During pregnancy every eighth woman is treated with glucocorticoids. Glucocorticoids inhibit cell division but are assumed to accelerate the differentiation of cells. In this review animal models for the development of the human fetal and neonatal hypothalamic-pituitary-adrenal (HPA) axis are investigated. It is possible to show that during pregnancy in humans, as in most of the here-investigated animal models, a stress hyporesponsive period (SHRP) is present. In this period, the fetus is facing reduced glucocorticoid concentrations, by low or absent fetal glucocorticoid synthesis and by reduced exposure to maternal glucocorticoids. During that phase, sensitive maturational processes in the brain are assumed, which could be inhibited by high glucocorticoid concentrations. In the SHRP, species-specific maximal brain growth spurt and neurogenesis of the somatosensory cortex take place. The latter is critical for the development of social and communication skills and the secure attachment of mother and child. Glucocorticoid treatment during pregnancy needs to be further investigated especially during this vulnerable SHRP. The hypothalamus and the pituitary stimulate the adrenal glucocorticoid production. On the other hand, glucocorticoids can inhibit the synthesis of corticotropin-releasing hormone (CRH) in the hypothalamus and of adrenocorticotropic hormone (ACTH) in the pituitary. Alterations in this negative feedback are assumed among others in the development of fibromyalgia, diabetes and factors of the metabolic syndrome. In this work it is shown that the fetal cortisol surge at the end of gestation is at least partially due to reduced glucocorticoid negative feedback. It is also assumed that androgens are involved in the control of fetal glucocorticoid synthesis. Glucocorticoids seem to prevent masculinization of the female fetus by androgens during the sexual gonadal development. In this work a negative interaction of glucocorticoids and androgens is detectable.
Die vorliegende Arbeit verbindet die Konzepte Komorbidität und naturalistische Forschung, indem hier Mehrfachdiagnosen in einer großen längsschnittlich angelegten Studie zur Qualitätssicherung in der ambulanten Psychotherapie betrachtet wurden. Untersucht wurde die Frage, ob und inwieweit Mehrfachdiagnosen im Vergleich zu einfachen Diagnosen Einfluss auf den Status zu Beginn einer Therapie, den Therapieverlauf, ihre Dauer und das Ergebnis ausüben und ob daraus Ableitungen für eine differenzielle Anpassung therapeutischer Interventionen getroffen werden können. Die in dieser Arbeit analysierten Daten stammen aus dem Modellprojekt "Qualitätsmonitoring in der ambulanten Psychotherapie" der Techniker Krankenkasse und umfassen Eingangsinformationen von N=1154 verhaltenstherapeutisch behandelten ambulanten Psychotherapiepatienten. Zur Überprüfung der Fragestellungen kamen regressions- und korrelationsanalytische Verfahren, Latente Wachstumsmodelle sowie Verfahren zur Klassifikation von Personen in latente Subgruppen zur Anwendung. Es resultierten höhere Komorbiditätsraten unter strukturierter Diagnostik. Bei komorbider Persönlichkeitsstörung oder einer Kombination aus Angst- und Affektiven Störungen wurde in vergleichbarem Ausmaß wie bei Vorliegen nur einer Diagnose profitiert, allerdings wiesen diese Patienten aufgrund einer höheren Ausgangsbelastung ein schlechteres absolutes Therapieergebnis auf. Die Variable Komorbidität erwies sich als bedeutsam für die Prädiktion der Sitzungsanzahl, indem komorbide Patienten und insbesondere solche mit Persönlichkeitsstörungen längere Therapiedauern aufwiesen. Die sich auf mehreren Ebenen manifestierenden Besonderheiten komorbider im Vergleich zu monomorbiden Patienten weisen darauf hin, dass das Konzept Komorbidität nicht ausschließlich als Artefakt bestehender Diagnosesysteme gesehen werden kann. Der längere Verbleib komorbider Patienten in der Psychotherapie lässt auf ein differenzielles Vorgehen der Therapeuten schließen. Dieses könnte durch individualisierte Rückmeldungen noch unterstützt werden, im Rahmen derer von vornherein Abschätzungen für spezifische Subgruppen von Patienten vorgenommen werden und in welchen Komorbidität als ein Indikator zu besseren Ressourcensteuerung in der Psychotherapie genutzt werden könnte.
Background: Psychotherapy is successful for the majority of patients , but not for every patient. Hence, further knowledge is needed on how treatments should be adapted for those who do not profit or deteriorate. In the last years prediction tools as well as feedback interventions were part of a trend to more personalized approaches in psychotherapy. Research on psychometric prediction and feedback into ongoing treatment has the potential to enhance treatment outcomes, especially for patients with an increased risk of treatment failure or drop-out.rnMethods/design: The research project investigates in a randomized controlled trial the effectiveness as well as moderating and mediating factors of psychometric feedback to therapists. In the intended study a total of 423 patients, who applied for a cognitive-behavioral therapy at the psychotherapy clinic of the University Trier and suffer from a depressive and/or an anxietyrndisorder (SCID interviews), will be included. The patients will be randomly assigned either to one therapist as well as to one of two intervention groups (CG, IG2). An additional intervention group (IG1) will be generated from an existing archival data set via propensity score matching. Patients of the control group (CG; n = 85) will be monitored concerning psychological impairment but therapists will not be provided with any feedback about the patients assessments. In both intervention groups (IG1: n = 169; IG2: n = 169) the therapists are provided with feedback about the patients self-evaluation in a computerized feedback portal. Therapists of the IG2 will additionally be provided with clinical support tools, which will be developed in thisrnproject, on the basis of existing systems. Therapists will also be provided with a personalized treatment recommendation based on similar patients (Nearest Neighbors) at the beginning of treatment. Besides the general effectiveness of feedback and the clinical support tools for negatively developing patients, further mediating and moderating variables on this feedback effectrnshould be examined: treatment length, frequency of feedback use, therapist effects, therapist- experience, attitude towards feedback as well as congruence of therapist-andpatient- evaluation concerning the progress. Additional procedures will be implemented to assess treatment adherence as well as the reliability of diagnosis and to include it into the analyses.rnDiscussion: The current trial tests a comprehensive feedback system which combines precision mental health predictions with routine outcome monitoring and feedback tools in routine outpatient psychotherapy. It also adds to previous feedback research a stricter design by investigating another repeated measurement CG as well as a stricter control of treatment integrity. It also includes a structured clinical interview (SCID) and controls for comorbidity (within depression and anxiety). This study also investigates moderators (attitudes towards, use of the feedback system, diagnoses) and mediators (therapists" awareness of negative change and treatment length) in one study.