Evidence Based Medicine and Psychiatry has had a (controversial) success in the last years. Narrative Based Medicine and Psychiatry has emerged subsequently as a complementary (not an alternative) movement. The object of this presentation is the following question: To what extent are these movements something new for medical science? Or, to what extent are they simply the current expression of an age-old tradition in the history of medicine and psychiatry? Our objective here is to review a series of possible (and scantily commented) historical antecedents, not so much of Evidence- and Narrative- Based Medicine and Psychiatry in themselves, as of the scientific aspirations and the human needs that are behind them.

This paper is included in the Research Project Ref. HUM2005-02105/FISO, Ministerio de Educación y Ciencia (Ministry of Education and Science), Madrid, Spain.

Keeping in mind the constrictions and limitations that have marked the development of Spanish psychiatry during a good part of the 20th century, it is not surprising that its contributions to the epistemological and methodological foundations of psychopathological knowledge have been relatively scarce if compared with other countries and national traditions. Nevertheless, the writings of some outstanding authors include valuable reflections and theoretical insights that go beyond the mere reception of foreign ideas. Apart from the intense concern for anthropological questions or for the problems of existential analysis which were so typical during the central decades of the century, there have been a series of notable contributions related to the concept of understanding in psychiatry, to the development of psychopathology as an objective hermeneutics, to the historical and empirical calibration of the mental symptom and to the theoretical implications stemming from the nature of the psychiatric experience which will be presented and reassessed in the course of this presentation.

Obsessive compulsive disorder (OCD) is observed at increased rates in first-degree relatives of probands with autism spectrum disorders (ASDs). In addition, OCD-like traits are observed in autism, and in Asperger syndrome. Furthermore, subjects with OCD may have traits that overlap with some aspects of higher functioning ASDs. These observations suggest that OCD and ASDs may share some genetic risk factors. In support of this, it has recently been suggested that both common and rare functional variants in the serotonin transporter (SLC6A4) may increase risk for OCD and/or ASD. We will review our large-scale analysis of common and rare functional variants SLC6A4 in ASDs and relate these results to studies of OCD. In parallel studies, we have carried our linkage analysis in families with ASDs, focusing on those with more severe OCD-like traits. These families demonstrated increased evidence for linkage to chromosomes 1, 6, and 19. Evidence for linkage to chromosomes 6 and 19 have been observed in other studies, which we will summarize. Finally, we have examined the evidence that common variants in the NrCAM, TPH1 and TPH2 genes are associated with ASDs, particularly in patients with more severe OCD-like traits, and these results will be summarized.

ADHD and autism spectrum disorders (ASD) are neurodevelopmental disorders with a complex presentation and etiology. They are both considered to be heritable conditions with a widely accepted genetic component to the etiology and efforts to find susceptibility genes underlying these disorders are gradually yielding interesting findings (Faraone, 2006, Grice, 2006). The challenge for genetics studies for the individual disorders will be elucidation of the relationships between susceptibility genes and the complex phenotype.

Given the genetic underpinnings of both disorders it is not unreasonable to ask the question as to whether there is shared genetic vulnerability. Genetic overlap is not widely reported in the literature and there is a relative dearth of direct investigation of this question. Evidence suggests a role for genes involved in the dopaminergic and serotonergic systems in both ADHD and autism but it is not clear if genetic variation in genes involved in these systems is similar. Further investigation is warranted to directly investigate potential overlap and subsequently to address the complex task of understanding the relationship between genetic susceptibility, possible common endophenotypes and the clinical phenotype. It is likely that multiple mechanisms, both genetic and environmental may be at play.

A discussion of the existing literature with respect a putative overlap in genetic vulnerability and the clinical phenotype is presented. Furthermore the specific challenges for research in assessing these factors in future studies is discussed.

Cultural and social barriers often prevent migrants in Germany from frequenting centers for information, counseling and treatment of psychiatric disorders. To verify existing hypothesis and to discover further reasons for the low accessibility rate of health care system in a first step we conducted 16 qualitative interviews with professionals of the drug treatment facilities in Germany, 15 with opiate dependent Turkish patients, 3 with alcohol addicted Germans and 3 with alcohol addicted ethnic Germans from the former Soviet Union. Also we examined cultural differences in the explanatory models of psychiatric disorders including addictive behavior among Turkish and German adolescents as well as among ethnic German adolescents who migrated to Germany from the former Soviet Union. The statistical device ANTHROPAC was applied to map the semantic space of concepts associated with problems of addiction and psychiatric disorders.

Relevant barriers which prevent migrants from frequenting drug treatment facilities were found out. Frustration, missing of integration and loss of perspectives, which have a big influence on the maintaining of addiction in general.

Ethnic German migrants from the former Soviet Union and native German youths used addiction concepts in a rather similar way.

Preventive information programs may profit from considering these differences and need to use concepts that are accepted and clearly associated with psychiatric disorders by immigrant populations.

Although about 20% of German population are migrants not enough knowledge exists about health status, alcohol and tobacco addiction and preventive health behaviors with respect to addiction in migrants. The largest populations of migrants in Germany are Turks and Russians. The goal of the project presented in this paper is to investigate the relationship between health status, alcohol and tobacco addiction and preventive health behaviors of Russian and Turkish speaking migrants in Hannover, Germany. Additionally, the project deals with the question of possible barriers migrants experience on the way to the health service system in Germany. For example, cultural differences in understanding of health and decease concepts, language difficulties, lack of knowledge about possible preventive measures and lack of information in mother tongue could be possible barriers that make the access to a healthy way of living more difficult for migrants. To investigate possible barriers migrants experience we apply the mother tongue mediator approach that allows better access to the community of migrants, helps to overcome cultural differences in understanding of health related concepts, and makes the information on preventive behaviors in community of migrants more acceptable. Results of a pilot study in Russian speaking migrants (N=18) are in line with hypotheses. 28.6% of the sample report alcohol addiction, high level of psychological distress and depression, low level of perceived social support and low level of physical health. Language difficulties and lack of bilingual information on health topics are most frequent barriers experienced in this sample.

Abstract not available at the time of printing.

The article examines infection with viral hepatitis A, B, and C and socio-ethnic factors in a population of injection drug users seeking treatment. The study was conducted between 2001 and 2003 in a rural German hospital; selected sociodemographic and drug-related data as well as a serology for hepatitis A, B and C were obtained from 1499 patients. Statistical analyses were performed by univariate analysis of variance and post-hoc Scheffé tests or with the c2-test and Bonferroni-adjustment. Ethnic minority patients manifested a more severe course of addiction and showed a higher frequency of infection with hepatitis A, B, and C. Low-threshold culture sensitive drug user treatment programs should be implemented and evaluated.

It is perhaps the scientific ‘law’ in suicidology that suicidal individuals are experiencing psychological pain or suffering and that suicide may be, at least in part, an attempt to escape from this suffering. Suicide occurs when the psychological pain or psychache is deemed by the person to be unbearable. Shneidman proposed that the key questions to ask a suicidal person are ‘Where do you hurt?’ and ‘How may I help you?’ If the function of suicide is to put a stop to an unbearable flow of painful consciousness, then it follows that the clinician's main task is to mollify that pain. Shneidman also pointed out that the main source of psychological pain is frustrated or thwarted psychological needs. These psychological needs include the needs for achievement, affiliation, autonomy, counteraction, exhibition, nurturance, order and understanding.

Although the concept of psychache is used in discussions of suicidal behavior, there have not been many attempts to devise quantitative measures of the variable for research. Also, for suicidal psychiatric patients, amelioration of symptoms is not sufficient to reduce pain associated with certain events, probably because of the lack of proper management. In addition, efforts should be made to reduce the psychache currently experienced and to restructure the cognitions of the patients about the traumata that they have experienced in the past. Asking of the suicidal person about psychache and suicidality may be useful in establishing rapport with the patient and in assessment, beyond psychometric scores.

Although suicidal behaviour is a rare event in the community, it is very common among psychiatric (mostly depressive) patients who contact different levels of healthcare (mostly GPs) before the suicide event. The most common current psychiatric diagnosis among suicide victims and suicide attempters is major depressive episode (56-87%), which, in the majority of cases is unreferred, unrecognised and untreated. The current prevalence of major depressive episode in the primary care practice is between 8 and 12%, and earlier studies reported that only a minority of these cases are recognized and treated adequately by GPs. Fortunately, most recent studies reported much higher (62-85%) recognition and treatment rates. Since successful acute and log-term pharmacotherapy of depression significantly reduces the risk of suicidal behaviour and 34-66% of suicide victims (two-thirds of them should have current major depression) contact their GPs 4 weeks before their death, GPs play an important role in suicide prevention (Luoma et al, 2003). In fact, several large-scale community studies (The Swedish Gotland and Jamtland Studies, the Nuremberg Alliance Against Depression, the Japanese Elderly Suicide Prevention study and the most recent Hungarian Kiskunhalas GP Suicide Prevention Study) demonstrated that education of GPs on the diagnosis and treatment of depression, particularly in combination with public education, improves the referral, identification and treatment of depression and reduces the frequency of committed and attempted suicides in the areas served by trained GPs.

The act of suicide and the consequential death provoke a lot of different emotions and reactions in those who used to be involved in the life of the deceased.

The group most affected by the aftermath of suicide are members of the family, but the same can be true with friends, colleagues, teachers, a therapist, if the person had been in treatment, and a general physician, who took care of his/her health. Who is suffering most and who needs most help can be different in every case, depending on the circumstances. Every suicide produces a unique emotional response in the bereaved survivors, ranging from desbelief, despair, sorrow, guilt, shame and anger, and this is why some of the survivors search professional help and support, either individual or in a group. This therapy has a dual purpose: first, it helps the individual or family to go through rather extreme and very difficult time while also getting more insight, understanding and accepting of their own feelings and reactions, and second, it presents a good example of practical prevention of further potential dysfunctioning of an individual or the family as a whole (e.g. suicide). Some practical examples of cases based on seventeen years of therapeutic work with suicide survivors will be discussed to show possibilities and limitations of such help.

The workshop will give an overview of distinct neurophysiological and brain imaging studies with patients suffering from Borderline personality disorder and from depressive affective disorder. The contribution of Jose Manuel De la Fuente will report findings of sleep EEG recordings of patients with Borderline personality disorder (BPD), Major Depression (MD), Recurrent Brief Depression (RBD), and of controls. It was detected that BPD patients expressed less slow wave sleep than MD and RBD patients without BPD. Oliver Pogarell performed a radioligand brain imaging study that revealed an increase of the availability of the specific serotonin transporter (SERT) in the hypothalamus and brain stem of BPD patients which is in contrast to the findings of a SERT decrease in patients with depression. Christine Norra recorded event-related auditory evoked potentials (AEP) obtained through the application of various loudness stimuli. The strong loudness dependency of AEP in patients with BPD correlated with aspects of impulsiveness which may point to a serotonin disturbance in this disorder. Thomas Zetzsche and his collegues performed a quantitative volumetric magnetic resonance imaging (MRI) analysis of temporolimbic regions in patients with BPD and MD. They found a significant increase of amygdala volume both in BPD patients with comorbid MD and in MD patients without BPD. Comparison of abnormal neurobiological findings between BPD and MD could provide a better insight into potential differences but also into similarities of the pathophysiology of these important psychiatric disorders.

Similar to the different suicide rates in Europe (also in EU countries) also the European suicide attempt rates in various areas are quite different. The results of the WHO Multicentre Study on Suicidal behaviour show a ratio between the catchment area with the highest suicide rates (Tallin) and the catchment area with the lowest rates with 1: for males and 1: for females. Over the period covered by the study the rates changed, however the rank order between the various catchment areas remained stable, thus showing that the differences can not only be caused due to different assessment procedures. In all catchment areas the suicide attempters belonged more often to the lower social classes, were more often unemployed and showed in general more detrimental social factors. Repetition of suicide attempts were often made in a relatively short period after the first suicide attempt. One reason for this can be that the time lag before the uptake of the first psychotherapeutic treatment (appointment) for many cases was very long, more than 20% of the patients had the first psychotherapeutic treatment only after six months. Also the stability of the therapeutic contacts was not very consistent after the suicide attempt: many patients had contacts with more than five care providers. This pattern changed only a little during the period under investigation.

Although suicide is a very complex, multicausal behaviour, Hungarian and international results show that untreated or unsuccessfully treated major depressive episode is the leading cause of suicide, particularly in the presence of other suicide risk factors. However, large-scale, long-term clinical follow-up studies clearly demonstrate that appropriate acute and prophylactic pharmacotherapy of major mood disorders substantially reduces the suicide mortality even in this high-risk population.

Between 1980 and 2003, in Western and Central Europe, out of the 13 countries with high baseline suicide rates (20 or more) in 1980/1981, 10 countries (Denmark, Hungary, Austria, Switzerland, Estonia, Slovenia, Latvia, Finland, Czech Republic and Belgium) showed decrease (in average: 26.9%, range: 6-57%), and 3 countries (Lithuania, Russian Federation Ukraine) showed increase (in average: 15.7%, range: 10-25%). Out of the 16 countries with low baseline suicide rates (less than 20) 9 countries (Sweden, Germany, U.K., Norway, Greece, Slovakia, Netherlands, France and Italy) showed decrease (in average 15.2%, range: 7-31%), and 7 countries (Ireland, Spain, Romania, Poland, Portugal, Iceland and Bulgaria) showed increase (in average 49.1%, range: 3-102%). In the vast majority of the countries, unemployment, alcohol consumption, GDP, and divorce rate did not correlate with changing suicide rates and the only and mostly consistent (negative) correlation has been found between increase in antidepressant-prescription (9-fold increase in Hungary) and declining suicide rates (38% decrease in Hungary. Political / economic changes after 1990 does not seem to have a fundamental role in changing suicide rates in Western and Central Europe.

Using WHO “Health for all” database we looked at suicide rates in 15 former USSR republics up to latest data. Since A.Värnik and D.Wasserman in the end of 90s have described an effect of anti-alcohol campaign during “perestroika”, in the period from 1991-1992 to 1995-1996 there was a sharp rise in suicide rates in the majority of new independent states. Two main clusters can be distinguished: 1) countries with prevailing ethno-cultural factor (Azerbaijan, Georgia, Armenia, Tajikistan, Turkmenistan, Uzbekistan, partly Republic of Moldova) - general rise was not so marked or did not happen, highest rates were registered in Soviet times and even painful period of transition did not cause higher suicidal activity; 2) countries with prevailing economic factor (Baltic countries, Belarus, Russian Federation, Ukraine, Kazakhstan and Kyrgyzstan) - on the contrary, lowest rates were registered in the Soviet times and maximums were achieved after USSR split. These are mostly industrial countries and dramatic rise in suicides may be attributed to severe economic problems and “shock therapy”. Since 1994-1996 and especially after 2001 in these countries a gradual lowering of suicide rates started, which may be attributed to overcoming main economic difficulties. However in the Russian Federation there was a sharp rise in 1999, shortly after default in summer of 1998. Emerging of new independent states on the world map made it possible to see the interplay of economical, social, political and ethno-cultural factors in provoking (or protecting) populations from suicidal behavior in the transition periods.

In Europes countries of heavy societal transition, especially male patterns of suicide reflect seismographically the stress load in a country, induced by societal and individual transition.

Suicidality is hereby embedded in stress related morbidity and mortality, mediated by risk taking behaviour and lifestyles, cardiovascular and cerebrovascular morbidity and mortality as well as addictive behaviour and violence.

Male suicide rates are highest in societies where a stressful transition even afflict gender roles that untill recently had been traditional. They seem even connected to males shortcomings in their ability to cope with changes regarding their societal status, dignity, self estimation social significance and sense of existential cohesion.

Most male suicides are commited without help seeking and contact with medical or other support systems.

Thus, problems are aggravated by males traditional inability to seek help and be compliant - combined with the incapacity of mental health support structures to provide services that not only are accessible but also acceptable for men.

In addition to this, there are problems of diagnosing males typical “atypical” symptoms of depression and suicidality by traditional depression assessment criteria, leading to both underdiagnosis of male depressive states as well as a consequent male oversuicidality.

Between 1984-88 in USSR male suicide rates decreased by 40% and female by 18%, as compared with 22 European countries where the decrease was 3% and 7% respectively. Decreases in suicide rates occurred in all republics and for both sexes, but most in the republics where alcohol consumption was high and for men aged 25-54 years. Analyses of the impact of restrictive anti-alcohol policy during perestroika on suicide rates showed that alcohol has a considerable explanatory value for falling suicide rates during this period. The estimated attributable fraction of alcohol in the whole USSR in this period was approximately 50% for male, and 27% for female suicides.

The natural experiment that took place in all 15 republics of the former USSR during perestroika (“restructuring", 1985-90) appears to have been one of the most effective programmes for suicide prevention in modern history.

The results of a case-control study psychological autopsy study performed with relatives of people who committed suicide and with controls confirmed our previous results on the aggregate level and showed that alcohol abuse and dependence (AAD) was diagnosed in 68% of male and 29% of female suicides.

35-59-year old males who committed suicide had the highest risk of alcohol dependence. Among suicide cases only 29% had received life-time diagnoses of alcohol abuse and dependence.

AAD is markedly underdiagnosed by general practitioners and clinicians. In suicide prevention it is important to screen for AAD among patients in both general practices and in psychiatric out- and in patient clinics.

Firstly the descriptive phenomenology of impulse control disorders will briefly be delineated with its focus on the heterogeneity with regard to etiology and psychotherapeutic access.

Secondly the functional findings will be reported which suggest very different categorisations and different psychotherapeutic techniques with the domains of dysfunctions characteristic for addiction, OCD, and impulse control disorder sensu strictu.

The nosological and functional heterogeneity becomes a special difficulty for forensic assessment since psychopathological context, functional underpinnings and societal attitude are very different across the category of impulse control disorders. Categorical and dimensional concepts are intermingled.

Thirdly special aspects of the phenomenological approach will be given eventually with a concluding consideration of what we can make clinically of this heterogenic cluster of disorders and what needs to be clarified by future research.