Language and Movement Synchronization in Dyadic Psychotherapeutic Interaction - A Qualitative Review and a Proposal for a Classification.

In individual psychotherapy verbal communication and movement synchronization are closely interrelated. The microanalysis of timing, rhythm and gestalt of movement has established dynamic movement coordination as a systemic property of the dyadic interaction. Movement synchronization supports and enhances the unfolding of linguistic meaning. In order to substantiate the importance of the concept of synchrony for adult psychotherapy we review evidence from developmental psychology and discuss approaches to measure synchrony with particular reference to the naturalistic setting of dyadic psychotherapy. As the concept of synchrony is still ambiguous, and the respective interactional phenomena are ephemeral and fluid, in the current paper we suggest a set of five criteria for the description of synchronization in general terms and eight additional criteria which specifically enable the description of phenomena of movement synchronization. The five general dimensions are: (1) context, (2) modality, (3) resources, (4) entrainment, and (5) time-lag. The eight categories for the description of movement synchrony are: (1) spatial direction, (2) amplitude, (3) sinuosity, (4) duration, (5) event structure, (6) phase, (7) frequency, and (8) content. To understand the process of participatory sense-making and the emergence of meaning in psychotherapy, synchrony research has to cope with the multimodality of the embodied interaction. This requires an integrated perspective of movement and language. A system for the classification of synchrony phenomena may contribute to the linking of variations and patterns of movement with language and linguistic utterances.

Positioning Shifts From Told Self to Performative Self in Psychotherapy.

According to Positioning Theory, participants in narrative interaction can position themselves on a representational level concerning the autobiographical, told self, and a performative level concerning the interactive and emotional self of the tellers. The performative self is usually much harder to pin down, because it is a non-propositional, enacted self. In contrast to everyday interaction, psychotherapists regularly topicalize the performative self explicitly. In our paper, we study how therapists respond to clients' narratives by interpretations of the client's conduct, shifting from the autobiographical identity of the told self, which is the focus of the client's story, to the present performative self of the client. Drawing on video recordings from three psychodynamic therapies (tiefenpsychologisch fundierte Psychotherapie) with 25 sessions each, we will analyze in detail five extracts of therapists' shifts from the representational to the performative self. We highlight four findings: • Whereas, clients' narratives often serve to support identity claims in terms of personal psychological and moral characteristics, therapists rather tend to focus on clients' feelings, motives, current behavior, and ways of interacting. • In response to clients' stories, therapists first show empathy and confirm clients' accounts, before shifting to clients' performative self. • Therapists ground the shift to clients' performative self by references to clients' observable behavior. • Therapists do not simply expect affiliation with their views on clients' performative self. Rather, they use such shifts to promote the clients' self-exploration. Yet, if clients resist to explore their selves in more detail, therapists more explicitly ascribe motives and feelings that clients do not seem to be aware of. The shift in positioning levels thus seems to have a preparatory function for engendering therapeutic insights.

[Therapeutic Effort in Inpatient or Day Patient Treatments and Therapy Success in Patients with Depressive Disorders]. / Therapeutischer Aufwand in stationärer oder tagesklinischer Behandlung und Therapieerfolg bei Patienten mit depressiven Störungen.

Several therapeutic treatments like individual psychotherapy, group therapy, creative therapies and talks with the nursing staff are components in an inpatient psychosomatic (psychotherapeutic) treatment or a psychosomatic day hospital treatment. In Germany, these therapies have to be documented by the administration with so called OPS-Codes. These codes are reported to the Institute for Reimbursement in Hospitals (InEK). With the data of the INDDEP-study it should be investigated how the therapies of 7 hospitals and 8 day-hospitals compare to each other. In addition, it should be studied, if the amount of the documented therapies is connected to the outcome in these hospitals. In the INDDEP-study, data of patients with major depression were assessed at 4 measurement points (admission, discharge, 3 months and 12 months follow up). In addition, the OPS codes of the treatments were documented. The results show that it is possible to get a rough estimation of the psychotherapeutic doses by the OPS-codes. The results show significant differences between the hospitals in terms of the intensity and professional group composition of the treatments. This result is confirmed for in-patient and day hospital treatments. Correlation analyses showed no significant correlation between the total amount of therapy and the improvement in depressive symptoms. It is assumed that there are moderating variables (patient-, therapy and process-related) which moderate the relation between doses and outcome. This should be identified in further studies.

Effect of acceptance and commitment therapy on body image flexibility and body awareness in patients with psychosomatic disorders: a randomized clinical trial.

OBJECTIVE: The aim of this research was to examine the effectiveness of the acceptance and commitment therapy (ACT) for body image flexibility and body awareness in these patients. METHODS: A randomized clinical trial was conducted at Kashan University of Medical Sciences clinics in Kashan, Iran, from December 1, 2017 to March 30, 2018. A sample of 75 patients with psychosomatic disorders was selected by convenience sampling. The selected patients were randomly divided into three 25-member groups. The experimental group received medicinal treatment combined with the (ACT). The active control group received the usual treatment plus psycho education in general psychology, and the treatment group solely received the medicinal treatment usually used in the treatment centers. The results were obtained using the following scales in the pretest and posttest phases and the two-month follow-up: the demographic questionnaire; Shields' body awareness questionnaire; and Sandoz's body image flexibility questionnaire. The data were analyzed using the descriptive statistics tests (mean and standard deviation) and the repeated measures analysis of variance and chi-square tests in IBM-SPSS version 21. RESULTS: There was no significant difference among the three groups in terms of body image flexibility, body awareness, somatic symptoms, and demographic variables. The results of the posttest and follow-up examinations suggested that the ACT group more effectively and significantly improved body image flexibility and body awareness as compared to both of the control groups (p=0.02). CONCLUSIONS: The ACT successfully improves body image flexibility and body awareness in patients with psychosomatic disorders. CLINICAL TRIAL REGISTRATION: This research was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT ID: IRCT2017092532057N2. FUNDING: Research and Technology Department of Kashan University of Medical Sciences funded the study (Ref: 96053).

Prognostic and prescriptive predictors of improvement in a naturalistic study on inpatient and day hospital treatment of depression.

BACKGROUND: The study aimed to identify prognostic (associated with general outcome) and prescriptive (associated with differential outcome in two different settings) predictors of improvement in a naturalistic multi-center study on inpatient and day hospital treatment in major depressive disorder (MDD). METHODS: 250 inpatients and 250 day hospital patients of eight psychosomatic hospitals were assessed at admission, discharge and a 3-months follow-up. Primary outcome was defined as a reduction of depressive symptomatology from admission to discharge and from discharge to follow-up (QIDS-C, total score). Percent improvement scores at discharge and at follow-up were entered as dependent variables into two General Linear Models with a set of predictor variables and the respective interaction terms with treatment setting. The selection of predictor sets was guided by statistical methods of variable preselection (LASSO). RESULTS: Three variables were associated with less improvement from admission to discharge: the number of additional axis-I diagnoses, axis-II co-morbidity (SCID) and lower motivation (expert assessment). Social support (F-SozU) predicted symptom course between discharge and 3-month follow-up. Patients with no absent / sick days prior to admission showed a less favorable symptom course after discharge when treated as inpatients. CONCLUSIONS: Patients with co-morbidity show less improvement during the active treatment phase. Motivation can be considered a prerequisite for symptom reduction, whereas social support seems to be an important factor for the maintenance of treatment gains. The lack in prescriptive predictors found may point to the fact that inpatient and day hospital treatment have comparable effects for most subgroups of patients with MDD.

Pretreatment and process predictors of nonresponse at different stages of inpatient psychotherapy.

OBJECTIVE: Up to 50% of psychotherapeutic treatments end without significant improvements. While there is first evidence about predictors of nonresponse in outpatient psychotherapy, there are currently no studies investigating predictors of nonresponse in inpatient settings. Based upon a previous systematic literature review, we analyzed the predictive value of initial patient characteristics on nonresponse in symptom distress. METHODS: Treatment episodes from 546 patients, treated for at least 4 weeks, were assessed under naturalistic conditions. Nonresponse status (i.e., lack of a reliable improvement in symptom distress) was investigated at four different time points: at week 4, at discharge, and at a two follow-ups (3 and 12 months after discharge). Hierarchical binary logistic regression models were used to predict nonresponse. Sociodemographic data, clinical variables, and the previous response status were entered subsequently in the model. RESULTS: A moderate or functional level of initial symptom distress, a comorbid personality disorder, and previous nonresponse were the most consistent predictors of nonresponse. CONCLUSIONS: The results point to the importance of early outcome assessment and suggest the implementation of more symptom-specific treatments.

Development and validation of cardiac patient competence questionnaire, Iranian version.

BACKGROUND: The aim was to translate and develop a patient competence (PC) questionnaire in the context of cardiology and test its validity and reliability. METHODS: In total, 148 cardiac patients who have inclusion criteria of the study were completed cardiac PC (CPC) questionnaire. Hospital Anxiety and Depression Scale and self-administered instrument European quality of life 5-dimensions were used to further validate the CPC questionnaire. The CPC was translated according to the recommended methodology for translating questionnaires, and psychometric properties including internal consistency, factor analysis, discriminant validity, construct validity, and concurrent criterion validity were tested. RESULTS: Five domains in problem-focused task including search for information, self-regulation, being assertive, independent decision-making, and looking for social services, and three domains in emotion-focused task including stress management, confronting the threat, and avoidance were obtained by factor analysis. The standardized Cronbach's α of all domains were statistically significant (P < 0.001) and internal consistency for all domains was acceptable. Significant intercorrelations of CPC domains also indicated good criterion validity. As there were no cross-loadings, the domains have demonstrated good construct validity and discriminant validity. CONCLUSION: The results of this study show that the Persian version of the CPC is a reliable and valid questionnaire. Although further improvement of this measure is clearly required, it suggests being a potential basis for investigating the determinants and health effects of CPC.

Self-perspective leads to increased activation of pain processing brain regions in fibromyalgia.

BACKGROUND: Dysfunction of central nervous pain processing is assumed to play a key role in primary fibromyalgia (FM) syndrome. This pilot study examined differences of pain processing associated with adopting different interpersonal perspectives. METHODS: Eleven FM patients and 11 healthy controls (HC) were scanned with functional magnetic resonance imaging. Participants were trained to take either a self-perspective or another person's perspective when viewing the visual stimuli. Stimuli showed body parts in painful situations of varying intensity (low, medium, and high) and visually similar but neutral situations. RESULTS: Patients with FM showed a higher increase in blood oxygen level dependent (BOLD) response, particularly in the supplementary motor area (SMA). All pain-related regions of interest (anterior insula, somatosensory cortices, anterior cingulate cortex, and SMA) showed stronger modulation of BOLD responses in FM patients in the self-perspective. In contrast to pain processing regions, perspective-related regions (e.g. temporoparietal junction) did not differ between FM and HC. CONCLUSIONS: The stronger response of all four pain processing cerebral regions during self-perspective is discussed in the light of disturbed bottom-up processing. Furthermore, the results confirm earlier reports of augmented pain processing in FM, and provide evidence for sensitization of central nervous pain processing.

[Non-response to therapy in acute and rehabilitative psychosomatic inpatient care - a systematic review]. / Therapie-Non-Response in der psychosomatischen Krankenhausbehandlung und Rehabilitation - Eine systematische Übersicht.

OBJECTIVES: The study reviews the state-of-the art on failure research in acute and rehabilitative psychosomatic inpatient care. The main focus of interest lies in describing the frequency and possible predictors of unsuccessful therapeutic treatments. METHODS: We systematically searched the databases MEDLINE, PsycARTICLES, PsycINFO und PSYNDEX and selected studies from the past 20 years focusing on treatment failure in the inpatient psychosomatic treatment of adult patients. RESULTS: A total of 31 studies were included, 15 of which allowed the extraction of predictors of non-response or deterioration. 20 %to 30%of patients leave psychotherapeutic treatment without any significant change; 5 %to 10%deteriorate during their stay.A high level of symptom distress at intake, a chronic course of the disease as well as somatoform or personality disorders are associated with non-response and deterioration. Early response to treatment and a dysfunctional therapeutic alliance are possible further predictors, whereas sociodemographic and sociomedical variables are unlikely to have a predictive validity. CONCLUSIONS: Hypotheses about possible predictors can be derived from the results of this review. However, the interpretation of the results is limited by the heterogeneity of the methodology and of the samples of the studies included. Nevertheless the results can be used as a basis for further hypothesis-driven research.

[Premature termination of inpatient psychotherapy]. / Vorzeitige Beendigung der Therapie in der stationären psychosomatischen Krankenhausbehandlung und Rehabilitation.

This systematic review examines the frequency and possible causes of premature termination of psychotherapeutic treatments. The literature search focused on adult patients who drop-out of acute and rehabilitative inpatient psychosomatic care in Germany. The weighted average drop-out-rate of the 15 included studies was 12.5%. Young age, unemployment, inability to work, the diagnosis of an eating disorder, a somatoform disorder or a personality disorder and a low impairment at intake show a relation to a higher risk for a premature termination of the treatment. Beside these sociodemographic and clinical variables, the motivation for treatment as well as treatment expectations seem to play a role in the prediction of attrition.

Self-reported symptoms of pain and depression in primary fibromyalgia syndrome and rheumatoid arthritis.

BACKGROUND: Primary fibromyalgia syndrome (FMS) is associated with substantial psychiatric comorbidity. The aim of the present study was to investigate the interrelationship between self-reported symptoms of depression and pain in FMS compared with rheumatoid arthritis (RA). METHODS: In a cross-sectional study, 100 patients with FMS and 50 patients with RA were compared with regard to depression and psychopathology using the Symptom Check List (SCL-27). Group comparisons were calculated by parametric and non-parametric tests. The association between pain intensity and depression was determined by correlation analyses and multivariate statistical procedures (CATREG). RESULTS: Pain intensity was significantly higher in FMS compared with RA. FMS patients also scored significantly higher on all subscales of the SCL-27 including the depression scale and the General Symptom Index (GSI) (P < 0.001). These group differences remained stable even after correcting for pain intensity. Correlation analyses revealed an association between pain intensity and depression in FMS but not in RA (R = 0.419, P < 0.001). CONCLUSION: FMS patients in tertiary referral centers suffer from higher levels of pain intensity than RA patients. Depression predicts levels of pain in FMS but not in RA and is therefore an important target of intervention.

A comparison of schemas, schema modes and childhood traumas in obsessive-compulsive disorder, chronic pain disorder and eating disorders.

BACKGROUND: In this study, we investigated early maladaptive schemas (EMS), schema modes and childhood traumas in patients suffering from obsessive-compulsive disorder (OCD) in contrast to patients with other Axis I disorders. Based on cognitive theories on OCD, our main research question was whether schemas belonging to the domain of 'impaired autonomy and performance' are more prevalent in OCD than in both eating disorders (ED) and chronic pain disorder (CPD). SAMPLING AND METHODS: EMS, schema modes and traumatic childhood experiences were measured in 60 patients with OCD, 41 with ED, 40 with CPD and 142 healthy controls. To analyze differences between the groups, MANCOVAs were conducted followed by deviation contrasts. Depression level, age and gender were considered as possible covariates. RESULTS: OCD patients scored higher on 4 EMS, 2 of which belong to the domain 'impaired autonomy and performance'. ED patients had higher scores in the EMS 'emotional inhibition' and CPD patients on the Childhood Trauma Questionnaire subscale 'physical neglect'. CONCLUSIONS: These results suggest that there might be typical schema patterns associated with OCD and ED. We can also conclude that a higher prevalence of traumatic experiences does not necessarily coincide with more EMS and schema modes.

Is brief psychodynamic psychotherapy in primary fibromyalgia syndrome with concurrent depression an effective treatment? A randomized controlled trial.

OBJECTIVE: There are no studies investigating the efficacy of short-term psychodynamic psychotherapy in primary fibromyalgia syndrome (FMS). We conducted a randomized controlled trial evaluating an adapted form of individual short-term psychodynamic psychotherapy (ASTPP) versus primary care management (TAU). The study focused on FMS patients with psychiatric comorbidity. METHODS: Forty-six female patients with FMS and an International Classification of Diseases, 10th Revision diagnosis of a comorbid depression or anxiety disorder were recruited in a hospital setting. Participants were randomized to receive either ASTPP (25 sessions, 1 session/week) or TAU (4 consultations/6 months). Outcome measures included the Fibromyalgia Impact Questionnaire (FIQ), the Hospital Anxiety and Depression Scale (HADS), the Pain Disability Index, the Symptom Checklist 27 and the health-related quality of life. Primary endpoints of the outcome assessment were the FIQ total score and the HADS depression scale at 12-month follow-up. RESULTS: Both treatments were effective in reducing the FIQ total score (ES=0.56 and ES=0.75, respectively). Intent-to-treat analyses failed to provide evidence suggesting a marked superiority of individual psychodynamic psychotherapy as compared to TAU. CONCLUSIONS: A high-standard routine treatment focusing on the improvement of health behavior and including antidepressant and analgesic medication is equally effective as a short-term individual psychodynamic psychotherapy in improving fibromyalgia-related symptoms.

[The project of the Techniker-Krankenkasse: some comments on the results by the project's scientific advisory board]. / Das Modellprojekt der Techniker-Krankenkasse: Eine Kommentierung der Ergebnisse aus der Sicht des wissenschaftlichen Projektbeirates.

The Project of the Techniker Krankenkasse compared 2 systems of quality assurance in outpatient psychotherapy, the established peer review system based on qualitative individual case reports and a new model based on psychometric assessment and feed-back systems. In this publication the members of the project advisory board comment on the results and limitations of the study. 400 psychotherapists in private practice participated in a cluster-randomized comparison study, 200 were allocated to the intervention group, and 200 to the control group. In both groups assessments were performed at 3 points in time, one at the beginning of treatment, one at the end of treatment and one at follow-up 12 months post-treatment. No significant differences in psychotherapeutic outcome were observed in the 2 groups. The hypothesis of a better outcome associated with the psychometric assessment and benchmarking procedure was not confirmed.

[Narration as a means of restoring self-coherency: Thoughts on processing traumatic experiences]. / Erzählen als Prozess der (Wieder-) Herstellung von Selbstkohärenz. Uberlegungen zur Verarbeitung traumatischer Erfahrungen.

OBJECTIVE: Traumatic memories are characterized by not being accessible to intentional recall nor being integrated into the matrix of autobiographical memory. Based on this description, the authors discuss the process of narration as a central means of regaining a sense of self-coherence after traumatic experiences. Formally correct narratives are characterized by three functions: orientation, reference and evaluation. Through so-called "memory talk" with socio-culturally competent partners, children learn how to reconstruct memories and to represent experience by narration. It is therefore suggested that narratives are the basic ingredient of autobiographical memory. The process of re-establishing a sense of coherence after trauma relies on the capacity for coherent narration. The latter is often not possible with traumatic experiences. METHOD AND RESULT: We conducted a literature search in multiple databases for linguistic analyses of trauma narratives empirically correlating narrative style and posttraumatic psychopathology. DISCUSSION: It is recommended that research in psychopathology and psychotherapy should take issues of language into account more systematically.

The relationship between alexithymia and salivary cortisol levels in somatoform disorders.

The purpose of this study was to investigate cortisol levels as a function of the hypothalamic-pituitary-adrenal axis (HPA) in relation to alexithymia in patients with somatoform disorders (SFD). Diurnal salivary cortisol was sampled in 32 patients with SFD who also underwent a psychiatric examination and filled in questionnaires (Toronto Alexithymia Scale, TAS scale; Screening for Somatoform Symptoms, SOMS scale; Hamilton Depression Scale, HAMD). The mean TAS total score in the sample was 55.6+/-9.6, 32% of patients being classified as alexithymic on the basis of their TAS scores. Depression scores were moderate (HAMD=13.2, Beck Depression Inventory, BDI=16.5). The patients' alexithymia scores (TAS scale "Difficulty identifying feelings") correlated significantly positively with their somatization scale scores (Symptom Checklist-90 Revised, SCL-90-R); r=0.3438 (P<0.05) and their scores on the Global Severity Index (GSI) on the SCL-90-R; r=0.781 (P<0.01). Regression analysis was performed with cortisol variables as the dependent variables. Cortisol levels [measured by the area under the curve-ground (AUC-G), area under the curve-increase (AUC-I) and morning cortisol (MCS)] were best predicted in a multiple linear regression model by lower depressive scores (HAMD) and more psychopathological symptoms (SCL-90-R). No significant correlations were found between the patients' alexithymia scores (TAS) and cortisol levels. The healthy control group (n=25) demonstrated significantly higher cortisol levels than did the patients with SFD; in both tests P<0.001 for AUC-G and AUC-I. However, the two groups did not differ in terms of their mean morning cortisol levels (P>0.05). The results suggest that pre-existing hypocortisolism might possibly be associated with SFD.

Relationship between attachment style, parental bonding and alexithymia in adults with somatoform disorders.

BACKGROUND: This study examines the relationship between parental bonding, adult attachment, and alexithymia in patients with Somatoform Disorders (SFD). There are few empirical studies to support the clinical hypothesis that alexithymia may be due to disturbances in the early parent-child relationship. SAMPLING AND METHODS: In a cross-sectional study, data from 76 patients with SFD were obtained, consisting of questionnaire measures of alexithymia (TAS scale), attachment style (BFKE), and also the German version of the MOPS (Measure of Parental Style), the FDEB scale for measuring perceived parental attitude. RESULTS: A higher than average prevalence of insecure attachment (n = 67, 88.2%) was found in our sample with SFD and a T-value of 54.3 (9.5) in the TAS total score, 22% reaching clinically significant alexithymia. Regression analyses demonstrated the relationship between the "ambivalent clinging" and "ambivalent withdrawing" attachment style and more marked alexithymia features. Furthermore, alexithymia was positively predicted by "indifference" in the relationship to the father, BDI, and Global severity index (SCL-90-R). CONCLUSION: The results of this study support the hypothesis that alexithymia is associated with perceived parental bonding and attachment style.