Vocational training integrated into inpatient psychosomatic rehabilitation--short and long-term results from a controlled study

PURPOSE

The aim of this study was to determine the impact of a vocational training programme on short- and long-term results after psychosomatic rehabilitation.

METHOD

1,590 inpatients were screened for vocational integration. A high-risk group of 266 patients was randomly assigned to the vocational training programme plus psychosomatic treatment; treatment- as- usual served as a control condition. An occupational training was conducted at local companies, closely integrated into psychosomatic treatment. Vocational attitudes and adjustment were studied at intake, discharge, three, 12 and 24 month follow-ups.

RESULTS

More than half of the study participants were unemployment and/or long-term work-disabled harbouring strong negative attitudes toward return to work. Forty-six percent of the intervention group declined from participation, but complied with follow-up investigation. At discharge, participants of the vocational training programme had become more optimistic regarding resuming work. One year following discharge, participants of the training programme reported less absence from work. After 24 months, vocational adjustment had improved considerably among programme participants, and declined among controls and refusers.

CONCLUSION

An intensive vocational training programme is effective in promoting positive attitudes to work, reducing work disability and promoting return-to-work. However, a randomized design may be not optimal; evaluation necessitates long-term follow-up.

[Utilization and significance of self-help groups in treatment careers of psychosomatic inpatients]

OBJECTIVES

Patients' self-help group participation has been neglected in psychotherapy research. This study determines previous self-help group experience, therapist recommendations and plans for future participation.

METHODS

1,604 patients were surveyed by questionnaire at intake and discharge from psychosomatic treatment regarding previous self-help experiences, therapist recommendation and plans for future self-help participation.

RESULTS

Patients with self-help experience (12 %) were slightly older and more educated. They reported a longer duration of disease, more previous psychotherapy, more interpersonal problems and less social support compared to non-participants. At discharge, a total of 23 % intended to participate in a self-help group. Therapist recommendations (in 19 %) influenced patients' choices.

CONCLUSIONS

The significance of self-help group participation in inpatient care, its significance in treatment careers and implications for consulting patients are discussed.

Stationäre Kurz- und Langzeitpsychotherapie - Indikationen, Ergebnisse, Prädiktoren/ Short-term and Long-term Inpatient Psychotherapy – Indications, Results, Predictors

OBJECTIVES

This study investigated differences between patients in both short-term and long-term inpatient psychotherapy. Results for both settings as well as predictors of treatment outcomes were determined.

METHODS

Consecutive patients of the Giessen University Clinic for Psychosomatics and Psychotherapy, who were treated during a two-year period in both short- and long-term treatment settings, were studied prospectively (N = 166; return-rate 70 %). Standardized questionnaires were applied for distress (SCL-90 R), physical complaints (GBB 24) and interpersonal problems (IIP-D) as well as for object relationships (IPO).

RESULTS

In concordance with treatment concepts, patients in short-term psychotherapy had a more acute onset of symptoms, were more highly distressed and better occupationally integrated; patients in long-term treatment suffered more frequently from chronic psychosomatic disorders, personality disorders and comorbid somatic conditions. In both treatment settings distress and physical complaints decreased considerably and remained quite stable during follow-up. Concurring predictors of outcome were more adaptive patterns of object and interpersonal relationships as well as social resources. No differences were seen between the short-term and long-term treatment for utilization of ambulatory psychotherapy after discharge.

DISCUSSION

The study shows that a differentiation between short- and long-term treatments, even within one psychosomatic hospital unit, allows for differential indication and treatment concepts.

The 'wish to have a child', childlessness and infertility in Germany

BACKGROUND

Based on the declining birth rates in Germany, one might assume that the number of people who unintentionally are without children is growing. However, studies over recent years have documented that the number of people who deliberately have no children is growing instead.

METHODS

This report focuses on attitudes and motives which influence the realization of the desire to have a child. In a representative survey, 785 women and 795 men were questioned about their current wish to have a child, their ideal number of children and the motives for or against the decision to have a child.

RESULTS AND CONCLUSIONS

Emotional aspects are the most important motives in favour of having children, and financial restraints are most frequently cited as arguments against parenthood in German society. Thus, deciding in favour or against having children still appears to be an indicator of social disparity, due to the fact that every realized child wish underlines the differences between parents and childless individuals through the increasing financial burdens. As a large number of individuals and couples in Germany postpone realization of their desire to have a child, this may lead to a change from a voluntary to an involuntary childlessness in the individual decision process. Therefore, education about fertility as a resource should be promoted.

Correlations between Hormones, Physical, and Affective Parameters in Aging Urologic Outpatients

OBJECTIVE

To determine the relationship between sex hormones, physical complaints, depression, sexuality, and life satisfaction in aging men.

METHODS

263 outpatients aged 40 years and above (M=56.2; 40-84 years) were recruited from 6 andrological outpatient departments in Germany to evaluate "aging male" symptoms. Subjects were assessed by standardised self-report questionnaires, physical, and endocrinological examination.

RESULTS

Total and free testosterone as well as DHEA-S (dehydroepiandrosterone-sulfate) levels decreased significantly with age. SHBG (sex hormone binding globulin) and LH (luteinizing hormone) increased; estradiol remained unchanged. Inactivity, lower urinary tract symptoms, erectile and orgasmic dysfunction also increased significantly with age. A low testosterone level was significantly associated with a reduced motivation and a lack of sexual desire. In addition to reduced testosterone levels, a reduced motivation was also predicted by depression and an impaired physical self-concept. Reduced activity, erectile dysfunction, and low testosterone levels contributed significantly to the lack of sexual desire.

CONCLUSIONS

Aging men are frequently afflicted with a wide range of physical complaints (e.g. fatigue, prostate symptoms), erectile and orgasmic dysfunction, reflected in a reduced physical self-concept. Assessment and treatment of age-related physical and affective alterations must consider their close interplay with hormonal and lifestyle variables.

Who benefits from inpatient short-term psychotherapy in the long run? Patients' evaluations, outpatient after-care and determinants of outcome

BACKGROUND

Little work has been published on short-term inpatient treatments combining the virtues of inpatient treatments and short-term psychotherapy. The purposes of this study are to (a) determine the outcomes of short-term psychodynamic inpatient psychotherapy from patients' and therapists' perspectives, (b) assess the stability of changes, and (c) identify predictors of long-term outcome.

METHODS

83 consecutive inpatients (76% of those eligible) were assessed at intake, discharge, and 1 year follow-up by standardized questionnaires regarding symptoms (SCL-90R), interpersonal problems (IIP), object relationships (IPO), and the therapeutic relationship (HAQ). Diagnoses and functioning (GAF) were assessed by the therapists.

RESULTS

Psychological distress (effect size S = 1.14) and physical complaints (ES = 1.03) decreased strongly from intake to discharge, the majority of patients moving from the pathological to the normal range of the global severity index GSI (SCL-90R). At follow-up, average distress remained at a low level, and the majority of patients, and their therapists and physicians, regarded their well-being as improved. In a multivariate approach, a substantial proportion of variance of the distress at follow-up (42%) was explained by an infantile object relationship pattern (IPO), social avoidance (IIP), negative vocational changes, and a lack of a confidant at follow-up. A delayed start of subsequent ambulatory psychotherapy was another negative outcome predictor.

CONCLUSIONS

Attention should be given to maladaptive interpersonal relationship patterns, to vocational reintegration, and a confiding relationship as potential predictors of long-term outcome. Also, patterns of ambulatory after-care following inpatient treatment need further scrutiny.

Alexithymic characteristics and patient-therapist interaction: a video analysis of facial affect display

Alexithymia as a disorder of affect regulation entails a patient's reduced ability to process emotional information. The purpose of this study was to evaluate the impact of alexithymia [as measured by the Toronto Alexithymia Scale (TAS)-26, German version] on affective correlates in a dyadic therapeutic interaction (as recorded by the Emotional Facial Action Coding System). Interviews with 12 in-patients with various psychosomatic disorders (anxiety, depression, somatisation) were videotaped and evaluated for facial affect display. The corresponding emotional reactions of the therapists (split screen) were recorded separately. Patients with high alexithymia scores (TAS-26 total score) tended to display less aggressive affects than those with low scores. The therapists' predominant emotional reaction to alexithymic patients was contempt. Our findings underscore the deep-rooted nature of alexithymia as a disorder of affect regulation. Since facial affects play a major role in the regulation of emotional interaction, this disorder may evoke negative reactions of potential caregivers.

Pr�valenz der Urininkontinenz in der deutschen Bev�lkerung

The purpose of this study was to determine the frequency of incontinence in men and women in different age groups. In a representative survey, 883 men and 1,182 women with a mean age of 50 years (18-92 years) were studied based on standardized questionnaires on physical and psychological complaints, and quality of life. Participants suffering from involuntary loss of urine were considered "incontinent". The frequency of incontinence strongly increased with age, from 6.9% among the 18-40 year old population to 9.5% among the 41-60 year olds and 23% over the age of 60 years. Women complained more frequently of incontinence (15%) than men (9.5%; total of 12.6% in the population). The majority of the participants with incontinence also suffered from urinary urge, multiple disorders of digestion, pelvic pain and sexual dysfunction. There was also a strong increase in exhaustion, gastric pain, joint pain and cardiac complaints. The younger participants were more strongly affected by incontinence. When patients complain of incontinence, strong impairments in physical and psychological well-being, and quality of life are to be expected.

Motivation zur psychosomatisch-psychotherapeutischen Bearbeitung von beruflichen Belastungen - Entwicklung und Validierung eines Fragebogens

BACKGROUND

There is a lack of questionnaires assessing the motivation of inpatients to scrutinize occupational stresses and deal with them as part of their psychotherapeutic treatment. Work-related stress contributes significantly to the development of mental disorders. Vocational reintegration is an outcome criterion for the success of vocational rehabilitation. Patients are often not motivated for dealing with occupational stresses during inpatient medical rehabilitation. Therefore it is necessary to assess patient motivation at the beginning of treatment, in order to assign them to specific interventions, e. g. promoting motivation.

METHOD

A questionnaire (Fragebogen zur berufsbezogenen Therapiemotivation -- FBTM) consisting of 84 items was developed, based on published questionnaires for psychotherapy motivation. 283 psychosomatic rehabilitation inpatients were administered the FBTM, subsequently analyzed by item and factor analyses. Based on a second sample (n = 282) confirmatory factor analyses and validation of the questionnaire were executed.

RESULTS

Item and factor analyses revealed a four factor structure. 24 items constituted the subscales that could be described as "intention to change", "wish for pension", "negative treatment expectations" and "active coping". Reliability (Cronbach's Alpha) was satisfactory with coefficients between 0.69 and 0.87, and only low correlations could be found between the four subscales. Correlations with other measures were most pronounced for the subscale "intention to change". Some significant but low correlations could be reported between the FBTM and a standardized questionnaire of psychotherapy motivation (FMP). Confirmatory factor analyses of a second sample (n = 282) confirmed the original four factors. First evidence of sensitivity could be observed in a sample of patients who took part in an intervention promoting work-related therapy motivation during psychosomatic inpatient rehabilitation.

CONCLUSIONS

The FBTM is a reliable and valid instrument assessing work-related therapy motivation of inpatients, as a relevant therapeutic measure in psychosomatic rehabilitation. Further validation, especially the analysis of predictive validity is desirable.

Age-related complaints in women and their determinants based on a representative community study

OBJECTIVES

To determine (a) the relationship between physical and somatoform complaints, distress, life satisfaction and ageing in the female community and (b) to identify their psychosocial determinants.

METHODS

Two stratified random samples of the German female population (total of 2771 women) were investigated by standardised questionnaires of complaints (MFI-20, GBB), distress (HADS) and life satisfaction (LSQ).

RESULTS

When participants were divided into six age groups (18-30, 31-40, 41-50, 51-60, 61-70, >70 years), we found a continuous increase of physical, mental and general fatigue, inactivity and reduced motivation. Age-associated increases were also observed for exhaustion, cardiovascular and musculoskeletal complaints, but not for gastrointestinal complaints. This was accompanied by a reduced satisfaction with health and sexuality and increased depression and anxiety scores. Marked increases of complaints were mostly found in the sixth decade. However, depression already increased in the fourth decade, musculoskeletal complaints and reduced motivation peaked in the fifth decade, whereas mental fatigue did not increase significantly before the seventh decade followed by a rise of anxiety in women over 70 years. Most consistently, complaints were predicted by a combination of negative subjective health, higher age, lack of a partnership, and additional sociodemographic vulnerability (unemployment, low income, residence) and protective (religion) factors.

CONCLUSIONS

Community data provide important reference points in evaluating the ageing female. Based on regression analyses, we could also demonstrate the contribution of psychosocial vulnerability and protective factors to the development of age-related symptoms.

[Symptoms or complaints in the aging male--which questionnaires are available?]

Age associated hypoandrogenism and related changes in sexual function, as well as multiple physical complaints, and affective and cognitive changes have all been described in the aging male. In addition to decreased testosterone levels, clinical symptoms are required in order to perform substitution therapy. The assessment of symptoms and complaints in the aging male is discussed based on scientific test criteria. Commonly used questionnaires have the advantages of economy and independence from the investigator. In order to cover the broad range of age associated changes, numerous standardized and reliable procedures are available. However, these have usually not been developed specifically in order to assess androgen dependent changes. Preliminary, specific "aging male" questionnaires do not correlate reliably with the levels of testosterone. Thus there is a need for research and development in order to identify and assess androgen dependent complaints.

[Sexual disorders in the aging male]

Sexual dysfunction in the aging male has only recently found widespread attention. As apposed to enduring conceptions of "asexual" elderly, recent representative surveys show that the majority of men maintain sexual wishes and fantasies into old age. Sexual activity primarily depends on the availability of a partner and on maintaining intimacy and sexuality in the face of changes in the sexual response cycle and increasing morbidity. Sexual dysfunctions in aging result from physical, psychological, partner-related changes and lifestyles. These should be considered in the diagnosis and treatment of sexual dysfunctions in the aging male.

[Work-related stress and resources of psychosomatic patients compared to the general population]

Work-related stress is an important determinant of the development of psychosomatic complaints and of the success of psychosomatic treatments. In order to specify work-related stress and resources in relation to the general population, 461 consecutive inpatients in psychosomatic rehabilitation were compared to matched pairs (age, sex, occupational status) from a representative community survey, the German Socio-economic Panel (GSOEP). Psychosomatic inpatients reported overall higher work stress than their matched pairs of the general population, the rank order of the stress factors as well as sociodemographic and occupational determinants were comparable. Patients also rated resources lower than their matched pairs. They reported much higher strains due to conflicts with supervisors and found less support among their colleagues. The items studied are useful to describe work stress profiles of psychosomatic rehabilitation patients and serve as a basis for therapeutic work.

Verminderung von Technologie�ngsten in der psychosomatischen Rehabilitation?Konzepte und Ergebnisse zu einem Computertraining f�r �ltere Arbeitnehmer*

A computer training program was developed specifically oriented toward middle-aged employees, their learning needs and their computer-related fears. This program was based on a pilot study showing a high degree of stresses associated with the introduction of computer technology at the workplace in this age group (50-59 years). A survey of 623 patients confirmed that these persons experienced technological change predominantly as disadvantageous or threatening. Based on 114 patients, concepts and results of the computer training are presented. Participation reduced avoidance behaviors, fears and increased interest and initiative based both on the patients' and their trainers' perspectives.

Berufsbezogene Einstellungen, Ressourcen und Risikomerkmale im Therapieverlauf:

Zusammenfassung. Hintergrund. Das Fehlen standardisierter Messverfahren ist hinderlich für die psychotherapeutische Diagnostik und Bearbeitung berufsbezogener Belastungen und Konflikte. Der AVEM (Arbeitsbezogenes Verhaltens- und Erlebensmuster) erfasst Selbstbeschreibungen berufsbezogener Einstellungen, Bewältigungsressourcen und Risikomerkmale differenziert und ökonomisch, wurde allerdings an nicht- klinischen Stichproben (Lehrerinnen, Führungskräfte) entwickelt. Fragestellung: Überprüfung der Eignung des AVEM für psychisch und psychosomatisch Kranke. Methode: 644 Patientinnen und Patienten wurden bei Aufnahme zur stationären psychosomatischen Rehabilitation, Entlassung und 3-Monatskatamnese (N = 329) untersucht. Ergebnisse: Faktorenstruktur und Reliabilität wurden repliziert. Korrelationen mit weiteren Selbstbeschreibungsverfahren ergaben Validitätshinweise. Selbsteinschätzungen berufsbezogener Ressourcen veränderten sich während der Therapie in Richtung auf die Normstichprobe. Schlussfolgerungen: Es handelt sich um ein diagnostisch vielversprechendes Verfahren; prädiktive Validität und komplexere Auswertungsstrategien bedürfen weiterer Überprüfung.

Der chronische Beckenschmerz und seine Komorbidit�t

The diagnosis of chronic pelvic pain syndrome takes into account the fact that no clear etiology has been identified underlying chronic prostatitis and its associations with multiple somatic and psychological complaints. Based on a representative survey, this study enquires into the prevalence of pelvic pain in the community, its association with sexual dysfunction, somatic complaints and aging. Of the 770 men surveyed, 60 (7.8%) fulfilled the criteria for pelvic pain syndrome. This was assessed by a validated Giessen Prostatitis Symptom Score. Sexual dysfunction (particularly erectile dysfunction and loss of libido) were more frequently reported by men with pelvic pain than by men without a pain syndrome. The great majority of men afflicted by pelvic pain complained of additional pain symptoms (particularly back and joint pain) and fatigue. While sexual and somatic complaints were age-associated in the asymptomatic men, this was not the case for the symptomatic men. Our findings stress the fact that chronic pelvic pain syndrome is a major health problem in middle and late adulthood in men. Differentiated knowledge about comorbidity is a prerequisite for developing new interdisciplinary approaches to the diagnosis and therapy of this to date unsatisfactorily treated syndrome.

Validation of the German version of the International Index of Erectile Function (IIEF) in patients with erectile dysfunction, Peyronie's disease and controls

The objective of this study was to validate the German translation of the International Index of Erectile Function (IIEF). The IIEF was administered to 59 patients with erectile dysfunction (ED), to 38 patients with Peyronie's disease and to 33 controls. All patients were investigated by standardized German versions of international questionnaires of anxiety, depression, social desirability, quality of partnership, physical complaints and life-satisfaction. The five subscales of the English version, however, could not be replicated. Internal consistency for the complete questionnaire of 15 items was high (Cronbach's alpha=0.95). Based on the total scale and two subscales, we were able to discriminate sexual function between the ED group and the comparison groups. There was no significant correlation between the IIEF scores and anxiety, depression, somatic complaints and life-satisfaction. The German version of the IIEF has found good comprehension, and acceptance by the majority of patients. Its use is somewhat limited by its focus on sexual activity in partnership. In contrast to the English version, it mainly addresses a single factor of sexual function.