Eileen Wollburg

Construct validity and descriptive validity of somatoform disorders in light of proposed changes for the DSM-5

OBJECTIVE Current diagnostic criteria for somatoform disorders demand revisions due to their insufficient clinical as well as scientific usability. Various psychological and behavioral characteristics have been considered for the proposed new category Somatic Symptom Disorder (SSD). With this study, we were able to jointly assess the validity of these variables in an inpatient sample. METHODS Using a cross-sectional design, we investigated N=456 patients suffering from somatoform disorder, anxiety, or depression. Within one week after admission to the hospital, informed consent was obtained and afterwards, a diagnostic interview and a battery of self-report questionnaires were administered. Logistic regression analyses were performed to determine which variables significantly add to construct and descriptive validity. RESULTS Several features, such as somatic symptom severity, health worries, health habits, a self-concept of being weak, and symptom attribution, predicted physical health status in somatization. Overall, our model explained about 50% of the total variance. Furthermore, in comparison with anxious and depressed patients, health anxiety, body scanning, and a self-concept of bodily weakness were specific for DSM-IV somatoform disorders and the proposed SSD. CONCLUSIONS The present study supports the inclusion of psychological and behavioral characteristics in the DSM-5 diagnostic criteria for somatoform disorders. Based on our results, we make suggestions for a slight modification of criterion B to enhance construct validity of the Somatic Symptom Disorder.

Predictive validity and clinical utility of DSM-5 Somatic Symptom Disorder: Prospective 1-year follow-up study

OBJECTIVE To compare the predictive validity and clinical utility of DSM-IV somatoform disorders and DSM-5 Somatic Symptom Disorder (SSD) at 12-month follow-up. METHODS In a sample of psychosomatic inpatients (n=322, mean age=45.6 years (SD 10.0), 60.6% females) we prospectively investigated DSM-IV somatoform disorders and the DSM-5 diagnosis of SSD plus a variety of psychological characteristics, somatic symptom severity, and health-related quality of life at admission, discharge, and follow-up. RESULTS DSM-IV diagnoses and DSM-5 SSD similarly predicted physical functioning at follow-up; SSD also predicted mental functioning at follow-up. Bodily weakness, intolerance of bodily complaints, health habits, and somatic attribution at admission were significant predictors of physical functioning at follow-up. The change in physical functioning during inpatient therapy was a significant predictor for the course of physical functioning until follow-up. CONCLUSIONS Psychological symptoms appear to be predictively valid diagnostic criteria for the 12-month functional outcome in patients with SSD. Mental functioning can be better predicted by the DSM-5 diagnosis than by DSM-IV diagnoses. Not the change in single psychological features but in physical functioning during the treatment interval predicted the change in physical functioning until follow-up.

Psychological Change Mechanisms in Anorexia Nervosa Treatments: How Much Do We Know?

OBJECTIVE Anorexia nervosa (AN) is a debilitating and often chronic and treatment-resistant disorder. Despite decades of theoretical progress and research, many questions remain with regard to the psychological mechanisms explaining why and how some AN patients respond to treatment whereas others do not. Based on the premise that the broader, noneating disorders psychotherapy research literature, and particularly the common factors literature, can inform AN treatment development efforts, we review a set of selected psychological change mechanisms and describe how they might be relevant in the context of AN treatment response. Specifically, we suggest that a systematic consideration of constructs such as basic psychological needs, expectancies, the therapeutic alliance, experiential avoidance, and patient motivation for change might help illuminate how patients do or do not benefit from AN treatment. We briefly describe an ongoing multicenter trial in which the constructs introduced here are being measured on a weekly basis and are examined as potential mediators of treatment response. The article aims to contribute to the AN literature by introducing a set of potentially important change constructs that we think ought to be studied in greater depth by AN researchers.

Predictors of Outcome in Inpatients with Anorexia Nervosa: A Prospective Multi-Center Study

to study inclusion. The local research ethics committees (the Medical Associations of Hamburg and Schleswig-Holstein and the University Medical Centre of Munich) approved the study. At admission (t0) and discharge (t1), the participants completed a battery of standardized questionnaires (ED pathology: EDI-2 [5] ; depressive symptoms: PHQ-9; anxiety symptoms: GAD-7; somatic symptoms: PHQ-15 [6] , and therapy motivation: FEVER [7] ). Patient weight was measured at t0 and t1 and weekly during treatment by a staff member. Patients with missing data for all BMI measurements after t0 or missing t0 BMI were excluded from the analysis. We tested for baseline differences between the therapy completers and noncompleters using twotailed t tests and χ 2 tests. For t0 and t1 BMIs, paired sample t tests and effect sizes (Cohen’s d) were conducted. Inpatient BMI gain was predicted using stepwise linear regression analysis with the following predictors: therapy duration; median split age; age of onset; living alone; partnership; education; previous hospitalizations; AN subtype; BMI t0 ; centers; PHQ-9 t0 ; PHQ-15 t0 ; GAD-7 t0 ; median split FEVER t0 , and all EDI-2 t0 subscales. All analyses were calculated for the therapy completers and the intention-totreat (ITT) sample. We recruited 233 patients (April 2010–July 2012). Twenty-five patients were removed from the analysis because of implausible or missing BMI measurements. In 3 cases, BMI t1 was imputed using the last observation carried forward (the BMI 1 week earlier). Of the 208 patients analyzed, 176 completed the therapy (noncompletion rate: 15.4%). The regression analyses included the patients who had complete data for all predictor variables. The ITT study sample consisted of patients with a mean age of 26.9 years (SD = 8.6, range: 17–58) and an average age of illness onset of 17.8 years (SD = 5.9). The majority had a restrictive AN subtype (n = 103, 53.7 %) and at least one previous psychiatric or psychosomatic inpatient stay (n = 120, 57.7 %). Only about one third of the patients (n = 67, 32.2 %) were currently in a partnership. Therapy completers stayed longer in the hospital compared to noncompleters (t = 7.01, p < 0.001, mean Completers = 11.8 weeks, SD Completers = 5.2; mean Noncompleters = 5.1, SD Noncompleters = 3.1). We found no baseline differences between therapy completers and therapy noncompleters with respect to clinical or demographic variables. As expected, the BMI significantly improved from t0 to t1 with an effect size of 1.16 within the ITT sample (t = –19.7, p < 0.001; mean t0 = 15.0, SD t0 = 1.6, range t0 : 10.8–18.0; mean t1 = 16.9, SD t1 = 1.7, range t1 = 11.8–20.7) and an effect size of 1.35 for completers (t = –20.1, p < 0.001; mean t0 = 15.0, SD t0 = 1.6, range t0 = 10.8–18.0; mean t1 = 17.1, SD t1 = 1.5, range t1 = 12.8–20.7). Inpatient treatments for anorexia nervosa (AN) are highly effective with respect to rapid weight gain. Nevertheless, the proportion of patients with poor responses in recent naturalistic studies appears to be critically high: more than half of the patients remain underweight (BMI <17.5) at discharge [1, 2] , and there is a strong need for more effective treatments for inpatients with AN [3] . An important starting point for evidence-based improvements and tailored recommendations is knowledge of the factors associated with poor responses. However, only one study predicted adult inpatient BMI gain using a comprehensive set of potential predictors [4] . This study found that BMI gain depended solely on the therapy duration. Thus, the predictive value of the remaining variables was judged to be insufficient, and the need for future research was highlighted. Other studies focused on the influence of one specific factor on BMI gain, potentially ignoring yet unidentified but important control variables. Consequently, we aimed to analyze predictors of BMI gain in a large sample of adult inpatients with AN. We conducted a prospective multi-center study with a prepost design. Three participating hospitals offering adult eating disorder (ED) specialist treatment (Schön clinics Bad Bramstedt, Prien, and Hamburg-Eilbek) recruited patients who met the following inclusion criteria: primary DSM-IV diagnosis of AN; female gender; a minimum age of 16 years, and sufficient German language skills. The exclusion criteria were acute drug or alcohol abuse, acute suicidality, psychotic or bipolar disorders, or severe somatic disorders. Written informed consent was obtained prior Received: October 14, 2014 Accepted after revision: March 3, 2015 Published online: May 23, 2015

Psychological and interactional characteristics of patients with somatoform disorders: Validation of the Somatic Symptoms Experiences Questionnaire (SSEQ) in a clinical psychosomatic population

OBJECTIVE The new DSM-5 Somatic Symptom Disorder (SSD) emphasizes the importance of psychological processes related to somatic symptoms in patients with somatoform disorders. To address this, the Somatic Symptoms Experiences Questionnaire (SSEQ), the first self-report scale that assesses a broad range of psychological and interactional characteristics relevant to patients with a somatoform disorder or SSD, was developed. This prospective study was conducted to validate the SSEQ. METHODS The 15-item SSEQ was administered along with a battery of self-report questionnaires to psychosomatic inpatients. Patients were assessed with the Structured Clinical Interview for DSM-IV to confirm a somatoform, depressive, or anxiety disorder. Confirmatory factor analyses, tests of internal consistency and tests of validity were performed. RESULTS Patients (n=262) with a mean age of 43.4 years, 60.3% women, were included in the analyses. The previously observed four-factor model was replicated and internal consistency was good (Cronbachs α=.90). Patients with a somatoform disorder had significantly higher scores on the SSEQ (t=4.24, p<.001) than patients with a depressive/anxiety disorder. Construct validity was shown by high correlations with other instruments measuring related constructs. Hierarchical multiple regression analyses showed that the questionnaire predicted health-related quality of life. Sensitivity to change was shown by significantly higher effect sizes of the SSEQ change scores for improved patients than for patients without improvement. CONCLUSION The SSEQ appears to be a reliable, valid, and efficient instrument to assess a broad range of psychological and interactional features related to the experience of somatic symptoms.

Aggregating factors of the change process in the treatment of anorexia nervosa

PURPOSE We aimed to reduce the large body of factors which may be associated with the change process in treatments for Anorexia Nervosa (AN) into a clinically and scientifically useful number of higher-rank dimensions. In addition, we examined the associations between the identified factors and eating disorder psychopathology and body mass index (BMI) in exploratory analyses. METHODS Within a naturalistic multicenter study we administered the Change Process Questionnaire (CPQ-AN) to inpatients with AN upon admission. The factorial structure of the CPQ-AN was explored via factor analysis. Multiple regression analyses were performed to examine the associations with BMI and eating disorder symptomatology (EDI-2). RESULTS In total 233 female inpatients with AN (mean BMI=14.9 kg/m(2), SD=1.7) participated. The factor analysis yielded four latent factors: basic need satisfaction, AN-specific cognitions and behavior, emotional involvement and commitment to treatment, and alliance and treatment confidence. Furthermore, greater basic need satisfaction and less AN-specific cognitions and behavior predicted lower EDI-2 scores. Higher alliance and treatment confidence were associated with higher BMI as well as a lower EDI-2 score. CONCLUSION The associations between the newly derived dimensions and BMI and AN-psychopathology provide evidence to support the clinical relevance of the identified change process dimensions. Future investigations could provide further insights to deepen our understanding of the change process in AN.

Der benachteiligte Mann? Analysen zur (Gleich-)Behandlung von Männern und Frauen mit Depressionen

Hintergrund: Geschlechtsspezifische Prävalenzen legen die Vermutung nahe, dass sich Depressionen von Männern und Frauen unterscheiden. Gleichzeitig erfahren die Patienten in der Versorgung eine «Gleichbehandlung», die im Rahmen dieser Arbeit auf eine etwaige Benachteiligung vor allem der Männer hin überprüft werden sollte. Methoden: Insgesamt wurden 3 Aspekte untersucht: 1) Unterschiede in der Phänomenologie, 2) Unterschiede im Behandlungseffekt und 3) geschlechtsspezifische Unterschiede bezüglich der Behandlung durch männliche bzw. weibliche Therapeuten. Die Ergebnisse basieren auf einer retrospektiven Datenanalyse von 551 Männern und 1035 Frauen, die 2006-2008 mit dem Behandlungsschwerpunkt Depression vollstationär in der Schön Klinik Bad Bramstedt behandelt wurden. Ergebnisse: Die Analysen konnten belegen, dass die Symptomausprägung bei Männern zwar quantitativ geringer, jedoch qualitativ ähnlich ist. Bei geringerer Symptomlast ist die Effektstärke der Behandlung bei Männern zwar etwas geringer, diese sind jedoch mit der Behandlung zufriedener. Das Geschlecht des Therapeuten hatte lediglich auf Frauen einen Effekt: Diejenigen, die von männlichen Therapeuten behandelt wurden, wollten die Klinik signifikant häufiger weiterempfehlen als diejenigen, die von weiblichen Therapeuten betreut wurden. Schlussfolgerung: Aus den Ergebnissen ist zu schließen, dass die derzeitige «Gleichbehandlung» in der untersuchten Klinik zu keiner Benachteiligung der quantitativ kleineren Gruppe von Männern mit Depressionen führt.

Front & Back Matter

Abstracts should be no longer than 250 words for regular articles, and no longer than 150 words for clinical notes. They should include the following information: Background: the problem that prompted the study and the purpose of the study; Methods: data sources, subjects, design, measurements, data analysis; Results: most important findings; Conclusions: implications, future directions. Abstracts for Special Articles do not need to be structured. Editorials, Case Management articles and Letters to the Editor should not have an abstract. Footnotes: Avoid footnotes. When essential, they are numbered consecutively and typed at the foot of the appropriate page. Tables and illustrations: Tables and illustrations (both numbered in Arabic numerals) should be prepared on separate sheets. Tables require a heading and figures a legend, also prepared on a separate sheet. For the reproduction of illustrations, only good drawings and original photographs can be accepted; negatives or photocopies cannot be used. Due to technical reasons, figures with a screen background should not be submitted. When possible, group several illustrations on one block for reproduction (max. size 180  223 mm) or provide crop marks. On the back of each illustration, indicate its number, the author’s name, and ‘top’ with a soft pencil. Electronically submitted b/w half-tone and color illustrations must have a final resolution of 300 dpi after scaling, line drawings one of 800–1,200 dpi. Color illustrations Online edition: Color illustrations are reproduced free of charge. In the print version, the illustrations are reproduced in black and white. Please avoid referring to the colors in the text and figure legends. Print edition: Up to 6 color illustrations per page can be integrated within the text at CHF 800.– per page. Data analysis: Adequate description of statistical analysis should be provided, including the types of statistical tests and whether they were oneor two-tailed. Standard deviations, instead of standard errors of the mean, are preferred. All significant results must include the test value, degree(s) of freedom, and probability level. References: In the text identify references by Arabic numerals [in square brackets]. Material submitted for publication but not yet accepted should be noted as [unpublished data] and not be included in the reference list. The list of references should include only those publications which are cited in the text. Do not alphabetize; number references in the order in which they are first mentioned in the text. The surnames of the authors followed by initials should be given. There should be no punctuation other than a comma to separate the authors. Preferably, please cite all authors. Abbreviate journal names according to the Index Medicus system. Also see International Committee of Medical Journal Editors: Uniform requirements for manuscripts submitted to biomedical journals (www.icmje.org). Examples (a) Papers published in periodicals: Sun J, Koto H, Chung KF: Interaction of ozone and allergen challenges on bronchial responsiveness and inflammation in sensitised guinea pigs. Int Arch Allergy Immunol 1997;112:191–195. (b) Papers published only with DOI numbers: Theoharides TC, Boucher W, Spear K: Serum interleukin-6 reflects disease severity and osteoporosis in mastocytosis patients. Int Arch Allergy Immunol DOI: 10.1159/000063858. (c) Monographs: Matthews DE, Farewell VT: Using and Understanding Medical Statistics, ed 3, revised. Basel, Karger, 1996. (d) Edited books: Parren PWHI, Burton DR: Antibodies against HIV-1 from phage display libraries: Mapping of an immune response and progress towards antiviral immunotherapy; in Capra JD (ed): Antibody Engineering. Chem Immunol. Basel, Kar ger, 1997, vol 65, pp 18–56. Reference Management Software: Use of EndNote is recommended for easy management and formatting of citations and reference lists. Digital Object Identifier (DOI) S. Karger Publishers supports DOIs as unique identifiers for articles. A DOI number will be printed on the title page of each article. DOIs can be useful in the future for identifying and citing articles published online without volume or issue information. More information can be found at www.doi.org. Supplementary Material Supplementary material is restricted to additional data that are not necessary for the scientific integrity and conclusions of the paper. Please note that all supplementary files will undergo editorial review and should be submitted together with the original manuscript. The Editors reserve the right to limit the scope and length of the supplementary material. Supplementary material must meet production quality standards for Web publication without the need for any modification or editing. In general, supplementary files should not exceed 10 Mb in size. All figures and tables should have titles and legends and all files should be supplied separately and named clearly. Acceptable files and formats are: Word or PDF files, Excel spreadsheets (only if the data cannot be converted properly to a PDF file), and video files (.mov, .avi, .mpeg). Author’s ChoiceTM Karger’s Author’s ChoiceTM service broadens the reach of your article and gives all users worldwide free and full access for reading, downloading and printing at www. Karger.com. The option is available for a one-time fee of CHF 3,000.–, which is a permissible cost in grant allocation. More information can be found at www.karger.com/ authors_choice. NIH-Funded Research The U.S. National Institutes of Health (NIH) mandates under the NIH Public Access Policy that final, peer-reviewed manuscripts appear in its digital database within 12 months of the official publication date. As a service to authors, Karger submits the final version of your article on your behalf to PubMed Central. For those selecting our premium Author’s ChoiceTM service, we will send your article immediately upon publishing, accelerating the accessibility of your work without the usual embargo. More details on NIH’s Public Access Policy is available at http://publicaccess.nih.gov/policy.htm Self-Archiving Karger permits authors to archive their pre-prints (i.e. prerefereeing) or post-prints (i.e. final draft post-refereeing) on their personal or institution’s servers, provided the following conditions are met: Articles may not be used for commercial purposes, must be linked to the publisher’s version, and must acknowledge the publisher’s copyright. Authors selecting Karger’s Author’s ChoiceTM feature, however, are also permitted to archive the final, published version of their article, which includes copyediting and design improvements as well as citation links. Page Limitations and Charges There are no page charges for papers of 7 or fewer printed pages (including tables, illustrations and references). Each additional complete or partial page is charged to the author at CHF 325.–. The allotted size of a paper is equal to approx. 18 manuscript pages (including tables, illustrations and references). Letters commenting on published articles should not exceed 500 words of text plus references. Research letters should not exceed 1,000 words of text plus a maximum of 10 references. They may have only one table or figure. Proofs Unless indicated otherwise, proofs are sent to the corresponding author and should be returned with the least possible delay. Alterations other than the correction of printer’s errors are charged to the author. Reprints Order forms and a price list are sent with the proofs. Orders submitted after the issue is printed are subject to considerably higher prices.

Brauchen wir mehr Spezialisierung in der Psychotherapie

Accessible online at: www.karger.com/ver Fax +49 761 4 52 07 14 Information@Karger.com www.karger.com Ein Hauptgrund liegt in der Ausbildung psychologischer und ärztlicher Psychotherapeuten. Viele Ausbildungsinstitute bieten zwar ein breites Spektrum an Krankheitsbildern für ihre Ausbildungsfälle an, Analysen zeigen jedoch, dass viele Psychotherapeuten oft vornehmlich Patienten mit Depressionen und Angststörungen unter Supervision zu behandeln lernen und eine breite klinische Ausbildung nicht mehr gewährleistet ist. In der Weiterbildung zu den Fachärzten für Wenn man für einen Patienten einen ambulanten Psychotherapeuten sucht, ist es immer noch schwierig jemanden zu finden, der freie Kapazitäten hat. Besonders schwer wird es, wenn man für jemanden einen Psychotherapeuten sucht, der z.B. an einer Borderline-Störung, an einer Zwangsstörung, an einer Essstörung oder an einer anderen eher komplexen Störung leidet. Worin sehen Sie die Hauptursache für diesen massiven Ver sorgungsmangel? Brauchen wir mehr Spezialisierung in der Psychotherapie?