Resource activation for treating post-traumatic stress disorder, co-morbid symptoms and impaired functioning: a randomized controlled trial in Cambodia.

BACKGROUND: Mental health morbidity in post-conflict settings is high. Nevertheless, randomized controlled trials of psychotherapy on site are rare. Our aim was to integrate rigorous research procedures into a humanitarian programme and test the efficacy of resource activation (ROTATE) in treating post-traumatic stress disorder (PTSD), co-morbid symptoms and impaired functioning in Cambodia. METHOD: A total of 86 out-patients with PTSD were randomly assigned to five sessions of ROTATE (n = 53) or a 5-week waiting-list control (WLC) condition (n = 33). Treatment was provided by six Cambodian psychologists who had received extensive training in ROTATE. Masked assessments were made before and after therapy. RESULTS: PTSD remission rates according to the DSM-IV algorithm of the Harvard Trauma Questionnaire were 95.9% in ROTATE and 24.1% in the WLC condition. Thus, patients receiving ROTATE had a significantly higher likelihood of PTSD remission (odds ratio 0.012, 95% confidence interval 0.002-0.071, p < 0.00001). Additionally, levels of anxiety, depression and impaired functioning were significantly reduced compared with the WLC condition (p < 0.00001, between-group effect sizes d = 2.41, 2.26 and 2.54, respectively). No harms were reported. CONCLUSIONS: ROTATE was efficacious in treating Cambodian patients with high symptom levels of PTSD, emotional distress and impaired functioning. ROTATE is a brief, culturally adaptable intervention focusing on stabilization and strengthening resources rather than trauma confrontation. It can be taught to local professionals and paraprofessionals and enhance access to mental health care for patients in need.

[Low dose naltrexone in the treatment of dissociative symptoms]. / Niedrig dosiertes Naltrexon in der Behandlung dissoziativer Symptome.

BACKGROUND: Following the hypothesis that blocking opioid receptors leads to a decline in opiate-modulated dissociative phenomena, experiences with naltrexone as medication for dissociative symptoms have been gained since 1999 (mainly in doses of 25-100 mg/day). PATIENTS AND METHODS: In this study patients with severe trauma-related and dissociative disorders were treated with naltrexone in doses of 2-6 mg/day (0.06 mg/kg body weight). RESULTS: The low dose treatment with naltrexone proved to be effective whereby 11 out of 15 patients reported immediate positive effects and 7 described a lasting helpful effect. The majority of patients who felt positive effects reported a clearer perception of both their surroundings and their inner life. Assessment of reality and dealing with it improved as did the perception of their own body and affects as well as self-regulation. The treatment was very low in side effects. CONCLUSION: Treatment with low-dose naltrexone may be a helpful element in the treatment of patients with complex posttraumatic stress disorder. However, it has to be realized that the decrease of dissociation may lead patients to a not yet resolvable challenge, in as much as dissociation had previously been a necessary mechanism of self-protection.

[Psychotherapeutic treatment concepts of personality disorders in patients with childhood traumatization]. / Psychotherapeutische Konzepte zur Behandlung von Persönlichkeitsstörungen bei chronischen Kindheitstraumatisierungen.

The psychotherapeutic treatment of personality disorders in patients with childhood traumatization is still a major challenge. The broad range of clinical problems includes disturbed emotion regulation, reduced mentalization function, impaired integration of personality, maladaptive patterns of behavior and a high degree of comorbidity. A variety of treatment concepts of psychodynamic, cognitive-behavioral, and other origin have been developed to treat this patient population. The aim of this paper is to identifiy those concepts whose effectiveness has been sufficienty demonstrated by controlled studies. The concepts will be briefly described and evaluated with regard to their utility in focusing specific clinical problem areas. While a variety of treatment approaches has been developed for this condition, only a limited number of concepts of cognitive-behavioral and psychodynamic origin show up with sufficient evidence in terms of controlled studies. Among the cognitive-behaviorally oriented concepts are: Dialectical-behavioral Psychotherapy (Linehan), Affect Management Training (e. g. Cloitre), and Schema Therapy (Young). The psychodynamic concepts with evidence of effectiveness are: Tranference-focused Psychotherapy (Kernberg/Clarkin), Psychodynamic-interactional and Structure-related Psychotherapy (Heigl-Evers & Heigl, Rudolf), Mentalization-based Treatment (Bateman & Fonagy), and Psychodynamically Oriented Trauma Therapy (Reddemann, Sachsse). However, a critical discussion of these concepts reveals that, because of the heterogeneity of the patient population, none of these concepts is able to cover all types of clinical problems presented by the patients.

[Psychotherapeutic intervention for disturbed emotional regulation in complex post-traumatic stress disorder]. / Störungen der Emotionsregulierung bei komplexen Traumafolgestörungen. Psychotherapeutische Interventionen.

Pervasive disturbances in emotional regulation are a frequent problem for patients with complex trauma disorders. Emotional instability is a core diagnostic criterion of borderline personality disorder, in which a high prevalence of physical and sexual childhood abuse has been found. Self-injury, substance abuse, and binge-eating are strategies for coping with unbearable traumatic emotions. Therapeutic strategies for improving emotion regulation include pharmacological and psychological approaches. For the former, serotonin reuptake inhibitors have been shown to improve emotion regulation. The latter, psychotherapeutic techniques are: refocusing attention on positive emotions, imaginative distancing, resource activation, cognitive methods for improving affect differentiation, and fostering confidence in relationships and emotional attachment through the experience of a positive therapeutic relationship.

[Trauma repetition and revictimization following physical and sexual abuse]. / Traumawiederholung und Reviktimisierung nach körperlicher und sexueller Traumatisierung.

The tendency of victims of physical or sexual childhood abuse to become revictimized in later life has well been documented empirically. Moreover, there is a high stability of violent and abusive relationships. The aim of this paper was to summarize perspectives from psychodynamic theory, attachment theory, and posttraumatic stress research to explain revictimization phenomena. The term repetition compulsion has little explanatory value without additional theoretical assumptions. Within the psychodynamic framework, an ego-psychological view conceives trauma repetition as an attempt to master traumatic experience, while in the object relations perspective, revictimization is explained by the influence of traumatic introjects. Negative cognitions of being worthless, bad and guilty can endorse the conviction that abuse is justified and reduce the capacity of self-care. Negative learning experiences from traumatic helplessness and powerlessness account for low self-efficacy expectations and prevent the establishment of self-boundaries. Trauma repetition can also be understood as an enactment in the service of affect regulation. Research in the field of attachment theory identified attachment styles predisposing to revictimization. Research dealing with posttraumatic stress disorder emphasizes the importance of traumatic affects recurring in daily life and, consequently, the tendency of abuse victims to actively produce dangerous situations in order to cope with these affects, furthermore, the role of dissociation in missing warning signals of impending traumatization. For therapeutically addressing revictimization, a detailed analysis of underlying phenomena is required.

[Personality disorders and psychopathology following trauma. Reflection on diagnostic classification]. / Persönlichkeitsstörungen und die Psychopathologie in der Folge von Traumen. Uberlegungen zur diagnostischen Klassifikation.

Pervasive personality disorders have been shown to be long-term sequelae of cumulative childhood physical and sexual traumatization. This finding is not reflected in DSM-IV and ICD-10 classifications where post-traumatic stress disorder is confined to intrusions, avoidance, numbing, and hyperarousal. However, there is growing evidence that trauma etiology should be taken into account in planning treatment for personality disorders. It is not yet clear whether childhood traumatization is more strongly associated with borderline personality disorder than with other personality disorders. The finding of a substantial overlap between borderline personality disorder and dissociative identity disorder gives rise to discussions concerning the relationship of these two pathologies.

[Indications for inpatient psychotherapy. When does your patient belong in a clinic?]. / Indikationen für die stationäre Psychotherapie. Wann gehört Ihr Patient in die Klinik?

Institutionalized psychotherapy is indicated for specific disorders, the treatment of which at certain times or phases cannot be implemented in the doctor's office. Further Indications are patient denial and lack of motivation, a need to remove the patient from a pathogenic environment, a need for outpatient treatment initiation, and, in selected patients, a crisis situation, when the symptoms become acute or when internistic reasons are present. When these positive indication criteria apply--apart from emergency and crisis situations--a mental and somatic pre-evaluation--best done by the admitting institution--should be part of the pre-diagnostic work-up.

[Narcissistic regulation and metabolic control in type-II diabetics]. / Narzisstische Regulation und diabetische Stoffwechseleinstellung bei Typ-II-Diabetikern.

The influence of narcissistic regulation on metabolic control was investigated in 130 patients with Type-II-diabetes in the course of a rehabilitation programme. Two groups were studied: a) diabetics on a non-drug therapy regimen, b) diabetics treated by insulin. At the end of the rehabilitation programme 55.6% of the non-insulin patients and 60.1% of the insulin treated patients exhibited a clinically significant improvement as measured by HbA1c. On the basis of the Düsseldorf Questionnaire for Narcissistic Regulation in Chronic Disease (DNACE) predictors of metabolic control were established. Using decision analysis, a correct prediction was possible in 73.1% resp. 85.4% of the cases. In the non-drug group, low values of the "helplessness/powerlessness" scale and high values of the "mourning" scale predicted an improvement of metabolic control at the end of the rehabilitation programme. On the other hand, in the insulin treated group the more successful patients were shown to have low values in the scales "distrust", "feeling of being ashamed of disease", "feeling of inferiority" and "fighting self-image" and high values in the scales "value ideal" and "symbiotic protection of the self". The results are discussed within the theoretical framework.

Development and evaluation of a new alcohol-based surgical hand scrub formulation with persistent antimicrobial characteristics and brushless application.

BACKGROUND: Since the introduction in the 1970s of surgical hand scrub formulations that contain 4% chlorhexidine gluconate (CHG), new surgical scrub formulations that have improved efficacy, persistence, or significantly improved use characteristics have not been forthcoming. In addition, the manufacturer's labeling for popular hand scrub products generally requires scrub times in excess of 6 minutes, whereas current practical needs call for products with substantially shorter scrub times. A new alcohol-based surgical scrub formulation, which has ingredients that provide emollient, surfactant, and antimicrobial persistence characteristics to complement the rapid and broad-spectrum antiseptic qualities of alcohol, has been developed in an effort to address these current practical needs. METHODS: The relative efficacy of a new alcohol-based surgical scrub formulation that contains ingredients that provide surfactant and antimicrobial persistence characteristics was compared with that of commercial 4% CHG and 7.5% povidone iodine (PVPI) formulations with use of human subjects. Hand antimicrobial count sampling was performed by using standardized "glove juice" methodology. RESULTS: The efficacy and persistence results of the new formulation showed statistically significant improvement over both CHG and PVPI at a substantially lessened scrub time (3 minutes). In addition, use of the new formulation without a scrub brush produced results statistically similar to 3-minute applications with either a brush or a sponge. CONCLUSIONS: The new alcohol-based formulation demonstrates promise as a new surgical hand scrub formulation with antimicrobial and use characteristics that are significantly improved over current CHG and PVPI formulations. These studies demonstrate the suitability of this formulation for use as a surgical hand scrub and for brushless application.

[Determinants of high risk illness behavior in patients with bronchial asthma]. / Determinanten von Risikokrankheitsverhalten bei Patienten mit Asthma bronchiale.

The aim of this study was to identify factors influencing high-risk illness behaviour in patients with bronchial asthma. High-risk illness behaviour was defined as 1. non-compliance with antiasthmatic medication and 2. delaying or avoiding medical help when facing airways deterioration or severe attacks. 150 patients with bronchial asthma were investigated; 60 of them had participated in the structured Asthma Treatment and Teaching Programme (ATTP), 90 had not taken part in such a programme by then. Using structural equation models, lack of emotional support by a key figure, poor doctor-patient relationship, and a negative cortisone image were identified as predictors of high-risk illness behaviour in patients who had attended ATTP, while in patients without participation in a treatment and teaching programme, only a negative cortisone image was predictive of this criterion.

[What is supportive psychotherapy?]. / Was ist supportive Psychotherapie?

Although supportive psychotherapy is of great importance in psychiatry and psychosomatic medicine, supportive treatment strategies have not been paid much attention so far in literature and training. Clinical indication criteria for supportive techniques are: lack of treatment motivation and introspection, impairment of object relations and impulse control, inadequate modulation of affect and difficulties in establishing a therapeutic working alliance. After reviewing the principles of supportive psychotherapy, special aspects of supportive treatment techniques are discussed.

[Perceived emotional support of HIV-positive men in relation to the stage of the disease]. / Wahrgenommene emotionale Unterstützung bei HIV-positiven Männern in Abhängigkeit vom Krankheitsstadium.

Perceived emotional support is considered important in buffering the adverse effects of life-threatening conditions, e.g. AIDS. The aim of the present study was to investigate (1) which aspects of perceived emotional support are associated with depression, anxiety and suicidality in patients with HIV-infection, and (2) whether perception of emotional support is influenced by the stage of disease. 40 male patients with HIV-infection, most of them homosexuals (no drug-addicts, no signs of neuropsychiatric impairment) were investigated. A Perceived Emotional Support Scale, Zung's Self-rating Depression Scale and Spielberger's State-Trait-Anxiety Inventory were administered. To assess suicidality, a clinical interview was carried out. Stage of disease was determined according to CDC-classification and CD4-cell count. The data indicate that (1) aspects of perceived emotional support concerning regulation of self-esteem in relation to a key figure are of greatest importance in predicting depression and state-anxiety and (2) emotional support is perceived significantly better in patients with low CD4-count, i.e. in those patients facing the greatest threat.

[Trauma of illness--crises in self concept regulation by cancer patients]. / Das Trauma der Erkrankung--Krisen der Selbstwertregulation bei Krebskranken.

Oncological diseases often represent a psychic trauma, which leads affected patients into a narcissistic crisis. Starting from the concept of narcissistic regulation system (Deneke, 1989), the origins of the destabilisation of the self are described, and parallels to persecution trauma will be drawn. The longing of the patients for symbiotic relationships are investigated in their double sense. On the one hand they serve the patient to stabilise his self, on the other hand they involve the danger of traumatisation within an object relation. The consequences for the process of mourning and integration will be discussed.

[Cortisone level and emotional support by key figures in patients with bronchial asthma]. / Kortisonbild und emotionale Unterstützung durch Schlüsselfiguren bei Patienten mit Asthma bronchiale.

In a subgroup of patients with bronchial asthma, irrational fears of cortisone medication can be observed beyond justified worries about side-effects. A cortisone image which involves overemphasizing the threatening aspects of cortisone, often underlies noncompliant illness behaviour. In the present study, cortisone image and subjectively experienced emotional support by a key figure was investigated in 62 patients, all of whom had participated in the Düsseldorf Asthma treatment and teaching programme (ATTP). The data show that patients having a supportive relationship with their key figures are less likely to experience threatening aspects of cortisone. The findings are discussed in light of psychoanalytic object relations theory.

Cortisone image and emotional support by key figures in patients with bronchial asthma. An empirical study.

In a subgroup of patients with bronchial asthma, irrational fears of steroid medication can be observed beyond justified worries about side-effects. A cortisone image which involves overemphasizing the threatening aspects of cortisone often underlies non-compliant illness behaviour. In the present study, cortisone image and the relationship with a key figure was investigated in 62 patients with bronchial asthma, all of whom had participated in a structured asthma treatment and teaching programme (ATTP). The data show that (1) perceiving cortisone as threatening predicts poor adherence to ATTP guidelines how to manage severe attacks, and (2) patients having a supportive relationship with their key figure are less likely to experience threatening aspects of cortisone.

[Negative cortisone attitude in patients with bronchial asthma]. / Negatives Kortisonbild bei Patienten mit Asthma bronchiale.

Patients with bronchial asthma often exhibit irrational fears of cortisone medication beyond justified worries about side-effects. A negative cortisone image, which means overemphasizing the damaging and threatening aspects of cortisone, often underlies non-compliant illness behaviour. In the present study, cortisone image was investigated in 54 patients with bronchial asthma before and after participation in the Düsseldorf Asthma treatment and teaching programme (ATTP) and one year later. By participating in ATTP, a significant reduction of the negative cortisone image and thus a more realistic view of cortisone could be achieved in most patients. This effect was also evident at the follow-up examination one year later. On the other hand, persistence of a negative cortisone image in a subgroup of patients turned out to be a potent predictor of later non-compliant illness behaviour. Psychological implications of a persistent negative cortisone image are discussed.

[Affective-cognitive coping with attacks and illness behavior in patients with bronchial asthma]. / Affektiv-kognitive Anfallsverarbeitung und Krankheitsverhalten bei Patienten mit Asthma bronchiale.

The purpose of this study was to investigate attack-related cognitive coping styles in 80 patients with bronchial asthma and to relate them to outcome parameters of illness behaviour. All patients had participated in a 5-day-lasting asthma treatment and teaching programme (ATTP). Outcome variables to be predicted were: The number of days in hospital due to asthma during the year following the training programme and the patients' adherence to the recommendations of the programme one year later. Independent predictor variables were: pre-training attack frequency, hospitalization due to asthma, medication intensity, pulmonary function, asthma symptom anxiety, trait anxiety and attack-related cognitive coping styles. Multiple regression analyses show the importance of a "minimizing/self-confident" coping style in predicting days in hospital, while a "diverting" style predicts best a poor management of attacks in patients on oral steroids.

[Anxiety and illness behavior in bronchial asthma]. / Angst und Krankheitsverhalten bei Asthma bronchiale.

In 82 patients attending a one-week asthma self-management education program, asthma symptom anxiety, personality trait anxiety, and attack-related coping styles were correlated with attack frequency, medication regimen and pulmonary function parameters. In 21 patients, asthma symptoms anxiety was shown to influence illness behaviour at follow-up one year later: in patients with severe asthma, greater symptom anxiety was associated with more suitable illness behaviour. Moreover, suitable illness behaviour appears to be related to cognitive coping styles that take into account the asthmatic's feeling of dependency in attacks without denying them.

[Borderline--a diagnostic entity?]. / Borderline--eine diagnostische Einheit?

In the last years, there has been considerable controversy as to whether the term "borderline" should be introduced into psychiatric diagnostic nomenclature to designate psychiatric disorders not classifiable as psychoses, neuroses or traditional forms of personality disorders. Whereas many psychiatrists, especially those who are psychodynamically oriented, have been using this term for a long time, the more phenomenologically oriented psychiatrists refuse to do so while pointing to its lack of clear-cut definitions and its confusing abundance of meanings. The definitions of the term "borderline" used in the various "borderline" -concepts are reviewed. Some authors (Knight, Kety et al.) consider "borderline schizophrenia" to be a subgroup of schizophrenic psychoses. Others (Klein, Stone) take "borderline" disorders as a heterogeneous group of psychiatric illness encompassing especially some atypical affective disorders. Thirdly the concepts of those authors who conceive "borderline" as a distinct diagnostic entity are reviewed: Kernberg's "Borderline personality organization", Grinker's "Borderline syndrome", Gunderson and Singer's "Borderline personality disorders", Spitzer and Endicott's "Borderline (unstable) personality disorder" and "Schizotypical personality". The "borderline" definitions of all concepts are examined as to whether they fulfil the requirements of a "useful" (according to Kendell) diagnostic category, i.e. whether they yield reliably defined diagnostic criteria, and whether they can be validated by genetic and biological studies, therapy response, and long-term studies. It is pointed out that attempts have been made to establish operationally defined diagnostic criteria for some of the "borderline" concepts, but that research aiming at their validation is still in an initial stage.