Tötung mit und ohne tiefgreifende Bewusstseinsstörung

The category of “serious disturbance of consciousness” within the regulations for criminal responsibility has caused some uncertainty since is implementation in German Penal Law in 1975. It is applicable for those cases of “crimes of passion” where the mental functioning is heavily disturbed by massive affective arousal. A proposal for assessment and evaluation of such cases with a psychopathological approach is presented. The forensic-psychiatric examination contains 3 elements: (1) the formulation of the case in terms of biography, personality and special situation in the time before the criminal act, (2) a systematic analysis of the act according to two sets of specific criteria for such cases, (3) an evaluation of the state of consciousness by means of a “psychopathological reference system”, comparing all states of normal, abnormal and pathologically disturbed consciousness     

Deutende Interventionstechniken bei Patienten mit schweren Persönlichkeitsstörungen

The growing influence of ego-psychology, self psychology, object relations theory, and interpersonal concepts on the psychoanalytic psychotherapy of patients with personality disorders is reflected in a preference of relational therapeutic strategies and in a controversial discussion of interpretative techniques. It is shown that interpretative strategies are of invaluable importance in many patients with personality disorders. However, modifications of technique necessary for this group of patients should be considered. Especially, transference interpretation in the here and now can be of great use even in the treatment of patients with severe personality disorders. It is of outstanding relevance for the therapist to understand the interactional message a patients infers from his interpretation and to take into account the patient's reaction to the interpretation.     

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.     

Traumatische Erfahrungen und Posttraumatische Belastungsstörung bei Journalisten

A questionnaire study on work-related trauma of journalists was conducted on the internet. 61 journalists (22 women) provided information about the type and frequency of highly stressful assignments and traumatic life events, symptoms of post-traumatic stress disorder (PCL-C), depression (CES-D) and coping style (emotional competence, FAPK, 3; sense of coherence, SOC). 46% of the participants lived in the USA, 41% in Europe; their mean age was 37 years and they had an average job experience of 13 years. They reported an average of 81 assignments in which they had been confronted with seriously injured, dying or dead persons or had worked at the risk of their own life. 13% had developed a full and 15% a partial post-traumatic stress disorder (PTSD). Compared to less disturbed individuals, the participants with (full or partial) PTSD reported significantly more often about violence in their original families, depressive symptoms and deficiencies in their emotional competence.     

Psychodynamische Kurzzeittherapie bei dependenter und vermeidender Persönlichkeitsstörung

Although dependent and avoidant personality disorders are frequent in patient populations, there are only few studies in which the efficacy of psychotherapeutic interventions for these two personality disorders was reviewed. The purpose of this study was to examine whether psychodynamic short-term therapy based on the model of the cyclic maladaptive pattern (CMP) is effective for reducing the mental impairment of patients diagnosed with a dependent or an avoidant personality disorder. Data were collected via a self-report scale (Symptom-Checklist, SCL) and expert ratings by therapists [Global Assessment of Functioning (GAF) Scale and Severity of Impairment-Score (Beeinträchtigungsschwere-Score, BSS)]. In the study 20 patients received 25 sessions of outpatient therapy. Mental impairment decreased significantly from the beginning to the end of the therapy; moreover this decrease remained stable over a 2-year period following completion of the therapy. The findings show that psychodynamic short-term therapy can lead to an enduring improvement in the mental health of patients with a dependent or an avoidant personality disorder.     

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.     

Angststörungen bei Patienten mit implantiertem Kardioverter-Defibrillator (ICD)

Patients with an implantable cardioverter defibrillator (ICD) often show anxiety disorders as comorbid psychologycal disturbances. In a short review we discuss psychosocial aspects of the ICD-implantation. A case study of a 38 year old patient in inpatient treatment is presented for illustration of a cognitive-behavioral treatment method. The psychotherapeutic treatment was carried out in close cooperation with the clinic for cardiology.     

Verhaltenstherapie bei Kindern und Jugendlichen mit Angststörungen

Research into anxiety disorders of children and adolescents have been neglected for a long time. Current work on the prevalence and on the course of anxiety disorders of children and adolescents impressively substantiates that (1) anxiety disturbances are the most frequent mental disorders of children and adolescents and, (2) represent important factors of risk for the development of anxiety disorders, depression and substance dependence/abuse in adulthood. The recent developments in behavior therapy on anxiety disorders with children and adolescents are presented first and the results of a meta-analysis of behavior therapy studies are summarized. The results of the meta-analysis show that anxiety disorders can be treated successfully in children and adolescents with behavior therapy. The follow up data show that therapy successes remain stable over a timespan of several years. In comparison of individual and group therapy as well as child and family-based therapy, there are no important differences with regard to therapy success.     

Lärmendes Verhalten und störende Lautäußerungen bei Patienten mit Demenz

Loud behavior and disruptive vocalizations occur relatively frequently in patients with dementia together with agitation and other behavioral problems. An unambiguous diagnosis is important to take targeted therapeutic measures. First, nonpharmacological measures should be tried and the triggering stressors should be identified and eliminated if possible. Guidelines for the treatment of behavioral disorders, thus also for loud behavior, recommend behavioral therapy, cognitive–emotional training, sensory stimulation therapy, and psychosocial interventions. Targeted therapeutic measures can provide relief for the person with dementia and the relatives and nurses.     

Alkoholismus und Selbstzerstörung

First, the development of addiction theory in psychoanalysis is recapitulated on the basis of the works of W.D. Rost and A. Heigl-Evers. For the understanding of alcoholism two concepts are fundamental. The ego-psychological concept postulates addiction as an attempt of a weak ego to help itself, while the object-psychological concept of Rost considers some forms of alcoholism as an expression of unconscious self-destruction.The author of the present article examines on the basis of a case study of autodestructive alcoholism the strength and weak points of the approach of Rost and proposes certain expansions of the model regarding first the object relations of the addict and the counter-transference, where a strong entanglement of the therapist with the destructivity of the patient is obvious. In addition, further considerations about the role of the superego are necessary, which faces the ego with hostility. Finally, the nature of the primary object of the addict person and the nature of the substance as transferential object should be examined. In the case of these inner objects there is a strange mixture of positive and negative aspects having in their consequence a great destructive potential for the person. This constellation bears resemblance to the pathological personality organisation as understood in Kleinian literature.     

Persönlichkeitsstörung und Intelligenzminderung

There have previously been only few objective investigations on the combined occurrence of intellectual disability and personality disorder. Despite this difficulty, from the current clinical viewpoint there is no doubt that at least people with mild intellectual disability can also develop personality disorders. In slight degrees of intellectual disability it is possible to psychopathologically describe the typical symptoms objectively. For the disorder symptomatic of combined personality disorder in people with an intellectual disability, there are no confirmed facts, publications or diagnostic rules. The diagnostic assignment of behavioral abnormalites as combined personality disorder with dependent and infantile components in people with intellectual diasabilities still does not seem to be justified. In people with medium to severe mental disorders only the comprehensive term “behavioral abnormalities” should be applied.     

Beziehungsökologische Therapie bei Panikstörung

Background

In 2000/2001 the authors presented the theory and practice of the ecological approach to the psychotherapy of panic disorders. The aim of the present study was to investigate the psychotherapeutic effectiveness of its application, supplemented by cognitive behavioural elements. According to the ecological approach, panic disorder arises whenever external changes in the living conditions enforce changes in professional or interpersonal relationships, which had been previously postponed and/or avoided out of fear of their consequences.

Methods

A total of 24 therapies consisting of 11–20 sessions were examined. Patients were examined 5 times from the beginning of the therapy until at least 1 year after cessation. Standardized questionnaires for the diagnosis and severity of the panic syndrome were used including the Panic and Agoraphobia Scale (PAS), the Hamilton Anxiety Scale (HAMA), the Symptom Checklist (SCL) 90-R and a relationship questionnaire.

Results

In the subjects’ self-evaluation 67% had recovered or showed only mild symptoms 1 year after therapy compared to 75% in the evaluation by the therapists. Effect sizes before and after therapy varied between 0.78 and 2.73 and all were significant. In addition, we developed a questionnaire on relationships, according to the ecological hypothesis. This showed that more than 80% of the subjects experienced essential changes in their relationships prior to the onset of the panic disorder requiring further developmental changes, which could be mastered with increasing success in the course of therapy.

Conclusions

Compared to other studies the combination of ecological and cognitive-behavioural approaches in this study resulted in impressive symptom and therapy reduction in less than 20 sessions.