[Interactive Health Literacy, Sociodemographic Characteristics and the Uptake of Psychotherapeutic or Pharmacological Interventions - are there Social Inequalities in the Treatment of Social Anxiety Disorder?] / Interaktive Gesundheitskompetenz, soziodemografische Faktoren und der Zeitraum bis zur Inanspruchnahme psychotherapeutischer oder medikamentöser Behandlung ­ gibt es Hinweise auf soziale Ungleichheiten in der Therapie der Sozialen Angststörung?

AIM: The aim is to investigate the association between sociodemographic characteristics and the interactive health literacy and the time to treatment of social anxiety disorder. METHODS: An online survey of N = 311 patients was carried out (response rate 54.1 %). Descriptive statistical analysis and a logistic regression analysis were carried out. RESULTS: The respondents are on average 46 years old (20-81), 59 % are women. Older age (OR 2,579), not living in partnership (OR 1,963), fear of personal contact (OR 5,716) and low (OR 3,585) or moderate (OR 3,144) interactive health literacy were significantly associated with the time to treatment. CONCLUSION: The data suggest that social inequalities exist regarding the use of psychotherapeutic or pharmacological interventions in people with social anxiety disorder.

Childhood adversities, bonding, and personality in social anxiety disorder with alcohol use disorder.

Social anxiety disorder (SAD) is frequently associated with alcohol use disorders (abuse/dependence). However, there has been little research on the characteristics of this subgroup so far. In the current study we investigated individuals with SAD and comorbid alcohol use disorder (AUD) with regard to socialization experiences and personality. The sample comprised 410 individuals diagnosed with SAD by the Structured Clinical Interview of DSM-IV. 108 participants with comorbid AUD were compared to 302 participants without comorbid AUD concerning traumatic experiences during childhood and adolescence (Adverse Childhood Experiences Questionnaire; ACE), parental bonding (Parental Bonding Instrument; PBI), and personality (Temperament and Character Inventory; TCI). MANCOVA with covariates sex and depression displayed that individuals with SAD plus AUD reported significantly more traumatic events during childhood and adolescence, lower levels of maternal care, as well as lower cooperativeness. Our results highlight that adverse childhood experiences and unfavourable maternal bonding characterize individuals suffering from SAD plus AUD. These experiences might be reflected in a personality-based tendency to distance themselves from others, which corresponds to low scores on the character dimension cooperativeness. A deeper understanding of personality and specific socialization experiences is necessary to develop new treatment options in this clinically challenging subgroup.

Suicidality in patients with somatoform disorder - the speechless expression of anger?

OBJECTIVE: To identify emotion-associated risk factors for suicidality in patients with somatoform disorders. METHODS: A sample of 155 consecutive patients diagnosed with somatoform disorders at the Psychosomatic Ambulance of Bonn University Hospital filled in several questionnaires including the Symptom Checklist 90-Revised Version (SCL-90-R), the Toronto Alexithymia Scale (TAS-20), and the State Trait Anger Expression Inventory (STAXI). Our aim was to compare patients with suicide attempts to patients without suicide attempts via a MANCOVA (IV: Group; DV: SCL-90-R, TAS-20, STAXI; covariates: sex, age, depression, borderline personality disorder). RESULTS: Lifetime suicide attempts were documented in 20 patients (12.9%), current active suicidal ideation in 33.6%, and thoughts of death or dying in 55.9%. Patients with lifetime suicide attempts showed significantly more psychological distress, a significantly higher alexithymia sum score, a significantly higher score on trait anger, state anger, and a stronger tendency to express anger. CONCLUSION: Somatoform disorder patients with lifetime suicide attempts might have greater difficulties in identifying and describing emotions, and a tendency to intensely experience and express anger. Future longitudinal studies should further investigate possible links between difficulties in coping with anger and suicidality to improve prophylaxis and treatment of suicidal behaviour in somatoform disorder patients.

Psychosocial assessment of living kidney donors: What implications have temperament and character for decision-making?

OBJECTIVE: We compared the personality of kidney donor candidates to non-donor controls and analyzed the personality profile of candidates psychosocially at risk. METHODS: 49 consecutive living kidney donor candidates underwent an extensive psychosocial evaluation. Psychosocial risk factors concerning knowledge of donation risks (1), donor-recipient-relationship (2), and/or mental health (3) were rated on a 3-point rating scale (0=high risk, 2=no risk). Furthermore, candidates as well as 49 age-and gender-matched non-donor controls filled in questionnaires concerning psychological distress (Symptom Checklist 90-R) and personality (Temperament and Character Inventory). RESULTS: There were no significant differences between candidates and controls concerning psychological distress or personality. Psychosocial assessment identified 13 candidates (26.5%) with increased psychosocial risk. This group displayed compared to candidates without psychosocial risk no difference concerning age, gender, formal education, donor-recipient relationship and psychological distress. However, this group scored significantly higher on reward dependence compared to suitable donors and controls (p<0.05). Reward dependence was associated with a lack of adequate knowledge on donation (r=-0.35, p<0.05). CONCLUSION: Reward dependence has important implications for decision-making, because it is associated with an increased tendency to deny potential risks of donation. Careful identification and assessment of reward dependent donor candidates is needed to ensure a free-willed decision.

Psychophysiological decoupling in alexithymic pain disorder patients.

Considering that impaired coping with stress is closely linked with emergence of stress-sensitive disorders most notably in alexithymic individuals, we conducted the first study examining stress-related autonomic reactivity in alexithymic pain disorder patients. Twenty-one pain disorder patients with high and an equivalent patient group with low alexithymia scores were exposed to three types of affect-inductive stimuli with variable affective involvement: arithmetic task, watching arousing video material and giving an oral presentation. Subjective appraisal of the induced emotional experience and physiological reactivity (heart rate, muscle tension and skin conductance) was documented. During oral presentation high alexithymia patients showed significantly lower skin conductance in combination with increased subjective negative affect compared to low alexithymia patients. Our results thus demonstrate a decoupling between physiological and affect processing in pain disorder patients with high alexithymia during a stressful situation that was subjectively associated with negative affect.

The German Version of the Herth Hope Index (HHI-D): Development and Psychometric Properties.

BACKGROUND: The importance of hope is evident in clinical oncological care. Hope is associated with psychological and also physical functioning. However, there is still a dearth of empirical research on hope as a multidimensional concept. The Herth Hope Index is a reliable and valid instrument for the measurement of hope and is available in many languages. Until now no authorized German translation has been published and validated. METHODS: After translation, the questionnaire was completed by 192 patients with different tumor entities in radiation therapy. Reliability, concurrent validity, and factor structure of the questionnaire were determined. RESULTS: Correlations were high with depression and anxiety as well as optimism and pessimism. As expected, correlations with coping styles were moderate. Internal consistency and test-retest reliability were satisfactory. We could not replicate the original 3-factor model. Application of the scree plot criterion in an exploratory factor analysis resulted in a single-factor structure. CONCLUSIONS: The Herth Hope Index - German Version (HHI-D) is a short, reliable, and valid instrument for the assessment of hope in patient populations. We recommend using only the HHI-D total score until further research gives more insights into possible factorial solutions and subscales.

Changes of explicitly and implicitly measured self-esteem in the treatment of major depression: evidence for implicit self-esteem compensation.

BACKGROUND AND OBJECTIVES: Self-esteem has been claimed to be an important factor in the development and maintenance of depression. Whereas explicit self-esteem is usually reduced in depressed individuals, studies on implicitly measured self-esteem in depression exhibit a more heterogeneous pattern of results, and the role of implicit self-esteem in depression is still ambiguous. Previous research on implicit self-esteem compensation (ISEC) revealed that implicit self-esteem can mirror processes of self-esteem compensation under conditions that threaten self-esteem. We assume that depressed individuals experience a permanent threat to their selves resulting in enduring processes of ISEC. We hypothesize that ISEC as measured by implicit self-esteem will decrease when individuals recover from depression. METHODS: 45 patients with major depression received an integrative in-patient treatment in the Psychosomatic University Hospital Bonn, Germany. Depression was measured by the depression score of the Hospital Anxiety and Depression Scale (HADS-D). Self-esteem was assessed explicitly using the Rosenberg Self-Esteem Scale (RSES) and implicitly by the Implicit Association Test (IAT) and the Name Letter Test (NLT). RESULTS: As expected for a successful treatment of depression, depression scores declined during the eight weeks of treatment and explicit self-esteem rose. In line with our hypothesis, both measures of implicit self-esteem decreased, indicating reduced processes of ISEC. LIMITATIONS: It still remains unclear, under which conditions there is an overlap of measures of implicit and explicit self-esteem. CONCLUSIONS: The results lend support to the concept of ISEC and demonstrate the relevance of implicit self-esteem and self-esteem compensation for the understanding of depression.

Factorial structure of the 20-item Toronto Alexithymia Scale in a large sample of somatoform patients.

Although a strong association between alexithymia and somatization has been postulated in numerous studies, no systematic study has investigated the psychometric properties of the 20-item Toronto Alexithymia Scale (TAS-20) in a sample of patients with somatoform disorder yet. The purpose of this study was to ensure a valid assessment by the German version of the TAS-20 in somatoform samples. We investigated whether the original three-factor model proposed by Bagby et al. (1994a), which is widely used in clinical research and practice, is replicable in a large sample of somatoform patients (n=806). Using confirmatory factor analysis (CFA) the goodness-of-fit of the originally proposed factor structure was compared to three factor models generated with exploratory factor analysis (EFA) and other factorial solutions derived from the literature. Our results demonstrate that the original three-factor model is not replicable in somatoform patients. Instead, the four-factor model by Franz et al. (2001b) described the data best. However, none of the models met all criteria of confirmatory factor analysis. Our results indicate that the three-factor model is not robust in the German version of the TAS-20. At this state of research we recommend to use the TAS-20 sum-score as a measure of alexithymia in somatoform patients in clinical practice.

[Evaluation of outpatient psychodynamic psychotherapy: results of a controlled field study ]. / Evaluation ambulanter tiefenpsychologischer Psychotherapie: Ergebnisse einer kontrollierten Feldstudie.

OBJECTIVES: The discussion about the effectivity of psychodynamic psychotherapy is being renewed by recent meta-analyses. Although some well-designed studies have been presented, there is still a dearth of research in this field. METHODS: In a controlled prospective field study we investigated the outcome of outpatient psychodynamic psychotherapy in a pre-post design. This evaluation includes data from the symptom inventories VDS90, VDS30, and HEALTH for 90 patients with different mental disorders before therapy and after the regular end of therapy, compared to a waiting list control group. RESULTS: We found a significant improvement in symptoms, dysfunctional personality features, and quality of life. Rates of statistically and clinically significant improvement were markedly higher after therapy than in the waiting list condition. CONCLUSIONS: Psychodynamic psychotherapy shows an effect on symptoms, dysfunctional personality features, and quality of life.

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.

Temperament, character, and personality disorders in chronic pain.

In the past decades investigators have used personality inventories to help explain the relationship between personality and pain experience. This article reviews empirical research, which has examined temperament and character features in chronic pain patients. Robert Cloninger's temperament and character model of personality based on a bio-psychosocial approach to personality and psychopathology has been used in multiple studies investigating the temperament and character profile of chronic pain patients. According to Cloninger's model, research portrayed a common personality profile of chronic pain patients characterized by prevailing harm avoidance and lower self-directedness, which has been shown to predict the presence of a personality disorder. Pain-prone patients could benefit from the measurement of personality by the temperament and character inventory with improved treatment response.

Temperament and character in relation to sick leave duration in mentally disordered outpatients-the downside of novelty seeking and cooperativeness.

In 1254 mentally disordered outpatients (941 women, 313 men) length of sick leave in the preceding 12 months was documented (median 2 weeks) and axis I and axis II disorder (SCID screening, clinical interview), psychological distress (SCL-90-R), work-related distress and personality (Temperament and Character Inventory (TCI)) were assessed. Compared to healthy controls (N=152) patients scored lower on self-directedness and higher on harm avoidance. Longer incapacitated patients were more often female. On the basis of absence duration (<2 weeks; ≥2<4 weeks; ≥4 weeks) male and female patients were analysed separately. Main findings showed that women longer on sick leave scored significantly higher on novelty seeking and cooperativeness. Further analysis yielded a significant contribution of personality dimensions, including novelty seeking and cooperativeness to work-related distress in women, explaining 21.5% of variance. An association between lower formal education, older age and duration of work incapacity could only be confirmed in male patients. Personality-based difficulties in adequate distancing from professional demands, as well as personality-based problems in interpersonal conflict management, are discussed as possible explanations for study findings.

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.

Detecting high-order interactions of single nucleotide polymorphisms using genetic programming.

MOTIVATION: Not individual single nucleotide polymorphisms (SNPs), but high-order interactions of SNPs are assumed to be responsible for complex diseases such as cancer. Therefore, one of the major goals of genetic association studies concerned with such genotype data is the identification of these high-order interactions. This search is additionally impeded by the fact that these interactions often are only explanatory for a relatively small subgroup of patients. Most of the feature selection methods proposed in the literature, unfortunately, fail at this task, since they can either only identify individual variables or interactions of a low order, or try to find rules that are explanatory for a high percentage of the observations. In this article, we present a procedure based on genetic programming and multi-valued logic that enables the identification of high-order interactions of categorical variables such as SNPs. This method called GPAS cannot only be used for feature selection, but can also be employed for discrimination. RESULTS: In an application to the genotype data from the GENICA study, an association study concerned with sporadic breast cancer, GPAS is able to identify high-order interactions of SNPs leading to a considerably increased breast cancer risk for different subsets of patients that are not found by other feature selection methods. As an application to a subset of the HapMap data shows, GPAS is not restricted to association studies comprising several 10 SNPs, but can also be employed to analyze whole-genome data. AVAILABILITY: Software can be downloaded from http://ls2-www.cs.uni-dortmund.de/~nunkesser/#Software

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.