Liebowitz Social Anxiety Scale (LSAS): Optimal cut points for remission and response in a German sample.

The Liebowitz Social Anxiety Scale (LSAS) is the most frequently used instrument to assess social anxiety disorder (SAD) in clinical research and practice. Both a self-reported (LSAS-SR) and a clinician-administered (LSAS-CA) version are available. The aim of the present study was to define optimal cut-off (OC) scores for remission and response to treatment for the LSAS in a German sample. Data of N = 311 patients with SAD were used who had completed psychotherapeutic treatment within a multicentre randomized controlled trial. Diagnosis of SAD and reduction in symptom severity according to the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, served as gold standard. OCs yielding the best balance between sensitivity and specificity were determined using receiver operating characteristics. The variability of the resulting OCs was estimated by nonparametric bootstrapping. Using diagnosis of SAD (present vs. absent) as a criterion, results for remission indicated cut-off values of 35 for the LSAS-SR and 30 for the LSAS-CA, with acceptable sensitivity (LSAS-SR: .83, LSAS-CA: .88) and specificity (LSAS-SR: .82, LSAS-CA: .87). For detection of response to treatment, assessed by a 1-point reduction in the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, rating, a reduction of 28% for the LSAS-SR and 29% for the LSAS-CA yielded the best balance between sensitivity (LSAS-SR: .75, LSAS-CA: .83) and specificity (LSAS-SR: .76, LSAS-CA: .80). To our knowledge, we are the first to define cut points for the LSAS in a German sample. Overall, the cut points for remission and response corroborate previously reported cut points, now building on a broader data basis.

Enzymes and signal pathways in the pathogenesis of alcoholic cardiomyopathy.

Owing to its acute psychotropic effects, ethanol is the most frequently consumed toxic agent worldwide. However, excessive alcohol intake results in an array of health, social, and economic consequences, which are related to its property as an addictive substance. It has been well established that exposure to high levels of alcohol for a long period leads to the onset and progression of nonischemic cardiomyopathy through direct toxic mechanisms of ethanol and its metabolite, acetaldehyde. Excessive alcohol ingestion causes myocardial damage including disruptions of the myofibrillar architecture and is associated with reduced myocardial contractility and decreased ejection volumes. Key features of alcoholic cardiomyopathy are cardiac hypertrophy and ventricular dilatation, and the disease is manifested mainly as cardiomegaly, congestive heart failure, and even cardiac death. Mechanisms that have been postulated to underlie the pathogenesis of alcoholic cardiomyopathy include apoptosis, mitochondrial alterations, acetaldehyde protein adduct formation, oxidative stress, and imbalances in fatty acid metabolism. In the following, we give a brief overview of the molecular effects of ethanol-metabolizing enzymes and their impact on myocardial signal transduction pathways.

The social phobia psychotherapy research network. The first multicenter randomized controlled trial of psychotherapy for social phobia: rationale, methods and patient characteristics.

This paper presents the Social Phobia Psychotherapy Research Network. The research program encompasses a coordinated group of studies adopting a standard protocol and an agreed-on set of standardized measures for the assessment and treatment of social phobia (SP). In the central project (study A), a multicenter randomized controlled trial, refined models of manualized cognitive-behavioral therapy and manualized short-term psychodynamic psychotherapy are compared in the treatment of SP. A sample of 512 outpatients will be randomized to either cognitive-behavioral therapy, short-term psychodynamic psychotherapy or waiting list. Assessments will be made at baseline, at the end of treatment and 6 and 12 months after the end of treatment. For quality assurance and treatment integrity, a specific project using highly elaborated measures has been established (project Q). Study A is complemented by 4 interrelated add-on projects focusing on attachment style (study B1), on cost-effectiveness (study B2), on variation in the serotonin transporter gene in SP (study C1) and on structural and functional deviations of the hippocampus and amygdala (study C2). Thus, the Social Phobia Psychotherapy Research Network program enables a highly interdisciplinary research into SP. The unique sample size achieved by the multicenter approach allows for studies of subgroups (e.g. comorbid disorders, isolated vs. generalized SP), of responders and nonresponders of each treatment approach, for generalization of results and for a sufficient power to detect differences between treatments. Psychological and biological parameters will be related to treatment outcome, and variables for differential treatment indication will be gained. Thus, the results provided by the network may have an important impact on the treatment of SP and on the development of treatment guidelines for SP.

Fear-avoidance behavior and anticipation of pain in patients with chronic low back pain: a randomized controlled study.

OBJECTIVE AND DESIGN: In a randomized controlled study, we investigated whether pain anticipation and fear-avoidance beliefs will lead to behavioral avoidance. PATIENTS: Fifty patients with chronic low back pain (CLBP) performed a simple leg-flexion task. Before the test, members of a control group were informed that the movement would not result in any increase of pain, whereas experimental group participants were told that a slight increase of pain could occur. OUTCOME MEASURES: All patients completed the Fear-Avoidance-Beliefs Questionnaire (FABQ) and the Pain Disability Index (PDI). As dependent variables, different behavioral performance parameters were registered by a computerized protocol: number of flexion movements, mean range of motion, and mean work ratio. Furthermore, patients were asked about their pain intensity as well as their fear (at the moment) and finally were asked to judge the unpleasantness of the experiment (using visual analogue scales for each of the three variables). RESULTS: Inducing pain anticipation (by instruction) led to significantly lower levels of behavioral performance as well as increased pain intensity and fear during the test. Behavioral performance was significantly correlated with fear-avoidance beliefs. CONCLUSIONS: Results confirm that pain anticipation and fear-avoidance beliefs significantly influence the behavior of patients with low back pain in that they motivate avoidance behavior. Therapists must be aware of the powerful effects of cognitive processes, which can give rise to fear of pain and, consequently, avoidance behavior.

Validation of the German version of the Fear-Avoidance Beliefs Questionnaire (FABQ).

Fearful avoidance of physical activities is a major factor in low back pain (LBP) and disability. In 1993 Waddell et al. developed the Fear-Avoidance Beliefs Questionnaire (FABQ) focusing on patients' beliefs about how physical activity and work affect LBP. The focus of our study was to analyse and validate the German version of the FABQ. Three-hundred and two consecutive LBP outpatients participating on a functional restoration programme filled in the FABQ. Factor analysis yielded three factors which accounted for nearly 65% of the total variance of the questionnaire. Whereas the factor 'physical activity' (8.9% of the variance) remained the same as in the English version, the second factor of the original version split into two: one related to, 'work as cause of pain' (43.4% of the variance) and the other to patients' assumptions of their probable return to work (11.8% of the variance). Both work-related subscales showed a good internal consistency (alpha = 0.89, resp. alpha = 0.94), whereas the consistency of the subscale 3 'physical activity' was only modest (alpha = 0.64). Test-re-test reliability score was fair to good for the whole scale (r = 0.87;n = 30). Regression analysis demonstrated that fear-avoidance beliefs account for the highest proportion of variance (35%) regarding disability in activities of daily living and work loss. Patients out of work demonstrated more fear-avoidance beliefs in comparison to those who were still working. It can be concluded that the German version of the FAQB is a reliable and valid instrument, but it shows a different factor structure from the original English version. The FABQ has been proven to identify patients with maladaptive beliefs which have to be focused on in proper treatment.

Cognitive-behavioral treatment in unselected rheumatoid arthritis outpatients.

OBJECTIVE: This trial was performed to evaluate the efficacy of an adjunctive cognitive-behavioral treatment compared with rheumatological treatment alone in unselected rheumatoid arthritis outpatients. DESIGN: A prospective randomized control design was used. Change in medication during treatment was controlled by matching therapy- and control-group subjects according to this change in medication, sex, age, duration of disease, and functional class. SETTING: A rheumatological outpatient clinic, University of Goettingen, Germany. PATIENTS: Fifty-five consecutive outpatients with a diagnosis of rheumatoid arthritis (age 52.7 years, 74.5% female, duration of disease 9.4 years) finished the study. INTERVENTIONS: Subjects received routine care by the rheumatologists and routine medical treatment. Cognitive-behavioral treatment subjects (n = 19) received adjunctive standardized cognitive-behavioral group treatment with 12 weekly sessions. OUTCOME MEASURES: Outcome measures included disease activity variables, pain variables (pain intensity, affective pain), psychological symptoms, and coping. RESULTS: Subjects mostly demonstrated an increasing disease activity during treatment; change in medication during treatment was necessary in some patients. In the cognitive-behavioral treatment group the course of rheumatoid arthritis seemed less progressive than in the control group. The core effects of cognitive-behavioral treatment pertain more to improved coping, emotional stabilization, and reduced impairment than to reduced pain intensity. Passive, emotion-focused coping, helplessness, depression, anxiety, affective pain, and fluctuation of pain are reduced, "Acceptance of Illness" is improved. CONCLUSIONS: Cognitive-behavioral therapy has proven an effective adjunct to standard treatment of rheumatoid arthritis outpatients. These effects were shown in an unselected sample with increasing disease activity and with comparable changes in medication during treatment. We recommend cognitive-behavioral treatment as an desirable adjunct to standard medical treatment of rheumatoid arthritis.

Diagnostic groups and depressed mood as predictors of 22-month mortality in medical inpatients.

OBJECTIVE: While depression has been found to predict mortality in acute myocardial infarction, results from many other groups of medical patients are inconclusive. It is, therefore, unclear whether depression also predicts mortality in the typical mixed patient populations treated on medical hospital wards and whether an increased risk can be identified by means of patients' self ratings of depression. METHOD: The Hospital Anxiety and Depression scale was used as a routine screening tool in consecutive admissions to the general medical wards of a university hospital. The official survival data were obtained 22 months later. For all 454 patients who completed the screening questionnaire, complete survival data were available. RESULTS: High depression scores significantly predicted mortality in univariate comparisons (odds ratio 3.2; 95% CI 1.9-5.5) and in multivariate Cox regression analyses controlling for demographic and medical baseline variables (multivariate odds ratio 1.9; 95% CI 1.2-3.1; p < .01). Other significant predictors in the multivariate model were having a principal diagnosis of hematological disease or cancer, and older age. Disability, as assessed by nurses' ratings, and gender were not related to mortality. Subgroup analyses showed that the effect of depression scores was greatest in cardiopulmonary patients, but there was also a uniform trend toward higher mortality in depressed patients with other diagnoses. CONCLUSION: Depressed mood is an independent risk factor for all-cause mortality in medical inpatients. Identifying patients at risk does not require formal psychiatric diagnoses, but can be achieved by means of a short, routinely administered self-rating questionnaire.

[Psychiatric disorder or coronary heart disease? Psychological test data and ICD-10 diagnoses in patients undergoing coronary angiography]. / Psychische Störung oder koronare Herzkrankheit? Testpsychologische Befunde und Diagnosen nach ICD-10 bei Patienten vor Koronarangiographie.

Cardiac complaints can indicate the presence of coronary heart disease or psychological disorders. In this prospective study we examined forty patients undergoing coronary angiography. As expected psychological disorders diagnosed according to ICD-10, especially anxiety disorders, were more frequent in patients with normal coronary arteries (60% vs. 25%; p = 0.025). Anxiety symptoms predicted coronary status in uni- and multivariate models. Especially the HADS-D proved useful for this purpose. We propose a graded psychosomatic approach consisting of an anxiety screening test and a standardised interview. This is practicable under medical routine conditions, can facilitate the initiation of proper treatment, and reduce individual distress as well as economical costs by preventing chronification.

Effectiveness of a multimodal treatment program for chronic low-back pain.

In recent years, multidisciplinary pain programs were seen to successfully treat patients by basing treatment on a combination of physical exercise and psychological interventions. However, in spite of their effectiveness, it still remains to be clarified exactly which features of these programs were responsible for patient improvement. Cognitive-behavioral models posit that improvement is due, in part, to changes in patient coping strategies. Nonetheless, as reflected by the conflicting opinions present in the literature, it is questionable whether a so-called 'cognitive shift' is an accurate indicator for return to work of disabled patients. Ninety patients with chronic low back pain took part in a multidisciplinary treatment program. Therapeutic environment reinforces wellness behavior and enhances the patients' sense of control over their pain and resulting disability. The main therapeutic target point was to facilitate return to work. Ways of coping were measured by a well studied coping inventory in the German language (FEKB). Factor analysis revealed three factors: 'catastrophizing', 'search for information' and 'cognitive control'. In addition, assessment included measurements of pain intensity, depression, disability, flexibility of the lumbar spine, and different performance parameters. All of them were measured prior to and at the end of treatment, and following intervals of 6 and 12 months after discharge from program. Measurements showed significant changes over time, but more importantly, nearly all results were seen to stabilize at the 6- and 12-month evaluation following treatment. The coping strategies demonstrated little or poor change. In addition, coping measures and change in coping behavior showed poor prognostic relevance. But other psycho-social parameters like self-evaluation of potential return-to-work, application for pension, the length of pre-absence from work, and a decrease in subjective disability following treatment were effective indicators for 'back-to-work'. Other objective parameters, such as medical history, physical impairment and general physical variables were seen to have little predictive value in determining a return to work. The results suggest that the primary target point for further investigation is the analysis of the patients' beliefs about their pain. Our results indicate that future research must be attentive to the complex interactions between environmental factors and the coping demands posed by the specific nature of pain problems.

[The importance of bodily complaints in patients with chronic back pain]. / Bedeutung körperlicher Beschwerden bei Patienten mit chronischen Rückenschmerzen.

UNLABELLED: Pain perception is a complex psychosomatic phenomenon and is influenced by different psychological variables. Apart from their pain perception, chronic pain patients also suffer from different bodily complaints. The clinical significance of this finding is not yet clear. Bodily complaints in chronic pain patients may represent (a) a bodily expression of depressive symptoms, (b) a sign of chronicity, and (c) the expression of a heightened bodily awareness in the sense of hypochondriasis. METHODS: A psychometric study was done with 83 patients with chronic low-back pain. The patients were interviewed and tested psychometrically. We administered a German scale to measure bodily complaints (BL), an inventory to measure the extent of depressive symptoms (DS) and two subscales of an personality inventory (bodily complaints and hypochondriasis). In addition, patients were evaluated according to three stages of chronification ("Mainz Pain Staging System"). Ten anamnestic variables from four dimensions (temporal aspects, spatial aspects, medication usage behavior and patient's health care history) are added to yield a total chronification stage with three stages ranging from acute to chronic pain. RESULTS: Results indicate that bodily complaints have to be interpreted as signs of depressive disorder and chronicity. Signs of bodily 'awareness' or 'somatic anxiety'- in the sense of hypochondriasis - could not be found. Hypochondriasis does not seem to play a significant role in chronification of low back pain. CONCLUSIONS: From a cognitive-behavioral perspective the results support the hypothesis that psychological disturbance in chronic pain is a cause of long-standing pain perception and the result of the chronification process.

[Fear-avoidance-beliefs in patients with backpain]. / Erfassung der "fear-avoidance-beliefs" bei Patienten mit Rückenschmerzen. Deutsche Version des "fear-avoidance-beliefs questionnaire" (FABQ-D).

INTRODUCTION: In recent years most industrialized nations have been confronted with a dramatic increase in cases dealing with back pain which, because of the associated costs, has put a strain on health care systems. Because of the tremendous costs caused by patients with chronic illnesses, there is a common interest in identifying determinants responsible for the pain becoming chronic. According to the fear-avoidance model, chronic back pain is the cause of specific patient beliefs according to their perception and appraisal of back pain and their assumptions about the connection between pain and work activities. These fear-avoidance beliefs are assumed as the main cognitive factors of adapting to chronic invalidism. In this study a German version of a self-reporting instrument that assesses fear-avoidance beliefs (FABQ, Waddell et al. 1993) is presented. METHODS: A translated version of the "Fear-Avoidance Beliefs Questionnaire" was given to 87 patients with back pain, who took part in a multimodal treatment program in an outpatient pain unit. The questionnaire was administered at different times in the therapeutic process. We examined the factor structure of the questionnaire and conducted the first examinations concerning its psychometric properties. RESULTS: The results of our data set concerning different aspects of reliability and validity conform the good psychometric properties of the questionnaire. The factor analysis revealed a three-factor solution, which accounted for nearly 60% of the variance. The first factor made up 34% of the variance. The six corresponding items dealt with "back pain caused by work". The second factor made up 13% of the variance. The content of the 5 items is focused on the patients' view about his/her probable return to work. Beliefs about physical activity in back pain (factor 3, 5 items) accounted for 12% of the variance. Correlation analysis demonstrated that all three factors are of independent value, which showed satisfactory reliability. Furthermore, we analyzed the prognostic value of the three factor dimensions. Patients completed multidisciplinary treatment according to the concept of "functional restoration". At the end of treatment, factor 1 (causation by work) was not diminished, but both other factors showed significant reductions. In a discriminant factor analysis, back-to-work could be significantly predicted by factor 3 (beliefs about physical activity) and factor 2 (patients' prognosis about their probable return to work at the beginning of treatment). Furthermore, length of time off work and age accounted for an additive classification rate of 77%. The FABfactor 1 (causation by work) was of no predictive value. CONCLUSIONS: The results suggest that primary target points for further investigation include an analysis of the patients' beliefs about their pain, with special emphasis on fear-avoidance beliefs. It is also necessary to analyze the behavioral assumptions of the fear-avoidance model in an experimental design. Furthermore, our results concerning the psychometric properties of the questionnaire should be proved in a far larger sample of back pain patients.

[Diagnosis of interpersonal problems in depressive disorders]. / Diagnostik interpersonaler Probleme bei depressiven Störungen.

Questionnaires assessing interpersonal problems may be of relevance in the field of psychotherapy not only to determine therapeutic goals but also for predicting the quality of the therapeutic alliance. Our study on the clinical validity of the Inventory of Interpersonal Problems-IIP (Horowitz) focussed on patients with affective disorders. According to the literature we hypothesized two subgroups with different areas of problems: one with high interpersonal dependency, one with an overly autonomous stance. Our sample comprises 169 patients of a psychotherapeutic outpatient clinic for students with the diagnosis of an affective disorder according to ICD 10 and a partly (age, sex, subject) comparison group of 119 students. The IIP was able to replicate the aforementioned groups. The instrument therefore may be applied to measure change in depressive psychopathology. It also might offer help for differential indication in psychotherapy.

[Prognostic criteria of behavioral pain treatment in groups of patients with rheumatoid arthritis]. / Prognosekriterien einer verhaltenstherapeutischen Schmerzbehandlung in Gruppen bei rheumatoider Arthritis.

The effectiveness of behavior therapy programs for the treatment of pain of various origin can be regarded as proven. However, there is a general lack of information about prognostic and indication criteria. These questions were investigated by means of a controlled, cognitive-behavioral orientated clinical study on 79 patients with the certified diagnosis of rheumatoid arthritis. While our study was also able to prove short-term effectiveness for all patients, some exhibited regressive effects during the six-month follow-up period. A lack of regular practice and the presence of neurotic disorders were responsible for this instability. Patients who already have neurotic disorders prior to arthritis should accordingly be given more intensive psychotherapy. In this exceeding a standard-program psychotherapy can be dealt with the disease-related and other psychosocial problems and conflicts on an integrative basis.

[Empirical assessment of defense mechanisms with a self evaluation questionnaire (according to Bond et al.)]. / Empirische Erfassung von Abwehrmechanismen mit einem Selbsteinschätzungsfragebogen (nach Bond et al).

A survey is given on the concept of "defense" and its evaluation in empirical studies. There are serious methodological difficulties in testing the validity of the concept. We translated the "Defense Mechanism Questionnaire" by Bond and collegues and carried out a study on 180 psychotherapeutic out-patients and 100 students as a control group. The results indicate some "pathological" mechanisms without an internal hierarchy or specifity to diagnosis. Self-rating and expert-rating of defense in a sample of 20 patients show very little correlation. The value of selfadministered questionnaires for the investigation of defense mechanisms in our view is at least questionable.

[Multi-axial diagnosis in psychosomatic medicine and psychotherapy--a report of experiences]. / Multiaxiale Diagnostik in der Psychosomatik und Psychotherapie--ein Erfahrungsbericht.

A certain number of attempts to establish a multi-axial classification system in psychiatry go back to before the introduction of the DSM-III. Such diagnostic and classificatory attempts are almost totally lacking, however, in the fields of psychotherapy and psychosomatic medicine. This discussion presents and evaluates a multi-axial diagnostic and documentary system that has been under development and testing in the Department of Psychotherapy and Psychosomatic Medicine at the University of Göttingen since 1986 as well as first empirical results from the year 1987. Results show that multi-axial diagnostics represent a useful and promising approach, particularly for psychosomatic medicine and psychotherapy.