En ny tvångsvårdslag trädde i kraft 2008 som gjorde det möjligt för psykiatrin att ställa särskilda villkor till patienter som vårdats i psykiatrisk slutenvård för att få bli utskrivna. Detta öppnade upp möjligheten för att patienter kan få villkor ställda till att ta emot kommunal hälso-och sjukvård samt kommunala insatser. Tvångsvård får enligt lag enbart bedrivas inom sluten psykiatrisk vård och kommunen får i hemmet enbart bedriva frivilliga insatser. Syftet med denna undersökning är att belysa hur psykiatrisjuksköterskorna i den kommunala hälso-och sjukvården upplever att vårda utifrån en frivillighet, som är beslutad utifrån en tvångsvårdslag. Undersökningen är genomförd utifrån en kvalitativ metod, med intervjuer av psykiatrisjuksköterskor i kommunal hälso- och sjukvård. Resultatet visade att psykiatrisjuksköterskorna har en komplex uppgift att utföra och blir ofta bärare av tvångsvårdsvillkoren. Detta utifrån att samarbetet med öppenvårdspsykiatrin många gånger är bristfällig. Psykiatrisjuksköterskan blir ofta ensam i sitt arbete och får använda sin egen känsla i att sätta gränser för vad som är tvångsvård och inte. En otydlighet om vem som ansvarar för vad framkommer, samt en känsla av rättsosäkerhet för patienterna utifrån att tolkningsutrymmet är så stort kring vad de särskilda villkoren innebär. Det visade att det finns ett stort behov av att belysa och tydliggöra den kommunala psykiatrisjuksköterskans möjligheter att ansvara och bedriva denna vård utifrån sin yrkesroll. / Program: Fristående kurs

<p>People with severe mental illness and co-occurring substance abuse are an especially vulnerable group in society as health care for those is shared between municipality and county council. There is an associated health need of this target group so the interaction of the social services and the psychiatric care is of great importance. However, there are shortcomings in this interaction with results in that people with dual diagnosis do not always receive adequate care. Diverse knowledge and explanatory models may create problems for the interaction as they include different ways to define, understand, explain and deal with a problem. The purpose of this study was to examine how the interaction between the social service addiction treatment and the psychiatric care is, concerning people with dual diagnosis, focusing on how their respective knowledge and explanatory models affect the interaction. The study was conducted in a county where we interviewed seven people in the social services addiction treatment and the psychiatric care. We used qualitative interviews conducted with the help of a semi-structured variant. The theoretical perspectives that were applied in the study were the theories of; interaction, science- and knowledge-based controversies, and some concepts from the new institutionalism. We concluded that interactions occur in various forms and at a high level of ambition between the social services addiction treatment and the psychiatric care in regards to people with dual diagnosis. We also concluded that the diverse professional knowledge and explanatory models affects the interoperability through the creation of theoretical controversies.</p> / <p>Personer med en allvarlig psykisk sjukdom och ett samtidigt missbruk är en extra utsatt grupp i samhället då vården för dessa delas mellan kommun och landsting. Det föreligger ett kombinerat vårdbehov för denna målgrupp vilket medför att en samverkan mellan socialtjänstens missbruksvård och psykiatrin är av stor vikt. Dock föreligger brister i denna samverkan vilket medför att personer med dubbla diagnoser inte alltid erhåller adekvat vård. Skilda kunskaps- och förklaringsmodeller kan skapa problem för samverkan då de inkluderar olika sätt att definiera, förstå, förklara och hantera ett problem. Syftet med denna studie var att undersöka hur samverkan mellan socialtjänstens missbruksvård och psykiatrin sker kring personer med dubbeldiagnos, med fokus på hur deras respektive kunskaps- och förklaringsmodeller påverkar samverkan. Studien utfördes i ett län där vi intervjuade sju personer inom socialtjänstens missbruksvård och psykiatrin. Vi använde oss av kvalitativa intervjuer som utfördes med hjälp av den semistrukturerade varianten. De teoretiska utgångspunkter som tillämpades i studien var teorier om; samverkan, vetenskaps- och kunskapsbaserade kontroverser samt vissa begrepp ur nyinstitutionalismen. Vi drog slutsatsen att samverkan mellan socialtjänstens missbruksvård och psykiatrin kring personer med dubbeldiagnos sker i olika former och på en hög ambitionsnivå. Vi drog även slutsatsen att verksamheternas skilda kunskaps- och förklaringsmodeller påverkar samverkan genom att det uppstår teoretiska kontroverser.</p>

In schizophrenia, subtle aberrations in the brain cause functional disturbances like psychotic symptoms and social disability. There are, however, also disturbances outside the CNS indicating a systemic manifestation in the disease. The aim of the present thesis was to gain deeper understanding of the pathophysiological mechanisms underlying schizophrenia with a particular interest in peripheral and systemic manifestations with relevance for the increased risk of obesity and metabolic complications seen in the disease. Therefore, resting energy expenditure (REE), physical capacity, and relevant body composition variables were measured in patients with schizophrenia and in healthy controls. Also niacin skin flush response and electrodermal activity (EDA) were studied. Patients with schizophrenia exhibited significantly lower REE expressed as kJ/kg, and also lower values compared with predicted levels than the controls. The difference could not be attributed to medication or variations in body composition between the two groups. There was a gender difference with the lowest levels found in male patients. Male patients exhibited significantly lower physical capacity in terms of predicted maximal oxygen uptake capacity and faster increase in respiratory quotient than male controls. The oral niacin test revealed a significantly delayed skin flush reaction in patients compared with controls. The patients also exhibited lower EDA response. There was a significant association in response patterns for the niacin and the EDA tests in the patients, but not in controls. In a test-retest study in patients there was acceptable stability for EDA measures but low test-retest stability for niacin variables. The previously found association in responses for the two tests was, however, replicated. The results gain support for the concept of schizophrenia as a disease with systemic manifestations including metabolic dysregulation. The findings add to the understanding of the weight gain and the increased risk for cardiovascular morbidity seen in this condition.

Our knowledge of prognostic factors and optimal treatment organisation in schizophrenia is incomplete. The disparity of outcome measures used has been a major obstacle for research. Increasing evidence has shown that schizophrenia is associated with increased cardiovascular mortality, development of obesity and autonomic nervous system imbalance. Assertive community treatment (ACT) has been suggested as a promising direction for organising treatment services for first-episode schizophrenia, but its long-term effect has not been evaluated. One aim of the present thesis was to investigate prognostic factors for 5-year symptomatic and functional outcome and obesity development. A further aim was to evaluate a recently proposed definition of remission and examine the long-term effects of introducing a modified ACT programme (mACT). Thus, we performed a follow-up study of all consecutive first-episode psychosis patients in Uppsala County, Sweden during 1995-2000 (n=144). In the first study we investigated the changes in a broad 5-year outcome of symptoms and function among patients presenting first time ever to psychiatric health care during 3 years before and during 3 years after the implementation of mACT. This change in the psychiatric service, however, was not followed by any long-term clinical benefits. In the second study, we examined the association between remission of eight core schizophrenia symptoms and functional outcome. Remission was strongly associated with having good function and having a higher self-rated satisfaction with life. In the third study, we explored a set of biochemical markers as predictors of weight gain and development of obesity. Haemoglobin, red blood cell count, hematocrit, γ-glutamyltransferase and creatinine were associated with the development of obesity in first-episode schizophrenia. In the fourth and final study, we tested electrocardiographic measures of autonomic imbalance as predictors of symptomatic remission. Higher heart rate and high ST and T-wave amplitudes were related to symptomatic remission, indicating that cardiac autonomic imbalance at baseline may have a prognostic value in first-episode schizophrenia.

International studies of disasters indicate the risk for developing posttraumatic stress reactions among survivors is high. Modern life implicates increased traveling. During the last decades a large number of Swedish citizens were confronted with disasters taking place outside of their country. The prevalence of trauma reactions in a population that does not  normally  experience natural disasters, but are able to return to a community unaffected by the catastrophe, is not well studied. In addition, the effects of bereavement after traumatic circumstances have not been satisfactorily explored. Longitudinal studies on the effects of natural disasters are underrepresented and there are few studies investigating the course of recovery after traumatic exposure. The aim for this thesis was to examine long-term post-traumatic stress reactions, mental health, and complicated grief after disaster exposure and traumatic bereavement.  Data from returned questionnaires were analysed from bereaved Italian and Swedish relatives 18 months after the Linate airplane disaster 2001, and at 14 months and three years from Swedish travelers returning from Southeast Asia after the 2004 tsunami disaster, and from home staying bereaved relatives within the second year after the tsunami disaster. The main outcome measures were GHQ-12, IES-R and Inventory of Complicated Grief. The findings indicated many survivors were resilient and had ability to recover, but severe exposure to a disaster had considerable impact on psychological distress. Life threat was associated with higher levels of post-traumatic stress reactions, and increased the risk for affected mental health and suicidal ideation. Loss in combination with severe life threat exposure indicated a further increased risk of posttraumatic stress reactions and for complicated grief; this should be considered a substantial risk factor for general mental health. Loss of close relatives, especially loss of children, was associated with higher levels of posttraumatic stress and created a greater risk for complicated grief. Many survivors recovered over time; however, severe exposure and traumatic loss appeared to slow the recovery process. The findings have implications for government and health agencies, regarding the importance of knowledge and awareness of these risks for health, and for organizational structure, training, and accessibility of support and adequate treatment.

This work in two parts – entitled Symbolic Function and Meaning: An Investigation of the Species-Specific Essence of Psychoanalytic Psychotherapy – could be characterized as an interpretation of the above-mentioned therapy and the meaning of its particular experience. In the first part, besides a licentiate thesis, four topics are examined: the therapeutic framework, the transference – especially in neurotic form – and its interpretation, psychotherapy with borderline patients, and therapy with psychotics. This has been done by combining studies of literature with analyses of the transference meaning of a number of illuminative clinical examples or vignettes – anecdotes, i.e. narratives with a significant point – the main part of which are the outcome of the author’s own activity in the form of participant observation as a psychotherapist. The general conclusion is that promoting the symbolic function is the essential ingredient in the psychoanalytic form of therapy – its very rationality – and how it effectuates its unique therapeutic potentiality; a characterization which, despite obvious differences in the adequacy of symbolic functioning, is valid irrespective of whether the patient is diagnosed as neurotic, borderline or psychotic. In the second part – essentially of a theoretical nature in contrast to the preceding one – the study is influenced by philosophical hermeneutics, and in this process assimilates its particular conceptuality. The continued analysis of the research object shows that it is misleading, in view of its ontology, to conceptualize it in medical terms as treatment. Aimed at promoting the symbolic function by the transference being interpreted, psychoanalytic psychotherapy instead operates in an ethical dimension and is rather what Aristotle terms a praxis, on the one hand; on the other hand, it is moreover implicitly human science action research into intersubjective appropriation of meaning. In this latter respect, the investigation highlights the fact that the very special interview method in the form of free associations, with their reflexivity, gives the psychoanalytic form of psychotherapy the potential to be not only a qualitative research method but also simultaneously metaresearch. The analyses of the transference meaning of clinical anecdotes in the first part have thereby been able to be methodologically clarified retroactively as psychoanalytic metaresearch.

Background Affective disorders are poorly defined and studied in sub-Saharan Africa despite their substantial public health impact. Objectives Overall objective: To describe the epidemiology of selected affective disorders in rural Ethiopia. Specific objectives 1. To describe the validity and utility of the concept of minor depressive disorder (mD). 2. To describe the manifestation, prevalence and the short-term clinical and functional course and outcome of bipolar disorder. Subjects and methods Population: Zay community residents (age ≥16), and residents of Butajira (ages 15-49), in Southern Ethiopia. Study design: Population-based cross-sectional and longitudinal studies Case identification: For the identification of cases with bipolar disorder, a two stage process was employed. An initial screen used key informants and interview with the Composite International Diagnostic Interview (CIDI) to identify cases with probable bipolar disorder. A second confirmatory diagnostic assessment stage employed the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). For the identification of cases with mD, data from the CIDI was used. Follow-up: 312 cases with bipolar disorder from Butajira were followed up for a mean of 2.5 years (ranging 1-4 years) through monthly clinical assessments and annual symptom and functional ratings. Results The CIDI was administered to 1714 adults among the Zay and to 68, 378 adults among the Butajira residents. The prevalence of mD among the Zay and Butajira was 20.5% and 2.2% respectively. Up to 80% of cases with mD had used services for their symptoms, while a third to a half of cases had thought about self harm. Up to a sixth of cases had attempted suicide. Age, marital status, education and somatic symptoms were independently associated with mD. The prevalence of bipolar disorder among the Zay was 1.8%. During a 2.5-year follow-up of 312 cases with bipolar disorder from Butajira, 65.9% relapsed (47.8% manic, 44.3% depressive and 7.7% mixed episodes) while 31.1% experienced persistent illness. Female gender predicted depressive relapse whereas male gender predicted manic relapse. Only being on psychotropic medication predicted remission (OR=3.42; 95% CI=1.82, 6.45). Disability was much worse among bipolar patients than in the general population and was predicted by symptom se3verity. Conclusions This is the largest study on mD and bipolar disorder in Africa. mD appears to have potential clinical utility in this setting given its association with service use and risk. The identified risk factors for mD also suggest potential aetiological continuity with major depression. The relatively high prevalence of bipolar disorder among the Zay may be related to genetic predisposition perhaps mediated through a founder effect, but other factors need exploring. In relation to the outcome of bipolar disorder, this study indicates that, contrary to previous assumptions, the course of bipolar disorder is characterised by both manic and depressive relapses in a relatively proportionate fashion. Bipolar disorder also leads to significant levels of disability. This is the only prospective outcome study of bipolar disorder in Africa where cases were monitored systematically at short assessment intervals. Therefore, findings are likely to be more robust than previous reports.

Psykoanalysen är ingen vetenskap eftersom den saknar kunskapsobjekt. Med syftet att finna detta objekt och därmed grunda en vetenskap togs avstamp i Freuds begrepp Det Omedvetna. Genom begreppsanalys av Freuds texter och med hjälp av matematisk mängdlära samt nedslag i filosofi och ontologi kunde en första beskrivning av objektet göras. Freuds begrepp visade sig då syfta på ett inlärt men bortträngt Omedvetet som i sin uppbyggnad ligger nära vårt medvetna tänkande. Det sökta objektet däremot, var ett medfött och inte bortträngt psykiskt system med en egen logik, symmetrisk logik, och sannolikt också vårt känslocentrum. Studier av neuropsykoanalys band sedan objektet till Limbiska systemet och det implicita minnet. Här bekräftades att systemet bär våra känslor. Ur författarens praktik hade samtidigt vuxit en idé om att vi föds med en uppsättning bilder av oss själva som är systematiskt ordnade i ett självbildssystem och av grandios natur. Till systemet kunde en livsåskådning knytas som primärt är en idealism. Självbildssystemet skyddades av en homeostatiskt fungerande sjävbildsbevarande drift. Denna drift framstod som vår viktigaste drift. Sexualdrift och självbevarelsedrift intog en sekundär roll. Det fanns sedan fog för att sammanföra det inte bortträngda Omedvetna och självbildssystemet till en enhet och betrakta kombinationen som psykoanalysens kunskapsobjekt. Resultatet hade inflytande på frågor som: den fria viljan, moral, determinism och kunskapssubjektets status. / Psychoanalysis is not a science since it does not have an object of knowledge. With the objective to find such an object and thereby establish a science Freud´s concept the Unconscious was taken as a point of departure with concept analysis of some of Freud´s texts and with help of mathematical set theory and the impact of philosophy and ontology an initial description of the object was made. What Freud had in mind with his concept was a system that was learned and then repressed, a repressed Unconscious, which in its structure is close to our conscious thinking. The requested object of knowledge of psychoanalysis was shown to be an inborn psychical system, which is not repressed, and with its own logic, symmetrical logic, and probably also our centre of feeling/emotion. Studies of neuro-psychoanalysis situated the object in the Limbic system and the implicit memory. This confirmed that the system carries our feelings and emotions. From the author´s practice had grown, at the same time, an idea that we are born with a set of images of ourselves that are systematically arranged in a self-image system of a grandiose nature. The system could be associated with a philosophy that primarily is an idealism. The self-image system was protected by a homeostatic subsystem which aim was conservation of the system. This subsystem took its power from a self-image protecting drive. This drive was found to be our most powerful drive. Sexual desire and self-preservation took a secondary role. It was substantiated that the unrepressed unconscious and the system of self-images shall be treated as one unit and that this combination is the sought for object of knowledge of psychoanalysis. The result had influence on the issues: free will, morality, determinism and the status of the subject of knowledge.

People with severe mental illness and co-occurring substance abuse are an especially vulnerable group in society as health care for those is shared between municipality and county council. There is an associated health need of this target group so the interaction of the social services and the psychiatric care is of great importance. However, there are shortcomings in this interaction with results in that people with dual diagnosis do not always receive adequate care. Diverse knowledge and explanatory models may create problems for the interaction as they include different ways to define, understand, explain and deal with a problem. The purpose of this study was to examine how the interaction between the social service addiction treatment and the psychiatric care is, concerning people with dual diagnosis, focusing on how their respective knowledge and explanatory models affect the interaction. The study was conducted in a county where we interviewed seven people in the social services addiction treatment and the psychiatric care. We used qualitative interviews conducted with the help of a semi-structured variant. The theoretical perspectives that were applied in the study were the theories of; interaction, science- and knowledge-based controversies, and some concepts from the new institutionalism. We concluded that interactions occur in various forms and at a high level of ambition between the social services addiction treatment and the psychiatric care in regards to people with dual diagnosis. We also concluded that the diverse professional knowledge and explanatory models affects the interoperability through the creation of theoretical controversies. / Personer med en allvarlig psykisk sjukdom och ett samtidigt missbruk är en extra utsatt grupp i samhället då vården för dessa delas mellan kommun och landsting. Det föreligger ett kombinerat vårdbehov för denna målgrupp vilket medför att en samverkan mellan socialtjänstens missbruksvård och psykiatrin är av stor vikt. Dock föreligger brister i denna samverkan vilket medför att personer med dubbla diagnoser inte alltid erhåller adekvat vård. Skilda kunskaps- och förklaringsmodeller kan skapa problem för samverkan då de inkluderar olika sätt att definiera, förstå, förklara och hantera ett problem. Syftet med denna studie var att undersöka hur samverkan mellan socialtjänstens missbruksvård och psykiatrin sker kring personer med dubbeldiagnos, med fokus på hur deras respektive kunskaps- och förklaringsmodeller påverkar samverkan. Studien utfördes i ett län där vi intervjuade sju personer inom socialtjänstens missbruksvård och psykiatrin. Vi använde oss av kvalitativa intervjuer som utfördes med hjälp av den semistrukturerade varianten. De teoretiska utgångspunkter som tillämpades i studien var teorier om; samverkan, vetenskaps- och kunskapsbaserade kontroverser samt vissa begrepp ur nyinstitutionalismen. Vi drog slutsatsen att samverkan mellan socialtjänstens missbruksvård och psykiatrin kring personer med dubbeldiagnos sker i olika former och på en hög ambitionsnivå. Vi drog även slutsatsen att verksamheternas skilda kunskaps- och förklaringsmodeller påverkar samverkan genom att det uppstår teoretiska kontroverser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2009.