Militaire Geestelijke Gezondheidszorg

INTRODUCTION: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) introduced a dissociative subtype for patients with posttraumatic stress disorder (PTSD) and depersonalization and/or derealization symptoms. Despite high comorbidity rates between PTSD and dissociative disorders (DDs), research has not paid attention to the differentiation or overlap between the dissociative subtype of PTSD and DDs. This raises a question: To what extent do patients with dissociative PTSD differ from patients with PTSD and comorbid DDs? METHOD: We compared three groups of complex patients with trauma-related disorders and/or personality disorders (n = 150): a dissociative PTSD, a nondissociative PTSD, and a non-PTSD group of patients with mainly personality disorders. We used structured clinical interviews and self-administered questionnaires on dissociative symptoms and disorders, personality disorders, trauma histories, depression, anxiety, and general psychopathology. The Dissociative Experiences Scale (DES; ≥20) and the depersonalization/derealization subscale of the DES were used for differentiating dissociative PTSD from nondissociative PTSD. RESULTS: Of all patients, 33% met criteria for dissociative PTSD. More than half of the dissociative PTSD patients (54%) met criteria for one or more DDs; using the depersonalization/derealization subscale of the DES, even 66% had a comorbid DD. But also of the non-PTSD patients, 24% had a mean DES score of ≥20. There were no symptomatic differences (e.g., depression and anxiety) between dissociative PTSD with and without comorbid DDs. CONCLUSION: Overlap between dissociative PTSD and DD is large and we recommend replication of previous studies, using structured clinical assessment of DDs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The manifestation of lung disease associated with rheumatoid arthritis including pulmonary nodules, pleurisy and pleural involvement is described in a 62-year-old white male.The pleural nodules were composed of a central ulcerated zone rimmed by proliferating fibroblasts showing a palisading arrangement.Reaction to antirheumatic therapy including high dosages of steroids was favorable.

Patients with advanced triple-negative breast cancer (TNBC) benefit from treatment with atezolizumab, provided that the tumor contains ≥1% of PD-L1/SP142-positive immune cells. Numbers of tumor-infiltrating lymphocytes (TILs) vary strongly according to the anatomic localization of TNBC metastases. We investigated inter-pathologist agreement in the assessment of PD-L1/SP142 immunohistochemistry and TILs. Ten pathologists evaluated PD-L1/SP142 expression in a proficiency test comprising 28 primary TNBCs, as well as PD-L1/SP142 expression and levels of TILs in 49 distant TNBC metastases with various localizations. Interobserver agreement for PD-L1 status (positive vs. negative) was high in the proficiency test: the corresponding scores as percentages showed good agreement with the consensus diagnosis. In TNBC metastases, there was substantial variability in PD-L1 status at the individual patient level. For one in five patients, the chance of treatment was essentially random, with half of the pathologists designating them as positive and half negative. Assessment of PD-L1/SP142 and TILs as percentages in TNBC metastases showed poor and moderate agreement, respectively. Additional training for metastatic TNBC is required to enhance interobserver agreement. Such training, focusing on metastatic specimens, seems worthwhile, since the same pathologists obtained high percentages of concordance (ranging from 93% to 100%) on the PD-L1 status of primary TNBCs.

Abstract Verdenoide, aus den 1.2‐Bis‐[äthinyl]‐benzolen 1, 2, 7 und 8 durch photochemische Dimerisierung gewonnen, sind Azulene mit zwei C  C‐Gruppen als Substituenten. Bisherige Befunde am Verden (aus 3 ), Tetramethylverden (aus 6b ) und Octafluorverden (aus 5 ) sprechen weitgehend für eine „ringgeschlossene”︁ Form ( D ). Die Röntgenstrukturermittlung (W. Hoppe und Mitarbb.) des Tetramethylverdens beweist dagegen die „offene”︁ Azulen‐Strukturen mit 2 C  C‐Gruppen. Neue, Fluor‐haltige Verdenoide aus 7 haben ebenfalls diese „offene”︁ Azulen‐Struktur. Octafluorverden sowie Verden werden daher „offene”︁ Azulen‐Strukturen mit 2 Acetylen‐Gruppen zugeschrieben. Die auffälligen und täuschenden Befunde am Verden und einigen Verdenoiden werden erörtert.

Due to its novelty and lack of empirical study it remains unclear if a service dog truly mitigates the burden of post-traumatic stress disorder (PTSD) symptoms. To cross sectionally investigate the effect of service dogs on veterans and first aid responders with PTSD, we studied subjective and physiological parameters in 65 individuals divided over four groups. These groups were: veterans and first aid responders with PTSD and a service dog ( n = 20), with PTSD and a companion dog ( n = 10), with PTSD without a dog ( n = 12) and a group without PTSD ( n = 23). We found that veterans and first aid responders with PTSD who had a service dog showed significantly less PTSD related symptoms, better sleep quality, and better wellbeing experience, than those with a companion dog. Those with a service dog additionally experienced fewer PTSD related symptoms than those without a service dog and tended to walk more than individuals without PTSD. No differences were found in cortisol levels between groups though and changes in both salivary cortisol and activity were not linked to improved welfare experience. Though the use of physiological measurement methods thus warrants more research, our study indicates that the subjective experience of wellbeing, sleep quality and PTSD related symptoms is improved by the presence of a service dog.

OBJECTIVES How GPs describe their patients who they did not identify as suffering from depression but who were classified as such by PHQ-9? What conclusions can be drawn with regard to how depression is dealt with and the illness model in use? METHOD GPs who took part in a screening study were asked in interviews to talk about some of their patients - not being informed that these were those not identified as depressive by them. This study comprises 21 narrative interviews from 18 GPs. Analysis by Framework method by Lewis and Ritchie. RESULTS The low identification rate of depression is not the result of failed recognition of "psychological problems" but of other factors centring on GPs' particular way of working and their concepts about mental illness: making a diagnosis only in a contextual way of interpreting symptoms; using the time passing as a help for diagnosing; emphasis on the impairment rather the diagnosis; considering the therapeutic consequences before making a diagnosis; a tolerance concerning "deviation" respectively wider view on "normality". CONCLUSION Understanding the different ways of conceptionalizing mental illness by psychiatrists and general practitioners is basic for their cooperation.

OBJECTIVE: To collect information for the purpose of establishing starting points and possibilities for a cost-effectiveness analysis of screening for adolescent idiopathic scoliosis (AIS). DESIGN: Interviews, literature review, questionnaires, an estimation of costs and discussions with experts and involved parties. METHOD: Following an initial interview with 16 orthopaedic surgeons and school doctors a literature study into the efficacy of treatment was carried out regarding the years 1989-1999. The variation in current practice was delineated by means of a questionnaire sent to all 51 municipal health services in the Netherlands. The costs of screening and treatment were estimated on the basis of health insurance premiums and a municipal health service cost model. All of the results were presented to five methodological experts and finally the study results and the recommendations of the five methodological experts were evaluated during a meeting of persons especially invited for this purpose. RESULTS: Screening for AIS was established to realise early diagnosis and treatment with a brace, so as to reduce unsatisfactory cosmetic outcomes and the need for surgery. Screening was performed using the bending test and was performed in 40/48 (83%) of the participating municipal health services. The overall costs of screening and treatment amount to 6 million euros per year. There was no convincing evidence that the screening programme was sufficiently sensitive and bracing sufficiently effective. Neither was there proof of the opposite. The following was recommended: obtain reliable data by carrying out a randomised controlled trial on the effectiveness of treating AIS with bracing in an early stage; carry out a case-control study combined with a retrospective patient follow-up study to evaluate the current screening practice; draw up a national standard for the screening of postural disorders in youth healthcare to ensure effective practice.

This paper explores recently emerging challenges in Medical Assistance in Dying on Psychiatric Grounds (MAID-PG), focusing on ethical, clinical, and societal perspectives. Two themes are explored. First, the growing number of young MAID-PG requestors and the public platform given to MAID-PG requests. Ethically, media portrayal, particularly of young patients' testimonials, requires scrutiny for oversimplification, acknowledging the potential for a Werther effect alongside the absence of a Papageno effect. This highlights the need for better communication policies for media purposes. Second, cautionary considerations regarding psychiatric care adequacy are addressed. In MAID-PG this includes reasons underlying psychiatrist reluctance to engage in MAID-PG trajectories, leading to growing waiting lists at end-of-life-care centers. Addressing current shortages in psychiatric care adequacy is crucial, necessitating less narrow focus on short-term care trajectories and recovery beside transdiagnostic treatment approaches, expanded palliative care strategies, and integrated MAID-PG care.

OBJECTIVE: To determine whether the 1996 implementation of new guidelines for the classification and management of cervical smears in the Dutch population screening programme for cervical cancer (i.e. inflammatory symptoms are no longer classified as moderate dysplasia and women with two smears with moderate dysplasia are referred directly to the gynaecologist) was followed by a reduction in both the number of women with repeat smears and the length of follow-up. METHODS: The results of all smears of women aged 35-54 years from 1990 onwards, were retrieved from the Dutch Network and National Database for Pathology (PALGA). The percentage of smears with moderate dysplasia was analysed with respect to time. The percentage of women with a histological examination during the follow-up phase of the population screening programme (1990 and 1991) was compared with that for the new screening programme (1996). RESULTS: Following the implementation of the new guidelines, the percentage of smears with moderate dysplasia was reduced from 10% to 2%. The percentage of women with a histological examination during the follow up of two smears with moderate dysplasia remained the same. The new recommendations for additional smears were not followed: for 28% no repeat smear was available after 2.25 years versus 10% in 1992. There were indications that the referral of women with two cases of moderate dysplasia to a gynaecologist was not strictly adhered to either. Since the introduction of the new guidelines, the estimated percentage of women that should be referred to the gynaecologist following smears with moderate dysplasia has not changed. CONCLUSION: The new recommendations have lead to fewer smears being classified as moderate dysplasia. The long-term effects, such as a reduction in the length of the follow-up period, can only be analysed in a few years time.

Sexsomnia is a parasomnia characterised by sexual behaviour. A 30-year-old man, with no history of parasomnias or related precipitating factors, developed sexual behaviour during sleep after three weeks of treatment with escitalopram 10 mg daily. The parasomnia disappeared on the sixth day after the escitalopram had been stopped. The temporal relationship between the use of this selective serotonin reuptake inhibitor and the occurrence of the parasomnia suggests a causal relationship, possibly related to increased serotonergic neurotransmission in the raphe nucleus.

This paper provides a brief review of the developments in neurobiological research of posttraumatic stress disorder (ptsd), particularly into the link between the disorder and the central and peripheral stress-regulating processes. ptsd is an impairment of neuronal circuits and stress-regulating systems in the brain, where a critical note is played by limbic structures such as the hippocampus, the amygdala and the medial prefrontal cortex. In patients with ptsd the 'behaviour' of these neuronal circuits and systems is chronically disturbed. Characteristic symptoms are increased stress reactivity, reduction of declarative memory performance, high emotionality in response to trauma-related stimuli and over-representation of traumatic memory, all of which can be described as chronic dysregulated processes. Because of improvements in research designs and stratification of research populations, the specificity of research findings has improved and the developmental trajectories of specific ptsd parameters have been described more clearly. One of the most promising developments in the field of research designs is the current shift away from cross-sectional research designs to 'true prospective' research designs.

A 51-year-old man with amyloidosis of the lungs, skin and testes, is described. For 7 years, there was an unusually slow progression of the disease and - compared to the literature - an uncommonly long survival.

BACKGROUND: Nightmares and insomnia are experienced by 70% of patients suffering from post-traumatic stress disorder (PTSD). These sleep problems are often resistant to treatment and exert a strong negative influence on the quality of life. In the last few decades several studies have reported on the characteristics of sleep disturbances in PTSD. AIM: To provide an overview of objective features of sleep disturbances - as opposed to self-report methods - in patients with PTSD. METHOD: Articles on this topic, published in peer-reviewed journals between 1980 and the present, were retrieved from Medline and Embase, using the search terms 'PTSD', 'sleep', 'nightmares', 'insomnia', 'polysomnography'. RESULTS: Studies reported on changes in sleep efficiency, arousal regulation, motor activity during sleep, rem characteristics and delta sleep activity during sleep. Also, correlations were found between nightmares and sleep apnoea in ptsd. In some studies on sleep disturbance no objective sleep disturbances were found in PTSD patients. However, most studies on PTSD related sleep disturbances were conducted in small, heterogeneous groups, and results were therefore inconsistent. Even the results of larger and more homogeneous studies were sometimes contradictory. CONCLUSION: There is a discrepancy between the clinical importance of sleep problems in PTSD and unambiguous objective sleep disorders. Future research should try to establish objective criteria for identifying the altered sleep patterns in PTSD. These criteria should help us to understand the neurobiological mechanisms of sleep disturbances in PTSD and develop new treatment strategies.

Abstract Phthalaldehyd (1) reagiert mit Phthalimidin (3) über 5 und 6 zu den 3‐Phenylisochinolin‐Derivaten 7a und 7b . Aus dem “Carbinolamin” 6 lassen sich Acyliminiumsalze 12 darstellen.

Dealing with refusal of care by patients with a severe psychiatric disorder in combination with a life-threatening condition: a case report Providing good care for persons with a severe psychiatric disorder in combination with a life-threatening condition is a major challenge for health care providers. By means of a case report, the authors analyze the situation of a 65-year-old woman with Korsakov’s disease, depressive symptoms and aplastic anemia. She refuses to be examined and treated, despite many efforts on the part of the caregivers and relatives, as well as the seriousness of the situation. The team has to switch from a curative to a palliative approach in a short space of time. Various areas of tension are assessed: appraising the decision-making capacity of the person requesting care, dealing with refusal of care in a life-threatening situation, and involving and coordinating the various parties concerned, including the psychiatric and somatic care providers, administrator and family. The case uniquely illustrates the challenges described in international literature and recent local studies. The authors plead for the importance of the liaison function between psychiatric and somatic care and the central role of the general practitioner associated with the psychiatric facility. The careful clarification of the legal capacity of the patient who refuses life-saving care, the added value of ethical consultation in order to come to a supported approach and to channel moral distress, and the involvement of a palliative support team within a psychiatric setting are also crucial elements in the approach.

A recent Cochrane review stated that there was a lack of evidence for a decrease in mortality as a result of population breast-cancer screening. The principal data were drawn from five Swedish randomized controlled trials and one Canadian trial. However, the studies cannot be so easily combined because there were important differences in the attendance rate, detection rate, technical quality, referral rate, clinical baseline situation and screening interval. For example, in one of the studies the women from the control arm underwent an annual clinical palpation carried out by a trained nurse or physician, which could have led to an underestimation of the screening effect. Further breast-cancer mortality might not be a good outcome measure because this was not reliably determined; only total mortality was to be observed. This is clinically and methodologically incorrect because breast-cancer mortality was meticulously studied, documented and validated. In the Cochrane review it is suggested that the randomisation was inadequate, but evidence for this was not supplied. The discussion about age differences as a marker for incorrect randomisation is out of date and has been revealed to be unjust. It seems likely that an important part of the decreasing trend in breast-cancer mortality in several countries (including the Netherlands) is due to screening programmes. However, the evaluation of breast-cancer mortality over the next five years is crucial, if greater certainty is to be gained about this.

Objective: More empirical research is needed to disentangle the phenotypes of autism spectrum disorder (ASD) and cluster C personality symptomatology (CCPD), as both show similarities in their clinical presentation. We explored personality and psychopathology dimensions as conceptualized in contemporary dimensional taxonomies (i.e., hierarchical taxonomy of psychopathology; HiTOP) in adults with ASD without intellectual disability operationalized by the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF). Method: = 28) by conducting nonparametric tests and assessing effect sizes. Results: The profiles of the ASD and CCPD groups evidenced to be similar, and both average clinical profiles diverged from the average control group profiles by elevated levels of demoralization, internalizing, and somatization symptomatology. There were small differences between the average profiles of adults with ASD and adults with CCPD. Additional research using dimensional measures of psychopathology could elucidate the dimensional phenotypes of ASD and CCPD. Conclusions: Based on the results in this study, the MMPI-2-RF may not meaningfully discriminate between the two clinical presentations, with the exception of various externalizing scales.

A 72-year-old depressed woman was admitted by court order after a long history of ¿successful' resistance to any treatment, both at home and in a psychiatric hospital. The nature of her disorder had not been recognised and she was diagnosed elsewhere as suffering from factitious disorder, probably based on intense countertransference. The diagnosis of depression with mood-congruent psychotic features was made. After several unsuccessful combination treatments and refusal of electroshock therapy, she finally responded to combination therapy with tranylcypromine, lithium carbonate and clozapine. Dutch medicolegal regulations need not be an impediment in such cases, intercollegiate consultation is most useful and strict adherence to therapy guidelines is beneficial.

Previous studies have shown that there has been an increase in the empowerment of different groups of patients in their contact with physicians and nurses. However, no research to date has specifically focussed on the empowerment of elderly patients from the geriatrician's perspective . Research in this area is important in view of the rise in the ageing population, as elderly patients more frequently come into contact with physicians and more patient participation is required in care through processess such as 'shared decision making' and 'informed consent'. Through interviews with geriatricians from hospitals, this study attempted to gain insights into empowerment of elderly patients in consultations with geriatric physicians. Results show that there is a large degree of variation in empowerment among patients. The main factors that hinder or promote empowerment are the patients' cognitive state, their medical knowledge and educational level. Family and caregivers also appear to play a large role in the empowerment that elderly patients show in the physician's office. Three forms of active communication (asking questians, giving opinions, and expressing concerns) are the predominant manifestations of empowerment in elderly patients. Geriatricians unanimously agreed that empowerment influences the communication and relationship between the physician and the patient and also impacts decision making. Empowerment usually leads to greater therapy adherence and to more extensive patient examinations.

De posttraumatische stressstoornis (PTSS) is een chronische stoornis die ontstaat bij ongeveer 10 % van de mensen na een ingrijpende gebeurtenis (o.a. met gevaar voor eigen leven en/of lichamelijke integriteit). Hoewel de gevaarlijke situatie voorbij is, persisteren herbelevingen van de gebeurtenis, hetgeen gepaard gaat met angst, emotionele onrust en vermijdingsgedrag. Het is een stoornis waarvan de symptomen bestaan uit een combinatie van fysieke manifestaties, zoals verhoogde arousal, spierspanning, schrikreacties en intrusieve ervaringen, alsook psychische manifestaties, zoals flashbacks, veranderde cognities en verstoorde emotieregulatie. Slaapproblemen zijn de belangrijkste klacht bij PTSS: nachtmerries worden het vaakst gerapporteerd, maar insomnie, slaapapneu, pavor nocturnus en nachtelijke arousals komen ook veel voor. In dit hoofdstuk gaan we in op de etiologie, prevalentie en diagnostiek van PTSS en slaapproblemen, hoe deze fenomenen elkaar versterken en wat dit betekent voor diagnostiek en behandeling.