What Kind of Patients Receive Inpatient and Day-Hospital Treatment in Departments of Psychosomatic Medicine and Psychotherapy in Germany?

INTRODUCTION: Germany is one of the few countries with a medical specialty of psychosomatic medicine and psychotherapy and many treatment resources of this kind. OBJECTIVE: This observational study describes the psychosomatic treatment programs as well as a large sample of day-hospital and inpatients in great detail using structured diagnostic interviews. METHODS: Mental disorders were diagnosed according to ICD-10 and DSM-IV by means of Mini-DIPS and SCID-II. In addition to the case records, a modified version of the CSSRI was employed to collect demographic data and service use. The PHQ-D was used to assess depression, anxiety, and somatization. RESULTS: 2,094 patients from 19 departments participated in the study after giving informed consent. The sample consisted of a high proportion of "complex patients" with high comorbidity of mental and somatic diseases, severe psychopathology, and considerable social and occupational dysfunction including more than 50 days of sick leave per year in half of the sample. The most frequent diagnoses were depression, somatoform and anxiety disorders, eating disorders, personality disorders, and somato-psychic conditions. CONCLUSIONS: Inpatient and day-hospital treatment in German university departments of psychosomatic medicine and psychotherapy is an intensive multimodal treatment for complex patients with high comorbidity and social as well as occupational dysfunction.

Mentalization-enhancing therapeutic interventions in the psychotherapy of anorexia nervosa: An analysis of use and influence on patients' mentalizing capacity.

OBJECTIVE: Improvement in patients' mentalizing capacities is considered a possible mechanism of change in psychotherapy. This improvement might take place via mentalization-enhancing interventions (MEIs) performed by psychotherapists. The study aimed to explore the use of MEIs in two evidence-based psychotherapeutic treatments for patients with anorexia nervosa (enhanced cognitive-behavior therapy, focal psychodynamic therapy) and their association with the patients' capacity to mentalize in sessions ("in-session reflective functioning" / in-session RF). Additionally, it was explored, if the amount of MEIs used could either predict change in in-session RF or outcome (end of treatment, one year follow-up). METHOD: 84 audiotapes from psychotherapy sessions of 28 patients of the ANTOP-study (three sessions per patient) were transcribed and rated with both the MEI Rating Scale and the In-Session RF Scale by trained raters. RESULTS: MEIs were applied in both treatments. A moderate correlation between the amount of MEIs and patients' in-session RF as well as its change over the course of treatment was found, but no relation to change in BMI or eating disorder symptoms. CONCLUSION: A greater use of MEIs was related to patients' in-session-mentalizing. However, there seems to be no simple relation between RF as shown in sessions and symptom change.

Mental distress and need for psychosocial support in prostate cancer patients: An observational cross-sectional study.

OBJECTIVE: Prostate cancer is the most common cancer in German men and associated with various physical and psychosocial problems. This study investigated the association between mental distress and the subjective need for psychosocial support comparing subgroups of patients with different treatments and disease stages. METHOD: We performed an observational, cross-sectional study including patients with four medical conditions: Active Surveillance, radical prostatectomy, biochemical relapse, metastasized disease. Mental distress (NCCN Distress-Thermometer), symptoms of depression and anxiety (PHQ-9, GAD-7), psychosocial needs and coping resources (self-designed questionnaire) were assessed. RESULTS: N = 130 patients were included. 33.3% showed distress, 16.5% symptoms of moderate depression and 13% symptoms of moderate anxiety. We found no significant differences between the four groups. An association was present between distress and wish for psychosocial support (χ2 = 4.3; p < 0.05; ϕ = 0.19). Almost 90% lived with a partner, which represents a resource. CONCLUSIONS: Prostate cancer patients showed low levels of mental distress, depression and anxiety with no difference in terms of disease stage and treatment modality. Therefore, careful psychosocial screening of all patients is essential to identify those in need for support. Distressed patients express a need for psychosocial support more often. Interpersonal relationships, most often wives and children, represent important coping resources.

Implementation of mentalization-based treatment in a day hospital program for eating disorders-A pilot study.

OBJECTIVE: Aim of the pilot study was to evaluate the effectiveness of a day hospital program for eating disorders (EDs) after implementation of mentalization-based treatment (MBT), including a comparison to a historical matched control group. METHOD: All consecutively admitted patients with an ED were included in a prospective, observational study over a period of 2 years. Main outcome criteria were eating and overall psychopathology. Furthermore, changes in the capacity to mentalize (reflective functioning [RF]), difficulties with affect regulation and interpersonal problems were assessed at admission, discharge and a three months follow-up. RESULTS: Thirty-eight out of fourty patients could be included. The program led to significant reductions in eating and general pathology. There was significant improvement in RF, difficulties in emotion regulation and interpersonal functioning. However, there was no advantage in comparison to a matched control group (main outcomes). ED symptoms showed a slight renewed increase after discharge, while body mass index further increased. RF change was predictive of change in overall psychopathology, but not ED symptoms. Drop-out rate was 13.2%. CONCLUSION: The program showed no advantage in comparison to a historical control group concerning a reduction in eating and overall psychopathology. However, it was associated with low drop-out rates, and changes which MBT targets: An increase in RF and a reduction of interpersonal problems as well as difficulties in emotion regulation.

The personal self of psychotherapists: Dimensions, correlates, and relations with clients.

OBJECTIVE: The personal self of psychotherapists, that is, experiences of self in close personal relationships and its association with therapists' individual and professional attributes is explored. The study aimed to: (a) describe therapists' self-ratings on specific self-attributes; (b) determine their dimensionality; (c) explore demographic, psychological, and professional correlates; and (d) assess the convergence with professional self. METHOD: Data from the Development of Psychotherapists Common Core Questionnaire were available for > 10,000 psychotherapists of various professions, theoretical orientations, career levels, and nations. RESULTS: Most psychotherapists described themselves in close relationships in affirming terms (e.g., warm/friendly), although a substantial minority also described themselves in negative terms. Factor analyses yielded four dimensions: Genial/Caring, Forceful/Exacting, Reclusive/Remote, and Ardent/Expressive. Being Genial/Caring was associated with life satisfaction. Among professional attributes, personal self-experiences, and parallel dimensions of relationship with clients correlated strongly. CONCLUSIONS: Analyses of > 10,000 psychotherapists revealed meaningful variations in personal self relevant to personal and professional life.

[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.

Neurobiological signature of intimacy in anorexia nervosa.

BACKGROUND: Intimacy and psychosexual development represent core problems of anorexia nervosa (AN). Experiential and neurobiological evidence however is scarce. MATERIAL AND METHODS: Thirty-one female AN patients were compared with 35 non-patients (NP) and 22 recovered participants (REC) by using functional magnetic resonance imaging. Participants viewed pictures of couples in intimate relationships and control stimuli. RESULTS: AN patients experienced intimate stimuli with lower valence and dominance. AN showed decreased activation of parietal cortices. NP decreased the prefrontal cortex response, which AN patients did not. REC participants did not differ from NP on a behavioural level, though with regard to the neural signature. DISCUSSION: Parietal cortices are related to processing of erotic themes, which seems to be deficient in AN. Dysfunction of prefrontal cortices likely mirrors dysfunctional control in AN. The neural signature does not seem to be state-related considering results of REC.

Reasons for non-response and recommendations for optimal outpatient treatment of bulimia nervosa: A survey on German expert therapists' views.

Objectives: Remission rates after treatment for bulimia nervosa can be considered insufficient. The study aimed to explore the perspective of expert psychotherapists on possible reasons for non-response and recommendations for an optimized treatment. Methods: Experts filled in a questionnaire that comprised questions about possible reasons for low remission rates as well as ratings of interventions suggested for different treatment phases and subgroups of patients. Results: 56 experienced therapists could be included in the survey. Ambivalence of patients, insufficient training of therapists and heterogeneity of the patient group were most often rated as possible reasons for insufficient outcomes. For optimized treatment, therapists recommended a combination of cognitive-behavioral and psychodynamic techniques, depending on treatment phase and patient characteristics. Conclusions: Further research should examine, if a more specific training of therapists, a more integrative approach and flexible adaptations of interventions to patients' characteristics are effective strategies to improve outcome.

[Psychotherapy training in Austria: Baseline and socio-demographic background data from a SPRISTAD (Society of Psychotherapy Research Interest Section on Therapist Training and Development)-Pilotstudy]. / Psychotherapie-Berufsausbildung in Österreich: Basis- und soziodemographische Hintergrunddaten aus einer SPRISTAD-Pilotstudie (Society of Psychotherapy Research Interest Section on Therapist Training and Development).

Objectives: Description of the qualifications of psychotherapy-training candidates in Austria at the beginning of their training. Methods: Psychotherapists in training in Austria were interviewed at the beginning of their training concerning their socio-demographic background and prior education. These background data were collected using the Trainee Background Information Form (TBIF), which was designed by the Society for Psychotherapy Research Interest Section on Therapist Training and Development (SPRISTAD). Results: The group of 197 psychotherapy trainees from Austria consists largely of women, of persons with high school education and with a satisfactory, financially secure life situation. One-third of them show a "second career" pattern, which is in line with the predominantly part-time training programs in Austria. A high percentage of the candidates have previous professional experience in the psychosocial field. Conclusions: As this is a pilot study, results can be seen as a starting point for further research in psychotherapy training and competence development. In discussing the findings, both national conditions and opportunities for future interdisciplinary research are considered.

Recovery of cortical volume and thickness after remission from acute anorexia nervosa.

OBJECTIVE: Reduced grey (GM) and white matter (WM) volumes and increased cerebrospinal fluid (CSF) have been frequently reported in anorexia nervosa (AN), but studies focusing on cortical thickness (CT) are scarce and findings inconsistent. We conducted the first study in AN that analyzed both parameters in the same study to gain novel and comprehensive insight. METHOD: Voxel-based morphometry (VBM) analysis was performed on T1-weighted magnetic resonance images from 34 predominantly adult women with acute AN, 24 REC participants, and 41 healthy controls (HC). Global brain segment volumes (GM, WM, and CSF), regional GM volume, and cortical thickness measures were obtained from the same study sample. We further focused on recovery by including a REC group. RESULTS: The GM and WM volumes were decreased, and correspondingly, the CSF volume increased in the AN in comparison to the HC and REC groups. No significant volume differences between the REC and HC groups could be observed. AN patients showed reduced regional GM volumes in the right hippocampus and the left middle and right inferior frontal gyrus. Cortical thinning occurred in the AN group, which was particularly robust in fronto-parietal areas. The REC and HC groups failed to show any regional GM or cortical thickness differences. DISCUSSION: AN is accompanied by severe loss of brain volume and cortical thickness as assessed by complementary investigation tools. However, these changes seem to be largely reversible, which should be encouraging for therapists and patients. The underlying neurobiological mechanisms remain unclear and should be assessed in further studies.

Validation of the German Version of the Commitment to Exercise Scale.

Pathological forms of exercising are a topic of debate in terms of classification, etiology, and treatment. Validated instruments are a precondition for research in this field. The aim of this study was to validate the German version of the Commitment to Exercise Scale (CES-de). A confirmatory factor analysis was conducted using data from a large community sample (n = 571). In a second study, 100 eating disordered patients, 107 elite athletes and 100 individuals engaged in leisure time sporting activities were compared to assess discriminant validity and psychological correlates. A 1-factor solution showed the best fit to the data. The CES-de differentiated between the eating disordered group and individuals engaged in leisure time sporting activities, but not between those with an eating disorder and competitive athletes. The total score was significantly correlated with drive for thinness, perfectionism, and overall psychopathology. The CES-de can be considered a valid instrument for measuring problematic behavioral and attitudinal aspects of the commitment to exercise. The use of the CES-de total score is recommended. However, a more specific instrument should be used for athletes. A limitation of the study is that the samples were not stratified by age and gender.

Body image after heart transplantation compared to mechanical aortic valve insertion.

OBJECTIVE: Heart transplantation (HT) obviously affects body image and integrity. However, there are very few empirical data post-transplant. METHODS: In a cross-sectional study, 57 HT patients were compared with 47 subjects with mechanical aortic valve replacement (AVR) using the Dresden-Body-Image questionnaire (DKB) and specific questions regarding integration of the organ/device. In addition, affective symptoms and quality of life (QoL) were assessed (12-Item Short-Form Health Survey and Hospital Anxiety and Depression Scale, HADS). RESULTS: DKB-35 scores did not differ. HT patients scored higher than AVR on specific questions regarding integration of the organ/device. AVR patients showed more affective disturbance and lower mental QoL than HT subjects. Affective scores correlated negatively with body image scores. Seventeen percent of all patients showed psychological distress (HADS scores >8). CONCLUSIONS: HT patients integrated the new organ well - and even better than AVR subjects did with the device. In general, our data corroborate a good adaptation process, in particular in HT patients. Similar to other reported data, a subgroup of 15-20% of patients shows stronger mental distress, including body image problems. These must be identified and treated by professionals. Patients with AVR deserve more attention in the future.

Decreased Emotional Perception in Obesity.

BACKGROUND: There is hardly any empirical evidence on emotion processing by controlled studies in obesity. MATERIAL AND METHODS: Participants rated their emotions in response to visual emotional stimuli from the International Affective Picture System. Study 1 compared obese women with normal-weight controls and women with eating disorders. Study 2 compared obese men with normal-weight controls. RESULTS: Obese women had reduced emotional intensity scores for all basic emotions and the mixed emotion sadness-fear. Obese men had reduced scores for all emotions except happiness and disgust; anger showed a trend towards significance. The results were mainly based on ratings from non-depressed obese individuals. DISCUSSION: Obese men and women scored significantly lower on most basic and mixed emotions. Non-depressed obese subjects seem particularly affected. These new findings must be validated by further study, and longitudinal evaluation after weight loss, e.g. by bariatric surgery, will be of interest. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

The Intersession Process in Psychotherapy for Anorexia Nervosa: Characteristics and Relation to Outcome.

OBJECTIVE: The "inter session process" (ISP) is defined as therapy-related conscious thoughts, memories, and emotions that patients and therapists experience between psychotherapy sessions. It indicates how the participants process and use treatment. The main aim of this study is to describe the ISP characteristics of patients in outpatient treatment for anorexia nervosa (AN). An additional aim is to explore the relation between patients' ISP and treatment outcome. METHOD: Patients taking part in a randomized controlled trial on outpatient psychotherapy for AN (ANTOP) filled in the Intersession Experience Questionnaire before each of the 40 psychotherapy sessions. Trajectories of different aspects of the ISP were analyzed with growth curve models based on orthogonal polynomials and tested for differences between 3 outcome categories (recovery, partially recovered, full syndrome AN). RESULTS: Data from 108 cases were available for analysis. ISP facets showed diverse, mostly nonlinear, trajectories over the course of treatment. Less favorable outcomes were associated with higher levels of patients' experiencing negative emotions when recalling therapeutic dialogue, thinking about therapy during dreaming/drowsy states, and applying therapeutic learning (in the second half of treatment). CONCLUSIONS: Findings confirm an overall relation between ISP and treatment outcome. In outpatient treatment in AN, patients with a less successful course seem to be more preoccupied with therapy and therapist between sessions. For the ISP facet "applying therapeutic learning," findings point to an optimal range dependent on treatment phase. Growth curve modeling is required to describe the nonlinear trajectories of ISP facets.

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.

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.

The Freiburg sport therapy program for eating disordered outpatients: a pilot study.

PURPOSE: Many patients with anorexia or bulimia nervosa use physical activity as a method to influence weight and shape and/or exercise in a compulsive manner. This form of exercising is associated with a more severe illness and higher relapse rates. In a proof-of-concept study, effects of a newly developed sport therapy program aiming to reduce unhealthy exercising were assessed. METHODS: Thirty-six patients with eating disorders took part in four group terms of the program, each lasting 3 months. They were compared to a matched control group. Main outcome criterion was a reduction in the total score of the commitment to exercise scale (CES). RESULTS: In the completer analysis, we found statistically significant reductions in the CES total score over time (time × group; p = 0.003) and significant improvements in overall eating psychopathology and quality of life (pre â†’ post). The dropout rate was high (34 %), mainly due to external reasons (time schedule, etc.). CONCLUSIONS: Findings point to specific effects of a newly developed outpatient sport therapy program for eating disorders. Detailed assessments of patients before assigning them to the program will be necessary to reduce dropout rates. The next step has to be a randomized controlled study.

Accuracy of therapist perceptions of patients' alliance: Exploring the divergence.

OBJECTIVE: The therapeutic alliance is a well-established predictor of psychotherapy outcome, yet much research has shown that therapists' and patients' views of the alliance can diverge substantially. Therapists systematically underestimate their patients' perceived level of alliance, and the correlation between therapist and patient estimates of patient alliance is only moderate. The present study explored the divergence between therapists' and patients' perspectives on patients' alliance experience, and its relations to therapists' concurrent work involvement and session process experiences. METHOD: Data from 98 patients treated by 26 therapists with psychodynamic psychotherapy were analyzed. RESULTS: Therapist-patient divergence was significantly related to therapists' case-wise work involvement, but not to therapist's views of session process. The best predictor of therapist-patient divergence was therapists experiencing a "distressed practice" work involvement pattern. CONCLUSION: Although therapists' work involvement experiences are not commonly investigated, they can be a relevant predictor of therapy processes.