Specificity of cognitive biases in patients with current depression and remitted depression and in patients with asthma.

BACKGROUND: Previous studies have demonstrated a specific cognitive bias for sad stimuli in currently depressed patients; little is known, however, about whether this bias persists after recovery from the depressive episode. Depression is frequently observed in patients with asthma and is associated with a worse course of the disease. Given these high rates of co-morbidity, we could expect to observe a similar bias towards sad stimuli in patients with asthma. METHOD: We therefore examined cognitive biases in memory and attention in 20 currently and 20 formerly depressed participants, 20 never-depressed patients diagnosed with asthma, and 20 healthy control participants. All participants completed three cognitive tasks: the self-referential encoding and incidental recall task, the emotion face dot-probe task and the emotional Stroop task. RESULTS: Compared with healthy participants, currently and formerly depressed participants, but not patients with asthma, exhibited specific biases for sad stimuli. CONCLUSIONS: These results suggest that cognitive biases are evident in depression even after recovery from an acute episode but are not found in never-depressed patients with asthma.

[Pharmacological treatment of fibromyalgia syndrome]. / Medikamentöse Therapie des Fibromyalgiesyndroms.

BACKGROUND: An interdisciplinary guideline for the treatment of fibromyalgia syndrome (FMS) and chronic widespread pain (CWP) was developed in cooperation with ten German medical and psychological associations and two patients' self-help organizations. METHODS: Using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/ 2006) a systematic literature search was performed, which included all randomised controlled trials (RCT) evaluating multicomponent therapy in FMS and CWP. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of recommendation was graded according to the German program for disease management guidelines. Consensus was achieved using a multi-step nominal group procedure. RESULTS: The short-term use of amitriptyline is strongly recommended (grade A) and the short-term use of fluoxetine und duloxetine is recommended (grade B). CONCLUSIONS: The recommendations regarding pharmacological treatment of FMS are limited by the short duration of the RCT, the lack of follow-ups and absence of cost-effectiveness studies.

Conditional-associative learning in eating disorders: a comparison with OCD.

The acquisition of conditional associations using neutral and individually threatening verbal stimuli was assessed in 16 females with anorexia nervosa (AN), obsessive-compulsive disorder (OCD), bulimia nervosa and normal controls, respectively. Groups did not differ in terms of age, sex, intelligence, depression, verbal memory and verbal fluency measures. Patients and controls were widely comparable on tests assessing neuropsychological functioning. In the conditional-associative learning (CAL)-task only anorectic and OCD-patients displayed an impaired performance with neutral material but not with individually threatening material. Such a deficit was not evident in bulimics or in normal controls. These findings support the assumptions from functional neuroimaging investigations in AN and OCD and provide evidence that obsessive and compulsive behavior could have its origin within common neurobiological dysfunctions. The CAL possibly serves as a functional correlate of a neurophysiological dysfunction in obsessive-compulsive spectrum disorders.

The hypothalamic-pituitary-thyroid axis in agoraphobia, panic disorder, major depression and normal controls.

BACKGROUND: Much interest has been drawn to the investigation of the hypothalamic-pituitary-thyroid (HPT)-axis in patients suffering from depression or panic disorder. However, there is no data concerning agoraphobia. METHODS: Patients with panic disorder, agoraphobia, major depression were compared to normal controls (total n=88) in respect to HPT axis, obtaining basal TSH and administering a TRH test. RESULTS: Normal controls and agoraphobics showed significantly higher Delta(max) TSH than depressives and panic patients. There were no differences between agoraphobics and normal controls. CONCLUSIONS: Agoraphobia, unlike depression or panic disorder, seems to be less biologically determined in respect to the HPT-axis.

[A German version of the Eating Disorder Inventory EDI-2]. / Eine deutschsprachige Version des Eating Disorder Inventory EDI-2.

The paper presents a German version of the second revised edition of the Eating Disorder Inventory EDI-2 (Garner 1991). The EDI-2 is a self-rating inventory (self-report measure) with 91 items and 11 subscales designed for the assessment of attitudinal and behavioural dimensions relevant to anorexia and bulimia nervosa. It consists of the eight original subscales: drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoception and maturity fears, and the three new subscales: asceticism, impulse regulation and social insecurity. The German EDI-2 was given to 71 patients with anorexia or bulimia nervosa, 30 patients with binge eating disorder, a control group of 186 women and a further control group of 102 men. In comparison to the female control group, patient groups showed significantly elevated means on all subscales. Item analysis revealed sufficient internal consistencies for all subscales except subscale 9 (asceticism) with Cronbachs alpha ranging from 0.58 to 0.90. Twelve of the 91 items showed poor item total scale correlations below 0.40. Factor analysis supported a six-factor-structure. Hence, the reliability and validity of the three new subscales was confirmed only partially. The use of the EDI-2 in therapy research and clinical practice is critically discussed.

Effect of fluvoxamine on total serum cholesterol levels during weight reduction.

BACKGROUND: The effect of fluvoxamine versus placebo on serum cholesterol levels in obese women undergoing behavior therapy for weight reduction was evaluated. METHOD: Forty obese female outpatients undergoing 13 weeks of a behaviorally oriented treatment program for weight reduction were randomly assigned to double-blind treatment with fluvoxamine 100 mg/day (N = 18) or placebo (N = 22). Total serum cholesterol levels were measured before and after the 13-week study period. RESULTS: Patients of the two treatment groups did not differ in age, weight, body mass index, cholesterol levels before treatment, and the extent of weight reduction during treatment. Cholesterol levels were significantly lower after fluvoxamine treatment than before, whereas cholesterol levels remained unaltered after placebo administration. Patients with initially high total cholesterol levels (> or = 200 mg/dL) showed a significantly larger reduction than patients with desirable cholesterol levels. However, there was no interaction between treatment and initial cholesterol level. CONCLUSION: The results might suggest a cholesterol-lowering effect of fluvoxamine.

Comorbidity of anxiety disorders and hypochondriasis considering different diagnostic systems.

The influence of different hierarchical guidelines in various classification systems on the diagnosis of anxiety disorders and hypochondriasis was investigated. Using a semistructured polydiagnostic interview (including DSM-III, DSM-III-R, and the 1987 draft version of ICD-10), lifetime diagnoses were determined in B2 outpatients with a DSM-III-R anxiety disorder. In all diagnostic systems, half of our patients exhibited the descriptive features of hypochondriasis. As demonstrated, the formulation of restrictive hierarchical rules--as in DSM-III--contributes to the concept of "primary" hypochondriasis, while secondary hypochondriasis remains underdiagnosed. Concordance rates for hypochondriasis were high between DSM-III-R and ICD-10, but not with DSM-III. Although hypochondriasis showed a strong association with the clinical course of panic disorder (PD), it could not be explained as a consequence of greater illness severity of PD with agoraphobia (AP). Our data underline the conceptualization of hypochondriasis as a phenomenologically homogeneous diagnostic category that may be differentiated from comorbid psychiatric conditions.

Alexithymia and somatization: relationship to DSM-III-R diagnoses.

In previous studies, results from psychometric measures suggested an association between alexithymia and somatization. However, alexithymia has not been examined in relation to somatoform disorders and other standard psychiatric diagnoses. In the present study, the prevalence of DSM-III-R diagnoses was determined by SCID interviews among 45 psychiatric inpatients with functional somatic syndromes. In addition, the Toronto Alexithymia Scale (TAS) and the SCL-90-R were administered. Of the sample, 42.2% scored in the alexithymic range of the TAS. The alexithymic patients presented significantly more psychological turmoil and overall psychopathology on the SCL-90-R, as well as a significantly higher number of current DSM-III-R diagnoses. However, alexithymia was unrelated to DSM-III-R somatoform disorders and other DSM-III-R diagnoses, as well as the course of illness. These results suggest that assessing clinical features in addition to psychometric measures seems to be necessary for further validating the potential role of the alexithymia construct in somatic symptom formation.

Alexithymia: relationship to personality disorders.

Previous studies suggested an association of alexithymia with other personality models, as well as with various psychiatric syndromes. However, with regard to current diagnostic systems, the clinical validity of alexithymia remains to be established. In a sample of 182 psychiatric outpatients, the lifetime prevalence of DSM-III-R axis I disorders was determined by Structured Clinical Interview for DSM-III-R (SCID) interviews. In addition, DSM-III-R personality disorders were assessed using the Personality Diagnostic Questionnaire-Revised (PDQ-R). On the Toronto Alexithymia Scale (TAS), 17% of the sample scored in the alexithymic range. A series of stepwise multiple regression analyses were performed, exhibiting no relationship between alexithymia and any of the DSM-III-R axis I lifetime diagnoses. In contrast, schizotypal, dependent, and avoidant personality dimensions, as well as a lack of histrionic features, emerged as significant predictors of alexithymia, which further supports the conceptualization of alexithymia as a personality dimension.

Binge eating in overweight women.

Data on the prevalence and characteristics of binge eating in a series of 64 obese women participating in a controlled weight-reduction program are presented. Twenty-two (34.4%) reported recurrent binge eating episodes defined as overeating plus loss of control as assessed by patients' self-report and confirmed by a clinical interview. Six of those indicated that they engaged in either self-induced vomiting or laxative use to control their weight, but only two met full criteria for current bulimia nervosa according to DSM-III-R. A detailed description of the binge eating behavior revealed similarities to the eating pattern described in patients with bulimia nervosa: obese binge eaters tended to overeat in the evening, when they were alone and at home. Compared with their non-binge eating counterparts, binge eaters were significantly younger when they presented for treatment. The prevalence of childhood obesity was higher, and they were significantly younger when they first started on a diet than the non-binge eaters. Binge eaters reported more psychological problems such as body image distortion, and there was a slight tendency for binge eaters to exhibit more depressive symptomatology at baseline. No association between binge eating and weight at baseline, or weight loss during therapy or at follow-up could be found. Fluvoxamine (100 mg) did not seem to be of specific benefit in this subgroup of the obese with regard to weight loss.

[Cardiovascular factors of cardiac phobia--a field study]. / Kardiovaskuläre Faktoren der Herzphobie--Eine Felduntersuchung.

The interaction between psychological and physiological factors was studied with a field approach in 28 patients with cardiac phobia and 20 healthy controls. A 24-hour ambulatory ECG was recorded, and the subjects were instructed to report their activities and any cardiac perception during this period. Additionally, psychological tests assessing well-being (Bf-S), bodily complaints (B-L), and state and trait anxiety (Stai-S and Stai-T) were administered. The groups did not differ in the mean cardiovascular parameters, however patients with cardiac phobia and healthy controls showed clear differences in the strength and direction of correlations between psychological and physiological variables. The incidence of cardiac perceptions was about the same in both groups, but only patients with cardiac phobia attributed the perceptions to an internal stimulus and associated the perceptions with anxiety. Depending on the anxiety elicited by the cardiac perceptions, the patients with cardiac phobia showed heart rate accelerations, which did not occur in healthy controls. This study confirms a psychosomatic process between psychological and physiological variables, which seems to be able to explain the development and maintenance of cardiac phobia.

Anxiety induced by cardiac perceptions in patients with panic attacks: a field study.

In panic disorder bodily sensations appear to play an important role as a trigger for anxiety. In our psychophysiological model of panic attacks we postulate the following vicious circle: individuals with panic attacks perceive even quite small increases in heart rate and interpret these changes as being catastrophic. This elicits anxiety and a further increase in heart rate. To evaluate this model we conducted a field study of 28 subjects with panic attacks and 20 healthy controls. A 24 hr ambulatory ECG was recorded and the subjects were instructed to report any cardiac perceptions during this period and to rate the anxiety elicited by these perceptions. The incidence of cardiac perceptions was about the same in both groups, but only subjects with panic attacks reported anxiety associated with such perceptions. Analysis of the ECGs revealed that in both groups heart rate accelerations preceded cardiac perceptions. Following cardiac perceptions, the healthy controls showed a heart rate deceleration, whereas the subjects with panic attacks had a further acceleration. This heart rate increase after cardiac perceptions was positively related to the level of anxiety elicited by the perceptions. These results provide clear evidence in support of the vicious circle model of panic attacks.

[Depression and anxiety--a study for validating subtypes of depression]. / Depression und Angst--Eine Untersuchung zur Validierung von Subtypen der Depression.

Psychopathological analysis of the patterns of symptoms in 176 depressive in-patients disclosed in 73.3% of all patients the presence of anxiety symptoms: of these, 38.6% merely had diffuse anxiety, whereas 34.7% showed either additionally or alone specific anxiety symptoms such as phobias and panic attacks. Similar to the results obtained by dividing the patients into an "endogenous" and "neurotic" group, namely, that there was no difference between the subtypes in respect of triggering the depressive episodes by life events, or in respect of the suicide rate 30 months after discharge and in respect of a chronic course developing during the 2 years following the discharge, there was likewise no difference with regard to these criteria if the patients were subdivided into depressive patients without anxiety and those with anxiety symptoms. However, a subdivision of the depressive patients with anxiety symptoms into a group having only free-floating anxiety and a group with specific anxiety symptoms, resulted in a clear association with these criteria: If a phobia or panic attacks were present, triggering by life events was far more frequent than if there was only free-floating was more often chronic in the first group, but there was no difference in suicidality. The results indicate that it will be necessary to provide for a more differentiated classification of anxiety symptoms before deciding in clinical routine what steps to take wherever depression and anxiety symptoms are present side by side. The same applies to treatment studies.

Prognosis of cardiac phobia.

The 36 inpatients who entered this prospective study were admitted to hospital because of cardiac phobia. Their treatment consisted of a behavior therapy program. Twenty-nine of them could be reexamined after 2 1/2 years: 41% were free of symptoms during more than 75% of the follow-up period; 59% suffered recurrences of their anxiety. One patient had committed suicide. A lower educational level, being single, and interpersonal difficulties and conflicts were the sociodemographic factors associated with a poor prognosis; a long pretreatment period of illness and the presence of depression or agoraphobia on admission were significantly more frequently correlated with an unfavorable outcome. The onset sequence of depression, agoraphobia and anxiety attacks was also of prognostic relevance.

[Psychosocial and clinical predictors of the disease course in patients with cardiac phobia and panic attacks]. / Psychosoziale und klinische Prädiktoren für den Krankheitsverlauf bei Patienten mit Herzphobie und Panikattacken.

Patients suffering from cardiac phobia or neurocirculatory asthenia (also known as cardiac neurosis or effort syndrome) represent a uniform disease group due to the typicality of the signs and symptoms and of the course of the disease; this group should be distinguished from the broad spectrum of cardiovascular disorders. There is close agreement with panic disorder according to DSM III, one of the reasons being that cardiac phobia was originally the model pattern for defining that disorder. In the present prospective study the significance of psychosocial and clinical factors for the prediction of the further course of the disease was studied in 36 patients with cardiac phobia treated on an inpatient basis for the first time, 29 of whom could be followed up by a checkup 2 1/2 years later. The duration of the disease before treatment, as well as difficulties in various social spheres, especially in partnership problems, were found to be variables exercising a particularly strong influence on the course of illness. The variables concerning the marital status and school education were also found to be statistically relevant predictors. Familial stress and the appeal-for-help behaviour of these patients were also recorded. The results of the study point to the importance of psychosocial factors as major coursemodifying factors and underline the need to pay particular attention to this part of the treatment.

[Panic attacks and panic syndrome--diagnosis and therapy]. / Panikattacken und Paniksyndrom--Diagnostik und Therapie.

Paroxysmal states of anxiety that cannot be traced back to somatic causes have been called panic attacks since the publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) of the American Psychiatric Association. This term has since been accepted as part of psychiatric everyday language in many countries. The present review discusses initially the diagnostic and differential diagnostic aspects against the background of nosological classifications as practised to date, with particular emphasis on the requirements of the practising psychiatrist. The authors of this review hold the opinion that whereas the phenomenon of panic attack is a valid concept, the conceptualisation of a panic disorder is still largely hypothetical. The often observed "natural history"--after panic attacks, anticipatory anxiety, coupling of attacks to certain situations, avoidance of these situations, as well as agoraphobia, depressivity, self-medication with tranquilisers and alcohol, hypochondriacal fears with increased consultation of doctors, and family conflicts may develop--requires early therapeutic intervention. Hence, the second part of this article presents the pharmacological and psychotherapeutical treatment methods for panic attacks and their complications as developed and successfully tried out during the past few years. The efficacy has been proven of drug therapy on the one hand of prophylactic treatment using tricyclic antidepressives, MAO-inhibitors and alprazolam or clonazepam, and on the other hand also of a non-continuous attack-related treatment strategy. Of the more recent psychotherapeutic methods, relaxation methods and the cognitive treatment of panic attacks are discussed. This direct focus on panic attacks seems to be more promising than the conventional treatment methods centered on secondary symptoms such as anticipatory anxiety or agoraphobia.

[Panic attacks and cardiac phobia]. / Panikattacken und Herzphobie.

In this study 36 patients with cardiac phobia were examined prior to hospitalisation and 29 of them were re-examined after 2.5 years. An analysis of the clinical pictures showed that all of the patients met the DSM III criteria for panic disorder. The follow-up results indicated that the anxiety attacks often recurred despite treatment; on the other hand, the patients felt significantly less threatened by the symptoms and consequently showed less help-seeking behaviour. The attack symptomatology was characterized by a uniform picture and thus played, at best, a limited role in predicting the course of the illness. According to DSM III cardiac phobia is listed under the somatoform disorders as hypochondriasis; this seems to be an unfortunate decision and ought to be revised.