Karin Pöhlmann

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.

Structural properties of personal meaning systems: A new approach to measuring meaning of life

This article introduces a new qualitative–quantitative approach to assess meaning of life. The participants described their sources of meaning and how they were interconnected. Four quantitative measures for (1) the accessibility of meaning-related knowledge, the degree of (2) differentiation and (3) elaboration of personal meaning systems, and (4) their coherence were calculated. The sample consisted of 59 theology and science students. The study tested (a) whether the structural properties of personal meaning systems predicted health and well-being, and (b) reflected different degrees of expertise in constructing meaning. Differentiation, elaboration, and coherence measures correlated with health and well-being and predicted life satisfaction. Theology students presented more differentiated, elaborated, and coherent personal meaning systems than science students. Both results indicate that assessing structural properties of personal meaning systems can be a promising new approach to measure meaning of life.

Der Dresdner Körperbildfragebogen (DKB-35): Validierung auf der Basis einer klinischen Stichprobe

The Dresden Body Image Questionnaire (DKB-35) measures 5 dimensions of body image: vitality, self-acceptance, self-aggrandisement, physical closeness, and sexual fulfilment. This article presents data on the reliability and validity of the DKB-35. The sample consisted of 560 pa-tients with psychosomatic disorders. To analyse the factor structure, a confirmatory factor analysis was conducted. To examine the convergent validity, correlations between the DKB-35 scales and the Frankfurt Body Concept Scales (FKKS, [1]), the Narcissism Personality Inventory (NPI, [2]) and the self-esteem subscale of the Frankfurt Self-Concept Scales (FSKN, [3]) were computed. The 5 scales of the DKB-35 showed excellent reliability. Between the 5 DKB-35 scales and the corresponding scales of the FKKS, the NPI, and the FSKN, moderate correlations were found. The results confirm the reliability and validity of the DKB-35. Possible fields of applications and further developments are discussed.

Reliability, validity and responsiveness of the EQ-5D in assessing and valuing health status in patients with social phobia

ObjectiveThe aim of the study was to analyse the psychometric properties of the EQ-5D in patients with social phobia.MethodsWe used a sample of 445 patients with social phobia with five measurement points over a 30 month period. The discriminative ability of the EQ-5D was analysed by comparing the patients’ responses with the general population and between different disease severity levels. For test-retest reliability we assessed the level of agreement in patients’ responses over time, when there was no change in the Liebowitz Social Anxiety Scale (LSAS). Construct validity was analysed by identifying correlations of the EQ-5D with more specific instruments. For responsiveness we compared the means of EQ VAS/EQ-5D index anchored on improved (deteriorated) health status and computed effect sizes as well as a receiver operating characteristic (ROC) curve.ResultsCompared to the general population, patients with social phobia reported more problems in the dimensions “usual activities”, “pain/discomfort”, and “anxiety/depression” and less problems in “mobility” and “self-care”. The EQ-5D was able to distinguish between different disease severity levels. The test-retest reliability was moderate (intraclass correlation coefficient > 0.6). Correlations between the EQ-5D and other instruments were mostly small except for correlations with Beck Depression Inventory. The EQ-5D index seemed to be more responsive than the EQ VAS, but with only medium effect sizes (0.5 < effect size < 0.8) in the British EQ-5D index and only significant in patients with improved health status. The ROC analysis revealed no significant results.ConclusionsThe EQ-5D was moderately reliable and responsive in patients with improved health status. Construct validity was limited.Trial registrationCurrent controlled trials ISRCTN53517394

Patterns of Childhood Abuse and Neglect in a Representative German Population Sample

Background Different types of childhood maltreatment, like emotional abuse, emotional neglect, physical abuse, physical neglect and sexual abuse are interrelated because of their co-occurrence. Different patterns of childhood abuse and neglect are associated with the degree of severity of mental disorders in adulthood. The purpose of this study was (a) to identify different patterns of childhood maltreatment in a representative German community sample, (b) to replicate the patterns of childhood neglect and abuse recently found in a clinical German sample, (c) to examine whether participants reporting exposure to specific patterns of child maltreatment would report different levels of psychological distress, and (d) to compare the results of the typological approach and the results of a cumulative risk model based on our data set. Methods In a cross-sectional survey conducted in 2010, a representative random sample of 2504 German participants aged between 14 and 92 years completed the Childhood Trauma Questionnaire (CTQ). General anxiety and depression were assessed by standardized questionnaires (GAD-2, PHQ-2). Cluster analysis was conducted with the CTQ-subscales to identify different patterns of childhood maltreatment. Results Three different patterns of childhood abuse and neglect could be identified by cluster analysis. Cluster one showed low values on all CTQ-scales. Cluster two showed high values in emotional and physical neglect. Only cluster three showed high values in physical and sexual abuse. The three patterns of childhood maltreatment showed different degrees of depression (PHQ-2) and anxiety (GAD-2). Cluster one showed lowest levels of psychological distress, cluster three showed highest levels of mental distress. Conclusion The results show that different types of childhood maltreatment are interrelated and can be grouped into specific patterns of childhood abuse and neglect, which are associated with differing severity of psychological distress in adulthood. The results correspond to those recently found in a German clinical sample and support a typological approach in the research of maltreatment. While cumulative risk models focus on the number of maltreatment types, the typological approach takes the number as well as the severity of the maltreatment types into account. Thus, specific patterns of maltreatment can be examined with regard to specific long-term psychological consequences.

Patterns of childhood abuse and neglect as predictors of treatment outcome in inpatient psychotherapy: a typological approach.

Background: Childhood maltreatment is associated with the development and maintenance of mental disorders. The purpose of this naturalistic study was (a) to identify different patterns of childhood maltreatment, (b) to examine how these patterns are linked to the severity of mental disorders and (c) whether they are predictive of treatment outcome. Methods: 742 adult patients of a university hospital for psychotherapy and psychosomatics were assessed at intake and discharge by standardized questionnaires assessing depression (Beck Depression Inventory, BDI) and general mental distress (Symptom Check List-90-R, SCL-90-R). Traumatic childhood experience (using the Childhood Trauma Questionnaire, CTQ) and ICD-10 diagnoses were assessed at intake. Results: The patients could be allocated to three different patterns of early childhood trauma experience: mild traumatization, multiple traumatization without sexual abuse and multiple traumatization with sexual abuse. The three patterns showed highly significant differences in BDI, General Severity Index (GSI) and in the number of comorbidity at intake. For both BDI and GSI a general decrease in depression and general mental distress from intake to discharge could be shown. The three patterns differed in BDI and GSI at intake and discharge, indicating lowest values for mild traumatization and highest values for multiple traumatization with sexual abuse. Patients with multiple traumatization with sexual abuse showed the least favourable outcome. Conclusion: The results provide evidence that the severity of childhood traumatization is linked to the severity of mental disorders and also to the treatment outcome in inpatient psychotherapy. In the study, three different patterns of childhood traumatization (mild traumatization, multiple traumatization without sexual abuse, multiple traumatization with sexual abuse) showed differences in the severity of mental disorder and in the course of treatment within the same therapy setting.

Do Patient Characteristics Predict Outcome of Psychodynamic Psychotherapy for Social Anxiety Disorder

Objectives Little is known about patient characteristics as predictors for outcome in manualized short term psychodynamic psychotherapy (PDT). No study has addressed which patient variables predict outcome of PDT for social anxiety disorder. Research Design and Methods In the largest multicenter trial on psychotherapy of social anxiety (SA) to date comparing cognitive therapy, PDT and wait list condition N = 230 patients were assigned to receive PDT, of which N = 166 completed treatment. Treatment outcome was assessed based on diverse parameters such as endstate functioning, remission, response, and drop-out. The relationship between patient characteristics (demographic variables, mental co-morbidity, personality, interpersonal problems) and outcome was analysed using logistic and linear regressions. Results Pre-treatment SA predicted up to 39 percent of variance of outcome. Only few additional baseline characteristics predicted better treatment outcome (namely, lower comorbidity and interpersonal problems) with a limited proportion of incremental variance (5.5 to 10 percent), while, e.g., shame, self-esteem or harm avoidance did not. Conclusions We argue that the central importance of pre-treatment symptom severity for predicting outcomes should advocate alternative treatment strategies (e.g. longer treatments, combination of psychotherapy and medication) in those who are most disturbed. Given the relatively small amount of variance explained by the other patient characteristics, process variables and patient-therapist interaction should additionally be taken into account in future research. Trial Registration Controlled-trials.com/ISRCTN53517394

Transfer of manualized Short Term Psychodynamic Psychotherapy (STPP) for social phobia into clinical practice: study protocol for a cluster-randomised controlled trial

BackgroundPsychodynamic psychotherapy is frequently applied in the treatment of social phobia. Nevertheless, there has been a lack of studies on the transfer of manualized treatments to routine psychodynamic practice. Our study is the first one to examine the effects of additional training in a manualized Short Term Psychodynamic Psychotherapy (STPP) procedure on outcome in routine psychotherapy for social phobia. This study is an extension to a large multi-site RCT (N = 512) comparing the efficacy of STPP to Cognitive-Behavioral Therapy (CBT) of Social Phobia.Methods/DesignThe manualized treatment is designed for a time limited approach with 25 individual sessions of STPP over 6 months. Private practitioners will be randomized to training in manualized STPP vs. treatment as usual without a specific training (control condition). We plan to enrol a total of 105 patients (84 completers). Assessments will be conducted before treatment starts, after 8 and 15 weeks, after 25 treatment sessions, at the end of treatment, 6 months and 12 months after termination of treatment. The primary outcome measure is the Liebowitz Social Anxiety Scale. Remission from social phobia is defined scoring with 30 or less points on this scale.DiscussionWe will investigate how the treatment can be transferred from a controlled trial into the less structured setting of routine clinical care. This question represents Phase IV of psychotherapy research. It combines the benefits of randomized controlled and naturalistic research. The study is genuinely designed to promote faster and more widespread dissemination of effective interventions. It will answer the questions whether manualized STPP can be implemented into routine outpatient care, whether the new methods improve treatment courses and outcomes and whether treatment effects reached in routine psychotherapeutic treatments are comparable to those of the controlled, strictly manualized treatment of the main study.Trial RegistrationGerman Clinical Trials Register (DRKS) DRKS00000570

Differenzielle Therapieverläufe in der stationären Psychotherapie: Eine störungsübergreifende clusteranalytische Differenzierung von Verlaufstypen auf der Basis des Merkmals Depressivität

Depressive Storungen sind in der psychosomatischen Akutversorgung eine haufige Erkrankung. Der Anteil der Patienten, die an einer Depression oder einer klinisch relevanten Auspragung der Depressivitat leiden, liegt in der untersuchten Stichprobe bei 67%. Auf der Basis des Merkmals Depressivitat wurden clusteranalytisch funf Verlaufstypen identifiziert: Patienten mit masig ausgepragter, kontinuierlich abnehmender Depressivitat (Cluster 1, n = 80, 41.2%), Patienten mit hoher Depressivitat und kontinuierlicher, stabiler Verbesserung (Cluster 2, n = 41, 21.1%), Patienten mit hoher, stabiler Depressivitat (Cluster 3, n = 32, 16.5%), Patienten mit masiger Depressivitat und instabiler Verbesserung (Cluster 4, n = 28, 14.4%) sowie Patienten mit starken Schwankungen in der Depressivitat (Cluster 5, n = 13, 6.7%). Die Analyse von Pra- (Komorbiditat, seelische Gesundheit, relevante Problembereiche) und Post-Differenzen (Zielerreichung und Problemverbesserungen am Ende der Therapie und ein Jahr spater) zeigte, dass Patienten in Cluster 1 sich deutlich von den anderen Gruppen unterschieden. Sie waren weniger belastet (Depressivitat, Komorbiditat) und seelisch gesunder. Ihr Therapieerfolg (Zielerreichung und Problemreduktion) war groser. Die erzielten Therapieergebnisse blieben im Katamnesezeitraum nicht in allen Patientengruppen stabil. Ein groser Teil der Patienten (Cluster 1 und Cluster 3, n = 121) konnte das erzielte Therapieergebnis halten, in zwei Gruppen (Cluster 4 und Cluster 5, n = 41) kam es allerdings im Vergleich zum Therapiebeginn zu einem deutlichen Anstieg der Depressivitat. Die Ursachen dafur sind moglicherweise negative Therapieeff ekte (Cluster 5) und Ruckfalle und soziale Probleme im Katamnesezeitraum (Cluster 4). Offen bleibt, was die unterschiedlichen Verlaufe von Cluster 2 und Cluster 3 erklaren kann. Beide Gruppen wiesen zu Beginn der Therapie gleich hohe Depressionswerte auf und unterschieden sich in der weiteren Entwicklung deutlich.

Das Selbstkonzept von Patienten mit sozialer Angststörung:Ausprägung und Veränderung durch Psychotherapie

OBJECTIVES To determine whether the self-concept of patients with Social Anxiety Disorder deviates significantly from that found in the normative sample, to what extent it changes through psychotherapeutic short-term interventions and how such changes in self-concept relate to changes in the level of social anxiety. METHODS The self-concept of N = 86 patients with Social Anxiety Disorder was assessed using the Frankfurter-Selbstkonzeptskalen (FSKN; Deusinger 1986). Patients were treated with a manualized cognitive (CT) or psychodynamic (PDT) short-term intervention. The level of social anxiety was assessed pre-therapy and post-therapy via the Liebowitz Social Anxiety Scale (Stangier & Heidenreich 2004) and the Social Phobia and Anxiety Scale (Fydrich 2002). RESULTS Patients with Social Anxiety Disorder exhibited a significantly more negative self-concept than the norm (all ps0.001). Their self-concept improved significantly in all facets following psychotherapeutic short-term intervention (all ps0.01). No significant difference was found between cognitive and psychodynamic therapy. Improvements in self-concept correlate with reductions in social anxiety. CONCLUSIONS The results confirm the relevance of self-concept in Social Anxiety Disorder and its susceptibility to short-term-therapy.