[Workplace-related anxiety, workplace phobia and disorders of participation]

Work is an important domain of life. It is therefore clear that problems at the workplace and mental disorders will have negative interactions. Job-related anxieties are of special importance as any workplace causes or intensifies anxiety by its very nature. A common final pathway of mental disorders in general and workplace-related anxieties in particular is workplace phobia. Similarly to agoraphobia, it is characterised by panic when approaching or even thinking of the stimulus, in this case the workplace. Workplace phobia has serious negative consequences for the further course of illness. It impairs the ability to work, and can lead to sick leave and early retirement. It requires special therapeutic interventions. This paper describes workplace-related anxieties and workplace phobia and gives a conceptual framework for their understanding.

Training Workshop: Cognitive Psychotherapy and Wisdom Strategies in the Treatment of Adjustment Disorders

The goal of this training workshop is to give an introduction in recent developments of wisdom psychology and their bearing for cognitive psychotherapy of adjustment disorders.

Negative life events like divorce, dead of a beloved one, job loss etc. require enhanced coping. If this is not sufficient it can result in adjustment or other mental disorders. One factor which often contributes to pathological developments in the context of negative life events is embitterment because of the feeling of having been treated unfair, been let down or been humiliated. If embitterment is present then there is a tendency not to recover spontaneously but rather to take a chronic course.

There is a new approach in the treatment for such adjustment disorders which is based on recent developments in wisdom psychology. Wisdom has been defined as the capacity to cope with unsolvable and serious problems and questions in life. It has been shown:a.

This training workshop will:•

Work Place Phobia and Type of Job

Background:

Conditions at the work place affect in many ways the well being of empoyees. One frequent reaction is anxiety because opf threads by superiors, colleagues or customers, the possibility of failing and not fullfilling job demands, accidents, or the possiblity to lose the job.

Method:

230 patients (71% female) from a psychosomatic inpatient unit were interviewed with as DSM-based half standardized interview in respect to work related anxiety.

Results:

58% of the patients reported about work related anxieties.

Across all areas generalized work related worrying is most frequent (26% service, 35% office/civil servants).

Anxieties related to specific situations at work were most frequent in patients working in schools/education (32%) and in production/construction workers (28%).

Anxiety related to feelings of insufficency and adjustment related anxiety were most often seen in office workers/civil servant (37% and 26%).

Hypochondriac anxieties were mostly reported by school/education employees (18%) and construction/production workers (17%) but to a much lower degree by health workers (6%).

Work related phobic reactions were reported by 17% of all patients and most frequent by office workers/civil servants (22%), followed by health workers (21%), service jobs (16%), construction/producrtion workers (11%) and patients working in schools and education (9%).

Conclusion:

Work related anxieties are frequently seen in patients with mental and psychosomatic disorders. There are different types of anxieties which are differently related to different types of jobs.

Disorders of functions and disorders of capacity in relation to sick leave in mental disorders

BACKGROUND

With the publication of the International Classification of Functioning, Disability and Health (ICF), the description of functional health as opposed to symptoms of illness has gained in importance.

AIMS

To study the interrelation between disorders of functions, capacity and participation in mental disorders.

METHOD

Two hundred and thirteen psychosomatic inpatients were assessed with the Mini-ICF-Rating for Mental Disorders (Mini-ICF-P), the Symptom Checklist (SCL-90-R) and an interview on sick leave.

RESULTS

The highest scores in the Mini-ICF-P were found for 'flexibility' (M = 1.64, SD = 0.94), 'structuring of tasks' (M = 1.12, SD = 1.05) and 'endurance' (M = 1.12, SD = 1.02), the lowest for 'self maintenance' (M = 0.19, SD = 0.44), 'mobility' (M = 0.43, SD = 0.85) and 'adherence to regulations' (M = 0.74, SD = 0.98). The correlation between Mini-ICF-P and SCL-90-R GSI is r = 0.51 (p < 0.001), between sick leave and GSI is r = -0.05 and between sick leave and Mini-ICF-P r = 0.34 ( p < 0.001).

CONCLUSION

Disorders of capacity are more closely related to disorders of participation/sick leave than disorders of functions.

Percutaneous dilatational tracheostomy: a self-drive control technique with video fiberoptic bronchoscopy reduces perioperative complications

BACKGROUND

The aim of this study was to demonstrate that performance of percutaneous dilatational tracheostomy (PDT) associated with a self-drive control technique lowers the incidence of complications.

METHODS

A case-control, before-and-after, retrospective study. Place of study: A major teaching hospital in the Department of Emergency, Intensive Care Unit.

PATIENTS

we studied 128 patients who underwent fiberoptic-guided PDT over an 18 month period of time. Thirty-nine patients were assisted by conventional fiberoptic bronchoscopy, while 89 video-assisted fiberoptic procedures were performed in which the operator controlled his own actions on a screen. We defined perioperative complications as accidental extubation, perioperative hemorrhage, tracheal ring rupture, lesions of the tracheal wall, and abnormal insertion of the cannula. A Chi-square test, Student's t-test and U Mann Whitney test were used to compare the incidence of complications and the duration of procedure in the traditional fiberoptic PDT group and in the video-guided group.

RESULTS

Procedure time was significantly shorter in the group with the self-drive control technique. There was also a reduction of the number of perioperative complications.

CONCLUSION

Fiberoptic bronchoscopy associated with a video system seems effective in reducing the risk of perioperative complications.

[Increased sensitivity to pain in long-term opioid treatment]

Recent years have seen a rise in the prescription of strong opioids for chronic and even subthreshold forms of pain. Animal and human experiments and clinical observations have shown that, compared to placebos, chronic opioid administration results in not only tolerance to its analgesic effects but also in heightened pain sensitivity. Therefore chronic, especially high-dose, opioid treatment can not be recommended for chronic pain but is instead contraindicated. Patients on long-term opioids will often reject proposals to withdraw the drug. Important elements of treatment are patient education, empathy and unconditional acceptance by the patient, motivation enhancement and psychological support, collaboration with other prescribers and therapists, detoxification, measures to increase pain tolerance, encouragement of general health behavior and salutotherapy, treatment of the primary illness, and prescription of participation oriented alternative analgesics.

Non-pharmacological treatment of psychiatrists in addition to the prescribing of an antidepressant drug

BACKGROUND

Guidelines for the treatment of depression regularly emphasize that pharmacotherapy of depression should be accompanied by supportive counseling and other psychotherapeutic interventions. It is unknown which role psychiatrists in routine care give to such verbal therapies.

METHODS

In a drug utilization study of venlafaxine, psychiatrists in private practice and in hospitals were asked to tell what non-pharmacological therapies they saw as an important part of the treatment of the present depressive episode. Additionally patient characteristics, treatment variables, setting characteristics and physician characteristics were assessed.

RESULTS

Psychiatrists reported some kind of verbal therapies in 19.0% of outpatients and 36.8% of inpatients. Verbal therapies were reported more often for younger patients, who got more double diagnoses and were more severely ill. Patients with verbal therapies got more psychotropic medication. In the inpatient setting verbal therapies were related to generally more treatment overall and a higher rate of treatment response. In both treatment settings verbal therapies were related to lower rates of discontinuation of the antidepressant.

CONCLUSION

Verbal interactions are part of any patient-physician encounter and should be theory guided as part of the therapeutic process in the treatment of depressive disorders. Under this assumption the rate of patients for which psychiatrists reported some kind of verbal therapy as explicit part of their treatment could be higher. More research is needed on patient guidance, counseling and supportive psychotherapy in psychiatry.

A Randomized Controlled Clinical Trial Comparing “Guideline Exposed” and “Guideline Naive” Physicians in Respect to Dosage Selection and Treatment Outcome with Doxepin in Depressive Disorders

INTRODUCTION

Can prescribing of insufficient dosages and outcome of treatment with antidepressants in routine care be improved by guidelines?

METHODS

161 general practitioners and 162 psychiatrists in private practice documented 1319 patients, receiving doxepin for individual clinical reasons. Physicians were randomly divided into a guideline exposed and a control group. All physicians treated their patients according to individual clinical considerations.

RESULTS

Average maximum daily dosage was 83 mg/d in the control and 95 mg/d in the intervention group (F=19.15; p<0). Only 3% of patients in both groups got the recommended dosage of 150 mg/d. Guideline exposure resulted in increased dosages preferably for milder forms of depression and in comparatively lower rates of improvement.

CONCLUSION

Guideline exposure did not reach its goal in respect to the recommended dosage. It missed its goal in respect to improvement of outcome and even showed negative effects. Guidelines should be evidence-based not only by referring to literature reviews but by testing their clinical effects in controlled clinical trials.

Optimization of wireless Bluetooth sensor systems

Within this study, three different Bluetooth sensor systems, replacing cables for transmission of biomedical sensor data, have been designed and evaluated. The three sensor architectures are built on 1-, 2- and 3-chip solutions and depending on the monitoring situation and signal character, different solutions are optimal. Essential parameters for all systems have been low physical weight and small size, resistance to interference and interoperability with other technologies as global- or local networks, PC's and mobile phones. Two different biomedical input signals, ECG and PPG (photoplethysmography), have been used to evaluate the three solutions. The study shows that it is possibly to continuously transmit an analogue signal. At low sampling rates and slowly varying parameters, as monitoring the heart rate with PPG, the 1-chip solution is the most suitable, offering low power consumption and thus a longer battery lifetime or a smaller battery, minimizing the weight of the sensor system. On the other hand, when a higher sampling rate is required, as an ECG, the 3-chip architecture, with a FPGA or micro-controller, offers the best solution and performance. Our conclusion is that Bluetooth might be useful in replacing cables of medical monitoring systems.

Remission of severely impaired subjective wellbeing in 727 patients with schizophrenia treated with amisulpride

Studies of subjective wellbeing (SW) in schizophrenia have missed to define and to assess rate and predictors of SW response (SW-res) and SW remission (SW-rem).

METHOD

A total of 727 patients with schizophrenia and severely impaired SW at entry (Subjective Wellbeing under Neuroleptics Scale, short version, SWN-K, total score < or =60) were treated with amisulpride over 12 weeks. SW-res was defined as SWN total score increase of at least 20% and by at least 10 points and SW-rem as total score of > or =80 points.

RESULTS

Seventy percent fulfilled the SW-res criterion at week 4. At week 4 and week 12 (endpoint), the SW response criterion distinguished between patients with or without later SW remission and overall symptomatic and functional response. While 39% fulfilled the SW-rem criterion at endpoint, only 9.1% without early SW-res were in SW-rem at follow-up. Regression analyses indicated that SW-res was mainly predicted by greater severity of positive symptoms at baseline and SW-rem by lower severity of negative symptoms and better social functioning, and particularly by early SW-res.

CONCLUSION

Patients with a risk of SW non-remission need to be identified early with subsequent treatment adaptation according to recommendations for incomplete remission and treatment resistance in schizophrenia.

Arbeitsplatzbezogene Ängste und Arbeitsplatzphobie

Work is an important aspect of life. Problems at the workplace must therefore have negative consequences on the mental status and mental problems will interfere with the working place. The relation between anxiety and the workplace is especially important because the workplace causes anxiety due to its very nature. A common final pathway of mental disorders in general, and work related anxieties in particular, are workplace phobias, with panic when approaching or even thinking of the workplace. This is a serious complication with negative consequences for the further course of illness. It makes special therapeutic intervention necessary. This paper describes the phenomenon of workplace related anxieties and phobia and provides a conceptual framework for their understanding.

Die Vor- und Nachbehandlung in der stationären psychosomatischen Rehabilitation

Patients who are referred to psychosomatic inpatient rehabilitation are mostly suffering from long-term illnesses. Therefore, it is necessary to take pre- and post-treatment into account. Epidemiological questions are frequency and type of pre- and post-treatment and their relation to course and outcome of rehabilitation. Pre-treatment, recommendations for follow-up treatment, and course of treatment in 1284 patients of the department of behaviour therapy and psychosomatics of the rehabilitation centre Seehof were assessed. Before admission, 75.4 % of patients had been in psychiatric treatment, and 31.3 % had received psychotherapy. The inpatient stay was significantly longer in patients with psychiatric pre-treatment and those with a combination of psychiatric treatment and psychotherapy. These patients were more often unemployed and showing an insufficient social network. Pre-treatment was unrelated to changes in the SCL-90-R, to physician ratings of therapeutic outcome or the ability to work at the end of rehabilitation. Patients pre-treated by a general practitioner, psychiatrist or psychotherapist returned to that therapeutic setting after rehabilitation. Patients only treated by general practitioners were referred to specialist treatment. These data show the need to integrate inpatient rehabilitation in long-term pre- and post-treatment. One effect of inpatient rehabilitation is to optimize treatment. This requires good communication across different areas of health care.

Topography and surface energy dependent calcium phosphate formation on Sol-Gel derived TiO2 coatings

Heterogeneous nucleation and growth of calcium phosphate (CaP) on sol-gel derived TiO(2) coatings was investigated in terms of surface topography and surface energy. The topography of the coatings was derived from AFM measurements, while the surface energy was determined with contact angle measurements. The degree of precipitation was examined with scanning electron microscopy (SEM) and X-ray photoelectron spectroscopy (XPS). The precipitation of CaP was found to be dependent on both topography and surface energy. A high roughness value when combining the RMS roughness parameter S(q) with the number of local maxima per unit area parameter S(ds) enhances CaP formation. The hydrophilicity of the coating was also found to be of importance for CaP formation. We suggest that the water contact angle, which is a direct measure of the hydrophilicity of the surface, may be used to evaluate the surface energy dependent precipitation kinetics rather than using the often applied Lewis base parameter.

Detailed in Situ XRD and Calorimetric Study of the Formation of Silicate/Mixed Surfactant Mesophases under Alkaline Conditions. Influence of Surfactant Chain Length and Synthesis Temperature

The formation of mesoscopically ordered silica/surfactant composites under alkaline synthesis conditions has been studied by time-resolved in situ small-angle X-ray diffraction with synchrotron radiation. Alkyltrimethylammoniumbromide surfactants, C(n)()TAB, of different chain lengths (n = 14, 16, and 18) as well as mixtures thereof were used as structure directing agents and the measurements were carried out at two different temperatures. A linear relationship between the mean surfactant chain length and the d spacing of the hexagonal phase was observed, suggesting an ideal mixing of the surfactants in the supramolecular surfactant aggregates. It is shown that the formation of the hexagonal phase is kinetically controlled mainly by the rate of silicate condensation, while the effect of changes in the surfactant chain length on the kinetics is small under the studied conditions. Two concominant, albeit partly interlinked, processes, suggested being intra- and intermicellar condensation, followed by aggregate-aggregate condensation, govern the nucleation and growth of the hexagonal phase. The two-step mechanism is confirmed by a microcalorimetric study where the heat evolved during the hydrolysis-condensation reactions is followed as a function of time.

Surface nanopatterning by organic/inorganic self-assembly and selective local functionalization

Patterning silicon surfaces by well-ordered nanoperforated TiO(2) layers is achieved through a simple block copolymer-assisted liquid deposition technique followed by direct thermal treatment. The crater diameters are tuned between 10 and 50 nm, depending on the molecular weight of the surfactant patterning agent. The formation mechanism of such systems is discussed. The present nanopatterned heterogeneous surfaces (nanoholes with SiO(2) bottom surfaces and TiO(2) walls) are selectively functionalized with two different perfluorinated organic groups. The accessibility to the substrate surface through such nanoholes and the selective distribution of both functions on the surface is evidenced by water-contact-angle measurements, which satisfactorily verify the Cassie relationship. Such systems have wide application prospects in varied fields such as nanotechnology and engineering.

Arbeitsunfähigkeit bei psychischen Störungen

Sick leave certifications allow patients to stay away from work without negative consequences. German regulations state that patients can be granted sick leave when duties can no longer be fulfilled or may endanger health status and when there is a causal relationship between illness and disability. Relevant is not the presence of illness but of a disability which interferes with work requirements. In Germany, an average of 4% of workers are on sick leave at any given time, corresponding to about 2 weeks per year and person. The level of sick leave depends not only on the patient's health status but also on social factors. Mental disorders are a major reason for sick leave. Sick leave can have negative effects by fostering chronicity. In 75% of cases, physicians have been found to grant sick leave incorrectly. It must be kept in mind that not illness per se but only disorders of participation justify sick leave.

[Well-being therapy]

Well-being and quality of life are leading psychological factors that are basically independent of disease and the burdens of life. The more problems a person has to cope with, the more important they become as factors impacting upon an illness. Well-being Therapy (WBT) is a novel psychotherapeutic strategy aimed at promoting psychological well-being. WBT is based on Ryff's multidimensional model of subjective well-being which comprises six subdivisions: mastery of the environment, personal growth, purpose and meaning of life, autonomy, self-acceptance and positive relationships. The aim of this therapy is to improve the patient's performance/activities in all of these areas.

Psychotropic drug presentation in medical and lay press journals

OBJECTIVE

Media coverage of psychotropic medications affects public views and patients' and therapists' compliance. This study is aimed to identify characteristics of and differences between medical and lay press presentations of psychotropic drugs.

METHODS

Two leading German medical and three lay press journals were analyzed in seven annual sets, ranging from 1963 to 1996.

RESULTS

There is a clear difference in the reporting on psychotropic drugs between the different types of journals. Lay press journals primarily focus on minor tranquilizers and hypnotics which are indiscriminately presented as one group with other psychotropics, have a rather critical view on these drugs and underrepresent the needs for treatment of major mental illnesses. There were no marked trends over time in the attitude towards psychotropics. On comparing the publications before and after 1984, when benzodiazepines were put under schedule IV by WHO, differences in reports on dependency problems can only be found for the daily newspaper.

CONCLUSION

It is the responsibility of psychiatrists to enter the public discussion on how psychiatric disorders should be treated and to run public "awareness programmes".

[Significance of the chronic fatigue syndrome in rehabilitation medicine--status and perspectives]

It appears that from a clinical point of view chronic exhaustion or fatigue is an important factor in rehabilitation. This is, however, first of all a phenomenon that can be described as a function in accordance with the International Classification of Functioning, Disability and Health (JCF), caused by chronic illnesses or chronic excessive stress. The clinical and sociomedical ranking of chronic fatigue or exhaustion in respect of rehabilitation was discussed in the framework of a Workshop at the 12th Rehabilitation Science Colloquium, 2003 from the viewpoints of psychiatric rehabilitation, methodology, sociology and practical rehabilitation, and conclusions for future research were drawn. The definition of chronic fatigue is first of all mainly based on the feeling of chronic tiredness but also on phenomena of disturbed concentration, physical discomfort, headache and disorders of "drive" and mood. A psychiatric diagnosis linked with symptoms of chronic fatigue is neurasthenia, which is arrived at according to precisely defined criteria. Depressive disorder is one of the most important differential diagnoses in this sphere. Examinations by general practitioners revealed that about 90 % of the patients who had been diagnosed as suffering from psychovegetative disorders completely agreed with the diagnosis of neurasthenia. Neurasthenia resulted more often in work disability periods than disorders of somatisation and other psychosomatic diagnoses. Basing on the "IRES" scale "vital exhaustion", singular of even serious changes become evident in about 50 % to 90 % of the patients undergoing rehabilitation, depending on their individual range of indications. As was to be expected, the majority of pathologic findings concerns patients undergoing psychosomatic rehabilitation, since in such cases there is an overlapping with symptoms of psychosomatic diseases. It is, however, remarkable that also in somatically oriented orthopaedic rehabilitation symptoms of fatigue are seen in up to 50 % of the patients. Preliminary studies have shown that these symptoms can be definitely ameliorated within the rehabilitation framework, although pathological signs are still abundantly apparent in follow-up examinations. Markedly severe degrees of "vital exhaustion" and "vocational exhaustion" are also seen in rheumatology patients undergoing somatic rehabilitation. This agrees with case history details related by many female and male patients. Hence, it appears necessary to adapt rehabilitative intervention to both the psychovegetative and the medical behavioural aspects of this symptom. Scientific classification of the entire sphere of chronic fatigue in respect of rehabilitation requires classification of the relevant functions within the ICF framework. To this end it would be necessary to conduct patient inquiries within cross-sectional studies on the one hand and, on the other, a systematic consensus process among experts would have to be used for allocation to the relevant functions. This is the basis for development of suitable assessment tools for use in prospective studies in order to systematically evaluate the impact on functions and especially their effects on activities and participation.

Das „Mini-ICF-Rating für psychische Störungen (Mini-ICF-P)”. Ein Kurzinstrument zur Beurteilung von Fähigkeitsstörungen bei psychischen Erkrankungen

Supplementary to the description of diseases at symptom level, the International Classification of Functioning, Disability and Health (ICF), edited by the WHO, for the first time enables a systematic description also at the level of disabilities and impairments. The Mini-ICF-Rating for Mental Disorders (Mini-ICF-P) is a short observer rating instrument for the assessment of disabilities, especially with regard to occupational functioning. The Mini-ICF-P was first evaluated empirically in 125 patients of a Department of Behavioural Medicine and Psychosomatics. Parallel-test reliability was r = 0.59. Correlates were found with cognitive and motivational variables and duration of sick leave from work. In summary, the Mini-ICF-P is a quick and practicable instrument.

Efficacy of cognitive behaviour therapy in generalized anxiety disorders. Results of a controlled clinical trial (Berlin CBT-GAD Study)

BACKGROUND

Generalized anxiety disorders (GAD) are amongst the most prevalent mental disorders. Recent studies have suggested that cognitive behaviour therapy (CBT) is an effective treatment for GAD. A controlled clinical trial was done to evaluate the efficacy of CBT treatment in outpatients with pure GAD who were treated by a therapist working in routine care.

METHODS

Seventy-two outpatients, fulfilling GAD criteria according to DSM-IV, were included in the study. From this group, 36 patients (CBT-A) were randomly assigned to 25 sessions of CBT and the other 36 formed a contact control group (CCG). After the contact control period (CC period), these patients were also treated with CBT (CBT-B), allowing not only a parallel group comparison but also an A-B comparison. Therapists were licensed full-time psychologists who worked routinely in outpatient care and had a professional training in CBT. Treatment was done in accordance with a manual, and treatment conformity was controlled by several methods.

RESULTS

The reduction in the score on the Hamilton Anxiety Observer Rating Scale was 6.4% (1.5 points) in the CCG, 35.4% (9.5 points) in the CBT-A and 47.3% (10.3 points) in the CBT-B. In the self-rating Spielberger State-Trait Anxiety Inventory, a reduction of 2.7% was seen in CCG, 14.6% in CBT-A, and 11.6% in CBT-B. According to the Clinical Global Impression Rating, 65.6% of patients were still at least moderately ill at the end of the CC period, while this rate was 33.4% at the end of CBT-A, or 15.7% at the end of CBT-B. All these differences between treatment and control group are statistically highly significant. The clinical improvement remained stable over a follow-up period of 8 months.

CONCLUSIONS

CBT is an effective method of treatment for GAD. Differences between control and treatment group are comparable to or larger than those reported in studies on antidepressant drugs.

Wohnortnahe Rehabilitation

In recent years new avenues of medical rehabilitation have been made possible in order to allow a more flexible and better care for patients. This includes day care and outpatient treatment additional to inpatient services. A further new development are centers which provide "residential rehabilitation". It allows a continuous cooperation with physicians and therapists who send patients or take care of them after discharge. Cooperation with acute care hospitals is easier. Inpatient care, day care and outpatient care can be better integrated. The social network of the patient can easier be taken into account in treatment planning. Patients can be supported when going back to work. Contact with self-help groups can be arranged while the patient is still in treatment.

Leitlinien und die Psychologie medizinischer Entscheidungsprozesse bei der Behandlung depressiver Erkrankungen

Guidelines aim at improving medical decision making. Guidelines try to influence medical behaviour in contrast to textbooks and reviews which want to improve medical knowledge. Scientific models of medical decision making such as the action theory and empirical data on the effects of guidelines suggest that guidelines will not always reach their goal but instead can even deteriorate medical quality. The problem of guidelines in medicine is discussed in reference to depressive disorders. The problems at stake are nevertheless valid for medicine as a whole. Therefore it must be tested in controlled clinical trials whether guideline exposed physicians have better results with their patients than guideline naive physicians. Only such guidelines should be called evidence based for which positive effects have been empirically demonstrated.

Topographical parameters for specifying a three-dimensional surface

The importance of different surface geometries and thereby the need for versatile surface identification by describing a number of different surface features is emphasized. A set of topographical parameters for the description of the amplitude and spatial and hybrid properties of surfaces was utilized for a versatile three-dimensional surface characterization of sol-gel samples with different topographies. The image data were measured by atomic force microscopy. The results demonstrate the power of the roughness parameters to identify surfaces according to their specific characteristics. An example is also given about how certain surface topographical properties may control the material reactivity.