Alcohol consumption and other psycho-social conditions as important factors in the development of diabetic foot ulcers.

AIMS: To characterize bio-psycho-social factors, particularly mental disorders and self-harm behaviour, associated with the development of diabetic foot ulcers. METHODS: Two groups of diabetic patients with and without foot ulcers (n=47 in each group) with similar sex, age and diabetes duration were assessed for mental disorders using the Composite International Diagnostic Interview. Self-harm behaviour, quality of life, depressive symptoms and self-compassion were rated using different standard questionnaires. RESULTS: Patients from the ulcer group visited their practitioners and/or psychotherapists less frequently in the last 12 months than patients in the control group 0 vs. 13%; P=0.026). The ulcer group patients had a history of increased alcohol consumption (43 vs. 19%; P=0.025), lower levels of education (8 vs. 10 grades; P=0.014) and income (1190 vs. 1535 €/month; P=0.039). Additionally, they were less likely to be diagnosed with anxiety disorders (11 vs. 32%; P=0.022). No significant differences in glycated haemoglobin, body mass index, smoking and direct self-harm behaviour were identified. CONCLUSIONS: Patients with foot ulcers tend to exhibit lower health-conscious behaviour, particularly higher lifetime alcohol consumption, lower utilization of medical services and less general anxiety. Practitioners should be aware of these behaviours, since early detection of diabetes patients at psycho-social risk and consecutive psychological intervention may be an effective preventive strategy in avoiding the development of foot ulcers.

Reduced olfactory bulb volume and olfactory sensitivity in patients with acute major depression.

The purpose of this study was to assess olfactory function and olfactory bulb volume in patients with acute major depression in comparison to a normal population. Twenty-one patients diagnosed with acute major depressive disorder and 21 healthy controls matched by age, sex and smoking behavior participated in this study. Olfactory function was assessed in a lateralized fashion using measures of odor threshold, discrimination and identification. Olfactory bulb volumes were calculated by manual segmentation of acquired T2-weighted coronal slices according to a standardized protocol. Patients with acute major depressive disorder showed significantly lower olfactory sensitivity and smaller olfactory bulb volumes. Additionally, a significant negative correlation between olfactory bulb volume and depression scores was detected. Their results provide the first evidence, to our knowledge, of decreased olfactory bulb volume in patients with acute major depression. These results might be related to reduced neurogenesis in major depression that could be reflected also at the level of the olfactory bulb.

The social phobia psychotherapy research network. The first multicenter randomized controlled trial of psychotherapy for social phobia: rationale, methods and patient characteristics.

This paper presents the Social Phobia Psychotherapy Research Network. The research program encompasses a coordinated group of studies adopting a standard protocol and an agreed-on set of standardized measures for the assessment and treatment of social phobia (SP). In the central project (study A), a multicenter randomized controlled trial, refined models of manualized cognitive-behavioral therapy and manualized short-term psychodynamic psychotherapy are compared in the treatment of SP. A sample of 512 outpatients will be randomized to either cognitive-behavioral therapy, short-term psychodynamic psychotherapy or waiting list. Assessments will be made at baseline, at the end of treatment and 6 and 12 months after the end of treatment. For quality assurance and treatment integrity, a specific project using highly elaborated measures has been established (project Q). Study A is complemented by 4 interrelated add-on projects focusing on attachment style (study B1), on cost-effectiveness (study B2), on variation in the serotonin transporter gene in SP (study C1) and on structural and functional deviations of the hippocampus and amygdala (study C2). Thus, the Social Phobia Psychotherapy Research Network program enables a highly interdisciplinary research into SP. The unique sample size achieved by the multicenter approach allows for studies of subgroups (e.g. comorbid disorders, isolated vs. generalized SP), of responders and nonresponders of each treatment approach, for generalization of results and for a sufficient power to detect differences between treatments. Psychological and biological parameters will be related to treatment outcome, and variables for differential treatment indication will be gained. Thus, the results provided by the network may have an important impact on the treatment of SP and on the development of treatment guidelines for SP.

[The Dachau multidisciplinary treatment program for chronic pain. Efficacy data of a diagnosis-independent multidisciplinary treatment program for back pain and other types of chronic pain]. / Die Multimodale Schmerztherapie Dachau (MSD). Daten zur Wirksamkeit eines diagnose-unabhängigen multimodalen Therapieprogramms bei Rückenschmerzen und anderen Schmerzen.

BACKGROUND: Data on the efficacy of the Dachau multidisciplinary treatment program for chronic pain is presented. The treatment is administered in a primary care day clinic and the treatment period is 5 weeks plus 5 booster days 6 months later. The program is characterized by high treatment intensity (122.5 h over 5 weeks) and is aimed at patients where outpatient pain therapy proved to be insufficient. The treatment plan is applicable to different types of chronic pain and the main treatment objective is functional restoration. METHODS: Outcome criteria were pain intensity, disability, vitality, depression, catastrophizing, and employment status. The data was assessed at the beginning of treatment, after 5 weeks and 6 months after therapy. The patient population consisted of 189 chronic pain patients. RESULTS: All outcome criteria showed a significant and stable improvement over 6 months. Effect sizes demonstrated medium and high treatment effects. The back to work rate was 63% at 6 months follow-up. DISCUSSION: The Dachau multidisciplinary treatment for chronic pain achieved significant improvements which remained stable for 6 months after treatment.

Which gynecological and obstetric patients want to attend psychosomatic services?

OBJECTIVE: The aim of this study is to explore the wish of gynecological and obstetric inpatients to attend psychosomatic services. Predictors influencing this wish are evaluated. METHOD: Three groups of patients participated in the study. The groups consisted of patients diagnosed with malignant gynecological diseases (n = 175), benign gynecological diseases (n = 302), and obstetric diseases (n = 238). The following domains were assessed in a cross-sectional design: symptoms of anxiety and depression (HADS), physical complaints (GBB-24), health-related quality of life (SF-12), and the wish to attend psychosomatic services. RESULTS: 34% of the participants indicated that they wanted to attend psychosomatic services during their stay in the hospital. The group of patients diagnosed with malignant gynecological diseases had the highest proportion of women who stated that wish (43%). Multiple logistic regression models showed that former psychotherapeutic experiences as well as low psychological quality of life predicted the wish to attend psychosomatic services in patients diagnosed with malignant gynecological or obstetric diseases. CONCLUSION: It was shown that a considerable proportion of patients wanted to attend psychosomatic care during their hospitalization. Contrary to physical and sociodemographic variables, psychological factors were significant predictors of the inpatient's wish to attend psychosomatic services. This suggests that the subjective estimation of impairments is a major predictor of the wish to attend psychosomatic care.

[Etiology and pathophysiology of fibromyalgia syndrome and chronic widespread pain]. / Atiopathogenese und pathophysiologie des fibromyalgiesyndroms und chronischer schmerzen in mehreren körperregionen.

OBJECTIVE: To write a systematic review on the etiology and pathophysiology of the fibromyalgia syndrome (FMS) and of chronic widespread pain (CWP). METHODS: An interdisciplinary level-3 guideline (i.e. systematic literature search and assessment, logic analysis, formal consensus procedure) for the diagnosis and therapy of FMS was created in cooperation with 10 medical and psychological societies and 2 patient self-help organizations. A literature search was performed covering all available review articles on the etiology and pathophysiology of FMS and CWP using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/2006). For the assignment of evidence classes the system of the Oxford Centre for Evidence-Based Medicine was applied. Consensus was achieved by a multi-step nominal group procedure. RESULTS: FMS aggregates in families (evidence level 2c). Physical and psychological stress at the workplace are risk factors for the development of CWP and FMS. Affective disorders are risk factors for the development and maintenance of FMS. Operant learning mechanisms and sensitization are risk factors for the chronification of FMS (evidence levels 2b). Several factors are associated with the pathophysiology of FMS, but the causal relationship is unclear. This includes alterations of central pain pathways, hyporeactivity of the hypothalamus-pituitary-adrenal axis, increased systemic pro-inflammatory and reduced anti-inflammatory cytokine profiles and disturbances in the dopaminergic and serotonergic systems. CONCLUSIONS: FMS is the common final product of various etiological factors and pathophysiological mechanisms.

Psychological and physical factors influencing the health-related quality of life of patients of a department of gynecology in a university hospital.

The aim of our study was to assess the physical and mental quality of life of in-patients of a Gynecological University Hospital and the factors influencing the quality of life. 715 women, who were treated in hospital with non-malignant or malignant gynecological or obstetrical diseases, took part in the study. Besides demographical data and relevant medical parameters the quality of life (SF-12), anxiety and depression (HADS) as well as physical discomforts (GBB) were assessed. The physical quality of life of the study population was significantly lower than that of the normal population (p < 0.001). Patients with obstetric diseases in comparison with patients with malignant gynecological and other gynecological diseases had the lowest physical quality of life. Regarding the mental factor, patients with malignant gynecological diseases feel most impaired, followed by those with other gynecological and obstetrical conditions. The multivariate analysis of the quality of life showed that up to 60% of the variance could be explained. The lowest variance elucidation was found in obstetrical patients in whom the physical complaints elucidated only a small part of the variance. Our results show on the one hand the high impairment of mental and especially of physical quality of life in women who are in hospital with gynecological or obstetrical diseases. On the other hand they show the great significance of the quality of life as an outcome parameter. These findings should be considered in gynecological in-patient treatments by using integrated psychosomatic care.

[Effects of distress and coping on quality of life in HIV-positive patients: results of a longitudinal study]. / Wirkung von Belastung und Krankheitsbewältigung auf die Lebensqualität bei HIV-Positiven. Ergebnisse einer Längsschnittuntersuchung.

Preserving health-related quality of life (QOL) is an important approach with HIV-positive patients. In a longitudinal study over 3 years, with three measurements each 18 months, we examined 56 of these patients for the influence of distress and coping (assessed by interviews) on physical, cognitive-emotional, and social QOL (using the SEL questionnaire). The patients were 32.9 years old on average, with 28.3 months since diagnosis. Seventy percent were male, 82% asymptomatic, 14% with ARC, and 4% with AIDS. Forty-five percent had been infected by homosexual intercourse, 14% by heterosexual intercourse, and 41% by iv drug abuse. The patients reported significantly worse physical and cognitive-emotional QOL than healthy subjects. Those HIV-positive persons with great distress showed significantly lower QOL scores. Multiple analyses of regression showed evasive-regressive coping at the T1, T2, and T3 levels as negative predictors, vs active, problem-focused coping as a positive predictor for nearly all QOL parameters at T3. HIV-positive patients with ARC or AIDS reported more physical complaints and lower physical QOL than asymptomatic persons. Physicians should suggest psychosocial support to patients with poor QOL scores.

Pain perception in patients undergoing bone marrow puncture--a pilot study.

The objective of this study was to establish the relationship between the perception of pain, anxiety, and depressive tendency in performance of bone marrow puncture. 93 consecutive patients (62% men, 38% women) from a hematological oncology outpatient department ages 20 to 85 years (M age = 53.7, SD = 15.1) were questioned. On average, the patients had undergone 2.5 (+/- 2.6) punctures. The underlying disease was leukemia in 49%, malignant lymphoma in 41%, another malignant disease in 2%, and there was a benign condition in 8%. Depression and general anxiety were measured using the Hospital Depression and Anxiety Scale (HADS-D). Fear of puncture and perception of pain were registered with visual analog scales. Patients with increased scores of anxiety or depressive tendency on the HADS-D suffered significantly more severely from fear of puncture and pain than patients with normal scores. However, the puncture-related fear in the group as a whole correlated markedly more closely with the intensity and tolerability of pain than did general fear and depressive tendency. This finding must be considered when planning psychological interventions in this group of patients.

The effects of St John's wort extract on heart rate variability, cognitive function and quantitative EEG: a comparison with amitriptyline and placebo in healthy men.

AIMS: To compare the effects of multiple dosing with St John's wort (Hypericum perforatum) extract and amitriptyline on heart rate variability, cognitive function and quantitative EEG (qEEG) with placebo in healthy humans. METHODS: A randomized, double-blind, cross over study of 12 healthy male volunteers. Subjects orally received capsules with 255-285 mg St John's wort extract (900 micro g hypericin content), 25 mg amitriptyline and placebo three times daily for periods of 14 days each with at least 14 days between. The doses of amitriptyline and St John's wort extract are comparable with respect to their antidepressant activity. Compliance was confirmed by coadministration of 10 mg of riboflavin with each capsule and detection of urinary vitamin B2 on treatment day 11 with high performance liquid chromatography. Measurements of heart rate variability, psychometric tests and qEEG were performed before start of medication and repeatedly on the last treatment day. RESULTS: St John's wort extract did not affect heart rate variability (HRV) whereas amitripytline significantly decreased it: the difference in the percentage number of adjacent RR intervals> 50 ms (pNN50) was 8.6 (-2.6, 19.9; mean; 95% confidence interval) between St John's wort extract and placebo and -17.6 (-24.7, -10.4) between amitriptyline and placebo. Neither St John's wort extract nor amitriptyline had an influence on cognitive performance such as choice reaction, psychomotor coordination, short-term memory and responsiveness to distractive stimuli. Amitriptyline but not St John's wort extract decreased self rated activity (P < 0.05). Both drugs caused significant qEEG changes. St John's wort extract increased theta power density. Amitriptyline increased theta as well as fast alpha power density. CONCLUSIONS: Multiple doses of St John's wort extract do not affect heart rate variability nor cognitive function. Chronic administration of amitriptyline causes a decrement of HRV and subjective sedation but it does not impair cognitive performance.

[Evaluation of therapeutic success by patients with anxiety disorders after inpatient psychotherapy]. / Bewertung des Therapieerfolgs durch Patienten mit Angststörungen nach stationärer Psychotherapie.

OBJECTIVE: To identify factors influencing the subjective assessment of patients regarding the outcome of in-patient psychotherapy for anxiety disorders. METHODS: A total of 231 patients were tested at admission, discharge and 1-year follow-up in a multi-center study. Subjective outcome assessment was measured with the revised German version of the Helping Alliance Questionnaire. The use of the term "outcome satisfaction" is discussed. RESULTS: Patient outcome assessment did not correlate with age, sex, or education, or with duration or severity of illness or duration of treatment. Outcome assessment was closely connected with therapy success. Reaching a low symptom level ("clinical significance") had a higher impact than a high pre-post-difference ("statistical significance"). CONCLUSIONS: Anxiety patients give a generally positive assessment of their therapy outcome, which is most determined by symptom-related treatment success. The differentiation of "clinical" and "statistical significance" of success is of importance for the patient's subjective view of the therapy outcome.

[Coping of diseases in old age--partnership as a resource]. / Krankheitsbewältigung im Alter--die Partnerschaft als Ressource.

Somatic as well as mental health of the elderly are to a high extent determined by the quality of their marriage, the reciprocity of social support, and the available socio-economic resources. The coping behavior does not change very much in the course ofa person's life. If he or she has sufficient skills and resources, the elderly person will engage in problem-focused coping. If demands are appraised as outside of the person's control, secondary control strategies aiming at a reappraisal are more frequently applied. A crucial coping resource in old age is the availability of social support that is experienced as adequate and useful by the recipient. The spouse and members and close family members are the most important sources of social support for the elderly.

The effects of reboxetine on autonomic and cognitive functions in healthy volunteers.

RATIONALE: Though reboxetine, a selective noradrenaline reuptake inhibitor, causes autonomic and cognitive adverse events there is a paucity of appropriately designed studies on the cognitive and autonomic effects of the drug in the literature. OBJECTIVE: To compare the effects of reboxetine on cognitive and autonomic functions with those of placebo in healthy humans. METHOD: A randomised, double-blind, crossover study of 12 healthy male volunteers aged 25 (21-27; median, range) years. Subjects orally received 4 mg reboxetine and placebo twice daily for periods of 14 days each with at least 14 days in between. Vasoconstrictory response of cutaneous vessels (VR) and skin conductance response (SCR) following sudden deep breath were employed as parameters for autonomic function. Quantitative EEG (qEEG) and psychometric tests served as parameters for cognitive function. RESULTS: Reboxetine decreased SCR and prolonged the dilation phase of VR (P<0.05). It did not affect cognitive functions such as flicker fusion frequency, choice reaction, memory and psychomotor coordination but increased slow beta (beta1) power density in the qEEG. Tiredness (n=12), dry mouth (n=9), delayed urination (n=3) and constipation (n=1) were noted with reboxetine. CONCLUSION: Sustained peripheral and/or central sympathetic activation accounts for the prolongation of VR. The decrease of SCR and typical side effects suggest a relevant antimuscarinic drug action. Chronic administration of reboxetine at therapeutic doses causes autonomic dysfunction and subjective sedation but does not impair cognitive and psychomotor abilities in healthy humans.

Rhythmical changes of the cutaneous blood flow in the forehead region under the condition of hypnoid relaxation.

BACKGROUND: A characteristic and stable blood flow rhythm can be detected for the skin of the forehead and ear lobes with frequencies of approx. 0.15 Hz (9/min), which were primarily not related to the respiratory rhythm. PATIENTS AND METHODS: The perfusion of the skin in the forehead region was investigated non-invasively with laser Doppler fluxmetry in ten healthy subjects before and during Hypnoid Relaxation (HyR). The HyR-state was induced by suggesting formulas regarding to the well known Autgeneous Training. RESULTS: In all test subjects rhythmical fluctuations of bloodflow with a frequency of approx. 0.15 Hz could be observed both, before and during HyR. We found that the amplitude of these fluctuations clearly (> 20% from individual baseline) increased in five of ten test subjects under the condition of HyR. Furthermore, in three of ten cases the spontaneous respiration under HyR adjusted to the frequency of the described bloodflow rhythm, which exists both, before and during HyR. CONCLUSIONS: These phenomena suggest an individually stabil and autonomous rhythm which is effected by alterations in the level of conciousness and which may be caused by the close linkage between the nerval structures for control of respiratory and circulatory systems. May be, this autonomic rhythm could be used as a trigger for breathing therapies or as a parameter for the impact of relaxation techniques on hemodynamics, e.g. in complementary therapy of vascular diseases like systemic sclerosis.

Alterations of autonomic cardiac control in anorexia nervosa.

BACKGROUND: The authors investigated autonomic cardiac function in anorexia nervosa. METHODS: Forty-eight patients, who in the present or past met the DSM-III-R criteria for anorexia nervosa, and 16 normal control subjects participated in a standardized analysis of heart rate variability during supine and standing postures. RESULTS: Several heart rate variability parameters showed an inverse correlation to the present weight of the anorexic subjects. The values of the spectral power analyses were significantly (p < .01) lower in patients (n = 18) weighing less than 75% of ideal weight when compared to the results found in the control group; however, the heart rate variability parameters of anorexic subjects with restored weight (n = 12) did not differ from those of the control subjects. CONCLUSIONS: The obtained results provide evidence for autonomic cardiac dysfunction in acutely ill anorexic patients. Further research is required to elucidate possible clinical consequences of these findings.

Pseudoseizure "status".

Psychogenic pain, disturbances of gait and stance, sensory symptoms, dizziness, and psychogenic seizures have been found to be the most common conversion symptoms in neurology clinics. A retrospective analysis of 18 patients suffering from pseudoseizure "status" is presented in this study. All of the patients fulfilled the DSM-III-R criteria of conversion disorder. However, 5 of them had concomitant major depression, 6 suffered from bulimia nervosa, and 7 met the criteria for substance abuse. On Axis II, 10 cases of borderline personality disorder, 2 cases of antisocial personality disorder, and 3 cases of histrionic personality disorder were diagnosed. The majority of the patients had attempted suicide and other forms of self-destructive behavior. The findings suggest that patients with pseudoseizure "status" suffer from severe affective imbalances and disturbed impulse control.

Longitudinal development of distress, coping and quality of life in HIV-positive persons.

BACKGROUND: Longitudinal study on burdens, quality of life and coping strategies of HIV-positive persons to identify patterns of successful adaptation to the demands of the infection. METHODS: In a semiprospective multimodal approach, 61 HIV-positive persons in all stages of the infection attending an HIV ambulatorium were assessed by inventories (3 times) and by a half-standardized interview (baseline T1 focussing on first reactions after diagnosis, follow-up T3 1.5 years later). Subjects had a mean age of 35.3 years and 69% were male. Forty-four percent were infected via homosexual intercourse, 46% via intravenous needle sharing and 10% via heterosexual intercourse or an unknown source. RESULTS: Global, psychic and familial distress decreased significantly from the first period after the diagnosis of HIV to the third time of measurement, while somatic complaints increased. Most test persons were able to deal effectively with the demands of the infection and showed a great degree of flexibility in their use of cognitive-actional and emotional-palliative strategies; they achieved a high quality of life. In contrast, highly distressed individuals, mainly drug users, tended to cope in an evasive-regressive way and reported a low quality of life. Correlations between ineffective coping strategies and low quality of life were found to be significant. CONCLUSIONS: After an initial phase of sorrow and lack of orientation regarding their future life, most HIV-positive persons deal effectively with the demands of the HIV infection and report a good quality of life. In contrast, HIV-positive persons with a high degree of distress and an evasive-regressive coping pattern need professional support, such as psychotherapy.