Claudia Subic-Wrana

Minimization of childhood maltreatment is common and consequential: results from a large, multinational sample using the childhood trauma questionnaire

Childhood maltreatment has diverse, lifelong impact on morbidity and mortality. The Childhood Trauma Questionnaire (CTQ) is one of the most commonly used scales to assess and quantify these experiences and their impact. Curiously, despite very widespread use of the CTQ, scores on its Minimization-Denial (MD) subscale—originally designed to assess a positive response bias—are rarely reported. Hence, little is known about this measure. If response biases are either common or consequential, current practices of ignoring the MD scale deserve revision. Therewith, we designed a study to investigate 3 aspects of minimization, as defined by the CTQ’s MD scale: 1) its prevalence; 2) its latent structure; and finally 3) whether minimization moderates the CTQ’s discriminative validity in terms of distinguishing between psychiatric patients and community volunteers. Archival, item-level CTQ data from 24 multinational samples were combined for a total of 19,652 participants. Analyses indicated: 1) minimization is common; 2) minimization functions as a continuous construct; and 3) high MD scores attenuate the ability of the CTQ to distinguish between psychiatric patients and community volunteers. Overall, results suggest that a minimizing response bias—as detected by the MD subscale—has a small but significant moderating effect on the CTQ’s discriminative validity. Results also may suggest that some prior analyses of maltreatment rates or the effects of early maltreatment that have used the CTQ may have underestimated its incidence and impact. We caution researchers and clinicians about the widespread practice of using the CTQ without the MD or collecting MD data but failing to assess and control for its effects on outcomes or dependent variables.

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.

Dizziness: Anxiety, health care utilization and health behavior—: Results from a representative German community survey

BACKGROUND Due to the lack of epidemiological data on the relation of dizziness and anxiety, we investigated the prevalence of dizziness and anxiety in a representative sample of the German population. We explored the consequences of comorbid anxiety for emotional distress, functional impairment, health care utilization, and health behavior in dizziness. METHODS By the end of 2006, we surveyed a total of 1287 persons between 14 and 90 years of age in their homes by trained interviewers with standardized self-rating questionnaires on anxiety (Patient Health Questionnaire, Generalized Anxiety Disorder Scale, Mini-Social Phobia Inventory) and dizziness (Vertigo Symptom Scale). The sample was representative for the German population in terms of age, sex, and education. RESULTS Symptoms of dizziness were reported by 15.8% of the participants. Of the participants with dizziness, 28.3% reported symptoms of at least one anxiety disorder (generalized anxiety, social phobia, panic). Persons with dizziness reported more somatic problems such as hypertension, migraine, diabetes, etc. Comorbid anxiety was associated with increased health care use and impairment. CONCLUSION Dizziness is a highly prevalent symptom in the general population. A subgroup with comorbid anxiety is characterized by an increased subjective impairment and health care utilization due to their dizziness. Because treatment options for distinct neurotologic disorders are also known to reduce psychological symptoms, and in order to avoid unnecessary medical treatment, early neurologic and psychiatric/psychotherapeutic referral may be indicated.

The Social Phobia Psychotherapy Research Network : The First Multicenter Randomized Controlled Trial of Psychotherapy for Social Phobia: Rationale, Methods and Patient Characteristics

This paper presents the Social Phobia Psychotherapy Research Network. The research program encompasses a coordinated group of studies adopting a standard protocol and an agreed-on set of standardized measures for the assessment and treatment of social phobia (SP). In the central project (study A), a multicenter randomized controlled trial, refined models of manualized cognitive-behavioral therapy and manualized short-term psychodynamic psychotherapy are compared in the treatment of SP. A sample of 512 outpatients will be randomized to either cognitive-behavioral therapy, short-term psychodynamic psychotherapy or waiting list. Assessments will be made at baseline, at the end of treatment and 6 and 12 months after the end of treatment. For quality assurance and treatment integrity, a specific project using highly elaborated measures has been established (project Q). Study A is complemented by 4 interrelated add-on projects focusing on attachment style (study B1), on cost-effectiveness (study B2), on variation in the serotonin transporter gene in SP (study C1) and on structural and functional deviations of the hippocampus and amygdala (study C2). Thus, the Social Phobia Psychotherapy Research Network program enables a highly interdisciplinary research into SP. The unique sample size achieved by the multicenter approach allows for studies of subgroups (e.g. comorbid disorders, isolated vs. generalized SP), of responders and nonresponders of each treatment approach, for generalization of results and for a sufficient power to detect differences between treatments. Psychological and biological parameters will be related to treatment outcome, and variables for differential treatment indication will be gained. Thus, the results provided by the network may have an important impact on the treatment of SP and on the development of treatment guidelines for SP.

Prevalence, correlates, and predictors of depersonalization experiences in the German general population.

The survey aimed to investigate the prevalence of depersonalization (DP) experiences, its sociodemographic characteristics and its associations with medical conditions, illness behavior, and potential etiologic factors. A representative face-to-face household survey was conducted. The sample consists of n = 1,287 participants aged 14 to 90 years. Sociodemographic variables, medical conditions, current mental disorders, health care utilization, and childhood adversities were assessed. A total of 1.9% participants scored in the range of clinically significant DP (DP-C) and 9.7% reported at least some impairment through DP (DP-I). DP-C/DP-I were strongly associated with depression and anxiety. After adjustment for depression and anxiety, DP-C and DP-I were independently associated with hypertension, diabetes mellitus, chronic pulmonary disease, severe pain, and childhood adversities. We conclude that DP is common, it can not be reduced to a negligible variant of depression or anxiety and that more awareness about DP with respect to detection and research is urgently required.

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)

Psychoanalytically-oriented inpatient psychotherapy of somatoform disorders.

Somatoform disorders have been neglected in psychoanalytic publications. Unlike the descriptive approach of DSM-IV and ICD-10, sophisticated psychoanalytical models have been proposed for many years explaining the development of physical symptoms without definable medical cause. Based on a review of the psychoanalytic models of somatization and conversion, this article explores difficulties in the medical and psychotherapeutic treatments of somatoform disorders. The unique tradition of psychosomatic inpatient treatment in Germany is illustrated by the psychoanalytic treatment setting at the University of Mainz. A case report of a somatoform patient shows how childhood trauma is activated and integrated in the course of inpatient treatment. In a multimodal approach, psychoanalytic individual and group therapy may interact beneficially with body-oriented, art therapy, and other treatment elements to gain therapeutic access to chronic somatoform patients, activate and work through trauma and conflict. Regardless of the specific setting, analytic treatments need to do justice to the specific deficits (e.g., symbolization of affect, mentalization) and defences of somatoform patients.

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.

Neural correlates of deficits in pain-related affective meaning construction in patients with chronic pain disorder.

Objective Psychological and neural mechanisms of the affective dimension of pain are known to be disturbed in patients with chronic pain disorder. The aim of this functional magnetic resonance imaging study was to assess the neurofunctional and behavioral measures underlying the ability to construct pain-related affective meaning in a painful situation by comparing 21 clinically and psychometrically well-characterized patients with persistent non-nociceptive somatoform pain with 19 healthy controls. Methods The functional magnetic resonance imaging task involved viewing pictures depicting human hands and feet in different painful and nonpainful situations. Participants were asked to estimate the perceived pain intensity. These data were correlated with behavioral measures of depression, alexithymia, and general cognitive and emotional empathy. Results In a hypothesis-driven region-of-interest analysis, the healthy control group exhibited greater activation of the left perigenual anterior cingulate cortex than patients with pain (Montreal Neurological Institute coordinates (x y z) = −8 38 0; cluster extent = 54 voxels; T = 4.28; p = .006 corrected for multiple comparisons at cluster level). No group differences in the activation of the anterior insular cortex were found. Scores on self-assessment instruments (Beck Depression Inventory I, Interpersonal Reactivity Index, and 20-item Toronto Alexithymia Scale) did not influence neuroimaging results. Conclusions Our results suggest that patients with chronic medically unexplained pain have an altered neural pain perception process owing to decreased activation of empathetic-affective networks, which we interpret as a deficit in pain-related affective meaning construction. These findings may lead to a more specific and detailed neurobiological understanding of the clinical impression of disturbed affect in patients with chronic pain disorder.

Levels of emotional awareness: A model for conceptualizing and measuring emotion‐centered structural change

The need to establish the efficacy of psychoanalytic long‐term treatments has promoted efforts to operationalize psychic structure and structural change as key elements of psychoanalytic treatments and their outcomes. Current, promising measures of structural change, however, require extensive interviews and rater training. The purpose of this paper is to present the theory and measurement of Levels of Emotional Awareness (LEA) and to illustrate its use based on clinical case vignettes. The LEA model lays out a developmental trajectory of affective processing, akin to Piaget’s theory of sensory–cognitive development, from implicit to explicit processing. Unlike other current assessments of psychic structure (Scales of Psychological Capacities, Reflective Functioning, Operationalized Psychodynamic Diagnostics) requiring intensive rater and interviewer training, it is easily assessed based on a self‐report performance test. The LEA model conceptualizes a basic psychological capacity, affect processing. As we will illustrate using two case vignettes, by operationalizing implicit and explicit modes of affect processing, it provides a clinical measure of emotional awareness that is highly pertinent to the ongoing psychoanalytic debate on the nature and mechanisms of structural change.