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.     

Diagnostik in der Verhaltenstherapie

After an introduction, a short historical review of the development of behaviour therapy and the importance of categorical classification of mental disorders is given. We present different assessment approaches that are important in behaviour therapy. They comprise anamnesis, categorical classification, somatic differential diagnosis, psychometric methods, ratings scales, and diaries. As the core assessment strategy in cognitive behaviour therapy, functional behavioural analysis is introduced in detail, in which methods of horizontal analysis of behaviour (SORKC model proposed by Kanfer) and the vertical analysis of behaviour are explained. The importance of computer-based assessment and specific approaches of assessment within behaviour therapy for children and adolescents are presented. By way of conclusion, the prospects of possible new developments of assessment in behaviour therapy are outlined.     

Sozialmedizinische Begutachtung der beruflichen Leistungsfähigkeit

The ?Interview for the Evaluation of Psychosocial Dimensions of Performance Capability“ represents a potentially suitable instrument for the assessment of performance capability in various contexts. Regarding time expenditure, it is very viable and can be applied without special training. Test statistics for subscales derived from factor analysis are satisfying. The modified scales should be subject to further studies of validity and reliability. However, the instrument is already suited as a tool for the assessment of performance capability, represents an algorithm for decision-making and is related to the concepts of the International Classification of Functioning (ICF).     

Weinen, ein Bindungsverhalten

Crying is an age-independent behavior of attachment of the (at that moment) weaker part, who cannot cope with a special experience alone. To cry because of anxiety, anger and mourning expresses helplessness and at the same time is an appeal to others to give help and comfort. Crying creates the chance to show relatedness. The considerate other person perceives himself at that moment to be the stronger one when he sees and hears the crying and usually feels the need to comfort and care. The crying of a newborn baby expresses fear to be abandoned, not to be protected and looked after which means to have to die. With growing experience about the reactions to crying the infant quickly learns which behavior is apt to bring the protecting attachment person closer to him. Crying is synchronized with the expectations of others even at the end of the first year of life, especially with those of the attachment person. Whether a child or an adult cries in a manner appropriate to the situation, or surprisingly does not cry or cries in an exaggerated dramatic manner, very much depends on the experiences made in attachment relationships with crying. In the same way, how effective the comfort can be and whether the other wants to care at all, depends on the experiences of both persons concerning crying and comforting in preceding relationships. If those experiences were reassuring then as adults they can also cry or care and comfort, but if crying even aggravates painful experiences then the adult will have difficulties to desire and to accept comfort from others or offer comfort to others himself.     

Die Rolle positiver Emotionen in der frühen Sozialisation

Emotions are vital characteristics of the evolved human nature. Expression and function of emotions, however, vary substantially depending on socio-cultural contexts. This paper focuses on two strategies concerning the expression of positive emotionality in early mother-child interactions. Western middle class families emphasize the expression of positive emotions in early social interactions from early infancy. Positive emotionality is associated with personal autonomy and individual uniqueness. In traditional farmer families in the non-western world emotional control is emphasized from birth. Emotional inexpressiveness is part of a socialization strategy that is oriented towards hierarchical relatedness. The early socialization experiences have measurable effects on emotion regulation of 1-year-old children. The confrontation of different cultural models in multicultural societies is inherently fraught with confliction. These implications are discussed.     

Zur Instrumentalisierung des Opferstatus

The article deals with the instrumentalization of victim status, which achieves a definite material psychosocial and narcissistic advantage. Talk shows cultivate victims and idealize them as heroes thus producing ersatz identities. To be singled out from society as ?innocent“ and to be pitied, admired and perhaps envied by others for the attention they attract, might prove to be a source of narcissistic gratification. So whilst victim identity may transform impotence and weakness into a medium for approval, it also fixes the dichotomy between offender and victim.     

Arbeitsstörungen und Prokrastination

Work disruption and procrastination include dysfunctional behavior in the context of completion of tasks in occupational and personal fields as well as in school and professional training. A psychological model for the explanation of work disruption and procrastination is presented. Based on this model dysfunctional behavior occurs when individual skills and personality factors do not fit with the demands and conditions of the task. Especially when depression, some anxiety disorders, test anxiety as well as adjustment disorders and personality traits related to personality disorders are present, work disruption and procrastination can play an important role as additional problems. A modularized intervention program is presented which can serve as a support for self-help, counseling as well as professional psychotherapy. It includes the analysis of dysfunctional behavior and cognition, improvement of work-related techniques, time-management and work conditions and reduction of distraction from work as well as improvement of work-life balance.     

Die Psychotherapeutenausbildung aus Sicht der Teilnehmer

Background

A survey was performed to assess the current situation in education and to identify critical issues 10 years after the inception of the German law regulating the education of psychological psychotherapists and child and adolescent psychotherapists. The study reports the results of a nationwide survey of German psychological psychotherapists and child and adolescent psychotherapists currently in training. The aim of the survey was to evaluate the individual sections of training, desired alterations and structural and financial conditions.

Methods

All trainees were contacted via the training institutes and the umbrella organizations. A total of 3,223 trainees participated and answered questions mainly using an online questionnaire.

Results

Most respondents practiced their training part-time and in most cases the trainees thought that the training would last longer than initially expected. The practical training was rated most poorly, whereas practical education and individual supervision were rated as most useful. The survey revealed deficits concerning the evaluation of the quality of several components of the training.

Conclusions

From the perspective of the trainees there is a necessity to modify the financial conditions of the training. This result has been considered in the recommendations of a research expertise on psychotherapy training and should stimulate further research.