[Interdisciplinary, collaborative D-A-CH (Germany, Austria and Switzerland) consensus statement concerning the diagnostic and treatment of myalgic encephalomyelitis/chronic fatigue syndrome]. / Interdisziplinäres, kollaboratives D-A-CH Konsensus-Statement zur Diagnostik und Behandlung von Myalgischer Enzephalomyelitis/Chronischem Fatigue-Syndrom.

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a severe, chronic multisystemic disease which, depending on its severity, can lead to considerable physical and cognitive impairment, loss of ability to work and the need for nursing care including artificial nutrition and, in very severe cases, even death.The aim of this D-A-CH (Germany, Austria, Switzerland) consensus statement is 1) to summarize the current state of knowledge on ME/CFS, 2) to highlight the Canadian Consensus Criteria (CCC) as clinical criteria for diagnostics with a focus on the leading symptom post-exertional malaise (PEM) and 3) to provide an overview of current options and possible future developments, particularly with regard to diagnostics and therapy. The D-A-CH consensus statement is intended to support physicians, therapists and valuer in diagnosing patients with suspected ME/CFS by means of adequate anamnesis and clinical-physical examinations as well as the recommended clinical CCC, using the questionnaires and other examination methods presented. The overview of the two pillars of therapy for ME/CFS, pacing and symptom-relieving therapy options, is intended not only to provide orientation for physicians and therapists, but also to support decision-makers from healthcare policy and insurance companies in determining which therapy options should already be reimbursable by them at this point in time for the indication ME/CFS.

The Role of Psychotherapy in the Care of Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.

Myalgic encephalomyelitis/chronic fatigue (ME/CFS) is a post-infectious, chronic disease that can lead to severe impairment and, even, total disability. Although the disease has been known for a long time, and has been coded in the ICD since 1969 (G93.3), medical research has not yet been able to reach a consensus regarding its physiological basis and how best to treat it. Against the background of these shortcomings, psychosomatic disease models have been developed and psychotherapeutic treatments have been derived from them, but their empirical testing has led to sobering results. According to the current state of research, psychotherapy and psychosomatic rehabilitation have no curative effect in the treatment of ME/CFS. Nevertheless, we see numerous patients in practices and outpatient clinics who suffer severely as a result of their illness and whose mental well-being and coping strategies would benefit from psychotherapeutic help. In this article, we outline a psychotherapeutic approach that serves this need, taking into account two basic characteristics of ME/CFS: firstly, the fact that ME/CFS is a physical illness and that curative treatment must therefore be physical; and secondly, the fact that post exertional malaise (PEM) is a cardinal symptom of ME/CFS and thus warrants tailored psychotherapeutic attention.

Self-report and observer ratings of personality functioning: a study of the OPD system.

Recent considerations around DSM-5 criteria of personality disorders (PDs) demand new concepts of assessing levels of personality functioning. Of special interest are multiperspective approaches accounting for clinicians' as well as patients' points of view. The study investigates observer-rated and self-assessed levels of personality functioning measured by the level of structural integration as defined by the Operationalized Psychodynamic Diagnosis System (OPD). Both perspectives were positively related. The combination of both measures was most efficient in discriminating among 3 diagnostic groups of varying degrees of personality dysfunction. Future studies should take into account expert ratings as well as self-report data.

[Structural change as an outcome paradigm in psychodynamic psychotherapy - results of the PAL-Study (long-term psychoanalytic psychotherapy study]. / Umstrukturierung als Ergebnisparadigma der psychodynamischen Psychotherapie - Ergebnisse aus der Praxisstudie Analytische Langzeittherapie.

OBJECTIVE: Psychodynamic psychotherapies have proved to lead to relevant symptomatic improvement. An unresolved question, however, is what amount of psychodynamic change can be expected beyond symptom relief. For theoretical and methodological reasons rooted in the psychodynamic approach, this question has been difficult to answer until now. METHOD: In the German study PAL (long-term psychoanalytic psychotherapy), 32 patients in psychoanalytic therapy and 27 patients in psychodynamic psychotherapy were studied from the perspective of therapists, patients and researchers through three years post-treatment. In this paper we study the aspect of psychodynamic change of dysfunctional relations, unconscious conflicts and structural aspects as diagnosed by the Operationalized Psychodynamic Diagnostic method. Structural change is rated by the Heidelberg Structural Change Scale. RESULTS: A comparison of the two forms of therapy shows more structural change in long-term psychoanalytic psychotherapy compared to the shorter psychodynamic psychotherapy. A comparison of patients with a high level and a low level of structural change revealed that the highly changed patients showed greater symptom relief and greater satisfaction with therapy, and that their therapists perceived a better overall result of treatment. DISCUSSION: For psychodynamic psychotherapies structural change seems to be a relevant paradigm of outcome in addition to symptom relief. In longer and more frequent psychoanalytic therapies more structural change occurs compared to shorter psychodynamic psychotherapies. Beside the amount and length of treatment, the different therapy targets - working through vs. supportive - seem to be important.

[The OPD Structure Questionnaire (OPD-SQ): first results on reliability and validity]. / Der OPD-Strukturfragebogen (OPD-SF): Erste Ergebnisse zu Reliabilität und Validität.

The concept of psychic structure plays a central role in the Operationalised Psychodynamic Diagnosis (OPD) system. Until recently, its reliable and valid assessment had to be based on expert ratings of clinical interviews, limiting the use of the OPD in routine measurements and research, and excluding the patients' perspective. The current study describes the development and evaluation of a questionnaire on the OPD structure axis (OPD-SQ) in several clinical and non-clinical samples (N = 1 112). The questionnaire demonstrated good internal consistency for all the sub-scales of the OPD-SQ. Differences in mean values between the samples and between patients with vs. without personality disorders were as expected. We also found correlations with other relevant aspects of personality (attachment security, neuroticism). There were no to minimal effect of age and gender. The OPD-SQ is a helpful tool for a broad use in clinical routine as well as research projects.

A longitudinal study of emotional experience, expressivity, and psychopathology in psychotherapy inpatients and psychologically healthy persons.

The authors investigated changes of emotional experience and expressivity in 34 inpatients undergoing psychodynamic therapy and in 29 healthy persons who were assessed at parallel time intervals. Participants completed 2 measures of psychopathology (Symptom Checklist-90 Revised and Inventory of Interpersonal Problems-64) and took part in relationship episode interviews. The emotional experiences they reported and their nonverbal emotional expressivity during the interviews were assessed by independent raters. Regardless of when they were assessed, the patients reported a greater number of emotions and a greater variety of emotions. Psychopathology in the patient group decreased in the course of treatment, but there were no systematic changes in the emotional domain. The findings challenge the common notion of psychopathology being associated with impaired awareness and expression of emotions.

Educational multidisciplinary training programme for patients with chronic pruritus.

Chronic pruritus (> 6 weeks) is a worldwide symptom and a burden in many dermatological, systemic and psychosomatic/psychiatric diseases. Patients with chronic pruritus frequently endure a long and complicated disease course, failure of therapy and a substantial reduction in quality of life. Psychological mechanisms may be involved in eliciting and coping with chronic pruritus. Treatment of pruritus aims to be aetiological, but as a primary illness it is symptomatic. The needs of patients with chronic pruritus are diverse. Multi-disciplinary educational and psychological training programmes aim to improve patients' understanding of the disease, raise the motivation to apply more adaptive self-care measures, and consequently improve quality of life. Maintenance of health through educational programmes, such as the one presented here, can be considered as important complementary measures in the field of medicine and psychosomatics, which should also be offered to patients with chronic pruritus.

Structural change as a predictor of long-term follow-up outcome.

Based on data from psychoanalytic long-term psychotherapies, the predictive value of three measures of pre-post change for retrospective patient assessments of outcome at 1-year and 3-year follow-up was investigated. Pre-post changes were measured using the Global Severity Index (GSI), the Inventory of Interpersonal Problems (IIP) total score, and the Heidelberg Structural Change Scale (HSCS). In line with psychoanalytic theory, it was assumed that structural changes cause especially persistent changes and would, therefore, be most suitable to predict the follow-up criterion. This expectation was confirmed: Pre-post changes in GSI and IIP were only weakly associated with assessments at 1-year follow-up and not at all with assessments at 3-year follow-up. In contrast, correlations between changes in HSCS and outcome assessments were highly significant at both occasions.

[Results of psychoanalytic long-term therapy in specific diagnostic groups: improvement in symptoms and interpersonal relationships]. / Ergebnisse analytischer Langzeitpsychotherapien bei spezifischen psychischen Störungen: Verbesserungen in der Symptomatik und in interpersonellen Beziehungen.

OBJECTIVES: In the present paper, data from four German studies on the efficacy of outpatient psychoanalytic long-term psychotherapy were examined for symptom reduction (SCL-90-R) and reduction of interpersonal problems (IIP-D). Specifically, the research question addressed the efficacy of long-term therapy in specific diagnostic groups and was was compared with that of a parallel group who underwent shorter-term psychodynamic therapy. METHODS: Data from four German studies addressing the efficacy of outpatient psychoanalytic long-term therapy were collected. Evaluation of these data was carried for specific diagnostic groups allowing for comorbid diagnoses. The effects of psychoanalytic therapy were assessed by pre-post and pre-follow-up comparisons using paired t-tests. Additionally, effect sizes were calculated. Psychoanalytic long-term psychotherapy and shorter-term psychodynamic therapy were compared by using a repeated measure ANOVA: Pretreatment vs. posttreatment/follow-up (two-levels) with the between subject factor "therapy conditions" (two levels). RESULTS: The results showed that in terms of improvement of symptoms and interpersonal problems, psychoanalytic long-term therapy was at least as effective as shorter term psychodynamic therapy with regard to the following ICD-10 diagnostic groups: affective disorders (F3), anxiety disorders (F40; F41; F42), personality disorders (F60; F61; F62), and a group of mixed neurotic disorders (F43; F50; F51; F1; F55). Effect sizes were large and remained stable at follow-up. CONCLUSIONS: The authors emphasize the clinical relevance of the examined diagnostic groups and relatively large effects achieved by the psychoanalytic treatment. Furthermore, the occurrence of comorbid diagnoses and their consequences are discussed. The authors stress that the specific effects of psychoanalytic therapy can only be very insufficiently tapped by the outcome measures referring to symptoms and interpersonal problems.

[How do conflict and structure present themselves in relationships?]. / Wie stellen sich Konflikt und Struktur in Beziehungen dar?

It is argued that the approaches used up to now for analyzing dysfunctional relationship patterns are more or less explicitly based on a conflict model and therefore not adequate for describing relationships characterized by structural impairments of a patient's personality. Using the concepts of conflict and structure as derived from the Operationalized Psychodynamic Diagnostic system (OPD-2), four principles of a dysfunctional relationship formation are discussed. It is shown that the differentiation of conflict- and structure-related pathology is highly significant with regard to the selection of an appropriate psychotherapeutic strategy. Furthermore, the connections between the OPD axes relationship, conflict, and structure are conceptualized.

[How are dysfunctional relationship patterns re-enacted in the therapist-patient interaction?]. / Wie inszenieren sich dysfunktionale Beziehungsmuster in der Therapeut-Patient-Interaktion?

Using Structural Analysis of Social Behaviour (SASB), the communicative means by which a patient succeeds in re-enacting his or her own maladaptive relationship patterns in the interaction with the therapist is examined. This line of investigation stems from the work of Henry and co-workers, who have shown that therapists often unknowingly allow themselves to be drawn into subtly hostile interactions with patients, and that such interactions are associated with a negative outcome. In a mixed quantitative-qualitative single case study, the relationship narratives of a female patient from two therapy sessions are analysed using a cluster-analytic procedure in order to identify her repetitive relationship patterns. Then, using a short sequence of interaction, it is demonstrated how a central maladaptive pattern is re-enacted in the therapeutic interaction and gradually takes hold. These results are interpreted as evidence that patient communication contains paradoxical demands which can lead therapists to become part of the maladaptive pattern of interaction.

[Changes in emotional experience during the course of psychoanalytic therapy]. / Veränderungen des Emotionserlebens im Verlauf psychoanalytischer Langzeitbehandlungen.

OBJECTIVES: Does the subjective emotional experience of patients change in the course of psychoanalytic treatment? METHODS: Ten patients were interviewed four times during their first two years in psychoanalytic therapy. Interviews were coded with regard to the patients' subjective emotional experience. Changes in individual emotion profiles were then tested for associations with therapy outcome using a hierarchical linear model. RESULTS: Better therapy outcome was associated with an increase in emotional variability and a decrease in the proportion of negative emotions. In contrast, neither the number of emotions verbalized by the patients nor the frequencies of specific emotion categories were associated with therapy outcome. CONCLUSIONS: Remarkable changes of emotional experience during the course of psychoanalytic treatment could be demonstrated. Particularly, a more variable emotional experience proved to be closely associated with improvement in mental health.

[New diagnostic alternatives for dysfunctional relationships: the relationship axis of the OPD-2]. / Neue Möglichkeiten der Diagnostik dysfunktionaler Beziehungen--die Bezeihungsachse der OPD-2.

As a part of the new version of Operationalized Psychodynamic Diagnosis (OPD-2), the relationship axis is introduced which was developed on the basis of research and clinical work with the OPD-1. It provides a procedure indicating dysfunctional relationship patterns. The new version is characterized by the following qualities: The relationship axis is based more consequently on the circumplex model of interpersonal behaviour. Therefore, it is suitable for a broader range of evaluation methods linked to this model. It also contains instructions on how to draw a summary of relationship dynamics. Thus the results of the diagnostic assessment can be summarized for clinical and practical purposes and used directly for therapeutic work. In addition, a simplified version of the rating procedure enables identification of the patient's significant problematic relationship themes and his or her personal resources.

[The clinical emotions list - a procedure for assessing patients' affective repertoires]. / Die Klinische Emotionsliste - ein Verfahren zur Erfassung des affektiven Erlebensrepertoires von Patienten.

Using 20 video-interviews with psychosomatic outpatients we developed a category system that should allow a differentiated and complete assessment of a person's affective repertoire. In doing so we considered the psychological literature on verbal expression of emotions. Semantic construction, distinguishing emotion categories from one another, was chosen as the main criterion for coding. The final version of the Clinical Emotions List contained 48 items. An exploratory analysis of another ten Interviews with patients showed satisfactory reliability of the system.

Do interpersonal behavior and emotional experience change in the course of successful long-term psychoanalytic therapies?

The way in which patients behave toward others is considered to be a correlate of mental health and thus of successful psychotherapy. Until now, research regarding the extent to which this assumption is justified has produced contradictory findings. On the basis of 2 definitions of normal interpersonal behavior (Benjamin, 1993; Crits-Christoph, Demorest, Muenz, & Baranackie, 1994), the authors studied 10 patients undergoing psychoanalytic therapy to determine whether changes in their descriptions of interpersonal relationships were associated with a decrease in self-reported symptoms and interpersonal problems during the first 2 years of treatment. Using a hierarchical linear model, the authors identified moderate to high correlations in the expected direction: The patients' affiliative behavior toward their objects as well as the average valence and variability of their affective experience increased when therapy was successful. In contrast, patients' descriptions of their objects' behavior did not change in a systematic manner.