[Psychological stress in patients with environmentally-induced disorders. A comparison between self concept and expert assessment]. / Seelische Belastung bei Menschen mit umweltbezogenen Störungen Ein Vergleich zwischen Selbstbild und Fremdeinschätzung.

Environmental illnesses raise diagnostic and therapeutic conflicts in scientific discussions and clinical practice. When a patient's health-belief model, based on environmental origins, does not match that of the expert, the therapeutic relationship can be endangered. Our study investigates this discrepancy, which has not been empirically evaluated so far. Patient (n=61) and expert disease concepts were systematically investigated. Our results indicate that in cases in which both concepts are favourable, the patient suffered minor psychiatric disorders with stable psychic structures and the symptoms were associated with medical or environmental causes. If both concepts were unfavourable, a higher proportion of psychiatric disorders with unstable psychic structures were present. In the case of incongruent concepts, the expert evaluations allow a more accurate assessment of the psychiatric diagnoses, psychic states and the psychic attribution of somatic and psychic burden.

[Structural dynamics and psychoanalysis -- plea for a dialogue]. / Strukturdynamik und Psychoanalyse -- Plädoyer für einen Dialog.

The present paper argues in favour of a dialogue between the structural dynamics and psychodynamics. This dialogue has not really taken place, but it would yield important benefits for both sides. First of all, like any other psychiatric discipline psychoanalysis needs a psychopathology as a basic science in order to find its proper place within the psychiatric field; this basic theory is granted by the structural dynamic approach. Both theories encompass many areas of clinical practice and psychological-psychiatric theory. It is worthwhile to try to translate the main concepts of the one approach into the other's terminology. Thus, specific advantages and specific shortcomings in each theory can be unveiled. Three examples are presented, the concept of the unconscious, representational theories and the concept of desactualisation. As an example of how psychoanalysis could profit from structural dynamics, the integration of neurobiological basis into a psychological concept is mentioned. The structural dynamic psychopathology may likewise profit from psychoanalysis, mainly in terms of its therapeutic application.

[Perspectives of psychoanalytic psychosomatics]. / Perspektiven der psychoanalytischen Psychosomatik.

The paper discusses a variety of perspectives of psychoanalytic psychosomatics in the past, the present and the future. An epigenetic model of scientific development is introduced and developmental strains in psychosomatic medicine are evaluated according to the claims of the bio-psycho-social model. In historical terms, the psychological dimension of psychoanalytic psychosomatics has been the first strain to be elaborated; it is being extended still. The biological, somatic and bodily dimension of psychosomatic medicine was the next to be explored; during the last decade, this strain has found increasing interest, especially neurobiological research. Though the social dimension has not been neglected, it will be the main task for psychoanalytic psychosomatics to consider in the future. Likewise, a mandatory future challenge will be a more intensive discussion of the epistemological basis of psychosomatic medicine and psychoanalytic psychosomatics. The historical development of psychosomatic medicine is highlighted by examples drawn mainly from the history of Heidelberg Psychosomatic University Clinic that has its 50th anniversary in 2000.

[Disorder specific therapy and psychoanalysis--a contradiction?]. / Störungsspezifität und psychoanalytische Psychotherapie--Ein Widerspruch?

The concept of disorder in the ICD-10 is self-contradictory as it is not purely descriptive and neutral in nosological terms. If a concept of disorder is used instead that avoids ideology and normative presuppositions it can easily be reconciled with psychoanalytic theory and practice. Likewise, concepts of specificity are compatible with psychoanalytic thinking. specificity in psychoanalytic terms is not a strict and narrow concept; it is linked to a peculiar and interesting understanding of the interrelations between theory and practice: clinical practice is not only a form of theory application but can influence theory. The discussion on disorder specific therapy is a challenge for psychoanalysis in 2 respects: 1. Psychoanalysis still needs a differentiated clinical theory on how to deal with symptoms in a concrete and practical sense. 2. In order to remain attractive for psychiatric postgraduate students or others, psychoanalytic teaching has to consider the disorder specific classification systems as a didactic starting point.

[Evaluation of infertile men after 1 year of andrological therapy. Results of treatment and its effect on desire for children and self-esteem]. / Ungewollt kinderlose Männer nach einem Jahr andrologischer Therapie. Der Behandlungserfolg und seine Auswirkungen auf Kinderwunsch und Selbstwerterleben.

BACKGROUND AND OBJECTIVE: Many couples have to cope with periods of involuntary childlessness and they often ask for medical help. In the Heidelberg Project of involuntary childlessness in men, andrological patients were surveyed from the time before diagnosis till the end of 1 year's andrological treatment. PATIENTS/METHODS: 145 andrological patients were interviewed and filled out questionnaires to assess their wishes for parenting and their self-esteem. RESULTS: As expected men with a normal spermiographic finding had an increased chance to father a child--even more so, when no andrological treatment was performed. For those who remained childless, the wish for parenting had a higher importance than for the eventual fathers. There was little change in self-esteem, either at the beginning of treatment or one year later--with one exception: men who became fathers and had been treated suffered from more social isolation than those who became fathers and had not been treated. CONCLUSIONS: Beyond the desired effects of medical treatment, psychological and social effects have to be considered in men with involuntary childlessness, especially with those patients whose spermiogram is not severely reduced.

Environmental psychosomatics--an integrative model.

Patients presenting with new clinical syndromes such as multiple chemical sensitivities (MCS) or other environmental illnesses confront us with the necessity to have valid models of how psychological, environmental, social and biological factors interact with each other. Whilst MCS is influenced by psychiatric and psychological factors, the scientific evidence does not allow to regard MCS as a psychiatric disorder only. Objective environmental factors have to be taken into account as well. As causation of MCS seems to be very complex, a complex model is needed to integrate the various pathogenetical factors. After reviewing the psychiatric research findings on MCS, such a model is introduced in the paper; it is called the dialectical model of environmental psychosomatics. This model has implications for further research and clinical practice; it advocates a process of simultaneous diagnostic processes covering biological environmental analysis as well as psychiatric diagnostics.

[Coping with involuntary childlessness in men]. / Zur Verarbeitung ungewollter Kinderlosigkeit von Männern im Verlauf.

Somatic causes are equally distributed between the sexes, as are challenges in coping with infertility. The present paper is concerned with the hypothesis that coping mechanisms are influenced by personal motives for parenting and by the narcissistic demands of the personality. In the Heidelberg project on male infertility, 136 (80) male patients seeking andrological treatment were assessed before the onset of andrological diagnosis and one year later. Questionnaires on the motivation for parenting, narcissistic self-regulation, and coping mechanisms were submitted. Among the results, two correlational patterns that were stable over time are especially important: 1. "fragile self" pattern consisting of correlations between an endangered self image, depressive coping, and the wish to be emotionally stabilized by a child. 2. "symbiotic" pattern characterized by self-stabilization through symbiotic wishes expressed regarding the partner or the desired child, or by commitment to religion. The relevance of these patterns for men coping with infertility is discussed.

[Unfulfilled desire for children--what is the grief for men?]. / Der unerfüllte Kinderwunsch--worunter leiden die Männer?

The present paper addresses the topic of involuntary childlessness and its psychological sequelae for the fathers-to-be. There are at least two different psychological stresses men have to cope with: not being able to generate a child, and missing a child as one's life fulfillment. A short review of empirical research on male coping with infertility illustrates that men suffer from involuntary childlessness as do women. Nevertheless, the quality of the psychological burden remains open. Results from the Heidelberg Research Project on Male Infertility are summarized to assess this quality. Involuntary childlessness does not entail psychological sufferings for all patients; indeed, it is only a subgroup that remains fixated to the wish to have a child for psychological reasons. The project data elucidate the motives behind this fixation. They show that the most important psychological burden is not the narcissistic wound not to be able to generate a child, but the frustration of hope invested into the longed--for child on whom many otherwise unfulfilled aspirations are projected.

[Not Available]. / Männlicher Kinderwunsch und Unfruchtbarkeit - eine multimethodale Untersuchung/ Male motives for parenting and in/ertility - a multimethodical enquiry.

Infertility means psychological stress for both sexes if their wish to have a child remains unfulfilled. The way men cope with infertility is partly due to the psychodynamics of their motives for parenting. In the paper, these motives are analysed by a combination of statistical and qualitative methods (content analysis). 137 Patients addressing an andrological outpatient department were asked to fill in a questionnaire of their motives for parenting. A cluster analysis yielded a four cluster solution, two of them being contrary to each other. One was interpreted as characterising "ambivalence towards the child", the other as "child-dependent or offspring-fixated". This interpretation was validated by qualitative data drawn from content analyses of psychodynamic interviews performed with a subgroup of 80 andrological patients. The results do have clinical relevance; they allow to better understand the psychological and psychodynamic sequelae of male infertility thus providing some cues for specific therapeutic interventions. In addition, the study is of methodological interest, because of the combination of quantitative and qualitative empirical methods.

[Operationalized Psychodynamic Diagnosis in a trial--results of multicenter acceptability and practicability study]. / Operationalisierte psychodynamische Diagnostik (OPD) in der Erprobung--Ergebnisse einer multizentrischen Anwendungs- und Praktikabilitätsstudie.

During a multicentric field trial involving 134 diagnosticans from 16 centres in a first phase and 38 diagnosticans from 5 centres in a second phase a preliminary version of the manual "Operational Psychodynamic Diagnosis (OPD)" was tested. Focussing on feasibility, practicability and interrater-reliability the different axes of the new system were assessed as comparatively easy to use. The goodness of fit for diagnostic categories and the confidence in the diagnostic process showed a sufficient acceptance of the system. The percentage and chance-corrected inter-rater-reliability coefficients were acceptable for the most axes. It could be demonstrated that interrater-reliability depends on the degree of experiences with the OPD approach. Therefore a systematic training is necessary to use the system.

[Unfulfilled desire for children in the man: coping and pain. Results of a psychosomatic-andrologic cooperative study]. / Der unerfüllte Kinderwunsch beim Mann: Bewältigung und Erleiden. Ergebnisse einer psychosomatisch-andrologischen Kooperationsstudie.

115 andrological patients were studied with psychological self-assessment tests to assess both their motivation concerning parenthood, and their own explanations for the causes. Additionally self-esteem was evaluated in 51 patients. The main results were: Motivation concerning parenthood is of greater importance in coping with involuntary childlessness than objective andrological data. Patients assess their situation quite realistically; no tendency to misinterpret the medical data in order to defend negative feelings and to protect self-esteem could be found. Most patients with reduced fertility consider this situation a challenge and are willing to mobilize resources and the help of others in order to cope. Self-esteem was only threatened in those patients with longlasting unvoluntary childlessness and little acceptance of medical infertility treatment and parenting substitutes, e.g. adopting a child.

Psychological factors in the diagnosis and pathogenesis of stiff-man syndrome.

Retrospective psychological evaluation of nine patients with stiff-man syndrome (SMS), seven of whom evidenced autoimmune disease, revealed a characteristic set of psychological symptoms or features: Major stressful life events preceded the development of permanent symptoms by 6 months or less (seven patients); transient motor symptoms occurred in emotionally distressing situations months or even years before the onset of a permanent motor deficit (five patients); after onset, similar situations specifically precipitated or augmented stiffness and spasms (five patients). We also found task-specific fear resembling agoraphobia (six patients) and loss or invalidation of one or both parents, or loss of home, in childhood (seven patients). Eight patients were initially misdiagnosed as having psychogenic movement disorder. We conclude that the common misdiagnosis of SMS as a psychogenic movement disorder is due to the compelling association of a set of salient psychological features, bizarre and fluctuating motor symptoms, and lack of approved neurologic signs.

[The role of biography in psychoanalysis]. / Zum Stellenwert der Biographie in der Psychoanalyse.

The construction of biographical data by the analyst and the remembrance of the past by the patient were regarded as vital for the psychoanalytic cure by Freud. Today the working-through of the transference in the actual therapeutic relationship is regarded as much more important. Whether the past is constructed or reconstructed, whether past events can explain present experiences etc., these questions are discussed not only in psychoanalysis, but also in the historical sciences and in philosophy. The dialogue with these can offer new insights into the relation of past to present, the importance of narrativity etc. to psychoanalysis; at the same time by comparison psychoanalysis can define its proper and specific approach to biography more clearly. These specific methods include the intersubjectivity of psychoanalytic experience in general and of reconstruction of the past, particularly, and the psychoanalytic process of remembering that leads to a differentiation of presence and past. Psychoanalysis is no psychosynthesis; it de-constructs experience, whereas the synthesis of the past is left to the patient's synthetic functions.

[Theory and practice of psychodynamic supervision in psychiatry]. / Zur Theorie und Praxis psychodynamischer Supervision in der Psychiatrie.

Supervision has become a canonical part of psychotherapeutic training. Supervision has been increasingly introduced into general psychiatric treatment, especially where the team is subjected to increased psychological stress. Some psychodynamic models of the functioning of team supervision in psychiatry are presented, esp. support of the team's "synthetic functions" and the use of "mirror phenomena". Case vignettes drawn from supervisory sessions may help to illustrate the models. Finally the institutional prerequisites for establishing team supervision are pointed out.

[What modifies the course of Crohn disease?]. / Was beeinflusst den Krankheitsverlauf des Morbus Crohn?

This paper presents empirical results concerning the interdependency of somatic and psychological factors in the course of Crohn's disease. Data derived from the Heidelberg psychosomatic study on Crohn's disease are explored with the help of canonical correlation analysis. Somatic data recorded in the acute stage of Crohn's disease were not empirically found to be predictive of the psychological status after convalescence empirically. On the other hand, we did find psychological data that allowed prediction of the somatic status when the patients were in remission. Of these psychological data, coping resources are the most important predictors of the course of the disease. In particular, depressive forms of coping are correlated with personality factors, whereas active coping forms are not. The results have implications for scientific theory as well as for clinical practice.

[Bio-psychosocial interactions in follow-up of Crohn disease]. / Biopsychosoziale Wechselwirkungen im Krankheitsverlauf des Morbus Crohn.

The bio-psycho-social model serves as a guideline to the presentation of the main results of a longitudinal study of Crohn's disease (Heidelberg research project on Crohn's disease). The interactions and interrelations of the biological, psychological and social dimension during a 3 years' course of the disease are presented; in addition, the psychological data based on different theoretical concepts are compared to and linked with each other (defense/coping; disease concepts/personality and coping). Conclusions are drawn in respect to the biopsychosocial research on Crohn's disease and, more generally, to bio-psycho-social research designs and research methodology.

[Structure and structural disorder]. / Struktur und strukturelle Störung.

One of the central tasks of psychodynamic diagnosis, next to determining intrapsychic conflicts, central relational patterns, and subjective forms of experiencing is assessing the psychic structure or the structural disorder. This article develops the structure term from object relationship theoretical, ego-psychological, and self-psychological concepts of psychoanalysis. This "Structure of the self in the relationship to others" thus obtained is described with six structural criteria (self-perception, self-control, defence, object perception, communication, attachment). In order to be able to distinguish the extent and the quality of structural disorders four structure levels of integration based on psychoanalytic experience in the out-patient and the in-patient setting are differentiated. A basis for an operationalization is then made; it is made in the system OPD (Operationalized Psychodynamic Diagnostics). First studies regarding practicalibility and reliability are promising.