Christian Fazekas

Perceived social justice, long-term unemployment and health. A survey among marginalised groups in Austria.

ObjectiveAlthough socially disadvantaged groups are known to have a high risk of poor health the involved mechanisms and psychosocial dynamics are not fully understood. Long-term unemployment and the perception of social justice may both additionally endanger health. We therefore set out to explore the specific impact of these two context variables on self-reported health, health behaviour, and resources in marginalised groups.MethodsA structured interview survey was conducted in three federal provinces in Austria, which targeted a quota sample of 486 subjects in long-term unemployment.ResultsBoth, duration of long-term unemployment and low perceived social justice, are strongly associated with self-reported poor health and low personal (internal) and social (external) health resources. The best differentiation of dependent variables concerning the univariate analyses was found with respect to social health resources, as all variables on this level significantly correlated with perceived social justice but not with duration of long-term unemployment.ConclusionWhile this study does not allow to establish causal relationships, the associations we found suggest that also perceived social justice needs to be taken into account in interventions that are intended to foster equity in health among socially disadvantaged groups.

Biopsychosocial Health Care Needs at the Emergency Room: Challenge of Complexity

Background In an emergency room of internal medicine, triage and treatment of patients deserve first priority. However, biopsychosocial case complexity may also affect patient health outcome but has not yet been explored in this setting. Therefore, the aims of the study are (1) to estimate prevalence rates of complex patients in the emergency room (ER), (2) to describe biopsychosocial complexity in this population and (3) to evaluate possible correlations between patient profiles regarding case complexity and further clinical treatment. Methods During a study period of one week, all patients of an emergency room of internal medicine who were triaged to Manchester levels three to five were invited to participate in the study. Biopsychosocial case complexity was assessed by the INTERMED method. Psychosocial interventions were evaluated based on all documented interventions and recommendations given at the emergency room and during inpatient treatment. Results Study participants consisted of 167 patients with a subgroup of 19% (n = 32) receiving subsequent inpatient-treatment at the department. High biopsychosocial case complexity was found in 12% (n = 20) of the total sample (INTERMED score >20). This finding was paralleled by a cluster analysis suggesting three clusters with one highly complex patient group of 14%. These highly complex patients differed significantly from the other clusters as they had visited the emergency room more often within the last year and lived alone more frequently. In addition, admission rates were highest in this group. During ER treatment and subsequent inpatient treatment, 21% of highly complex patients received interventions addressing psychosocial factors as compared to 6% and 7%, respectively, in the other clusters. Conclusions A standardized screening of biopsychosocial case complexity among ‘frequent utilizers’ of the ER would be helpful to detect specific multidisciplinary health care needs among this particularly burdened patient group.

Empowerment bei Diabetes mellitus: Theorie und Praxis

SummarySince 1989 the concept of empowerment and the promotion of self-care management have been generally proposed for Diabetes care. The bio-psycho-social concept of empowerment aims at encouraging the patient to develop self-care management for Diabetes treatment that is evidence-based and in accordance with the patient’s goals and life style. It therefore promotes the patient’s autonomy. With regard to HbA1c and life-quality parameters, it has been proven to be effective. Prerequisites for implementing empowerment as therapeutic intervention are: interest in the individual reality of the patient, a patient-centred communication style and an adequate time management. In this article we describe the theoretical aspects of the concept of empowerment and propose practical recommendations for the empowerment of patients suffering from Diabetes mellitus.ZusammenfassungDas Empowerment-Konzept und die Förderung von Selbstmanagement-Fähigkeiten gilt bereits seit 1989 als zentrale Behandlungsphilosophie in der Diabetestherapie. Ausgehend von den individuellen Behandlungszielen und von Evidence based medicine soll der Patient dabei Unterstützung finden, ein Selbstmanagement hinsichtlich der Diabetesbehandlung umzusetzen, das mit seiner Lebensgestaltung kompatibel ist. In diesem biopsychosozial orientierten Konzept steht die Förderung der Autonomie des Patienten im Mittelpunkt. Es prägt auch die aktuellen Schulungsprogramme und ist hinsichtlich des Behandlungserfolges, etwa bezüglich HbA1c und Lebensqualität, empirisch abgesichert. Neben dem prinzipiellen Interesse an der individuellen Wirklichkeit des Patienten erfordert es einen patientenzentrierten Gesprächs- und Interaktionsstil sowie ein entsprechendes Zeitmanagement. In diesem Beitrag werden der theoretische Hintergrund des Empowerment Konzeptes skizziert und praxisrelevante Empfehlungen für die Umsetzung, insbesondere in Hinblick auf die Behandler-Patient-Kommunikation, vorgestellt.

No impact of adult attachment and temperament on clinical variability in patients with clinically isolated syndrome and early multiple sclerosis

OBJECTIVE Attachment style and temperament could influence a stress-relapse relationship in multiple sclerosis. We therefore aimed to probe for an association of these personality-related variables with disease activity in patients with clinically isolated syndrome and early multiple sclerosis (MS). METHODS Study participants completed following psychometric instruments: Adult Attachment Scale (AAS), Temperament and Character Inventory (TCI-125), Hospital Anxiety and Depression Scale (HADS). Clinical data encompassed the expanded disability status scale (EDSS), annualized relapse rate, disease duration and therapy. Relapses and MRI data were recorded at regular outpatient visits. RESULTS Study participants (n=84), 38 with a clinically isolated syndrome suggestive of MS (CIS) and 46 with relapsing remitting MS (RRMS), were assessed with a low EDSS (median 2). No significant differences concerning personality-related variables were revealed by group comparisons between CIS and RRMS and within the RRMS subgroup based on clinical measures (EDSS/year; within RRMS subgroup: annualized relapse rate). However, a higher lesion load per years of disease duration within the RRMS subgroup was associated with higher values in the temperament trait harm avoidance (p<0.05). CONCLUSIONS Although harm avoidance may be related to subclinical disease activity in early RRMS adult attachment and temperament do not seem to contribute to differences between CIS and RRMS or clinical variability in early multiple sclerosis.

Towards Implementing the Biopsychosocial Factor in National Health Care Systems: The Role of Postgraduate Training in Austria

who have graduated at a medical university and work either as resident physicians or fully licensed physicians. Tuition fees have to be paid for all parts of these courses. The Psy-Curricula are geared towards doctors of all medical fields to facilitate integration of psychosomatic medicine into several areas, e.g. primary care, psychiatry, internal medicine and gynaecology. However, there is no medical specialty or subspecialty in psychosomatic medicine in Austria. The Psy-Curricula consist of three consecutive levels: ‘psychosocial, psychosomatic and psychotherapeutic medicine’ ( table 1 ). Graduation at each level is documented by a diploma. Training for level 1 (Psy-1, Diploma for Psychosocial Medicine) takes approximately 1 year (180 h). At this level, training focuses on medical history taking based on the biopsychosocial model and on improving communication strategies. Furthermore, it informs physicians about treatment options in the psychosocial field [4] . After an additional 2 years (480 h), trainees can complete level 2 (Psy-2, Diploma for Psychosomatic Medicine). Training at this level qualifies doctors for psychosomatic care including the diagnosis of complex biopsychosocial interaction and integrative approaches to treatment. At level 3 (Psy-3, Diploma for Psychotherapeutic Medicine), after a further 3 years of training (1,870 h), full psychotherapeutic competence is achieved. Supervision, Balint group training and participation in self-awareness groups are integrative parts of these Psy-Curricula. A continuously growing number of medical doctors has already completed one or more levels of this programme and has been certified by the Austrian Medical Association. Among all 39,123 medical doctors in Austria in 2009, 2,101 medical doctors have obtained the Psy-1 diploma, 1,669 have reached the Psy-2 level and 1,232 have been certified with a Psy-3 diploma. About 10% of all Austrian general practitioners who work in private practice have successfully attended at least one of these courses [4] . About half of all physicians who have graduated with a Psy-3 diploma are psychiatrists. Thus, general practice and psychiatry contribute to this programme with the largest groups of participants. In 1 of 6 training centres for the Psy-Curricula two evaluation studies focused on the effects of this programme [5, 6] . Results of one of these studies, based on 30 study participants, suggested a significant increase in patient-centred communication of medical doctors before they had started Psy-1 and after completion of Psy2 [5] . Another study investigated the effectiveness of therapeutic interventions of 35 medical doctors at level Psy-3 with 135 patients and demonstrated significant clinical improvement with regard to different aspects of psychosocial burden as measured by SCL90R, IIP-C, ADS-L and STAI-G after treatment, and even more so half a year later [6] . A third research project aimed to explore In this year’s opening editorial, Fava et al. [1] introduced the ‘biopsychosocial factor’. They referred to George Engel’s publication [2] in Science on the need for a new medical model and pointed to the ‘dangerous’ parts of this paper. These parts deal with Engel’s remarks on the significance of commercial interests in medicine, the impact of a decline of clinical observation, and the clinical inadequacy of the concept of disease. In this context, in accordance with Tinetti and Fried [3] , Fava et al. argued that clinical decision-making for all patients should be addressed to the attainment of individual goals and the identification and treatment of all modifiable factors, including non-biological ones, rather than solely on the diagnosis and treatment of individual diseases. In order to provide a stimulus for a psychosomatic renewal of health care, the authors proposed the ‘biopsychosocial factor’ as a more dynamic concept than a ‘model’ implies. In addition, they pointed to novel assessment methods that could help improve the clinical process. In this contribution we aim to underline and amplify the suggestion of the biopsychosocial factor by relating it to the Austrian national health care system approach to psychosomatic medicine. This approach has developed a strong focus on postgraduate training which is open to several medical specialties. It is intended to lead to a more structured implementation of biopsychosocial medicine. It should be mentioned that the Austrian health care system is financed by public money. Additional health care services are provided by the private sector. A comparison of national health care systems suggests different ways to integrate psychosomatic medicine in medical education and clinical practice. Accordingly, in several health care systems the term ‘psychosomatic medicine’ is used with a different meaning. As in many other countries, in Austria it is primarily interpreted as a comprehensive field with relevance to most if not all medical specialties. Thus, 20 years ago, a continuing medical education programme called ‘Psy-Curricula’ has been established. This long-term programme can be attended by physicians Received: March 20, 2012 Accepted after revision: June 18, 2012 Published online: September 20, 2012

Admission Exam at a Medical School: Correlation Between Symptoms of Somatization and Performance

Zusammenfassung Auswahlverfahren fur ein Medizinstudium: Korrelation zwischen Somatisierungssymptomen und Prufungserfolg Fragestellung: Zulassungsverfahren zu Universitaten stellen ein quasi-experimentelles Setting fur die Stressforschung dar,wurden aber bislang kaum genutzt,um Somatisierungphanomene zu erforschen. Wir untersuchten in der vorliegenden Studie, wie Somatisierungssymptome und Erfolg bei einem Auswahlverfahren zum Medizinstudium miteinander assoziiert sind. Methoden: Teilnehmer an einem Auswahlverfahren zumMedizinstudium erhielten einen personlichen Link zu drei Onlinefragebogen (SOMS-7, HADS-D,WHOQOL-BREF),welche drei Wochen vor, zwei bis einen Tag vor dem Auswahlverfahren und nach Bekanntgabe der Ergebnisse beantwortet werden mussten. Ergebnisse: 43 Teilnehmer (24 weiblich) wurden eingeschlossen. Die Anzahl an Somatisierungssymptomen reduzierte sich nach dem Auswahlverfahren signifikant (p ≤ 0.004) bei allen Teilnehmern. Signifikant hohereWerte wurden bei denjenigen festgestellt, welche kei...

Grundzüge einer Theoretischen Pathologie

Die Verfasser — Dr. Walter Pieringer, Univ.-Prof. fur Medizinische Psychologie und Psychotherapie und Vorstand der gleichnamigen Universitatsklinik in Graz, und Dr. Christian Fazekas, Arzt fur Psychotherapeutische Medizin ebendort, sind in einem grosen Universitatsklinikum tatig und fur die Patientenversorgung wie die Arzte-Aus- und Weiterbildung mitverantwortlich. Die problematische Spaltung zwischen natur- und humanwissenschaftlichen Ansichten ist hier tagliches Dilemma. Organpathologische und psychopathologische Befunde finden keinen gemeinsamen Nenner.

Tako-tsubo cardiomyopathy and post-traumatic stress disorder after a skiing accident: a case report

SummaryBackgroundSymptoms of a post-traumatic stress disorder can follow Tako-tsubo cardiomyopathy. This vignette describes such a linkage and exemplifies the risk that these symptoms may remain undetected.Case presentationAfter a skiing accident that had evoked existential fear of suffocation, a post-menopausal woman was diagnosed with Tako-tsubo syndrome and myocardial contusion. Symptoms of post-traumatic stress disorder appeared 2 weeks after remission of the cardiomyopathy. Two months later, a psychological assessment was conducted during cardiac rehabilitation. A post-traumatic stress disorder was diagnosed and successfully treated by narrative exposure.ConclusionThis case report suggests that these patients should be informed during the initial hospital stay that post-traumatic stress symptoms could appear. It also suggests including a screening for post-traumatic stress disorder in the follow-up of these patients.ZusammenfassungHintergrundSymptome einer posttraumatischen Belastungsstörung können einer Tako Tsubo Kardiomyopathie folgen. Diese Fallvignette beschreibt einen solchen Zusammenhang und weist auf das Risiko hin, dass solche Symptome unerkannt bleiben.FallberichtNach einem Schiunfall, der mit der Angst zu ersticken einhergeht, wird bei einer Patientin eine Tako Tsubo Kardiomyopathie und eine contusio cordis diagnostiziert. Zwei Wochen nach Remission der Kardiomyopathie treten Symptome einer posttraumatischen Belastungsstörung auf. Zwei Monate später wird im Rahmen einer kardiologischen Rehabilitation eine psychologische Diagnostik durchgeführt. Eine posttraumatische Belastungsstörung wird diagnostiziert und mittels Narrative Exposure Therapie erfolgreich behandelt.SchlussfolgerungenDiese Fallvignette legt nahe, dass diese Patienten während des initialen stationären Aufenthaltes über ein mögliches Auftreten posttraumatischer Belastungssymptome informiert werden sollten. Sie weist auch darauf hin, dass eine Nachuntersuchung ein Screening hinsichtlich posttraumatischer Belastungsstörung einschließen sollte.

Contents Vol. 81, 2012

R. Balon, Detroit, Mich. A. Barbosa, Lisboa P. Bech, Hillerød M. Biondi, Roma M. Bouvard, Chambery G. Chouinard, Montréal, Qué. P.M.G. Emmelkamp, Amsterdam S. Fassino, Torino M. Fava, Boston, Mass. H.J. Freyberger, Greifswald/Stralsund S. Grandi, Bologna J.I. Hudson, Belmont, Mass. I.M. Marks, London M.W. Otto, Boston, Mass. E.S. Paykel, Cambridge P. Porcelli, Castellana Grotte C. Rafanelli, Bologna C.D. Ryff , Madison, Wisc. U. Schnyder, Zürich J. Scott, Newcastle T. Sensky, London T. Th eorell, Stockholm E. Vieta, Barcelona T. Wise, Falls Church, Va. J.H. Wright, Louisville, Ky. R. Zachariae, Aarhus Offi cial Journal of the International College of Psychosomatic Medicine (ICPM) Offi cial Journal of the International Federation for Psychotherapy (IFP)

Health, self-regulation of bodily signals and intelligence: Review and hypothesis

ZusammenfassungDer Intelligenzquotient (IQ) in der Kindheit und die Morbidität im Erwachsenenalter stehen miteinander in einer Verbindung, die bislang noch unzureichend geklärt ist und über den Einfluss sozioökonomischer Variablen hinausreicht. Es wird vermutet, dass die Wahrnehmung körperlicher Signale in der Steuerung des eigenen Gesundheitsverhaltens eine zentrale Rolle spielt und der IQ dabei die Qualität der Informationsverarbeitung dieser Signale beeinflussen könnte. Diese Annahme stützt sich auf empirische Zusammenhänge zwischen IQ und der Wahrnehmung und Verarbeitung körperlicher Signale in der Exterozeption (visuell, auditiv) und in der Interozeption (Viscerozeption, Propriozeption). Dies ist der Hintergrund der Hypothese einer Psychosomatischen Intelligenz (PI). Sie könnte zur Klärung des Zusammenhangs zwischen IQ in der Kindheit und Morbidität im Erwachsenenalter beitragen und es ermöglichen, den Einfluss menschlicher Intelligenz auf bewusst steuerbare körperliche Prozesse systematisch zu erforschen.SummaryChildhood IQ and adult morbidity and mortality are known to be linked even beyond socioeconomic variables. Yet, their interrelations are insufficiently understood. It has been suggested that bodily sensations play a fundamental role in health-related self-regulation and that intelligence can influence the information processing of these somatic signals. This assumption is supported by reports on the influence of IQ on the exteroceptive (e.g. visual and auditory) and interoceptive (e.g. autonomic nervous system and posture) perception and processing of somatic information. Based on these findings the hypothesis of Psychosomatic Intelligence (PI) is introduced as an additional conceptual framework to probe the link between childhood IQ and adult health status. It implies a specific cognitive ability concerning the perception, interpretation, and self-regulation of bodily sensations. In this model, somatic signals are considered to reflect both intra-individual processes and individual-environment interactions. Based on this hypothesis the influence of intelligence on cognitive efforts to self-regulate somatic phenomena is amenable to systematic testing.