Why are some cases not on track? An item analysis of the Assessment for Signal Cases during inpatient psychotherapy.

Within the Routine Outcome Monitoring system "OQ-Analyst," the questionnaire "Assessment for Signal Cases" (ASC) supports therapists in detecting potential reasons for not-on-track trajectories. Factor analysis and a machine learning algorithm (LASSO with 10-fold cross-validation) were applied, and potential predictors of not-on-track classifications were tested using logistic multilevel modeling methods. The factor analysis revealed a shortened (30 items) version of the ASC with good internal consistency (α = 0.72-0.89) and excellent predictive value (area under the curve = 0.98; positive predictive value = 0.95; negative predictive value = 0.94). Item-level analyses showed that interpersonal problems captured by specific ASC items (not feeling able to speak about problems with family members; feeling rejected or betrayed) are the most important predictors of not-on-track trajectories. It should be considered that our results are based on analyses of ASC items only. Our findings need to be replicated in future studies including other potential predictors of not-on-track trajectories (e.g., changes in medication, specific therapeutic techniques, or treatment adherence), which were not measured this study.

[Development of a 12-item version of the OPD-Structure Questionnaire (OPD-SQS)]. / Entwicklung einer Zwölf-Item-Version des OPD-Strukturfragebogens (OPD-SFK).

OBJECTIVES: Screening for personality dysfunction is relevant to treatment planning in psychotherapy, psychosomatic medicine and psychiatry. This makes short versions of field-tested approaches such as the OPD Structure Questionnaire (OPD-SQ) necessary. METHODS: With the aim of developing a screening version, the original sample of the OPD-SQ was divided into two subsamples. After developing a preliminary 12-item version in one subsample, we used confirmatory factor-analysis in the second subsample as well as an independent sample to test the factor structure. RESULTS: The analyses confirmed a structure of three correlating factors with adequate fit indices. Other findings relating to the validity of the long version were replicated as well. In addition, data from an independent sample of psychotherapy inpatients confirmed the factor structure and provided further evidence for its validity. CONCLUSIONS: The OPD-SQS is a viable screening instrument for supporting clinical decision making in stepped-care approaches in psychotherapy, psychosomatic medicine and psychiatry.

Extreme deviations from expected recovery curves and their associations with therapeutic alliance, social support, motivation, and life events in psychosomatic in-patient therapy.

OBJECTIVES: Within the clinical support tools (CST) of the OQ-Analyst, the "Assessment for Signal Cases" (ASC) evaluates the therapeutic alliance, social support, motivation, and life events. We investigated whether the ASC covers domains of importance in treatment weeks with extreme deviations from expected recovery curves (ERCs). METHODS: Psychosomatic in-patients were monitored weekly with the ASC and the "Outcome Questionnaire" (OQ-45). The ERCs of the OQ-45 empirical algorithm were used to define treatment weeks with extreme positive deviations (EPD), extreme negative deviations (END), or without extreme deviations (NO). Associations between the ASC scales and EPD as well as END were analyzed by multilevel models. RESULTS: While each ASC scale was positively associated with EPD, only the social support and life events scales were negatively related to END. CONCLUSIONS: CSTs prioritizing social support and life events might be more effective in preventing treatment failure.

[The OPD structure questionnaire captures the general features of personality disorder]. / Der OPD-Strukturfragebogen erfasst die allgemeinen Merkmale einer Persönlichkeitsstörung.

INTRODUCTION: The alternative DSM-5 model of personality disorder (PD) links general criteria and severity of PD to impairments in self and interpersonal functioning. This approach is very similar to the Level of Structural Impairment Axis of the Operationalized Psychodynamic Diagnosis (OPD-2). In this study we investigate the relationship of these 2 approaches based on 2 new self-report questionnaires. METHODS: 228 psychotherapeutic inpatients filled out the OPD Structure Questionnaire (OPD-SQ), the General Assessment of Personality Disorder (GAPD), and the Patient Health Questionnaire (PHQ-D). RESULTS: The correlation between the latent general factors of OPD-SQ and GAPD was 0,91. After controlling for depressive symptoms the correlation was 0,86. DISCUSSION: The general factors of the OPD-SQ and the GAPD are almost identical. CONCLUSION: The OPD-SQ captures the general features of PD in terms of self-reported impairments in self and interpersonal functioning.

Providing patient progress feedback and clinical support tools to therapists: is the therapeutic process of patients on-track to recovery enhanced in psychosomatic in-patient therapy under the conditions of routine practice?

OBJECTIVES: In previous studies of patients on-track to recovery (OT) involving therapists receiving only patient progress feedback without clinical support tools (CST) inconsistent results were found. Possible effects of combining patient progress feedback with CST on OT patients remain unclear. METHODS: At intake (t1), 252 patients of two in-patient psychosomatic clinics were randomized either into the experimental group (EG) or the treatment-as-usual control group (CG). Both groups were monitored weekly using the self-report instruments "Outcome Questionnaire" (OQ-45) and "Assessment of Signal Cases" (ASC). Therapists received weekly patient progress feedback (OQ-45) and CST feedback (ASC) only for EG patients starting at the week following intake (t2). Patients who did not deviate negatively from expected recovery curves by at least one standard deviation were considered OT patients (N=209; NEG=111; NCG=98). Since therapists received feedback at t2 for the first time, different patterns of change (OQ-45 scales) between the groups from t1 to t2, t2 to t3 (intake+two weeks), t2 to t4 (intake+three weeks), and t2 to t5 (last available OQ-45 score) were evaluated by multilevel models. RESULTS: Merely from t2 to t3, the EG improved significantly more on the OQ-45 symptom distress scale than the CG (p<0.05; g=0.12). CONCLUSION: Providing patient progress feedback and CST to therapists did not substantially surpass treatment-as-usual for OT patients in this explorative study except for a very small time-limited enhancement of symptom change.

Feedback on patient progress and clinical support tools for therapists: improved outcome for patients at risk of treatment failure in psychosomatic in-patient therapy under the conditions of routine practice.

OBJECTIVES: Although psychosomatic in-patient treatment is effective, 5-10% of the patients deteriorate. Providing patient progress feedback and clinical support tools to therapists improves the outcome for patients at risk of deterioration in counseling, outpatient psychotherapy, and substance abuse treatment. This study investigated the effects of feedback on psychosomatically treated in-patients at risk of treatment failure. METHODS: At intake, all patients of two psychosomatic clinics were randomized either into the experimental group or the treatment-as-usual control group. Both groups were tracked weekly with the "Outcome Questionnaire" (OQ-45) measuring patient progress and with the clinical support tool "Assessment of Signal Cases" (ASC). Therapists received feedback from both instruments for all their experimental group patients. "Patients at risk" were defined as patients who deviated from expected recovery curves by at least one standard deviation. Of 252 patients, 43 patients were at risk: 23 belonged to the experimental group, 20 to the control group. The feedback effect was analyzed using a level-2-model for discontinuous change, effect size (d), reliable change index (RCI), and odds ratio for reliable deterioration. RESULTS: For patients at risk, the experimental group showed an improved outcome on the OQ-45 total scale compared to the control group (p<0.05, d=0.54). By providing feedback, the rate of reliably deteriorated patients at risk was reduced from 25.0% (control group) to 8.7% (experimental group) - odds ratio=0.29. All reliably improved patients at risk belonged to the experimental group. CONCLUSION: Feedback improves the outcome of patients at risk undergoing psychosomatic in-patient treatment.

[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.

[Psychometric analysis of the Turkish speaking version of the "Hamburg Modules for the Assessment of Psychosocial Health" (T-HEALTH-49)]. / Psychometrische Überprüfung der türkischsprachigen Version der "Hamburger Module zur Erfassung allgemeiner Aspekte psychosozialer Gesundheit" (T-HEALTH-49).

Based on the German original questionnaire of the "Hamburger modules for measuring generic aspects of psycho-social health in the therapeutic practice" (HEALTH-49) a Turkish speaking version (T-HEALTH-49) was cross-cultural sensitively developed. The psychometric properties have been analysed by means of a clinical sample of Turkish speaking patients (N=311). The questionnaire proves to be practical, the dimensional structure and the relatively independence of the modules have been confirmed by factor analysis. The single scales are characterised by satisfactory to high reliability and satisfactory validity. The T-HEALTH-49 considers adequately psychosocial aspects in diagnostic, therapy planning and quality assurance. The questionnaire can be downloaded for free (www.hamburger-module.de).

[The clinical relevance of defense mechanisms in inpatients and outpatients]. / Die klinische Bedeutung der Abwehrmechanismen bei ambulanten und stationären Patienten.

OBJECTIVES: How clearcut is the clinical significance of mature and immature defense mechanisms in psychological symptoms? METHODS: Defense mechanisms, symptoms and well-being were assessed in 293 inpatients, 316 outpatients and 157 students. RESULTS: The factors "mature defense" and "immature defense" predict well-being/symptoms to a substantial degree. DISCUSSION: The assessment of defense mechanism via self-report is clinically useful.

[First results on the reliability and validity of the OPD-2 axis structure]. / Erste Ergebnisse zu Reliabilität und Validität der OPD-2 Strukturachse.

OBJECTIVES: In 2006, the manual of the Operationalized Psychodynamic Diagnostics (OPD) was revised and published in its second edition (OPD-2; Arbeitskreis OPD2006). In particular the axis structure was markedly changed. This study assessed the interrater reliability and validity. METHODS: Two independent raters judged 139 persons with OPD-2 on the axis structure (a third rater judged a partial sample of 20 persons). In addition, patients were investigated with SCID-Interviews for DSM-IV diagnosis and with the following questionnaires: Brief-Symptom-Checklist (BSI), Inventory of Personality Organisation (IPO), and Borderline Personality Inventory (BPI). RESULTS: Interrater agreement for the axis structure showed sufficient to good results for weighted kappas. The axis structure showed high correlations with the number of DSM-IV diagnoses and the main scales of the BSI, IPO, and BPI. CONCLUSION: The OPD-2 axis structure is a reliable and valid instrument for the assessment of the crucial clinical dimension of "psychic structure".

El sistema Diagnóstico Psicodinámico Operacionalizado (OPD): Concepto, confiabilidad y validez / Operationalized Pshychodinamic Diagnosis (OPD): Concept, reliability and validity

This paper presents the system "Operationalized Psychodynamic Diagnosis (OPD), which has been applied in the German speaking countries very successfully during the last 10 years. The OPD is the operationalization of the psychodynamically oriented clinical assessment. The clinical material assessed during the initial interview with the patient is described in a way which is close to the level of observation. The classification system OPD serves as a clinically relevant and process oriented tool for psychotherapists. The multidimensional psychodynamically oriented approach is based on five axes. Axis I: Experience with the illness and treatment preconditions, axis II: habituated relationships of the patient, axis III: the intrapsychic conflicts of the patient; axis IV: The psychic structure of the patient, axis V: syndromatic, according to chapter V (F) of the ICD 10. The fifth axis is conzeptualized as a linking tool to ICD-10. Reliability studies on OPD show good to satisfying scores for interrater agreement for the research context. The results derived from the validity studies support the validity of the OPD system. There are also hints for improvements of multiple categories or items within each axis.

Este artículo presenta el sistema de "diagnóstico psicodinámico operacionalizado" (OPD), que en los últimos 10 años se ha difundido ampliamente en los países de habla germana. El OPD tiene como meta operacionalizar los constructos psicoanalíticos clínicamente probados. El material clínico presentado por el paciente en la primera entrevista puede ser estimado y clasificado en un nivel lo más cercano posible a lo directamente observable. Con la OPD se puede formular un diagnóstico psicodinámico clínicamente relevante y orientador para los psicoterapeutas. El diagnóstico psicodinámico multiaxial se basa en 5 ejes diferentes: eje 1: experiencia de enfermedad y prerrequisitos para el tratamiento, eje 2: relaciones interpersonales, eje 3: conflicto, eje 4: estructura, eje 5: diagnóstico sindromático (según el capítulo V (F) del CIE 10). El eje 5 de la OPD genera un punto de unión del instrumento con el modelo del CIE. Los estudios sobre confiabilidad muestran un nivel bueno a satisfactorio de confiabilidad en el contexto investigativo. Los resultados de los estudios sobre la validez evidencian un buen nivel de validez de cada eje. Los múltiples estudios con el OPD ofrecen guías para perfeccionar las categorías.

[The burn-out syndrome and restoring mental health at the working place]. / Burn-out und Wiedergewinnung seelischer Gesundheit am Arbeitsplatz.

This paper reviews the scientific concepts and the clinical aspects of the burn-out syndrome. According to recent studies, up to 25 % of the German working population appear to suffer from what the Amercan physician and psychoanalyst, Herbert Freudenberger, has designated in 1974 as "burn-out syndrome". Characteristic features of this syndrome are emotional exhaustion, depersonalization and low personal accomplishment. People affected by the burn-out syndrome may suffer from depressive or anxious symptoms, from sleep disorders, chronic pain syndromes, or functional disorders of the cardiovascular or gastrointestinal system. Primary causes of the burnout syndrome include high demand combined with low influence, a high level of engagement without sufficient rewards or gratification, and a low level of social support. Preventive measures against burn-out include Balint-like supervision groups. In cases of a fully developed burn-out syndrome, affected persons should undergo either psychotherapy or a multimodal psychosomatic therapy.