[Psychosomatic aspects of living donor liver transplantation]. / Psychosomatische Aspekte der Leberlebendspende.

Living donor liver transplantation (LDLT) offers the option to reduce organ scarcity and thereby waiting list mortality. The crucial ethical problem of LDLT is the fact that the well being of a donor is being jeopardized for the improvement of quality of life of the recipient. To preserve mental health of the donors, psychosomatic evaluation should be conducted including examination of the coping capacity, the mental stability of the donor and the voluntary nature of the donation. Thus a comprehensive disclosure of information to donors is necessary. Realistic outcome expectations, family relationships without extreme conflicts, sufficient autonomy of the donor-recipient relationship and social and familiar support are predictors facilitating a favorable psychosocial outcome for the donor. Before and after LDLT the health-related quality of life of the donors is similar or increased in comparison to the general population. Psychiatric complications following LDLT can occur in 13% of the donors. Female donors, donors who have surgical complications themselves and donors with unrealistic outcome expectations should be given psychotherapeutic support before they are admitted to living liver donation. Urgent indications in the case of acute liver failure and the donation by adult children for their parents are particular stress factors. For the safety of the donor, these combinations should be avoided whenever possible.

Is there any association between disturbed gastrointestinal visceromotor and sensory function and impaired quality of life in functional dyspepsia?

BACKGROUND Functional dyspepsia (FD) is now categorized into the epigastric pain syndrome (EPS) and the postprandial distress syndrome (PDS). However, the role of disturbed gastric emptying and sensory function for the reduction of health-related quality of life (HRQOL) has not yet been studied in EPS and PDS. METHODS A total of 300 refractory FD patients and 450 healthy blood donors (BD) were studied. BD were stratified in subjects with (BD+) and without (BD-) concomitant FD symptoms. Gastric motor and sensory function, generic and disease-specific HRQOL [physical (PCS) and mental component summary (MCS)] and affective disorders were assessed. Twenty randomly selected BD-, 50 BD+ (36 PDS, 72%), and 110 FD (95 PDS, 86.4%) patients had additional function testing. KEY RESULTS Health-related quality of life was significantly reduced in FD patients (PCS = 40.7 +/- 8.8, MCS = 39.7 +/- 11.3, both P < 0.0001) compared to BD+ (PCS = 52.0 +/- 7.6, MCS = 49.0 +/- 9.4) and BD- (PCS = 56.0 +/- 4.3, MCS = 52.8 +/- 7.2). GET (t((1/2)), min) was significantly (both P < 0.0001) longer in FD patients (143.0 +/- 7.3) compared to BD+ (101.1 +/- 6.3) and BD- (73.8 +/- 7.6). FD patients scored significantly higher for 'pain' (P < 0.0001) and 'nausea' (P = 0.023), there was no difference for 'fullness' compared to BD. Impairment of GET was not associated with HRQOL. In FD patients, an augmented symptom response to the test meal (fullness, nausea) was associated with MCS, there was no difference between FD patients with EPS or PDS. CONCLUSIONS & INFERENCES In EPS and PDS, delayed gastric empting and altered sensory function are disease markers but not directly linked to the severity of HRQOL impairment or clinical presentation of FD.

Psychosomatic evaluation of patients awaiting lung transplantation.

Levels of psychosocial functioning were assessed according to Transplantation Evaluation Rating Scale (TERS) in 113 patients prior to lung transplantation. The prevalence of mental disorders was 20%; in addition impaired mental status was observed in 12 (11%) patients. The most frequent diagnoses were dependence on tobacco (9%), adjustment disorders (4%), and dependence on alcohol (2%). In the clinical interview, 87 patients (77%) were assessed as eligible, 20 (18%) as risky, and 6 (5%) as high-risk candidates. The TERS total scores between the eligibility groups differed significantly (F = 19.5; df = 112; P < .001). There were no significant effects of gender and age. Significant inverse correlations were estimated between the TERS score and educational status (r = -.291; P = .002). TERS allows a standardized evaluation of lung transplant candidates with good discrimination into eligibility groups. General psychosocial adaptation is mainly based on the educational level, a factor that should be examined in psychosomatic assessments.

Impairment of health-related quality of life in functional dyspepsia and chronic liver disease: the influence of depression and anxiety.

BACKGROUND: Health-related quality of life (HRQOL) is a marker of disease severity. Data on the relative impairment of HRQOL in chronic liver disease (CLD) and functional gastrointestinal disorders are lacking and no studies have assessed the link between impairment of HRQOL and psychosocial factors yet. AIM: To assess predictors for, and the impairment of, HRQOL in CLD and FD. METHODS: In 181 functional dyspepsia (FD) patients, 204 CLD patients and 337 healthy blood donors, HRQOL was assessed with the Short Form-36 (mental and physical component), and anxiety and depression utilizing the Hospital Anxiety and Depression Scale. RESULTS: Compared with HC, HRQOL is significantly lower in FD and CLD (P-value for all <0.001). The mental but not physical component of HRQOL was significantly more impaired in FD compared with CLD (P < 0.05). After adjusting for confounders, impairment of mental (P < 0.001) and physical (P = 0.005) component of HRQOL was associated with the severity of CLD and FD. In FD, the multivariate analysis revealed depression and severity of symptoms as the most important predictors of HRQOL (R2 = 21.9 and 7.1). In CLD, the mental component of HRQOL was associated with depression and anxiety (R(2) = 9.9 and 9.7). CONCLUSIONS: In tertiary care, HRQOL is more severely impaired in FD compared with CLD. Co-morbid psychiatric conditions significantly contribute to the impairment of HRQOL.

Is there a benefit from intensified medical and psychological interventions in patients with functional dyspepsia not responding to conventional therapy?

AIM: In a prospective randomized, controlled trial, to compare the long-term outcome of intensive medical therapy (with or without cognitive-behavioural or muscle relaxation therapy) vs. standard medical therapy in patients with refractory functional dyspepsia (FD), referred to a tertiary referral medical center. METHODS: A total of 100 consecutive FD patients were allocated to a standardized symptom-oriented 4 month therapy (SMT, n = 24), intensive medical therapy (IMT, medical therapy with testing-for and targeting-of abnormalities of motor-and-sensory function, n = 28) or IMT plus psychological interventions (either progressive-muscle relaxation (IMT-MR, n = 20) or cognitive-behavioural therapy (IMT-CBT, n = 28). The symptom intensity (SI) and health-related quality-of-life (HRQoL) after 12 months were prespecified primary outcome parameters. RESULTS: After 12 months, significantly greater improvement of SI occurred in patients with IMT-all (with or without psychological interventions) compared with SMT (P < 0.025 vs. IMT-all). IMT, IMT-MR and IMT-CBT alone also resulted in significantly better improvement of the primary outcome parameters (P all < 0.025 vs. SMT). HRQoL significantly improved in all groups with intensive medical therapy but not standard medical therapy. Differences between intensive medical therapy-all and standard medical therapy were not significant. Concomitant anxiety and depression was improved significantly by IMT-CBT (vs. SMT) but not other treatments. CONCLUSIONS: In FD patients with refractory symptoms, intensified medical management involving function testing and psychological intervention yields superior long-term-outcomes. Additional CBT may be effective for the control of concomitant anxiety and depression.

Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review.

OBJECTIVE: The objective of this study was to present a systematic review of psychological and psychosocial predictors of weight loss and mental health after bariatric surgery. This systematic review included all controlled and noncontrolled trials of the last 2 decades with either a retrospective or prospective design and a follow-up period of at least 1 year. RESEARCH METHODS AND PROCEDURES: The relevant literature was identified by a search of computerized databases. All articles published in English and German between 1980 and 2002 were reviewed. RESULTS: Using the above inclusion/exclusion criteria, 29 articles were identified focusing on psychosocial predictors of weight loss and mental health after obesity surgery. DISCUSSION: Personality traits have no predictive value for the postoperative course of weight or mental state. Apart from serious psychiatric disorders including personality disorders, psychiatric comorbidity seems to be of more predictive value for mental and physical well-being as two essential aspects of quality of life than for weight loss postsurgery. However, depressive and anxiety symptoms as correlates of psychological stress with regard to obesity seem to be positive predictors of weight loss postsurgery. The severity of the symptoms or the disorder is more relevant for the outcome of obesity surgery than the specificity of the symptoms. It is also not solely the consumption of distinct "forbidden" foods, such as sweets or soft drinks, but rather a general hypercaloric eating behavior, either as an expression of the patient's inadequate compliance or a dysregulation in energy balance, which is associated with a poor weight loss postsurgery.

Does obesity surgery improve psychosocial functioning? A systematic review.

OBJECTIVE: The objective of this study is to present a review of the psychosocial outcome of bariatric surgery with special consideration of psychiatric comorbidity, psychopathology, psychosocial functioning, econometric data, and general quality of life (QoL). PURPOSE: A review of all (non-) controlled trials of the last two decades both with a retrospective and prospective design and a follow-up period of at least 1 y. RESEARCH METHODS AND PROCEDURES: The relevant literature was identified by a search of computerized databases. All articles published in English and German since 1980 were reviewed. Based on the requirements of the evidenced-based guidelines of the Agency for Health Care Policy and Research and the Scottish Intercollegiate Guidelines Network, each study was rated by a level of evidence. RESULTS: In all, 171 publications were reviewed. Using the above inclusion/exclusion criteria, 63 articles including two systematic reviews were identified. A total of 40 studies focused on psychosocial outcome after obesity surgery. CONCLUSION: Mental health and psychosocial status including social relations and employment opportunities improve for the majority of people after bariatric surgery thus leading to an improved QoL. Psychiatric comorbidity, predominantly affective disorders, and psychopathologic symptoms decrease postsurgically. A substantial percentage of bariatric surgery patients suffer from binge eating disorder or binge eating symptoms. The effect of bariatric surgery on the outcome of binge eating symptoms largely depends on the type of operation. With the exception of patients with a severe psychiatric comorbidity, the concern that obesity surgery will reinforce psychic symptoms and lead to a reduction in the QoL seems to be unfounded.

Comorbidity of diabetes mellitus and eating disorders: a follow-up study.

OBJECTIVE: There is increasing evidence that the coexistence of diabetes and eating disorders (ED) leads to poor glycemic control and an increased risk of long-term complications. METHODS: In a questionnaire- and interview-based study, a sample of 36 out of originally 38 (94.7%) diabetic patients with an ED (type-1: n=13, type-2: n=23) was assessed after a period of about 2 years in order to determine the course of EDs, body mass index (BMI), glycemic control, and psychiatric symptomatology. RESULTS: Five patients (13.9%) of the total sample showed full remission for at least 12 consecutive weeks. Twenty-two patients (61.6%) showed no change in the diagnosis of the ED. Four patients (11.1%) shifted from subclinical to clinical EDs and five patients (13.9%) vice versa. Of the eight patients who went on to psychotherapy, only one patient (12.5%) showed full remission. Emotional distress of type-2 diabetics was considerably higher compared to type-1 diabetics, which was rather low at baseline. Except interpersonal distrust as one ED-related variable, no significant change of any psychological variable could be observed in the type-1 diabetic sample during follow-up. Of the 13 type-1 diabetic patients with an ED, five patients deliberately omitted insulin in order to lose weight. These patients showed a more serious psychopathology with regard to each measured psychological variable, a higher BMI, and worse metabolic control compared to those without insulin omission. Type-2 diabetics showed a significant increase in drive for thinness and body dissatisfaction. No considerable change could be observed with regard to BMI, glycemic control, and depressive and global psychiatric symptomatology in either diabetic subsample during follow-up. CONCLUSION: EDs tended to persist over time with a considerable shift within the different types of EDs. Insulin-purging in type-1 diabetics was associated with enhanced psychopathology, higher BMI, and worse metabolic control. Both mean body mass and ED-related symptoms such as "drive for thinness" and "body dissatisfaction" increased in the average obese type-2 diabetic sample, illustrating the vicious circle of low self-esteem, enhanced restraint eating, and binge eating in weight control measures.

[Psychosomatic selection of living liver donors]. / Psychosomatische Auswahl der Leberlebendspender.

In the Essen University Clinic for Psychotherapy and Psychosomatics, between January and December 2000, 54 potential liver donors and 12 kidney donors were examined. All the kidney donors were found to be suitable; 7 potential liver donors were rejected on psychosomatic grounds. Reasons for the rejection were addiction (1 donor), suspected financial dependency of the donor on the recipient (1 donor) and, in the case of one donor not related to the recipient, the apparent lack of a special emotional attachment. During the actual evaluation interview, 4 potential donors reversed their original decision. Such a psychosomatic evaluation is a great help for donors in clarifying their motives and their decision.

The prevalence and differential diagnosis of subclinical depressive syndromes in inpatients 60 years and older.

BACKGROUND: Depressive syndromes that do not comply with the diagnostic criteria for specific depressive disorders are designated as 'subclinical' or 'subsyndromal' depressive syndromes. Using our own data from a clinical study, this paper outlines the significance of subclinical depressive syndromes and demonstrates the problems of differentiating between depressive and subclinical depression (SD) syndromes and organic mood disorders especially in an elderly population with medical comorbidity. METHODS: Two hundred and sixty-two patients aged 60 years and older in a general hospital were investigated, using a clinical psychiatric interview, expert ratings and self-report scales after extensive internal medical diagnostic evaluation. RESULTS: When, without further differentiation as to their origin, all symptoms required by symptom checklists according to ICD-10 were considered for the diagnosis of major depression (MD), 35.5% of the study participants fulfilled the diagnostic criteria. After differentiating for etiology of symptoms, MD was found in only 14.1%, SD was diagnosed in 17.6% and organic mood disorder in 12.2% of the study participants. In another 41 patients (15.6%), symptoms of depression not fulfilling ICD-10 criteria were classified as being of organic or drug-induced origin. SD patients were in a mean position between nondepressive and depressive patients with regard to social isolation and physical impairment; women were overrepresented in the depressive and subdepressive groups. CONCLUSIONS: SD and organic mood disorder are common and helpful diagnostic categories in the elderly. The results show that in old age there is substantial danger of confounding MD, SD and organic mood disorder, thus leading to erroneously high prevalence rates of MD and underestimations of organic mood disorder if depressive symptoms are recorded only by self-report scales or a symptom checklist. Both internal and psychosomatic-psychotherapeutic competence as well as a liaison service in general hospitals are necessary for the differential diagnosis of MD, SD and organic mood disorder in the elderly with medical comorbidity.

[Patients with diabetes mellitus: psychosocial stress and use of psychosocial support: a multicenter study]. / Patienten mit Diabetes mellitus: psychosoziale Belastung und Inanspruchnahme von psychosozialen Angeboten. Eine multizentrische Studie.

BACKGROUND: In a multicenter study the association of psychosocial stress and the use of psychosocial support in patients with diabetes mellitus was evaluated. PATIENTS AND METHOD: In a sample of 410 patients with diabetes mellitus (Type I: n 157, Type II: n = 253) stress in different facets of daily life was assessed using the revised Questionnaire on Stress in Patients with Diabetes (QSD-R). Self-constructed items were used to assess the use of psychosocial support during the course of the illness. Diabetics with a mean global stress score above standard deviation were defined as extremely handicapped and compared to the less handicapped sample. RESULTS: Extreme psychosocial stress could be found in 68 diabetics (16.6%). Not the type of diabetes but the use of insulin within the Type-II diabetic sample revealed an impact on psychosocial stress. Diabetics with extreme psychosocial stress showed worse diabetic control compared to less stressed diabetics. Profiles of psychosocial stress showed maximal stress with regard to depression in both types of diabetes; this was followed by fear of hypoglycemia in the sub-sample of Type I and physical complaints in the sub-sample of Type-II diabetics. Family members, primary care physicians and diabetologists were the main sources of psychosocial support. CONCLUSION: A considerable number of diabetic patients suffers from extreme psychosocial stress often associated with poor diabetic control. These patients need psychosocial care which should primarily be offered in diabetologic centers incorporating both the patients' family and family background.

Relationship of weight and eating disorders in type 2 diabetic patients: a multicenter study.

OBJECTIVE: Previous work suggested that the degree of psychiatric symptomatology evidenced in overweight individuals was related to the severity of binge eating problems and not related to the severity of overweight. In a multicenter study, we investigated the relationship between weight and eating disorders (EDs) in a sample of type 2 diabetic patients. METHODS: Three hundred twenty-two patients with type 2 diabetes were stratified to various weight categories. Glycemic control, eating and body-related psychological problems, self-esteem, depressive, and general psychopathology of diaetic patients with and without an ED were compared. RESULTS: Eighty-one percent of all type 2 diabetic patients were overweight or obese. Prevalence rates of EDs ranged from 6.5% to 9.0%. Binge eating disorder was the most diagnosed ED. There was a strong relationship between body mass index (BMI) and eating disturbance-related variables and a weak or no relationship between BMI and depression or general psychopathologic variables. Patients with an ED showed a greater psychopathology compared to patients without an ED. The diagnosis of an ED did not seem to have a specific influence on glycemic control. CONCLUSIONS: Our results in a type 2 diabetic sample indicate that weight might have an impact on body and eating-related psychological distress in type 2 diabetic patients, but is of minor or no importance for depressive symptomatology, lower self-esteem, and general psychiatric symptomatology. Type 2 diabetic patients with an ED, however, suffer from considerable psychiatric symptomatology.

[Comorbidity of diabetes mellitus and eating disorders. A comparison of psychological features of eating disordered and non-eating disordered patients with diabetes mellitus]. / Komorbidität von Diabetes mellitus und Essstörungen. Ein Vergleich psychologischer Störungsmerkmale essgestörter und nicht-essgestörter Patienten mit Diabetes mellitus.

As part of a multicentre study on the comorbidity of diabetes mellitus and eating disorders, the following paper compares the psychological features of diabetic patients with and without an eating disorder. In a sample of 663 diabetic patients (type 1: n = 341 type 2: n = 322), eating disorder related variables, self-esteem, body acceptance and emotional distress, especially depression in diabetic patients with and without an eating disorder, were compared. A possible relationship to diabetic control was investigated. Type 2 diabetics revealed more pronounced psychopathology in comparison to type 1 diabetics. According to our assumption, diabetic patients with an eating disorder and diabetic patients who deliberately reduced insulin in order to loose weight (insulin purging) revealed a much more severe psychopathology compared to diabetics without an eating disorder. The type of diabetes was of no importance. With the exception of the variable body and figure satisfaction in the sample of type 1 diabetes and the variable self-acceptance in the sample of type 2 diabetes, no relationship to diabetic control could be found.

Longitudinal changes of circadian leptin, insulin and cortisol plasma levels and their correlation during refeeding in patients with anorexia nervosa.

OBJECTIVE: To study the longitudinal changes in plasma levels of leptin, insulin and cortisol during the transition from the state of starvation to the state of refeeding focussing on diurnal secretion characteristics and their temporal relationships. DESIGN: Leptin, insulin and cortisol were measured every 2h for 24h during acute starvation (T1). Sampling was repeated after reaching half the target-body mass index (BMI) (T2) and again at target-BMI (17. 5kg/m(2); T3). The temporal relationships between the diurnal secretion patterns were assessed by cross-correlation analysis. RESULTS: Although BMIs at T1 were uniformly low, leptin levels varied widely within a range clearly below normal levels (0.03-1. 7microg/l). With increasing body fat during the course of refeeding, mean leptin levels increased from 0.64microg/l (range: 0.27-1. 73microg/l) (T1) to 1.61microg/l (range: 0.36-4.2microg/l) (T2) and to 3.67microg/l (range: 0.7-9.8microg/l) (T3). Circadian leptin secretion patterns showed maximal values uniformly around 0200h and minimal values around 0800h at all stages of the study. At all three weight levels, plasma leptin levels were highest between midnight and the early morning hours and lowest around the late morning hours. Refeeding neither profoundly changed secretion patterns of leptin nor did it change the positive, time-delayed relationship between leptin and insulin with increments in insulin secretion preceding those of leptin by 6h. A temporal relationship between leptin and cortisol could not be demonstrated in the state of semistarvation but emerged after a substantial weight gain; at that time, leptin increases preceded cortisol increases by 8h. CONCLUSIONS: Absolute leptin, insulin and cortisol levels are profoundly changed during starvation in anorectic patients, while refeeding, paralleled by a BMI gain, reverses these changes. During refeeding the relationship between leptin and cortisol changed profoundly, showing no significant correlation in the state of starvation, whereas at T3 after refeeding a strong inverse relationship could be observed. Leptin and insulin did not correlate significantly at any of the three stages studied.

Time relationship between circadian variation of serum levels of leptin, insulin and cortisol in healthy subjects.

BACKGROUND: Leptin is involved in the regulation of eating behavior. Its serum levels are determined by fat mass but a diurnal rhythm is also described. It is not clear whether leptin levels are also controlled in vivo by hormonal stimuli, like insulin or cortisol. METHODS AND RESULTS: This possible temporal relation was investigated by serial measurements during 24 h (group A) and 46 h (group B) in 15 healthy volunteers and another 10 subjects (group C) while fasting for 72 h. Maximal leptin levels were observed at 4:00 a.m. and 4:00 p.m. in subjects on a normal diet. During 24 h starvation (group B), there was a 40% decrease of mean leptin concentration when compared to baseline values. In group C, the leptin concentration under starvation dropped to 25% of basal levels after 72 h. Pooled data from group A and the nonfasting data from group B showed an insulin increase preceding leptin increase by 6 h (r = 0.405, p < 0.0001), while cortisol decreased 4 h (r = 0.361, p < 0.001) after leptin decrease. CONCLUSION: Starvation results in a fall of circulating leptin, ending leptin rhythmicity. Food intake is causally involved in the fluctuation of leptin levels in serum. Presumably this effect is mediated by insulin, while cortisol does not seem to affect leptin release directly in vivo.