Psychische Betreuung von Patienten und Angehörigen in der Transplantationsmedizin

During the decision making process and waiting period before organ transplantation patients and their families often suffer from psychological distress. After transplantation a subgroup of patients keeps showing psychological symptoms and also impairments of quality of life. Psychological treatment manuals are often demanded, but are rarely achieved. This study describes the experience with a low frequent (8 sessions/year) therapeutic group for lung transplant candidates. The group, which is based on a cognitive behavioural concept, is lead by a physician (internal medicine), a psychotherapist and a physiotherapist. This therapeutic group has been continuously offered for patients and their caregivers for the past 7 years. About 50% of all patients participated in this program before transplantation, after transplantation only a few patients visited the group sessions. On average 12 patients and 8 caregivers visited each session. One problem for these patients with severe lung-disease was the long distance between patient’s homes and the hospital. This has been the reason for self-help organisations to demand better psychotherapeutic outpatient support for patients and their families before and after organ transplantation.     

Response und Non-Response in der station?ren Psychotherapie depressiver Patienten

Background

Poor outcome of psychotherapeutic treatment has not yet been sufficiently investigated. It is assumed that approximately 25–30% of patients are treatment non-responders and about 5–10% suffer deterioration.

Study design and methods

The therapeutic success of a total of 2,323 consecutively admitted inpatients with a depressive episode (F32.0-2, F33.0-2) was evaluated by using different strategies based on self ratings at admission and at discharge, i.e. the Beck depression inventory II (BDI-II) and the brief symptom inventory (BSI). In intention to treat (ITT) and completer analyses various measures of therapy success were compared (e.g. statistical significance, effect sizes and clinical significance).

Results

Effect sizes were 1.59 (BDI-II) and 0.86 (BSI) for the ITT sample and 1.64 and 0.89 for the completer sample. Analyses using criteria of clinical significance resulted in response rates of 75.5% (BDI-II) and of 68.7% (BSI) for completer analyses and remission rates of 62.2% (BDI-II) and of 40.8% (BSI). Non-Response rates, also including minor responders, varied between 23.4% (BDI-II) and 27.4% (BSI). Deterioration was observed in only 1% (BDI-II) and 3.9% (BSI) of the patients.

Discussion

The results demonstrate that about two thirds of depressive patients show clinically significant improvements within a multimodal, primarily psychotherapeutic inpatient setting, whereas the rates of deterioration are lower than expected. The aim for the future should be to identify poor or minor response as early as possible in order to optimize treatment.     

Misserfolge in der station?ren Therapie von Patienten mit Pers?nlichkeitsst?rungen

While psychotherapy has proven its efficacy and effectiveness in the treatment of personality disorders (PD) there is a lack of studies on treatment failure, i.e. non-response or deterioration of psychopathology. In a naturalistic approach the failed treatment of1,239 inpatients with PD was studied by means of direct and indirect assessment of change from patient and therapist perspectives. For indirect assessment the global severity index of the symptom checklist SCL-90-R (self-report by patients) and the impairment severity score (judgement by therapists) were used. Depending on the method between 11% and 31% of inpatients did not show any relevant improvement in symptoms but concordance between the methods was poor (Cohen’s kappa between 0.10 and 0.30). Patients with treatment failure did not differ from those with successful treatment with respect to sociodemographic and clinical features. The findings are discussed with respect to methodological limitations but also reflect possible clinical and therapeutic implications as well as future research approaches.     

Primärversorgung von psychischen und psychosomatischen Patienten

Zusammenfassung Der Erstkontakt psychisch und psychosomatisch Erkrankter findet im deutschen Gesundheitssystem meist unter der Präsentation von körperlichen Störungen in einer Hausarztpraxis statt. Aufgrund der speziellen äußeren Strukturen der hausärztlichen Praxisführung und einem besonders dem Hausarzt eigenen pragmatischen lösungsorientierten Umgang mit seinen Patienten begegnet er den Patienten mit psychischen und psychosomatischen Krankheiten in anderer Weise, als es der Psychotherapeut für adäquat hält. Der vorliegende Text will das gegenseitige Verständnis für die unterschiedlichen Typen der Therapeut-Patienten-Interaktionen zwischen den Hausärzten und den Psychotherapeuten fördern. Die psychotherapeutischen Leser werden zu neuen Kooperations- und Kommunikationsformen mit Hausärzten ermutigt, dem hausärztlichen Leser werden Fallstricke im therapeutischen Kontakt zu psychisch und psychosomatisch Erkrankten aufgezeigt, und er wird ermuntert, strukturierter und kompetenter als bisher mit diesen schwierigen Patienten zum Wohle dieser Patienten umzugehen.     

Somatoforme Störungen bei ambulanten dermatologischen Patienten

Zusammenfassung In der vorliegenden Studie wurde die Häufigkeit somatoformer Symptome in einer dermatologischen Universitätsambulanz untersucht. An der Studie nahmen n=195 Patienten teil, die Screeningfragen zu somatoformen, dermatologischen und depressiven Symptomen ausfüllten. Zusätzlich wurde eine dermatologische Beurteilung der Symptome hinsichtlich der Ätiologie erfasst. Danach wiesen 26,2% der Patienten Hinweise auf eine somatoforme Störung auf; am häufigsten waren somatoforme Schmerzstörung (16,9%) und körperdysmorphe Störung (15,4%). Unter den spezifischen dermatologischen Symptomen wurde Juckreiz besonders häufig (10,3%) als somatoform klassifiziert. Der Anteil von Patienten mit erhöhten depressiven Beschwerden lag bei 17,3%. Die Ergebnisse sprechen für eine erhöhte Prävalenz somatoformer Störungen bei dermatologischen Patienten. Die Identifizierung und psychotherapeutische Versorgung dieser Patientengruppe sollte in der dermatologischen Routineversorgung mehr Beachtung finden.     

Ersch?pfung und Depression in der Schwangerschaft

For women pregnancy represents a condition of intense physical and psychological changes which subject the pregnant women to a number of potentially stressful situations. Hormonal changes during pregnancy predispose to exhaustion and therefore to an increased vulnerability to affective disorders. Depression is one of the most commonly diagnosed psychiatric disorders in the female population with an increased incidence during the reproductive years. Recent studies showed that approximately 10?C13% of patients suffer from a depressive episode in the perinatal period requiring specialized treatment including psychotherapy and/or pharmacotherapy. Underestimation of this condition and a lack of proper management can hinder normal mother-child bonding leading to impaired cognitive and emotional long-term development of the child. In this article the medical literature related to the prevalence and clinical presentation of depression during the perinatal period and its association to maternal exhaustion is reviewed. The clinical implications and therapeutic options are discussed.     

Transparenz und Fairness in der Therapie von Sexualstraftätern in Haft und Maßregelvollzug

It makes sense to treat sexual offenders in prison. Treatment can be successful even if coerced. However, particular difficulties arise due to the great power disparity between therapist and patient and the latter’s remoteness from normal living conditions. This report will describe the current status of treatment techniques/approaches for sexual offenders in prison (with particular regard to social therapy) and special forensic hospitals as viewed by an external reviewer judging the process, methods and success of treatment for preventing relapse and estimating criminal prognosis. We mention standards for a respectful and positive approach towards the patient client. With regard to the Good Lives Model, it is supportive to develop positive resources in the perpetrator. This also requires a heightened readiness from therapist and team for transparency (instead of confidentiality) towards the perpetrator as to the assessment of progress and status of therapy. We criticize tendencies for a confrontative, if not humiliating approach, which undermines the self-esteem of the client and exploits the power disparity between therapist and perpetrator.     

Kriminogene Entwicklungsrisiken von Jugendlichen mit Zuwanderungsgeschichte und M?glichkeiten der Pr?vention und Intervention

The higher rates of violence in the group of juveniles with a migrational background play a prominent role for criminology as well as for pedagogical and social practice in Germany. The following article gives an insight into some environmental and personal risk factors of this group, which could be responsible for their higher susceptibility to violence and delinquency. In the next step some conceptual questions of prevention and intervention are identified and illustrated with existing practical examples. Finally, the author makes some suggestions for further ways of violence prevention and analyzes the efficacy and ways of optimizing the existing programs for young migrants and their families.     

Qualifizierung und Qualit?tskontrolle in der forensischen Psychiatrie

At the end of the last decade severely violent and sexual crimes by previously convicted persistent offenders initiated a discussion about the necessity of quality control in the forensic psychiatric practice in Switzerland. Subsequently, measures similar to those in Germany were adopted, e.g. the implementation of a specialisation in forensic psychiatry. In addition, they included the creation of commissions with the duty of evaluating the dangerousness of serious offenders, the implementation of a standardized and certificated postgraduate training in forensic psychiatry and guidelines for the qualification of forensic assessment experts and the quality of reports. The following article presents the implemented measures and discusses their possible consequences for the quality of forensic psychiatric work.     

Das Image von Psychologen, Psychotherapeuten und Psychiatern in der Öffentlichkeit

This is a systematic review of studies about the public image of or attitudes toward mental health professionals, particularly psychologists, psychiatrists, and psychotherapists (including psychoanalysts) on the basis of computerized medical and psychological databases (PsycLIT, Pub Med, Google Scholar) and their cross-references with 43 new articles. It is an update of an older meta-content analysis of the same topic (N= 60 primary studies) which analyzed studies, published between 1948 and 1995. Data about their perceived social status, field of activity and clinical expertise, their sex/gender and physical appearance, personality and social interaction (especially those between therapists and clients), their work setting and about differential effects are presented. It becomes obvious that there exists a “shrink”-stereotype, which refers equally to psychologists, psychotherapists and psychiatrists, and which differs from the stereotype of physicians. The appearance of the “shrink” stereotype is male and psychoanalytically influenced (looking as Sigmund Freud in the setting “couch”). The stereotypes of “shrink’s” personality are partially idealisations (warm, intelligent, understanding parental figures) and partially very negative images (the neurotic; the dangerous, manipulative abuser). Public image of “shrinks”, research deficits, methodological problems, and sex/gender issues are critically discussed.     

Zeitlosigkeit und Verg?nglichkeit (in) der Psychoanalyse

The author shows that the accessible psychoanalytic unconscious is not timeless. Freud??s ??timeless unconscious??, which was ontologized by himself and his successors, proves to be fiction with negative consequences. Assuming ??timeless?? primary processes psychoanalysis as a therapy would bite the hand which feeds it. Instead of contrasting linear time to the cyclic personal experience of time, the author suggests to speak about the ??emergence of lived time?? and the ??new moments?? of encounter in the therapeutic situation, to emphasize the importance of the opportune moment for change in contrast to the cyclic repetition of transference. In order to understand and approach disorders of time perception knowledge of unconscious conflicts and defense processes remains crucial. Even dreams are not timeless. While our conscious mind works according to chronological patterns, the pictorial representation in the particular form of thinking asleep, dreaming, makes it possible to map different memory traces simultaneously. Freud??s speculations about the ??timeless unconscious?? and Nirvana may originate from a longing for redemption. In contrast the author??s final chapter deals with the potential life span and transience of some central psychoanalytic concepts. Not even those who prove to be very close to observation can be attributed with ??eternal life??.     

Autismus und Autismustherapie in Zeiten von Corona: eine Chance?

psychopraxis. neuropraxis - Die weltweite Coronakrise stellt uns alle vor eine neue, unerwartete und besonders herausfordernde Situation und geht für Menschen mit und ohne Autismus mit starken...     

Belastungen in der Kindheit und in der Jugend Essgestörter

Depending on definition and sample, a minority of varying size of women with eating disorders report to be victims of sexual and/or physical abuse. These stressful experiences are risk factors for mental disorders in general and not specifically for eating disorders. Parental high expectations and pre-morbid negative self-evaluation seem to be specific risk factors for anorexia nervosa and bulimia nervosa. Probably, patients with bulimia nervosa suffered more childhood adversity than those with restrictive anorexia nervosa. Patients with a history of sexual and/or physical abuse may be more severely ill and more difficult to treat than other patients with eating disorders. Careful questioning about childhood adversity seems advisable. In therapy, maintaining factors—like problems of self-esteem—are more important than predisposing or precipitating factors. For prevention, it is recommended to provide for the safety of children when treating their parents with mental illness—particularly substance use disorders—and to avoid parental high expectations.     

Zur Prävalenz von Depersonalisation und Derealisation in der stationären Psychotherapie

Depersonalization (DP) and derealization (DR) remain poorly recognized in clinical routine. Active exploration through structured interviews is strongly recommended, because patients rarely describe spontaneously their experiences with DP/DR. 143 psychosomatic, first-admission inpatients were interviewed about the 1-month prevalence of DP/DR using the Structured Clinical Interview for DSM-IV dissociative disorders. Additionally, the German questionnaires of the Cambridge Depersonalization Scale, the Dissociative Experiences Scale, the SCL-90-R and the Inventory of Interpersonal Problems were used. In the sample we found a prevalence of 23.1% (N=33) for depersonalization-derealization syndrom (ICD-10 F48.1) and 7% (N=10) for secondary pathological DP/DR. A total percentage of 62.9% reported DP/DR to some degree or other. There was a noticeably high co-occurrence of anxiety disorders in patients with pathological DP/DR. Patients with pathological DP/DR were generally more impaired, suffered many more interpersonal problems and were particularly characterized by introversion. Considering the high prevalence of this phenomenon, more attention should be paid to DP/DR in routine diagnostic procedures, treatment and research.     

Evaluation der polizeilichen Kriminalpr?vention bei Mehrfach- und Intensivt?tern in NRW

Recent years have seen the development of a range of concepts throughout Germany addressing how the police should deal with persistent offenders in order to reduce the amount of offending. The State Office of Criminal Investigations in North Rhine-Westphalia commissioned an evaluation of the concepts applied in four different district police authorities in the state. The offence records of almost 300 young persistent offenders from the year they entered until the year they left the program were compared with those of a matched control group with a similarly high rate of offending who were not included in the measures. The summative evaluation showed a higher reduction in crime in the treatment group compared to controls by a factor of 1.31 with an effect size ofd?=?0.26. Further analyses indicated the effect of the program was independent of the persistent offenders?? age, gender or migration status. The discussion on this positive outcome focuses on the methodological problems in the study and also on the very low intensity of the measures compared to other offender treatment programs.