Coronary artery bypass grafting (CABG) is a worldwide used myocardial revascularization procedure, which despite the modern advantages still has a spectrum of complications, especially in old age population.

The relatively old age of the patients who undergo CABG and their widespread atherosclerotic disease are possible reasons for vascular sequels leading to neurological and psychic dysfunctions. Delirium in the elderly after CABG surgery is common, according to some authors and our investigation, is detected in about 20- 34% causes and is often under-diagnosed. Its occurrence may be predisposed by a history a stroke and precipitated by a longer duration of cardiopulmonary bypass.

Increasing age, blood urea level, cardio-thoracic index, hypertension, smoking habits, blood replacement during bypass, atrial fibrillation(AF), pneumonia and blood balance in the post-operative period are the main risk factors for delirium. No specific factor associated with the CABG (eg. perfusion pressure, number of grafts) is correlated with increased risk for delirium post-operatively.

The number of studies (and our observations) have shown that patients in whom delirium develop have more complication rates, longer hospital stays, an increased rates of transfer to rehabilitation or long –term care facilties.

Finally, the identification and control of the risk factors for delirium should bring a decrease in delirium morbidity and mortality.

Suicide rates in elderly people have been high, worldwide. Suicide in elderly people is multifactorial. Mood disorders, physical illnesses, and previous suicide attempt, has been associated with increased risk of suicide in elderly people. Delirium or acute confusional state, also, has been proposed as a risk factor. Delirium is characterized by a disturbance in consciousness, change in cognition, perceptual disturbances, and often has multiple underlying causes. Delirium is often undetected or misdiagnosed, and is difficult to evaluate suicidal thoughts and intent in delirious patients. There is a debate in the medical literature concerning the role of delirium as a risk factor of suicidal behaviour. It has been proposed that, confusional state contribute to impulsive suicide attempts, as could occur, in cancer or in AIDS patients. However, past work suggested that delirium was a protective factor for suicide.

Cocaine produces its psychoactive effects primarily by blocking presynaptic transporters for biogenic amine neurotransmitters, especially dopamine and serotonin. This has the effect of increasing activity in the brain's mesocorticolimbic dopaminergic reward circuit. There is no proven medication to treat cocaine dependence. The difficulty in developing an effective medication may derive from cocaine's direct activation of the reward circuit, its ability to generate sensitization with repeated use, and its rapid access to the brain when smoked or injected. Attempts to directly affect the reward circuit, e.g., by blocking the dopamine transporter or dopamine receptors, have not been successful. Attempts to indirectly influence the reward circuit by affecting other neurotransmitters that modulate it have been more promising. These include increasing activity of GABA (an inhibitory neurotransmitter) with baclofen, vigabatrin, or topiramate (which also decreases glutamate activity); and increasing the activity of glutamate (an excitatory neurotransmitter) with N-acetylcysteine. Also somewhat promising are agonist substitution approaches using long-acting amphetamine preparations. Medications that are promising in animal studies, but not yet tested in humans, include dopamine D3 receptor partial agonists and cannabinoid CB1 receptor antagonists. In addition to these pharmacodynamic approaches, pharmacokinetic approaches, which reduce cocaine's access to the brain or enhance its metabolism, are being studied. An anti-cocaine vaccine, which binds cocaine and keeps it from crossing the blood-brain barrier, has been safe and effective in early clinical trials. Administration of cocaine-metabolizing enzymes, e.g., butyrylcholinesterase, has been effective in animal studies, but not yet studied in humans.

Although no pharmacological treatment has proved to be highly effective for reducing cocaine dependence, several medications have been tested over the last decade and have shown promising efficacy. Modafinil (Provigil), known as a treatment for day time sleepiness, and Topiramate (Topamax), an anti-epileptic medication also prescribed for migraine, have been shown to be effective in controlled clinical trials. We have recently started a major study utilizing Positron Emission Tomography (PET) brain imaging to monitor the progress of pharmacotherapy with modafinil or topiramate in cocaine-dependent and methadone-maintained cocaine-dependent patients. Patients will be assessed before treatment, and again after 4 weeks of pharmacotherapy. The aims of the project are to study effects of the two medications on cocaine dependence and craving, and on dopamine binding in the brain. At each assessment session, patients will undergo PET with [11C] raclopride to image the dopamine receptor DRD2. To trigger craving, patients will then be exposed to a videotape showing cocaine use; a questionnaire will be used to record their subjective responses, and a second PET scan will be performed with [18F] fluorodeoxyglucose (FDG) to image cerebral glucose metabolism during craving. This protocol was designed to enable us to study changes resulting from pharmacotherapy on dopamine binding in the brain, and on craving as reflected both in subjective measures and regional cerebral glucose metabolism. In addition, we will investigate the association between subjective measures of craving for cocaine and the level of dopamine DRD2 receptor occupancy in the brain before and after treatment. Notwithstanding the complexity of the clinical and therapeutic reality characterizing cocaine dependence, we hope to present preliminary evidence for the relative efficacy of these two promising medications in treatment for cocaine. dependence. This evidence could also elucidate the brain mechanisms underlying cocaine craving and dependence in cocaine-dependent patients.

The development of medications for the treatment of cocaine dependence has been a high priority of the U.S. National Institute on Drug Abuse, National Institutes of Health. One of the main strategies has been to test available, marketed medications that affect CNS function and have a rationale for testing in a cocaine dependent population. The Cocaine Rapid Evaluation Screening Trials (CREST) utilized a randomized, controlled, parallel group, blinded methodology for comparing one or more medications against a placebo. Subjects were evaluated for a 2-4 week baseline and then randomized to a treatment group for 8 weeks. Standardized measures of outcome were used: urinary benzoylecgonine, retention, craving, depression, clinical global impressions, HIV risk behaviors. Counseling and procedures were also standardized across studies to facilitate data comparisons across drug classes. A total of 19 drugs were evaluated in 5 research clinics. Results from the studies suggested that cabergoline and reserpine should be further evaluated. Less robust effects were seen with sertraline and tiagabine although the sample size in each group was small (n= 15/group). Trials were analyzed separately and then a pooled analysis was performed. For example, an analysis of characteristics leading to at least 2 weeks of abstinence was performed. Being female with at most 5 years of prior use and being over 40, being a non-African-American male with at least four baseline uses and more than 4 years of prior use, and males with at most three baseline uses and less than 20 years of prior use were associated with abstinence rates of 25, 30, and 42 %, respectively. One of the lessons learned was the potential value of assessing cocaine use during the baseline period prior to randomization. Another lesson learned was the use of both standardized assessments across sites and outcome measures that were also employed within individual sites. This allowed exploratory analyses within sites to determine sensitivity of outcome measures.

Cocaine, already a significant drug problem in North and South America, has become a more prominent part of the European drug scene. No specific effective pharmacological treatment is available for cocaine addiction, although a number of medications have shown promising results. Behavioural therapies have demonstrated some effectiveness and are currently the standard type of treatment for cocaine addiction. At the present time, Cognitive-Behaviour Therapy (CBT) and Contingency Management (CM) techniques have the strongest empirical support for application with cocaine users. Cognitive behaviour approaches, such as relapse prevention, are grounded in social learning theories and principles of operant conditioning. Several randomised clinical trials have demonstrated the efficacy of cognitive-behaviour therapy (CBT) in the treatment of cocaine-dependent outpatients, particularly more severely dependent cocaine users and depressed. Contingency management approaches are based on principles of behavioural pharmacology and operant conditioning. It is a procedure that decreases the reinforcing efficacy of cocaine via the delivery of reinforcement contingent on abstinence and/or the delivery of punishment contingent on cocaine use. The two most commonly used CM strategies for treating cocaine and stimulant use disorders are voucher-based reinforcement therapy extensively investigated by Higgins and colleagues, and variable magnitude of reinforcement popularized by Petry and colleagues. CBT and/or CM possibly have additive effects when combined with pharmacotherapies.

A variety of other types of behavioural treatment like motivational therapy (MT), community reinforcement and the Matrix model have also been shown to be potent interventions for cocaine addiction. These behavioural interventions, excepted CBT and MT, are not used in France. It seems necessary to evaluate these approaches.

To date, there is an absence of curative treatment for very early onset schizophrenia. The antipsychotic drugs that are currently recommended have very little effect and are often badly tolerated by children. We report a case-study which results show a beneficial and significant efficacy of fMRI-guided rTMS in the treatment of pharmaco-resistant hallucinations. Moreover, rTMS applied over several cortical regions provided the means to reveal for the first time a functional dissociation between auditory-verbal hallucinations and agency impairments. These results demonstrate the efficacy of rTMS for young patients suffering from drug-resistant hallucinations but they furthermore question the physiopathology of the hallucinatory process by suggesting that agency and hallucinations may be sub served by different neural networks.

In neuropsychiatric disorders, serotonergic dysfunction may contribute to negative affect in alcoholism and major depression, while dysfunction of central dopaminergic neurotransmission has been associated with motivational disorders in addiction and schizophrenia. Animal experiments revealed that 1) neurodevelopmentally early social isolation stress exposure is associated with altered serotonin turnover and transporters and 2), neurodevelopmentally early lesion of the temporolimbic cortex is associated with increased striatal dopamine release. In human studies, dopamine and serotonin transporters and receptors interact with central processing of reward-indicating and affectively positive and negative stimuli, and specific alterations in these interactions can be observed in schizophrenic, alcoholics and affective disorders. Monoamine effects on central processing of emotionally salient stimuli are genetically influenced, and besides single gene effect, gene-gene interactions have been postulated. Additive gene-gene effects are often assumed but difficult to test in behavioral genetics due to the small explained behavioral variance. Processing of unpleasant stimuli in the amygdala has been associated with a functional polymorphism (val158-met) in the catechol-O-methyltransferase (COMT) gene and independently with a functional polymorphism in the regulatory region of the serotonin transporter (5-HTT) gene. 5-HTT function may also be affected by a recently detected A/G exchange in the long allele (insertion) of the 5-HTT regulatory region. In individuals with more COMT met158 alleles and with more s or lG alleles of the 5-HTT regulatory region, aversive stimuli elicited greater neuronal activity in the bilateral amygdalae and hippocampi. These genotype effects were additive on amygdala and hippocampus activation by aversive versus neutral stimuli, indicating that COMT val158-met and 5-HTT genotype were additively associated with increased processing of aversive stimuli in the amygdalae. Functional brain imaging may be used to assess the interaction of multiple genotypes on neuronal activation in neuropsychiatric disorders.

One hundred consecutive Turkish female immigrants referred by their General Practitioner to a mental clinic between 1998 – 2000 were assessed for their social background, educational, linguistic capabilities and support network. They were assessed for their mental health problems and were given psychiatric diagnosis including mixed anxiety depression, panic attacks, PTSD, obsessionality and severe mental health problems i.e. bipolar affective disorder and psychosis.

7 years later the same cohort were reviewed for their psychiatric problems.

It is interesting to note that 75% of all women who warranted a psychiatric diagnosis on the first assessment were free of symptoms on the second assessment. They had aclimatised to their host country and had improved psychologically.

The study will present the personal and social factors that contributed to the psychological well-being, stability and integration of this cohort.

Clinical experiences in war areas: Croatia for Bosnian Women, Rwanda and kabul

1. 1. Immediate reaction

   1. 1.1 Disclose of war rape in medical secrecy following

   2. - Mental health acute disorder

   3. - Genital Infections or haemorrhages

   4. - and mostly when women got unwanted pregnancy

   5. 1.2 Unwanted pregnancies may be an indicator of war rape

   6. - Some women disclose rape during the first trimester and ask for terminations even if the country has not legalized abortion in its law.

   7. - Other book lately their pregnancy because either they conceal it to their family or they deny it. Some experience harmful or violent thoughts against the fetus. Newborns are at risk of neonaticide and abandonment at birth. Some do not want to disclose their identity while coming to maternity wards.

   8. 1.3 A collective panic may happen if the war rape is disclosed in the media. In this case every effort should be made to prevent stigmatization of babies born as the result of war rape.

2. 2. Long-term reaction

3. Most of women victim of war rape keep silent for a long time.If they develop symptoms like depression, PTSD, social phobia, sexual dysfunction, psychosomatic diseases, etc., they may disclose later the abuse during a medical examination, another pregnancy, a psychiatry follow up or a psychotherapy.

4. Women who have brought up children as the result of rape may ask child psychiatrists for managing their boundings and their questions.

Mental health care shifts from the hospital to the community. Belgium has a nation wide network of specialized mental health centres for the community treatment of sexual offenders. These centers are linked to three centres of reference, one in Flanders, Wallonia and Brussels. Our Flemish reference centre (Universitair Forensisch Centrum, www.ufc.be) treated and/or assessed 835 sexual offenders or patients with abnormalities of sexual preference (paraphilias). Most of them are sexual abusers of children or adolescents (87%). We developed an original out patient treatment program based on cognitive behavioral therapy combined if necessary with medication (SSRI or hormonal therapy).

The following problems will be presented and discussed:

• • A multi step treatment model in order to enhance the motivation and adherence of the offender for the proposed treatment

• • The best interest of the patient versus public safety issues in the treatment approach

Catamnestic studies of sexually abused children have found an elevated risk of adulthood offending. Studies among offenders have repeatedly reported an elevated prevalence of childhood sexual abuse (CSA), especially among sex offenders. This study aimed to examine differences between offenders with and without a history of CSA. From correctional and court files socio-demographic, psychiatric and criminological data were collected for a representative sample of violent (n = 292) and sex offenders (n = 159) in the Canton of Zurich, Switzerland. Logistic regression analysis showed sexually abused offenders differed substantially from those not sexually abused. They were more likely to have grown up under a combination of distressing living conditions, to be mentally ill, and to prostitute themselves. They were also more likely to commit a sex offence, to have a pertinent criminal record (OR = 2.6) and a history of court-ordered therapy (OR = 2.6). The findings corroborate the association between CSA and sex offending. CSA appears to be associated with persistent offending and lack of therapy success.