Zeitschrift fur Psychosomatische Medizin und Psychoanalyse最新文献

Coronary Angioplasty (PTCA) has become one of the standard procedures in the therapy of coronary heart disease. One of the main issues is the 20-40% incidence of restenosis of the dilated vessel. Up to now, the subject of predictors of restenosis has not yet been sufficiently clarified. Our study is concerned with two questions; first, is it possible to prove any connections between the amount of restenosis and psychosocial factors? Second, is it possible to distinguish groups of patients with and without subsequent restenosis on the basis of psychosocial variables, even before the diagnostic coronary angiography? 138 (91m, 47f) patients were assessed before the diagnostic coronarangiography, the 25 PTCA-patients (20m, 5f) were furthermore reassessed three months after the PTCA (the time of the angiographic control). Somatic and social data were collected and a semistandardised interview was conducted. In addition, coping, stress-coping control over disease and health and life-contentment were determined. Highly significant correlations was found between the amount of restenosis and resignative stress-coping, self-pity, depressive coping and flight-tendency. With the help of stress-coping-subtests (which were given at the first examination) it was possible to separate the group of patients with restenosis from the group without it.

A short survey on results and theories in psychosomatic and neurobiologic stress research is presented. Based on a comprehensive definition of the stress-reaction process, the biological and psychological consequences are described which are elicited by either controllable or uncontrollable stress. We conclude that controllable stress triggers the stabilization and facilitation of neuronal networks involved in the generation of appropriate patterns of appraisal and coping, whereas uncontrollable stress favours the extinction of inappropriate patterns and the reorganisation of neuronal connections underlying certain inappropriate behaviors. Both, controllable an uncontrollable stress-reaction-processes are therefore essential prerequisites of, and inherent challenges to, the development and adaptation of an individual in an ever changing external world but may also lead to psychodevelopmental failures and psychosomatic diseases.

The correlation between causal attributions of symptoms and sociodemographic, psychometric and clinical variables among psychogenic impaired persons is investigated in this paper. 114 individuals, who had presented psychogenic symptoms in the last year, were selected from the representative sample of the Mannheim Cohort Study. Two extreme groups have been identified through one Scale of Disease Conception: one with a somatogenic (n = 80) and the other with a psychogenic conception (n = 34). Female, younger and well educated individuals predominate in the group with psychogenic conception. In FPI the group with psychogenic conception is characterized by high depressivity, emotional lability, aggressivity, inhibition, irritability, anxiety and frankness. The diagnosis psychoneurose (ICD) is also more frequent in this group. The psychic impairment is more severe in the group with psychogenic conception (Impairment Score). Subjects of the group with psychogenic conception utilized psychotherapeutic services more frequently. In the logistical regression the variables agecohort, the FPIdimensions "Sociability" and "Inhibition", the number of psychic and physical symptoms in the last year and the BSS-subscale "psychic impairment" prove to be relevant in the estimate of relative risk for the type of causal explanation for symptoms.

The therapeutic process is influenced significantly from the outside conditions of the therapy setting. Changes in the setting in an ongoing therapy process are a special aspect. The Mannheim psychosomatic clinic has four conceptually different wards. This structure makes it possible to change settings during current therapy by moving patients from one ward to another within the clinic. With three case examples the significance of the move for the therapeutic process is described. The possibility of trial actions and gains in insight is compared with the danger of fixating pathological conflict solutions. Special attention is paid to aspects of power-powerlessness and coping with separation wishes and separation anxieties. Moving a patient to a different ward during an ongoing therapy process contains in a special way the possibility for development but also the danger of disintegration.

In the field of psychotherapy one can see that many psychotherapists develop a special identification with the form of therapy which they learned and practice. One cannot find this kind of identification with the chosen therapeutic method in other fields of medicine (surgery, radiology, internal medicine, etc). The factors which lead to such a special identification of the therapist with the psychotherapeutic method he practices are reflected and described: They include first of all the hardly thought about motives of the therapist to chose psychotherapeutic training in a particular school. Then the influences of the peculiarities of the institutionalized work-parallel continuing education develop: The risk of emotionalized trainee-trainer dependencies, trainee-trainer identification with the associated strong delimitation towards the outside evolves.

Psychodynamic and coping processes in patients with somatic diseases are described on the background of clinical case examples. Here the connection between coping and defending is discussed whereby the special characteristics of somatic disease are taken into consideration. The secondary function, which a somatic disease can gain in an intrapsychic balance system which was already in a weak or dysregulated state is also discussed. Finally the role of social support in coping with somatic diseases is described. From this different therapeutic consequences for patients with somatic diseases are derived.

Many incidents awake the old suspicions about what kind of people the Germans really are, but the media are always poised to pounce on anything which looks like a reemergence of Nazi attitudes. So from this angle Germans seem to be a society which as a whole disapproves of violence and destructive behaviour. Both these images prove to be misleading. A kind of collective reaction formation has developed in Germany: intellectuals automatically assume that one can only speak about the Germans as a whole in critical and derogatory terms. Their views have developed a collective identity in which the Nazi past and the Holocaust play a central role. This deep-rooted distrust against one's own people reveals a more or less well concealed hatred directed against oneself. In the book of Alexander and Margarete Mitscherlich "The Inability to Mourn", which became a kind of credo for a whole generation of thoughtful young Germans, the authors prescribed a diet of restricted perceptions and collective self-hatred. The result is: German moral thinking shows signs of a aggressive, negative ego-ideal, and one aspect of this is collective self-castigation in the sense of a latent melancholic mechanism punishing the internalised father, because the bad past seems to have been his fault.

In the accompanying paper two fifteen-hour psychoanalytical therapies were investigated with regard to the temporal distribution of Luborskian relationship episodes and the facial expressions of both protagonists. The two therapies were taken from a sample of eleven treatments: one had had the most success; the other, the least. The investigation focussed on what type of interaction between the recollective narration of past relationships and the present form of relationships could be expected, and whether the relation between these two would be dependent upon the success of the therapy. The hypothesis that a parallel processing of the narrated episode and the exhibited emotion would occur within the patient could not be confirmed. The frequency of recollective narration correlated negatively--in line with a hypothesis of Freud's--with the frequency of exhibited emotions. In the successful treatment, however, the therapist exhibited the emotions which one would have expected the patient to show. The results are discussed in terms of a theory of the psychotherapeutical process and containing.

103 male patients with coronary heart disease and their partners filled out the Questionnaire about the Perception of an Illness and its Consequences (Fragebogen zur Wahrnehmung der Krankheit und ihrer Folgen, FWKF) which is available for both the patient and his partner. Factor analyses were done separately for the items of both FWKF versions, which examine with the consequences of coronary heart disease. Four interpretable factors were calculated, which are highly congruent in both versions: "dependency vs. independency", "resignation vs. hope regarding the physical condition", "positive vs. negative anticipation regarding social resonance" and " self and partner orientation vs. achievement". Four scales were derived which enable a diagnosis of the perception and coping modi of the patient and his partner and to draw conclusions about the partner interaction. Couples could be identified where both partners take similar extreme positions. They thus leave themselves little room for development. The significance of these results for more well-directed and therefore more improved psychosocial counselling of coronary patients and their partners is discussed.

Within a study concerning process and outcome of inpatient longterm group treatments the specific question was tested to what extent characteristics of the "fit" between the therapist and the patients were related to treatment outcome. The study shows that a concordance in the formulation of the treatment goals seems to be favorable for a positive outcome. Similarly, congruences between the therapeutic factors of the group treatment, subjectively important for the patients, and those factors classified as typical for the treatment concept by the therapists, were related to treatment success. The results can be discussed within the context of concepts of the therapeutic alliance and might help to operationalize those concepts in a more specific manner.