M. von Rad

Success and Failure in Psychotherapy: Hypotheses and Results from the Heidelberg Follow-Up Project

Within the Heidelberg Follow-Up Project all treatments of the clinic regardless of the type of psychodynamic technique used are investigated. The outlet is both prospective and retrospective. There are four points of investigation: (1) immediately after the first contact with the hospital (2) at the beginning; (3) at the end of therapy, and (4) after a 2-year follow-up period. Immediately after the first contact with the patient a test battery (Giessen Test, Holzman Inkblot Technique, Gottschalk-Gleser Method, symptom checklist) is administered. This is repeated after a waiting period at the beginning of therapy, where in addition the therapist formulates a psychodynamic hypothesis and defines 3-5 individual treatment goals in connection with the individual pathology of the patient. At the end of the therapy the tests are repeated and the therapist assesses the success or failure of the therapy with regard to symptoms, object relations and psychodynamic change, while the patient fills out a special questionnaire dealing with his personal view of the therapy, the therapist and his own treatment experiences. The first results of about 100 combined inpatient and outpatient psychotherapies are presented (third test-round at the end of treatment). The results are discussed on the basis of the involved tests and ratings with respect to success and failure in the view of patients, therapists and independent clinical experts. Since the study is still under way, reports of the follow-up data are not yet evaluated.

Ophthalmoplegie, Ataxie, Areflexie (Fisher-Syndrom)

Es werden funf Falle eines in der Literatur gewohnlich nach M. Fisher benannten und im deutschen Sprachraum bislang noch nicht beschriebenen Syndroms dargestellt und in ihrer Atiologie, klinischen Symptomatik und nosologischen Zuordnung diskutiert.SummaryFive cases of a syndrome usually named after M. Fisher are presented regarding etiology, clinical symptomatology and nosological classification.The main features of the clinical course correlate in all details with published reports: 1. antecedent infection, 2. paresthesias in the hands, 3. cerebellar ataxia, 4. diplopia, 5. external ophthalmoplegia, 6. slowing of pupillary reactions, 7. generalized areflexia, 8. minimal or no sensory impairment and paresis, 9. retention of consciousness, 10. albuminocytologic dissociation in the cerebrospinal fluid, 11. recovery without specific therapy.Virological studies in two cases showed a cytopathic effect on monkey kidney cells, which up to now was extented to three other passages. The noteworthy and uniform clinical course of the syndrome is considered to be an atypical polyradiculitis (Guillain-Barré syndrome) with particular involvement of the brain stem. This also explains the debatable problem of cerebellar ataxia as issuing from damage to the cerebellar tracts in the brain stem.ZusammenfassungEs werden fünf Fälle eines in der Literatur gewöhnlich nach M. Fisher benannten und im deutschen Sprachraum bislang noch nicht beschriebenen Syndroms dargestellt und in ihrer Ätiologie, klinischen Symptomatik und nosologischen Zuordnung diskutiert.Die Hauptmerkmale des klinischen Verlaufs (1. vorangehender Infekt, 2. Paraesthesien in den Händen, 3. cerebelläre Ataxie, 4. Doppelbilder, 5. komplette externe Ophthalmoplegie, 6. kurzfristig träge Pupillenreaktionen, 7. Areflexie, 8. minimale oder ganz fehlende Sensibilitätsstörungen und Paresen, 9. vollständig erhaltendes Bewußtsein, 10. cyto-albuminäre Dissoziation im Liquor, 11. Rückbildung ohne spezifische Therapie) entsprechen in allen Einzelheiten den bisherigen Beschreibungen. Virologiseh konnte in zwei Fällen ein cytopathischer Effekt auf Affennierenzellen nachgewiesen und bislang über drei Passagen fortgeführt werden. Die Untersuchungen sind noch nicht abgeschlossen.Die auffallende und sehr gleichförmig verlaufende Symptomatik des Syndroms wird als atypische Polyradiculitis (Guillain-Barrésches Syndrom) mit bevorzugter Beteiligung des Hirnstammes aufgefaßt. Dadurch erklärt sich auch das in der ausführlich diskutierten Literatur umstrittene Problem der cerebellären Ataxie als Folge eines Befalls cerebellärer Bahnen im Hirnstamm.

Spontane Carotis-cavernosus-Fistel bei Morbus Osler-Rendu

A 37-year-old woman suffered from headaches, right facial pain, double vision and occasional tinnitus. On examination there was only a slightly dilated right pupil, weakened corneal reflex and capillary bleeding from telangiectasia of both hands. Similar bleedings occured in her mother (mouth and hands) and son (nose). The arteriography of the right carotid artery showed a cavernous sinus fistula with a small shunt. Steady compression of the carotid artery by hand caused a marked improvement in the subjective symptomatology.SummaryA 37-year-old woman suffered from headaches, right facial pain, double vision and occasional tinnitus. On examination there was only a slightly dilatated right pupil, weakened corneal reflex and capillary bleeding from telangiectasia of both hands. Similar bleedings occured in her mother (mouth and hands) and son (nose). The arteriography of the right carotid artery showed a cavernous sinus fistula with a small shunt. Steady compression of the carotid artery by hand caused a marked improvement in the subjective symptomatology.

Towards a Theory of Psychosomatic Disorders

Towards a Theory of Psychosomatic Disorders W. Bräutigam M. von Rad Psychosomatic medicine had its origin in psychoanalysis at the beginning of this century and has only struck out on its own in the last few decades. Psychoanalysts were the first to trace causal and theoretical connections between mental conflicts or situational stresses and physical symptoms. Today it is still the subjective dimension – a person’s experience of his own inner life history – as reflected in the psychoanalytical situation and in the course of psychotherapy, which is the corner stone of clinical research. The first attempts to define psychosomatic disorders were variants of concepts stemming from neurosis theory; the physical symptom was seen as a special case of neurotic conversion and was attributed to the psyche. However, the question of whether psychosomatic medicine can ‘emancipate’ itself from psychoanalysis has been in existence for a long time: must it not give its research into aetiology, its concepts and theories and its methods of treatment more well-defined contours, if it is to exist as a separate entity? One thing seems to us to be an established fact in psychosomatics as opposed to neurosis psychology: a psychosomatic medicine conscious of its own individuality sees its circumstances and its existential justification to a much lesser degree purely in the conditions of psychogenesis. This can be seen most clearly in the field of somato-psychosomatic problems. Here, the question arises of how primary physical disorders are psychologically assimilated and their subsequent course influenced by this psychological reaction. The experience of physical sickness is open to multi-factorial interpretation with regard to its origin, and invites a number of independent somatic and psychological theoretical approaches. Today we attempt to understand physical sickness in the interaction of somatic and psychic influences. From a historical point of view, a differentiation can perhaps be made between two different developmental tendencies in psychosomatic medicine Bråutigamivon Rad XII which exist in a fruitful opposition to each other and which have proved to be relevant questions in research. The one direction tends more towards specifying a disease, locating an internal or external conflict, or a trait of personality – the other seeks to determine the common denominator of various psychosomatic diseases and to comprehend and work on this aspect. This last approach, which is the more recent, was magnificently formulated in the work of Jürgen Ruesch, to which far too little attention has been paid. Shortly after the second world war, Ruesch very accurately described the affective disorder in communication and the restricted fantasy life, the object dependency and the overadapted social behaviour of the ‘infantile personality’ as the ‘core problem’ of psychosomatic patients. Thus, it is against this background, but in a new terminological guise -pensée opératoire, alexithymia, psychosomatic phenomenon – that the 11th European Conference presents an old

Ein Fall von isoliertem epileptischem Nystagmus

SummaryThe case of a 28-year-old male patient with epileptic nystagmus is described and the results of the electrophysiological evaluation are presented.The EEG equivalent of the clinical course of the fits with an indifferent aura (a), jerking nystagmus with a slight rotatory component to the left (b), and slow disappearance of a complete visual blackout with porroscopy (c) consisted of focal spikes originating from the right occipital lobe (a), desynchronization without paroxysmal potentiale during the nystagmus (b), and finally a prolonged discharge of regular alpha spikes (c). The ENG during the fit showed a quite regular nystagmus directed to the left; otherwise the optokinetic nystagmus was normal. The neurological and neuroradiological status was entirely normal.Contrary to all the other cases hitherto reported there are no concurrent symptoms like impaired consciousness or motor activity (e. g. deviations of the eyes or the head, facial cloni, etc.) On the basis of the course of the fits a microlesion in the right occipital lobe appears to be the presumable cause.ZusammenfassungBei einem 28jährigen Mann wird ein epileptischer Nystagmus beschrieben und elektrophysiologisch dargestellt.Dem klinischen Anfallsverlauf mit indifferenter Aura (a), Rucknystagmus nach links (b) sowie langsamer Rückbildung einer totalen Gesichtsfeldverdunkelung mit Porroskopie (c) entsprach im EEG eine von occipital rechts ausgehende Salve fokaler spikes (a), während des Nystagmus eine Desynchronisation ohne paroxysmale Potentiale (b) sowie eine terminale Folge regelmäßiger Alpha-Spitzen (c). Das ENG im Anfall zeigte einen nach links gerichteten Sägezahnnystagmus. Der neurologische und neuroradiologische Befund war völlig regelrecht.Im Gegensatz zu allen bisher mitgeteilten Fällen fehlt im Anfallsbild jede Begleitsymptomatik im Sinne einer Bewußtseinstrübung oder zusätzlicher motorischer Entäußerungen. Auf Grund des Anfallverlaufs wird eine Mikroläsion im rechten Occipitalhirn als Ursache angenommen.

Some Remarks about the College and Its Future

Some Remarks about the College and Its Future We are now 13 years old. Proverbally, we have reached our manhood and womanhood. But more likely we have only been thrown into the maelstrom of adolescence. This is our 7th congress and it seems we are in an appropriate identity crisis – who we are, where do we wish to go? We have lost our founding father. We have a membership of 400. We have wandered from Kyoto to Jerusalem. Our attendance has been as high as 1,300 and as low as the current conference. It gives us an opportunity to ask if smaller more focussed congresses are better? Will they get us beyond the platitudes and reiterations of the past toward more mature formulations of integration and synthesis? Perhaps we are establishing an identity. However, there are whole continents in which our presence and our effect is either limited or nonexistent. There is a second and a third world that we have failed to align. We have prestigious vice presidents and councillors, as well as a body of delegates whose use the Administration has tapped limitedly. We are a body without a head in the sense that we have failed in our efforts to establish a journal. The quality of our meetings has been increasingly good, as I am confident this congress will demonstrate. However, the work in their formation has been that of a few. We need to inquire of ourselves of the forwardness of our theories and of the originality of our research. How often do we confuse statistical correlations ofendless variables as proof and substantiation, independent of critical reasoning? Future administrations will need to develop communicative and directive skills in order to tap its officers, as well as its younger members at large to do the job that they have been expected to do. I believe that under the auspices of the Program Committee, with frequent communication, the officers and commitee chairpersons should be responsible for the organization of symposia in the area they share, drawing on their knowledge of the new and seminal work that is under investigation, often outside of our purview. The delegation and tendering of this responsibility will insure the quality ouf our presentations and discussions, allowing our congresses to be more scientific, more communicative, and more conceptual. Several of us believe that our congresses should return to the campus where there is a natural environment for the membership to interact and participate as scholars in a setting conducive for the intimacy of scholarship outside of, as well as within, our more formal sessions. Would this not be a more facile environment in which to bring in our students and associates from other disciplines? Within these settings, there Some Remarks about the College and Its Future 11

Opening Remarks to the 7th World Congress of the International College of Psychosomatic Medicine

Opening Remarks to the 7th World Congress of the International College of Psychosomatic Medicine Standing here, opening our 7th World Congress I am at the same time breaking a very solemn promise – practically an oath -given or sworn 24 years ago. Then – in the spring of 1959 – having been at the Hamburg Clinic for only a year, I watched Jores and Freyberger hosting and organizing the European Congress of Psychosomatic Medicine. What I perceived from my lowly position were hurt vanities of speakers or chairpersons for not having been attributed an adequate position, fights for more speaking time, and delays in the delivery of manuscripts. In my eyes – and this made the whole process simply agonizing – all these troubles seemed fully uncompensated by clear success experiences. As a consequence I gave myself the solemn promise to do anything and everything humanly possible to evade ever hosting an international congress. Having broken my oath with qualms and apprehensions, I can tell you now that the latter were completely unfounded. However, this may be a stroke of luck due to two external but mutually interacting factors. One is the cooperative dedication and zeal of the whole staff of our Psychosomatic Department. It is a very small team, but we managed with only two outside cooperations: Bernd Dahme from the Department of Medical Psychology, and – and this is the second factorthe expert help of the professionals of the Congress Center Hamburg. I am thanking them all for their work and for their dedication. Their cooperation achieved that computer outprints of plenary and symposium speakers were correct, the layout of programs attained expectations, the budget was updated regularly, and the timetable was kept throughout. Thus we have already had our success experiences and our narcissistic support, and therefore we can invite you to feel free of moral obligations and just give vent to your feelings. However, if we are quite honest, we would prefer you to enjoy the V∏th ICPM World Congress and we believe there is an objective albeit predictive reason for this. You certainly never have heard of the Meyer/Freyberger PPWC theorem, because we have only discovered it – independently but convergently – ad hoc of this world congress. PPWC stands for Progressive Pauperization of World Congresses. Its mechanism is an exceedingly simple and easy to understand economic process, one could call it the leverage depression acceleration for certain taxo-nomic subgroups of society (here scientists Opening Remarks 9

Prevalence and Incidence of Psychic Disorders and the Provision of Psychotherapeutic Care: An Epidemiological Field Study in the Andorran Lake District 1950–1980

In a field study with observers acting at the same time as educators the whole population of Srbt/Andorra has been the subject of detailed evaluation with regard to its psychosocial health. With the very special help of 2 (female) methodologists the initial data suggesting ‘normality’ were soon proved to be ‘pseudonormal’ in nature (BJAQ Score > 7). This dangerous situation is now under control since in 1984 the total number of psychotherapists in Andorra will be larger than that of the patients.

Combined Inpatient and Outpatient Psychotherapy — Theoretical Considerations and Empirical Results

Inpatient psychotherapy on a psychoanalytic basis can look back to a long tradition, since simmel formulated it comprehensively in 1928 for the first time. Today inpatient psychotherapy is considered an independent procedure alongside other forms of management. As a consequence, it is generally agreed that the psychosomatic ward is a dynamic, therapeutic unit and an instrument for treatment with defined indicators, the concept of which has found its way into a broad spectrum of publications (Beese 1978; Heigl a.; Neun 1981). The writers’ therapeutic point of departure used at their hospital makes use of a complex supply of possibilities for the treatment in which different procedures are conceived as integrated and related to each other as a whole. This is not achieved through the simple addition of different techniques, but through the integration of different procedures in a stringently coordinated and organized setting. In this way the patient, in accordance with his ability and the current condition, can be approached and reached either verbally or nonverbally, either through interpretation or reality-related intervention.

Comments on Theory and Therapy of Psychosomatic Patients with a Follow-Up Study

Given the specific problems of the physically sick, the psychoanalytic therapy of psychosomatic patients normally calls for modification of treatment concepts that have proved viable for patients with