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The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017. The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A literature search for systematic reviews of randomized controlled drug trials from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines. Amitriptyline and duloxetine are recommended in the case of comorbid depressive disorders or generalized anxiety disorder and pregabalin in the case of generalized anxiety disorder. Off-label use of duloxetine and pregabalin can be considered if there are no comorbid mental disorders or no generalized anxiety disorder. Strong opioids are not recommended.

Die planmasige Aktualisierung der S3-Leitlinie „Fibromyalgiesyndrom“, AWMF-Registernummer 145/004, war fur April 2017 geplant. Die Leitlinie wurde unter Koordination der Deutschen Schmerzgesellschaft von dreizehn Fachgesellschaften und zwei Patientenselbsthilfeorganisationen entwickelt. Acht Arbeitsgruppen mit insgesamt 42 Mitgliedern wurden ausgewogen in Bezug auf Geschlecht, medizinischen Versorgungsbereich, potenzielle Interessenkonflikte und hierarchische Position im medizinischen bzw. wissenschaftlichen System besetzt. Die Literaturrecherche erfolgte uber die Datenbanken MEDLINE, PsycINFO, Scopus und Cochrane Library (von Dezember 2010 bis Mai 2016). Die Graduierung der Evidenzstarke erfolgte nach dem Schema des Oxford Centre for Evidence-Based Medicine, Version 2009. Die Formulierung und Graduierung der Empfehlungen erfolgte in einem mehrstufigen, formalisierten Konsensusverfahren. Der Leitlinie wurde von den Vorstanden der beteiligten Fachgesellschaften nach Uberprufung zugestimmt. Die klinische Diagnose des Fibromyalgiesyndroms kann sowohl nach den Klassifikationskriterien des American College of Rheumatology (ACR) von 1990 (mit Untersuchung der „tender points“) als auch ohne Untersuchung von „tender points“ anhand der modifizierten vorlaufigen diagnostischen Kriterien des ACR von 2010 bzw. der 2011-Kriterien erfolgen.

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017.The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A literature search for systematic reviews of randomized controlled drug trials from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines.Amitriptyline and duloxetine are recommended in the case of comorbid depressive disorders or generalized anxiety disorder and pregabalin in the case of generalized anxiety disorder. Off-label use of duloxetine and pregabalin can be considered if there are no comorbid mental disorders or no generalized anxiety disorder. Strong opioids are not recommended.

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017.The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A systematic search of the literature from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines.The clinical diagnosis of fibromyalgia syndrome can be established by the American College of Rheumatology (ACR) 1990 classification criteria (with examination of tender points) or without the examination of tender points by the modified preliminary diagnostic ACR 2010 or 2011 criteria.

BACKGROUND AND OBJECTIVE Psychotropic drugs are among the most widely prescribed drugs. We aimed to systematically analyze the use of psychotropic drugs among inhospital patients in a large university department of internal medicine. METHODS All discharge letters from the Department of Internal Medicine III, University Hospital Jena, Germany, in the year 2010 were retrospectively screened for the use of psychotropic drugs. Metabolic parameters, blood pressure and blood counts were compared to those of a control group; psychiatric diagnoses and consultation of a psychiatrist were noted. RESULTS Data from 2160 patients were examined (54.5% female, 45,5% male). In 371 patients (17.2%, 63.3% female, 36.4% male) the prescription of psychotropic drugs was recorded. The remaining 1789 patients without psychotropic drugs were used as control group. Patients with psychotropic drugs were significantly older (median 69 vs. 61 years) and more frequently female (p < 0.001). The most frequently used drug group were antidepressants. Both obesity (43.3 vs. 32.3%) and cachexia (9.1 vs. 2.8%) were significantly more common in the psychotropic drug group (p < 0.001). There were also more patients with diabetes (p < 0.001), but their HbA1c levels were not different from the control group. In 44.5% of the patients no psychiatric diagnosis was noted, in only 14.5% a psychiatrist had been consulted. Rather frequently (10% of patients) therapy with benzodiazepine receptor agonists or benzodiazepines was mentioned in the discharge letters. CONCLUSION The indication for psychotropic drug use could not be reproduced exactly in each case. Psychiatric diagnoses lacked in a substantial part of cases. As to the rest, affective disorders and organic mental disorders were rather frequent indications. Closer interdisciplinary cooperation between internists and psychiatrists is recommended to improve psychotropic drug therapy in older, often multimorbid patients in internal medical wards.

Viele psychiatrische Erkrankungen gehen mit einer veranderten Schmerzwahrnehmung einher. In einer groben Einteilung konnte man Erkrankungen mit reduzierter Schmerzwahrnehmung (z. B. Borderline-Personlichkeitsstorung) von Erkrankungen mit verstarkter Schmerzwahrnehmung (z. B. Alkohol- oder Drogenentzug) unterscheiden. Die enge Beziehung zwischen psychiatrischen Erkrankungen und Schmerz ist am ehesten auf Hirnstrukturen zuruckzufuhren, die bei psychiatrischen Erkrankungen in ihrer Funktion und Struktur verandert sind und wesentlich zur Schmerzverarbeitung beitragen. Am Beispiel der Anorexie soll dies exemplifiziert werden. Viele Studien haben eine Dysfunktion der Insel mit Symptomen der Erkrankung in Zusammenhang gebracht. In diesem Artikel wird dargestellt, dass eine Minderaktivierung der hinteren Insel sowohl die reduzierte Schmerzwahrnehmung aufgrund einer verstarkten adrenergen, deszendierenden Hemmung als auch einen erhohten Sympathikotonus erklaren konnte. So kann beschrieben werden, dass Schmerzforschung bei psychiatrischen Erkrankungen nicht nur schmerzrelevante Ergebnisse liefert, sondern auch die Pathophysiologie der Erkrankung besser verstehen hilft.

Hintergrund Die planmasige Aktualisierung der S3-Leitlinie zum Fibromyalgiesyndrom (FMS; AWMF-Registernummer 041/004) wurde ab Marz 2011 vorgenommen.

Lange wurde angenommen, dass Frauen wahrend einer Schwangerschaft vor psychiatrischen Erkrankungen geschutzt sind. Leider entspricht dies nicht der Realitat. Depressive Episoden und bipolare Erkrankungen sind sehr haufig, aber auch Psychosen, Drogen- und Alkoholabhangigkeit sowie Zwangserkrankungen konnen auftreten. Die Patientinnen sollten nach typischen Symptomen gefragt werden, z. B. mit Hilfe eines Fragebogens. Aufgrund des bestehenden Risikos schwerer depressiver oder psychotischer Symptome, die eventuell mit Suizidalitat einhergehen, sollte eine bestehende psychiatrische Medikation nicht abgesetzt werden. Bei nichtmedizierten Patientinnen sollte mit einer Monotherapie begonnen werden. Ausfuhrliche Studien, die eine Teratogenitat widerlegen, existieren fur manche SSRIs (selektive Serotoninwiederaufnahmehemmer) sowie SNRIs (selektive Noradrenalinaufnahmehemmer), fur Benzodiazepine und Neuroleptika. In schweren Fallen kann eine Elektrokrampftherapie (EKT) zur Behandlung depressiver oder psychotischer Symptome eingesetzt werden. Neben der medikamentosen Therapie und der EKT bietet die Psychotherapie eine wirksame Alternative bzw. Zusatzbehandlung.

Drug-induced stuttering has been described in association with several drugs, in particular antidepressants and low-potency neuroleptics. Here we describe a case series of stuttering induced by the atypical neuroleptics olanzapine and clozapine. Patients receiving neuroleptic treatment were carefully screened for stuttering as a possible side effect. We have studied all patients in the outpatient department (800 per year) as well as most inpatients (1300 per year) within 3 years. Seven cases of drug-induced stuttering were observed. Six patients suffered from stuttering in association with olanzapine treatment, and one received clozapine. Stuttering arose on average 2-21 days after initiation of treatment and ceased 2-5 days after discontinuation. Most patients suffered from additional diseases, such as brain pathology due to cortical atrophy or celiac disease, or received concomitant medication (i.e. intrathecal morphine pump). Our case series suggests that the atypical neuroleptic olanzapine can induce stuttering in the absence of a history of stuttering without accompanying akathisia or general decline of function. It appears that preexisting brain pathology or concomitant anti-depressant medication might predispose some patients to this side effect.

Psychotropic drugs are among the most widely prescribed drugs. We aimed to systematically analyze the use of psychotropic drugs among inhospital patients in a large university department of internal medicine.All discharge letters from the Department of Internal Medicine III, University Hospital Jena, Germany, in the year 2010 were retrospectively screened for the use of psychotropic drugs. Metabolic parameters, blood pressure and blood counts were compared to those of a control group; psychiatric diagnoses and consultation of a psychiatrist were noted.Data from 2160 patients were examined (54.5% female, 45,5% male). In 371 patients (17.2%, 63.3% female, 36.4% male) the prescription of psychotropic drugs was recorded. The remaining 1789 patients without psychotropic drugs were used as control group. Patients with psychotropic drugs were significantly older (median 69 vs. 61 years) and more frequently female (p0.001). The most frequently used drug group were antidepressants. Both obesity (43.3 vs. 32.3%) and cachexia (9.1 vs. 2.8%) were significantly more common in the psychotropic drug group (p0.001). There were also more patients with diabetes (p0.001), but their HbA1c levels were not different from the control group. In 44.5% of the patients no psychiatric diagnosis was noted, in only 14.5% a psychiatrist had been consulted. Rather frequently (10% of patients) therapy with benzodiazepine receptor agonists or benzodiazepines was mentioned in the discharge letters.The indication for psychotropic drug use could not be reproduced exactly in each case. Psychiatric diagnoses lacked in a substantial part of cases. As to the rest, affective disorders and organic mental disorders were rather frequent indications. Closer interdisciplinary cooperation between internists and psychiatrists is recommended to improve psychotropic drug therapy in older, often multimorbid patients in internal medical wards.

Glial cell line-derived neurotrophic factor (GDNF) is trophic to motor and sensory neurones in animal models. GDNF mRNA is up-regulated in Schwann cells after peripheral nerve injury in rats. We have quantified and localized GDNF and its receptor component Ret, for the first time in any species, in injured human peripheral nerves and dorsal root ganglia (DRG) avulsed from the spinal cord. Significantly higher levels of GDNF were found in nerve distal to the site of the injury than in proximal or intact nerve, and in avulsed DRG than in post-mortem control DRG. GDNF immunostaining was seen in Schwann cells and in DRG neurones, especially of small and medium size, with significantly increased numbers of medium sized sensory neurones immunoreactive for GDNF after avulsion. Ret immunoreactivity was restricted to DRG neurones and axons, with no significant changes in numbers of positive DRG cells after injury. Our findings suggest that GDNF may play a role in injured human nerves and sensory ganglia, particularly in medium sized sensory neurones.

The perception and processing of pain is disturbed in many psychiatric diseases. Some diseases are known to show decreased perception of pain (e.g. borderline personality disorder), while others are associated with augmented pain perception (e.g. alcohol and drug dependence). The close relationship between psychiatric diseases and pain is most probably caused by aberrant processing of pain in brain structures, known to be involved in psychiatric disorders as well. Aberrant perception and processing of pain in patients with anorexia nervosa (AN) will be used to demonstrate this close relationship. Dysfunction within the insula has been suggested to account for many features of AN and might contribute to reduced pain perception. Moreover, it might lead to increased adrenergic descending inhibition associated with increased sympathetic modulation. Thus, pain research might be able to alter our view on autonomic regulation, which is putatively associated with increased cardiac mortality of the disease.

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The recommendations were based on level of evidence, efficacy (meta-analysis of the outcomes pain, sleep, fatigue and health-related quality of life), acceptability (total dropout rate), risks (adverse events) and applicability of treatment modalities in the German health care system. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.Amitriptyline and-in case of comorbid depressive disorder or generalized anxiety disorder-duloxetine are recommended. Off-label use of duloxetine and pregabalin can be considered in case of no comorbid mental disorder. Strong opioids are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Reduced perception of pain is a well-established phenomenon in patients with anorexia nervosa (AN). We tested the hypothesis that altered processing of pain within the insula might account for reduced perception of pain.Heat pain thresholds were obtained in nineteen patients with AN and matched controls. Thereafter, a thermode was used to deliver thermal painful stimuli to the right arm during functional magnetic resonance imaging (fMRI) measurements. Stimuli were initiated for 10 s from a baseline resting temperature (32°C) to three different levels (37, 42, 45°C).Significantly increased heat pain thresholds were observed in patients. A stronger activation during heat pain perception was found in the left posterior insula in controls. In contrast, higher levels of activity were shown in the ipsilateral pons in patients when compared to controls. In patients, we found a significant interrelation between the depression score (Beck depression inventory) and heat pain activations.We suggest that reduced activity in the left posterior insula might contribute to increased pain thresholds in patients, while increased activations in the right anterior insula and pons mirror augmented sympathetic modulation putatively related to amplification of adrenergic descending pain inhibition. In addition, pain thresholds and brain activations were influenced by disease-inherent depressed mood.

Patients with schizophrenia show decreased sensitivity towards clinical and experimental painful conditions. To date, the exact underlying mechanisms are not completely understood. One method to examine central integrative processes of pain perception is the thermal grill illusion (TGI), in which interlacing cold and warm bars create the illusion of a painful sensation.In 18 unmedicated patients with acute paranoid schizophrenia, cold and heat pain thresholds (CPT/HPT) as well as the perception of the TGI were examined and compared to 18 matched controls. In addition, symptom scales were obtained in order to relate pain perception to psychopathology.CPT and HPT were significantly increased in patients compared to controls. In the range of TGI stimuli that were perceived painful by controls, patients did not indicate painful sensations, instead the stimulus response curve of TGI pain perception was shifted towards higher stimulus intensities, i.e., greater temperature differentials between cold and warm bars. This increase was comparable to that seen in CPT and HPT. There was no association with psychopathology for any pain parameter.CPT and HPT, as well as temperature differentials for the perception of the TGI were increased in patients with schizophrenia as compared to controls. Similar to visual illusions, in which reduced contrast sensitivity has been shown to alter the perception of illusions, the discriminatory somatosensory deficit, which is reflected in higher CPT and HPT as well as the previously reported increased warmth perception thresholds, might account for the attenuation of TGI in patients.

BackgroundSchizophrenia is associated with increased cardiac mortality. A disturbed autonomic modulation of heart rate (HR) has been described in patients with schizophrenia in whom antipsychotic medication may represent an additional cardiac risk. The novel measure deceleration capacity (DC) of heart rate predicts cardiac mortality in patients with cardiovascular illnesses. The aim of the present paper was to calculate DC in patients with schizophrenia and to compare this measure with established parameters of heart rate variability (HRV).MethodsHRV and DC were calculated in 24-hour electrocardiogram (ECG) recordings of 20 unmedicated, 40 medicated patients with schizophrenia and 40 controls. As activity has a major influence on HRV, 4-hour periods of “sleep-” and “wake-” ECG were evaluated as additional parameters. Actigraphy was used to ensure comparable levels of activity in patients and controls.ResultsThe DC as well as the other established HRV measures were not significantly different comparing unmedicated patients with schizophrenia to healthy controls. However, medicated patients showed a significant reduction of DC calculated from ECG recordings during 4 hour over night periods.ConclusionCalculation of DC might contribute to a better monitoring and identification of an increased risk of cardiac mortality in patients with schizophrenia undergoing antipsychotic treatment.

Connectivity analysis was used to investigate the processing of intracutaneous stimuli and directed interactions within the pain matrix in patients with major depression (MD) and healthy controls (HCs), by means of frequency selective generalized partial directed coherence (gPDC).Eighteen patients with MD and 18 HCs underwent stimulations consisting of moderately painful intracutaneous electrical stimuli to the right and left middle fingers. Connectivity analysis was based on nine selected EEG electrodes.Stimulus-induced changes of the gPDC in a pre/post stimulus comparison and changes in the connectivity pattern in the post-stimulus condition were found. We could identify network changes correlating to the side stimulated, as well as differences between HCs and MD patients.These data support the suggestion that pain processing in response to noxious stimulation in MD patients is different compared to healthy controls, suggesting aberrant functional connectivity. Generalized partial directed coherence is shown to be a promising method to detect changes in connectivity in both within- and between-subject designs.

Both, major depression and schizophrenia, are associated with a cholinergic autonomic dysfunction. Based on previous studies we investigated the hypothesis, that this aspect of neuropsychiatric disorders can be evaluated by indices of heart rate variability (HRV).

We report a patient with early-onset autosomal dominant dementia. The CSF showed increased levels of tau protein and decreased amyloid beta (ratio 42:40) typical for Alzheimer's disease. Cerebral MRI revealed vascular lesions and white-matter changes around the posterior horns of the ventricles with only moderate atrophy of the brain. Susceptibility-weighted imaging detected multiple small hemorrhagic changes. Gene analysis revealed amyloid precursor protein (APP) locus duplication as the cause of hereditary Alzheimer's dementia. The co-occurrence of CSF changes typical for Alzheimer's disease and MRI findings of cerebral amyloid angiopathy is remarkable, as it is also described for APP locus duplication. In conjunction with a family history suggestive of hereditary dementia, such a constellation should lead to enhanced gene analysis.

Menschen, die an einer lebensbedrohlichen Erkrankung leiden, erleben enorme intrapsychische Konflikte, die — so sie ein pathologisches Ausmas erreichen — zu erheblichen Konsequenzen fur das Wohlbefinden und die Lebensqualitat fuhren, aber auch wichtige Behandlungsentscheidungen beeinflussen konnen. Die Pravalenz psychiatrischer Erkrankungen bei onkologischen Patienten variiert je nach Studie und untersuchter spezifischer Storung von 25–50%, wobei die Anpassungsstorungen und depressive Episoden am haufigsten vertreten sind (Alexander et al. 1993; Berard et al. 1998). Fur eine adaquate onkologische Therapie ist das Erkennen und Behandeln solcher Erkrankungen essentiell.

Nerve injury, particularly of the brachial plexus, may result in lifelong disability and chronic pain, despite technically excellent reconstructive surgery. Studies of molecular changes in injured nerves may identify new treatments to enhance the success of nerve repair, such as with recombinant human neurotrophic factors. Interleukin-6 (IL-6) is a member of the neuropoietic cytokine family that includes ciliary neurotrophic factor (CNTF), leukaemia inhibitory factor (LIF), and oncostatin M. As there is increasing evidence of a neurotrophic role for IL-6 in animal models of nerve injury and inflammation,1 2 we have studied, for the first time in humans, IL-6 protein in injured and control peripheral nerve and dorsal root ganglia, using specific immunoassay, immunocytochemistry, and western blotting. We report a most remarkable increase of IL-6 concentrations in acutely avulsed dorsal root ganglia and injured nerves. Proximal and distal injured nerve segments were obtained from six adult patients with traction brachial plexus injury, ranging from 2 weeks to 10 weeks after trauma. Injured dorsal root ganglia were collected from seven adult patients with brachial spinal root avulsion injuries (central axotomy), ranging from 3 days to 15 months after trauma. Tissue removal was a necessary part …