Theory of mind and emotional awareness deficits in patients with somatoform disorders.

OBJECTIVE: To explore whether deficits are present in the mental representation of emotion signals and whether these are related to more general deficits in Theory of Mind (ToM) functioning test. To test this hypothesis in patients suffering from somatoform disorders, we used the Frith-Happé-Animations Task (AT)-an established ToM measure. We previously demonstrated that somatization in psychiatric patients is associated with decreased emotional awareness as measured by the Levels of Emotional Awareness Scale (LEAS). These findings suggest that individuals with decreased emotional awareness often fail to experience affective arousal as feelings and instead experience emotional distress somatically. METHODS: We administered the AT and the LEAS to 30 hospitalized patients with somatoform disorders and 30 healthy controls matched for sex, age, and educational level. Emotional awareness on the LEAS, the emotional content of AT narratives, and ToM content on the AT were assessed. RESULTS: Patients with somatoform disorders scored significantly lower on the LEAS than healthy controls. Patients also demonstrated both reduced emotional content and reduced ToM functioning on the AT compared with control subjects. Deficits in ToM functioning in patients overlapped with but were not fully explained by deficits in the emotional content of animation narratives. The combination of ToM functioning and LEAS scores permitted a correct classification of 80% of patients and 73% of controls. CONCLUSIONS: Patients with somatoform disorders requiring inpatient treatment manifest deficits in both emotional awareness and ToM functioning. These deficits may underlie the phenomenon of somatization.

[Social phobia--an anxiety disorder underdiagnosed in outpatient and consultation-liaison service?]. / Soziale Phobie--eine im psychosomatischen Ambulanz- und Konsildienst unterdiagnostizierte Angsterkrankung?

Social fears are common, whereas Social Phobia is diagnosed infrequently. Therefore, we compared the clinical diagnoses (ICD-10) in an outpatient and CL service of a psychosomatic university hospital to patients' self ratings in social fears on the Liebowitz Social Anxiety Scale (LSAS). Over the course of one year 688 patients could be characterized regarding their clinical diagnoses, LSAS-scores, symptom severity (SCL-90R) and psychosomatic complaints (GBB-24). Patients were assigned to three groups by their levels of social fears (LSAS). Social Phobia was diagnosed rarely by clinicians (5.5%), but generalized social fears (LSAS>60) were commonly reported by patients (14.6%). Patients with social fears reported higher distress and more psychosomatic complaints. They were more often diagnosed with Depression, Agoraphobia or Panic Disorder and Posttraumatic Stress Disorder. Effective manualized psychotherapeutic short-term approaches are available for patients with Social Phobia. Therefore, a better clinical identification of this group of patients is desirable.

[Depersonalization-derealization in the psychosomatic outpatient and consultation-liaison service]. / Depersonalisation-derealisation im psychosomatischen Ambulanz- und Konsildienst.

OBJECTIVES: First, to determine the prevalence of symptoms of depersonalization (DP) and derealization (DR) in psychosomatic consultation-liaison patients and psychosomatic outpatients; second, to examine how DP-DR contributes to differences among patients with respect to the spectrum of other diagnoses, disease severity, history of psychotherapeutic outpatient treatment and psychiatric/psychosomatic inpatient treatments as well as to self-rated distress. METHODS: The sample comprises n=825 patients. In order to analyze the effects of DP-DR, the sample was divided into three subgroups of DP-DR severity: patients without symptoms of DP-DR, patients with mild DP-DR, and patients with clinical significant DP-DR. RESULTS: 34.8% patients had no symptoms of DP-DR, 48.2% mild DP-DR, and 17.0% scored clinical significant DP-DR. The severity of DP-DR was associated with other indicators of self- and observer-rated disease severity as well as with greater psychosomatic and psychiatric health care use. However, after adjustment for indicators of disease severity, the significant association between the use of psychotherapeutic outpatient treatment and psychiatric or psychosomatic inpatient treatment in the medical history disappeared. CONCLUSIONS: Symptoms of DP-DR are very common in psychosomatic patients. They represent an indicator of disease severity, which however is paradoxically not associated with increased use of psychotherapeutic health care.

Altered orientation of spatial attention in depersonalization disorder.

Difficulties with concentration are frequent complaints of patients with depersonalization disorder (DPD). Standard neuropsychological tests suggested alterations of the attentional and perceptual systems. To investigate this, the well-validated Spatial Cueing paradigm was used with two different tasks, consisting either in the detection or in the discrimination of visual stimuli. At the start of each trial a cue indicated either the correct (valid) or the incorrect (invalid) position of the upcoming stimulus or was uninformative (neutral). Only under the condition of increased task difficulty (discrimination task) differences between DPD patients and controls were observed. DPD patients showed a smaller total attention directing effect (RT in valid vs. invalid trials) compared to healthy controls only in the discrimination condition. RT costs (i.e., prolonged RT in neutral vs. invalid trials) mainly accounted for this difference. These results indicate that DPD is associated with altered attentional mechanisms, especially with a stronger responsiveness to unexpected events. From an evolutionary perspective this may be advantageous in a dangerous environment, in daily life it may be experienced as high distractibility.

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).

Base rates for depersonalization according to the 2-item version of the Cambridge Depersonalization Scale (CDS-2) and its associations with depression/anxiety in the general population.

BACKGROUND: Recently, the two item version of the Cambridge Depersonalization Scale (CDS-2) has been validated in a clinical sample and has demonstrated that it is a useful tool for the detection of clinically significant depersonalization (DP). In order to provide a framework for the interpretation of the CDS-2 scores the aim of this study was to achieve normative data of a representative sample of the German population and to evaluate the associations with depression, anxiety and sociodemographic characteristics. METHODS: A nationally representative face-to-face household survey was conducted during the mid of 2009 in Germany. The sample comprised N = 2512 participants. The survey questionnaire consisted of the CDS-2, the Hospital Anxiety and Depression Scale, and demographic characteristics. RESULTS: Case level of DP was found for 3.4% of the participants without significant sex and age differences. Although DP was strongly associated with depression and anxiety, principal component analysis clearly supported the distinctiveness of the psychopathological syndromes of depression, anxiety and DP. LIMITATIONS: A criterion standard diagnostic interview for DP, anxiety and depression was not included. CONCLUSIONS: The results provide a framework for the interpretation of the CDS-2 scores and support the view that DP is a common and distinct psychopathological syndrome.

Patients' psychological well-being and resilient coping protect from secondary somatoform vertigo and dizziness (SVD) 1 year after vestibular disease.

Secondary somatoform dizziness and vertigo (SVD) is an underdiagnosed and handicapping psychosomatic disorder, leading to extensive utilization of health care and maladaptive coping. Few long-term follow-up studies have focused on the assessment of risk factors and little is known about protective factors. The aim of this 1-year follow-up study was to identify neurootological patients at risk for the development of secondary SVD with respect to individual psychopathological disposition, subjective well-being and resilient coping. In a prospective interdisciplinary study, we assessed mental disorders in n=59 patients with peripheral and central vestibular disorders (n=15 benign paroxysmal positional vertigo, n=15 vestibular neuritis, n=8 Menière's disease, n=24 vestibular migraine) at baseline (T0) and 1 year after admission (T1). Psychosomatic examinations included the structured clinical interview for DSM-IV, the Vertigo Symptom Scale (VSS), and a psychometric test battery measuring resilience (RS), sense of coherence (SOC), and satisfaction with life (SWLS). Subjective well-being significantly predicted the development of secondary SVD: Patients with higher scores of RS, SOC, and SWLS at T0 were less likely to acquire secondary SVD at T1. Lifetime mental disorders correlated with a reduced subjective well-being at T0. Patients with mental comorbidity at T0 were generally more at risk for developing secondary SVD at T1. Patients' dispositional psychopathology and subjective well-being play a major predictive role for the long-term prognosis of dizziness and vertigo. To prevent secondary SVD, patients should be screened for risk and preventive factors, and offered psychotherapeutic treatment in case of insufficient coping capacity.

Regulation of emotions in the community: suppression and reappraisal strategies and its psychometric properties.

OBJECTIVE: The German Version of the Emotion Regulation Questionnaire (ERQ) has recently been published. The questionnaire investigates two common emotion regulation strategies (10 items) on two scales (suppression, reappraisal). Major aims of the study were to assess the reliability and factor structure of the ERQ, to determine population based norms and to investigate relations of suppression and reappraisal to anxiety, depression and demographic characteristics. METHODS: In a representative community study (N=2524) we assessed emotion regulation strategies, anxiety, depression (Hospital Anxiety and Depression Scale), and demographic variables. The mean age of the participants was 49.4 (SD 18.2) years. 55.5% were female. The age-groups were represented in comparable proportions. The representativeness of the sample was ensured by drawings of ADM (Arbeitskreis Deutscher Marktforscher) samples und by comparison with the data of German Federal Statistical Office. RESULTS: Confirmatory factor analysis could not fully confirm the original factor structure, we kept the original scaling, except a modification regarding item 8. Internal consistencies were acceptable for the original and the modified version: reappraisal (Cronbach's alpha = 0.82) and suppression (alpha = 0.76). Norms are presented as percentile scores for age groups and gender. Reappraisal correlated negative with anxiety and depression, whereas we could find a positive relationship of suppression with anxiety and depression. In a linear regression model suppression was predicted by depression, a lower level of education, male gender, and lower income. CONCLUSIONS: The ERQ is a short instrument to assess emotion regulation strategies economically, e.g. in larger community based studies. We could demonstrate sufficient psychometric properties of the German version of the ERQ: reliability, factor structure and indicators for construct validity. Because of the cross sectional character of our study it remains unclear whether reappraisal is protective and suppression is unfavourable regarding mental health or whether life circumstances and psychic symptoms lead to a suppression of emotions.