How can learning effects be measured in Balint groups? Validation of a Balint group questionnaire in China.

BACKGROUND: Balint groups aim to reflect doctor-patient relationships on the basis of personal cases. This study reports the validation of a questionnaire aimed at the identification of learning processes among Balint group participants in China. METHODS: This multicenter cross-sectional study was conducted during Balint group sessions in Beijing, Guangzhou and Shanghai. A heterogeneous sample of different professional groups was intended to adequately capture the reality of Balint work in China. After a Balint group session, the participants were asked to complete the Mandarin version of the Balint group session questionnaire (BGQ-C) and the group questionnaire (GQ), an internationally validated instrument to assess central dimensions of therapeutic relationships during group processes. RESULTS: Questionnaires from n = 806 participants from 55 Chinese Balint groups, predominantly comprising individuals with a medical background, were analyzed. Most participants were female (74.6%), and the average age was 34.2 years old (SD = 9.4). The results indicated good to very good reliability (Cronbach's α = .70 to .86; retest rs = .430 to .697). The verification of the construct validity of the BGQ-C showed satisfying convergent (rs = .465 to .574) and discriminant validity (rs = -.117 to -.209). The model was tested with a confirmatory factor analysis of a three-factor model (standardized root mean square residual = .025; comparative fit index = .977; Tucker-Lewis index = .971). The 3 empirically identified scales resulted in good model fit with the theoretical dimensions of Balint work postulated in the literature: "reflection of transference dynamics in the doctor-patient relationship", "emotional and cognitive learning" and "case mirroring in the dynamic of the group". Due to the high correlations between the factors, a single-factor model was possible. A group comparison between the German and Chinese samples showed different loadings across cultures. CONCLUSIONS: The BGQ-C is a quick-to-complete, item-based measuring instrument that allows the relevant dimensions of Balint group work to be recorded. This study suggests good psychometric properties of the Chinese version. Nevertheless, it must be assumed that the composition of constructs in the two countries is different.

[Balint group as a mandatory training - Effects of Balint work as part of the psychosomatic basic care course]. / Balintgruppe als Pflichtveranstaltung ­ Effekte von Balintarbeit im Rahmen des Kurses Psychosomatische Grundversorgung.

Balint group as a mandatory training - Effects of Balint work as part of the psychosomatic basic care course Objectives: Participants in the psychosomatic basic care course often lack a genuine interest in Balint work. What effects does Balint work have on these inexperienced and less motivated participants? Are there differences between male and female participants and between surgical and non-surgical specialties? What are the relationships between the group leaders and the results achieved? Methods: Between 2004 and 2019, a total of 1,667 doctors completed the feedback form for the Balint group as part of the psychosomatic basic care course. The learning objectives included cognitive and emotional items, as well as questions about the group atmosphere and leadership, about the transfer to everyday medical practice and interest in further Balint work. Results: 170 Balint groups took place during the investigation period. The overall grade was on a scale from 1 to 6 with M = 1.80 (SD = 0.72). Good to very good ratings were awarded to the motivation and competence of the group leaders and the group atmosphere, as well as gaining knowledge and positive effects on everyday medical practice. There were hardly any differences between female and male participants and between surgical and non-surgical participants. However, there were significant correlations between the assessment of the leader and the effects of group work. Discussion: The predominantly positive assessment of Balint's work is surprising, both in terms of cognitive and emotional learning goals. In addition to the group atmosphere, the motivation and competence of the group leader, perceived by the participants, are closely related to the learning effects achieved. The survey shows that Balint work can achieve positive results even with less motivated participants on a compulsory course. Balint work should therefore remain an integral part of the qualification in psychosomatic basic care. Sound training and supervision of Balint group leaders are necessary.

Rt-fMRI neurofeedback-guided cognitive reappraisal training modulates amygdala responsivity in posttraumatic stress disorder.

BACKGROUND: Traumatic experiences are associated with neurofunctional dysregulations in key regions of the emotion regulation circuits. In particular, amygdala responsivity to negative stimuli is exaggerated while engagement of prefrontal regulatory control regions is attenuated. Successful application of emotion regulation (ER) strategies may counteract this disbalance, however, application of learned strategies in daily life is hampered in individuals afflicted by posttraumatic stress disorder (PTSD). We hypothesized that a single session of real-time fMRI (rtfMRI) guided upregulation of prefrontal regions during an emotion regulation task enhances self-control during exposure to negative stimuli and facilitates transfer of the learned ER skills to daily life. METHODS: In a cross-over design, individuals with a PTSD diagnosis after a single traumatic event (n = 20) according to DSM-IV-TR criteria and individuals without a formal psychiatric diagnosis (n = 21) underwent a cognitive reappraisal training. In randomized order, all participants completed two rtfMRI neurofeedback (NF) runs targeting the left lateral prefrontal cortex (lPFC) and two control runs without NF (NoNF) while using cognitive reappraisal to reduce their emotional response to negative scenes. During the NoNF runs, two %%-signs were displayed instead of the two-digit feedback (FB) to achieve a comparable visual stimulation. The project aimed at defining the clinical potential of the training according to three success markers: (1) NF induced changes in left lateral prefrontal cortex and bilateral amygdala activity during the regulation of aversive scenes compared to cognitive reappraisal alone (primary registered outcome), (2) associated changes on the symptomatic and behavioral level such as indicated by PTSD symptom severity and affect ratings, (3) clinical utility such as indicated by perceived efficacy, acceptance, and transfer to daily life measured four weeks after the training. RESULTS: In comparison to the reappraisal without feedback, a neurofeedback-specific decrease in the left lateral PFC (d = 0.54) alongside an attenuation of amygdala responses (d = 0.33) emerged. Reduced amygdala responses during NF were associated with symptom improvement (r = -0.42) and less negative affect (r = -0.63) at follow-up. The difference in symptom scores exceeds requirements for a minimal clinically important difference and corresponds to a medium effect size (d = 0.64). Importantly, 75% of individuals with PTSD used the strategies in daily life during a one-month follow-up period and perceived the training as efficient. CONCLUSION: Our findings suggest beneficial effects of the NF training indicated by reduced amygdala responses that were associated with improved symptom severity and affective state four weeks after the NF training as well as patient-centered perceived control during the training, helpfulness and application of strategies in daily life. However, reduced prefrontal involvement was unexpected. The study suggests good tolerability of the training protocol and potential for clinical use in the treatment of PTSD.

[How effective are Balint group leaders?] / Wie wirksam sind Balintgruppen-Leiter?

How effective are Balint group leaders? OBJECTIVES: Balint leadership until today is based on views of experts. Empirical research is still lacking. This paper reports about leadership effects in Balint groups measured by the newly developed Balint Group Questionnaire (BGSQ). The questionnaire comprises three scales: Scale 1 - Reflection of Transference Dynamics in the Doctor-Patient Relationship, Scale 2 - Emotional and Cognitive Learning, Scale 3 - Case Mirroring in the Group Dynamic. RESULTS: 87 out of 107 cooperating Balint group leaders had six or more participants who filled out the questionnaire after a Balint session. Based on the scale scores of the BGSQ from 1459 medical participants we found three clusters of differentially effective leadership. 52 leaders (59.8 %) belonged to the most effective cluster in scale 1, 11 leaders (12.6 %) were particularly effective in scale 2, and 21 leaders (24.1 %) in scale 3. Five out of 87 leaders were found most effective for all three scales. No other influencing factors predicted leadership effectiveness. CONCLUSIONS: This is the first quantitative study to differentiate leadership effects on learning processes of participants of Balint groups. The importance for training of Balint group leaders is discussed. More research regarding predictive variables and helpful leadership interventions is needed.

Effect of group leaders on doctors' learning in Balint groups.

OBJECTIVE: Although effective Balint leadership is viewed as essential for good Balint practice, nearly no quantitative research is available regarding the importance of the person of the group leader in Balint group outcome. This study aims to identify Balint group leaders' impact on "typical Balint" learning processes in Balint groups. METHOD: A total of 1460 medical doctors in 352 Balint groups in Germany, Austria, and Switzerland were investigated. Based on the three learning dimensions of the Balint Group Session Questionnaire, statistical analyses were conducted to identify differential effectiveness in Balint leadership. RESULTS: On the basis of the mean scores of the Balint Group Session Questionnaire items across all group participants of each group leader, the 80 certified Balint group leaders were clustered into two groups of more and less effective leaders by a hierarchichal cluster analysis. Mixed model analyses revealed that the effectiveness of the person of the Balint group leader was the most predictive factor for learning effects. CONCLUSIONS: Training for Balint group leaders should take into account that effective learning processes in Balint groups are strongly related not only to the method itself but also to the person of the group leader.

Impaired Voluntary Control in PTSD: Probing Self-Regulation of the ACC With Real-Time fMRI.

Background: Post-traumatic stress disorder (PTSD) is characterized by deficits in the self-regulation of cognitions and emotions. Neural networks of emotion regulation may exhibit reduced control mediated by the anterior cingulate cortex (ACC), contributing to aberrant limbic responses in PTSD. Methods: Real-time fMRI neurofeedback (rt-fMRI NF) assessed self-regulation of the ACC in nine patients with PTSD after single trauma exposure and nine matched healthy controls. All participants were instructed to train ACC upregulation on three training days. Results: Both groups achieved regulation, which was associated with wide-spread brain activation encompassing the ACC. Compared to the controls, regulation amplitude and learning rate was lower in patients, correlating with symptom severity. In addition, a frontopolar activation cluster was associated with self-regulation efforts in patients. Conclusions: For the first time, we tested self-regulation of the ACC in patients with PTSD. The observed impairment supports models of ACC-mediated regulation deficits that may contribute to the psychopathology of PTSD. Controlled trials in a larger sample are needed to confirm our findings and to directly investigate whether training of central regulation mechanisms improves emotion regulation in PTSD.

[Designing the doctor-patient relationship]. / Die Arzt-Patient-Beziehung gestalten.

Designing the doctor-patient relationship: How beneficial are Balint groups and for whom? OBJECTIVES: Participation in Balint groups is obligatory for some medical specialist trainings. Yet there is a substantial lack of empirical evidence for Balint group effects. METHODS: 1,460 medical specialists who participated in 352 different Balint groups were investigated using the Balint Group Questionnaire (BG-F) at the end of a Balint group session. Using mixed-model analyses, we examined the predictive value of the independent variables Experience in Balint Groups (in years), Clinical Experience in General (in years), Case Presentation vs. Nonpresentation, Facultative vs. Obligatory Participation (status) with regard to scale characteristics of the BG-F: Scale 1: Reflection of Transference Dynamics in the Doctor-Patient Relationship, Scale 2: Emotional and Cognitive Learning, Scale 3: Case Mirroring in the Group Dynamic. Mixed-model analyses were calculated separately for the subgroups Balint Experience < 1 year (vs. > 1 year) and for Balint Experience < 2 years (vs. > 2 years). RESULTS: Complete data were available for 1,400 participants. On Scale 1, "somatic" doctors scored significantly higher than "psyche" doctors. Case presenters scored significantly higher than nonpresenters. On Scale 2, "somatic" doctors showed highly significantly higher scores than "psyche" doctors. Case presenters also scored highly significantly higher than nonpresenters. Doctors with < 2 years of Balint group experience had significantly higher scores than those with > 2 years. On Scale 3, case presenters scored highly significantly higher than nonpresenters. Group participants with less Balint group experience (< 1 year) had significantly lower scores on Scale 3 than group participants with more experience with Balint groups (> 1 year). CONCLUSIONS: Participation in Balint groups generates important effects on doctors' knowledge regarding the doctor-patient relationship, both privately as well as professionally. These results confirm scientifically specific effects of Balint groups, providing empirical evidence for the importance of Balint group experiences for professionals in the medical field.

Self-efficacy in acutely traumatized patients and the risk of developing a posttraumatic stress syndrome.

Post traumatic stress disorder (PTSD) occurs across 15-20% of victims suffering physical injury. The occurrence of PTSD has been attributed to both the trauma and the victim's individual resources, such as resilience, coping strategies, and social support systems. In the present study, we explored the role of self-efficacy for cognitive self-regulation in the posttraumatic adaptation process of sixty-five patients immediately following trauma (T1) and approximately four months later (T2) assessing posttraumatic stress syndrome according to DSM-IV criteria. We hypothesized perceived self-efficacy as a predictor for an increased risk of developing posttraumatic stress symptoms. Self-efficacy measured immediately following trauma correlated significantly with the development of posttraumatic stress syndromes. This finding suggests that the evaluation of cognitive adaptation to trauma is a helpful marker for clinical outcome assessment and can therefore be used for the identification of patients needing psychotherapeutic intervention.

The neurofunctional mechanisms of traumatic and non-traumatic memory in patients with acute PTSD following accident trauma.

Neurofunctional alterations in acute posttraumatic stress disorder (PTSD) and changes thereof during the course of the disease are not well investigated. We used functional magnetic resonance imaging to assess the functional neuroanatomy of emotional memory in surgical patients with acute PTSD. Traumatic (relative to non-traumatic) memories increased neural activity in the amygdala, hippocampus, lateral temporal, retrosplenial, and anterior cingulate cortices. These regions are all implicated in memory and emotion. A comparison of findings with data on chronic PTSD suggests that brain circuits affected by the acute disorder are extended and unstable while chronic disease is characterized by circumscribed and stable neurofunctional abnormalities.

[Synergetics of hypnoid relaxation]. / Synergetik der hypnoiden Relaxation.

The Autogenic Training (AT) is a well established relaxation technique and psychotherapy tool. We report the use of nonlinear routines, the Multi-scaled Time-Frequency-Distribution (mTFD) for the graphical display of vegetative rhythms, and Post-Event-Scan (PES) for the direct visual identification of coupling between physiological subsystems. Applying these methods to time series of respiration, arterial blood pressure, and cutaneous forehead blood content fluctuations in controls (n = 11) or AT-experts (ATE, n = 11) induced psychomotor drive reduction during orthostatic stress allowed the instantaneous identification of a 0.15 Hz-rhythm. This rhythm prevailed in ATE significantly longer resulting a significantly robust 1 : 1 coupling between cutaneous blood content fluctuations and respiration. Consequently, we hypothesize that the "0.15 Hz-rhythm" in the cutaneous blood content fluctuations described previously which was associated with the subjective experience of profound psychomotor relaxation reflects an order-order transition in peripheral signals of central nervous origin. Results produced with the aid of these analytic tools support the efficacy of the AT induced, synergetic relaxation response.

Cardiovascular rhythms in the 0.15-Hz band: common origin of identical phenomena in man and dog in the reticular formation of the brain stem?

Selected examples from experiments in humans and dogs with time series of reticular neurons, respiration, arterial blood pressure and cutaneous forehead blood content fluctuations were analysed using multiscaled time-frequency distribution, post-event-scan and pointwise transinformation. We found in both experiments a "0.15-Hz rhythm" exhibiting periods of spindle waves (increasing and decreasing amplitudes), phase synchronized with respiration at 1:2 and 1:1 integer number ratios. At times of wave-epochs and n:m phase synchronization, the 0.15-Hz rhythm appeared in heart rate and arterial blood pressure. As phase synchronization of the 0.15-Hz rhythm with respiration was established at a 1:1 integer number ratio, all cardiovascular-respiratory oscillations were synchronized at 0.15 Hz. Analysis of a canine experiment supplied evidence that the emergence of the 0.15-Hz rhythm and n:m phase synchronization appears to result from a decline in the level of the general activity of the organism associated with a decline in the level of activity of reticular neurons in the lower brainstem network. These findings corroborate the notion of the 0.15-Hz rhythm as a marker of the "trophotropic mode of operation" first introduced by W.R. Hess.

Neural processing of traumatic events in subjects suffering PTSD - a case study of two surgical patients with severe accident trauma.

Neuroimaging research on the neurobiology of chronic PTSD (posttraumatic stress disorder) has revealed structural and functional alterations primarily affecting areas of the medial temporal lobe (hippocampus, amygdala, and parahippocampal gyrus) and the frontal cortex known to be associated with the disorder. Using functional magnetic resonance imaging (fMRI), the present study studied the functional neuroanatomy of traumatic and non-traumatic emotional memory in two surgical patients who had sustained severe accident trauma. While patient 1 had developed acute PTSD following the traumatic event, patient 2 (control) did not. When confronted with traumatic (relative to negatively valenced non-traumatic) memory, the PTSD patient exhibited evidence for increased neural activity in the right and the left superior temporal lobe, the amygdala, the left angular gyrus, and the medial frontal gyrus, while the non-PTSD patient exposed to identical conditions showed increased activations in frontal and parietal regions. Both patients exhibited identical activation patterns when recalling non-traumatic memories relative to neutral memories. It is concluded that the pronounced activation patterns in the PTSD patient may be considered specific for acute PTSD, involved with the emotional arousal and the vivid visual recollections typical for the acute phase of the disorder.

[Traumatic and psychosocial distress in patients with acute tumors]. / Traumatische und psychosoziale Belastungen bei Patienten mit akuter Tumorerkrankung.

For patients, being diagnosed with cancer means being confronted with a life-threatening illness and can thus be considered a traumatic experience. This situation is compounded by the fact that having cancer is usually not an isolated event but is generally a long-term stressor. The aim of the present study was a) the assessment of psychotraumatic and comorbid distress in tumor patients both in the acute stage (T1) and over time (T2), b) the identification of possible protective factors, and c) the identification of risk factors for the development of a posttraumatic stress reaction (PTSR) following the diagnosis of a tumor. The sample consisted of 46 patients who had to undergo surgical treatment for a newly developed tumor for either diagnostic or therapeutic purposes. The following psychosocial factors were examined: posttraumatic stress, dissociative reactions, anxiety, depression, cognitive-emotional distress, social support and processing the illness. More than 25 % of the patients demonstrated signs of a clinically relevant PTSR at the acute stage (T1) and almost 40 % did so four months later (T2). Significantly more women showed a PTSR at both points of measurement, but particularly at follow-up. No significant relationship could be found between the type of the tumor at T1 and the emergence of a PTSR at T2. Patients with PTSR at T2 showed higher scores for anxiety and depression. The most important predictors for the development of clinically relevant posttraumatic symptoms at the four-month follow-up examination were female sex, PTSR at T1 as well as elevated levels of depression. The results indicate the clinical relevance of psychotraumatic screening examinations in patients with acute cancer illnesses both for diagnostic as well as therapeutic investigations.

[The Aachen liaison model] / Das Aachener Psychosomatische Liaisonmodell.

The encounter between physician and patient is impregnated by contemporary theories of disease. From the point of view of psychotherapeutic medicine, the physician-patient-relationship fuses normative and relationship-oriented thinking. The disease as the object of treatment is being supplemented by the care for the patient as a subject. The participating observation and the respective reflection are professional tools of the medical carer. The realisation of this point of view in clinical practice is exemplified using the Aachen Psychosomatic model of Liaison. The importance of this model for interdisciplinary cooperation is being discussed.