Johannes Thome

University of Rostock, Rostock, Mecklenburg-Vorpommern, Germany

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Publications (195)655.08 Total impact

  • Karolina Furczyk, Johannes Thome
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    ABSTRACT: While suicidal behaviour has been implicated in a plethora of psychiatric disorders including depression, psychoses and substance abuse, its association with adult ADHD is largely under-researched. Given that emotional instability and the high prevalence of comorbid conditions such as mood disorders and alcohol/drug dependence are typical for ADHD, the question of suicide risk must not be neglected in this patient group. A review of the current literature focusing on this issue provides strong evidence that ADHD patients are at a significant risk for experiencing suicidal ideations and committing suicide. For daily clinical practice, it is therefore essential to incorporate this aspect into the diagnostic and therapeutic process and to take preventive measures.
    ADHD Attention Deficit and Hyperactivity Disorders 07/2014;
  • Frank Häβler, Johannes Thome, Olaf Reis
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    ABSTRACT: People with intellectual disabilities often suffer from mental disorders or display challenging behavior. For both impairments, treatment with more than one psychopharmacological drug is common, although little is known about efficacy and side effects of polypharmacological treatment. The paper reviews studies on treatment of people with intellectual disability (ID) with more than one psychoactive drug. Many studies rely on poor evidence and are supplemented with data from our own research. Risks and benefits of different combinations containing neuroleptics are listed. Ethical considerations for the use of different drugs combined are discussed. The use of combinations of neuroleptics on people with ID should be carried out with great care, since side effects may be amplified in people with ID, depending on the combination.
    Journal of neural transmission (Vienna, Austria : 1996). 05/2014;
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    ABSTRACT: Schizophrenia is a severe mental illness with a biological basis. However, the search for reliable biomarkers suitable for clinical routine has been futile so far. Accordingly, there is a need for innovative approaches such as genomics and proteomics to achieve this goal. In the present study, we compared metabolomic and proteomic data from 26 schizophrenia patients as well as from unaffected controls carefully matched for age and gender in a multi-platform approach. The combined analysis identified many signatures with initially good biomarker characteristics. After statistical analysis and comparison of these identified serum metabolites (analysed by Gas Chromatography Mass Spectrometry) and hydrophobic serum proteins (analysed by matrix-assisted laser desorption ionisation mass spectrometry), several markers (e.g., 2-piperidinec carboxylic acid, 6-deoxy-mannofuranose, galactoseoxime and a serum peptide of m/z 3177) were determined as having the best discriminating value between the groups. Our findings represent a proof of principle indicating that metabolomic and proteomic approaches can be successfully used in psychiatric biomarker research, even though the results should be regarded as preliminary with a need for replication in larger samples.
    Journal of Neural Transmission 05/2014; · 3.05 Impact Factor
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    ABSTRACT: The identification of peripheral biomarkers for schizophrenia is of great clinical importance, with the potential to considerably improve its diagnosis, treatment and prognosis. However, despite intense research efforts and the discovery of several potential candidates for markers, no biomarker assay developed so far possesses sufficient sensitivity and specificity for clinical use. Nevertheless, with the advent of innovative technologies and methods on an analytical and statistical level, including hypothesis-free proteomic and epigenetic procedures and advanced bioinformatics, establishing biomarkers for clinical use may lay within reach. To date, the most promising candidates for biomarkers are linked to neural transmission, neural plasticity (e.g. neurotrophic factors), oxidative stress/free radicals, endocrinology, immunology, signalling pathways, gene expression regulation/activation and lipidomics. © 2014 S. Karger AG, Basel Introduction
    Proteomics and Metabolomics in Psychiatry., Edited by Martins-de-Souza D (ed, 05/2014: pages 16-26; Adv Biol Psychiatry. Basel, Karger.
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    ABSTRACT: Autism spectrum disorder (ASD) diagnosis is increasing, with 1/88 children believed to be affected by the disorder, with a most recent survey suggesting numbers as high as 1/50. Treatment and understanding of ASD causes is a pressing health concern. ASD protein biomarkers may provide clues about ASD cause. Protein biomarkers for ASDs could be used for ASD diagnosis, subtyping, treatment monitoring and identifying therapeutic targets. Here we analyzed the sera from 7 children with ASD and 7 matched controls using Tricine gel electrophoresis (Tricine-PAGE) and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Overall, we found increased levels of apolipoproteins (Apos) ApoA1 and ApoA4, involved in cholesterol metabolism and of serum paraoxanase/arylesterase 1 (PON1), involved in preventing oxidative damage, in the sera of children with ASD, compared with their matched controls. All three proteins are predicted to interact with each other and are parts of High Density Lipoproteins (HDLs). Further studies are needed to validate these findings in larger subject numbers.This article is protected by copyright. All rights reserved
    Electrophoresis 04/2014; · 3.26 Impact Factor
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    ABSTRACT: Findings from molecular genetic studies and analyses of postmortem and peripheral tissue led to the hypothesis that neurotrophins-as crucial moderators of neuroplasticity-impact on the pathophysiology of autism spectrum disorder (ASD). The study projects aimed to complement former results on the role of brain-derived neurotrophic factor (BDNF), a member of the neurotrophin family with fundamental impact on brain development and function. The purpose of this work was to investigate peripheral BDNF mRNA expression and BDNF protein concentrations in ASD as potential surrogates for the effects observed in the central nervous system. In a BDNF protein quantification study, serum concentrations were analyzed using Enzyme-Linked Immunosorbent Assays in 24 male patients with ASD, all with an IQ > 70 (age 13.9 ± 3.0 years) and 20 age- and gender-matched healthy control subjects (age 14.4 ± 2.1 years; p = 0.522). In a further independent project, a BDNF mRNA expression analysis, mRNA levels from total blood were assessed by quantitative real-time polymerase chain reaction in a sample of 16 male ASD patients (age 10.8 ± 2.2), 15 age- and gender-matched healthy controls (age 12.1 ± 2.2) and 15 patients with attention deficit hyperactivity disorder as a clinical control group (age 11.8 ± 2.2; p = 0.207). In the protein quantification project, significantly decreased BDNF serum concentrations were found in ASD cases compared to healthy control children (t = -2.123, df = 42, p < 0.05). Analysis of covariance (ANCOVA) revealed this result in accordance with significant reductions in BDNF mRNA expression in ASD, observed in the mRNA expression study (F = 3.65; df = 2.43; p < 0.05); neither age nor IQ confounded the result, as indicated by ANCOVA (F = 3.961; df = 2.41; p < 0.05, η (2) = 0.162). Our study projects supported the notion that neurotrophins are involved in the pathophysiology of ASD. Further studies may eventually contribute to the identification of distinct peripheral mRNA expression and protein concentration patterns possibly supporting diagnostic and therapeutic processes.
    Journal of Neural Transmission 02/2014; · 3.05 Impact Factor
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    ABSTRACT: Major self-mutilation is one of the most hazardous complications encountered in psychiatric patients, and is generally associated with auditory verbal hallucinations as part of a psychotic syndrome. This case report exemplarily discusses the treatment of such hallucinations with repeated (20 sessions) low-frequency (1 Hz) transcranial magnetic stimulation targeting areas of elevated metabolic activity in the temporo-parietal cortex ('neuronavigated rTMS'), drawing upon experience concerning treatment of a patient with chronic auditory verbal hallucinations that had proved intractable to antipsychotic medication combined with cognitive behavioural therapy, and who had severed a forearm because of the content of these hallucinations. This example of major self-mutilation underscores the urgent requirement for effective management of chronic auditory verbal hallucinations in patients suffering from psychiatric disease, and neuronavigated rTMS represents an approach that deserves further exploration in this regard.
    Journal of Neural Transmission 01/2014; · 3.05 Impact Factor
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    ABSTRACT: The etiology and pathogenesis of many psychiatric disorders are unclear with many signaling pathways and complex interactions still unknown. Primary information provided from gene expression or brain activity imaging experiments is useful, but can have limitations. There is a current effort focusing on the discovery of diagnostic and prognostic proteomic potential biomarkers for psychiatric disorders. Despite this work, there is still no biological diagnostic test available for any mental disorder. Biomarkers may advance the care of psychiatric illnesses and have great potential to knowledge of psychiatric disorders but several drawbacks must be considered. Here, we describe the potential of proteomic biomarkers for better understanding and diagnosis of psychiatric disorders and current putative biomarkers for schizophrenia, depression, autism spectrum disorder and attention deficit/hyperactivity disorder.
    Journal of Neural Transmission 12/2013; · 3.05 Impact Factor
  • J Thome, P Foley
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    ABSTRACT: Anhedonia and abulia are syndromes often presented as components of various psychiatric and neurological disorders, including depression, schizophrenia, stroke, multiple sclerosis and brain injury. On the basis of the hypothesis that alterations in the dopaminergic motivational system might be involved in the etiopathogenesis of these clinical phenomena, the antidepressant agomelatine is a highly interesting candidate substance for their treatment because of its indirect dopaminergic effects resulting from its melatoninergic and partial anti-serotoninergic properties. Systematic clinical studies are urgently needed to test the hypothesis that agomelatine might be a clinically useful and versatile anti-anhedonic and/or anti-abulic substance.
    Journal of Neural Transmission 12/2013; · 3.05 Impact Factor
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    ABSTRACT: The trial was a double-blind, placebo-controlled comparison with a discontinuation design. 49 mentally retarded patients with aggressive behaviour were treated with zuclopenthixol at a dose of 2-20 mg/d. At each visit the clinical effect was evaluated. Correlations between dose, serum concentration, and efficacy measures were calculated. The mean dose was 10.0 mg/day (±5.17); the mean serum concentration 4.19 ng/mL (±3.16). Associations of dosage, serum concentration and clinical efficiency did not result in coherent patterns. Correlations with clinical efficiency measures appeared to be contradictory for dosage and serum concentrations, respectively. As no consistent associations between dosage, serum concentration, and clinical efficiency measures were found, different hypotheses explaining the results are discussed.
    Pharmacopsychiatry 12/2013; · 2.11 Impact Factor
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    ABSTRACT: In patients with attention deficit hyperactivity disorder (ADHD), quantitative neuroimaging techniques have revealed abnormalities in various brain regions, including the frontal cortex, striatum, cerebellum, and occipital cortex. Nonlinear signal processing techniques such as sample entropy have been used to probe the regularity of brain magnetoencephalography signals in patients with ADHD. In the present study, we extend this technique to analyse the complex output patterns of the 4 dimensional resting state functional magnetic resonance imaging signals in adult patients with ADHD. After adjusting for the effect of age, we found whole brain entropy differences (P=0.002) between groups and negative correlation (r=-0.45) between symptom scores and mean whole brain entropy values, indicating lower complexity in patients. In the regional analysis, patients showed reduced entropy in frontal and occipital regions bilaterally and a significant negative correlation between the symptom scores and the entropy maps at a family-wise error corrected cluster level of P<0.05 (P=0.001, initial threshold). Our findings support the hypothesis of abnormal frontal-striatal-cerebellar circuits in ADHD and the suggestion that sample entropy is a useful tool in revealing abnormalities in the brain dynamics of patients with psychiatric disorders.
    Psychiatry Research Neuroimaging 10/2013; · 3.36 Impact Factor
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    ABSTRACT: Alcohol-induced damages such as brain atrophy and fatty liver are closely related to a disturbed lipid metabolism. In animal models, a linkage between chronic alcohol consumption and changes in fatty acid (FA) composition in various organs and cells is well known and there is some indication that this phenomenon could be linked to behavioural alterations associated with alcohol addiction such as craving. However, the influence of ethanol on secretory FA has not been investigated so far. In this study, we therefore aimed at investigating whether there is a significant change of serum FA composition in patients suffering from alcohol dependence. We compared patients before and after treatment (detoxication) with control individuals who did not suffer from addiction. The roles of age, the duration and intensity of alcohol use and lifestyles were considered. Serum FA was measured in 73 male ethanol dependent patients before and after alcohol withdrawal in an in-patient setting. Additionally, of this group, 45 patients were matched with 45 healthy male volunteers as controls. We found significant differences in the FA composition before and after detoxication as well as between patients and controls. After detoxication, the values changed towards the ones in healthy controls. The main finding during acute alcohol use was an increased oleic acid concentration above the level of the linoleic acid concentration. An elevated oleic/linoleic acid ratio seems to be a state marker for acute alcohol use and may be a relevant trait marker during detoxification and possibly the subsequent therapeutic measures. The results of this pilot study need to be replicated in a larger study also including female patients. Further, the specificity of this potential biomarker needs to be determined.
    Journal of Molecular Psychiatry. 08/2013; 1:13.
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    ABSTRACT: The fractal concept developed by Mandelbrot provides a useful tool for examining a variety of naturally occurring phenomena. Fractals are signals that display scale-invariant or self-similar behaviour. They can be found everywhere in nature including fractional Gaussian noise (fGn). Resting state fMRI signals can be modelled as fGn which makes them appropriate for fractal analysis. The Hurst exponent, H, is a measure of fractal processes and has values ranging between 0 and 1. Fractional Gaussian noise with 0<H<0.5 demonstrates negatively autocorrelated or antipersistent behaviour; fGn with 0.5<H<1 demonstrates a positively correlated, relatively persistent, predictable, long memory behaviour; and fGn with H = 0.5 corresponds to classical Gaussian white noise. In the present study, we aim to estimate the fractal behaviour of adult ADHD patients when compared to age-matched healthy controls using dispersional analysis. We hypothesize that ADHD patients will demonstrate more predictable (higher H values) fractal behaviour. Ten ADHD patients (5 female, mean age (32.60±10.46)) and ten controls (7 female, mean age (30.10±8.49)) were brain imaged by 3T MRI scanner. All patients and control participants completed the Conners’ Adult ADHD Rating Scales (ADHD scores). Our analysis shows that the ADHD patients demonstrate more positively correlated, relatively persistent, predictable and longer memory fractal behaviour in regards to healthy controls. The discriminated brain regions are part of the frontal-striatal-cerebellar circuits and are consistent with the hypothesis of abnormal frontal-striatal-cerebellar circuits in ADHD. We have shown that the analysis of fractal behaviour may be a useful tool in revealing abnormalities in ADHD brain dynamics.
    19th Annual Meeting of the Organization for Human Brain Mapping, Seattle, USA.; 06/2013
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    ABSTRACT: Autism spectrum disorders (ASDs) are increasing in incidence but have an incompletely understood etiology. Tools for uncovering clues to the cause of ASDs and means for diagnoses are valuable to the field. Mass Spectrometry (MS) has been a useful method for evaluating differences between individuals with ASDs versus matched controls. Different biological substances can be evaluated using MS, including urine, blood, saliva, and hair. This technique has been used to evaluate relatively unsupported hypotheses based on introduction of exogenous factors, such as opiate and heavy metal excretion theories of ASDs. MS has also been used to support disturbances in serotonin-related molecules, which have been more consistently observed in ASDs. Serotonergic system markers, markers for oxidative stress, cholesterol system disturbances, peptide hypo-phosphorylation and methylation have been measured using MS in ASDs, although further analyses with larger numbers of subjects are needed (as well as consideration of behavioral data). Refinements in MS and data analysis are ongoing, allowing for the possibility that future studies examining body fluids and specimens from ASD subjects could continue to yield novel insights. This review summarizes MS investigations that have been conducted to study ASD to date and provides insight into future promising applications for this technique, with focus on proteomic studies.
    Journal of Molecular Psychiatry. 05/2013;
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    ABSTRACT: Other than in children diagnosed with attention deficit hyperactivity disorder (ADHD), the connection between ADHD and lipids has not been sufficiently investigated so far in adults. Blood serum lipoproteins and fatty acids (FA) composition were measured and analyzed by colorimetry and gaschromatography in eight male and seven female adults diagnosed with ADHD as well as in 15 age- and gender-matched healthy control subjects. In ADHD patients, polyunsaturated FAs [docosahexaenoic, arachidonic and dihomogammalinolenic acid (p = 0.048; 0.003; 0.012)] showed lower concentrations, while monounsaturated acids (palmitoleic and oleic acid) as well as total and LDL cholesterol showed higher concentrations (p = 0.011; 0.005). ADHD scores positively correlated with palmitoleic (R = -0.56; p = 0.032), stearic (R = 0.53; p = 0.044), eicosapentaenoic (R = 0.62; p = 0.014), docosahexaenoic (R = 0.51; p = 0.050), gammalinolenic (R = 0.62; p = 0.018) and alphalinolenic acid (R = 0.56; p = 0.031) concentration. Even though the total and LDL cholesterol concentrations in blood serum were significantly higher among the ADHD patients than in controls, none of the ADHD symptom scores were significantly associated with any of the lipoproteine measures. We could demonstrate that a lack of polyunsaturated FAs in blood serum of subjects with ADHD persists into adulthood. Furthermore, we could show that adult ADHD symptomatology positively correlates with elevated levels of saturated stearic and monounsaturated FAs.
    ADHD Attention Deficit and Hyperactivity Disorders 04/2013;
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    ABSTRACT: Circadian rhythms are repeating patterns of physiological and other parameters that recur with periods of approximately twenty four hours, and are generated by an endogenous circadian timekeeping mechanism. Such circadian rhythms, and their underlying molecular mechanisms, are known to be altered by a number of central nervous system acting pharmacological compounds, as well as becoming perturbed in a number of common psychiatric and neurological conditions. The psychostimulant methylphenidate and the non-stimulant atomoxetine are used in the pharmacotherapy of attention deficit hyperactivity disorder, a common condition in which circadian rhythms have been reported to be altered. In the present study we have examined the effects of daily methylphenidate or atomoxetine treatment across 7 days on circadian clock gene product expression across numerous brain regions in the male mouse to test the potential impact of such compounds on circadian timing. We report drug, brain region and molecular specific effects of such treatments, including alterations in expression profiles in the suprachiasmatic nucleus, the master circadian pacemaker. These results indicate that drugs used in the clinical management of attention deficit hyperactivity disorder can alter molecular factors that are believed to underpin circadian timekeeping, and such effects may be of importance in both the therapeutic and side effect profiles of such drugs.
    Brain research 04/2013; · 2.46 Impact Factor
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    ABSTRACT: Background: Genetic susceptibility to schizophrenia (SZ) has been suggested to influence the cortical systems supporting working memory (WM) and face processing. Genetic imaging studies link the SZ risk variant rs1344706 on the ZNF804A gene to psychosis via alterations in functional brain connectivity during WM, but no work has looked at the effects of ZNF804A on WM with face-processing components. Methods: We therefore investigated healthy controls that were genotyped for rs1344706 with a face WM task during functional magnetic resonance imaging. We suggested that variation at the rs1344706 locus would be associated with similar alterations as patients previously tested using the same WM task for faces. Results: The rs1344706 risk allele was indeed associated with altered activation in the right dorsolateral prefrontal (rDLPFC) cortex. We established that the rDLPFC was activated in a task-dependent manner, suggesting that the differences in activation between rs1344706 genotype groups reflected alterations in task processing. Furthermore, we demonstrated that the rDLPFC region showed significant volumetric overlap with the rDLPFC which had previously been reported to be altered during task processing for patients with SZ. Conclusions: The findings support an association between rs1344706 and alterations in DLPFC activity during WM for faces. We further suggest that WM for faces may be a useful intermediate phenotype in the investigation of genetic susceptibility to psychosis.
    Neuropsychobiology 01/2013; 67(2):84-92. · 2.37 Impact Factor
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    ABSTRACT: The search for molecules that can act as potential biomarkers is increasing in the scientific community, including in the field of psychiatry. The field of proteomics is evolving and its indispensability for identifying biomarkers is clear. Among proteomic tools, mass spectrometry is the core technique for qualitative and quantitative identification of protein markers. While significant progress has been made in the understanding of biomarkers for neurodegenerative diseases such as Alzheimer’s disease, multiple sclerosis and Parkinson’s disease, psychiatric disorders have not been as extensively investigated. Recent and successful applications of mass spectrometry-based proteomics in fields such as cardiovascular disease, cancer, infectious diseases and neurodegenerative disorders suggest a similar path for psychiatric disorders. In this brief review, we describe mass spectrometry and its use in psychiatric biomarker research and highlight some of the possible challenges of undertaking this type of work. Further, specific examples of candidate biomarkers are highlighted. A short comparison of proteomic with genomic methods for biomarker discovery research is presented. In summary, mass spectrometry-based techniques may greatly facilitate ongoing efforts to understand molecular mechanisms of psychiatric disorders.
    Journal of Molecular Psychiatry. 01/2013; 1(1).
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    ABSTRACT: The neurotrophins brain-derived neurotrophic factor (BDNF) and neurotrophic factor 3 (NT3) could play a role in addictive behavior. Interactions between BDNF and dopamine transmission influence the alcohol intake. It has been hypothesized that extensive alcohol consumption leads to diminished circulating BDNF levels and impaired BDNF-mediated protective mechanisms. What is more, alcohol dependency causes changes in lipid metabolism which in turn may influence the neurotrophin system. In this study, we tested the hypothesis that alcohol withdrawal increases the serum levels of BDNF in alcoholic patients and investigated correlations between serum BDNF and NT3 and alcohol in breath as well as with the body-mass-index (BMI), lipoprotein profiles and lifestyle factors in 110 male in-patients diagnosed with alcohol addiction on the first day after admission and at discharge. The intoxication level (alcohol in breath at admission) was significantly correlated with liver enzymes and BDNF concentrations (R = .28; p = .004). Patients with positive breath-alcohol test at admission had about 9 times higher NT3 levels and higher liver enzyme concentration levels than nonintoxicated subjects. Alcohol intoxicated patients with pathological aspartate aminase (ASAT) levels had even higher NT3 level (F = 5.41; p = .022). The concentration of NT3 was positively associated with the (BMI) (admission R = .36; p = .004; discharge R = .33; p = .001), and the obese patients had 3 to 5 times higher NT3 concentration than the others. Low-density lipoprotein (LDL) concentration levels were found to positively correlate with NT3 concentration levels (admission R = .025; p = .015 discharge R = .24; p = .23). Other than expected, the levels of NT3 and to a lesser extent BDNF levels, were found to be significantly increased in acute alcohol abuse. Alcohol deprivation did not significantly change the serum neurotrophin levels at admission. NT3 levels were positively correlated with the BMI and LDL levels. Because of expected difference between genders, we recommend investigating these correlations further in patients of both genders.
    Journal of molecular psychiatry. 01/2013; 1(1):20.
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    Johannes Thome
    Journal of Molecular Psychiatry. 01/2013; 1(1).

Publication Stats

4k Citations
655.08 Total Impact Points

Institutions

  • 2012–2014
    • University of Rostock
      • Klinik für Psychiatrie, Neurologie, Psychosomatik und Psychotherapie im Kindes- und Jugendalter
      Rostock, Mecklenburg-Vorpommern, Germany
    • Clarkson University
      • Department of Chemistry & Biomolecular Science
      Potsdam, NY, United States
  • 2009–2013
    • Cardiff University
      • • Centre for Neuropsychiatric Genetics and Genomics
      • • Department of Psychological Medicine and Neurology
      • • Department of Medical Biochemistry and Immunology
      Cardiff, WLS, United Kingdom
  • 2004–2013
    • Swansea University
      • • Department of Psychology
      • • Institute of Life Science "ILS"
      Swansea, Wales, United Kingdom
    • Universitat Internacional de Catalunya
      Barcino, Catalonia, Spain
  • 2011
    • French National Centre for Scientific Research
      Lutetia Parisorum, Île-de-France, France
    • Universitäre Psychiatrische Kliniken Basel
      Bâle, Basel-City, Switzerland
    • University of Gambia
      Bathurst, Banjul, Gambia
    • University of Adelaide
      • Discipline of Medicine
      Adelaide, South Australia, Australia
    • National University of Ireland, Maynooth
      Maigh Nuad, Leinster, Ireland
  • 2010
    • Johannes Gutenberg-Universität Mainz
      Mayence, Rheinland-Pfalz, Germany
  • 2000–2010
    • Central Institute of Mental Health
      • • Klinik für Abhängiges Verhalten und Suchtmedizin
      • • Biochemical Laboratory
      Mannheim, Baden-Württemberg, Germany
  • 2004–2009
    • University of Wales
      Cardiff, Wales, United Kingdom
  • 1994–2009
    • University of Wuerzburg
      • • Department of Psychiatry, Psychosomatics, and Psychotherapy
      • • Division of Forensic Psychiatry
      Würzburg, Bavaria, Germany
  • 2001–2008
    • Universität des Saarlandes
      • Institut für Gerichtliche Psychologie und Psychatrie
      Homburg, Saarland, Germany
  • 2002–2004
    • Universität Heidelberg
      • Central Institute of Mental Health
      Heidelburg, Baden-Württemberg, Germany
  • 1999–2003
    • Yale University
      • Department of Psychiatry
      New Haven, CT, United States
  • 1999–2000
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States