Violent and aggressive behavior in prison is considered to be a constant problem in most penal institutions and it not only poses a threat to prison staff and fellow inmates, but is also a source of additional cost. An early identification of inmates who tend towards violent or ag-gressive behavior in prison should therefore be a central goal, in order to both protect the staff and other inmates from becoming victims of violent actions and to lower the overall costs of the penal system. Furthermore in-prison behavior is suspected to be good predictor of legal probation after release to the community. There is an ongoing debate concerning the useful-ness of actuarial risk assessment instruments in predicting intramural violence as studies on their predictive validity show mixed results. In this study the predictive validity of PCL-R, PCL:SV and the VRAG for different types of prison misconduct (violent and verbally violent infractions) was examined on a sample of 106 violent and sex offenders of the largest Swiss state penitentiary.

The relationship between physical violence and PCL-R score was not significant but the sum score did predict the occurrence of verbal aggression. For the PCL:SV and the VRAG similar results were found as there were significant effect sizes for verbal aggressive behavior of sex-ual offenders but not for violent offenders.

These results highlight the need for further research on the usefulness of risk assessment instrument in the prediction of intramural violence.

Suicidal behaviours comprise significant part of the workload of Accident and Emergency (A&E) departments. In the UK around 140,000 young people present to A&E with self harm, and there are 6000 deaths from suicide each year. Substance misuse is an acknowledged risk factor for suicide and self harm: the mortality of substance misusers is between 9-16 times higher than the general population. The UK has some of the highest levels of substance misuse in young people in Europe, this relationship give rise to particular concern.

Previous self harm is the strongest predictor of subsequent suicide. Thus it is important to detect and treat effectively as it is estimated that approximately 20% of suicides are likely to be preventable. Indeed, reduction of suicide is a key aim of the National Suicide Prevention Strategy which has a specific objective of promoting the mental health of substance misusers.

However, the indications are that self-harmers are not receiving adequate assessment and treatment. Furthermore, while some forms of psychological and pharmacological treatments are effective for self harm, these results are limited. Most studies do not include substance misusers or have substance misuse as an outcome measure. Effective treatment interventions for substance misusers generally do not focus on suicide or self harm. Indeed, such patients are often excluded. Recent epidemiological evidence that that suggests that attendance for substance misuse treatment may impact upon suicide will be outlined, and the clinical practice and policy implications will be explored with reference to young people.

The treatment of alcohol withdrawal with delirium implicate evaluations of multiple factors and even numerous guidelines are available the clinical practice shows important differences between centres.

The purpose of study is to evaluate the pharmacological intervention in delirium tremens in different Romanian settings.

Alcohol related visits account for 10 to 46 % of all emergency department visits each year (D'Onofrio et al. 2006; Nassisi et al. 2006; Baleydier et al. 2003). This presentation focused on psychiatric guidelines and the clinicians’ position about the management of agitation due to substance intoxication. American Psychiatric Experts' recommendations (Allen, 2005) for managing agitation are discussed.

The use of psychiatric validated scales to assess agitation seems to ameliorate the quality of care in emergency psychiatry. Several standardized tools could be useful for assess a diagnosis of alcohol abuse or dependence in emergency for adults and adolescents (AUDIT, CAGE, CRAFFT, et RAPS-QF), even if the clinicians are often sceptical about this issue.

The use of medication to protect the patient, staff and to prevent an escalation of violence remains a personal choice for each practitioner, depending on individual patient needs and context. In the treatment of agitation due to substance intoxication in emergency, a balance needs to be found between the subjective dimension and data issue from evidence based medicine.

Personality disorders represent the dominant background features in evolution of addictive behaviours. In psychiatric emergency units these kind of conducts are able to start or maintain psychopathological manifestations and behaviours which have at their limits manifest selfaggression and on others and the irreversible failure of vital organs.

We have evaluated these specific conditions considering the main premorbid personality dimensions in two groups of pacients on records of Psychiatric Clinique 2 from Tg. Mureş.

The agravant and/or pathoplastic role of personality disorders is confirmed, considering that it influents also – and sometime in a decisive way – the compliance and efficiency of therapeutic relation and of rehabilitation strategies.

The presence of a personality disorder proves itself to be also a predictive factor for the precocity of psychopathological manifestations which require emergency assistance as well as for the frequency and complexity of associations between them.

About 800.000 people in Germany suffer from a BMI > 40 kg/m2. Obesity surgery is one of the most effective strategies for weight loss in this population.

We assessed 150 patients prior to bariatric surgery and are at present conducting follow-up assessments after surgery. Evaluation included the Eating Disorder Examination for the assessment of eating patterns and eating related psychopathology. The SCID Interview was used to assess lifetime eating disorders.

At the time of abstract submission 49 patients had completed pre-surgery evaluation as well as the 1 year follow-up; 73.5% (n = 36) were female, mean BMI pre-surgery was 52.4 (SD = 7.9). At baseline 24.7% met full criteria for Binge Eating Disorder (BED), an additional 10.2% met all but one criteria (sub-threshold BED). 46.9% reported any eating disorder lifetime, among these 8.2% met criteria for lifetime Bulimia Nervosa.

59.1% of the patients reported Binge Eating (loss of control & a large amount of food) prior to the surgery, post surgery only 16.3% (n = 8) reported occurrence of loss of control over eating. Symptoms of BED re-occurred in only 6.1% (n = 3) of the patients, none of them meeting the full criteria for BED any more. 53.1% reported an increase in enjoyment in eating 1 year after surgery. Vomiting occurred frequently: 81.6% (n = 40) reported vomiting 1 year after surgery; however, vomiting with the intention to reduce weight was extremely rare (n = 1).

Several lines of evidence suggest disturbances of serotonin (5-HT) and dopamine (DA) pathways play a role in the pathogenesis and pathophysiology of anorexia nervosa (AN) and bulimia nervosa (BN). Studies using imaging with radioligands specific for 5HT and DA components, have found alterations of the 5-HT1A and 5-HT2A receptors, and DA D2/D3 receptors in AN and BN. In addition, some studies suggest relationships between these components and traits often found in individuals with AN and BN, such as harm avoidance and drive for thinness. Moreover, subtypes may have different patterns of 5-HT-DA dysfunction which may shed light on understanding specific symptoms such as inflexibility and rigidity and disregard of normal rewards in AN, or unstable mood and impulse dyscontrol in BN. The 5HT and DA systems are highly complex. Thus disturbances of these components may reflect dysregulation of these neuronal systems, rather than identify the exact etiology. In summary, new technologies such as PET and/or fMRI offer the promise of understanding the relationship of behavior and neurocircuits contributing to ED. Futhermore PET and radioligand studies may be a useful tool for investigating and managing medication response in treatment resistant individuals.

This presentation will outline the reasons for international collaboration as well as its possible benefits and risks. It will propose a series of principles that have been developed in the course of international projects in which the author was involved. These principles have proved useful in ensuring that international collaborative efforts were productive and useful to the participants as well as to science and countries involved.

An overview with practical experiences from teaching medical -ethical values and ethical conduct based on the international medico-legal declarations on patient human rights is presented. Weight is put on ways and means of organizing collegial workshops with emphasis on sharing supposed common values as doctors of medicine and psychiatry. Special target groups have been colleagues in countries under armed conflict, respective unstable political conditions.

The development of the International Classification of Diseases has been a major step in the development of a common understanding of mental disorders. But classification by symptoms limits professional communication especially when we want to focus on functional problems caused by persisting mental health conditions. “Functioning? concerns all areas of life of affected persons and represents that side of their illness which interests patients mostly. Before this background an additional classification system has been developed aside from the International Classification of Diseases. The International Classification of Health and Functioning describes not only the deficits of disabled persons but also their resources. As such this classification system is not just an add-on to another classification system but it also expresses a new treatment approach directed toward recovery and remission. It also involves affected persons in their rehabilitation und treatment and indicates a new relationship between patients and professionals.

The usual diagnostic systems of the ICD and the DSM offer no adequate solution to the problem of classification and assessment of social dysfunction. Social dysfunction as a consequence of disease or disorder has been conceptualised in terms of (social) disabilities, and (role) handicaps (according to the ICIDH 1980) and as activities limitations and participation restrictions (according to the ICF 2001). Conceptual models of disability or social dysfunction reflect various ways of a normative perspective on a person's integration in the community and determine to a large extent its measurement, which has been criticised because of this perspective but also with respect to the independence of psychopathology, actual behaviour, opportunities, criteria of assessment, source of information, etc.. These crucial issues in the assessment of disability will be addressed from a methodological point of view.

The disability adjusted life year (DALY) concept has been developed as a universal measure of the burden of disease at the country or regional level. The DALY combines years of life lost due to premature death and quality of life lost due to disability to a sum of total lost years of healthy life. First applied in the burden of disease studies conducted in 1990 and 2001, the DALY concept allowed the first international comparison of the burden caused by the most important acute and chronic diseases. Mental disorders were identified in these studies as the most important causes of lost healthy life years worldwide. Meanwhile the DALY concept has been established as basis of effectiveness measures in the international health economic evaluation of health care interventions by the WHO-CHOICE programme. Resulting from the CHOICE studies data on cost-effectiveness of the most important standard interventions for depression, bipolar disorder, schizophrenia and alcohol abuse are available for all WHO regions. In recent studies the DALY concept has been used to predict the consequences of optimizing the mental health care resource allocation on the efficiency of mental health care systems at the national level. Regarding these research activities the DALY concept can be considered as an important methodological tool for mental health services research and the improvement of international mental health care systems.

Ethical issues around the use of integrative approaches in child and adolescent psychiatry arise in relation to diverse aspects of practice but especially in collaborative work with other disciplines. Child and adolescent psychiatrists work with nurses, social workers, psychologists, psychotherapists, family practitioners, paediatricians, those working in the juvenile justice system and educationists. Different ethical issues arise in relation to work with different disciplines and examples will be given. But there are common ethical issues arising from different standards of confidentiality and the communication of information as well as in the exercise of medical responsibility. Ethical issues can sometimes hinder the delivery of effective, evidence-based care. This is paradoxical for failure to deliver such care itself offends against ethical principles.

There is no possibility of progress for psychiatry in the world if there is a too wide gap between the quality of psychiatric practice and research in developing and in industrialized countries. The reason for that is because bad image which might emerge from developing countries, in a media globalized world, impacts negatively on the mental health work all over the world. Examples will be given for such statement.

On the other hand, collaboration existed for a long period of time between these two categories of countries in the education of psychiatrists. It is necessary, but at the same time creates major problems, such as the brain drain which is a direct consequence of learning psychiatry abroad for students coming from developing countries. There are more psychiatrists from Pakistan, India or South Africa practicing in the UK or the USA than in their country of origin. Another problem is the lack of transcultural sensitivity, making the training of these students insufficient when they come back home.

On the other hand, collaboration in research must take into account the cultural specificities of the developing country, and in anyway should avoid a “safari research”. Respect of ethical guidelines in all collaborative studies is an essential ingredient of success.

Increasing predominance of evidence-based therapies and standardisation of their clinical application as well as financial limitations narrow the therapists view and leaving out of account the patients` individual specificities and demands. Consequently patients try to get their subjective needs met by alternative approaches, such as self-medication, procedures of unknown quality, consultation of healers outside the medical professions. According to the prevailing ethical principles the following ethical questions will be discussed:

1. • Respect of the patients` dignity and autonomy means to take him/her seriously. However, what are the limits of taking the view of the patient, particularly in cases of a discrepancy between the patients will and his welfare, and especially in cases of incapacity to decide competently on therapeutic alternatives?

2. • Harm avoidance should keep away from the patient unproven approaches with both the risks of unknown unwanted effects and of omission of an efficient treatment. But how to sail safe through the narrowness of Skylla and Charybdis: to convince the patient of the advantages of the proposed quality proven approach without chasing him away out of medical services to unqualified and uncontrolled approaches?

3. • With regard to justice it seems clear that approaches without proven quality should not be paid by insurance companies in order not to reduce the limited resources for the whole of all its members. However, will this be acceptable also in cases in which there are no efficient treatments, but the alternative approach demanded by the patient may improve his quality of life?