Increased Alexithymia But No Profound Emotion Processing Disorder in Burnout Syndrome.

Our objectives were to investigate alexithymia in burnout patients while controlling for depression and anxiety, as well as to evaluate whether alexithymia may be part of a profound emotional processing disorder or of a mentalization deficit. Alexithymia, depressive, and anxious feelings were compared in patients with burnout, depression, and healthy controls using an age-, sex-, and education-matched cross-sectional design (n = 60). A facial emotion recognition task and an emotional mentalizing performance test as well as physical and emotional violation experiences were conducted. Alexithymia was significantly increased in burnout patients, mediated by negative affect in this group. No impairment of facial emotion recognition or mental attribution could be shown. Burnout patients demonstrated slightly increased emotional abuse experiences in early childhood. The present results corroborate the supposition that alexithymia in burnout primarily depends on affect and may rise due to current strain and overload experience, rather than based on a profound developmental disorder in emotion processing.

Modern peptide biomarkers and echocardiography in cardiac healthy haemodialysis patients.

BACKGROUND: In this prospective study, we aimed to assess the haemodynamic changes before and after haemodialysis (HD) in cardiac healthy subjects on chronic HD by imaging methods and endocrine markers of fluid balance. METHODS: Mid-regional pro-atrial natriuretic peptide (MR-proANP), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), vasopressin (AVP) and copeptin (CT-proAVP), metanephrines and normetanephrines, renin and aldosterone, standard transthoracic echocardiography and diameter of vena cava inferior (VCID) were performed in 20 patients with end stage renal disease (CKD5D) before and after HD and were stratified in residual excretion (RE, less or more 0.5 l) and ultrafiltration rate (UF, less or more 2 l). RESULTS: Copeptin was significantly higher in patients before HD. Copeptin was inversely correlated with haemodialysis treatment adequacy (KT/v), RE and UF, but was not significantly influenced by age, gender and body mass index (BMI). MR-proANP was significantly reduced by haemodialysis by 27% and was inversely correlated with KT/v, but there was a significant influence by UF, RE, age, gender and BMI. NT-proBNP was significantly higher in patients before HD and was not influenced by RE and UF. Renin, aldosterone, metanephrines and normetanephrines did not demonstrate significant differences. Echocardiographic parameters and VCID were significantly correlated with RE, UF and copeptin. CONCLUSION: Modern biomarkers will provide cardiovascular risk assessment, but elimination (UF), RE and other factors may influence the serum concentrations, e.g. in patients with renal impairment. The interpretation will be limited by altered reference ranges, and will be restricted to individual courses combined with clinical and echocardiographic data.

Effects of intranasal oxytocin on thermal pain in healthy men: a randomized functional magnetic resonance imaging study.

OBJECTIVE: Intranasal oxytocin has been shown to affect human social and emotional processing, but its potential to affect pain remains elusive. This randomized, placebo-controlled, double-blind, crossover trial investigated the effect of intranasal oxytocin on the perception and processing of noxious experimental heat in 36 healthy male volunteers. METHODS: Thermal thresholds were determined according to the Quantitative Sensory Testing protocol. A functional magnetic resonance imaging experiment including intensity and unpleasantness ratings of tonic heat was used to investigate the effects of oxytocin within the brain. RESULTS: Thirty men (aged 18-50 years) were included in the study. Intranasal oxytocin had no significant effect on thermal thresholds, but significantly (t = -2.06, p = .046) reduced heat intensity ratings during functional magnetic resonance imaging. The effect on intensity ratings was small (-3.46 points on a 100-point visual analog scale [95% confidence interval {CI} = -6.86 to -0.07] and independent of temperature. No effects of oxytocin on stimulus- or temperature-related processing were found at the whole-brain level at a robust statistical threshold. A region of interest analysis indicated that oxytocin caused small but significant decreases in left (-0.045%, 95% CI = -0.087 to -0.003, t = -2.19, p = .037) and right (-0.051%, 95% CI = -0.088 to -0.014], t = -2.82, p = .008) amygdala activity across all temperatures. CONCLUSIONS: The present study provides evidence for a significant but subtle inhibitory effect of oxytocin on thermal stimulus ratings and concurrent amygdala activity. Neither of the two effects significantly depended of temperature; therefore, the hypothesis of a pain-specific effect of oxytocin could not be confirmed. TRIAL REGISTRATION: EUDRA-CT 2009-015115-40.

Severe chronic insomnia is not associated with higher body mass index.

Short sleep duration is widely considered to be a risk factor for weight gain, suggesting that patients suffering from sleep disorders are a risk group. Despite some positive preliminary data on patients with organic sleep disorders, empirical evidence for an increased body mass index in patients with insomnia is scarce. Two-hundred and thirty-three patients with a confirmed diagnosis of severe and chronic insomnia without co-morbidity showing objectively impaired sleep quality were compared with respect to their body mass index with control data derived from a representative population survey matched in gender and age. As a result, patients with insomnia showed a lower body mass index (23.8 kg m(-2) versus 27.1 kg m(-2) ; P < 0.0005). Our findings suggest that patients with chronic insomnia do not exhibit overweight. These data are a valuable educational tool to calm patients' fears about the consequences of insomnia, and contribute to the understanding of chronically disturbed sleep and weight regulation.

Effectiveness of a multimodal treatment program for somatoform pain disorder.

Chronic pain conditions are highly prevalent, with somatoform pain disorder accounting for a large proportion. However, the psychological forms of treatment currently used achieve only small to medium effect sizes. This retrospective study investigated the effectiveness of a 5-week multimodal pain program for patients with somatoform pain disorder. The diagnosis of somatoform pain disorder was confirmed by a specialist for anesthesiology and pain management and a specialist for psychosomatic medicine. Therapy outcome was evaluated with a Numeric Rating Scale (NRS), the Pain Disability Index (PDI), and the Pain Perception Scale. Within the study sample (n = 100), all parameters showed a significant and clinically relevant improvement at the end of therapy (P values < 0.001). The highest effect sizes (d) were found for reduction in average pain rating (NRS: d = 1.00) and the affective items of the Pain Perception Scale (SES-A: d = 0.07). The lowest effect sizes were found for improvement of pain-related disabilities (PDI: d = 0.42) and sensory items of the Pain Perception Scale (SES-S: d = 0.50). Despite high chronification of pain condition, with average pain duration of greater than 8 years, the multimodal treatment program showed medium to large effect sizes on the outcome of patients with somatoform pain disorder. Compared with previous data with small to moderate effect sizes, a multimodal program seems to be more effective than other interventions to address somatoform pain disorder.

Do cardiorespiratory variables predict the antinociceptive effects of deep and slow breathing?

UNLABELLED: Deep and slow breathing (DSB) is a central part of behavioral exercises used for acute and chronic pain management. Its mechanisms of action are incompletely understood. OBJECTIVES: 1) To test the effects of breathing frequency on experimental pain perception in a dose dependent fashion. 2) To test the effects of breathing frequency on cardiorespiratory variables hypothesized to mediate DSB analgesia. 3) To determine the potential of the cardiorespiratory variables to mediate antinociceptive DSB effects by regression analysis. DESIGN: Single-blind, randomized, crossover trial. SUBJECTS: Twenty healthy participants. INTERVENTIONS: Visually paced breathing at 0.14 Hz, 0.10 Hz, 0.06 Hz, and resting frequency. OUTCOME MEASURES: Cardiorespiratory variables: RR-interval (= 60 seconds/heart rate), standard deviation of the RR-interval (SDRR), and respiratory CO2 . Experimental pain measures: heat pain thresholds, cold pain thresholds, pain intensity ratings, and pain unpleasantness ratings. RESULTS: 1) There was no effect of DSB frequency on experimental pain perception. 2) SDRR and respiratory CO2 were significantly modulated by DSB frequency, while RR-interval was not. 3) Baseline-to-DSB and session-to-session differences in RR-interval significantly predicted pain perception within participants: Prolonged RR-intervals predicted lower pain ratings, while shortened RR-intervals predicted higher pain ratings. SDRR and respiratory CO2 were not found to predict pain perception. CONCLUSIONS: The present study could not confirm hypotheses that the antinociceptive effects of DSB are related to changes in breathing frequency, heart rate variability, or hypoventilation/hyperventilation when applied as a short-term intervention. It could confirm the notion that increased cardiac parasympathetic activity is associated with reduced pain perception.

Sleep deprivation in chronic somatoform pain-effects on mood and pain regulation.

Sleep deprivation was found to exert complex effects on affective dimensions and modalities of pain perception both in healthy volunteers and patients with major depression. Considering multifaceted links between mood and pain regulation in patients with chronic somatoform pain, it is intriguing to study sleep deprivation effects for the first time in this group of patients. Twenty patients with a somatoform pain disorder according to ICD-10 diagnostic criteria were sleep-deprived for one night, followed by one recovery night. Clinical pain complaints (visual analog scale), detection- and pain thresholds (temperature and pressure) as well as mood states (Profile of Mood States) were assessed on the day prior to the experiment, on the day after sleep deprivation and on the day after recovery sleep. We found a discrepancy between significantly increased clinical pain complaints and unaltered experimental pain perception after sleep deprivation. Only the clinical pain complaints, but not the experimental pain thresholds were correlated with tiredness-associated symptoms. Total mood disturbances decreased and feelings of depression and anger improved significantly after sleep deprivation. However, these changes were not correlated with a change in clinical pain perception. We conclude that sleep deprivation may generally change the reagibility of the limbic system, but mood processing and pain processing may be affected in an opposite way reflecting neurobiological differences between emotional regulation and interoceptive pain processing.

Phantom limb pain in daily practice--still a lot of work to do!

OBJECTIVES: Effective treatment of phantom limb pain (PLP, pain felt in the part of the body of an amputated limb) is still difficult to achieve, and improved treatment is needed. It is therefore of paramount interest to understand the current practice of PLP therapy outside pain centers. DESIGN: As a part of a nationwide survey, 537 amputees were asked 11 questions related to their treatment experiences and the pain relief. Furthermore, the patients' opinion about the quality of medical care was also asked. RESULTS: Five hundred thirty-seven out of 1088 amputees returned the questionnaire (49.4%). Four hundred (74.5%) suffered from PLP. The patients rated their caregivers' knowledge about PLP lower than their own. Many (41.6%) of PLP patients had never been informed about the possibility of occurrence and mechanisms of PLP. The vast majority of the PLP patients did not try any treatment. Among those treated, more than 30% consulted more than three physicians for beneficial treatment. A >50% pain reduction was achieved in only 12.7% of PLP patients. The most successful treatments were opioids (67.4%) and anticonvulsants (51.7%). Surgery was performed in 46.4% of all PLP patients and in 29.7% due to a clinically suspected neuroma. After surgery, pain was worse or unchanged in 50% and improved in 41.6%, and 7.4% were pain-free. CONCLUSIONS: Our results suggest that there are primary needs for better information about PLP pathophysiology and treatment not only for patients but also for caregivers. Limited therapeutic success reveals a further need for increased research in PLP management.

The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing--an experimental study.

OBJECTIVE: Deep and slow breathing (DSB) techniques, as a component of various relaxation techniques, have been reported as complementary approaches in the treatment of chronic pain syndromes, but the relevance of relaxation for alleviating pain during a breathing intervention was not evaluated so far. METHODS: In order to disentangle the effects of relaxation and respiration, we investigated two different DSB techniques at the same respiration rates and depths on pain perception, autonomic activity, and mood in 16 healthy subjects. In the attentive DSB intervention, subjects were asked to breathe guided by a respiratory feedback task requiring a high degree of concentration and constant attention. In the relaxing DSB intervention, the subjects relaxed during the breathing training. The skin conductance levels, indicating sympathetic tone, were measured during the breathing maneuvers. Thermal detection and pain thresholds for cold and hot stimuli and profile of mood states were examined before and after the breathing sessions. RESULTS: The mean detection and pain thresholds showed a significant increase resulting from the relaxing DSB, whereas no significant changes of these thresholds were found associated with the attentive DSB. The mean skin conductance levels indicating sympathetic activity decreased significantly during the relaxing DSB intervention but not during the attentive DSB. Both breathing interventions showed similar reductions in negative feelings (tension, anger, and depression). CONCLUSION: Our results suggest that the way of breathing decisively influences autonomic and pain processing, thereby identifying DSB in concert with relaxation as the essential feature in the modulation of sympathetic arousal and pain perception.

[Prevalence and comorbidity of somatoform disorder in psychosomatic inpatients: a multicentre study]. / Pravalenz und Komorbiditat der somatoformen Storung: Eine Multicenter-Studie.

OBJECTIVES: This epidemiological multicenter study investigates the prevalence and comorbidity of somatoform disorder in psychosomatic inpatients. METHODS: Twenty psychosomatic hospitals collected the diagnoses of all treated patients in the years 1998 to 2007. The data were analysed at the "Institute for Quality Assurance in Psychotherapy and Psychosomatic Medicine" (IQP),Munich. RESULTS: Of the 100,607 patients surveyed, 18,492 (18.4 %) fulfilled the ICD-10 criteria for a somatoform disorder. 91.9 % of patients with somatoform disorder have at least one, on average 2.8 additional psychiatric disorders. The mean duration of the symptoms before current treatment was 62.6 months. CONCLUSIONS: The prevalence of somatoform disorder in psychosomatic inpatients is comparable to that found in data from internal or general medicine patients. However, there are major differences in the distribution of the diagnostic subgroups of somatoform disorder.

The effect of alexithymia and depressive feelings on pain perception in somatoform pain disorder.

OBJECTIVE: To investigate the relationship between alexithymia and depression and their influence on the subjective versus experimental pain perception in somatoform pain disorder. METHODS: Three groups consisting of 40 patients with somatoform pain disorder, 40 patients with depression, and 40 healthy controls were matched. They completed questionnaires regarding alexithymia (TAS26) and depressive feelings (BDI-II). In addition, pain patients rated their subjective pain intensity (NRS). Quantitative sensory testings were conducted in all participants examining temperature (CPT, HPT) and mechanical (MPT, PPT) thresholds. RESULTS: Analysis of variance showed that alexithymia was significantly increased in both patient groups compared to healthy controls, but with the highest amount in somatoform pain. Regression analyses confirmed that this finding was in part due to a high comorbidity of depressive feelings in both patient groups. We found a discrepancy between increased clinical pain ratings and elevated pressure pain thresholds, indicating a less intense mechanical pain perception in somatoform pain. Correlation analyses demonstrated a significant connection of subjective pain ratings and pressure pain thresholds with depressive feelings. CONCLUSION: Contrary to the results of other experimental pain studies on chronic muskuloskeletal pain syndromes, we could not confirm central sensitization in somatoform pain disorder. Our findings place the somatoform pain disorder more in the direction of affective disorder such as depression. These findings may improve a better understanding of the disease and also have direct therapeutic implications. The high occurrence of alexithymia and depressive feelings in somatoform pain should be considered in diagnostic and therapeutic regimens of these patients.

Exercise in migraine therapy--is there any evidence for efficacy? A critical review.

BACKGROUND: Some migraine patients find that regular exercise helps in reducing the frequency of headache attacks. In addition, exercise in migraine is recommended from many headache experts. However, most of these recommendations refer to some anecdotal reports or observational studies in literature stating that regular exercise can reduce the frequency and severity of migraine. OBJECTIVE: The purpose of this review is to investigate whether recommendations for exercise in migraine are based on sufficient data to cope with requirements of an evidence-based modern migraine therapy. The review summarizes and discusses all available trials on this topic. RESULTS: Eight studies und 4 case reports investigated the therapeutic role of aerobic exercise on migraine headache. Some results are controversial regarding the efficacy of sports intervention in migraine. The majority of studies did not find a significant reduction of headache attacks or headache duration and only indicate a reduction of pain intensities in migraine patients due to regular exercise. The grade of recommendation of exercise in migraine based on evidence based medicine (EBM)-criteria is presently B-C. But due to methodological limitations, the available data are insufficient for a final statement on this topic. CONCLUSIONS: To further recommend exercise in migraine based on EBM-criteria, more studies are imperative. Future studies should adhere to the rules for randomized clinical trials in pharmacological migraines prophylaxis. Implications for further studies are given.

Mechanical Pain Thresholds and the Rubber Hand Illusion.

We manipulated the sense of body ownership with the rubber hand illusion (RHI) to determine if perception of a potentially painful threat to the rubber hand can modify the mechanical pain threshold (MPT). Simultaneous tactile stimulation of the subject's concealed hand and the appropriately positioned visible rubber hand generated the illusion of false body ownership. The MPT was recorded on the left hand of the subjects before and after induction of the RHI, as well as during the phase in which the model hand was pricked with a sharp knife or touched by the blunt knife handle. The results indicate that the RHI could be successfully generated with our set-up. Mechanical stimuli were perceived as more painful in the condition where the rubber hand was simultaneously pricked with a knife. Our findings suggest that the illusion of body ownership gates nociceptive processing of potentially painful stimuli.

Dual RAAS Blockade with Aliskiren in Patients with Severely Impaired Chronic Kidney Disease.

Dual renin-angiotensin-aldosterone blockade (dRAASb) is purposed in the prevention of the cardiorenal syndrome (CRS). However, all attempts with dRAASb even in patients with moderate impaired chronic kidney disease (CKD) were terminated due to the typical severe adverse events (SAE), e. g., hyperkalemia and rise of serum creatinine. The aim of our study with the direct renin inhibitor aliskiren was to evaluate the effect of dRAASb with a washout phase in patients with severely advanced CKD. We have studied 45 patients (G3b to 4, A2 and >A3; median glomerular filtration rate (GFR) CKD-EPI 31 (23-40) ml/min per 1.73 m² BSA (body surface area), albumin-creatinine-ratio in urine (UACR) (0.413 (0.164 to 1.39) g/g) and proteinuria (0.5 (0.2 to 0.9) g/l) before, with and without aliskiren (150 respectively 300 mg per day) added to an angiotensin-converting enzyme inhibitor (ACEi) or an AT1-receptor blocker (ARB) over 4 ½ years. The dRAASb with aliskiren showed a significant decrease of proteinuria (0.5 to 0.38 g/l), especially in patients with an UACR≥350 mg/g and in the subgroup analysis e. g., in patients with diabetes, but proteinuria increased in the washout phase again. The blood pressure (130/80 mm Hg), serum potassium (4.9 to 5.0 mmol/l) and GFR remained nearly constant (31 to 29.5 ml/min per 1.73 m2 BSA). A more than 30% increase in serum creatinine was associated with an UACR>300 mg/g. The dRAASb has beneficial effects on proteinuria and is safe in patients with severely advanced CKD. However, in patients with high UACR (>300 mg/g) raise of creatinine and potassium have to be controlled.

Influence of Erythropoiesis-Stimulating Agents on HbA1c and Fructosamine in Patients with Haemodialysis.

HbA1c is the most accepted laboratory parameter for the long term observation of glucose control. There is still much of a debate about the use of HbA1c as a metabolic indicator in diabetic patients (DM) on haemodialysis (HD) and erythropoiesis-stimulating agent (ESA) therapy because of the altered erythrocyte turn over in patients with chronic kidney disease and haemodialysis (CKD5D). In 102 CKD5 patients with and without diabetes mellitus, we examined the dose dependent variability in HbA1c and fructosamine levels under haemodialysis and treated with epoetin α (n=48) and a new generation agent with continuous stimulation of methoxy polyethylene glycol epoetin beta (C.E.R.A.; n=54). HbA1c levels were affected by therapy with ESA treatments. ESA dose was inversely correlated with HbA1c and an escalation of 10.000 IU per week induced an estimated decrease of HbA1c of 0.6 percent. In addition, the increase of reticulocyte number as a marker for erythropoiesis was significantly inversely correlated with the increase of ΔHbA1c. ESA treatments had no such effect on the alternative metabolic parameter fructosamine. When compared, both therapeutic agents had comparable success in attaining haemoglobin (Hb) target values. C.E.R.A. showed better correlation and was more effective over a longer dose interval. Our results show that HbA1c levels in patients should be carefully interpreted based on interfering factors. Nevertheless, HbA1c is currently the most consistent parameter for use ascertaining metabolic status of patients suffering from diabetes mellitus.

Impaired Recognition of Facially Expressed Emotions in Different Groups of Patients with Sleep Disorders.

INTRODUCTION: Recently it has been shown that acute sleep loss has a direct impact on emotional processing in healthy individuals. Here we studied the effect of chronically disturbed sleep on emotional processing by investigating two samples of patients with sleep disorders. METHODS: 25 patients with psychophysiologic insomnia (23 women and 2 men, mean age: 51.6 SD; 10.9 years), 19 patients with sleep apnea syndrome (4 women and 15 men, mean age: 51.9; SD 11.1) and a control sample of 24 subjects with normal sleep (15 women and 9 men, mean age 45.3; SD 8.8) completed a Facial Expressed Emotion Labelling (FEEL) task, requiring participants to categorize and rate the intensity of six emotional expression categories: anger, anxiety, fear, happiness, disgust and sadness. Differences in FEEL score and its subscales among the three samples were analysed using ANOVA with gender as a covariate. RESULTS: Both patients with psychophysiologic insomnia and patients with sleep apnea showed significantly lower performance in the FEEL test as compared to the control group. Differences were seen in the scales happiness and sadness. Patient groups did not differ from each other. CONCLUSION: By demonstrating that previously known effects of acute sleep deprivation on emotional processing can be extended to persons experiencing chronically disturbed sleep, our data contribute to a deeper understanding of the relationship between sleep loss and emotions.

Pain modulation by intranasal oxytocin and emotional picture viewing - a randomized double-blind fMRI study.

The hormone oxytocin has been hypothesized to influence the emotional dimension of pain. This randomized, placebo-controlled, double-blind, crossover study explored whether intranasal oxytocin and emotional context can affect heat pain perception in 30 healthy male volunteers. After receiving 36 IU oxytocin or placebo, participants underwent functional Magnetic Resonance Imaging (fMRI) during which noxious and non-noxious thermode heat stimuli were applied. Simultaneously, scenes from the International Affective Pictures System (IAPS) with positive, neutral, and negative emotional valence were shown. Heat intensity and unpleasantness ratings were obtained. The activity of whole-brain correlates of heat processing was quantified via multi-voxel pattern analysis. We observed no appreciable main effects of oxytocin on ratings or neural pain correlates. Effects of emotional picture valence on ratings were smaller than reported in previous studies. Nevertheless, oxytocin was found to significantly enhance the influence of picture valence on unpleasantness ratings at noxious heat levels. No corresponding changes in whole-brain correlates of heat intensity processing were found. Our study provides evidence that intranasal oxytocin increases the effects of emotional context on the subjective unpleasantness of experimental heat pain. Future studies are needed to determine whether this effect can be utilized in clinical settings.

Theory of Mind and Emotional Awareness in Chronic Somatoform Pain Patients.

OBJECTIVE: The present study aimed at investigating whether chronic pain patients are impaired in Theory of Mind (ToM), or Emotional Awareness. METHODS: Thirty inpatients suffering from chronic somatoform pain, as well as thirty healthy controls matched for age, sex, and education were recruited. ToM abilities were measured using the Frith-Happé animation task, in which participants interpret video-clips depicting moving geometric forms that mimic social interactions. The responses given were scored for appropriateness and the degree of inferred intentionality according to established protocols. Emotional awareness was measured using the Levels of Emotional Awareness Scale (LEAS), for which participants provide written descriptions of feelings in imaginary emotional situations. Standardized scoring was performed to capture the number and quality of emotional terms used. RESULTS: Responses lengths were similar in both groups and for both tasks. Patients attained significantly lower intentionality but not appropriateness scores when interpreting ToM interactions. No significant group differences were found when interpreting goal directed interactions. Emotional awareness scores were significantly lower in patients compared to healthy controls. CONCLUSIONS: Our results suggest that chronic pain patients are impaired in mentalizing and emotional awareness. Future studies are needed to determine whether these ToM and emotional awareness deficits contribute to the etiology of somatoform pain and whether addressing these deficits in therapeutic interventions can improve polymodal pain therapy.