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Social anxiety disorder is one of the most prevalent mental disorders and often manifests in youth or adolescence. Our aim was to determine direct costs of adolescents with social anxiety disorder and the cost-effectiveness of cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) compared to waiting list (WL).Baseline data (n = 103) of a randomized controlled trial was used to determine direct costs. Cost-effectiveness of CBT and PDT compared to WL was analyzed using quality-adjusted life years (QALYs) based on the EQ-5D index as measure of health effects.Total six-month direct costs were 809 € (SE 508 €). Especially costs of outpatient physician treatment (325 €; SE 301 €) and psychiatric hospital stays (377 €; SE 258 €) were high. The incremental cost-effectiveness ratio (ICER) of CBT compared to WL was 18,824 €/QALY, with a probability of 63 % for the ICER being below 50,000 €/QALY. PDT did not prove to be cost-effective.Direct costs were mainly caused by psychiatric hospital stays and outpatient physician treatments. CBT is likely to be cost-effective compared to WL, whereas PDT is unlikely to be cost-effective.Ziel war die Analyse direkter Kosten sozialer Angststörung (SAD) bei Jugendlichen und der Kosteneffektivität von CBT bzw. PDT.Multizentrische randomisierte Studie mit N = 103 Patienten. Krankheitskosten wurden zur Baseline und Kosteneffektivität nach der Behandlung analysiert.Direkte 6-Monats-Kosten zu Baseline lagen bei 809 €. Während die inkrementelle Kosten-Effektivitäts-Relation von CBT im Vergleich zur Warteliste bei 18 824 €/QALY lag, war PDT nicht kosteneffektiv.SAD verursacht hohe direkte Kosten. CBT ist wahrscheinlich kosteneffektiv.

With a lifetime prevalence of about 17% depression is the most common mental disorder. Psychotherapy is efficacious in the treatment of depression, with no significant differences between different forms of psychotherapies. For psychodynamic therapy (PDT) various models proved to be efficacious in randomized controlled trials (RCTs). As a consequence the evidence for PDT is scattered between different forms or orientations of PDT entailing problems regarding psychotherapy training and the transfer of research into clinical practice. Thus, our aim was to develop a unified protocol for the dynamic treatment of depression that is based on those models of PDT that proved efficacious in randomized controlled trials (RCTs). As a first step we conducted a systematic search of RCTs investigating manualized or manual-based individual psychodynamic therapy for depressive disorders in adults that proved to be efficacious compared to comparison conditions. 11 studies fulfilled our inclusion criteria. In a second step we systematically reviewed the studies with regard to the treatment concepts they had applied. 7 highly consistent treatment components could be identified. We conceptualized them in the form of 7 interrelated treatment modules which constitute the unified psychodynamic protocol for depression. The protocol may enhance the empirical status of PDT and facilitate both psychotherapy training as well as the transfer of research to clinical practice. Through the focused use of techniques that proofed efficacious it is expected to bring more benefit to depressed patients and therefore also have a positive impact on the health care system.

To determine whether the self-concept of patients with Social Anxiety Disorder deviates significantly from that found in the normative sample, to what extent it changes through psychotherapeutic short-term interventions and how such changes in self-concept relate to changes in the level of social anxiety.The self-concept of N = 86 patients with Social Anxiety Disorder was assessed using the Frankfurter-Selbstkonzeptskalen (FSKN; Deusinger 1986). Patients were treated with a manualized cognitive (CT) or psychodynamic (PDT) short-term intervention. The level of social anxiety was assessed pre-therapy and post-therapy via the Liebowitz Social Anxiety Scale (StangierHeidenreich 2004) and the Social Phobia and Anxiety Scale (Fydrich 2002).Patients with Social Anxiety Disorder exhibited a significantly more negative self-concept than the norm (all ps0.001). Their self-concept improved significantly in all facets following psychotherapeutic short-term intervention (all ps0.01). No significant difference was found between cognitive and psychodynamic therapy. Improvements in self-concept correlate with reductions in social anxiety.The results confirm the relevance of self-concept in Social Anxiety Disorder and its susceptibility to short-term-therapy.

Research on common and differential factors in the therapeutic process is impeded by the lack of instruments suitable for assessing common change mechanisms. This study presents the psychometric properties of a newly developed time-economic instrument (WIFA-k), which was designed to assess common factors of psychotherapy as designed by Grawe. Within a multi-center study comparing the efficacy of cognitive therapy and psychodynamic therapy in the treatment of social phobia, 6 raters assessed 25 randomly selected, videotaped therapy sessions of each treatment approach, and evaluated common factors using the Wifa-k. Interrater-reliability was found to be high for the items "resource activation", "motivational clarification" and "mastery" and low for the items "therapeutic relationship" and "problem activation". Ways to increase reliability and validity of the scale are discussed.

There is growing evidence from randomized controlled trials supporting the efficacy of psychodynamic psychotherapy (PDT) in specific mental disorders. Yet the evidence for the efficacy of psychodynamic psychotherapy has not gone unchallenged. Several responses have addressed these concerns, showing that most of the criticism was not justified. Nevertheless, the evidence for psychodynamic psychotherapy continues to be frequently ignored, criticized or presented in a distorted way. A recent controversy published in the Nervenarzt may serve as an illustrative example, which is discussed here more in detail. This example shows that some authors are not interested in a truly scientific discussion, but rather try to discredit a rival method of psychotherapy and its scientific representatives for political reasons.

Die Identifikation spezifischer und allgemeiner Wirkfaktoren in psychotherapeutischen Behandlungen wird durch das Fehlen geeigneter Messinstrumente erschwert. Die vorliegende Arbeit stellt die psychometrischen Eigenschaften der Wirkfaktoren-Skala-kurz (WIFA-k) vor, eines neuen, zeitokonomischen Messinstrumentes zur Fremdeinschatzung allgemeiner Wirkfaktoren sensu Grawe. Im Rahmen einer Studie zum Vergleich von Kognitiver Therapie und Psychodynamischer Kurzzeit-Therapie bei Sozialer Phobie wurden jeweils 25 videografierte Sitzungen ausgewahlt. Beurteiler schatzten mit Hilfe der WIFA-k den Therapieprozess hinsichtlich der allgemeinen Wirkfaktoren ein. Ressourcenaktivierung, Klarung und Problembewaltigung konnten zeitokonomisch mit moderater Ubereinstimmung bewertet werden, wahrend Problemaktualisierung und therapeutische Beziehung nur mit geringer Ubereinstimmung erfasst wurden. Moglichkeiten zur Verbesserung der Reliabilitat und zur Validierung der Skala werden diskutiert.

Alexithymia is characterized by deficits in perceiving, differentiating and regulating affects, both one's own affects and those of others. It is often related to interpersonal problems which are a major reason for seeking psychotherapy. This study assesses the relationship between alexithymia, specific relationship patterns and interpersonal problems in a clinical inpatient sample.We evaluated alexithymia (Toronto-Alexithymia-Scale-26: TAS-26), relationship patterns (Relationship Patterns Questionnaire-II; RPQ-II) and interpersonal problems (Inventory of Interpersonal Problems: IIP) in 152 patients with various mental disorders upon admission to an inpatient clinic for psychosomatic medicine and psychotherapy.Alexithymia (TAS-20) was significantly negatively associated with self-assertion (RPQII) and significantly positively associated with overall interpersonal problems (IIP-total score). Specifically, the interpersonal style associated with alexithymia was characterized by cold, socially avoidant, nonassertive and exploitable behavior (IIP-subscales).Alexithymia in patients with mental disorders is linked to specific relationship patterns and interpersonal problems at the beginning of an inpatient psychotherapy. Because interpersonal problems, and especially the therapeutic alliance, are strong predictors of outcome in individual psychotherapy, specific attention should be paid to this relationship in the treatment of alexithymic patients.

Reduced concentrations of dopamine in prefrontal brain structures may play a role in alexithymia. Dopamine degradation in the orbitofrontal cortex is regulated by catechol-O-methyltransferase (COMT), and a functional single nucleotide polymorphism of the COMT gene, Val158Met, has been related to psychiatric illness. This study examines the association between the COMT Val158Met gene polymorphism, and alexithymia.120 healthy students and 120 patients with mental disorders were genotyped for the COMT Val158Met polymorphism. Additionally, the Toronto Alexithymia Scale (TAS-20) was administered.COMT genotype did not show a significant correlation with the TAS-20 in either group.COMT Val158Met polymorphism alone does not seem to be a major factor in alexithymia in healthy students. This is true even if patients with mental disorders covering a broader range of alexithymia are included. Thus, other genes, possibly interacting with cultural, environmental, and developmental factors, may be implicated.

Interpersonal problems are typically assessed with the Inventory of interpersonal Problems (IIP; Horowitz et al. 2000). Although patients show different interpersonal profiles, these have to date not been considered in outcome evaluation. We examined whether interpersonal subtypes can be found in inpatients, and whether they differ in the modification of interpersonal problems. Furthermore, we examined the impact of subtypes regarding overall outcome.The Structural Summary Method for Circumplex Data was used to examine the interpersonal problems of N=2809 inpatients from the Asklepios Clinic Tiefenbrunn. Subtypes of interpersonal problems were determined by the centroid method of cluster analysis and were compared with regard to treatment effects.Patients were distributed in the interpersonal Circumplex and were assigned to eight IIP subtypes, which differed in improvement with regard to interpersonal problems and overall outcome.According to the circumplex structure of IIP data, for group level evaluation it is necessary to generate interpersonal subtypes so that clinically relevant results can be demonstrated.

The diagnosis PTSD does not adequately describe the impact of exposure to childhood trauma of the developing child. The objective of the study was to examine the prevalence of different interpersonal trauma types and to describe the long-term effects of maltreatment and neglect in a clinical sample of 34 adolescents. The majority (62%) of the sample was exposed to two different types of trauma during childhood. Emotional abuse and emotional neglect have been the most common trauma types (59%; 53%). 71% of the traumatized adolescents did not meet the criteria for PTSD. The most common diagnosis in the sample was Borderline Personality Disorder. All average scores at SCL-90-Symptom-Scale were clinical significant. Half of the sample reported suicide attempts and self destructive behavior. One third reported substance abuse and aggressive behavior against others respectively. None of the traumatized adolescents had a positive Self-concept. Altogether the results show that abused children and adolescents have a range of psychological sequelae that are not captured in the PTSD diagnostic criteria. Therefore the results support the necessity for a new and more precise diagnosis for chronically traumatized children and adolescents.

This paper presents the Social Phobia Psychotherapy Research Network (SOPHO-NET). SOPHO-NET is among the five research networks on psychotherapy funded by "Bundesministerium für Bildung und Forschung". The research program encompasses a coordinated group of studies of social phobia. In the central project (Study A), a multi-center randomized controlled trial, refined models of manualized cognitive-behavioral therapy (CBT) and manualized short-term psychodynamic psychotherapy (STPP) are compared in the treatment of social phobia. A sample of n=512 outpatients will be randomized to either CBT, STPP or wait list. For quality assurance and treatment integrity, a specific project has been established (Project Q). Study A is complemented by four interrelated projects focusing on attachment style (Study B1), cost-effectiveness (Study B2), polymorphisms in the serotonin transporter gene (Study C1) and on structural and functional deviations of hippocampus and amygdala (Study C2). Thus, the SOPHO-NET program allows for a highly interdisciplinary research of psychotherapy in social phobia.

Examined here is the degree to which particular aspects of treatment experience in the inpatient psychotherapy of children and adolescents correlate significantly with the actual success of treatment.Data of 95 patients hospitalised between 2002 and 2006 in the Department of Child and Adolescent Clinical Psychotherapy at the NLKH Tiefenbrunn were analysed. To assess the relationships multiple regression analyses were carried out, whereby the dependent variable was on the one hand, the retrospective estimate of treatment success by the patients by means of the Questionnaire to Assess Treatment (Fragebögen zur Beurteilung der Behandlung/FBB), and on the other, the difference on the General-Severity-Index (GSI) of the Symptom Checklist 90-R (SCL-90-R) between the time of admission and release from hospital. Patients' experience of treatment was assessed by MEANS OF THE WARD EXPERIENCE QUESTIONNAIRE (STATIONSERFAHRUNGSBOGEN/SEB) BY SAMMET AND SCHAUENBURG (1999).The direct measurement of success (FBB-P-Scale Success of Treatment) correlated highly significantly with the SEB scales Expectation of Self-Efficacy, Individual Therapeutic Relationship, Atmosphere among Co-Patients, Group Cohesion, Relationship to Therapy Team, Intensity of Treatment, and with the Difference in the Estimate of Individual Therapeutic Relationship between Patient and Therapist. The indirect measure of success also correlated highly significantly with the Atmosphere among Co-Patients and the perceived Expectation of Self-Efficacy. The relationship between the Relationship to Therapy Team was also significant at the 5% level. In the subsequent regression analyses the SEB scales explained 51% of the variance between the retrospective estimates of success (FBB). The subscales Relationship to Therapy Team (beta= 0.47, t(df) = 4.15(84), p.01) and Expectation of Self-Efficacy (beta = 0.32, t(df) = 3.30(84), p.01) proved to be significant predictors of treatment success. Using the difference in the GSI values on the SCL-90-R as the dependent variable, the SEB scales explained 23% of the variance in treatment success, whereby Atmosphere among Co-Patients was the only significant individual subscale (beta = 0.35, t(df) = 2.63(84), p.01).The success of inpatient psychotherapy treatment among children and adolescents in the sample studied correlated significantly with particular aspects of treatment experience. In this connection, the reduction in symptoms apparent in the comparison of values at admission with those at release seems to be primarily related to the Atmosphere among Co-Patients, whereas the success of treatment as estimated directly by the patients correlates more strongly with Relationship to Therapy Team and Expectation of Self-Efficacy. Due to the correlative design of the study, the issue of causality could not be completely resolved.

In the present paper, data from four German studies on the efficacy of outpatient psychoanalytic long-term psychotherapy were examined for symptom reduction (SCL-90-R) and reduction of interpersonal problems (IIP-D). Specifically, the research question addressed the efficacy of long-term therapy in specific diagnostic groups and was was compared with that of a parallel group who underwent shorter-term psychodynamic therapy.Data from four German studies addressing the efficacy of outpatient psychoanalytic long-term therapy were collected. Evaluation of these data was carried for specific diagnostic groups allowing for comorbid diagnoses. The effects of psychoanalytic therapy were assessed by pre-post and pre-follow-up comparisons using paired t-tests. Additionally, effect sizes were calculated. Psychoanalytic long-term psychotherapy and shorter-term psychodynamic therapy were compared by using a repeated measure ANOVA: Pretreatment vs. posttreatment/follow-up (two-levels) with the between subject factor "therapy conditions" (two levels).The results showed that in terms of improvement of symptoms and interpersonal problems, psychoanalytic long-term therapy was at least as effective as shorter term psychodynamic therapy with regard to the following ICD-10 diagnostic groups: affective disorders (F3), anxiety disorders (F40; F41; F42), personality disorders (F60; F61; F62), and a group of mixed neurotic disorders (F43; F50; F51; F1; F55). Effect sizes were large and remained stable at follow-up.The authors emphasize the clinical relevance of the examined diagnostic groups and relatively large effects achieved by the psychoanalytic treatment. Furthermore, the occurrence of comorbid diagnoses and their consequences are discussed. The authors stress that the specific effects of psychoanalytic therapy can only be very insufficiently tapped by the outcome measures referring to symptoms and interpersonal problems.

Different methods are available for the psychotherapeutic treatment of patients with severe structural mental disorders. Psychoanalytic-interactional therapy is among those methods which have been clinically proven to be effective for many years. Psychoanalytic-interactional therapy was derived from analytic psychotherapy specifically to allow for the treatment of severely disturbed patients, e.g. patients with borderline personality disorders, prepsychotic disorders, addictions and perversions.In a naturalistic study, the effectiveness of psychoanalytic-interactional therapy was tested in a sample of patients with borderline personality disorders (N = 132). The patients were treated at the Clinic Tiefenbrunn near Goettingen, Germany. Standardized, reliable and valid diagnostic instruments were used to study the treatment effects.Psychoanalytic-interactional therapy was found to significantly improve target symptoms, general symptoms, interpersonal problems and life satisfaction.The results are discussed with regard to the treatment of severely disturbed patients.

At the Tiefenbrunn hospital, patients suffering from severe psychiatric and psychosomatic disorders are treated. The treatment concept is psychodynamically oriented. Psychopharmacological treatments are included if necessary. This article reports the results of the treatment of a sample of patients with schizophrenic and other psychotic disorders (ICD-10: F20-F25).An unselected sample of N = 33 patients was studied upon admission and before discharge with a set of routinely administered standardized instruments.According to the data, all of these patients were severely disturbed: Upon admission to the clinic, they showed high pathological values in the Beeintrachtigungs- Schwere-Score (degree of impairment score; Schepank 1995), the Symptom Checklist SCL-90-R (Franke 1995), the Inventory of Interpersonal Problems (Horowitz et al. 1994), as well as a high degree of comorbid disorders. A comparison of the data at admission and at discharge shows that these patients improved significantly and substantially concerning symptoms, interpersonal problems, contentedness with life and individually formulated target problems.The results of the present study are discussed with regard to both the treatment of psychotic patients and the results of other studies.

Under the label of social phobia a complex of ailments was introduced into the syndromal diagnostic classification system of ICD-10 and DSM-IV, which is characterized by fear of embarrassing and humiliating experiences in relation to other persons. According to our experiences, however, social phobias and other problems in interpersonal relations are not yet paid the clinical attention that these problems deserve, when the severity of impairments subjects affected by social phobias suffer from is taken into account. There is a considerable lack of research of the psychodynamic aspects of social phobia as well. For this reason, we studied the frequency and extent of social anxieties in a sample of patients requiring psychiatric-psychotherapeutic inpatient treatment suffering from social anxieties (N = 930). This sample was compared to another sample of patients without social anxieties. We applied standardized diagnostic and psychometric instruments in order to collect information about anamnestic and social data as well as data about symptom severity, interpersonal impairments and comorbid disorders. The results do not only show the high frequency of social anxieties (45 %), but also the severe impairments in various domains of personal functioning of patients suffering from social anxieties compared to the patients without severe social anxieties. According to our clinical experiences and to the results presented here, the construct of social phobia as it is currently used in the psychiatric classification systems is an syndromal additive description that falls short of a form of suffering that is characterized by the facts that it is interwoven with the complete social existence of an affected person. For this reason, the term social phobia should be replaced by the more appropriate term of social anxiety.

This paper presents a review of the phenomenology and psychodynamics of affects in borderline patients. The first part demonstrates that in most current conceptions of the borderline disorder affective disturbances are regarded as to be characteristic. In this context, the strong overlap between borderline disorders and affective disorders found in many empirical studies is described and different hypotheses are presented to explain this phenomenon. The second part of this review is concerned with the psychodynamics of affects in borderline patients. The role of affects in thinking, behaviour, self perception and the regulation of object relations is discussed. Borderline and other severe personality disorders are assessed from the perspective of affective disturbances. The psychodynamic functions of particularly characteristic affects such as anger, anxiety, depression and boredom are discussed. The close connection between affective and cognitive functioning in borderline patients is described and evaluated with regard to modern theories of affect and cognition. Finally, the role of affects in the treatment of borderline patients is discussed.

The present article deals with the question as to which kind of evidence is necessary to demonstrate the effectiveness of a psychotherapeutic method.The authors point out that randomized controlled studies (RCTs) are carried out in standardized laboratory contexts, whereas naturalistic studies are based on conditions in the psychotherapeutic practice. Accordingly, RCTs and naturalistic studies address different questions of research (laboratory vs. field).This view has several important implications: (1.) RCTs and naturalistic studies do not differ concerning their internal and external validity. (2.) In principal, naturalistic studies do not provide lower level evidence than RCTs. (3.) Evidence from RCTs cannot be transferred to psychotherapeutic practice in the field: If a therapy has worked in an RCT, this does not necessarily imply that it will work in the field as well. (4.) Naturalistic studies provide important evidence for determining the effectiveness of a therapy in practice. (5.) The proposed catalogues for levels of evidence focus on RCTs. Thus, they cannot be applied to hypotheses on the effectiveness of a therapy in the field (naturalistic studies). (6.) It is necessary to define separate criteria for levels of evidence of naturalistic studies. In this article, criteria and levels of evidence of naturalistic studies are defined. The implications of the differentiation of randomized controlled vs. naturalistic studies is discussed.

The existing studies on the effectiveness of psychodynamic therapy are reviewed. All studies published between 1960 and 2001 were collected. In the first part of this survey, the focus is on short-term psychodynamic therapy, the second part focuses on longer-term psychoanalytic and psychodynamic therapy. The studies are reviewed with regard to forms of disorders. The methodological quality of the studies is judged according to criteria of evidence-based medicine. These criteria themselves are also critically discussed. Although they vary concerning their methodological quality, the studies reveal evidence of the effectiveness of both short-term and long-term psychodynamic therapy. In a meta-analytic evaluation performed by the author, substantial effects were found for psychodynamic therapy of personality disorders, i.e. 1.13 (self-report measures) and 1.57 (observer-rated measures) for short-term psychodynamic therapy and 1.05 (self-report measures) and 2.11 (observer-rated measures) for longer term psychodynamic therapy. Although there is evidence of the effectiveness of psychodynamic therapy, further research of specific forms of psychodynamic therapy in specific disorders is necessary.