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The illness-related evaluation of bodily symptoms is considered to be an important maintaining factor in somatoform disorders. However, little is known about context variables that could influence this evaluation process. In the current study, participants completed three versions of the Health Norms Sorting Task (HNST) and evaluated bodily symptoms in different contexts (i.e., different evaluation perspectives and time frames of evaluation). Additionally, the three HNST versions were presented in different orders. Bodily symptoms were evaluated more often as a sign of illness when a specific time frame (i.e., one week) was given. However, this context effect was only large when participants had previously evaluated symptoms existing without a concrete duration. Thus, previously completed symptom evaluations appear to represent an important frame of reference in terms of a cue that makes specific context variables salient. The results further suggested that these cueing effects might be less relevant for participants with elevated somatic symptom reports.
Previous studies found high prevalence rates of personality disorders (PDs) in patients with hypochondriasis; however, assessment was often based only on questionnaires. In the current study, a sample of 68 patients with hypochondriasis was compared to 31 patients with panic disorder and to 94 healthy controls. Participants were investigated with the Structured Clinical Interview for DSM-IV Personality Disorders questionnaire (SCID-II questionnaire) and the SCID-II interview. Based on the cut-off scores of the SCID-II questionnaire, we found a prevalence rate of 45.6% for PD in patients with hypochondriasis. In comparison to healthy controls, patients with hypochondriasis showed characteristics of paranoid, borderline, avoid ant, and-dependent PDs in the dimensional assessment significantly more often. However, no significant differences were found between the clinical samples. Based on the SCID-II interview, only 2.9% of the patients with hypochondriasis fulfilled the criteria for a PD. These results suggest that PDs are not a specific characteristic of hypochondriasis.
Objective: Cognitive-behavioral therapy (CBT) has been shown to be effective in treating hypochondriasis. However, there are doubts regarding the long-term effectiveness of CBT for hypochondriasis, in particular for follow-up periods longer than 1 year. The aim of the present study was to evaluate the long-term effectiveness of cognitive therapy (CT) and exposure therapy (ET) for the treatment of hypochondriasis. Method: Seventy-five patients with a diagnosis of hypochondriasis who were previously treated with CT or ET were contacted 3 years after treatment. Fifty (67%) patients participated and were interviewed by an independent and blinded diagnostician using standardized interviews. Results: We found further improvements after therapy in primary outcome measures (d = .37), general functioning (d = .38), and reduced doctor visits (d = .30) during the naturalistic follow-up period. At the 3-year follow-up, 72% of the patients no longer fulfilled the diagnosis of hypochondriasis. Based on the main outcome measure, we found response rates of 76% and remission rates of 68%. At follow-up, only 4% of patients were taking antidepressant medication. Additional psychological treatment was utilized by 18% of the patients during the follow-up period (only 8% because of health anxiety). We found no overall differences between CT and ET. Only a trend for a greater deterioration rate in CT (13%) in comparison to ET (0%) was found. Conclusions: Our results suggest that 2/3 of the patients with hypochondriasis were remitted in the long term. Thus, remission rates after CBT were twice as high as in untreated samples.
Clinical supervision is regarded as one of the most important components of psychotherapy training. In clinical practice, it has been found that the implementation of clinical supervision varies substantially and often differs from the recommendations made in the literature. The objective of the current study was to investigate the frequency of topics (e.g. ethical issues) and techniques (e.g. role play) in the clinical supervision of psychotherapy trainees in Germany. To this end, we considered supervisions in cognitive behavioural therapy (CBT) and psychodynamic therapy (PT). A total of 791 psychotherapy trainees (533 CBT and 242 PT) were asked via the internet to provide information about their current supervision sessions. We found that clinical supervision in psychotherapy training addressed topics that are central for the effective treatment of supervised patients (i.e. therapeutic interventions, therapeutic alliance, maintaining factors, and therapeutic goals). However, the most frequently used intervention in clinical supervision in psychotherapy training was case discussion. Rarely were techniques used that allowed the supervisor to give the supervisee feedback based on the supervisee's demonstrated competencies. For example, 46% of the supervisors never used audiotapes or videotapes in the supervision. Differences between CBT and PT were rather small. Current practice regarding the techniques used in clinical supervision for psychotherapy trainees contradicts recommendations for active and feedback-oriented clinical supervision. Thus the potential of clinical supervision might not be fully used in clinical practice.
Objective:
Therapist competence is considered essential for the success of psychotherapy. Feedback is an intervention which has the potential to improve therapist competence. The present study investigated whether competence feedback leads to an improvement of therapist competence and patient outcome.
Method:
Sixty-seven master-level clinical trainees were randomly assigned to either a competence feedback group (CFG) or a control group (CG). Patients with a diagnosis of major depression (N = 114) were randomly assigned to CFG or CG. Treatment included 20 individual sessions of cognitive behavioral therapy (CBT). In CFG, therapists received, parallel to the treatment, five competence feedbacks, based on videotaped therapy sessions. Independent raters assessed therapist competence with the Cognitive Therapy Scale (CTS) and provided the competence feedback. Patient outcome was evaluated with the Beck Depression Inventory-II (BDI-II) and therapeutic alliance (Helping Alliance Questionnaire [HAQ]) from both therapist's (HAQ-T) and patient's (HAQ-P) perspective were evaluated after each of the 20 sessions.
Results:
(a) Therapist competence (CTS) increased significantly more for CFG than CG. (b) Depression (BDI-II) decreased significantly across sessions for both groups, but without evidence for a group-differential benefit for the CFG. (c) Therapeutic alliance (HAQ-T/P) increased significantly across sessions for both groups from both perspectives, but without group differences. (d) There is a positive effect of BDI-II on CTS at the beginning and a negative effect of CTS on BDI-II at the end of therapy.
Conclusion:
Competence feedback improves therapists' independently rated competence, but there is no evidence that competence feedback in CBT leads to better outcome.
What is the public health significance of this article? This study suggests the substantial value of systematic competence feedback for improving therapist competence in the psychotherapy of depression. No significant effect of competence feedback on the reduction of reported depressive symptoms was found.
Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients’ interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists’ adherence (r = 0.54) and therapeutic alliance (r = 0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients’ interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 (r = 0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG.
Seit dem 01. 04. 2017 erfolgte eine umfangreiche Reform der Psychotherapie-Richtlinie. Neben der Einführung neuer Leistungen (z. B. Akutbehandlung, psychotherapeutische Sprechstunde) wurden auch Änderungen im Ablauf und der Beantragung von Psychotherapie beschlossen. Beispielsweise ist der Bericht an den Gutachter bzw. die Gutachterin seltener eine notwendige Voraussetzung zur Durchführung einer psychotherapeutischen Behandlung, als dass zuvor der Fall war. Im Zuge der Reform wurde auch der Leitfaden für die Gestaltung des Berichts an den Gutachter bzw. die Gutachterin überarbeitet.
Vor dem Hintergrund der Psychotherapie-Richtlinien-Reform ist das Werk „Leitfaden für den VT-Bericht an den Gutachter“ von Daniel Surall und Oliver Kunz sehr willkommen. Das Buch gliedert sich insgesamt in zehn Kapitel, in denen die Autoren ausführlich auf den reformierten Bericht an den Gutachter bzw. an die Gutachterin eingehen. In den ersten beiden Kapiteln fassen die Autoren die Änderungen zur Psychotherapie-Richtlinie und im Bericht an den Gutachter / die Gutachterin zusammen. In den folgenden sechs Kapiteln wird auf die einzelnen Abschnitte des neuen Berichts an den Gutachter/die Gutachterin eingegangen. Sehr hilfreich ist hierbei, dass die Autoren zahlreiche Fallbeispiele nutzen, um die einzelnen Abschnitte des Berichts an den Gutachter/die Gutachterin zu erläutern. Auch die übersichtliche Darstellungsform in Form von Tabellen (z. B. zur Darstellung der Verhaltensanalyse) erleichtert den Leser_innen die Nachvollziehbarkeit der Inhalte. Erfreulich ist auch, dass die Autoren hinsichtlich der Antragstellung auch immer auf Unterschiede zwischen erwachsenen Patient_innen und Kindern und Jugendlichen eingehen. Im neunten Kapitel des Leitfadens wird ausführlicher das Thema Umwandlungs- und Fortführungsanträge aufgegriffen. Dies ist insbesondere sinnvoll, da nach der neuen Psychotherapie-Richtlinie für Kurzzeitanträge in der Regel keine Berichtspflicht besteht und Umwandlungs- und Fortführungsanträge in der Praxis häufiger als zuvor von Relevanz sein dürften. Im zehnten Kapitel wird in knapper Weise darauf eingegangen, wie bei Ablehnung oder Kürzung von beantragten Leistungen vorgegangen werden kann.
Das Buch umfasst einen umfangreichen Anhang (67 Seiten), in dem Beispiele für Berichte an den Gutachter / die Gutachterin und Behandlungspläne für verschiedene psychische Störungen zu finden sind. Auch hierbei werden sowohl Berichte für Erwachsene als auch für Kinder und Jugendliche präsentiert. Zudem beinhaltet der Anhang des Buches das Berner Inventar für Therapieziele, Auszüge aus dem AMDP-Befundbogen (Arbeitsgemeinschaft Methodik und Dokumentation in der Psychiatrie, 2018)<\litr>, den Leitfaden zum Erstellen des Berichts an die Gutachter_innen (PTV 3) sowie einer Gegenüberstellung des alten und des neuen Leitfadens für den Bericht an die Gutachter_innen.
Bei dem von Surall und Kunz vorgelegten Buch handelt es sich um einen äußerst hilfreichen Leitfaden, der Therapeut:innen bei der Abfassung des Berichts an den Gutachter / die Gutachterin im Rahmen der Verhaltenstherapie unterstützen kann. Hierbei kann der Leitfaden Psychotherapeut_innen in Ausbildung bei der Abfassung ihrer ersten Anträge unterstützen. Aber auch erfahrenen Kolleg_innen können bei dem Übergang in die neuen Antragsformalitäten, die mit der Reform der Psychotherapie-Richtlinie einhergingen, unterstützen werden. Hierbei ist insbesondere die Im Anhang befindliche Gegenüberstellung des alten und des neuen Leitfadens für den Bericht an den Gutachter / die Gutachterin hilfreich, um sich einen schnellen Überblick über die Änderungen zu verschaffen. Insgesamt werden die einzelnen Abschnitte des Berichts an den Gutachter / die Gutachterin sehr gut strukturiert und verständlich erläutert. Die vielen Beispiele und die ausführlichen Materialien im Anhang ergänzen zudem die Erläuterungen und erleichtern das Verständnis. Zu Beginn des Buches wäre zudem noch eine Abbildung hilfreich gewesen, die den Ablauf der Beantragung von Psychotherapie schematisch darstellt, um einen genaueren Überblick über die Beantragung von Psychotherapie nach der neuen Psychotherapie-Richtlinie zu erhalten. Auch ein Stichwortverzeichnis würde die Suche nach bestimmten Inhalten erleichtern.
Zusammenfassend kann festgehalten werden, dass es sich bei dem Werk von Surall und Kunz um einen sehr empfehlenswerten Leitfaden handelt, der im Rahmen der Antragstellung von Verhaltenstherapie genutzt werden kann. Aufgrund der klaren Struktur und Anschaulichkeit durch viele Beispielanträge bringt das Buch alle Voraussetzungen mit, um sich als Standartwerk zu etablieren, dass Therapeut_innen bei der Beantragung von Verhaltenstherapie in äußerst hilfreicher Weise unterstützt.
Changes in Free Symptom Attributions in Hypochondriasis after Cognitive Therapy and Exposure Therapy
(2016)
Changes in free symptom attributions in hypochondriasis after cognitive therapy and exposure therapy
(2016)
Background: Cognitive-behavioural therapy can change dysfunctional symptom attributions in patients with hypochondriasis. Past research has used forced-choice answer formats, such as questionnaires, to assess these misattributions; however, with this approach, idiosyncratic attributions cannot be assessed. Free associations are an important complement to existing approaches that assess symptom attributions. Aims: With this study, we contribute to the current literature by using an open-response instrument to investigate changes in freely associated attributions after exposure therapy (ET) and cognitive therapy (CT) compared with a wait list (WL). Method: The current study is a re-examination of a formerly published randomized controlled trial (Weck, Neng, Richtberg, Jakob and Stangier, 2015) that investigated the effectiveness of CT and ET. Seventy-three patients with hypochondriasis were randomly assigned to CT, ET or a WL, and completed a 12-week treatment (or waiting period). Before and after the treatment or waiting period, patients completed an Attribution task in which they had to spontaneously attribute nine common bodily sensations to possible causes in an open-response format. Results: Compared with the WL, both CT and ET reduced the frequency of somatic attributions regarding severe diseases (CT: Hedges's g = 1.12; ET: Hedges's g = 1.03) and increased the frequency of normalizing attributions (CT: Hedges's g = 1.17; ET: Hedges's g = 1.24). Only CT changed the attributions regarding moderate diseases (Hedges's g = 0.69). Changes in somatic attributions regarding mild diseases and psychological attributions were not observed. Conclusions: Both CT and ET are effective for treating freely associated misattributions in patients with hypochondriasis. This study supplements research that used a forced-choice assessment.