mothers in the postpartum period. A large figure of severely depressed and psychotic mothers admited to have had some thoughts of harming or to killing the baby. Some of them have already done harmful things to their babies. Ideations of infanticide or child abuse are not always associated with psychiatric disorders (i.e. depressive symptoms or delusion). They could be a consequence of a severe Bonding disorder.     

Rechtliche Gesichtspunkte zur Rückfallprognose und Vollstreckung bei älteren Straftätern

As our society ages, the number of offenders who are older than 60 when they are up to release from prison or forensic hospital also increases steadily. Instruments of prognosis (e.g. HCR-20, PCL, SVR, Static-99, Dittmann-List) currently in use are not validated for this group, which means that forensic-psychiatric and -psychological experts have to rely on casuistry with all it’s methodical problems for their reports on whether or not there is a risk for relapse (which are obligatory by German law). Therefore the Courts of Execution Matters (in Germany dealing with conditional discharge; same question for any kind of Parole Board in other countries) have to apply standards as provided by the law and the jurisdiction up to the Constitutional Court to a much higher degree than they have to do regarding the much better researched group of younger offenders. In doing so, the focus has to be much more on the special circumstances of senior citizen in general and specifically on the aged offender’s life. There is a urgent need to intensify research on this group of offenders.     

Angstzustände bei Patienten mit schweren Persönlichkeitsstörungen

States of anxiety are very common problems in patients with severe personality disorders. All phenomena of anxiety can be observed. In this connection a continuum of the severity of impairment of structural personality organisation can be postulated. In many cases proper anxiety disorders exist as comorbid disorders. Anxiety is esteemed to be the central affective problem of borderline patients. In spite of these relations, states of anxiety in patients with personality disorders are often underdiagnosed or misdiagnosed. For the treatment of neurotic anxiety disorders (for example panic disorders), there exist disorder-specific therapy manuals that proceed from behavioural as well as psychodynamic perspectives. Nevertheless, for the treatment of anxiety states in personality disordered patients, the techniques that focus heavily on symptomatology appear often contraindicated. In our opinion, treatment of these typically severe anxieties must be contained within a therapeutic framework, which essentially takes into account the personality organisation of this group of patients. Such treatment makes special demands on the therapist for working with transference and countertransference processes. From a disorder-specific psychodynamic perspective recommendations are given for psychotherapy.     

Psychotherapieplanung bei “schwierigen Patienten”

This article describes a model of comprehensive psychotherapy planning for difficult patients, especially patients with borderline personality disorders and psychotic disorders. Its aim is to develop a psychotherapeutically orientated approach to treatment corresponding to the individual needs of the patient and the people closest to them (e.g. family).Central elements of the planning process are diagnostic/therapeutical family meetings in which psychoanalytic and systemic conceptualisations are applied together. The main features of this context oriented model development are described and illustrated by case studies.The article also presents first results of an analysis of the therapy plannings and discusses the questions arising.     

Lärmendes Verhalten und störende Lautäußerungen bei Patienten mit Demenz

Loud behavior and disruptive vocalizations occur relatively frequently in patients with dementia together with agitation and other behavioral problems. An unambiguous diagnosis is important to take targeted therapeutic measures. First, nonpharmacological measures should be tried and the triggering stressors should be identified and eliminated if possible. Guidelines for the treatment of behavioral disorders, thus also for loud behavior, recommend behavioral therapy, cognitive–emotional training, sensory stimulation therapy, and psychosocial interventions. Targeted therapeutic measures can provide relief for the person with dementia and the relatives and nurses.     

Stationäre Rehabilitation alkoholabhängiger Patienten

Systemic therapy concepts are widely used in therapy and rehabilitation of alcohol addictive patients. Although very useful in practice, evaluation studies are rare. Adequate evaluation strategies should be developed and implemented. This study was realized in a clinical rehabilitation centre (Hirtenstein, Allgäu/Germany), whose systemic concept is characterized by patient's wideranged possibilities of choice concerning therapy measures and therapy goals, the activation of social and personal resources, the development of an individually appropriate life-style, the training of desired competencies, and an offer for marital and family therapy. The evaluation is based on a repeated measures design without control group. The instruments and constructs of the evaluation are: F-SOZU (perceived social support), IIP (perceived interpersonal problems), MLDL (quality of life), SOC (sense of coherence), and an assessment sheet for personal resources (RI). Patients (n= 44) reported increased personal ressources as well as an increased level of quality of life. Perceived social support and the sense of coherence changed only moderately. Scaling of treatment satisfaction and goal attainment at the end of the rehabilitation program resulted in high positive scores. Patients reported only positive, no negative treatment side effects. The results indicate the usefulness of systemic and resource oriented concepts in the rehabilitation of alcohol addictive patients.     

Depression som social intärning

Sammanfattning: Depression kan bero på felaktigt given förstärkning i uppfostran eller på ringa positiv förstärkning från omgivningen. Behandling av depression med metoder, som utvecklats vid universitetet i Oregon, bygger på kodning av interaktioner, daglig skattning av sinnestillstand och aktiviteter samt tids—begransning av behandlingen, hemobservationer, gruppinteraktion. Därigenom får man informa—tion om beteende, som utgör grund för testning av hypoteser, för utveckling av behandlings-strategier och for evaluering av beteendeför-ändringar     

Somatoforme Störungen bei ambulanten dermatologischen Patienten

Zusammenfassung In der vorliegenden Studie wurde die Häufigkeit somatoformer Symptome in einer dermatologischen Universitätsambulanz untersucht. An der Studie nahmen n=195 Patienten teil, die Screeningfragen zu somatoformen, dermatologischen und depressiven Symptomen ausfüllten. Zusätzlich wurde eine dermatologische Beurteilung der Symptome hinsichtlich der Ätiologie erfasst. Danach wiesen 26,2% der Patienten Hinweise auf eine somatoforme Störung auf; am häufigsten waren somatoforme Schmerzstörung (16,9%) und körperdysmorphe Störung (15,4%). Unter den spezifischen dermatologischen Symptomen wurde Juckreiz besonders häufig (10,3%) als somatoform klassifiziert. Der Anteil von Patienten mit erhöhten depressiven Beschwerden lag bei 17,3%. Die Ergebnisse sprechen für eine erhöhte Prävalenz somatoformer Störungen bei dermatologischen Patienten. Die Identifizierung und psychotherapeutische Versorgung dieser Patientengruppe sollte in der dermatologischen Routineversorgung mehr Beachtung finden.     

Juvenile Depression mit psychosomatischer Ausprägung

Die Patientin (Jahrgang 1994) litt an einer Depression mit schwerer psychosomatischer Auspr?gung – maskiert durch chronische Schmerzen. Mit einer relativ niedrig dosierten Gabe von Sertralin konnte eine vollst?ndige Remission erreicht werden.     

Therapeutischer Stil und psychotherapeutische Behandlung älterer Patienten

Although the clinical field of psychotherapy for elderly patients is gradually developing, there is still a considerable gap in research on the topic. This mainly concerns questions about the characteristics of psychotherapy for elderly people. Based on clinical experience the therapeutic relationship and therapeutic style are of particular importance. This article presents a survey of psychotherapists who were asked with a questionnaire on their therapeutic style in the treatment of both elderly and younger patients. Data analysis showed differences between the two groups of patients concerning therapeutic technique and the assumed impact factors. In addition, differences between behavioral therapists and psychodynamic psychotherapists are important. The findings are discussed in the context of necessary modifications in the treatment of elderly people and training requirements.