Achim Knebel

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. ToM = Theory of Mind; GD = goal-directedness; LEAS = Levels of Emotional Awareness Scale; AT = Frith-Happé Animations Task.

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)

[Screening for depersonalization-derealization with two items of the cambridge depersonalization scale].

Depersonalization (DP) and derealization (DR) are considered to be highly underdiagnosed. Therefore the development of screening instruments is important. From the Cambridge Depersonalization Scale (CDS) two items were extracted discriminating best patients with clinical significant DP from patients without DP. These two Items were assembled to a short version of the CDS. This short version (CDS-2) was tested in a sample of 38 patients with clinical significant DP-DR and 49 patients without or only mild DP-DR. Scores were compared against clinical diagnoses based on a structured interview (gold standard). The CDS-2 was able to differentiate patients with clinical significant DP well from other groups (cut-off of CDS-2>or=3, sensitivity=78.9%, specifity=85.7%) and also showed high reliability (Cronbachs alpha=0.92). Therefore the CDS-2 can be considered as a useful tool for screening and identification of DP-DR.

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.

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.

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 ones 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.

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.

Emotionsregulation in der Allgemeinbevölkerung – Bevölkerungskennwerte des Emotion Regulation Questionnaire (ERQ)

Mit dem ERQ (Gross & John 2003; Abler & Kessler 2009) liegt ein validiertes Kurzverfahren mit 10 Items zur Erfassung gewohnheitsmasiger Praferenzen von Strategien zur Emotionsregulation (expressive Unterdruckung und Neubewertung) vor. Ziele der Studie waren die Untersuchung der Reliabilitat und Faktorenstruktur des Verfahrens, Ermittlung von Alters- und Geschlechtsnormen und Uberprufung des Zusammenhangs der beiden Skalen mit Angst und Depression, sowie soziodemographischen Merkmalen. In einer Reprasentativerhebung (N=2524) wurden Strategien zur Emotionsregulation (ERQ), Angst und Depression (HADS) sowie soziodemographische Merkmale erfasst. Konfirmatorisch konnte die Faktorenstruktur nicht voll bestatigt werden (Doppelladungen Item 8 und 9), dennoch wurde die ursprungliche Faktorenstruktur aus Grunden der Vergleichbarkeit beibehalten. Die internen Konsistenzen waren fur beide Skalen akzeptabel. Neubewertung korrelierte negativ mit Angst und Depressivitat, Unterdruckung dagegen positiv. Unterdruckung wurde in einer linearen Regressionsanalyse vorhergesagt durch Depressivitat, geringeres Bildungsniveau, mannliches Geschlecht und geringeres Haushaltseinkommen. Aufgrund der querschnittlichen Betrachtung muss offen bleiben, ob Neubewertung als protektiver und Unterdruckung als ungunstiger Faktor hinsichtlich der psychischen Gesundheit (Depression) gelten konnen, oder ob Lebensumstande und psychische Symptome schlieslich zu einer unterdruckenden Emotionsverarbeitung fuhren. Literatur: Abler, B. & Kessler, H. (2009). Emotion Regulation Questionnaire – Eine deutsche Version des ERQ von Gross & John. Diagnostica, 55, 144-152. Gross, J.J. & John, O.P. (2003). Individual differences in two emotion regulation processes: implications for affect, relationships, and well being. Journal of Personality and Social Psychology, 85, 348-362.