[Lifestyle interventions for patients with personality disorder]. / Leefstijlinterventies bij patiënten met een persoonlijkheidsstoornis.

It has been known for some time that patients with severe mental disorders often suffer from somatic comorbidity and that they have a shorter life expectancy. However, also patients with personality pathology often suffer from a poorer somatic health associated with a shorter life expectancy. In daily practice a poor somatic condition in these patients seems often due to a maladaptive life style. Moreover, clinical evidence suggests that a maladaptive life style hinders a good outcome of the (psychotherapeutic) treatment. In this article I present a brief review of the literature, describe three fictitious cases and give suggestions how to diagnose and intervene on a maladaptive life style. One had to take in account that a maladaptive life style often is used as a coping mechanism to combat one's difficulties.

[Measuring mentalization: an attempt using the Reflective Functioning Rating Scale]. / Het meten van mentaliseren; een poging met de Reflective Functioning Rating Scale.

BACKGROUND: The ability to mentalise or continue to mentalise is considered relevant for our understanding of the progenesis of various psychiatric disorders and is seen as a common factor in various forms of psychotherapy. Until now, however, there has not been any easy to handle instrument available which clinicians can use to measure the nature and degree of a patient's mentalisation ability. The Reflective Functioning Rating Scale (RFRS) is an instrument that is developed to meet the need for such measurements. AIM: To investigate the scale structure, reliability, validity and usefulness of this new rating scale in a psychotherapeutic population. METHOD: We conducted a cross-sectional study among psychotherapy patients and their therapists using the infrastructure of routine outcome monitoring for data sampling. RESULTS: The items in the RFRS could be grouped in three clinically meaningful dimensions: Adequate Mentalising (AM), Blocked Mentalising (BM) and Non-Mentalised Behaviour (NMB). The first two dimensions had an excellent internal consistency, the third (NMB) fell short. The inter-rater reliability of all three scales was unsatisfactory. The construct and concurrent validity were disappointing. Finally, the usefulness of the instrument, as experienced by the therapists was below the required standard and needs to be upgraded. CONCLUSION: In psychotherapeutic and psychiatric practice mentalising is a frequently used concept. So far, there is no instrument available which allows clinicians to measure the nature and degree of mentalisation. In its present form the RFRS is not up to the required standard.

[Transference focused psychotherapy (TFP) and principles of mentalisation in inpatient psychotherapy; a matter of form and content]. / Transference-focused psychotherapie en mentaliseren in de klinische psychotherapie; een kwestie van vorm én vent.

BACKGROUND: General principles of milieu therapy together with a general psychodynamic frame of reference were felt to have become inadequate in providing an adequate and coherent treatment program in an inpatient psychotherapeutic setting. Both Transference Focused Psychotherapy (TFP) and Mentalization Based Treatment (MBT) are individual psychotherapy models developed for use in outpatient practice. Theoretically, both models could be adjusted for use in an inpatient setting. However, despite their common psychodynamic roots they differ fundamentally on some theoretical and practical issues. AIM: To reorganize the inpatient group psychotherapeutic program using TFP as the frame of reference supported with principles from MBT to provide strong guidelines for the multidisciplinary treatment. METHOD: We describe the basic principles and procedures of both psychotherapy models and their modifications to adjust these models for inpatient group psychotherapy. RESULTS: From both a theoretical and a pragmatic point of view the TFP and MBT models complement each other extremely well. The modified TFP model seemed to work well in an inpatient psychotherapy setting. With the help of the detailed frame of reference, the working methods of the various disciplines could be better aligned and coordinated so that they bolster each other. The use of video registration, common practice in TFP treatments, made a major contribution to this process. CONCLUSION: Working with the TFP model enriched with MBT principles was successful in optimizing the treatment program.

The assessment of alexithymia: a critical review of the literature and a psychometric study of the Toronto Alexithymia Scale-20.

OBJECTIVE: The objectives were to give an overview of studies on the validity of the Toronto Alexithymia Scale (TAS-20) and to present data regarding the validity of the TAS-20. METHODS: The literature on the psychometric properties of the TAS-20 was reviewed and a study was conducted of its psychometric properties in a sample of students and a sample of psychiatric outpatients using a statistical method allowing identification of a stable factor structure. RESULTS: The review revealed that the majority of studies on the TAS-20 were conducted with nonpatient samples. The factorial validity and reliability of the dimensions 'identifying feelings' (DIF) and 'describing feelings' (DDF) could be replicated in many of these studies. However, in practically all studies the dimension 'externally oriented thinking' (EOT) appears to be unreliable. In addition, the presupposed fantasy aspect of the alexithymia construct is not included in the TAS-20. Although many studies were conducted on the construct validity of the TAS-20, no studies have been published on its criterion validity. Some studies show a different factor structure to exist in patient samples. This was confirmed in our own study in which the dimensions 'identifying feelings' and 'describing feelings' collapsed into one single subscale. As in other studies, the reliability of the dimension 'EOT' was low. CONCLUSION: The TAS-20 has some important shortcomings with respect to validity and reliability. For the assessment of alexithymia in empirical research, it is recommended to use the TAS-20 in combination with other instruments. We do not recommend the TAS-20 to be used in clinical practice.

The Sexual and Physical Abuse Questionnaire (SPAQ). A screening instrument for adults to assess past and current experiences of abuse.

OBJECTIVE: We reconstructed and validated a simple questionnaire to be completed by adult respondents for the assessment of sexual and physical abuse during childhood and later life, the Sexual and Physical Abuse Questionnaire (SPAQ). METHOD: The criterion validity of the questionnaire was investigated in a population of psychiatric outpatients (n = 134) using the Structured Trauma Interview [Am. J. Psychiatr. 156 (1999) 379] as gold standard for the assessment of sexual and physical abuse. RESULTS: All questionnaires were returned fully completed. The measures of agreement and the predictive measures of the questionnaire were satisfactory, in particular with respect to experiences of sexual abuse. Positive answering of the questionnaire increased the odds for sexual abuse by a factor of 12-17.5, and negative answering of the questionnaire reduced the odds by a third. The odds for physical abuse were increased by a factor of 8 with positive answering of the questionnaire, and reduced by a third with negative answering. CONCLUSION: The questionnaire may be a useful screening instrument in research and in clinical practice to assess sexual abuse during childhood and later years. As a screening instrument for physical abuse it is less satisfactory.

Is alexithymia a risk factor for unexplained physical symptoms in general medical outpatients?

OBJECTIVE: Alexithymia is presumed to play an important predisposing role in the pathogenesis of medically unexplained physical symptoms. However, no research on alexithymia has been done among general medical outpatients who present with medically unexplained physical symptoms as their main problem and in which anxiety and depression have been considered as possible confounding factors. This study investigated whether patients with medically unexplained physical symptoms are more alexithymic than those with explained symptoms and whether, in patients with unexplained symptoms, alexithymia is associated with subjective health experience and use of medical services. METHODS: We conducted a cross-sectional study among patients attending an internal medicine outpatient clinic. All patients were given a standardized interview and completed a number of questionnaires. RESULTS: After complete physical examinations, 169 of 321 patients had unexplained physical symptoms according to two independent raters. Patients with medically unexplained symptoms more often had a mental disorder, but overall they were not more alexithymic. In patients with unexplained physical symptoms, alexithymia was not associated with subjective health experience or use of medical services. However, patients with both unexplained symptoms and a mental disorder who also denied any possible connection between emotional problems and their physical symptoms did have more alexithymic traits. CONCLUSIONS: In the majority of patients with medically unexplained physical symptoms, alexithymia does not play a role of clinical significance. Patients with unexplained physical symptoms are heterogeneous with respect to psychiatric syndrome pathology and probably also with respect to personality pathology.

The status of alexithymia as a risk factor in medically unexplained physical symptoms.

Some decennia ago, the concept of alexithymia was developed from the clinical experience of psychosomaticians who at the time were largely working within a psychoanalytic frame of reference. Alexithymia can briefly be described as a cognitive-affective disturbance characterized by difficulties in differentiating one's feelings and expressing them in words. Clinicians who treat patients with medically unexplained physical symptoms may often recognize alexithymic features in their patients. It is supposed that alexithymia could be a predisposing factor for the development or persistence of medically unexplained physical symptoms. In this review, the concept of alexithymia as well as paradigmatic shifts in psychoanalysis and psychosomatics are discussed to place the concept of alexithymia in its epistemiological context. Furthermore, the empirical literature on the association between alexithymia and medically unexplained physical symptoms is reviewed. The main conclusions are that alexithymia appears to be a theoretically important and clinically appealing concept, but that so far the empirical evidence that alexithymia predisposes to the development or persistence of medically unexplained physical symptoms is imperfect. This is mainly because of the cross-sectional design of most studies and is due to other methodological shortcomings, such as the lack of allowance for depression and anxiety as possible confounding factors. Suggestions for future research are made.

Perceived parental attitude, alexithymia and defense style in psychiatric outpatients.

BACKGROUND: Although it is the clinical impression that alexithymia may be due to disturbances in the early parent-child relationship and that it is associated with primitive defense mechanisms, a possible association with neurotic defense mechanisms, such as repression and reaction formation, has also been mentioned. However, empirical studies on these and related issues are scarce. The aim of this study was to determine the association between perceived parental attitude, defense mechanisms and alexithymia. METHODS: In a cross-sectional study we obtained data from 78 psychiatric outpatients. Alexithymia, defense mechanisms and perceived parental attitude were measured with the Toronto Alexithymia Scale, the Defense Style Questionnaire and the Parental Bonding Instrument. RESULTS: We found only weak associations between perceived parental attitude and alexithymic features. Primitive and adaptive defenses were associated with alexithymic features in a clinically sensible way. The strongest association was found between primitive defense mechanisms and alexithymic features. There was hardly any association between neurotic defense mechanisms and alexithymic features. CONCLUSIONS: The results of our study support the hypothesis that alexithymia is associated with a primitive defense style, whereas a relation to disturbances in early parent-child relationship could not be confirmed. It is argued that possibly more severe traumatic experiences, such as physical and sexual abuse, than merely a negatively perceived parental attitude, are necessary to develop alexithymic features.

Defense style in depressed and anxious psychiatric outpatients: an explorative study.

The aim of the present study was threefold: (a) to investigate whether anxiety or depressive disorders are related to the use of specific defenses; (b) to evaluate which defenses are associated with self-report measures for anxiety and depression; and (c) to assess whether the association between defenses and anxiety or depression is gender specific. Subjects were 483 consecutive psychiatric outpatients with the following DSM-III-R diagnoses: (a) V-code or no psychiatric diagnosis (N = 71) (controls); (b) one or two anxiety diagnoses (N = 116), among which 47 patients with a single diagnosis of panic disorder; (c) one or two depressive disorder diagnoses (N = 93), among which 35 patients with a single diagnosis of dysthymia and 51 with a single diagnosis of major depression; and (d) 203 otherwise. Defense use was measured with the Defense Style Questionnaire-36 and level of anxiety and depression with the Symptom Checklist-90. Compared to controls, anxiety and depressive disorder patients scored higher for the immature defense style. Moreover, anxiety disorder patients obtained significantly higher scores for the neurotic defense style than both depressive disorder patients and controls. Panic patients made more use of the defense mechanisms of somatization, devaluation, and idealization, and dysthymic patients of somatization, devaluation, and isolation. Both anxiety and depression scores were positively related to the immature and neurotic, and negatively to the mature defense style. Anxiety was predominantly related to somatization and depression to projection. No evidence for a gender specific association between defense and anxiety or depression was found. It is concluded that the observed differences in defense between groups may be a consequence of the nature of the psychiatric disorder irrespective of gender. Prospective studies of persons at risk are needed to evaluate whether specific defenses are predictive of anxiety or depressive disorders and/or symptoms.

Induced psychotic disorder: clinical aspects, theoretical considerations, and some guidelines for treatment.

We describe our experience with a case of folie à famille with role reversal, including the long-term course. In addition, the case reports published since 1974 were reviewed and an overview is given of the psychoanalytic and system theory concepts on the pathogenesis of induced psychotic disorder. The inductor often appears to be suffering from schizophrenia. No further indications could be found in the literature for a hereditary predisposition in the recipient. It is sometimes difficult to distinguish between the inductor and the recipient, owing to the circular character of induced psychotic disorder and the role reversal that sometimes occurs. The DSM-III-R criteria for induced psychotic disorder were found to be lacking in practice because of their disregard for the circular causality and the strict exclusion criteria. In the short term, physical separation of the inductor and recipient leads to better treatment results than nonseparation, particularly in the case of recipient children. Long-term results are seldom mentioned. On the basis of theoretical considerations, interventions that aim at separation in psychological terms are necessary to achieve favorable long-term treatment results.

[Non-urgent patients in a non-traumatology Emergency Service; general aspects and screening for psychiatric disorders]. / Non-urgente patiënten op een niet-traumatologische afdeling Spoedeisende Hulp; algemene kenmerken en een screening op psychiatrische stoornissen.

The Emergency Department is used by a rather large number of patients with a non-urgent condition. It is unknown whether the request for medical assistance for non-urgent conditions is partly due to the presence of a mental disorder. We conducted a cross-sectional study of 711 patients of a non-traumatic Emergency Department. The prevalence and determinants of non-urgent conditions and of mental disorders of non-urgent patients were studied. Of all patients, 31% had a non-urgent condition. Self-referrals and young adults more often had a non-urgent condition. However, in our study only 17% of all patients were self-referred. The prevalence of a score greater than or equal to 5 on the general health questionnaire (GHQ), an indication of the presence of a mental disorder, in the non-urgent patients was 59%. Non-acute symptoms, life events, the use of psychotropic drugs and alcoholism were determinants for a high GHQ score, but their specificity was low. It is advised to include questions concerning mental disorders in the medical interview of non-urgent patients.

Clinical and demographic characteristics of emergency department patients in The Netherlands: a review of the literature and a preliminary study.

A review of the literature and a preliminary study were carried out on demographic and clinical characteristics of patients who make use of emergency departments (EDs). The central concern was whether self-referred patients differ in these respects from patients who are not self-referred. Several studies were conducted to determine the characteristics of ED patients in general. Very little research exists on the characteristics of self-referred patients' use of EDs. The preliminary study indicates that self-referred ED patients with nontraumatic complaints differ from those referred by physicians, especially with regard to the urgency of their somatic conditions. More research, including psychiatric research, should be done to clarify the underlying motives of the distinct patient groups in their visits to EDs.