Markus Stingl

Alexithymia as a predictor of outcome of psychodynamically oriented inpatient treatment

Abstract This naturalistic study aimed to determine whether the initial degree of alexithymia can predict treatment outcome of psychodynamically oriented multimodal therapy. The Toronto Alexithymia Scale–26, the Global Severity Index (GSI), and the Depression subscale of the Symptom Checklist-90-Revised were administered at hospital admission and at discharge to 480 inpatients with various psychological disorders. GSI and depressive symptoms decreased significantly during treatment. High initial alexithymia total scores significantly predicted treatment outcome, especially in patients with somatoform disorders. Difficulties in verbalizing feelings had the strongest association with less favourable symptom improvement. Although significant, the predictive values were relatively small, and patients with alexithymia indeed benefited from therapy. Implications of these results are discussed for the specificity of disorders and therapeutic approach.

Effects of inpatient psychotherapy on the stability of alexithymia characteristics

BACKGROUND Although alexithymia is associated with several psychiatric disorders, there has been little research into the effects of psychodynamic psychotherapies on this condition. Here, the influence of inpatient multimodal psychodynamic psychotherapy on alexithymia and symptom load was evaluated in a large sample of patients. METHODS Alexithymia [measured with the Toronto Alexithymia Scale (TAS)-26] and psychological stress and depression [measured with the Symptom Checklist 90 Revised (SCL-90-R)] were evaluated at admission and after inpatient multimodal psychotherapy in patients with various psychosomatic and psychiatric disorders admitted to this unit between 2002 and 2005. Patients undergoing both short-term (up to 4 weeks) and long-term treatment (8-12 weeks) were studied. Analyses of covariance were used to analyse the data on depression (SCL-90-R) and psychological stress (SCL-90-R), and correlations between admission and discharge scores for the TAS-26 were computed to evaluate mean and relative stability of alexithymia. RESULTS Data on 397 of the 568 patients admitted were analysed. Psychological stress and depression (SCL-90-R) decreased significantly during the study across all diagnostic groups. The TAS-26 total score also decreased significantly, showing that there was no mean stability of alexithymic characteristics. However, the significance of decrease was lost when psychological stress and depression were controlled for. Highly significant correlations between TAS-26 sores before and after treatment reflected high relative stability of alexithymia. CONCLUSIONS During inpatient multimodal psychodynamic treatment, the symptom load and alexithymia in our patients decreased. The high relative stability of alexithymia shown supports the view that alexithymia is a relative stable personality trait.

Alexithymia and script‐driven emotional imagery in healthy female subjects: no support for deficiencies in imagination

Alexithymia is associated with a limited access to inner emotional processes. Furthermore, alexithymia is assumed to be characterized by a limited ability to use imagination. To evaluate the frequently proposed thesis of a reduced imagination ability in alexithymic persons, 25 high and 24 low alexithymic women self-rated their imagination ability. Furthermore, the electrodermal activity (EDA) during script-driven emotional imagination was determined and valence, arousal, and vividness of the respective imaginations were rated. Our results indicate no significant differences between high and low alexithymic women in the self-rated imagination ability, the EDA during imagination and the ratings of valence, arousal and vividness. The study provides evidence that healthy high alexithymic women are capable of differentiated emotional imagination.

A Comparison of Dual Attention, Eye Movements, and Exposure Only during Eye Movement Desensitization and Reprocessing for Posttraumatic Stress Disorder: Results from a Randomized Clinical Trial.

Background: Currently, there is controversy on the possible benefits of dual-attention tasks during eye movement desensitization and reprocessing (EMDR) for patients with posttraumatic stress disorder (PTSD). Methods: A total of 139 consecutive patients (including 85 females) suffering from PTSD were allocated randomly among 3 different treatment conditions: exposure with eyes moving while fixating on the therapists moving hand (EM), exposure with eyes fixating on the therapists nonmoving hand (EF), and exposure without explicit visual focus of attention as control condition (EC). Except for the variation in stimulation, treatment strictly followed the standard EMDR manual. Symptom changes from pre- to posttreatment were measured with the Clinician-Administered PTSD Scale (CAPS) by an investigator blinded to treatment allocation. Results: In total, 116 patients completed the treatment, with an average of 4.6 sessions applied. Intention-to-treat analysis revealed a significant improvement in PTSD symptoms with a high overall effect size (Cohens d = 1.96, 95% CI: 1.67-2.24) and a high remission rate of PTSD diagnosis (79.8%). In comparison to the control condition, EM and EF were associated with significantly larger pre-post symptom decrease (ΔCAPS: EM = 35.8, EF = 40.5, EC = 31.0) and significantly larger effect sizes (EM: d = 2.06, 95% CI: 1.55-2.57, EF: d = 2.58, 95% CI: 2.01-3.11, EC: d = 1.44, 95% CI: 0.97-1.91). No significant differences in symptom decrease and effect size were found between EM and EF. Conclusions: Exposure in combination with an explicit external focus of attention leads to larger PTSD symptom reduction than exposure alone. Eye movements have no advantage compared to visually fixating on a nonmoving hand.

Treating post-traumatic stress disorder by resource activation in Cambodia.

There is a need for effective, low‐threshold psychotherapeutic treatments in post‐conflict settings1. However, systematic outcome research on site is still extremely rare. To address this problem we integrated rigorous research procedures into a humanitarian program, the so called Mekong Project, and conducted a randomized controlled trial for the treatment of post‐traumatic stress disorder (PTSD) in Cambodia. In short, the Mekong Project aims at establishing independent psychotherapeutic services in several Southeast Asian countries via the systematic training of local health professionals and offering free of charge psychological help to traumatized civilians. Cambodia is one of the least developed countries in Asia, facing many challenges (e.g., poor standards of health and education, rural exodus, and political instability). Mental health morbidity in Cambodia is high. It has been found that 53.4% of the Cambodian population suffer from a mental disorder, with anxiety and PTSD being the most frequent (40.0% and 28.4% respectively)2. Thus, although some stability has returned to the country during the past decades, there are urgent mental health care needs, including the need for individualized psychiatric services. Our aim was to test the efficacy of a non‐confrontational psychotherapeutic treatment for PTSD. The therapy includes two main treatment principles described in treatment manuals: resource‐oriented trauma therapy and resource installation with eye movement desensitization and reprocessing (EMDR) (short: ROTATE). ROTATE aims at strengthening resilience and coping capacities by activating positive personal resources, and largely draws on psychodynamic principles of the therapeutic relationship. It includes a variety of imaginative resource‐activating methods3, 4 as well as resource development and installation, an EMDR technique aiming at systematically developing and anchoring resources using alternating bilateral stimulation5. ROTATE has several advantages: a) it can be safely applied even to complex trauma conditions, with no major side effects being observed so far; b) instead of solely focusing on PTSD symptoms, it also considers the mental comorbidities typically found in these clients, notably depression and anxiety; c) it is especially suitable for clients from non‐Western countries, as traditional healing resources like mindfulness strategies can be integrated in an overall framework of resource activation; d) its basic elements can easily be taught, even to paraprofessionals. Our trial was carried out in cooperation with the Royal University of Phnom Penh and was located in Phnom Penh City and the nearby Kandal Province. Help‐seeking outpatients screening positively for PTSD (PTSD Check List ≥ 446) were eligible for inclusion. We allowed for comorbid mental health disorders except for psychosis, organic brain disorder, cognitive impairment, dementia, acute suicidality, and acute need for treatment. Overall, 800 patients were screened for eligibility, of whom 86 (mean age 27 years, 61% female) fulfilled the selection criteria and were randomly assigned to either 5 weekly sessions of ROTATE (N=53) or a 5‐week waiting list control group (N=33). Symptoms were measured before and after the intervention (or waiting period). Assessments were performed via personal interview by an investigator blind to treatment allocation. All patients in the control group were offered treatment after the end of the waiting period. The primary outcome was PTSD symptom change on the Indochinese version of the Harvard Trauma Questionnaire (HTQ)7. The PTSD scale of the HTQ includes 16 items reflecting the DSM‐IV criteria for PTSD. Secondary outcomes included depression, anxiety and social functioning. All applied instruments have been validated for the Cambodian population7. The therapy was provided by six Cambodian psychologists who had completed a 3‐year course in trauma therapy as part of the Mekong Project. Based on previous findings of psychological therapies for PTSD8, we expected ROTATE to be superior to waiting list with a between group effect size of at least d=0.65 on the primary outcome. To detect this difference with a power of 0.80 at α=0.05, 2‐sided test, 2 × 40 patients were required. Unfortunately, the concept of randomization, especially being randomized to a waiting list, was very difficult for some clients. As a consequence, randomization failed in 38 patients, leading to an unbalanced allocation ratio (1.6:1), with an overrepresentation of patients randomized to treatment. The trial stopped when the necessary sample size to achieve a power of 0.80 was reached. Data were analyzed by general linear regression models, controlling for baseline symptom severity. The drop‐out rate during the intervention was very low (N=2, one in each group), thus only completer data were analyzed (N=84). Most frequent types of trauma were traffic accidents (24%), domestic violence (23%) and sexual abuse (16%). Patients receiving ROTATE showed significant reductions in PTSD symptoms compared to the waiting list (baseline adjusted means post‐treatment: 1.39, 95% CI: 1.23‐1.54 for ROTATE, and 2.86, 95% CI: 2.66‐3.06 for waiting list, p<0.00001). The between‐group effect size was large (d=2.59). The within‐group effect size was also large for ROTATE (d=4.43), while it was moderate in the control group (d=0.52). No harms were reported. We conclude that a treatment focusing on stabilization rather than confrontation, by establishing a secure patient‐therapist relationship, applying stabilization techniques, and putting an emphasis on a patients own resources, significantly reduced symptoms of PTSD in comparison to a waiting list. The strengths of our study are the following: a) it was conducted on site by local psychologists, which meant that communication between therapists and patients was natural and no interpreters were needed; b) therapists and patients had similar cultural backgrounds, so that culture specific interpretations of symptoms could be taken into account, a factor that has been identified as vital in the therapeutic work with Cambodian patients9; c) local psychologists were trained in ROTATE, which is expected to facilitate patient access to a psychological treatment in a country struggling with insufficient mental health care. Conducting a randomized controlled trial in a developing country is challenging. Nevertheless, we were able to show that the implementation of such a trial was possible and that this specific form of trauma therapy was well accepted by therapists and patients. Our results are preliminary but promising. Further research is required to corroborate the findings. Christiane Steinert1, Peter J. Bumke2, Rosa L. Hollekamp1, Astrid Larisch1, Falk Leichsenring1, Helga Matthes3, Sek Sisokhom4, Ute Sodemann2, Markus Stingl1, Ret Thearom4, Hana Vojtova5, Wolfgang Woller6, Johannes Kruse1,7 1Clinic for Psychosomatic Medicine and Psychotherapy, University of Giessen, Giessen, Germany; 2Trauma Aid Germany, Berlin, Germany; 3Psychotraumatology Institute Europe, Duisburg, Germany; 4Department of Psychology, Royal University of Phnom Penh, Phnom Penh, Cambodia; 5Slovak Institute for Psychotraumatology and EMDR, Trencin, Slovakia, and Center for Neuropsychiatric Research of Traumatic Stress, Charles University, Prague, Czech Republic; 6Hospital for Psychosomatic Medicine and Psychotherapy, Rhein‐Klinik, Bad Honnef, Germany; 7Clinic for Psychosomatic Medicine and Psychotherapy, University of Marburg, Marburg, Germany

A Concept of Clinical Care for Refugees on a General Psychiatric Ward

Refugees and asylums seekers can present as a highly vulnerable group with an increased risk for the development of mental disorders. We developed and established a concept of clinical psychiatric care for refugees on a general psychiatric ward that systematically takes into account the social, cultural and legal dimensions relevant for mental health of refugees. This concept presents a framework for treatment, which not only offers security and orientation for the patients but also for the treatment team. The present treatment guide should provide structured working in apparently hopeless situations, which due to language difficulties, trans-cultural features and serious diseases at least in the short term seem to be unchangeable. Due to the implementation of the treatment concept, from the perspective of the team, there is a noticeable relief and significant improvement concerning the interaction with refugees on the ward. We have experienced that handling patients according to this treatment concept has mutually influenced both, the treatment outcome of refugees as well as the clinical setting. It became possible not only to integrate refugees on a common psychiatric ward but opens the way for reciprocal exchange between treatment team, refugees and other patients in terms of acculturation. We expect that in the future the number of asylum seekers will remain high because of wars across the globe. Therefore, it can be assumed that there will be a need for differentiated and flexible treatment concepts for the inpatient treatment of refugees also in the future.

Assessing the special need for protection of vulnerable refugees: testing the applicability of a screening method (RHS-15) to detect traumatic disorders in a refugee sample in Germany

ABSTRACT Objectives: Although EU member states are obligated to take special account of the situation of particularly vulnerable refugees, appropriate and specific measures to detect affected asylum seekers are not yet available. This study tries to pave the way for the implementation of an adequate instrument which at the same time assesses these needs of suffering people whilst responding to the need for mental health assessments specifically designed for refugees. This was done by testing the implementation of a screening method (Refugee Health Screener RHS-15) for trauma related mental health problems in refugees. Design: Two refugee samples in Germany (differing in arrival time: 126 applicants for asylum residing in the initial reception center and 116 living in long term communal accommodations) were assessed with the culturally sensitive Refugee Health Screener (RHS-15) to detect the incidence of mental health problems amongst them. Test fairness, reasonableness, susceptibility, transparency, acceptance, external design, utility and economy of the instrument were examined to check the applicability of the RHS-15 standardization test. Results: The RHS-15 indicates a good practical feasibility as the examination of the focused psychometric characteristics suggests. It became apparent, that implementing a screening procedure depends on political, legal and medical context factors that need to be considered. 2/3 of the participants had a positive screening result, which needs further diagnostic clarification in a second step. Conclusion: The RHS-15 seems to be practicable, economical, and rapidly deployable for the widespread detection of traumatic disorders in refugees living in Europe. The tool proved useful to aid diagnostic assessments and provide treatment to individuals in need, however the time of examination (resp. the duration of staying in the target land) influences the results.

Migration-Related Stressors and Their Effect on the Severity Level and Symptom Pattern of Depression among Vietnamese in Germany

Objectives Vietnamese in Germany represent a scarcely researched and vulnerable group for mental health problems, especially under exposure to migration-related stressors (MRS). This study analyzes the effect of those MRS on the severity level and symptom pattern of depression. Design We analyzed the data of 137 depressed Vietnamese patients utilizing Germanys first Vietnamese psychiatric outpatient clinic. Hierarchical linear regression models were applied to investigate how the quantity of MRS influenced (1) the overall severity of self-reported depression symptoms; (2) the cognitive, affective, and somatic BDI-II subscale; and (3) the single BDI-II items of these subscales. Results A greater number of MRS were related to a higher severity level of depression in general, as well as to a higher level on the cognitive depression subscale in particular. The BDI-II single items pessimism, past failure, guilt feelings, punishment feelings, and suicidal thoughts were particularly associated with a higher quantity of perceived MRS. Conclusion Among depressed Vietnamese migrants in Germany, a higher number of reported MRS were associated with higher overall depression severity. Within the domains of depression, particularly the cognitive domain was linked to perceived MRS. The association between MRS and suicidal thoughts is clinically highly relevant.