[Eating disorders in childhood and adolescence. Anorexia nervosa, bulimia nervosa, binge eating disorder]. / Essstörungen im Kindes- und Jugendalter. Anorexia nervosa, bulimia nervosa, binge eating disorder.

The most important eating disorders are anorexia and bulimia, which most frequently occur for the first time during adolescence and continue into adulthood. Medical complications and accompanying psychological disturbances cause a significant mortality rate of up to 6% in anorexia and up to 3% in bulimia. The pathogenesis of eating disorders is still unclear. Current etiological concepts are multidimensional including biological, individual, familial, and sociocultural factors. In spite of a great variety of therapeutic possibilities, the prognosis for eating disorders is quite poor. In the long term, only about 50% of the persons affected overcome their illness. Preventive measures are therefore indispensable.

Eating disturbances in siblings of patients with eating disorders.

OBJECTIVE: The purpose of this study was to investigate whether siblings of patients with eating disorders show a more disturbed eating behavior and a higher proneness to associated psychological characteristics than controls. METHOD: 84 patients with eating disorders of an outpatient clinic, their siblings (n=84) and a control group (n=84) with an age range 14-34 for the total sample were evaluated using the Eating Disorder Inventory-2. RESULTS: There was no significant difference between the siblings and the controls in disturbed eating behavior. DISCUSSION: The existence of an eating disorder in patients does not seem to be related to the development of eating disturbed behavior in their siblings.

Serum leptin monitoring in anorectic patients during refeeding therapy.

Circulating concentrations of leptin are exceedingly low in severe malnutrition as seen in the acute state of anorexia nervosa (AN). During refeeding therapy plasma leptin levels increase to normal and in some cases peak at values in excess of the BMI of matched controls even before a normal body weight has been achieved. Peak leptin levels are possibly the cause of an increased energy expenditure during this stage of the disorder and might predispose to renewed weight loss (rebound phenomenon). In this study we investigated the role of leptin fluctuations as a prognostic factor of therapeutic success in AN. In 11 anorectic female patients serum leptin levels, BMI and body fat percentage were evaluated in four-week intervals during a conventional refeeding program over three months (group 1). The results of the first two measurements were used to determine a range of increases in leptin levels in relation to increases in BMI. The values between the 25th and 75th percentiles determined the reference range. In a second group of 9 anorectic female patients serum leptin levels, BMI, body fat percentage and the increase in the leptin level in relation to the BMI of each subject were investigated for three months every two weeks. These patients were also treated according to the same conventional refeeding program, but the caloric intake was reduced or increased (+/-250 kcal/d) if the increase in the leptin level, in relation to the increase in the BMI, had exceeded or fallen short of the reference range. During the refeeding therapy every subject of each group experienced increases in serum leptin levels, BMI and body fat percentage. Six subjects of group 1 and six subjects of the second group had an increase in leptin levels in relation to the increase of the BMI out of the reference range at least once. To investigate the therapeutic outcome of leptin monitoring and the following alteration of caloric intake, weight gain of the patients of both groups during the whole treatment was compared. No significant difference was found. Our results probably do not support the findings that high leptin levels predispose to a renewed loss of weight. The outcome in our patients whose caloric intake was modified due to their serum leptin levels was not significantly improved.

[A group therapy programme for eating disorders with preventive goal]. / Von der Therapie zur Prävention: Ein Therapiemodell für Essstörungen.

Eating disorders tend to take a prolonged course because of high rates of comorbid psychiatric disorders and medical complications. We developed a cognitive behavioural group therapy programme, divided in 4 consecutively phases in a special unit. Included in the programme are therapeutic residence groups. Current and former patients are regular involved in preventive activities.

Eating disorder therapy concepts with a preventive goal.

In this paper, we describe our 4-phase-therapy program for eating disorders at a specialized unit. Core of the treatment is a 4-month day patient phase. Our approach, which implies a fixed structure in terms of time and content, is based on cognitive-behavioral group therapy. It follows the principle of self-management developed by Kanfer and involves patients in organizational and therapeutic activities. Patients' participation in our extensive efforts aiming at the prevention of eating disorders is invaluable for therapists and serves patients as an important protective factor.

Binding characteristics of the glucocorticoid receptor in peripheral blood lymphocytes in multiple sclerosis.

Although the exact etiology of multiple sclerosis (MS) remains unresolved, immune reactions are believed to be the central pathogenic mechanisms. Endogenous and therapeutic steroid hormones affect the immune system, and inflammatory diseases are associated with activation of the hypothalamic-pituitary-adrenal axis, providing evidence of an immune-endocrine interplay. Function tests in MS have revealed dysregulation of the hypothalamic-pituitary-adrenal system in a substantial proportion of patients. We characterized glucocorticoid receptor (GR) binding in peripheral blood lymphocytes from 39 MS patients and 14 age- and sex-matched controls with respect to dissociation constant and binding capacity, using a whole-cell binding assay with [3H]dexamethasone as the ligand. GR binding parameters did not differ significantly between patients (Kd 8.98 +/- 1.07 nM, Bmax 183 +/- 29.8 fmol/mg) and controls (Kd 9.36 +/- 1.17 nM, Bmax 158 +/- 16 fmol/mg). No effect of age, sex, course, duration or severity of disease, or prior steroid treatments was detected. GR binding parameters were analyzed in relation to the results of the combined dexamethasone-CRH test, which reflects corticosteroid receptor function at the hypothalamus, in 30 patients and 9 controls. While controls showed a moderate correlation between binding affinity of the GR in lymphocytes and regulatory function at the hypothalamic level, the patients did not. These data suggest that the physiological relationship between binding and function of the glucocorticoid receptor is disturbed in MS.

Neuropsychological assessments before and after treatment in patients with anorexia nervosa and bulimia nervosa.

In psychiatric patients the identification of cognitive deficits which predict a poor clinical outcome is important for the development of specific treatment strategies aimed at the amelioration of these impaired cognitive functions to increase the likelihood of full clinical remission. However, such attempts are absent in bulimia nervosa (BU), are scarce in anorexia nervosa (AN) and, furthermore, provide conflicting results. In the present prospective study we investigated the neuropsychological demands in 12 patients with AN and in 14 patients with BU before, during, and after a treatment period. At the initial testing session, both patients samples showed similar and impaired performance levels on tasks measuring attentional demands and problem solving abilities, while their mnemonic functions were preserved. At the final testing session, which took place 7 months thereafter, the impaired cognitive functions had improved to a similar degree in the AN and the BU subgroups. However, although the eating disorder symptomatology had ameliorated in parallel, no direct associations could be established with the initial neuropsychological demands and their rectification, respectively. On an individual level, 11 patients initially showed obvious cognitive deficits. However, the clinical characteristics of this subgroup differed not from that found in the 15 'good performers'. These findings indicate that the cognitive functions in the acute AN and BU are similarly impaired, but also ameliorate in a similar manner with clinical remission. Because no associations were obvious between cognitive and clinical rectifications, significant contributions of mediating factors (e.g., changes in metabolic brain turnover and in steroid hormones) are suggested.

Cardiovascular and renin responses to head-up tilt tests in parkinsonism.

OBJECTIVES: We investigated cardiovascular and renin responses to head-up tilt tests in patients with Parkinson's disease (PD), multiple system atrophy (MSA), and in controls to determine variables for the assignment of parkinsonism to the potential underlying neurologic condition. PATIENTS AND METHODS: Sequential changes in sympathetic-mediated circulatory variables such as heart rate, blood pressure, and plasma renin concentration during head-up tilt tests were studied in 14 patients with PD and 11 patients with MSA. Twelve subjects with normal autonomic functions were studied as controls. RESULTS: Head-up tilt resulted in significant differences in blood pressure and heart rate responses between PD, MSA, and controls. The baseline plasma renin concentration was significantly lower in MSA than in controls. Twenty min head-up tilt revealed significant differences in plasma renin concentration between PD, MSA, and controls. CONCLUSION: We conclude that investigating sequential changes in mean arterial blood pressure, heart rate, and plasma renin concentration during head-up tilt test can potentially support differential diagnosis of PD and MSA.

[Neurologic and psychiatric symptoms of legionella infection. Case report and overview of the clinical spectrum]. / Neurologische und psychiatrische Symptomatik bei der Legionellainfektion. Fallbericht und Ubersicht über das klinische Spektrum.

Legionella is a frequent etiologic agent in the development of both nosocomial and community acquired pneumonias. Involvement of the nervous system is common in Legionella infections. We present a case of Legionnaires' disease which illustrates distinctive neurologic findings including delirium and cerebellar dysfunction. Furthermore, this paper reviews the neurological and psychiatric features of 609 Legionella infected patients with involvement of the nervous system. The most common signs were disorientation (58%), headache (52.4%), and somnolence (39.7%). Less frequent or rare were: cerebellar dysfunction (11.2%), hallucinations (8.4%), agitation or stupor (4.1%), affective disorders (3.1%), peripheral neuropathy (2.8%), pyramidal disturbances (2.1%), memory loss (1.6%), seizures (1.5%), cranial nerve palsies (1.5%), incontinence (0.7%), and extrapyramidal disturbances (0.3%). Cranial CT scans, cerebrospinal fluid findings, and nerve and muscle biopsies were usually unremarkable. Neuropathologic examinations failed to demonstrate specific characteristics. Hyponatremia and serum CPK level elevation were present in up to 89% and 50% of patients, respectively. Prognosis of disturbances of the nervous system was mainly good. We conclude that in the presence of definite neurological findings, pulmonary infection, hyponatremia, and CPK elevation Legionella infection should be considered.

[Structured day care therapy program for eating disorders]. / Strukturiertes tagklinisches Therapie-Programm für Essstörungen.

A day hospital group treatment program is detailed which could offer effective treatment to many patients with anorexia nervosa and bulimia nervosa who would otherwise require inpatient treatment. Important clinical advantages over an inpatient program are described. The psychotherapy is cognitive-behavioral oriented and is done in groups. A multi-disciplinary team approach is used. The day hospital treatment program includes psychological, social and eating-related interventions. Main characteristics are the motivation-phase, the contact between patients of different therapy-phases, the involvement of families in therapy and the support of self-help. First empirical outcome results are presented.

Heterogeneity of hypothalamic-pituitary-adrenal system response to a combined dexamethasone-CRH test in multiple sclerosis.

The endocrine system participates in the regulation of the immune and neural systems and therefore hormonal factors probably play an important role in the development and course of multiple sclerosis (MS). Specifically, the hypothalamic-pituitary-adrenal (HPA) system seems crucial because (a) the inflammatory response is accompanied by HPA activation; (b) animal models with an inherited HPA defect are prone to developing experimental autoimmune encephalitis; and (c) most important, corticosteroids are still the most widely used treatment. We administered a recently developed neuroendocrine function test that combines dexamethasone suppression (1.5 mg orally at 2300 h) and corticotropin-releasing hormone (CRH) stimulation (100 micrograms i.v. at 1500 h the following day) and measured the response of plasma cortisol and corticotrophin (ACTH) secretion in 19 patients with an acute exacerbation of MS. These patients had a significantly higher mean plasma cortisol response than age-matched controls (peak minus baseline; 48.1 +/- 10.5 ng/ml [mean +/- SEM] versus 19.8 +/- 4.2 ng/ml; p < 0.05), but the corresponding ACTH values for the two groups were indistinguishable (13.4 +/- 1.4 pg/ml [mean +/- SEM] versus 11.3 +/- 1.4 pg/ml; n.s.). The response range in the patients was broader and we identified six patients with excessive cortisol release (peak minus baseline: 100.5 +/- 14.4 ng/ml [mean +/- SEM]), whereas four patients failed to respond at all. The hormonal response patterns were not related to previous treatments with corticosteroids or other immunosuppressants or to psychopathological features. These results point to a heterogeneity of HPA system function, most likely at the corticosteroid receptor level, which has clinical implications for all those treatments that affect the HPA system and the course of MS.

Correlates of cognitive impairment and depressive mood disorder in multiple sclerosis.

The psychopathological status of 25 inpatients suffering from clinically definite multiple sclerosis (MS) according to Poser criteria was assessed by using standardized methods (Structured Clinical Interview for DSM-III-R, Inpatient Multidimensional Psychiatric Scale, Hamilton and Montgomery-Asberg Depression Rating Scales and the Structured Interview for the Diagnosis of Alzheimer Dementia and Dementias of other Aetiology (SIDAM). Magnetic resonance (MRT) (0.5 T; T2-weighted sequence) of the brain was analysed by measuring the ventricular brain ration (VBR), the area of the corpus callosum (CC) and the extension of hyperintense lesions of the brainstem, the temporal lobes and the brain at all. Six of 25 (24%) of these moderately disabled patients (mean Extended Disability Score (EDSS) 3.3) were diagnosed to suffer from depressive mood disorder (major depression or dysthymia); 2 were demented. In correlation analysis, depression was unrelated to age, gender, duration of illness, status of disability (EDSS) or the results of cognitive assessment. No relationship between the depression scores and the different MRT measures could be identified. The presence or absence of gadolinium enhancement was also uncorrelated to depressive symptoms. Fatigue as measured by the Fatigue Severity Scale was unrelated to depression or subcortical brain atrophy (increased VBR) but significantly correlated to the area of hyperintense MRT changes in brainstem and midbrain. Cognitive impairment (decreased SIDAM scores) was correlated to the total area of hyperintense MRT changes of the brain parenchyma. The type of clinical course (relapsing-remitting vs chronic progredient) was not found to influence the affective or cognitive state in our MS patient's sample.

Self-reported sleep quality in HIV infection: correlation to the stage of infection and zidovudine therapy.

We investigated self-reported sleep quality in a group of 50 patients in different stages of HIV-1 infection by using a standardized questionnaire (Pittsburgh Sleep Quality Index). Alterations of sleep were found to be significantly correlated with the most severe stage of infection in AIDS patients. Analysis of data failed to indicate a significant influence of zidovudine on self-reported sleep quality.

Ventricle brain ratio in the clinical course of HIV infection.

As part of the computerized tomographic assessment of an unselected group of 47 patients in different stages of HIV infection we determined the ventricle brain ratio (VBR) and the width of several cortical sulci. We compared the findings for subgroups of patients defined by their stage in the Walter Reed Staging Classification. There was a significant increase in VBR only in the subgroup of patients with manifest acquired immune deficiency syndrome (AIDS) (WR 6). The findings are discussed in connection with the question of the likelihood that dementia will develop even in stages of HIV-infection preceding AIDS.

CT findings in different stages of HIV infection: a prospective study.

In the acquired immunodeficiency syndrome (AIDS), different patterns of CT findings have been described. In a prospective and unselected CT study we examined 200 patients in different stages of HIV-1 infection, 14% of whom had focal lesions, 37% atrophic changes and 49% normal findings. The differential diagnosis is discussed. Depending on the patient's complaints and clinical findings, even when the CT scan is normal there may be treatable complications that must be detected by other diagnostic techniques, such as lumbar puncture.

[Life-threatening complications and death in anorexia nervosa]. / Lebensbedrohung und Tod bei Anorexia nervosa.

The medical complications of anorexia nervosa may endanger the patient in several ways; the severity of somatic complications may be underestimated; medical findings may be assigned to other diagnoses than anorexia nervosa or complications may indicate an emergency, leading to therapeutic activities which may result in a life-threatening situation for the patient. There are some indications that phosphate depletion is involved in medical complications in anorexia nervosa, even in those cases with fatal outcome. Acute hypophosphatemia may be induced by hyperalimentation.

[Suicidal tendency of epilepsy patients]. / Zur Suizidalität des Epilepsiepatienten.

Epileptic and diabetic patients with suicidal tendency are compared in a retrospective study, both types of patients being characterized by chronic disease and social handicaps. Both these groups are predominantly preoccupied with self-intoxication by tranquilisers and/or alcohol, whereas in the group of epileptics examined in this study there is a predominance of "cruel" kinds of self-destruction, i.e. suicide, without any obvious connection with the type of the epileptic attacks. Patients repeatedly attempting suicide are not definitely subject to any higher incidence of attacks compared with the other patients, the frequency of attacks being within a wide range among these relapsing suicides. Epileptic patients who are potential suicides are more often found to have been suffering from an affective disorders for a prolonged period than those of the diabetic group (dysthymic disturbance according to DSM III).