Begutachtung von somatoformen Störungen

As a result of their prevalence somatoform disorders represent a substantial burden not only for health care systems but also for social security and pension programs around the world. In fact, in recent years there has been a steady increase in the number of applicants filing for disability pensions due to such disorders. Recent studies focus on the relationship between biological, psychological and social factors and the subjective experience of somatoform symptoms and their concomitant impairments. Despite this progress, diagnostic work in general remains a challenge. The purpose of this paper is first to discuss a dimensional diagnostic system for somatoform disorders. Secondly based on the dimensions of this diagnostic system, considerations regarding the differentiation of the diagnosis “pain disorder” will be made. Furthermore, considerations concerning the severity and prognosis of somatoform disorders are presented. These considerations should help to assess vocational disability.     

Einschränkungen der Willensfreiheit bei somatoformen Störungen

Etiopathogenetic models of somatoform disorders and philosophical concepts of free will refer to theories of affect processing: affective dysregulation can promote psychosomatic ailments as well as problems in decision making. This observation brings forth the question if freedom of will is impaired in persons with somatoform disorders. By compiling, analyzing and contextualizing relevant models of current neuroscience, psychosomatic medicine and philosophy the psychodynamic construct of alexithymia as an etiologic factor of somatoform disorders and the conceptual integration of affective factors in a model of free will are developed on the basis of a common concept of affect. The synthesis of the discussed results and considerations, the multidimensional impairment of the ability to decide freely and self-determinedly due to somatoform disorders, is critically reflected; however, a blanket assumption is not admissible.     

Zur Inanspruchnahme medizinischer Leistungen bei Patienten mit somatoformen Störungen

Zusammenfassung Somatoforme Störungen sind für das Gesundheitssystem sowohl wegen ihrer hohen Prävalenz und auch wegen der intensiven Inanspruchnahme medizinischer Leistungen von großer Bedeutung. Auch bei psychotherapeutischen Interventionen muss dies berücksichtigt werden, da eine Normalisierung des Inanspruchnahmeverhaltens ein zentrales Behandlungsziel sein sollte. In der vorliegenden Studie wurden Häufigkeit ambulanter Arztbesuche und Variablen des Inanspruchnahmeverhaltens untersucht. Insgesamt wurden 295 Allgemeinarztpatienten mit mindestens zwei organisch nicht hinreichend begründbaren Beschwerden in die Studie aufgenommen. Psychische Störungen und die Inanspruchnahme des Versorgungssystems wurden mit einem strukturierten Interview erhoben; daneben wurden zahlreiche Fragebögen eingesetzt. Die Mehrheit (82%) der untersuchten Patienten erfüllte die Kriterien von mindestens einer somatoformen Störung. Die Anzahl der Arztbesuche in den letzten 6 Monaten belief sich im Mittel auf 15 Kontakte. Sie korrelierten mit der Anzahl somatoformer Symptome, dem Alter, Gesundheitsängsten, genereller Angst und Depressivität. Die Regressionsanalyse bestätigt nur die Symptomanzahl und das Alter als signifikante Prädiktoren des Inanspruchnahmeverhaltens. Implikationen für die Therapie dieser Patientengruppe unter besonderer Berücksichtigung des Hausarztes werden diskutiert.     

Psychische Störungen bei HIV-Infektion und Aids

The human immunodeficiency virus (HIV) is the pathogen responsible for acquired immune deficiency syndrome (AIDS). Worldwide there are currently about 40 million people infected with HIV and an estimated 44,000 in Germany. If left untreated after a few years the infection leads to the manifestation of AIDS and eventually to death through opportunistic infections and malignant tumors. Infection with HIV is not curable. Nevertheless, antiretroviral treatment can slow the progress of the disease and prolong life expectancy significantly. Once antiretroviral treatment has started the medication must be taken regularly and lifelong. Serious side effects of the medication pose a significant stress on physical and psychological well-being and impair adherence. Infection with HIV means a total change in life perspectives and requires extensive adaptations in lifestyle. Problems with adaptation and mental disorders (e.g. depression, anxiety disorders, adjustment disorder) are, therefore, frequent. With disease progression neurocognitive impairments are increasingly likely. Mental disorders and neurocognitive impairments adversely affect treatment adherence, increase health risk behavior and reduce immune function. Psychological interventions contribute significantly to the reduction in health risk behavior, improve treatment adherence and are successful in the treatment of depression and anxiety.     

Verhaltenstherapie bei dissoziativen Störungen

Zusammenfassung Epidemiologische Daten bezüglich dissoziativer Auffälligkeiten werden vorgestellt. Diagnostizierbare dissoziative Störungen werden im Bereich des pathologischen Pols eines Kontinuums dissoziativer Phänomene eingeordnet. Ausgehend von der allen dissoziativen Störungen gemeinsamen Kernsymptomatik der strukturierten Separation mentaler Prozesse aus der ganzheitlichen Wahrnehmung wird ein universelles Ätiologiemodell dieser Erkrankungen dargestellt. Es basiert im Wesentlichen auf neueren Erkenntnissen der Neurobiologie und Gedächtnisforschung und bezieht sich auf die Traumatisierung als zentralem pathologenetischem Agens. Hiervon ausgehend, wird ein 2-phasiges Therapiemodell vorgestellt. Als Ziel wird ein Aussetzen bzw. eine Reduktion der dissoziativen Symptome über eine Integration der traumatischen Erfahrungen angestrebt. Die beschriebenen therapeutischen Vorgehensweisen sind grundsätzlich bei allen traumatisch bedingten dissoziativen Störungen anwendbar. Auf Konversionssymptome sowie die dissoziative Identitätsstörung wird als Sonderfälle separat eingegangen.Der Text basiert auf dem gleichnamigen Vortrag, den die Autorin am 24.10.2003 auf dem 5. Wissenschaftlichen Kongress der Deutschen Ärztlichen Gesellschaft für Verhaltenstherapie in Bad Pyrmont gehalten hat.     

Videotherapie bei postpartalen Störungen

Video recording is currently part of in- and out-patient therapy programs for parents with infants. The observation and analysis of video sequences allow the patient to gain an extraordinary insight with respect to its own experience and behaviour. Video Microanalytical Therapy (VMT) looks for the mother’s positive qualities in her relationship to the child and employs these qualities in order to support successful interactions. VMT is well-suited to the treatment of mothers with postpartal affective or psychotic disorders, because the typical cognitive distortions and reduced perception shown by these mothers can be avoided to a large extent through the use of pictures. In this study, a video microanalytical therapy concept will be presented, that was developed for the treatment of postpartally disordered mothers at the Psychiatric Centre Nordbaden in Wiesloch, Germany.     

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.     

Angst- und stressbedingte Störungen

Anxiety and stress-induced disorders are used in this contribution as an example to demonstrate how effectively neurobiological research findings can be used to improve psychotherapeutical interventions. The acquisition and facilitation of maladaptive coping strategies is the result of the activation of a cascade of emergency reactions which cannot be halted by the activation of available pro-adaptive coping strategies. Such experiences of uncontrollability and helplessness undermine the most essential resources to deal with stress and pave the way to the manifestation of disturbances at the level of secure attachment, self-efficacy, trust, affect control, self-regulation etc. Psychotherapeutic interventions will be most effective if they focus on the restoration of the resources at the level at which the maladaptive coping pattern became primarily stabilized (relational, emotional, cognitive approaches).     

Somatoforme Störungen und Bindungstheorie

Somatoform disorders are not only marked by somatic symptoms, but also by significant disturbances in interpersonal relationships. Interpersonal difficulties – including the maladaptive pattern of illness behavior and the resulting difficult doctor-patient-relationship – are an important field of therapeutic intervention (Nickel u. Egle 1999). The interpersonal problems which are characteristic in patients with somatoform disorders draw attention to the developmental aspects of these conditions. Attachment theory provides a promising framework for understanding these developmental features. In the paper presented we therefore apply concepts and observations from attachment theory to somatoform disorders. After a brief review of attachment theory we specifically discuss the developmental aspects of representation formation in somatization. As next, empirical evidence is reviewed that link attachment insecurity to the development of somatoform disorders. Finally a vulnerability model of somatoform disorders is outlined.     

Psychodynamische Psychotherapie bei antisozialen und psychopathischen Störungen der Persönlichkeit

Important theoretical basic principles of the psychodynamic treatment of patients with antisocial and psychopathic personality disorders are presented. Focusing on delinquency and general orientation to the structural level of the personality organization should be integrated. Indications of treatment difficulties, countertransference problems and technical principles are given. Skepticism of the treatment is poorly evidence-based and forensic psychotherapy of these patient groups should be intensified.     

Psychotische Störungen und komorbide Suchterkrankungen

Approximately half of the people with psychotic disorders from the schizophrenia group also develop a comorbid addictive disorder during their lifetime. These so-called dual diagnosis patients (DD) are difficult to treat. They have poor compliance and frequent relapses, they often present with aggressive behavior towards themselves and others and the long-term sociorehabilitative outcomes are poor.In this article the different models for the understanding of the high comorbidity between psychoses and substance use disorders are explained and the principles for an integrated treatment of DD patients are outlined. Low-threshold, motivational, integrated treatment programs with psychoeducative and behavioral therapeutic elements are helpful and should be more extensively implemented; however, long-term treatment methods are needed and therapeutic goals must be realistic and not set too high.     

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.