[Subjectivity and objectivity, illness and disease]. / Subjektivität und Objektivität, Kranksein und Krankheit.

When we are ill, what helps us recover? What constitutes disease, what legitimates it and what role do subjective complaints play? A medicine that focuses on measuring and correcting facts but ignores individual illness experience and context wastes diagnostic and therapeutic potential.

[Complementary and alternative procedures for fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. / Komplementäre und alternative Verfahren beim Fibromyalgiesyndrom : 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 search of the literature for systematic reviews of randomized controlled trials of complementary and alternative therapies 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 formed by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines. RESULTS AND CONCLUSION: Meditative movement therapies (e.g. qi gong, tai chi and yoga) are strongly recommended. Acupuncture and weight reduction in cases of obesity can be considered.

[Physiotherapy, occupational therapy and physical therapy in fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. / Physiotherapie, Ergotherapie und physikalische Verfahren beim Fibromyalgiesyndrom : 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 literature search for systematic reviews of randomized, controlled trials on physiotherapy, occupational therapy and physical therapy 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. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines. RESULTS AND CONCLUSION: Low to moderate intensity endurance and strength training are strongly recommended. Chiropractic, laser therapy, magnetic field therapy, massage and transcranial magnetic stimulation are not recommended.

[Drug therapy of fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. / Medikamentöse Therapie 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 literature search for systematic reviews of randomized controlled drug trials 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. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines. RESULTS AND CONCLUSION: Amitriptyline and duloxetine are recommended in the case of comorbid depressive disorders or generalized anxiety disorder and pregabalin in the case of generalized anxiety disorder. Off-label use of duloxetine and pregabalin can be considered if there are no comorbid mental disorders or no generalized anxiety disorder. Strong opioids are not recommended.

[Chronic pain, pain disease, and satisfaction of patients with pain treatment in Germany. Results of a representative population survey]. / Chronische Schmerzen, Schmerzkrankheit und Zufriedenheit der Betroffenen mit der Schmerzbehandlung in Deutschland. Ergebnisse einer repräsentativen Bevölkerungsstichprobe.

BACKGROUND: There are only few data from representative samples of the general German population on the prevalence of a "pain disease" and on satisfaction with pain therapy of persons with chronic pain available. METHODS: A cross-sectional survey with people aged ≥ 14 years representative for the German population was conducted in 2013. Measures were obtained for presence of chronic pain (based on the definition of the International Association for the Study of Pain) and for "pain disease" by the presence of disabling pain in the Chronic Pain Grade Questionnaire and increased psychological distress in the Patient Health Questionnaire 4. In case of chronic pain reports, the satisfaction with current pain treatment and current treatment by a pain specialist were assessed. RESULTS: Responses were received from 2508 (57.5 %) of the 4360 people contacted. The prevalence of chronic pain was 26.9 % [95 % confidence interval (CI) 25.2-28.6 %]. A total of 7.4 % (95 % CI 5.0-9.9 %) met the criteria for chronic disabling nonmalignant pain, while 2.8 % (95 % CI 2.2-3.4 %) of participants met the criteria of a pain disease. In all, 31.9 % of persons with disabling pain reported current treatment by a pain specialist and 33.1 % of persons with disabling pain were (very) dissatisfied with current pain treatment. Treatment by a pain specialist was associated with higher health care use and lower treatment satisfaction. CONCLUSION: There is a need to improve the care of persons with chronic disabling pain. Whether pain specialist treatment is (cost) effective in chronic disabling pain needs to be examined by longitudinal studies.

[Administrative prevalence, treatment and costs of somatoform pain disorder. Analysis of data of the BARMER GEK for the years 2008-2010]. / Administrative Prävalenz, Behandlung und Krankheitskosten der somatoformen Schmerzstörung. Analyse von Daten der BARMER GEK für die Jahre 2008-2010.

INTRODUCTION: Data on administrative prevalence, types of treatment and disease costs of patients diagnosed with somatoform pain disorder (according to ICD 10) in Germany were not previously available. MATERIALS AND METHODS: We analysed health insurance data from 2008-2010 of 8.5 million people of the German statutory health insurance company BARMER GEK on administrative prevalence of insurants with at least one billing code F 45.4x in 2009 and at least one second billing code F 45.4x in the time period 2008-2010 stratified by age and gender, different professions being involved in treatment, diagnostics and treatment methods applied. The types and costs of out-patient treatment and of in-patient treatment in case of any discharge with diagnosis of F45.4 were analysed. RESULTS: The administrative prevalence doubled from 2008 to 2010 after the separation of the previous code F45.4 into F45.40 and F45.41. In 2009, 0.5 % of the insurants were diagnosed with F 45.4, whereby F 45.4 was diagnosed 2.3-fold more often in women than in men. Family practitioners (41 %) and anaesthesiologists (28 %) were the leading specialties in the care of chronic patients. In 2009, 54 % of patients underwent x-ray examination, 25 % magnetic resonance imaging and 11 % computed tomography. In all, 66 % of the chronic patients received basic psychosomatic care, 38 % were prescribed opioids, 12 % underwent spinal nerve anaesthesia and 14 % received psychotherapy. In 2009, the average direct and indirect treatment costs per patient with somatoform pain disorder were 5500 . CONCLUSION: Insurants diagnosed with somatoform pain disorder were probably overtreated with radiology and invasive procedures and with opioids.

Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial.

BACKGROUND: Multisomatoform disorder is characterised by severe and disabling bodily symptoms, and pain is one of the most common and impairing of these. Furthermore, these bodily symptoms cannot be explained by an underlying organic disorder. Patients with multisomatoform disorder are commonly found at all levels of healthcare and are typically difficult to treat for physicians as well as for mental health specialists. AIMS: To test whether brief psychodynamic interpersonal therapy (PIT) effectively improves the physical quality of life in patients who have had multisomatoform disorder for at least 2 years. METHOD: We recruited 211 patients (from six German academic outpatient centres) who met the criteria for multisomatoform disorder for a randomised, controlled, 12-week, parallelgroup trial from 1 July 2006 to 1 January 2009 (International Standard Randomised Controlled Trial Number ISRCTN23215121). We randomly assigned the patients to receive either 12 weekly sessions of PIT (n = 107) or three sessions of enhanced medical care (EMC, n = 104). The physical component summary of the Short Form Health Survey (SF-36) was the pre-specified primary outcome at a 9-month follow-up. RESULTS: Psychodynamic interpersonal therapy improved patients' physical quality of life at follow-up better than EMC (mean improvement in SF-36 score: PIT 5.3, EMC 2.2), with a small to medium between-group effect size (d = 0.42, 95% CI 0.15-0.69, P = 0.001). We also observed a significant improvement in somatisation but not in depression, health anxiety or healthcare utilisation. CONCLUSIONS: This trial documents the long-term efficacy of brief PIT for improving the physical quality of life in patients with multiple, difficult-to-treat, medically unexplained symptoms.

[Fibromyalgia syndrome. Definition, classification, clinical diagnosis and prognosis]. / Das Fibromyalgiesyndrom. Definition, Klassifikation, klinische Diagnose und Prognose.

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. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION: The clinical diagnosis of FMS can be established by the American College of Rheumatology (ACR) 1990 classification criteria (with tender point examination), by the modified preliminary diagnostic ACR 2010 criteria or by the diagnostic criteria of the German interdisciplinary guideline (AWMF) on FMS. The English full-text version of this article is available at SpringerLink (under "Supplemental").

[Somatoform disorders: discussion on conceptual and diagnostic issues]. / Diskussion um Konzepte und Diagnostik somatoformer Störungen.

In view of the forthcoming revisions of DSM-5 and ICD-11, conceptual and diagnostic issues of somatoform disorders are being discussed. Current diagnostic categories as well as criteria have been shown to have limited validity and practicability. In particular, the requirement for a lacking somatic explanation of symptoms poses several methodological and practical problems. A confusing terminology including the parallel classification of functional and somatoform disorders constitutes additional barriers to improving treatment.New classificatory approaches will probably drop the demand for the complaints to be insufficiently explained by somatic disease and thus emphasize the similarities of somatoform and somatopsychic disorders. For DSM-5, the implementation of psychobehavioral positive criteria has been suggested as contributing to both illness severity and clinical need for action.

Predictors and outcomes in primary depression care (POKAL) - a research training group develops an innovative approach to collaborative care.

BACKGROUND: The interdisciplinary research training group (POKAL) aims to improve care for patients with depression and multimorbidity in primary care. POKAL includes nine projects within the framework of the Chronic Care Model (CCM). In addition, POKAL will train young (mental) health professionals in research competences within primary care settings. POKAL will address specific challenges in diagnosis (reliability of diagnosis, ignoring suicidal risks), in treatment (insufficient patient involvement, highly fragmented care and inappropriate long-time anti-depressive medication) and in implementation of innovations (insufficient guideline adherence, use of irrelevant patient outcomes, ignoring relevant context factors) in primary depression care. METHODS: In 2021 POKAL started with a first group of 16 trainees in general practice (GPs), pharmacy, psychology, public health, informatics, etc. The program is scheduled for at least 6 years, so a second group of trainees starting in 2024 will also have three years of research-time. Experienced principal investigators (PIs) supervise all trainees in their specific projects. All projects refer to the CCM and focus on the diagnostic, therapeutic, and implementation challenges. RESULTS: The first cohort of the POKAL research training group will develop and test new depression-specific diagnostics (hermeneutical strategies, predicting models, screening for suicidal ideation), treatment (primary-care based psycho-education, modulating factors in depression monitoring, strategies of de-prescribing) and implementation in primary care (guideline implementation, use of patient-assessed data, identification of relevant context factors). Based on those results the second cohort of trainees and their PIs will run two major trials to proof innovations in primary care-based a) diagnostics and b) treatment for depression. CONCLUSION: The research and training programme POKAL aims to provide appropriate approaches for depression diagnosis and treatment in primary care.

Psychotherapy in dizziness: a systematic review.

BACKGROUND: About 30-50% of complex dizziness disorders are organically not sufficiently explained or related to a psychiatric disorder. Of patients with such dizziness disorders, 80% are severely impaired by dizziness in their daily and working lives; nevertheless, they are often not diagnosed or treated adequately. OBJECTIVES: This review aims to give a systematic overview of psychotherapeutic approaches and their efficacy regarding the treatment of dizziness that is medically not sufficiently explained or related to a psychiatric disorder. METHODS: A systematic literature search was conducted in Medline, PSYNDEX and PsycINFO. Included in this systematic review were (randomised) controlled trials ((R)CTs) concerning psychotherapy in patients with dizziness, medically not sufficiently explained or associated with a psychiatric disorder. If possible, Hedges' g was used to express the effect sizes (ES) of the treatment. Heterogeneity was assessed using the Q statistic. In addition, the quality of the studies was rated. RESULTS: Three (R)CTs were included. All studies used cognitive-behavioural treatment methods in combination with relaxation techniques or vestibular rehabilitation. All studies suggested that psychotherapy may provide improvement. The mean ES in the treatment groups was 0.46 (95% CI 0.05 to 0.88) for dizziness related outcome, 0.10 (-0.44 to 0.64) for anxiety and 0.17 (-0.24 to 0.58) for depression whereas in the control groups the mean dizziness related ES was -0.04 (-0.44 to 0.37), anxiety related ES was -0.03 (-0.43 to 0.38) and depression related ES was -0.02 (-0.42 to 0.38). The quality of the studies was average. Sample sizes were small, however, and there was a lack of long term studies. CONCLUSION: This systematic review provides some preliminary evidence that psychotherapy may be effective in patients with dizziness that is medically not sufficiently explained or due to a psychiatric disorder. The results should be replicated in larger samples and follow-up RCTs.

[Somatoform disorders and functional somatic syndromes]. / Somatoforme und funktionelle Störungen.

Somatoform symptoms occur in the absence of clear organic pathology. Typically, such symptoms are long-lasting and disabling. Somatoform symptoms and disorders are highly prevalent in primary care. The course of somatoform disorders is mostly chronic, and remission rates are low. Multiple factors influence the development and perpetuation of somatoform disorders. Currently, there is strong debate about the classification of somatoform disorders, and it is very likely that there will be significant changes in the classification of somatoform disorders in the upcoming DSM-V. With regard to the psychotherapeutic treatment of somatoform disorders, there is empirical evidence for the efficacy of cognitive-behavioral as well as psychodynamic-interpersonal strategies. Pharmacotherapy plays a minor role, but it can be useful mainly in cases of comorbid depression or anxiety.

Dysfunctional cognitions in idiopathic environmental intolerances (IEI)--an integrative psychiatric perspective.

Idiopathic environmental intolerances (IEI) - formerly multiple chemical sensitivities (MCS) - are characterized by diffuse symptoms reported after exposure to low doses of everyday chemicals. Previous theories about the origin of IEI have emphasized either biological or psychological factors, neglecting a probable interplay. Many have suggested classifying IEI as a somatoform or an anxiety disorder, irrespective of some incongruities. By focusing on dysfunctional cognitions we discuss obvious parallels of IEI with somatoform disorders, and also indicate overlaps with anxiety and delusional disorders. To propose a hypothetical psycho-neurobiological basis of IEI, recent evidence about cortically represented symptoms in the absence of peripheral stimuli is briefly summarized. We conclude that IEI can serve as an illustrative example for the impact of cognitive, representational processes in symptom generation.

Cardiac metabolic and hemodynamic effects of insulin in patients with coronary artery disease.

To assess the effects of insulin in stable coronary artery disease (CAD), 2 U i.v. insulin was given to 9 control and 10 CAD patients during coronary sinus catheterization. Hemodynamic and metabolic data were obtained before and for 90 min after insulin injection. Insulin induced no changes in heart rate, mean aortic pressure, rate-pressure product, coronary sinus flow, or coronary resistance. Metabolic changes were similar in both groups and included 1) 30% decrease of arterial glucose (P less than .001) and 3-fold increase of myocardial glucose uptake (P less than .001), 2) 1.5- to 2.5-fold elevation of arterial lactate (P less than .001) and myocardial lactate usage (P less than .001), respectively, 3) 50-70% suppression of arterial levels (P less than .001) and myocardial uptake of free fatty acids (P less than .01), and 4) 10% reduction of myocardial net oxygen consumption (P less than .05). Myocardial citrate efflux increased in the CAD patients (P less than .05), whereas alanine release rose only in control patients (P less than .01), suggesting that glucose enters glycogen production in the CAD patients and pyruvate production in the control patients to a high degree. Myocardial glutamate uptake remained unchanged. In conclusion, insulin sensitivity was not altered in CAD. The insulin-induced shift from myocardial free fatty acid to carbohydrate usage may be beneficial to the ischemic heart by increasing glycogen stores, saving oxygen, and inhibiting an excess free-fatty acid concentration, which may be toxic during ischemia.

Cardiac hyperfunction in insulin-dependent diabetic patients developing microvascular complications.

Cardiac function was studied by echocardiography in 80 insulin-dependent diabetic patients with no signs of ischemic heart disease and in 40 healthy control subjects. Echocardiographic findings were related to the urinary albumin excretion rate (UAE). In the diabetes group, fractional shortening of the left ventricle (FS) was 37.3% versus 34.3% (P less than .01) in the control group, whereas indices of preload and afterload were at the same levels as in control subjects. In diabetic patients with preclinical nephropathy (UAE 20-200 micrograms/min), FS was 41.1% compared to 37.0% (P less than .002) in patients with no signs of nephropathy (UAE less than 20 micrograms/min) and 34.8% (P less than .001) in patients with clinical nephropathy (UAE less than 200 micrograms/min). Furthermore, in patients with preclinical nephropathy, afterload was significantly decreased, whereas preload was at the same level as in the other two groups of UAE. In conclusion, a condition of cardiac hyperfunction has been found in diabetic patients with no signs of ischemic heart disease and seems pronounced in diabetic patients developing microvascular disease (patients with preclinical nephropathy), probably secondarily to a condition of hyperperfusion in these patients.

Tailored care for somatoform vertigo/dizziness: study protocol for a randomised controlled trial evaluating integrative group psychotherapy.

UNLABELLED: Vertigo/dizziness (VD) ranks high in lifetime prevalence and clinical relevance. Nearly half of the complex VD disorders presenting at specialised units for vertigo or otoneurological disorders are not fully explained by an identifiable medical illness, but instead are related to anxiety, depressive, or somatoform disorders. Although there is some evidence that psychotherapy may be effective for these patients, therapeutic options remain unsatisfactory. This report describes the objectives, design and methods of a randomised, controlled clinical trial, evaluating the efficacy of manualised, multimodal group psychotherapy, based on integrative psychotherapy (IPT) and tailored to subgroups of mental disorders in medically unexplained VD. This psychotherapeutic approach will be compared to self-help groups (n = 172; n = 86 per study arm). Improvements with regard to handicap due to VD at 12 months follow-up will serve as primary outcome. Additionally, measures of generic quality of life, severity of vertigo, depression, anxiety, somatisation as well as Head Impulse Test and Computerized Static Posturography will be applied. We will also analyse the cost-effectiveness of this trial. The study aims to improve treatment of this therapeutically underserved population who are often severely impaired in their working and daily lives. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02320851. TRIAL STATUS: This is an on-going study; recruitment for the study is about to start.

Psychological factors in the diagnosis and pathogenesis of stiff-man syndrome.

Retrospective psychological evaluation of nine patients with stiff-man syndrome (SMS), seven of whom evidenced autoimmune disease, revealed a characteristic set of psychological symptoms or features: Major stressful life events preceded the development of permanent symptoms by 6 months or less (seven patients); transient motor symptoms occurred in emotionally distressing situations months or even years before the onset of a permanent motor deficit (five patients); after onset, similar situations specifically precipitated or augmented stiffness and spasms (five patients). We also found task-specific fear resembling agoraphobia (six patients) and loss or invalidation of one or both parents, or loss of home, in childhood (seven patients). Eight patients were initially misdiagnosed as having psychogenic movement disorder. We conclude that the common misdiagnosis of SMS as a psychogenic movement disorder is due to the compelling association of a set of salient psychological features, bizarre and fluctuating motor symptoms, and lack of approved neurologic signs.

Usefulness of ST deviation induced by prolonged hyperventilation as a predictor of cardiac death in angina pectoris.

One hundred ninety patients with chronic angina for an average of 2 years were followed. Forty-seven had at least 1 mm of ST deviation in response to provocation of coronary vasoconstriction by prolonged hyperventilation (group I); 143 had no ST deviation (group II). The angiographic response to this test was studied in 21 patients from group I, and revealed 25 to 100% diameter reduction; in group II 9 patients showed a 5 to 14% diameter reduction. In group I, 15 patients (32%) died (hazard rate = 0.17 deaths/patients X years) vs 18 (13%) in group II (hazard rate = 0.06) (p less than 0.01). Seven patients in group I (15%) and 3 in group 2 (2%) died while waiting for surgery (p less than 0.01). All patients who died had coronary stenoses of at least 70%. A Cox regression analysis, using 24 variables (invasive and noninvasive), showed a positive hyperventilation test (ST deviation at least 1 mm), low ejection fraction and systolic blood pressure of at least 160 mm Hg to be independent predictors of death (p less than 0.05). Considering only deaths in non-operated patients (patients waiting for surgery and patients not planned to undergo operation), a rate-pressure product/100 of 150 or less at exercise stress testing, left ventricular end-diastolic pressure of 15 mm Hg or more and duration of angina less than 1 year were also independent predictors of death. Thus, the hyperventilation test may be useful for identifying angina patients who are at high risk of cardiac death due to dynamic coronary obstructions.