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- Sekundärkrankheit (2) (entfernen)
In addition to the well-recognised effects of both, genes and adult environment, it is now broadly accepted that adverse conditions during pregnancy contribute to the development of mental and somatic disorders in the offspring, such as cardiovascular disorders, endocrinological disorders, metabolic disorders, schizophrenia, anxious and depressive behaviour and attention deficit hyperactivity disorder (ADHD). Early life events may have long lasting impact on tissue structure and function and these effects appear to underlie the developmental origins of vulnerability to chronic diseases. The assumption that prenatal adversity, such as maternal emotional states during pregnancy, may have adverse effects on the developing infant is not new. Accordant references can be found in an ancient Indian text (ca. 1050 before Christ), in biblical texts and in documents originating during the Middle Ages. Even Hippocrates stated possible effects of maternal emotional states on the developing fetus. Since the mid-1950s, research examining the effects of maternal psychosocial stress during pregnancy appeared in the literature. Extensive research in this field has been conducted since the early 1990s. Thus, the relationship between early life events and long-term health outcomes was already postulated over 20 years ago. David Barker and colleagues demonstrated that children of lower birth weight - which represents a crude marker of an adverse intrauterine environment - were at increased risk of high blood pressure, cardiovascular disorders, and type-2 diabetes later in life. These provocative findings led to a large amount of subsequent research, initially focussing on the role of undernutrition in determining fetal outcomes. The phenomenon of prenatal influences that determine in part the risk of suffering from chronic disease later in life has been named the "fetal origins of health and disease" paradigm. The concept of "prenatal programming" has now been extended to many other domains, such as the effects of prenatal maternal stress, prenatal tobacco exposure, alcohol intake, medication, toxins, as well as maternal infection and diseases. During the process of prenatal programming, environmental agents are transmitted across the placenta and act on specific fetal tissues during sensitive periods of development. Thus, developmental trajectories are changed and the organisation and function of tissue structure and organ system is altered. The biological purpose of those "early life programming" may consist in evolutionary advantages. The offspring adapts its development to the expected extrauterine environment which is forecast by the clues available during fetal life. If the fetus receives signals of a challenging environment, e.g. due to maternal stress hormones or maternal undernutrition, its survival may be promoted due to developmental adaptation processes. However, if the expected environment does not match with the real environment, maladapation and later disease risk may result. For example, a possible indicator of a "response ready" trait, such as hyperactivity/inattention may have been advantageous in an adverse ancient environment. However, it is of disadvantage when the postnatal environment demands oppositional skills, such as attention and concentration " e.g. in the classroom, at school, to achieve academic success. Borderline personality disorder (BPD) is a prevalent psychiatric disorder, characterized by impulsivity, affective instability, dysfunctional interpersonal relationships and identity disturbance. Although many studies report different risk factors, the exact etiologic mechanisms are not yet understood. In addition to the well-recognised effects of genetic components and adverse childhood experiences, BPD may potentially be co-determined by further environmental influences, acting very early in life: during pre- and perinatal period. There are several hints that may suggest possible prenatal programming processes in BPD. For example, patients with BPD are characterized by elevated stress sensitivity and reactivity and dysfunctions of the neuroendocrine stress system, such as the hypothalamic pituitary adrenal (HPA) axis. Furthermore, patients with BPD show a broad range of somatic comorbidities " especially those disorders for which prenatal programming processes have been described. During infancy and childhood, BPD patients already show behavioural and emotional abnormalities as well as pronounced temperamental traits, such as impulsivity, emotional dysregulation and inattention that may potentially be co-determined by prenatal programming processes. Such temperamental traits - similar to those, seen in patients with ADHD - have been described to be associated with low birthweight which indicates a suboptimal intrauterine environment. Moreover, the functional and structural alterations in the central nervous system (CNS) in patients with BPD might also be mediated in part by prenatal agents, such as prenatal tobacco exposure. Prenatal adversity may thus constitute a further, additional component in the multifactorial genesis of BPD. The association between BPD and prenatal risk factors has not yet been studied in such detail. We are not aware of any further study that assessed pre- and perinatal risk factors, such as maternal psychoscocial stress, smoking, alcohol intake, obstetric complications and lack of breastfeeding in patients with BPD.
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.