Tijdschrift voor psychiatrie最新文献

Background: In a minority of patients with substance use disorders, there is both unwillingness to treat and serious harm or damage to the patient or society. In these situations, compulsory treatment may be considered. However, it is unclear whether compulsory care is effective in reduction of substance use.

Aim: To describe the literature on the effect of compulsory care (in criminal or civil law settings) on substance use in adult patients with substance use disorders.

Method: Literature review, including 17 articles through PRISMA analysis. The risk of bias was severe to critical in most studies.

Results: Compulsory treatment was imposed in 16 studies (similar to a ‘voorwaardelijke strafrechtelijke machtiging’ in the Netherlands), in one study also from the youth protection system and one from the civil law framework. In seven studies there were no significant differences in substance use between compulsory and voluntary treatment, in two studies outcomes were better in the compulsory group and in four studies outcomes were better in the voluntarily treated group. Four studies did not compare the two groups or did not describe significance.

Conclusion: The 17 included studies found varying outcomes regarding the effectiveness of compulsory treatment for substance use disorder, with a considerable risk of bias, ranging from methodological shortcomings to selective reporting of results. This makes it impossible to draw unequivocal conclusions about the effectiveness of compulsory care in achieving long-term abstinence or reducing substance use.

A 55-year-old man with recurrent depressive episodes, with onset at age 45, was admitted to hospital after a suicide attempt. Due to a recent stroke as well as a family history of stroke and depression, CADASIL (prevalence of 2-5 per 100.000) was considered as a possible diagnosis. Although depression is common in CADASIL, the initial presentation is not typically comprised of recurrent depressions. Brain MRI, however, did not show the characteristic white matter lesions in the anterior temporal lobe. Genetic analysis revealed a cysteine-sparing mutation (Arg61Trp) in the NOTCH3 gene. Recently, several such mutations have been associated with CADASIL presenting with an atypical phenotype including a lower prevalence of recurrent stroke. This suggests that the prevalence of CADASIL may be higher than estimated in depressed patients. This case demonstrates the importance of considering CADASIL as a possible etiology of depression as this has consequences for prognosis, treatment and genetic counseling.

Background: Residents in psychiatry can be confronted with patient-related stressful experiences which can be impactful. Guidelines for dealing with these are lacking.

Aim: Questioning residents in psychiatry about patient-related stressful adversities, their impact and resources to contribute to the existing literature.

Method: Qualitative study through semi-structured interviews of six psychiatry residents, followed by data-analysis using thematic analysis.

Results: Reported patient-related stressful experiences were suicide, verbal and imminent physical aggression, questioning expertise, concerns about legal consequences, powerlessness and expectations. Cognitive and physical impact was experienced with symptoms similar to acute stress disorder. The most important resource is social support.

Conclusion: In this study new patient related stressful experiences are reported that have not previously been described in the literature. Since estimating the impact of a patient related stressful experience proves difficult, it seems appropriate that the environment of the resident offers active support and further development of residents’ skills is stimulated.

The absence of treatment studies for obsessive compulsive disorder (OCD) in older adults and the fact that OCD typically starts at a young age and often follows a chronic, fluctuating course quickly leads to therapeutic nihilism for older adults with OCD. In this case report, we present a 72-year-old man with OCD symptoms from the age of 35, who has only been treated with medication and psychotherapy for a recurrent depressive disorder. After a short, intensive exposure and response prevention treatment (four days in two weeks), the OCD symptoms and the depressive symptoms were fully in remission and all medications (venlafaxine, olanzapine, depakine) were discontinued. Treatment gains were maintained with persistent remission until 18 months follow up. This case report shows that a comorbid depressive disorder may lead to undertreatment of OCD. It also shows that long standing OCD can be successfully treated in older adults.

The differential diagnosis of chorea encompasses a broad range of disorders. In psychiatry, tardive dyskinesia may be difficult to discern from other causes, particularly when the family history is negative. A 59-year-old man with an unclear medical history had been using risperidone for over a decade when we first saw him. He presented with severe dyskinesia in all extremities. The family history for neuropsychiatric disorders was negative. We interpreted the movement disorder as tardive dyskinesia, but later he turned out to suffer from Huntington’s disease. To improve diagnostic accuracy, we should have more frequently re-evaluated the differential diagnosis and our family history should have been more thorough. We outline the diagnostic considerations in patients presenting with chorea. Finally, we highlight the value of diagnostic re-evaluation and thorough family history taking to optimize diagnostic accuracy in neuropsychiatry.

Clozapine is effective in treatment-resistant schizophrenia. However, clozapine has its own (well-) known side effects. We describe a case of a patient who developed epileptic seizures after starting clozapine. First he had a tonic-clonic seizure and subsequently myoclonic seizures. It is relevant to recognize the epileptic origin of these events. If tapering the clozapine dosage is not possible, the myoclonic seizures are treatable with anti-epileptic drugs. We describe the case history of this patient, the differential diagnosis and the evidence of a correlation between myoclonic epilepsy and clozapine based on international literature.

Background: As a result of a common misunderstanding of the concepts of generalization, discrimination and prejudice, their methodological significance for a scientific psychiatry gets out of sight.

Aim: An attempt to rehabilitate these concepts METHOD: An explorative consideration based on actual trends in society and mental health care RESULTS: Examples are given of the one-sided framing of these concepts in society and psychiatric practice as well as of their positive contribution to a better understanding of psychiatric problems, to better diagnostics and, as a result, psychiatry as a scientific discipline.

Conclusion: It remains necessary to take a critical look at one’s own bias in the form of generalization, discrimination and prejudices. On the other hand, we also know the heuristic and methodological value of these concepts for psychiatry as a science. We should not only discriminate patients as unique individuals, but also generalize them to a variety of complex groups using biases that are subject to adjustment.