Functional relaxation as a somatopsychotherapeutic intervention: a prospective controlled study.

CONTEXT: Functional relaxation is based on concentration on body perception while moving the joints of the skeleton smoothly and simultaneously breathing out. Case reports have shown that patients with headaches can profit from functional relaxation. OBJECTIVE: To examine whether patients with chronic tension headaches (International Headache Society diagnosis) who use functional relaxation as a complementary treatment will report less pain than before they learned this technique. DESIGN: Randomized, prospective, single-blind, controlled trial. Standardized elements of functional relaxation were compared to a placebo-relaxation technique, a simple isotomic exercise of the hand. SETTING: Primary care, ambulatory private practice. PARTICIPANTS: Twelve matched pairs were chosen according to age, sex, and initial pain intensity. This poststratification was performed on patients, who kept a complete pain diary covering 60 days before and 60 days after the introduction to the therapy. After a 45-minute introduction in small groups, the patients were told to do the exercises as often as possible for the following 2 months. MAIN OUTCOME MEASURES: Pain diary. RESULTS: In the functional-relaxation group, a significant reduction was found in the sum of total pain hours and in high- and medium-intensive pain (Wilcoxon signed rank test). CONCLUSIONS: This study supports the concept that this psychosomatic therapy can bring relief from tension headaches. This procedure can be viewed as an easy-to-learn relaxation technique to be used either prophylactic or complementary to pharmaceutical treatment.

Correlation between plasma clozapine concentration and heart rate variability in schizophrenic patients.

Forty schizophrenic patients treated with 50-600 mg/day of clozapine as monotherapy and 40 normal control subjects were tested for heart rate variability (HRV) which is mediated by the vagus nerve using acetylcholine as neurotransmitter. As compared to the control subjects, the patients showed essentially reduced HRV parameters which were negatively correlated with the plasma clozapine levels. Therefore, clozapine's anticholinergic effect is correlated to the plasma clozapine level when measured by the decrease of HRV. We suggest that HRV data might be useful as a predictor for plasma clozapine levels.

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.

[Managing life and death wishes of invasively ventilated amyotrophic lateral sclerosis patients]. / Der Umgang mit Lebens- und Todeswünschen bei invasiv beatmeten ALS-Patienten.

BACKGROUND: Find of life decisions of patients with amyotrophic lateral sclerosis and respiratory failure are influenced by several environmental factors. PATIENTS AND METHODS: We describe the course of disease and decision making of four of these patients. RESULTS: Most decisions have been inconsistent and were seen to be depending on actual situations. Main factors were: 1. preclinically (before respiratory failure) medical information, 2. during respirator dependency in the hospital's intensive care unit the clinical setting and the individual perspective depending on the patient's private situation, 3. at home ventilation the family's situation and conflicts. Especially the patients requests for disconnection from the respirator overtaxed their carers capacities. CONCLUSION: We conclude that there is need for professional psychosocial intervention for the patients and their families.

Autonomic cardiac abnormalities in alcohol-dependent patients admitted to a psychiatric department.

Standardized heart rate analyses were performed in 60 drug-free patients with alcohol dependence, who were admitted consecutively to a psychiatric department, and in 60 healthy normal matched subjects. The procedure included time and frequency derived measurements of heart rate variability (HRV). The investigations were carried out 3 weeks after admission and treatment on a closed ward to avoid autonomic hyperexcitability during withdrawal or relapse. The patients showed a significantly increased heart rate (p < 0.05), a significant reduction in the coefficient of variation while resting (p < 0.01) and a significant decrease of the high frequency power of spectral analysis (p < 0.01) compared with the normal subjects. Cardiovascular autonomic dysfunction was found in 12 of the patients, but in only one of the normal subjects (p < 0.01). The results indicated moderate parasympathetic (vagal) alteration in alcohol-dependent patients treated in a psychiatric department. This may have implications for psychotherapeutic or psychopharmacological treatment strategies and prognosis in such patients with alcohol dependence.

Reflexes of the cutaneous microcirculation in amitriptyline and in fluoxetine treated patients.

Cutaneous microcirculation was investigated in 30 major depressed inpatients receiving either 150 mg amitriptyline (n = 15) or 30 mg fluoxetine (n = 15) as monotherapy, and in 15 normal control subjects matched for age and sex. The laser Doppler flux (LDF) was recorded while resting and under the condition of a sudden deep breath ("inspiratory gasp response"). In normal subjects this autonomic function test caused a marked decrement of LDF signal, which rapidly returned to the baseline value. In both groups of drug treated patients the decrements of LDF signal after a sudden deep breath did not differ from those found in the normal control subjects. However, in the amitriptyline-treated patients the return of LDF-signal to the baseline values was significantly delayed (P = 0.0007), while patients treated with fluoxetine showed the same behaviour as normal subjects. With a discriminant analysis using the results of the inspiratory gasp responses, 100% of the amitriptyline treated patients were correctly classified. Since both groups of depressed patients revealed comparable depression scores, the differences found are probably due to the side effects of amitriptyline. Possible clinical implications of these findings are discussed.

[Effects of psychopharmacologic therapy on heart rate variation]. / Die Auswirkungen der psychopharmakologischen Therapie auf die Herzfrequenzvariation.

Twenty patients suffering from schizophrenia and 36 patients suffering from endogenous depression underwent a standardized heart rate analysis before drug therapy. The patient's parameters of heart rate variability (HRV), which are controlled by the parasympathetic nervous system and which are independent of heart rate, did not significantly differ from the HRV parameters of normal control subjects. Ten of the patients with schizophrenia were treated with 200-400 mg of clozapine/day as monotherapy, while the other ten patients received a combination of different psychotropic drugs. The depressed patients were either treated with 150 mg of amitriptyline/d (n = 24) or 20 mg of paroxetine/d (n = 12) as monotherapy, respectively. After treatment with an average of 300 mg of clozapine/d for 4 weeks or with 150 mg of amitriptyline/day for 2 weeks, all of the patients HRV parameters had significantly decreased (P < 0.001). At this time, about 90% of these patients fulfilled the criteria of cardiovascular autonomic neuropathy. However, treatment with 20 mg of paroxetine/day for 2 weeks had no impact on any of the heart rate parameters. Under amitriptyline treatment, HRV parameters were found to correlate significantly with the plasma levels of amitriptyline/nortriptyline in a group of 104 depressed patients. Thus, determination of decreased HRV parameters is suggested to be a useful tool for the detection of overdosage with amitriptyline. It has not yet been elucidated whether or not the observed HRV decrease, which is probably at least in part due to the anticholinergic side effects of clozapine and amitriptyline, has any impact on patient health.(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased R-R variation: a criterium for overdosage of tricyclic psychotropic drugs.

OBJECTIVE: Since intoxication with tricyclic antidepressants is common, a supplementary screening method for differentiation between therapeutic and supratherapeutic ranges would be a valuable diagnostic tool, particularly in delirious and unconscious patients. SETTING: 108 patients treated with amitriptyline, 8 patients treated with doxepin, 10 patients treated with clozapine, and 72 normal control subjects matched for age and sex were tested for heart rate variability while resting. RESULTS: Considering time and frequency derived measures, which are rather independent of heart rate, the patients showed significantly decreased heart rate variability parameters (p < 0.0001), as compared with the normal subjects. Of the patients presenting delirious symptoms 6 showed coefficients of variation more than 4 standard deviations below the mean control value. CONCLUSIONS: As heart rate variability can be easily calculated, this measurement is suggested as a useful tool to quickly exclude or support the diagnosis of chronic intoxication with tricyclic antidepressants or clozapine.

Is diurnal variation of mood associated with parasympathetic activity?

18 patients with distinct improvement of mood in the evening and 18 patients without, both suffering from major depression and equally treated with tricyclic antidepressants (TCA), and an age- and sex-matched group of 18 normal control subjects underwent a standardized heart-rate (HR) analysis (HRA) in the morning (08:00) and 12 h later in the evening (20:00). The battery of cardiovascular reflex tests included the determination of HR variability (HRV) while resting and during deep breathing, and a spectral HRA. The depressed patients with diurnal variation of mood showed significantly decreased HR and significantly increased HRV parameters while resting and during deep respiration in the evening. On the contrary, patients without diurnal changes of mood just showed a significant HRV increase during deep respiration in the evening. No statistically significant changes of these parameters were detected in the healthy subjects. It is not known if the observed changes of HR parameters representing increment of parasympathetic tone are intrinsically related to the mood swings or if this rhythm just becomes visible under the circumstances of depression. Also, the impact of TCA treatment upon the results remains to be elucidated.

Does bright-light therapy influence autonomic heart-rate parameters?

30 inpatients suffering from major depression (DSM-III-R), who did not fulfill the criteria of seasonal affective disorder (SAD), were treated with either doxepin or amitripytyline as monotherapy and supportively with bright light for 14 days. From days 15 to 19, bright light was replaced by dim light. 18 drug-free control subjects underwent an analogous sequence of bright- and dim-light applications. Phototherapy was applied between 06:00 and 07:30. Heart-rate (HR) analysis was performed in the patients and control subjects before and after the 5th session of bright and dim lights, respectively. 12 patients (40%) experienced improvement of mood during bright-light therapy (group I) while 18 (60%) did not (group II). Patients of group I, who reached significantly higher scores in the seasonal pattern assessment questionnaire than patients of group II, showed an increase of the coefficient of HR variation (HRV) during deep breathing as well as an increment of the high-frequency (HF) peak of spectral analysis exclusively after the bright-light sessions. Patients of group II did not show a significant alteration of these parameters, neither under the conditions of bright-light treatment nor under dim light. The control subjects experienced an increment of the HF power exclusively after bright light. The results suggest that a distinct subgroup of patients with non-SAD major depression shows a more pronounced light-associated increment of parasympathetically controlled cardiac functions than the other depressed patients and the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Identifying delirious states and autonomic cardiovascular dysfunction associated with amitriptyline treatment by standardized analysis of heart rate.

Ninety-one patients treated with amitriptyline and 60 normal control subjects underwent a standardized heart rate analysis in supine posture. Tests included the determination of time- and frequency-derived measurements of heart rate variability. The patients differed significantly from the control subjects in all parameters investigated. Two-thirds of the patients treated with a tricyclic antidepressant (TCA) reached values that met the criteria for cardiovascular autonomic neuropathy. Our results provide evidence that heart rate analysis might be a more sensitive tool in diagnosing amitriptyline-associated anticholinergic delirium than determination of TCA plasma levels. Further research is needed to elucidate what implications the TCA-associated alteration of autonomic cardiovascular function might have for patients.

[The significance of heart rate analysis in psychiatric questions]. / Die Bedeutung von Herzfrequenzanalysen bei psychiatrischen Fragestellungen.

Heart rate analyses have become an important diagnostic tool for the assessment of autonomic nervous system function. Measurements of heart rate variability (HRV) have been frequently used to establish criteria for a cardiovascular autonomic neuropathy (CAN). Methods of HRV have also been applied to unmedicated patients with psychiatric disorders and to investigate the impact of psychotropic drugs on autonomic cardiac functions. In one of our studies 20% of patients with alcohol dependence (n = 60) fulfilled the criteria of CAN as a result of vagal neuropathy. In other psychiatric disorders clearcut abnormalities of autonomic regulation have not yet been found. However, there is an increasing number of pointers suggesting that patients with panic disorders show a predominance of sympathetic cardiac control, while patients with melancholic depression might show a lack of parasympathetic control. Under the condition of treatment with either 150 mg of a tricyclic antidepressant (TCA) or 300 mg of clozapine per day, HRV-parameters were found to be significantly decreased and the majority of the patients fulfilled the criteria of CAN, whereas the selective inhibitors of serotonin (SSRI) given in usual dosages had no effect on HRV-parameters. In another study with depressed patients treated with TCA, HRV-parameters were found to be helpful in understanding mood-altering chronobiological mechanisms. The results presented make clear that research on autonomic functions is not only useful in neurological diseases, but also in psychiatric disorders especially under the conditions of psychopharmacological treatment.

Ascending central nervous spreading of a spinal astrocytoma.

A 43-year-old man died from the complications of astrocytoma metastasis. He first noticed symptoms of a lumbar disc prolapse in 1979. In 1987 a pilocytic astrocytoma (grade I) of the spinal cauda was removed. In 1989 a tumor recidivation at the same site was partially removed. Histology showed a grade II astrocytoma. Two months later the patient developed symptoms of increased intracerebral pressure. CSF cytology showed polymorphic giant tumor cells with hyperchromatic nuclei and a glioblastoma of the cerebral ventricles was diagnosed. The patient died from cardiovascular complications. The post-mortem investigation revealed an astrocytoma of the conus medullaris with an anaplastic ventral area (grade IV). This area was inaccessible to the biopsy. It is believed that tumor metastases from anaplastic parts spread along the spinal cord and brainstem and finally invaded the brain and cerebral ventricles.

Decreased heart rate variability parameters in amitriptyline treated depressed patients: biological and clinical significance.

One hundred-four depressed patients treated with amitriptyline (mean dosage: 163 mg/d; mean plasma level: 239 ng/ml) and 52 normal control subjects matched for age and sex underwent a standardized cardiovascular test battery (various autonomic cardiac parameters, which are largely independent from heart rate, namely the coefficients of variation (CV) while resting and during deep respiration, a spectral analysis of heart rate, the Valsalva ratio, and a posture index were determined). The tests included the determination of time and frequency-derived measurements of heart rate variability (HRV), which is rather independent from heart rate. As compared to the controls the patients showed a significant plasma concentration-dependent decrease of R-R variation in the electrocardiogram (p < 0.0001), while their heart rate was significantly elevated (p < 0.0001). The markedly reduced parameters of sinus arrhythmia in amitriptyline treated patients are suggested to be mainly due to the anticholinergic effect of this drug, although it can not be excluded that the affective disorder itself might be associated with low heart rate variability. The results indicate that autonomic heart rate parameters are a valuable tool for the detection of tricyclic antidepressant (TCA) intake in unconscious patients, especially in intensive care and emergency wards.

Are affective disorders associated with alterations of heart rate variability?

A standardized heart rate analysis was carried out in unmedicated patients with major depression, melancholic type (n = 16), panic disorder (n = 16), reactive depression with suicide attempts during the preceding 24 h (n = 16) and in 16 normal control subjects. The investigations included time- and frequency-derived measurements of heart rate variability. In the patients with reactive depression, no differences could be detected as compared with the control group. The patients with panic disorder showed a significantly increased low-frequency band of spectral analysis (P < 0.01) and a marginally significant increment of heart rate (P = 0.05), probably indicating predominance of sympathetic control of heart rate. In the patients with major depression, we found significantly lower values of heart's beat-to-beat intervals and of the high-frequency peak of spectral analysis than in the other groups (P < 0.025), indicating decreased parasympathetic activity.