Incidence of dementia in the elderly: review of age and sex effects

A review of epidemiological studies about incidence of dementia among the aged is presented. Empirical studies on incidence of dementia have shown considerably differing estimations. Nevertheless, in all studies, an age-related increase in incidence becomes clearly apparent. Epidemiological field-studies could not yield consistent findings concerning the association of incidence and gender. However, most studies found an increased incidence for men until the age of 70–80 years. In older age most studies reported the same incidence for men and women or found an increased incidence of dementia in women. The findings are reviewed and discussed in the context of methodological issues.

Alcoholism among homeless men in Munich, Germany

Probably in association with changes in the economic structure and high unemployment rates in western industrialized countries, homelessness is becoming more apparent publicly and receiving increased media attention. More studies on the issue of mental illness and homelessness have been performed in recent years in North America while hardly any representative and reliable data exists concerning Germany and some other European countries. The aim of our study was 1) to assess alcohol abuse and dependency as well as other mental disorders in a representative sample of homeless men in Munich using reliable methods of case identification (Diagnostic Interview Schedule [DIS and DIS/DSM-III diagnoses); 2) to compare homeless alcoholics with homeless non-alcoholics in our sample on relevant variables and issues and 3) to compare our data from the sample of homeless men in Munich with data obtained by others using the same case identification procedure (DIS/DSM-III diagnoses). According to our results, the lifetime prevalence of any DIS/DSM-III Axis I diagnoses was 94.5% and the lifetime prevalence of substance use disorder was 91.8%. The single most prevalent diagnosis among homeless males in Munich was alcohol dependency (lifetime 82.9%), while alcohol abuse (lifetime 8.2%) and drug abuse/dependency were considerably lower (lifetime 17.8%). Data show that alcoholism and its consequences were more severe in the Munich as compared to the Los Angeles homeless sample. Homeless alcoholics showed a high comorbidity with other mental disorders (lifetime) such as affective disorders (44.4%), anxiety disorders (22.6%), drug abuse/dependence (18.8%) and schizophrenia (12.0%); 64% of those with alcoholism at some time during their life had at least one other lifetime mental disorder. Alcohol-related patterns of living and symptoms as well as social or role functioning are described for homeless alcoholics in Munich and compared with data from other relevant studies. Considering the extremely high prevalence of alcohol dependence frequently in combination with other mental disorders, the use of alcohol rehabilitation and other services as well as self-help groups was minimum among Munich homeless alcoholics. New concepts to deal with these problems are needed and if they exist, they need to be implemented.

Frequent expression of the high molecular, 673-bp CD44v3,v8-10 variant in colorectal adenomas and carcinomas

CD44 is a transmembrane glycoprotein involved in the interaction between cells and the extracellular matrix. A large variety of alternatively spliced CD44 variants are expressed by different tumors with possible implication for tumor progression, formation of metastasis and survival. In colon carcinomas, previous reports described higher molecular bands of CD44 transcripts in neoplastic colonic tissue, although a complete analysis of multiple combinations of CD44v transcripts were not performed. We therefore analyzed the pattern of CD44 standard and variant (v2-v10) transcripts in colorectal adenomas and carcinomas by exon-specific RT-PCR amplification and sought CD44v transcripts specific for colonic neoplasias. Our data indicate that CD44 standard transcripts, including the epithelial form (C-v8,v9,v10-C) corresponding to a 720 bp transcript, were detected in 2/38 (5.2%) samples of normal mucosa, 20/20 (100%) adenomas and in 21/33 (63%) colorectal carcinomas. High molecular CD44v3,v8-10 (673 bp) transcripts were found in 2/33 (6%) samples from normal mucosa, 19/20 (95%) from adenomas and in 29/31 from colorectal carcinomas (93%). Similar CD44v3,v8-10 transcripts were detected in five from seven colorectal liver metastases, while normal liver did not contain high molecular CD44v3 variants. The same CD44v3,v8-10 (673 bp) variant was detected in HT-29 human colon carcinoma cells. Direct sequencing of the CD44v3 (673 bp) transcript in samples from colorectal carcinomas and HT-29 cells confirmed the assumed CD44v (-C-v3-v8-v9-v10-C-) cDNA sequence. Analysis of other CD44 variant transcripts (v4-v10) using exon specific primers were less frequently associated with colorectal neoplasias. These data report for the first time frequent expression of neoplasia-associated CD44v3,v8-10 variants in colorectal adenomas and carcinomas supporting the role of increased CD44 variant expression as an early event in colorectal carcinogenesis. The described CD44v3,v8-10 (673 bp) variant might be relevant for diagnosis and treatment of colorectal cancer.

Butyrate-induced alterations of phosphoinositide metabolism, protein kinase C activity and reduced CD44 variant expression in HT-29 colon cancer cells

Initiation of cell growth and neoplastic transformation frequently involves activation of growth factor receptor-coupled tyrosine kinases and stimulation of the phosphoinositide second messenger system. Altered expression of CD44 variants was reported in several malignant tumor types with possible implications for tumor progression and prognosis. CD44 variant expression was reported to be associated with second messenger activation and differentiation. We therefore investigated the effects of butyrate-induced short-term differentiation on phosphoinositide signaling, phospholipase C and protein kinase C activity and alteration of CD44 variant expression in human HT-29 colon carcinoma cells. HT-29 cells were cultured with sodium butyrate for 6 days. Phosphoinositide turnover was measured by [32P]orthophosphate incorporation and phospholipase C activity by determination of the release of [3H]inositolphosphates from [3H]myoinositol prelabeled cells. Protein kinase C activity was determined by histone III-S phosphorylation, PKC subtype expression by RNase protection analysis, and CD44 variant expression was determined by RT-PCR using variant-specific primers. Treatment of HT-29 human colon carcinoma cells with sodium butyrate caused a dose-dependent inhibition of cell proliferation (IC50, 2.5 mM) with morphologic signs of an enterocytic differentiation following 6 days of treatment. The phosphoinositide turnover as determined by 32P-incorporation under non-equilibrium conditions showed a 30-40% inhibition of labeled phosphoinositides and phosphatidic acid and a dose-dependent inhibition of cholinergically stimulated phospholipase C activity as a secondary event following butyrate-induced enterocytic differentiation. However, long-term incubation of HT-29 cells with phorbol ester or an inhibitor of classical and novel PKC subtypes did not affect cell proliferation. In butyrate-treated HT-29 cells activation of calcium-dependent protein kinase C by cholinergic stimulation or phorbolester treatment induced an increase in membrane-bound cPKC activity, while expression of distinct high- molecular CD44 variant transcripts v3 (670 bp), v5 (940 bp) and v8 (535 bp) were drastically reduced after butyrate pretreatment. Enterocytic differentiation of HT-29 colon carcinoma cells seems to be associated with alterations in phosphoinositide resynthesis, phospholipase C activity and ligand/receptor-induced PKC translocation. The observed reduction of distinct high-molecular CD44v3, v5 and v8 variants following butyrate-induced differentiation indicates an association of specific CD44 variant expression with the malignant phenotype of HT-29 colon cancer cells, thus being possible targets for new diagnostic and therapeutic strategies.

15-year prospective follow-up study of behavioral therapy in a large sample of inpatients with chronic tinnitus

CONCLUSION

The results of this study are in accordance with the assumption that cognitive-oriented therapy enabling the patient to live with tinnitus is of primary importance to enhance quality of life.

BACKGROUND AND OBJECTIVES

This study describes the success of an integrative behavioral-medicine inpatient treatment for complex chronic tinnitus and presents its long-term effects. In 1987 we developed and evaluated a new treatment concept of psychological treatment of complex chronic tinnitus based on international experience and results. To evaluate the influence, effects and individual results of the specific therapy we analyzed the data of 434 consecutively treated patients. To investigate the long-term effects of the treatment, we contacted the patients 15 years after discharge from the hospital.

PATIENTS AND METHODS

We used the tinnitus questionnaire (TQ) and visual analog scales (VAS) for specific tinnitus variables (loudness, discomfort, control of tinnitus, stress, general mood). The German version of the Derogatis psychopathology checklist (SCL-90-R) was used to analyze the impact of additional symptoms (depression, anxiety, introversion, etc.).

RESULTS

Compared with a control group (patients on a waiting list) significant and clinically relevant effects were found. At the outcome, there were significant improvements in almost all parameters measured. For evaluation of the long-term effect we succeeded in contacting 312 of 434 former patients. Data were assessed using the same questionnaires that had been employed at the first contact. In all, 271 patients (86%) returned the questionnaires. Data for 244 cases (mean age 63 years; 79 females, 165 males) were complete enough to be used for data analysis. The results of the follow-up were as unexpected as clear: 15 years after conclusion of the treatment, the improvements of the tinnitus parameters and additional symptoms were stable when compared with the end of therapy.

[New ways to combat eating disorders-evaluation of an internet-based self-help program in bulimia nervosa]

CONTENT

Results of the German part of a European multicenter study on the effectiveness and practicability of an internet-based self-help program (SHG self-help guide) in bulimia nervosa (BN).

METHOD

The internet-based program SHG builds on the principles of cognitive behavioral therapy (CBT) and comprises seven cumulative therapeutic steps. Twenty-two women with BN made use of the program over a period of six months. The patients were supported by three evaluation interviews and a once-weekly email contact with a female psychologist. During the interview, data on general psychopathology, specific eating disorder complaints and symptoms of depression were collected.

RESULTS

The examination showed definite effects both in terms of a reduction in eating disorder-specific behavior and a statistically and clinically relevant improvement in the symptoms of depression.

CONCLUSION

After working with the SHG, the patient sample studied here registered improvements in eating disorder and depressive symptoms. The design of the study, however, made it impossible to assess effectiveness. Practicability and usefulness were positively assessed by the patients. Thanks to its considerable flexibility in terms of time and place, the method could well be a valuable supplementary building block in the treatment of bulimia nervosa.

Collagen degradation products modulate matrix metalloproteinase expression in cultured articular chondrocytes

Destruction of collagen within osteoarthritic cartilage depends in part on collagen-degrading matrix metalloproteases (MMP). Degradative fragments of type II collagen (Col II) occur in normal and in osteoarthritic cartilage, and may contribute to regulation of matrix turnover by interfering with normal cell-matrix communication pathways. Therefore, the effects of different types of collagen fragments on mRNA and protein levels of MMP-2, MMP-3, MMP-9, and MMP-13 in cultured bovine articular knee chondrocytes and explants were examined. Primary chondrocytes and explants were incubated with fragments from whole cartilage collagen matrix (Colf) and from purified type II collagen (Col2f), or with a synthetic 29-mer peptide representing the amino-terminal domain of type II collagen (Ntelo). Gelatin zymography revealed increases of proMMP-2, a shift towards active MMP-2 and increases in proMMP-9, depending on the type of fragment. In situ hybridization of cartilage sections displayed MMP-3 mRNA in virtually all cells. Moderate to strong increases in MMP-2, MMP-3, MMP-9, and MMP-13 mRNA levels were detected by quantitative PCR. The results demonstrate stimulating effects of collagen fragments on both mRNA and/or protein from MMP -2, -3, -9, and -13, and suggest a novel mechanism of MMP induction and activation that includes a particular role for N-telo in controlling catabolic pathways of matrix turnover.

Postprandial ghrelin release in anorectic patients before and after weight gain

The appetite-modulating hormone ghrelin transmits changes in food intake to the central nervous system. In patients with anorexia nervosa, weight gain reduces elevated fasting ghrelin levels to normal, however, less is known about the effects on postprandial ghrelin levels. In 20 female anorectic in-patients (25.6 +/- 1.0 years; body mass index (BMI) 15.1 +/- 0.3 kg/m2) a standardized test with 250 ml fluid meal (250 kcal: 9.4 g protein, 34.4 g carbohydrates, and 8.3 g fat) was performed at three different times (at admission, after partial weight gain of at least 2 kg, and at discharge) and compared to healthy controls (n = 6; BMI 21.1 +/- 0.7 kg/m2). Plasma ghrelin levels were measured preprandially as well as 20 and 60 min postprandially by a commercially available radioimmunoassay (Phoenix Pharmaceuticals, USA). At admission plasma ghrelin levels significantly decreased postprandially (from 871.9 +/- 124 to 620.3 +/- 80 pg/ml 60 min after meal; P < 0.005). After partial weight gain (2.8 +/- 0.1 kg; BMI 16.1 +/- 0.3 kg/m2) postprandial ghrelin concentrations decreased from 597.0 +/- 79 to 414.7 +/- 39 pg/ml (P < 0.0001), at discharge (weight gain: 7.6 +/- 0.5 kg; BMI 17.9 +/- 0.4 kg/m2) from 570.4 +/- 78 to 395.4 +/- 44 pg/ml (P < 0.0001). Mean postprandial ghrelin decrease was not significantly different between the three tests (29, 25, and 26%, respectively) or to controls (20%). In anorectic patients mean postprandial ghrelin decrease did not change during weight gain. These findings indicate that in anorexia nervosa the suppression of ghrelin release by acute changes of energy balance (feeding) is not disturbed and that it is independent from chronic changes in energy balance (weight gain).

Candidate genes for anorexia nervosa in the 1p33-36 linkage region: serotonin 1D and delta opioid receptor loci exhibit significant association to anorexia nervosa

Serotonergic and opioidergic neurotransmitter system alterations have been observed in people with eating disorders; the genes for the serotonin 1D receptor (HTR1D) and the opioid delta receptor (OPRD1) are found on chr1p36.3-34.3, a region identified by our group in a linkage analysis of anorexia nervosa (AN). These candidate genes were evaluated for sequence variation and for linkage and association of this sequence variation to AN in family and case : control data sets. Resequencing of the HTR1D locus and a portion of the OPRD1 locus identified novel SNPs and confirmed existing SNPs. Genotype assay development and genotyping of nine SNPs (four at HTR1D and five at OPRD1) was performed on 191 unrelated individuals fulfilling DSM-IV criteria (w/o amenorrhea criterion) for AN, 442 relatives of AN probands and 98 psychiatrically screened controls. Linkage analysis of these candidate gene SNPs with 33 microsatellite markers in families including relative pairs concordantly affected with restricting AN (N=37) substantially increased the evidence for linkage of this region to restricting AN to an NPL score of 3.91. Statistically significant genotypic, allelic, and haplotypic association to AN in the case : control design was observed at HTR1D and OPRD1 with effect sizes for individual SNPs of 2.63 (95% CI=1.21-5.75) for HTR1D and 1.61 (95% CI=1.11-2.44) for OPRD1. Using genotype data on parents and AN probands, three SNPs at HTR1D were found to exhibit significant transmission disequilibrium (P&<0.05). The combined statistical genetic evidence suggests that HTR1D and OPRD1 or linked genes may be involved in the etiology of AN.

Genetic predisposition to obesity in bulimia nervosa: a mutation screen of the melanocortin-4 receptor gene

Obesity has been identified as a risk factor for the development of bulimia nervosa (BN). Accordingly, we hypothesize that genotypes predisposing to obesity can be detected in patients with this eating disorder. In order to investigate this hypothesis we screened the melanocortin-4 receptor gene (MC4R) for mutations using single strand conformation analysis in 81 female inpatients treated for BN. A single patient with both extreme obesity and BN had a haplo-insufficiency mutation in the MC4R. Comparison of current and maximal body mass index (BMI) of all patients with cross-sectionally obtained BMI in the general population revealed an age appropriate distribution for current BMI and a substantially increased frequency for overweight at time of maximal BMI. Our findings suggest that overweight is a risk factor for BN in clinically ascertained patients. For the first time a genotype predisposing to obesity has been detected in an extremely obese patient with BN.

Weight gain decreases elevated plasma ghrelin concentrations of patients with anorexia nervosa

OBJECTIVE

Ghrelin is a new gastric hormone that has been identified as an endogenous ligand for the growth hormone (GH) secretagogue receptor subtype 1a (GHS-R1a). Ghrelin administration however not only stimulates GH secretion but also induces adiposity in rodents by increasing food intake and decreasing fat utilization. We hypothesized that impaired ghrelin secretion in anorexia nervosa may be involved in the pathogenesis of this eating disorder. To examine this hypothesis and to further investigate the role for ghrelin in regulating energy homeostasis, we analyzed circulating ghrelin levels in patients with anorexia nervosa and examined possible correlations with clinical parameters before and after weight gain.

METHODS

Plasma ghrelin levels were measured in overnight fasting plasma samples from 36 female patients with anorexia nervosa (age: 25.0+/-1.2 years, BMI: 15.2+/-0.2 kg/m(2)) before and after weight gain following psychotherapeutic treatment intervention in a psychosomatic institution. Plasma ghrelin levels were also measured in fasting plasma samples from 24 age-matched female controls (31+/-1.4 years, BMI: 22.9+/-0.45 kg/m(2)). For quantification of ghrelin levels a commercially available radioimmunoassay (Phoenix Pharmaceuticals, USA) was used.

RESULTS

Fasting plasma ghrelin levels in anorectic patients were significantly higher (1057+/-95 pg/ml) than in normal age-matched female controls (514+/-63 pg/ml n=24, P=0.02). Therapeutic intervention in a psychosomatic institution caused an BMI increase of 14% (P<0.001) leading to a significant decrease in circulating ghrelin levels of 25%, (P=0.001). A significant negative correlation between Deltaghrelin and DeltaBMI was observed (correlation coefficient: -0.47, P=0.005, n=36).

CONCLUSION

We show for the first time that fasting plasma levels of the novel appetite-modulating hormone ghrelin are elevated in anorexia nervosa and return to normal levels after partial weight recovery. These observations suggest the possible existence of ghrelin resistance in cachectic states such as caused by eating disorders. Future studies are necessary to investigate putative mechanisms of ghrelin resistance such as a possible impairment of intracellular ghrelin receptor signaling in pathophysiological states presenting with cachexia.

[Bulimia nervosa in homosexuality and HIV infection in the man. Case report]

A male with bulimia nervosa is reported whose homosexual behavior resulted in HIV infection. The goal of this case study is to shed light on the course characteristics of bulimia nervosa occurring together with HIV infection in connection with homosexuality. The patient had experienced a number of traumas including sexual abuse, which surely had an influence on his developing bulimia nervosa. His longing for slimness, shown by the excessive preoccupation and dissatisfaction with body shape and weight may be considered typical for bulimia nervosa in homosexual men. Furthermore, male subjects with eating disorders often seem to be overweight prior to the start of bulimia nervosa, which also was the case in this subject. The course of his HIV infection so far has had no effect on severity of the bulimic symptoms. However, his bulimia nervosa apparently did had negative effects on the course of the HIV infection.

The structured interview for anorexic and bulimic disorders for DSM-IV and ICD-10 (SIAB-EX): reliability and validity

OBJECTIVE

For reliable and valid assessment and diagnostic categorization of eating disorders, self-report measures have considerable limitations. A semi-structured interview - the SIAB-EX - was developed for a more reliable and valid assessment of eating disorders.

METHODS

One study (videotapes of 31 inpatients, seven raters) was made to establish inter-rater reliability; in another study with 80 patients the SIAB-EX was compared to another semi-structured interview designed for comparable purposes (EDE). In a third study data was obtained on 377 eating disorder patients seeking treatment to explore discriminant and convergent (construct) validity using the following self-rating scales: EDI, TFEQ, SCL-90, BDI, and the PERI Demoralization Scale.

RESULTS

Inter-rater reliability of dichotomous ratings was good with mean kappa values of.81 (current) and.85 (past). Comparison of the SIAB-EX with the EDE generally showed quite similar results and higher intercorrelation of the total scale (.77). There are, however, a number of differences between the two scales, which are discussed in detail. Construct validity of the SIAB-EX was established.

CONCLUSION

Inter-rater reliability was good. Convergent and discriminant (construct) validity of the SIAB-EX was demonstrated. The constructs assessed by the SIAB and its subscales and items are discussed in the context of their correlations with other well-known scales.

Perfectionism in anorexia nervosa: variation by clinical subtype, obsessionality, and pathological eating behavior

OBJECTIVE

The purpose of this study was to examine the role of perfectionism as a phenotypic trait in anorexia nervosa and its relevance across clinical subtypes of this illness.

METHOD

The Multidimensional Perfectionism Scale and the perfectionism subscale of the Eating Disorder Inventory were administered to 322 women with a history of anorexia nervosa who were participating in an international, multicenter genetic study of anorexia nervosa. All participants were additionally interviewed with the Yale-Brown Obsessive Compulsive Scale and the Yale-Brown-Cornell Eating Disorder Scale. Mean differences on dependent measures among women with anorexia nervosa and comparison subjects were examined by using generalized estimating equations.

RESULTS

Persons who had had anorexia nervosa had significantly higher total scores on the Multidimensional Perfectionism Scale than did the healthy comparison subjects. In addition, scores of the anorexia subjects on the Eating Disorder Inventory-2 perfectionism subscale exceeded Eating Disorder Inventory-2 normative data. For the anorexia nervosa participants, the total score on the Multidimensional Perfectionism Scale and the Eating Disorder Inventory-2 perfectionism subscale score were highly correlated. Total score on the Multidimensional Perfectionism Scale was also significantly related to the total score and the motivation-for-change subscale score of the Yale-Brown-Cornell Eating Disorder Scale.

CONCLUSIONS

These data show that perfectionism is a robust, discriminating characteristic of anorexia nervosa. Perfectionism is likely to be one of a cluster of phenotypic trait variables associated with a genetic diathesis for anorexia nervosa.

[Utilization of medical and psychosocial services by mentally ill homeless persons. Results of an epidemiological study]

The aim of this study was to ascertain to what extent homeless, mentally ill subjects in Munich take advantage of available psychosocial services. To obtain a representative picture of the situation, the first step was to ascertain how many people in Munich are actually homeless. The next step was to ascertain what proportion of them are in need of psychotherapy. Using the standardized Diagnostic Interview Schedule (DIS), 146 men and 32 women were interviewed. The results according to the DSM-III demonstrated high lifelong and 6-month prevalence of psychic disturbances. Medical and social services were often enjoyed, but mostly over a short period of time in particularly critical situations. Continued treatment rarely followed. Women were treated more often than men. Elements such as age and level of education hardly influenced patients' seeking help. Despite a high prevalence of addictive disease, alcohol and drug clinics were rarely consulted. The increase in the number of diagnoses was paralleled by an increase in the number of patients seeking help. Most treatments involved schizophrenia and anxiety. By means of logistic regression models, predictors of the extent to which these services were used were analysed. We conclude that new clinical models are needed and that the aversion to the present care system is too great. Continued treatment occurs only rarely.

[Institutional care for the very old. Results of the Munich study of the very old]

In a two-wave community study in Munich, Germany, a representative sample of 402 people older than 85 years was restudied 1 year later. In the first cross-section a total of 358 (89.1%) subjects were interviewed. One year later 263 (73.5%) subjects were reexamined. Several diagnostic systems were used. We analysed the living situation in different risk groups. Women, singles and the older ones more often lived in institutions. Women suffering from dementia and men suffering from depression were more often in homes. Need for care and subjective health status influenced the living situation.

Interrelationships between the size of the pancreas and the weight of patients with eating disorders

OBJECTIVE

Starvation severely affects normal pancreatic function in children suffering from Kwashiorkor and in animals undergoing food deprivation. This study examines whether pancreatic size, as determined by ultrasound, is dependent on starvation or on eating patterns in patients with eating disorders.

METHOD

In 109 inpatients with eating disorders, 86 with anorexia nervosa and 23 with bulimia nervosa, we determined the pancreatic size by means of abdominal ultrasonography before increase in weight. Twenty-four inpatients with other psychiatric disorders served as controls. Pancreatic size was defined by the maximal diameter and the length of the head, the diameter of the head at the confluence of the splenic and mesenteric veins, and the diameters of the body and tail. In 41 eating disorder patients, pancreatic size was also measured during the course of therapy and increase in weight.

RESULTS

Pancreatic size correlates highly with body mass index (BMI). Counteracting actions such as purging do not seem to influence this pathophysiologic finding. Dystrophy of the pancreas is reversible in a short period of time. The increase in pancreatic size after maintenance of a normal eating pattern, however, exceeded the size expected by regression equation with an increase in the BMI. Pancreatic size seems to correlate with the actual amount of digested food. The increase in BMI is only an indicator of food intake.

DISCUSSION

Pancreatic size might therefore be useful for the assessment of normalization of the eating pattern. Future research is necessary to investigate the impairment of pancreatic function resulting from dystrophy, the impact of possible pancreatic malfunction on the course of eating disorders, and the regulatory mechanisms responsible for the change of pancreatic size.

[Psychosomatic disease in female teachers. Social context, contents and perspectives of inpatient treatment with a goal of rehabilitation and return to work]

Despite the considerable consequences, school teachers treated in psychosomatic in-patient settings, have not yet been the subject of investigations. Whether, for whom and which kind of job related treatment can be helpful for teachers returning to work can only be discussed if the specific stress and the social situation of teachers as public officials ("Beamtenstatus") are taken into consideration. On this point of view a systematic evaluation of 63 psychosomatically ill teachers consecutively admitted in a psychosomatic hospital was performed. The average age was 50, suffering mostly from depression or/and tinnitus. Most teachers rated job related stress as influencing their symptomatologies. A program focusing on discrepancies between personal ideals versus real situations in school, problems in social interactions and time management, should be a valuable part of the teachers' psychosomatic inpatient treatment. This approach was affected by a strong desire for early retirement in about half of the teachers.

Alcoholism in homeless men in the mid-nineties: results from the Bavarian Public Health Study on homelessness

Parallel to structural economic changes homelessness has become publicly more visible and has received increased media attention in Western industrialized countries. Most studies on mental illness and homelessness in recent years were carried out in North America but only few studies in Europe have dealt with these issues. The goals of the present study were (1) to assess alcohol abuse and dependence as well as other mental disorders in a representative sample of homeless men in Munich using reliable methods of case identification (Structured Clinical Interview for DSM-IV (SCID)), (2) to compare homeless alcoholics with homeless non-alcoholics in our sample on relevant variables, and (3) to compare our data from the Munich sample with data obtained by others. According to our results, the life-time prevalence of any SCID-DSM-IV Axis I diagnoses was 93.2% and the lifetime prevalence of substance use disorder was 79.6%. The single most prevalent diagnosis among homeless males in Munich was alcohol dependence (life-time 72.7%); alcohol abuse (life-time 5.5%) and drug abuse/dependence were considerably lower in prevalence (life-time 19.1%) (weighted data). A higher rate of psychotic disorders was found for non-alcoholic homeless men. Data show that alcoholism and its consequences were more severe in the Munich as compared to North American samples. Homeless alcohol dependent men showed a high comorbidity with other mental disorders (life-time) such as mood disorders (36.4%), anxiety disorders (16.4%), drug abuse/dependence (18.9%) and psychotic disorders (4.5%). Of those with alcohol dependence at some time during their life 59.1% had experienced at least one other life-time mental disorder. Alcohol-related behavioral patterns and symptoms as well as general social functioning are described. Considering the very high prevalence of alcohol dependence (frequently in combination with other mental disorders), the participation in alcohol rehabilitation and other services as well as self-help groups was rather low among Munich homeless alcoholics. Currently homeless men in Germany are adequately supplied with food, clothes, and shelter but psychiatrically (and medically) neglected. Existing concepts and programs for dealing with these problems need to be implemented.

Several mutations in the melanocortin-4 receptor gene including a nonsense and a frameshift mutation associated with dominantly inherited obesity in humans

The melanocortin-4 receptor gene (MC4-R) has been implicated in weight regulation. Recently, two independent groups reported frameshift mutations associated with a dominant form of obesity (1, 2). We screened the coding region of the MC4-R in 306 extremely obese children and adolescents (mean body mass index: BMI 34.4 +/- 6.6 kg/m2), 25 healthy underweight students (mean BMI 17.1 +/- 0.8 kg/m2), 52 normal weight individuals (mean BMI 22.0 +/- 1.0 kg/m2), 51 inpatients with anorexia nervosa (AN, DSM IV criteria, mean BMI 14.3 +/- 1.5 kg/m2) and 27 patients with bulimia nervosa (BN, DSM IV criteria, mean BMI 21.7 +/- 5.8 kg/m2) by single strand conformation polymorphism analysis (SSCP). Several mutations were identified, including the frameshift mutation described (1). The mutations were as follows: a) The deletion of 4 bp (delta of CTCT at codon 211) results in a frameshift, thus rendering a truncated protein. This mutation has been assumed to be associated with dominantly-inherited morbid obesity in humans (1). Both the index patient (BMI 42.06 kg/m2, height 171 cm, age 19.6 years) and her mother (BMI 37.55 kg/m2, height 164 cm, age 42.5 years) were heterozygous for the deletion. b) A nonsense mutation at position 35 of the MC4-R was detected in two obese probands (BMI 31.29 kg/m2 and BMI 45.91 kg/m2). This mutation leads to a truncated protein that encompasses the N-terminal extracellular domain. Both carriers additionally showed (c) a missense mutation (Asp-37-Val). In both of these cases Tyr-35-Stop and Asp-37-Val were maternally transmitted, thus these variations form a haplotype. d) e) A male obese proband harbored two missense mutations (Ser-30-Phe, Gly-252-Ser). f)-i) Four different missense mutations (Pro-78-Leu, Thr-112-Met, Arg-165-Trp, Ile-317-Thr) were detected in four different male probands, respectively. All of these mutations (a to i) were found solely in extremely obese individuals whose BMIs were all above the 99th percentile. j) A silent mutation (C-579-T, Val-193-Val) was detected in a male underweight individual. k) A previously described polymorphism (Val-103-Ile; 3) was detected with similar frequencies in all different study groups. 1) We identified a novel polymorphism (Ile-251-Leu) with similar allele frequencies in all groups under study. In conclusion, our data indicate that mutations in the MC4-R are not uncommon. Whereas our data support the evidence for dominantly inherited obesity as revealed by the three obese probands with haplo-insufficiency, the functional significance of the missense mutations remains to be determined.

Cross-cultural comparison of depressive symptoms in Europe does not support stereotypes of ageing

BACKGROUND

Stereotypes of older people suggest that they are depressed.

AIMS

To examine depression symptoms among people aged > or = 65 in the general population and to ask the following questions. Are there high proportions of depressive symptoms among otherwise well people? Do these levels reflect the prevalence of depression? Do key symptoms vary with age and do they confirm stereotypes?

METHOD

Nine centres contributed data from community-based random samples, using standardised methods (GMS-AGECAT package).

RESULTS

Proportions of depressive symptoms varied between centres. Some often associated with ageing were rare. Many were more common in women. Low-prevalence centres tended to have fewer symptoms among 'well' people, but there were inconsistencies. Low levels of symptoms among the well population of a centre did not necessarily predict lower levels in the depressed.

CONCLUSIONS

Variations in the prevalence of depressive symptoms occurred between centres, not always related to levels of illness. There was no consistent relationship between proportions of symptoms in well persons and cases for all centres. Few symptoms were present in > 60% of the older population--stereotypes of old age were not upheld.

Development of the EURO-D scale--a European, Union initiative to compare symptoms of depression in 14 European centres

BACKGROUND

In an 11-country European collaboration, 14 population-based surveys included 21,724 subjects aged > or = 65 years. Most participating centres used the Geriatric Mental State (GMS), but other measures were also used.

AIMS

To derive from these instruments a common depression symptoms scale, the EURO-D, to allow comparison of risk factor profiles between centres.

METHOD

Common items were identified from the instruments. Algorithms for fitting items to GMS were derived by observation of item correspondence or expert opinion. The resulting 12-item scale was checked for internal consistency, criterion validity and uniformity of factor-analytic profile.

RESULTS

The EURO-D is internally consistent, capturing the essence of its parent instrument. A two-factor solution seemed appropriate: depression, tearfulness and wishing to die loaded on the first factor (affective suffering), and loss of interest, poor concentration and lack of enjoyment on the second (motivation).

CONCLUSIONS

The EURO-D scale should permit valid comparison of risk-factor associations between centres, even if between-centre variation remains difficult to attribute.

[Mental illness in homeless men and women in Munich]

PURPOSE

Mental illness appears to be overrepresented among homeless individuals. The purpose of this study was the standardised assessment of mental illness in a representative sample of homeless men and of homeless women in the city of Munich, Germany.

METHODS

In order to get a very good estimate of the population of homeless individuals in Munich, a pre-sampling survey was conducted. On the basis of this pre-sampling survey the size and relevant characteristics of the total population of homeless individuals in Munich were defined. Individuals of the sample were randomly selected from the population. 146 men and 32 women were interviewed using the Diagnostic Interview Schedule (DIS).

RESULTS

Homeless men were on the average 43 years of age; most of them unmarried or divorced, had a relatively low degree of school education and a relatively long duration of homelessness. The prevalence of mental illness (lifetime) was very high: 91.8% had a substance abuse disorder (82.9% alcohol dependence), 41.8% had an affective disorder, 22.6% had an anxiety disorder and 12.4% suffered from schizophrenia. Of the homeless men in Munich 94.5% had at least one DIS/DSM-III axis I diagnosis 6-month prevalence data is also presented.

CONCLUSIONS

The results confirm the findings of other studies in other countries of high rates of mental illness among homeless individuals. In comparison to a study in Los Angeles using the same methodology, prevalence rates were even higher in Munich. Implications for health care planning are discussed.

Systematic mutation screening of the estrogen receptor beta gene in probands of different weight extremes: identification of several genetic variants

Estrogens are known to have an inhibitory effect on food intake in rodents and primates. Decreased estrogen levels that are found for instance in menopausal woman and in ovarectomized rodents result in body weight gain. Estrogen can act both in the periphery and in the central nervous system via at least two different estrogen receptors (alpha and beta). We systematically screened the coding region and part of the 5' and 3'regions of the estrogen receptor beta gene (ER beta) in 96 extremely obese children and adolescents, 50 patients with anorexia nervosa (AN), 28 patients with bulimia nervosa (BN), and 25 healthy underweight individuals. We detected five different sequence variants in the ER beta: a) A 21 bp deletion (codons 238 to 244) was detected in two obese probands and an underweight individual. b) An 846G-->A transition leading to a nonconservative amino acid substitution (G-250-S) was found in two obese male probands. Both a) and b) were located within the flexible hinge region between DNA and ligand binding domain. c) For a 1082G-->A polymorphism we found suggestive evidence for an association between the more common 1082G-allele and anorexia nervosa (nominal p=0.04). d) One silent mutation (1421T-->C) was found solely in two obese probands. e) A common variant is located in the 3' nontranslated region at position 1730(A-->G). We did not detect association of this polymorphism to any of the analyzed phenotypes. We conclude that the ER beta harbors several different mutations and polymorphisms, none of which can readily be associated with the phenotypes under study.

No evidence for involvement of the leptin gene in anorexia nervosa, bulimia nervosa, underweight or early onset extreme obesity: identification of two novel mutations in the coding sequence and a novel polymorphism in the leptin gene linked upstream region

Mutations in the leptin gene can result in profound obesity in both rodents and humans. In humans, serum leptin levels correlate with body mass index (BMI: kg m(-2)). However, in patients with anorexia nervosa (AN) leptin levels are lower than in BMI-matched healthy controls. We had previously argued that genes involved in weight regulation should be considered as candidate genes for AN. To investigate this hypothesis we screened the coding region of the leptin gene and part of the leptin gene linked upstream region (LEGLUR) in 49 patients with AN and 315 children and adolescents with extreme obesity. Two novel mutations in the coding region (Ser-91-Ser; Glu-126-Gln), each found in a single proband, and a novel polymorphism in the LEGLUR (position -1387 G/A; frequency of both alleles approximately 0.50) were identified. Tests for association of LEGLUR polymorphism alleles were negative by comparing allele frequencies between 115 AN patients, 71 bulimia nervosa patients, 315 extremely obese children and adolescents, 141 healthy underweights and 50 controls that were not selected for body weight. Tests for transmission disequilibrium were also negative. Hence, an influence of variations in the leptin gene on eating disorders or extreme early onset obesity could not be detected.

[Inpatient behavioral medicine in chronic skin diseases]

Behavioral medicine is a newer approach in the management of various diseases. In the last years, special programs have been developed for atopic dermatitis, psoriasis vulgaris and other chronic skin diseases. An increase in the patient's self-control could be achieved by optimizing the patient's skills in dealing with their skin disease. The article summarizes the principles and procedures of in-patient behavioral medicine, especially the strategies employed by dermatological training groups and psychotherapeutical groups to help the patient deal with their skin disorder.

Expression of CD44 isoforms in neuroblastoma cells is regulated by PI 3-kinase and protein kinase C

With respect to a potential role for CD44 in neuronal tumors, we investigated the regulation of variant CD44 exon containing isoforms (CD44V) in the human neuroblastoma cell line SK-N-SH in response to treatment with differentiation-inducing and mitogenic factors. While the standard form of CD44 was expressed at high levels in both treated and untreated cells, variant isoforms were strongly upregulated in response to treatment with 12-O-tetradecanoyl phorbol-13-acetate (TPA), insulin-like growth factor-1 (IGF-1) and platelet-derived growth factor (PDGF) as shown by RT-PCR and immunofluorescence. One of the CD44 isoforms contains sequences encoded by variant exon v6 (CD44V6), which was originally described as a metastasis-associated antigen. Using specific inhibitors, we explored the signal transduction pathways involved in the expression of variant CD44. GF-109203X, a specific inhibitor of protein kinase C effectively blocked TPA- and IGF-1-upregulated expression of CD44v6. Wortmannin, a specific inhibitor of phosphoinositide 3-kinase (PI 3-kinase) partly reduced IGF-1 and PDGF induced CD44v6 expression. The induction of CD44V by TPA, IGF-1 or PDGF was correlated with an increased cellular binding to hyaluronic acid, a major counterreceptor for CD44. The increased binding caused by TPA or IGF-1 could specifically be blocked by the above inhibitors. Thus, PKC and PI 3-kinase are likely to transduce growth factor induced signals that upregulate specific CD44 splice variants.

[Therapeutic effects of the Feldenkrais method "awareness through movement" in patients with eating disorders]

Based on the movement-pedagogical concept of Feldenkrais and the findings-of disturbed body perception by eating disordered patients this research aimed at studying the therapeutical effects of the Feldenkrais Method "Awareness through Movement" with eating disorder patients, 15 eating disordered patients treated at the Roseneck hospital for behavioural medicine rated-by means of a questionnaire consisting of scales of the Body Cathexis Scale (BCS), the Body Parts Satisfaction Scale (BPSS), the questionnaire for body perception (Fragebogen zum Körpererleben; FKE), the Emotion inventory (Emotionalitätsinventar; EMI-B), the Anorexia-Nervosa-Inventory for Self-rating (ANIS) and the Eating Disorder Inventory-2 (EDI)-various aspects of their eating disorder before and after participating in a nine hour course of the Feldenkrais Method. The data of these patients were compared to those of the members of a control group, also consisting of 15 eating disordered patients who did not participate in a Feldenkrais course. The participants of the Feldenkrais-course showed increasing contentment with regard to problematic zones of their body and their own health as well as concerning acceptance and familiarity with their own body. Other results were a more spontaneous, open and self-confident behaviour, the decrease of feelings of helplessness and decrease of the wish to return to the security of the early childhood, which indicates the development of felt sense of self, self-confidence and a general process of maturation of the whole personality. The outcome points to the therapeutical effectiveness of the Feldenkrais Method with eating-disorder patients within a multimodal treatment program.

Mental illness in homeless women: an epidemiological study in Munich, Germany

In an epidemiological survey of the prevalence of mental illness in homeless individuals in Munich, Germany, a probability sample of 32 homeless women were interviewed using a standardized diagnostic instrument (Diagnostic Interview Schedule for DSM-III diagnoses). Results point to very high prevalence rates of mental disorders among homeless women. The most frequent diagnostic groups were alcohol and drug abuse (lifetime prevalence rate 90.6%), affective disorders (50.0%), anxiety disorders (43.8%) and schizophrenia (21.9%). Prevalence rates are compared with a female household sample (Epidemiological Catchment Area Study in New Haven, Connecticut). All disorders tended to be more frequent in homeless women as compared with the household sample. Our results show the urgent need to provide medical and other assistance to homeless women. There is a need for adequate psychiatric care, supply with food and housing and the development of concepts for personal and vocational rehabilitation considering the specific needs of women.

[Psychiatric homelessness research. From "psychopathology of the vagrant" to "homeless mentally ill"]

German psychiatrists around 1900 reported that dementia praecox and other mental disorders were common among homeless individuals. On the basis of the concept of psychopathy, homelessness in the 1920s was viewed as an "inferiority of character". The combination of psychiatric diagnosis and social prejudice was used as a justification for the "elimination of abnormal personalities" during the Third Reich. Growing numbers of homeless individuals in the last two decades stimulated a new interest in psychiatric research on the homeless. Larger epidemiological studies show high prevalence rates for severe mental disorders (schizophrenia, affective disorders, substance abuse). This points to the urgent need to develop sophisticated and sensible concepts to deal effectively with the complex problems associated with homelessness.

Mental and somatic health and need for care in octo- and nonagenerians. An epidemiological community study

Mental and somatic illness, utilization of psychosocial facilities and need for care in persons aged 85 years and older were examined. Data were based on a representative community sample (n = 402) of Munich city. A total of 358 (89%) subjects of the sample were interviewed, 42 subjects (10.5%) refused, and 2 persons could not be traced. Dementia and depression had the highest prevalence of mental disorders according to the AGECAT (automated geriatric examination for computer assisted taxonomy) computer program of the Geriatric Mental State Interview. In all, 23.6% of the interviewees fulfilled criteria for depression, 25.4% for dementia. We analysed somatic illness according to mental status, the utilization of psychosocial facilities and need for care with regard to mental and somatic illness.

The Symptom Check List SCL-90-R and its ability to discriminate between dysthymia, anxiety disorders, and anorexia nervosa

The factorial and discriminative validity of the Hopkins Symptom Check List SCL-90-R were examined in the light of criticism that clinical self-rating scales primarily express a general distress factor. In a population of 899 psychosomatic patients, high intercorrelations were found between the individual dimensions of the SCL-90-R. A subsequent Principal Components Analysis obtained 9 factors which were markedly less interdependent than those in the original version. The ability of the questionnaire to distinguish between patients with dysthymia, anxiety disorders and anorexia nervosa was examined. The average hit rate in the discriminant analysis was 67% using the original version and 74% with the proposed new factorial structure of the SCL-90-R, confirming the discriminative validity of the inventory. The present results as well as earlier studies suggest that the factor 'anxiety' should be included in the factor 'phobic anxiety', the factors 'paranoid ideation' and 'psychoticism' should be reformulated, and a new factor 'sleep disturbances' should be added to the original version of the SCL-90-R.

Hypnotizability in bulimic patients and controls. A pilot study

Various studies have indicated that bulimics are more easily hypnotized and dissociate more readily than control groups and patients with other eating disorders. A comparison is reported of 15 inpatients with bulimia nervosa (DSM III-R) with 15 subjects in a control group comparable in age and education. The instrument used was the Harvard Group Scale of Hypnotic Susceptibility/Form A (HSGHS:A), which includes 12 standardized test suggestions. The results show that bulimics have higher scores in hypnotizability than the control group. A method study (comparison of self-evaluation with a video recording) shows that this is a result of the behaviour itself and not of the answering pattern used by the subjects in the questionnaire. It is possible that differing expectations regarding the experiment may have influenced the results. Considerations concerning the increased ability of bulimics to dissociate as a causal factor versus an accompanying phenomenon of the disorder are discussed.

Average total energy expenditure in anorexia nervosa, bulimia nervosa, and healthy young women

The double-labeled water method was used to measure average daily total energy expenditure (EE) in 11 healthy normal-weight women classified as unrestrained eaters, in 8 patients with anorexia nervosa, and in 8 patients with bulimia nervosa. The body mass index was 20.0 +/- 1.3 kg/m2 in the control group, 15.2 +/- 5.6 kg/m2 in the anorectic groups, and 19.7 +/- 1.9 kg/m2 in the bulimic group. EE was measured over a 2-week period during which weight remained constant in all groups and was 2357 +/- 504 kcal/day for the controls, 2510 +/- 920 kcal/day for the bulimics, and 2899 +/- 656 kcal/day for the anorectics. Differences were not significant among groups. Physical activity was recorded in diaries by all subjects. Anorectic patients showed significantly more activity than all other groups. The data suggest that EE is high in anorectic patients as a consequence of physical activity.

[New aspects of complex chronic tinnitus. II: The lost silence: effects and psychotherapeutic possibilities in complex chronic tinnitus]

"Complex tinnitus" is a diagnostic term denoting a disturbance pattern where the patient hears highly annoying and painful noises or sounds that do not originate from a recognisable external source and can be described only by the patient himself. It seems that the suffering mainly depends upon the extent to which the tinnitus is experienced as a phenomenon that is beyond control. Part I reports on an examination of the treatment success achieved with 28 consecutive patients who had been treated according to an integrative multimodal behavioural medicine concept. This resulted--despite continual loudness--in a decrease in the degree of unpleasantness of the tinnitus, by 17% (p less than 0.01) with corresponding normalisation of decisive symptom factors in Hopkins-Symptom-Check-List (SCL-90-R) and Freiburg Personality-Inventary (FPI-R). On the whole, 19 out of the total of 28 patients showed essential to marked improvement of the disturbance pattern. Part II presents a multidimensional tinnitus model and the essential psychotherapeutic focal points of a multimodal psychotherapy concept in complex chronic tinnitus, as well as the parallel phenomena in the chronic pain syndrome.

[New aspects of complex chronic tinnitus. I: Assessment of a multi-modality behavioral medicine treatment concept]

"Complex tinnitus" is a diagnostic term denoting a disturbance pattern where the patient hears highly annoying and painful noises or sounds that do not originate from a recognisable external source and can be described only by the patient himself. It seems that the suffering mainly depends upon the extent to which the tinnitus is experienced as a phenomenon that is beyond control. Part I reports on an examination of the treatment success achieved with 28 consecutive patients who had been treated according to an integrative multimodal behavioural medicine concept. This resulted--despite continual loudness--in a decrease in the degree of unpleasantness of the tinnitus, by 17% (p less than 0.01) with corresponding normalisation of decisive symptom factors in Hopkins Symptom-Check-List (SCL-90-R) and Freiburg Personality-Inventary (FPI-R). On the whole, 19 out of the total of 28 patients showed essential to marked improvement of the disturbance pattern. Part II presents a multidimensional tinnitus model and the essential psychotherapeutic focal points of a multimodal psychotherapy concept in complex chronic tinnitus, as well as the parallel phenomena in the chronic pain syndrome.

[Hyperamylasemia in anorexia nervosa and bulimia nervosa. Indication of a pancreatic disease?]

Serum concentrations of amylase, lipase, human pancreatic lipase and phospholipase A were measured in 34 patients (average age 28.5 [18-64] years) with anorexia nervosa (9 patients) and bulimia (25 patients). Hyperamylasaemia was demonstrated in 13 of the 34 patients (38%). But in only two of them was there also an elevated concentration of lipase and human pancreatic lipase. Phospholipase A was normal in all. Only one patient with isolated hyperamylasaemia had cholecystolithiasis, which was asymptomatic. In none of the patients with raised enzyme values was there otherwise any evidence of pancreatic or biliary tract disease, of alcohol or drug abuse, hyperlipoproteinaemia or abnormal renal function. In the great majority of patients with anorexia nervosa or bulimia who had hyperamylasaemia, this could not be ascribed to pancreatic disease. Even in the two patients who also had an increase in lipase and pancreatic isolipase, there was no clinical and ultrasound evidence of pancreatic disease.