[Not Available]. / Wenn der Vater fehlt. Epidemiologische Befunde zur Bedeutung früher Abwesenheit des Vaters für die psychische Gesundheit im späteren Leben/ The missingfather. Epidemiological findings on the significance of early absence of the father for mental health in later life.

Facing the increasing number of single-parent-families we investigated the impact of fathers absence within the first six years of childhood on psychic/psychosomatic impairment in later life. We used data from the Mannheim Cohort Study on the Epidemiology of Psychogenic (neurotic spectrum) Disorders for a comparison of extreme groups with a favourable or bad course of clinical impairment. In adition we performed regression analysis of the long term course of clinical impairment for the total follow-up sample (mean follow-up intervall 11 years, N=301) with psychometric, clinical and childhood variables. The absence of the probands father (> six months within the first six years of life) was a significant independend predictor of clinical impairment in later life, accompanied by clinical and psychometric variables. A significant and increasing impairment existed even in 73 of 125 older probands (birth cohort 1935), who missed their father in early childhood. The sociopolitical implications of these findings are discussed.

A decade of spontaneous long-term course of psychogenic impairment in a community population sample.

BACKGROUND: Our epidemiological study demonstrates the spontaneous long-term course of predominantly psychosocially influenced ("psychogenic") disorders (neurotic spectrum disorders, personality disorders, stress reactions and somatoform disorders) in a representative community sample of the normal adult population of Mannheim, an industrial and university town in Germany. The natural spontaneous course of these disorders in a population sample over a long period remains largely unknown. METHOD: Beginning in 1979 (nt1 = 600) a random population sample was investigated three times over a mean period of approximately 11 years. The last follow-up study ended in 1994 (nt3 = 301). The follow-up sample was representative of the t1 sample. Psychodynamically trained and clinically experienced interviewers used a semi-structured interview and standardized clinical and psychometric instruments. Psychogenic impairment was assessed using a standardized expert rating (Impairment Score, IS). RESULTS: The mean sum-score of psychogenic impairment after 11 years exceeded the value at t1. The case rate (point prevalence, ICD diagnosis + clinical cut-off/IS) increased from 21.6% at t1 to 26.2% at t3 in the investigated follow-up sample. Intra-individual correlation of psychogenic impairment between t1 and t3 was high (r = 0.55). We found strong evidence for an unfavorable long-term course of psychogenic impairment and only a weak tendency (23.1%) for spontaneous remission of clinically relevant psychogenic impairment. Within a regression model clinical variables, childhood development conditions and personality traits at t1 predicted psychogenic impairment at t3. CONCLUSION: All clinical variables conclusively indicate an unfavorable spontaneous long-term course of psychogenic impairment. Together with the well-known high prevalence of psychogenic disorders in the normal population, this underlines the need for early therapeutic and preventive intervention.

[Emotional disorders. Stable mental health and chronic illnesses over a 10-year course in the general population]. / Seelische Störungen. Stabile Gesundheit und chronische Erkrankungen in der Allgemeinbevölkerung im 10-Jahres-Verlauf.

In a comparison of extreme groups 124 german inhabitants of the city of Mannheim were investigated. They descended from a representative sample with 600 persons out of 3 years of birth (1935, 1945, 1955) in the general population (psychotic disorders were excluded). They were within a period of 10 years either in stable mental health or in chronic illness. The comparison between this two groups concerned demographic variables, development during childhood, personality, stressful life events, social network and clinical data. The ascertained prevalence is 12.7% (from n = 600) for stable mental health and 3.5% for chronic illness. The group with the highest risk of chronic diseases is those of women and men with bad achievement and small social competence.

Predicting extreme patterns of long-term course of psychogenic impairment: a ten-year follow-up.

This longitudinal study identifies predictors of course and etiologically relevant factors of psychogenic disorders. Since 1979, the Mannheim Cohort Project on the Epidemiology of Psychogenic Disorders has investigated neurotic spectrum disorders, personality disorders, stress reactions, and somatoform disorders in the normal population. Using these data, a cohort of probands suffering from moderate psychogenic impairment (N = 240; 121 men, 119 women) based on a representative sample of the urban adult population (N = 600; with cohorts 1935, 1945, 1955; gender distribution 1:1) of Mannheim, an industrial and university town in Germany, was followed up for almost 10 years. The cohort was investigated three times by psychodynamically trained physicians and psychologists. Tests were performed by means of cluster analysis. Different types of course of psychogenic impairment were identified. Both extreme types--the probands with the most positive and the most negative spontaneous long-term course--were investigated with regard to potential course-determining variables. Personality variables and conditions of early childhood development considerably influenced the spontaneous long-term course.

[Changes in pensioning and psychosomatic assessment]. / Rentenentwicklungen und ihre psychosomatische Beurteilung.

Appropriate evaluation of a patient's handicapping or disabling conditions, of his or her capacity for work and gainful activity rank among the recurring tasks in inpatient rehabilitation. Published recently, the Beeinträchtigungsschwere-Score (BSS; a score for determining the severity of a condition) constitutes a highly practicable instrument for these purposes, well suited to the clinical setting. Particular difficulties are encountered in the assessment of patients already in the pension award process, a population where the original disease picture has been superimposed by numerous chronification factors of a psychological, social and economic nature so that a so-called invalidity pensioning career has set in. The article gives an overview of this phenomenon of invalidity pensioning career and the sequence of its various phases, setting out the use of the BSS for social-medical evaluation in an inpatient rehabilitation setting.

[Mood disorders. Prevalence and course of unspecified functional disorders from the epidemiologic and psychosomatic viewpoint]. / Befindlichkeitsstörungen. Häufigkeit und Verlauf unspezifischer und funktioneller Beschwerden aus epidemiologisch-psychosomatischer Sicht.

Subjective complaints or somatoform symptoms beyond the case threshold (ICD-diagnoses) occur in 12% of the normal population. In recent studies prevalence is at least 17% in primary care. Somatoform complaints (e.g. headache with 38.7%) or non-specific common symptoms (e.g. feeling of inner restlessness with 41.3%) are much more widespread. Mostly, several symptoms together are forming a multiple somatoform syndrome. As well known from other psychogenic disorders, spontaneous long-term course of somatoform symptoms is variable due to the psychic co-morbidity (in particular anxiety and depression) and a strong tendency to symptomatic shift. The long-term course of total impairment by additional psychogenic symptoms is rather bad in somatoform disorders. Clinically significant personality traits and traumatic influences during early childhood development are correlated with somatoform disorders. Within the traditional role patterns of the relation between physician and patient, somatoform complaints often communicate or indicate a psychodynamic conflict. In this case, a psychosomatic/psychotherapeutic approach in primary care or a specialized psychotherapy is indicated.

[Different lay etiologic attributions of psychogenically ill probrands from an epidemiologic field study]. / Differente Laienätiologien bei psychogen beeinträchtigten Probanden aus einer epidemiologischen Feldstudie.

The correlation between causal attributions of symptoms and sociodemographic, psychometric and clinical variables among psychogenic impaired persons is investigated in this paper. 114 individuals, who had presented psychogenic symptoms in the last year, were selected from the representative sample of the Mannheim Cohort Study. Two extreme groups have been identified through one Scale of Disease Conception: one with a somatogenic (n = 80) and the other with a psychogenic conception (n = 34). Female, younger and well educated individuals predominate in the group with psychogenic conception. In FPI the group with psychogenic conception is characterized by high depressivity, emotional lability, aggressivity, inhibition, irritability, anxiety and frankness. The diagnosis psychoneurose (ICD) is also more frequent in this group. The psychic impairment is more severe in the group with psychogenic conception (Impairment Score). Subjects of the group with psychogenic conception utilized psychotherapeutic services more frequently. In the logistical regression the variables agecohort, the FPIdimensions "Sociability" and "Inhibition", the number of psychic and physical symptoms in the last year and the BSS-subscale "psychic impairment" prove to be relevant in the estimate of relative risk for the type of causal explanation for symptoms.

[Indicators and factors of influence on the long-term follow-up of psychogenic diseases--a comparison of extreme groups]. / Indikatoren und Einflussfaktoren des Langzeitspontanverlaufs psychogener Erkrankungen--Ein Extremgruppenvergleich.

The present investigation aimed at the identification of possible indicators of course, predictors, and etiologically relevant factors of psychogenic diseases. According to their complaints a sample of probands suffering from psychogenic impairment of medium degree (n = 240) was chosen out of a representative sample of an urban adult population (n = 528). This procedure should ensure a relatively high intraindividual variance of course of the criterion, since a sufficient variability of course seems improbable with chronic and severe psychogenic impaired or stabile healthy probands. Within 10 years the sample was investigated three times by psychodynamically trained physicians and psychologists. By means of cluster analysis the sample was subdivided in different types of course of psychogenic impairment. Both extreme types of course-the probands who showed the most positive and the most negative spontaneous longterm course-were investigated univariately and by means of a multivariate discriminant analysis with regard to potentially course determining variables. It became obvious that personality variables and conditions of early childhood considerably influenced the spontaneous longterm course of psychogenic impairment.

[Psychological versus psychogenic--a necessary clarification of terminology]. / Psychisch versus psychogen--Eine notwendige Begriffsklärung.

Confusion exists regarding the usage of the two adjectives psychic and psychogenic. Therefore a differentiation of the two words is necessary. We will try to do this with the help of concrete examples. Regarding the pair of terms psychic versus somatic one has to differentiate strictly between (psychic or somatic) causes on the one hand and the forms of manifestation in the psychic or somatic field of observation on the other hand. The discussion about the linguistic ruling of psychic versus psychogenic has important consequences for the responsibilities and care of the different professions: psychiatrist, psychosomatist/psychotherapist, other specialists, general physician.

Influence of hereditary factors in psychogenic disorders.

As part of a research project, a sample of 50 pairs of twins (21 pairs of identical twins, 16 pairs of nonidentical twins of the same sex, and 13 pairs of male-female twins, n = 100 test persons) was examined between 1963 and 1969 and recently, 20 years later, followed up. The index twins were drawn from among the patients making use of the services of an outpatient clinic; they had been diagnosed as having psychoneurotic, character-neurotic of psychosomatic disorders. The question again looked into was that of nature versus nurture: identical twins displayed significantly higher similarity with regard to both severity of their neuroses and manifestation of neurotic symptoms than did nonidentical twins. The hereditary factor proved to be of greater import for the continuing childhood neuroses than for the subsiding childhood neuroses. Yet a certain hereditary factor effect was observed for the neuroses which first manifest themselves in adulthood. Our findings indicate that the hereditary factor is not more pronounced in childhood than in adulthood; it is equally effective in adults.

[Inadequate utilization of somato-medical services by psychogenically ill patients]. / Zur inadäquaten Inanspruchnahme somato-medizinischer Leistungsangebote durch psychogen erkrankte Patienten.

Within the Mannheim Cohort Project on the epidemiology of psychogenic disorders 240 probands of a high risk sample (suffering from medium psychogenic impairment) were randomly selected from the general population and investigated with regard to their realized utilization of the medical and/or psychotherapeutic services of the health care system. On the basis of clinical criteria the probands were classified as case (n = 78) of psychogenic disorder or non-case (n = 162). Increased psychogenic impairment caused by psychoneurotic, character neurotic, or psychosomatic-functional disorders was primarily combined with an intensified utilization of the somatically oriented medical services. Only 2.5% of the cases indicated that the reason for their most recent visit to a physician was psychotherapeutic treatment. In view of the high percentage of psychogenic impaired patients in private practices and general hospitals this seems to be a particularly discrepant finding. In spite of the psychogenic nature of their complaints the cases were confronted with somatically oriented therapy offers like the non-cases. An increased psychogenic impairment did not lead to a qualitative alteration of the utilization of medical and/or psychotherapeutic services. Facing the fact that the utilization of somatically oriented medical services by psychogenic ill patients is still widespread but inadequate this finding is interpreted as indication for an essential demand of further studies on the determinants of psychotherapy acceptance.

[Genetic or psychogenic. On the heredity-environment question of psychogenic diseases]. / Gen oder Psychogen. Zur Erbe-Umwelt-Frage bei psychogenen Erkrankungen.

In the introduction the problems of and access to human genetical gains of knowledge are described, especially the research theoretical paradigm of the classic twin method. The article shows: In the last decades with the help of twin research hereditary determinants have been found also for many (so-called and predominantly) psychogenic illnesses: For personality disorders, for psychoneurosis as well as for several psychosomatic illnesses. In the sense of a complementary list--more psychogenic/environmentally determined or primarily somatically/hereditarily determined--several normal characteristics and clinical pictures are listed.

[Epidemiologic findings on the spontaneous long-term course of psychogenic disease over 10 years]. / Epidemiologische Befunde zum Langzeitspontanverlauf psychogener Erkrankung über 10 Jahre.

207 individuals were selected from a random sample of the adult urban population of Mannheim according to the criterion of medium psychogenic impairment (high-risk population) and investigated three times between 1979 and 1991 with regard to prevalence and severity of psychogenic disorders. In contrast to clinical investigations, the present data render statements on the spontaneous course of psychogenic disorders in the general population. The existing psychogenic impairment was determined by means of various operationalizations (symptomatology, ICD-diagnoses, severity of impairment). The available data indicate a high stability of psychogenic impairment in the spontaneous course. Group statistically the severity of impairment even increases in the long term course. However, different subtypes of course in the investigated high-risk population can be identified by a cluster analysis.

[Why "no" to psychotherapy? Cognitive stereotypes of psychosomatic patients of a population sample in correlation with refusal of offered psychotherapy]. / Warum "Nein" zur Psychotherapie? Kognitive Stereotypien psychogen erkrankter Patienten aus einer Bevölkerungsstichprobe im Zusammenhang mit der Ablehnung eines Psychotherapieangebots.

Practical and organizational reasons, e.g. problems of timing, and strain factors in private or professional life are cited predominantly when probands spontaneously utter their motives for the non-acceptance of an offer of psychotherapy. In the second place, a lack of insight into the necessity of this kind of treatment is indicated as motive for the rejection of a therapy offer. An exploration of the probands leads to a change in the frequently distribution of the motives uttered to refuse psychotherapeutic treatment. Basically, the differentiation of the answers increases (indication of more than one category of motives). A negative attitude to or fear of psychotherapy was indicated considerably more often, especially by women. Those--mostly male--probands, who had pointed out that a lack of insight into the necessity of psychotherapeutic treatment was the decisive factor for their non-acceptance of the therapy offer, adhered most consistently to their argumentation also after exploration. The statistical analysis of possible determinants for the different styles in which probands state the motives for their rejection revealed significant sex differences. These findings suggest that the uptake of psychotherapeutic treatment is also guided by sex role sterotypes.

[Incidence and follow-up characteristics of neurologically relevant psychogenic symptoms]. / Häufigkeit und Verlaufscharakteristika neurologisch relevanter psychogener Symptome.

The author reports on the prevalence and stability of the course of neurologically relevant psychogenic symptoms as well as their dependence on age and sex. Altogether 240 probands from the Mannheim Cohort Study on the epidemiology of psychogenic disorders were examined for psychogenic impairment over a 10-year period during three investigation periods. On the whole, seven neurologically relevant groups of symptoms (headache, lumbar and cervical vertebral complaints, non-systematic vertigo, functional hyperkinesia, functional paresis, sleep disturbances, concentration disturbances) differ clearly in frequency, characteristics of the course and clinical relevance.

[Is there a typical conflict in dyspepsia? An epidemiologic psychoanalytic contribution to the topic of a specific conflict in psychosomatic medicine]. / Gibt es einen typischen Konflikt bei Magenbeschwerden? Ein epidemiologisch-tiefenpsychologischer Beitrag zur Frage des spezifischen Konfliktes in der psychosomatischen Medizin.

The question whether a dependency-independency-conflict is specific for subjects with gastric complaints was investigated by means of a representative, psychoanalytic-epidemiologic field study (Mannheimer Kohortenprojekt). Out of a population of 600 adults probands with dyspepsia were compared with individuals with musculoskeletal symptoms and "healthy" subjects. Using interview protocols of these individuals two "blinded" raters judged whether the conflict under consideration was present in different aspects of life. It could be confirmed that subjects with gastric complaints showed the conflict significantly more often than either control group. However, the conflict was also found among individuals of either control group. It can be concluded that the dependency-independency-conflict is typical, but not specific for subjects suffering from dyspepsia.

[KOPS: a self-rating instrument for assessment of physical, psychological and social communication impairments]. / KOPS: Ein Selbstrating-Instrument zu Erfassung körperlicher, psychischer und sozial-kommunikativer Beeinträchtigungen.

In this article the development of a self-rating symptom questionnaire is described. The questionnaire records physical, psychological and social-interactionary impairments typical for neurotic and psychosomatic disorders. Contrary to most of the established self-assessment instruments the KOPS-questionnaire consequently records symptoms from these three areas. The questionnaire contains 64 items scaled on four steps and can be filled out by the test person in a short period of time. The results depicted here from different sample groups which were examined verify the differential and criterion related validity and furthermore an explorative factor analysis also verifies the content validity. The instrument is suited for screening purposes as well as for clinical course studies of psychological disorders. The problems of the assessor perspective (by an expert or by a patient) in recording symptoms is discussed.

[Psychometric assessment of defense mechanisms: correlation between questionnaire and expert rating. Initial study of validity]. / Psychometrische Erfassung von Abwehrmechanismen: Zusammenhang zwischen Fragebogen und Expertenrating. Erste Validitätsuntersuchungen.

Within the limits of an epidemiological longitudinal field survey on prevalence and course of psychogenic disorders a high-risk-population suffering from medical psychogenic impairment was investigated. The study was conducted in order to verify an etiological multi-level-model of psychogenic disorders in relation to the socialempiric variables "critical life events" and "social support" as well as the depth psychological oriented construct "personality". Besides other instruments a self rating scale based on Vallant's hierarchical model of defense, i.e. the german adaptation of the DSQ (Defense Style Questionnaire) of Bond and coworkers, was used for the accurate measurement of relevant personality parameters. Although defense processes predominantly work unconscious, manifestations of defense mechanisms could be measured indirectly by means of the rating scale. Its essential dimensions separated clinical patients from a group of healthy controls. Furthermore an immature organisation of defense was found to be related to psychogenic impairment. Concerning self- and expert-rating a significant correlation between "immature defense" and the defense mechanisms "schizoid phantasy", "projection" and "acting out" was proved.

Unspecific neurologic symptoms as possible psychogenic complaints.

Prevalence and course of psychogenically influenced symptoms in neurology and their dependence on age and gender are reported. The epidemiological basis of the data is a long-term follow-up investigation of a high-risk population for about 10 years (n = 240): the Mannheim Cohort Study on Epidemiology of Psychogenic Disorders. Seven psychogenic symptoms of neurologic relevance (headache, lumbar and cervical vertebral complaints, functional vertigo, hyperkinesias, pareses, sleep and concentration disturbances) are characterized in regard to frequency, course and diagnostic significance.

[Discordance analytic studies of monozygotic twins]. / Diskordanzanalytische Untersuchungen an eineiigen Zwillingen.

Discordance analyses of monozygotic twins make it possible to study the influence of neurotic pathogenic situations of early childhood upon later neurotic developments. The analysis offers the advantage of having a genetic double who was shaped by the same psychosocial macro influences and went through a sound development as a comparison for an examination of the course of psychogenic illnesses. However, two prerequisites are necessary: 1. the human genetic/anthropological or serological diagnosis in order to be able to definitely say whether the twins are monozygotic or not and 2. both twins must be alive. A strong discordance regarding markedness of characteristics or a varying degree of symptom manifestation as well as a longer period of observation are further conditions. With the example of four short casuistries of monozygotic twins the environmental variables which are decisive in the individual cases for the discordant development are described: A highly ambivalent early childhood relationship in contrast to a mostly balanced relationship is the foundation for a neurotic course in connection with pathological conspicuous behavior of the parents, sibling rivalry and differing attitudes of the parents regarding each of the twin siblings. As a result each twin identifies with a different parent, leads in development and dominance positions are also consequences. Later the course set in school and career, orientation regarding an intimate partner and the neurotically preformed personality structure, which is the basis for differing degrees of being able to cope successfully with threshold situations, become framing situations of discordant neurotic versus stable and sound development.