DRG-Vergütung und Kosten stationärer integrierter psychosomatischer Behandlung

Ohne ZusammenfassungDie Autoren M. Rose und R. Lohmann zeichnen für den Beitrag als gleichberechtigte Erstautoren.     

Muster früher Traumatisierung und die Effekte stationärer Psychotherapie

Early traumatic experiences of neglect, physical and sexual abuse in adult patients undergoing inpatient psychotherapeutic treatment were retrospectively assessed. Associations between these three forms of trauma and with patient gender were analyzed. The effects of early traumatization in general, gender and patterns of specific experiences on the symptom level, level of everyday functioning and treatment outcome were also investigated. A total of 191 patients in a psychosomatic psychotherapy ward of a university hospital were assessed using standardized questionnaires on sociodemographic and clinical variables on admission and at discharge. The type and extent of early traumatization before the age of 18 years were estimated after the initial interview from standardized reports of the therapists. The results indicate that the probability of being exposed to one of the traumatic experiences under study are not independent of each other. Furthermore, female patients were victims of sexual abuse and neglect more often than males. Compared to non-traumatized patients, trauma victims exhibited more psychological symptoms in the symptom checklist 90 revised (SCL-90-R) and a lower level of functioning according to the global assessment of functioning (GAF) but achieved a comparable relative benefit from treatment. Sexual abuse (SCL-90-R and GAF) and neglect (SCL-90-R only) affected the levels of impairment on admission and at discharge in a similar way; however, only weak evidence for differential effects of trauma patterns on therapy outcomes was found. Methodological limitations of the present approach and implications for the design of inpatient psychotherapeutic interventions in adult patients with early traumatic experiences are discussed.     

Rückfallanalyse und -bearbeitung bei Alkoholabhängigen

An approach for the psychodynamically oriented work with relapsed alcohol-dependent patients is outlined. A distinction between two types of relapse is made which is based on different motivational and behavioral systems. Type 1 is characterized by the aim to return to self-regulated drinking, beginning with low doses and gradually increasing levels of consumption. Type 2 aims at the immediate elimination of subjectively unbearable emotions and starts with an excessive level of alcohol intake. The distinction is related to the concept of subjective appropriation of dependency and to the personality background of the patient. Consequences for the practical therapeutic work with relapsed alcoholics are proposed.     

Die analytische Monade als Wiege der Realitätsprüfung

The relocation of my practice caused a lot of irritation and trouble, but triggered also psychic improvements in the analytic process with my patients, which is interpreted by referring to the theories of M. Balint and B. Grunberger. It is helpful to focus here on a narcissism concept which is not under instinctual control and to distinguish it from the transference rooted in drive theory. Especially useful proves to be the statement of both M. Balint and B. Grunberger that it is necessary to acknowledge and to affirm the wish of the analysand to establish and experience a pre-objectal “primary love” resp. an analytic monad. In case studies I try to show that the acceptance and affirmation of the projection of not drive-controlled narcissistic omnipotence feelings to the analyst are apt to secure and to preserve the narcissism of the analysand. Only this way can idealization and a stabilizing ego ideal initiate the integration of narcissistic exigencies and instinctual drives and organize the establishment of the reality principle.     

Tatcharakteristika, Rückfallrisiko und Rückfallprognose bei Sexualstraftätern vom Jugend- bis ins Seniorenalter

The basis of this study was a census of all offenses of sexual assault and sexual abuse that were reported to the Berlin police between 1994 and 1999 (N?=?2,446). The purpose was to analyse the particularities of elderly offenders (60 years or older, n?=?68) compared to the 273 juvenile and the 2,105 younger adult offenders with regard to prior offenses, index offenses and recidivism rates. Furthermore, the analysis focused on the prediction of sexual and violent reoffence by means of the static-99 within the elderly age group. The analysis showed that the rate of former sexual offence committed by seniors was comparable to the younger adults; however, sexual and non-sexual violent pre-offences were much less frequent. On the other hand, the seniors were more frequently involved in sexual abuse, their modus operandi showed lesser degrees of intensity of the sexual acts and less use of force and violence (even among sexual abusers only) and group-offence was definitely uncommon. Furthermore the rate of sexual reoffence was similar to the juvenile offenders, but lower in comparison to adult offenders younger than 60 years. A more sophisticated analysis of the age-effects on recidivism-rates confirmed the anticipation of growing risks until middle adulthood and decreasing risks of reoffence afterwards. However, an explicit trajectory of first growing and than decreasing risks in the course of aging could only be found among offenders with sexual abuse, whereas the zenith was shifted in elderly stages of age. On the other hand, among offenders with sexual assaults, the risks of sexual reoffending seemed rather similar until the middle adulthood and increasingly lower in later stages. In spite of these aging-effects and the particularities of the elderly sexual offenders, the static-99 predicted sexual reoffence among the senior offenders quite well and there was no difference in comparison with the total sample.     

Rechtliche Gesichtspunkte zur Rückfallprognose und Vollstreckung bei älteren Straftätern

As our society ages, the number of offenders who are older than 60 when they are up to release from prison or forensic hospital also increases steadily. Instruments of prognosis (e.g. HCR-20, PCL, SVR, Static-99, Dittmann-List) currently in use are not validated for this group, which means that forensic-psychiatric and -psychological experts have to rely on casuistry with all it’s methodical problems for their reports on whether or not there is a risk for relapse (which are obligatory by German law). Therefore the Courts of Execution Matters (in Germany dealing with conditional discharge; same question for any kind of Parole Board in other countries) have to apply standards as provided by the law and the jurisdiction up to the Constitutional Court to a much higher degree than they have to do regarding the much better researched group of younger offenders. In doing so, the focus has to be much more on the special circumstances of senior citizen in general and specifically on the aged offender’s life. There is a urgent need to intensify research on this group of offenders.     

Über Rückfälligkeit bei Umgewöhnung. Teil II. Über Handlungsganzheiten und ihre Bedeutung für die Rückfälligkeit

Ohne Zusammenfassung Mit 6 Textabbildungen (Abb. 8–13). Teil I: Psychol. Forsch.9, 86f. (1927). Infolge verschiedener Umst?nde gelangt Teil II der bereits früher durchgeführten Arbeit erst jetzt zum Abdruck.     

Die psychiatrische Vorgeschichte schizophrener Maßregelpatienten -Rahmenbedingungen der Deliktprävention durch die Allgemeinpsychiatrie

Background

People suffering from schizophrenic disorders are at increased risk of committing violent crimes. In the present study, we investigated the conditions of preventing offences by general inpatient psychiatric services.

Method

The sample enclosed 75 patients treated at forensic hospitals in Baden-Württemberg, Germany. Data on frequency and date of previous delinquency and general psychiatric treatments were collected from the clinical records and from the psychiatric expertise provided for the sentencing.

Results

Prior to the severe offence leading to forensic detainment, eighty-three per cent of the cases had been treated at least once at a general psychiatric hospital while indications of a risk of delinquency were already present. Even if more specific risk indicators were used and patients with only one general psychiatric treatment episode were excluded, nearly two thirds of cases remain as target group for prospective general psychiatric prevention programs. On average, six inpatient treatments during the course of six years would have provided opportunities to prevent delinquency. However, in twenty-five per cent of the cases, the crime leading to admission to a forensic unit took place within an institutional environment (wards, penal institution). Of the offences that were committed outside of an institution, fifty per cent occurred during the first year after a general psychiatric treatment. Two thirds of the sample had committed an offence before first admission to general psychiatric treatment. On average, the first offence preceded the first admission by 4,6 years.

Conclusions

General psychiatric services provide promising opportunities to prevent delinquency among schizophrenics at risk for criminal offending. Specific programs that are effective beyond discharge from a general psychiatric ward should be developed and evaluated.     

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.     

Die Durchführung antiandrogener Behandlung von Sexualstraftätern im Berliner Maßregelvollzug

In 2002, the Forensic Psychiatric Hospital in Berlin started a pilot project for combined treatment of sex-offenders with anti-androgenic LH-RH agonists and psychotherapy. On the basis of experience-based knowledge transfer and with almost six years of practical experience, this article reports results of this new approach of combined psychotherapy and drug treatment from medical and psychological viewpoints. First, a short history and general information about the combined treatment are provided. Secondly, its effects on patients’ sexual self-perception, personality disorders and aspects of prognosis are explored. Thirdly, a medical therapy scheme, possible side effects, as well as issues of patients’ rights and approvals are discussed.     

Zum Problem der methodischen Zugänglichkeit frühkindlicher Formwahrnehmung: Eine Antwort an Rüssel

Ohne Zusammenfassung     

Die Möglichkeit einer objektiven Messung der Stärke von Gefühlen

Zusammenfassung Es war das Ziel, ein Maß für die Stärke von Gefühlen aus einem ihrer physischen Korrelate, der sog. psychogalvanischen Reaktion, zu gewinnen. Zu diesem Zweck wurden Vergleichsurteile über die Gefühlsbetonung von Reizwortpaaren den durch die Darbietung der Wörter ausgelösten Hautreaktionen zugeordnet. Mit den Maßzahlen wurden eine logarithmische Transformation und eine Quadratwurzeltransformation vorgenommen. Die Auswertung erfolgte jeweils gemäß dem Skalierungsverfahren für Vergleichsurteile. Es zeigte sich, daß die auf Grund der Quadratwurzeltransformation erhaltenen Skalenwerte für die Gefühlsstärke in voll befriedigender Weise durch eine Gerade angenähert werden können, während dies mit der logarithmischen Transformation weniger gut gelingt.Um aus der gefundenen Intervallskala der Gefühlsstärke eine Verhältnisskala zu erhalten, wurde die Gefühlsschwelle der galvanischen Hautreaktion zu bestimmen versucht. Es ergab sich, daß der Schwellenwert der emotionalen Veränderung bei der Größe 0 der Hautwiderstandsänderung liegt. Es folgt daraus, daß die Stärke eines Gefühls als der Quadratwurzel der relativen Widerstandsänderung proportional anzunehmen ist.Dieses Ergebnis wird durch ein Anwendungsbeispiel veranschaulicht.     

Die Vorhersage der Rückfälligkeit entlassener Sexualstraftäter mittels des Sexual Offender Risk Appraisal Guide (SORAG) und dessen Screening-Version (SORAG-SV): Darstellung der differentiellen und prädiktiven Validität

The Sex Offender Risk Appraisal Guide (SORAG) is one of the most important actuarial risk assessment instruments for sexual offenders. In the meantime, the application of actuarial instruments in recidivism risk assessment for sexual offenders is regarded as state of the art. In addition to results about interrater reliability and concurrent validity we present results about the differential and predictive validity of the SORAG and a screening version of the SORAG (SORAG-SV), which relies only on file information. In order to examine the predictive validity, we used a representative sample of 519 male sexual offenders released from a prison sentence served in one of Austrian´s prisons with a mean follow-up period of 3½ years. Furthermore, we tested the differential validity by dividing the whole sample in different subsamples regarding age, index offense type, and degree of antisociality. Both SORAG and SORAG-SV showed predominantly good predictive accuracy which, however, varied depending on offender subgroup and recidivism category.     

Die Bedeutung der Säuglingsforschung, Bindungstheorie und Neurowissenschaften für den psychoanalytischen Prozess

Zusammenfassung Die Ergebnisse von Säuglingsbeobachtungen und der Interaktionen in der Mutter-Kind-Dyade gingen bereits früh im Verlauf der Theoriegeschichte der Psychoanalyse in deren entwicklungspsychologische, psychodynamische und behandlungstechnische Überlegungen ein, beispielsweise bei Spitz und Winnicott. Winnicotts Konzept vom wahren Selbst (1960) hat noch heute Aktualität. Aus heutiger Sicht (Fonagy et al. 2004) fällt ein Teil des Selbst bereits früh aus dem Mutter-Kind-Dialog heraus, indem er von der Mutter nicht oder nur unzulänglich gespiegelt wird und deshalb nicht integriert werden kann. Klöpper zeigt, dass es zum impliziten Beziehungswissen des Kindes und des späteren Patienten gehört, dass bestimmte Seiten seines emotional-affektiven Erlebens keinen Eingang in seine aktuellen Beziehungen finden können. Hier setzen behandlungstechnische Konzepte von Psychoanalytikern unter den Säuglingsforschern (Beebe u. Lachmann 2002; Stern 1998) an und zeigen Wege auf, wie das wahre Selbst wieder zu beleben ist. So jedenfalls interpretiert der Autor deren Konzepte und zeigt an einer Behandlungsvignette die Grundzüge des behandlungstechnischen Vorgehens dabei. Klöpper schlägt vor, den Zustand des Selbst während der analytischen Arbeit stets unter drei Gesichtpunkten zu reflektieren: (1) entwicklungsbedingte Defizite, (2) ungelöste Konflikte und (3) Kolonisierung durch Affektzustände der primären Beziehungspersonen (Fonagy et al. 2004). Den Ergebnissen der Säuglingsforschung entnimmt er drei behandlungstechnische Prinzipien: (1) ständige Beachtung der gegenseitigen regulatorischen Prozesse in der analytischen Dyade mit deren Unterbrechung und Wiederherstellung; (2) ständige Bereitschaft des Analytikers, in diesem Kontext seine Selbstobjektfunktion zur Verfügung zu stellen; (3) ständiges Bestreben des Analytikers, die zugehörigen Beziehungszusammenhänge im Hier und Jetzt explizit deutend bewusst werden zu lassen. Die kontinuierliche Beachtung dieser Prinzipien ermöglicht das Bewusstwerden impliziten Beziehungswissens (Lyons-Ruth 1998), lässt neues implizites Beziehungswissen entstehen und ermöglicht dem Analysanden die Bildung sekundärer Repräsentanzen seiner Affekte (Fonagy et al. 2004).

---

The importance of infant research, attachment theory and neurosciences for the psychoanalytic process

The results of infant observation and of the ineractions in the mother-child-dyad were early in the development of psychoanalytic theory included into the considerations about developmental psychology, psychodynamics and treatment techniques, e.g. by Spitz and Winnicott. Winnicotts concept of the true self (1960) is still valid. In contemporary view (Fonagy et al. 2004) one part of the self is excluded from the mother-child-dialogue being not at all or insufficiently mirrored by the mother. Consequently, it cannot be integrated. Klöpper shows that implicit relational knowledge of the child or patient includes the recognition, that some parts of his emotional-affective experience cannot be brought into his actual relationships. At this point, technical concepts of the psychoanalysts among the infant researchers (Beebe u. Lachmann 2004; Stern et al.1998) are helpful to show the ways how to revive the true self. At least, this is the view of the author about these concepts. He also presents a case study to demonstrate the technical procedure in this reviving process. Klöpper proposes to reflect the state of self during the analytical process continously under three point of views: 1. developmental deficits; 2. unsolved conflicts; 3. colonization by the affective states of primary attachment persons (Fonagy et al. 2004). The results of infant research show him three treatment technical principles: 1) constantly paying attention to the mutual regulatory processes in the analytical dyad, and to its disruption and repair; 2) constant readiness of the analyst to offer his self-object-function in this context; 3) constant effort of the analyst to make possible by explicit interpretations to become aware of the connected implicit relational contexts in the Here-and-Now of the actual relationships. The continuous application of these principles allow that implicit relational knowledge becomes conscious (Lyons-Ruth 1998), new implicit knowledge can develop and secondary representations of the own affects can be formed (Fonagy et al. 2004)

---

---

Überarbeitete Fassung eines Vortrages vor der Arbeitsgemeinschaft für integrative Psychoanalyse, Psychotherapie u. Psychosomatik (APH, Hamburg) am 06.04.2003 und anlässlich der Psychotherapie-Tage auf Langeoog im Mai 2003.