Relations between a standardized experimental stressor and cutaneous sensory function in patients with chronic pruritus and healthy controls: an experimental case-control study.

BACKGROUND: While chronic pruritus (CP) is a frequent symptom, many aspects of its underlying pathophysiological mechanisms still need elucidation. Research on sensory cutaneous function and on the influence of stress has been conducted mainly in patients with atopic dermatitis but is lacking for patients with CP. OBJECTIVE: To assess whether a standardized social stressor influences cutaneous sensory function in patients with CP in comparison with healthy controls (HC). METHODS: Case-control study; 33 CP and 30 HC were submitted to the standardized quantitative sensory testing protocol before and after the Trier Social Stress Test and 1 h later. Intraepidermal nerve fibre density (IENFD) was determined. RESULTS: Mechanical pain sensitivity and mechanical detection thresholds were significantly higher in CP than in HC, and mechanical detection thresholds increased more in CP than in HC over the three measurements. In both groups, cold pain threshold increased and heat pain threshold decreased from before to after the stress test and remained constant 1 h later. Only in CP, almost all QST tests induced at least a small amount of pruritus, which was not significantly altered by the stress test. IENFD in pruritic skin was significantly reduced in CP when compared to healthy controls. CONCLUSION: Peripheral thermal sensory function was not altered in CP despite reduced IENFD in lesional skin, but we could demonstrate central sensitization processes specifically in CP and influences of an acute stressor inducing more sensitivity to thermal pain in both groups.

How do patients with anorexia nervosa "process" psychotherapy between sessions? A comparison of cognitive-behavioral and psychodynamic interventions.

OBJECTIVE: Patients' processing of psychotherapy between sessions ("inter-session process" (ISP)) has been repeatedly shown to be related to outcome. The aim of this study was to compare ISP characteristics of cognitive-behavioral vs. psychodynamic psychotherapy in the treatment of anorexia nervosa (AN) and their relation to outcome. METHODS: Data of 106 patients participating in a randomized-controlled trial who received either 40 sessions of enhanced cognitive-behavioral therapy (CBT-E) or focal psychodynamic therapy (FPT) were analyzed. The ISP was measured with the Inter-session Experience Questionnaire (IEQ). Three outcome classes were distinguished: full recovery, partial recovery, and still fulfilling all AN criteria. RESULTS: Patients receiving CBT-E reported more on "applying therapy" in the initial and the final treatment phase compared to FPT patients. In terms of process-outcome relations, higher levels of "recreating the therapeutic dialogue between sessions," "recreating the therapeutic dialogue with negative emotions" as well as "applying therapy with negative emotions" in the final phase of treatment predicted negative outcome in FPT, whereas overall higher levels of negative emotions predicted negative outcome in CBT-E. CONCLUSIONS: In outpatient treatment in AN, the processing of therapy as measured by the IEQ showed surprisingly few differences between CBT-E and FPT. However, different ISP patterns were predictive of outcome, pointing to different mechanisms of change.

[Definition, classification, clinical diagnosis and prognosis of fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. / Definition, Klassifikation, klinische Diagnose und Prognose des Fibromyalgiesyndroms : Aktualisierte Leitlinie 2017 und Übersicht von systematischen Übersichtsarbeiten.

BACKGROUND: The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017. METHODS: The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A systematic search of the literature from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines. RESULTS AND CONCLUSION: The clinical diagnosis of fibromyalgia syndrome can be established by the American College of Rheumatology (ACR) 1990 classification criteria (with examination of tender points) or without the examination of tender points by the modified preliminary diagnostic ACR 2010 or 2011 criteria.

[Etiology and pathophysiology of fibromyalgia syndrome : Updated guidelines 2017, overview of systematic review articles and overview of studies on small fiber neuropathy in FMS subgroups]. / Ätiologie und Pathophysiologie des Fibromyalgiesyndroms : Aktualisierte Leitlinie 2017 und Übersicht von systematischen Übersichtsarbeiten sowie eine Übersicht über Studien zur Kleinfaserpathologie bei Subgruppen des FMS.

BACKGROUND: The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was planned for April 2017. METHODS: The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A systematic search of the literature from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Prospective population-based studies and systematic reviews with meta-analyses of case control studies were taken into consideration for the statements. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The statements were generated by multiple step formalized procedures. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines. RESULTS: Current data do not enable identification of distinct factors in the etiology and pathophysiology of fibromyalgia syndrome. Fibromyalgia syndrome can be associated with inflammatory rheumatic diseases, gene polymorphisms, life style factors (e.g. smoking, obesity and lack of physical activity), depressive disorders as well as physical and sexual abuse in childhood and adulthood. CONCLUSION: Fibromyalgia syndrome is most probably the end result of various pathogenetic factors and pathophysiological mechanisms.

Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive-behavioural therapy in out-patients with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive-behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN. METHOD: The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost-utility and assumptions underlying the base case were investigated in exploratory analyses. RESULTS: Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends. CONCLUSIONS: Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

[Psychological consequences of earlier and acute traumatization in the elderly. Clinical presentation, diagnosis, and therapy]. / Psychische Folgen von früheren und akuten Traumatisierungen bei Älteren. Klinische Präsentation, Diagnostik und Therapie.

BACKGROUND: The general scientific literature of psychotraumatology does not pay regard to people older than 60 years, although the generation of children who experienced World War II in Europe was severely affected. In addition, there is the possibility of acute traumatic experiences in old age. METHODS: Based on a literature search, we provide a survey of the symptomatology of acute and earlier trauma in older people and of the psychotherapeutic and pharmacological treatment options. CONCLUSION: It is essential to establish a careful differential diagnosis to distinguish somatization from trauma reactivation in the elderly. The prognosis regarding relief of post-traumatic stress symptoms by trauma-exposing methods appears to be as good as in middle-aged adults; however, limitations on the patient's side should be taken into consideration.

[Etiology and pathophysiology of fibromyalgia syndrome]. / Ätiologie und Pathophysiologie des Fibromyalgiesyndroms.

BACKGROUND: The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS: The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. RESULTS: Current data do not identify distinct etiologic or pathophysiological factors mediating development of FMS. The development of FMS is associated with inflammatory rheumatic diseases (EL2b), with gene polymorphisms of the 5-hydroxytryptamine (HT)(2) receptor (EL3a), lifestyle factors (smoking, obesity, lack of physical activity; EL2b), physical and sexual abuse in childhood and adulthood (EL3a). CONCLUSION: FMS is most likely the result of various pathogenetic factors and pathophysiological mechanisms. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Brain correlates of hypnotic paralysis-a resting-state fMRI study.

Hypnotic paralysis has been used since the times of Charcot to study altered states of consciousness; however, the underlying neurobiological correlates are poorly understood. We investigated human brain function during hypnotic paralysis using resting-state functional magnetic resonance imaging (fMRI), focussing on two core regions of the default mode network and the representation of the paralysed hand in the primary motor cortex. Hypnotic suggestion induced an observable left-hand paralysis in 19 participants. Resting-state fMRI at 3T was performed in pseudo-randomised order awake and in the hypnotic condition. Functional connectivity analyses revealed increased connectivity of the precuneus with the right dorsolateral prefrontal cortex, angular gyrus, and a dorsal part of the precuneus. Functional connectivity of the medial frontal cortex and the primary motor cortex remained unchanged. Our results reveal that the precuneus plays a pivotal role during maintenance of an altered state of consciousness. The increased coupling of selective cortical areas with the precuneus supports the concept that hypnotic paralysis may be mediated by a modified representation of the self which impacts motor abilities.

Cerebral mechanisms of experimental hyperalgesia in fibromyalgia.

The present study examined the hyperresponsiveness of the central nervous system in patients with fibromyalgia syndrome (FMS) related to mechanical hyperalgesia. The goals were to differentiate between increased pain ratings and hyperalgesia related either to peripheral or to central sensitization and to correlate with cerebral activation pattern. Seventeen patients and 17 healthy controls were examined, placing an experimental incision in the right volar forearm and causing tonic pain. Experimental pain, primary and secondary hyperalgesia were assessed during the time course of the experimental pain, and the changes in hyperalgesia were correlated to brain activation (functional magnetic resonance imaging). Patients with FMS experienced the experimental pain during the time course as more painful than healthy controls (F(score) = 3.93, p(score) = 0.008). While they did not present a different course of primary hyperalgesia (F(score) = 1.01, p(score) = 0.40), they did show greater secondary hyperalgesia (F(score) = 5.45, p(score) = 0.004). In patients with FMS, the cerebral pattern corresponding to secondary hyperalgesia was altered. The activity in the dorsolateral prefrontal cortex was inversely correlated with secondary hyperalgesia in healthy controls (R = -0.34 p = 0.005); in patients, this correlation was disrupted (R = 0.19 p = 0.12). These findings point to an alteration of pain transmission at the central level in FMS (e.g., loss of inhibition) and might be related to changes in cerebral-midbrain-spinal mechanisms of pain inhibition.

[The "Sisi syndrome": a new form of depression?]. / Das "Sisi-Syndrom"--eine neue Depression?

A new depressive entity called the "Sisi syndrome," named in reference to the former empress of Austria, was introduced by a drug company in 1998. Their advertising campaign presents information about nosology, symptoms, and recommended therapy. We review the relevant literature about this syndrome and are not able to confirm the statements about it. The lack of scientific proof of it as an independent entity of depression stands in contrast to the widespread media coverage in Germany, which was organized by a public relations company. Therefore, we discuss new kinds of marketing strategies ("disease mongering") by drug companies and conclude with some preventive recommendations.

[The operational diagnostic approach of the borderline personality disorder. An interview of psychiatrists and psychologists according to their concept of the syndrome]. / Operationalisierte Diagnostik der Borderline-Persönlichkeitsstörung. Eine Befragung von Psychiatern und Psychologen bezüglich ihrer Syndromvorstellungen.

Despite the diagnostic criteria of the ICD-10 and DSM-IV, the term borderline has been used in a non-specific way for a long time. For our investigation we constructed a questionnaire, which contained the ICD-10 diagnostic criteria for the borderline personality disorder (BPD), plus the criteria for the other personality disorders and for the schizotype disorder. The two additional criteria for the BPD used by the DSM-IV were added. 800 psychiatrists and psychologists were asked to mark all criteria, which they thought were typical for the BPD. By using the operational diagnostic approach for ICD-10 and DSM-IV a disorder was diagnosed from each of the 162 received questionnaires based on the marked criteria. 92.0% of the questionnaires contained marked criteria for the diagnosis of the BPD by ICD-10 and 96.3% by DSM-IV. In addition each questionnaire contained up to eight other diagnosis. This is a sign for the difficulty to separate the BPD from other personality disorders or the schizotype disorder by using operationalized criteria. Looking at the lack of specificity of the operational diagnostic systems for personality disorders, e.g. for the BPD which has been discussed by many authors for years, modification of the diagnostic systems should be considered.

Polythetic diagnostic approach to the borderline personality disorder. the valency of the single criterion in the concept of professional therapists.

The present study addresses the question whether the polythetic approach of ICD-10 and DSM-IV is useful in clinical practice for the diagnosis 'Borderline' personality disorder (BPD). A questionnaire containing all individual criteria for the 9 personality disorders and the schizotypal disorder used by the ICD-10, completed by the DSM-IV criteria for the BPD not covered by the ICD-10, was developed. Eight hundred therapists were asked to mark the importance of every single criterion for forming the diagnosis or for ruling out BPD. Our data analysis of the received questionnaires performed a rankscore based on an altered calculation of the mean value. The criteria which described the patients' instability in relationship and mood, and identity disturbances were seen as the most important features for the diagnosis of BPD. The criterion of cognitive disturbances, newly introduced in DSM-IV, was not felt to be a major clinical feature. In conclusion, our study reflects the results of other authors in the sense that a single criterion cannot be considered pathognomonic for BPD, but has greater importance and a higher priority in establishing the diagnosis BPD. This should be taken into account to reconsider the polythetic concept in favor of a hierarchical approach with core criteria.

[Diagnosis related groups in psychiatry and psychotherapy--alternatives to DRGs]. / DRGs in der Psychiatrie und Psychotherapeutischen Medizin. Uberblick über die Entwicklung alternativer Klassifikation.

Diagnosis related groups (DRGs) will be introduced in Germany in 2003 as a basis for hospital funding in all areas except for psychiatry and psychotherapeutic medicine. The following article provides an overview of the use of alternative casemix-systems in the treatment of patients with mental disorders. Overall, DRGs and alternative systems have proven to be poor predictors of resource consumption due to the high variation in the length of stay and the variable treatment opportunities. Therefore, a DRG-system must include the possibility of coded therapeutic treatments, analogous to the procedures used in surgical DRGs, in order to integrate psychiatry and psychotherapeutic medicine into a DRG-based payment system.