[Psychological aspects of "reasonable efforts" for the prediction of mental disorder-related disability]

Current standards by which socio-medical expert opinions are furnished and how they forecast the effects of mental disorder on the individual level of performance are discussed. Expert reports generally focus on assessing how the impact of mental illness can be overcome by reasonable "efforts of volition", using a number of criteria within the scope of psychiatric and psychosomatic models of explanation. The article reasons that prognoses concerning impaired performance due to health problems should to a lesser degree be based on illness-related parameters and analyses which are not subject to will and intention. Instead, it asks for a clear distinction between controlled coping processes on the one hand and psychodynamic defence mechanisms and illness-related processes on the other. Forecasts should take into greater consideration to what extent the effects of mental disorder on individual behaviour can also be attributed to a wide range of deliberate, non-pathological factors. Psychological motivation and action theories should become an integral part of expert reports, as they offer some useful tools for differentiating between those disabilities that are caused by controlled action and others that can be attributed to disorder-related factors.

[Assessment of the capability of performance of patients with psychic and psychosomatic diseases--a diagnostic model]

The limited availability of appropriate methods and criteria makes the assessment of capability by psychic and psychosomatic disorders difficult. This article displays and discusses the standards relating to content and method in capability assessments. The underlying diagnostic model of assessment capability has been conceptualised and tested empirically by a multicentric and interdisciplinary work-group. Different diagnostic levels of the manual are outlined as well as the procedures of operationalisation of the diagnostic categories. Furthermore, first results of empirical analysis are described and important conditions of the application of the diagnostic model are discussed.

[Assessment of malingering and dissimulation in the examination of subjects with mental and psychosomatic disorders]

The consideration of response bias is essential in the assessment of mental and psychosomatic disorders. In forensic contexts, as compared to clinical evaluations, an elevated rate of response distortions must be expected. Assessment methods should be selected with respect to the risk of either malingering or defensiveness. The choice of assessment strategies and instruments depends on the legal context of the examination. It is recommended that the consistency and plausibility of data from different levels and sources should be systematically analysed. Psychological test results should be integrated in this analysis. If the purpose of a test is obvious to the patient, the test result should be interpreted with respect to results from additional validity scales or symptom validity tests. In civil forensic evaluations of mental and psychosomatic disorders, the use of criterion-based content analysis is expected to be of limited benefit for the validation of symptoms and disability.

[Integration of psychological tests into clinical expert reports on mental disorders]

Norm-referenced psychological tests may provide crucial information that cannot be derived from non-standardised assessment techniques. However, little is known about the use of psychological tests in medical expert reports. Based on 90 medical expert reports from private invalidity insurances, the use of psychological tests and the appropriateness of test-score interpretation was analysed. About 60% of the reports included test-related data. Two-third of these reports revealed deficits of either test description or interpretation or utilisation of test results. It was recommended how to interpret test results appropriately. Psychological tests should be used to validate diagnostic findings. Tests should be integrated into a multi-method assessment strategy.

[Risk assessment of work disability due to mental disorders]

For more than 20 years, the rate of work disability pensions due to mental disorders has been rising. This development is in contrast to an overall decrease in the use of disability pension for other diseases. According to an exploratory study by the German state chamber of psychotherapy, most German insurance companies have hindered or excluded insurance protection for customers who have undergone psychotherapy. This practice will be analysed critically because it does not seem to be based on empirical evidence or on established risk algorithms. Results of empirical studies suggest that the use of psychotherapy is not a suitable criterion for the prediction of vocational disabilities due to mental disorders. In contrast, socio-demographic factors such as age or education level, personality factors like neuroticism or attribution style, coping characteristics like exhaustion and cynism, features of the working place like stress or payment conditions, and the type of mental disorder provide better information to calculate the risk of later long-term disability and disability pension caused by mental illness. The impact of these factors has mainly been proven by epidemiological studies from different European countries.

CONCLUSION

Assessment of risk for the use of disability pensions should be based on evidence from epidemiological studies.

[How reliable are statements on extensive noninflammatory pain? Comparison of patients with fibromyalgia, backache, and other local pain]

PURPOSE

The effect yielded by the degree of differentiation of two methods for measuring pain on patient statements regarding the extent of clinical pain was analyzed. At the same time, the reference time frame for the patient reports was varied.

METHODS

The influence exerted by differentiated questioning was determined by comparing two pictorial body diagrams. Three reference time frames were specified (current pain, last week, last half year).

RESULTS

Patients with wide-spread pain reacted stronger to variations in differentiated questioning the older the pain experienced was and the longer the time frame reported on. Upon differentiated questioning, patients with juxta-articular pain however remembered a lower number of pain sites in the past than on global assessment. Patients with backache reported their current pain to be less widely spread when assessed differentially than on global assessment.

CONCLUSION

Patient reports on the extent of pain mainly differ in those patients with extensive pain depending on the degree of differentiation during questioning. In these cases, the probability is high that the symptomatic complaints first became established, at least in part, as a reaction to the situational questioning conditions and therefore cannot be generalized to other questioning conditions.

[Are patients with fibromyalgia "hypervigilant"?]

INTRODUCTION

Clinical and experimental studies suggest that a generalized style of hypervigilant information processing may influence the pathogenesis of fibromyalgia (FM). This article deals with the question whether perception and processing of sensory stimuli in patients suffering from FM can be described in terms of "generalized hypervigilance".

METHODS

The components of hypervigilant stimulus processing were defined and discussed with reference to the current literature.

RESULTS

This literature review indicates that perceptual thresholds are not reduced in the majority of FM-patients. A strategy of hypervigilant information processing has consistently been shown only for suprathreshold aversive stimuli or under pressure to perform well. This is true for psychophysical as well as for neurophysiological parameters. The results concerning information processing of external stimuli cannot be transferred easily to the processing of somatosensory stimuli.

CONCLUSION

On the whole the existing studies argue against the assumption of trait-like hypervigilant information processing in FM-patients. A more appropriate explanation of the results is in terms of the interaction of situational and personal factors.

Fibromyalgia as a disorder of perceptual organization? An analysis of acoustic stimulus processing in patients with widespread pain

We examined to what extent patients with fibromyalgia differ from painfree control subjects in the perception and processing not only of somatosensory but also of external stimuli. For this purpose the acoustic perception of 30 patients with fibromyalgia was compared with that of 36 generally pain-free age and gender matched subjects. The groups were also controlled for organic disease of pathological dysfunction of the ear and auditory nerves. Thresholds of unpleasantness and hearing thresholds were determined autiometrically for various frequencies. In addition the participants rated their experience of daily noise, vulnerability to acoustic stress, and functional and affective complaints associated with fibromyalgia. As expected the results show reduced unpleasantness thresholds for all frequencies and a nonsymptomatic hearing loss for higher frequencies. The elevated hearing threshold correlated significantly with experience of noise at the place of work, which was also elevated in the fibromyalgia group. Generalized pain had a high impact on the interaction between threshold of unpleasantness and daily noise experience. We interpret the differences in thresholds of hearing and of unpleasantness in patients with fibromyalgia as a form of either preconscious or conscious acts to protect against disturbing stimulation. Our results support the notion of a generalized disturbancy of perceptual thresholds in patients with fibromyalgia not restricted to the perception of pain.

[Fibromyalgia and Sjögren syndrome--clinical and methodological aspects]

The prevalence of fibromyalgia in primary (n = 18) or secondary (n = 20) Sjögren's syndrome was examined. In all patients with Sjögren's syndrome as well as in 31 fibromyalgia patients and 20 healthy individuals measurements of pressure pain threshold were done by palpation and dolorimetry. Widespread pain, functional complaints, as well as depression were determined by a questionnaire. The results show a high frequency of fibromyalgia in the group of patients with pSS (44%), 72% of pSS patients reported widespread pain. Only 5% of the sSS patients fulfilled the ACR criteria for fibromyalgia and 40% of this group reported on widespread pain. Dolorimetry measures at tender or control points revealed that the pressure pain threshold was significantly reduced in all patient groups with healthy controls. There were only small differences between the clinical groups. Within the different groups examined there was a close correlation between dolorimetric threshold at tender and control points. In contrast to self-estimated widespread pain the pressure pain threshold was not closely related to functional complaints in the patient groups. The prevalence of depression was increased in both pSS and FM patients, in contrast to the other groups. The results suggest to include Sjögren's syndrome into the differential diagnosis of FM. The dolorimetric results were interpreted as an argument against the actual tenderpoint concept. They support the view that patients with FM rather represent an arbitrary coincidence of widespread pain and elevated tenderness on pressure.