Psychoanalytically-oriented inpatient psychotherapy of somatoform disorders

Somatoform disorders have been neglected in psychoanalytic publications. Unlike the descriptive approach of DSM-IV and ICD-10, sophisticated psychoanalytical models have been proposed for many years explaining the development of physical symptoms without definable medical cause. Based on a review of the psychoanalytic models of somatization and conversion, this article explores difficulties in the medical and psychotherapeutic treatments of somatoform disorders. The unique tradition of psychosomatic inpatient treatment in Germany is illustrated by the psychoanalytic treatment setting at the University of Mainz. A case report of a somatoform patient shows how childhood trauma is activated and integrated in the course of inpatient treatment. In a multimodal approach, psychoanalytic individual and group therapy may interact beneficially with body-oriented, art therapy, and other treatment elements to gain therapeutic access to chronic somatoform patients, activate and work through trauma and conflict. Regardless of the specific setting, analytic treatments need to do justice to the specific deficits (e.g., symbolization of affect, mentalization) and defences of somatoform patients.

[Mental co-morbidity, health care utilization and illness behaviour in overweight and obese subjects--results from a representative German community survey]

Obesity is associated with an increased somatic morbidity and mortality. This paper focuses on the controversial issue of mental co-morbidity in various populations of overweight and obese persons and the relationship to the utilization of medical care and health behaviour. Therefore, this paper focuses on health care utilization and health behaviour in overweight/obese with mental co-morbidity. In a representative German community sample with n=1281 we administered valid self-rating scales on depression and anxiety. Using established cut-off scores we identified 61 subjects with both overweight/obesity and at least one mental disorder. Compared to the overweight/obese without mental co-morbidity, those subjects showed a more extensive health care utilization of psychiatric and psychotherapeutic services and reported more smoking. Beside the number of somatic problems, age, BMI, female gender and residence in Eastern-Germany a lower subjective health in overweight/obese subjects could be predicted by the occurrence of at least one mental disorder. Our results implicate the need to focus on psychotherapy in weight reduction programmes for participants with mental co-morbidity.

Sexual desire and sexual activity of men and women across their lifespans: results from a representative German community survey

OBJECTIVES

To present data on sexual desire and sexual activity from a representative survey of men and women covering the total age range of the adult German population, as previous studies have usually been based on samples selected for gender (either men or women) and age (ageing populations).

SUBJECTS AND METHODS

A representative sample of 2341 men and women aged 18-93 years were surveyed to determine frequency and intensity of sexual desire and sexual activity, and their social, individual and interpersonal characteristics.

RESULTS

Sexual desire declined with advancing age; overall, men reported more frequent and stronger sexual desire than women. However, there were important interactions between gender and age indicating an earlier decline among women. For both men and women, sexual activity in older participants was mostly an issue of the presence of a partnership. There were additional social and personality determinants of a lack of sexual desire and sexual inactivity: in men, sexual desire was compromised by social factors (unemployment, low income), while in women these were previous sexual traumas (childhood sexual abuse, rape).

CONCLUSION

Community surveys elucidate the trajectory of sexual desire and activity across the lifespan. Further research on the determinants and risk factors for a lack of sexual desire and sexual inactivity is recommendable taking gender and age composition of the samples into account.

[Attitudes of medical students towards psychotherapeutic treatment and training]

OBJECTIVES

Against the background of insufficient medical care for patients with psychiatric and psychosomatic disorders it is important to ascertain the interests and attitudes of medical students towards mental disorders, psychotherapeutic treatment and training.

METHODS

Medical students (N = 366) in their clinical training were given half-standardized questionnaires about their attitudes towards psychotherapeutic treatments, their career plans, psychosocial distress and sociodemographic characteristics.

RESULTS

There was an overall high interest in psychological distress of patients and in psychotherapeutic treatment methods. Contrary to these findings, however, only few medical students were willing to specialize in psychosomatic medicine, psychiatry or psychotherapy. Psychosomatic and psychotherapeutic career choices were more frequent in women as well as in students who had experienced psychological distress themselves, and who had undergone psychotherapy, and who were less oriented toward economic success and careers.

CONCLUSIONS

Medical students regarded psychological characteristics as generally interesting and important for medical care, but rarely considered specializing in these medical fields after graduation. Potential remedies (e.g., improved teaching of psychosocial competences and psychotherapeutic knowledge, career counselling) are discussed.

Depersonalization, mindfulness, and childhood trauma

Depersonalization (DP), i.e., feelings of being detached from one's own mental processes or body, can be considered as a form of mental escape from the full experience of reality. This mental escape is thought to be etiologically linked with maltreatment during childhood. The detached state of consciousness in DP contrasts with certain aspects of mindfulness, a state of consciousness characterized by being in touch with the present moment. Against this background, the present article investigates potential connections between DP severity, mindfulness, and childhood trauma in a mixed sample of nonpatients and chronic nonmalignant pain patients. We found a strong inverse correlation between DP severity and mindfulness in both samples, which persisted after partialing out general psychological distress. In the nonpatient sample, we additionally found significant correlations between emotional maltreatment on the one hand and DP severity (positive) and mindfulness (negative) on the other. We conclude that the results first argue for an antithetical relationship between DP and certain aspects of mindfulness and thus encourage future studies on mindfulness-based interventions for DP and second throw light on potential developmental factors contributing to mindfulness.

Long-term weight loss maintenance after inpatient psychotherapy of severely obese patients based on a randomized study: predictors and maintaining factors of health behavior

OBJECTIVE

The objective of this study was to identify predictors of long-term weight loss after inpatient psychodynamic or behavioral psychotherapy of severely obese patients.

METHODS

In a longitudinal study, obese patients [body mass index (BMI)>or=35 kg/m(2)] were randomly assigned to behavioral or psychodynamic inpatient treatment. The average treatment duration was 7 weeks. Two hundred sixty-seven obese patients, mostly female (85%), with psychiatric and somatic comorbidity (age, 20-64 years; BMI=35-74 kg/m(2)) were examined with standardized self-report scales at intake, discharge, 1-year follow-up, and 3-year follow-up.

RESULTS

Overall, 3 years after inpatient psychotherapy, irrespective of treatment setting, we found an average weight loss of about 1 BMI unit (2% or 3 kg). Effect size for weight loss was small (ES=0.26); changes in body image were stronger (ES=0.56). About 32% of patients achieved a long-term weight loss of >5%. In multiple regressions, weight loss was predicted by the attribution of overweight to eating habits, low dominance (Inventory of Interpersonal Problems), low life satisfaction, higher initial weight loss, and higher self-efficacy. Weight loss maintenance was predicted by cognitive control and current physical activity on follow-up.

CONCLUSION

In the long run, one third of patients could maintain or improve weight loss by inpatient psychotherapy. Lasting beneficial changes in body image and distress could also be found. The predictors of weight loss and weight loss maintenance identified in this study may be helpful for future modifications of psychotherapeutic intervention strategies.

[Utilization of self-help groups and psychotherapy after psychosomatic-psychotherapeutic in-patient treatment]

Until now little is known about the role of participation in self-help groups alone or combined with psychotherapy in post-in-patient care. In the present study 2933 patients were questioned about their experience of self-help groups and psychotherapy after discharge from a clinic for psychosomatic medicine and psychotherapy. Nearly 8 % of them utilized self-help groups (mostly combined with out-patient psychotherapy), and altogether 68 % out-patient psychotherapy following in-patient treatment. Patients without out-patient treatment were psychologically less burdened and had better resources than participants of self-help groups or psychotherapy. Self-help group members differed from patients in out-patient psychotherapy by expressing a more positive opinion of groupwork and higher openness to new experiences. Additionly, they had discussed the topic of self-help groups more frequently with their therapists. This may be a starting-point for promoting more self-help activities of patients in the future.

A German version of the Shedler-Westen Assessment Procedure (SWAP-200) for the dimensional assessment of personality disorders

THEORETICAL BACKGROUND

The traditional diagnosis of personality disorders has been criticized for lack of empirical support, reliance on categorical classifications and low validity.

OBJECTIVE

A German version of the Shedler-Westen Assessment Procedure (SWAP-200) is presented. This Q-Sort procedure is well-established in the USA and facilitates the dimensional diagnosis of personality pathology in accordance with DSM-IV. In addition, a taxonomy of personality has been derived using factor analyses.

METHODS

The SWAP-200 was applied to 18 patients on the basis of semi-structured interviews. Interviewer ratings were correlated with the SWAP-200 completed by an independent observer and the patients' therapists.

RESULTS

Good inter-rater reliability (between r=.69 and r=.76) was found. While average convergent validity coefficients between interviewer, observer and therapist were satisfactory (between r=.54 and r=.68), outliers were observed. RESULTS suggest that the factor analytically derived taxonomy may be more valid.

Mid-term effectiveness of behavioral and psychodynamic inpatient treatments of severe obesity based on a randomized study

BACKGROUND

The objective of this study was to compare the effectiveness of psychodynamic and behavioral inpatient treatments of severely obese patients regarding weight and distress.

METHODS

In a longitudinal study obese patients (body mass index, BMI >or=35) were randomly assigned to behavioral or to psychodynamic inpatient treatment. Mostly female (n = 267; 85%) obese patients with psychiatric and somatic comorbidity (age 20-64 years, BMI 35-74) were examined with standardized self-report scales on distress (SCL-90R), interpersonal problems (Inventory of Interpersonal Problems), eating behavior (Fragebogen zum Essverhalten) and body image (Fragebogen zum Korperbild).

RESULTS

During 49 days (mean) of inpatient treatment, patients lost an average of 5.6 kg (4.4%) in the behavioral (n = 130) and 5.7 kg (4.4%) in the psychodynamic setting (n = 137). In both settings, eating behavior, well-being and body image also improved significantly. One year after discharge, return rate was 73%. Forty percent had further reduced their weight (by more than 5% compared to intake), 36% had regained weight, but were still below intake level, and another 24% had increased weight above intake.

CONCLUSION

Behavioral and psychodynamic treatments were equally effective reducing weight and distress over 1 year.

Fatigue assessment questionnaire: standardization of a cancer-specific instrument based on the general population

OBJECTIVES

Fatigue has become a major issue of concern in the care of cancer patients, as it has been shown to compromise their quality of life in a significant and lasting way. However, there is a lack of economic and specific measures. The Fatigue Assessment Questionnaire (FAQ) has been developed based on thorough interviews and tested on a large mixed sample of cancer patients. The purposes of this paper are to test the psychometric properties of the FAQ and to provide norms for the German population.

METHODS

The FAQ was administered to a representative sample of the German population (1,340 female and 1,101 male participants) along with standardized scales of depression, mood and life satisfaction.

RESULTS

We could confirm that fatigue is multidimensional and can be measured by the scales of physical, affective and cognitive fatigue with good reliability and validity. The dependency of fatigue on sex and age makes it useful to have standard fatigue scores for oncological research as provided in this paper.

CONCLUSION

The FAQ is a promising, differentiated, yet economic instrument for further use in oncological research.

Temperament and personality: the German version of the Adult Temperament Questionnaire (ATQ)

The psychobiological orientation inherent in temperament concepts permits a close tie between temperament and the rapidly proliferating research areas of neurosciences and behavioural genetics. Based on developmental and psychobiological studies, the Adult Temperament Questionnaire (ATQ) by Rothbart measures self-regulatory processes in addition to constitutionally based individual reactivity. The purpose of this paper is to validate a German version of the short form of the ATQ with 77 items. 213 psychosomatic inpatients and outpatients and 116 control subjects took part in this study. The study included standardized measures of personality and symptoms. The German version reliably measures the four dimensions negative affect, extraversion, orienting sensitivity and effortful control; subscales were moderately correlated. We found a consistent pattern of correlation to personality (NEO-FFI) and interpersonal problems (IIP), negative affect strongly correlated with neuroticism; effortful control correlated with conscientiousness, orienting sensitivity with openness, and extraversion correlated with the corresponding scale of the NEO-FFI. According to our hypothesis, negative affect was positively correlated with higher distress and physical complaints, while effortful control was negatively correlated with them. When negative affect and effortful control were combined, effortful control had a moderating effect on distress. Clinical and non-clinical samples differed significantly on all dimensions; the ATQ appears to be suitable for differentiating subgroups of patients according to self-regulation.

Einstellungen zur postmortalen Organspende - Ergebnisse einer Repräsentativerhebung der deutschen Bevölkerung

The increasing deficit of organs causes a drastic decline in the quality of life and survival of numerous patients in need of a transplantation. The purpose of this representative community study was to survey attitudes toward transplantation in the German population and to identify underlying determinants. Unlike previous surveys, fears and concerns were elicited based on a concrete case vignette. Among the 1,002 participants, 90 % were in favour of organ donation in general; 21 % reported having signed an organ donor card. Consent to organ donation was associated with younger age and higher social class; the same was true for the possession of an organ donor card. In the virtual decision situation, the majority (77 %) voted in favour of an organ donation based on saving lives, consolation for bereaved and the absence of disadvantages for the donor. Common (up to 50 %), however, were also fears and concerns regarding determination of the time of death, displacement of medical concern from the donor to the recipient of the organ, utilisation of organs for other purposes, or explantation before death. The knowledge of the determinants identified, of existing fears and concerns are helpful not only for informing the public, but also for the dialogue with the next of kin of potential donors. Here, it may be helpful not only to address arguments pro organ donation, but also to address potential fears and concerns.

Aufmerksamkeit und exekutive Funktionen bei Patienten mit Adipositas per magna

In this paper, attention and temperament are compared between 41 severely obese patients with psychiatric comorbidity and 45 control persons. Networks of attention were assessed by the Attention Network Test: alerting (ability to achieve and maintain an alert state), orienting (ability to orient to a stimulus), and executive attention (ability to resolve conflict). According to hypotheses, obese patients show reduced executive attention, more effortful control, and higher negative affectivity than controls. The concept of attention networks is related to cognitive mechanisms of self-regulation, opening new perspectives for understanding psychiatric disorders.

Kognitive Auffälligkeiten, Depressivität und Leistungsfähigkeit bei älteren Arbeitnehmern in stationärer psychosomatischer Behandlung

Due to aging of the population and a possible rise in retirement age, the cognitive capacity of older people is gaining great importance. As evidenced by the increase in early retirement due to psychosomatic disease, many employees are not capable of working at a higher age. Decreasing cognitive abilities have usually been studied in subjects over 65 years based on the heterogeneous construct of mild cognitive impairment (MCI). This study investigates the prevalence of cognitive impairments in the age group from 50 to 59 years and their reflections in subjective vocational achievement and social medical evaluation. Having been assigned to inpatient rehabilitation due to decreasing work performance, these patients could be considered a risk group for developing MCI. A battery of standardized cognitive tests was conducted with patients at a psychosomatic hospital (Termine Test, CVLT, Block Design, TAP, and Tower of Hanoi). The MCI was defined by performance below the average age norm in at least two of five functional areas. Depression was assessed by the Beck Depression Inventory. Cognitive impairment was observed in 24% of participants. These patients also described vocational difficulties. Cognitive impairments of older employees could possibly be compensated for by specific training programs in order to maintain or rebuild their work capacity.