Harald Guendel

Frequency shifts in the anterior default mode network and the salience network in chronic pain disorder

BackgroundRecent functional imaging studies on chronic pain of various organic etiologies have shown significant alterations in both the spatial and the temporal dimensions of the functional connectivity of the human brain in its resting state. However, it remains unclear whether similar changes in intrinsic connectivity networks (ICNs) also occur in patients with chronic pain disorder, defined as persistent, medically unexplained pain.MethodsWe compared 21 patients who suffered from chronic pain disorder with 19 age- and gender-matched controls using 3T-fMRI. All neuroimaging data were analyzed using both independent component analysis (ICA) and power spectra analysis.ResultsIn patients suffering from chronic pain disorder, the fronto-insular ‘salience’ network (FIN) and the anterior default mode network (aDMN) predominantly oscillated at higher frequencies (0.20 - 0.24 Hz), whereas no significant differences were observed in the posterior DMN (pDMN) and the sensorimotor network (SMN).ConclusionsOur results indicate that chronic pain disorder may be a self-sustaining and endogenous mental process that affects temporal organization in terms of a frequency shift in the rhythmical dynamics of cortical networks associated with emotional homeostasis and introspection.

Functional network connectivity of pain-related resting state networks in somatoform pain disorder: an exploratory fMRI study.

BACKGROUND Without stimulation, the human brain spontaneously produces highly organized, low-frequency fluctuations of neural activity in intrinsic connectivity networks (ICNs). Furthermore, without adequate explanatory nociceptive input, patients with somatoform pain disorder experience pain symptoms, thus implicating a central dysregulation of pain homeostasis. The present study aimed to test whether interactions among pain-related ICNs, such as the default mode network (DMN), cingular-insular network (CIN) and sensorimotor network (SMN), are altered in somatoform pain during resting conditions. METHODS Patients with somatoform pain disorder and healthy controls underwent resting functional magnetic resonance imaging that lasted 370 seconds. Using a data-driven approach, the ICNs were isolated, and the functional network connectivity (FNC) was computed. RESULTS Twenty-one patients and 19 controls enrolled in the study. Significant FNC (p < 0.05, corrected for false discovery rate) was detected between the CIN and SMN/anterior DMN, the anterior DMN and posterior DMN/SMN, and the posterior DMN and SMN. Interestingly, no group differences in FNC were detected. LIMITATIONS The most important limitation of this study was the relatively short resting state paradigm. CONCLUSION To our knowledge, our results demonstrated for the first time the resting FNC among pain-related ICNs. However, our results suggest that FNC signatures alone are not able to characterize the putative central dysfunction underpinning somatoform pain disorder.

Neural correlates of deficits in pain-related affective meaning construction in patients with chronic pain disorder.

Objective Psychological and neural mechanisms of the affective dimension of pain are known to be disturbed in patients with chronic pain disorder. The aim of this functional magnetic resonance imaging study was to assess the neurofunctional and behavioral measures underlying the ability to construct pain-related affective meaning in a painful situation by comparing 21 clinically and psychometrically well-characterized patients with persistent non-nociceptive somatoform pain with 19 healthy controls. Methods The functional magnetic resonance imaging task involved viewing pictures depicting human hands and feet in different painful and nonpainful situations. Participants were asked to estimate the perceived pain intensity. These data were correlated with behavioral measures of depression, alexithymia, and general cognitive and emotional empathy. Results In a hypothesis-driven region-of-interest analysis, the healthy control group exhibited greater activation of the left perigenual anterior cingulate cortex than patients with pain (Montreal Neurological Institute coordinates (x y z) = −8 38 0; cluster extent = 54 voxels; T = 4.28; p = .006 corrected for multiple comparisons at cluster level). No group differences in the activation of the anterior insular cortex were found. Scores on self-assessment instruments (Beck Depression Inventory I, Interpersonal Reactivity Index, and 20-item Toronto Alexithymia Scale) did not influence neuroimaging results. Conclusions Our results suggest that patients with chronic medically unexplained pain have an altered neural pain perception process owing to decreased activation of empathetic-affective networks, which we interpret as a deficit in pain-related affective meaning construction. These findings may lead to a more specific and detailed neurobiological understanding of the clinical impression of disturbed affect in patients with chronic pain disorder.

The grapes of war. Somatoform pain disorder and history of early war traumatization in older people.

Persistent pain is not a normal part of aging. Nevertheless, many older patients have long-lasting, more or less medically unexplained pain symptoms and, consequently, are often severely disabled, incur high health care costs, and have high comorbidity rates. Moreover, the effects of early traumatization, especially due to wars, and even below the level of posttraumatic stress disorder (PTSD) are apparent. However, the developmental and neurobiological underpinnings of somatoform pain disorder, especially in pain-prone elderly patients, and its correlations with a history of war traumatization even decades after the incident remain unclear. Furthermore, a management strategy for this disorder tailored to older people and their special needs is lacking. Adequate therapeutic regimens such as adjusted psychotherapeutic procedures for elderly patients can only be promoted through a better understanding of the neurobiological and biographical underpinnings of this still controversial disorder.ZusammenfassungAnhaltende Schmerzen sind kein normaler Bestandteil des Alterns. Dennoch haben viele ältere Patienten dauerhaft eine mehr oder weniger medizinisch nicht erklärbare Schmerzsymptomatik. Sie sind damit oft schwer beeinträchtigt, verursachen hohe Kosten im Gesundheitswesen und zeigen eine hohe Komorbiditätsrate. Auch sind die Folgen früher Traumatisierungen, insbesondere durch Kriege und sogar unterhalb der Ausprägung einer posttraumatischen Belastungsstörung (PTSD), offensichtlich. Jedoch bleiben die Entstehungs- und neurobiologischen Grundlagen der somatoformen Schmerzstörung, vor allem in schmerzgeneigten, älteren Patienten, und ihre Zusammenhänge mit einer Vorgeschichte von Kriegstraumatisierung – sogar Jahrzehnte nach dem Ereignis – unklar. Darüber hinaus fehlt für diese Erkrankung eine Behandlungsstrategie, die auf ältere Menschen und ihre besonderen Bedürfnisse zugeschnitten wäre. Adäquates therapeutisches Vorgehen, wie angepasste psychotherapeutische Prozeduren für ältere Patienten, können nur durch ein besseres Verständnis der neurobiologischen und biographischen Grundlagen dieser nach wie vor kontroversen Störung gefördert werden.

Psychosomatic consultation in the workplace - a new model of care at the interface of company-supported mental health care and consultation-liaison psychosomatics: design of a mixed methods implementation study

BackgroundMental health issues are gaining in importance in society and the economic system. At the same time, the accessibility and stigmatisation of the mental health care system in Germany can obstruct help-seeking behavior and delay early psychotherapeutic interventions. Therefore, new models of care are being established at the interface of company-supported health promotion and conventional health insurance sponsored outpatient care for people developing mental illnesses. Two large industrial companies, in cooperation with two psychosomatic clinics, have recently established a model of “psychosomatic consultation in the workplace“. This new model of care offers the opportunity for a first psychotherapeutic door to door consultation with occupational medicine within the industrial workplace. The main empirical goals of this study are:1) Describing the differences between patients who use this new diagnostic and therapeutic offer within the industrial workplace vs. patients who visit a conventional regional outpatient clinic, especially in regard to symptom duration and severity, work ability, and demographic characteristics, and2) A first evaluation of how patients may benefit more from this new model of care compared to those first seen by standard outpatient care.In the qualitative part of the study, occupational physicians, psychosomatic therapists, involved personnel and select employees of the involved companies will be asked to comment on their experiences with this new approach.Methods/DesignThe implementation study will take place in Ulm and in Stuttgart, with each site looking at one regional conventional psychosomatic outpatient clinic and one psychosomatic consultation offer within the workplace. 70 consecutive patients in each setting will be recruited (overall n = 280). For the cross-sectional study and pre-post comparison we will use established and validated survey instruments (PHQ, SF-12, WAI, MBI, IS) as well as standardized questions about health care use. For data analysis, we will use uni- and multivariate analytical methods. Qualitative data analysis (expert interviews) will be carried out using Mayring’s content analysis method.DiscussionThe results of this study have the potential to provide evidence-based knowledge about an innovative model of psychotherapeutic outpatient care and to further promote tailored solutions for early psychotherapeutic interventions within the worksite.Trial RegistrationDRKS00003184

High prevalence of posttraumatic stress in patients with primary hypertension

OBJECTIVE Posttraumatic stress disorder (PTSD) is associated with a higher rate of arterial hypertension. However, data about prevalence rates of PTSD in patients suffering from arterial hypertension as well as the relation to blood pressure (BP) control are lacking. METHODS We recruited 145 patients with primary hypertension from March to November 2012 at the cardiologic outpatient clinic at Ulm University Medical Center. Symptoms of PTSD (assessed with the Posttraumatic Diagnostic Scale), perceived stress (Perceived Stress Scale; Trier Inventory for Chronic Stress), depression and anxiety (Hospital Anxiety and Depression Scale) were assessed by self-report. Office BP was measured and medical data were collected. RESULTS Criteria for a full PTSD syndrome were met by 13 patients (9%). Posttraumatic stress was higher in the group of patients with controlled (M=10.9, S.D.=9.8) than in those with uncontrolled hypertension (M=3.9, S.D.=5.4; P<.001). In linear regression, only status of hypertension control (beta=.39, P<.001) predicted posttraumatic stress significantly, even after controlling for important cofactors. CONCLUSIONS PTSD is highly prevalent in hypertensive patients, especially in those with controlled hypertension. An explaining mechanism could be the higher use of health care by patients suffering from PTSD. The mental needs of these patients should be focused in addition to the well-established somatic care.

Psychosomatic consultation in the workplace: do we reach different users by changing the context?

Background In Germany, the proportion of mental health diagnoses in early retirement is currently at 40%, constituting the largest diagnostic group. Due to demographic changes, shortage of qualified staff is an increasing challenge for social insurance funds and the labour market. Work-related stress is known to promote common mental disorders (CMD) like depression, anxiety, functional somatoform disorder or adjustment disorders and results in a declining quality of life and work performance. Although the landscape of mental health services is well established in Germany, only 40% of affected individuals managed to obtain professional care. The unmet need for easily accessible and early interventions and the economic impact of CMD led to the development of a variety of offers at the interface between company supported and conventional mental health care (CAU) e.g. the “psychosomatic consultation in the workplace” (PCIW). To learn more about this complex system we set out to analyse user profile and change 12-weeks after consultation.

The grapes of war@@@Die Früchte des Krieges: Somatoform pain disorder and history of early war traumatization in older people@@@Somatoforme Schmerzstörungen und Vorgeschichten von früher Kriegstraumatisierung bei Älteren

Persistent pain is not a normal part of aging. Nevertheless, many older patients have long-lasting, more or less medically unexplained pain symptoms and, consequently, are often severely disabled, incur high health care costs, and have high comorbidity rates. Moreover, the effects of early traumatization, especially due to wars, and even below the level of posttraumatic stress disorder (PTSD) are apparent. However, the developmental and neurobiological underpinnings of somatoform pain disorder, especially in pain-prone elderly patients, and its correlations with a history of war traumatization even decades after the incident remain unclear. Furthermore, a management strategy for this disorder tailored to older people and their special needs is lacking. Adequate therapeutic regimens such as adjusted psychotherapeutic procedures for elderly patients can only be promoted through a better understanding of the neurobiological and biographical underpinnings of this still controversial disorder.ZusammenfassungAnhaltende Schmerzen sind kein normaler Bestandteil des Alterns. Dennoch haben viele ältere Patienten dauerhaft eine mehr oder weniger medizinisch nicht erklärbare Schmerzsymptomatik. Sie sind damit oft schwer beeinträchtigt, verursachen hohe Kosten im Gesundheitswesen und zeigen eine hohe Komorbiditätsrate. Auch sind die Folgen früher Traumatisierungen, insbesondere durch Kriege und sogar unterhalb der Ausprägung einer posttraumatischen Belastungsstörung (PTSD), offensichtlich. Jedoch bleiben die Entstehungs- und neurobiologischen Grundlagen der somatoformen Schmerzstörung, vor allem in schmerzgeneigten, älteren Patienten, und ihre Zusammenhänge mit einer Vorgeschichte von Kriegstraumatisierung – sogar Jahrzehnte nach dem Ereignis – unklar. Darüber hinaus fehlt für diese Erkrankung eine Behandlungsstrategie, die auf ältere Menschen und ihre besonderen Bedürfnisse zugeschnitten wäre. Adäquates therapeutisches Vorgehen, wie angepasste psychotherapeutische Prozeduren für ältere Patienten, können nur durch ein besseres Verständnis der neurobiologischen und biographischen Grundlagen dieser nach wie vor kontroversen Störung gefördert werden.