Carl Eduard Scheidt

Somatoform disorders as disorders of affect regulation: A study comparing the TAS-20 with non-self-report measures of alexithymia

OBJECTIVE To determine the role of undifferentiated and dysregulated affects in somatoform disorders by using a multimethod assessment approach of alexithymia. METHODS Forty patients with ICD-10 somatoform disorders (SoD) and 20 healthy controls, matched for age, education and sex, were included in the study. Alexithymia was assessed using the Toronto Alexithymia Scale (TAS-20), the Affect Consciousness Interview (ACI), and the Levels of Emotional Awareness Scale (LEAS). All classifications were made blinded with regard to clinical status. RESULTS Scores of the ACI and the TAS-20 showed that alexithymia is higher in SoD than in healthy controls. No differences were found on the LEAS. In terms of the multidimensionality of the alexithymia construct, our results indicate a specific positive association between SoD and a proneness to experience undifferentiated affects. The three subfactors of the TAS-20 were differentially related to non-self-report measures of alexithymia and to negative affectivity (NA). Only the cognitive facet of the TAS-20 (externally oriented thinking [EOT]) was related to the LEAS and the ACI. In contrast, the affective facets of the TAS-20-difficulties identifying feelings (DIF) and difficulties describing feelings (DDF)-were substantially related to NA. CONCLUSION The findings highlight the important role of impaired affect regulation and NA in the process of somatization.

Somatoform disorders as disorders of affect regulation: A development perspective

This paper considers the role of disturbances in affect regulation in the development and course of somatoform disorders. We first give an overview of contemporary theories in the field of psychosomatic medicine that links deficits in emotion regulation to the process of somatization, and then review recent empirical research that focuses on the association between affect regulation and somatoform disorders, with an emphasis on studies investigating the alexithymia construct. Overall, the findings suggest that somatoform disorders are linked to a diminished capacity to consciously experience and differentiate affects and express them in an adequate or healthy way. It must be noted, however, that this result has not been obtained exclusively for somatoform disorders. A promising approach to further our understanding of the developmental roots of impaired affect regulation in somatoform disorders is attachment research. The attachment research reviewed in this paper indicates that a dismissing status of attachment is linked to defensive forms of processing and expressing emotions. We present some new data that not only provide empirical support of a high proportion of dismissing attachment in somatoform disorders but also suggest that the degree to which somatoform disorder patients employ dismissing attachment strategies is strongly related to affect dysregulation. Finally, some implications for psychotherapeutic interventions in patients with somatoform disorders are considered.

Attachment Representation and Illness Behavior in Somatoform Disorders

Somatoform disorders are characterized by high health care utilization and conflictual interactions with health care providers. The aim of the present study was to explore whether patterns of insecure attachment are a prominent feature of somatoform disorder. In addition, the links between insecure attachment and health care utilization were evaluated. Thirty-seven patients with an International Classification of Diseases, 10th Revision diagnosis of somatoform disorders and 20 healthy control subjects matched for age, sex, and education were administered the Adult Attachment Interview. Psychological symptoms and health care utilization were assessed using various self-report measures. There was a clearly higher incidence of insecure attachment in the somatoform group compared with the nonclinical control subjects. In the somatoform group, dismissing attachment occurred approximately twice as frequently as the preoccupied pattern of attachment. The results provide evidence for an association between health care utilization and insecure attachment. Insecure attachment in somatoform disorder may underlie problems in interpersonal functioning and in health care behavior.

Alexithymia and attachment representation in idiopathic spasmodic torticollis.

We investigated alexithymia and the mental representation of attachment in idiopathic spasmodic torticollis (IST). It was hypothesized a) that alexithymia in IST is more prevalent than in a nonclinical control group and b) that significant correlations emerge between alexithymia and a dismissing attachment representation. Twenty patients with IST and 20 healthy controls matched for age and sex were administered the Toronto Alexithymia Scale (TAS-20) and the Adult Attachment Interview (AAI). Attachment was classified using the Attachment Interview Q-sort. IST patients scored significantly higher on the measure of alexithymia than subjects in the comparison group. In IST a dismissing attachment representation was significantly more frequent than in the control group. Across the total sample, externally oriented thinking correlated positively with dismissing attachment, and both externally oriented thinking and difficulty communicating feelings (two of the three subscales of the TAS-20) correlated inversely with secure attachment. Alexithymia is more prevalent in IST than in normals. As was hypothesized, alexithymia in adults is significantly interrelated with the mental representation of attachment.

Benefits and challenges in practice-oriented psychotherapy research in Germany: The TK and the QS-PSY-BAY projects of quality assurance in outpatient psychotherapy

Abstract Objective: Two patient-focused long-term research projects performed in the German outpatient psychotherapy system are focused on in this article. The TK (Techniker Krankenkasse) project is the first study to evaluate a quality assurance and feedback system with regard to its practical feasibility in German routine care. The other study (“Quality Assurance in Outpatient Psychotherapy in Bavaria”; QS-PSY-BAY) was designed to test a new approach for quality assurance in outpatient psychotherapy using electronic documentation of patient characteristics and outcome parameters. In addition this project provides the opportunity to analyze data on health-related costs for the patients undergoing outpatient psychotherapy. Method: Both projects and their results indicating high effect sizes are briefly described. Results: From the perspectives of the research teams, advisory boards and other stakeholders, the experiences with these projects are discussed focusing on obstacles, challenges, difficulties, and benefits in developing and implementing the studies. The triangle collaboration of therapists, researchers, and health insurance companies/health service institutions turned out to be fruitful in both studies. Conclusions: Despite some controversies between the partners the experiences indicate the importance of practiced-research collaborations to provide relevant information about the delivery of outpatient psychotherapy in the health system.

Is brief psychodynamic psychotherapy in primary fibromyalgia syndrome with concurrent depression an effective treatment? A randomized controlled trial

OBJECTIVE There are no studies investigating the efficacy of short-term psychodynamic psychotherapy in primary fibromyalgia syndrome (FMS). We conducted a randomized controlled trial evaluating an adapted form of individual short-term psychodynamic psychotherapy (ASTPP) versus primary care management (TAU). The study focused on FMS patients with psychiatric comorbidity. METHODS Forty-six female patients with FMS and an International Classification of Diseases, 10th Revision diagnosis of a comorbid depression or anxiety disorder were recruited in a hospital setting. Participants were randomized to receive either ASTPP (25 sessions, 1 session/week) or TAU (4 consultations/6 months). Outcome measures included the Fibromyalgia Impact Questionnaire (FIQ), the Hospital Anxiety and Depression Scale (HADS), the Pain Disability Index, the Symptom Checklist 27 and the health-related quality of life. Primary endpoints of the outcome assessment were the FIQ total score and the HADS depression scale at 12-month follow-up. RESULTS Both treatments were effective in reducing the FIQ total score (ES=0.56 and ES=0.75, respectively). Intent-to-treat analyses failed to provide evidence suggesting a marked superiority of individual psychodynamic psychotherapy as compared to TAU. CONCLUSIONS A high-standard routine treatment focusing on the improvement of health behavior and including antidepressant and analgesic medication is equally effective as a short-term individual psychodynamic psychotherapy in improving fibromyalgia-related symptoms.

Are individual differences of attachment predicting bereavement outcome after perinatal loss? A prospective cohort study

OBJECTIVE The purpose of this study was to examine the influence of attachment, social support and the quality of the current partnership on the outcome of bereavement after perinatal loss. METHODS In a prospective cohort design 33 women after perinatal loss were approached on admission to hospital and reassessed four weeks, four months and nine months later. The initial assessment included the Adult Attachment Interview and self-report questionnaires for social support and quality of the current partnership. Bereavement outcome was assessed using measures of grief (MTS), depression and anxiety (HADS), psychological distress (BSI), somatisation (BSI-SOM) and symptoms of PTSD (PDS). RESULTS All measures of outcome showed a significant improvement over time. Standardized effect sizes between the initial assessment and nine month follow-up ranged between .36 for anxiety (HADS) and 1.02 for grief (MTS). Social support, quality of the partnership and secure attachment correlated inversely, and insecure preoccupied attachment correlated positively with the outcome measures. Preoccupied attachment was included as a predictor in two multivariate statistical models of non-linear regression analysis, one with somatisation (adjusted R2=.698, P=.016), the other with posttraumatic stress symptoms at nine month follow-up (adjusted R2=.416, P=.002) as target variable. Initial assessment scores of psychological distress predicted the course of the respective measure during follow-up (adjusted R2=.432, P=.014). CONCLUSION Attachment, social support and the quality of the current partnership have an impact on the course of bereavement after perinatal loss. Secondary prevention after the event may focus on these factors in order to offer specific counselling and support.

Attachment Representation and Cortisol Response to the Adult Attachment Interview in Idiopathic Spasmodic Torticollis

Objective: The study investigates individual differences in the mental representation of attachment and their impact on the cortisol response to psychosocial stress in idiopathic spasmodic torticollis (IST). It was hypothesized (a) that in IST insecure attachment is more prevalent than in a non-clinical control group and (b) that subjects with dismissing attachment respond with higher physiological arousal to a specific stimulus activating the attachment behavioural system than subjects with secure attachment. Method: 20 patients with IST and 20 healthy controls matched for age and sex underwent the Adult Attachment Interview, an hour-long, semiclinical interview on attachment experiences. During the interview salivary cortisol levels were monitored. The subjects’ mental state with regard to attachment was classified using the attachment Q-sort method. Anxiety and depression were measured as potential covariates of the adrenocortical stress response. Results: Compared to the non-clinical group, dismissing attachment was strongly overrepresented in IST. In IST, but not in the healthy control group, dismissing attachment correlated with an elevated cortisol response to the interview. Conclusion: In clinical, but not in non-clinical samples dismissing attachment may be associated with increased vulnerability to psychosocial stress. The factors contributing to this interaction are not yet fully elucidated.

Inpatient versus Day Treatment for Bulimia Nervosa: Results of a One-Year Follow-Up

Descriptive statistics were used to characterize the sample. Differences between groups were tested by t tests, analysis of variance and 2 statistics (all tests two-sided). Change effects were tested by ANOVA for repeated measurement. The data were administered using Microsoft Access 2002 databases. The statistical analysis was performed with SAS-JMP version 6. Medication and outpatient treatment after discharge were controlled for. We report on complete (paired) data as well as intention-to-treat analyses (last value carried forward, in order to replace missing data), as relevant covariates like medication or maintenance treatment after discharge are only known if patients were seen at followup. The groups were neither significantly different when starting treatment nor on any outcome variable at discharge [10] . The small sample size prevents testing significance of equivalence, but the differences of means between groups could be considered to be clinically irrelevant. Of all patients, 85.4% could be evaluated at 12-month follow-up (complete data sets: 35/43). Primary Outcome (EDI-2). We found a statistically significant difference in the improvement of bulimic symptoms with an advantage for the day clinic program (discharge ] 12-month follow-up, time ! setting; paired data: exact F = 11.41, df = 1,34, p ! 0.002; intention to treat: exact F = 4.99, df = 1,41, p ! 0.03). This result was stable when controlling for medication or intensity of psychotherapy after discharge ( table 1 ). One third (5 of 15) of the patients that were treated as inpatients deteriorated compared to 1 patient from the day clinic group (1 of 21; Fisher’s exact test: p ! 0.005; no intention-to-treat analysis possible, as deterioration is undefined for patients missing at 12-month follow-up). Secondary Outcomes. We found highly significant interactions between setting and frequency ratings of binges (SIAB-EX: discharge ] 12-month follow-up, time ! setting, exact F = 14.4, df = 1,35, p ! 0.0008), also after controlling for medication and outpatient psychotherapy sessions. Day clinic patients showed a significantly higher reduction in the number of binges. This was not the case for purging behavior (SIAB-EX: discharge ] 12month follow-up, time, exact F = 0.000, df = 1,34, p ! 0.999; table 1 ). Using the criteria of full and partial remission, we found no statistically significant difference between settings: 1 year after inpatient treatment, 9 of 15 patients still fulfilled all criteria of the disorder, 3 had a partial remission and 3 patients were in full remission. There were missing data on 6 further cases. One year after day clinic treatment, 10 of 22 patients were still fully symptomatic, 6 in partial remission and 6 in full remission (all tests nonsignificant). There was no significant change in general psychopathology after treatment (discharge ] 12-month follow-up; GSI, SCL-90R; table 1 ) and no significant difference between the 2 groups (time ! setting; paired data: exact F = 0.003, df = 1,33, p ! 0.970; intention to treat: exact F = 0.371, df = 1,41, p ! 0.546). There are no randomized controlled trials comparing inpatient and day clinic treatment for bulimia nervosa [1] , although naturalistic studies give evidence of the effectiveness of day clinic [2–5] as well as inpatient treatment [6–8] . As day clinic treatment is more cost-effective [9] , it might be an alternative to inpatient care if it comprises a comparable ‘dose’ of interventions and similar treatment components. The aim of this study was a comparison of day clinic and inpatient treatment for bulimia nervosa including a 3and 12-month follow-up. We reported in detail on the design and 3-month outcome in a previous article [10] and present the results of the 12-month follow-up in this letter. Fifty-five of 204 patients screened at our outpatient clinic fulfilled the inclusion criteria [10] , gave informed consent and could be randomized. Twenty-one percent were lost before admission. Finally, 22 patients could be treated in the day clinic and 21 in the inpatient group. The treatments represent common multimodal inpatient and day clinic programs in Germany, integrating psychodynamic, cognitive-behavioral and systemic components. Medication (selective serotonin reuptake inhibitor) was given when needed [10] . Treatment length was about 12 weeks of inpatient or day clinic treatment, with some flexibility ( 8 1–3 weeks) [10] . Before treatment, at discharge as well as at 3and 12-month follow-up, eating behavior and general psychopathology was assessed by the EDI-2 [11, 12] , the expert rating form of the SIAB-EX [13] and the SCL-90-R [14, 15] . Diagnoses were given according to SCID I+II [16] . At 12-month follow-up, treatment since discharge, life events and medication were documented. As the primary outcome criterion, a change on the EDI scale ‘bulimia’ was used [discharge ] 1 year after discharge (12-month follow-up)]. Deterioration was defined as a worsening on this scale (difference 1 RCI = 2.4 and score 1 C = 4.5 [17] ). As secondary outcomes we assessed remission rates, changes in frequency of binges and vomiting (SIAB-EX) and changes in overall psychopathology (global severity index, GSI, SCL-90-R). Complete remission was defined according to the criteria of a large multicenter trial of inpatient treatment for eating disorders [7, 10] . Published online: July 24, 2009

Self-reported symptoms of pain and depression in primary fibromyalgia syndrome and rheumatoid arthritis

Abstract Background: Primary fibromyalgia syndrome (FMS) is associated with substantial psychiatric comorbidity. The aim of the present study was to investigate the interrelationship between self-reported symptoms of depression and pain in FMS compared with rheumatoid arthritis (RA). Methods: In a cross-sectional study, 100 patients with FMS and 50 patients with RA were compared with regard to depression and psychopathology using the Symptom Check List (SCL-27). Group comparisons were calculated by parametric and non-parametric tests. The association between pain intensity and depression was determined by correlation analyses and multivariate statistical procedures (CATREG). Results: Pain intensity was significantly higher in FMS compared with RA. FMS patients also scored significantly higher on all subscales of the SCL-27 including the depression scale and the General Symptom Index (GSI) (P < 0.001). These group differences remained stable even after correcting for pain intensity. Correlation analyses revealed an association between pain intensity and depression in FMS but not in RA (R = 0.419, P < 0.001). Conclusion: FMS patients in tertiary referral centers suffer from higher levels of pain intensity than RA patients. Depression predicts levels of pain in FMS but not in RA and is therefore an important target of intervention.