[Differential diagnosis of dissociative seizures]. / Differenzialdiagnose dissoziativer Anfälle.

Patient history taking and semiology provide seminal clues to the diagnosis of dissociative seizures. Openness and alertness of the treating physician are essential. Video-electroencephalogram(EEG)-based analyses of the events are crucial to establish the correct diagnosis, particularly in complex cases. The patient-doctor relationship is of particular importance in order to successfully motivate the patient for psychotherapeutic treatment. Coexisting psychiatric morbidity as well as other functional somatic symptoms must be actively explored. Current changes in the established diagnostic manuals, including ICD-11, reflect the ongoing vivid interest and controversial discussions in the field of dissociative disorders.

[Ways to psychosomatic rehabilitation--differential treatment selection between psychosomatic acute care and rehabilitation]. / Wege in die psychosomatische Rehabilitation--differenzielle Indikationsstellung an der Schnittstelle zwischen Krankenhaus und psychosomatischer Rehabilitationsklinik.

Consecutive admissions to the psychosomatic departments of 5 hospital units in southwest Germany registered between October 2012 and October 2013 were asked to participate in a study investigating the treatment selection process for psychosomatic rehabilitation. 527 patients were included in the study, 269 outpatients and 258 inpatients at the end of their inpatient treatment. 52 patients (10.1%) received the recommendation for rehabilitation. 47 (90.4%) could be followed up 3 months later. 22 patients had applied for a rehabilitation treatment, 11 (50%) had obtained an approval for their rehabilitation, 5 had still no answer and for 6 patients the request was refused. 4 of the latter had objected their refusal and were still waiting for an answer. Only one patient was already admitted to a rehabilitation center. Possible reasons for the low permeability at the interface between hospital care and rehabilitation are discussed.

Relative absence of psychopathology in benign essential blepharospasm and hemifacial spasm.

We report on the psychopathology and illness-related changes of life in patients with benign essential blepharospasm (BEB) or hemifacial spasm (HFS). Fifty-six patients with BEB and 40 patients with HFS completed the SCL 90R, a screening instrument for psychiatric symptomatology, and the Freiburg Questionnaire for Dystonia (FQD), a questionnaire about psychosocial changes in subjects with movement disorders. In both BEB and HFS patients, the mean scores on all but one subscale of the SCL 90R remained within the double standard deviation of normal. In comparing BEB to HFS patients in illness-related changes of life, BEB patients were more severely disabled in all areas of life examined. Psychological distress in BEB, but not in HFS, correlated with physical disability and in particular with impairment of vision.

Spasmodic torticollis - a multicentre study on behavioural aspects II: signs, symptoms and course.

This paper deals with signs, symptoms and course in spasmodic torticollis (ST). Two hundred and fifty-six patients were included in the study, 59.3% women, 40.7% men. The mean age was 49.1 years. Rotating torticollis out-numbered latero- and antero-retrocollis. A family history of ST occurred in 3.1% of the total sample. First degree relatives were affected in 2.3%. Thirty-four per cent of the patients had additional dystonic symptoms. Most frequently these affected the upper extremities (13%), and less often the legs. Of the patients 19.1% had experienced a period of complete remission. The correlations between the severity of the signs and the neurological symptoms are surprisingly weak.

Spasmodic torticollis - a multicentre study on behavioural aspects IV: psychopathology.

The GSI (General Symptom Index) of the Symptom Checklist 90 R (SCL 90 R) (as a global indicator of the severity of psychiatric symptoms) of 27% of the spasmodic torticollis (ST) sample fell outside the 95% range of the normal control group (two standard deviations). Patients with a higher GSI were younger, more functionally disabled and subject to higher psychosocial stress due to the illness. The highest scores were reached on the subscales of somatization, interpersonal sensitivity and depression. On the depression scale, 23% of the patients' scores were abnormal. This scale correlated significantly with the neurological signs, particularly the TSUI-index and laterocollis. A statistically significant correlation also existed between psychiatric morbidity and a family history of mental disorder. More than 50% of the patients reported that stressful life events had triggered their illness. In order of frequency, a death came first, followed by marital strife, changes in employment and family arguments. The data suggest that psychopathology in ST should generally be considered as a result of a variety of interacting factors, biological, psychological and social.

Spasmodic torticollis - a multicentre study on behavioural aspects III: psychosocial changes and coping.

Psychosocial changes in spasmodic torticollis (ST) affect predominantly social life, professional life and psychological well-being. Concerning social life, 84.6% of the patients felt that they attracted considerable public attention due to their neurological illness and 65% had reduced participation in social events. A substantial number of patients had retired from professional activities; others felt severely impaired in their working capacity. The psychosocial sequelae in ST, however, seemed to depend less on the neurological signs per se than on the physical symptoms and on coping. Depressive coping in particular emerged as a predictor of psychosocial distress.

[Not Available]. / Bindungsrepräsentation, Affektregulation und psychophysiologische Reaktionsbereitschaft - Anmerkungen zur Bedeutung neuerer Ergebnisse der Bindungsforschung für die Psychosomatik/ Attachment representation, affict regulation and psychophysiological reactivity - Comments on the relevance of current findings in the field of attachment research for psychosomatic medicin.

Theoretical issues and research emphasis within the field of attachment theory have shifted from attachment behavior "to the level of representation" (Bretherton, 1985) since the middle of the 80ies. The paper presents an overview on basic assumptions, research methodology and empirical findings in the field of attachment research. Four issues are addressed, which are relevant for psychosomatic research. These concern: (1) The prevalence of insecure attachment representation in psychosomatic disorders; (2) the association between insecure attachment representation and an increased psychophysiological reactivity; (3) the potential link between attachment and affect regulation and (4) the question, whether the classification of attachment representations may increase our understanding of specific aspects of illness behavior in psychosomatic conditions such as somatoform disorders.

[Somatisizing patients. Concrete recommendations for a stepwise therapy in general practice]. / Somatisierende Patienten. Konkrete Vorschläge für eine Stufentherapie in der Hausarztpraxis.

Patients with physical symptoms but no detectable organic substrate often present a challenge for the family doctor. The therapeutic approach discussed herein focuses on the development of a psychosomatic model of the problem. In this step-by-step approach, the patient's subjective understanding of, and attitude towards, his illness and its treatment are established, alternative psychosomatic models of disease based on a consideration of psychophysiological interactions are worked out jointly with the patient, and, finally, thought is given to the current complaints within the context of the patient's personality and life situation. The basis for successful treatment is an empathic and sound doctor-patient relationship based on trust that gives the patient the feeling that he and his problem are being taken seriously. The prerequisite for the use of such a program is appropriate training in basic psychosomatic care.

Are individual differences of attachment predicting bereavement outcome after perinatal loss? A prospective cohort study.

OBJECTIVE: The purpose of this study was to examine the influence of attachment, social support and the quality of the current partnership on the outcome of bereavement after perinatal loss. METHODS: In a prospective cohort design 33 women after perinatal loss were approached on admission to hospital and reassessed four weeks, four months and nine months later. The initial assessment included the Adult Attachment Interview and self-report questionnaires for social support and quality of the current partnership. Bereavement outcome was assessed using measures of grief (MTS), depression and anxiety (HADS), psychological distress (BSI), somatisation (BSI-SOM) and symptoms of PTSD (PDS). RESULTS: All measures of outcome showed a significant improvement over time. Standardized effect sizes between the initial assessment and nine month follow-up ranged between .36 for anxiety (HADS) and 1.02 for grief (MTS). Social support, quality of the partnership and secure attachment correlated inversely, and insecure preoccupied attachment correlated positively with the outcome measures. Preoccupied attachment was included as a predictor in two multivariate statistical models of non-linear regression analysis, one with somatisation (adjusted R2=.698, P=.016), the other with posttraumatic stress symptoms at nine month follow-up (adjusted R2=.416, P=.002) as target variable. Initial assessment scores of psychological distress predicted the course of the respective measure during follow-up (adjusted R2=.432, P=.014). CONCLUSION: Attachment, social support and the quality of the current partnership have an impact on the course of bereavement after perinatal loss. Secondary prevention after the event may focus on these factors in order to offer specific counselling and support.

[Clinical and psychometric findings in spasmodic torticollis]. / Klinische und psychometrische Befunde beim spasmodischen Tortikollis.

In a previous study screening for psychopathological symptoms in a sample of 256 patients with spasmodic torticollis had resulted in 27% of patients, whose mean score of the GSI of the SCL-90-R was above the double standard deviation of the control group of normals (Scheidt et al. 1994). In this study the self-reported psychopathology of a subsample of 19 TS patients was controlled for its agreement with a clinical assessment in a psychiatric interview. The results of the study confirm the validity of the SCL-90-R as a screening instrument for psychological distress and psychopathology. However a tendency for social desirability in a subgroup of patients might lead to underestimate the degree of psychological distress in this patient group and might als account for some of the discrepant findings concerning psychological distress and psychopathology in TS in former studies. Furthermore the clinical assessment revealed a high psychiatric and psychosomatic morbidity prior to the onset of the spasmodic torticollis as well as a high frequency of traumatic life events (e.g. bereavement) in the patients premorbid history. In addition to coping with a crippling neurological condition concurrent psychopathology in TS therefore should be considered also in terms of the individuals premorbid psychological vulnerability.

[Psychotherapy of somatoform pain disorders in the elderly]. / Zur Psychotherapie somatoformer Schmerzstörungen im Alter.

This article focuses on somatoform pain disorders in elderly patients. Defined as a variant of the somatoform disorders, somatoform pain represents a disorder characterized by significant, physically experienced pain that is not (fully) explained by a medical condition. Although epidemiological data are sparse, the prevalence of somatoform pain disorders appears to decline with aging. Psychological factors are assumed to have an important role in the onset, severity, and maintenance of somatoform pain. In this article, two case reports are presented in order to illustrate the phenomenon that earlier pain experiences, e.g., in the context of a physical disorder or in the context of traumatic events, may "pave the way" for somatoform pain syndromes. Later acute mental stress or psychological conflicts may then precipitate the onset of somatoform pain. With respect to therapy, one should consider that patients with somatoform pain experience and interprete their suffering as a physical disorder. When applying psychotherapy to patients with somatoform pain disorders the therapist has to recognize and to appreciate eventual previous pain experiences which may have "paved the way" for the present disorder. Only after having established a therapeutic relationship can one try to interest the patient in the individual emotional and cognitive aspects that may underly the disorder. In addition to depressive feelings and feelings of guilt, grief about the loss of bodily functions may be of special significance for the onset and maintenance of somatoform pain disorders in elderly persons.

[Psychodynamic aspects of coping with illness in stroke--experiences with a psychotherapy group]. / Zur Psychodynamik der Krankheitsverarbeitung bei Schlaganfall--Erfahrungen einer psychotherapeutischen Gruppe.

The authors describe their experience of a group--psychotherapy with stroke patients during the phase of inpatient neurological rehabilitation. The process of coping in stroke patients shows similarities with grief reactions following the loss of important objects. But it is usually complicated by the fact that the physical injury is experienced as a narcissistic trauma resulting in low self--esteem and in feelings of anger and despair. Psychotherapeutic interventions can help to deal with such negative affects and should facilitate a mourning process, which is inevitable if adaptation to a life with a physical handicap should succeed.

[Subgroups of torticollis spasmodicus from the psychosomatic viewpoint. Results of a cluster analysis of 144 cases. German Study Group of Dystonia Research]. / Subgruppen bei Torticollis spasmodicus aus psychosomatischer Sicht. Ergebnisse einer Clusteranalyse von 144 Fällen. Deutsche Arbeitsgemeinschaft für Dystonieforschung.

The question of subgroups in idiopathic spasmodic torticollis, which has been discussed in earlier studies in order to define etiologically heterogeneous patient populations has lost some of its relevance since with the injection of botulinum toxin an effective treatment is available. However, psychosocial distress is linked with spasmodic torticollis in a substantial number of patients. In order to define criteria for psychosocial interventions in addition to the treatment with botulinum toxin, a cluster analysis was carried out to identify high-risk populations in terms of psychological and social distress. Five subgroups were defined on the basis of eight variables. Two of these five groups, one group with rotational torticollis and one with laterocollis, emerged as particularly distressed by their physical complaints, the effects of their illness on various areas of life and in terms of psychological functioning. The consistency of the subgroups was tested and statistically confirmed by analysis of variance. In a cross-validation 83.02% of the ungrouped cases were predicted correctly. The authors suggest that the evaluation of psychological and social aspects of the condition should be part of the neurological assessment in order to offer appropriate support to patients, who reveal a high degree of psychological distress.

[Diagnosis, symptoms and follow-up of psychogenic tremor]. / Diagnose, Symptomatik und Verlauf des psychogenen Tremors.

A total of 21 patients with psychogenic tremor (PT) were asked to take part in a neurologic and psychosomatic assessment; for 17 patients follow-up information was also recorded. Women out-numbered men in the sample. In the majority of patients the tremor was associated with a variety of other conversion symptoms. The clinical picture of the tremor varied. After beginning exclusively in the extremities, it tended to spread to other parts of the body. Other psychopathology (depression and histrionic personality disorder) existed in almost a third of the sample. Many patients had retired from professional life, or planned to do so in the near future, because of PT. At follow up the initial diagnosis was confirmed in all patients although in some patients additional physical illness had developed during the follow-up period. When neurological and psychiatric/psychosomatic criteria are applied the diagnosis of PT can be established reliably. Studies that have questioned the validity of the conversion concept on the basis of frequent misdiagnoses may indicate problems in the diagnostic procedure rather than an invalid theoretical construct.

[Adaptive indication in outpatient psychodynamic short-term psychotherapy. Results of a prospective naturalistic research study]. / Adaptive Indikationsstellung in der ambulanten psychodynamischen Kurzzeitpsychotherapie. Ergebnisse einer prospektiven naturalistischen Verlaufsuntersuchung.

Health care insurers in Germany fund long-term psychotherapy of up to 240 sessions as well as brief psychotherapeutic interventions of up to 25 sessions. In a former study, it was observed that a substantial proportion of interventions initially designed as brief psychotherapy were changed into long-term therapy. The present study investigated the criteria of such decisions to change treatment plans and is part of a more comprehensive auditing study in outpatient psychotherapy. Twenty-six psychotherapists in private practice participated in the study. During a 12-month recruitment period, 70 patients started with brief psychodynamic psychotherapy. Thirty-six therapies were evaluated according to the study protocol. The results provide evidence that motivation for psychotherapy, satisfaction with the results of therapy, persistence of psychological symptoms at the end of short-term intervention, and aspects of the patient's personality are factors predictive of treatment selection. Patients who changed from short-term to long-term therapy were more motivated towards their therapy (prognostic indication), displayed more severe symptoms, were less satisfied with the results of short-term psychotherapy (adaptive indication), and scored higher on the "structure of personality organization" parameter according to the OPD diagnostic system.

Attachment representation and cortisol response to the adult attachment interview in idiopathic spasmodic torticollis.

OBJECTIVE: The study investigates individual differences in the mental representation of attachment and their impact on the cortisol response to psychosocial stress in idiopathic spasmodic torticollis (IST). It was hypothesized (a) that in IST insecure attachment is more prevalent than in a non-clinical control group and (b) that subjects with dismissing attachment respond with higher physiological arousal to a specific stimulus activating the attachment behavioural system than subjects with secure attachment. METHOD: 20 patients with IST and 20 healthy controls matched for age and sex underwent the Adult Attachment Interview, an hour-long, semiclinical interview on attachment experiences. During the interview salivary cortisol levels were monitored. The subjects' mental state with regard to attachment was classified using the attachment Q-sort method. Anxiety and depression were measured as potential covariates of the adrenocortical stress response. RESULTS: Compared to the non-clinical group, dismissing attachment was strongly overrepresented in IST. In IST, but not in the healthy control group, dismissing attachment correlated with an elevated cortisol response to the interview. CONCLUSION: In clinical, but not in non-clinical samples dismissing attachment may be associated with increased vulnerability to psychosocial stress. The factors contributing to this interaction are not yet fully elucidated.

Alexithymia and attachment representation in idiopathic spasmodic torticollis.

We investigated alexithymia and the mental representation of attachment in idiopathic spasmodic torticollis (IST). It was hypothesized a) that alexithymia in IST is more prevalent than in a nonclinical control group and b) that significant correlations emerge between alexithymia and a dismissing attachment representation. Twenty patients with IST and 20 healthy controls matched for age and sex were administered the Toronto Alexithymia Scale (TAS-20) and the Adult Attachment Interview (AAI). Attachment was classified using the Attachment Interview Q-sort. IST patients scored significantly higher on the measure of alexithymia than subjects in the comparison group. In IST a dismissing attachment representation was significantly more frequent than in the control group. Across the total sample, externally oriented thinking correlated positively with dismissing attachment, and both externally oriented thinking and difficulty communicating feelings (two of the three subscales of the TAS-20) correlated inversely with secure attachment. Alexithymia is more prevalent in IST than in normals. As was hypothesized, alexithymia in adults is significantly interrelated with the mental representation of attachment.

[Psychosomatic aspects of idiopathic spasmodic torticollis. Results of a multicenter study]. / Psychosomatische Aspekte des idiopathischen spasmodischen Torticollis. Ergebnisse einer multizentrischen Untersuchung.

Idiopathic spasmodic torticollis (IST) is one of the most frequent dystonic movement disorders. Its classification as a focal dystonia, as well as its treatment with botulinum toxin resulted in groups of patients being regularly seen by neurologic specialists. In a multicentre study, we investigated psychosocial changes, coping and psychopathology, and their interrelations with signs, symptoms and course. 256 patients were included in the study (59.3% women, 40.7% men). The mean age was 49.1 years. Rotating torticollis occurred more often than latero-retrocollis and antero-retrocollis. A family history of IST was seen in 3.1% of the total sample. 34% of the patients had additional dystonic symptoms. Most frequently, these affected the upper extremities (13%), less often the legs. 19.1% of the patients had experienced a period of complete remission. The General Symptom Index of the SCL 90-R in 27% of the patients ranged above the double standard deviation of the normal controls, indicating a clinically significant psychopathology.