Schwierigkeiten in der psychotherapeutischen Arbeit

Dealing with difficult clients, situations and their own emotions is an integral part of psychotherapists’ daily work; however, what is the nature of difficulties in psychotherapy and how should therapists’ deal with them? In spite of the high relevance of these topics for therapeutic practice, scientific research in this area lacks consistent definitions of difficulties and the respective coping strategies. This article summarizes the development of current research approaches and respective results.     

Verläufe bei sexuellen Tötungen

This article summarizes main results of studies on forensic psychiatric court reports on 166 men who had been persecuted between 1963 and 1991 for a sexual offence leading to the death of the victim. Comparing perpetrators with a single victim and those with multiple victims we found similar results as in two previous studies with smaller samples: Multiple sexual homicide perpetrators showed more often sexual sadism and other paraphilias, as well as antisocial, schizoid and sadistic personality disorders. Follow-up data from the federal criminal records could be obtained for 139 offenders. Ninety perpetrators had been released after a mean detention of 12.2 years, whereas the 49 offenders who were still in prison or forensic psychiatric hospitals had been detained for a mean period of 20.6 years. The non-released offenders showed more often paraphilias as well as antisocial and sadistic personality disorders than the released perpetrators. Paraphilias and antisocial personality traits are empirically well proven risk factors for criminal recidivism with sexual reoffences. In addition, the non-released sexual homicide perpetrators had higher scores in all applied risk assessment instruments (PCL-R, HCR-20, SVR-20, Static-99). Among the released offenders only 1.1% (n=1) reoffended with a completed homicide and 2.2% (n=2) with attempted homicide. The recidivism rates with sexual and other violent reoffences in this sample of sexual homicide perpetrators were similar to those in a large meta-analysis on recidivism in sexual offenders by Hanson and Morton-Bourgon (4). Since well established risk factors had apparently been “used-up” for the decisions about release or non-release, in the follow-up data about the released offenders only age at the sexual homicide and age at the time of release were found as risk factors for recidivism with any violent (sexual or non-sexual) reoffence, i.e. the younger the offender at the time of the homicide and the younger at the time of release, the more likely is the risk of violent reoffending.     

Directionality of affective priming: effects of trait anxiety and activation level

Among the most influential models of automatic affective processing is the spreading activation account (Fazio, Sanbonmatsu, Powell, & Kardes, 1986). However, investigations of this model by different research groups using the pronunciation task in an affective priming paradigm yielded contradictory results. Whereas one research group reported congruency effects, another obtained reversed priming effects (contrast effects), and still another found null effects. In Experiment 1, we were able to show an influence of trait anxiety on the direction of the affective priming effect. By using a multiple priming paradigm in Experiment 2, we were able to link the occurrence of reversed priming effects to increased levels of activation of affective representations. We propose that this relation might underlie the influence of trait anxiety on the direction of affective priming effects. Both experiments indicate that automatic evaluation in an affective network is substantially moderated by personality traits and activation level.     

Sadistic personality disorder in sex offenders: relationship to antisocial personality disorder and sexual sadism.

To investigate the relationship of sadistic personality disorder (SPD), as defined in the appendix of DSM-III-R, to other personality disorders and to sexual sadism, 70 sex offenders (27 child molesters, 33 rapists, and 10 murderers) were assessed by the International Personality Disorder Examination. In 19 subjects (27.2%) from the total sample, SPD was diagnosed. The highest overlap appeared with borderline personality disorder (31.6%) and antisocial personality disorder (42.1%). However, in four cases SPD was the only personality disorder diagnosed. Factor analysis of the antisocial and sadistic criteria resulted in four major factors--one factor with high loadings on the sadistic criteria and the violent criteria of antisocial personality disorder, two factors with different forms of adult and juvenile aggression, and a fourth factor with high loadings on the antisocial criteria covering exploitative behavior. The results do not support SPD as a discrete disorder. Nevertheless, SPD may be seen as an important subdimension of antisocial personality disorder, distinct from more exploitative forms of antisocial behavior with less violence. Of those patients with SPD, 42.1% also had a DSM-III-R diagnosis of sexual sadism, which may be the most dangerous configuration.     

Cognitive functioning and cortisol profiles in first episode major depression

Major Depressive Disorder (MDD) is often associated with high levels of stress and disturbances in the Hypothalamic Pituitary Adrenal (HPA) system, yielding high levels of cortisol, in addition to cognitive dysfunction. Previous studies have shown a relationship between cortisol profile and cognitive functioning in recurrent MDD in general. More specifically, the association between hypercortisolism and cognitive functioning, such as memory and Executive Functioning (EF), and also more recently cortisol suppression has been explored. However, no studies have investigated these relationships in patients diagnosed with first episode MDD. The aim of the present study was to examine the relationship between cortisol levels before and after the Dexamethasone suppression test (DST) and cognitive function in first episode MDD patients. Twenty‐one patients meeting the DSM‐IV criteria for a first episode of MDD diagnosis were included in the study. The control group was matched for age, gender and education level. Cortisol was measured in saliva collected with Salivette sampling devices. Saliva samples were collected 4 times during a 24 hours period over two consecutive days: at awakening, after 45 minutes, after 7 hours and at 11 pm. Dexamethasone (1.0 mg) was given orally on Day 1 at 11 pm. The neuropsychological test battery consisted of standardized tests measuring executive functioning (EF) and memory functioning. Cortisol levels did not differ significantly between patients and controls on Day 1, except for the last sample before Dexamethasone administration, where the control group showed higher levels. Both groups showed suppression after Dexamethasone. On Day 2 there was a significant difference between groups at the third sample, showing a significantly lower level in the control group, suggesting that the controls have a more effective suppression profile than the patients. There were no significant correlations between cortisol levels before or after Dexamethasone and cognitive measures. The results indicate impairment on HPA‐axis functioning in first episode MDD patients, with less suppression functioning compared to healthy controls, but no relationship between cortisol profile and cognitive functioning in EF or Memory.     

Sexualität und Gewalt

Sexual assault as defined by law, psychiatry and sociological research is contrasted to the everyday definition of rape. Official figures on the frequency of sexual assaults as communicated in annual reports by the police differ greatly from figures found by research on sexual victimization or representative studies using different definitions of violence and abuse in sexual relations. Overpowering and violence is not a rare phenomenon in sexual relations – nearly every second woman and 10% of men are familiar with such situations. There are not only biological conditions (individual variance in neurophysiological parameters) but also psychological conditions favoring the use of power and threat instead of courting in sexual partnerships. External conditions are certain popular opinions in parts of society and certain subcultures which may also be more or less in favor of male superiority, thus helping the perpetrator to justify his assault or on the contrary helping the victim to find support in court procedures and therapy if necessary. Prevention therefore has two targets: a general one by changing popular opinions which are in favor of the use of power in sexual relations and informing persons in danger of becoming victims about the risks and the possibilities to protect themselves and an individual one by treating victims to overcome their psychological injuries and to treat perpetrators inside and outside the judicial system. The current discussion on increased availability of pornography in the internet shows both aspects: a general target to reduce negative influences of pornography which produces devaluating views on sexuality and women and the more individual task of tackling new forms of pathology created by the media at least for some of the consumers.     

Sexueller Sadismus und Sexualkriminalität

The categorization of sadism has turned out to be a versatile phenomenon, which covers a spectrum from harmless symbolic rituals to extremely violent acts where strong impulses or prolonged fantasies and rituals are involved. As the phenomenon is versatile its causes and appearances vary as well, although so-called BDSM (bondage & discipline & dominance & submission & sadism & masochism) practitioners and persons with severe sadism in a forensic context share only few common preferences. Based on own clinical experiences with sadism in forensic patients the authors support the proposed revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) especially the diagnostic disjuncture of sadism and masochism. Sexual sadism appears more frequently in forensic contexts in combination with sadistic, antisocial and borderline personality disorders but rarely with masochism. Masochism is otherwise reported to be more prevalent in patients of general psychiatry, however, combined with depression or dependent personality traits rather than with sadism. Moreover, the authors believe that if use of the diagnostic term sadism is perpetuated the establishment of the proposed new diagnosis “paraphilic coercive disorder” is unnecessary. The diagnostic term is also important for treatment and assessment. Despite the lack of reliable long-term studies with larger samples, it is reasonable to assume that medication, sometimes even anti-androgenic treatment, can be indicated in patients with severe sadism.