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Psychische Komorbiditaten bei Tinnituspatienten sind haufig und ihre Diagnostik ist wichtig fur Interventionen und Therapieerfolg. Hierbei ist die Auswahl geeigneter Fragebogen entscheidend. Ziel dieser Studie war es, das ICD-10-Symptom-Rating (ISR) fur die Diagnostik psychologischer Komorbiditaten zu untersuchen. In der vorliegende Studie wurden Tinnitusbelastung und psychische Komorbiditat bei n = 311 Patienten mit chronischem Tinnitus untersucht, die eine 7‑tagige multimodale tinnitusspezifische Intensivtherapie absolvierten. Zur Messung der Tinnitusbelastung wurde die deutsche Version des Tinnitus-Fragebogens (TF) eingesetzt. Psychische Komorbiditat wurde mit dem ISR (Gesamtbelastung, depressives Syndrom, Angstsyndrom, Zwangssyndrom, somatoformes Syndrom, Essstorungssyndrom), Perceived Stress Questionnaire (PSQ: Gesamtwert fur subjektive Stressbelastung, „Anspannung“, „Sorgen“, „Freude“ und „Anforderungen“) sowie der Allgemeinen Depressionsskala (ADS) gemessen. Bei 65 % der Patienten bestanden psychische Komorbiditaten. Die Gesamtwerte des TF, ISR, PSQ und ADS zeigten signifikante Verbesserungen nach der Therapie. Zu Beginn der Therapie fanden sich signifikante Korrelationen der eingesetzten Messinstrumente, d. h., die Tinnitusbelastung konnte durch ISR-Gesamtbelastung, -Zwangssyndrom und PSQ-Anspannung vorhergesagt werden. Nach der Therapie wurde die – nun verringerte – Tinnitusbelastung zusatzlich durch die ISR-Unterskalen „Depression“ und „Esstorungssyndrom“ vorhergesagt. Der ISR ist zur Erfassung komorbider psychischer Belastung bei Patienten mit chronischem Tinnitus und zur Erfassung kurzfristiger Therapieeffekte geeignet. Bei der Therapie des chronischen Tinnitus sollten stressassoziierte Anspannung, depressives Erleben und dysfunktionales Coping, z. B. uber maladaptives Essverhalten, berucksichtigt werden.

Tinnitus frequently occurs alongside psychological comorbidities whose assessment is important for treatment planning and -success. The selection of suitable questionnaires is thus crucial. The present study aims to investigate the ICD-10 Symptom Rating (ISR) to this regard. The current study investigated tinnitus burden and psychological comorbidities in a sample of N = 311 patients with chronic tinnitus. All participants completed an intensive 7‑day multimodal tinnitus-specific therapy. Tinnitus burden was measured using the German version of the Tinnitus Questionnaire (TQ). Psychological comorbidities were measured using the ISR (total score, depressive disorder, anxiety disorder, obsessive–compulsive disorder, somatoform disorder, and eating disorder), the Perceived Stress Questionnaire (PSQ; total score, tension, worries, joy, and demands), and the General Depression Scale (Allgemeine Depressionsskala, ADS). Sixty-five percent of participants suffered from psychological comorbidities. Treatment response comprised improvements in the TQ, ISQ, PSQ and ADS. At baseline, tinnitus-burden correlated with the ISR-total, ISR-obsessive-compulsive disorder and PSQ-tension scores. Post treatment, the—now reduced—tinnitus burden was additionally predicted by ISR-depressive and eating disorder scores. The ISR is a useful tool for measuring psychological comorbidities in patients with chronic tinnitus as well as short-term treatment response. Therapeutic approaches for chronic tinnitus should address stress-related tension, depressive symptomatology and coping strategies such as maladaptive eating behaviours.

Psychological comorbidities are frequent in tinnitus patients and their diagnosis is important for both interventions as well as treatment success. The selection of suitable questionnaires is thus crucial. The present study aimed to investigate the ICD-10 Symptom Rating (ISR) questionnaire for the diagnosis of psychological comorbidities.The current study investigated tinnitus burden and psychological comorbidities in a sample of n = 311 patients with chronic tinnitus. All participants completed an intensive 7‑day multimodal tinnitus-specific therapy. Tinnitus burden was measured using the German version of the Tinnitus Questionnaire (TQ). Psychological comorbidities were measured using the ISR (total score, depressive disorder, anxiety disorder, obsessive-compulsive disorder, somatoform disorder, and eating disorder), the Perceived Stress Questionnaire (PSQ; total score, tension, worries, joy, and demands), and the General Depression Scale (Allgemeine Depressionsskala, ADS).Psychological comorbidities were suffered by 65% of participants. Treatment response comprised improvements in TQ, ISR, PSQ, and ADS. At baseline, tinnitus burden correlated with the ISR total, ISR obsessive-compulsive disorder, and PSQ tension scores. Post-treatment, the now reduced tinnitus burden was also predicted by the ISR depressive and eating disorder scores.The ISR is a useful tool for measuring psychological comorbidities in patients with chronic tinnitus as well as for assessing short-term treatment response. Therapeutic approaches for chronic tinnitus should also consider stress-related tension, depressive symptomatology, and coping strategies such as maladaptive eating behaviors.

We introduce the new class of Performance measures Adjusted for the Risk Situation (PARS), which incorporate individual risk characteristics in the financial performance measure. The (risk) situation of an individual or company is represented by all of its future cash flows including (financial) consumption preferences; due to the effected risk transformation, PARS have zero volatility under the investment strategy replicating these future cash flows. We give several examples of cash flow structures for individuals and companies, showing how their PARS could be defined. In the context of a debt manager, we demonstrate how the PARS can be applied to the dynamic control of bond portfolios via sensitivities.

Successful management of patients with chronic tinnitus is an important health issue. One of the tinnitus management strategies used at our Tinnitus Center is a combination of tinnitus retraining therapy (TRT) with physiotherapy and psychological management [called modified TRT (MTRT)]. We have used this type of management for over a decade and have described the protocol in detail elsewhere. In the present study, we wanted to determine the effect of MTRT on the well-being of tinnitus patients 3 years after treatment onset. One hundred and thirty patients with chronic tinnitus were assessed using psychometric instruments immediately before 7-day MTRT, immediately after the therapy and 3 years later. Patients with very severe tinnitus-related distress associated with major depression and a risk of suicide were excluded from this study. MTRT resulted in a sustained reduction of tinnitus-related distress. Moreover, the quality of life of patients had increased, as assessed by a separate questionnaire. The effect of MTRT was influenced by the degree of tinnitus-related distress and by the patients' age, the latter being gender dependent. Hearing loss and tinnitus duration had only a minor influence on the therapeutic effect. Taken together, we report a positive change in the state of well-being of patients with chronic tinnitus measurable with various psychometric instruments 3 years after the onset of MTRT. i 2014 S. Karger AG, Basel

Conflicting data about the role of gender in tinnitus distress exist in the literature. In addition, little is known about gender differences regarding age and duration of tinnitus. Tinnitus was shown to be related to stress and impairment of coping, sense of coherence, and personal resources. There are known differences in the aforementioned psychological parameters between man and women or among different age groups. The authors hypothesized that this may also be true for patients with chronic tinnitus in addition to gender- and age-related differences in tinnitus annoyance. Therefore, using a large number of patients with chronic tinnitus, the authors analyzed pretherapeutic scores of tinnitus annoyance, perceived stress, proactive coping strategies, sense of coherence, and personal resources in addition to hearing loss and tinnitus pitch and loudness in respect to gender and age of the patients as well as duration of tinnitus.The study group included 607 female and 573 male patients who reported tinnitus for longer than 3 months. The age of the patients ranged from 17 to 81 years in both gender groups. Pretherapeutic scores of tinnitus annoyance, perceived stress, proactive coping strategies, sense of coherence, and personal resources as well as the degree of hearing loss and tinnitus pitch and loudness were analyzed.Irrespective of age and tinnitus duration, women were more annoyed by tinnitus and perceived more stress than men did. In addition, women scored lower than men in proactive coping, sense of coherence, and personal resources but had lower levels of hearing loss and tinnitus loudness than men did. The differences were small, but statistically significant. Analysis of three age groups revealed significant differences between older female and male patients. Tinnitus annoyance was stronger in the middle-age groups of women and men (45-59 years of age) than in younger patients and decreased again in older men (≥60 years of age), but not in older women. Women, but not men, had cognitive distress scores that progressed with age. Older women (≥60 years of age) reported more sleep disturbances than older men. Women had more somatic complaints and coped less efficiently than men, except for younger patients (45 years of age). The scores of perceived stress decreased whereas scores of sense of coherence and self-efficacy increased in older men and women (≥60 years of age). However, women scored worse than men did in this age group. Hearing loss was found to be correlated with tinnitus loudness and age in both gender groups. The duration of tinnitus affected subjective hearing problems, intrusiveness of tinnitus, and proactive coping. This association was in part age-dependent.The authors found gender differences regarding tinnitus-related distress in patients with chronic tinnitus; however, these differences depended on age and in part on duration of tinnitus. Addressing these differences could result in improved, tailored therapy approaches. For instance, applying physical exercise and relaxation techniques could be of special help for older women to reduce their somatic complaints and sleep disturbances. Similarly, cognitive behavioral therapy could reduce their cognitive distress. Therapy for younger patients should in particular include stress management.

Tinnitus gilt als komplexes Phanomen mit multiplen Entstehungsmechanismen. Die Therapie des chronischen Tinnitus verfolgt einen multimodalen, interdisziplinaren Ansatz. Zur Beurteilung bestehender Komorbiditaten bei Tinnituspatienten sowie zur optimalen und vor allem individuellen Behandlung ist eine umfassende differenzierte psychometrische Diagnostik erforderlich. Da bisher keine einheitliche Leitlinie zur Verwendung psychometrischer Testverfahren in der Tinnitusdiagnostik existiert, werden in diesem Artikel relevante Fragebogen vorgestellt, die im Rahmen der Tinnitusforschung, -diagnostik und -therapie bereits effektiv eingesetzt wurden. Diese Fragebogen erfassen den Schweregrad von Tinnitus, Angst und Depression, die Stressbelastung und Ressourcen sowie die Lebensqualitat der Patienten.

AIM OF THE STUDY: The therapy of the chronic tinnitus is aimed at improving the way patients cope with their tinnitus and at reducing the tinnitus-related distress. The present study investigated the changes of psychometric parameters that occurred in patients with chronic tinnitus after 7-days outpatient multidisciplinary therapy. The changes were monitored for up to 1 year in order to evaluate the long-term efficiency. METHODS: Main emphasis of the intensive tinnitus therapy applied was placed on tinnitus habituation and on teaching the patients how to apply coping strategies. The main elements of the multimodal concept included progressive muscle relaxation according to Jacobson, physiotherapy, educative seminars, training of selective attention and, lastly, the change of judgment, attitude and behaviour towards tinnitus. Psychometric parameters and tinnitus-related distress were assessed prior to and after the therapy (at 3, 6 and 12 months) using the tinnitus questionnaire (TQ) according to Goebel and Hiller. Furthermore, subjects waiting for therapy (waiting list) were recruited to the control group and compared with the therapy group which had received therapy 3 months earlier. RESULTS: The therapy group showed a significant reduction of the TQ total score after 3 months as compared to the control group. Moreover, we observed a long-term, progressive positive outcome during the one-year follow-up. The TQ total score was reduced by 10.9 points. There was an obvious decrease of the emotional and cognitive distress as well as of the intrusiveness of tinnitus, as per evaluation of TQ subscales. CONCLUSIONS: The outpatient intensive multidisciplinary tinnitus therapy with long-term aftercare has proved to be an effective method in the treatment of patients with chronic tinnitus. The outpatient setting enables the instant implementation of strategies learned during therapy in the patients’ everyday life.

We consider an insurance risk process with the possibility to invest the capital reserve into a portfolio consisting of a risky asset and a riskless asset. The stock price is modelled by an exponential Levy process and the riskless interest rate is assumed to be constant. We aim at the risk assessment of the integrated risk process in terms of a high quantile or the far out distribution tail. We indicate an application to an optimal investment strategy of an insurer.

The aim of this article is to show an established group therapeutic concept for chronic tinnitus. The treatment of chronic tinnitus is intended to improve the way patients cope with tinnitus but it does not eliminate it. It means that patients learn how to reduce the impairment they are experiencing. Patients with tinnitus are supported in the process of habituation through the treatment. Multimodal cognitive behavioral therapeutic interventions in a group setting are particularly helpful because they may demonstrate differences in the influence of cognitive processes on the emotional perception of the tinnitus between the patients. Psychological factors like emotional support through other patients and learning from other examples can ease the process of internalizing coping strategies. Psychological processes seem to be of particular importance. Those processes can have an effect on concentration, appraisal, and coping with the tinnitus. Progressive muscle relaxation using Jacobson's technique, physical therapy, education via lectures, training of selective attention and change of appraisal, mental attitude and behavior concerning the tinnitus are the main factors in tinnitus therapy and can enable tinnitus patients to decrease their psychological strain.

Besides the impairment of somatic functions, other factors including stress, and psychological and social characteristics are known to be important factors in the pathogenesis of tinnitus and the ability to cope with it. Existing coping strategies and psychosocial factors may have an influence on the degree of stress perceived through tinnitus. In the case of missing habituation, serious psychological, neurological and immunological responses to tinnitus are possible. In order to reduce the cognitive and emotional tinnitus-distress associated with this, there should be a focus on providing functional coping strategies combined with cognitive behavioural elements.

In recent years, no major advances have been made in understanding the mechanisms underlying the development of tinnitus. Hence, the present therapeutic strategies aim at decoupling the subconscious from the perception of tinnitus. Mindful of the lessons drawn from existing tinnitus retraining and desensitisation therapies, a new integrated day hospital strategy of treatment lasting 7-14 days has been developed at the Charite Hospital and is presented in the present paper. The strategy for treating tinnitus in the proximity of patient domicile is designed for patients who feel disturbed in their world of perception and their efficiency due to tinnitus and give evidence of mental and physical strain. In view of the etiologically non-uniform and multiple events connected with tinnitus, consideration was also given to the fact that somatic and psychosocial factors are equally involved. Therefore, therapy should aim at diagnosing and therapeutically influencing those psychosocial factors that reduce the hearing impression to such an extent that the affected persons suffer from strain. The first results of therapy-dependent changes of 46 patients suffering from chronic tinnitus are presented. The data were evaluated before and after 7 days of treatment and 6 months after the end of treatment. Immediately after the treatment, the scores of both the tinnitus questionnaire (Goebel and Hiller) and the subscales improved significantly. These results were maintained during the 6-month post-treatment period and even improved.

Many cancer patients use complementary alternative medicines (CAMs) but may not be aware of the potential risks. There are no studies quantifying such risks, but there is some evidence of patient risk from case reports in the literature. A cross-sectional survey of patients attending the outpatient department at a specialist cancer centre was carried out to establish a pattern of herbal remedy or supplement use and to identify potential adverse side effects or drug interactions with conventional medicines. If potential risks were identified, a health warning was issued by a pharmacist. A total of 318 patients participated in the study. Of these, 164 (51.6%) took CAMs, and 133 different combinations were recorded. Of these, 10.4% only took herbal remedies, 42.1% only supplements and 47.6% a combination of both. In all, 18 (11.0%) reported supplements in higher than recommended doses. Health warnings were issued to 20 (12.2%) patients. Most warnings concerned echinacea in patients with lymphoma. Further warnings were issued for cod liver/fish oil, evening primrose oil, gingko, garlic, ginseng, kava kava and beta-carotene. In conclusion, medical practitioners need to be able to identify the potential risks of CAMs. Equally, patients should be encouraged to disclose their use. Also, more research is needed to quantify the actual health risks.

We present an affine arbitrage-free dynamic term-structure model based on a representation of instantaneous forward rates as sum of exponentials. The model, which is Gaussian and belongs to the class of Heath-Jarrow-Morton-type models, is intuitively appealing as a suitable linear combination of the stochastic factors can be interpreted as stochastic evolution of stable principal components of the yield curve. Focusing on applications, we derive general principal components in such an affine-linear model, calibrate the model to government bond prices, and derive simple formulas to price caps and floors.

Known association between tinnitus and psychological distress prompted us to examine patients with chronic tinnitus by using the Composite International Diagnostic Interview (CIDI), which is a standardized and reliable method used for the diagnosis of mental disorders. One hundred patients with chronic tinnitus admitted to the Tinnitus Center, Charite-Universitatsmedizin Berlin, were included in this study. Data were collected between February 2008 and February 2009. Besides CIDI, the Tinnitus Questionnaire according to Goebel and Hiller, the Hospital Anxiety Depression Scale, and the General Anxiety Disorder—7 were used. Using CIDI, we have identified one or more mental disorders in 46 tinnitus patients. In that group, we found persistent affective disorders (37 %), anxiety disorders (32 %), and somatoform disorders (27 %). Those patients who had affective or anxiety disorders were more distressed by tinnitus and were more anxious and more depressed than tinnitus patients without mental disorders. Psychological impairment positively correlated with tinnitus distress: Patients with decompensated tinnitus had significantly more affective and anxiety disorders than patients with compensated tinnitus. In the present study, we have detected a high rate (almost half of the cases) of psychological disorders occurring in patients with chronic tinnitus. The patients diagnosed with psychological disorders were predominantly affected by affective and anxiety disorders. Psychological disorders were associated with severity of tinnitus distress. Our findings imply a need for routine comprehensive screening of mental disorders in patients with chronic tinnitus.

To determine the prevalence and severity of psychological comorbidity in patients with chronic tinnitus in comparison with other chronic illnesses, namely chronic pain, chronic asthma and atopic dermatitis. Psychological diagnoses were done according to ICD-10 Chapter V(F). Subjective impairment was evaluated using 5 psychometric questionnaires: tinnitus questionnaire, Berlin mood questionnaire, sense of coherence (SOC-L9) and perceived stress questionnaire. Sleep disturbance was measured by the subdomain ‘exhaustion’ of the Giessen physical complaints inventory. Somatoform or affective disorders were most frequent in all disease groups. Patients with chronic tinnitus had a stronger SOC and better subjective mood, stronger commitment, and less anger and anxious depression than the patients with chronic pain, chronic asthma or atopic dermatitis. However, in patients with higher tinnitus annoyance, psychological comorbidity was similar to that found in patients with other chronic diseases. Besides collecting medical and social history, special psychometric instruments should be used for the diagnosis of tinnitus patients. Based on relative high frequency of psychological comorbidity, we recommend interdisciplinary cooperation between otorhinolaryngologists and other specialists (psychosomatic medicine, psychology or psychiatry) during the treatment of tinnitus patients, especially when high degree of tinnitus annoyance is involved.

Tinnitus is a very complex phenomenon with various mechanisms of origin. Multimodal and interdisciplinary treatment is the most effective form of treatment for patients with chronic tinnitus. In order to assess existing comorbidity in tinnitus patients as well as to treat the patients individually, a comprehensive and differentiated diagnosis is needed. Since standardized guidelines for the use of relevant instruments in the diagnosis of tinnitus have been lacking hitherto, we present here psychometric questionnaires which have already been used effectively in the research, diagnosis and therapy of tinnitus in the present article. The questionnaires measure the severity of tinnitus, depression and anxiety, the perceived stress, personal resources as well as the quality of life of patients.

We study the optimal loan securitization policy of a commercial bank which is mainly engaged in lending activities. For this we propose a stylized dynamic model which contains the main features affecting the securitization decision. In line with reality we assume that there are non-negligible fixed and variable transaction costs associated with each securitization. The fixed transaction costs lead to a formulation of the optimization problem in an impulse control framework. We prove viscosity solution existence and uniqueness for the quasi-variational inequality associated with this impulse control problem. Iterated optimal stopping is used to find a numerical solution of this PDE, and numerical examples are discussed.

The therapy of the chronic tinnitus is aimed at improving the way patients cope with their tinnitus and at reducing the tinnitus-related distress. The present study investigated the changes of psychometric parameters that occurred in patients with chronic tinnitus after 7-days outpatient multidisciplinary therapy. The changes were monitored for up to 1 year in order to evaluate the long-term efficiency.Main emphasis of the intensive tinnitus therapy applied was placed on tinnitus habituation and on teaching the patients how to apply coping strategies. The main elements of the multimodal concept included progressive muscle relaxation according to Jacobson, physiotherapy, educative seminars, training of selective attention and, lastly, the change of judgment, attitude and behaviour towards tinnitus. Psychometric parameters and tinnitus-related distress were assessed prior to and after the therapy (at 3, 6 and 12 months) using the tinnitus questionnaire (TQ) according to Goebel and Hiller. Furthermore, subjects waiting for therapy (waiting list) were recruited to the control group and compared with the therapy group which had received therapy 3 months earlier.The therapy group showed a significant reduction of the TQ total score after 3 months as compared to the control group. Moreover, we observed a long-term, progressive positive outcome during the one-year follow-up. The TQ total score was reduced by 10.9 points. There was an obvious decrease of the emotional and cognitive distress as well as of the intrusiveness of tinnitus, as per evaluation of TQ subscales.The outpatient intensive multidisciplinary tinnitus therapy with long-term aftercare has proved to be an effective method in the treatment of patients with chronic tinnitus. The outpatient setting enables the instant implementation of strategies learned during therapy in the patients' everyday life.

This work evaluates an enhanced tinnitus retraining therapy (TRT) for patients with chronic tinnitus based on different group therapeutic interventions in a day hospital setting. Therapy for chronic tinnitus is intended to improve the way patients cope with tinnitus by learning how to reduce tinnitus-induced impairments. Short-term and long-term changes in stress variables and tinnitus-related distress were investigated using 3 psychometric instruments. Patients received 7 consecutive days of a multidisciplinary therapy at the Charité University Hospital in Berlin. The data were assessed before and after therapy, either immediately or after 3, 6 or 12 months. As a control, we used scores of tinnitus patients from the waiting list, and compared these to the scores of the therapy group 3 months after the end of treatment. The main factors of the modified TRT were Jacobson’s progressive muscle relaxation, physiotherapy, education via lectures and training of selective attention, as well as changes of appraisal, mental attitude and behavior towards tinnitus. The therapy resulted in a significant reduction in both short-term and long-term tinnitus-related distress and psychometric stress variables, with the latter being more reduced in patients with higher initial scores. Moreover, our study revealed differences in psychometric parameters concerning duration of tinnitus, age and gender, which may explain the different outcomes of therapy. The outpatient setting enables the patients to test, practice and transfer strategies into their everyday life.

The aim of this article is to show an established group therapeutic concept for chronic tinnitus. The treatment of chronic tinnitus is intended to improve the way patients cope with tinnitus but it does not eliminate it. It means that patients learn how to reduce the impairment they are experiencing. Patients with tinnitus are supported in the process of habituation through the treatment. Multimodal cognitive behavioral therapeutic interventions in a group setting are particularly helpful because they may demonstrate differences in the influence of cognitive processes on the emotional perception of the tinnitus between the patients. Psychological factors like emotional support through other patients and learning from other examples can ease the process of internalizing coping strategies. Psychological processes seem to be of particular importance. Those processes can have an effect on concentration, appraisal, and coping with the tinnitus. Progressive muscle relaxation using Jacobson's technique, physical therapy, education via lectures, training of selective attention and change of appraisal, mental attitude and behavior concerning the tinnitus are the main factors in tinnitus therapy and can enable tinnitus patients to decrease their psychological strain.

Einleitung: In einem aktuellen Uberblick von Henry et al. (2005) liegt die auf epidemiologischen Studien verschiedener Lander basierende Tinnituspravalenz schatzungsweise bei 10 bis 15%. Bleibt eine Habituation aus, kann der Tinnitus ernsthaften psychologischen Distress nach sich ziehen. Das Symptom Tinnitus ist also von groser psychosozialer Bedeutung. Stress und andere psychologische Faktoren sind von wesentlicher Bedeutung bei der Tinnitusentstehung und Prognose. Das Ziel der vorliegenden Studie ist die Untersuchung von psychometrischen Effekten einer multimodalen 7-tagigen Tinnitus-Kurzzeittherapie im Vergleich zu einer Wartekontrollgruppe ohne Intervention. Schwerpunkt der auf dem erweiterten TRT-Konzept basierenden Therapie ist eine Tinnitushabituation und die Vermittlung von Coping-Strategien wie das Erlernen von Entspannungsverfahren. Methode: Standardisierte psychometrische Testverfahren zur Untersuchung von: Von Interesse sind bei der Pra-Poststudie mit Follow-up-Messungen nach 6 Monaten und einem Jahr die Veranderungen der subjektiven Tinnitusbelastung und psychometrischer Stressvariablen. Dazu soll eine Auswertung der Daten von insgesamt 153 Patienten erfolgen. Ergebnisse: Erste Ergebnisse der Studie am Tinnituszentrum der Charite deuten auf eine signifikante Verringerung der Tinnitusbelastung (nach 7 Tagen um 6,1 Punkte und nach einem Jahr um weitere 5,8 Punkte), des Stresserlebens (nach 7 Tagen um 4,94 Punkte) und der Auspragung einer depressiven Symptomatik sowohl kurz- als auch langfristig hin. Zur weiteren Uberprufung von Langzeiteffekten der Therapie ist eine Katamnese fur zwei Jahre geplant. Literatur: 1. Anderson G (2002) Psychological aspects of tinnitus and the application of cogitive-behavioral therapy. Clin Psychol Rev 22, 977-990. 2. Caffier PP, Haupt H, Scherer H, Mazurek B (2006) Outcomes of long-term outpatient tinnitus-coping therapy (TCT) – Psychometric changes and value of tinnitus control instruments. Ear and Hearing. 3. Delb W, D´Amelio R, Boisten CJM, Plinkert PK (2002) Kombinierte Anwendung von Tinnitusretrainingtherapie (TRT) und Gruppenverhaltenstherapie. HNO 50: 997-1004. 4. Fliege H (2005) The Perceived Stress Questionnaire (PSQ) Reconsidered: Validation and Reference Values from Different Clinical and Healthy Adult. Psychosom Med 67: 78-88. 5. Goebel G, Hiller W (1998) Tinnitusfragebogen (TF) - Ein Instrument zur Erfassung von Belastung und Schweregrad bei Tinnitus. Hogrefe, Gottingen. 6. Harter M, Maurischat C, Weske G, Laszig R, Berger M (2004) Psychological stress and impaired quality of life in patients with tinnitus. HNO 52: 125-31. 7. Hautzinger M, Bailer M (1993) Allgemeine Depressionsskala. Verlag fur Psychologie, Hogrefe. 8. Henry JA, Dennis KC, Schechter MA (2005) General review of tinnitus: prevalence, mechanisms, effects, and management. J Speech Lang Hear Res 48 (5), 1204-35. 9. Jastreboff PJ, Hazell JPW (1993) A neurophysiological approach to tinnitus: Clinical Implications. Br J Audiol 27: 7-17. 10. Kroner-Herwig B (1997) Psychologische Behandlung des chronischen Tinnitus. Psychologische Verlagsunion Beltz, Weinheim. 11. Levenstein S (1993) Perceived Stress Questionnaire. Verlag fur Psychologie, Hogrefe. 12. Mazurek B (2005) Integrierte Tinnitusintensivbehandlung: Konzept und erste praktische Erfahrungen. Gesundheitswesen 67: 485-491. 13. Seydel C, Reisshauer A, Haupt H, Klapp BF, Mazurek B (2006) Stress bei der Tinnitusentstehung und -verarbeitung. HNO 54: 709-714. 14. Stobik C, Weber RK, Munte TF, Frommer J (2003) Psychosomatic stress factors in compensated and decompensated tinnitus. Psychother Psychosom Med Psychol 53: 344-52. 15. Stobik C, Weber RK, Munte TF, Walter M, Frommer J (2005) Evidence of psychosomatic influences in compensated and decompensated tinnitus. Int J Audiol 44: 370-8. 16. Weber C, Arck P, Mazurek B, Klapp B (2002) Impact of a relaxation training on psychometric and immunologic parameters in tinnitus sufferers. J Psychosom Res 52: 29-33. 17. Zumbaum-Fischer F, Klutentreter A, Georgiewa P, Mazurek B, Seydel C, Walter O, Schmidt M, Klapp B (2005) Stresserleben von Patienten mit dekompensiertem und kompensiertem chronischen Tinnitus – eine Vergleichsstudie. Psychother Psych Med., 55, S 160

Besides the impairment of somatic functions, other factors including stress, and psychological and social characteristics are known to be important factors in the pathogenesis of tinnitus and the ability to cope with it. Existing coping strategies and psychosocial factors may have an influence on the degree of stress perceived through tinnitus. In the case of missing habituation, serious psychological, neurological and immunological responses to tinnitus are possible. In order to reduce the cognitive and emotional tinnitus-distress associated with this, there should be a focus on providing functional coping strategies combined with cognitive behavioural elements.

In recent years, no major advances have been made in understanding the mechanisms underlying the development of tinnitus. Hence, the present therapeutic strategies aim at decoupling the subconscious from the perception of tinnitus. Mindful of the lessons drawn from existing tinnitus retraining and desensitisation therapies, a new integrated day hospital strategy of treatment lasting 7-14 days has been developed at the Charité Hospital and is presented in the present paper. The strategy for treating tinnitus in the proximity of patient domicile is designed for patients who feel disturbed in their world of perception and their efficiency due to tinnitus and give evidence of mental and physical strain. In view of the etiologically non-uniform and multiple events connected with tinnitus, consideration was also given to the fact that somatic and psychosocial factors are equally involved. Therefore, therapy should aim at diagnosing and therapeutically influencing those psychosocial factors that reduce the hearing impression to such an extent that the affected persons suffer from strain. The first results of therapy-dependent changes of 46 patients suffering from chronic tinnitus are presented. The data were evaluated before and after 7 days of treatment and 6 months after the end of treatment. Immediately after the treatment, the scores of both the tinnitus questionnaire (Goebel and Hiller) and the subscales improved significantly. These results were maintained during the 6-month post-treatment period and even improved.

Fragile X (fra(X)) males with a standardized IQ score of 70 or higher represent a high functioning (HF) or nonretarded fra(X) male group. This group, which does not include nonpenetrant males, has received little research attention to date. Of 221 fra(X) males who had been evaluated through The Children's Hospital in Denver since 1981 and had completed cognitive or developmental testing, 29 (13%) were high functioning by the above definition. We found that HF males on the whole had a lower cytogenetic score and were younger than retarded fra(X) males, but there was no difference between these two groups in the number of typical fra(X) physical manifestations present. FMR-1 DNA testing was performed on 134 fra(X) males and methylation status was determined for 51 of these. A greater percentage of HF males had a mosaic pattern or an incompletely methylated full mutation than did retarded males. A unique DNA pattern, an unmethylated fully expanded mutation, was discovered in 3 of the highest functioning fra(X) males. Protein studies performed on 2 of these males demonstrated the presence of FMR-1 protein, albeit at lower levels than normal. FMR-1 protein was not present in retarded fra(X) males. Significant FMR-1 protein expression may be responsible for higher cognitive functioning in the 2 males with unmethylated fully expanded mutations compared to retarded fra(X) males.

General theorems for existence and uniqueness of viscosity solutions for Hamilton–Jacobi–Bellman quasi-variational inequalities (HJBQVI) with integral term are established. Such nonlinear partial integro-differential equations (PIDE) arise in the study of combined impulse and stochastic control for jump-diffusion processes. The HJBQVI consists of an HJB part (for stochastic control) combined with a nonlocal impulse intervention term. Existence results are proved via stochastic means, whereas our uniqueness (comparison) results adapt techniques from viscosity solution theory. This paper, to our knowledge is the first treating rigorously impulse control for jump-diffusion processes in a general viscosity solution framework; the jump part may have infinite activity. In the proofs, no prior continuity of the value function is assumed, quadratic costs are allowed, and elliptic and parabolic results are presented for solutions possibly unbounded at infinity.

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Sir, Drug information services such as the Chinese Medicine Advisory Service at the Medical Toxicology Unit at Guy's and St Thomas' Hospital Trust make an important contribution to the safety management of patients taking complementary alternative medicines (CAMs). We are aware that these services exist and increased resort to the service they offer is needed. Our proposal is that doctors will need to devote time to discussing CAM use in outpatient clinics although the complexities of side effects and interactions may require clinics which are run jointly with a local medicines information and toxicology services (Werneke et al, 2004). Such work may not be feasible in routine outpatient clinics where patients may be seen only briefly. Joint clinics would not only address drug safety concerns but also the patients' motivation for opting for CAMs, for instance to gain a greater degree of control over their illness and its treatment, and thereby to regain control over their lives (Sparber et al, 2000). We agree with Shia et al that herbal remedies may have beneficial synergistic effects with conventional therapies. However, patients may take CAMs for a variety of reasons including reduction of cytotoxicity and its associated side effects rather than increasing it. This is highlighted by an e-mail we received in response to out study from a naturopath who asserted:’ …you will find that more people die of the chemotherapy than the cancer itself. Therefore if the herbs are making the chemo less effective this could be a beneficial thing…’. Thus, there is a need to work out and implement an individualised treatment plan for each patient wishing to use CAMs, and this may be beyond the scope of a drug information service. Shia et al suggest prospective studies to evaluate the interactions between conventional and complementary medicines. However, such studies may be difficult to conduct if there are reasons to suspect potentially serious interactions or a significant reduction in efficacy of the conventional treatment, which could lead to a reduction in survival time. It may not be ethically acceptable to opt for ‘watchful waiting’ in such cases, and one may wish to err on the side of caution. In view of this, we recommended stopping CAMs in some cases while monitoring for adverse effects in others. Prospective studies could be further complicated by the fact that many patients take combinations of remedies rather than one substance only, which may not always make it possible to attribute an adverse reaction unambiguously to one agent. In consequence, we feel that the research on and management of CAMs should be integrated into the conventional cancer care to provide a truly holistic approach and to enable clinicians to adapt CAMs and conventional therapies to patients' individual requirements and to take account of changes in the clinical course whenever they occur.