[Stress-induced hyperalgesia (SIH) as a consequence of emotional deprivation and psychosocial traumatization in childhood : Implications for the treatment of chronic pain]. / Stressinduzierte Hyperalgesie (SIH) als Folge von emotionaler Deprivation und psychischer Traumatisierung in der Kindheit : Konsequenzen für die Schmerztherapie.

It is now widely recognized that in many chronic pain syndromes the intensity and severity of individually perceived pain does not correlate consistently with the degree of peripheral nervous system tissue damage or with the intensity of primary afferent or spinal nociceptive neurone activity. In particular, stress and anxiety exert modulatory influences on pain depending on the nature, duration and intensity of the stressor and developmental influences on the maturation of the stress as well as the pain system. In some chronic pain syndromes, e. g. fibromyalgia, TMD or somatoform disorders, no nociceptive or neuropathic input is detectable. We summarise the studies investigating the neural substrates and neurobiological mechanisms of stress-induced hyperalgesia (SIH) in animals and humans. The review provides new perspectives and challenges for the current and future treatment of chronic pain.

Implications of proposed fibromyalgia criteria across other functional pain syndromes.

OBJECTIVES: In 2010, the American College of Rheumatology (ACR) proposed new criteria for the diagnosis of fibromyalgia (FM) in the context of objections to components of the criteria of 1990. The new criteria consider the Widespread Pain Index (WPI) and the Symptom Severity Score (SSS). This study evaluated the implications of the new diagnostic criteria for FM across other functional pain syndromes. METHOD: A cohort of 300 consecutive in-patients with functional pain syndromes underwent a diagnostic screen according to the ACR 2010 criteria. Additionally, systematic pain assessment including algometric and psychometric data was carried out. RESULTS: Twenty-five patients (8.3%) had been diagnosed with FM according to the ACR 1990 criteria. Twenty-one of them (84%) also met the new ACR 2010 criteria. In total, 130 patients (43%) fulfilled the new ACR 2010 criteria. A comparison of new vs. old cases showed a high degree of conformity in most of the pain characteristics. The new FM cases, however, revealed a pronounced heterogeneity in the anatomical pain locations, including several types of localized pain syndromes. Furthermore, patients fulfilling the ACR 2010 FM criteria differed from those with other functional pain syndromes; they had increased pain sensitivity scores and increased psychometric values for depression, anxiety, and psychological distress (p<0.01). CONCLUSIONS: FM according to the ACR 2010 criteria describes the 'severe half' of the spectrum of functional pain syndromes. By dropping the requirement of 'generalized pain', these criteria result in a blurring of the distinction between FM and more localized functional pain syndromes.

[Expert testimony in post-traumatic stress disorder with pain as the main symptom]. / Begutachtung bei Posttraumatischer Belastungsstörung mit Leitsymptom Schmerz.

Post-traumatic stress disorder (PTSD) is one of the most relevant disorders of patients with chronic pain, but is often underdiagnosed. This also applies to expert testimony. Further complicating the assessment are the different definitions of PTSD in ICD-10 and DSM-IV; the new DSM-5 has added a further definition. The present review aims to provide guidance for making a valid diagnosis. This forms the basis for a differentiated expert testimony in the different fields of law (e.g., criminal law, statutory or private accident insurance or social security benefits), in which different requirements must be taken into consideration by the expert. The recognition of malingering is described at length, which plays a major role in PTSD expert testimony in all fields of law.

[Female patients with fibromyalgia syndrome in somatic and psychosomatic rehabilitation center - an exploratory study on access routes and differences in patient characteristics]. / Fibromyalgiesyndrom-Patientinnen in psychosomatischen und somatischen Rehabilitationseinrichtungen - eine explorative Studie zu Zugangswegen und Unterschieden in Patientenmerkmalen.

STUDY OBJECTIVE: Fibromyalgia syndrome (FMS) is characterized by e. g. chronic, multilocular pain, and mental health problems. In Germany, patients with FMS are treated in somatic and psychosomatic rehabilitation centers - specialized for rheumatic diseases (somatic) or psychosomatic diseases. The aim of this study is to identify the status quo of FMS patients' access routes to the rehabilitation system, and to identify their predictors for being assigned to one or the other indication group. METHOD: Our cohort consists of 197 FMS patients from 3 psychosomatic (M=49.9 years) and 223 FMS patients (M=50.2 years) from 3 somatic rehabilitation centers. At the beginning of rehabilitation, patients filled out a questionnaire packet to identify their access routes to the rehabilitation centers and to record patients' disease-related, psychosocial and socio-demographic characteristics. To analyze the results we used descriptive calculations, calculated bivariate correlations, and conducted binary logistic regression analysis for the prediction of group membership. RESULTS: The access routes of FMS patients to a somatic or a psychosomatic rehabilitation center were often similar. Some items revealed significant group differences, i. e., a higher primary -rejection rate, longer waiting period between application for rehabilitation and its approval, and between the application itself and initiation of psychosomatic rehabilitation in comparison to somatic FMS patients. Prior experience of out-patient psychotherapy, and expectations ("psychological support") for the rehabilitation were predictive patient characteristics for the assignment into a psychosomatic rehabilitation center. Marriage, motivation, and expectations ("physical improvement" and "interaction with other patients") for the rehabilitation were predictive patient characteristics for the assignment in a somatic rehabilitation center. The predictors clarified 32% of the variance of group membership. CONCLUSION: Our results provide initial evidence of how FMS patients access the German rehabilitation system and which of their characteristics are responsible for being assigned to a particular rehabilitation setting.

[Somatoform disorders with pain as the predominant symptom: results to distinguish a common group of diseases]. / Somatoforme Störungen mit Leitsymptom Schmerz: Ergebnisse zur Differenzierung einer häufigen Krankheitsgruppe.

According to a population-based prevalence study, medically unexplained pain syndromes are highly prevalent in the German general population. With a 1-year prevalence of 8% for somatoform pain disorders and a lifetime prevalence of 12.7%, they rank among the most prevalent conditions in the community. Until now, few studies have been conducted to characterize and differentiate patients with somatoform pain disorders in more detail. The present study is the first to examine a large patient cohort from a university hospital outpatient unit with somatoform disorders presenting with pain as the predominant complaint (n=282). Patients with a nociceptive or neuropathic pain mechanism were excluded after interdisciplinary diagnostic procedures, and all patients were differentiated in terms of comorbid psychic disorders and their symptom presentation. Psychic disorders were assessed using a standardized structured interview (SCID-I and SCID-II) and a structured biographical case history (MSBI) to assess chronification factors. The extent and distribution of bodily symptoms were collected using the screening for somatoform disorders (SOMS). A total of 69% of the patients examined suffered from anxiety and depressive disorders or other mental disorders, and only 14% had a comorbid personality disorder. More than 90% had further bodily symptoms apart from pain. The presence of mental disorders and the duration of the illness were associated with a higher number of bodily symptoms (e.g., fatigue, dizziness), for which they may also consult a doctor. In addition, the frequency of fibromyalgia syndrome increases with the extent of somatization. Our results ultimately support the idea of classifying this group of patients as an independent diagnostic group. They further suggest a future differentiation regarding the degree of impairment within this group similar to the systems of stages used in depressive disorders.

[Therapy of disorders with central pain sensitization.]. / Therapie zentralisierter Schmerzstörungen.

Previous somatic pain experience (priming), psychobiographic imprinting (pain proneness), and stress (action proneness) are key to an enhanced centralised pain response. This centralised pain response clinically manifests itself in pain sensitization and chronification. The therapeutic approach to chronic centralised pain disorders is multimodal. The overarching aim of the various interventions of a multimodal treatment program is to activate anti-nociceptive areas of the cerebral matrix involved in pain processing. The lists of medications targeting neuropathic and somatoform pain disorder show considerable overlap. Psychotherapy helps patients with central pain sensitization to improve pain control, emotional regulation and pain behaviour.

[Neither Descartes nor Freud? current pain models in psychosomatic medicine]. / Weder Descartes noch Freud? Aktuelle Schmerzmodelle in der Psychosomatik.

Models explaining chronic pain based on the mere presence or absence of peripheral somatic findings or which view pain of psychological origin when there is no somatic explanation, have their shortcomings. Current scientific knowledge calls for distinct pain concepts, which integrate neurobiological and neuropsychological aspects of pain processing.

[Chronic low back pain as a somatoform pain disorder]. / Chronischer Rückenschmerz als somatoforme Schmerzstörung.

Chronic low back pain as a leading symptom of a somatoform pain disorder is a remnant diagnostic category for many physicians, general practitioners and orthopaedic surgeons. Patients with somatoform pain disorder (ICD-10: F45.4) are often not diagnosed until after several years and multiple diagnostic procedures, in some cases after iatrogenic impairment. A more precise knowledge of the disorder can prevent chronification. This article outlines the clinical features, diagnostic procedure and differential diagnosis in somatoform pain patients and presents current psychotherapeutic approaches.

Cerebral activation in patients with somatoform pain disorder exposed to pain and stress: an fMRI study.

Patients with somatoform pain disorders are supposed to suffer from an early acquired defect in stress regulation. In order to look for common alterations of the pain- and stress-responsive cortical areas, we prospectively recorded cerebral activations induced by pin-prick pain, by cognitive stress and emotional stress using functional magnetic resonance imaging (fMRI) in a group of 17 patients and an age-matched control group. In addition, the hippocampal volumes of both groups were measured. Patients showed increased activations of the known pain-processing areas (thalamus, basal ganglia, operculo-insular cortex), but also of some prefrontal, temporal and parietal regions during first pain exposure and of temporal and parietal areas during cognitive stress, but reduced activations during emotional stress. In contrast to these functional differences, hippocampal volume was not significantly reduced in patients. Although the superior temporal gyrus was the only common area of an "overactivation" in patients in the pain and stress condition, findings of our study support the current concept of mechanisms involved in somatoform pain disorders: central processing of pain and of cognitive stress is increased in patients possibly due to exaggerated memory and/or anticipation of pain exposure and to a disturbance of stress-regulating systems which has to be worked out on a cortical level in more detail. Our finding of a reduced responsiveness to emotional stress is surprising, but not contradictive to these results because some sort of neglect or coping mechanisms may have developed over time as a response to early adversities.

Suicide attempts and retrospective reports about parent-child relationships: evidence for the affectionless control hypothesis.

OBJECTIVE: To compare the characteristics of recalled parent-child relationships in suicide attempters vs. non-attempters METHODS: A total of 509 patients - 249 presenting with pain at a psychosomatic clinic and 260 from the offices of general practitioners - were interviewed retrospectively about suicide attempts and parent-child relationships. RESULTS: The overall rate of those reporting a suicide attempt was 17%. Bivariate analyses showed associations of poor parent-child relationships with suicide attempts throughout. In a multivariate analysis, the combinations high maternal control*low perceived love (p<.001) and high control*high role reversal (p=.002) were associated with particularly elevated risks for suicide attempts. CONCLUSION: Beside the two most extensively explored dimensions of parent-child relationships, parental affection and control, one other dimension, role reversal, also contributes strongly to risk for offspring suicide attempts and should be considered in future studies.

Positron emission tomography reveals correlations between brain metabolism and mood changes in hyperthyroidism.

CONTEXT: Hyperthyroidism is frequently associated with emotional distress. The underlying cerebral processes of the endocrine-induced mood changes are unclear. OBJECTIVE: The objective of this study was to investigate, for the first time, the neuronal correlates of thyrotoxicosis-associated psychic symptoms using positron emission tomography (PET). DESIGN: The study was designed as a cross-sectional trial. SETTING: The study was performed at joint nuclear medicine and thyroid clinics. PATIENTS: Twelve patients with untreated Graves' hyperthyroidism were evaluated. METHODS: Levels of emotional distress were self-rated by means of the Hospital Anxiety and Depression Scale. Both patients and 20 age- and gender-matched euthyroid controls underwent a brain fluorodeoxyglucose PET scan. Subsequently, the functional relationship between brain metabolism and the psychometric scores was analyzed. RESULTS: Compared with controls and visualized by fluorodeoxyglucose PET, hyperthyroid patients showed a decreased (P < 0.0001) glucose metabolism in the limbic system (uncus and inferior temporal gyrus). Activation foci in the posterior cingulate and in the inferior parietal lobe were correlated with both anxiety and depression scales (P < 0.001). Compared with patients with normal anxiety levels, those with increased anxiety yielded an enhanced glucose metabolism (P < 0.001) in the bilateral sensory association cortex. Serum free T3/free T4 levels negatively correlated with regional glucose metabolism in the medial posterior cingulate. CONCLUSIONS: Thyrotoxicosis and associated psychic symptoms are correlated to regional metabolic changes in the main structures of the limbic/paralimbic system.

Psychological defense styles, childhood adversities and psychopathology in adulthood.

OBJECTIVE: The present study explores the link between reported sexual and/or physical abuse and psychological defense styles, as well as the association of both with psychological distress in adulthood. In two patient samples that differ in psychological distress and somatization, we examine whether the adversities reported and immature defense styles are associated with psychopathological symptoms. METHOD: We examined 266 consecutive inpatients in the psychosomatic department and 109 consecutive inpatients who had been treated for low-back pain in the orthopedic department of a German university hospital. Psychological defense styles were assessed by a two-factor solution of the German modified adaptation of the Defense Mechanism Inventory (DMI), childhood adversities by a structured interview, psychological distress by the SCL-90-R, and somatization by the Screening for Somatoform Disorders (SOMS). RESULTS: Both samples demonstrated a significant link between immature defense styles and the extent of overall psychological distress as well as somatization. Reported sexual and/or physical abuse of patients in both patient samples was directly associated with somatization. CONCLUSION: Recollections of sexual and/or physical abuse in childhood and immature defense styles have an association with psychopathology in adulthood. This finding suggests that immature defense styles may act, in part, as mediators between the adversities investigated and adult psychopathology.

Psychosocial morbidity of Graves' orbitopathy.

OBJECTIVE: Ocular diseases markedly impair daily function. In Graves' orbitopathy (GO), an associated psychosocial burden is present due to disfiguring proptosis and/or diplopia, signs with significant impact on functional status and well-being. We have therefore surveyed and assessed the psychosocial morbidity of GO. DESIGN: A prospective controlled study on subjects with GO using internationally validated, self-reporting questionnaires. PATIENTS: One hundred and two consecutive patients with varying degrees of severity and activity of GO. Measurements Emotional distress, coping styles and quality of life (QoL) were assessed by the Hospital Anxiety and Depression Scale, by a German adaptation of the Ways-of-Coping Checklist, and with the 36-item Short Form, respectively. Stressful events in the 6 months preceding diagnosis were registered with the Life Experience Survey. QoL findings were compared to German reference values, as well as to 102 age- and gender-matched patients, each with type 1 diabetes (insulin-dependent diabetes mellitus, IDDM) and inflammatory bowel disease (IBD), respectively. RESULTS: Compared to the German reference population, all QoL scales were at a lower rate and were especially decreased in subjects with active and/or severe GO, orbital pain, diplopia and stressful life events. Compared to diabetics, psychosocial scales were considerably reduced in GO (z = -1 vs. 0.1, P < 0.001) and higher scores for depressive coping (2.32 vs. 1.71, P < 0.001) and trivializing (2.37 vs. 1.97, P < 0.006) were noted. In GO, depressive coping and trivializing were negatively correlated with the mental (r = -0.603 and r =-0.411, both P < 0.001) and physical (r = -0.487 and r = -0.354, both P < 0.001) components of QoL. Depressive coping also positively correlated with anxiety (r = 0.636) and depression (r = 0.590), respectively, both P < 0.001. Emotional distress noted in 46 subjects, mostly with active and severe GO, was associated with poor QoL. Anxiety and depression were present in 41 and 24 GO patients, respectively. The number of stressful events positively correlated with the scores of anxiety (r = 0.3335) and depression (r = 0.3178), both P = 0.001. Foremost emotional distress, but also diplopia, stressful events and depressive coping had a major impact on QoL (proportion of variance explained = 13.1%, P < 0.001, multiple regression analysis). More than 75% of the psychosocial impairment in GO (R2= 0.76, P < 0.001) was associated with seven variables only (e.g. depression and anxiety). Six months prior to GO onset, 74 patients experienced a mean of 4 (range 0-13) stressful life events. Subjects with optic neuropathy had more stressful events than those without nerve involvement (5.1 vs. 2.7, P = 0.0425). CONCLUSIONS: Psychosocial morbidity is present in severe and/or active GO, which negatively affects QoL. The patients are not only physically ill, they also exhibit emotional distress. Accompanying psychosomatic treatment is indicated among about half of all GO patients.

Adaptation to life after surgical removal of the bladder-an application of graphical Markov models for analysing longitudinal data.

Graphical Markov models have been developed particularly for the analysis of observational data. They allow the control of various background variables when analysing theoretically relevant associations. This paper demonstrates the application and some advantages of graphical Markov models in comparison to conventional statistical analyses. The aim of the study was to identify patients at risk for developing decreased health-related quality of life (QoL) after cystectomy and to explore the influence of coping on QoL in this situation. Therefore, the method was applied to analyse the data of a prospective study, in which 81 patients with bladder cancer were interviewed pre-operatively and in a 1-year follow-up. QoL was assessed both times, and two basic coping strategies (active and depressive) were measured preoperatively. The explanatory variables of theoretical interest were active and depressive coping strategies. As a result of the analysis, relevant proportions of variance in the development of QoL could be explained by the suggested model (60 per cent in mental component, 40 per cent in physical component of QoL). Active coping was positively related to QoL, depressive coping negatively. These effects were linear in the physical component of QoL, moderated by working status and the type of urinary diversion in the mental component of QoL.

Metabolic and psychosocial effects of minimal invasive gastric banding for morbid obesity.

Obesity is considered a primary risk factor for cardiovascular disease and related mortality. The current study aimed to investigate the efficacy of minimal invasive gastric banding (GB) surgery for reducing caloric intake in morbid obesity, and to analyze the effects of weight loss on body composition and metabolic and psychosocial outcomes. Twenty-six adult severely obese patients (mean body mass index [BMI], 48.1 kg/m(2); range, 42 to 56) underwent adjustable silicone laparoscopic GB. Nine additional obese patients who declined surgery were treated with metformin (2 g daily) and served as a small additional group (BMI, 50.5 kg/m(2); range, 41 to 68). Presurgery and 17 +/- 2.2 months postoperatively, body composition (fat mass [FM], lean body mass [LBM], body water) and serum parameters (lipids, glucose, thyrotropin-stimulating hormone [TSH]) were determined. Quality of life (QoL) was evaluated by a standardized self-rating questionnaire (Short Form-36 [SF-36]), and supplemented by measures of physical complaints and psychological distress. After GB, weight loss was 21 +/- 14.9 kg (14%, P <.001). It was associated with a decrease in FM by 14 +/- 8.6 kg (18%, P <.001), LBM by 4 +/- 2.7 kg (5%, P <.001), body water by 4 +/- 3.4 L (7%, P <.01), systolic blood pressure by 16 +/- 26.3 mm Hg (10%, P <.05), total cholesterol by 0.69 +/- 1.29 mmol/L (12%, P <.05), and low-density lipoprotein cholesterol (LDL-C) by 0.38 +/- 0.39 mmol/L (10%, P <.05). Highly significant interactions between surgery and time were noted for weight (P <.005), BMI (P <.005), and FM (P <.007, analysis of variance [ANOVA]). Preoperatively, 14 of 26 patients (54%) had high fasting blood sugar levels (type 2 diabetics) and 11 (42%) had impaired glucose tolerance, whereas postoperatively, for baseline glucose levels a trend to decrease was noted. Neither malabsorption nor anemia was observed. QoL improved after GB; in particular, physical functioning and well being increased (P <.01), and somatic complaints (eg, dyspnea and heart complaints, pain in legs and arms) markedly decreased (P =.008). In the metformin group, neither relevant weight loss nor a significant decrease of biochemical values was observed. Minimal invasive GB is a successful therapeutic tool for reducing FM in morbidly obese patients. Weight loss resulted in improved metabolic parameters, suggesting a lowered atherogenic risk.

Observer independent analysis of cerebral glucose metabolism in patients with chronic fatigue syndrome.

OBJECTIVES: To evaluate cerebral glucose metabolism, assessed by 18-fluorodeoxyglucose positron emission tomography (FDG-PET), in patients with chronic fatigue syndrome (CFS), using an observer independent analytical approach; and to characterise any observed alterations by correlating them with neuropsychological deficits. METHODS: 26 patients (13 female, 13 male) were examined. They all fulfilled the CDC diagnostic criteria for CFS. Their ages ranged from 26 to 61 years (mean (SD) age, 43 (9.3) years). They underwent extensive psychometric testing including the hospital anxiety and depression scale (HADS) and the short form 36 item health questionnaire (SF-36). Brain FDG-PET was done in all the subjects. After stereotactic normalisation, single subject comparisons with an age and sex matched normal database (n = 18) and a group comparison between the patients and normal controls were undertaken, along with additional correlation analyses between brain metabolism and psychometric test scores. RESULTS: 12 of the 26 patients showed no significant decrease in FDG uptake compared with the controls. Of the remaining 14, 12 showed hypometabolism bilaterally in the cingulate gyrus and the adjacent mesial cortical areas. Five of these 12 patients also had decreased metabolism in the orbitofrontal cortex. The two remaining patients had hypometabolism in the cuneus/praecuneus. Correlation analyses showed significant correlations between some test scores (anxiety, depression, health related quality of life) but not fatigue and regional reductions in glucose metabolism. CONCLUSIONS: Although abnormalities in FDG-PET were only detectable in approximately half the CFS patients examined, and no specific pattern for CFS could be identified, PET may provide valuable information in helping to separate CFS patients into subpopulations with and without apparent alterations in the central nervous system.

Are childhood adversities relevant in patients with chronic low back pain?

Previous studies have found a high number of childhood adversities in patients with chronic low back pain, particularly in patients reporting persisting problems after back surgery. Our aim was to reproduce these results. Within the framework of a comprehensive diagnostic assessment and psychometric evaluation, 109 inpatients who had been treated for low back pain were examined in the orthopedics department of a German university hospital. Five risk factors investigated by Schofferman and his staff (Schofferman et al., 1993) were re-assessed in all of our patients using a structured biographical interview. The German chronic low back pain group was also compared with an age- and gender-matched control group of 109 non-chronic pain patients with respect to these childhood adversities and additional ones. Only approximately 11% of the German chronic low back pain sample demonstrated three or more risk factors, compared with more than 50% in Schofferman's sample, and 47.7% showed none of the five risk factors, compared to only 11% in the Schofferman sample. Moreover, no significant differences in distribution either in terms of the individual risk factors or their cumulative frequency were found in the German chronic low back pain group compared with an age and gender-matched control group without chronic pain. Childhood adversities do not occur frequently in a non-selected group of patients with chronic low back pain. Earlier results showing an increased likelihood of the occurrence of psychosocial risk factors could not be confirmed. As a consequence, further psychic or psychosomatic diagnostics of patients with chronic low back pain are needed to define diagnostic subgroups.

[Differential diagnosis of chronic pain syndromes of the musculoskeletal system--coding according to ICD-10]. / Differenzielle Diagnostik chronischer Schmerzsyndrome am Bewegungsapparat-Codierung nach der ICD-10.

Primary care for patients suffering from chronic pain is regularly provided by either family physicians or inpatient medical wards. A delay in initiating specific pain treatment is associated with poor outcome in terms of pain intensity, work disability and diminished quality of life. We present a diagnostic classification scheme for chronic pain disorders following the biopsychosocial disease model. This classification may help primary care providers initiate appropriate treatment early in the course of chronic pain, and aid in referral of their patients to services familiar with the treatment of chronic pain. Given increasing requests for quality control in health care and for transparency in disease management by health insurance companies, we propose a coding system of chronic non-malignant pain syndromes with the ICD-10.