Affective disorders cluster in patients with cardiac diseases, in particular in coronary artery disease (CAD) which has become one of the most prevalent chronic disorders in the western world. Affective dysregulation has been recognized as a major riskfactor for cardiac death in patients with CAD. Therefore treatment of affective dysregulation is important from both the psychiatric and cardiac perspective. An evidence based treatment algorithm for affective disorders is as yet not available. In this paper a possible etiological model for the relationship between affective and cardiac dysregulation is proposed, based on the stress-diathesis model.

Given the diagnostic ambiguity of physically unexplained complaints we wanted to study whether the clinically and symptomatically characterized groups, all of them defined according to DSM-III-R criteria, could be reclassified using selected empirical and theoretical variables of operationally defined parameters.

Patients with conversion (N = 75), somatization or undifferentiated somatoform disorders (N = 74) and major depression (N = 70) according to DSM-III-R underwent multidimensional work-up including psychopathological, personality-psychological, illness, behavioral and coping assessment. The clinically characterized groups should be statistically reclassified by discriminant analytic techniques.

The existing diagnostic categories according to DSM-III-R could be widely confirmed by the statistical reconstitution of the clinical groups. Conversion, somatization and depressive disorder presented as distinct clinical categories.

A classification relying widely on symptoms still seems to be too superficial and does not represent the complexity of these patients. Thus, the modern classification systems with their purely phenomenological criteria should be added with further dimensions.

Immunotherapy with interferon-alfa has become standard therapy in selected patients with viral hepatitis and chronic myelogenous leukemia. In addition, it is used in a variety of other diseases, both as standard therapy and in clinical trials. Its use is expected to expand in the following decade. Interferon can cause (severe) neuropsychiatric side effects. These side effects are discussed. Adequate management of these side effects is important, as is close collaboration between the oncologist and the psychiatrist. The cornerstone of management is patient education: this prevents interruption of therapy by patients who were not warned for neuropsychiatric side effects. Furthermore, patients should report in case of rapidly arising mood disorders. Interferon-alfa induced mood disorder is reported to be treatable. Three case descriptions illustrate this, but also illustrate some limits to successful treatment.

The alterations in the inflammatory response system (IRS) appear to be quite different between OCD and anorexia nervosa and are also different from the changes observed in major depression. In anorexia nervosa, there is some evidence for increased production of monocytic cytokines, i.e. tumor necrosis factor-α (TNFα) and interleukin-6 (IL-6), and decreased production of Th-1 like cytokines, i.e. IL-2 and IFNγ. In the same patients there are also signs of immunosuppression, e.g. lowered numbers of CD4 and CD8 T cells and increased production of transforming growth factor-beta (TGFβ). The increased production of monocytic cytokines may be the consequence of the hyponutritional status of those patients. The diminished production of the Th-1 like cytokines may be the consequence of at least four different factors: 1) the deficiency in nutritional factors; 2) neuroendocrine disorders, such as increased Cortisol production; 3) the increased TGFβ production; and 4) lower serum dipeptidyl peptidase activity. In OCD no consistent or specific alterations in the IRS are observed. There is no evidence that IRS activation may play a role in the pathophysiology of OCD and anorexia nervosa.

Fatigue is a common symptom in the community and the commonest associations are with stress or mood disturbance. One in a hundred people complain of unexplained and prolonged fatigue, with half that number meeting the strictest criteria for the chronic fatigue syndrome (CFS). Discrete fatigue syndromes have been described, particularly after Epstein Barr virus infection. The majority of patients with CFS have a syndrome similar to the ICD-10 definition of neurasthenia. Mood and somatoform disorders are common comorbid or differential diagnoses.

The prognosis is poor, particularly in patients attending hospitals and those with comorbid psychiatric disorders. The aetiology of both CFS and chronic unexplained fatigue are essentially unknown, perhaps reflecting the heterogenenous natures of both the symptom and syndrome. There is reasonable evidence to suggest that particular infections may trigger both prolonged fatigue and CFS. Maintaining factors are different from triggering factors and include mood and sleep disorders, illness beliefs and behaviours, and possibly inactivity. Treatments aimed at reversing these maintaining factors show promise.

Between 25 and 30% of the victims of a whiplash injury have complaints after one year. This condition is referred to as late whiplash syndrome. This syndrome is characterized by pain of the neck, headache, forgetfulness, poor concentration, mental fatigue, and affective symptoms. The causes of the persistent symptoms are unknown. In all, the evidence that late-whiplash syndrome is a neurological disorder is flimsy. Current opinion holds that the acute basis is the painful injury of the neck. In the months following the accident, pain is the substrate on which psychological and social factors may act. Emotional symptoms such as lability of affect and disturbed mood, or posttraumatic stress disorders are common after whiplash. Although there is definitely a place for psychiatrists and psychologists in the treatment of late whiplash syndrome, these professionals are not involved in late whiplash disorder as much as they should be. Brief psychological treatment has proven to significantly reduce the severity and duration of symptoms. Optimal management must cover the treatment of pain, depression, anxiety, and fatigue; adequate psycho-education, stressing the good long-term outcome; and education of patients and relatives on possible cognitive symptoms.

The relationship between epilepsy and behavior disorders will be briefly outlined, and an initial distinction between periictal and interictal disorders made. This paper will concentrate on the periictal disorders. These include the ictally driven psychoses, such as complex partial seizure status and absence status. There will then be a discussion of the postictal psychoses. It will be noted how these form a constant clinical picture, which sometimes goes unrecognized. The phenomenology may be typically paranoid or schizophrenia-like, andpatients often present in a setting of clear consciousness. The fascinating phenomenon of the lucid interval will be noted. Following this there will be some discussions on the management of these disorders. The rest of the paper will discuss the phenomenon of forced normalization, first discovered by Landolt. This often remains unrecognised, but is of interest to both neurology and psychiatry. Essentially this is about patients who, following suppression of seizures, develop an acute psychotic state or some other kind of behavior disorder. With the return of the seizures the behavior disorder resolves. Various theories in relationship to this condition will be noted, and the fascinating paradox that in psychiatry we give a seizure to resolve a psychosis, whereas in epileptology suppression of seizures can lead to a psychosis will be presented.

Med Psych Units (MPU) are neither clear-cut medical nor psychiatric units. This makes it difficult to acquire funding for these often expensive units. Despite this, there are many reasons why MPU's should be a necessary part of any larger scale inpatient service of a general and teaching hospital. It is therefore even more remarkable that such units hardly exist in Europe and that only about twenty exist in the USA. Five main reasons why such units should be opened are:

1. The increasing average age of the population of the Western World, with high co-morbidity and polypharmacy in the elderly and elderly elderly.

2. An increase in the number of chronic physical diseases resulting in co-morbid psychiatric disorders. This increase in chronicity is the consequence of increasingly successful treatment of acute and potentially lethal diseases; for example, acute myocardial infarction and the subsequent development of chronic heart disease.

3. The decreasing duration of hospital admission. On average the duration of stay in a general hospital in The Netherlands is now nine days. The number of day-treatments has doubled in the last decade. This situation means that it is not possible to observe the behavior of patients on a general medical ward or to carry out a psychiatric consultation.

4. Inadequate medical evaluation of psychiatric patients. According to a recent survey by the Dutch Ministry of Health, the care given for physical disease to psychiatric patients in mental hospitals in The Netherlands needs much to be desired for.

5. The psychiatric co-morbidity of somatic diseases is accompanied by a high consumption of medical facilities and high economic losses, unless adequately recognized and treated.

Het mag als een verworvenheid beschouwd worden dat er sinds kort stoffen op de markt zijn die de kans op terugval van alcoholisten verkleinen. Natuurlijk hebben deze stoffen, zoals acamprosaat en naltrexon indicaties en contra-indicaties, en die zijn in de voorgaande artikelen beschreven. Het is daarmee echter nog niet gemakkelijk geworden een richtlijn voor de dagelijkse praktijk te formuleren. Dat blijkt wel uit deze artikelen. Immers, acamprosaat is effectief gebleken, maar nu ook weer niet zó effectief dat het niet voorschrijven ervan per definitie een gemiste kans moet worden beschouwd. De Jong en Schippers wijzen er terecht op dat als stoffen té enthousiast worden voorgeschreven, zoals dat met disulfiram is gebeurd, het grote aantal mislukkingen ertoe kan leiden dat men zich weer teleurgesteld van zo'n stof afwendt. En het risico op dit soort therapeutisch enthousiasme is juist bij de behandeling van verslavingen levensgroot. Er zijn weinig ziektebeelden die bij een behandelaar zoveel machteloosheid kunnen oproepen en dus zoveel neiging naar strohalmen te grijpen.