Auch wenn die Wirksamkeit psychotherapeutischer Interventionen als belegt gilt, scheint es doch immer Patienten zu geben, deren Beschwerden sich durch derartige Behandlungen nicht verbessern. Es kann davon ausgegangen werden, dass sich 5–10% aller Patienten während der Therapie verschlechtern und bei 30% keine Veränderung der Beschwerden auftritt (non-response). Die vorliegende Studie widmet sich den Misserfolgen in der stationären psychosomatischen Akutbehandlung. Dabei wird der Frage nachgegangen, ob sich unterschiedliche Verlaufstypen identifizieren lassen, und ob sich diese anhand von Patienten-, Therapeuten- und Therapievariablen vorhersagen lassen. Zur Untersuchung dieser Frage wurde auf Routinedaten (IIP, SCL90, BDI, HAQ) aus 2 psychosomatischen Abteilungen in Freiburg zurückgegriffen (N=1397). Non-responder wurden anhand des Reliable Clinical Change Index identifiziert. Zur Vorhersage der Prädiktoren von Non-response wurde eine bivariate logistische Regression berechnet. Patienten mit Persönlichkeitsstörungen und Somatoformen Störungen reagieren mit höherer Wahrscheinlichkeit nicht auf die Therapie. Des weiteren sind sehr abweisende (DE Skala, IIP) bzw. introvertierte (FG Skala IIP) Patienten anfälliger für einen ungünstigen Therapieverlauf. Die Ergebnisse der Untersuchung negativer Therapieverläufe und –ergebnissen können genutzt werden, um negative Verläufe frühzeitig zu erkennen, korrigierend einzugreifen und somit therapeutische Misserfolge zu reduzieren.

Fragestellung: In der Pathogenese der Fibromyalgie (FM) sind katastrophisierende Gedanken, interpersonelle Probleme und unverarbeitete Traumatisierungen von Bedeutung. Hieraus ergeben sich Therapieverfahren auf kognitiv-behavioraler und auf psychodynamischer Basis. Die Effektivität kognitiv-behavioraler Behandlungsverfahren wurde in mehreren Studien überprüft. In der hier durchgeführten Studie wurde erstmals eine psychodynamische Einzeltherapie als störungsspezifische Kurzzeittherapie über 25 Sitzungen evaluiert. Methode: In einer prospektiven kontrollierten, randomisierten Therapiestudie wurden bisher 28 FM-Patientinnen auf zwei Behandlungsarme verteilt (störungsspezifische Psychotherapie vs. hausärztliche Betreuung). Beide Behandlungsmodule sind manualisiert. Da die Studie noch nicht abgeschlossen ist, können nur Ergebnisse einer Zwischenauswertung vorgestellt werden. Ergebnisse: In der 12-Monats-Katamnese zeigte sich in der Psychotherapiegruppe (n=9) gegenüber der Hausarztgruppe (n=11) eine signifikante Verbesserung der FM-bezogenen Schmerzsymptomatik (ANOVA mit Messwiederholung, F=5,2; p=0,04). In der Psychotherapiegruppe (n=12) zeigte sich ferner gegenüber der Hausarztgruppe (n=10) eine signifikante Verbesserung der Arbeitsfähigkeit bereits in der 6-Monats-Katamnese (ANOVA mit Messwiederholung, F=15,8; p=0,001).

Fragestellung: Aus Neuroimaging-Studien ist bekannt, dass periphere Schmerzreize bei Fibromyalgie (FM) eine Sensibilisierung der Schmerzneuromatrix fördern und zur Entstehung einer chronischen Schmerzverarbeitungsstörung beitragen. Ferner ist bekannt, dass die Ausprägung depressiver Symptome bzw. katastrophisierender Gedanken bei appliziertem Schmerz bei FM-Patientinnen zu einer verstärkten neuronalen Aktivierung der anterioren Insula und Amygdala bzw. des ACC, SII Cortex und des inferioren parietalen Lobulus führen. Ungeklärt ist bisher, ob auch visuell miterlebter Schmerz bei FM eine verstärkte Aktivierung der Schmerzneuromatrix bewirkt. Methode: In einer fMRI-Studie wurden 10 FM-Patientinnen und 10 gesunden Probandinnen standardisierte Bilder von schmerzhaften und nicht schmerzhaften Alltagssituationen im Blockdesign gezeigt. Ergebnisse: Im Gruppenvergleich zeigten die FM-Patientinnen im Kontrast “Schmerz > kein Schmerz“ gegenüber den gesunden Probandinnen verstärkte Aktivierungen in den affektverarbeitenden und für die somatosensorisch-diskriminativen Funktionen zuständigen Hirnarealen der Schmerzneuromatrix. Diskussion: Die Studienergebnisse sprechen dafür, dass emphatisch miterlebter Schmerz ähnlich wie periphere Schmerzreize zu einer Sensibilisierung der Schmerzneuromatrix führt und damit zu einer Chronifizierung der Fibromyalgie beiträgt.

Hintergrund: Die Ätiologie und Pathogenese des Fibromyalgiesyndroms (FM) ist nicht ausreichend geklärt. Aus psychotherapeutischer Sicht kommt der Klärung des Zusammenhangs zwischen FM und depressiven Störungen eine große Bedeutung zu. In der folgenden Querschnittsuntersuchung wurde dieser mögliche Zusammenhang im Zwei-Gruppen-Vergleich (Patienten mit FM vs. Rheumatoide Arthritis–RA) weiter analysiert. Methoden: Es wurden 75 Patientinnen mit primärer FM und 35 Patientinnen mit RA verglichen. Depressive und dysthyme Symptome sowie die globale psychische Belastung (Global Severity Index – GSI) wurden mit dem SCL–27 erfasst. Zur Erfassung früher Traumatisierungen und depressiver Persönlichkeitsmerkmale wurden der CTQ und der IPP-C verwendet. Die Messung der Schmerzintensität erfolgte mit dem MPI-D. Nach Ermittlung der Mittelwertsunterschiede, der Korrektur der Gruppenunterschiede in Bezug auf die Schmerzintensität (FM > RA) wurden verschiedene lineare Regressionsanalysen (abhängige Variable: Schmerzintensität, unabhängige Variablen: Depressive und dysthyme Symptomatik, globale psychische Belastung) durchgeführt. Ergebnisse: Es ergaben sich signifikante Unterschiede (FM > RA) in Bezug auf depressive und dysthyme Symptome (SCL–27), in Bezug auf die globale psychische Belastung (GSI) sowie einzelne Dimensionen des IPP-C und des CTQ. Ferner ergaben sich in der Gruppe der Patientinnen mit FM signifikante lineare Korrelationen zwischen Schmerzintensität und depressiven Symptomen bzw. der globalen psychischen Belastung. In Bezug auf dysthyme Symptome fand sich eine deutliche Tendenz für eine lineare Korrelation in der FM-Gruppe. In der Gruppe der Patientinnen mit RA fanden sich keine linearen Korrelationen in Bezug auf die o.g. Dimensionen. Diskussion: Die Ergebnisse sprechen für einen ätiologischen Zusammenhang zwischen Depression und FM (somatisierte Depression). Dies trifft u.E. zumindest auf eine signifikante Teilgruppe von Patientinnen mit Fibromyalgiesyndrom zu.

Idiopathic spasmodic torticollis (IST) is one of the most frequent dystonic movement disorders. Its classification as a focal dystonia, as well as its treatment with botulinum toxin resulted in groups of patients being regularly seen by neurologic specialists. In a multicentre study, we investigated psychosocial changes, coping and psychopathology, and their interrelations with signs, symptoms and course. 256 patients were included in the study (59.3% women, 40.7% men). The mean age was 49.1 years. Rotating torticollis occurred more often than latero-retrocollis and antero-retrocollis. A family history of IST was seen in 3.1 % of the total sample, 34% of the patients had additional dystonic symptoms. Most frequently, these affected the upper extremities (13%), less often the legs. 19.1% of the patients had experienced a period of complete remission. The General Symptom index of the SCL 90-R in 27% of the patients ranged above the double standard deviation of the normal controls, indicating a clinically significant psychopathology.

This review is based on a survey of the empirical literature on hypochondriasis since 1980. It is suggested that despite the use of operationalized diagnostic criteria the definition of hypochondriasis remains unclear in many respects: the integration of hypochondriasis within the somatoform disorders instead of the anxiety disorders and the role of bodily complaints are important questions here. Hypochondriacal fears and disease convictions are nevertheless important far beyond hypochondriasis itself. As far as can be judged from the literature so far, the treatment of hypochondriasis has to be based on an acceptance of the patient's fears and disease convictions. In the initial phase, therapeutic interventions based on insight are not primarily indicated. The disputed role of reassurance can be handled in an adaptive manner, when the working alliance and personality factors are taken into acount.

This paper gives an overwiew of the international empiric literature on somatization disorder (ICD-IO F45.0) and undifferentiated somatization disorder (ICD-10 F45.1) from 1980 to 9/1997. While there is a number of studies on diagnostic criteria, epidemiology, and comorbydity of these disorders, we found a lack of investigations in treatment by primary physicians and specialized psychotherapists. Empirically proofed management guidelines are reported and necessary goals of further investigations are pointed out.

Conversion disorders are symptoms or deficits of voluntary movement or of the sensorium which are not due to neurologic or other medical disease. Historically the concept of conversion in psychoanalytic theory has been closely related to hysteria. According to the current psychiatric classification (DSMIV) conversion disorder is a subdiagnosis of somatoform disorder. Conversion disorder presents with functional impairment varying in severity. Some forms of the disorder manifest with severe physical handicap. The paper gives an overview on definition, classification, diagnosis, course and treatment. Since this review is part of the process of developing guidelines for the diagnosis and treatment of the disorder some of the intrinsic methodological aspects of evaluating clinical and empirical evidence in the field of psychotherapy and psychosomatics are discussed.

Psychogenic seizures may be difficult to differentiate from epileptic seizures. Two case-reports illustrate the criteria for the diagnosis and comment on psychological and behavioural aspects of the condition. Sexual abuse is not rare in patients with psychogenic seizures. A detailed assessment of potential social and psychological risk factors is therefore necessary. Psychotherapy has particulary to take into account the sequelea of trauma in those patients who have suffered from abuse or other trauma.

Psychosocial changes in spasmodic torticollis (ST) affect predominantly social life, professional life and psychological well-being. Concerning social life, 84.6% of the patients felt that they attracted considerable public attention due to their neurological illness and 65% had reduced participation in social events. A substantial number of patients had retired from professional activities; others felt severely impaired in their working capacity. The psychosocial sequelae in ST, however, seemed to depend less on the neurological signs per se than on the physical symptoms and on coping. Depressive coping in particular emerged as a predictor of psychosocial distress.

We report on the psychopathology and illness-related changes of life in patients with benign essential blepharospasm (BEB) or hemifacial spasm (HFS). Fifty-six patients with BEB and 40 patients with HFS completed the SCL 90R, a screening instrument for psychiatric symptomatology, and the Freiburg Questionnaire for Dystonia (FQD), a questionnaire about psychosocial changes in subjects with movement disorders. In both BEB and HFS patients, the mean scores on all but one subscale of the SCL 90R remained within the double standard deviation of normal. In comparing BEB to HFS patients in illness-related changes of life, BEB patients were more severely disabled in all areas of life examined. Psychological distress in BEB, but not in HFS, correlated with physical disability and in particular with impairment of vision.

In a one-year follow-up of 29 patients with idiopathic spasmodic torticollis (ITS), psychological functioning and social adaptation in different areas of life before and after treatment with botulinumtoxin were studied. The results show a highly significant improvement of the neurologic symptoms. Psychological functioning also improved, but to a smaller extent than expected according to the neurologic improvement. The subgroups with regard to the outcome of the neurologic treatment differed already before treatment in their level of psychosocial distress. The differences increased during the follow-up period as the more successful treatment group improved in psychological functioning while the less successful groups remained unchanged or even deteriorated. This supports that psychological dysfunction in ITS is at least in part secondary to the neurologic disorder and can be influenced by symptomatic relief. However, additional psychotherapeutic support is indicated for those who benefit less from botulinumtoxin A.

The GSI (General Symptom Index) of the Symptom Checklist 90 R (SCL 90 R) (as a global indicator of the severity of psychiatric symptoms) of 27% of the spasmodic torticollis (ST) sample fell outside the 95% range of the normal control group (two standard deviations). Patients with a higher GSI were younger, more functionally disabled and subject to higher psychosocial stress due to the illness. The highest scores were reached on the subscales of somatization, interpersonal sensitivity and depression. On the depression scale, 23% of the patients' scores were abnormal. This scale correlated significantly with the neurological signs, particularly the TSUI-index and laterocollis. A statistically significant correlation also existed between psychiatric morbidity and a family history of mental disorder. More than 50% of the patients reported that stressful life events had triggered their illness. In order of frequency, a death came first, followed by marital strife, changes in employment and family arguments. The data suggest that psychopathology in ST should generally be considered as a result of a variety of interacting factors, biological, psychological and social.

In a previous study screening for psychopathological symptoms in a sample of 256 patients with spasmodic torticollis had resulted in 27% of patients, whose mean score of the GSI of the SCL-90-R was above the double standard deviation of the control group of normals (Scheidt et al. 1994). In this study the self-reported psychopathology of a subsample of 19 TS patients was controlled for its agreement with a clinical assessment in a psychiatric interview. The results of the study confirm the validity of the SCL-90-R as a screening instrument for psychological distress and psychopathology. However a tendency for social desirability in a subgroup of patients might lead to underestimate the degree of psychological distress in this patient group and might als account for some of the discrepant findings concerning psychological distress and psychopathology in TS in former studies. Furthermore the clinical assessment revealed a high psychiatric and psychosomatic morbidity prior to the onset of the spasmodic torticollis as well as a high frequency of traumatic life events (e.g. bereavement) in the patients premorbid history. In addition to coping with a crippling neurological condition concurrent psychopathology in TS therefore should be considered also in terms of the individuals premorbid psychological vulnerability.

Idiopathic spasmodic torticollis (ST) is one of the most frequent dystonic movement disorders. Its classification as a focal dystonia as well as its treatment with botulinum toxin has led to larger groups of patients being seen regularly by neurological specialists. In a multicentre study we investigated psychosocial changes, coping and psychopathology and their interrelations with signs, symptoms and course. The study is reported in a series of four papers. Section I gives an introduction to psychiatric research on ST, the goals of the study and the method.

This paper deals with signs, symptoms and course in spasmodic torticollis (ST). Two hundred and fifty-six patients were included in the study, 59.3% women, 40.7% men. The mean age was 49.1 years. Rotating torticollis out-numbered latero- and antero-retrocollis. A family history of ST occurred in 3.1% of the total sample. First degree relatives were affected in 2.3%. Thirty-four per cent of the patients had additional dystonic symptoms. Most frequently these affected the upper extremities (13%), and less often the legs. Of the patients 19.1% had experienced a period of complete remission. The correlations between the severity of the signs and the neurological symptoms are surprisingly weak.

A total of 21 patients with psychogenic tremor (PT) were asked tc, take part in a neurologic and psychosomatic assessment; for 17 patients follow-up information was also recorded. Women outnumbered men in the sample. In tire majority of patients the tremor was associated with a variety of other conversion symptoms. The clinical picture of the tremor varied. After beginning exclusively in the extremities, it tended to spread to other parts of the body. Other psychopathology (depression and histrionic personality disorder) existed in almost a third of the sample. Many patients had retired from professional life, or planned to do so in the near future, because of PT. At follow up the initial diagnosis was confirmed in all patients although in some patients additional physical illness had developed during the follow-up period. When neurological and psychiatric/psychosomatic criteria are applied the diagnosis of PT can be established reliably. Studies that have questioned the validity of the conversion concept on the basis of frequent misdiagnoses may indicate problems in the diagnostic procedure rather than an invalid theoretical construct.

The question of subgroups in idiopathic spasmodic torticollis, which has been discussed in earlier studies in order to define etiologically heterogeneous patient populations has lost some of its relevance since with the injection of botulinum toxin an effective treatment is available. However, psychosocial distress is linked with spasmodic torticollis in a substantial number of patients. In order to define criteria for psychosocial interventions in addition to the treatment with botulinum toxin, a cluster analysis was carried out to identify high-risk populations in terms of psychological and social distress. Five subgroups were defined on the basis of eight variables. Two of these five groups, one group with rotational torticollis and one with laterocollis, emerged as particularly distressed by their physical complaints, the effects of their illness on various areas of life and in terms of psychological functioning. The consistency of the subgroups was tested and statistically confirmed by analysis of variance. In a cross-validation 83.02% of the ungrouped cases were predicted correctly, The authors suggest that the evaluation of psychological and social aspects of the condition should be part of the neurological assessment in order to offer appropiate support to patients, who reveal a high degree of psychological distress.