How not to miss a somatic needle in the haystack of chronic pain.

Interviews with 18 male patients with predominantly psychogenic pain (DSM-III and DSM-III-R) and with 18 male patients with pain of mainly physical origin, consecutively admitted to a medical department, were rated by blinded and independent raters with respect to "symptom description," "manner of speech," "personality characteristics," "interviewer reactions," "interpersonal relationships," and "relationships at work." Patients with predominantly organic pain significantly more often described a clear localization of the pain symptom, used more sensory words for the description of pain quality; more often described discrete changes of pain intensity and periodicity; more often showed pain-intensifying factors dependent on movement and pain-decreasing factors; more often believed pain to be a symptom versus as a disease itself, and tended to have fewer difficulties in their interpersonal relationships than those with predominantly psychogenic pain (p < 0.05 for all factors, two-tailed Fisher's Exact test).

Clinical speculation: is specificity back? This time thromboangiitis obliterans.

Do men with thrombangiitis obliterans (TO) show conspicuous personality features and behavior? Twenty-one men with TO were compared with 20 men with coronary artery disease (CAD). All diagnoses were angiographically confirmed. Mean ages were 40.1 (TO) and 43.4 years (CAD). Semistructured, open-ended interviews were conducted. Interview-behavior: TOs were more hostile, minimizing, evasive, and complicated than CADs (p < .001). The interviewer reacted with more anger, impatience, boredom, astonishment, and less empathy towards TOs (p < .001). Adult behavior: TOs had changed their place of work more often (p < .001), had more absentism from work (p < .001), and had more debts (p = .01) unrelated to the present illness. They smoked more before the illness (p = .01) and continued to smoke more frequently during their illness than CADs (p < .003). They were more often single or divorced (p < .05) and had more conflicts in their relationships (p < .001) than CADs. During conflicts, TOs more often shouted or withdrew and less frequently tried to resolve conflicts with humor and discussions (p < .001) than CADs. TOs were more frequently dissatisfied with their life situation than CADs (p < .001). TOs more often passively submitted to their illness than CADs, who tried to cope by giving up smoking and by exercising (p < .001). Childhood: TOs more often mentioned a bad relationship with their father than CADS (p = .01) and had more disciplinary problems at home and in school (p = .002). TOs show remarkable personality features.(ABSTRACT TRUNCATED AT 250 WORDS)

[Spontaneous course of allergic bronchopulmonary aspergillosis]. / Spontanverlauf einer allergischen bronchopulmonalen Aspergillose.

This case report illustrates the spontaneous course of allergic bronchopulmonary aspergillosis (ABPA). The x-ray images cover a time-frame of nearly 20 years. All of the main criteria of ABPA are fulfilled. Despite intermittent oral corticosteroid treatment, recurrent eosinophilic infiltrates of the lungs occurred. New strategies in diagnosis and treatment of ABPA are discussed.

[Intense fatigue in humans. Psychosocial and cultural aspects]. / Die grosse Müdigkeit des Menschen. Psychosoziale und kulturelle Aspekte.

A differentiation between the normal sensation of tiredness and the symptom "fatigue" is often difficult. Both are influenced by cultural, social, psychological and biological factors, which can lead--interactively--to symptom formation. Psychiatric disorders frequently associated with fatigue are all forms of depression, somatization and anxiety disorders, chronic pain states and drug abuse among many others. In at least 2/3 of patients with the fashionable chronic fatigue syndrome--formerly called neurasthenia--a psychiatric diagnosis can be made, most of them also suffer from many symptoms attributes to the autonomous nervous system. The clinical approach should be cautious avoiding diagnostic and therapeutic overaction and therapy should emerge from a diagnosis properly assessed.

[Ergometric assessment of functional performance deficit in psychosomatic patients]. / Ergometrische Objektivierung der "funktionellen Leistungs-insuffizienz" bei psychosomatisch Kranken.

Patients with marked loss of physical and psychological fitness and cardiovascular symptoms without objective findings often pose diagnostic problems. Fifteen patients hospitalized for general incapacity with normal cardiovascular findings were tested in the ECG laboratory on a conventional bicycle ergometer and in a more natural environment climbing stairs in a windowed staircase. Work capacity in the two tests was compared. Eight out of fifteen patients achieved only 40% of their age and weight adjusted nominal value on the bicycle ergometer, while they were fully efficient on the staircase (= discordant result). Four patients reached their expected nominal values in both tests. The performance of three patients was much lower than expected, more markedly so in the laboratory situation on the bicycle. All patients' performance was limited by central nervous incapacitating cardiovascular symptoms. Diagnosis of psychosomatic situational cardiovascular insufficiency in the absence of pathological findings can be substantiated by comparing exercise tests in a physiological and non-physiological environment. This is helpful to both patient and physician by facilitating a more precise diagnostic process and documentation of therapeutic improvement.

[Psychosocial aspects of obesity]. / Psychosoziale Aspekte der Adipositas.

There is a strong psychosocial prejudice and discrimination against obese persons. Despite this pressure, they show no greater psychological disturbance than normal-weight persons do. Patients with bulimia, distortion of body image and - to a lesser degree - with extreme obesity are an exception to the rule and often require psychiatric help. There is no evidence for an obesity-specific disturbance of personality or of eating behavior. Behavior modification - with or without anorectic agents is still a matter of debate - has been the most successful form of therapy. As dieting carries the danger of psychosocial stress and morbidity its indication has to be carefully considered. With the high attrition rate, low compliance of obese persons and the poor outlook for a permanent therapeutic effect supportive care and guidance of obese patients is the most important and difficult task for the physician.

The development of a German language (Berne) pain questionnaire and its application in a situation causing acute pain.

The adjectives used in the McGill Pain Questionnaire were translated into German. Nine of the 76 adjectives could not be translated satisfactorily. Accordingly, 10 new German adjectives were added by 22 physicians and psychologists, who were also asked to judge the grouping of the words and how adequately they express pain. Concordance of grouping was reached by more than 82% of the raters. The adjectives were assigned to 20 groups. In a next step 80 subjects assessed the words in each group on a visual analogue scale (VAS) with respect to intensity: for 3 of the 20 groups we found no difference in intensity between the adjectives within a group. They were not retained in the final version tested. Additionally each group was reduced to 3 adjectives by dropping the least discriminating words of each group; 17 groups of 3 words each were retained. In a third step a comparably composed group of 82 subjects rated the words in each group on VAS with respect to intensity: for each of the 17 triads there was a significant overall difference between the 3 adjectives on the VAS. In all but 4 of the 17 triads all 3 possible pairwise differences were significant as well. In spite of the significant differences of mean values there was considerable disagreement in individual intensity rankings of the 3 adjectives within the 17 groups. The validity of the German language (Berne) pain questionnaire (BPQ) was tested together with a verbal rating scale (VRS) and a VAS in a double-blind, complete cross-over study. A low osmolar (LO), a high osmolar (conventional) (HO) compound and 0.9% NaCl (placebo) (PL) were injected intra-arterially in patients with arteriovascular disease. We expected the LO compound to cause much less pain than the HO compound. The 3 conditions HO, LO and PL had significantly different effects on all 4 scales: VAS, VRS, RaW (scale of rank of words), and NoW (scale of number of words). The pairwise comparisons of PL with HO and LO resulted in significant differences also. The square of the correlation r for VAS/VRS was 0.64, for RaW/NoW 0.61, all other possible correlations were not significant. Our conclusions are: the translation of the MPQ into German was successful, and its validity could be shown. In our experiment, it differentiated acute, short lasting pain as well as the visual analogue and the verbal rating scales. The BPQ is a tool worth being examined in the laboratory and in studies of clinical pain syndromes.

[The hyperventilation syndrome]. / Das Hyperventilationssyndrom.

Acute hyperventilation (HV) rarely poses diagnostic or therapeutic problems. Chronic hyperventilation, however, with vague and multiple symptomatology due to respiratory alkalosis and increased breathing work, is often overlooked or misinterpreted, though it is a very common disorder of the general patient population. Chronic HV is frequently associated with emotional disturbances such as anxiety, panic and depression, or with psychosomatic disorders such as irritable bowel, effort syndrome and chronic pain. The diagnosis of chronic HV relies primarily on taking of a thorough history and is confirmed by an HV provocation test and arterial or cutaneous measurements of pCO2. Therapeutic measurements include psychotherapy, psychoactive drugs (antidepressants and benzodiazepines), beta-blockers and modification of abnormal breathing patterns.

[Immigrant osteomalacia]. / Immigranten-Osteomalazie.

The case is reported of a 32-year-old female Asian immigrant admitted with incapacitating pain and suspected diffuse malignant neoplasia. A detailed history and typical laboratory and radiological findings confirmed the diagnosis of osteomalacia caused by lack of sun exposure and a diet poor in vitamin D. Pathogenetic, diagnostic and therapeutic aspects of "immigrant osteomalacia" are discussed.

Inhibition of thyroglobulin biosynthesis and degradation by excess iodide. Synergism with lithium.

Lithium and excess iodide inhibit the release of thyroid hormone from preformed stores. We thus tested the hypothesis that this was due to an inhibition of thyroglobulin breakdown. Rats were pre-treated with propyl-thiouracil (PTU) for 3 weeks in order to deplete their thyroids of thyroglobulin. While the PTU was continued, lithium chloride (0.25 mEq./100 g weight) or potassium iodide (3 mg per rat) were injected every 12 h for d days. Thereafter the thyroglobulin content in thyroid gland homogenates was measured. PTU pre-treatment lowered the thyroglobulin content from 4.21 to 0.22 mg/100 mg gland. Lithium caused a marked re-accumulation of thyroglobulin to 0.60 mg/100 mg within 3 days. While iodide alone had only a borderline effect, it markedly potentiated the action of lithium and a combination of the two drugs increased the thyroglobulin content to 1.04 mg/100 mg. Thyroxine was injected into similarly pre-treated animals to suppress secretion of thyrotrophic hormone. This markedly inhibited the proteolysis of thyroglobulin and 1.3 mg/100 mg gland accumulated after 3 days. Excess iodide, given in addition to thyroxine, decreased the amount of thyroglobulin accumulated to 0.75 mg/100 mg gland. To study whether this could be explained by an inhibitory action of iodide on thyroglobulin biosynthesis, thyroid glands from animals treated with excess iodide were incubated in vitro in the presence of 0.2 mM iodide for 3 h. Iodide decreased the incorporation of radioactive leucine into total thyroidal protein and into thyroglobulin by 25 and 35% respectively. Iodide did not inhibit protein synthesis in the kidney, liver or muscle tissue. Thus, large doses of iodide selectively inhibit thyroglobulin biosynthesis.