Thomas Klauer

Self-stigma in alcohol dependence: consequences for drinking-refusal self-efficacy.

BACKGROUND Public stigma and self-stigma are two facets of mental illness stigma. Self-stigma denotes the internalization of negative public perceptions by persons with mental illness and has been shown to decrease general self-efficacy. To date, self-stigma has not been examined in people suffering from alcohol dependence, a particularly severely stigmatized mental disorder. METHODS By adopting the Self-Stigma in Mental Illness Scale (SSMI), we developed the Self-Stigma in Alcohol Dependence Scale (SSAD). The scale is based on a focus-group derived list of 16 negative stereotypes about alcohol dependent persons. It consists of four 16-item subscales measuring four hypothetical stages of self-stigma, stereotype awareness (aware), stereotype agreement (agree), self-concurrence (apply), and self-esteem decrement (harm). We employed the SSAD in a cross-sectional study of 153 patients hospitalized for alcohol detoxification to examine its reliability and validity. RESULTS The four stages of self-stigma could be reliably measured with the SSAD (Cronbachs alpha, 0.86-0.93). Each step in the process of self-stigmatization was most closely associated with its preceding step. Other significantly related independent variables in multiple regression analyses included desire for social distance (associated with agree), duration of drinking problems (associated with apply) and depressive symptoms (associated with apply and harm). Both apply and harm were significantly related to reduced drinking-refusal self-efficacy in analyses controlling for depressive symptoms and variables related to duration and severity of the drinking problem. DISCUSSION The SSAD showed good validity and reliability measuring the stages of self-stigma in this group. Self-stigma appears to be associated with lower drinking-refusal self-efficacy.

Compliance, adherence, and the treatment of multiple sclerosis.

With the availability of disease-modifying, immunomodulatory therapies (DMT) for multiple sclerosis (MS) and the first long-term studies, it became obvious that problems of compliance to complex treatment regimens under chronic conditions would also apply to these approaches. In a selective overview, problems and findings of adherence research are depicted. Based on a discussion of basic concepts, issues of operationally defining and measuring adherence are outlined. Descriptive findings on adherence to DMTs and empirical predictors of nonadherence are then discussed. Referring to theoretical models of treatment motivation, selected problems (e. g., indication) and strategies of promoting adherence are described. Finally, implications of modern concepts of the patient-therapist relationship for the issue of patient adherence are considered.

Differential effects of childhood abuse and neglect: Mediation by posttraumatic distress in neurotic disorder and negative symptoms in schizophrenia?

Dissociation, though understood as a response to trauma, lacks a proven etiology. The assumption of a dose-response relationship between trauma, dissociation and Schneiderian symptoms led to the proposal of a dissociative subtype of schizophrenia characterized by severe child maltreatment, dissociation and psychosis. Child maltreatment and dissociation are common features of neurotic disorders as well, and the link between trauma, dissociation, and hallucinations is not specific for schizophrenia. This study compares childhood abuse and neglect, posttraumatic distress and adult dissociation in patients with psychotic vs. non-psychotic disorder. Thirty-five participants with non-psychotic disorder and twenty-five with schizophrenia were analyzed using the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), the Montgomery-Åsberg Depression Rating Scale (MADRS), the Posttraumatic Stress Diagnostic Scale PDS (PDS), the Childhood Trauma Questionnaire (CTO) and the Arbeitsgemeinschaft Methodik und Dokumentation in der Psychiatrie (AMDP)-module on dissociation. Trauma and clinical syndromes were compared by means of T-testing and logistic regression between 1) the diagnoses and 2) groups with and without post-traumatic stress disorder (PTSD), marked dissociation and psychotic symptoms. While non-psychotic disorder was related to abuse, schizophrenia showed an association with neglect. Childhood trauma predicted posttraumatic symptomatology and negative symptoms. Childhood abuse and neglect may effectuate different outcomes in neurotic and psychotic disorder. The underlying mechanisms, including dissociation, dovetail with cognitive, emotional and behavioural changes involved in depression, posttraumatic distress and chronic schizophrenia symptoms rather than being directly linked to trauma.

Trauma and Current Posttraumatic Stress Symptoms in Elderly German Women Who Experienced Wartime Rapes in 1945

The aim of this study was to determine the persistent trauma impact and significant posttraumatic stress symptoms in a sample of very elderly German women who survived the mass rapes committed by soldiers at the end of World War II. A total of 27 women were recruited, interviewed, and then administered a modified Posttraumatic Diagnostic Scale. They all reported a very severe degree of trauma exposure in 1945; 19% reported significant current posttraumatic stress symptoms indicating a possible posttraumatic stress disorder at the time of the study, and 30% fulfilled the criteria of a current partial posttraumatic stress disorder. The results highlight the necessity for prevention and treatment programs for women exposed to wartime rapes in current conflict settings worldwide, and the need to identify and treat posttraumatic conditions in the elderly generation of all countries exposed to World War II trauma.

A surveillance tool using mobile phone short message service to reduce alcohol consumption among alcohol-dependent patients.

BACKGROUND In public health settings, short message service (SMS) appears to be a promising low-cost modality for reducing alcohol consumption. Here, we test a simple interactive SMS-based helpline with detoxified alcohol-dependent patients to extend findings to curative settings. METHODS This controlled, prospective, 2-group before-after block-assignment, open pilot study tested the feasibility and efficacy of an 8-week outpatient interactive mobile phone SMS intervention (n = 42) against treatment as usual (TAU; n = 38) after inpatient detoxification. Patients were asked whether they needed any help via an automatically generated text message twice a week. A therapist called the individual back when notified. Alcohol consumption was assessed using the telephone version of Form-90 4 and 8 weeks after discharge from inpatient detoxification. The primary end point was defined as attaining low-risk consumption (males ≤30 g or 3.75 units per drinking day (DDD); females ≤20 g or 2.5 units per DDD) 8 weeks after discharge. Missing data were replaced by multiple imputation. RESULTS Among all messages sent, 20.5% were followed by a phone call. Feasibility and acceptability were good, as indicated by successful implementation of the SMS procedure and the rapid inclusion of patients. Adherence was satisfactory with 57.14% of the participants replying to at least 50% of the prompts. Patients reported a typical preadmission DDD of 281.25 ± 244.61 g. In the SMS group, 55.7% of 42 patients, and 40% of 38 patients in the TAU group, achieved low-risk consumption (risk diff: 0.16; 95% CI -0.06 to 0.37; p = 0.122). CONCLUSIONS In detoxified alcohol-dependent patients, relapse prevention based on SMS was well received and implemented efficiently and rapidly. An adequately powered multicenter study is currently being conducted to test the nonsignificant but encouraging findings of this exploratory study with more rigorous trial methods (ISRCTN78350716).

Detachment, Compartmentalization, and Schizophrenia: Linking Dissociation and Psychosis by Subtype

To explain the phenomenological overlap between dissociation and schizophrenia, a dissociative subtype of schizophrenia has been proposed as a possibility. Dissociation is often believed to be organized on a continuum, although 2 qualitatively different phenomena can be distinguished in theory, research, and clinical practice: (a) states of separation from self or environment (detachment dissociation) and (b) inaccessibility of normally accessible mental contents (compartmentalization dissociation). This study used the Positive and Negative Syndrome Scale (PANSS) and the Association for Methodology and Documentation in Psychiatry module for the interview assessment of dissociation to investigate the relationships between PANSS subscales, detachment dissociation, and compartmentalization dissociation in a sample of 72 patients with schizophrenia. A confirmatory factor analysis sustained the bipartite model, yielding factors that grouped dissociative items around amnesia and depersonalization/derealization. The latter factor also contained identity disturbances and was therefore not entirely consistent with the theoretical formulations of detachment dissociation. It is important to note that the structure of those factors may be influenced by the symptoms of schizophrenia to which they were specifically linked: The factor containing depersonalization/derealization was connected to the positive symptoms subscale of the PANSS, whereas the factor containing amnesia was associated with the negative subscale. Hence, a dichotomy of dissociation is confirmed inasmuch as its subtypes are as distinguishable as PANSS subscales. This has implications on theoretical and clinical levels.

Selbst- und Fremdeinschätzungen der Therapiemotivation als Prädiktoren von Behandlungsabbrüchen in der stationären Psychotherapie

Zusammenfassung. In den meisten Studien irregularer Entlassungen aus der stationaren Psychotherapie wurden soziodemographische und klinische Variablen als Pradiktoren des Behandlungsabbruchs untersucht. Die vorliegende Studie ging der Frage nach, ob Charakteristika der individuellen Behandlungsmotivation (z. B. Leidensdruck; sekundarer Krankheitsgewinn; Behandlungserwartungen; erfasst uber Selbst- und Fremdberichte) zusatzliche Varianz in Abbruchraten erklaren konnen. Eine Stichprobe von insgesamt 402 stationaren Psychotherapie-Patienten wurde bei Erstinterview und Aufnahme mit einem Fragebogenverfahren (FMP) und einem klinischen Rating-System (OPD) untersucht. Zur Vorhersage irregularer Entlassungen uber die gesamte Behandlungszeit sowie fruher Therapieabbruche vor dem zehnten Behandlungstag wurden hierarchische logistische Regressionsanalysen eingesetzt. Die Befunde zeigen zunachst, dass das Vorhandensein einer Partnerschaft der beste Pradiktor fur Behandlungsabbruche unter den betrachteten soziodemogra...

Coping with neuroimmunological diseases

Although there is little doubt about a considerable need for psychosocial support in patients with severe neuroimmunological diseases, the theoretical elaboration of stressful illness consequences as well as the development of standardised intervention programs are still in their beginnings. In the present paper, models of coping with chronic illness are characterised as a suitable framework. After a short overview of psychological dimensions of physical illness, concepts from the coping literature that seem to meet these demands are briefly introduced. Furthermore, recent results of coping research especially in multiple sclerosis (MS) are outlined in an overview which also includes findings from evaluation studies. Moreover, aims and techniques, which constitute necessary elements of coping skills training for patients with neuroimmunological disease, are described. Questions of suitability of coping interventions for subgroups of patients with multiple sclerosis are finally discussed.

Bewältigungsstrategien und wahrgenommene soziale Unterstützung bei deutschen Langzeitüberlebenden der Vergewaltigungen am Ende des II. Weltkriegs

OBJECTIVE The aim of the study was to document perceived social support in a sample of German war-raped women in World War II. Furthermore the impact of this potential resource on todays posttraumatic symptoms should be pointed out. METHODS 27 women (M = 80.3 years, SD = 3.1 years) answered each a semi-structured interview and several questionnaires. RESULTS Perceived social support shows clearly lower values than in the comparative samples. The measured degree of the variable in the present sample bears negative relationship to the actual posttraumatic symptoms of the women. CONCLUSIONS In World War II sexually traumatized women could profit only few from the examined resource. The found negative relationship between perceived social support and posttraumatic symptoms shows additionally the potentially long-lasting impact of these form of coping on psychological health in trauma victims.

Alexithymia and Psychotherapeutic Treatment Motivation: Main and Interactional Effects on Treatment Outcome

cluded due to discontinuation of the treatment program or missing data. Thus, an analytic sample of 518 patients, treated in 6 psychiatric day hospitals located in the region of Western Pomerania, Germany (all part of the University Hospital Greifswald), completed the German versions of the Toronto Alexithymia Scale 20 (TAS-20) [8] and the Symptom Checklist-90-Revised [9] to assess the global symptom severity (GSI) at admission (t 0 ) and discharge (t 1 ). Treatment motivation was assessed using the Questionnaire for the Measurement of Psychotherapy Motivation (FMP-30) at t 0 [7] . The treatment program included art therapy, relaxation therapy, and body and movement therapy on a daily basis. Each patient received an individual psychotherapy session of 1 h per week, with either a psychodynamic or cognitive-behavioral approach. Psychotropic medication was offered if clinically indicated. The duration of the treatment program ranged generally between 6 and 8 weeks. All patients gave written informed consent prior to inclusion in the study. Of the analytic sample, 70.2% were female, and the mean age was 43.1 years (SD 11.3). At admission, the mean TAS-20 score was 55.9 (SD 11.4); 185 subjects (35.7%) were alexithymic according to common TAS-20 cutoff scores of >60. Hierarchical linear regression analysis with sex, age, and GSIt 0 as control variables was applied to calculate the predictive power of TAS-20 and FMP subscales on GSIt 1 in the total sample ( Table 1 ). TAS-20 (β = 0.08; p = 0.035) and treatment expectations (β = –0.100; p = 0.009) were found as significant predictors of GSIt 1 . Partial correlation analyses of TAS-20 and the FMP subscales, adjusted for age, sex, and GSIt 0 , revealed significant negative correlations of TAS-20 and treatment expectations ( r = –0.116; p = 0.008), demonstrating that with increasing alexithymia scores perceived suitability and expected outcome of the treatment decrease. We also observed a significant positive correlation between TAS-20 and the degree of suffering ( r = 0.122; p = 0.005), showing that the perceived suffering is related with alexithymic personality features over and above GSI scores. Conditional regression analyses were performed to calculate interactional effects between TAS-20 (grouped variable, alexithymic vs. nonalexithymic) and each FMP subscale (z-standardized). Models were adjusted for sex, age, and GSIt 0 (z-standardized). We found a TAS-20 by “degree of suffering” interaction (β = 0.086; p = 0.019), showing that the treatment outcome of alexithymic patients is independent from the degree of suffering, while in nonalexithymic patients this PTM dimension is related with a more beneficial treatment outcome. Additional analysis of variance showed significant between-center effects on the treatment outcome. However, predictive effects of alexithymia and treatment motivation stayed stable. Consistent with previous studies, our results lend further support to the role of psychotherapeutic treatment expectations and alexithymia on the treatment outcome [4, 10] . However, the novAlexithymia is a personality style regularly found among patients seeking psychotherapeutic help and is associated with various psychiatric and psychosomatic disorders including depression [1] , somatization disorder [2] , and chronic somatoform pain [3] . While different studies found alexithymia to be associated with unbeneficial treatment outcome [1, 4] , the mechanism remains incompletely understood. Psychotherapeutic treatment motivation (PTM) has been suggested as a key factor for the acceptance of, adherence to, and engagement in psychotherapeutic processes across different methods and techniques [5, 6] . A recent concept of PTM includes the dimensions psychotherapeutic treatment expectations, degree of suffering, psychosocial lay etiology, and, as a negative motivational factor, secondary illness benefits [7] . Alexithymic subjects experience psychological distress as somatic symptoms which cannot be interpreted in a meaningful way. These patients may favor a more somatic causal model compared to psychosocial explanations for their complaints. Moreover, the attitudes of alexithymic patients towards psychotherapy and their expectations for the treatment outcome may be limited, which may reduce their treatment motivation. However, to our knowledge, no study has systematically investigated the relationship of alexithymia and dimensions of PTM in their effect on the treatment outcome. In detail, we investigated whether (1) alexithymia and the dimensions of PTM predicted the treatment outcome in terms of symptom reduction, (2) alexithymic personality features were correlated with the dimensions of PTM, and (3) alexithymia and dimensions of PTM interact in their effects on the treatment outcome. A total of 991 patients were consecutively admitted. Of these, 778 patients agreed to participate while 260 subjects had to be exReceived: December 15, 2016 Accepted after revision: January 24, 2017 Published online: May 11, 2017