Recurrent Tako-Tsubo cardiomyopathy (TTC) in a pre-menopausal woman: late sequelae of a traumatic event?

BACKGROUND: "Tako-Tsubo cardiomyopathy" (TTC) is a syndrome characterized by left ventricular (LV) wall motion abnormalities, usually without coronary artery disease, mimicking the diagnosis of acute coronary syndrome. It most often affects post-menopausal women and TTC tends to run a benign course with very low rates of recurrence, complications or mortality. The condition is also called "stress-induced cardiomyopathy" because acute physical or emotional stress appears to be frequently related to its onset. The pathogenic role of premorbid or comorbid psychiatric illnesses has been discussed controversially. For the first time, we present a case of fourfold recurrent TTC with severe complications in a pre-menopausal woman. Furthermore, a long history of flaring posttraumatic stress symptoms anteceded the first event. CASE PRESENTATION: A 43-year old, pre-menopausal Caucasian woman was hospitalized with symptoms of acute coronary syndrome. Clinical examination revealed hypokinetic wall motion in the apical ventricular region with no signs of coronary artery disease and diagnosis of TTC was established. She experienced recurrence three times within the following ten months, which led to thrombembolism and myocardial scarring among others. The circumstances of chronic distress were striking. 16 years ago she miscarried after having removed a myoma according to her doctor's suggestion. Since then, she has suffered from symptoms of posttraumatic distress which peaked annually at the day of abortion. Chronic distress became even more pronounced after the premature birth of a daughter some years later. The first event of TTC occurred after a family dispute about parenting. CONCLUSION: This is the first case report of fourfold TTC in a pre-menopausal woman. From somatic perspectives, the course of the disease with recurrences and complications underlines the fact that TTC is not entirely benign. Furthermore, it is the first case report of long lasting symptoms of traumatic stress anteceding TTC. Close connections between adrenergic signaling and late onset of clinical stress symptoms are well known in the psychopathology of traumatization. Although larger clinical trials are needed to elucidate possible interactions of premorbid psychiatric illnesses and TTC, cardiologists should be vigilant especially in cases of recurrent TTC.

Individual quality of life in patients with multiple myeloma.

OBJECTIVE: The situation of patients with multiple myeloma, whose treatment often implies high-dose chemotherapy and stem cell transplantation that can be associated with severe symptoms and psychological distress, has gained attention in recent psychooncological research. This study followed an idiographic approach in order to identify the areas of life most relevant for the interviewed myeloma patients' quality of life (QoL) as well as their current satisfaction with these. METHODS: 64 patients took part in semi-structured interviews according to the SEIQoL-DW Manual (Schedule for the Evaluation of Individual Quality of Life - Direct Weighting). Visual analogue scales (VAS) were used to gain additional information about a general assessment of the present QoL. Qualitative data evaluation preceded quantitative processing. Groups were compared according to the time elapsed since diagnosis regarding specified areas of life, satisfaction with these and their relative weighting. SEIQoL-DW-indices were correlated to the VAS to reflect on an interindividually comparable parameter. RESULTS: Personal social relationships were mentioned significantly more often as important for QoL than health-related aspects, and in direct comparison were weighted significantly stronger. Regarding the change of areas relevant for QoL over the time elapsed since diagnosis, there was a significant difference between groups concerning the area of spirituality. Satisfaction differed significantly between groups for the field of leisure. CONCLUSION: The results for the interviewed patients with multiple myeloma point out the need to take into account the importance of social and individual aspects when reflecting on QoL. Similar findings have been reported for different samples. The relevance of an individualized approach is illustrated by the fact that individually named areas of life were rated comparatively strongly in their importance for the patients' QoL. An overall assessment for the current QoL by means of VAS is regarded as an adequate supplement to the SEIQoL-Profile and an alternative to the SEIQoL-DW-Index.

Psychiatric side effects of pegylated interferon alfa-2b as compared to conventional interferon alfa-2b in patients with chronic hepatitis C.

AIM: To assess systematically the spectrum and extent of depressive symptoms comparing patient groups receiving peginterferon or conventional interferon. METHODS: Ninety-eight patients with chronic hepatitis C and interferon-based therapy (+ribavirin) were consecutively enrolled in a longitudinal study. Patients were treated with conventional interferon alfa-2b (48/98 patients; 5 MIU interferon alfa-2b thrice weekly) or peginterferon alfa-2b (50/98 patients; 80-150 mug peginterferon alfa-2b) in combination with weight-adapted ribavirin (800-1 200 mg/d). Repeated psychometric testing was performed before, three times during and once after antiviral therapy: Depression was evaluated by the Hospital Anxiety and Depression Scale (HADS), anger/hostility by the Symptom Checklist-90 Items Revised (SCL-90-R). RESULTS: Therapy with pegylated interferon alfa-2b produces comparable scores for depression (ANOVA: P = 0.875) as compared to conventional interferon. Maximums of depression scores were even higher and cases of clinically relevant depression were frequent during therapy with peginterferon. Scores for anger/hostility were comparable for both therapy subgroups. CONCLUSION: Our findings suggest that the extent and frequency of depressive symptoms in total are not reduced by peginterferon. Monitoring and management of neuropsychiatric toxicity especially depression have to be considered as much as in antiviral therapy with unmodified interferon.

Nuevas enfermedades ¿del alma?: reflexiones psicosomáticas a propósito de algunas analogías estructurales entre síndrome de fatiga crónica, fibromialgia y sensitividad química múltiple / New maladies - of the soul?: reflections concerning some structural analogies among chronic fatigue syndrome fibromyalgie and multiple chemical sensitivities

Introducción. En los últimos años se ha observado la expansión de una serie de cuadros clínicos situados en la frontera entre el soma y la psique. Entre ellos cabe destacar el síndrome de fatiga crónica (CFS), la fibromialgia (FM) y la enfermedad medioambiental sensitividad química múltiple (MCS). En la actualidad, no hay un consenso científico a propósito de etiología, patogénesis y tratamiento de las afecciones nombradas, lo que ha impedido que se formula una respuesta clínica adecuada a dichas molestias. Dada la mencionada falta de homogeneización de criterios los autores proponen someter a dichas enfermedades a un análisis crítico desde un punto de vista comparativo. CFS, FM y MCS, pensadas desde una perspectiva interdisciplinaria, más que genuinas enfermedades orgánicas parecen ser el resultado sobredeterminado de la confluencia simultánea de múltiples factores psicosociales. Recuperando el concepto de somatización, por un lado, y el de angustia, por el otro, los autores proponen un enfoque psicosomático de CFS, FM y MCS, basado en sus respectivas analogías estructurales.

Introduction. Recent years have seen an increase in several illnesses located on the border between body and mind. Chronic fatigue syndrome (CFS), fibromyalgia (FM) and multiple chemical sensitivities (MCS) are particularly prominent members of this group. There is currently no scientific consensus on the etiology, pathogenesis and medical treatment of these maladies, and, consequently, no adequate clinical response has been formulated. Considering the lack of homogeneous criteria, the authors carry out a critical analysis from a comparative point of view. CFS, FM and CFS, seen from an interdisciplinary perspective, seem to be more the result of the simultaneous confluence of multiple psychosocial factors than genuine organic diseases. Using the concepts of somatization and anxiety, the authors propose a complementary psychosomatic approach based on the structural analogies of CFS, FM and MCS.

Psychiatric symptoms in patients with chronic hepatitis C receiving interferon alfa-2b therapy.

BACKGROUND: Psychiatric side effects of interferon alfa are frequently observed in the therapy of patients with chronic hepatitis C infection. The goal of the present study was to assess prospectively the incidence, spectrum, and extent of psychiatric symptoms of patients receiving interferon alfa therapy as compared with an untreated reference group. METHOD: 104 patients with chronic hepatitis C were consecutively enrolled in a prospective longitudinal study. The treatment group (N = 84) received interferon alfa-2b for up to 12 months, and the reference group (N = 20) received no treatment. Patients who began treatment between November 1996 and August 1998 (N = 44) received interferon alfa-2b, 5 million units 3 times per week. Patients who began treatment in September 1998 or later (N = 40) received a combination of interferon alfa-2b, 3 to 5 million units 3 times per week, and ribavirin, 1000-1200 mg/day. Diagnostic scores for depression and anxiety were obtained by means of the psychometric instrument Hospital Anxiety and Depression Scale, and scores for anger/hostility were obtained with the Symptom Checklist-90 Revised. RESULTS: In contrast to the untreated reference group, we found significantly increased scores for depression (p <.001) and anger/hostility (p <.001) during interferon alfa therapy in the treatment group. Even before therapy, scores of those in the treatment group were above the respective cutoff values for clinically relevant symptoms of depression in 15.5% of the patients, anxiety in 13.1% of the patients, and anger/hostility in 11.3% of the patients. These proportions rose to 35.0% (depression), 25.6% (anxiety), and 24.5% (anger/hostility). The cumulative frequency of clinically relevant emotional distress (depression, anxiety, or anger/hostility) during interferon alfa therapy was 57.7%, as compared with 22.5% before therapy. However, interferon alfa therapy had to be stopped prematurely because of untreatable psychiatric symptoms in only 8.3% of patients. CONCLUSION: In view of the high frequency and extent of psychiatric symptoms with interferon alfa therapy, we recommend a close follow-up of patients receiving this therapy with respect to potential limiting mood changes.