Transfer of manualized Short Term Psychodynamic Psychotherapy (STPP) for social anxiety disorder into clinical practice: results from a cluster-randomised controlled trial.

BACKGROUND: Despite growing evidence for manualized psychodynamic treatments, there is a lack of studies on their transfer to routine practice. This is the first study to examine the effects of an additional training in manualized Short Term Psychodynamic Psychotherapy (STPP) on the outcome in routine psychotherapy for social anxiety disorder (SAD). The study is an extension to a large RCT comparing STPP to Cognitive-Behavioral Therapy of SAD. METHODS: The manualized treatment was designed for a time limited approach with 25 individual sessions of STPP over 6 months. Private practitioners were randomized to training in manualized STPP (mSTPP) vs. treatment as usual without a specific training (tauSTPP). A total of 109 patients were enrolled (105 started treatment; 75 completed at least 20 treatment sessions). Assessments were conducted pre-treatment, after 8 and 15 weeks, after 25 treatment sessions, at the end of treatment, 6 and 12 months after termination of treatment. Remission as primary outcome was defined by the Liebowitz-Social-Anxiety-Scale (LSAS) score ≤30. Secondary outcomes were response (at least 31% reduction in LSAS), treatment duration and number of sessions, changes in social anxiety (LSAS, SPAI), depression (BDI), clinical global impression (CGI), and quality of life (EQ-5D). RESULTS: Remission rates of mSTPP (9%) resp. tauSTPP (16%) and also response rates of 33% resp. 28% were comparable between the two treatment approaches as well as treatment duration and number of sessions. Most of the within-group differences (baseline to 25 sessions) indicated moderate to large improvements in both treatments; within-group differences from baseline to 12 months follow-up (LSAS, SPAI, BDI, CGI) were large ranging from d = -0.605 to d = -2.937. Benefits of mSTPP were limited to single outcomes. CONCLUSIONS: Findings are discussed with regard to implementation and dissemination of empirically validated treatments in psychodynamic training and practice. SAD patients with a high comorbidity of personality disorders and a long treatment history may need longer treatments. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) DRKS00000570 , registered 03. March 2011.

Patterns of Childhood Abuse and Neglect in a Representative German Population Sample.

BACKGROUND: Different types of childhood maltreatment, like emotional abuse, emotional neglect, physical abuse, physical neglect and sexual abuse are interrelated because of their co-occurrence. Different patterns of childhood abuse and neglect are associated with the degree of severity of mental disorders in adulthood. The purpose of this study was (a) to identify different patterns of childhood maltreatment in a representative German community sample, (b) to replicate the patterns of childhood neglect and abuse recently found in a clinical German sample, (c) to examine whether participants reporting exposure to specific patterns of child maltreatment would report different levels of psychological distress, and (d) to compare the results of the typological approach and the results of a cumulative risk model based on our data set. METHODS: In a cross-sectional survey conducted in 2010, a representative random sample of 2504 German participants aged between 14 and 92 years completed the Childhood Trauma Questionnaire (CTQ). General anxiety and depression were assessed by standardized questionnaires (GAD-2, PHQ-2). Cluster analysis was conducted with the CTQ-subscales to identify different patterns of childhood maltreatment. RESULTS: Three different patterns of childhood abuse and neglect could be identified by cluster analysis. Cluster one showed low values on all CTQ-scales. Cluster two showed high values in emotional and physical neglect. Only cluster three showed high values in physical and sexual abuse. The three patterns of childhood maltreatment showed different degrees of depression (PHQ-2) and anxiety (GAD-2). Cluster one showed lowest levels of psychological distress, cluster three showed highest levels of mental distress. CONCLUSION: The results show that different types of childhood maltreatment are interrelated and can be grouped into specific patterns of childhood abuse and neglect, which are associated with differing severity of psychological distress in adulthood. The results correspond to those recently found in a German clinical sample and support a typological approach in the research of maltreatment. While cumulative risk models focus on the number of maltreatment types, the typological approach takes the number as well as the severity of the maltreatment types into account. Thus, specific patterns of maltreatment can be examined with regard to specific long-term psychological consequences.

Do Patient Characteristics Predict Outcome of Psychodynamic Psychotherapy for Social Anxiety Disorder?

OBJECTIVES: Little is known about patient characteristics as predictors for outcome in manualized short term psychodynamic psychotherapy (PDT). No study has addressed which patient variables predict outcome of PDT for social anxiety disorder. RESEARCH DESIGN AND METHODS: In the largest multicenter trial on psychotherapy of social anxiety (SA) to date comparing cognitive therapy, PDT and wait list condition N = 230 patients were assigned to receive PDT, of which N = 166 completed treatment. Treatment outcome was assessed based on diverse parameters such as endstate functioning, remission, response, and drop-out. The relationship between patient characteristics (demographic variables, mental co-morbidity, personality, interpersonal problems) and outcome was analysed using logistic and linear regressions. RESULTS: Pre-treatment SA predicted up to 39 percent of variance of outcome. Only few additional baseline characteristics predicted better treatment outcome (namely, lower comorbidity and interpersonal problems) with a limited proportion of incremental variance (5.5 to 10 percent), while, e.g., shame, self-esteem or harm avoidance did not. CONCLUSIONS: We argue that the central importance of pre-treatment symptom severity for predicting outcomes should advocate alternative treatment strategies (e.g. longer treatments, combination of psychotherapy and medication) in those who are most disturbed. Given the relatively small amount of variance explained by the other patient characteristics, process variables and patient-therapist interaction should additionally be taken into account in future research. TRIAL REGISTRATION: Controlled-trials.com/ISRCTN53517394.

Patterns of childhood abuse and neglect as predictors of treatment outcome in inpatient psychotherapy: a typological approach.

BACKGROUND: Childhood maltreatment is associated with the development and maintenance of mental disorders. The purpose of this naturalistic study was (a) to identify different patterns of childhood maltreatment, (b) to examine how these patterns are linked to the severity of mental disorders and (c) whether they are predictive of treatment outcome. METHODS: 742 adult patients of a university hospital for psychotherapy and psychosomatics were assessed at intake and discharge by standardized questionnaires assessing depression (Beck Depression Inventory, BDI) and general mental distress (Symptom Check List-90-R, SCL-90-R). Traumatic childhood experience (using the Childhood Trauma Questionnaire, CTQ) and ICD-10 diagnoses were assessed at intake. RESULTS: The patients could be allocated to three different patterns of early childhood trauma experience: mild traumatization, multiple traumatization without sexual abuse and multiple traumatization with sexual abuse. The three patterns showed highly significant differences in BDI, General Severity Index (GSI) and in the number of comorbidity at intake. For both BDI and GSI a general decrease in depression and general mental distress from intake to discharge could be shown. The three patterns differed in BDI and GSI at intake and discharge, indicating lowest values for mild traumatization and highest values for multiple traumatization with sexual abuse. Patients with multiple traumatization with sexual abuse showed the least favourable outcome. CONCLUSION: The results provide evidence that the severity of childhood traumatization is linked to the severity of mental disorders and also to the treatment outcome in inpatient psychotherapy. In the study, three different patterns of childhood traumatization (mild traumatization, multiple traumatization without sexual abuse, multiple traumatization with sexual abuse) showed differences in the severity of mental disorder and in the course of treatment within the same therapy setting.

[The self-concept of patients with Social Anxiety Disorder: manifestation and change through psychotherapy ]. / Das Selbstkonzept von Patienten mit sozialer Angststörung:Ausprägung und Veränderung durch Psychotherapie.

OBJECTIVES: To determine whether the self-concept of patients with Social Anxiety Disorder deviates significantly from that found in the normative sample, to what extent it changes through psychotherapeutic short-term interventions and how such changes in self-concept relate to changes in the level of social anxiety. METHODS: The self-concept of N = 86 patients with Social Anxiety Disorder was assessed using the Frankfurter-Selbstkonzeptskalen (FSKN; Deusinger 1986). Patients were treated with a manualized cognitive (CT) or psychodynamic (PDT) short-term intervention. The level of social anxiety was assessed pre-therapy and post-therapy via the Liebowitz Social Anxiety Scale (Stangier & Heidenreich 2004) and the Social Phobia and Anxiety Scale (Fydrich 2002). RESULTS: Patients with Social Anxiety Disorder exhibited a significantly more negative self-concept than the norm (all ps0.001). Their self-concept improved significantly in all facets following psychotherapeutic short-term intervention (all ps0.01). No significant difference was found between cognitive and psychodynamic therapy. Improvements in self-concept correlate with reductions in social anxiety. CONCLUSIONS: The results confirm the relevance of self-concept in Social Anxiety Disorder and its susceptibility to short-term-therapy.

[The Dresden Body Image Inventory (DKB-35): validity in a clinical sample]. / Der Dresdner Körperbildfragebogen (DKB-35): Validierung auf der Basis einer klinischen Stichprobe.

The Dresden Body Image Questionnaire (DKB-35) measures 5 dimensions of body image: vitality, self-acceptance, self-aggrandisement, physical closeness, and sexual fulfilment. This article presents data on the reliability and validity of the DKB-35. The sample consisted of 560 pa-tients with psychosomatic disorders. To analyse the factor structure, a confirmatory factor analysis was conducted. To examine the convergent validity, correlations between the DKB-35 scales and the Frankfurt Body Concept Scales (FKKS, [1]), the Narcissism Personality Inventory (NPI, [2]) and the self-esteem subscale of the Frankfurt Self-Concept Scales (FSKN, [3]) were computed. The 5 scales of the DKB-35 showed excellent reliability. Between the 5 DKB-35 scales and the corresponding scales of the FKKS, the NPI, and the FSKN, moderate correlations were found. The results confirm the reliability and validity of the DKB-35. Possible fields of applications and further developments are discussed.

Reliability, validity and responsiveness of the EQ-5D in assessing and valuing health status in patients with social phobia.

OBJECTIVE: The aim of the study was to analyse the psychometric properties of the EQ-5D in patients with social phobia. METHODS: We used a sample of 445 patients with social phobia with five measurement points over a 30 month period. The discriminative ability of the EQ-5D was analysed by comparing the patients' responses with the general population and between different disease severity levels. For test-retest reliability we assessed the level of agreement in patients' responses over time, when there was no change in the Liebowitz Social Anxiety Scale (LSAS). Construct validity was analysed by identifying correlations of the EQ-5D with more specific instruments. For responsiveness we compared the means of EQ VAS/EQ-5D index anchored on improved (deteriorated) health status and computed effect sizes as well as a receiver operating characteristic (ROC) curve. RESULTS: Compared to the general population, patients with social phobia reported more problems in the dimensions "usual activities", "pain/discomfort", and "anxiety/depression" and less problems in "mobility" and "self-care". The EQ-5D was able to distinguish between different disease severity levels. The test-retest reliability was moderate (intraclass correlation coefficient > 0.6). Correlations between the EQ-5D and other instruments were mostly small except for correlations with Beck Depression Inventory. The EQ-5D index seemed to be more responsive than the EQ VAS, but with only medium effect sizes (0.5 < effect size < 0.8) in the British EQ-5D index and only significant in patients with improved health status. The ROC analysis revealed no significant results. CONCLUSIONS: The EQ-5D was moderately reliable and responsive in patients with improved health status. Construct validity was limited. TRIAL REGISTRATION: Current controlled trials ISRCTN53517394.

[Path to growth or open wound? The quest for meaning and coping with trauma in patients with posttraumatic stress disorder]. / Wachstum oder Wunde? Sinnfindung und Traumabewaltigung bei Patienten mit posttraumatischer Belastungsstorung.

OBJECTIVES: This study investigated the relationship between meaning in life and coping with trauma, and correlations between posttraumatic growth and mental health. METHODS: The content and structure of the personal meaning systems of 62 patients suffering from posttraumatic stress disorder (PTSD) were assessed qualitatively. In addition, the participants completed questionnaires measuring meaning in life (LRI-r-d; MLQ), PTSD symptoms (IES-R), depression (BDI-II), health-related quality of life (EQ-5D), satisfaction with life (SWLS) and posttraumatic growth (PPR-r). RESULTS: A stronger sense of meaning in life and a more elaborately structured personal meaning system correlated with a better mental health and more posttraumatic growth. Posttraumatic growth was also associated with mental health. CONCLUSIONS: Patients with coherent personal meaning systems are more successful in coping with traumatic life events. They also reported more posttraumatic growth.

Transfer of manualized Short Term Psychodynamic Psychotherapy (STPP) for social phobia into clinical practice: study protocol for a cluster-randomised controlled trial.

BACKGROUND: Psychodynamic psychotherapy is frequently applied in the treatment of social phobia. Nevertheless, there has been a lack of studies on the transfer of manualized treatments to routine psychodynamic practice. Our study is the first one to examine the effects of additional training in a manualized Short Term Psychodynamic Psychotherapy (STPP) procedure on outcome in routine psychotherapy for social phobia. This study is an extension to a large multi-site RCT (N = 512) comparing the efficacy of STPP to Cognitive-Behavioral Therapy (CBT) of Social Phobia. METHODS/DESIGN: The manualized treatment is designed for a time limited approach with 25 individual sessions of STPP over 6 months. Private practitioners will be randomized to training in manualized STPP vs. treatment as usual without a specific training (control condition). We plan to enrol a total of 105 patients (84 completers). Assessments will be conducted before treatment starts, after 8 and 15 weeks, after 25 treatment sessions, at the end of treatment, 6 months and 12 months after termination of treatment. The primary outcome measure is the Liebowitz Social Anxiety Scale. Remission from social phobia is defined scoring with 30 or less points on this scale. DISCUSSION: We will investigate how the treatment can be transferred from a controlled trial into the less structured setting of routine clinical care. This question represents Phase IV of psychotherapy research. It combines the benefits of randomized controlled and naturalistic research. The study is genuinely designed to promote faster and more widespread dissemination of effective interventions. It will answer the questions whether manualized STPP can be implemented into routine outpatient care, whether the new methods improve treatment courses and outcomes and whether treatment effects reached in routine psychotherapeutic treatments are comparable to those of the controlled, strictly manualized treatment of the main study. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) DRKS00000570.

[Meaning in life and mental health: personal meaning systems of psychotherapists and psychotherapy patients]. / Individuelle Sinnkonstruktionen und seelische Gesundheit: Ein Vergleich von Psychotherapeuten und Psychotherapiepatienten.

OBJECTIVES: This study investigated differences in the personal meaning systems of psychotherapists and psychotherapy patients as well as correlations between meaning in life and mental health. METHODS: We qualitatively assessed the content and structure of the personal meaning systems of 41 psychotherapists and 77 psychotherapy patients. In addition, the participants completed questionnaires measuring meaning in life (LRI-r-d), sense of coherence (SOC-9L), self-esteem (RSES), satisfaction with life (SWLS), self-efficacy (SWK), and depression (BDI). RESULTS: The personal meaning systems of psychotherapists were more complex and coherent compared to psychotherapy patients. In the group of psychotherapy patients, a more elaborate structure of the personal meaning system correlated with the subjective sense of meaning. We were able to confirm correlations between meaning in life and mental health for most of the instances. CONCLUSIONS: Psychotherapists had more elaborate and coherent meaning systems than psychotherapy patients. Especially for psychotherapy patients elaborate and coherent meaning systems turned out to be important for mental health.

[SOPHO-NET - a research network on psychotherapy for social phobia]. / SOPHO-NET - Forschungsverbund zur Psychotherapie der Sozialen Phobie.

This paper presents the Social Phobia Psychotherapy Research Network (SOPHO-NET). SOPHO-NET is among the five research networks on psychotherapy funded by "Bundesministerium für Bildung und Forschung". The research program encompasses a coordinated group of studies of social phobia. In the central project (Study A), a multi-center randomized controlled trial, refined models of manualized cognitive-behavioral therapy (CBT) and manualized short-term psychodynamic psychotherapy (STPP) are compared in the treatment of social phobia. A sample of n=512 outpatients will be randomized to either CBT, STPP or wait list. For quality assurance and treatment integrity, a specific project has been established (Project Q). Study A is complemented by four interrelated projects focusing on attachment style (Study B1), cost-effectiveness (Study B2), polymorphisms in the serotonin transporter gene (Study C1) and on structural and functional deviations of hippocampus and amygdala (Study C2). Thus, the SOPHO-NET program allows for a highly interdisciplinary research of psychotherapy in social phobia.

[Social phobia - the blind spot: infrequently diagnosed, highly complex, and a predictor for unfavourable therapy outcomes?]. / Die Sozialphobie als blinder Fleck: Klinisch unterdiagnostiziert, hoher Schweregrad und ungünstiger Verlauf?

OBJECTIVES: The objectives of the study were to examine (1) whether patients with social phobia report higher symptom load at the beginning and at the end of treatment and 1 year after treatment; and (2) whether the presence of social phobia is a factor that influences the course of treatment. METHODS: 613 patients from a university hospital for psychosomatic medicine filled out questionnaires assessing symptom load (SCL 90-R, KOPS), physical symptoms, psychological and social impairment (KOPS), and depression (BDI). Social phobia was diagnosed based on a standardized diagnostic interview. RESULTS: 25%of the patients suffered from social phobia. They had significantly more concurrent mental disorders (4.18 vs. 2.41) and a higher symptom load than patients suffering from other mental disorders. They reported more physical complaints and depression and felt more impaired psychologically as well as socially. Even though both groups of patients profited from the treatment, compared to other patients, social phobia patients still had higher symptom load, impairment, and depression scores at the end of treatment and even at the follow-up 1 year after treatment. DISCUSSION: Social phobia is a severe disorder in which concurrent disorders frequently cause a high level of distress and impairment. These patients may benefit more from longer courses of treatment and/or disorder-specific treatment elements. Diagnostic and therapy approaches tailored to the generalized type of social anxiety are discussed.