Burkard Jäger

Stress-Induced Endocrine and Immunological Changes in Psoriasis Patients and Healthy Controls

Background: Clinical observations suggest that psychological stress can induce exacerbation of psoriasis. It is hypothesized that these stress effects on the course and outcome of psoriasis are caused by neuroendocrine modulation of immune functions. Therefore we investigated the cardiovascular, endocrine and immunological response to a laboratory stressor in psoriasis patients and healthy controls. Methods: Untreated (n = 7) and PUVA-treated (n = 4) psoriatics and healthy controls (n = 7) were exposed to a brief laboratory stressor (public speaking and mental arithmetic). Heart rate and blood pressure, catecholamine, cortisol, and DHEA plasma concentration, as well as distribution of T and NK lymphocytes were analyzed before, immediately after and 1 h after stress exposure. Results: Heart rate and blood pressure increased in all three groups during stress exposure with the most pronounced changes in PUVA-treated patients. Psoriasis patients displayed higher adrenaline values but diminished cortisol and DHEA plasma concentrations compared to controls. NK cell numbers (CD16+, CD56+), but not T lymphocyte subsets, increased immediately after stress exposure in untreated patients and controls. This effect was significantly diminished in PUVA-treated patients. Conclusions: The data of this pilot study indicate an enhanced stress-induced autonomic response and diminished pituitary-adrenal activity in psoriasis patients. PUVA treatment seems to interfere with the cardiovascular and NK cell response to acute psychological stress. Future studies will analyze the stress-induced neuroimmunological mechanisms in psoriatics in more detail.

Medikamentöse und psychologische Therapien bei chronischem subjektivem Tinnitus Metaanalyse zur Therapieeffektivität

ZusammenfassungZur Abschätzung der Therapieeffektivität medikamentöser und psychologischer Verfahren wurde eine Metaanalyse der publizierten Therapiestudien durchgeführt. Aus den unmittelbaren Erfolgsmaßen der Primärstudien wurden direkt vergleichbare Effektstärken berechnet. Zur Auswertung kamen 109 Therapiestudien, die zwischen 1976 und 3/1995 publiziert wurden. Die methodische Qualität der Primärstudien wurde nach einem Kriterienkatalog bestimmt, dabei fand sich eine vielfach recht unbefriedigende methodische Qualität der Primärstudien. Die jeweils gefundene Methodenqualität wurde zur Gewichtung der Therapieeffektivität herangezogen. Aufgrund unzureichender Daten in den Primärstudien konnten nur 24 Studien metaanalytisch ausgewertet werden. Die Effektstärken für die medikamentösen Therapien liegen mit ES=1,27 höher als die für die psychologischen mit ES=0,88. Dieser Befund wird durch die hohen unspezifischen (“Placebo-”) Effekte von ES=0,65 bei den medikamentösen Studien und ES=0,10 bei den psychologischen Studien relativiert. Soweit Katamnesen durchgeführt wurden, erfahren Patienten nach psychologischen Therapien im Gegensatz zu medikamentösen Therapien in der Regel noch eine Steigerung des therapeutischen Effekts.AbstractA metaanalysis on pharmacological and psychological treatment reports was conducted in order to evaluate the overall effectiveness of these treatment conditions in chronic tinnitus. A totality of 109 treatment studies published between 1976 and 3/1995 and meeting minimal inclusion criteria was located, but only 24 studies reporting sufficient information could be analyzed. The methodological quality of the studies was evaluated by a coding scheme, and the resulting index of effectiveness has been weighted by this standard as well as by sample size. Effect sizes of pharmacological studies were ES=1.27 and by this higher than the ones for psychological studies with ES=0.88. This finding is attenuated by high (unspecific) placebo effects of ES=0.65 in pharmacological studies compared to ES=0.10 in psychological studies. In general, patients from psychological studies further improve after treatment in cases where catamnestic measurements have been conducted.

Krankheitsbezogener Stress bei der Psoriasis vulgaris Validierung des "Psoriasis- Alltagsstress-Inventars" (PAI)

ZusammenfassungHintergrund und Fragestellung. Der krankheitsspezifische Alltagsstress stellt einen wichtigen Ausschnitt im Leben von Psoriasispatientinnen und -patienten dar. Bisher existierte für seine Messung lediglich das “Psoriasis Life Stress Inventory” (PLSI) von Gupta und Gupta; mit dem “Psoriasis-Alltagsstress-Inventar” (PAI) wird eine deutsche Fassung des PLSI vorgestellt, und seine psychometrischen Eigenschaften werden diskutiert. Patienten/Methodik. Insgesamt 385 stationäre Patientinnen und Patienten füllten den PAI aus, dessen interne Validität durch eine Faktorenanalyse überprüft wurde. Außerdem wurden die Zusammenhänge zwischen dem PAI-Gesamtwert und soziodemographischen Variablen (Varianzanalyse) sowie dem Hautbefall (multiple Regression) bestimmt. Ergebnisse. Der Alltagsstress (PAI) zeigt sich relativ unabhängig von Alter, Geschlecht und Zeitpunkt des Beginns der Erkrankung sowie dem generellen Hautbefall, wird jedoch stark von dem Befall der Hände, des Unterleibs und des Genitalbereichs beeinflusst. Ebenso finden sich ausgeprägte Zusammenhänge mit dem Stigmatisierungserleben (“Fragebogen zum Erleben von Hautbeschwerden”, FEH, [13]). Schlussfolgerungen. Bei dem PAI handelt es sich hinsichtlich psychometrischer Qualität und praktischer Einsetzbarkeit um ein praktikables und relevantes psychologisches Untersuchungsinstrument für Psoriasispatientinnen und -patienten.AbstractBackground and Objective. Illness specific stress plays an important part in the daily life of psoriatic patients. Until now for the measurement of relevant aspects of daily stress only the “Psoriasis Life Stress Inventory” (PLSI) of Gupta & Gupta exists; with the “Psoriasis-Alltagsstress-Inventar” (PAI), a German version of the PLSI is presented and its psychometric properties are discussed. Patients/Methods. 385 in-patients completed the PAI. The internal validity was examined by factor analysis. Moreover, the correlations between the PAI total score and sociodemographic parameters (ANOVA) and extent of skin involvement (multiple regression) were determined. Results. The PLSI score proves to be sufficiently independent of age, sex, age at onset, and general extent of skin involvement. However, affections of the hands, the lower abdomen and the genitals show a strong influence on the total score. We found marked interrelations with the stigmatization feeling (“Questionnaire on Experience with Skin Complaints” QES, Schmid-Ott et al. 1998). Conclusions. The results suggest that the PAI is a useful and psychologically relevant questionnaire for psoriatic patients.

Subgruppen der Krankheitsbewältigung beim chronischen Tinnitus - Eine clusteranalytische Taxonomie

Zusammenfassung. Theoretischer Hintergrund: Bei ca. 20% der Patienten mit chronischem Tinnitus kommt es zu Krankheitsfolgen wie Schlafstorungen, Depressivitat und Suizidalitat. Bis heute ist unklar, welche Patientenmerkmale fur einen gunstigen vs. einen ungunstigen Krankheitsverlauf verantwortlich sind. Fragestellungen: Welche Subgruppen sind innerhalb der Gesamtgruppe chronisch kranker Tinnitus-Patienten identifizierbar? Unterscheiden sich diese Subgruppen hinsichtlich der Krankheitsfolgen und der Krankheitsbewaltigung? Methode: Von einer konsekutiv erhobenen Stichprobe von Patientinnen und Patienten mit Tinnitus litten 255 unter einem chronischen Tinnitus, 219 gingen in eine clusteranalytische Taxonomie ein. Es wurde eine 6-Cluster-Losung gewahlt, die durch eine Reanalyse von 94,5% richtig zugeordneter Falle abgesichert werden konnte. Ergebnisse: Die 6 Gruppen unterschieden sich deutlich hinsichtlich der Belastung durch den Tinnitus, obgleich die Belastung nicht als Merkmalsvariablen in die Cluster-anal...

Zur interdisziplinären S3-Leitlinie für die Therapie des chronisch-idiopathischen Tinnitus

INTRODUCTION Tinnitus is a frequent symptom, which, particularly in combination with comorbidities, can result in a severe disease-related burden. Chronic idiopathic tinnitus (CIT) is the most frequent type of tinnitus. A considerable number of treatment strategies are used to treat CIT-for many of which there is no evidence of efficacy. In order to enable scientific evidence-based treatment of CIT, German interdisciplinary S3 guidelines have recently been constructed for the first time. Here we present a short form of these S3 guidelines. MATERIALS AND METHODS The guidelines were constructed based on a meta-analysis of the treatment of chronic tinnitus performed by the authors. Additionally, a systematic literature search was performed in the PubMed and Cochrane Library databases. Furthermore, a systematic search for international guidelines was performed in Google, as well as in the Guidelines International Network and National Guideline Clearinghouse (USA) database. Evidence was classified according to the Oxford Centre for Evidence-Based Medicine system. RESULTS According to the guidelines, alongside counselling, manualized structured tinnitus-specific cognitive behavioral therapy (tCBT) with a validated treatment manual is available as evidence-based therapy. In addition, the guidelines recommend concurrent treatment of comorbidities, including drug-based treatment, where appropriate. Particularly important is treatment of anxiety and depression. Where a psychic or psychiatric comorbidity is suspected, further diagnosis and treatment should be performed by an appropriately qualified specialist (psychiatrist, neurologist, psychosomatic medicine consultant) or psychological psychotherapist. In cases accompanied by deafness or hearing loss bordering on deafness, cochlear implants may be indicated. CONCLUSION No recommendations can be made for drug-based treatment of CIT, audiotherapy, transcranial magnetic or electrical stimulation, specific forms of acoustic stimulation or music therapy; or such recommendations must remain open due to the lack of available evidence. Polypragmatic tinnitus treatment with therapeutic strategies for which there is no evidence of efficacy from controlled studies is to be refused.

On the interdisciplinary S3 guidelines for the treatment of chronic idiopathic tinnitus

INTRODUCTION Tinnitus is a frequent symptom, which, particularly in combination with comorbidities, can result in a severe disease-related burden. Chronic idiopathic tinnitus (CIT) is the most frequent type of tinnitus. A considerable number of treatment strategies are used to treat CIT-for many of which there is no evidence of efficacy. In order to enable scientific evidence-based treatment of CIT, German interdisciplinary S3 guidelines have recently been constructed for the first time. Here we present a short form of these S3 guidelines. MATERIALS AND METHODS The guidelines were constructed based on a meta-analysis of the treatment of chronic tinnitus performed by the authors. Additionally, a systematic literature search was performed in the PubMed and Cochrane Library databases. Furthermore, a systematic search for international guidelines was performed in Google, as well as in the Guidelines International Network and National Guideline Clearinghouse (USA) database. Evidence was classified according to the Oxford Centre for Evidence-Based Medicine system. RESULTS According to the guidelines, alongside counselling, manualized structured tinnitus-specific cognitive behavioral therapy (tCBT) with a validated treatment manual is available as evidence-based therapy. In addition, the guidelines recommend concurrent treatment of comorbidities, including drug-based treatment, where appropriate. Particularly important is treatment of anxiety and depression. Where a psychic or psychiatric comorbidity is suspected, further diagnosis and treatment should be performed by an appropriately qualified specialist (psychiatrist, neurologist, psychosomatic medicine consultant) or psychological psychotherapist. In cases accompanied by deafness or hearing loss bordering on deafness, cochlear implants may be indicated. CONCLUSION No recommendations can be made for drug-based treatment of CIT, audiotherapy, transcranial magnetic or electrical stimulation, specific forms of acoustic stimulation or music therapy; or such recommendations must remain open due to the lack of available evidence. Polypragmatic tinnitus treatment with therapeutic strategies for which there is no evidence of efficacy from controlled studies is to be refused.

Komorbidität von Diabetes mellitus Typ 2 und Night Eating

The core symptoms of the night eating syndrome (NES) are overeating in the evening and/or nocturnal awakenings with the ingestion of food. The aim of this study was to examine metabolic and psychopathological differences between patients with type 2 diabetes mellitus with and with-out night eating (NE). A total of 226 individuals with type 2 diabetes mellitus participated in the study. Night eating (NE), defined as the ingestion of ≥25% of the daily food intake in the evening or nighttime, was reported by 28 (12.4%) of the participants. In addition, diabetes-related variables, eating and dieting behavior as well as eating-related and general psychopathology (depression, quality of life) were assessed. Compared to pa-tients without NE patients with NE showed higher HbA1c values, higher scores on the disinhibition and the perceived hunger scale, lower scores on the quality of life scale and higher depression scores.

Krankheitserleben und Therapieinanspruch-nahmeverhalten bei Psoriasispatienten

ZusammenfassungZiel der vorliegenden Untersuchung war die Vorhersage der Inanspruchnahme medizinischer Leistungen im Zusammenhang mit dem Krankheitserleben und der empfundenen Stigmatisierung bei Patienten mit Psoriasis vulgaris. Es wurde eine Reanalyse der Daten eines von einem Marktforschungsinstitut an 400 Psoriasispatienten erhobenen teilstrukturierten Interviews durchgeführt. Untersucht wurde die Bedeutung des Krankheitserlebens bei Diagnosestellung für das Inanspruchnahmeverhalten von und die Einstellung gegenüber der medizinischen Versorgung. Eine Clusteranalyse zum Krankheitserleben bei Diagnosestellung ergab 4 homogene Gruppen typischer initialer Erlebnisweisen (die „Isolierten”, die „Stigmatisierten”, die „Unterstützten” und die „Nicht-Stigmatisierten”). Eine zweite Clusteranalyse zum späteren Therapieinanspruchnahmeverhalten ergab 5 homogene Gruppen (die „Multi-User”, die „Arrangierten Mini-User”, die „Wartezimmerpatienten”, die „Hoffnungsvollen” sowie die Gruppe der „Eigentherapeuten”). Um mögliche Verlaufstypen zu identifizieren, wurden in dem folgenden Analyseschritt diese beiden Taxonomien zueinander in Beziehung gesetzt (Chi2-Analyse). Die Ergebnisse werden vor dem Hintergrund der wünschenswerten frühzeitigen Identifikation von „Problempatienten” diskutiert.SummaryWe analyzed how psoriasis patients sought professional help and correlated it to their illness attitudes and feelings of stigmatization. Semi-structured interviews of 400 patients were reanalyzed to identify homogeneous groups concerning initial reactions at first manifestations of the disease. Four groups (”isolated”, ”stigmatized”, ”socially supported” and ”non-stigmatized” patients) were found and cross-tabulated with five resulting groups of a second cluster-analysis concerning the ”style” of the seeking behaviour of professional and paraprofessional help and medical measures against the psoriasis (”multi-users”, ”arranged mini-users”, ”waiting-room patients”, ”optimists” and ”self- therapists”). We were able to describe typical courses of illness behaviour depending on the initial reaction. The results are discussed with regard to the desirable identification of problematic patients within professional care units.

Übereinstimmung zwischen nicht-strukturierter klinischer und strukturierter klinischer Diagnosestellung bei stationären psychosomatischen Patienten

The goal of this study was to determine the agreement between axis I mental disorders assessed with a structured clinical interview (SCID) and independently obtained non-structured clinical diagnoses in 185 psychosomatic in-patients. Additionally, the study focuses on the detection of potential predictors for the level of agreement. Diagnostic agreement was poor to moderate for the mood, anxiety and somatoform disorder cluster (κ = 0.293-0.444). Only for eating disorders an almost complete concordance could be found (κ = 0.812). The predictor analysis indicated a significant positive association between the comorbidity rate and the agreement in mood disorders. Furthermore, the diagnostic agreement of anxiety disorders was significantly higher for female than for male patients. These results reveal that even a team-based clinical diagnosis, assessed over the period of a hospital stay, shows little agreement with SCID-diagnoses. The predictor analysis as well as the poor correlation in 3 of 4 diagnostic clusters suggest that conceptual differences of the disorder criteria as well as their clinical interpretation might influence the concordance between diagnoses. Further studies focusing on methodical factors might reveal further insights to the cause of the diagnostic discrepancies.

Zur interdisziplinären S3-Leitlinie für die Therapie des chronisch-idiopathischen Tinnitus@@@On the interdisciplinary S3 guidelines for the treatment of chronic idiopathic tinnitus

INTRODUCTION Tinnitus is a frequent symptom, which, particularly in combination with comorbidities, can result in a severe disease-related burden. Chronic idiopathic tinnitus (CIT) is the most frequent type of tinnitus. A considerable number of treatment strategies are used to treat CIT-for many of which there is no evidence of efficacy. In order to enable scientific evidence-based treatment of CIT, German interdisciplinary S3 guidelines have recently been constructed for the first time. Here we present a short form of these S3 guidelines. MATERIALS AND METHODS The guidelines were constructed based on a meta-analysis of the treatment of chronic tinnitus performed by the authors. Additionally, a systematic literature search was performed in the PubMed and Cochrane Library databases. Furthermore, a systematic search for international guidelines was performed in Google, as well as in the Guidelines International Network and National Guideline Clearinghouse (USA) database. Evidence was classified according to the Oxford Centre for Evidence-Based Medicine system. RESULTS According to the guidelines, alongside counselling, manualized structured tinnitus-specific cognitive behavioral therapy (tCBT) with a validated treatment manual is available as evidence-based therapy. In addition, the guidelines recommend concurrent treatment of comorbidities, including drug-based treatment, where appropriate. Particularly important is treatment of anxiety and depression. Where a psychic or psychiatric comorbidity is suspected, further diagnosis and treatment should be performed by an appropriately qualified specialist (psychiatrist, neurologist, psychosomatic medicine consultant) or psychological psychotherapist. In cases accompanied by deafness or hearing loss bordering on deafness, cochlear implants may be indicated. CONCLUSION No recommendations can be made for drug-based treatment of CIT, audiotherapy, transcranial magnetic or electrical stimulation, specific forms of acoustic stimulation or music therapy; or such recommendations must remain open due to the lack of available evidence. Polypragmatic tinnitus treatment with therapeutic strategies for which there is no evidence of efficacy from controlled studies is to be refused.