Negative life events can result in adjustment disorders. If there are feelings of having been treated unfair, been let down or been humiliated one type of reaction are prolonged states of embitterment, which has been described as Posttraumatic Embitterment Disorder, PTED. A new approach in the treatment of PTED is cognitive behavioral psychotherapy which uses special strategies based on wisdom psychology. Wisdom has been defined as the capacity to cope with unsolvable and serious problems and questions in life.

In a controlled clinical trial psychosomatic inpatients which suffered from PTED, were randomly assigned to “wisdom therapy” (N=28), which focusses on the reframing of the traumatic event and to “wisdom and headonia therapy” (N=29), which additionally encourages patients to focus on positive aspects in life. Another group of PTED patients (N=50) and patients with other mental disorders (N=50) received treatment as usual.

PTED patients who were treated with wisdom psychotherapy showed a reduction in the SCL-90-PST score of initially 55,7 and at the end of 40,1 and those treated with hedonia therapy of initially 58,7 and at the end of 41,3. Measures of therapist adherence showed that therapists in both groups used wisdom strategies. PTED controls started initially with a SCL-90-PST score of 52,2 and ended with 50,2. Other patients started treatment with 39,3 and finished with 25,9.

This first treatment study on cognitive wisdom therapy suggests that wisdom can be helpful in the treatment of adjustment and embitterment disorders.

Pathological anxiety is characterized by the absence of a reason for anxiety. However, the presence of fear provoking stimuli does not exclude the possibility for a pathological course of anxiety, i.e. “Pathological Realangst”. An example are hypochondriac anxieties in patients with severe somatic disorders. An open question is to what degree severity of somatic morbidity is related with anxiety.

In 209 patients (37,8% women) from a cardiology inpatient unit general anxiety, heart-related anxiety, progression anxiety, and job-anxiety were measured. Physicians rated the degree of severity of the somatic (heart-)disorder using the Multidimensional Severity of Morbidity Rating (MSM rating). Relationships between the degree of anxiety and somatic morbidity parameters were investigated.

Anxiety did not or to a very low degree correlate with objective indicators of somatic morbidity. Subjective suffering showed a moderate significant correlation with heart-related anxiety and progression anxiety, and was also correlated with sick leave duration.

Severity of somatic illness is a multidimensional phenomenon and not regularly related in a special way with anxiety, except the dimension of subjective suffering. Pathological fears, even when occurring in the context of somatic disorders, are not related to objective endangerment, but have to be described as mental problems.

Health problems are often associated with activity limitations and participation restrictions (ICF, WHO, 2001). An example are problems at work or sick leave. The research question has been whether in these cases activity limitations and participation restrictions refer only to the workplace, or whether and to which degree other areas of life are similarly affected.

Type and degree of participation restrictions in different domains of life were assessed in 382 primary health care patients (aged 18-65) with the IMET, a questionnaire which measures participation restrictions across several domains of life. Additionally, the patients were interviewed about health-related problems at work. IMET scores were compared between patients with and without health related problems at work.

27% of 299 presently employed patients were suffering from workplace problems. These patients had significantly longer durations of sick leave than patients without problems at work and also reported significantly more problems in functioning in general daily activities.

Workplace problems are a frequent topic in primary health care and related to sick leave. Health related problems at work are indicative for problems in functioning in other areas of life as well. Participation restrictions in non-work areas can be early indicators for participation problems at work.

Generalized anxiety disorders (GAD) are characterized by persistent excessive worrying about minor hassles. GAD patients are high utilizers of medical services and medication.

According to an analysis of 21 double-blind placebo-controlled trials by of Hidalgo et al. (2007) highest effect sizes are reproted for pregabalin (0.50), hydroxyzine (0.45), venlafaxine XR (0.42), benzodiazepines (0.38), SSRIs (0.36), buspirone (0.17) and herbal medicines (-0.31). The question is how GAD is treated under conditions of routine treatment. This was studied in patients were admitted to inpatient treatment.

Psychotropic premedication and changes in medication during the inpatient treatment were analyzed in 107 patients.

Before admission, 27,1% of GAD patients got tricyclic antidepressants, 25,2% SSRI, 8,4% benzodiazepines, 7,4% atypical antidepressants, 1,9% anticonvulsants/pregabaline, 1,9% herbal drugs. Furthermore, 20,6% got betablocker, preferably because of hypertension.

During the inpatient stay changes in medication were made according to the clinical discretion of the therapist. At discharge 41,1% of GAD patients received SSRI, 23,4% tricyclic antidepressants, 22,4% pregabaline, 9,4% atypical antidepressants.

SSRI and tricyclic antidepressants play the major role in the drug treatment of GAD. Under clinical conditions there has been an optimization of treatment by increasing preferably the rate of SSRI treatments and of pregabaline treatment, while reducing benzodiazepine treatment and to some degree tricyclic antidepressants.

Hidalgo RB, Tupler LA, Davidson JRT (2007): An effect-size analysis of pharmacologic treatments for generalized anxiety disorder. J Psychopharmacol 21(8):864-872.

In an interim evaluation on baseline data of the German PADRE observational study the correlation between physician- and patient assessment of emotional and physical symptoms of depressed patients was evaluated.

This multicenter, prospective, 6-month observational study focused on adult outpatients with a depressive episode as diagnosed according to ICD-10 criteria, chosen by their physician to start new anti-depressive treatment with duloxetine. Correlations between the applied depression and/or pain scales were calculated via Spearman's correlation coefficient. Symptoms were evaluated via clinician rated 'Inventory for Depressive Symptomatology' ([IDS-C], total score, including item 25), patient rated 5-item scale 'KUSTA', (rating mood, activity, tension-relaxation, sleep and appetite on visual analog scales [VAS]), and patient rated VAS for 'Pain'.

All participating physicians are psychiatrists/neurologists. 2.748 patients (71% female, mean age 52.7 yrs) were evaluated. Any pain symptoms were documented in 88.9% of patients at baseline. When comparing patient- with physician-assessments, correlation of PPS scales was low to moderate and varied for different pain types: IDS-C item 25 (="somatic disorders") vs. overall pain-VAS: r=0.421 (95% CI 0.390, 0.452), IDS-C item 25 vs. abdominal pain: r=0.189; IDS-C item 25 vs. chest-pain: r=0.179. When comparing IDS-C total vs. the KUSTA items, correlation was moderate in all cases (e.g.: r= -0.510 for IDS total vs. KUSTA mood).

Only a low to moderate correlation was observed between physician- and patient assessment for PPS in depressed patients. Therefore, patient pain ratings should explicitly be included in the assessment of depressed patients.

Pathological anxiety is typically characterized by the absence of a real threat or danger. But, a persistent reason for anxiety, such as a severe life threatening illness, does not prevent the development of additional pathological anxieties, which has been described as “Pathological Realangst”.

The question is to what degree pathological realangst can be explained by the real threat or preexisting anxiety.

209 patients (37,8% female) of a cardiology inpatient unit were given the State-Trait-Anxiety-Inventory, the Heart-Anxiety-Questionnaire, and the Progression Anxiety Questionnaire. Treating physicians gave a rating on the severity of somatic morbidity including subjective suffering, short and long term prognosis, impairment in daily living, degree of acute and chronic multimorbitity, and objective parameters of the cardiac condition.

Global or specific ratings on the severity of somatic morbidity did not correlate with general or heart related anxiety. Correlation coefficients ranged between .001 and a maximum of .22 (heart anxiety and subjective suffering).

The results speak against the assumption that the threat by the illness is the explanation for the present anxiety. Instead, anxious patients who are suffering from a somatic illness are also afraid of their health status and present this as cause of their anxiety. Inspite of the persistent threat this anxiety is pathological i.e. realangst. It should be treated like other anxiety disorders, although it is more difficult to convince the patient and possibly their treating physicians that the present anxiety is not “normal” but pathological and in need of treatment.

The International Classification of Functioning, Disability and Health, ICF, discriminates between functions, activities/capacities, context factors and participation. There is only limited information on disorders of capacity in neurotic disorders.

213 inpatients of a department of behavioral and psychosomatic medicine (70% women, median age 45 years) were rated with the “Mini-ICF-Rating for Pychological Disorders, Mini-ICF-P”. This instrument assesses thirteen dimensions of capacity, derived fom the ICF, which can be impaired by mental disorders. Rating varies between 0 (no problem) to 4 (can not fullfill respective requirements at all).

61% of patients suffered from disorders from section F4 (neurotic, adjustment and somatoform disorders) of the ICD-10 (WHO, 1991), 29% from F3 (affective disorders) and 10% from F6 (personality disorders).

41% were on sick leave before admission. The average global score of the Mini-ICF-P was 0,84 (SD = 0,56), corresponding to “mild disability”. Highest disability was found for “flexibility” (M = 1,64, SD = 0,94), and lowest for “self maintenance” (M = 0,19, SD = 0,44) and “mobility” (M = 0,43, SD = 0,85). The Mini-ICF-P-score and profile was correlated with rate and duration of sick leave, but also type of disorder (e.g. depression vs. phobias), and course of treatment.

Comparatively minor disorders of capacity are associated with high rates of sick leave, i.e. disorders of participation. Not only restoration of functons but also of capacities should be targets of treatment.

This study examined the relation between schizotypy and the encoding style in a sub-clinical sample. We evaluated, first, the level of schizotypy with the Schizotypal Personality Questionnaire (SPQB) (Raine and al, 1995). Three factors are evaluated

1. a) cognitive-perceptual factor,

2. b) b) interpersonal factor and disorganisation.

A total of 184 students (113 women and 71 men) participated at this study. The mean age of the sample was 22,58 years (SD = 1,96). They were test using a French version of the ESQ, the brief SPQB, State-Trait Anxiety Inventory (STAI), The Center for Epidemiologic Studies Depression (CES-D) Scale.

The results demonstrated that we have a positive correlation between internal encoding style, schizotypy, depression and anxiety. Secondly, a high level of internal encoding style means a high level of congnitivo-perceptual and for interpersonal factors with an impact of depression and anxiety.

An internal encoding style is link with a high score in schizotypy.