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.     

Gegenübertragungsdiagnostik in der Psychotherapie suizidaler Männer

The diagnosis of suicidality is an important challenge in psychotherapy: The threat of life has to be determined, decisions in differential therapy must be made and the therapeutical relationship must be established. The psychoanalytical contribution to the diagnostics of suicidality is the analysis of transference and countertransference phenomena, of "scenic" actions and of enactments between patient and therapist. By a systematic qualitative research method ("forming ideal types by understanding") 5 prototypical transference-/countertransference situations at the beginning of outpatient psychodynamic psychotherapy of suicidal men are identified and out of them 3 ideal types are constructed. The object-alienated ideal type with an avoidant transference and "weak", e.g. unemotional complementary countertransference appears to be a special problem. If aggression and strong attachment wishes toward the object come into the therapeutic relationship, this often is an indicator for the contacts’strength and can lead to deactualisation of suicidality. The results are discussed with and supported by methodically different publications on object relations orientated aspects of suicidality.     

Paruresis

The paruretic disorder, a special subtype of social phobia, is presented. It has been almost completely neglected by German research. The disorder manifests in an inability to urinate in public rest rooms. The corresponding fears concern the loss of visual and/or acoustic privacy. Based on considerations about its etiology and pathogenesis a cognitive behavior-therapeutic intervention is recommended. This is illustrated by a case vignette of a 29-year-old male patient.     

Gewalt und Missbrauch in der Psychotherapie

Starting from the fundamental ethical principles of medicine, the different forms of abuse in psychotherapy are described and discussed in the context of particular case studies. Besides sexual abuse, also the more subtle violations of basic ethical principles are taken into consideration. These include especially orally-exploitative forms of abuse, therapists’ improper acting-out of their own desires for close attachment or dominance conflicts, and narcissictic abuse. Finally, a particular type of narcissistic abuse is dealt with: the over-emphasis on the therapist’s own therapeutic method, with a tendency to dismiss alternative treatment strategies that might be more appropriate for the individual patient.     

Die Therapie-Vorbereitungsgruppe

There are different kinds of pretraining for psychotherapeutic treatment. They have two objectives: to get future patients in the right frame of mind for the imminent psychotherapy by informing them about the treatment, and to support therapists while clarifying the indication and selecting patients. Pretherapy training for group psychotherapy is frequently offered in Anglo-American countries. So far empirical studies have only partly been able to prove the supposed positive effects of pretraining on process and outcome of psychotherapy treatment, particularly as the studies showed profound flaws with regard to methods and pretraining concepts. The “Therapie-Vorbereitungsgruppe” presented here is a pretherapy training group in the run-up to inpatient group psychotherapy at a German university clinic. In Germany, such groups are rarely offered. The “Therapie-Vorbereitungsgruppe” consists of weekly meetings of therapists of a psychotherapeutic ward and applicants for inpatient treatment. Ward members introduce the applicants into the concept of treatment and the treatment setting and they explore the psychological background of each of the applicants. Besides economical the concept has clinical and therapeutic advantages. Future inpatients get a realistic view of the treatment, they can build up a relationship to other inpatients and to therapists, and besides waiting for the admission to the clinic is made more bearable. Therapists are helped with their decision on the admission. The concept has proved itself in clinical practice for many years. The empirical proof of its effectiveness and a comparison with other, similar concepts fall due.     

Das Klimakterium als Herausforderung

The menopause is like puberty a period of life, which implies an interaction between hormonal changes and personal reorientation. In addition to the hormonal changes a variety of psychosocial changes occur. Complaints may indicate a lack of orientation in this phase. One third of German women experience a significant deterioration in life quality because of their complaints related to menopause. These women attribute their complaints mainly to their individual life-attitudes and the hormonal changes. The gynaecologist has, therefore, a high responsibility in counselling, since empirical studies have shown, that psychosocial factors like self-confidence, quality of partnership, job-satisfaction and family network substantially influence the occurrence of specific complaints and the life-quality during that time. Furthermore, social aspects are very important. The results of the German cohort study of women’s health, showing a generally better psychological well-being as compared to younger women, are remarkable in this context. The present generation of women perceive midlife positively as a period of life allowing a fresh start.     

Road victim trauma: an investigation of the impact on the injured and bereaved*

Every day in the United Kingdom ten people are killed and between 900 and 1,000 injured on the roads and, consequently, the health of large numbers of the victims, relatives and friends are adversely affected. Yet despite the magnitude of the problem little has been done to assess the full impact of road crashes on those involved, or to identify the best ways to provide help and support. This paper describes the impact of road traffic incidents on a large group of injured and bereaved victims, who approached Road Peace (a national charity for road traffic victims) for support. The research that examined data collected over an eight-year period was able to identify the nature of the impact of the traumatic exposure of these victims. The paper goes on to examine the needs of the road crash victims and suggests ways that timely support and advice could help to reduce the levels of distress.     

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.     

Frühe Störungen aus der Sicht zunehmender Mentalisierung

The term “mentalization” describes the capacity to judge other humans in terms of their mental activities such as wishes, hopes, beliefs and intentions, as well as the ability to think about one’s own thinking. Mentalization and reflective function are equivalent to each other. They play an important role in selforganization, impulse control, and affect regulation. Mentalization develops during approximately the first five years of life on the basis of attachment in Bowlby’s sense. Around the 9th month of life the child begins to understand her mother as an intentional agent. Mirroring by the mother, in a way of reproducing the child’s state of mind but in a slightly different “marked” manner, enables the child to establish a second “objectified” representation of her condition besides her primary unreflected one. Consequences of lacking, unmarked, or distorted mirroring for later narcissistic or borderline personality are discussed. The child begins now thinking, i.e. playing with representations, but the state of brain development allows to conceive of only one reality. Internal world and external reality appear undistinguishably identical. This is called the “equivalence mode” of psychic functioning. As-if-games open, in a further developmental step, the possibility of including a second reality, namely a pretended one. This is called the “pretend mode” of psychic functioning. At age four to five the child has reached the capacity to take multiple realities into consideration, to take the perspective of an other and to decentrate. She now has a “theory of mind”. Patients with early disturbances have reached this stage only partially. They may also regress to one of the earlier modes of psychic functioning as a consequence of stress or trauma. The knowledge of these early mechanisms helps to identify and understand them when they appear in our clinical practice.