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Contains fulltext : 214849.pdf (Publisher’s version ) (Open Access) Whereas sudden gains and losses (large shifts in symptom severity) in patients receiving psychotherapy appear abrupt and hence may seem unexpected, hypotheses from complex-systems theory suggest that sudden gains and losses are actually preceded by certain early-warning signals (EWSs). We tested whether EWSs in patients' daily self-ratings of the psychotherapeutic process predicted future sudden gains and losses. Data were collected from 328 patients receiving psychotherapy for mood disorders who completed daily self-ratings about their therapeutic process using the Therapy Process Questionnaire (TPQ). Sudden gains and losses were classified from the Problem Intensity scale of the TPQ. The other items of the TPQ were used to compute the EWSs. EWSs predicted an increased probability for sudden gains and losses in a 4-day predictive window. These results show that EWSs can be used for real-time prediction of sudden gains and losses in clinical practice. 11 p.

Contains fulltext : 217460.pdf (Publisher’s version ) (Open Access) Objective: While destabilization periods characterized by high variability and turbulence in a patient's psychological state might seem obstructive for psychotherapy, a complex systems approach to psychopathology predicts that these periods are actually beneficial as they indicate possibilities for reorganization within the patient. The present study tested the hypothesis that destabilization is related to better treatment outcome. Method: 328 patients who received psychotherapy for mood disorders completed daily self-ratings about their psychotherapeutic process. A continuous measure of destabilization was defined as the relative strength of the highest peak in dynamic complexity, a measure for variability and turbulence, in the self-ratings of individual patients. Results: Destabilization was found to be related to better treatment outcome. When improvers and non-improvers were analyzed separately, destabilization was found to be related to better treatment outcome in improvers but not in non-improvers. Conclusions: Destabilization in daily self-ratings of the psychotherapeutic process is associated with better treatment outcome. The identification of destabilization periods in process-monitoring data is clinically relevant. During destabilization, patients are believed to be increasingly sensitive to the effects of therapy. Clinicians could tailor their interventions to these sensitive periods. 12 p.

Background While considerable progress has been made in exploring the psychological, the neural, and the neurochemical dimensions of OCD separately, their interplay is still an open question, especially their changes during psychotherapy. Methods Seventeen patients were assessed at these three levels by psychological questionnaires, fMRI, and venipuncture before and after inpatient psychotherapy. Seventeen controls were scanned at comparable time intervals. First, pre/post treatment changes were investigated for all three levels separately: symptom severity, whole-brain and regional activity, and the concentrations of cortisol, serotonin, dopamine, brain-derived neurotrophic factor (BDNF), and immunological parameters (IL-6, IL-10, TNFα). Second, stepwise linear modeling was used to find relations between the variables of the levels. Results The obsessive-compulsive, depressive, and overall symptom severity was significantly reduced after psychotherapy. At the neural level, the activity in the anterior cingulate cortex (ACC), in frontal regions, in the precuneus, and in the putamen had significantly decreased. No significant changes were found on the neurochemical level. When connecting the levels, a highly significant model was found that explains the decrease in neural activity of the putamen by increases of the concentrations of cortisol, IL-6, and dopamine. Conclusion Multivariate approaches offer insight on the influences that the different levels of the psychiatric disorder OCD have on each other. More research and adapted models are needed.

OBJECTIVE: Home-based treatment of families with low socio-economic status and multiple psychosocial problems (multi-problem families, MPFs) is gaining importance in clinical social epidemiology and health services research. The sustainability of the treatment is of special importance in order to breach transgenerational effects. METHODS: We examined outcome, effect size, and clinical significance of home-based treatment for 84 multi-problem families in a naturalistic setting. 48 of the families were available for a follow-up after 3 years. The baseline characteristics of these family systems included low collaboration, an increased family adversity index, minors with high rates of child psychiatric disorders, a high prevalence of comorbidity, low relational family functioning, and adolescents who refused any form of treatment or had unilaterally terminated different forms of treatment before. The home-based family therapy consisted of one or two face-to-face counseling sessions per week over an average of 28.8 months (SD = 19.2). The symptoms and competence of the adolescents, the caregivers, and the family structure were assessed with 13 variables. RESULTS: All variables showed significant improvement rates (pre- vs. post- treatment) with medium to high effect sizes (mean of Cohen’s d = 1.04, range = .34 – 2.18). All variables showed a sustained or even further improvement at follow-up. CONCLUSION: This study provides evidence of statistically (p), practically (d), and clinically (RCI) significant changes in symptom and competence-related variables among adolescents and caregivers in MPFs with sustainable long-term effects in the 3-year follow-up period.

Hintergrund: Anhand eines Fallbeispiels soll gezeigt werden, wie Real-Time-Monitoring die Therapie von PatientInnen mit komplexer posttraumatischer Belastungsstörung (PTBS) wirksamer gestalten hilft. Patient und Methoden: Die Fallkonzeption und Behandlung fußten auf einem störungsspezifischen stationären Behandlungsprogramm für komplex traumatisierte Erwachsene und orientierten sich an Empfehlungen bezüglich der traumafokussierten Behandlung von Patienten mit pathologischem Narzissmus. Der Veränderungsprozess des Patienten wurde mit einem webgestützten Tool für Real-Time-Monitoring (Synergetic Navigation System) erfasst und im Therapieverlauf wiederholt gemeinsam mit dem Patienten reflektiert. Ergebnisse: Der Patient remittierte hinsichtlich PTBS, Depression, somatoformer Beschwerden, interaktioneller Schwierigkeiten, Selbstwirksamkeit und Beeinträchtigungen des psychischen Wohlbefindens. Insbesondere konnten im Rahmen von Feedback-Gesprächen die persönlichkeitsspezifischen affektiven Dynamiken von Scham, Schuld und Wut des Patienten sowie deren kritische Instabilitäten und Phasenübergänge im Rahmen der Traumakonfrontation reflektiert werden. Der Patient entwickelte neue Selbstfürsorgemuster und lernte, eigene Gefühle wahrzunehmen, zu verantworten und zu regulieren. Schlussfolgerungen: Die auf Traumakonfrontation ausgerichtete multimodale Therapie erwies sich im vorliegenden Fall als geeignet, neben den Kernsymptomen der PTBS auch bedeutsame komorbide Symptome wirksam zu reduzieren. Das Real-Time-Monitoring unterstützt die Identifizierung und Bearbeitung zentraler affektiver Dynamiken eines Patienten und erlaubt so, die Therapie von Patienten mit komplexen Traumafolgestörungen und persönlichkeitsprägender Symptomatik effektiver zu gestalten.

Objective: fMRI scans of patients with obsessive-compulsive disorder (OCD) consistently show a hyperactivity of the insular cortex, a region responsible for disgust-processing, when confronted with symptom-triggering stimuli. This asks for an investigation of the role of disgust and the insula in OCD patients. Methods: Seventeen inpatients with OCD and 17 healthy controls (HC) underwent fMRI scanning. Whole-brain contrasts were calculated for "Disgust vs. Neutral" for both groups, plus an analysis of variance (ANOVA) to assess the interaction between group and condition. Additionally, the emotional dimensions of valence and arousal, along with the ability to cope, were assessed by picture ratings. Results: The picture ratings confirmed the patients' heightened sensitivity to disgust with higher values for arousal and inability to cope, but not for valence. fMRI scans revealed no hyperactivity of the insula in patients compared to controls for the condition "Disgust vs. Neutral," indicating no basic hypersensitivity to disgusting stimuli. Increased activity in the precuneus in controls for this condition might correspond to the downregulation of arousal. Conclusions: The absent differences in neural activity of the insula in patients compared to controls for the disgust-condition, but heightened activity for symptom-provoking conditions, suggests that the illness is due to an erroneous recruitment of the insula cortex for OCD-stimuli. The finding is interpreted within the framework of the neural reuse hypothesis.

Objective. The aim of this case report is to demonstrate the feasibility of a systemic procedure (synergetic process management) including modeling of the idiographic psychological system and continuous high-frequency monitoring of change dynamics in a case of dissociative identity disorder. The psychotherapy was realized in a day treatment center with a female client diagnosed with borderline personality disorder (BPD) and dissociative identity disorder. Methods. A three hour long co-creative session at the beginning of the treatment period allowed for modeling the systemic network of the client’s dynamics of cognitions, emotions, and behavior. The components (variables) of this idiographic system model (ISM) were used to create items for an individualized process questionnaire for the client. The questionnaire was administered daily through an internet-based monitoring tool (Synergetic Navigation System, SNS), to capture the client’s individual change process continuously throughout the therapy and after-care period. The resulting time series were reflected by therapist and client in therapeutic feedback sessions. Results. For the client it was important to see how the personality states dominating her daily life were represented by her idiographic system model and how the transitions between each state could be explained and understood by the activating and inhibiting relations between the cognitive-emotional components of that system. Continuous monitoring of her cognitions, emotions, and behavior via SNS allowed for identification of important triggers, dynamic patterns, and psychological mechanisms behind seemingly erratic state fluctuations. These insights enabled a change in management of the dynamics and an intensified trauma-focused therapy. Conclusion. By making use of the systemic case formulation technique and subsequent daily online monitoring, client and therapist continuously refer to detailed visualizations of the mental and behavioral network and its dynamics (e.g., order transitions). Effects on self-related information processing, on identity development, and towards a more pronounced autonomy in life (instead of feeling helpless against the chaoticity of state dynamics) were evident in the presented case and documented by the monitoring system.