Günter Schiepek

A controlled single case study with repeated fMRI measurements during the treatment of a patient with obsessive-compulsive disorder: Testing the nonlinear dynamics approach to psychotherapy

There is increasing evidence that obsessive-compulsive disorder (OCD) is associated with a dysfunction of cortico-striato-thalamo-cortical neuronal circuits. In order to examine treatment-related changes in neuronal processes, a drug-naive female patient with OCD (subtype: washing/contamination fear) and an age- and gender-matched healthy control were repeatedly tested using functional magnetic resonance imaging (MRI) during the presentation of a symptom provocation task. Patient-specific visual stimuli of symptom provoking situations were compared with disgust provoking and neutral pictures. FMRI scanning was conducted at the beginning, during and upon completion of an inpatient treatment. During the treatment period of more than eight weeks (combined behavioural and systemic couple therapy) the patient filled out a therapy process questionnaire (TPQ) which was administered daily. Results show a phase transition-like change characterized by a sudden reduction of clinical symptoms as assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) in the middle of the treatment period. Before the discontinuous symptom reduction occurred, the dynamic complexity of the TPQ-time series increased which might be indicative for a critical instability of the system. The fMRI results at the beginning of the treatment suggest strong activities in various brain regions, especially in the anterior cingulate cortex. The results of the second and third acquisition revealed comparably smaller OCD-related neuronal responses. The results may indicate that important clinical changes are taking place during the psychotherapy process which correspond to changing patterns of brain activation as well as to critical instabilities and phase-transition like phenomena in the time-series of the patients daily self-report data.

Real-Time Monitoring of Psychotherapeutic Processes: Concept and Compliance

Objective: The feasibility of a high-frequency real-time monitoring approach to psychotherapy is outlined and tested for patients compliance to evaluate its integration to everyday practice. Criteria concern the ecological momentary assessment, the assessment of therapy-related cognitions and emotions, equidistant time sampling, real-time nonlinear time series analysis, continuous participative process control by client and therapist, and the application of idiographic (person-specific) surveys. Methods: The process-outcome monitoring is technically realized by an internet-based device for data collection and data analysis, the Synergetic Navigation System. Its feasibility is documented by a compliance study on 151 clients treated in an inpatient and a day-treatment clinic. Results: We found high compliance rates (mean: 78.3%, median: 89.4%) amongst the respondents, independent of the severity of symptoms or the degree of impairment. Compared to other diagnoses, the compliance rate was lower in the group diagnosed with personality disorders. Conclusion: The results support the feasibility of high-frequency monitoring in routine psychotherapy settings. Daily collection of psychological surveys allows for the assessment of highly resolved, equidistant time series data which gives insight into the nonlinear qualities of therapeutic change processes (e.g., pattern transitions, critical instabilities).

Psychotherapy Is Chaotic-(Not Only) in a Computational World

Objective: The aim of this article is to outline the role of chaotic dynamics in psychotherapy. Besides some empirical findings of chaos at different time scales, the focus is on theoretical modeling of change processes explaining and simulating chaotic dynamics. It will be illustrated how some common factors of psychotherapeutic change and psychological hypotheses on motivation, emotion regulation, and information processing of the clients functioning can be integrated into a comprehensive nonlinear model of human change processes. Methods: The model combines 5 variables (intensity of emotions, problem intensity, motivation to change, insight and new perspectives, therapeutic success) and 4 parameters into a set of 5 coupled nonlinear difference equations. The results of these simulations are presented as time series, as phase space embedding of these time series (i.e., attractors), and as bifurcation diagrams. Results: The model creates chaotic dynamics, phase transition-like phenomena, bi- or multi-stability, and sensibility of the dynamic patterns on parameter drift. These features are predicted by chaos theory and by Synergetics and correspond to empirical findings. The spectrum of these behaviors illustrates the complexity of psychotherapeutic processes. Conclusion: The model contributes to the development of an integrative conceptualization of psychotherapy. It is consistent with the state of scientific knowledge of common factors, as well as other psychological topics, such as: motivation, emotion regulation, and cognitive processing. The role of chaos theory is underpinned, not only in the world of computer simulations, but also in practice. In practice, chaos demands technologies capable of real-time monitoring and reporting on the nonlinear features of the ongoing process (e.g., its stability or instability). Based on this monitoring, a client-centered, continuous, and cooperative process of feedback and control becomes possible. By contrast, restricted predictability and spontaneous changes challenge the usefulness of prescriptive treatment manuals or other predefined programs of psychotherapy.

Real-Time-Monitoring in der Behandlung von Zwangsstörungen: Technologie und Fallbeispiel

Hintergrund: Dargestellt wird die Möglichkeit, Behandlungsverläufe mit Hilfe von Internet-basierten Fragebögen abzubilden und zu analysieren. Tägliche Selbsteinschätzungen des Patienten erlauben es, ein detailliertes Bild des Therapieverlaufs darzustellen und für Interventionsentscheidungen zu nutzen. Patient und Methoden: Bei dem in diesem Beitrag exemplarisch ausgewählten Patienten lagen eine Zwangsstörung und eine komorbide depressive Episode vor, die in einer psychosomatischen Tagesklinik behandelt wurden. Ergebnis: Quantitative Zeitreihen und qualitative Angabe im Rahmen des Internet-basierten Tagebuchs spiegeln wichtige Phasen im Veränderungsprozess wider. Schlussfolgerungen: Die EDV-basierte Auswertung der Fragebögen unmittelbar nach Eingabe der Antworten durch den Patienten ermöglicht ein Behandlungsfeedback für Patient und Therapeut, steigert die Transparenz des Therapieverlaufs, unterstützt das Selbstwirksamkeitserleben der Patienten und generiert ohne Zusatzaufwand eine Prozess-Outcome-Dokumentation.

Systemic Case Formulation, Individualized Process Monitoring, and State Dynamics in a Case of Dissociative Identity Disorder

Objective: The aim of this case report is to demonstrate the feasibility of a systemic procedure (synergetic process management) including modeling of the idiographic psychological system and continuous high-frequency monitoring of change dynamics in a case of dissociative identity disorder. The psychotherapy was realized in a day treatment center with a female client diagnosed with borderline personality disorder (BPD) and dissociative identity disorder. Methods: A three hour long co-creative session at the beginning of the treatment period allowed for modeling the systemic network of the clients dynamics of cognitions, emotions, and behavior. The components (variables) of this idiographic system model (ISM) were used to create items for an individualized process questionnaire for the client. The questionnaire was administered daily through an internet-based monitoring tool (Synergetic Navigation System, SNS), to capture the clients individual change process continuously throughout the therapy and after-care period. The resulting time series were reflected by therapist and client in therapeutic feedback sessions. Results: For the client it was important to see how the personality states dominating her daily life were represented by her idiographic system model and how the transitions between each state could be explained and understood by the activating and inhibiting relations between the cognitive-emotional components of that system. Continuous monitoring of her cognitions, emotions, and behavior via SNS allowed for identification of important triggers, dynamic patterns, and psychological mechanisms behind seemingly erratic state fluctuations. These insights enabled a change in management of the dynamics and an intensified trauma-focused therapy. Conclusion: By making use of the systemic case formulation technique and subsequent daily online monitoring, client and therapist continuously refer to detailed visualizations of the mental and behavioral network and its dynamics (e.g., order transitions). Effects on self-related information processing, on identity development, and toward a more pronounced autonomy in life (instead of feeling helpless against the chaoticity of state dynamics) were evident in the presented case and documented by the monitoring system.

Systemische Fallkonzeption und State-Dynamik bei einer Patientin mit struktureller Dissoziation der Persönlichkeit

Das Fallbeispiel beschreibt die Vorgehensweise des synergetischen Prozessmanagements in einem tagesklinischen Setting. Dargestellt wird der therapeutische Prozess einer Patientin mit Borderline-Personlichkeitsstorung und komplexer dissoziativer Storung. Die Entwicklung der Patientin wurde begleitet und reflektiert mit einem Prozessmonitoring, welches auf einem taglich ausgefullten personlichen Fragebogen beruht. Am Beginn des Monitorings und des regelmasigen Prozessfeedbacks, das im Rahmen der therapeutischen Einzelgesprache stattfand, stand die Entwicklung eines idiographischen Systemmodells, welches in einer etwa dreistundigen Arbeit zusammen mit der Patientin entwickelt wurde. Fur die Patientin war es entscheidend zu erkennen, wie ihre verschiedenen Personlichkeits-States in den Komponenten des Modells reprasentiert waren und wie sich die Ubergange zwischen den States und deren jeweilige Trigger psychologisch nachvollziehen und erklaren liesen. Der mit dem »Synergetischen Navigationssystem« (SNS) mogliche Einblick in die Dynamik und die Verlaufsmuster ihrer Personlichkeitszustande (erfasst mithilfe taglicher Selbsteinschatzungen) lieferte die Grundlage fur einen veranderten Umgang mit diesen. Die Effekte im Bereich der selbstbezogenen Informationsverarbeitung und Identitatsentwicklung waren bemerkenswert. Die idiographische Systemmodellierung und das SNS in Kombination ermoglichten sowohl der Therapeutin als auch der Patientin ein umfassendes Verstandnis der personlichen Psychodynamik und der Prozessmuster der Therapie.

Neuronal connectivity in major depressive disorder: a systematic review

Background The causes of major depressive disorder (MDD), as one of the most common psychiatric disorders, still remain unclear. Neuroimaging has substantially contributed to understanding the putative neuronal mechanisms underlying depressed mood and motivational as well as cognitive impairments in depressed individuals. In particular, analyses addressing changes in interregional connectivity seem to be a promising approach to capture the effects of MDD at a systems level. However, a plethora of different, sometimes contradicting results have been published so far, making general conclusions difficult. Here we provide a systematic overview about connectivity studies published in the field over the last decade considering different methodological as well as clinical issues. Methods A systematic review was conducted extracting neuronal connectivity results from studies published between 2002 and 2015. The findings were summarized in tables and were graphically visualized. Results The review supports and summarizes the notion of an altered frontolimbic mood regulation circuitry in MDD patients, but also stresses the heterogeneity of the findings. The brain regions that are most consistently affected across studies are the orbitomedial prefrontal cortex, anterior cingulate cortex, amygdala, hippocampus, cerebellum and the basal ganglia. Conclusion The results on connectivity in MDD are very heterogeneous, partly due to different methods and study designs, but also due to the temporal dynamics of connectivity. While connectivity research is an important step toward a complex systems approach to brain functioning, future research should focus on the dynamics of functional and effective connectivity.