[Spontaneous carotid cavernous fistula in a case of hereditary hemorrhagic telangiectasia (Osler-Rendu) (author's transl)]. / Spontane Carotis-cavernosus-Fistel bei Morbus Osler-Rendu (Teleangiektasia hereditaria)

A 37-year-old woman suffered from headaches, right facial pain, double vision and occasional tinnitus. On examination there was only a slightly dilated right pupil, weakened corneal reflex and capillary bleeding from telangiectasia of both hands. Similar bleedings occured in her mother (mouth and hands) and son (nose). The arteriography of the right carotid artery showed a cavernous sinus fistula with a small shunt. Steady compression of the carotid artery by hand caused a marked improvement in the subjective symptomatology.

Similarities and differences in couples' grief reactions following a miscarriage: results from a longitudinal study.

Recent studies have documented grief and depressive reactions in women after a miscarriage. However, the men's reactions to their partner's experience have been neglected. In a controlled follow-up study, 56 couples were studied shortly after the miscarriage, and 6 (N = 47) and 12 months later (N = 45). The participants completed standardized questionnaires for depression, physical complaints, anxiety, and grief. Contrary to commonly held beliefs, men do grieve, but less intensely and enduringly than their partners. The manner in which they experience their grief is similar to that of the women, except that the men cry less and feel less need to talk about it. Unlike the women they do not react with an increased depressive reaction (compared to age- and sex-matched community control groups). Giving up their personal expectations, hopes for, and fantasies about the unborn child is a major source of grieving for both. Some men feel burdened by their wives' grief or depressive reactions. Conflicting reactions may affect the couples' interactions and promote depressive reactions in the women.

Alexithymia is no risk factor for exacerbation in spasmodic torticollis patients.

OBJECTIVE: To assess whether alexithymia is a risk factor for exacerbation in spasmodic torticollis (ST). METHODS: ST patients (2 x 10) with high vs. low alexithymia scores (mean score on the 20-item Toronto Alexithymia Scale [TAS-20]=69.2 vs. 28.7) were compared on physiological, motor and subjective responses to a cognitive and an emotional laboratory stressor. Changes in sustained abnormal head/shoulder positions and maximum range of motion (ROM) of the cervical spine were kinematically quantified. Skin conductance level (SCL), nonspecific skin conductance fluctuations (NS.SCF), heart rate (HR) and skin temperature (T) were measured. RESULTS: High alexithymia had no effect on the abnormal head posture or movements, but high-alexithymic ST patients showed generally increased levels of autonomic arousal (more NS.SCF, higher SCL; analysis of variance [ANOVA]: P=.016 and P=.051, respectively) under all experimental conditions. When ST symptom severity (TSUI-score) was partialled out, these group differences were somewhat reduced (analysis of covariance [ANCOVA]: P=.052 and P=.143). CONCLUSIONS: High alexithymia did not lead to increased abnormal head movements to stressors, but may result in a subtle increase in tonic level of sympathetic activity.

Alexithymia and symptom formation.

In regard to its clinical descriptive aspects the concept of alexithymia is based on a broad consensus of the investigators. However, with respect to its etiopathogenesis (hereditary, neurophysiological, sociogenic, psychogenic) and its relevance for the formation and maintenance of psychosomatic symptoms, this concept is controversial and unclear. In this context the psychodynamic aspects which are under discussion for the development and maintenance of alexithymic behavior are reported particularly from an object relations point of view. Some resulting principles for a possible psychotherapy of these patients are finally presented.

[Psychotherapy as a career]. / Psychotherapie als Beruf.

The author discusses the professional world and setting of a psychotherapist against the background of his subjective and personal experience manifested by typical polarities and fields of tension that exemplify in equal measure both the special features and the risks inherent in this "impossible vocation". The following problems and polarities are dealt with in detail: 1. Who chooses or is apt to become a psychotherapist? 2. Vocational training somewhere between method-oriented meticulousness and innovative keenness to experiment. 3. Self-image--projected (foreign) image. 4. Own life--foreign life. 5. Innermost reality and individual difficulty in respect of external reality and social integration.

[Theory and therapy of psychosomatic disorders]. / Zur Theorie und Therapie psychosomatisch Kranker.

Given the specific problems of the physically sick, the psychoanalytical therapy of psychosomatic patients normally calls for modification of therapy concepts that have proved viable for patients with mental disorders (neuroses) alone. The patients' difficulty in experiencing and expressing the experience of feelings as well as the fixation on one kind of physical complaint render it essential that the patient be unconditionally "accepted" and offered translation aids so that within the patient-doctor relationship the "mute" physical complaints can be assisted towards verbalisation and new emotional experiencing. The special kind of therapy form indicated is determined by the extent of healthy personality elements. Here, in addition to non-verbal procedures, techniques as combined inpatient-outpatient group psychotherapy, the subject of the present follow up study, have proved to be helpful.

Comments on theory and therapy of psychosomatic patients with a follow-up study.

Given the specific problems of the physically sick, the psychoanalytic therapy of psychosomatic patients normally calls for modification of treatment concepts that have proved viable for patients with mental disorders (neuroses) alone. The patients' difficulty in experiencing and expressing the experience of feelings as well as the fixation on one kind of physical complaint make it essential that the patient be unconditionally 'accepted' and offered translation aids so that within the patient-doctor relationship the 'mute' physical complaints can be assisted towards verbalisation and new emotional experiencing. The kind of special treatment forms indicated is determined by the extent of healthy personality elements. Here, in addition to nonverbal procedures, such techniques as combined inpatient--outpatient group psychotherapy, the subject of the present follow-up study, have proved to be helpful.

Combined inpatient and outpatient group psychotherapy: a therapeutic model for psychosomatics.

A special strategy of psychotherapeutic approach to psychosomatic patients is described including a 3-month period of inpatient and a 2-year period of outpatient group psychotherapy. Additional therapeutic procedures applied during the time of hospitalization are a special kind of sensitivity training ('sensual awareness' -- 'konzentrative Bewegungstherapie') and analytic ergotherapy. The therapeutic techniques used are psychoanalytic with special regard to the scenic figures which arise during the course of a session. The 'scenic function of the ego' represented in, e.g., certain body movements, sitting-arrangments, and talking-sequences offers the opportunity of a possible access to the often poor phantasy life of the psychosomatic patient, suffering from what we call the Pinocchio syndrome. The key structure of the model implies the arrangement fixed prior to the onset of therapy between patients and therapist, to stay together as a closed in- and outpatient group for 2 years. This enables the patients to take the risk of new emotional experiences under the cover of protected living conditions in the hospital, as well as the chance to check and confirm these experiences under the pressure of the regular social conditions they live in.

[Alcohol and malabsorption in the pathogenesis of peripheral and central nerve damage (author's transl)]. / Alkohol und Malabsorption in der Genese peripherer und zentraler Nervenschäden

Xylose absorption was measured, within ten days of being admitted to hospital, in 54 alcoholics with neurological abnormalities. Small-intestine malabsorption was demonstrated in 19. Classified according to the customary clinical diagnoses, 16 of 49 with alcohol polyneuropathy had abnormal values, with no correlation to nerve conduction velocity. There was also no difference among 14 in predelirium and eight in delirium. However, all four patients with Wernicke's encephalopathy had a malabsorption syndrome. These results are similar, also quantitatively, to those reported in the literature in alcoholics without neurological signs. Alcohol may be involved in the pathogenesis of alcoholic polyneuropathy both as a toxic factor and also via nutritional deficiency.

Empirical evidence of alexithymia.

In spite of the wide discussion on alexithymia for the last years, empirical research aimed at its testing or validation has been remarkably scarce. Two basic approaches can be distinguished: psychometric investigations (for instance, using questionnaires) based upon previous operationalization of 'alexithymic' behavior and direct observation of behavioral patterns in different types of individuals. This second approach entails the relating of these behavioral features to alexithymia. As an example, our research results from these situations will be presented and discussed. The emphasis will be placed upon psychodynamic models. It is shown that the conditions under which the exploration is carried out are particularly important for the manifestation of 'alexithymic' characteristics in speech.

The integrated psychosomatic inpatient unit. A new approach to hospital medical care.

In contrast to the liaison psychiatry model, various types of psychosomatic inpatient units have been established successfully especially in Europe. Since Simmel's first attempt, they all use the unique possibility to create a special milieu of psychosomatic understanding and treatment of patients with all kinds of illnesses and somatic diseases. To fulfill this goal, the psychosomatic unit has to rely on three conditions: it must (1) be institution-independent as well as integrated within a large hospital system; (2) provide psychotherapeutic and somatic care of equally high standard, and (3) have the possibility to keep the patient sometimes for a longer duration than in other (e.g. internal) medical inpatient units. Principles, experiences and results of a psychosomatic unit with 60 beds integrated in a large municipal hospital are presented as an example for this promising approach to modern medicine.

Success and failure in psychotherapy: hypotheses and results from the Heidelberg Follow-Up Project.

Within the Heidelberg Follow-Up Project all treatments of the clinic regardless of the type of psychodynamic technique used are investigated. The outlet is both prospective and retrospective. There are four points of investigation: (1) immediately after the first contact with the hospital (2) at the beginning; (3) at the end of therapy, and (4) after a 2-year follow-up period. Immediately after the first contact with the patient a test battery (Giessen Test, Holzman Inkblot Technique, Gottschalk-Gleser Method, symptom checklist) is administered. This is repeated after a waiting period at the beginning of therapy, where in addition the therapist formulates a psychodynamic hypothesis and defines 3-5 individual treatment goals in connection with the individual pathology of the patient. At the end of the therapy the tests are repeated and the therapist assesses the success or failure of the therapy with regard to symptoms, object relations and psychodynamic change, while the patient fills out a special questionnaire dealing with his personal view of the therapy, the therapist and his own treatment experiences. The first results of about 100 combined inpatient and outpatient psychotherapies are presented (third test-round at the end of treatment). The results are discussed on the basis of the involved tests and ratings with respect to success and failure in the view of patients, therapists and independent clinical experts. Since the study is still under way, reports of the follow-up data are not yet evaluated.

Indication in psychotherapy on the basis of a follow-up study.

The problem of indication is a central one of psychotherapy research. Unfortunately up to now only few scientific results contribute to a therapist's decision in selecting patients for a specific therapeutic setting. Thus, indication and outcome research should be combined. A critical view on traditional research strategies demonstrates that psychotherapy research should replace the ideal of normative and general rules by the rational investigation of one's own therapeutic practice. From this point of view some results of the Heidelberg Follow-Up Project of 110 psychotherapies which were started on an inpatient and continued on an outpatient basis are presented. Based on the therapeutic changes of these 110 patients the question is investigated whether the decisions of the indications correspond with the therapeutic goals of the treatment models. Moreover, the question is discussed what kind of success a specific treatment model offers for 'problem patients'.

[Psychological factors of non-ulcer dyspepsia]. / Psychologische Faktoren der Non-Ulcer Dyspepsia (NUD).

Given the absence of any demonstrable organic reason for non-ulcer dyspepsia, and the well known fact, that the psyche influences stomach function, it is widely held, that psychological factors cause NUD. To now, studies are concerned with the psychopathology and personality of NUD-patients, their illness behaviour, and with the relation between stress and abdominal pain. A critical review of these studies revealed, that among the psychological variables mainly anxiety and illness behaviour seems to play a central role in NUD. However, future studies should focus more on the distinction towards other functional disorders and on the differentiation within the heterogeneous group of NUD-patients (especially with regard to physiological variables). Besides this, it seems rewarding to examine the so far scientifically neglected group of subjects with abdominal pain, who do not contact a physician.

[The effectiveness of the initial interview at a psychosomatic- psychotherapeutic outpatient unit]. / Uber den Nutzen von Beratungsgesprächen einer psychosomatisch-psychotherapeutischen Ambulanz.

In a cross sectional study of 1945 consecutive patients seen at a psychosomatic-psychotherapeutic outpatient unit between 1993 and 1995, we investigated how the therapists assessed the effectiveness of their work and what correlations there were with patient characteristics and with the way the therapists conducted the initial session. The therapists' ratings indicated that about two thirds of the patients benefited from the consultation. In the multivariate analysis of the data the most important determinants of effectiveness were found to be the patient's motivation, the ICD diagnosis, the patient's level of personality organisation and the reason for the consultation. In addition, we did a one-year follow-up of 260 patients to analyse the determinants that help patients to agree to the proposed treatment plan. Of the 235 patients for whom treatment was recommended, 174 (74%) actually began a treatment program. Our results show that a patient is more likely to accept the treatment recommendation if the therapist conducts the session in a certain way (e.g. provides detailed information) and helps the patient to find an appropriate therapist.