Two separable mechanisms are responsible for mental stress effects on high frequency heart rate variability: an intra-individual approach in a healthy and a diabetic sample.

Central withdrawal of parasympathetic cardiac control and increased respiratory frequency represent two important determinants of reduced respiratory-related heart rate variability (HRV). However, studies are missing to disentangle their relative contribution during mental stress. Healthy subjects (n=10) and type 2 diabetic patients (n=8), the latter with evidence of cardiac autonomic neuropathy, participated in this study. Using an intra-individual approach, high-frequency (hf) HRV was assessed for spontaneous (during rest and mental stress) and paced breathing (0.15, 0.2, 0.25, 0.3, 0.35, 0.4 and 0.45 Hz; randomized sequence). Mental stress was induced by a challenging reaction time task. Effects of respiratory frequency on hf HRV were individually predicted by paced breathing data. Mental stress decreased hf HRV (p<.001), and increased respiratory frequency (p=.01). Individual prediction of hf HRV by stress respiratory frequency resulted in lower values (p=.02) than observed during rest, indicating that respiratory stress effects were sufficient to reduce hf HRV. However, observed hf HRV values during stress were even lower (p<.001). These results indicate that hf HRV reductions during stress can only partly be explained by concomitant respiratory frequency changes. This effect is detectable in healthy subjects and in patients with evidence of diabetic cardiac autonomic neuropathy.

[Development and validation of a German questionnaire assessing motivation to change in eating disorders - the Stages of Change Questionnaire for Eating Disorders (SOCQ-ED)]. / Entwicklung und Validierung einer deutschsprachigen Skala zur Erfassung der Veränderungsmotivation bei Essstörungen - The Stages of Change Questionnaire for Eating Disorders (SOCQ-ED).

The present study describes the development and validation of a German questionnaire assessing motivation to change in individuals with eating disorders (Stages of Change Questionnaire-Eating Disorders, SOCQ-ED). The SOCQ-ED measures stages of change separately for each eating disorder symptom domain. Psychometric properties were assessed in a sample of N=63 women with Anorexia Nervosa or Bulimia Nervosa. Test-retest reliability ranged from rtt=0.42 to 0.78 (Mdn=0.56), correlations with the University of Rhode Island Change Assessment were between r=0.21 and 0.32 and correlations with measurements of eating pathology ranged from r=0.19 to 0.46. The results provide initial support for the reliability and validity of the SOCQ-ED.

Longer term outcome of cognitive-behavioural and psychodynamic psychotherapy in routine mental health care: randomised controlled trial.

We investigated the comparative effectiveness of cognitive-behavioural (CBT) and psychodynamic therapy (PDT) under clinically representative conditions as a subtrial of a prior study (Watzke et al., 2010, BJP). A consecutive sample of 147 patients with common mental disorders was randomised to either CBT or PDT in routine mental health care. In a primary per-protocol analysis patients randomised to CBT had a significantly better longer term outcome in the primary outcome symptom severity (General Severity Index of the SCL-14; p=.001; partial η(2)=0.073) as well as in health related quality of life (Mental Component Summary of the SF-8; p=.013; partial η(2)=.041) and concerning interpersonal issues (Inventory of Interpersonal Problems, IIP-C; p=.001; partial η(2)=.070) 6 months after treatment than patients randomised to PDT. These results could be confirmed in intention-to-treat analyses (n=180) suggesting that there was no substantial attrition bias due to drop outs at the follow-up assessment. Thus, the so called equivalence outcome paradox was not replicated in this study.

Construct validity of the Anxiety Sensitivity Index-3 in clinical samples.

Using two clinical samples of patients, the presented studies examined the construct validity of the recently revised Anxiety Sensitivity Index-3 (ASI-3). Confirmatory factor analyses established a clear three-factor structure that corresponds to the postulated subdivision of the construct into correlated somatic, social, and cognitive components. Participants with different primary clinical diagnoses differed from each other on the ASI-3 subscales in theoretically meaningful ways. Specifically, the ASI-3 successfully discriminated patients with anxiety disorders from patients with nonanxiety disorders. Moreover, patients with panic disorder or agoraphobia manifested more somatic concerns than patients with other anxiety disorders and patients with nonanxiety disorders. Finally, correlations of the ASI-3 scales with other measures of clinical symptoms and negative affect substantiated convergent and discriminant validity. Substantial positive correlations were found between the ASI-3 Somatic Concerns and body vigilance, between Social Concerns and fear of negative evaluation and socially inhibited behavior, and between Cognitive Concerns and depression symptoms, anxiety, fear of negative evaluation, and subjective complaints. Moreover, Social Concerns correlated negatively with dominant and intrusive behavior. Results are discussed with respect to the contribution of the ASI-3 to the assessment of anxiety-related disorders.

Differences in the nature of body image disturbances between female obese individuals with versus without a comorbid binge eating disorder: an exploratory study including static and dynamic aspects of body image.

Various components of body image were measured to assess body image disturbances in patients with obesity. To overcome limitations of previous studies, a photo distortion technique and a biological motion distortion device were included to assess static and dynamic aspects of body image. Questionnaires assessed cognitive-affective aspects, bodily attitudes, and eating behavior. Patients with obesity and a binge eating disorder (OBE, n = 15) were compared with patients with obesity only (ONB; n = 15), to determine the nature of any differences in body image disturbances. Both groups had high levels of body image disturbances with cognitive-affective deficits. Binge eating disorder (BED) participants also had perceptual difficulties (static only). Both groups reported high importance of weight and shape for self-esteem. There were some significant differences between the groups suggesting that a comorbid BED causes further aggravation. Body image interventions in obesity treatment may be warranted.

Effectiveness of systematic treatment selection for psychodynamic and cognitive-behavioural therapy: randomised controlled trial in routine mental healthcare.

BACKGROUND: Although cognitive-behavioural therapy (CBT) and psychodynamic therapy (PDT) are both effective treatments for mental disorders, they show clear dissimilarities concerning their therapeutic models and treatment rationales. AIMS: To determine the effectiveness of systematic treatment selection (STS) to CBT or PDT in a mental healthcare setting compared with a control procedure of random treatment selection (RTS). METHOD: A randomised controlled trial in a consecutive sample of 291 in-patients with at least one ICD-10 mental disorder was performed. The primary outcome was symptom severity (General Severity Index of the Symptom Checklist-14) at 6-month follow-up. Health-related quality of life was the secondary outcome, determined using the Short Form-8. RESULTS: Analyses revealed no general effect for systematic treatment selection. However, there was a differential effect: systematic selection resulted in a better longer-term outcome for PDT, but not for CBT; STS-PDT patients showed a significantly larger reduction in symptom severity than RTS-PDT patients. This difference was not observed in CBT. CONCLUSIONS: Since systematic treatment selection seems to be able to optimise treatment outcome, at least for PDT, pursuing systematic treatment assignment strategies in mental healthcare settings is a worthwhile endeavour.

Alteration of delay and trace eyeblink conditioning in fibromyalgia patients.

OBJECTIVE: Classical conditioning processes are important for the generation and persistence of symptoms in psychosomatic disorders, such as the fibromyalgia syndrome (FMS). Pharmacologically induced hyper- and hypocortisolism were shown to affect trace but not delay classical eyeblink conditioning. As previous studies revealed a relative hypocortisolism in FMS patients, we hypothesized that FMS patients also show altered eyeblink conditioning. METHODS: FMS patients (n = 30) and healthy control subjects (n = 20) matched for gender and age were randomly assigned to a delay or trace eyeblink conditioning protocol, where conditioned eyeblink response probability was assessed by electromyogram. Morning cortisol levels, ratings of depression, anxiety as well as psychosomatic complaints, general symptomatology, and psychological distress were assessed. RESULTS: As compared with healthy controls, FMS patients showed lower morning cortisol levels, corroborating previously described disturbances in neuroendocrine regulation of the hypothalamus-pituitary-adrenal axis in these patients. Trace eyeblink conditioning was facilitated in FMS patients, whereas delay eyeblink conditioning was reduced, and cortisol measures correlated significantly only with trace eyeblink conditioning. CONCLUSION: We conclude that FMS patients characterized by decreased cortisol levels differ in classical trace eyeblink conditioning from healthy controls, suggesting that endocrine mechanisms affecting hippocampus-mediated forms of associative learning may play a role in the generation of symptoms in these patients.

Pathological baroreceptor sensitivity in patients suffering from somatization disorders: do they correlate with symptoms?

AIM: We conducted a study to investigate whether patients with somatization disorders (ICD-10, F45.0) show abnormal values in autonomic testing. METHOD: 35 patients with a diagnosis of somatization disorder (SP) were matched to 35 healthy volunteers (HV). International standardized autonomic testing based on heart rate variation and continuously measured blood pressure signals was used to assess autonomic activity and establish baroreceptor sensitivity (BRS). Three different statistical procedures were used to confirm the reliability of the findings. RESULTS: There were no statistical differences between the 2 groups in age, BMI, systolic and diastolic blood pressures, and spectral values (total power, low, and high frequency power). However, heart rate was higher (p=0.044) and baroreceptor sensitivity was lower (p=0.002) in the patients compared to the healthy volunteers. Median BRS (+/-S.E.M.) of patients was 9.09+/-0.65 compared to 12.04+/-0.94 ms/mmHg in healthy volunteers. Twenty-two of the 35 patients had a BRS of -1.0S.D. below the mean of HV. SP with lower values differed from SP with normal BRS in values of total power, low-, mid-, and high-frequency bands (p<0.01 to <0.0001). No differences in psychometric testing were found between patients with lower or higher BRS. In addition, no correlation whatsoever was found in relation to autonomic variables between HV and SP, except for a higher LF/HF quotient in the latter (p<0.05). CONCLUSION: Autonomic regulation was impaired in 62% of patients with a somatization disorder. Severity of clinical symptoms measured by psychometric instruments did not preclude autonomic function impairment. Accordingly, autonomic dysfunction may constitute an independent somatic factor in this patient group.

Emotion recognition, emotional awareness and cognitive bias in individuals with bulimia nervosa.

Difficulties recognizing emotion have been reported for eating disordered individuals in relation to perception of emotions in others and emotional self-awareness. It remains unclear whether this is a perceptual or cognitive-affective problem. Clarification is sought and the question of a cognitive bias is addressed when interpreting facially expressed emotions. Twenty participants with bulimia nervosa (BN) and 20 normal controls (NC) were assessed for ability to recognize emotional and neutral expressions. Emotional self-awareness was also assessed. Significant differences were found for emotional self-awareness. For emotional faces, only a poorer recognition of the emotion, surprise, for BN was found. Problems with emotional self-awareness suggest a cognitive-affective disturbance in emotion recognition. Implications for therapy are discussed.

Redefining (somatoform) pain disorder in ICD-10: a compromise of different interest groups in Germany.

PURPOSE OF REVIEW: Pain is one of the most frequent reasons to visit health professionals. Many patients suffering from chronic pain conditions not only need medical treatment but also psychiatric or psychological interventions. This additional treatment need should be underlined using an ICD section F diagnosis. The current ICD-10 diagnosis of somatoform pain disorder requests psychological causation of the pain, which is frequently unclear or difficult to decide. RECENT FINDINGS: In Germany, the different interest groups, namely of psychiatry, pain research, psychosomatic medicine and clinical psychology, met to find a consensus on how to re-classify pain disorder under section F of ICD-10. This manuscript summarizes the result. SUMMARY: A diagnosis of pain disorder is necessary to underline the additional need of psychiatric/psychological interventions in chronic pain conditions. This diagnosis should include psychological features that are relevant for development or maintenance of chronic pain. In contrast to earlier attempts of redefining pain diagnoses, our attempt included representatives of the association for the study of pain.

Patients with obesity show reduced memory for others' body shape.

Social comparison theory assumes that individuals regularly compare themselves to others and that the comparisons are relevant for their self-esteem. For individuals with obesity, these social comparisons will yield a negative outcome with respect to body shape in the majority of social contacts. It is proposed that, when confronted with other persons, individuals with obesity avoid social comparisons on the dimension of body shape. Using a multinomial account of social categorization, 19 female psychotherapy patients with morbid obesity were compared to 19 non-obese female psychotherapy patients. As predicted, results reveal reduced memory for body shape categories in patients with obesity, indicating a reduced processing of body shape information.

Static and dynamic body image in bulimia nervosa: mental representation of body dimensions and biological motion patterns.

OBJECTIVE: The aim of the present study was to find out whether in bulimia nervosa the perceptual component of a disturbed body image is restricted to the overestimation of one's own body dimensions (static body image) or can be extended to a misperception of one's own motion patterns (dynamic body image). METHOD: Participants with bulimia nervosa (n = 30) and normal controls (n = 55) estimated their body dimensions by means of a photo distortion technique and their walking patterns using a biological motion distortion device. RESULTS: Not only did participants with bulimia nervosa overestimate their own body dimensions, but also they perceived their own motion patterns corresponding to a higher BMI than did controls. Static body image was correlated with shape/weight concerns and drive for thinness, whereas dynamic body image was associated with social insecurity and body image avoidance. CONCLUSION: In bulimia nervosa, body image disturbances can be extended to a dynamic component.

Why reassurance fails in patients with unexplained symptoms--an experimental investigation of remembered probabilities.

BACKGROUND: Providing reassurance is one of physicians' most frequently used verbal interventions. However, medical reassurance can fail or even have negative effects. This is frequently the case in patients with medically unexplained symptoms. It is hypothesized that these patients are more likely than patients from other groups to incorrectly recall the likelihoods of medical explanations provided by doctors. METHODS AND FINDINGS: Thirty-three patients with medically unexplained symptoms, 22 patients with major depression, and 30 healthy controls listened to an audiotaped medical report, as well as to two control reports. After listening to the reports, participants were asked to rate what the doctor thinks the likelihood is that the complaints are caused by a specific medical condition. Although the doctor rejected most of the medical explanations for the symptoms in his verbal report, the patients with medically unexplained complaints remembered a higher likelihood for medical explanations for their symptoms. No differences were found between patients in the other groups, and for the control conditions. When asked to imagine that the reports were applicable to themselves, patients with multiple medical complaints reported more concerns about their health state than individuals in the other groups. CONCLUSIONS: Physicians should be aware that patients with medically unexplained symptoms recall the likelihood of medical causes for their complaints incorrectly. Therefore, physicians should verify correct understanding by using check-back questions and asking for summaries, to improve the effect of reassurance.

Blood pressure reactivity can be reduced by a cognitive behavioral stress management program.

Although enhanced cardiovascular reactivity is extensively discussed as a relevant negative factor in the alteration of vascular structure, only a few controlled studies have been published presenting approaches to alter reactivity. Therefore, we examined whether enhanced reactivity could be reduced by stress management training (SMT). To control for expectation effects, progressive muscular relaxation (PMR) was the control condition. Forty-four patients with a blood pressure response greater than 15 mm Hg to a mental stress test participated in this study. Participants who took part in SMT showed a significantly stronger reduction of diastolic blood pressure reactivity to a mental stress test from pretest to posttest than the controls. Furthermore, patients who took part in SMT showed significantly smaller systolic blood pressure reactions to mental arithmetic and 2 social stress tests than the controls after the trainings. This study indicates that enhanced blood pressure reactivity can be reduced by SMT.

[Differential group experiences of cognitive-behavioral and psychodynamic group psychotherapy]. / Differenzielle Gruppenerfahrungen in psychoanalytisch und verhaltenstherapeutisch begründeten Gruppenpsychotherapien.

Research concerning the question, whether and to what extent cognitive-behavioral (CB) and psychodynamic (PD) therapy consist of differing process components under clinical representative conditions, is relevant especially for a valid interpretation of comparative outcome research, for identifying differential beneficial factors of psychotherapy and for a systematic indication for, respectively assignment of, patients to the two treatments. In this study it is investigated whether PD and CB differ concerning the realisation of factors of group experience, respectively of beneficial group elements (e. g. cohesion, catharsis, learning by feedback). For this purpose, in a naturalistic design, a stratified sample (N = 36) of 104 videotaped sessions (PD groups, interactional CB groups and indicative CB groups; N = 171 patients with a broad spectrum of F-diagnoses of ICD-10, especially F3/F4) were rated by observers using the Kieler-Gruppenpsychotherapie-Prozess-Skala (KGPPS). Analyses of variance and a priori Helmert-contrasts reveal differences between PD and CB with at least medium effect sizes in 12 of the 16 factors of group experience. However, differences also were found between the two CB group treatments (9 factors of group experience with differences with large effect sizes). The results suggest that the different treatment approaches foster different qualities and quantities of group experience and that the latter seems not to evolve from the group context "per se" (i. e. by the plurality of the group).

Anticipatory effects of food exposure in women diagnosed with bulimia nervosa.

OBJECTIVE: To investigate cephalic phase responses (CPRs) in women diagnosed with bulimia nervosa and to test the assumption that eating disordered individuals respond with more marked CPRs and higher increases in psychophysiological arousal to the presentation of food cues. METHOD: Thirteen female inpatients diagnosed with bulimia nervosa were compared to 15 non-eating disordered female volunteers. Participants were exposed to their preferred binge food in a single laboratory session with the possibility to eat immediately after the exposure trial. RESULTS: The results show greater salivation responses to food exposure and lower sympathetic arousal in patients diagnosed with bulimia nervosa than in non-eating-disordered participants. Distress and feelings of tension and insecurity during food exposure were higher in patients compared to controls. DISCUSSION: These results support the hypothesis that anticipatory cephalic phase responses are more marked in eating disordered individuals and may therefore play a role in the maintenance of binge eating behavior.

Biofeedback of baroreflex sensitivity in patients with mild essential hypertension.

An attempt was made to reduce blood pressure by increasing the baroreflex sensitivity (BRS) via biofeedback. Six patients with mild essential hypertension and 5 normotensive participants were studied during 8 biofeedback sessions. Each session consisted of 5 trials, 5 min each. The first and the last trials served as baselines of heart rate, blood pressure, respiration, and BRS. During the 3 middle trials the BRS was calculated online using the sequencing technique. The resulting value was used as a visual analogue feedback signal. Participants were asked to increase BRS. The mean BRS was 8.3 [ms/mmHg] for the hypertensive patients and 12.2 [ms/mmHg] for the normotensive participants. During biofeedback trials as well as across sessions neither the hypertensive nor the normotensive group showed a statistically significant increase of BRS, only heart rate variability increased significantly. Contrary to expectation blood pressure increased in both groups. One hypertensive subject made significant progress during the training by performing valsalva maneuvers. The data show that BRS is reduced in hypertensive subjects. The increase of the heart rate variability could be a sign of the activation of the baroreflex although the BRS itself did not increase. Despite the successful technical and organizational implementation of this biofeedback approach, it was not effective to systematically reduce blood pressure. A further development in the direction of guiding the patient to use the valsalva breathing pattern and/or a prolonged duration of the biofeedback training might be promising.

[Autonomic neuropathy in somatization disorders]. / Autonome Neuropathie bei Patienten mit Somatisierungsstörungen.

AIM: We conducted a study to investigate whether patients with somatization disorder show abnormal values in autonomic testing, especially in the central baroreceptor sensitivity. PATIENTS AND METHODS: Seventy-one patients were included. All had a diagnosis of somatization disorder (ICD-10, F45.0). Psychometric testing was performed by means of validated questionnaires (STAI, STAXI, FPI, GBB, ADS, SOMS, SCL-90-R). Autonomic regulation was analyzed by international standards using frequency spectral calculation by fast Fourier transformation. Thereby 3 different groups were detected: 12 patients with a baroreceptor sensitivity (BRS) of less than 3.0 ms/mm Hg, 20 patients with normal BRS (> 9.0 ms/mm Hg), and an in-between group (n = 39) with intermediate BRS. Controlling for age, a covariance analysis was calculated. RESULTS: The two extreme groups showed no difference in psychometric testing. However, significant differences were discernible in spectral values of mid-frequency-band (p < 0.05) in a covariance analysis with age as covariate. Equally the 24 h blood pressure determination showed significantly higher values for the group with BRS < 3.0 ms/mm Hg (p < 0.05 to 0.001). CONCLUSIONS: In a high percentage (17 %) of patients diagnosed to have somatization disorder autonomic dysregulation becomes apparent and is accompanied by increased blood pressure. Therefore it doesn't seem accurate to overlook concomitant organic lesions in somatization disorders despite patients lacking overtly clinical signs but suffering from various unspecific symptoms.

Patients with erythrophobia (fear of blushing) show abnormal autonomic regulation in mental stress conditions.

OBJECTIVE: The objective of this study was to analyze the autonomic functions of patients with erythrophobia. METHODS: Forty patients with a diagnosis of erythrophobia (female/male ratio 18/22) without any other organic lesions and 20 healthy volunteers (female/male ratio 10/10) were assessed. Clinical evaluation was performed using a modified version of semistructured interviews. Autonomic testing was performed by means of spectral analysis of heart rate and continuous blood pressure by sparse discrete Fourier transformation at rest and under mental stress. RESULTS: There were no significant difference between the two samples in age, sex distribution, BMI, resting systolic, or diastolic blood pressure, nor was there a difference in autonomic baseline functioning between the 40 patients with erythrophobia and the control subjects. On the other hand, patients with erythrophobia consistently showed higher pulse rates (88 +/- 20 vs. 78 +/- 9 bpm, p <.05), higher total heart rate power values (8.40 +/- 0.63 vs. 8.07 +/- 1.02 p <.05), higher midfrequency spectral values (7.38 +/- 0.66 vs. 7.02 +/- 1.18, p <.01), higher high-frequency spectral values (6.89 +/- 0.86 vs. 6.48 +/- 1.44, p <.05), and lower baroreceptor sensitivity (8.62 +/- 8.16 vs. 11.65 +/- 4.42, p <.005) than the healthy subjects. ANOVA showed a significant group interaction (p <.0001) between the samples. CONCLUSIONS: This study provides evidence for abnormal autonomic functioning in patients with erythrophobia when under mental stress.