[Differential diagnosis of dissociative seizures]. / Differenzialdiagnose dissoziativer Anfälle.

Patient history taking and semiology provide seminal clues to the diagnosis of dissociative seizures. Openness and alertness of the treating physician are essential. Video-electroencephalogram(EEG)-based analyses of the events are crucial to establish the correct diagnosis, particularly in complex cases. The patient-doctor relationship is of particular importance in order to successfully motivate the patient for psychotherapeutic treatment. Coexisting psychiatric morbidity as well as other functional somatic symptoms must be actively explored. Current changes in the established diagnostic manuals, including ICD-11, reflect the ongoing vivid interest and controversial discussions in the field of dissociative disorders.

[Ways to psychosomatic rehabilitation--differential treatment selection between psychosomatic acute care and rehabilitation]. / Wege in die psychosomatische Rehabilitation--differenzielle Indikationsstellung an der Schnittstelle zwischen Krankenhaus und psychosomatischer Rehabilitationsklinik.

Consecutive admissions to the psychosomatic departments of 5 hospital units in southwest Germany registered between October 2012 and October 2013 were asked to participate in a study investigating the treatment selection process for psychosomatic rehabilitation. 527 patients were included in the study, 269 outpatients and 258 inpatients at the end of their inpatient treatment. 52 patients (10.1%) received the recommendation for rehabilitation. 47 (90.4%) could be followed up 3 months later. 22 patients had applied for a rehabilitation treatment, 11 (50%) had obtained an approval for their rehabilitation, 5 had still no answer and for 6 patients the request was refused. 4 of the latter had objected their refusal and were still waiting for an answer. Only one patient was already admitted to a rehabilitation center. Possible reasons for the low permeability at the interface between hospital care and rehabilitation are discussed.

Are individual differences of attachment predicting bereavement outcome after perinatal loss? A prospective cohort study.

OBJECTIVE: The purpose of this study was to examine the influence of attachment, social support and the quality of the current partnership on the outcome of bereavement after perinatal loss. METHODS: In a prospective cohort design 33 women after perinatal loss were approached on admission to hospital and reassessed four weeks, four months and nine months later. The initial assessment included the Adult Attachment Interview and self-report questionnaires for social support and quality of the current partnership. Bereavement outcome was assessed using measures of grief (MTS), depression and anxiety (HADS), psychological distress (BSI), somatisation (BSI-SOM) and symptoms of PTSD (PDS). RESULTS: All measures of outcome showed a significant improvement over time. Standardized effect sizes between the initial assessment and nine month follow-up ranged between .36 for anxiety (HADS) and 1.02 for grief (MTS). Social support, quality of the partnership and secure attachment correlated inversely, and insecure preoccupied attachment correlated positively with the outcome measures. Preoccupied attachment was included as a predictor in two multivariate statistical models of non-linear regression analysis, one with somatisation (adjusted R2=.698, P=.016), the other with posttraumatic stress symptoms at nine month follow-up (adjusted R2=.416, P=.002) as target variable. Initial assessment scores of psychological distress predicted the course of the respective measure during follow-up (adjusted R2=.432, P=.014). CONCLUSION: Attachment, social support and the quality of the current partnership have an impact on the course of bereavement after perinatal loss. Secondary prevention after the event may focus on these factors in order to offer specific counselling and support.

[Adaptive indication in outpatient psychodynamic short-term psychotherapy. Results of a prospective naturalistic research study]. / Adaptive Indikationsstellung in der ambulanten psychodynamischen Kurzzeitpsychotherapie. Ergebnisse einer prospektiven naturalistischen Verlaufsuntersuchung.

Health care insurers in Germany fund long-term psychotherapy of up to 240 sessions as well as brief psychotherapeutic interventions of up to 25 sessions. In a former study, it was observed that a substantial proportion of interventions initially designed as brief psychotherapy were changed into long-term therapy. The present study investigated the criteria of such decisions to change treatment plans and is part of a more comprehensive auditing study in outpatient psychotherapy. Twenty-six psychotherapists in private practice participated in the study. During a 12-month recruitment period, 70 patients started with brief psychodynamic psychotherapy. Thirty-six therapies were evaluated according to the study protocol. The results provide evidence that motivation for psychotherapy, satisfaction with the results of therapy, persistence of psychological symptoms at the end of short-term intervention, and aspects of the patient's personality are factors predictive of treatment selection. Patients who changed from short-term to long-term therapy were more motivated towards their therapy (prognostic indication), displayed more severe symptoms, were less satisfied with the results of short-term psychotherapy (adaptive indication), and scored higher on the "structure of personality organization" parameter according to the OPD diagnostic system.

Evidence for the involvement of glutamatergic receptors in the antinociception caused in mice by the sesquiterpene drimanial.

Drimanial, a new sesquiterpene isolated from the barks of the plant Drimys winteri (Winteraceae), given systemically, intraplantarly, or by spinal or supraspinal routes, produced pronounced antinociception against both phases of formalin-induced licking. The systemic injection of drimanial also inhibited, in a graded manner, the pain-related behaviours induced by intraplantar or intrathecal (i.t.) administration of glutamate. Moreover, drimanial also caused marked inhibition of the nociception induced by i.t. administration of a metabotropic glutamate agonist (1S,3R)-ACPD, without affecting nociceptive responses induced by ionotropic agonists (NMDA, kainate, AMPA) or by substance P. The antinociception caused by drimanial was not influenced by naloxone, nor did it interfere with the motor coordination of animals in the rota-rod test. Furthermore, drimanial caused graded inhibition of [(3)H]glutamate binding in cerebral cortical membranes from mice, with an IC(50) value of 4.39 micro M. Together, these results provide strong evidence indicating that the sesquiterpene drimanial produces antinociception in mice at peripheral, spinal and supraspinal sites. An interaction with metabotropic glutamate receptors seems to contribute to the mechanisms underlying its antinociceptive action.

A sesquiterpene drimane with antinociceptive activity from Drimys winteri bark.

Along with three known drimanes, polygodial. 1-beta-(p-methoxycinnamoyl) polygodial and mukaadial, the sesquiterpene drimane named drimanial was isolated from the bark of Drimys winteri (Winteraceae). Its structure was elucidated based on spectroscopic evidence. Drimanial exhibited antinociceptive action against acetic acid induced pain, being about 3-fold less active than polygodial.

Biological activity of plant extracts: novel analgesic drugs.

The plant-derived secondary metabolites have, over the years, greatly contributed to our current understanding of the important mechanisms related to the process of pain transmission and treatment. Furthermore, they have permitted us to characterise receptor types and identify endogenous ligands involved in the mechanism of nociception. In this review, we discuss the recent advances that have occurred regarding plant-derived substances in the process of development of new analgesic drugs. Plants, such as Papaver somniferum, Cannabis sativa and those of the Capsicum and Salix species, have greatly accounted for the development of clinically relevant drugs which are useful for the management of pain disorders. The recent advances in our understanding of the mechanisms of action of the above plant-derived substances, together with use of molecular biology techniques, have greatly accelerated attempts to identify promising targets for the discovery of new, safe and efficient analgesic drugs. Despite the great progress which has occurred in the elucidation of pain transmission and despite decades of use, leaving aside its known undesirable sides effects, morphine continues to be one of the most used drugs in clinical practice for the treatment of pain disorders. Thus, safer and more efficacious analgesic drugs are urgently needed. A search through the literature reveals that many potentially active antinociceptive plant-derived compounds have been identified. However, studies aiming to investigate their cellular and molecular mechanisms of action and well-controlled clinical trials to prove their efficacy in humans are still lacking. Nevertheless, natural or synthetic substances that bind to vanilloid or cannabinoid receptors, or even those that are capable of modulating the endogenous ligands which bind to these receptors, are expected to soon appear to assist in the treatment of several pain disorders, including those of neuropathic or neurogenic origin.

Antinociceptive activity of a hydroalcoholic extract obtained from aerial parts of Sebastiania schottiana (Euphorbiaceae).

This study analyzed the antinociceptive effects of a hydroalcoholic extract obtained from the aerial parts of Sebastiania schottiana, a Brazilian medicinal plant used to treat various painful diseases. For this purpose, the writhing test, capsaicin and formalin induced-pain in mice were used. The results showed that the hydroalcoholic extract exhibited considerable antinociception in all the models studied, being more potent than aspirin.

[Somatisizing patients. Concrete recommendations for a stepwise therapy in general practice]. / Somatisierende Patienten. Konkrete Vorschläge für eine Stufentherapie in der Hausarztpraxis.

Patients with physical symptoms but no detectable organic substrate often present a challenge for the family doctor. The therapeutic approach discussed herein focuses on the development of a psychosomatic model of the problem. In this step-by-step approach, the patient's subjective understanding of, and attitude towards, his illness and its treatment are established, alternative psychosomatic models of disease based on a consideration of psychophysiological interactions are worked out jointly with the patient, and, finally, thought is given to the current complaints within the context of the patient's personality and life situation. The basis for successful treatment is an empathic and sound doctor-patient relationship based on trust that gives the patient the feeling that he and his problem are being taken seriously. The prerequisite for the use of such a program is appropriate training in basic psychosomatic care.

Attachment representation and cortisol response to the adult attachment interview in idiopathic spasmodic torticollis.

OBJECTIVE: The study investigates individual differences in the mental representation of attachment and their impact on the cortisol response to psychosocial stress in idiopathic spasmodic torticollis (IST). It was hypothesized (a) that in IST insecure attachment is more prevalent than in a non-clinical control group and (b) that subjects with dismissing attachment respond with higher physiological arousal to a specific stimulus activating the attachment behavioural system than subjects with secure attachment. METHOD: 20 patients with IST and 20 healthy controls matched for age and sex underwent the Adult Attachment Interview, an hour-long, semiclinical interview on attachment experiences. During the interview salivary cortisol levels were monitored. The subjects' mental state with regard to attachment was classified using the attachment Q-sort method. Anxiety and depression were measured as potential covariates of the adrenocortical stress response. RESULTS: Compared to the non-clinical group, dismissing attachment was strongly overrepresented in IST. In IST, but not in the healthy control group, dismissing attachment correlated with an elevated cortisol response to the interview. CONCLUSION: In clinical, but not in non-clinical samples dismissing attachment may be associated with increased vulnerability to psychosocial stress. The factors contributing to this interaction are not yet fully elucidated.

Alexithymia and attachment representation in idiopathic spasmodic torticollis.

We investigated alexithymia and the mental representation of attachment in idiopathic spasmodic torticollis (IST). It was hypothesized a) that alexithymia in IST is more prevalent than in a nonclinical control group and b) that significant correlations emerge between alexithymia and a dismissing attachment representation. Twenty patients with IST and 20 healthy controls matched for age and sex were administered the Toronto Alexithymia Scale (TAS-20) and the Adult Attachment Interview (AAI). Attachment was classified using the Attachment Interview Q-sort. IST patients scored significantly higher on the measure of alexithymia than subjects in the comparison group. In IST a dismissing attachment representation was significantly more frequent than in the control group. Across the total sample, externally oriented thinking correlated positively with dismissing attachment, and both externally oriented thinking and difficulty communicating feelings (two of the three subscales of the TAS-20) correlated inversely with secure attachment. Alexithymia is more prevalent in IST than in normals. As was hypothesized, alexithymia in adults is significantly interrelated with the mental representation of attachment.

[Not Available]. / Bindungsrepräsentation, Affektregulation und psychophysiologische Reaktionsbereitschaft - Anmerkungen zur Bedeutung neuerer Ergebnisse der Bindungsforschung für die Psychosomatik/ Attachment representation, affict regulation and psychophysiological reactivity - Comments on the relevance of current findings in the field of attachment research for psychosomatic medicin.

Theoretical issues and research emphasis within the field of attachment theory have shifted from attachment behavior "to the level of representation" (Bretherton, 1985) since the middle of the 80ies. The paper presents an overview on basic assumptions, research methodology and empirical findings in the field of attachment research. Four issues are addressed, which are relevant for psychosomatic research. These concern: (1) The prevalence of insecure attachment representation in psychosomatic disorders; (2) the association between insecure attachment representation and an increased psychophysiological reactivity; (3) the potential link between attachment and affect regulation and (4) the question, whether the classification of attachment representations may increase our understanding of specific aspects of illness behavior in psychosomatic conditions such as somatoform disorders.

Phytochemical and pharmacological analysis of different parts of Wedelia paludosa DC. (Compositae).

This study demonstrates the chromatographic profile and antinociceptive action of methanolic extracts obtained from different parts of Wedelia paludosa, a medicinal plant employed in folk medicine to treat dolorous processes. The results indicated that the root was the most potent part whereas the flower exhibited a weak antinociceptive activity. Comparative TLC suggested that all extract show different constituents or concentrations. Kaurenoic acid and stigmasterol were detected in all extracts and luteolin is present only in leaves and stems, but in small quantities. These results confirm our previous investigation on this plant and support its popular use for the treatment of algesic processes.

Chemical and pharmacological examination of antinociceptive constituents of Wedelia paludosa.

The present work describes the antinociceptive effects of some fractions and two pure compounds obtained from the Wedelia paludosa, a Brazilian medicinal plant employed in folk medicine against a variety of diseases, including dolorous pathologies. It was found that such fractions as well as kaurenoic acid and luteolin exhibit marked antinociceptive action in mice using acetic acid-induced writhing. They were more active than some well-known analgesic drugs, such as acetyl salicylic acid, acetaminophen, dipyrone and indomethacin. The results confirm our previous studies conducted with this plant, suggesting that different chemical constituents are responsible for the antinociceptive activity shown by the extracts and fractions prepared from W. paludosa.

Diagnostic and pathophysiological aspects of psychogenic tremors.

Psychogenic tremor has become a rare movement disorder. Twenty-five patients from our movement disorder unit presented either with obviously nonorganic body shaking during stance or with extremity tremors. A sudden onset and a variable but rarely remitting course of the condition was common. The "coactivation sign of psychogenic tremor" and absent finger tremor were the most consistent criteria to separate them from organic tremors. Quantitative analysis of tremor shows decreasing amplitudes in most organic tremors when the extremity is loaded with additional weights. In contrast, we found an increase of tremor amplitude for most of the cases with psychogenic tremor. This might be caused by increased coactivation to maintain the oscillation. These clinical and electrophysiological features suggest a clonus mechanism induced by coactivation as the pathophysiological basis of psychogenic extremity tremor. Psychiatric evaluation did not show overt signs of hysteria for the majority of the patients. However, we found depression and functional somatic or psychosomatic conditions to be frequent among the patients. A reduced ability to cope with stressful situations may play a significant role. The clinical course of the condition is usually far from benign. We conclude that psychogenic tremor can be positively diagnosed by means of neurologic signs in the majority of patients and is not only a diagnosis of exclusion. The poor outcome makes early and serious neuropsychiatric attempts at therapy necessary.

[Psychosomatic aspects of idiopathic spasmodic torticollis. Results of a multicenter study]. / Psychosomatische Aspekte des idiopathischen spasmodischen Torticollis. Ergebnisse einer multizentrischen Untersuchung.

Idiopathic spasmodic torticollis (IST) is one of the most frequent dystonic movement disorders. Its classification as a focal dystonia, as well as its treatment with botulinum toxin resulted in groups of patients being regularly seen by neurologic specialists. In a multicentre study, we investigated psychosocial changes, coping and psychopathology, and their interrelations with signs, symptoms and course. 256 patients were included in the study (59.3% women, 40.7% men). The mean age was 49.1 years. Rotating torticollis occurred more often than latero-retrocollis and antero-retrocollis. A family history of IST was seen in 3.1% of the total sample. 34% of the patients had additional dystonic symptoms. Most frequently, these affected the upper extremities (13%), less often the legs. 19.1% of the patients had experienced a period of complete remission. The General Symptom Index of the SCL 90-R in 27% of the patients ranged above the double standard deviation of the normal controls, indicating a clinically significant psychopathology.

Relative absence of psychopathology in benign essential blepharospasm and hemifacial spasm.

We report on the psychopathology and illness-related changes of life in patients with benign essential blepharospasm (BEB) or hemifacial spasm (HFS). Fifty-six patients with BEB and 40 patients with HFS completed the SCL 90R, a screening instrument for psychiatric symptomatology, and the Freiburg Questionnaire for Dystonia (FQD), a questionnaire about psychosocial changes in subjects with movement disorders. In both BEB and HFS patients, the mean scores on all but one subscale of the SCL 90R remained within the double standard deviation of normal. In comparing BEB to HFS patients in illness-related changes of life, BEB patients were more severely disabled in all areas of life examined. Psychological distress in BEB, but not in HFS, correlated with physical disability and in particular with impairment of vision.

[Diagnosis, symptoms and follow-up of psychogenic tremor]. / Diagnose, Symptomatik und Verlauf des psychogenen Tremors.

A total of 21 patients with psychogenic tremor (PT) were asked to take part in a neurologic and psychosomatic assessment; for 17 patients follow-up information was also recorded. Women out-numbered men in the sample. In the majority of patients the tremor was associated with a variety of other conversion symptoms. The clinical picture of the tremor varied. After beginning exclusively in the extremities, it tended to spread to other parts of the body. Other psychopathology (depression and histrionic personality disorder) existed in almost a third of the sample. Many patients had retired from professional life, or planned to do so in the near future, because of PT. At follow up the initial diagnosis was confirmed in all patients although in some patients additional physical illness had developed during the follow-up period. When neurological and psychiatric/psychosomatic criteria are applied the diagnosis of PT can be established reliably. Studies that have questioned the validity of the conversion concept on the basis of frequent misdiagnoses may indicate problems in the diagnostic procedure rather than an invalid theoretical construct.

Spasmodic torticollis - a multicentre study on behavioural aspects II: signs, symptoms and course.

This paper deals with signs, symptoms and course in spasmodic torticollis (ST). Two hundred and fifty-six patients were included in the study, 59.3% women, 40.7% men. The mean age was 49.1 years. Rotating torticollis out-numbered latero- and antero-retrocollis. A family history of ST occurred in 3.1% of the total sample. First degree relatives were affected in 2.3%. Thirty-four per cent of the patients had additional dystonic symptoms. Most frequently these affected the upper extremities (13%), and less often the legs. Of the patients 19.1% had experienced a period of complete remission. The correlations between the severity of the signs and the neurological symptoms are surprisingly weak.