[A palliative approach for severest anorexia nervosa?] / Ein palliativer Ansatz für schwerste Anorexia nervosa?

Even with guideline-conform treatment in specialized outpatient clinics and intensive treatment programs, some patients suffering from severe and enduring anorexia nervosa do not achieve a satisfying level of mental health and quality of life. As this patient group is associated with a high mortality, a palliative stage of anorexia nervosa is postulated. In these cases, treatment decisions should factor in not only a prolongation of life but also quality of life, especially when compulsory treatment is considered. In doubtful cases, a palliative care physician and the clinical ethics committee should be consulted.

[Relational Frame Theory--A Theoretical Framework for Contextual Behavioral Science]. / Die Bezugsrahmentheorie--Eine Grundlage zum Verständnis von kontextuellen Psychotherapiemethoden.

Therapists have to deal with verbal systems and often work with verbal exchange. Therefore, a psychological theory is required, which teaches the therapist how to accomplish this task. The BRT is a theory of human language and cognition that explains how people use their verbal behavior as stimuli in their interrelations and how they act and react, based on the resulting relationships. This behavior is learned very early in the course of language acquisition and functions as a generalized operant. A prerequisite for this is the ability of people to undergo mental simulation. This enables them to construct diverse relational frameworks between individual stimuli. Without relational frameworks, people cannot function. The ability to establish a relational framework is a prerequisite for the formation of rule-governed behavior. Rule-governed behavior economizes complex decision processes, creates interpersonal security and enables dealing with events before they take place. On the other hand, the same properties that enable people to solve problems effectively can also contribute to rigid adherence to rules and experience avoidance. Relational frameworks, once established, outweigh other sources of behavioral regulation. Thus, it can become the basis of psychopathology. Poor contextual control makes it difficult for people to devote flexible, focused and voluntary attention to the present and align their actions with the immediate present. Contextual psychotherapy methods that are based on the BRT start precisely at this point: Targeted establishment of new contingencies in the therapeutic interaction through systematic strengthening of metacognitive mode and through the establishment of new rules that make possible a change in the rule-governed behavior enable undermining of dysfunctional rule-governed behavior and build up desirable behavior. This allows any therapeutic process to be more effective--regardless of the patient's expressed symptoms.

[Cardiac and metabolic risk factors in severe mental disorders. Task of a prevention manager]. / Kardiale und metabolische Risikofaktoren bei schweren psychischen Erkrankungen. Aufgaben eines Präventionsmanagers.

People with severe mental disorders have a reduction in life expectancy of 13-30 % compared with the general population. This severe disadvantage is primarily due to an increased prevalence of cardiac and metabolic disorders, especially coronary heart disease (CHD) and type 2 diabetes mellitus and are the result of untoward health behavior characterized by smoking, low levels of physical activity and unhealthy dietary habits. Obesity, arterial hypertension and lipid disorders are also associated with this behavior and further increase the risk of CHD and type 2 diabetes. Thus, people with mental disorders constitute a population with a high risk of cardiovascular events. Appropriate measures for prevention and therapy are urgently indicated but rarely applied. This article presents new organizational structures to overcome this deficit with a prevention manager playing a central role in organizing and applying preventive and therapeutic care. Results from cardiology and diabetic medicine have shown the effectiveness of pooling this responsibility. The measure has the potential to reduce the increased mortality of people with severe mental disorders.

[Relational frame theory - a theoretical framework for contextual behavioral science]. / Die Bezugsrahmentheorie - Eine Grundlage zum Verständnis von kontextuellen Psychotherapiemethoden.

Therapists have to deal with verbal systems and often work with verbal exchange. Therefore, a psychological theory is required, which teaches the therapist how to accomplish this task. The BRT is a theory of human language and cognition that explains how people use their verbal behavior as stimuli in their interrelations and how they act and react, based on the resulting relationships. This behavior is learned very early in the course of language acquisition and functions as a generalized operant. A prerequisite for this is the ability of people to undergo mental simulation. This enables them to construct diverse relational frameworks between individual stimuli. Without relational frameworks, people cannot function. The ability to establish a relational framework is a prerequisite for the formation of rule-governed behavior. Rule-governed behavior economizes complex decision processes, creates interpersonal security and enables dealing with events before they take place. On the other hand, the same properties that enable people to solve problems effectively can also contribute to rigid adherence to rules and experience avoidance. Relational frameworks, once established, outweigh other sources of behavioral regulation. Thus, it can become the basis of psychopathology. Poor contextual control makes it difficult for people to devote flexible, focused and voluntary attention to the present and align their actions with the immediate present. Contextual psychotherapy methods that are based on the BRT start precisely at this point: Targeted establishment of new contingencies in the therapeutic interaction through systematic strengthening of metacognitive mode and through the establishment of new rules that make possible a change in the rule-governed behavior enable undermining of dysfunctional rule-governed behavior and build up desirable behavior. This allows any therapeutic process to be more effective - regardless of the patient's expressed symptoms.

A Psychometric Evaluation of the German Version of the Quick Inventory of Depressive Symptomatology (QIDS-SR16) in Outpatients with Depression.

BACKGROUND: The self-rated, 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16) is a well-established measure of depression severity. This study aimed to evaluate the psychometric properties of the German translation of the QIDS-SR16. METHODS: 332 depressed German adults awaiting psychotherapy were assessed with the German translations of the QIDS-SR16, the Beck Depression Inventory (BDI-II) and the 24-item Hamilton Rating Scale for Depression (HRSD-24). RESULTS: Internal consistency for the QIDS-SR16 was acceptable (Cronbach's alpha = .77). Corrected item-total correlations indicated adequate discriminatory power of all the items. The QIDS-SR16 highly correlated with the BDI-II (r = .810) but only moderately correlated with the HRSD-24 (r = .581). Regarding discriminant validity, the QIDS-SR16 discriminated between patients with and without a depressive episode but not between patients with and without panic disorder. CONCLUSION: The German translation of the QIDS-SR16 has adequate psychometric properties. Our results support the usefulness of the German version of the QIDS-SR16 as a brief depression rating scale in clinical and research settings.

Pericardial, intra-abdominal, and subcutaneous adipose tissue in patients with major depressive disorder.

OBJECTIVE: Major depressive disorder (MDD) is associated with an increased risk for developing coronary artery disease (CAD). Recently, pericardial adipose tissue, a metabolically active visceral fat depot surrounding the heart, has been implicated in the pathogenesis of CAD. Therefore, we investigated pericardial adipose tissue volumes in patients with MDD and compared them to healthy comparison subjects. METHOD: In this case-control study at a university medical center, 50 male and female in-patients with MDD and 25 healthy men and women were examined. The main outcome measures were the volumes of pericardial adipose tissue, intra-abdominal adipose tissue (IaAT) and subcutaneous adipose tissue (ScAT) which were measured using magnetic resonance imaging. RESULTS: The pericardial adipose tissue volumes were greater in men and women with MDD compared with the healthy comparison group following adjustments for the effects of age, weight, height, and physical activity. CONCLUSION: This study expands our knowledge about the alterations in body composition that occur in patients with MDD. The findings are highly relevant for understanding the comorbidity between heart disease and depressive disorders.

Oral contraception enhances growth hormone responsiveness to hyper- and hypoglycaemia.

AIMS: Plasma glucose levels influence growth hormone concentrations. Oral contraceptives are known to affect circulating growth hormone levels and glucose metabolism. While growth hormone plays an important role in hypoglycaemia counter-regulation, it has been shown that oral contraceptives increase growth hormone concentrations. In this context, we tested if serum growth hormone concentrations display a differential response on glycaemic variations in healthy women using oral contraceptives and those not using contraceptives. METHODS: Fifteen healthy women with oral contraceptive treatment and 10 without participated in a stepwise hyper- and hypoglycaemic glucose clamp procedure. Serum growth hormone concentrations were measured at euglycaemic baseline and subsequently at plasma glucose plateaus of 8.8, 6.8, 4.8 and 2.8 mmol/l. RESULTS: Growth hormone values were significantly higher in women using oral contraceptives throughout the experiments (P = 0.001). Hyperglycaemia decreased growth hormone concentrations in women using oral contraceptives (P = 0.009), but not in those who were not using oral contraceptives (P = 0.241). Hypoglycaemia significantly elevated growth hormone concentrations in women using oral contraceptives (P = 0.009), but not in those not using oral contraceptives (P = 0.094). Maximum growth hormone values were reached at the end of the hypoglycaemic plateau, with significantly higher concentrations in the group using oral contraceptives than in the group not using oral contraceptives (P = 0.016). CONCLUSION: Healthy women on oral contraceptive treatment display an increased responsiveness of growth hormone to hypoglycaemic, as well as hyperglycaemic conditions and generally higher serum growth hormone concentrations than women without oral contraceptives. Given the known boosting effects of growth hormone on hypoglycaemic hormonal counter-regulation, oral contraceptives may thus be a pharmacological candidate contributing to combat hypoglycaemia unawareness in women with diabetes in the future.

[Depression and diabetes mellitus type 2]. / Depression und Diabetes mellitus Typ 2.

Depression and diabetes mellitus type 2 are frequently comorbid conditions. Both disorders may increase the incidence of the other disorder and impair the prognosis. Thus, it is important for psychiatrists to consider depressed patients as high-risk diabetes subjects to screen for metabolic risks and to consider metabolic risks of antidepressant treatment.

[Mental disorders and female infertility]. / Psychische Störungen und weibliche Infertilität.

Approximately 5-10% of women in the reproductive years are affected by infertility which is associated with depression, anxiety and disturbed eating behavior. Part of this association can be explained by the emotional stress resulting from infertility. As mental disorders, such as depressive disorder or eating disorders are also prospectively associated with infertility, a bidirectional relationship is assumed. A special relationship exists between mental disorders and the main causes of ovulatory infertility, hypothalamic amenorrhea and polycystic ovary disease. The results of pilot studies support the assumption that psychotherapy may constitute an important component of the treatment of infertility.

[Training in iterative hypothesis testing as part of psychiatric education. A randomized study]. / Training in iterativer Hypothesenbildung in der psychiatrischen Lehre. Eine randomisierte Studie.

BACKGROUND: The improvement of medical education is at the center of efforts to reform the studies of medicine. Furthermore, an excellent teaching program for students is a quality feature of medical universities. Besides teaching of disease-specific contents, the acquisition of interpersonal and decision-making skills is important. However, the cognitive style of senior physicians leading to a diagnosis cannot easily be taught. Therefore, the following study aimed at examining whether specific training in iterative hypothesis testing (IHT) may improve the correctness of the diagnostic process. MATERIALS AND METHODS: Seventy-one medical students in their 9th-11th terms were randomized to medical teaching as usual or to IHT training for 4 weeks. The intervention group received specific training according to the method of IHT. All students were examined by a multiple choice (MC) exam and additionally by simulated patients (SP). The SPs were instructed to represent either a patient with depression and comorbid anxiety and substance use disorder (SP1) or to represent a patient with depression, obsessive-compulsive disorder and acute suicidal tendencies (SP2). RESULTS: All students identified the diagnosis of major depression in the SPs, but IHT-trained students recognized more diagnostic criteria. Furthermore, IHT-trained students recognized acute suicide tendencies in SP2 more often and identified more comorbid psychiatric disorders. The results of the MC exam were comparable in both groups. An analysis of the satisfaction with the different training programs revealed that the IHT training received a better appraisal. CONCLUSIONS: Our results point to the role of IHT in teaching diagnostic skills. However, the results of the MC exam were not influenced by IHT training. Furthermore, our results show that students are in need of training in practical clinical skills.

[The third wave of cognitive-behavioural psychotherapies: concepts and efficacy]. / Die Dritte Welle der Verhaltenstherapie.

During the last two decades a number of psychotherapies have been developed which are summarised as the third wave of cognitive behavioural therapies. Among these are dialectical behaviour therapy (DBT), acceptance and commitment therapy (ACT), schema therapy, cognitive behavioural analysis system of psychotherapy (CBASP), mindfulness-based cognitive therapy (MBCT), and metacognitive therapy (MCT). The purpose of this article is to describe the basic concepts of these treatments and to summarise available studies concerning their efficacy.

Time heals all wounds - Outcomes of deep palmar wrist injuries may improve long after reinnervation.

Despite the clinical importance of deep wrist injuries (DWIs), data on the timeframe of possible improvements in hand function are scarce. We tested the hypotheses that a) the length of follow-up is positively correlated with the outcome, and b) this correlation is tempered by nerve involvement. All patients admitted to the Clinic of Plastic Surgery with an acute DWI between 2008 and 2016 were contacted for a follow-up examination including two-point discrimination, range of motion, grip, and pinch strength, as well as DASH and MMWS questionnaires and employment status. Possible confounders such as age, handedness, and intentionality of the injury (accidental or suicidal) were assessed and controlled for statistically. Fifty-three patients were reviewed (74% male and 26% female, 86% right-handed, 70% accidental injuries, mean age at injury 42.0 ± 17.1 years), an average of 4.3 ± 2.9 years after their injury. In patients with a nerve injury, length of follow-up had significant effects on two-point discrimination, grip and pinch strength, self-reported symptom severity and impairment. Contrary to conventional knowledge, the clinical outcome of DWIs may improve beyond 3 years when there is nerve involvement. This important prognostic finding has far-reaching implications for both clinicians (e.g., asked to give their medical opinion) and patients (e.g., considering re-training after a DWI).

A randomized study of iterative hypothesis testing in undergraduate psychiatric education.

OBJECTIVE: Iterative hypothesis testing (IHT) or related strategies of diagnostic decision making have been taught in many curricula for medical students but not in psychiatry. We therefore asked whether the addition of training in IHT may add to the quality of the psychiatry course. METHOD: Seventy-two medical students were randomized to four weeks problem-based learning or to IHT. Knowledge and skills of the students were tested using a multiple choice exam and simulated patients. RESULTS: Iterative hypothesis testing-trained students recognized more diagnostic items and more often identified comorbid psychiatric disorders and acute suicidal tendencies. Acquisition of general psychiatric knowledge and global satisfaction with the course were similar in both groups. CONCLUSION: We conclude that teaching IHT to medical students may enhance their clinical ability to recognize complex disease patterns. Further studies are required concerning the enhancement of clinical skills in the psychiatric specialty.

Causes of obesity: looking beyond the hypothalamus.

The brain takes a primary position in the organism. We present the novel view that the brain gives priority to controlling its own adenosine triphosphate (ATP) concentration. It fulfils this tenet by orchestrating metabolism in the organism. The brain activates an energy-on-request system that directly couples cerebral supply with cerebral need. The request system is hierarchically organized among the cerebral hemispheres, the hypothalamus, and peripheral somatomotor, autonomic-visceromotor, and the neuroendocrine-secretomotor neurons. The system initiates allocative behavior (i.e. allocation of energy from body to brain), ingestive behavior (intake of energy from the immediate environment), or exploratory behavior (foraging in the distant environment). Cerebral projections coordinate all three behavioral strategies in such a way that the brain's energy supply is guaranteed continuously. In an ongoing learning process, the brain's request system adapts to various environmental conditions and stressful challenges. Disruption of a cerebral energy-request pathway is critical to the development of obesity: if the brain fails to receive sufficient energy from the peripheral body, it compensates for the undersupply by increasing energy intake from the immediate environment, leaving the body with a surplus. Obesity develops in the long term.

Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area.

BACKGROUND: The closure of the hiatal crura has proven to be a fundamental issue in laparoscopic antireflux surgery. In particular, the use of prosthetic meshes for crural closure results in a significantly lower rate of postoperative hiatal hernia recurrence with or without intrathoracic migration of the fundic wrap. The aim of the present study was to evaluate different methods of crural closure depending on the size of the hiatal defect by measuring the hiatal surface area. METHODS: Fifty-five consecutive patients (mean age = 53 years) with symptomatic gastroesophageal reflux disease (GERD) were scheduled for laparoscopic antireflux surgery (LARS) in our surgical unit. Intraoperatively, the length, breadth, and diameter of the hiatal defect was measured using an endoscopic ruler. In every patient, the hiatal surface area (HSA) was calculated using an arithmetic formula. Depending on the calculated HSA, hiatal closure was performed by (1) simple sutures, (2) simple sutures with a 1 x 3-cm polypropylene mesh, (3) simple sutures with dual Parietex dual mesh, or (4) "tension-free" polytetrafluoroethylene BARD Crurasoft mesh. RESULTS: Twenty-six patients (47.2%) underwent laparoscopic 360 degree "floppy" Nissen fundoplication. The remaining 29 patients (52.8%) with esophageal body motility disorder underwent laparoscopic 270 degree Toupet fundoplication. Mean calculated HSA in all patients was 5.092 cm2. Thirty-two patients (58.2%) with a smaller hiatal defect (mean HSA = 3.859 cm2) underwent hiatal closure with simple sutures (mean number of sutures: = 2.0). In 12 patients (21.8%) with a mean HSA of 7.148 cm2, hiatal closure was performed with a 1 x 3-cm polypropylene mesh in addition to simple sutures. Five patients with a mean HSA of 6.703 cm2 underwent hiatal closure with Parietex mesh, and in the remaining six patients, who had a mean HSA of 8.483 cm2, the hiatus was closed using BARD Crurasoft mesh. For a mean followup period of 6.3 months, only one patient (1.8%) developed a postoperative partial intrathoracic wrap migration. CONCLUSION: Measurement of HSA with subsequent tailoring of the hiatal closure to the hiatal defect is an effective procedure to prevent hiatal hernia recurrence and/or intrathoracic wrap migration in laparoscopic antireflux surgery.

Pericardial adipose tissue and the metabolic syndrome is increased in patients with chronic major depressive disorder compared to acute depression and controls.

OBJECTIVE: Major depressive disorder (MDD) is associated with an estimated fourfold risk for premature death, largely attributed to cardiovascular disorders. Pericardial adipose tissue (PAT), a fat compartment surrounding the heart, has been implicated in the development of coronary artery disease. An unanswered question is whether people with chronic MDD are more likely to have elevated PAT volumes versus acute MDD and controls (CTRL). METHODS: The study group consists of sixteen patients with chronic MDD, thirty-four patients with acute MDD, and twenty-five CTRL. PAT and adrenal gland volume were measured by magnetic resonance tomography. Additional measures comprised factors of the metabolic syndrome, cortisol, relative insulin resistance, and pro-inflammatory cytokines (interleukin-6; IL-6 and tumor necrosis factor-α, TNF-α). RESULTS: PAT volumes were significantly increased in patients with chronic MDD>patients with acute MDD>CTRL. Adrenal gland volume was slightly enlarged in patients with chronic MDD>acute MDD>CTRL, although this difference failed to reach significance. The PAT volume was correlated with adrenal gland volume, and cortisol concentrations were correlated with depression severity, measured by BDI-2 and MADRS. Group differences were found concerning the rate of the metabolic syndrome, being most frequent in chronic MDD>acute MDD>CTRL. Further findings comprised increased fasting cortisol, increased TNF-α concentration, and decreased physical activity level in MDD compared to CTRL. CONCLUSION: Our results extend the existing literature in demonstrating that patients with chronic MDD have the highest risk for developing cardiovascular disorders, indicated by the highest PAT volume and prevalence of metabolic syndrome. The correlation of PAT with adrenal gland volume underscores the role of the hypothalamus-pituitary-adrenal system as mediator for body-composition changes. Metabolic monitoring, health advices and motivation for the improvement of physical fitness may be recommended in depressed patients, in particular in chronic depression.

[Borderline personality disorder]. / Patienten mit Borderline-persönlichkeitsstörung müssen Sie direkt ansprechen. "Wollten Sie sterben oder innere Anspannung loswerden"?

Characteristics of a borderline personality disorder include emotional instability and a self-threatening lack of impulsive control. As a result, interpersonal relationships are rendered difficult. The central elements of treatment are psychoeducation, self-management, improved stress tolerance and awareness, emotion managment and training in social competence.

[Anxious (avoidant) personality disorder]. / Bloss nicht den Arzt beunruhigen.

The anxious (avoidant or fearful) type of personality disorder has a lifetime prevalence of 5%, which makes it the most common form of personality disorder. Although it is one of the leading risk factors for severe depressive illnesses, anxiety disorders, substance dependence, eating disorders and chronic pain, its importance is frequently underestimated. Ambulatory treatment comprises psychoeducation, self-management and training in social competence.