Bulimiebehandlung im stationären und teilstationären Setting

While treatment guidelines for outpatient psychotherapy for bulimia nervosa are known, it is hard to find published concepts for inpatient or day clinic settings. We will describe a treatment program developed in Freiburg/Germany, which integrates symptomoriented, cognitive-behavioral elements into a psychodynamic concept. The program presented can be seen as an example. For implementation at other clinics, it should be adapted to their special context and structure.     

Qualitätssicherung von Gerichtsgutachten im Familienrecht

In recent years many controversial verdicts and studies have brought discussions about the quality of expert opinions in family law into the focus of the media, political and expert public spheres. With the coalition contract, the ruling parties agreed on improving the quality of expert opinions, especially in the sector of family law, in collaboration with professional institutions. Representatives of the legal, psychological and medical associations, the Federal Bar Association and the Federal Chamber of Psychotherapists worked out guidelines for expert opinions in family law in cooperation with the Federal Ministry of Justice and Consumer Protection. The three main quality assurance aspects are scientifically founded procedures, transparency and traceability. These requirements are concretely illustrated in this article with recommendations concerning the procedure and composition of expert opinions.     

Psychiatrische Versorgung im europäischen Strafvollzug

Objective and methods:

We analysed administrative national data regarding mental health care and psychiatric prevalence in the penitentiary systems of 24 European countries. Data was provided by national experts via questionnaire.

Results:

There is a mixed approach for prison mental health care in European countries that either rely on separated psychiatric prison services or collaborate with specialized forensic or general mental health care services. Care provision in general is assessed as deficient. At all decisive points of detention, adequate screening or diagnostic routines are lacking. As a consequence, nothing is known about the prevalence of mental disorders in European prisons. At the moment, only a very limited number of secondary indicators are available for describing the problem.

Conclusion:

There is an urgent need for improving the reporting routines on mental disorders in prison inmates as a first step for improving substantially the mental health care provision for prisoners in European countries.     

Zur Häufigkeit der Schuldfähigkeitsbegutachtung von Sexualstraftätern im Erkenntnisverfahren

This study investigated how often and depending on which factors sexual offenders are examined by mental health experts regarding their criminal responsibility. Out of a total of 306 legal charges against sex offenders accused of child sexual abuse (CSA: n?=?145), rape or sexual assault (n?=?89), exhibitionism (n?=?39), sexual abuse of adolescents, mentally defective, physically helpless or warded persons (n?=?18) that were admitted by a criminal court in 2001 in the German federal state of Schleswig-Holstein, 209 (95.6 %) were analyzed regarding the following questions: how often was the accused examined by a mental health professional regarding mental responsibility? Was the chance of being examined systematically related to certain factors (e.g., personality of the accused)? Expert advice regarding the mental responsibility of the accused was obtained by the court in only 34 cases (11.7 %). No systematic relationships of personal variables as well as the modus operandi and the chance of commissioning a mental health expert were found. The main reason for assigning a forensic expert opinion was the vague impression of a psychic disorder. Re-offending increased the rate of a mental health examination only in CSA (34.6 % of re-offenders were examined compared to 9.2 % of first-time offenders), but not in rape or sexual assault. Also age does not predict the commissioning of an expert opinion. Only one fifth of all accused below the age of 21 were investigated by a mental health professional. Results are discussed in terms of legal background, consequences for risk assessment and relapse prevention.     

Gegenübertragung im stationären Therapie-Setting

Background

Countertransference is seen as an instrument of research into a patient’s unconscious and is therapeutically useful in furthering psychodynamic work. For inpatient psychodynamic psychotherapy, where patients are treated by a team of psychotherapists, countertransference is much more complex and makes consideration and integration of different countertransference feelings necessary. Using the first German translation of the countertransference questionnaire (CTQ, Zittel Conclin and Westen, the countertransference questionnaire, 2005) an attempt was made to identify differences in countertransference phenomena in a team of psychotherapists and to show the impact countertransference has on therapy outcome.

Materials and methods

A total of t multiprofessional teams of psychotherapists (15 physicians, 5 psychologists and 9 body and art therapy psychotherapists) took part in the study and completed the CTQ for 137 patients (100 female, 37 male) at the beginning and at the end of inpatient psychotherapy. In addition, the patients completed two questionnaires, the Symptom Check List Revised 90-R (SCL-90) for the severity of symptoms and the Assessment of DSM-IV Personality Disorders Questionnaire (ADP-IV) for personality disorders.

Results

Body and art therapy psychotherapists expressed more positive, protective and involved countertransference feelings whereas psychotherapists for single and group therapy expressed more aggressive and hopeless feelings. Countertransference has an impact on therapy outcome and feelings of a lack of interest, aggression and resignation at the beginning of therapy can point to a poor outcome. Patients with personality disorders activate more negative countertransference reactions than patients without personality disorders but at the same time they may also evoke parent-like feelings of protection.

Conclusions

Using the CTQ it is possible to differentiate countertransference phenomena in a team of psychotherapists treating inpatients with psychodynamic psychotherapy. The timely perception and integration of countertransference feelings has a positive influence on the therapeutic process and therapy outcome.     

Selbsthilfegruppen im Rahmen stationärer psychotherapeutischer Behandlungen

Psychosomatic in-patient treatment applies a combination of various methods in order to facilitate learning by insight and corrective emotional experiences in a therapeutic community. The establishment of a self-help group on the ward can be a useful complementary element in such a comprehensive approach. However, empirical research on this specific topic does not yet exist. Based on clinical experience, necessary preconditions as well as the pros and cons of integrating self-help into professional treatment are described. The assessment of 850 patients in a clinic for psychosomatic medicine and psychotherapy concerning a self-help group on the ward are presented. Relationships between patients’ evaluation of the self-help group and various other variables as well as the overall treatment effect were studied. Empirical data provide evidence of a differential effect of the self-help group on the ward: the majority of the patients experienced the self-help group as useful. Whether the patient is able to benefit from group therapy seems to be an intermediate variable and the therapists’ attitude towards self-help groups also seems to play an important role.     

Wiederkehrende,primäre Kopfschmerzen im Jugendalter

Background

Recurrent pain, especially primary headache, is a serious health problem in adolescents. Music therapy in the treatment of children with migraine has already been evaluated. The aim of this pilot study was to adopt this treatment manual for adolescent patients with recurrent primary headache in preparation for the main randomized controlled trial.

Patients and methods

In this pilot study two different modes of treatment (standard and compact treatment) were tested in an outpatient setting with 19 patients. Frequency and intensity of headache symptoms were evaluated using pain diaries for 8 weeks in a pre-post design.

Results

The pilot study showed good feasibility of both treatment conditions in outpatient practice. Patients reported a reduction of pain frequency and intensity in both groups. The evaluation of the clinical relevance of these effects remains the objective for the main trial.

Conclusions

The music therapeutic treatment plan for children with migraine is even feasible in the treatment of adolescents with recurrent, primary headache. Further evidence questioning the effectiveness of the treatment under controlled conditions is needed.

     

Primär- und Sekundärprozess bei Angst und Depressivität im psychoanalytischen Erstinterview

Zusammenfassung Vorgestellt wird eine quantitative inhaltsanalytische Untersuchung an 46 psychoanalytischen Erstinterviews, die mit Angstpatienten und depressiven Patienten in Düsseldorf und Magdeburg geführt wurden. Im Mittelpunkt der Methodik steht das Regressive Imagery Dictionary (RID), ein computergestütztes Verfahren mit 43 Einzelkategorien, die zu den drei Indikatoren primärprozesshafter Inhalt, sekundärprozesshafter Inhalt und Emotionalität zusammengefasst werden. Die durchgeführten Subgruppenvergleiche beziehen sich auf Unterschiede zwischen Angstpatienten und depressiven Patienten sowie ostdeutschen (Magdeburg) und westdeutschen (Düsseldorf) Patienten. Die Ergebnisse zeigen in den Texten der ostdeutschen Patienten ein höheres Maß an primärprozesshaften Inhalten, insbesondere in den Kategorien Passivität und regressive Kognition. Bezüglich der Diagnosegruppen zeigen die Angstpatienten gegenüber den depressiven Patienten ein höheres Maß an primärprozesshaften Inhalten in der Subkategorie Oralität. Es zeigt sich, dass in psychoanalytischen Interviews nicht nur diagnosespezifische Inhalte thematisiert werden, sondern auch kultureller Hintergrund, Geschlecht und Bildung von Bedeutung sind. Die Studie leistet einen Beitrag zur Identifizierung automatisch erfassbarer Textmerkmale, die charakteristisch für die in einer qualitativen Studie gefundenen idealtypischen nosologischen Konstrukte der neurotischen Depression und der phobisch-angstneurotischen Erkrankung sind. Hierbei ist der depressive Idealtypus durch eine Überidentifikation mit Werten, durch das Gefühl der Abhängigkeit von einer schädigenden Person, durch Selbstwertprobleme, Hemmung und den unerfüllten Wunsch, geliebt zu werden, gekennzeichnet. Der Angsttypus zeichnet sich durch ein klischeehaft positives Bild der eigenen Persönlichkeit aus sowie durch die Gefühle, falsch verstanden, ausgenutzt, nicht ernst genommen und zum Außenseiter gemacht zu werden, sodass er bei nachlassenden Kräften im Kampf um Leistung nicht mehr mithalten kann.

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Primary and secondary processes in psychoanalytic first interviews with patients suffering from anxiety and depressionA regressive imagery dictionary content analysis study in West and East German patients

The present paper describes a study on the intake interview narratives of psychotherapy patients with computer assisted content analysis methods. 46 psychoanalytic first interviews of patients suffering from depression or anxiety disorders were analysed with the Regressive Imagery Dictionary (RID), a computer assisted content analysis method with 43 subcategories, which were sumed up to three main categories: Primary Process, Secondary Process, and Emotion. Comparisons between different subgroups of this sample were made: Anxiety vs. depressive patients, and East Germans (Magdeburg) vs. West Germans (Düsseldorf). Significant correlations were found between the Primary Process subcategories Passivity and Regressive Cognition, and East German patients, as well as correlations between the Primary Process subcategory Orality, and anxiety patients. The results confirm our hypothesis, that the psychotherapist-patient-interaction sequences, which are the basis of diagnostic categorization, enclose as well elements which are specific for the disorders under study as elements which are specific for sex and culture (east vs. west). The study contributes to the identification of specific text markers, which can be found in the narratives of patients suffering from neurotic depression vs. patients with phobia and panic disorders. The results of the study are compared with a previous qualitative study. Using the ideal-type concept, our qualitative content analysis study showed as characteristic features of depressed patients overidentification with social roles and norms, feeling of being dependent and injured by another person, problems of self-esteem, shyness, and unfulfilled wishes to be loved and accepted. In contrast, phobic patients characterized the own personality as normal and without any problems in a stereotype way, at the same time feeling misunderstood and exploited by other persons, feeling as an outsider and left alone, and being no more able to compete with others.

     

Versuche über visuelle Formwahrnehmung im Säuglingsalter

Zusammenfassung Die vorliegende Untersuchung beschäftigt sich mit dem frühkind lichen Wahrnehmungskontakt in dem der Greifperiode vorausgehenden Lebensabschnitt dominierender visueller Aktivität (Lebensalter von 10 bis 13 Wochen): es soll der Einfluß von Formmerkmalen der Reizgebilde auf den Blickkontakt der Säuglinge festgestellt werden. Dafür erscheint die Methode des bevorzugten Anblickens besonders geeignet (§ 1). Es wurden verschiedene Figurformen zu 16 Figurenpaaren zusammengestellt (Abb. 1–4) und an zwölf Säuglingen dadurch verglichen, daß in wiederholten Versuchen ermittelt wurde, an welcher Figur des simultan dargebotenen Paares der Blick bevorzugt haften blieb (§ 3). Dabei konnte für den Blickkontakt der Säuglinge ein Einfluß von Formmerkmalen der Einzelfiguren festgestellt werden, der unabhängig von Flächengröße und Konturenlänge der Reizfiguren besteht (§ 4, 1). Die pauschale Frage, ob kompliziertere oder einfachere Formen bevorzugt angeblickt werden (§ 2), erwies sich als inadäquat für die Analyse der Untersuchungsergebnisse (§ 4, 2). Setzt man bestimmte Hypothesen axiomatisch voraus, so lassen sich die Befunde verwenden, um in den Wahrnehmungsgegebenheiten dieser Säuglinge wirksame Strukturmerkmale zu erkunden (§ 5). Als solche werden in vergleichender Analyse der Untersuchungsergebnisse erschlossen: 1. Mehrheitlichkeit, Geteiltheit des Gegebenen und 2. Erstrecktheit, Länglichkeit bzw. Geballtheit, kompakte Massiertheit des Gegebenen (§ 6). Interindividuelle Unterschiede hinsichtlich ihres Gegebenseins oder Fehlens treten dabei nicht auf für die Strukturmomente der Mehrheitlichkeit, wohl aber für die Strukturmomente der Erstrecktheit bzw. Geballtheit (§ 7). An diesen Befund anschließend wird die Hypothese aufgestellt, daß die frühkindlichen Wahrnehmungsstrukturen in folgender lebensgeschichtlichen Zeitreihe erworben werden: bloße Figur-Grund-Abhebung — Mehrheitlichkeit und Aufgeteiltheit abgehobener Gebilde — Erstrecktheit bzw. Geballtheit abgehobener Gebilde.     

Warum nachhaltige therapeutische Veränderungen im Gehirn Zeit brauchen

Successful psychotherapy requires structural and functional changes in limbic brain centers; however, these differ in manner, effectiveness and dynamics. One primary factor is the therapeutic alliance, i.?e. the mutual trust between patient and therapist. This factor reduces the level of stress hormones via release of the “bonding hormone” oxytocin and increases the production of serotonin and endogenous opioids. As a consequence, a rapid improvement of the mental emotional state of the patient often occurs; however, this is not accompanied by the deeper and longer lasting neuronal changes necessary to treat severe mental illnesses. This occurs only when dysfunctional habits of feeling, thinking and acting residing primarily in the basal ganglia (striatopallidum and nucleus accumbens) and amygdala are reorganized. Rather than being an explicit cognitive process this represents an implicit procedural process, which after an extensive search for resources requires a sufficient length of time and frequent rehearsal of more adaptive emotional attitudes and patterns of behavior. Apparently, this is promoted by the generation of new nerve cells from neural stem cells induced by oxytocin and neurotrophins, such as brain-derived neurotrophic factor (BDNF), taking place in the hippocampus and the basal ganglia. All these facts are in favor of a long-term psychotherapy at least in cases of severe mental diseases.     

Die Religionsfreiheit im Spiegel des Staat-Kirche-Verhältnisses in Finnland

Die Beziehung von Kirche und Staat hemmt seit langem nicht mehr die vollständige Verwirklichung der Religionsfreiheit in Finnland. Für das finnische Modelle ist es Ende des 20. Jahrhunderts kennzeichnend, dass die lutherische Kirche selbst ohne äußeren Druck das Verhältnis zum Staat geklärt hat. Heutzutage gehört Finnland zu den westeuropäischen Ländern, in denen sich der Staat neutral zu den mit der Religion ihrer einzelnen Bürger verknüpften Entscheidungen hält. Dabei gehört zur Religionsfreiheit sowohl das Recht, sich zu einer bestimmten Religion zu bekennen und sie zu praktizieren, als auch ein Recht darauf, sich zu keiner Religion zu bekennen. Die Verwirklichung der Religionsfreiheit des Einzelnen setzt keine einheitliche Verhaltensweise des Staates mit allen in seinem Bereich tätigen Kirchen und religiösen Gemeinschaften voraus. Man geht aber davon aus, dass die Ungleichheit zwischen den religiösen Gemeinschaften nicht die Verwirklichung der Religionsfreiheit aller Bürger aufs Spiel setzen darf. Weil die Entwicklung in Finnland auch in Richtung einer mehr gleichgestellten Stellung religiöser Gemeinschaften führt, so stärkt dies gleichzeitig auch die gesellschaftlichen Voraussetzungen für die Realisierung der Religionsfreiheit des Einzelnen.     

Von der symbolischen Gleichsetzung zur symbolischen Repräsentation im Traum

Since Freud published The Interpretation of Dreams in 1900, the manner in which psychoanalysts understand and interpret dreams has advanced considerably. At the beginning and right up to the 1950s psychoanalysts assumed that patients had the ability to find an access to the symbolic implications of their dreams and to understand the verbal interpretation suggested to them by therapists. Since the 1950s it has become clear that an increasing number of patients proved to be poorly accessible for symbolic implications and that the verbal interpretation of analysts had only little effect. Since then one of the aims of the psychoanalytical process with such patients has been to gradually allow them access to symbolic thinking, which represents the foundations of verbal communication with others and also with oneself.     

Dissoziation und Kreativität—Entrückungen im Alltag

Our everyday life is characterized by changing conditions of awareness up to ecstasy. Ecstasy is a special form of dissociation, which must be differentiated from the pathological-clinical forms of dissociation. Its psychic mechanisms are illustrated by the example of ecstasy during the process of reading. On the basic of the myths of Dionysos and Orpheus as well as in biographies of artists, the ability to reach the state of ecstasy is described as one of the presuppositions for creativity, which must be supplemented by the ability of working through. Reverie and interpretation are the corresponding creative abilities in the psychoanalytical process. Our psychic vitality and creativity results from permanent switches between these different spheres, which must be identifiable as being distinct. The disappearing fonction du réel (Janet)—because of the increasing virtualisation of our everyday life—should be discussed with respect to creativity.