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WHAT IS KNOWN ON THE SUBJECT?: In collaborative care models between psychiatry and general practice, mental health nurses are used as care managers who carry out the treatment of patients with anxiety or depression in general practice and establish a collaborating relationship with the general practitioner. Although the care manager is the key person in the collaborative care model, there is little knowledge about this role and the challenges involved in it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study shows that before the CMs could start treating patients in a routine collaborative relationship with GPs, they needed to carry out an extensive amount of implementation work. This included solving practical problems of location and logistics, engaging GPs in the intervention, and tailoring collaboration to meet the GP's particular preferences. Implementing the role requires high commitment and an enterprising approach on the part of the care managers. The very experienced mental health nurses of this study had these skills. However, the same expertise cannot be presumed in a disseminated model. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When introducing new collaborative care interventions, the care manager role should be well defined and be well prepared, especially as regards the arrival of the care manager in general practice, and supported during implementation by a coordinated leadership established in collaboration between hospital psychiatry and representatives from general practice. ABSTRACT: Introduction In collaborative care models for anxiety and depression, the care manager (CM), often a mental health nurse, has a key role. However, the work and challenges related to this role remain poorly investigated. Aim To explore CMs' experiences of their work and the challenges they face when implementing their role in a collaborative care intervention in the Capital Region of Denmark. Methods Interviews with eight CMs, a group interview with five CMs and a recording of one supervision session were analysed by thematic analysis. Results The CM carried out considerable implementation work. This included finding suitable locations; initiating and sustaining communication with the GPs and maintaining their engagement in the model; adapting to the patient population in general practice; dealing with personal security issues, and developing supportive peer relations and meaningful supervision. Discussion We compare our findings to previous studies of collaborative care and advanced nursing roles in general practice. The importance of organizational leadership to support the CM's bridge-building role is emphasized. Implications for practice The planners of new collaborative care interventions should not only focus on the CM's clinical tasks but also on ensuring the sufficient organizational conditions for carrying out the role.

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BACKGROUND: Body image distortion is a key symptom of anorexia nervosa. In behavioral research two components of body image have been defined: attitudes towards the body and body size experience. Neuroimaging studies concerning own body image distortions in anorexia nervosa have revealed an inconsistent pattern of results and are constrained by the fact that no direct distinction between the different parts of body image has been made. METHOD: The present study therefore set out to investigate the neural correlates of two parts of the own body image using functional magnetic resonance imaging (fMRI): satisfaction rating and size estimation for distorted own body photographs in patients with anorexia nervosa and controls. RESULTS: Anorectic patients were less satisfied with their current body shape than controls. Patients further demonstrated stronger activation of the insula and lateral prefrontal cortex during the satisfaction rating of thin self-images. This indicates a stronger emotional involvement when patients are presented with distorted images close to their own ideal body size. Patients also overestimated their own body size. We were able to show complex differential modulations in activation of the precuneus during body size estimation in control and anorectic subjects. It could be speculated that a deficit in the retrieval of a multimodal coded body schema in precuneus/posterior parietal cortex is related to body size overestimation. CONCLUSIONS: We were able to find specific behavioral responses and neural activation patterns for two parts of body image in anorexia nervosa and healthy controls. Thus, the present results underline the importance of developing research and therapeutic strategies that target the two different aspects of body image separately.

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BACKGROUND: Depersonalization (DP) is characterized by persistent or recurrent episodes of detachment from one's self with reduced pain perception being a common feature. Alterations in the body schema similar to the cortico-limbic disconnection syndrome of pain asymbolia are suggested to be responsible for DP. In this study we used hypnosis to induce DP in healthy subjects and to examine neural patterns of pain perception in the state of DP by means of functional magnetic resonance imaging (fMRI). METHODS: Pain perception was investigated in 7 healthy subjects with high susceptibility to hypnosis in three different mental states: waking state (N-W), hypnotic relaxation (H-R) and hypnotic DP (H-DP). Pain was induced with electrical stimulation to the median nerve at the right wrist. fMRI measurements were performed during all states. RESULTS: Nociceptive stimuli led to an activation of the well described pain network including somatosensory and insular regions and the cerebellum. Activation was markedly reduced in the contralateral somatosensory cortex, parietal cortex (Brodmann area 40, BA40), prefrontal cortex (BA9), putamen and the ipsilateral amygdala during H-DP. Subjects also reported a significant decrease in pain intensity from N-W to H-DP. CONCLUSION: Pain response during H-DP was reduced in sensory and affective pain-related areas, reflecting the diminished intensity of the perceived pain. Moreover, a network of cortical and subcortical areas that have been implicated in the perception of the own body was less responsive during DP, which might point to a specific neural mechanism underlying the 'out-of-body' experience. Although the small number of subjects does not allow a generalization of our findings, H-DP seems to be a promising tool for the investigation of psychological and biological mechanisms of self-inflicted injuries as well as the mind-body interplay within the realm of psychosomatic disorders.

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In regularly burned grassland on Morro Santana, Porto Alegre, RS, Brazil, we investigated differences in the floristic composition and their relation to soil properties, aspect and distance from the forest border. In 48 plots of 0.75 m², we identified a total of 201 species from a local species pool of approximately 450 to 500 species. Most species occurred in low frequencies, showing clumpy distribution patterns in the studied area. Multivariate analysis showed that plots close to the forest edge clearly differed from plots in the open grassland concerning composition and structure. Plots exposed to the north differed from plots on the top of the hill both in the composition of species as well as in soil variables, mainly due to shallower soil in the former. No strong relation between soil properties and variation in vegetation composition could be detected at a finer scale. The studied grassland, as all grassland vegetation in southern Brazil, is very rich in species compared to other grassland formations worldwide. However, this high biodiversity and conservational value of Campos vegetation in general has so far not been recognized properly. Disturbance is essential to maintain this open vegetation type and its species richness. Fire should be considered as a management option in the absence of grazing.

Em um campo regularmente queimado no Morro Santana, Porto Alegre, RS, Brasil, foram investigadas diferenças na composição florística e suas relações com as propriedades do solo, a distância da borda florestal e a exposição do relevo. Em 48 parcelas de 0,75 m², foram amostradas 201 espécies identificadas, de um total estimado para o local de aproximadamente 450 a 500 espécies. A maioria das espécies apresentou baixas freqüências e uma distribuição aglomerada na área de estudo. A análise multivariada dos dados indicou que as parcelas adjacentes à borda florestal claramente diferem florística e estruturalmente das parcelas do campo. As parcelas com exposição norte diferiram das do topo do morro, tanto pela composição florística quanto pelas variáveis do solo, principalmente em relação à menor profundidade do solo no norte. Nenhuma relação forte foi detectada entre as propriedades do solo e a variação na composição da comunidade em escala mais fina. A área estudada, assim como a vegetação campestre no sul do Brasil em geral, apresenta-se muito rica em espécies, se comparada a outras formações de campo ou savana no mundo. Apesar disso, a alta biodiversidade e o valor de conservação da vegetação campestre não têm sido reconhecidos. Na ausência do pastejo, o fogo é um imporante fator de manejo para a conservação da vegetação campestre, uma vez que o distúrbio parece ser necessário para manter esse tipo de vegetação aberta, com alta riqueza em espécies.

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BACKGROUND: Psychoanalytical theories coincide in understanding depersonalization (DP) as a disorder of narcissistic self-regulation. DP is described as an ego defense against overwhelming shame resulting in a splitting of an observing ego detached from the experiencing self. In contrast to a behavioral-cognitive theory on DP, which suggests that the catastrophic appraisal of normal transient DP maintains the disorder, psychodynamic approaches stress that DP is an important defensive function for the individual. We examine this psychodynamic aspect more closely as it relates to narcissistic self-regulation and interpersonal behavior in depersonalized patients. SAMPLING AND METHODS: Thirty-five patients with pathological DP are compared with 28 patient controls concerning their narcissistic self-regulation and interpersonal behavior. For the assessment, we used the German Narcissism Inventory and the Inventory of Interpersonal Problems. The two groups were controlled for sociodemographic data, comorbidity with a personality disorder, and the General Severity Index of the Symptom Check List-90-R. RESULTS: Bonferroni-corrected group comparison showed that the depersonalized patients are characterized by perceiving themselves as helpless, hopeless, socially isolated and worthless, perceiving others as bad and disappointing, and that they avoid interpersonal relations and reality significantly more than other patients with equal symptom severity. CONCLUSIONS: Treatment approaches on DP should take the issue of low self-esteem, pervasive shame and the related defensive social avoidance into account. Further empirical research on psychodynamic concepts of DP is warranted also for the sake of linking modern neurobiological findings with clinical experience.

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Disturbances of visual perception like micropsia, macropsia, teleopsia, pelopsia, metamorphopsia or loss of stereoscopic depth perception are usually considered in ophthalmology as symptoms of retinopathy, especially maculopathy or disorders of binocularity. Differential diagnostic considerations include disorders like migraine and epilepsy but not the visual disturbance pertaining to the depersonalization-de-realization syndrome, although the above-mentioned symptoms are more prevalent in this psychogenic disorder. This article gives a review of depersonalization-de-realization in order to enable the ophthalmologist to include this syndrome into his diagnostic considerations.

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In regularly burned grassland on Morro Santana, Porto Alegre, RS, Brazil, we investigated differences in the floristic composition and their relation to soil properties, aspect and distance from the forest border. In 48 plots of 0.75 m2, we identified a total of 201 species from a local species pool of approximately 450 to 500 species. Most species occurred in low frequencies, showing clumpy distribution patterns in the studied area. Multivariate analysis showed that plots close to the forest edge clearly differed from plots in the open grassland concerning composition and structure. Plots exposed to the north differed from plots on the top of the hill both in the composition of species as well as in soil variables, mainly due to shallower soil in the former. No strong relation between soil properties and variation in vegetation composition could be detected at a finer scale. The studied grassland, as all grassland vegetation in southern Brazil, is very rich in species compared to other grassland formations worldwide. However, this high biodiversity and conservational value of Campos vegetation in general has so far not been recognized properly. Disturbance is essential to maintain this open vegetation type and its species richness. Fire should be considered as a management option in the absence of grazing.

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OBJECTIVES: This multi-methodical single case study examines how relationship, resistance and insight, the important therapeutic factors, are conveyed in a therapeutic process. METHODS: For depicting interaction the textual parameters - direct speech, acknowledgement tokens, activity of speech and personal pronouns - of Formal Psycholinguistic Text Analysis (Overbeck et al., 1996) are applied. The activity of the unconscious theme is measured by the Interferenzindex (Argelander, 1984). The link of emotional experiences with words is depicted by the Computerized Referential Activity method (Mergenthaler and Bucci, 1999). The attainment of emotional insight in the Model of the Therapeutic Cycle is perceived via the Emotion-/Abstraction-Patterns (Mergenthaler, 1997). RESULTS: Three phases are discriminated accordingly: Resistance, characterised by defensive intellectualization, symbolic representation on the basis of the secure relationship and emotional insight and detachment. CONCLUSIONS: The validity of the results in this single case study is guaranteed by the multi-methodical strategy.

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In this article the results of a research with the CCRT-method on the psychotherapies of three in-patients suffering from eating disorders are presented. The CCRT describes recurrent internal and interpersonal relationship patterns in narratives. Each therapy session was recorded on tape and transcribed. The CCRT components were identified from the verbatim transcripts. All three patients clearly showed a negative self-perception and despite a more graded attitude regarding other people they felt rejected by the community throughout the entire therapy. The CCRT of each patient was different: patient 1. had conflicts between dependence and independence with increasing autonomy; patient 2. had great symbiotic desires, which at the beginning of the therapy were warded off with a performance ideal; patient 3. showed self-assertion and an increasing level of openness against the community, despite a high level of fear and self-isolation at the onset of therapy. Despite methodological deficiencies the CCRT method proved to be sensitive enough to show similarities and differences among the individual courses of treatment.

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The illicit use of cocaine has increased dramatically over the last 10-12 years. There has been a corresponding increase in cocaine abuse among obstetric patients and in the number of "cocaine babies." According to some estimates, these children make up more than half of the drug-associated births. This problem is therefore a major public health concern. Consequently, our laboratory investigated the effects of prenatal cocaine exposure on hearing, vision, growth, and exploratory/stress behavior. This chapter summarizes the literature on animals and humans on these topics and presents new observations from our laboratory. In terms of maternal toxicity, prenatal cocaine exposure causes hypertension, placental abruption, spontaneous abortion, poor pregnancy weight gain, and undernutrition secondary to appetite suppression. Some offspring effects include in utero growth retardation, cephalic hemorrhage, fetal edema, altered body composition, congenital malformations, and even pre- and postnatal death. The offspring can also exhibit a variety of behavioral, visual, hearing, and language disorders. Differential effects of animal strain and late gestational cocaine exposure are discussed. Comparisons are made between prenatal cocaine, the fetal alcohol syndrome, and the effects of prenatal undernutrition. Recommendations for clinical assessment and intervention are made.

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This study investigated select aspects of peripheral and central auditory dysfunction, as well as the pathological effects of aging, In an animal model of fetal alcohol syndrome (FAS). Pregnant rats consumed liquid alcohol diets containing 0, 17.5, or 35% ethanol-derived calories, from gestation day 7 to parturition. A fourth group was untreated. Offspring of these mothers were tested for auditory and neurological function, using the auditory brainstem response at 6, 12, and 18 months of age. Some animals in the alcohol-exposed groups showed a peripheral auditory disorder in the form of congenital sensorineural hearing loss. This was correlated with punctate lesions and malformed stereocilia on the auditory sensory receptor cells of the inner ear. Alcohol-exposed animals also showed a central auditory processing disorder characterized by prolonged transmission of neural potentials along the brainstem portion of the auditory pathway. Animals in the highest dose group also showed an augmentation in the age-related deterioration of auditory acuity. Thus, increased peripheral and central auditory dysfunctions and pathological deterioration of auditory function in old age may be sequelae of FAS. Such morbidities have important implications for the long-term clinical assessment and management of FAS patients.

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Although hypochondria is one of the earliest psychic conditions to be described, its nosological status is still uncertain and it has been largely neglected in theories of psychosomatics and neurosis. The authors undertake a detailed review of the literature and examine the psychodynamic concepts and theoretical approaches to the hypochondria phenomenon, from Freud, Ferenczi and Levy, through Klein and the ego psychologists, object-relation theories and the psychology of the self, all the way up to the present day. The authors trace the differences between hypochondria and other body-related disturbances and indicate the consequences for diagnosis and therapy.

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This paper is intended as a contribution to qualitative-quantitative research on the psychotherapeutic process. It reports on the course of a three-month inpatient psychosomatic treatment of a female patient with an eating disorder from the preferred point of view of psychoanalytically oriented individual therapy. Given the central role of the self-object relationship in women with eating disorders, changes that occur with regard to this aspect over the course of the therapy are recorded and described. In addition to the clinical perspective, the selected approach is based on a combination of methods, with an emphasis on the analysis of linguistic content using the Gottschalk-Gleser method, the Core Conflictual Relationship Theme method according to Luborsky and the projective procedure of Object Relations Technique according to Phillipson. In the course of treatment reveals changes in terms of reducing shame-anxiety and inwardly-directed aggressiveness as well as in the patient's object repproachement and to a more positive way of dealing with herself, all of which, on the whole, can be considered indicative of an increasing degree of self-object differentiation.

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Young adult male Sprague-Dawley (SD) and Long-Evans (LE) rats were evaluated using the auditory brainstem response (ABR). ABRs were evoked by stimuli with intensities ranging from 15 to 100 dB peSPL. Stimuli were tone bursts of 2000, 4000 and 8000 Hz. As stimulus intensity decreased from 100 to 15 dB, the ABR peak latencies prolonged, interpeak latencies (IPLs) shortened and amplitudes decreased. As stimulus frequency decreased from 8000 to 2000 Hz, ABR latencies prolonged, amplitudes decreased and ABR thresholds increased. The longest IPLs were in response to the 4000 Hz tone bursts. SD rats had ABRs with shorter peak latencies, larger amplitudes and lower thresholds than LE rats. The IPLs usually did not show significant strain-dependent differences. Our observations on stimulus intensity and frequency are consistent with previous reports. Our observations also suggest that the SD (albino) rat has better auditory acuity than the LE (pigmented) rat over the frequency range of 2000 to 8000 Hz. This implies that previous concerns about the use of albino animals in audiological research are somewhat overstated.

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Polydrug abuse has increased substantially in recent years amongst obstetric patients. One of the most common drug combinations is alcohol and cocaine. To better understand the adverse consequences of this drug combination on pregnancy and the offspring, alcohol (2 g/kg, b.i.d.) and cocaine HCl (30 mg/kg, b.i.d.) were administered individually and in combination to separate groups of pregnant Long-Evans rats from gestation days 7-20. The pregnant dams were evaluated for maternal weight gain, food and water consumption, mortality, and gestational length. The offspring were evaluated for physical maturation, mortality, and behavior. The drug combination was found to have greater effects regarding decreased birth weight, increased postnatal mortality, and delayed physical maturation than either drug alone. Drug treatments also influenced activity monitor behavior in that prenatal cocaine exposure was associated with hypoactivity while the alcohol and the alcohol-plus-cocaine treatments were associated with hyperactivity in periweanling pups. Drug treatments had no significant effects on passive or active avoidance behaviors. These results suggest that combining alcohol and cocaine increases the risk to the offspring.

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Prenatal cocaine exposure has been associated with a variety of adverse neurological effects. Three recent studies found evidence that prenatal cocaine exposure is associated with abnormal auditory electrophysiology, suggesting abnormal processing of auditory information. The present study used the auditory brainstem response to evaluate the effects of prenatal cocaine exposure on hearing in an animal model (Long-Evans rat). We report that prenatal cocaine exposure can cause elevated ABR thresholds and latency-intensity curves consistent with a recruitment-type sensorineural hearing loss.

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Pregnant Long-Evans rats were injected daily with 40, 60, 80 or 100 mg/kg cocaine HCl (SC, 2% solution) from gestational days 7-20 (sperm positive = day 0). Daily doses were split with half given between 9:00-10:00 a.m. and half between 3:00-4:00 p.m. An ad lib-fed group as well as nutritional control groups that were pair-fed to the 80 and 100 mg/kg cocaine dams were also evaluated (N = 11-18 litters/group). The negative geotactic reaction of the offspring, evaluated from day 2-14 (birth = day 0), showed no group differences. Spontaneous alternation behavior in a T-maze showed no evidence of perseveration in any group on either day 21 or day 80. Most cocaine-treated offspring showed an altered preference in turning right versus left on day 21. Activity monitor behavior showed that the cocaine-treated and pair-fed offspring were hypoactive on day 20. Some degree of hypoactivity was still evident on day 49, but absent on day 80. The passive avoidance behavior of day 19 offspring showed no group differences in acquisition of task learning. The 100 mg/kg cocaine offspring did show significantly poorer retention of task learning 48 hr later. On day 80, no group differences were seen in passive avoidance behavior. Acquisition of an active avoidance behavior on day 80 was significantly poorer in the 100 mg/kg cocaine group.

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Prenatal cocaine exposure has been associated with a variety of adverse neurological effects in infants and laboratory animals. Of particular interest, one group of investigators reported that exposed neonates have an abnormality in the brainstem auditory-evoked potential (BAEP). The particular abnormality, a prolongation in the wave I-V interpeak latency, suggested delayed or desynchronized transmission of subcortical auditory information. To further investigate this possible consequence of prenatal cocaine exposure, pregnant Long-Evans rats were injected daily with 60, 80 or 100 mg/kg cocaine HCl (SC, 2% solution) with half the daily dose given in the morning and the other half given in the afternoon. Treatment was given from gestation days 7 to 20 (sperm positive = GD 0). Ad lib-fed and pair-fed control groups were also used. Offspring were evaluated at the age of 35 days (birth = PD 0) and as adults (6-10 months). BAEPs were elicited by click stimuli presented over a broad range of intensities and repetition rates. Prolongation of the interpeak latencies and a reduction in BAEP amplitudes were observed only in the highest dose (C100) group, only at the age of 35 days, and only at the highest stimulus intensity. While these results support those found in exposed neonates, our data suggest a) that the effects are developmental delays which dissipate with aging and b) that the effects require high cocaine exposure.

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Pregnant Long-Evans rats were injected daily with 40, 60, 80, or 100 mg/kg cocaine HCl (SC, 2% solution) from gestational days 7-20 (sperm positive = day 0). Daily doses were split evenly with half given between 9:00-10:00 a.m. and half between 3:00-4:00 p.m. An ad lib-fed group as well as nutritional control groups that were pair-fed to the 80 and 100 mg/kg cocaine dams were also evaluated (N = 11-18 liters/group). Cocaine had no effect on gestational length but did cause dose-dependent decreases in maternal food consumption and weight gain and increases in maternal mortality. Interestingly, cocaine-treated dams shows a significant increase in water consumption. In terms of offspring variables, there was a dose-dependent decrease in birth weight and postnatal weight gain in both the cocaine and pair-fed groups. There were also dose-dependent effects on litter size, stillbirths and postnatal mortality in the cocaine-treated groups as compared to the control groups. High dose cocaine treatment caused delays in several indices of physical maturation (pinna detachment, fur growth, ear opening, eye opening, vaginal opening) but not in others (incisor eruption, testicular descent). Physical anomalies and postnatal morbidity, while uncommon, were observed in animals prenatally exposed to the higher cocaine doses. Collectively, these data suggest that prenatal cocaine exposure can increase postnatal morbidity as well as increase pre-and postnatal mortality in animal offspring.

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