Past clinical research has identified depression as the most common psychiatric disorder associated with cervical dystonia (CD). The purpose of our study is to document different patterns of psychopathology, the frequency of psychiatric disorders, and possible correlation with the neurological disorder in patients with CD. Forty patients with CD were investigated to assess levels of psychopathology on two self-rated scales: the Beck Depression Inventory (BDI) and Symptom Check List (SCL-90). To determine the presence of psychiatric disorders, the patients were evaluated using the standard instrument in the DSM-III-R (Structured Clinical Interview Schedule, SCID). A small group of dystonic patients (12%) had higher levels of psychopathology, with significant amounts of concomitant anxiety and depression on the BDI and SCL-90. SCID criteria for at least one psychiatric disorder were fulfilled in 22 patients (55%), including both the lifetime and current diagnoses. The most frequent diagnostic categories were anxiety (40%) and major depressive disorders (37.5%). In 17 patients (42.5%), criteria for at least one lifetime diagnosis were fulfilled prior to the onset of CD. Psychiatric evaluation does not indicate one specific disorder associated with CD. The presence of anxiety and depression symptoms before and during the course of dystonia, without a possible causal relationship, could mean that the alteration of a chain of physiological events in the central nervous system may not lead to a single clinical picture. The relatively high overall lifetime prevalence of anxiety and depressive disorders may indicate the need for a broader diagnostic and therapeutic approach to patients with focal dystonia.

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Post-traumatic stress disorder (PTSD) has been described as the characteristic sequel to extreme events in life such as war and especially torture. This limitation to a single approach in regard to diagnosis and treatment has been criticised as being a too narrow concept to describe the effects following extreme events in life, especially as most studies so far were limited to PTSD and a small range of symptoms or disorders. The study presents data on psychiatric disorders in a group of exiled survivors of torture presenting to an out-patient department for psychiatry. A DSM-III-R-based psychiatric interview, including the general assessment of functioning scale (GAF), an open list of symptoms and the Vienna diagnostic criteria in regard to depression were used to evaluate a broader range of possible sequels. The most frequent present diagnosis in 44 patients seen over a period of 3 years was PTSD (n = 40), but criteria for a present diagnosis of other disorders were fulfilled in 34 patients, even years after torture, mainly major depression or dysthymia (n = 26). Criteria for functional psychosis were fulfilled in 4 patients. Many patients reported symptoms not assessed by DSM-III-R criteria, including feelings of shame and guilt, and ruminations on existential fears. The impairment as indicated by the GAF (mean 59.1) correlated best with the presence of the endogenomorphic-depressive axial syndrome, but not with duration of imprisonment, age or other factors. Research on sequels to extreme trauma should not be restricted to a simple diagnosis of PTSD, but should continue to look for a broader conceptualisation, including neglected categories like the axial syndrome, as PTSD is common, but might not be the only factor of importance for research and treatment. ICD-10 might offer a more adequate interpretation of sequels.

Psychiatric wills are advance directives for an eventual involuntary treatment in psychiatry. We attempted to determine psychiatric professionals' knowledge and opinion about this legal option and obtain their formulations of advance directives for themselves. A total of 101 psychiatric nurses and psychiatrists at the Department of Psychiatry of the University of Vienna responded to a questionnaire about psychiatric wills and anonymously drafted advance directives for themselves concerning psychiatric treatment in case of an acute psychosis. Fifty-four percent knew about this legal option, 55% considered it an appropriate legal possibility, and 29% considered it inappropriate. The study also found that 75% of respondents reject certain methods of therapy, e.g. 30% want to exclude the use of neuroleptic medications, and 46% reject ECT. We conclude that although there is little experience so far with advance directives for psychiatric patients, there is an interest and predominance of positive attitudes towards this legal option among mental health professionals. Concerning their preferences, professionals felt inclined to make very specific statements as to which available treatment strategies they would reject and which they would request for their treatment. This bodes well for the widespread use of advance directives in mental health settings.

Naltrexone could be effective in reducing SIB in patients with psychiatric disorders by blocking the positive reinforcement of SIB, which is released by the release of endogenous opoides. Placebo-controlled studies of the efficacy of naltrexone in treating SIB should be undertaken.