Dokumentation ambulanter Diagnostik in psychosomatischer Medizin und Psychotherapie

Zusammenfassung Das vorgestellte Dokumentationssystem vereint in sich die folgenden Anforderungen: Die zeitökonomische Abbildung der aktuellen Befunde, die Visualisierung der Biographie bzw. Lerngeschichte, die strukturierte Erfassung der Operationalisierten Psychodynamischen Diagnostik (OPD), die psychische und somatische Diagnostik einschließlich Rating des Beeinträchtigungsschwere-Score (BSS) und der Global Assessment of Functioning Scale (GAF) sowie die psychotherapeutisch-psychiatrischen Vorbefunde und die abschließende Indikationsstellung. Lediglich der Arztbrief, der beispielhaft dargestellt wird, wird diktiert. Eine so strukturierte Dokumentation ist patientennah, zeitökonomisch und bewährt sich an den Schnittstellen einer ambulant-stationär-ambulanten Behandlungskette. Sie ist eine ideale Basis für ein Qualitätsmanagement sowie Evaluation in der niedergelassenen Praxis, Ambulanz sowie im Konsiliardienst.      

Psychotherapie bei Patienten mit koronarer Herzkrankheit

Zusammenfassung Psychosomatisch-somatopsychische Interaktionen sind bei Koronarpatienten häufig und verlaufsrelevant. Seit den 1960er-Jahren kommen daher psychosoziale Interventionen zur Verbesserung von Befinden und Krankheitsverlauf zum Einsatz. Neben psychoedukativen und unspezifisch-supportiven Angeboten oder Entspannungsverfahren finden sich auch explizit psychotherapeutische Interventionen. Diese beabsichtigen einerseits, durch Reduktion von Stressbelastungen und Förderung gesundheitsbewusster Verhaltensweisen den Krankheitsverlauf zu verlangsamen. Zuletzt wurde zudem auch die Psychotherapie psychischer Komorbiditäten untersucht. Hier spielt die prognostisch relevante Depression eine besondere Rolle. In der größten Psychotherapiestudie bei Koronarpatienten, der ENRICHD-Studie, wurde bei 2481 Infarktpatienten mit Depression oder mangelnder sozialer Unterstützung eine maximal halbjährige kognitive Verhaltenstherapie eingesetzt. Diese führte zur deutlichen Besserung der Depressivität; bei hoher Spontanremissionsrate in der Kontrollgruppe blieb der Nettoeffekt jedoch bescheiden. Eine Lebensverlängerung wurde in der Interventionsgruppe nicht erreicht. Die Befundlage verlangt differenzielle Indikationsstellungen und behandlungstechnische Weiterentwicklungen der therapeutischen Konzepte bzw. die Erprobung anderer Therapieverfahren, erlaubt jedoch noch keine evidenzbasierte allgemeine Behandlungsempfehlung. Therapieentscheidungen stützen sich heute auf die Würdigung des Einzelfalls, auf gut belegte subjektiven Therapieeffekte, theoretische Annahmen über Stressbewältigungs- und Entspannungsverfahren sowie die an anderen Patientenkollektiven gewonnenen Wirksamkeitsnachweise psychotherapeutischer Verfahren. Dabei sind generell eine Beachtung der kardialen Situation und der typischen Problembereiche der koronaren Herzkrankheit (KHK) sowie eine gute Abstimmung mit den somatischen Behandlern wichtig.     

Passt oder passt nicht?

Differential indication in psychotherapy should be a process of decision making, that takes multiple factors into account, and not just the assignment of a particular disorder to the adequate therapeutic method. Unspecific characteristics of the patient, instead of disorder-specific features, as well as personality characteristics of the therapist having therapeutic relevance are important factors either. In this way decisions for an indication then turn into the crucial question of matching between patient and therapist. The receptivity of the patient is a central component. As a result of successful maching, the therapeutic relationship will improve which has a positive influence on the outcome of psychotherapy. According to the generic model of psychotherapy 4 levels of the decision-making process are defined. They serve as orientation for a differential indication taking into account both persons and methods. The realization of this indication model in in-patient treatment has some preconditions. Obligatory is the availability of a variety of therapists differing in therapeutic methods and personal characteristics. The mostly applied principles of matching decisions are listed in tabular form and illustrated by a case report.     

Intentions are Optimality Beliefs – But Optimizing What?

In this paper an empirical theory about the nature of intention is sketched. After stressing the necessity of reckoning with intentions in philosophy of action a strategy for deciding empirically between competing theories of intention is exposed and applied for criticizing various philosophical theories of intention, among others that of Bratman. The hypothesis that intentions are optimality beliefs is defended on the basis of empirical decision theory. Present empirical decision theory however does not provide an empirically satisfying elaboration of the desirability concepts used in these optimality beliefs. Based on process theories of deliberation two hypotheses for filling this gap are developed.     

Posture based motor planning in a sequential grasping task

Movement planning in sequential tasks is revealed by grasping postures. We explored aspects of planning a sequential drawer opening and object manipulation task with regard to arm and torso postures. We conducted a detailed kinematic analysis of joint postures at the wrist, elbow, and shoulder for a one-grasp and a two-grasp sequence of movement. The second of the two-grasp sequence was constrained (uncomfortable). We predicted that planning for the second grasp in a two-grasp sequence would influence arm, torso, and whole-body postures at the first grasp. Participants prepared for the second grasp by adjusting the posture of the elbow and shoulder and the distance they stepped to the drawer. The joint postures at the elbow and shoulder changed in the direction of the intended object grasp. These findings show that anticipatory adjustments are revealed at postures other than the end-effector and lend insight into the mechanisms of sequential movement planning.     

Event-based plausibility immediately influences on-line language comprehension

In some theories of sentence comprehension, linguistically relevant lexical knowledge, such as selectional restrictions, is privileged in terms of the time-course of its access and influence. We examined whether event knowledge computed by combining multiple concepts can rapidly influence language understanding even in the absence of selectional restriction violations. Specifically, we investigated whether instruments can combine with actions to influence comprehension of ensuing patients of (as in Rayner, Warren, Juhuasz, & Liversedge, 2004; Warren & McConnell, 2007). Instrument-verb-patient triplets were created in a norming study designed to tap directly into event knowledge. In self-paced reading (Experiment 1), participants were faster to read patient nouns, such as hair, when they were typical of the instrument-action pair (Donna used the shampoo to wash vs. the hose to wash). Experiment 2 showed that these results were not due to direct instrument-patient relations. Experiment 3 replicated Experiment 1 using eyetracking, with effects of event typicality observed in first fixation and gaze durations on the patient noun. This research demonstrates that conceptual event-based expectations are computed and used rapidly and dynamically during on-line language comprehension. We discuss relationships among plausibility and predictability, as well as their implications. We conclude that selectional restrictions may be best considered as event-based conceptual knowledge rather than lexical-grammatical knowledge.     

Einzel- und Paarintervention f��r depressive Koronarpatienten

Depressive symptoms in patients presenting with coronary heart disease have an impact on quality of life, health behavior, and prognosis. The psychotherapeutic interventions which had been tested for their efficacy in previous randomized controlled trials, showed only minor effects. A stepwise approach consisting of individual and group psychotherapeutic interventions was tested for efficacy in a German multicenter study. The presented paper describes the therapeutic procedure for two individual sessions and one couple session by means of case examples. The main focus was to determine depressive symptoms along with underlying maladaptive personality traits such as negative affectivity and social inhibition (type D pattern). Depressive mood, disappointments and mortifications both in private and professional life and also during the previous treatment are verbalized. Dysfunctional relation patterns and maladaptive sickness behavior are taken up by the psychotherapist and alternative behavior patterns are developed. The objective of the couple session is strengthening the partnership resources and offering relief of fears and worries relative to the heart disease. The psychotherapeutic procedure is psychodynamically oriented but also contains cognitive-behavioral and interactional treatment approaches.     

Association between morningness-eveningness and mental and physical health in adolescents

Individuals differ in their biological rhythms and their preference for morning or evening hours. Morning types prefer morning hours for intellectual and physical activities while evening types feel and perform best at late afternoon or in the evening. This not only is a simple dichotomous classification but also can be viewed as a continuum. Individual differences in morningness-eveningness are an interesting facet of personality, but little is known about the relationship between psychological factors or health-related variables and morningness-eveningness in adolescents. In Study I, there were positive correlations between morningness and positive attitude towards life and a negative association between morningness and depression. In Study II, there were significant positive relationships between morningness and physical health, mental health, self-esteem, familial relationship, and school functioning. These results indicate that eveningness might be an unspecific risk factor for mental and physical health.     

The role of testosterone in social interaction

Although animal researchers established the role of testosterone as a 'social hormone' decades ago, the investigation of its causal influence on human social behaviors has only recently begun. Here, we review and discuss recent studies showing the causal effects of testosterone on social interactions in animals and humans, and outline the basic neurobiological mechanisms that might underlie these effects. Based on these recent findings, we argue that the role of testosterone in human social behavior might be best understood in terms of the search for, and maintenance of, social status.