Carsten Spitzer

Alexithymia and Outcome in Psychotherapy

Background: About 25% of all patients seeking psychotherapeutic treatment are considered to be alexithymic. Alexithymia has been assumed to be negatively associated with therapeutic outcome. On the other hand, it is unclear to which extent alexithymia itself may be modified by psychotherapeutic interventions. Methods: From 414 consecutively admitted inpatients, 297 were followed up after 4 weeks (t1) and after 8–12 weeks (t2) upon discharge. Patients were treated with psychodynamic group therapy in a naturalistic setting. The Toronto Alexithymia Scale (TAS-20) and the Symptom Checklist-90 were administered. Results: Twenty-seven percent of the patients were alexithymic (TAS-20 ≧61) at baseline. Multivariate models with repeated measurements indicated significant changes in Global Severity Index of the Symptom Checklist-90 in both alexithymic and nonalexithymic subjects. However, alexithymic subjects had significantly higher Global Severity Index scores than nonalexithymic subjects at t0, t1 and t2 (p < 0.001). The TAS-20 scores demonstrated a high relative stability in the total sample. However, in the alexithymic group, the TAS-20 scores changed considerably from baseline to discharge [66.3 (SD = 4.7) to 55.9 (SD = 9.9); t = 8.69; d.f. = 79; p < 0.001]. Conclusion: The inpatient treatment program including psychodynamic group therapy significantly reduced psychopathological distress and alexithymic features in alexithymic patients. Still, these patients suffered from higher psychopathological distress at discharge than nonalexithymics. Therefore, alexithymic features may negatively affect the long-term outcome.

The Relationship between Dimensions of Alexithymia and Dissociation

Background: The study investigated the following hypotheses: (1) Alexithymia is significantly associated with dissociation. (2) Pathological versus nonpathological dissociation is associated with alexithymic traits. Methods: Psychiatric in- and outpatients (n = 173) and nonclinical subjects (n = 38) were investigated with the Toronto Alexithymia Scale (TAS-20), the FDS (German version of Dissociation Experience Scale) and the Symptom Check List (SCL-90-R; GSI). Correlation analyses followed by MANOVA and logistic regression were performed. Results: Significant correlations and partial correlations, controlling for GSI, were observed between dissociation and alexithymia. The MANOVA demonstrated significantly higher scores for the two TAS-20 dimensions ‘difficulty identifying feelings’ and ‘difficulty expressing feelings’ in the group with pathological dissociation. On the basis of the TAS-20 subscores, logistic regression analysis correctly classified 72.5% of the cases into the pathological and the nonpathological dissociation group. Conclusions: These results support our hypothesis that pathological traits of dissociation are highly associated with alexithymia. A model is discussed in which alexithymic characteristics may contribute to the development of pathological dissociation and stress-related disorders such as posttraumatic stress disorder.

Alexithymia and the Temperament and Character Model of Personality

Objective: In our study we explored the associations between alexithymia (Toronto Alexithymia Scale 20, TAS-20) and the dimensions and subscales of Cloninger’s theoretically based and empirically validated psychobiological model of personality to further clarify the relationship between alexithymia and personality traits. Methods: Psychiatric in- and outpatients (n = 254) were investigated with the TAS-20, the Temperament and Character Inventory (TCI) and the Symptom Check List SCL-90-R to control for the severity of current psychopathology. Correlation and regression analyses were performed. Results: The regression analysis identified the TCI dimensions low self-directedness (SD), low reward dependence (RD) and to a minor degree harm avoidance (HA) as independent predictors for alexithymia. At the level of subscales, interpersonal detachment (RD3), low resourcefulness (SD3), low responsibility and blaming (SD1) and shyness with strangers (HA3) were predictors for alexithymia. The degree of explained variance of the TAS-20 scores by the TCI dimensions and subscales ranged between 43 and 45% whereas the inclusion of the general severity index into the regression models accounted for an additional 5% of the variance. Conclusions: Alexithymia is best explained by a mixture across different dimensions and subscales within Cloninger’s psychobiological model of personality. However, alexithymia is captured only partly by current concepts of personality, and additional contributing psychological and biological factors need to be identified to understand alexithymia more extensively.

Neurophysiological Correlates of Borderline Personality Disorder : A Transcranial Magnetic Stimulation Study

BACKGROUND Cortical inhibition deficits have been demonstrated in several disorders with deficits in impulsive control (e.g., attention-deficit/hyperactivity disorder [ADHD], tic disorder, Tourette syndrome) by using transcranial magnetic stimulation (TMS). With borderline personality disorder (BPD), we investigated another disorder associated with high impulsivity by TMS. We hypothesized that BPD patients display decreased cortical inhibition and/or increased cortical excitation as assessed with TMS. METHODS Different inhibitory and excitatory TMS parameters were investigated in 19 unmedicated female BPD patients and 19 healthy control subjects matched for sex, age, handedness, and body height. Additionally, the results were controlled for ADHD symptomatology. RESULTS A reduced cortical silent period (CSP) duration was found in BPD patients compared with healthy control subjects in the right cortex. Even after controlling for ADHD symptoms, this result remained significant. CONCLUSIONS These findings support an association between BPD and cortical inhibition deficits as indexed through TMS. The results are discussed considering basic neurobiological mechanisms that may explain our findings of decreased intracortical inhibition in BPD patients.

Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder

Background: Previous studies suggested an association between exposure to trauma or stressful life events and obsessive-compulsive disorder (OCD). This study investigates the hypothesis that traumatic events and posttraumatic stress disorders (PTSD) precede the onset of OCD. Sampling and Methods: 210 cases with OCD from university treatment facilities were compared with 133 sex- and age-matched controls from the adult general population. The data were derived from a German family study on OCD (GENOS). Direct interviews were carried out with the German version of the Schedule for Affective Disorders and Schizophrenia – Lifetime Version for Anxiety Disorders (DSM-IV). Results: Severe traumatization occurred in 6.2% of the OCD cases and in 8.3% of the controls. The lifetime prevalence rates of traumatization, PTSD and acute stress disorder were not different between the subjects with OCD and controls (p > 0.05). In 6 cases, acute stress disorder, subclinical or full PTSD preceded the onset of OCD, in 3 cases the trauma-related disorders and OCD occurred within the same year, in 5 other cases, the trauma-related disorders started after the onset of OCD. Conclusion: There is no significant association of traumatization or PTSD with OCD compared with controls. Given the low rate of trauma-related disorders occurring before (2.9%) or within (1.5%) the same year as the onset of OCD other factors than severe traumatic events determine the onset of OCD in most of the cases.

HDAC1 links early life stress to schizophrenia-like phenotypes

Significance Early life stress (ELS) is an important risk factor for schizophrenia. Our study shows that ELS in mice increases the levels of histone-deacetylase (HDAC) 1 in brain and blood. Although altered Hdac1 expression in response to ELS is widespread, increased Hdac1 levels in the prefrontal cortex are responsible for the development of schizophrenia-like phenotypes. In turn, administration of an HDAC inhibitor ameliorates ELS-induced schizophrenia-like phenotypes. We also show that Hdac1 levels are increased in the brains of patients with schizophrenia and in blood from patients who suffered from ELS, suggesting that the analysis of Hdac1 expression in blood could be used for patient stratification and individualized therapy. Schizophrenia is a devastating disease that arises on the background of genetic predisposition and environmental risk factors, such as early life stress (ELS). In this study, we show that ELS-induced schizophrenia-like phenotypes in mice correlate with a widespread increase of histone-deacetylase 1 (Hdac1) expression that is linked to altered DNA methylation. Hdac1 overexpression in neurons of the medial prefrontal cortex, but not in the dorsal or ventral hippocampus, mimics schizophrenia-like phenotypes induced by ELS. Systemic administration of an HDAC inhibitor rescues the detrimental effects of ELS when applied after the manifestation of disease phenotypes. In addition to the hippocampus and prefrontal cortex, mice subjected to ELS exhibit increased Hdac1 expression in blood. Moreover, Hdac1 levels are increased in blood samples from patients with schizophrenia who had encountered ELS, compared with patients without ELS experience. Our data suggest that HDAC1 inhibition should be considered as a therapeutic approach to treat schizophrenia.

Gruppenpsychotherapie in der Psychiatrie

Gruppen und Gruppenpsychotherapie auf verschiedensten Ebenen gehoren heute in der Mehrzahl der psychiatrischen Kliniken zur Behandlungsrealitat. Historisch fusen viele Konzepte auf dem Konstrukt der „therapeutischen Gemeinschaft“. Speziell fur die sozialpsychiatrische Versorgungslandschaft auserhalb der Klinik ist eine ausgesprochene Gruppenorientierung zu konstatieren, aber auch in der Klinik gibt es heute zahlreiche gruppentherapeutische Angebote, in die auch verschiedene Komplementartherapien einbezogen sind. Rahmenbedingungen der Anwendung von Gruppen in der Psychiatrie und verschiedene Formen von Gruppenangeboten (z. B. Angehorigengruppen, Gruppen in Tageskliniken) werden in diesem Kapitel beschrieben.