Perceptual body image of patients with anorexia or bulimia nervosa and their fathers.

PURPOSE: Little is known about how fathers of patients with eating disorders perceive their own body. In this study we investigated body image perception of patients with anorexia and bulimia nervosa and body image perception of their fathers in a computer assisted approach. METHODS: A computer program, the somatomorphic matrix, is presented that allows modeling of perceived and desired body-images of patients and their relatives. Patients and fathers rated their own body images and fathers additionally rated the body images of their daughters. The images implemented in the program correspond with defined percentages of body fat and muscularity. Selected images were compared with subjects' anthropometric data regarding body fat and muscularity. Data from 42 father-daughter-dyads (27 patients with anorexia, 15 with bulimia nervosa) were examined. Differences between both diagnostic groups were compared and associations between fathers' and daughters' body image perceptions within each group were investigated. RESULTS: Patients with anorexia nervosa overestimated their bodies on the body fat dimension. Patients with bulimia nervosa wished to have a body with less fat. Fathers of both groups of patients perceived their own bodies correctly but wished to have less body fat and to be more muscular. The wish for a change in body fat of anorexia nervosa patients was highly correlated with fathers' BMI (r=0.49; p=0.009). The wish for a change in body fat of bulimia nervosa patients was correlated with fathers' distorted body image perception in terms of muscularity (r=-0.66, p=0.007) and with fathers' wish for a more muscular body (r=-0.51, p=0.05). CONCLUSION: Body images of patients with eating disorders and their fathers are related in the group of patients with bulimia nervosa. Perhaps, body images of fathers should be addressed in family therapy with patients with bulimia nervosa.

The Luebeck interview for psychosocial screening in patients with inflammatory bowel disease.

BACKGROUND: Psychosocial factors play an important role in the course of inflammatory bowel disease (IBD). However, a simple, valid psychosocial screening instrument that is suitable for short patient-physician contacts does not exist. Therefore, the Luebeck semistructured Interview for Psychosocial Screening was developed as a rating tool for psychosocial stress in IBD patients (LIPS-IBD). METHOD: The entire interview requires approximately 10 minutes. Interrater reliability was tested. Depression, anxiety, social support, impact of the disease, global level of psychosocial stress, and demand for psychosocial support were rated in 92 patients with IBD on 5 point Likert scales. Patients from the in- and out-patient clinic for gastroenterology were included. In addition, patients filled out self-report questionnaires regarding depression, anxiety, social support, and impact of the disease. Indices of disease activity (Colitis Activity Index, Crohn's Disease Activity Index) were recorded. RESULTS: Both patients and physicians found the interview feasible. Reliability was good, with interrater reliability ranging from .76 to .94. Convergence with self-report instruments was also high (r = .5-.6). Ratings of depression and impact of the disease were correlated with indices of disease activity. DISCUSSION: LIPS helps to identify patients with high levels of psychosocial stress and provide them with more detailed psychologic assessments. It was found to be a suitable instrument for daily clinical routine. It is potentially a valuable screening tool to obtain reliable, valid, and useful information in daily practice in IBD treatment settings.

European evidence based consensus on the diagnosis and management of Crohn's disease: special situations.

This third section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn's disease.

Influence of anxiety on the course of heart disease after acute myocardial infarction - risk factor or protective function?

BACKGROUND: There is a lack of clarity concerning the effect of anxiety on the course of cardiac events following myocardial infarction. Some studies have identified anxiety as a risk factor for further cardiac events. However, it is also considered to be a protective factor, as a higher level of anxiety may improve patient compliance and regular medical checkups. METHODS: A group of 76 patients with myocardial infarction underwent physical examination and had their anxiety levels assessed within the first week, and 31 months after myocardial infarction. Cardiac events were documented during the follow-up period. We investigated the predictive value for the occurrence of cardiac events of sociodemographic, psychological and physical parameters when evaluated within the first week after myocardial infarction. Compliancy and regularity of medical checkups were registered. RESULTS: Cardiac events occurred in 24 patients during a mean follow-up period of 31 months. The group of anxious patients not only suffered more often from cardiac events, these events also occurred earlier than in nonanxious patients. Age, gender, partner status, level of anxiety and comorbid diabetes at the time of first assessment proved to be discriminatory variables between patients suffering further cardiac incidents and those free of further events. Anxious patients were more likely to continue smoking, whereas less anxious patients were more likely to give up smoking.

[Psychosocial screening in coronary heart disease: 5 decisive questions]. / Psychosoziales Screening bei koronarer Herzkrankheit: fünf entscheidende Fragen.

There is overwhelming convincing evidence linking psychosocial factors to outcome of patients with coronary heart disease. Thus, assessment of psychosocial variables should be an integrated part of risk stratification. To facilitate psychosocial assessment in clinical practice and to identify a subset of patients possibly benefitting from extended psychological measures, a new semistandardized interview instrument is presented, called LIPS ("Lübecker halbstandardisiertes Interview zum Psychosozialen Screening"). Beside the well-known and relevant domains social support, emotional stress/vital exhaustion, anxiety and depression, a score for the global psychosocial impairment can be documented. LIPS requires no specialized psychological training, its time requirement is five to ten minutes and it is easily integrated into routine physical and psychosocial assessment. The presentation includes the original instrument in addition to its validation on standardized self-administered questionnaires.

[Education of patients with inflammatory bowel diseases]. / Die Krankheitsaufklärung von Patienten mit entzündlichen Darmerkrankungen.

Patients with chronic inflammatory bowel disease were interviewed about their degree of satisfaction with the medical information provided by the professional staff and the reasons for their satisfaction. 30 patients, suffering from ulcerative colitis or Crohn's disease, underwent semistandardized interviews with the result that professional education about their disease was provided either in a single concluding session or in several consecutive sessions. The patients were informed about the diagnosis, the assumed etiology and medical treatment, yet much less frequently were they told about the course of their disease or its possible consequences. On the average the clarifying sessions did not take more than 10 to 15 minutes. Only 50% of the patients were able to fully understand the information they received. 40% were dissatisfied. Greater patient satisfaction was related to more time, more detailed explanation, and emotional support by the physician. These facts should be seriously considered during medical training.

Mesenteric blood flow is related to disease activity and risk of relapse in Crohn's disease: a prospective follow-up study.

OBJECTIVE: The diagnostic significance of increased splanchnic blood flow in Crohn's disease is unclear. This prospective study was therefore undertaken to define the role of Doppler sonography in the assessment of disease activity and in the prediction of early relapse. METHODS: Splanchnic flowmetry was performed in 59 patients with Crohn's disease and 20 healthy volunteers during fasting and 30 min after ingestion of a standardized meal. Twenty-one patients measured during the active state and in clinical remission were followed-up for 6 months. Hemodynamic parameters of the superior and inferior mesenteric arteries and the portal vein were related to clinical (Crohn's disease activity index [CDAI]), laboratory (C-reactive protein), and endoscopic (Crohn's Disease Endoscopic Index of Severity) parameters of disease activity. RESULTS: The postprandial mean velocity of the superior mesenteric artery correlated closest with clinical activity (CDAI, p < 0.005) and C-reactive protein (p < 0.01), but was unrelated to endoscopic activity. All patients in remission after 6 months (9/9) showed an increase in postprandial pulsatility index of the superior mesenteric artery, compared with an initial measurement during active disease (+28%). In contrast, the majority of patients with later relapse or surgery (11/12) had decreased pulsatility index during initial remission (-20%). The positive predictive value of this index for maintenance of remission was 0.82. CONCLUSIONS: Postprandial flow measurements in the superior mesenteric artery are closely related to clinical but not endoscopic disease activity in patients with Crohn's disease. The repeated measurement of the postprandial pulsatility index allows estimation of the risk of recurrence.

Mesenteric blood flow is related to disease activity and risk of relapse in ulcerative colitis: a prospective follow up study.

BACKGROUND: The diagnostic significance of increased splanchnic blood flow in ulcerative colitis is unclear. This prospective study was therefore undertaken to define the role of Doppler sonography in the assessment of disease activity and in the prediction of early relapse. SUBJECTS/METHODS: Splanchnic flowmetry was performed in 76 patients with ulcerative colitis (47 with active disease and 29 in remission), six with infectious colitis, and 13 healthy controls during fasting and 30 minutes after ingestion of a standardised meal. Twenty seven of the patients with ulcerative colitis and all patients with infectious colitis were investigated during the active state as well as in clinical remission and followed up for six months. Flow velocity and pulsatility index (PI) of the superior (SMA) and inferior (IMA) mesenteric arteries and the portal vein were related to clinical (Truelove index), laboratory (C-reactive protein), and endoscopic (Sutherland index) parameters of disease activity. RESULTS: The mean flow velocity of the IMA correlated closest with clinical activity (Truelove, r = 0.41, p<0.005), the PI with C-reactive protein (r = 0.30, p<0.05), and endoscopic activity (r = 0.45, p<0.001). All patients in remission after six months (14/14) or with infectious colitis (6/6) showed an increase in PI of the IMA compared with the initial measurement during active disease (mean increase for ulcerative colitis +36% and for infectious colitis +77%). In contrast, most patients with later relapse or surgery (11/13) had decreased PI during initial remission (mean decrease -12%). The positive predictive value of this index for maintenance of remission was 0.77. Flow variables of the SMA and portal vein displayed weaker correlations. CONCLUSIONS: Flow measurements in the IMA are closely related to clinical and endoscopic disease activity in patients with ulcerative colitis. Repeated measurement of the PI allows estimation of the risk of recurrence.

Mucosal cytokine expression, cellular markers and adhesion molecules in inflammatory bowel disease.

OBJECTIVE: To relate proinflammatory cytokines to leukocyte surface markers and adhesion molecules in the same paraffin-embedded biopsy specimen in inflammatory bowel disease (IBD) of varying activity. METHODS: Biopsies of seven cases of Crohn's disease, seven patients with ulcerative colitis, one case of intestinal infection and six control subjects were studied. We performed in situ hybridization on sections of tissue using probes specific to interleukin-1beta (IL-1beta), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF alpha). Leucocyte markers and adhesion molecules were investigated in subsequent slides of selected specimens by immunohistochemistry. RESULTS: Cytokine mRNA was found in large numbers of cells throughout the inflamed intestine but also in some macroscopically unaffected tissue specimens. Transcripts were predominantly located within the lamina propria where immunohistochemistry of parallel sections revealed numerous macrophages and the presence of endothelial adhesion molecules. The expression of the different cytokines was closely related to each other and to histological but not to macroscopic (endoscopic) activity. CONCLUSIONS: The synthesis of IL-1beta IL-6 and TNF alpha mRNA is coordinately regulated. Cytokine production is located mostly in the lamina propria at sites that are rich in macrophages and show abundant staining of vascular adhesion molecules. This cascade of immune events is related to inflammatory cell infiltration in both Crohn's disease and ulcerative colitis.

Fetal hemoglobin in starvation ketosis of young women.

Ketones can reactivate the production of fetal hemoglobin (HbF) in vitro and in vivo. A reactivation of HbF by ketones, which are generated during starvation, remains largely speculative. Therefore, we investigated HbF in 31 women with anorexia nervosa or bulimia, using both of these as models of intermittent starvation ketosis. For comparison, we also studied 42 female control subjects matched for age. beta-Hydroxybutyrate levels were higher in patients than in controls (460 +/- 90 v 110 +/- 20 mumol/L; P < .0001). We correlated beta-hydroxybutyrate, metabolic, and hematologic parameters with HbF. HbF was measured with high pressure liquid chromatography. The data were analyzed with logistic regression analysis. An elevated HbF fraction (> 0.87%) was observed four times as often in patients than in controls (29% v 7%, P = .01). After adjustment for age, we found HbF elevations associated with beta-hydroxybutyrate levels (P = .005). No other correlations between the various metabolic/ hematologic parameters and HbF were significant. In conclusion, beta-hydroxybutyrate generated in starvation is associated with increased levels of HbF. Thus, unrestrained lipolysis can produce beta-hydroxybutyrate in sufficient quantities to induce a clinically measurable amount of HbF. These findings suggest that intermittent ketosis might also explain some increases of HbF in type 1 diabetes and pregnancy.

Effect of psychotherapy on the course of Crohn's disease. Results of the German prospective multicenter psychotherapy treatment study on Crohn's disease. German Study Group on Psychosocial Intervention in Crohn's Disease.

BACKGROUND: Our aim was to study the influence of psychotherapy in addition to a standardized corticosteroid treatment on the somatic and psychosocial course of Crohn's disease. METHODS: In a prospective, randomized multicenter study 108 of 488 patients received either drug treatment or, in the intervention group, additionally psychotherapy in the first half of the 2-year follow-up period. RESULTS: Eighty-four patients (77.8%) completed the somatic and 81 (75%) the psychosocial follow-up. Twenty-three per cent of the control group and 30% of the psychotherapy group showed episode-free courses; 29% and 17%, respectively, underwent surgery due to failure of drug treatment. The main analysis, which was based on subranking by number, duration, and severity of relapses, failed to show significant differences between the two groups (P = 0.125). The same result was obtained for the psychosocial status after 1 year in the main target criteria depression, anxiety, psychosocio-communicative status, and quality of life. CONCLUSIONS: The confirmatory analysis did not prove significantly better courses after additional psychotherapy. There was a tendency towards fewer operations.

Concepts of psychosomatic disorders in ICD-10: results of the Research Criteria Study.

The multicenter study with the research criteria in the field of psychotherapy/psychosomatic medicine considered nine cases. One patient with cardiac neurosis (F45.3) and one patient with a persistent somatoform pain disorder (F54.4) were diagnosed in category F45.x. The rater agreement was 63-68%. 54% of the correct diagnoses made for three cases of colitis ulcerosa and Crohn's disease concurred (28%, 50%, and 80%). The case of anorexia nervosa (F50.0) was coded correctly by all of the raters, while the agreement for bulimia (F50.2) was 82%. Only 50% of the raters correctly assigned the dissociative disorder (F44.4). The agreement achieved for factitious disorder (F68.1) was 54%. Across all the psychosomatic disorders in ICD-10 there was an agreement of 65%. This result is markedly lower than the overall agreement of the Research Criteria Study (78%). Cardiac neurosis and bulimia were given a favorable prognosis. A more reticent psychotherapeutic commitment was seen for the classical psychosomatic disorders, persistent pain disorder, and factitious disorder. Anorexia nervosa and dissociative disorder assumed an intermediate position.

[Description of musical expression and initial results of the Lübeck music therapy model]. / Beschreibung des musikalischen Ausdrucks und erste Ergebnisse im Lübecker Musiktherapiemodell.

In the Medical University of Lübeck (Germany), T. Maler developed a music group therapy, which was based on psychoanalytic theories. In the years from 1984-1991, the behavior of 200 patients in the music therapy was assessed by means of new constructed rating scales. The patients had different kinds of psychosomatic and psychiatric disorders. The results show significant changes in the music playing behavior after 10 sessions of music therapy. The patients playing was louder, more free in the improvisation and showed more plasticity. There were no differences between the different diagnostic groups in the study.

[The significance of recurrence-inducing events for patients with chronic inflammatory bowel diseases. Results of a prospective longitudinal study over three years]. / Die Bedeutung rezidivauslösender Ereignisse bei Patienten mit chronisch entzündlichen Darmerkrankungen. Ergebnisse einer prospektiven Längsschnittstudie über drei Jahre.

This study examined whether life event stress under general or more specific conditions (fear of separation, feeling of being under pressure, feeling of being caught between two quarreling parties, separation experiences) contribute to the aggravation of inflammatory bowel disease. Firstly, 51 patients with ulcerative colitis, 57 patients with Crohn's disease, and 60 controls were compared in terms of these variables. In addition, the IBD patients filled out questionnaires regarding life events, the specific psychological conditions mentioned above, and their symptoms several times in the three years after the first measurement. By means of group comparisons and intraindividual correlations between relapse precipitating life events and illness activity, only feelings of being under pressure showed a modest correlation to the disease activity. We conclude that the variables in question have little influence on the beginning of the relapse.

[Presentation and initial results of an expanded diagnostic key for psychosomatic diseases in ICD-9 and ICD-10]. / Darstellung und erste Ergebnisse eines erweiterten Diagnoseschlüssels für psychosomatische Erkrankungen in ICD-9 und ICD-10.

In 1986, an extended diagnostical classification of psychophysiologic disorders (psychosomatic diseases, ICD-9: 316) was developed at the Medical University of Lübeck. The extension consisted of 3 additional code numbers, in which the attached organic system, the kind of the psychological symptoms and the kind of the underlying psychological disturbance could roughly be categorised. The experiences with this additional code numbers on 789 patients are reported. The results show that the additional code numbers are very practical and that they provide important therapeutical information. It is suggested, that in ICD-10 a differentiated classification of psychophysiologic disorders should be established.