Factitious disorders and pathological self-harm in a hospital population: an interdisciplinary challenge

Factitious disorder, Munchausen's Syndrome, and deliberate self-harm have recently been conceptualized as different facets of self-destructive behavior. A descriptive typological classification has been presented by Willenberg et al., but has not yet been tested with a clinical sample. The instrument distinguishes between direct self-harm (e.g., self-inflicted wounds), self-induced disease (e.g., factitious fever), and indirect self-harm delegated to medical staff (e.g., repeated operations occasioned by feigned symptoms). All patients referred to the psychosomatic-psychotherapeutic liaison-consultation service or to the outpatients' department within 14 months (n = 995) and all patients discharged from in-patient psychosomatic-psychotherapeutic treatment within 2 months (n = 62) were assessed. Expert instruction and supervision were provided for the diagnosticians. The assessment was continued for a subsequent year, without special supervision (n = 1,058). Self-destructive behaviors were diagnosed in 7.5% of the cases in the first sample, with certainty (59.5%) or on suspicion (40.5%). In the subsequent sample without supervision, the rate reduced to 3.6%. Referrals had come from almost all clinical departments, including the emergency unit (26%), surgery, internal intensive care, endocrinology (9.5% each), neurology, infectiology, nephrology (7.1% each), dermatology, gastro-enterology, cardiology (4.8% each) and surgical intensive care (2.4%). The occurrence of pathological self-destructive phenomena is underrated when using only the ICD-criteria. The rate is influenced by diagnostic attention.

Decreased plasma levels of amitriptyline and its metabolites on comedication with an extract from St. John's wort ( Hypericum perforatum )

Extracts of St. John's wort ( Hypericum perforatum ) became increasingly popular as easily available remedies for mild to moderate depression. Comedication with hypericum extract was recently shown to drastically reduce plasma concentration of ciclosporin, digoxin, and indinavir. We investigated the possible interaction of hypericum extract LI160 with amitriptyline. Both antidepressants have a high probability of concomitant use. Twelve patients requiring amitriptyline treatment received a single dose of hypericum extract (900 mg) at day 1, continued by a 12-to 14-day treatment with retarded amitriptyline (75 mg twice daily). Then hypericum (900 mg/day) was added for another 14 to 16 days. Steady-state pharmacokinetics of amitriptyline were compared before and after multiple-dose treatment with hypericum extract. Furthermore, comparisons were made for single-dose kinetics of hypericum-extract ingredients hypericin, pseudohypericin, and hyperforin between the first day of concomitant treatment and LI160 alone. Multiple-dose comedication with LI160 led to a statistically significant decrease in the area under the plasma concentration-time curve within one dosing interval of amitriptyline by 22% ( p = 0.03) and nortriptyline by 41% ( p = 0.002), as well as of all hydroxylated metabolites, except for 10-E-hydroxynortriptyline. Plasma levels of amitriptyline and hydroxylated metabolites gradually decreased, whereas nortriptyline concentrations were already markedly decreased after 3 days of cotreatment with hypericum. Cumulative urinary amounts of amitriptyline and metabolites decreased to the same extent as plasma concentrations upon hypericum comedication. Induction of cytochrome P-450 enzymes or drug transporters (P-glycoprotein) by St. John's wort extract may explain this pharmacokinetic interaction. Physicians should be aware of this interaction when treating patients with amitriptyline.

Patients' expressions of complaints as a predictor of the course of acute hepatitis A

OBJECTIVE

Physical complaints, emotional states, liver, and immune parameters were investigated as possible indicators of the course of hepatitis A.

METHODS

Forty-seven patients with hepatitis A were studied by means of the Giessen-Complaint-Inventory (GBB) and the Berlin Mood Questionnaire (BSF), as well as by taking into account their typical liver parameters and the following immune parameters: alphaInterferon (alphaIFN), soluble Interleukin 2 receptor (sIL-2R), Interleukin 6 (IL-6), Interleukin 1 receptor antagonist (IL-1Ra), and Immunoglobulin M or G (IgM, IgG). Two hundred twenty-nine medical students and a representative German sample (n = 1557, Braehler et al.) served as controls.

RESULTS

We found that the initial degree of change in permeability of the liver cells, complaints about abdominal symptoms, and extent of depressive mood were able to predict the length of hospital stay. Patients with the initial, more pronounced liver damage, as well as patients who articulated less subjective impairment proved to have a longer course of illness. Those patients who needed a significantly longer time for recovery report, at admission, very few complaints-fewer than even the normal population. We were not, however, able to demonstrate a significant difference in the investigated immune parameters.

CONCLUSION

A certain denial tendency seems to be harmful with respect to the recovery process and the immunological competence in the course of hepatitis A.

[Questionnaire of self-efficacy, optimism and pessimism: reconstruction, selection of items and validation of an instrument by means of examinations of clinical samples]

Self-efficacy and optimism are considered highly useful parameters in the context of therapeutic indication prognosis, and outcome evaluation. In our study, a combined questionnaire measuring "self-efficacy" (Schwarzer u. Jerusalem 1986) and "optimism" (Scheier u. Carver 1985) was restructured and reduced in length. The resulting instrument was compared with its original version in five different clinical samples comprising n = 726 inpatients. Factor analyses achieved the bidimensionality in the construct "optimism" as postulated by Scheier and Carver, this yielding the two factors "optimism" and "pessimism". The statistical validation resulted in good to optimal values. Factor analyses considering the different clinical groups showed that certain items failed to be invariably approprieted to one factor. Therefore, we decided in favor of an item reduction, resulting in half the original number: 5 items representing "self-efficacy" 2 for "optimism" and 2 for "pessimism". The scale values of the reduced version showed no relevant deviations compared to the original, and hence we conclude that the reduction does not result in a loss of information.

Determinants of the quality of life of patients with diabetes under intensified insulin therapy

OBJECTIVE

The concept of quality of life (QOL) is understood as a multidimensional construct made up of physiological, psychological, and social aspects, but their particular weightings for the global QOL are rarely investigated. We examined 1) the general QOL of patients with diabetes, 2) the significance of the individual QOL aspects for the overall assessment of QOL, and 3) the modulating function of coping mechanism and particular personality traits.

RESEARCH DESIGN AND METHODS

A total of 116 diabetes patients under intensified insulin therapy were studied, as were 107 patients with inflammatory bowel disease, 66 patients with chronic hepatitis C, and 229 students who served as control subjects. The examination was based on eight standardized QOL and personality questionnaires (354 items) and assessed by means of linear structural regression models (AMOS 3.6).

RESULTS

The QOL of diabetes patients appears to be higher than the QOL of other chronically ill patients. Social, psychological, and physical aspects contribute to the overall QOL, although physical complaints receive a comparatively low weighting. Coping behavior and particular personality traits covary with all QOL aspects, giving these variables greater significance for the QOL than the existence of secondary illnesses.

CONCLUSIONS

The hypothesis that the various factors involved in the multidimensional construct QOL receive different weightings was confirmed, making a simple summary score for the general QOL appear unjustifiable. In addition, all aspects that are commonly understood as parameters of QOL are influenced by external factors, such as coping behavior, based on individual personality characteristics.

[Biopsychological relationships and prediction of the course of acute viral hepatitis]

Psychosocial factors are discussed to influence the manifestation and course of infectious diseases. The results of psychoimmunological research during the past two decades have proved that different psychosocial factors can alter a great number of immune functions. Clinical studies on the relevance of such immune alterations are still rare. The course of viral hepatitis is strictly determined by individual immune-competence, and because it is not medically treated in acute stages it offers an ideal biopsychosocial research model. In 87 patients with acute viral hepatitis we measured every week complaints, moods (German adaptation of MACL), liver and immune-function (sIL-2R, alpha IFN, IL-1Ra, IL-6). It was shown that complaints are influenced by immune activity as well as by individual psychological factors. Patients could be differentiated by symptoms ad hospital admission into three groups: 1. with mainly bodily focused symptoms, 2. with predominantly anxious-depressive symptoms and 3. with elevated moods without complaints. In the further course patients in group 2 and 3 showed more often a delayed recovery, and hence we must presumed that the coping-process in group 1 is more likely to support immune functioning, whereas coping mechanisms in groups 2 and 3 are more likely to suppress it.

[Testing a screening strategy for identifying psychosomatic patients in gynecologic practice]

In a pilot-study 103 gynecological outpatients answered a gynecological questionnaire (FGB) including items of the (non-gynecological) complaints questionnaire (GBB) and a mood questionnaire (BSF). Cluster analyses of the FGB- and BSF-scores identify four groups. One group, consisting of 26 outpatients (= 25%), has as high GBB- and BSF-scores as a group of 256 psychosomatic in-patients answering these questionnaires at the beginning of their psychosomatic therapy. These 26 outpatients are labeled as high risk patients. Further results show high correlations between all FGB- and GBB-scores among the gynecological outpatients. A significant connection between the four group classification and ten biopsychosocial variables is found only for the variable professional state. The results are seen as a first confirmation of the tested screening-strategy. Moreover they give evidence that further investigations should pay more attention to the connection between job strain and gynecological complaints or disorders.