Results of a psychosomatic training program in China, Vietnam and Laos: successful cross-cultural transfer of a postgraduate training program for medical doctors.

BACKGROUND: With the "ASIA-LINK" program, the European Community has supported the development and implementation of a curriculum of postgraduate psychosomatic training for medical doctors in China, Vietnam and Laos. Currently, these three countries are undergoing great social, economic and cultural changes. The associated psychosocial stress has led to increases in psychological and psychosomatic problems, as well as disorders for which no adequate medical or psychological care is available, even in cities. Health care in these three countries is characterized by the coexistence of Western medicine and traditional medicine. Psychological and psychosomatic disorders and problems are insufficiently recognized and treated, and there is a need for biopsychosocially orientated medical care. Little is known about the transferability of Western-oriented psychosomatic training programs in the Southeast Asian cultural context. METHODS: The curriculum was developed and implemented in three steps: 1) an experimental phase to build a future teacher group; 2) a joint training program for future teachers and German teachers; and 3) training by Asian trainers that was supervised by German teachers. The didactic elements included live patient interviews, lectures, communication skills training and Balint groups. The training was evaluated using questionnaires for the participants and interviews of the German teachers and the future teachers. RESULTS: Regional training centers were formed in China (Shanghai), Vietnam (Ho Chi Minh City and Hue) and Laos (Vientiane). A total of 200 physicians completed the training, and 30 physicians acquired the status of future teacher. The acceptance of the training was high, and feelings of competence increased during the courses. The interactive training methods were greatly appreciated, with the skills training and self-experience ranked as the most important topics. Adaptations to the cultural background of the participants were necessary for the topics of "breaking bad news," the handling of negative emotions, discontinuities in participation, the hierarchical doctor-patient relationship, culture-specific syndromes and language barriers. In addition to practical skills for daily clinical practice, the participants wanted to learn more about didactic teaching methods. Half a year after the completion of the training program, the participants stated that the program had a great impact on their daily medical practice. CONCLUSIONS: The training in psychosomatic medicine for postgraduate medical doctors resulted in a positive response and is an important step in addressing the barriers in providing psychosomatic primary care. The transferability of western concepts should be tested locally, and adaptations should be undertaken where necessary. The revised curriculum forms the basis of training in psychosomatic medicine and psychotherapy for medical students and postgraduate doctors in China, Vietnam and Laos.

Stress system dynamics during "life as it is lived": an integrative single-case study on a healthy woman.

Little is known about the dynamic characteristics of stress system activity during "life as it is lived". Using as representative a study design as possible, this investigation sought to gain insights into this area. A healthy 25-year-old woman collected her entire urine over a period of 63 days in 12-h intervals (126 measurements) to determine cortisol and neopterin (immune activation marker) levels. In addition, she filled out questionnaires on emotional state and daily routine in 12-h intervals, and was interviewed weekly to identify emotionally negative and positive everyday incidents. Adjusted cross-correlational analyses revealed that stressful incidents were associated with cyclic response patterns in both urinary cortisol and urinary neopterin concentrations. Urinary cortisol levels first decreased 12-24 h after stressful incidents occurred (lag 1: -.178; p = 0.048) and then increased a total of 72-84 h later (lag 6: +.224; p = 0.013). Urinary neopterin levels first increased 0-12 h before the occurrence of stressful incidents (-lag 1: +.185; p = 0.040) and then decreased a total of 48-60 h following such stressors (lag 4: -.181; p = 0.044). Decreases in urinary neopterin levels were also found 24-36 and 48-60 h after increases in pensiveness (lag 2: -.215; p = 0.017) and depressiveness (lag 4: -.221; p = 0.014), respectively. Findings on emotionally positive incidents sharply contrasted with those dealing with negative experiences. Positive incidents were followed first by urinary cortisol concentration increases within 12 h (lag 0: +.290; p = 0.001) and then by decreases after a total of 60-72 h (lag 5: -.186; p = 0.039). Urinary neopterin levels first decreased 12-24 h before positive incidents occurred (-lag 2: -.233; p = 0.010) and then increased a total of 12-24 h following these incidents (lag 1: +.222; p = 0.014). As with previous investigations on patients with systemic lupus erythematosus (SLE), this study showed that stress system response can be considerably longer and more complex and differentiated than findings from conventional group studies have suggested. Further integrative single-case studies will need to be conducted in order to draw firm conclusions about stress system dynamics under real-life conditions.

[Changes in self-referent emotions during inpatient psychotherapy: the role of mindfulness and acceptance]. / Veranderung von selbst-bezogenen Emotionen im therapeutischen Prozess: Die Rolle von Achtsamkeit und Akzeptanz.

OBJECTIVES: Current theoretical and clinical approaches conceive the avoidance and acceptance of emotions as critical factors in the maintenance and alleviation of psychological problems. This study investigates the role of mindfulness, experiential avoidance (EA), and positive and negative meta-emotions (emotional reactions towards the emotional self) on the symptoms and psychological well-being of inpatients. METHOD: Changes of mindfulness measured during a 6-week stay at a psychosomatic clinic were explored in a sample of 293 inpatients with diverse psychological problems. Multivariate analyses were performed to determine the predictive power of mindfulness and acceptance on symptoms and psychological well-being. RESULTS: Staying on an inpatient ward was associated with reductions in EA and negative meta-emotions as well as improvements in mindful awareness and positive meta-emotions, i.e., participants reported greater acceptance of their own emotional reactions. These aspects were associated with a reduction in symptom severity and greater psychological well-being. A differentiation of meta-emotions allowed the meaningful identification of possible processes of change. CONCLUSIONS: Anger and contempt seem to have distinctive functions in self-regulation. Reducing the amount of contempt/shame for one's own emotions and generating greater interest were associated with symptom reduction and greater psychological well-being. Self-compassion was negatively associated with symptoms, though it had no association with psychological well-being. The theoretical implications are discussed.

[Psychotherapy research in the German-speaking community--a bibliometric analysis of three journals]. / Zum Status der Psychotherapieforschung im deutschen Sprachraum--Eine bibliometrische Analyse dreier deutschsprachiger Zeitschriften.

OBJECTIVES: Psychotherapy research has often been considered a neglected topic in clinical psychology, psychosomatic medicine, and psychiatry because of its massive organizational and financial demands. However, it is unclear whether this assumption actually reflects the research activities in the field. METHODS: We conducted a bibliometric analysis of the annual volumes for 2008 and 2009 of three clinical journals published in German. All publications referring to facets of psychotherapy research were analysed. RESULTS: About 30% of the publications dealt with issues of psychotherapy research. Outcome and process studies were about equally distributed. Process research frequently focused on patient variables as outcome predictors. Outcome studies most often presented effectiveness studies with rather small sample sizes. CONCLUSION: Psychotherapy research is a well-represented and multifaceted field in the German speaking research community. However, the traditional distinction between efficacy and process research among the various schools of psychotherapy research may be hampering further developments in this branch. The government-funded research networks may turn out to be promising approaches to overcoming some of the obstacles of classic psychotherapy research.

[Psychoneuroimmunology: an update]. / Psychoneuroimmunologie: Ein Update.

Psychoneuroimmunology (PNI) is closely associated with the bidirectional pathways between mind/brain and the immune system. PNI research represents a rapidly growing area within psychosomatic research. Recent studies in PNI are based mainly on the immunological concepts of Th1/Th2 dichotomy and inflammation. This review covers human PNI studies dealing with stress-associated changes in cytokine (Th1, Th2) levels in immune-related processes such as wound healing, atopic diseases as well as autoimmune and other inflammatory diseases. It is shown that PNI studies measuring immune activity near the site of the disease (e. g. woundhealing) and dealing with objective stressors show more consistent findings (stress-associated Th1/Th2 shift, stress-associated proinflammatory activation) than those dealing with chronic and complex diseases (e. g., autoimmune disease). This warrants the expansion of the methodological repertoire in future PNI research toward designs allowing for the investigation of complex psychosomatic phenomena.

[Treatment outcome of psychodynamic trauma therapy in an inpatient setting]. / Therapieevaluation der Psychodynamisch Imaginativen Traumatherapie (PITT) im stationären Setting.

OBJECTIVE: Chronic traumatization with the beginning in childhood may result in a number of additional problems not included in the diagnosis of Posttraumatic Stress Disorder (PTSD). The efficacy of a three-stage psychodynamically oriented inpatient treatment program (PITT) and the role of chronic childhood threat on treatment outcome was investigated. METHODS: A six-week treatment group of 84 inpatients were compared with 43 wait-list controls with "treatment as usual" (outpatient psychotherapy or psychiatric treatment in the meanwhile). Using measures on PTSD, dissociation, depression, selfsoothing, anxiety and somatization, assessments were made at admission, at discharge and 6 months postdischarge. Assessments for the outpatient control group were made at comparable time spans. RESULTS: In the treatment group significant improvements emerged on all investigated parameters (depression, intrusion, avoidance, anxiety, somatization, and self-soothing) from baseline to discharge, many of which could be maintained over a period for 6 months. PITT especially supports the stabilization of patients with experiences of childhood chronic threat and insecure attachment. Gains in depression, anxiety, somatization, and self-soothing were also significant in comparison to the control group. CONCLUSIONS: Our results suggest that PITT offered on an inpatient basis is an effective treatment for severely traumatized patients that gives impetus to change which should be supplemented with further trauma-specific outpatient therapy to stabilize gains.

Improving the psychosomatic competence of medical doctors in China, Vietnam and Laos-the Asia-Link Program.

OBJECTIVE: The European Union is supporting a 3-year cooperation project coordinated by the Freiburg University Clinic for the development and promotion of psychosomatic medicine in China, Vietnam, and Laos. The main objective is the development and performance of post-graduate training for medical doctors to improve doctor-patient communication and to acquire psychosomatic knowledge, skills, and attitudes. METHOD: The project is based on contacts which have existed for several years with the Tongji University and the affiliated Tongji Hospital in Shanghai. Medical doctors in all disciplines are to learn to promptly recognize emotional disorders which frequently present in the primary care setting, to offer limited treatment themselves, and to cooperate with mental health specialists. RESULTS: In the first year of the project, 50 medical doctors from different medical fields were trained as future teachers. In the second year, we are starting a pilot curriculum which will include 60 hours of theory and psychosocial interventions, divided into three blocks. CONCLUSIONS: Future developments will involve setting up a psychosomatic network in Southeast Asia to establish advanced training in psychosomatic medicine and psychotherapy and to promote psychiatric and psychosomatic consultation and liaison services in the general hospitals.

[Austrian Network for Psychosomatic Medicine: background, development and participation]. / Aktuelle Informationen aus der Deutschen Gesellschaft für Psychosomatische Medizin und Arztliche Psychotherapie.

OBJECTIVES: Physicians as well as the general public need easy access to information on regional psychosomatic treatment options as can be provided by a network website. We therefore set out to explore the readiness of the Austrian psychosomatic community to participate in a network for Psychosomatic Medicine and actively contribute to its website. METHODS: All Austrian psychosomatic societies and all psychosomatic in-patient facilities were addressed personally and/or by letter. Through articles published in medical journals, physicians in private practices specialized in psychosomatic-psychotherapeutic medicine were also invited to participate. RESULTS: All departments of medical psychology and psychotherapy, all psychosomatic societies and all psychosomatic in-patient facilities in Austria decided to participate in this network. In addition, 100 physicians in private practice applied for registration in the network. DISCUSSION: These results support the network concept and have led to its implementation, and clearly, the network should be further developed. The first precondition for its functioning seems to be met.

[Psychosomatic medicine and psychotherapy in Austria]. / Psychosomatik und Psychotherapie in Oösterreich.

In present-day Austria, psychosomatic medicine and psychotherapy enjoy significantly more sociopolitical and cultural recognition perhaps as a heritage from the days of the Austrian monarchy -- than is reflected in their real presence. This development can be traced back to prewar times and the repudiation of the destructive national socialistic ideology. There is an immanent conflict between specialization in psychosomatic medicine and psychotherapy as an independent field of medicine and the integration of a psychosomatic basic approach into the general fields of medicine. The organization of psychotherapy is doubly anchored in the laws governing medical practice (PSY diploma) and the statutes governing the practice of psychotherapy; this, however, has not resolved the sensitive and only partially creative tension between the two. Austrian medical health politics are currently characterized by renewed efforts to organize the field of psychosomatic medicine. Should medical psychology and psychotherapy, internal medicine, psychiatry or general medicine provide the foundations for this new organization? This conflict is crucial since it will influence the further development of the entire medical field.

[The current conception of the unconscious - empirical results of neurobiology, cognitive sciences, social psychology and emotion research]. / Aktuelle Konzeption des Unbewussten - Empirische Ergebnisse der Neurobiologie, Kognitionswissenschaften, Sozialpsychologie und Emotionsforschung.

The influence of the unconscious on psychosomatic medicine and psychotherapy: a comprehensive concept of unconscious processes based on empirical evidence. The theory of the Unconscious constitutes the basis of psychoanalysis and of psychodynamic therapy. The traditional description of the Unconscious as given by Freud is of historical significance and not only gained widespread acceptance but also attracted much criticism. The most important findings of neurobiology, the cognitive sciences, social psychology and emotion research in relation to the Unconscious are compared with this traditional definition. Empirical observations on defence mechanisms are of particular interest in this context. A comprehensive concept of unconscious processes is revealed: the fundamental process of brain function is unconscious. Parts of the symbolic-declarative and emotional-procedural processing by the brain are permanently unconscious. Other parts of these processing procedures are conscious or can be brought to the conscious or alternatively, can also be excluded from the conscious. Unconscious processes exert decisive influence on experience and behaviour; for this reason, every form of psychotherapy should take into account such unconscious processes.