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

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

Comorbidity of diabetes and eating disorders. Does diabetes control reflect disturbed eating behavior?

OBJECTIVE: This multicenter study was designed to explore the prevalence of clinical and subclinical eating disorders (EDs), the extent of intentional omission of insulin and oral antidiabetic agents, and its relationship to glycemic control in an inpatient and outpatient population of men and women with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS: Data have been collected from 12 diabetes medical centers in two German cities. In a questionnaire and interview-based study, a sample of male and female patients (n = 341 type 1, n = 322 type 2) was assessed for the following eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. For lack of interview data of several patients meeting the screening criteria, prevalence ranges were calculated. RESULTS: The overall prevalence range of current EDs was 5.9-8.0% (lifetime prevalence 10.3-14.0%). When patients were stratified according to type 1 and type 2 diabetes, there was no difference in prevalence of EDs. However, the distribution of the EDs was different in both types of diabetes, with a predominance of binge eating disorder in the type 2 diabetes sample. Type 1 (5.9%) and type 2 (2.2%) diabetic patients reported deliberate omission of hyperglycemic drugs (insulin or oral agents) in order to lose weight. Compared with control subjects, neither the presence of EDs nor insulin omission influenced diabetic control. CONCLUSIONS: There seems to be no difference in prevalence rates of EDs in both types of diabetes; however, distribution of EDs is different. The findings suggest that neither EDs nor insulin omission are necessarily associated with poor control of glycemia. Binge eating disorder seems to precede type 2 diabetes in most patients and could be one of the causes of obesity that often precedes type 2 diabetes.

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

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

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

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

Diabetes mellitus and eating disorders: a multicenter study on the comorbidity of the two diseases.

Because diet is a key issue in the treatment of diabetes mellitus, it is assumed that these patients are prone to eating disorders. In a multicenter study, we have therefore assessed the prevalence of eating disorders in 662 patients with insulin dependent diabetes mellitus (IDDM) (n = 340) and non-insulin-dependent diabetes mellitus (NIDDM) (n = 322). A two-stage study combining self-rating questionnaires and a standardized interview was carried out. We found a prevalence of eating disorders of 5.9% (lifetime prevalence of 10%), irrespective of gender and type of diabetes; 4.1% of the whole sample reported intentional insulin undertreatment or omission. When patients were stratified according to IDDM and NIDDM, there was no difference in the prevalence of all eating disorders (point prevalence 5.5% vs. 6.5%, lifetime prevalence 10.0% vs. 9.9%). Prevalence of bulimia nervosa (BN) was more frequent in IDDM patients (point prevalence 1.5% vs. 0.3%, lifetime prevalence 3.2% vs. 1.9%) and binge eating (BED) was more frequent in NIDDM patients (point prevalence 1.8% vs. 3.7%, lifetime prevalence 2.6% vs. 5.9%). We conclude that eating disorders seem to be equally frequent in IDDM and NIDDM patients. However, there might be different features of eating disorders in both types of diabetes.

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

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

[Individual therapy goals: on outcome documentation of inpatient psychotherapy from the patient and therapist viewpoint]. / Individuelle Therapieziele: Zur Ergebnisdokumentation stationärer Psychotherapie aus Patienten- und Therapeutensicht.

The results of a study evaluation in practicability of two newly developed documentation forms are presented. Examined are 82 inpatient treatment episodes in an already published clinical concept with different treatment settings. Parallel versions of the forms were completed by patients and therapists. The 'Erge-Doku-A-Form' allows for the naming of up to five therapy goals determined at the beginning of therapy and evaluated in relation to their achieved quality at the end of therapy. The 'Erge-Doku-B-Form' describes a variety of problem areas as well as questions related to medication and changes induced by therapy. Surprising there were a high number of 230 Individual Therapy Goals (ITG) by patients and 262 ITG by therapists which could be arranged into 89 content categories and 5 main categories. Outcome measurement shows different results. There was a significant relationship between the 'well-being', the impression of 'satisfying treatment' at the end of the inpatient period and 'success in the main ITG'. The documentation forms presented here allow an outcome-measurement depending on differential indications.

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

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

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

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

Psychosomatic evaluation of patients awaiting lung transplantation.

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

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

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

[Inpatient-ambulatory psychoanalytic group therapy, a useful concept]. / Stationär-ambulante psychoanalytische Gruppentherapie, ein brauchbares Konzept?

Concepts of group psychotherapy are standard in contemporary inpatient psychotherapy. The effective treatment combination of both inpatient and outpatient group psychotherapy, however, is less common. The following discussion evaluates the effectiveness of inpatient-outpatient group psychotherapy as a therapeutic method as well as its applicability for standard treatment.

Content analysis of follow-up interviews with inpatient/outpatient group psychotherapy patients.

In the follow-up project of the psychosomatic clinic at the University of Heidelberg, 45 patients were interviewed who had begun group psychotherapy in a closed group over 2.5 years with an inpatient treatment period of 3 months. The follow-up interviews carried out 2-5 years after the end of the outpatient treatment period are studied by content analysis. It could be demonstrated that the content of the two main categories 'Beginning' and 'End' of the inpatient period differs very much. Two patterns of 'beginners' could be distinguished. The importance of the evaluation of the former patients' spontaneous report as involved experts for psychotherapy research is discussed.

[Evaluative psychotherapy research: clinical relevance of psychotherapy catamnesis]. / Evaluative Psychotherapieforschung: Klinische Bedeutung von Psychotherapie-Katamnesen.

In this article we will depict the relevance of follow-up studies for evaluative psychotherapy research. Follow-up studies distinguish themselves from pure result studies in that they are clinically more meaningful as they examine the stability of psychotherapy results over a longer period of therapy-free time. The special methodical problems of follow-up studies are discussed and the minimal essentials for the research design of such studies are called for.

[Combination of methods and integration of methods as standard in psychotherapy?]. / Methodenkombination und Methodenintegration als Standard der Psychotherapie?

Psychotherapy has undergone a relatively brief but nonetheless dramatic development, but this resulted in an enormous variety, extensive diversity, and good treatment possibilities. Can we say at this stage that the combination and integration of different methods in psychotherapy are today's standards? The authors, a psychoanalyst and a behavioural therapist, consider a greater transparency between the various therapeutic schools as a goal that must still be aimed at before methods can be combined. If such a combination is finally achieved, a standard psychotherapeutic treatment may evolve, since patients suffering from eating disorders, compulsive behaviour or anxiety would profit more from such treatment than from a merely "school"-oriented therapy. Initial ideas for achieving an integration of methods are discussed in respect of inherent limitations and risks.

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

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

[Therapy dropouts in closed groups]. / Therapieabbrecher in geschlossenen Gruppen.

Drop-outs in group psychotherapy are an everyday clinical problem. A premature quitting by one patient may have great consequences, especially in closed groups, not only for the drop-out but also for the remaining group members. Compared to the clinical relevance, empirical research on the conditions leading to a premature termination is quite meagre. Empirical basis of the study presented here are 58 groups with a total of 445 patients with a variety of symptoms and personality structures. All groups started with a 3 month inpatient period and were continued as a closed outpatient group for about 2 years. 110 patients (24.7%) left the group at least 3 months before the agreed end of the group. Empirical research on conditions leading to the premature drop-out is based on three perspectives: 1. patient-oriented: The values of certain patient variables e.g. symptoms, personality structure, socio-economic status etc. are considered as potential predictors. 2. institution-oriented: Here group characteristics are considered as the pool of potential predictors: e.g. group size, decisions made under time pressure, cotherapy etc. 3. group-oriented: The values of patient variables for one patient in relation to other group members (e.g. "isolated position") is considered here. From each perspective we were able to find potential relevant predictors.