Primärprävention bei Essstörungen

Zusammenfassung Essstörungen gelten als schwer therapierbar. Mit einer Mortalitätsrate von 5–16% ist Magersucht die schwerste psychosomatische Erkrankung bei Mädchen und jungen Frauen. In den letzten Jahren wurde daher verstärkt versucht, der Entstehung von Essstörungen durch präventive Maßnahmen entgegenzuwirken. Der Schwerpunkt liegt hierbei auf der Primärprävention im Rahmen von Schulprojekten. Hierfür liegen bereits ermutigende Wirkungs- und Qualitätsnachweise vor. Entsprechende Projekte stehen im Zentrum der vorliegenden Übersichtsarbeit. Diese stellt keinen Anspruch auf vollständige Darstellung, sondern ist ein Versuch der Systematisierung unterschiedlicher Herangehensweisen und soll durch die kurze Beschreibung möglichst prototypischer und evaluierter Beispiele einen Einblick in die derzeitige Praxis der Primärprävention von Essstörungen geben. Quellen der Übersicht sind die Datenbank der Bundeszentrale für gesundheitliche Aufklärung (BZgA), Veröffentlichungen in Fachzeitschriften sowie Internetauftritte. Da Art, Umfang und Umsetzung der Präventionsprogramme sehr von politischen Bedingungen und Voraussetzungen innerhalb des Gesundheits- und Bildungssystems abhängen, bleibt die Übersicht auf Programme aus dem deutschen Sprachraum beschränkt.     

Evidenzbasierte Diagnostik und Psychotherapie bei Essstörungen

Along with the specific eating-related symptoms, eating disorders are associated with substantial psychological, social and medical sequelae. Overvaluation of body shape and weight and corresponding body dissatisfaction are a central feature of anorexia nervosa (AN) and bulimia nervosa (BN); additionally, these features are also a common symptom in individuals with binge eating disorder (BED). Regarding treatment, cognitive behavioral therapy (CBT) focuses on the distinctive features of the disorder, such as nutritional management and normalization of food intake, alteration of body image disturbances and negative feelings towards one’s body and alteration of the functional relationship between stress, negative emotions and pathological eating behavior. Interpersonal psychotherapy (IPT) instead focuses on the alteration and reduction of interpersonal problems. Following the German S3 guidelines, CBT should be the treatment of choice for BN and BED. Given the scarce empirical evidence of treatment effectiveness for AN, no specific treatment recommendation can be made for AN; however, psychotherapy and not medication should be the treatment of choice.     

Psychopharmakotherapie der Essstörungen

Es gibt eine Reihe von Studien zur Pharmakotherapie der Essst?rungen. Empfehlungen für die pharmakologische Behandlung von Essst?rungen (Anorexia nervosa (AN), Bulimia nervosa (BN), Binge Eating Disorder (BED)), basierend auf der verfügbaren Literatur, werden vorgestellt: Für AN gibt es Hinweise, dass eine ,,Zinksupplementierung“ oder der Einsatz von atypischen Antipsychotika hilfreich sein kann. Für BN zeigen die Studien positive Ergebnisse hinsichtlich des Einsatzes von Antidepressiva, insbesondere für Fluvoxamin und Fluoxetin. Auch für das Antiepilektum Topiramat gibt es positive Studienergebnisse. Bei BED k?nnen bestimmte Antidepressiva und Antiepileptika erfolgreich eingesetzt werden. Jedoch wird weitere Forschung für die Verbesserung der Behandlung von Essst?rungen ben?tigt. Speziell für Anorexia nervosa besteht ein Bedarf für weitere pharmakologische Behandlungsstrategien.     

Prävention seelischer Störungen bei Kindern

During the last years psychosocial prevention became more and more established. The need for a focus on “early intervention” is a consequence of scientific research on the effects of psychosocial stress in infant development. Mental and neural development in the infant years is very modifiable, thus primary prevention has to centre on advancements in the immediate conditions of maturation. This is exceedingly important for children in families at risk. This article gives an overview of actual preventive measures, especially of those in the German-speaking countries.     

Angstzustände bei Patienten mit schweren Persönlichkeitsstörungen

States of anxiety are very common problems in patients with severe personality disorders. All phenomena of anxiety can be observed. In this connection a continuum of the severity of impairment of structural personality organisation can be postulated. In many cases proper anxiety disorders exist as comorbid disorders. Anxiety is esteemed to be the central affective problem of borderline patients. In spite of these relations, states of anxiety in patients with personality disorders are often underdiagnosed or misdiagnosed. For the treatment of neurotic anxiety disorders (for example panic disorders), there exist disorder-specific therapy manuals that proceed from behavioural as well as psychodynamic perspectives. Nevertheless, for the treatment of anxiety states in personality disordered patients, the techniques that focus heavily on symptomatology appear often contraindicated. In our opinion, treatment of these typically severe anxieties must be contained within a therapeutic framework, which essentially takes into account the personality organisation of this group of patients. Such treatment makes special demands on the therapist for working with transference and countertransference processes. From a disorder-specific psychodynamic perspective recommendations are given for psychotherapy.     

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.     

Die Beurteilung der Steuerungsfähigkeit bei psychischen Störungen

Psychiatric assessment of culpability is conducted in two steps: firstly, the psychiatric diagnosis is to be made and attributed to one of the legal terms that entail the requirements for diminished or lack of legal responsibility. Secondly, one has to assess from a psychiatric perspective whether the mentally disturbed suspect who was aware of the unlawfulness of the actions was also able to act in accordance with awareness and to refrain from unlawful actions. The latter is called the capacity for self-control. The ultimately legal normative term of capacity for self-control corresponds to psychobiological concepts of executive and motivational self-control as well as to the psychological models of intentional control of actions (Goschke) and ”disactualization” (Janzarik). These concepts and models are outlined and discussed, particularly with regards to paraphilia and behavioral disorders. In the context of these conditions we sometimes find free-floating considerations about the capacity for self-control without even addressing the question whether the severity of the disorder has crossed the threshold for diminished legal responsibility. The author argues the case for an overall view of the suspect’s personality and abilities, weaknesses and decisions as displayed in the history of the criminal act.     

Spezielle Aspekte bei Angststörungen

Anxiety disorders are among the most common mental health conditions worldwide and frequently cause significant functional impairment. Generalized anxiety disorder is the most commonly occurring impairing anxiety disorder in primary care. The degree of disability attributable to generalized anxiety disorder is comparable to that of major depression and is similar to that of chronic physical illnesses, such as peptic ulceration, arthritis, asthma and diabetes mellitus. Comorbid illnesses, such as mood disorders are commonly seen in clinical practice and have a significant impact on the clinical presentation and the treatment approach. Both psychotherapeutic and pharmacological techniques are recognized as being effective management strategies. The present article focuses on two case-reports of patients with anxiety disorders in an inpatient setting. By describing comorbid conditions subsequent difficulties and challenges in treatment are underlined.     

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.     

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.     

Onlineberatung für Betroffene von Essstörungen und deren Angehörige

An independent online consulting service for persons with eating disorders and their relatives (www.ab-server.de) exists in Germany since 1998, which was developed by physicians and psychologists. This study aims to comprehend the individual use of the online consulting for affected persons and their relatives. In order to do this, two online questionnaires were developed for these two groups. The questionnaires were sent digitally in two phases to those people who had posted an e-mail to the online consulting service from January 1999 to November 2003 and from January 2004 to July 2006 (phase 1: n=2,760; phase 2: n=1,419). A total of 493 data sets of affected persons and 127 of relatives were included in the analysis. The online consulting service is of great importance especially to establish the user’s first contact with professional help. The main reported effects were an improved understanding of the disease and the motivation to seek further professional help. This specific setting of internet-based intervention fulfils the function of a signpost within the German supply system.     

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.     

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.