Evaluation einer kognitiv-verhaltensbezogenen Gruppen- und Einzeltherapie zur Behandlung von Patienten mit Hypochondrie

Das Störungsbild der Hypochondrie stellt für die Betroffenen eine erhebliche Belastung und Beeinträchtigung dar und ist zudem von hoher gesundheitspolitischer Relevanz. Hieraus ergibt sich die Notwendigkeit für die Entwicklung und Evaluation wirkungsvoller Behandlungsansätze. Mit der vorliegenden Untersuchung wird die bisher umfangreichste Studie zur Wirksamkeit von gruppentherapeutischen Interventionen bei Patienten mit Hypochondrie beschrieben. Insgesamt nahmen 35 Patienten, die die DSM-IV-Kriterien der Hypochondrie erfüllten, an der Studie teil. Die durchgeführte Behandlung bestand aus insgesamt acht Gruppen- und sechs Einzelsitzungen. Zur Beurteilung des Therapieerfolgs wurden standardisierte Fragebogen und Einschätzungen der behandelnden Therapeuten eingeholt. Zudem wurde vor und nach der Behandlung die implizite Ängstlichkeit der Patienten mit Hilfe des Ängstlichkeits-IATs (Egloff & Schmukle, 2002) erfasst. Die Datenerhebung der Fragebögen erfolgte zu vier Messzeitpunkten. Eine Teilgruppe der Patienten (n = 10) konnte zudem über eine zweimonatige Wartezeit befragt werden. Ingesamt wurde die Therapie von den Patienten gut akzeptiert. Im Laufe der Behandlung zeigten sich auf den Selbstbeurteilungsverfahren umfangreiche Veränderungen im Erleben und Verhalten der Patienten. Es zeigte sich eine Reduktion von krankheitsbezogenen Kognitionen und Ängsten, eine Abnahme des Krankheitsverhaltens und eine Zunahme von Störungs- und Bewältigungswissen. Die Reduktion der hypochondrischen Symptomatik stellte sich als klinisch relevant heraus. Zudem zeigte sich eine Reduktion der allgemeinen Belastung und Ängstlichkeit sowie depressiver und körperlicher Symptome. Die Einschätzungen der behandelnden Therapeuten bestätigten die mittels Fragebogen ermittelten Befunde. Mit Hilfe des Ängstlichkeits-IATs konnte eine Veränderung des angstbezogenen Selbstkonzepts nachgewiesen werden. In einer Wartekontrollzeit zeigten sich nur geringfügige Reduktionen der hypochondrischen Symptomatik und keine bedeutsamen Reduktionen der allgemeinen Psychopathologie. Die Ergebnisse der durchgeführten Kombinationstherapie sind mit den Befunden bisheriger Evaluationen zur Effektivität von Einzeltherapien bei Hypochondrie vergleichbar. Die Befunde unterstreichen die Gleichwertigkeit von ökonomischeren gruppentherapeutischen Interventionen bei der Behandlung der Hypochondrie.

Giochi di famiglia: dinamiche di potere tra Augusto e Tiberio

Il lungo processo che avrebbe portato Ottaviano alla conquista del potere e alla fondazione del principato è scandito da alcuni momenti chiave e da diversi personaggi che ne accompagnarono l'ascesa. Prima ancora che sul campo di battaglia, il figlio adottivo di Cesare riuscì a primeggiare per la grande capacità di gestire alleanze e rapporti personali, per la grande maestria con la quale riuscì a passare da capo rivoluzionario a rappresentante e membro dell'aristocrazia tradizionale. Non fu un cammino facile e lineare e forse il compito più difficile non fu sbaragliare gli avversari ad Azio, ma conservare un potere che gli fu costantemente contestato. Ancora dopo il 31 a.C., infatti, in più di un'occasione, Augusto fu chiamato a difendere la sua creatura (il principato) e a procedere a modificarne costantemente base di potere e struttura: solamente attraverso questa fondamentale, minuziosa, ma nascosta opera, egli riuscì a porre le basi per una struttura di potere destinata a durare immutata almeno per un secolo. In base a queste premesse, la ricerca è organizzata secondo un duplice criterio cronologico, inserendo -all'interno della cornice rappresentata dagli eventi- una partizione che tenga presente ulteriori cesure e momenti determinanti. Il proposito è quello di sottolineare come all'interno di un regno unitario, caratterizzato dalla permanenza di un unico sovrano, sia possibile intravedere l'alternarsi di situazioni storiche diverse, di rapporti di forze, alleanze e unioni in virtù delle quali si determinino orientamenti differenti nell'ambito tanto della politica interna quanto di quella esterna.

Effects of Alzheimer caregiving on allostatic load

This study aimed to determine if Alzheimer caregivers have increased allostatic load compared to non-caregivers. Potential psychological moderators (mastery, depression, and role overload) of the relationship between caregiving status and allostatic load were also explored. Eighty-seven caregivers and 43 non-caregivers underwent biological assessment of allostatic load and psychological assessments. Caregivers had significantly higher allostatic load compared to non-caregivers ( p < .05). Mastery, but not depression or overload, moderated the relationship between caregiving status and allostatic load. In conclusion, allostatic load may represent a link explaining how stress translates to downstream pathology, but more work is necessary to understand the role of psychological factors.

A 5-year longitudinal study of the relationships between stress, coping, and immune cell beta(2)-adrenergic receptor sensitivity

Caring for a spouse with Alzheimer's disease (AD) is associated with overall health decline and impaired cardiovascular functioning. This morbidity may be related to the effects of caregiving stress and impaired coping on beta(2)-adrenergic receptors, which mediate hemodynamic and vascular responses and are important for peripheral blood mononuclear cell (PBMC) trafficking and cytokine production. This study investigated the longitudinal relationship between stress, personal mastery, and beta(2)-adrenergic receptor sensitivity assessed in vitro on PBMC. Over a 5-year study, 115 spousal AD caregivers completed annual assessments of caregiving stress, mastery, and PBMC beta(2)-adrenergic receptor sensitivity, as assessed by in vitro isoproterenol stimulation. Heightened caregiving stress was associated with significantly decreased receptor sensitivity, whereas greater sense of personal mastery was associated with significantly increased receptor sensitivity. These results suggest that increased stress may be associated with a desensitization of beta(2)-receptors, which may contribute to the development of illness among caregivers. However, increased mastery is associated with increased receptor sensitivity, and may therefore serve as a resource factor for improved health in this population.

Fussball-Juniorennationalspieler im Spannungsfeld zwischen sportlichem Erfolg und Berufsausbildung

Da eine leistungssportliche Fussball Karriere mit Blick auf eine existenzsichernde Zukunft ein risikoreiches Unterfangen ist, absolvieren die meisten Schweizer Fussball-Juniorennationalspieler auch eine Berufsausbildung. Daher stellt sich die Frage, ob und unter welchen Bedingungen eine erfolgreiche Fussballkarriere möglich ist, wenn parallel ein Berufsabschluss angestrebt wird. Nach Mayer (2009) vollzieht sich der menschliche Lebensverlauf in verschiedenen Lebensbereichen, die sich gegenseitig beeinflussen. Um dieser Interdependenz gerecht zu werden, wurde von einem personorientierten Ansatz ausgegangen, der Entwicklungsprozesse möglichst ganzheitlich zu erfassen vermag. 159 ehemalige Schweizer Juniorennationalspieler wurden zu ihrer Karriere retrospektiv befragt und die Daten mittels LICUR-Methode (Bergman, Magnusson, & El-Khouri, 2003) ausgewertet. Dabei wurden auf der Grundlage relevanter Variablen der sportlichen Laufbahn, der beruflichen Ausbildung und der familialen Unterstützung spezifische Muster identifiziert und diese anschließend mit einem Leistungskriterium im Höchstleistungsalter verglichen. Dadurch konnten erfolgsversprechende Entwicklungsmuster aufgedeckt werden. Es zeigt sich, dass der kritische Übergang von der Development zur Mastery Phase (Salmela, 1994) insgesamt durch Kontinuität geprägt ist. Die erfolgreichsten Muster charakterisieren sich durch eine überdurchschnittlich hohe Unterstützung durch die Familie bei gleichzeitig überdurchschnittlich professionellen Förderbedingungen im Club.

Using 'Generic Abilities' to Foster Professionalism in a Post-Professional Program

Introduction To be successful in a profession, persons must have mastery of professional affective behaviors in addition to that profession’s core knowledge base. Health care delivery is more than just developing a good plan of care. The effective health care provider also will have good interpersonal and communication skills, have a commitment to learning, act professionally and responsibly, and have abilities in problem solving and critical thinking. But, these behaviors and characteristics are not taught directly in a professional program. This presentation will demonstrate how these ‘generic abilities’ have been incorporated in a post-professional program and how they can be used in other professional health care, professional development, and leadership programs. [See PDF for complete abstract]

Learning curve for robotic-assisted laparoscopic colorectal surgery.

BACKGROUND: Robotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of colorectal surgery. We aimed to evaluate the learning curve for RALS procedures involving resections of the rectum and rectosigmoid. METHODS: A series of 50 consecutive RALS procedures were performed between August 2008 and September 2009. Data were entered into a retrospective database and later abstracted for analysis. The surgical procedures included abdominoperineal resection (APR), anterior rectosigmoidectomy (AR), low anterior resection (LAR), and rectopexy (RP). Demographic data and intraoperative parameters including docking time (DT), surgeon console time (SCT), and total operative time (OT) were analyzed. The learning curve was evaluated using the cumulative sum (CUSUM) method. RESULTS: The procedures performed for 50 patients (54% male) included 25 AR (50%), 15 LAR (30%), 6 APR (12%), and 4 RP (8%). The mean age of the patients was 54.4 years, the mean BMI was 27.8 kg/m(2), and the median American Society of Anesthesiologists (ASA) classification was 2. The series had a mean DT of 14 min, a mean SCT of 115.1 min, and a mean OT of 246.1 min. The DT and SCT accounted for 6.3% and 46.8% of the OT, respectively. The SCT learning curve was analyzed. The CUSUM(SCT) learning curve was best modeled as a parabola, with equation CUSUM(SCT) in minutes equal to 0.73 × case number(2) - 31.54 × case number - 107.72 (R = 0.93). The learning curve consisted of three unique phases: phase 1 (the initial 15 cases), phase 2 (the middle 10 cases), and phase 3 (the subsequent cases). Phase 1 represented the initial learning curve, which spanned 15 cases. The phase 2 plateau represented increased competence with the robotic technology. Phase 3 was achieved after 25 cases and represented the mastery phase in which more challenging cases were managed. CONCLUSIONS: The three phases identified with CUSUM analysis of surgeon console time represented characteristic stages of the learning curve for robotic colorectal procedures. The data suggest that the learning phase was achieved after 15 to 25 cases.

Predicting premature termination within a randomized controlled trial for binge-eating patients

Understanding the dropout rates of efficacious forms of psychotherapy for patients with binge eating disorder (BED) is an unsolved problem within this increasing population. Up until now the role of psychotherapy process characteristics as predictors of premature termination has not been investigated in the BED literature. Within a randomized controlled trial (N=78) we investigated the degree to which early psychological process characteristics, such as components of the therapeutic relationship and the experiences of mastery and motivational clarification, predicted premature termination of treatment. We statistically controlled for the influences of covariates such as rapid response of treatment, treatment group, body mass index, Axis II disorder, and patients' preexisting generalized self-efficacy at baseline. Patients' postsession reports from Sessions 1 to 5 indicated that low self-esteem in-session experiences was a stable predictor of premature termination. Its predictive value persisted after controlling for the above-mentioned covariates. Exploratory analyses further revealed low self-esteem experiences, low global alliance, and low mastery and clarification experiences as predictors in those patients who explicitly specified discontentment with therapy as reason for premature termination. These results indicate that patients' self-esteem experiences may not be an epiphenomenon of their specific psychopathology but may represent general mechanisms on which remaining or withdrawing from psychotherapeutic treatment depends. Early psychotherapy process characteristics should therefore be considered in training and evaluation of psychotherapists carrying through BED treatments.

Wie PatientInnen ihre TherapeutInnen beeinflussen. Eine Prozessstudie

Theoretischer Hintergrund: Im Therapieprozess findet eine ständige reziproke Einflussnahme zwischen Patient und Therapeut statt (Strong & Claiborn, 1982). Ein hypothetisches Ziel des Patienten ist es dabei, einen bestimmten Eindruck von sich zu vermitteln. Dieses Ziel ist insbesondere im Erstkontakt wichtig. Während sich die Forschung v.a. mit den Beeinflussungsstrategien des Therapeuten beschäftigte, existieren bisher kaum Studien, die das Beeinflussungsverhalten des Patienten untersuchten. Diese Studie soll deshalb eine Übersicht über die häufigsten Beeinflussungstaktiken bieten, die Patienten im Erstgespräch zeigen. Methoden: 12 Beeinflussungsstrategien wurden aufgrund der Erfahrung von praktizierenden Psychotherapeuten sowie verschiedener theoretischer Konzeptionen der Therapiebeziehung formuliert. Die Taktiken lauten: Gute Stimmung erzeugen, positive Rückmeldungen geben, negative Rückmeldungen geben, inhaltliche Vermeidung, emotionale Vermeidung, Agenda setting, Therapeuten zu Stellungnahme bewegen, negative Berichte über Dritte, Plausibilitätsfallen, Leidensdruck verdeutlichen, Self-promotion und Psychologisieren. Die Daten wurden von vier geschulten Beurteilern analysiert. Ergebnisse: Untersucht wurden Video-Aufzeichnungen von 60 Erstgesprächen, die an der psychotherapeutischen Praxisstelle der Universität Bern durchgeführt wurden. Ergebnisse zur Häufigkeit der verschiedenen Beeinflussungstaktiken sowie deren Zusammenhang mit verschiedenen Patientenmerkmalen werden präsentiert. Diskussion: Die Resultate werden vor dem Hintergrund verschiedener Theorien der Therapiebeziehung (z.B. Interpersonale Theorie und Psychotherapie, Control Mastery Theorie, Plananalyse) diskutiert. In der Praxis kann die Kenntnis der Beeinflussungstaktiken insbesondere unerfahrenen Psychotherapeuten helfen, sich auf die Interaktion mit verschiedenen Patienten einzustellen und die Therapiebeziehung je nach Anforderungen individuell zu gestalten.

Metacognitive monitoring and control in elementary school children: Their interrelations and their role for test performance

Contemporary models of self-regulated learning emphasize the role of distal motivational factors for student's achievement, on the one side, and the proximal role of metacognitive monitoring and control for learning and test outcomes, on the other side. In the present study, two larger samples of elementary school children (9- and 11-year-olds) were included and their mastery-oriented motivation, metacognitive monitoring and control skills were integrated into structural equation models testing and comparing the relative impact of these different constituents for self-regulated learning. For one, results indicate that the factorial structure of monitoring, control and mastery motivation was invariant across the two age groups. Of specific interest was the finding that there were age-dependent structural links between monitoring, control, and test performance (closer links in the older compared to the younger children), with high confidence yielding a direct and positive effect on test performance and a direct and negative effect on adequate control behavior in the achievement test. Mastery-oriented motivation was not found to be substantially associated with monitoring (confidence), control (detection and correction of errors), or test performance underlining the importance of proximal, metacognitive factors for test performance in elementary school children.

Executive functions after pediatric mild traumatic brain injury: A prospective short-term longitudinal study

Traumatic brain injuries (TBIs) occur frequently in childhood and entail broad cognitive deficits, particularly in the domain of executive functions (EF). Concerning mild TBI (mTBI), only little empirical evidence is available on acute and postacute performance in EF. Given that EF are linked to school adaptation and achievement, even subtle deficits in performance may affect children's academic careers. The present study assessed performance in the EF components of inhibition, working memory (WM), and switching in children after mTBI. Regarding both acute and postacute consequences, performance trajectories were measured in 13 patients aged between 5 and 10 years and 13 controls who were closely matched in terms of sex, age, and education. Performance in the EF components of inhibition, switching, and WM was assessed in a short-term longitudinal design at 2, 6, and 12 weeks after the mTBI. Results indicate subtle deficits after mTBI, which became apparent in the longitudinal trajectory in the EF components of switching and WM. Compared with controls, children who sustained mTBI displayed an inferior performance enhancement across testing sessions in the first 6 weeks after the injury in switching and WM, resulting in a delayed deficit in the EF component of WM 12 weeks after the injury. Results are interpreted as mTBI-related deficits that become evident in terms of an inability to profit from previous learning opportunities, a finding that is potentially important for children's mastery of their daily lives.

Time-Series Panel Analysis (TSPA): Multivariate Modeling of Temporal Associations in Psychotherapy Process.

Objective: Processes occurring in the course of psychotherapy are characterized by the simple fact that they unfold in time and that the multiple factors engaged in change processes vary highly between individuals (idiographic phenomena). Previous research, however, has neglected the temporal perspective by its traditional focus on static phenomena, which were mainly assessed at the group level (nomothetic phenomena). To support a temporal approach, the authors introduce time-series panel analysis (TSPA), a statistical methodology explicitly focusing on the quantification of temporal, session-to-session aspects of change in psychotherapy. TSPA-models are initially built at the level of individuals and are subsequently aggregated at the group level, thus allowing the exploration of prototypical models. Method: TSPA is based on vector auto-regression (VAR), an extension of univariate auto-regression models to multivariate time-series data. The application of TSPA is demonstrated in a sample of 87 outpatient psychotherapy patients who were monitored by postsession questionnaires. Prototypical mechanisms of change were derived from the aggregation of individual multivariate models of psychotherapy process. In a 2nd step, the associations between mechanisms of change (TSPA) and pre- to postsymptom change were explored. Results: TSPA allowed a prototypical process pattern to be identified, where patient's alliance and self-efficacy were linked by a temporal feedback-loop. Furthermore, therapist's stability over time in both mastery and clarification interventions was positively associated with better outcomes. Conclusions: TSPA is a statistical tool that sheds new light on temporal mechanisms of change. Through this approach, clinicians may gain insight into prototypical patterns of change in psychotherapy.

Why does placement of persons with Alzheimer's disease into long-term care improve caregivers' well-being? Examination of psychological mediators.

Caregiving for individuals with Alzheimer's disease is associated with chronic stress and elevated symptoms of depression. Placement of the care receiver (CR) into a long-term care setting may be associated with improved caregiver well-being; however, the psychological mechanisms underlying this relationship are unclear. This study evaluated whether decreases in activity restriction and increases in personal mastery mediated placement-related reductions in caregiver depressive symptoms. In a 5-year longitudinal study of 126 spousal Alzheimer's disease caregivers, we used multilevel models to evaluate placement-related changes in depressive symptoms (short form of the Center for Epidemiologic Studies Depression scale), activity restriction (Activity Restriction Scale), and personal mastery (Pearlin Mastery Scale) in 44 caregivers who placed their spouses into long-term care relative to caregivers who never placed their CRs. The Monte Carlo method for assessing mediation was used to evaluate the significance of the indirect effect of activity restriction and personal mastery on postplacement changes in depressive symptoms. Placement of the CR was associated with significant reductions in depressive symptoms and activity restriction and was also associated with increased personal mastery. Lower activity restriction and higher personal mastery were associated with reduced depressive symptoms. Furthermore, both variables significantly mediated the effect of placement on depressive symptoms. Placement-related reductions in activity restriction and increases in personal mastery are important psychological factors that help explain postplacement reductions in depressive symptoms. The implications for clinical care provided to caregivers are discussed.

Predicting Psychotherapy Dropouts: A Multilevel Approach

The role of therapeutic processes in predicting premature termination of psychotherapy has been a particular focus of recent research. The purpose of this study was to contrast outpatients who completed therapy and those who dropped out with respect to their self-reported in-session experiences of self-esteem, mastery, clarification and the therapeutic alliance. The 296 patients with mixed disorders were treated with an integrative form of cognitive–behavioural therapy without pre-determined time limit (M = 20.2 sessions). Multilevel analyses indicated that patients who did not completetreatment reported, on average, lower levels of self-esteem, mastery and clarification and lower ratings of their therapeutic alliance in treatment in contrast to patients who completed therapy. Patient-reported change in self-esteem experiences over the course of treatment turned out to be the strongest predictor of dropout from psychotherapy or successful completion. When dropout occurred before the average treatment length was reached, patients reported fewer clarifying experiences as early as the first session and their ratings of the therapeutic alliance were characterized by an absence of positive development. Both of these aspects seem to be involved in patients' decisions to leave treatment early. The findings underscore the importance of the therapeutic process in understanding the mechanisms behind treatment dropout. Copyright © 2014 John Wiley & Sons, Ltd.

Self-esteem development from age 14 to 30 years: A longitudinal study

We examined the development of self-esteem in adolescence and young adulthood. Data came from the Young Adults section of the National Longitudinal Survey of Youth, which includes 8 assessments across a 14-year period of a national probability sample of 7,100 individuals age 14 to 30 years. Latent growth curve analyses indicated that self-esteem increases during adolescence and continues to increase more slowly in young adulthood. Women and men did not differ in their self-esteem trajectories. In adolescence, Hispanics had lower self-esteem than Blacks and Whites, but the self-esteem of Hispanics subsequently increased more strongly, so that at age 30 Blacks and Hispanics had higher self-esteem than Whites. At each age, emotionally stable, extraverted, and conscientious individuals experienced higher self-esteem than emotionally unstable, introverted, and less conscientious individuals. Moreover, at each age, high sense of mastery, low risk taking, and better health predicted higher self-esteem. Finally, the results suggest that normative increase in sense of mastery accounts for a large proportion of the normative increase in self-esteem.