In this presentation we will explore the different psychopathologic presentations and meanings of impulsive behaviour in psychotic patients. A first distinction will be made in schizophrenic patients between impulsive acts (previously conceptualized as impulsions), whose paroxysmal, automatic psychomotoric and internally generated nature could be close to catatatonic behaviour or immediate reflexive actions, and from other type of aggressive impulsivity, secondary to delusions or hallucinations with a strong self- implication. Quite a different phenomenon is observed in Bipolar patients (phase dependent) in which goal-directed impulsivity can assume two expressions: a “pure” appetitive impulsivity form connected with euphoric or dysphoric mood and a desinhibited impulsivity one close to a more labile mood. The later expressive behaviour is distinct from reckless and desinihibited impulsivity common to ADHD and hypertimic bipolar patients.

In schizophrenic psychotic patients, impulsive acts can be understood as psychopathological expressions of a morbid process at the same level of other psychotic symptoms. On contrary, in mood psychotic disorders the main emphasis is both on the role of self awareness and control, as well as on the understating of several types of impulsivity in a continuum between normal primary emotions and excessive emotional experiences and drives.

Abstract not available at the time of printing.

In ICD-10 we find pathological gambling in the rest-category “Habit and Impulse Disorders” together with pathological fire setting (pyromania), pathological stealing (kleptomania), trichotillomania and other habit and impulse disorders. In DSM-IV the same disorders have to be attributed to the rest-category named “Impulse control Disorders”. In ICD-10 as well as in DSM-IV the diagnosis impulse (control) disorders should be used for kinds of persistently repeated maladaptive behaviour that are not secondary to a recognized psychiatric syndrome, and in which it appears that there is repeated failure to resist impulses to carry out the behaviour and the patients report a prodromal period of tension with a feeling of release at the time of the act. Without any doubt, pathological gambling cannot be reduced to mere maladaptive behaviour. As we know from clinical praxis, patients suffering from pathological gambling show a much more complex psychopathology. Beside the signs of a strong desire or sense of compulsion to gamble and an impaired capacity to control gambling in terms of its onset, termination, or levels of gambling (which may seem similar to symptoms of impulse control disorders) all other signs of a dependence syndrome (e.g. evidence of tolerance with a need for significantly increased frequency of gambling, preoccupation with gambling, persistent gambling despite clear evidence of harmful consequences, physical withdrawal states) can be observed in patients suffering from pathological gambling. Concluding we may say that pathological gambling is a much more complex disorder than impulse control disorders. Beside phenomenological analyses also comorbidity studies indicate similarities of pathological gambling to substance-related addictions. Therefore we propose for DSM-V that pathological gambling should not longer be part of the rest-category “impulse control disorders” but should be attributed as gambling addiction (or gambling dependence syndrome) together with other substance-related and non-substance related addictions (e.g. internet addiction, buying addiction, working addiction) to a new group of dependence disorders.

Over the last decade there has been an increasing awareness of comorbidity in the adult population. It is also increasingly recognised that substance misuse is increasing in young people and the older population is increasing. Prevalence estimates and clinical experience point to more younger and older addicts attending clinical services. Substance problems are associated with psychological and physical comorbidities and social difficulties across the lifespan. This leads to poorer outcome. Inadequate assessment of substance problems, prescription and over the counter medication, including interactions and compliance, in younger and older age groups leads to ineffective management. The key principles which inform the implementation of effective pharmacological and psychological treatment interventions for nicotine, alcohol and illicit drugs treatment options in adults is well established. Outcome studies in the adult population suggest patient benefit. Although limited, studies of substance misuse treatment interventions that have been carried out in younger and older age groups demonstrate improvement. Although outcome studies that have been undertaken in comorbid groups do not yet point to a particular type of intervention or service model, administration of effective interventions for substance misuse may lead to improvements, which has policy ramifications. Most of the scientific research has been carried out is in the United States which has a very different health care system and there is need for a focus on neurobiological and social research in particularly vulnerable populations.

Despite legislation to harmonise mental health practice and convergence in systems of training there remains an extraordinary diversity in mental health practice in Europe. Approaches to tackling substance misuse and attitudes towards substance misuse and mental illness also show definite international differences.

Whilst mental health services are organised and financed in very different ways there are nevertheless a number of common trends and issues. The most obvious trend has been the run-down of psychiatric beds, giving rise to the problem of providing alternative services. Throughout Europe people are striving, with mixed success, to establish new community-orientated services, providing reasonable levels of clinical care, some continuity and co-ordination, and appropriate accommodation and day-time activities.

There is a need for researchers and policymakers in the area of co-morbid mental health and substance misuse to collaborate and develop shared methods of approach to evidence and research based policy. Although much is known about the prevalence and multiple needs of co-morbid individuals, there are a number of research questions that remain unanswered. By collaborating with colleagues in other European countries and encouraging generalization of results an understanding of the effect health and social care systems on the level and intensity of complexity dual diagnosis presentations will develop. Similarly, while previous research highlighted the complex needs of co-morbid individuals, future research should concentrate on factors that may help prevent the ‘ping-pong’ effect, resulting in co-morbid people being bounced around various organisations and agencies, most notably among mental health and substance misuse services.

Addictive behaviour associated with alcoholism is a brain disease characterized by craving for alcohol, loss of control over consumption, development of tolerance and dependence, while simultaneously the repertoire of social functioning not related to intake behaviour declines dramatically. To understand the factors that compel some individuals to drink excessively and to identify targets for pharmacological intervention, addiction research has focused on the identification of brain mechanisms that support reinforcing actions of alcohol and the progression of changes in neural function induced by chronic drug or ethanol intake. Cellular and molecular mechanisms of tolerance, sensitization, and dependence have been investigated intensively. The ability of most drugs to enhance dopamine neurotransmission particularly within the mesocorticolimbic dopamine (“reward”) system was demonstrated repeatedly. However, the past decade has placed the dopamine system within a broader context of neuronal circuitry involved in drug seeking, drug taking, and recovery. Specific effects on other receptors symptoms provide particular challenges given the almost ubiquitous expression of these receptors throughout the CNS. Additionally, new emphasis on various neuropeptide systems has reemerged, including opioid peptides and the stress-related peptides of the hypothalamus-pituitary-adrenal axis. Continued research is warranted on the various neurobiological based components that underlie the transition from drug intake to addiction to define drug targets for innovative pharmacological treatment options.

Attention-deficit/hyperactivity disorder (ADHD) is a chronic disease that is well accepted as a childhood condition. Despite increasing evidence of its clinical relevance in adults, it would appear that adult ADHD is underdiagnosed. This is particularly the case when comorbid with another mental disorder. Comorbidity across the life-span runs as high as 70% amongst adults diagnosed with ADHD. One of the most frequently occurring comorbidities in adult ADHD are substance use disorders (SUDs), which show a bi-directional relationship. ADHD is a risk factor for the development of later SUD to the extent that 9%-30% of adults with ADHD have a substance use problem. On the other hand, prevalence studies have shown that between 15% and 25% of patients with a SUD also have ADHD. The bi-directional relationship between ADHD and SUD can modify the clinical expression of symptoms, thus rendering difficult both correct diagnosis and appropriate treatment. ADHD is a strong risk factor for the subsequent development of an SUD and can jeopardize drug treatment. Assessment for ADHD is highly recommended amongst SUD patients as is a drug evaluation for those adults diagnosed with ADHD. An undiagnosed comorbidity can result in poor results as only part of the problem is treated. More research is needed to clarify relationship between adult ADHD and substance abuse, as well as to explore new psychopharmacological and psychotherapeutic treatments for this comorbidity.

Dementia is progressive, age related, chronic condition and can profoundly affect the lives of patients and their families.The main question in care becomes how to promote well being and maintain an optimal Quality of Life QOL. But is not always clear what QOL means.The conceptualizations of QOL vary because most instuments are developed for patients in different stages of dementia, and the relevant life domains for QOL vary with the progression of the disease. As a consequence most instruments are unsuitable for assessing QOL in the whole range of mild to severe dementia.This presents a problem for the daily care for people with dementia and for the evaluation of interventions aimed at improving QOL, as changes in QOL with the progression of the disease are difficult to detect and assess with existing instruments.This presentation following conceptual definition offered. Dementia specific QOL is the multidimensional evaluation of the person environment system of the individual, in terms of adaptation to the perceived consequences of the dementia.

Suicide is a major cause of death of older people. The most reason cited by older adults who consider suicide is loneliness. Feeling alone, worthless, helpless and hopeless are symptoms of depression which carries a high risk for suicide. The suicide risk in the elderly depends on the societies, communities and religious beliefs.

On the other hand the patients who believe that their quality of life would be disturbed by the continued treatment, have the right to ask to stop the treatment. The further extention of this issue involves the wish to die and physician-assisted suicide. The physician-assisted suicide raises several ethical questions beside the conflicting roles of physicians in preseving life versus ending suffering. In the Hippocratic oath, physicians swear not to precribe a deadly drug or give advise to a patient that may cause death. Or, nowadays euthanasia and physician-assisted suicide have become sources of continuing controversy and are likely to be so far forseeable future.

Once a physician swears to keep the patient alive, is it ethical when he / she administers a lethal dose of medication or another agent to a hopelessly ill or injured patient?

The achivement of modern medicine in terms off technology and treatment, enable physicians to prolong life and to delay that even the presence of severly debilitating conditions. However, benefical medicine technology may be harmful when used as a life-sustaining measure, in terminally ill patients. Elderly people themselves often fear and believe a zealous aplication of that kind of life-sustaining procedures will just prolong their suffering.

What the physician should do? To undertake the treatment and the life-support systems or follow the “do not resuscitate” order?

There appeared serious ethical challenges for psychiatry: to cut mental health costs and to provide care to as many as possible. The psychiatrists have to face these challenges and treat the elderly with or without mental disorders, assuring them the best quality of life as it is possible.

Multiple loses in old age are important in decreasing of quality of life and increasing of mental health problems in the elderly. Suicide and attempted suicide are one of the major health problems in the world. We discuss about the wish of die in elderly persons and about ‘the right to die’. We are questioning: whether it is natural for the elderly to wish to die, and whether the right to eventually kill oneself should be respected or whether suicidal intentions in old people are expressions of mental diseases.

To find predictors of suicide in old age is an urgent task for prevention. In more of the controlled studies depression and personality disorders are potentially important predictors of suicide in the elderly. The prevention of suicide in later life must account the educational program for primary care to enhance knowledge regarding the treatment of mental illnesses and recognize them. Thus we must use the newer antidepressants and community care to avoid the suicidal behaviour in the elderly, because the depression is under-diagnosed and often under-treated. We try to improve the quality of life of all elderly mentally ill patients, also solving the stigma and discrimination against the elderly with mental problems.

The number of persons affected with HIV/AIDS continues to increase dramatically. This epidemic, while being very devastating in Sub-Saharan Africa, is also rapidly spreading to other parts of the world; in particular, South East Asia. Recent data has shown that currently there are about 50 million people already suffering from AIDS. Of this number, one million alone are residents of the United States. It is, therefore, imperative that we advance the profession and field in all model and treatment approaches vis-à-vis psychiatric disorders and conditions that could affect people suffering from HIV/AIDS.

Among the illnesses affecting persons with HIV/AIDS, either independently or as a comorbid condition, mood disorders are very prominent. Major depression among them is oftenly observed in this patient population. In this presentation, focus will be given to the most advance methods of intervention for the treatment of HIV/AIDS patient who suffer from depression.

Educational Objectives:

At the end of this presentation, participants should be able to:

1. 1. Recognize the symptoms of depression among HIV/AIDS patient.

2. 2. Treat depression among HIV/AIDS population in accordance to the most far advance methods of intervention.

3. 3. Help to prevent relapse and complications, including suicide, in the HIV/AIDS patient population.

Abstract not available at the time of printing.

Abstract not available at the time of printing.

Abstract not available at the time of printing.

International studies showed that caregiver interventions are efficacious especially when they provide the possibility to be free from caregiver role for some hours (holidays for some hours). However, lay helpers should be trained for their role.

Based on the previous experiences of other groups the memory clinic of the Medical Faculty of the University of Goettingen, Germany initiated a cooperation with a diaconic social service provider. The latter provided the organisation of care (caregivers contact, a nurse makes a home visit to assess the needs, the lay helper is informed), while the memory clinic organises the selection and training of the helpers and the scientific evaluation, which has been paid by the government by the federal state of Lower Saxony.

Media promotion raised much interest. Sixty-four of 180 applicants finally finished a 40-hours-training including role play and group discussions. The training included information on the disease, its diagnosis and treatment, legal situation, caregiver burden and typical problems in communication. Noone regarded the training as too long. Lay helpers were mostly female and about every fifth had a professional background in the psychosocial area. They were attracted by the possibility to get further qualification and work in a more flexible setting. All lay helpers got a certificate and an insurance for the service related work. The service reached mostly caregivers of severely demented patients. It was for the first time, that lay help service ist organised by a medical (university) facility.