[What do Patients Experience between Group Sessions during Inpatient Psychotherapy? An Application of the Inter-Session-Questionnaire in Psychotherapeutic Hospitals]. / Was erleben Patienten in stationärer Psychotherapie zwischen den Gruppentherapie-Sitzungen? Eine Erprobung des Inter-Session-Fragebogens in der Klinik.

The study describes an application of the Inter-Session-Questionnaire (ISF) related to inpatient group psychotherapy. The instrument should be tested with the extension of differentiating intersession experiences related to the person of the therapist as well as the group. In a cross sectional study performed in 13 different hospitals, 702 patients were assessed. These patients were treated in rehab hospitals, acute hospitals as well as special hospitals providing treatment for eating disorders. The sample should be relatively representative for psychosomatic and psychotherapeutic hospitals in Germany. Besides the type of the hospital, we also analysed the influence of group characteristics (size of group, type of group and number of completed sessions) as well as the patients' sex. Surprisingly, there were almost no marked differences of inter-session-experiences related to the the therapist or the group. The profiles of the item judgements of the ISF were similar to those reported for outpatient and day treatment samples. Inter-session-experiences differed in part according to our expectation depending on the variables mentioned above which suggests to use the ISF in specific studies dealing with the process and outcome of inpatient group psychotherapy as well as the differentiation of relevant subgroups.

[Emotional childhood parentification and mental disorders in adulthood]. / Parentifizierung in der Kindheit und psychische Störungen im Erwachsenenalter.

BACKGROUND: Emotional parentification is considered harmful to a child's development. METHOD: A total of about 975 patients were examined at a Department of Psychosomatic Medicine and in the practices of general practitioners with regard to childhood adversities. RESULTS: Emotional parentification is a risk factor for 2 symptom groups: the patients with depression and the patients with somatoform pain. While the occurrence of depression is mainly predicted by maternal emotional parentification, paternal influences are also relevant in regard to the development of somatoform pain. CONCLUSION: Emotional parentification is an important risk factor for the occurrence of psychological and somatoform complaints in adulthood. This is especially apparent in combination with further risk factors, such as low reported values for love, sexual abuse, or being raised without a father.

Manualized psychodynamic-interactional group therapy for the treatment of somatoform pain disorders.

Medically unexplained and clinically significant symptoms of pain are highly prevalent in the general population. More than one third of all patients in general practices and various departments of hospitals suffer from somatoform disorders with pain being the main complaint of 70% of these patients. This treatment manual is the first disorder-specific, psychodynamically oriented treatment for these patients. Based on psychodynamic-interactional group psychotherapy, it focuses on disorder-specific aspects as well as on psychic and interpersonal problems which have resulted from adverse childhood experiences and insecure attachment. In three treatment phases comprising an "information and motivational phase" followed by "work" and ultimately "transfer" phase spread over a period of 6 to 7 months, between seven and nine patients were treated in 40 group therapy sessions. The group started with psychoeducational elements intended to inform them about their illness. Through the discussion and formulation of individual treatment goals, the patients are drawn into the work phase of the group therapy, in which the relationship of the patients in the group and their behavior is the main focus of the therapeutic interventions.

[Determinants of quality of life in patients with somatoform disorders with pain as main symptom - the case for differentiating subgroups]. / Determinanten der Lebensqualität bei somatoformen Störungen mit Leitsymptom Schmerz - Plädoyer für eine Subgruppen-Differenzierung im ICD-11.

OBJECTIVES: What impact do the degree of somatization and the presence of a comorbid psychological disorder have on health-related quality of life in patients with pain-dominated somatoform disorders? METHODS: 282 consecutive patients (57.6 %) from a total population of N=490 patients fulfilling the criteria of somatoform pain disorders were included in the study following a thorough interdisciplinary diagnostic process at a German university hospital. Structured interviews (SKIDI and SKID-II) to assess comorbid psychological disorders as well as a structured biographical interview to assess chronification factors were conducted. We employed the Screening for Somatoform Disorders form (SOMS) to discover the extent and distribution of somatic symptoms and the SF-36 to determine the health-related quality of life. RESULTS: The patients exhibited a multiplicity of further somatic complaints apart from pain. 69 % had a comorbid psychological disorder. The health-related physical and psychological quality of life was clearly impaired in patients with "small", "substantial" and "pronounced" somatization. Regression analysis explained 48 % of the variance of the body-related and 35 % of the variance of the psychological quality of life: Besides the extent of somatization, older age, duration of pain-associated hospitalizations and the subjective amount of occupational impairment proved to be important. With regard to the psychological (but not the somatic) health-related quality of life, the presence of a current comorbid psychological disorder was also relevant. CONCLUSION: Patients with pain-dominated somatoform disorders are substantially impaired in their quality of life. Because 31 % of the patients with such disorders have no additional comorbid psychic disorder and the existence of a comorbid psychic disorder impacts only the psychological domain of their health-related quality of life, the results appear to strongly support maintaining the diagnostic category of somatoform disorders in ICD-11 and DSM-V. They also support the grading of the severity of the somatization similar to the grading of depressive disorders.

Somatosensory profiles in subgroups of patients with myogenic temporomandibular disorders and Fibromyalgia Syndrome.

Some patients with myofascial pain from temporomandibular disorders (TMD) report pain in extra-trigeminal body regions. Our aim was to distinguish TMD as regional musculoskeletal pain syndrome (n=23) from a widespread pain syndrome (FMS; n=18) based on patients' tender point scores, pain drawings and quantitative sensory testing (QST) profiles. Referenced to 18 age- and gender-matched healthy subjects significant group differences for cold, pressure and pinprick pain thresholds, suprathreshold pinprick sensitivity and mechanical detection thresholds were found. Pain sensitivity in TMD patients ranged between those of FMS patients and healthy controls. The group of TMD patients was inhomogeneous with respect to their tender point count with an insensitive group (n=12) resembling healthy controls and a sensitive TMD group (n=9) resembling FMS patients. Nevertheless sensitive TMD patients did not fulfil diagnostic criteria for FMS in regard to widespread pain as shown by their pain drawings. TMD subgroups did not differ with respect to psychological parameters. The sensitive subgroup was more sensitive compared to healthy controls and to insensitive TMD patients in regard to their QST profile over all test areas as well as to their tenderness over orofacial muscles and trigeminal foramina. However, sensitive TMD patients had a short pain duration arguing against a transition from TMD to FMS over time. Data rather suggest an overlap in pathophysiology with FMS, e.g. a disturbance of central pain processing, in this subgroup of TMD patients. Those patients could be identified on the basis of their tender point count as an easy practicable screening tool.

Associations among attachment characteristics, patients' assessment of therapeutic factors, and treatment outcome following inpatient psychodynamic group psychotherapy.

Within a multisite study, including 289 inpatients from six different hospitals who underwent interpersonal-psychodynamic group psychotherapy, associations among attachment characteristics, therapeutic factors, and treatment outcome were investigated. Attachment characteristics were assessed with an interview-based measure (Adult Attachment Prototype Rating [AAPR]) as well as an attachment self-report (Bielefeld Questionnaire of Client Expectations [BQCE]). Therapeutic factors were measured retrospectively with the Dusseldorf Therapeutic Factors Questionnaire and treated as an individual- as well as a hospital-specific characteristic. On an individual level, only the group climate factor independently predicted treatment outcome (i.e., Symptom Checklist-90-R Global Severity Index and Inventory of Interpersonal Problems mean). If simultaneously but separately included into a path model, analyses revealed independent significant effects of AAPR-Security and BQCE-Security on group climate. If modeled as a latent variable (common attachment security), a substantially higher proportion of group climate variance could be explained. Further analyses revealed interactions between particular therapeutic factors and attachment characteristics, indicating a particular importance of these therapeutic factors for different attachment categories.

Prevalence of chronic pain in a representative sample in the United States.

OBJECTIVE: Chronic pain is a common reason for seeking medical care. We estimated the prevalence of chronic regional and widespread pain in the United States population overall, and by age, sex, and race/ethnicity. SETTING: We examined the data from 10,291 respondents who participated in the 1999-2002 NHANES (National Health and Nutrition Examination Survey) and completed a pain questionnaire. Items allowed classification of chronic (>or=3 months) pain as regional or widespread. We used regression models to test the association of sex and race/ethnicity with each pain outcome, adjusting for age. RESULTS: Chronic pain prevalence estimates were 10.1% for back pain, 7.1% for pain in the legs/feet, 4.1% for pain in the arms/hands, and 3.5% for headache. Chronic regional and widespread pain were reported by 11.0% and 3.6% of respondents, respectively. Women had higher odds than men for headache, abdominal pain, and chronic widespread pain. Mexican-Americans had lower odds compared with non-Hispanic whites and blacks for chronic back pain, legs/feet pain, arms/hands pain, and regional and widespread pain. CONCLUSION: The population prevalence of chronic pain in the United States was lower than previously reported, with smaller sex-related differences and some variation by race/ethnicity.

[Fibromyalgia as a dysfunction of the central pain and stress response]. / Fibromyalgie als Störung der zentralen Schmerz- und Stressverarbeitung - Ein neues biopsychosoziales Krankheitsmodell -

Fibromyalgia is often understood as a syndrome mainly characterised by widespread pain and tenderness and "unexplained" etiology and pathogenesis. In the last years evidence is growing that biological as well as psychosocial stress play a pathogenetic key-role. Beginning with the general function and development of the stress response system the actual knowledge of its relationship with central pain-processing mechanisms is reviewed. Early adverse childhood experiences can impair the function of the stress system all over the lifespan. Subsequently, research evidence for the role of stress in the etiopathogenesis of fibromyalgia is summarised. Psychological as well as psychobiological consequences are outlined. Finally, an integrative model of fibromyalgia is proposed, which may put several pieces of a biopsychosocial puzzle together. This model offers an approach for the differentiation of subgroups and a clinical orientation for developing an adequate therapy for the individual patient.

Determinants of health-related quality of life in patients with persistent somatoform pain disorder.

BACKGROUND: Health-related quality of life (HRQOL) has been investigated widely in patients with chronic pain, but no study has focused particularly on the situation of patients with persistent somatoform pain disorder. AIMS: To survey the impairments of patients with somatoform pain disorder (ICD-10: F45.4) and to predict pain-related impairments and HRQOL on the basis of coping styles. METHODS: A consecutively recruited sample of 100 patients (65% female) was examined in a cross-sectional study. Questionnaires were administered to assess pain intensity (visual analogue scale), pain-related disabilities (Pain Disability Index), quality of life (Short-Form Health Survey-36), and ways of coping with pain (Coping Strategies Questionnaire). To predict pain-related impairments and HRQOL, a multiple linear regression analysis was carried out. RESULTS: HRQOL of patients with somatoform pain is strongly and significantly reduced compared with the general population. Among the coping measures, Increasing Pain Behaviors and Catastrophizing have a negative influence on patients' pain-related impairments and the physical components of HRQOL. The mental component of HRQOL was predicted solely by Catastrophizing. No positive effect of active coping styles on health-related outcome variables could be observed. CONCLUSION: Patients with persistent somatoform pain disorder feel severely impaired. A clear pattern emerges for negative effects of the coping styles Increasing Pain Behaviors and Catastrophizing, while the identification of beneficial coping failed.

[Predictors of quality of life after orthopedic treatment of lower back pain due to lumbar intervertebral disc disorders]. / Prädiktoren der Lebensqualität nach orthopädischer Behandlung lumbaler "bandscheibenbedingter" Rückenschmerzen.

OBJECTIVES: To investigate the relevance of somatic, psychic and psychosocial factors on the health-related quality of life at the one year follow-up of patients with lower back pain. METHODS: Prospective cohort study of 109 patients recruited consecutively. At baseline and at one year follow-up self-report instruments were administered to evaluate health-related quality of life (SF-36), psychic or psychological distress (SF-36), and coping strategies (FKV-LIS). RESULTS: In regards to the physical and mental dimensions of the quality of life at follow-up, psychosocial factors evaluated at baseline were far more relevant. Using a multiple regression analysis we were able to account for 38 % of the variance in the physical dimension of the quality of life and 45 % of the variance in the mental dimension. In these two dimensions the factors "psychic distress" (GSI, SCL-90-R) and "sick leave" were significant predictors, in the mental dimension additionally "doctor shopping". Beyond that, impaired health-related quality of life at baseline as well as at follow-up was related to depressive coping (FKV-LIS). CONCLUSIONS: The study shows the high impact of psychic and psychosocial factors on health-related quality of life in patients with chronic lower back pain.

[Long-term effects of adverse childhood experiences - Actual evidence and needs for research1/2]. / Früher Stress und Langzeitfolgen für die Gesundheit - Wissenschaftlicher Erkenntnisstand und Forschungsdesiderate1/2.

There is evidence from some prospective and several retrospective studies that early biological and psychosocial stress in childhood is associated with long-term vulnerability to various mental and physical diseases. In the last few years research findings have accumulated on those emotional, behavioural and psychobiological factors which are responsible for the mediation of these lifelong consequences. They are the cause of an increased risk of somatization and other mental disorders. Particularly anxiety, depression and personality disorders often result in high-risk behaviour that itself is associated with physical disease (cardiovascular disorders, stroke, viral hepatitis, type 2 diabetes, chronic lung diseases) as well as with aggressive behaviour. A survey on the current knowledge of how these various factors interact is presented and a bio-psychopathological model of vulnerability is educed. Implications for future research are outlined and contrasted to actual political trends in Germany.

[Diagnostic subgroups and psychosocial characteristics in chronic non-malignant pain patients referred to an out-patient pain center]. / Diagnostische Subgruppen und psychosoziale Charakterisierung von Patienten einer universitären Schmerzambulanz.

The purpose of this study is to describe an out-patient Pain Center population on the basis of IASP Classification of Chronic Pain. Furthermore, the study investigates the relationship between diagnostic subgroups of chronic non-malignant pain patients and psychosocial parameters. The average age of the patients was 42 and the mean age at the onset of pain was 34.2. In the present study about x of all the patients had severe pain with a duration of 48 months (median value), patients with dysfunctional pain, one of three diagnostic subgroups, had a significantly longer pain duration (80 months). Nearly (1/3) of all patients are not able to work regularly and 85 % felt impaired in their daily work activities. Nearly (1/3) of the patients without any somatic pathological findings had at least one invasive intervention, just like the patients in the other diagnostic subgroups, and the need-controlled pain medication reached its highest level in this group (45 %). Only 19 % of the 323 patients investigated had nociceptive-neuropathic pain complaint, whereas 53 % were suffering from dysfunctional, and 28 % had a somatoform pain disorder. So, in patients suffering from chronic pain, simultaneous somatic and psychic or psychosomatic diagnostics are indispensable due to the relevance of psychic and psychosocial factors to pain genesis, modulation and persistence. For patients in each of the described subgroups additional psychological factors such as attitudes, beliefs, self-efficacy, fear-avoidance beliefs and motivational factors always have a significant influence on the persistence of chronic pain syndromes. So, as a rule, to make a reliable diagnosis and to give a profound prognosis for the course of treatment, a close interdisciplinary cooperation is required.

The relevance of anxiety, depression, and coping in patients after liver transplantation.

The aim of this study is to investigate the effects of anxiety, depression, and coping on quality of life in patients after liver transplantation. Patients were asked to fill out a postal survey. Two hundred thirty-six of 375 patients (63%) who entered the study returned the questionnaires, and 186 of these patients could be included in the assessment. Anxiety and depression were surveyed using the Hospital Anxiety and Depression Scale; health-related quality of life, using the 36-Item Short-Form Health Survey; and coping strategies, using the Freiburg Questionnaire on Coping With Illness. In terms of physical and mental dimensions of health-related quality of life, psychosocial factors are far more relevant in liver transplant recipients than purely somatic factors, such as the number of posttransplantation complications or length of hospital stay. Through multiple regression analysis, we were able to account for 51% of the variance in the physical dimension of health-related quality of life and 58% of the variance in the mental dimension. Physical factors of depression, age, and employment and mental factors of anxiety and depression were significant for predicting health-related quality of life after liver transplantation. Depressive coping, anxiety, and depression, as well as aspects of the social environment, contribute considerably to determine well-being and health-related quality of life of patients after liver transplantation.