Mathias Langkafel

Is there a benefit from intensified medical and psychological interventions in patients with functional dyspepsia not responding to conventional therapy

Aim In a prospective randomized, controlled trial, to compare the long‐term outcome of intensive medical therapy (with or without cognitive‐behavioural or muscle relaxation therapy) vs. standard medical therapy in patients with refractory functional dyspepsia (FD), referred to a tertiary referral medical center.

Clinical presentation and personality factors are predictors of the response to treatment in patients with functional dyspepsia ; a randomized, double-blind placebo-controlled crossover study

The role of psychological factors or symptom pattern for the response to treatment in patients with unexplained (functional) dyspepsia is unknown. We hypothesized that patients with reflux- and ulcer-like symptoms would be more likely to respond to acid-lowering therapy, while psychological disturbances would be associated with a less favorable response to treatment. Seventy-eight patients with a diagnosis of functional dyspepsia were recruited and 75 completed the trial. Patients were treated for 4 weeks in a double-blind, placebo-controlled crossover trial starting in random order with either active drug (ranitidine, 150 mg b.d.) or placebo. Every 7 days, medication was switched from active drug to placebo, or vice versa. At entry, patient characteristics were assessed utilizing a semistructured standardized interview and standardized questionnaires, and weekly intensity of symptoms was assessed utilizing a visual analogue scale. Patients with a greater reduction of the symptom score during active treatment and an overall reduction of the global symptom score by more than 50% at the end of the study period were categorized as responders. Logistic regression analysis was utilized to assess the influence of symptom type and presence of psychological disturbances on the treatment response. During treatment the symptom score decreased significantly, from 32.1 ± 1.44 (SD) to 21.3 ± 1.9 at the end of the trial (P < 0.001). Twenty of 75 were responders. High scores for somatization (OR, 3.6; 95% Cl, 1.2–11.4), anxiety (OR, 3.3; 95% Cl, 0.9–11.8), and reflux-like symptoms (OR, 5.3; 95% Cl, 1.7–16.7) were associated with response to treatment, while dysmotility-like symptoms were associated with an unfavorable response (OR, 0.3; 95% Cl, 0.1–0.9). Symptom pattern and psychological disturbances are independent predictors of treatment response. Patients with reflux-like symptoms and greater psychological disturbances are more likely to respond to an acid-lowering compound.

Circadian Plasma Leptin Levels in Patients with Anorexia nervosa: Relation to Insulin and Cortisol

In anorexia nervosa, underweight results from a loss of body mass due to a restricted energy intake. Circulating leptin levels have been shown to be low in the acute stage of the disorder. We studied diurnal secretion characteristics of leptin, insulin and cortisol in a study group of anorectic patients prior to refeeding, a second study group of anorectic patients after initiation of refeeding and study groups of healthy underweight and normal-weight controls. Spontaneous secretion of leptin, insulin and cortisol was measured by drawing blood samples every 2 h for 24 h. The temporal relationships between the diurnal secretion patterns of the three hormones were assessed by cross-correlation analysis in every study group. Plasma levels of leptin and cortisol were secreted with a specific circadian rhythmicity and displayed an intricate temporal relationship in anorectic patients. Semistarvation in the non-refed patients was associated with (1) exceedingly low plasma leptin levels, (2) a qualitative alteration in the circadian rhythm of leptin and cortisol levels and (3) an alteration in the temporal coupling between cortisol and leptin. In contrast, in the patients who had gained weight, leptin levels were higher; furthermore, the diurnal pattern of leptin and the temporal relationship between leptin and cortisol were similar to controls. Increments in insulin secretion preceded those of leptin by 4–6 h in both anorectic patients and in controls. Leptin levels increased 4 h prior to those of cortisol in controls and in refed patients, whereas in the non-refed patients cortisol increased prior to leptin. Thus, anorexia nervosa leads to pronounced, albeit reversible changes in the secretion dynamics of leptin and cortisol.

DIAGNOSTIK DER FUNKTIONELLEN HERZBESCHWERDEN AUS PSYCHOSOMATISCHER SICHT

ZusammenfassungStörungen des kardiovaskulären Systems sind weit verbreitet. Obwohl psychologische Auffälligkeiten bei Patienten mit funktionellen Herzbeschwerden lange bekannt sind, werden diese-wenn überhaupt-erst spät diagnostiziert. Es wird auf die deskriptive Diagnostik funktioneller Herzbeschwerden nach ICD-10 (Kapitel V) eingegangen. Nach Ausschluß einer körperlichen Ursache muß geprüft werden, ob die funktionellen Herzbeschwerden im Rahmen einer psychischen Grunderkrankung aufgetreten sind. Wichtig sind in diesem Zusammenhang die Gruppe der Angststörungen (von allem Panikstörungen und Agoraphobie) und die Gruppe der depressiven Erkrankungen. Kann eine solche psychische Erkrankung im engeren Sinne nicht nachgewiesen werden, kommt eine Diagnose aus der Gruppe der somatoformen Störungen in Betracht, wobei hier somatoforme autonome Funktionsstörungen, die hypochondrische Störung und die eigentlichen Somatisierungsstörungen unterschieden werden.Für die Frage der Indikation einer psychotherapeutischen Behandlung ist neben der deskriptiven Einordnung eine weitere Störungsanalyse notwendig. Hierbei sind Informationen, die den Kontext der Beschwerden sowohl auf der biologischphysiologischen als auch auf der intrapsychischen und interpersonellen Ebene betreffen, bedeutsam. Dabei ist die psychosomatische Diagnostik auf eine enge Kooperation mit den behandelnden Hausärzten und Internisten angewiesen.AbstractDisorders of the cardiovascular system are common. Heart pain is one of the most frequent complaints leading patients to seek medical help. Although psychologically conspicuous behavior in patients with functional cardiac complaints are well known, they are — if at all — diagnosed quite late. Descriptive diagnostics of functional cardiac complaints according to the International Classification of Diseases (ICD-10, Chapter 5) are discussed (Figure 1). Possible physical causes of the disease must first be excluded. In a second step it must be clarified whether the complaints even those non-verbally conveyed are due to psychic illness in a narrower sense. Anxiety and depressive disorders must be taken into consideration here. If the patient demonstrates an avoidance behavior in the case of anxiety, then an agoraphobia can be assumed: in episodic paroxysmal fear one can assume panic attacks in which vegetative anxiety equivalents such as shortness of breath, numbness, palpitation of the heart, tachycardia and chest pain are prominent often accompanied by trembling, perspiration, nausea and dizziness. The different depressive disorders are characterized by a dejected mood, loss of interest, loss of enthusiasm and drive reduction; the disorders are divided up according to intensity and course. Within the scope of depressive physical symptoms, frequently unpleasant sensations and pain in the chest area are described along with concern, despair, and an increase in self-observation.If no psychic disturbance in a narrower sense can be diagnosed. then the diagnosis of a somatoform disorder allows for this behavior. It is characteristic for this category of illnesses that the repeated presentation of physical symptoms in connection with the persistent demand for medical treatment may be observed although no physical causes can be demonstrated. The patients insist that their complaints are of a physical origin despite the doctor’s assertion that this is not the case. If the symptoms are related to vegetative innervated organs then one speaks of somatoform autonomous functional disorders (F45.3, Table 1). Cardiovascular disorders fall within this scope. Further diagnoses within the spectrum of somatoform disorders are hypochondric and somatization disorders which demonstrate a variety of symptoms and inconsistent and frequently changing complaints.If a descriptive diagnosis can correspondingly be made then further analysis of the disorder must be carried out in order to reach an indication for psychotherapeutic treatment. From a psychodynamic point of view, the personality- and comflict-related background of the disturbance is relevant. Quite often unconscious ambivalent separation conflicts-be they real or phantasized situations of being left or being left alone-may be observed to trigger cardiovascular symptoms. In the cognitive-behavioral therapeutic tradition an exact analysis of the patient’s symptomatology is carried out in which prior and actual causal factors of the symptoms are looked for.Irrespective of the different approaches, information on the context of the complaints both on a biological, intrapsychic and interpersonal level is necessary for psychosomatic diagnostics. The better the causal conditions are known on the basis of which functional cardiovascular complaints have arisen, the easier it is to recognize those factors that will influence a change and allow a therapeutic approach. This is best done in cooperation with practitioners and internists who still have a key position in the diagnosis and treatment of patients with functional cardiac disorders. The ways and means in which they conduct the anamnesis is decisive in leading their patients to regard psychosomatic diagnostics as being either stuck in the so-called “psycho corner” or as a helpful relationship which they can accept.

Die Lebensqualität bei chronischen Erkrankungen–funktionelle Dyspepsie vs. chronische Lebererkrankungen

Hintergrund und Ziele: Fur Erkrankungen, die nicht durch eine erhohte Mortalitat gekennzeichnet sind, ist die gesundheitsbezogene Lebensqualitat (HRQOL) ein wichtiger Indikator der Schwere der Erkrankung. Ziel war die Untersuchung der Bedeutung der HRQOL adjustiert nach Angst und Depression bei Patienten mit funktioneller Dyspepsie (FD) oder chronischer Lebererkrankung (CLD). Methodik: 100 konsekutive Patienten mit FD und 195 Patienten mit CLD wurden an zwei tertiaren Versorgungszentren untersucht. FD wurde anhand der gultigen Rom-II-Kriterien diagnostiziert. CLD wurde klinisch und histologisch diagnostiziert und klassifiziert (53,6% mit Zirrhose, 21,4% Child-Pugh A, 14,8% Child-Pugh B, 17,3% Child-Pugh C). Der Short Form Health Survey (SF-36) zur Erfassung der HRQOL und die Hospital Anxiety and Depression Scale (HADS) zur Erfassung von Angst und Depression wurden benutzt. Ergebnisse: Es gab keine signifikanten Unterschiede bezuglich Depression, aber FD-Patienten waren deutlich angstlicher als CLD-Patienten (9,6–2,6 vs. 7,0–4,7, p≤0,0001). FD-Patienten hatten eine bessere Korperfunktion (75,8–21,8 vs. 59,5–29,7, p≤0,0001), aber deutlich hohere Schmerzscores als CLD-Patienten (39,5–24,0 vs. 56,1–31,5, p≤0,0001). Soziale Rollenfunktion (56,6–26,7 vs. 67,0–30,4, p≤0,004) und mentaler Gesundheitsstatus (52,3–19,4 vs. 61,7–21,7, p≤0,0001) lagen bei FD- deutlich unterhalb der CLD-Patienten. Der mentale Gesamtscore war bei FD- im Vergleich zu CLD-Patienten deutlich reduziert (38,8–11,8 vs. 43,0–12,1, p≤0,0007). Diese Scores lagen bei FD- noch unterhalb derjenigen von Child-C-CLD Patienten. Diese Unterschiede blieben auch nach Adjustierung fur Alter, Geschlecht und HADS deutlich signifikant. Schlussfolgerung: Die HRQOL ist bei FD- im Vergleich zu CLD-Patienten, auch im fortgeschrittenen Erkrankungsstadium, deutlich reduziert. Angst scheint unabhangig mit FD assoziiert zu sein.