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BACKGROUND: The treatment of severe mental illnesses is increasingly taking place in a domiciliary setting due to the deinstitutionalisation.
AIM: Theoretical reflection on the influence of home treatment on the therapeutic alliance.
METHOD: Qualitative review of possible effects of home treatment based on own experiences, the scientific literature, and recent handbooks on community mental health.
RESULTS: The therapeutic relationship appears to be an important general factor in the outcomes of community mental health approaches. The working alliance has a more egalitarian and reciprocal nature. It improved when the scope of treatment was defined by the needs of the client. Boundaries concerning both the extent of personal involvement of the caregiver and the autonomy of the client presented important challenges in a context that lacks formal professional boundaries such as those seen in a consultation room or a hospital.
CONCLUSION: Characteristic features of the therapeutic alliance during home treatment pose a challenge to the caregiver in terms of balancing interpersonal involvement and distance. The need to intervene in the personal life of the patient often causes ethical dilemmas. A dialectical form of intervision is proposed to explore the emotional involvement of the caregiver and to systematically reflect on possible ethical issues as a tool for daily practice.

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BACKGROUND: Functional magnetic resonance imaging (fMRI) is an important technique for detecting neural network problems in patients with schizophrenia. Very often, however, the professionals involved are insufficiently aware of the fact that when fMRI scans are used for patients with schizophrenia, it is the type of task that patients are performing or failing to perform which is of vital importance for the correct interpretation of the results. AIM: To demonstrate that in scans of patients with schizophrenia the choice of task can influence neuroimaging results, particularly when the neural problems under study are performance-related. METHOD: We begin by presenting a brief history of functional neuroimaging techniques. This provides a context for the study of the potential role of fMRI in detecting dysfunctional brain networks in schizophrenia. In this way we demonstrate more clearly why the rapidly developing scanning techniques and analysis methods are becoming more and more important for measuring specific differences between psychiatric disorders. Then, we discuss the complex relationship between cognitive deficits in patients with schizophrenia, problems in task performance, and disease-related effects on brain activation measured by fMRI. RESULTS: This is illustrated by our own recent work, in which we demonstrate the complex relationship between cognitive deficits in the task performance of patients with schizophrenia and differences in brain activity measured with fMRI. We stress the importance of task-independent neural networks for the interpretation of results. These networks may play a role similar to that of the potentially confounding effects of task choice. Finally, we consider challenges for the future and comment on how fMRI needs to be developed so that it can be used successfully in clinical practice in order to assist with the diagnosis, prognosis and treatment of schizophrenia. CONCLUSION: It is crucial for neuroimaging research into schizophrenia, and for potential clinical applications, that new types of tasks are developed that avoid the confounding effects on neural activity which are caused by performance differences stemming from aspecific factors such as demotivation or task-disengagement.

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The PDSS is a potential side-effect of the intramuscular injection of olanzapine pamoate. We saw the typical symptoms develop in a 46-year-old man 4 hours after the injection. The syndrome is caused by a toxic concentration of olanzapine, and is possibly the result of the direct injection of the substance in the bloodstream. The most important measures that can be taken to prevent such an emergency are: a careful injection procedure, a 3-hour observation period following the injection and good counselling of the patient and his family. The treatment is conservative.

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BACKGROUND: In Article 107 of the hospital legislation the Belgian government provides for a possible reorganisation of current mental health care. According to the Article, hospital managers and the medical staff of residential care units in each region are permitted tot re-allocate resources in such a way that their current government allowance is used for the development of an alternative type of health care that is more community-based. AIM: To explore the possible consequences that such a step is likely to have on the current users of long-term residential care. METHOD: We looked critically at the draft text which was circulated in order tot explain the proposed reorganisation. We evaluated the scientific evidence concerning the feasibility of the ideas put forward in the text, focusing particularly on the care of patients with a serious mental illness. RESULTS: The method, which involves the re-allocation of funds in order to stimulate the reorganisation of care, is considered to be self-defeating. On the one hand, it constitutes a threat, leading to possible closure of the least profitable services, including hospital wards for long-stay patients. On the other hand, the proposed health care organisation poses a threat to the very group of patients who reside in such hospitals and it may in fact lower the level of care they receive. CONCLUSION: It will be necessary to check on the effects that this reorganisation will have on patients with a serious mental illness. We therefore propose some ways of monitoring the effects that the planned reorganisation is likely to have on this vulnerable group of patients.

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OBJECTIVES: A vast amount of studies demonstrates the presence of psychomotor slowing in schizophrenia. The objective of the present study was to investigate whether this overall psychomotor slowing can be divided into distinct processes that differentially affect cognitive functioning in schizophrenia. METHODS: The pen-tip movements of 30 schizophrenic inpatients and 30 matched controls were digitally recorded during performance of the Symbol Digit Substitution Test (SDST) and analysed to differentiate matching time and writing time, representing the cognitive and sensorimotor component of slowing, respectively. In addition, the results were compared to each other and to the scores of traditional neuropsychological tests that assess domains such as memory and attention. RESULTS: Both matching time and writing time were longer in the schizophrenic patients relative to the controls but did not correlate. Only matching time correlated significantly with the conventional neuropsychological test results. CONCLUSIONS: Although schizophrenic patients display both sensorimotor and cognitive slowing, the two processes are unrelated. Furthermore, only the cognitive component was associated with most of the cognitive deficits as measured by traditional neuropsychological tests.

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Anterograde amnesia in Wernicke-Korsakoff syndrome is associated with diencephalic lesions, mainly in the anterior thalamic nuclei. Whether diencephalic and temporal lobe amnesias are distinct entities is still not clear. We investigated episodic memory for faces using functional MRI (fMRI) in eight controls and in a 34-year-old man with Wernicke-Korsakoff syndrome and diencephalic lesions but without medial temporal lobe (MTL) involvement at MRI. fMRI was performed with a 1.5 tesla unit. Three dual-choice tasks were employed: (i) face encoding (18 faces were randomly presented three times and subjects were asked to memorize the faces); (ii) face perception (subjects indicated which of two faces matched a third face); and (iii) face recognition (subjects indicated which of two faces belonged to the group they had been asked to memorize during encoding). All activation was greater in the right hemisphere. In controls both the encoding and recognition tasks activated two hippocampal regions (anterior and posterior). The anterior hippocampal region was more activated during recognition. Activation in the prefrontal cortex was greater during recognition. In the subject with Wernicke-Korsakoff syndrome, fMRI did not show hippocampal activation during either encoding or recognition. During recognition, although behavioural data showed defective retrieval, the prefrontal regions were activated as in controls, except for the ventrolateral prefrontal cortex. fMRI activation of the visual cortices and the behavioural score on the perception task indicated that the subject with Wernicke-Korsakoff syndrome perceived the faces, paid attention to the task and demonstrated accurate judgement. In the subject with Wernicke-Korsakoff syndrome, although the anatomical damage does not involve the MTL, the hippocampal memory encoding has been lost, possibly as a consequence of the hippocampal-anterior thalamic axis involvement. Anterograde amnesia could therefore be the expression of damage to an extended hippocampal system, and the distinction between temporal lobe and diencephalic amnesia has limited value. In the subject with Wernicke-Korsakoff syndrome, the preserved dorsolateral prefrontal cortex activation during incorrect recognition suggests that this region is more involved in either the orientation or attention at retrieval than in retrieval. The lack of activation of the prefrontal ventrolateral cortex confirms the role of this area in episodic memory formation.

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Detailed analysis of the proton and carbon-13 NMR spectra of cyclo(L-prolyl-L-N-methylphenylalanyl) in chloroform and methanol in relation to its nonmethylated analog provided information on the conformation of the title compound in solution as well as on the effect of N-methylation and solvation. The X-ray structure of the title compound in the crystalline state showed the same conformational features as the solution structure. The phenyl group folds over the diketopiperazine ring which resembles a flattened half-chair. Both amide bonds are considerably nonplanar. The pyrrolidine ring of proline shows a strong pucker at the ring junction with the largest chi 5 value hitherto observed.

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