How do patients with anorexia nervosa "process" psychotherapy between sessions? A comparison of cognitive-behavioral and psychodynamic interventions.

OBJECTIVE: Patients' processing of psychotherapy between sessions ("inter-session process" (ISP)) has been repeatedly shown to be related to outcome. The aim of this study was to compare ISP characteristics of cognitive-behavioral vs. psychodynamic psychotherapy in the treatment of anorexia nervosa (AN) and their relation to outcome. METHODS: Data of 106 patients participating in a randomized-controlled trial who received either 40 sessions of enhanced cognitive-behavioral therapy (CBT-E) or focal psychodynamic therapy (FPT) were analyzed. The ISP was measured with the Inter-session Experience Questionnaire (IEQ). Three outcome classes were distinguished: full recovery, partial recovery, and still fulfilling all AN criteria. RESULTS: Patients receiving CBT-E reported more on "applying therapy" in the initial and the final treatment phase compared to FPT patients. In terms of process-outcome relations, higher levels of "recreating the therapeutic dialogue between sessions," "recreating the therapeutic dialogue with negative emotions" as well as "applying therapy with negative emotions" in the final phase of treatment predicted negative outcome in FPT, whereas overall higher levels of negative emotions predicted negative outcome in CBT-E. CONCLUSIONS: In outpatient treatment in AN, the processing of therapy as measured by the IEQ showed surprisingly few differences between CBT-E and FPT. However, different ISP patterns were predictive of outcome, pointing to different mechanisms of change.

[Gender aspects in female and male physicians : Occupational and psychosocial stress]. / Gender-Aspekte bei Ärztinnen und Ärzten : Berufsleben und psychosoziale Belastungen.

BACKGROUND: International studies have shown that physicians have an elevated risk of developing depression or burnout syndrome. Gender aspects with regard to occupation are discussed in German politics and society. Currently, there is little data comparing female and male physicians with regard to stress at work, depression, and burnout. OBJECTIVES: Are there differences between male and female physicians with respect to psychosocial strain, emotional exhaustion, and depression? METHODS: In different cross-sectional studies, anaesthetists, psychiatrists and dentists filled out a questionnaire containing questions on personal data, occupation, past medical history and medication intake. Additional standardized questionnaires (Beck Depression Inventory (BDI) and Maslach Burnout Inventory (MBI)) were performed. RESULTS: The return rate was 51.8 % (n = 3782). Male and female physicians vary significantly in social data, participation in the job, and health status. Female physicians are on average not married (p < 0.001) and have significantly fewer children (p < 0.05). Leading positions are mostly held by male physicians (p < 0.001); female physicians more often work in part-time jobs (p < 0.001). Female physicians reached higher scores of emotional exhaustion (MBI) (p < 0.01) and depression (BDI) (p < 0.001). DISCUSSION: The study shows big differences between male and female physicians with respect to their occupation, personal life, and psychosocial wellbeing. Female physicians more often report burnout and depression. Causes might be family and job strain, gender aspects in hierarchy, as well as different recognition and interpretation of symptoms.

Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive-behavioural therapy in out-patients with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive-behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN. METHOD: The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost-utility and assumptions underlying the base case were investigated in exploratory analyses. RESULTS: Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends. CONCLUSIONS: Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

[Effectiveness of Telephone and Face-to-Face Aftercare Conversations following Inpatient Psychosomatic Rehabilitation]. / Wirksamkeit von Nachsorgegesprächen via Telefon- und Face-to-Face-Kontakten nach der stationären psychosomatischen Rehabilitation.

AIM OF THE STUDY: The effectiveness of 2 aftercare treatments was examined with regard to patients' implementation of health-enhancing recommendations and changes in psychological distress, as well as mental and physical health. METHODS: Psychosomatic patients were randomly assigned to an intervention group (aftercare over the telephone or face-to-face) or to a control group without aftercare (n=62) at the end of their treatment. Patients in the intervention group (n=139) were offered up to 4 aftercare conversations during the 3 months after their rehabilitation. Data were collected at admission (t1), at discharge (t2) as well as 3 (t3) and 9 (t4) months after discharge. Patients were asked whether they implemented health-enhancing recommendations, recorded in the discharge report, at t3 and t4. Psychological distress (SCL-90-R) was measured at t1, t2, t3 and t4, mental and physical health (SF-12) at t2, t3 and t4. RESULTS: In the intervention group, more participants implemented the recommendations made at discharge such as sports and exercises or outpatient psychotherapy as compared to the control group. Likewise, participants of the intervention group maintained better their physical health. Aftercare over the telephone and face-to-face did not differ in their effectiveness; however, less time was required for aftercare conversations over the telephone. CONCLUSIONS: Aftercare over the telephone seems to be an economical approach to support patients in implementing healthcare recommendations made at discharge after inpatient rehabilitation.

[The influence of aftercare sessions on sociomedical development after an inpatient psychosomatic rehabilitation]. / Der Einfluss von Nachsorgegesprächen auf die sozialmedizinische Entwicklung nach einer stationären psychosomatischen Rehabilitation.

BACKGROUND: The aim of this study was to examine the influence of aftercare sessions in a psychosomatic rehabilitation on the sociomedical development. The after care group was compared with treatment as usual. METHODS: In a prospective, controlled and randomized longitudinal study data about the state of health and job status were assessed at 4 measured time points. As an indicator of the sociomedical development the current employment status was used. Aftercare treatment (n=139) included 2-4 interview contacts (via telephone or face-to-face) within the first 3 months after discharge from inpatient psychosomatic rehabilitation. A control group (n=62) received treatment as usual. RESULTS: 3 and 9 months after the end of rehabilitation participants in the aftercare showed a better sociomedical development than the participants in the control condition.

[BCG versus photodynamic therapy (PDT) for nonmuscle invasive bladder cancer-a multicentre clinical phase III study]. / BCG versus Photodynamische Therapie (PDT) beim nicht muskelinvasiven Harnblasenkarzinom--eine multizentrische Phase-III-Studie.

PURPOSE: This multicentre phase III study was designed to compare the efficacy of Bacillus Calmette Guérin (BCG) instillations and photodynamic therapy (PDT) in the treatment of patients with intermediate and high-risk nonmuscle invasive bladder cancer. MATERIAL AND METHODS: Inclusion criteria were multifocal pTaG1-G2 tumours, recurrent pTaG1-2 tumours, pTa / 1G3 tumours, and primary or recurrent carcinoma in situ (CIS). All patients were centrally randomised after transurethral resection (TUR) to receive BCG induction and maintenance therapy or a single PDT with Photofrin. The primary endpoint of the trial was recurrence-free survival. Secondary endpoints were the 2-year recurrence rate, the 2-year progression rate, survival, and quality of life. RESULTS: 124 patients (63 PDT group, 61 BCG group) were enrolled at 7 institutions in Germany and Austria. Each patient had a follow-up for 2 years. Of the 124 enrolled patients 105 were eligible for this analysis. Kaplan-Meier curves demonstrated no statistically significant differences between the two therapy arms with respect to recurrence-free survival after randomisation (p = 0.4598). After intention-to-treat analysis and after as-treated analysis, the estimated median recurrence-free survival periods were 24.9 (BCG) versus 16.6 months (PDT) and 25.8 (BCG) versus 14.7 (PDT) months, respectively. CONCLUSIONS: A single PDT with Photofrin(R) in intermediate and high-risk nonmuscle invasive bladder cancer patients could not be shown to be superior to BCG maintenance therapy. Vice versa, the results of this study cannot exclude a superiority of BCG.

Eating behavior differences and the perception of gender roles in Czech and German nonclinical samples.

This study compares non clinical subjects from the Czech Republic and Germany regarding their eating behavior and attributes they associate with female role models. We assessed Czech and German students and their mothers, 328 subjects in total, by having them complete 2 questionnaires related to weight, eating behavior, as well as different role models (a professionally successful woman, a good mother, etc.). The female Czech students had a lower ideal BMI than the German female students, and were more dissatisfied with their bodies. Thus, the higher drive for thinness in the Czech students could be an indicator for an increased risk regarding eating disorders. Regarding role models, the Czech results were very different from those of the Germans. The Czech women characterized female roles more with items like following own goals, competent in job, competing. The more professional female role description in the Czech Republic reflects the tradition of working women in former socialist states. But the relationship between eating behavior and gender roles remains unclear.

[The effects of psychodynamic inpatient treatments on personality data of patients with anorexia nervosa and bulimia nervosa - results of the German multicenter study (TR-EAT)]. / Der Einfluss von stationärer psychodynamischer Psychotherapie auf Persönlichkeitsmerkmale von Patientinnen mit Anorexia nervosa und Bulimia nervosa - Ergebnisse der multizentrischen Essstörungsstudie.

OBJECTIVES: How are the effects of a psychodynamic inpatient treatment on personality data of patients with anorexia nervosa and bulimia nervosa? In how many patients can a successful change in the personality area be observed? METHODS: 732 patients were assessed at the beginning and the end of an inpatient treatment as well as 2 1/2 years after this treatment. Data were collected by means of the personality inventories "Freiburger Persoenlichkeitsinventar (FPI-R)" and "Narzissmusinventar". A definition of success was constructed using the clinical significance concept. It is related to the scales life satisfaction, inhibition (FPI-R), powerless self and negative body self (Narzissmusinventar). RESULTS: The results in both questionnaires show the clinically well known psychopathology characteristics of eating disorder patients. During the inpatient treatment and also afterwards, there are improvements in the personality data, but not to the extent of the values obtained from a healthy control group. In the outcome measure, one third of the patients experienced remarkable improvements. The success in the personality area is positively correlated to the success in the eating disorder symptoms. This success could not be predicted by initial data or by therapy data. CONCLUSIONS: There are marked impairments of the patients in the personality data. Changes in this domain take time and are rather small.

[The effects of psychotherapy on Crohn's disease patients--results of a randomized multicenter study]. / Die Wirksamkeit psychotherapeutischer Massnahmen bei Morbus Crohn. Ergebnisse einer randomisierten, multizentrischen Studie.

In a prospective multicenter study of Crohn disease patients, the influence of psychotherapy on the course of the disease and on psychosocial variables (anxiety, depression, life satisfaction and data of the PSKB) was studied. Psychodynamic oriented psychotherapy was provided in addition to a standardized medical treatment and took place during the first year of the two-year observation period. 108 of 488 patients were recruited and randomly assigned to the psychotherapy and the control group. 84 patients completed the somatic and 81 the psychosocial follow up. 23% of the control group and 30% of the psychotherapy group showed episode-free courses, 29% and 17% respectively underwent surgery (worst outcome group). The ranking and comparisons of the disease course showed no significant difference (p = 0.125) between psychotherapy and control group. The psychosocial variables also showed no differences between these groups. Subjectively, the patients report favourable effects to psychotherapy.

[Axis I "illness experience and treatment preconditions" of operational psychodynamic diagnosis (OPD). Experiences in clinical practice]. / Die Achse I "Krankheitserleben und Behandlungsvoraussetzungen" der Operationalisierten Psychodynamischen Diagnostik (OPD). Erfahrungen in der klinischen Praxis.

In a selective survey, results on psychometric properties and aspects of application of the axis I, "illness experience and treatment preconditions" of the Operational Psychodynamic Diagnoses (OPD) are described. Following remarks on the role of defense and coping theories in the conceptualisation of the axis, its structure and contents are outlined. After a brief summary of findings on its interrater reliability, several aspects of validity are discussed. Results on discriminative validity show that axis I items are useful in the statistical discrimination of subsamples differing in age, clinical diagnoses, and diagnostic setting (psychotherapy outpatient vs. psychosomatic consultation-liasion services). The contribution of axis I items to prediction of treatment outcomes, moreover, reveals high degree of predictive or treatment validity. After an integrative discussion of these findings, implications of patient personality and coping behaviour for axis I ratings are highlighted as important objectives for future OPD research.

[Education of patients with inflammatory bowel diseases]. / Die Krankheitsaufklärung von Patienten mit entzündlichen Darmerkrankungen.

Patients with chronic inflammatory bowel disease were interviewed about their degree of satisfaction with the medical information provided by the professional staff and the reasons for their satisfaction. 30 patients, suffering from ulcerative colitis or Crohn's disease, underwent semistandardized interviews with the result that professional education about their disease was provided either in a single concluding session or in several consecutive sessions. The patients were informed about the diagnosis, the assumed etiology and medical treatment, yet much less frequently were they told about the course of their disease or its possible consequences. On the average the clarifying sessions did not take more than 10 to 15 minutes. Only 50% of the patients were able to fully understand the information they received. 40% were dissatisfied. Greater patient satisfaction was related to more time, more detailed explanation, and emotional support by the physician. These facts should be seriously considered during medical training.

[Psychoanalytically-based treatment of bulimia nervosa]. / Die tiefenpsychologisch fundierte Behandlung der Bulimia nervosa.

There is a long tradition of psychoanalytically oriented treatments for in-patients in Germany and a large proportion of bulimics is treated in this way, but there are very few reported controlled trials for this form of treatment. The treatment rationale for psychoanalytically orientated psychotherapy is discussed against the background of the specific psychopathology of bulimia and the principal elements of this form of treatment are presented. Recent results of a controlled study involving n = 32 Patients with a follow-up of 38 months are reported with regard to comparable evaluations. The possible healing factors via which psychoanalytically orientated treatments achieve their effects with bulimia nervosa are discussed.

Movement behaviour of patients with eating disorders and inflammatory bowel disease: a controlled study.

BACKGROUND: This study assessed the movement behaviour of patients with eating disorders and inflammatory bowel disease. METHODS: Ninety female patients with anorexia nervosa (n = 30), bulimia nervosa (n = 30), inflammatory bowel disease (n = 30) and a healthy control group (n = 30) were videotaped during a 10-min standardised movement sequence. A movement analysis instrument was developed for the evaluation. RESULTS: The patient groups had a significantly smaller area of movement, less weight shift, more isolated use of their body parts, less integration of the lower body, more peripheral initiation of movement, less strength. No significant differences could be found among the patient groups with eating disorders and inflammatory bowel disease. CONCLUSIONS: The findings are discussed in relation to body scheme disturbances and inhibition of nonverbal expression.

Concepts of psychosomatic disorders in ICD-10: results of the Research Criteria Study.

The multicenter study with the research criteria in the field of psychotherapy/psychosomatic medicine considered nine cases. One patient with cardiac neurosis (F45.3) and one patient with a persistent somatoform pain disorder (F54.4) were diagnosed in category F45.x. The rater agreement was 63-68%. 54% of the correct diagnoses made for three cases of colitis ulcerosa and Crohn's disease concurred (28%, 50%, and 80%). The case of anorexia nervosa (F50.0) was coded correctly by all of the raters, while the agreement for bulimia (F50.2) was 82%. Only 50% of the raters correctly assigned the dissociative disorder (F44.4). The agreement achieved for factitious disorder (F68.1) was 54%. Across all the psychosomatic disorders in ICD-10 there was an agreement of 65%. This result is markedly lower than the overall agreement of the Research Criteria Study (78%). Cardiac neurosis and bulimia were given a favorable prognosis. A more reticent psychotherapeutic commitment was seen for the classical psychosomatic disorders, persistent pain disorder, and factitious disorder. Anorexia nervosa and dissociative disorder assumed an intermediate position.

[Description of musical expression and initial results of the Lübeck music therapy model]. / Beschreibung des musikalischen Ausdrucks und erste Ergebnisse im Lübecker Musiktherapiemodell.

In the Medical University of Lübeck (Germany), T. Maler developed a music group therapy, which was based on psychoanalytic theories. In the years from 1984-1991, the behavior of 200 patients in the music therapy was assessed by means of new constructed rating scales. The patients had different kinds of psychosomatic and psychiatric disorders. The results show significant changes in the music playing behavior after 10 sessions of music therapy. The patients playing was louder, more free in the improvisation and showed more plasticity. There were no differences between the different diagnostic groups in the study.

[The significance of recurrence-inducing events for patients with chronic inflammatory bowel diseases. Results of a prospective longitudinal study over three years]. / Die Bedeutung rezidivauslösender Ereignisse bei Patienten mit chronisch entzündlichen Darmerkrankungen. Ergebnisse einer prospektiven Längsschnittstudie über drei Jahre.

This study examined whether life event stress under general or more specific conditions (fear of separation, feeling of being under pressure, feeling of being caught between two quarreling parties, separation experiences) contribute to the aggravation of inflammatory bowel disease. Firstly, 51 patients with ulcerative colitis, 57 patients with Crohn's disease, and 60 controls were compared in terms of these variables. In addition, the IBD patients filled out questionnaires regarding life events, the specific psychological conditions mentioned above, and their symptoms several times in the three years after the first measurement. By means of group comparisons and intraindividual correlations between relapse precipitating life events and illness activity, only feelings of being under pressure showed a modest correlation to the disease activity. We conclude that the variables in question have little influence on the beginning of the relapse.

[Specific characteristics of Crohn disease patients--results of a cluster analysis of personality markers]. / Zur Frage der Spezifität bei Morbus-Crohn-Patienten--Ergebnisse einer Clusteranalyse über Persönlichkeitsmerkmale.

The aim of this study was to find out, if patients with Crohn's disease share some personality traits or if it makes more sense to separate them into subgroups. Therefore, 52 patients took part in a psychoanalytic interview. The interview was composed in order to check personality characteristics as they were named in the literature. However, there could not be found any specific personality traits, but a cluster analysis revealed 7 subgroups. Two larger subgroups, together 22 patients, consisted of patients with inhibited aggression, who were closely connected to their families and showed illness inciting stressful life events. Another subgroup, 11 patients, showed a marked independent, aggressive and illness-dissimulating behavior. The hypothesis of a specific personality structure has to be rejected.

[Presentation and initial results of an expanded diagnostic key for psychosomatic diseases in ICD-9 and ICD-10]. / Darstellung und erste Ergebnisse eines erweiterten Diagnoseschlüssels für psychosomatische Erkrankungen in ICD-9 und ICD-10.

In 1986, an extended diagnostical classification of psychophysiologic disorders (psychosomatic diseases, ICD-9: 316) was developed at the Medical University of Lübeck. The extension consisted of 3 additional code numbers, in which the attached organic system, the kind of the psychological symptoms and the kind of the underlying psychological disturbance could roughly be categorised. The experiences with this additional code numbers on 789 patients are reported. The results show that the additional code numbers are very practical and that they provide important therapeutical information. It is suggested, that in ICD-10 a differentiated classification of psychophysiologic disorders should be established.

Relapse-precipitating life events and feelings in patients with inflammatory bowel disease.

This study examined whether life event stress under general or more specific conditions (fear of separation, feeling of being under pressure, feeling of being caught between two quarreling parties, separation experiences) contribute to the aggravation of inflammatory bowel disease (IBD). Firstly, 51 patients with ulcerative colitis, 57 patients with Crohn's disease, and 60 controls were compared in terms of these variables. In addition, the IBD patients filled out questionnaires asking for life events, the specific psychological conditions mentioned above, and their symptoms every 3 months for 1 year after the first measurement. Patients with Crohn's disease and patients with ulcerative colitis reported a lower amount of life event stress than members of the control group, but listed more feelings of being under pressure. Within group comparisons between patients in relapse and patients in remission, as well as comparisons between patients with recently increased disease activity and patients without increased disease activity did not yield clear results. We conclude that the variables in question have little influence on the beginning of a relapse.

[Social integration of patients with anorexia nervosa and bulimia]. / Die soziale Integration von Patientinnen mit Anorexia nervosa und Bulimie.

The current study investigated the psychological and social problems of 46 patients with anorexia nervosa and 34 patients with bulimia who met the DSM III-criteria. Data were compared with 50 normal controls, using the "Fragebogen zur Sozialen Integration" (FSI, a German translation of the social adjustment scale-self report) and the Freiburger Persönlichkeitsinventar (FPI, a German personality questionnaire). Women with anorexia nervosa as well as patients with bulimia demonstrated a significant impairment in all areas of social relationships, while there were no differences between these patient groups. On the FPI, both groups reported significantly more depressed, feelings of being nervous, neuroticism and femininity, less sociable and calm than the controls.