Symptomattributionsstile bei Hypochondrie

Background

Somatic symptom attributions are of central importance in cognitive-behavioral models of the development, maintenance and treatment of hypochondriasis. However, the mode of symptom attribution has rarely been systematically investigated in these patients. Is a somatic mode of symptom attribution indeed specific for hypochondriasis and furthermore, how strongly is it associated with “doctor shopping”, a typical behavioral consequence of hypochondriasis?

Patients and methods

In this study 88 hypochondriacal, 52 depressive and 52 healthy persons were asked to complete the symptom interpretations questionnaire and several standardized symptom questionnaires. They also took part in two structured clinical interviews for the diagnosis of hypochondriasis and various other psychological disorders according to DSM-IV.

Results

Somatic symptom attributions were associated specifically with hypochondriasis, while normalizing attributions characterized persons with low health anxiety. When examined as predictors in multiple regression models, in particular somatic attributions and the total of somatoform complaints predicted the intensity of health anxiety (R ²?=?0.69) and “doctor shopping” (R ²?=?0.48).

Conclusion

In the cognitive-behavioral treatment of hypochondriasis, patients should be encouraged to test normalizing explanations as alternatives to habitual somatic attributions of somatic disturbances.     

Positive und negative Metakognitionen über Krankheitssorgen

Background

Metacognitions have been shown to be relevant in the emergence and maintenance of worry processes, particularly for generalized anxiety disorder (GAD). In contrast, metacognitions have been neglected in hypochondriasis and health anxiety, perhaps due to the traditional assignment of hypochondriasis to the somatoform disorders. Is worrying about illness associated with metacognitions and are these associated with other features of health anxiety?

Material and methods

In this study 1,246 people took part in an online survey. Items capturing positive (PM) and negative metacognitions (NM) were presented together with instruments for the assessment of health anxiety and depressive symptoms. The dimensional structure of PM and NM over illness worries was examined with nonlinear confirmatory factor analyses. Associations with depressivity and the number of consultations by different physicians were examined in structural equation models (SEM), separately for subgroups with and without a diagnosed somatic disease.

Results

The PMs and NMs about illness worries varied relatively independently from one another along two dimensions. The PMs were specifically associated with health anxiety and the number of different physician consultations and NMs were related to all dimensions of the Whiteley index and particularly strongly to depressivity.

Conclusions

Illness-related anxiety provokes metacognitions, similar to other worries as known from GAD. Considering the strong associations of PMs and NMs with several facets of health anxiety found, it appears promising to take them into account for the formulation of cognitive-behavioral models of health anxiety and its treatment.     

Health anxiety and hypochondriasis in the light of DSM-5

Background: In the DSM-5, the diagnosis of hypochondriasis was replaced by two new diagnositic entities: somatic symptom disorder (SSD) and illness anxiety disorder (IAD). Both diagnoses share high health anxiety as a common criterion, but additonal somatic symptoms are only required for SSD but not IAD. Design: Our aim was to provide empirical evidence for the validity of these new diagnoses using data from a case–control study of highly health-anxious (n = 96), depressed (n = 52), and healthy (n = 52) individuals. Results: The individuals originally diagnosed as DSM-IV hypochondriasis predominantly met criteria for SSD (74%) and rarely for IAD (26%). Individuals with SSD were more impaired, had more often comorbid panic and generalized anxiety disorders, and had more medical consultations as those with IAD. Yet, no significant differences were found between SSD and IAD with regard to levels of health anxiety, other hypochondriacial characteristics, illness behavior, somatic symptom attributions, and physical concerns, whereas both groups differed significantly from clinical and healthy controls in all of these variables. Conclusion: These results do not support the proposed splitting of health anxiety/hypochondriasis into two diagnoses. Further validation studies with larger samples and additional control groups are warranted to prove the validity of the new diagnoses.     

Scham und Familienbeziehungen bei Bulimie

Background

Empirical studies show a relationship between family factors and disturbed eating behavior. Feelings of shame are associated with a higher level of eating disorder symptoms and with family relations perceived as being dysfunctional. Thus shame can be understood as a mediator of the relationship between dysfunctional family relations and eating disorder symptoms.

Material and methods

For 69 female patients, including 55 with bulimia nervosa and 14 with eating disorder not otherwise specified (EDNOS) between 14 and 22 years of age, who participated in a comparative study of psychotherapy outcome, eating disorder symptoms (EDI, EDE-Q), general psychiatric symptoms severity (SCL-90R), level of shame (TESE-KJ) and perceived family relations (FB-A) were measured at the beginning of psychotherapy.

Results

The higher the feeling of shame the more dysfunctional the perceived family relationships were and the more the eating disorders and general symptoms severity were reported. Shame was a partial mediator of the relationship between family functionality and symptoms.

Discussion

Feelings of shame could originate in dysfunctional family relationships but could also evoke more negative perceptions of interpersonal relationships. The direction of causality could not be proven in the correlative design; nevertheless, shame contributes to an understanding of the mechanisms between dysfunctional family relationships and eating disorder symptoms.     

Hypochondriasis Among Patients with Multiple Somatoform Symptoms—Psychopathology and Outcome of a Cognitive-Behavioral Therapy

As hypochondriasis often occurs with somatization, patients with somatization disorder plus hypochondriasis were compared to patients with somatization syndrome alone regarding psychopathology, patterns of physical symptoms and outcome of a cognitive-behavioral inpatient treatment. A sample of patients with DSM-IV hypochondriasis and multiple somatoform symptoms(N = 27) and a matched sample of patients with multiple somatoform symptoms but without hypochondriasis (N = 27) were assessed. All subjects obtained a cognitive-behavioral treatment for somatization and hypochondriasis. Assessment took place at admission and at one-year follow-up. Only a few differences between the groups were found: Hypochondriacs suffered more often from abdominal pain, and they reported a higher intolerance of bodily complaints. At follow-up, all outcome variables improved significantly. High effect sizes were found for the reduction of symptoms and the mean number of visits to the doctor. The specific effect on health care use highlights the socioeconomic relevance of these results.     

Krankheitsbelastung bei chronisch entzündlichen Darmerkrankungen

Background

Psychosocial distress is considerable in inflammatory bowel disease (IBD). The aim of this study was to assess the association of illness perceptions with disease-specific distress in patients with IBD in the context of various medical and psychological parameters.

Method

A total of 62 patients suffering from IBD were examined for illness perceptions using the illness perception questionnaire revised (IPQ-R), medical parameters and affective parameters using the hospital anxiety and depression scale (HADS) in a cross-sectional study. Associations with disease-specific distress were assessed.

Results

In multiple regression analyses illness perceptions and also physical well-being were identified as significant predictors of disease-specific distress and showed significant effects on the explanation for the amount of variance (R²=0.70).

Conclusion

Even in the context of various medical and psychological parameters illness perceptions showed significant associations with disease-specific distress in patients with IBD.     

Erfahrungsorientiertes Lernen in der Psychotherapie

Background

Based on principles of experiential learning, psychophysical exposure (PPE) on a tightrope course offers a promising intervention in the treatment of patients with mental disorders. A PPE program conducted on a hospital tightrope course is presented as an adjunct in inpatient psychotherapy.

Methods

The acceptance and effectiveness of the PPE were evaluated in a prospective controlled naturalistic study. A total of 155 patients, who were exposed at least once during their inpatient therapy, were compared with 92 control patients, who did not participate in the tightrope course. The main outcome criteria were self-reported depressive symptoms, state anxiety, locus of control, self-efficacy, and trait anxiety.

Results

The PPE was highly accepted by the participants. Patients who attended the tightrope courses showed greater improvement in the outcome criteria than patients who received inpatient treatment as usual. Particularly better effects were found on the personality variables.

Conclusions

Psychophysical exposure can successfully and effectively be integrated into a psychosomatic inpatient treatment program. Methodological limitations of the study, especially threats to internal validity, are discussed.     

Migranten in sozial schwachen Stadtteilen von Berlin

Background

The aim of the present study was to compare psychological distress and substance use between migrant and non-migrant populations in a socially deprived area of Berlin.

Methods

A population-based random sample stratified for age (18?C57?years) and gender (50% female) was retrieved from the registration office. A total of 143 persons were included in the study. The participation rate was 48.5% when contact was established. Psychological distress was assessed using the General Health Questionnaire (GHQ-28) with its four subscales, somatic symptoms, anxiety/insomnia, social dysfunction and severe depression. Substance use was quantified using the Alcohol Use Identification Disorder Test (AUDIT) and the Fagerstr?m Test for Nicotine Dependence (FTND).

Results

Of the study population 51.3% were first or second generation migrants and lived more often in single households. Migrants had lower educational levels and lower employment rates. The mean scores of migrants and non-migrants did not differ on any of the subscales somatic symptoms, anxiety/depression, social dysfunction or severe depression of the GHQ-28. Non-migrants showed significantly higher risks regarding alcohol use.

Discussion

The present study did not reveal any differences regarding symptom profiles in the spectrum of anxiety and depression between non-migrants and migrants who lived in a socially deprived area. Migrants may compensate higher social risk profiles with lower risks regarding alcohol use. Larger samples have to inform on possible differences regarding smoking and other substances.     

Diagnostik der Hypochondrie

In the current review the criteria for the diagnosis of hypochondriasis in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) are compared with the criteria for illness anxiety disorder in DSM-5 and differences are discussed. A current review of instruments for the dimensional assessment of the severity of hypochondriasis and associated characteristics (illness-related cognitions and safety behavior) is given. Possible ways of implementing these instruments for planning and evaluating therapy are specified. Furthermore, economical screening methods, which could be broadly applied in medical contexts to identify patients with pronounced illness anxiety in order to offer effective treatment are described and discussed. This procedure would not only lead to a reduction of strain in the person concerned, it would also be connected with financial relief for the health care system.     

Trauma und sexuelle Störungen

Background

Sexual disorders are common among patients with traumatic childhood experiences, especially when they were exposed to sexual abuse. Despite the fact that trauma-associated sexual disorders imply serious consequences for the persons concerned, to date the topic has not found much consideration in the research and clinical contexts.

Material and methods

This study investigated the prevalence and relationships of sexual disorders and experiences of sexual abuse in 189 patients (81?% women, 19?% men) with complex posttraumatic stress disorder. All participants completed the Interview zur Diagnostik der komplexen posttraumatischen Belastungsstörung (I-kPTBS, interview on diagnostics of complex posttraumatic stress disorder) and the traumatic antecedents questionnaire (TAQ).

Results

At least one sexual disorder was found in 77.2?% of the participants. In both sexes hyposexual disorders were more common than hypersexual disorders. Women showed more hyposexual disorders than men and men showed more hypersexual disorders than women. Of the participants 50.8?% reported experiences of sexual abuse and women were more often affected than men. The presence of hyposexual disorders was clearly associated with the existence of experiences of child sexual abuse.

Conclusion

There is a need for research on and effective treatment concepts for trauma-associated sexual disorders. The development of new therapeutic approaches should be realized in interdisciplinary cooperation.     

Schwere Anorexia nervosa

Background

Psychosomatic support during acute medical treatment of patients with anorexia nervosa is a special need but up to now a rare constellation. These patients can barely accept necessary somatic procedures even if they suffer from severe consequences of the eating disorder. The ambivalence of patients towards treatment is explained by the loss of the right perception of their bodies and the strong obsession with further weight loss.

Methods

This article reports on eight consecutively treated patients on a medical ward who received a liaison psychosomatic, psychotherapeutic visit twice a week. The aim was to maintain better therapy adherence, to support oral food intake and understanding of the disorder as well as to motivate patients for further psychosomatic treatment.

Results

By means of a respectful cooperation between the departments of internal medicine and psychosomatics it was possible to gain psychotherapeutic access to the patients in this highly complicated situation.

Consequence

The psychodynamic aspects of this collaboration are discussed with a focus on the triangulation of the therapeutic process.     

Systemische Therapie bei Störungen des Erwachsenenalters

Background

Systemic therapy is a scientifically acknowledged form of psychotherapy in the US and many European countries, but not yet in Germany.

Method

All randomized (or parallelized) controlled trials (RCT) evaluating systemic couples/family/individual therapy with adult index patients published in English, German or Spanish up to the end of 2004 were identified via data base searches and cross-references in other meta-analyses and reviews. A meta-analysis of the identified RCT was performed.

Results

28 RCT (43 publications) evaluating systemic therapy with adult index patients suffering from clinical disorders (ICD-10) were identified. Systemic therapy is efficacious with regard to substance disorders, mental/social factors interacting with somatic disorders, schizophrenia, depression and eating disorders. The results are stable across follow-up periods of up to 5 years.

Conclusion

According to the criteria of the German Scientific Advisory Board Psychotherapy (Wissenschaftlicher Beirat Psychotherapie) there seems to be good evidence for the efficacy of systemic therapy in at least four fields of application of adult psychotherapy.     

Die Abschaffung der somatoformen Störungen durch DSM-5 – ein akademischer Schildbürgerstreich?

The new fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has introduced “somatic symptom disorder” as a diagnosis which is no longer differentiated into medically unexplained and explained physical symptoms. As a consequence, the status of somatoform disorders as an independent clinical group is called into question. Against all original intentions, the semantic, conceptual and practical problems of the previous classification have not been solved. The validity of the new diagnosis is doubtful because of its over-inclusive character. Further points of criticism are the less than optimal selection of psychological features, the abandonment of hypochondriasis as a homogeneous concept and imprecise workmanship of the diagnostic criteria where exclusion criteria needed for differential diagnosis are missing.     

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.     

Cognitive-affective neuroscience of somatization disorder and functional somatic syndromes: reconceptualizing the triad of depression-anxiety-somatic symptoms

Somatization disorder is a somatoform disorder that overlaps with a number of functional somatic syndromes and has high comorbidity with major depression and anxiety disorders. Proposals have been made for revising the category of somatoform disorders, for simplifying the criteria for somatization disorder, and for emphasizing the unitary nature of the functional somatic syndromes in future classifications. A review of the cognitive-affective neuroscience of somatization disorder and related conditions suggests that overlapping psychobiological mechanisms mediate depression, anxiety, and somatization symptoms. Particular genes and environments may contribute to determining whether symptoms are predominantly depressive, anxious, or somatic, and there are perhaps also overlaps and distinctions in the distal evolutionary mechanisms that produce these symptoms.     

Klinisch-psychologische Intervention im Internet

Background

Currently a multitude of Internet-based intervention (IBI) programs exist for various disorders. These programs generally have the potential to reach a wide spectrum of the low threshold population and encourage them to play a more active role in managing individual healthcare. How effective are disorder and problem-specific IBI programs? This review aims to give a systematic overview of controlled evaluation studies available to date and contrast them with the state of research in 2003 (Ott 2003).

Method

References were analyzed in three steps: 1. Research in pertinent international scientific databases using specified keywords (result: more than 1,000 publications since 2003). 2. Selection: exclusion of publications which did not contain empirical evidence of effectiveness (with control group design) (result: 89 studies published between 2003 and 2009 as opposed to 30 up to 2003). 3. Systemization: classification of the analyzed studies based on two dimensions (type of syndrome, function of intervention).

Results

In most of the studies on hand (91.0%) the effectiveness of IBI could be confirmed. Among the methods used cognitive behavioral methods (cognitive, behavioral therapy, CBT) were used almost exclusively. In nearly three quarters of all studies (71.9%), IBI procedures were used for treatment. The remaining studies were on prevention (19.1%) and rehabilitation (9.0%).

Conclusion

Evaluation studies of IBIs are now available, particularly for anxiety disorders, depression, posttraumatic stress disorder, eating disorders including adiposity, substance-related and behavioral medical disorders, psychological problems related to physical illnesses, compulsive gambling and burnout. For each type of disorder, exemplary programs are described. Subsequently the methodical limitations of several of the studies are pointed out.     

Schizophrene Patienten der forensischen Psychiatrie im Vergleich zu schizophrenen Patienten der Allgemeinpsychiatrie

Background

The number of schizophrenic patients admitted to forensic hospitals according to section 63 of the German Criminal Code has increased continuously over the past years. Some researchers assume that these forensic patients form a group of patients with very complex mental disorders, a number of risk factors and insufficient pretreatment in general psychiatry. This study aimed to identify differences regarding the history of treatment of forensic and general psychiatric patients diagnosed with schizophrenia.

Method

The matched samples included 72 male patients from forensic wards and 72 male patients from general psychiatric institutions diagnosed with schizophrenia. The history of psychiatric treatment was reconstructed by interviewing the patients as well as outpatient psychiatrists and patients’ legal custodians and by analyzing patient medical records.

Results

In contrast to the general psychiatric patients, prior to admission forensic patients were less integrated into psychiatric care and showed a lower rate of treatment compliance. They also showed a higher rate of previous compulsory treatment because of aggressive behavior towards other persons as well as higher rates of treatment difficulties and violent behavior during previous inpatient treatment. Furthermore, forensic patients had a higher number of previous criminal convictions and had been convicted more often for violent offences. With regard to other relevant risk factors (e.g. comorbid substance abuse disorder, age, education, conduct disorder, antisocial personality disorder, previous exposure to violent and abusive behavior) the two patient groups were, however, comparable.

Conclusions

Regarding schizophrenic patients with comorbid substance abuse disorders, previous violent delinquency and violent behavior during previous inpatient treatment, an intensive outpatient aftercare should be arranged before they are discharged from general psychiatric institutions.     

Psychische Beschwerden und Störungen von Studierenden

Background

Psychological distress among students is receiving growing attention in the scientific community as well as in the general public. There are counseling services available in student societies and universities which address psychological distress among students but scientific research in this area is rudimentary and poorly represented.

Problem in question

In order to present the prevalence, extent and type of psychological disorders in students and the alterations over time, an investigation was carried out to show which psychological complaints and disorders were present in students who consulted a psychotherapeutic counseling center. These data were compared with the psychological complaints of a student field study population. Furthermore, alterations in the psychological complaints and disorders of students over periods of 10 and 15 years will be presented.

Methods

The prevalence and change over time of psychological syndromes in students were identified by a comparison between an unselected sample of counseling center clients and several student field samples from the previous 15 years. The type of distress and severity of symptoms were measured with a Symptom Checklist (SCL-90-R), the Psychosocial Complaints List (PSB), the Satisfaction With Life And Studies Scale (LSZ), the diagnostic assessment according to International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10), the Complaints Severity Score (BSS) and Global Assessment of Functioning (GAF).

Results

Previous results of investigations which showed that 20–25% of students suffer from psychological disorders could be confirmed in this study. However, 60–65% of the clients of a counseling center suffered from clinically relevant psychological disorders, which is significantly higher. The most common disorders were depressive moods, lack of self-confidence and exam anxiety, which can mostly be diagnostically assigned to adjustment, depression and anxiety disorders. The comparison with previous studies showed that the types and severity of psychological distress among students have remained stable over the last 15 years, with the exception of test anxiety which increased by 51% from 1993 to 2008. With respect to alcohol abuse, considerably less impairments were found than had been assumed based on the earlier investigations.

Conclusions

Psychological complaints and disorders are frequently found among students and they cause individual suffering as well as economic expenses. Noticeable was the obvious increase in clinically relevant exam anxiety. Psychological-psychotherapeutic counseling centers make an important contribution to screening, clinical assessment, primary health care and prevention of severe mental disorders among students and have shown a continuously increasing number of cases in recent years. Further studies especially in a process-outcome design of the mostly eclectic counseling centers are needed and possibilities will be presented.     

Dyadische Planungsintervention nach Prostatektomie

Background

Prostate cancer is one of the most prevalent forms of cancer in men. One treatment for localized prostate cancer is radical prostatectomy. Patients and partners have to deal with stressors associated with the diagnosis, the surgery and its consequences (e.g. incontinence). Dyadic planning prepares for the coping process with illness consequences in order to enhance self-regulation and reduce anxiety. Dyadic planning means generating plans together with a partner specifying when, where and how the target person wants to initiate a health behavior.

Patients and methods

In this longitudinal randomized controlled trial (RCT) 112 prostatectomy patients and their spouses were invited to participate in a dyadic planning intervention. Participants were randomly allocated to a dyadic pelvic floor exercise (pfe) planning group or one of three control groups (i.e., individual pfe planning, dyadic or individual nutrition planning). Patients and partners received questionnaires at baseline, 2 weeks and 6 months after surgery.

Results

Patients in the dyadic pfe planning group reported higher dyadic pfe planning 2 weeks after surgery than patients in the nutrition planning groups. No such differential effects were found in partners. Additionally, there were no group differences in patient reports on anxiety 6 months after surgery, whereas partners in the dyadic pfe planning group reported lower anxiety levels compared to partners in the individual pfe planning group. Self-reported pfe planning did not, however, mediate the effects of the intervention on partners?? anxiety.

Conclusion

Economical dyadic planning interventions may not only support change of health-relevant behaviour in target persons but also emotional adjustment of their partners.     

Nachsorge nach station?rer Psychotherapie f��r Essst?rungen

Background

Despite high relapse rates there is a lack of feasible, effective and efficient interventions to provide aftercare support to patients who complete treatment for an eating disorder. A program based on the short message service (SMS) and text messaging has been developed in order to provide such additional support to patients who undergo inpatient treatment for an eating disorder.

Materials and methods

A total of 165 patients with bulimia nervosa or an eating disorder not otherwise specified were randomly assigned either to the intervention group (n?=?82) with access to the text messaging intervention for 4 months following discharge from hospital or to the control group (n?=?83). The efficacy of the intervention was determined via the three eating disorder related subscales of the Eating Disorder Inventory (EDI-2) at 4 and 8 months follow-up and via the frequency of self-reported binge eating and compensatory behaviors (vomiting and abuse of laxatives) in the Short Evaluation of Eating Disorders (SEED) at 8 months follow-up.

Results

Participants in the intervention group reported significantly lower impairment on the EDI scales drive for thinness and body dissatisfaction both at 4 and 8 months follow-up. They also reported significantly fewer episodes of binge eating and vomiting. No differences were found for the EDI subscale bulimia and for the frequency of the use of laxatives.

Conclusion

The intervention based on text messaging proved efficacious in the aftercare treatment of patients with eating disorders. Chances and limitations concerning its use in the clinical routine as part of a stepped care model are discussed.