Stephan Zipfel

Management of functional somatic syndromes

Although functional somatic syndromes (FSS) show substantial overlap, treatment research is mostly confined to single syndromes, with a lack of valid and generally accepted diagnostic criteria across medical specialties. Here, we review management for the full variety of FSS, drawn from systematic reviews and meta-analyses since 2001, and give recommendations for a stepped care approach that differentiates between uncomplicated and complicated FSS. Non-pharmacological treatments involving active participation of patients, such as exercise and psychotherapy, seem to be more effective than those that involve passive physical measures, including injections and operations. Pharmacological agents with CNS action seem to be more consistently effective than drugs aiming at restoration of peripheral physiological dysfunction. A balance between biomedical, organ-oriented, and cognitive interpersonal approaches is most appropriate at this truly psychosomatic interface. In view of the iatrogenic component in the maintenance of FSS, doctor-centred interventions and close observation of the doctor-patient relationship are of particular importance.

Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study

In a prospective long-term follow-up of 84 patients 21 years after first hospitalisation for anorexia nervosa, we found that 50.6% had achieved a full recovery, 10.4% still met full diagnostic criteria for anorexia nervosa, and 15.6% had died from causes related to anorexia nervosa. Predictors of outcome included physical, social, and psychological variables.

Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study

BACKGROUND Given our poor understanding of the very long-term course of anorexia nervosa. many questions remain regarding the potential for recovery and relapse. The purpose of the present study was to investigate long-term outcome and prognosis in an anorexic sample 21 years after the initial treatment. METHOD A multidimensional and prospective design was used to assess outcome in 84 patients 9 years after a previous follow-up and 21 years after admission. Among the 70 living patients, the follow-up rate was 90%. Causes of death for the deceased patients were obtained through the attending physician. Predictors of a poor outcome at the 21-year follow-up were selected based on the results of a previous 12-year follow-up of these patients. RESULTS Fifty-one per cent of the patients were found to be fully recovered at follow-up, 21% were partially recovered and 10% still met full diagnostic criteria for anorexia nervosa. Sixteen per cent were deceased, due to causes related to anorexia nervosa. The standardized mortality rate was 9.8. The three groups also showed significant differences in psychosocial outcome. A low body mass index and a greater severity of social and psychological problems were identified as predictors of a poor outcome. CONCLUSIONS Recovery is still possible for anorexic patients after a period of 21 years. On the other hand, patients can relapse, becoming symptomatic again despite previously achieving recovery status. Only a few patients classified as having a poor outcome were found to seek any form of treatment, therefore, it is recommended that these patients should be monitored regularly and offered treatment whenever possible.

Screening psychischer Störungen mit dem “Gesundheitsfragebogen für Patienten (PHQ-D)“

Zusammenfassung. Ziel dieser Studie ist die Validierung der deutschen Version des „Patient Health Questionnaire (PHQ-D)“. Der PHQ wurde zum praktikablen Screening psychischer Storungen fur die Primarmedizin entwickelt und erfasst direkt die diagnostischen Kriterien des DSM-IV. N = 357 allgemeinmedizinische/internistische Patienten und N = 171 psychosomatische Patienten wurden mit dem PHQ-D und dem Strukturierten Klinischen Interview fur DSM-IV (SKID-I) untersucht, wobei das SKID-I als diagnostischer Goldstandard diente. Arzte und Patienten wurden zur Akzeptanz des PHQ-D befragt. Eine ausgezeichnete Kriteriumsvaliditat des PHQ-D zeigte sich insbesondere bei der Diagnose der Major Depression, wo die Sensitivitat fur die medizinische Stichprobe bei 95 % und die Spezifitat bei 86 % lag. Gute teststatistische Werte ergaben sich u. a. auch fur die Panikstorung. Die Anwendung des PHQ-D wurde von jeweils mehr als 90 % der Patienten und Arzte gut akzeptiert. Mit dem PHQ-D liegt ein praktikables, valides und gut akzeptiertes Instrument zur Anwendung in Forschung und klinischer Praxis vor. Sein Einsatz kann zur verbesserten Versorgung psychischer Storungen beitragen. Schlusselworter: Screening-Fragebogen, Validitat, psychische Storungen, medizinische Grundversorgung, psychosomatische Medizin Screening for psychiatric disorders with the Patient Health Questionnaire (PHQ). Results from the German validation study

Diagnosing ICD-10 Depressive Episodes: Superior Criterion Validity of the Patient Health Questionnaire

Background: Diagnosing and monitoring depression in primary care remains an issue of significant public health concern. Clinicians and researchers need to know if any one screening instrument is superior to the others in diagnosing ICD-10 depressive episodes. This study aimed to examine the criterion validity for diagnosing ICD-10 depressive episodes of the Patient Health Questionnaire (PHQ) in comparison with 2 well-established instruments, the Hospital Anxiety and Depression Scale (HADS), and the WHO Well-Being Index 5 (WBI-5). Methods: Five hundred and one medical outpatients completed the questionnaires and had a clinical interview. The presence of a depressive episode was determined with the International Diagnostic Checklists (IDCL) for ICD-10 as the criterion standard. Coefficient kappa (ĸ), sensitivities and specificities were calculated and a statistical comparison of the areas under the receiver operating characteristic curves was performed. Results: Diagnostic agreement between the questionnaires and the IDCL was moderate (ĸ = 0.34–0.56), with the highest values for the PHQ. While all 3 questionnaires had reasonable sensitivity and specificity, the operating characteristics for the PHQ were significantly superior to both the HADS and the WBI-5 (p = 0.02). Conclusions: Any of the 3 screening instruments can be recommended for clinical use. However, this is the first comparative study to demonstrate the diagnostic advantage of a particular depression-screening instrument using the ICD-10 diagnostic criteria. The superior criterion validity of the PHQ is likely attributable to its closer representation of the current concept of depressive disorders.

Food‐related impulsivity in obesity and Binge Eating Disorder – a systematic review

Impulsivity towards food has been recognized as a potential factor leading to increased food intake in obesity. Patients suffering from binge eating disorder (BED) form a specific subgroup of obese people that might be characterized by increased impulsivity. These assumptions, although, have yet to be verified. Therefore, this review evaluates evidence for food‐related impulsivity in obese people with and without BED and examines possible differences between both populations. More precisely, evidence for the two components of impulsivity is analyzed separately: evidence for reward sensitivity, specifically, the urge for appetitive stimuli and evidence for rash‐spontaneous behaviour such as acting disinhibited with no regard for the consequences. Our search resulted in 51 articles demonstrating generally increased food‐related impulsivity. We found particular emphasis on increased reward sensitivity in obese people, which appeared to be more pronounced in people with BED. There was little and conflicting evidence, however, concerning increased rash‐spontaneous behaviour in obese people without BED, but consistent evidence of an increase in obese people with BED. All in all, the evidence supports the view that BED represents a specific phenotype of obesity with increased food‐related impulsivity. Taking these specific deficits into account can enhance the effectiveness of weight reduction programmes and psychotherapy.

Depression increasingly predicts mortality in the course of congestive heart failure.

Congestive heart failure (CHF) is frequently associated with depression. However, the impact of depression on prognosis has not yet been sufficiently established.

Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial

BACKGROUND Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of two manual-based outpatient treatments for anorexia nervosa--focal psychodynamic therapy and enhanced cognitive behaviour therapy--versus optimised treatment as usual. METHODS The ANTOP study is a multicentre, randomised controlled efficacy trial in adults with anorexia nervosa. We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was weight gain, measured as increased body-mass index (BMI) at the end of treatment. A key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology). Analysis was by intention to treat. This trial is registered at http://isrctn.org, number ISRCTN72809357. FINDINGS Of 727 adults screened for inclusion, 242 underwent randomisation: 80 to focal psychodynamic therapy, 80 to enhanced cognitive behaviour therapy, and 82 to optimised treatment as usual. At the end of treatment, 54 patients (22%) were lost to follow-up, and at 12-month follow-up a total of 73 (30%) had dropped out. At the end of treatment, BMI had increased in all study groups (focal psychodynamic therapy 0·73 kg/m(2), enhanced cognitive behaviour therapy 0·93 kg/m(2), optimised treatment as usual 0·69 kg/m(2)); no differences were noted between groups (mean difference between focal psychodynamic therapy and enhanced cognitive behaviour therapy -0·45, 95% CI -0·96 to 0·07; focal psychodynamic therapy vs optimised treatment as usual -0·14, -0·68 to 0·39; enhanced cognitive behaviour therapy vs optimised treatment as usual -0·30, -0·22 to 0·83). At 12-month follow-up, the mean gain in BMI had risen further (1·64 kg/m(2), 1·30 kg/m(2), and 1·22 kg/m(2), respectively), but no differences between groups were recorded (0·10, -0·56 to 0·76; 0·25, -0·45 to 0·95; 0·15, -0·54 to 0·83, respectively). No serious adverse events attributable to weight loss or trial participation were recorded. INTERPRETATION Optimised treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology. Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches. FUNDING German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF), German Eating Disorders Diagnostic and Treatment Network (EDNET).

Acupuncture treatment in irritable bowel syndrome

Background and aims: Despite occasional positive reports on the efficacy of acupuncture (AC) on functions of the gastrointestinal tract, there is no conclusive evidence that AC is effective in the treatment of irritable bowel syndrome (IBS). Patients and methods: Forty three patients with IBS according to the Rome II criteria were randomly assigned to receive either AC (n = 22) or sham acupuncture (SAC) (n = 21) using the so-called “Streitberger needle”. Treatment duration was 10 sessions with an average of two AC sessions per week. The primary end point was improvement in quality of life (QOL) using the functional digestive diseases quality of life questionnaire (FDDQL) and a general quality of life questionnaire (SF-36), compared with baseline assessments. QOL measurements were repeated three months after treatment. Results: Both the AC and SAC groups improved significantly in global QOL, as assessed by the FDDQL, at the end of treatment (p = 0.022), with no differences between the groups. SF-36 was insensitive to these changes (except for pain). This effect was partially reversed three months later. Post hoc comparison of responders and non-responders in both groups combined revealed a significant prediction of the placebo response by two subscales of the FDDQL (sleep, coping) (F = 6.746, p = 0.003) in a stepwise regression model. Conclusions: Acupuncture in IBS is primarily a placebo response. Based on the small differences found between the AC and SAC groups, a study including 566 patients would be necessary to prove the efficacy of AC over SAC. The placebo response may be predicted by high coping capacity and low sleep quality in individual patients.

Anorexia nervosa: aetiology, assessment, and treatment

Anorexia nervosa is an important cause of physical and psychosocial morbidity. Recent years have brought advances in understanding of the underlying psychobiology that contributes to illness onset and maintenance. Genetic factors influence risk, psychosocial and interpersonal factors can trigger onset, and changes in neural networks can sustain the illness. Substantial advances in treatment, particularly for adolescent patients with anorexia nervosa, point to the benefits of specialised family-based interventions. Adults with anorexia nervosa too have a realistic chance of achieving recovery or at least substantial improvement, but no specific approach has shown clear superiority, suggesting a combination of re-nourishment and anorexia nervosa-specific psychotherapy is most effective. To successfully fight this enigmatic illness, we have to enhance understanding of the underlying biological and psychosocial mechanisms, improve strategies for prevention and early intervention, and better target our treatments through improved understanding of specific disease mechanisms.