Schema change without schema therapy: the role of early maladaptive schemata for a successful treatment of major depression.

Early maladaptive schemata (EMS) have repeatedly been shown to be associated with several psychopathological conditions, including depression. Schema therapy proposes interventions that aim at altering EMS. In the present study, we examined the effect of an integrative psychodynamic inpatient therapy without explicit focus on EMS in a sample with major depression. Forty-seven (38 female, 9 male) patients filled out the Symptom Checklist (SCL-90-R) and the Young Schema Questionnaire (YSQ) at the beginning and end of the treatment. Results revealed that EMS were significantly reduced in three out of five schema domains. Strong endorsement of EMS at the beginning of treatment tended to predict symptom reduction. More importantly, the reduction of symptom distress during treatment was strongly associated with a reduction in EMS of the schema domain Impaired Autonomy/Performance. We discuss that changes in EMS are highly relevant for changes in symptom distress but that EMS can not only be changed by schema therapy but also by other approaches, like psychodynamic therapy.

Coagulation activation and fibrinolysis impairment are reduced in patients with anxiety and depression when medicated with serotonergic antidepressants.

AIMS: Anxiety disorders have been shown to be correlated with an activation of coagulation and impairment of fibrinolysis. The aim of the study was to assess whether medication with a serotonergic antidepressant, which has been associated with abnormal bleeding, may modify this effect. METHODS: Thirty-one anxiety patients, mostly with comorbid depression, and 31 healthy controls were included in the study. Group differences between anxiety patients medicated with a serotonergic antidepressant, patients without serotonergic antidepressant and controls were assessed for activated partial thromboplastin time, fibrinogen, factor VII, factor VIII, von Willebrand factor, von Willebrand ristocetin cofactor activity, prothrombin fragment 1 + 2, thrombin-antithrombin complex, d-dimer, α2-antiplasmin, plasmin-α2-antiplasmin complex (PAP), tissue plasminogen activator and plasminogen activator inhibitor. Intervening variables, such as age, sex, body mass index and smoking, were accounted for. RESULTS: We found lower coagulation measures for fibrinogen (P = 0.03) and plasminogen activator inhibitor (P = 0.01), and higher levels of PAP (P = 0.046) in patients with serotonergic antidepressant than in patients without serotonergic antidepressant. When controlling for smoking and body mass index, differences between the two groups were significant for PAP (P = 0.02), von Willebrand ristocetin cofactor activity (P = 0.02) and activated partial thromboplastin time (P = 0.046). Coagulation scores were similar in patients with serotonergic antidepressant to those of healthy controls. CONCLUSIONS: Serotonergic antidepressants may counteract a procoagulant effect of anxiety and/or depression in anxiety patients.

Relative hyperhomocysteinemia in patients with panic disorder: a case-control study.

BACKGROUND: The aim of this work was to examine a possible association between a clinically relevant panic disorder and plasma total homocysteine concentration. METHODS: 23 patients with panic disorder with or without agoraphobia confirmed by a standardized clinical interview (Structural Clinical Interview for DSM-IV-German version) and 23 healthy controls matched for gender and age completed questionnaires (SCL-K9, STAI, ADS, STAXI) and had blood drawn after a 15 min rest. Plasma total homocysteine concentrations were measured by competitive enzyme immunoassay. Interfering variables such as age, gender, smoking status, comorbid depression and medication were controlled for. RESULTS: Patients with panic disorder had higher plasma homocysteine concentrations in comparison to the control group (mean value 11.00 vs. 9.14 mumol/l, p = 0.04 with age, gender, smoking status, comorbid depression and antidepressant medication being controlled for). Furthermore, homocysteine plasma concentration was positively correlated with Global Severity of Symptoms (SCL-K9, r(Pearson) = 0.41, p < 0.01). CONCLUSION: The findings of this study suggest a link between elevated plasma homocysteine levels and panic disorder. This raises a new hypothesis of another pathway to an increased risk of cardiovascular events in anxious individuals.

Structural and functional characterization of the trifunctional antibody catumaxomab.

The Triomab family of trifunctional, bispecific antibodies that maintain an IgG-like shape are novel tumor targeting agents. These chimeras consist of two half antibodies, each with one light and one heavy chain, that originate from parental mouse IgG2a and rat IgG2b isotypes. This combination allows cost-effective biopharmaceutical manufacturing at an industrial scale since this specific mouse/rat isotype combination favors matching of corresponding antibody halves during production by means of quadroma technology. Whereas every Triomab family member is composed of an anti-CD3 rat IgG2b half antibody for T cell recognition, the antigen binding site presented by the mouse IgG2a isotype is exchangeable. Several Triomab antibodies have been generated that bind to tumor-associated antigens, e.g., EpCAM (catumaxomab), HER2/neu (ertumaxomab), CD20 (FBTA05), gangliosides GD2/GD3 (Ektomun), on appropriate tumor target cells associated with carcinomas, lymphomas or melanomas. Catumaxomab (Removab) was launched in Europe for treatment of malignant ascites in April 2009. Here, we report the structural and functional characterization of this product. Mass spectrometry revealed an intact mass of 150511 Dalton (Da) and 23717 Da, 24716 Da, 51957 Da and 52019 Da of the reduced and alkylated rat light chain, mouse light chain, rat heavy chain, mouse heavy chain chains, respectively. The observed masses were in agreement with the expected masses based on the amino acid sequence obtained from cDNA sequencing. The glycosylation profile was similar to other human IgG consisting of biantennary oligosaccharides with different numbers of terminal galactose. CD spectroscopy showed mainly beta-sheets secondary structure that is typical for IgG antibodies. Binding measurement revealed the unique trifunctional features of catumaxomab. Other analytical tools were used to evaluate characteristics of catumaxomab preparations, including the presence of isoforms and aggregates.

Temperament and character personality profile in relation to suicidal ideation and suicide attempts in major depressed patients.

To prevent suicidal behaviour, it is important to better understand those personality traits associated with suicidal ideation and suicide attempts. A sample of 394 consecutive major depressed outpatients admitted to Bonn University Hospital was subdivided into three groups: Lifetime suicide attempters (N=32; 8.1%), suicide ideators (N=133) and patients without suicide ideation (N=229). Psychodiagnostic measures embraced the Temperament and Character Inventory (TCI), the Symptom Checklist-90-R and the Hamilton Depression Rating Scale. Suicide attempters and ideators showed higher scores on emotional distress and depression. Analysis of covariance (covariates: age, gender, depression) revealed that suicide attempters score higher on the temperament dimension harm avoidance compared with non-attempters. Suicide ideators could be distinguished from non-ideators by character dimensions in terms of lower self-directedness and higher self-transcendence. Our findings suggest that high harm avoidance is a personality trait associated with suicide attempt in major depression, whereas low self-directedness and high self-transcendence are related to suicidal ideation. As temperament dimensions represent the "emotional core" and character dimensions the "cognitive core" of personality, we discuss whether Cloninger's psychobiological model might be helpful to distinguish between non-suicide ideators, patients who do think about suicide, and patients initiating suicidal behaviour.

Alexithymia, temperament and character as predictors of psychopathology in patients with major depression.

The study investigated the capacity of alexithymic personality features, in combination with temperament and character traits, age and gender, to predict psychopathological symptoms in patients with major depression. Consecutive patients (n=339) were investigated using the Toronto Alexithymia Scale-20 (TAS-20), the Temperament and Character Inventory (TCI), the Symptom Checklist-90-R (SCL-90-R), and the Hamilton Depression and Anxiety Rating Scales (HDRS, HARS). The amount of variance in SCL-90-R subscales and Hamilton scales predicted by TAS-20, TCI, age and gender was calculated by linear regression analyses. The 'difficulties identifying feeling' facet of alexithymia appeared to be a significant predictor of all dimensions of psychopathology. Among TCI scales harm avoidance was the strongest predictor for somatization, phobic anxiety, and anxiety (SCL-90-R, HARS); low self-directedness was the strongest predictor for obsessionality, depression (SCL-90-R, HDRS), interpersonal sensitivity and psychoticism; and low cooperativeness was the strongest predictor for hostility and paranoia. In conclusion, many psychopathological symptoms in major depression are associated with difficulties in the identification of emotions. Relative to alexithymia, Cloninger's psychobiological model of personality could predict psychopathological symptoms in a distinct and meaningful manner. The TAS-20 and the TCI are useful questionnaires for a better understanding of the relationship between psychopathology and personality in major depression.

Evidence for attenuated affective processing in obesity.

Attenuated affective processing is hypothesized to play a role in the development and maintenance of obesity. Using an affective priming task measuring automatic affective processing of verbal stimuli, a group of 30 obese participants in a weight-loss program at the Psychosomatic University Clinic Bonn (M age = 48.3, SD = 10.7) was compared with a group of 25 participants of normal weight (M age = 43.6, SD = 12.5). A smaller affective priming effect was observed for participants with obesity, indicating less pronounced reactions to valenced adjectives. The generally reduced affective processing in obese participants was discussed as a possible factor in the etiology of obesity. Individuals who generally show less pronounced affective reactions to a given stimulus may also react with less negative affect when confronted with weight gain or less positive affect when weight is lost. Consequently, they could be expected to be less motivated to stop overeating or to engage in dieting and will have a higher risk of becoming or staying obese.

Nature against nurture: calcification in the right thalamus in a young man with anorexia nervosa and obsessive-compulsive personality disorder.

This report describes the case of a young man with a large calcification in the right thalamus that was first diagnosed at 9 years of age. Case history reveals specific eating rituals and other obsessive-compulsive personality traits during the patient's childhood and adolescence, fulfilling diagnostic criteria of obsessive-compulsive personality disorder. After a critical life event the patient develops anorexia nervosa. We suggest that our case and further literature provide evidence for an involvement of specific thalamic structures, such as the dorsomedial nucleus, in the development of anorexia nervosa. Furthermore, the treatment of the patient by a combined psychotherapeutic and pharmacotherapeutic approach is described. We focus on the beneficial effect of the atypical antipsychotic olanzapine, which can induce weight gain by an increase of leptin levels.

Association between anxiety and factors of coagulation and fibrinolysis.

BACKGROUND: Psychological stress and anxiety have been shown to produce an activation of coagulation and fibrinolysis. Resulting hypercoagulability is a risk factor for cardiovascular diseases, and could therefore contribute to an increased prevalence of coronary artery disease in anxiety patients. However, hemostasis function has not yet been studied in patients with clinically relevant anxiety disorders. METHODS: A group of anxiety patients (panic disorder with agoraphobia or social phobia) and a healthy control group (each n = 29) completed some questionnaires [SCL-K9 (a short form of the SCL-90-R), State Trait Anxiety Inventory, ADS (general depression scale)], and had blood drawn after a 15-min rest period. To assess the reaction of the hemostatic system by global entities, sum scores were computed from parameters of coagulation and fibrinolysis (fibrinogen, FVII, FVIII, vWF, F1 + 2, TAT, D-dimer, alpha(2)-AP, PAP, tPA, PAI-1). Interfering variables, such as age, gender, alcohol consumption and smoking status, were controlled. RESULTS: Anxiety patients scored higher in a composite hemostatic score and a sum score of fibrinolysis in comparison to the control group, with a predominant activation of inhibitors in fibrinolysis. However, the psychological variable with the closest association to hemostasis was not trait anxiety, but self-perceived worry about blood drawing before blood sampling was performed. CONCLUSIONS: The coagulation and fibrinolysis system is activated in the direction of a hypercoagulable state in patients with severe phobic anxiety, triggered by fear of blood drawing. This could be one mediating factor for the increased risk of cardiovascular diseases in this population. Acute situational phobic anxiety should be monitored closely when studying the association between anxiety and hemostasis.

Patients with obesity show reduced memory for others' body shape.

Social comparison theory assumes that individuals regularly compare themselves to others and that the comparisons are relevant for their self-esteem. For individuals with obesity, these social comparisons will yield a negative outcome with respect to body shape in the majority of social contacts. It is proposed that, when confronted with other persons, individuals with obesity avoid social comparisons on the dimension of body shape. Using a multinomial account of social categorization, 19 female psychotherapy patients with morbid obesity were compared to 19 non-obese female psychotherapy patients. As predicted, results reveal reduced memory for body shape categories in patients with obesity, indicating a reduced processing of body shape information.

Alexithymia and emotional distress in patients with central serous chorioretinopathy.

The authors studied 31 consecutive patients newly diagnosed with central serous chorioretinopathy (CSC) as compared with 31 age- and gender-matched control subjects, assessing emotional distress (ED), nine psychopathological symptoms, critical life events, and alexithymia. Results showed no difference in the number of critical life events; however CSC patients showed elevated ED and elevated scores on seven psychopathological symptoms, including hostility. Controlling for ED, CSC patients showed elevated alexithymia sum scores. Alexithymia was correlated with hostility. Our findings point to personality-based difficulties in emotional regulation associated with hostility in CSC.

Temperament and character personality profiles and personality disorders in chronic pain patients.

In his psychobiological model of personality, Cloninger developed a novel approach concerning the relationships between psychopathological syndromes and personality. We investigated 207 chronic pain patients (CPPs) and compared them to 105 pain-free control subjects. Participants were assessed using the Temperament and Character Inventory (TCI), the Structured-Clinical-Interview-II, the Beck Depression Inventory and the Spielberger Anxiety Inventory. The CPPs scored higher on the depression and state anxiety scales and 41% fulfilled the criteria of having at least one personality disorder (PD). We used a covariance analysis to control for depression and state anxiety and found that the CPPs scored higher on the Harm Avoidance Temperament Dimension and lower on the Self-Directedness and Cooperativeness Character Dimensions. In CPPs, the symptom counts of all PD subtypes were significantly related to low Self-Directedness and, to a lesser degree, low Cooperativeness. The PD symptoms in Cluster A were related to low Reward Dependence, those in Cluster B were related to high Novelty Seeking and the PD symptoms in Cluster C were related to high Harm Avoidance. In multiple hierarchical regression analyses, controlling for age, gender, depression and state anxiety, TCI scales predicted on average 23% in PD symptom counts. The Self-Directedness and Cooperativeness personality traits appeared to be significant predictors in determining the presence or absence of a PD by correctly classifying 75.8% of CPPs. The TCI provides further insight into the mechanisms underlying the development of chronic pain. This useful diagnostic instrument helps to economically and validly facilitate the identification of core PD features.

Interaction of psychological factors and the effect of epoetin-alfa treatment in cancer patients on hemoglobin and fatigue.

INTRODUCTION AND BACKGROUND: Epoetin alpha is known to produce a hematological response in anemic cancer patients. A concomitant reduction in fatigue as well as an improvement of depression and anxiety and of quality of life has been reported. However, these effects are discussed controversially. Psychological variables may have a moderating effect on fatigue reduction. MATERIALS AND METHODS: Fifty-four anemic cancer outpatients were treated with epoetin alpha over 26 weeks with an initial dose of 3 x 10,000 IU/week and further individually adapted dosage. Hemoglobin level, fatigue, depression, anxiety, and health-related quality of life were measured every 4 weeks. RESULTS: The hematological response rate was 50%, with 1/3 occurring after more than 8 weeks of treatment. Fatigue, depression, and quality of life improved significantly. Reduction in fatigue was associated with response, but the correlations between fatigue and hemoglobin were weak. Less depression and higher quality of life before treatment correlated with a better fatigue reduction when controlling for hemoglobin increase and initial fatigue level. CONCLUSION: Psychological variables influence the reduction of fatigue during therapy with epoetin alpha in anemic cancer patients and should therefore be assessed at the beginning of treatment.

Cross-cultural comparison of explanatory models of illness in schizophrenic patients in Jordan and Germany.

This study investigated illness concepts of schizophrenic patients in an Arab-Islamic and a western European cultural background. 24 Jordanian and 23 German inpatients were interviewed using an illness concept scale and a causal belief questionnaire. Jordanian patients tend to believe more in esoteric factors underlying their illness, and they perceive the illness to be more threatening. There were no differences regarding biological explanations of illness and trust in medication; however, Jordanian patients reported more trust in the treating physician. Nearly all patients mentioned psychosocial stress as an important factor underlying their illness. Concerning treatment, only Jordanian patients believed religion to be an important factor and mentioned distance from the family as beneficial. The study highlights that culturally specific factors influence illness concepts of schizophrenic patients from an Arab-Islamic and a western European cultural background. Knowledge of these illness concepts is important to establish a helpful relationship between physician and patient.

Disclosing the cancer diagnosis: what contributes to patient satisfaction?

BACKGROUND: Despite the growing attention to the how, when and where of disclosing a cancer diagnosis, not all patients are satisfied with how the news is broken to them. As in German-speaking countries there is a lack of empirical studies on this subject, this analysis was conducted to determine how the cancer diagnosis was given in a German sample, and how satisfied the patients are with the disclosure experience. PATIENTS AND METHODS: 162 outpatients received a self-report questionnaire focusing on their experiences with physician-patient communication when the diagnosis was disclosed. RESULTS: Guidelines had been respected in most cases. 17% of patients were dissatisfied with the diagnosis disclosure. They reported a significantly shorter duration of the interaction, lack of privacy, deficits in understanding the information, and less emotional support by the physician. CONCLUSION: Adherence to guidelines of diagnosis disclosure in the German sample was fairly high. Respecting both informational and emotional needs is essential for patient satisfaction and can be taught in communication training.

Parental coping with sudden infant death after donor insemination: case report.

We report the case of an artificial donor insemination couple experiencing sudden infant death of their 8-month-old child. Six months after the incident, the couple were investigated by means of an extensive interview, a repertory grid investigation and the Family Assessment Measure, as well as at 6 years after the incident by an extensive interview. The results show the importance of the diagnosis of male infertility and the preceding fertility treatment for coping with the death of their child. Six months after the incident, acute feelings associated with bereavement are mixed with feelings of anger and shame, apparently due to the experience of infertility. However, secrecy and shame associated with male infertility and donor insemination make it impossible for the couple to communicate their feelings to each other or to friends and relatives; furthermore, they decline psychological counselling. Repertory grid investigation and the Family Assessment Measure point to significant problems within the partnership. Six years after the incident, the couple's relationship is destabilized and both partners plan to divorce. We suggest a possible link between donor insemination secrecy and difficulties with coping. We discuss implications for couple counselling and emphasize the necessity for an improved legal framework for donor insemination in Germany.

[Impact of an additional behavioral anxiety intervention on therapy outcome in a psychodynamic inpatient setting]. / Verbessert die zusätzliche Durchführung einer verhaltenstherapeutischen Intervention die Ergebnisse stationärer psychodynamischer Therapie bei Panikstörung/Agoraphobie?

This naturalistic study aimed at evaluating the implementation of an additional symptom-oriented intervention program for patients with panic disorder and/or agoraphobia in a psychodynamic inpatient setting. Patients receiving this intervention showed a significantly better therapy outcome as measured by the symptom-specific scales of the SCL-90-R compared to anxiety patients who had not undergone this additional treatment. This specific improvement was stronger than the general improvement found in therapy outcome over time. Our findings show that the combination of different treatment strategies in one setting may prove effective. However, some problems are discussed which may emerge in clinical practice.

[Relationship of sick leave before treatment to severity of symptoms and treatment outcome in in-patients with anxiety disorders]. / Zusammenhang der Arbeitsunfähigkeit vor Therapiebeginn mit Störungsgrad und Therapieerfolg bei stationären Angstpatienten.

The aim of this study is to explore whether or not being already on sick leave at admission to a psychosomatic clinic indicates a higher level of severity of symptoms in patients with anxiety disorders, and whether or not this has an impact on therapy outcome. We examined 194 in-patients at 8 psychosomatic clinics upon admission and discharge by interview and psychometric testing. Being on sick leave before admission proved to be an indicator for higher global symptom distress as well as a higher severity of anxiety symptoms. Treatment duration was longer for the sick leave group than for the patients that had not been on sick leave, but each group experienced the same degree of change in pre-and-post treatment symptoms. We conclude that sick leave before admission does give information about illness severity and need of treatment in patients with anxiety disorders.

High-caloric supplements in anorexia treatment.

OBJECTIVE: This study compares weight gain and therapy duration in two groups of patients with anorexia nervosa, the first receiving a normal diet aimed at promoting weight gain, the second receiving high-caloric supplements in addition to this normal diet. The study includes patients from two clinics with comparable psychotherapeutic treatment settings except for the substitution. METHODS: Eighty-four patients were examined. Of these, 29 patients with substitution were compared with 29 patients without substitution. In addition, 13 patients without substitution from the first clinic were compared with 13 patients without substitution from the second clinic to exclude potential differences between the two institutions independent of the substitution. RESULTS: Substitution leads to more rapid weight gain, to greater weight on discharge, and to shorter therapy duration. Differences could be observed between patients severely or less severely underweight on admission and between patients with restrictive or bulimic anorexia. CONCLUSION: Within the framework of inpatient psychosomatic treatment involving a psychotherapeutic treatment setting, substitution facilitates weight gain.