Paraphilias are defined as sexually arousing fantasies, urges, or behaviors involving either nonhuman objects; suffering or humiliation of oneself or one's partner; or children or other non-consenting persons. In the DSM classification, paraphilias are subsumed under sexual disorders, while in the ICD paraphilias are classified as disorders of adult personality and behavior (disorders of sexual preference). Historically, some have advocated eliminating paraphilias or radically revising their definitions, while others suggested adhering to their traditional definitions. The classification and definition of paraphilias is complicated by cultural and societal underpinning, and the unclear boundaries between “normal” and “abnormal” sexuality. The diagnostic criteria of some paraphilias (e.g., pedophilia) are also complicated by the differences between the medical and the legal concepts of these entities. The recent attempts to introduce two new diagnoses, hypersexual disorder and paraphilic coercive disorder, into the DSM system stirred passionate scientific discussions about those two diagnoses and about paraphilias in general.

This presentation reviews the pros and cons of classifying paraphilias as sexual disorders and of including the new diagnoses of hypersexual disorder (unclear borders with “normality”) and paraphillic coercive disorder (unclear distinction between this entity and sexual sadism). In addition, this presentation reviews some of the more and/or less accepted methods of paraphilia management, such as pharmacotherapy and castration (chemical, surgical).

Several aspects of the classification and diagnosis of paraphilias remain controversial and some of the proposed changes seem unwarranted. Resolving diagnostic and management controversies could be helped by large multicenter and international field trials.

Current diagnositic criteiria for sexual dysfunctions in the ICD 10 and DSM IV have been criticized for their lack of precision and failure to differentiate normal variation in sexual function from disordered sexual behavior requiring medical intervention.

The objective of this presentation is to review the rationale for proposed changes in diagnositc criteria in DSM V.

The aims of this presentation are to review proposed changes in diagnositc criteiria for sexual disorders which set severity and duration criteira.

Evidence for proposed diagnostic thresholds will be presented.

Proposed new defintions will incorporate severity (present of 75% of occasions) and duration (present for 6 months) criteria.

Clinicians have criticized these diagnostic thresholds because many patients seeking treatment for sexual problems will not meet diagnostic criteira.

There are no perfect diagnositic thresholds. One always has to balance the risk of false positives (misclassifying normals as ill) versus the risk of false negatives (misclassifying the ill as normal).

Cognitive difficulties are prevalent in people with a diagnosis of schizophrenia and are associated with poor long term functioning. They interfere with recovery so that people with more severe deficits have difficulty taking advantage of rehabilitation techniques.

Three approaches to improving outcomes are possible: (i) target cognition, (ii) adapt rehabilitation programmes, (iii) adapt the environment. A number of psychological therapies have been developed that target cognition. This symposium will discuss and evaluate the similarities and differences between such therapies.

A review of randomised controlled trials and a new meta-analysis.

The form of therapy targeting cognition might be in groups, individual or computer presentation. They may be based on a clear theory about the deficits in schizophrenia or they may have borrowed from work on brain injury. They can last for a few sessions to two years and use different types of teaching, such as practice or strategic problem solving. Despite all these differences 40 randomised controlled trials have shown that they can produce modest improvements in cognition and a new meta-analysis has shown that there is some homogeneity of effects across different therapies but that methodology does make a difference.

Improvement in functioning is best achieved by combining therapies and by the remediation approach being to teach strategies rather than only practicing skills. Metacognition which is the awareness of thinking skills and when certain strategies should be implemented seems to be the key issue in transferring skills from the cognitive domain to general functioning.

While early detection strategies have been developed for schizophrenia, affective psychoses have long been relatively neglected in this domain. However, considering the difficulties met when attempting to define the onset of bipolar disorder, we felt prodrome to first episode mania would be a clinically relevant initial target for study.

Based on an extensive literature review we identified symptoms, risk factors and associated clinical features that may be present in the phase preceding first episode mania onset. In a sample of 20 first episode mania patients, we explored which of these elements were present in at least 50% of cases.

The study confirmed that a prodrome phase can be identified before onset of first episode mania. The symptoms presented felt under 3 categories (sleep problems, irritability, mood symptoms) and were rather unspecific. Various risk factors and markers of vulnerability could be identifed. On this basis a multi-dimensional scale grouped in 3 sub-scales was constructed.

Our exploration suggests that identification of patients in the prodromal phase to first episode mania needs to be based on a combination of dimensions rather than on symptoms only. The scale still needs to be validated prospectively.

Althouhg Bipolar Disorder (BD) is amongst the leading causes of disability worldwide patients experience delays in accurate diagnosis ranging between 5–10 years.

To develop a diagnostic aid for BD.

To evaluate the feasibility of applying pattern recognition techniques to structural magnetic resonance imaging (sMRI) data for the diagnostic classification of patients with BD.

Gaussian Process Classifiers (GPCs) were applied to gray (GM) and white matter (WM) sMRI data from 26 individuals with BD, 15 with Major Depressive Disorder (MDD) and 26 healthy controls.

The best classification accuracy was obtained using GPC analysis of GM images which differntiated patients from controls with 73% accuracy (sensitivity 69%, specificity 77%). The GM classification accuracy obtained for BD compared to MDD was 66% (sensitivity 40%, specificity 93%). GM discriminative clusters were widely distributed within cortical and subcortical structures including the ventral prefrontal and cingulate cortex and parahippocampal gyrus, insula, thalamus and striatum.

Our results demonstrate the predictive value of neuroanatomical data in discriminating patients with BD from healthy individuals and MDD patients.

There are no clinically useful biomarkers for the prediction of treatment response in bipolar depression (BD). One of the best-documented markers of response to an antidepressant therapy in patients with unipolar depression is a decrease in quantitative electroencephalography measure of prefrontal cordance in theta frequency band (Leuchter et al., 2010).

The aim of our study was to examine whether the change of theta prefrontal cordance after one week of various antidepressive interventions predicts response to a 4-week treatment in patients with BD.

We enrolled 24 inpatients into the study. Theta prefrontal cordance was computed at baseline and after 1 week of treatment. Depressive symptoms were evaluated using the Montgomery and Åsberg Depression Rating Scale.

Twenty patients finished the study. Seven of 8 responders and only 2 of 12 non-responders showed a decrease in prefrontal theta cordance after the first week of drug administration (p = 0.02). Using the decrease of prefrontal cordance value as a predictor of treatment response yielded Positive Predictive value of 0.78 and Negative Predictive Value of 0.91. We also found higher baseline theta cordance in responders. Nevertheless when baseline cordance and cordance change entered into the logistic regression model, only the latter emerged as a predictor of response (p = 0.007; correctly classified 85% cases).

The change in prefrontal theta cordance was associated with subsequent change in depressive symptoms and potentially might be a useful marker of response to antidepressive interventions in BD patients (Bares et al., 2011). Supported by a grant MSMT 1M0517.

Neuroprotective effects of lithium have been well documented in tissue cultures and animal models. The evidence for lithium related neuroprotection in human subjects is limited and inconsistent, likely due to methodological heterogeneity.

To investigate the effects of lithium on brain chemistry and structure, we recruited bipolar patients selected for substantial illness burden and varied the exposure to lithium by using strict inclusion criteria.

We obtained 1.5T magnetic resonance imaging data from 27 bipolar patients with at least 2 years of ongoing lithium treatment (Li group), 16 subjects with < 3 months lifetime exposure to lithium >2 years ago (non-Li group) and 21 healthy controls. Patient groups had to have at least 10 years of illness and 5 episodes.

The non-Li group had significantly lower hippocampal volumes (t = 4.68,corrected p < 0.05) and prefrontal cortex N-acetyl aspartate (NAA) levels (t = −2.91,corrected p < 0.05) than controls, who showed comparable hippocampal volumes and NAA levels to the Li treated subjects. Duration of illness was negatively associated with NAA levels only in the non-Li, but not the Li group.

Among patients selected for substantial illness burden, only those with no or minimal lifetime Li exposure had significantly lower prefrontal NAA levels and hippocampal volumes than controls. Patients with at least 2 years of ongoing Li treatment showed no such changes, despite substantial burden of illness. These findings provide indirect support for neuroprotective effects of lithium and negative effects of illness burden on brain chemistry and structure in patients with bipolar disorders.

Converging evidence from neuroimaging studies indicates that white matter abnormalities may be involved in bipolar disorder (BP). One most consistent finding, though not universal, has been the increased occurrence of white matter hyperintensities (WMH) in BP patients. The role of hyperintensities in the pathogenesis, and treatment of mood disorders remains unclear. However, the diffusion tensor imaging (DTI) has expanded somewhat our understanding of white matter in BP.

During this presentation I will give the overview of the white matter pathology in BP. In addition, I will introduce the results of our study concerning WMH, affective disorders, and neuropsychological functioning.

We have studied 13 BPI, 15 BPII, 16 major depressive patients, and 21 controls at baseline, and at 5-year follow-up. Besides clinical interviews, further detailed investigation comprised a neuropsychological test battery and structural brain imaging with DTI. WMH were calculated manually, and DTI will be analyzed using tract based statistical methods.

BPI patient group had increased risk for DWMH contrary to BPII and MDD patients when compared to controls. Increased DWMH grade together with age and BDI score predicted decreased capability of visual attention measured by visual span forward subtest of the WMS-R.

While suicidal behavior is frequently accompanied by serotonergic system alterations, specific associations with variants of the serotonin 2A receptor gene (HTR2A) have been inconsistent.

To confirm and extend previous associations of HTR2A with suicidal behavior.

To study genetic effects, as well as gene-environment interaction (GxE) and parent-of-origin effects (POE) that may further contribute to association.

Using a family-based study design of 660 offspring who have made a suicide attempt (SA) and both parents, we conducted an association and linkage analysis of single nucleotide polymorphisms (SNPs) with extensive gene coverage. We included the study of GxE with physical and sexual assault (with a cutoff age of 18 years), as well as cumulative types of stressful life events (lifetime SLEs). We also studied POE at SNP rs6313.

The main finding was a GxE between rs6313 and exposure to lifetime SLEs in the total sample, driven by overtransmission of CT and undertransmission of TT. Further exploratory analysis revealed a significant POE in this GxE in females which followed a polar overdominant imprinting pattern. In addition, several nominally significant findings were observed with other SNPs, many of which had previously reported and/or hypothesized functional effects.

This study found multiple associations of HTR2A with SA, and strongest statistical evidence for a GxE involving rs6313. It further suggested the importance of taking into account different genetic models of inheritance and GxEs with regard to HTR2A.