Development and validation of a computer program for measuring emotional awareness in German-The geLEAS (German electronic Levels of Emotional Awareness Scale).

Introduction: Emotional awareness is the ability to identify, interpret, and verbalize the emotional responses of oneself and those of others. The Levels of Emotional Awareness Scale (LEAS) is an objective performance inventory that accurately measures an individual's emotional awareness. LEAS assessments are typically scored manually and are therefore both time consuming and cognitively demanding. This study presents a German electronic scoring program for the LEAS (geLEAS), the first non-English computerized assessment approach of the LEAS. Methods: Data were collected from a healthy German community sample (N = 208). We developed a modern software for computerizing LEAS scoring, an open-source text-based emotion assessment tool called VETA (Verbal Emotion in Text Assessment). We investigated if the software would arrive at similar results as hand scoring in German and if emotional awareness would show similar associations to sociodemographic information and psychometric test results as in previous studies. Results: The most frequently used scoring method of the geLEAS shows excellent internal consistency (α = 0.94) and high correlations with hand scoring (r = 0.97, p < 0.001). Higher emotional awareness measured by the geLEAS is associated with female gender, older age, and higher academic achievement (all p < 0.001). Moreover, it is linked to the ability to identify emotions in facial expressions (p < 0.001) and more accurate theory of mind functioning (p < 0.001). Discussion: An automated method for evaluating emotional awareness greatly expands the ability to study emotional awareness in clinical care and research. This study aims to advance the use of emotional awareness as a clinical and scientific parameter.

Anxiety Disorders in Patients With Somatic Diseases.

OBJECTIVE: Anxiety disorders are among the most frequent mental disorders and are associated with a range of short- and long-term impairments and disabilities. Relatively little is known about anxiety disorders in patients with somatic diseases, and the present literature review highlights the current research in this field, data about prevalences of anxiety disorders in patients with somatic diseases, and the effectiveness of interventions. This article also introduces a comprehensive model of inpatient treatment and summarizes the evidence pertinent to this approach. METHODS: A narrative review is presented with regard to prevalence and treatment of anxiety disorders in patients with somatic diseases. The effects of inpatient treatment are illustrated based on a case report. RESULTS: This review indicates that anxiety disorders are more common in patients with somatic diseases, with prevalence estimates ranging from 2.5% to 55%, than in the general population. Several outpatient treatment options exist, with substantial support for the effectiveness of cognitive behavioral therapy, psychodynamic therapy, and pharmacotherapy. We also provide evidence in support of psychosomatic inpatient treatment for patients with anxiety disorders that are comorbid with somatic diseases. CONCLUSIONS: Anxiety disorders are common in patients with somatic diseases, and several effective treatment options exist, including cognitive behavioral therapy and pharmacological interventions. We also provide support for the effectiveness of inpatient treatment with unique opportunities for multidisciplinary psychosomatic treatment of anxiety disorders with comorbid somatic diseases.

Treating anxiety disorders by emotion-focused psychodynamic psychotherapy (EFPP)-An integrative, transdiagnostic approach.

Anxiety disorders are characterized by high levels of anxiety and avoidance of anxiety-inducing situations and of negative emotions such as anger. Emotion-focused therapy (EFT) and psychodynamic psychotherapy (PP) have underscored the therapeutic significance of processing and transforming repressed or disowned conflicted or painful emotions. Although PP provides sophisticated means of processing intrapsychic and interpersonal conflict, EFT has empirically tested a set of techniques to access, deepen, symbolize, and transform emotions consistent with current conceptualizations of emotions and memory. Based on our clinical experience, we propose that an integrative emotion-focused and psychodynamic approach opens new avenues for treating anxiety disorders effectively, and we present a transdiagnostic manual for emotion-focused psychodynamic psychotherapy. The therapeutic approach takes into account both the activation, processing, and modification of emotion and the underlying intrapsychic and interpersonal conflicts. The short-term treatment is based on the three phases of initiating treatment, therapeutic work with anxiety, and termination. Emotional poignancy (or liveliness) is an important marker for emotional processing throughout treatment. Instead of exposure to avoided situations, we endorse enacting the internal process of generating anxiety in the session providing a sense of agency and access to warded-off emotions. Interpretation serves to tie together emotional experience and insight into the patterns and the nature of underlying intrapersonal and interpersonal conflict. Treatment modules are illustrated by brief vignettes from pilot treatments.

The impact of attachment distress on affect-centered mentalization: An experimental study in psychosomatic patients and healthy adults.

INTRODUCTION: We investigated the impact of attachment distress on affect-centered mentalization in a clinical and a non-clinical sample, comparing mentalization in a baseline condition to mentalization under a condition of attachment distress. METHODS: The sample consisted of 127 adults who underwent inpatient psychosomatic treatment, and 34 mentally healthy adults. Affect-centered mentalization was assessed by analyzing participants' narratives on interpersonal situations in a baseline condition with the Levels of Emotional Awareness Scale (LEAS), and an experimental condition inducing attachment distress with the Adult Attachment Projective Picture System (AAP). Unlike the LEAS, the AAP is specifically designed to trigger attachment distress. In both conditions, the narratives were evaluated using the LEAS scoring system. Additionally, we assessed the impact of childhood trauma on affect-centered mentalization with the Childhood Trauma Questionnaire (CTQ). RESULTS: While the non-clinical sample displayed the same level of affect-centered mentalization in both conditions, the majority of the clinical sample reached higher scores in the attachment distress condition. There was no strong relationship between reported trauma and mentalization scores. DISCUSSION: Our findings lend strong empirical support to the assumption that affect-centered mentalization is modulated by attachment-related distress. Several possible explanations for the differences between and within the clinical and the non-clinical sample are discussed.

Mini - social phobia inventory (mini-SPIN): psychometric properties and population based norms of the German version.

BACKGROUND: A short screening for social anxiety disorder is useful in clinical and epidemiological contexts. However, the German version of the short form of the Social Phobia Inventory (mini-SPIN) has not been evaluated yet. Therefore, our aim was to determine reliability, validity and population based norms of the German mini-SPIN. METHODS: The mini-SPIN was evaluated in a clinical (N = 1254) and in a representative community sample (N = 1274). Clinical diagnoses, the Patient Health Questionnaire depression (PHQ-9) and somatization modules (PHQ-15), the Generalized Anxiety Disorder Scale (GAD-7), the Liebowitz Social Anxiety Scale (LSAS), and the Short-Form-12 Health Survey (SF-12) were used in the clinical sample. In the community sample, participants filled out socio-demographic and health related questions and short versions of the PHQ (PHQ-2, GAD-2, panic item). Internal consistency, test-retest reliability, sensitivity to change, discriminant validity, and convergent validity were examined. Receiver operating characteristic curve analyses were performed to determine cut-off scores. Population based norms were computed from the community sample. RESULTS: We found internal consistencies between 0.80 and 0.83. Test-retest correlation was Rho = 0.61; sensitivity to change was comparable to the LSAS. Correlations indicated good convergent and discriminant validity of the mini-SPIN. Strict measurement invariance can be assumed regarding age and gender. Receiver operating characteristic curve analysis suggested a cut-off of 6 or higher for a probable diagnosis of SAD. CONCLUSIONS: The German version of the mini-SPIN is a reliable and valid instrument. Its brevity makes it valuable for screening and assessing changes of social anxiety in clinical and epidemiological studies.

Prevalence and determinants of online-sex use in the German population.

INTRODUCTION: The unlimited access to sexual features in the World Wide Web has raised concerns about excessive and problematic online-sex use. However, little is known about antecedents of internet-sex use of different intensity. Based on a representative German sample of 2,522 participants between the ages of 14 and 97 years, the aims of the present study were (1) to determine the prevalence rates of online-sex users with the short version (ISSTGSV) of the Internet Sex Screening Test and (2) to associate online-sex use with anxious vs. avoidant partner attachment patterns and "Big Five" personality traits as potential antecedents. RESULTS: The ISST is a brief, one-dimensional and reliable measure of online-sex activities (rtt = .69). Overall, 14.7% of respondents reported occasional and 4.2% intensive online-sex use. In multivariate analysis, online-sex use was significantly positively associated with male sex, younger age, unemployment and an anxious partner attachment pattern and negatively with conscientiousness and agreeableness. CONCLUSIONS: Arousal and satisfaction by virtual enactment of sexual phantasies may be attractive for anxiously attached persons who find it difficult to commit to a real life relationship due to fear of rejection or low self-esteem. More knowledge about the individual antecedents of intensive online-sex use may also be helpful for the development of consultation and treatment strategies for excessive and addictive online-sex use.

DNA damage in lymphocytes of patients suffering from complex traumatization.

It has been shown that complex childhood traumatization (CCT) increases the risk for severe somatic and mental disorders. However, the somatic pathways linking maladaptive affect regulation and disease are not understood. Here we tested the hypothesis that traumatic stress is linked to the induction of DNA damage. We isolated peripheral lymphocytes (PBLCs) from blood of healthy donors and patients suffering from CCT. Cells were immobilised on slides and stained with anti-phosphohistone 2AX (γH2AX). The number of γH2AX foci, which are an accepted surrogate marker of DNA double-strand breaks (DSBs), was determined and set in relation to the patient characteristics. We show that CCT patients (HS) have higher levels of DSBs in PBLCs than healthy volunteers (CG) and psychiatric patients without CCT (LS) (HS: 0.88±0.46 foci/cell; LS: 0.31±0.23 foci/cell; CG: 0.15±0.10 foci/cell). The difference between HS and control group was highly significant (p<0.001). Insecure-dismissing attachment as a psychological marker was related to an increase in the γH2AX foci in all groups, but especially in the CCT patients. There was no significant correlation in the γH2AX level to potential external genotoxic influences such as smoking and alcohol consumption. In PBLCs, spontaneous occurring γH2AX foci partially colocalized with 53BP1 and pATM, supporting the notion they represent DSBs. Overall, our data indicate that complex traumatization is a source of genotoxic stress that can cause systemic DNA damage, pointing to the importance of emotional early life experiences for the genetically determined health status in later life periods. The finding of CCT to be interrelated to genomic instability opens new opportunities for a deeper understanding of the link between emotional stress, DNA damage and somatic disorders.

Affective Change in Psychodynamic Psychotherapy: Theoretical Models and Clinical Approaches to Changing Emotions.

OBJECTIVES: Affective change has been considered the hallmark of therapeutic change in psychoanalysis. Psychoanalytic writers have begun to incorporate theoretically the advanced understanding of emotional processing and transformation of the affective neurosciences. We ask if this theoretical advancement is reflected in treatment techniques addressing the processing of emotion. METHODS: We review psychoanalytic models and treatment recommendations of maladaptive affect processing in the light of a neuroscientifically informed model of achieving psychotherapeutic change by activation and reconsolidation of emotional memory. RESULTS: Emotions tend to be treated as other mental contents, resulting in a lack of specific psychodynamic techniques to work with emotions. Manualized technical modifications addressing affect regulation have been successfully tested in patients with personality pathology, but not for psychodynamic treatments of axis I disorders. CONCLUSIONS: Emotional memories need to be activated in order to be modified, therefore, we propose to include techniques into psychodynamic therapy that stimulate emotional experience.

A case series of 223 patients with depersonalization-derealization syndrome.

BACKGROUND: Depersonalization-derealization syndrome (DDS) is an underdiagnosed and underresearched clinical phenomenon. In Germany, its administrative prevalence is far below the threshold for orphan diseases, although according to epidemiological surveys the diagnosis should be comparable frequent as anorexia nervosa for instance. Against this background, we carried out a large comprehensive survey of a DDS series in a tertiary mental health center with a specialized depersonalization-derealization clinic. To reveal differential characteristics, we compared the DDS patients, who consulted the specialized depersonalization-derealization clinic, with a group of patients with depressive disorders without comorbid DDS from the regular outpatient clinic of the mental health center. METHODS: The sample comprised 223 patients with a diagnosis of depersonalization-derealization-syndrome and 1129 patients with a depressive disorder but without a comorbid diagnosis of DDS. DDS patients were described and compared with depressive outpatients in terms of sociodemographic characteristics, treatment history, treatment wishes, clinical symptomatology, prevailing psychosocial stressors, family history of common mental disorders and history of childhood trauma. RESULTS: Despite the high comorbidity of DDS patients with depressive disorders and comparable burden with symptoms of depression and anxiety, the clinical picture and course of both patient groups differed strongly. DDS patients were younger, had a significant preponderance of male sex, longer disease duration and an earlier age of onset, a higher education but were more often unemployed. They tended to show more severe functional impairment. They had higher rates of previous or current mental health care utilization. Nearly all DDS patients endorsed the wish for a symptom specific counseling and 70.7 % were interested in the internet-based treatment of their problems. DDS patients had lower levels of self-rated traumatic childhood experiences and current psychosocial stressors. However, they reported a family history of anxiety disorders more often. CONCLUSION: In consideration of the selection bias of this study, this case series supports the view that the course of the DDS tends to be long-lasting. DDS patients are severely impaired, utilizing mental health care to a high degree, which nevertheless might not meet their treatment needs, as patients strongly opt for obtaining disorder specific counseling. In view of the size of the problem, more research on the disorder, its course and its optimal treatment is urgently required.

[What do Patients Experience between Group Sessions during Inpatient Psychotherapy? An Application of the Inter-Session-Questionnaire in Psychotherapeutic Hospitals]. / Was erleben Patienten in stationärer Psychotherapie zwischen den Gruppentherapie-Sitzungen? Eine Erprobung des Inter-Session-Fragebogens in der Klinik.

The study describes an application of the Inter-Session-Questionnaire (ISF) related to inpatient group psychotherapy. The instrument should be tested with the extension of differentiating intersession experiences related to the person of the therapist as well as the group. In a cross sectional study performed in 13 different hospitals, 702 patients were assessed. These patients were treated in rehab hospitals, acute hospitals as well as special hospitals providing treatment for eating disorders. The sample should be relatively representative for psychosomatic and psychotherapeutic hospitals in Germany. Besides the type of the hospital, we also analysed the influence of group characteristics (size of group, type of group and number of completed sessions) as well as the patients' sex. Surprisingly, there were almost no marked differences of inter-session-experiences related to the the therapist or the group. The profiles of the item judgements of the ISF were similar to those reported for outpatient and day treatment samples. Inter-session-experiences differed in part according to our expectation depending on the variables mentioned above which suggests to use the ISF in specific studies dealing with the process and outcome of inpatient group psychotherapy as well as the differentiation of relevant subgroups.

Minimization of Childhood Maltreatment Is Common and Consequential: Results from a Large, Multinational Sample Using the Childhood Trauma Questionnaire.

Childhood maltreatment has diverse, lifelong impact on morbidity and mortality. The Childhood Trauma Questionnaire (CTQ) is one of the most commonly used scales to assess and quantify these experiences and their impact. Curiously, despite very widespread use of the CTQ, scores on its Minimization-Denial (MD) subscale-originally designed to assess a positive response bias-are rarely reported. Hence, little is known about this measure. If response biases are either common or consequential, current practices of ignoring the MD scale deserve revision. Therewith, we designed a study to investigate 3 aspects of minimization, as defined by the CTQ's MD scale: 1) its prevalence; 2) its latent structure; and finally 3) whether minimization moderates the CTQ's discriminative validity in terms of distinguishing between psychiatric patients and community volunteers. Archival, item-level CTQ data from 24 multinational samples were combined for a total of 19,652 participants. Analyses indicated: 1) minimization is common; 2) minimization functions as a continuous construct; and 3) high MD scores attenuate the ability of the CTQ to distinguish between psychiatric patients and community volunteers. Overall, results suggest that a minimizing response bias-as detected by the MD subscale-has a small but significant moderating effect on the CTQ's discriminative validity. Results also may suggest that some prior analyses of maltreatment rates or the effects of early maltreatment that have used the CTQ may have underestimated its incidence and impact. We caution researchers and clinicians about the widespread practice of using the CTQ without the MD or collecting MD data but failing to assess and control for its effects on outcomes or dependent variables.

[How timely are the methods taught in psychotherapy training and practice?]. / Wie zeitgemäß ist der Verfahrensbezug in psychotherapeutischer Ausbildung und Praxis?

ISSUES: Even though many psychotherapists consider themselves to be eclectic or integrative, training and reimbursement in the modern healthcare system are clearly oriented toward the model of distinct psychotherapy approaches. Prompted by the proposition to favor general, disorder-oriented psychotherapy, we investigate how timely distinctive methods are that are taught in training and practice. METHODS: We reviewed the pertinent literature regarding general and specific factors, the effectiveness of integrative and eclectic treatments, orientation toward specific disorders, manualization and psychotherapeutic training. RESULTS: There is a lack of systematic studies on the efficacy of combining therapy methods from different approaches. The first empirical findings reveal that a superiority of combined versus single treatmentmethods has yet to be demonstrated. The development of transnosological manuals shows the limits of disorder-specific treatment.General factors such as therapeutic alliance or education about the model of disease and treatment rationale require specific definitions. CONCLUSION: Taking reference to a specific treatment approach provides important consistency of theory, training therapy and supervision, though this does not preclude an openness toward other therapy concepts. Current manualized examples show that methods and techniques can indeed be integrated from other approaches. Integrating different methods can also be seen as a developmental task for practitioners and researchers which may be mastered increasingly better with more experience.

[Psychodynamic psychotherapy, lifestyle and prevention]. / Psychodynamische Psychotherapie, Lebensstil und Prävention.

OBJECTIVES: Patients with mental disorders frequently manifest unhealthy behavior, which contributes to their increased risk for chronic mental and somatic diseases as well as excess mortality rates of 10 years and more. It also impairs their well-being and the course of mental disorders.We analyzed whether by addressing unhealthy behavior prevention can be integrated into psychodynamic psychotherapy. METHODS: We reviewed the literature on the role of unhealthy behavior for mental disorders, on the role of lifestyle risk factors in psychodynamic theory, and on barriers to the integration of addressing lifestyle in psychodynamic psychotherapy. RESULTS: Smoking, unhealthy dietary habits, and physical inactivity constitute dysfunctional behavior, resulting from maladaptive self-representations and an impairment of emotion-regulation capacities. In psychodynamic psychotherapy this maladaptive behavior can be addressed and treated as a kind of defensive behavior and resistance. CONCLUSION: We believe that by addressing unhealthy behavior prevention can become a crucial task for psychodynamic psychotherapists today.

[Unhealthy lifestyle in patients of a psychosomatic outpatient and consultation-liaison clinic]. / Ungesunder Lebensstil bei Patienten einer psychosomatischen Poliklinik und Konsilambulanz.

Patients with mental disorders have an increased risk for somatic diseases. Especially life style risk factors contribute to this increased risk. In order to identify targets for preventive measures, we aimed to determine the prevalence of an unhealthy lifestyle in a clinical sample and to analyze associations with severity of mental disorders and somatic complaints. We analyzed the medical records of n=1 919 outpatients, who were treated between 2009-2011 in the Department of Psychosomatic Medicine and Psychotherapy of the University Medical Center Mainz. 62.4% of the patients were physically inactive, 33.2% were smokers and 17.4% were obese. Lifestyle risk factors were associated with increased symptom burden and impairment. Smoking was strongly associated with more previous psychiatric or psychosomatic inpatient treatments. These results indicate an urgent need for targeting health behavior more rigorously in the treatment of patients with common mental disorders.

How is emotional awareness related to emotion regulation strategies and self-reported negative affect in the general population?

OBJECTIVE: The Levels of Emotional Awareness Scale (LEAS) as a performance task discriminates between implicit or subconscious and explicit or conscious levels of emotional awareness. An impaired awareness of one's feeling states may influence emotion regulation strategies and self-reports of negative emotions. To determine this influence, we applied the LEAS and self-report measures for emotion regulation strategies and negative affect in a representative sample of the German general population. SAMPLE AND METHODS: A short version of the LEAS, the Hospital Anxiety and Depression Scale (HADS) and the Emotion Regulation Questionnaire (ERQ), assessing reappraisal and suppression as emotion regulation strategies, were presented to N = 2524 participants of a representative German community study. The questionnaire data were analyzed with regard to the level of emotional awareness. RESULTS: LEAS scores were independent from depression, but related to self-reported anxiety. Although of small or medium effect size, different correlational patters between emotion regulation strategies and negative affectivity were related to implict and explict levels of emotional awareness. In participants with implicit emotional awareness, suppression was related to higher anxiety and depression, whereas in participants with explicit emotional awareness, in addition to a positive relationship of suppression and depression, we found a negative relationship of reappraisal to depression. These findings were independent of age. In women high use of suppression and little use of reappraisal were more strongly related to negative affect than in men. DISCUSSION: Our first findings suggest that conscious awareness of emotions may be a precondition for the use of reappraisal as an adaptive emotion regulation strategy. They encourage further research in the relation between subconsious and conscious emotional awareness and the prefarance of adaptive or maladaptive emotion regulation strategies The correlational trends found in a representative sample of the general population may become more pronounced in clinical samples.

Implementing panic-focused psychodynamic psychotherapy into clinical practice.

OBJECTIVE: To determine the effectiveness of manualized panic-focused psychodynamic psychotherapy (PFPP) in routine care in Germany. METHOD: German psychoanalysts were trained according to the PFPP manual. Fifty-four consecutive outpatients with panic disorder (with or without agoraphobia) were randomly assigned in a 2:1 ratio to PFPP or cognitive-behavioural therapy (CBT) plus exposure therapy. Subjects (female 57.4%; mean age 36.2 years) had high rates of psychiatric (68.5%) and somatic (64.8%) comorbidity, and previous psychiatric treatments (57.4%). Assessments were performed pre- and posttreatment and at 6-month follow-up. The primary outcome measure was the Panic Disorder Severity Scale. RESULTS: Both treatments were highly effective. In patients randomized to PFPP, remission was achieved in 44.4% at termination and by 50% at follow-up (CBT 61.1% and 55.6%, respectively). No significant differences were found. Emotional awareness, a posited moderator of good outcome in psychotherapies, was significantly higher in the CBT group at baseline. It was found to be a strong moderator of treatment effectiveness in both treatments. After adjusting for initial Levels of Emotional Awareness Scale (LEAS) scores, effect sizes (ESs) for the primary outcome were Cohen d = 1.28, from pre- to posttreatment, and d = 1.03, from pretreatment to follow-up, for PFPP, and d = 1.81 and 1.28 for CBT, respectively. CONCLUSIONS: PFPP was implemented effectively into clinical practice by psychoanalysts in the community in a sample with severe mental illness with large ESs. Assessment of LEAS may facilitate the identification of patients suitable for short-term psychotherapy. ( CLINICAL TRIAL REGISTRATION NUMBER: German Clinical Trials Register, DRKS00000245; Universal Trial Number, U1111-1112-4245).

Objectif : Déterminer l'efficacité de la psychothérapie psychodynamique axée sur la panique (PPAP), pratiquée d'après un manuel, dans les soins courants en Allemagne. Méthode : Les psychanalystes allemands ont été formés en conformité avec le manuel de PPAP. Cinquante-quatre patients ambulatoires consécutifs souffrant de trouble panique (avec ou sans agoraphobie) ont été affectés au hasard dans un rapport de 2:1 à la PPAP ou la thérapie cognitivo-comportementale (TCC) en plus d'une thérapie d'exposition. Les sujets (femmes 57,4 %; âge moyen 36,2 ans) avaient des taux élevés de comorbidités psychiatriques (68,5 %) et somatiques (64,8 %), et de traitements psychiatriques précédents (57,4 %). Des évaluations ont été exécutées avant et après le traitement, et au suivi de 6 mois. La principale mesure des résultats était l'échelle de gravité du trouble panique. Résultats : Les deux traitements ont été très efficaces. Chez les patients affectés à la PPAP, la rémission a été atteinte chez 44,4 % des sujets au terme du traitement, et chez 50 % au suivi (TCC 61,1 % et 55,6 %, respectivement). Aucune différence significative n'a été observée. La conscience émotionnelle, un modérateur présumé de bons résultats en psychothérapie, était significativement plus élevée dans le groupe de la TCC au départ. Elle s'est révélée être un bon modérateur de l'efficacité du traitement dans les deux traitements. Après correction des scores initiaux à l'échelle des niveaux de conscience émotionnelle (LEAS), l'ampleur de l'effet (AE) des premiers résultats était d de Cohen = 1,28, d'avant à après traitement, et d = 1,03, d'avant le traitement au suivi, pour la PPAP, et d = 1,81 et 1,28 pour la TCC, respectivement. Conclusions : La PPAP a été mise en œuvre efficacement dans la pratique clinique par des psychanalystes de la communauté dans un échantillon souffrant de grave maladie mentale et présentant de larges AE. L'évaluation par la LEAS peut faciliter l'identification des patients à qui la psychothérapie à court terme convient. (Numéro d'enregistrement d'essai clinique : German Clinical Trials Register, DRKS00000245; Universal Trial Number, U1111­1112­4245).

Neural correlates of deficits in pain-related affective meaning construction in patients with chronic pain disorder.

OBJECTIVE: Psychological and neural mechanisms of the affective dimension of pain are known to be disturbed in patients with chronic pain disorder. The aim of this functional magnetic resonance imaging study was to assess the neurofunctional and behavioral measures underlying the ability to construct pain-related affective meaning in a painful situation by comparing 21 clinically and psychometrically well-characterized patients with persistent non-nociceptive somatoform pain with 19 healthy controls. METHODS: The functional magnetic resonance imaging task involved viewing pictures depicting human hands and feet in different painful and nonpainful situations. Participants were asked to estimate the perceived pain intensity. These data were correlated with behavioral measures of depression, alexithymia, and general cognitive and emotional empathy. RESULTS: In a hypothesis-driven region-of-interest analysis, the healthy control group exhibited greater activation of the left perigenual anterior cingulate cortex than patients with pain (Montreal Neurological Institute coordinates (x y z)=-8 38 0; cluster extent=54 voxels; T=4.28; p=.006 corrected for multiple comparisons at cluster level). No group differences in the activation of the anterior insular cortex were found. Scores on self-assessment instruments (Beck Depression Inventory I, Interpersonal Reactivity Index, and 20-item Toronto Alexithymia Scale) did not influence neuroimaging results. CONCLUSIONS: Our results suggest that patients with chronic medically unexplained pain have an altered neural pain perception process owing to decreased activation of empathetic-affective networks, which we interpret as a deficit in pain-related affective meaning construction. These findings may lead to a more specific and detailed neurobiological understanding of the clinical impression of disturbed affect in patients with chronic pain disorder.

Levels of Emotional Awareness: a model for conceptualizing and measuring emotion-centered structural change.

The need to establish the efficacy of psychoanalytic long-term treatments has promoted efforts to operationalize psychic structure and structural change as key elements of psychoanalytic treatments and their outcomes. Current, promising measures of structural change, however, require extensive interviews and rater training. The purpose of this paper is to present the theory and measurement of Levels of Emotional Awareness (LEA) and to illustrate its use based on clinical case vignettes. The LEA model lays out a developmental trajectory of affective processing, akin to Piaget's theory of sensory-cognitive development, from implicit to explicit processing. Unlike other current assessments of psychic structure (Scales of Psychological Capacities, Reflective Functioning, Operationalized Psychodynamic Diagnostics) requiring intensive rater and interviewer training, it is easily assessed based on a self-report performance test. The LEA model conceptualizes a basic psychological capacity, affect processing. As we will illustrate using two case vignettes, by operationalizing implicit and explicit modes of affect processing, it provides a clinical measure of emotional awareness that is highly pertinent to the ongoing psychoanalytic debate on the nature and mechanisms of structural change.

[Childhood trauma and its relation to diagnoses and psychic complaints in patients of an psychosomatic university ambulance]. / Kindheitstraumatisierungen, psychische Beschwerden und Diagnosen bei Patienten in einer psychosomatischen Universitätsambulanz.

The Childhood Trauma Questionnaire (CTQ) was given to 1 439 patients of the outpatient- and consultation/liaison unit of the psychosomatic department of a university hospital. Self-reported emotional, sexual and physical abuse and emotional and physical neglect were related to the mental diagnoses and distress. Patients with childhood trauma (41,4%) reported higher levels of social anxiety, distress and physical complaints than patients without traumatizing childhood experiences. We found relations between emotional abuse and depression and personality disorders, physical abuse and somatoform disorders and sexual abuse and posttraumatic stress disorder. The observed relation between specific dimensions of childhood trauma and psychiatric diagnoses is consistent with reports on other clinical samples.

[Unresolved attachment and remembered childhood trauma in patients undergoing psychosomatic inpatient treatment]. / Aktuelles Bindungstrauma und Retrospektiv Erinnerte Kindheitstraumatisierung bei Patienten in Psychosomatischer Akutbehandlung.

OBJECTIVE: Clinical populations are characterised by a high level of childhood trauma and unresolved attachment status ("U"). Unresolved attachment status indicates the inability to integrate attachment-related dangers. Little is known about the interaction of traumatic childhood experiences and an unresolved attachment status. METHOD: We administered the Adult Attachment Projective Picture System (AAP) to 45 newly admitted psychosomatic inpatients. Childhood trauma (CTQ) and distress were assessed by self-report questionnaires, and cognitive-emotional development was evaluated with the Levels of Emotional Awareness Scale (LEAS).We explored whether unresolved (U) and resolved (R) attachment status differentiated the sample with regard to childhood trauma, distress and cognitive-emotional development. RESULTS: 53 % of the sample was characterized by the attachment status U; physical abuse and neglect as well as emotional neglect were correlated with a diminished ability to integrate trauma indicators in the AAP. A resolved attachment status was related to higher LEAS scores. CONCLUSION: The level of cognitive-emotional development may mediate the actual integration of attachment-related dangers and the interaction between actual attachment-related anxiety and past traumatic experiences.