["Medical expert assessment in psychosomatic and psychotherapy medicine--social justice questions" guideline]. / Die Leitlinie "Arztliche Begutachtung in der Psychosomatik und Psychotherapeutischen Medizin--Sozialrechtsfragen".

Guidelines on the medico-legal assessment of patients in the field of psychosomatics and psychotherapy prepared by the "German Society für Psychotherapeutic Medicine" is presented. These guidelines are based on published evidence and on expert consensus among psychotherapists, psychiatrists, judges and social security experts. They give a systematic overview on aspects relevant to the assessment of persons suffering from somatoform disorders, psychological factors in organic diseases and posttraumatic, anxiety, depressive, personality and eating disorders. These aspects are disability, severity, assessment of malingering, of disability and causality.

Effects of anxiety and depression on 5-year mortality in 5,057 patients referred for exercise testing.

OBJECTIVE: Beyond acute myocardial infarction, little is known about the effect of depression, and especially anxiety, on prognosis in cardiology patients. The present study aims to examine the effect of anxiety and depression on 5-year mortality in patients referred for exercise testing. METHODS: A total of 5,057 patients referred for routine exercise testing completed the Hospital Anxiety and Depression Scale (HADS) before undergoing the exercise test. Survival data were obtained from 5,017 (99.2%) of those patients after 5.7 +/- 0.8 years. HADS scores and cardiological baseline data were used to predict mortality. RESULTS: In univariate analyses, HADS depression was not a significant predictor; high anxiety was associated with improved survival. Logistic regression revealed nine independent objective predictors from which we computed a composite somatic risk index. When controlling for this physical risk index, anxiety and depression had independent, opposite effects; that is, anxiety was associated with a lower mortality and depression with a higher mortality. CONCLUSION: Anxiety and depression scores have different predictive effects on mortality in patients referred for exercise testing. These effects are independent of a highly effective physical risk index, suggesting that psychological screening of cardiology patients might improve risk stratification.

The stress-reaction process and the adaptive modification and reorganization of neuronal networks.

On the basis of a comprehensive definition of the stress-reaction process (SRP), the neurobiological and psychological consequences of this process, which are elicited by either controllable or uncontrollable stress, are described. We conclude that controllable stress triggers the stabilization and facilitation of neuronal networks involved in the generation of appropriate patterns of appraisal and coping, whereas uncontrollable stress favors the extinction of inappropriate patterns and the reorganization of neuronal connections underlying certain inappropriate behaviors. Both controllable and uncontrollable stress-reaction processes are therefore inherent challenges to the development and essential prerequisites of the adaptation of an individual's behavior to the demands of the ever-changing external world. The overabundance, as well as the lack, of either kind of SRP may lead to different psychodevelopmental failures and psychiatric disturbances.

[Practicability and clinical relevance of routine psychological screening of patients in general internal medicine units]. / Praktikabilität und klinische Relevanz eines routinemässigen psychologischen Screenings von Patienten internistischer Allgemeinstationen.

In medical patients, anxiety and depression are frequent but often undiagnosed problems. The aim of the present study was to test and evaluate a psychological screening in medical in-patients. Using the Hospital Anxiety and Depression Scale (HADS), we screened 454 out of 743 consecutive medical in-patients. Physical symptoms and diagnoses were also recorded. Elevated scores for anxiety and depression were found in 20.8% and 23.9%, respectively. They were relatively independent of physical findings but correlated with subjective symptoms. In a subgroup who completed the questionnaire twice, HADS scores remained constant until discharge. Cardiological patients with abnormal baseline anxiety stayed significantly longer in hospital than those who were not anxious. Over a one-year follow-up, initially depressed patients had a risk of in-hospital death that was 2.5 times higher. This effect remained stable after controlling for baseline diagnoses and indices of severity of the disease.

Diagnostic groups and depressed mood as predictors of 22-month mortality in medical inpatients.

OBJECTIVE: While depression has been found to predict mortality in acute myocardial infarction, results from many other groups of medical patients are inconclusive. It is, therefore, unclear whether depression also predicts mortality in the typical mixed patient populations treated on medical hospital wards and whether an increased risk can be identified by means of patients' self ratings of depression. METHOD: The Hospital Anxiety and Depression scale was used as a routine screening tool in consecutive admissions to the general medical wards of a university hospital. The official survival data were obtained 22 months later. For all 454 patients who completed the screening questionnaire, complete survival data were available. RESULTS: High depression scores significantly predicted mortality in univariate comparisons (odds ratio 3.2; 95% CI 1.9-5.5) and in multivariate Cox regression analyses controlling for demographic and medical baseline variables (multivariate odds ratio 1.9; 95% CI 1.2-3.1; p < .01). Other significant predictors in the multivariate model were having a principal diagnosis of hematological disease or cancer, and older age. Disability, as assessed by nurses' ratings, and gender were not related to mortality. Subgroup analyses showed that the effect of depression scores was greatest in cardiopulmonary patients, but there was also a uniform trend toward higher mortality in depressed patients with other diagnoses. CONCLUSION: Depressed mood is an independent risk factor for all-cause mortality in medical inpatients. Identifying patients at risk does not require formal psychiatric diagnoses, but can be achieved by means of a short, routinely administered self-rating questionnaire.

[Psychiatric disorder or coronary heart disease? Psychological test data and ICD-10 diagnoses in patients undergoing coronary angiography]. / Psychische Störung oder koronare Herzkrankheit? Testpsychologische Befunde und Diagnosen nach ICD-10 bei Patienten vor Koronarangiographie.

Cardiac complaints can indicate the presence of coronary heart disease or psychological disorders. In this prospective study we examined forty patients undergoing coronary angiography. As expected psychological disorders diagnosed according to ICD-10, especially anxiety disorders, were more frequent in patients with normal coronary arteries (60% vs. 25%; p = 0.025). Anxiety symptoms predicted coronary status in uni- and multivariate models. Especially the HADS-D proved useful for this purpose. We propose a graded psychosomatic approach consisting of an anxiety screening test and a standardised interview. This is practicable under medical routine conditions, can facilitate the initiation of proper treatment, and reduce individual distress as well as economical costs by preventing chronification.

[Psychological stress and neuronal plasticity. An expanded model of the stress reaction process as the basis for understand central nervous system adaptation processes]. / Psychische Belastungen und neuronale Plastizität. Ein erweitertes Modell des Stress-Reaktions-Prozesses als Grundlage für das Verständnis zentralnervöser Anpassungsprozesse.

A short survey on results and theories in psychosomatic and neurobiologic stress research is presented. Based on a comprehensive definition of the stress-reaction process, the biological and psychological consequences are described which are elicited by either controllable or uncontrollable stress. We conclude that controllable stress triggers the stabilization and facilitation of neuronal networks involved in the generation of appropriate patterns of appraisal and coping, whereas uncontrollable stress favours the extinction of inappropriate patterns and the reorganisation of neuronal connections underlying certain inappropriate behaviors. Both, controllable an uncontrollable stress-reaction-processes are therefore essential prerequisites of, and inherent challenges to, the development and adaptation of an individual in an ever changing external world but may also lead to psychodevelopmental failures and psychosomatic diseases.

[Psychodynamic and coping processes in patients with physical illnesses]. / Psychodynamische und Coping-Prozesse bei Patienten mit körperlichen Erkrankungen.

Psychodynamic and coping processes in patients with somatic diseases are described on the background of clinical case examples. Here the connection between coping and defending is discussed whereby the special characteristics of somatic disease are taken into consideration. The secondary function, which a somatic disease can gain in an intrapsychic balance system which was already in a weak or dysregulated state is also discussed. Finally the role of social support in coping with somatic diseases is described. From this different therapeutic consequences for patients with somatic diseases are derived.

[Development of a model of operational psychodynamic diagnosis]. / Entwicklung eines Modells der operationalen psychodynamischen Diagnostik (OPD).

Since 1992 a working group called "Operationalized Psychodynamic diagnoses" conceptualized a model of operationalized psychodynamic diagnosis in Germany. This model includes the most important diagnostic dimensions from psychodynamic view which are: Axis I: Experience with illness and treatment preconditions. Axis II: Habituated relationships of the patient, Axis III: Intrapsychic conflicts of the patient, Axis IV: the structure of personality development of the patient, Axis V: The level of symptoms or syndromes. This axis is adapted to ICD-10. The development of these axis is done in special subgroups during 1992 and 1994 and in first empirical studies the reliability and other test-related dimensions of the model were proved. In this paper the essentials of the diagnostic model are shown and further developments are discussed.

[Structure and structural disorder]. / Struktur und strukturelle Störung.

One of the central tasks of psychodynamic diagnosis, next to determining intrapsychic conflicts, central relational patterns, and subjective forms of experiencing is assessing the psychic structure or the structural disorder. This article develops the structure term from object relationship theoretical, ego-psychological, and self-psychological concepts of psychoanalysis. This "Structure of the self in the relationship to others" thus obtained is described with six structural criteria (self-perception, self-control, defence, object perception, communication, attachment). In order to be able to distinguish the extent and the quality of structural disorders four structure levels of integration based on psychoanalytic experience in the out-patient and the in-patient setting are differentiated. A basis for an operationalization is then made; it is made in the system OPD (Operationalized Psychodynamic Diagnostics). First studies regarding practicalibility and reliability are promising.

[Inclusion of the family in inpatient psychotherapy]. / Die Einbeziehung der Familie in die stationäre Psychotherapie.

In many cases today successful psychotherapy does not seem to be conceivable without inclusion of the patient's family in the treatment. After a review of the literature the families' perception of the in-patient psychotherapy of one of their members, their transference-patterns towards the ward team, the typical counter-transference responses of the team to the family, indications and counter-indications to family therapy sessions as well as role-conflicts of the therapists are described.

[Prognostic criteria of behavioral pain treatment in groups of patients with rheumatoid arthritis]. / Prognosekriterien einer verhaltenstherapeutischen Schmerzbehandlung in Gruppen bei rheumatoider Arthritis.

The effectiveness of behavior therapy programs for the treatment of pain of various origin can be regarded as proven. However, there is a general lack of information about prognostic and indication criteria. These questions were investigated by means of a controlled, cognitive-behavioral orientated clinical study on 79 patients with the certified diagnosis of rheumatoid arthritis. While our study was also able to prove short-term effectiveness for all patients, some exhibited regressive effects during the six-month follow-up period. A lack of regular practice and the presence of neurotic disorders were responsible for this instability. Patients who already have neurotic disorders prior to arthritis should accordingly be given more intensive psychotherapy. In this exceeding a standard-program psychotherapy can be dealt with the disease-related and other psychosocial problems and conflicts on an integrative basis.

[Evaluative psychotherapy research: clinical relevance of psychotherapy catamnesis]. / Evaluative Psychotherapieforschung: Klinische Bedeutung von Psychotherapie-Katamnesen.

In this article we will depict the relevance of follow-up studies for evaluative psychotherapy research. Follow-up studies distinguish themselves from pure result studies in that they are clinically more meaningful as they examine the stability of psychotherapy results over a longer period of therapy-free time. The special methodical problems of follow-up studies are discussed and the minimal essentials for the research design of such studies are called for.

["The most ill go into psychoanalytic treatment"? Critical comments on an article in Report Psychologie]. / "Die Kränkesten gehen in eine psychoanalytische Behandlung"? Kritische Anmerkungen zu einem Artikel in Report Psychologie.

Thomas and Schmitz claim that they "deliver a proof for the effectiveness of humanistic methods" (p. 25) with their study. However, they did not or were not able to verify their claim due to several reasons: The authors did not say if and if so to what extent the treatments carried out within the framework of the TK-regulation were treatments using humanistic methods. The validity of the only criterium used by the authors, the average duration of the inability to work, must be questioned. The inferential statistical treatment of the data is insufficient; a non-parametrical evaluation is necessary. Especially missing are personal details concerning the treatment groups (age, sex, occupation, method, duration and frequency of therapy), which are indispensable for a differentiated interpretation. In addition there are numerous formal faults (wrong quotations, mistakes in tables, unclear terms etc.). In view of this criticism we come to the conclusion that the results are to a large degree worthless, at least until several of our objections have been refuted by further information and adequate inferential statistical methods. This study is especially unsuitable to prove a however defined "effectiveness of out-patient psychotherapies", therefore also not suitable to prove the effectiveness of those treatments conducted within the framework of the TK-regulation and especially not suitable to prove the superiority of humanistic methods in comparison with psychoanalytic methods and behavioural therapy.

[The psychosomatic aspects and results of rheumatoid arthritis and fibromyalgia]. / Psychosomatische Aspekte und Ergebnisse zur Rheumatischen Arthritis und Fibromyalgie.

The results of an empirical study on psychosomatic aspects of rheumatoid arthritis (RA) and fibromyalgia syndrome (FMS) are presented and discussed in the setting of previous concepts about rheumatoid arthritis. The patients investigated in the two disease groups represent an unselected population with regard to psychological abnormalities (from two internistic rheumatism outpatient clinics); the results can thus be considered to be representative and permit the following conclusions to be drawn: RA is not a psychosomatic disease in the strict sense; however, psychological factors must be adjudged to have a disease-modifying influence. FMS may be classified within the group of psychosomatic diseases, although it should be regarded as the final stage of a wide variety of different processes within the biological, psychological and social sphere.

[Coping with depressive disorders]. / Krankheitsbewältigung bei depressiven Erkrankungen.

Coping behavior was assessed in 40 depressed patients during their hospitalization and 2 months later. Patients completed an antidepressive activity questionnaire and were interviewed. External assessment and patient self-assessment showed significant differences between patients with monopolar or bipolar depressive disorders and those with neurotic/reactive disorders. Patients treated with antidepressants reported more frequent and effective coping behaviors. There is a fundamental difficulty in distinguishing differentiate between symptoms of depression and certain coping behaviors (eg withdrawal). Only a longitudinal analysis of individual cases could help us to differentiate.