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BACKGROUND: Depression predicts adverse prognosis in patients with coronary artery disease (CAD), but previous treatment trials yielded mixed results. We tested the hypothesis that stepwise psychotherapy improves depressive symptoms more than simple information. METHODS: In a multicenter trial, we randomized 570 CAD patients scoring higher than 7 on the Hospital Anxiety and Depression Scale-depression subscale to usual care plus either one information session (UC-IS) or stepwise psychotherapy (UC-PT). UC-PT patients received three individual psychotherapy sessions. Those still depressed were offered group psychotherapy (25 sessions). The primary outcome was changed in the Hospital Anxiety and Depression Scale-depression scores from baseline to 18 months. Preplanned subgroup analyses examined whether treatment responses differed by patients' sex and personality factors (Type D). RESULTS: The mean (standard deviation) depression scores declined from 10.4 (2.5) to 8.7 (4.1) at 18 months in UC-PT and from 10.4 (2.5) to 8.9 (3.9) in UC-IS (both p < .001). There was no significant group difference in change of depressive symptoms (group-by-time effect, p = .90). Preplanned subgroup analyses revealed no differences in treatment effects between men versus women (ptreatment-by-sex interaction = .799) but a significant treatment-by-Type D interaction on change in depressive symptoms (p = .026) with a trend for stronger improvement with UC-PT than UC-IS in Type D patients (n = 341, p = .057) and no such difference in improvement in patients without Type D (n = 227, p = .54). CONCLUSIONS: Stepwise psychotherapy failed to improve depressive symptoms in CAD patients more than UC-IS. The intervention might be beneficial for depressed CAD patients with Type D personality. However, this finding requires further study. TRIAL REGISTRATION: www.clinicaltrials.gov NCT00705965; www.isrctn.com ISRCTN76240576.

Prof. Jochen Jordan studierte Padagogik und Psychologie und habilitierte mit einer Arbeit „Zum Erleben und zur psychischen Bewaltigung medizinischer Technologie am Beispiel der perkutanen transluminalen Korona­r­angioplastie“. Nach Stationen in der Rehabilitationspsychologie (Universitat Freiburg) und der Klinik fur Psychosomatische Medizin und Psychotherapie (Universitat Frankfurt/Main) leitet er heute die Abteilung fur Psychokardiologie an der Kerckhoff-Klinik in Bad Nauheim. Gemeinsam mit Dr. B. Barde, Prof. A.M. Zeiher und 35 weiteren Kollegen initiierte er im Jahr 2000 das Projekt „Statuskonferenz Psychokardiologie. Im Gesprach mit der Erfahrungsheilkunde erlautert er u.a., wie psychosomatische Faktoren Herzkrankheiten beeinflussen, was die Psychokardiologie leisten kann und wann ein Herzpatient psychotherapeutische Hilfe braucht.

OBJECTIVE: The relationship between attachment orientations and the recovery from depressive symptoms in patients diagnosed with coronary artery disease (CAD) with and without a psychotherapeutic intervention was examined in this study. METHODS: In a multicenter trial of 570 depressed CAD patients (SPIRR-CAD), assigned to usual care plus either a stepwise psychotherapy intervention or one information session, 522 patients provided attachment data at baseline. Attachment was measured with the Relationship Scales Questionnaire (RSQ), yielding four attachment orientations. The primary outcome was change in Hospital Anxiety and Depression Scale depression (HADS-D) scores from baseline to follow-up at 18 months. Secondary outcomes were HADS-D scores at 1, 6, 12, and 24 months. RESULTS: Independent of treatment assignment, attachment was related to change in depression at 18 months (p

We deliver an overview of the psychological reactions and distress in ICD-patients (implantable cardioverter defibrillator), especially after experiencing multiple consecutive shocks. Psychodiagnostic assessment will be discussed. After reviewing the scientific literature concerning psychological interventions we describe the most important areas of coping and adjustment, indicating helpful psychological tools for the treatment of psychiatric disorders following ICD-shocks. Finally, we present a case study of a specific psychological treatment as part of an inpatient multimodal therapy setting (psychocardiological rehabilitation) for a patient, who had experienced about 35 ICD-shocks, and his partner.

Die Lüge gehört zur Psychologie des Alltagsverhaltens. Sie ist in jedem sozialen Kontext einsetzbar und mit jeder denkbaren Motivstruktur zu verbinden. Definitorisch ist davon auszugehen, dass nur dann von einer Lüge gesprochen werden kann, wenn eine bewusste Entscheidung des Akteurs vorliegt (nicht vollständig aufrichtig zu sein) und das Opfer keine Zustimmung zu dieser Verhaltensvariante gegeben hat. So wie man nicht nicht kommunizieren kann (Watzlawick), so kann man demnach nicht leben ohne zu lügen und dennoch unterscheiden sich Menschen beträchtlich hinsichtlich der Häufigkeit sowie der eingesetzten Technik des Lügens und vor allem bezüglich der implizierten Destruktivität. Es werden bedeutende Motivstränge des Lügens sowie die gängigen Techniken und deren Vor- und Nachteile erläutert. Die beiden großen Forschungszweige der Psychologie zur Aufdeckung von Lügen werden skizziert (der Lügendetektor und die Analyse der Körpersprache). Le mensonge est un comportement psychologique de la vie quotidienne qui peut donc apparaître dans tout contexte social et avoir un lien avec toutes les motivations possibles. La la présente analyse se fonde sur la définition suivante : le mensonge relève d’une décision consciente de son auteur (n’être pas tout à fait sincère), en l’absence de consentement de la victime. De même que l’on ne peut pas ne pas communiquer (Watzlawick), on ne peut pas vivre sans mentir. Toutefois, les humains sont très différents les uns des autres en ce qui concerne la fréquence de leurs mensonges, les techniques qu’ils utilisent et avant tout la destructivité impliquée. Sont abordées ici les motivations les plus importantes de l’acte de mentir et les techniques utilisées le plus couramment, dans leurs aspects positifs et négatifs. Sont ensuite évoqués rapidement deux grands domaines de recherche en psychologie sur le mensonge (détecteur de mensonge et analyse du langage corporel). Lying is part of our everyday behaviour: it appears in every social context and is linked with all existing motivations. For our understanding of this kind of behaviour it is necessary to claim that lying is always a clear decision of the acting person (not to state the truth) and that the victim did not declare his agreement. As one cannot help communicating (Watzlawick), one cannot live without lying. Nevertheless people greatly differ as to the occurrence, the techniques and the destructiveness of their lies. This article discusses the most important motivations and techniques as well as their advantages and disadvantages. It also outlines the most important areas of scientific research (for example, lie detector, polygraph and body language).

Objective Depressive symptoms are highly relevant for the quality of life, health behavior, and prognosis in patients with coronary artery disease (CAD). However, previous psychotherapy trials in depressed CAD patients produced small to moderate effects on depression, and null effects on cardiac events. In this multicentre psychotherapy trial, symptoms of depression are treated together with the Type D pattern (negative affectivity and social inhibition) in a stepwise approach. Methods Men and women (N=569, age 18–75 years) with any manifestation of CAD and depression scores ≥ 8 on the Hospital Anxiety and Depression Scale (HADS), will be randomized (allocation ratio 1:1) into the intervention or control group. Patients with severe heart failure, acutely life-threatening conditions, chronic inflammatory disease, severe depressive episodes or other severe mental illness are excluded. Both groups receive usual medical care. Patients in the intervention group receive three initial sessions of supportive individual psychotherapy. After re-evaluation of depression (weeks 4–8), patients with persisting symptoms receive an additional 25 sessions of combined psychodynamic and cognitive–behavioral group therapy. The control group receives one psychosocial counseling session. Primary efficacy variable is the change of depressive symptoms (HADS) from baseline to 18 months. Secondary endpoints include cardiac events, remission of depressive disorder (SCID) and Type D pattern, health-related quality of life, cardiovascular risk profile, neuroendocrine and immunological activation, heart rate variability, and health care utilization, up to 24 months of follow-up (ISRCTN: 76240576; NCT00705965). Funded by the German Research Foundation.

Eine depressive Symptomatik hat bei Patienten mit einer koronaren Herzerkrankung (KHK) Einfluss auf die Lebensqualitat, das Gesundheitsverhalten und die Prognose. Die bisher in kontrollierten randomisierten Studien hinsichtlich ihrer Wirksamkeit gepruften psychotherapeutischen Interventionen zeigten nur geringe Effekte. In einer deutschen Multizenterstudie soll ein gestuftes Angebot aus einzel- und gruppenpsychotherapeutischen Interventionen auf seine Wirksamkeit untersucht werden. Der vorliegende Beitrag beschreibt das therapeutische Vorgehen in 2 Einzelgesprachen und einem Paargesprach anhand von Fallbeispielen. Hauptfokusse sind die depressive Symptomatik und die damit im Zusammenhang stehenden maladaptiven Personlichkeitszuge wie negative Affektivitat und soziale Gehemmtheit (Typ-D-Muster). Depressive Stimmung, Enttauschungen und Krankungen im beruflichen sowie privaten Bereich und bei den bisherigen Behandlungserfahrungen werden verbalisiert. Dysfunktionale Beziehungsmuster und maladaptives Krankheitsverhalten werden vom Psychotherapeuten aufgegriffen und alternative Verhaltensweisen erarbeitet. Ziele des Paargesprachs sind die Starkung der partnerschaftlichen Ressourcen sowie der Abbau von Angsten und Befurchtungen im Zusammenhang mit der KHK. Das psychotherapeutische Vorgehen ist psychodynamisch orientiert, beinhaltet aber auch kognitiv-behaviorale und interaktionelle Behandlungsansatze.

Wachsende Evidenz fur eine Interaktion zwischen dem Ausbruch und dem Voranschreiten einer Vielzahl von kardialen Erkrankungen mit psychosozialen Faktoren hat die Klinische Kommission der DGK dazu bewogen, ein Positionspapier zu diesem Gegenstandsbereich anzuregen. In einem formalisierten Expertenrating wurden von den 10 teilnehmenden Experten die fur die Fragestellung relevanten Subdisziplinen, in denen gegenwartig eine kritische Masse umsetzungsrelevanten psychokardiologischen Wissens vorhanden ist, ermittelt, die Evidenz zusammengetragen und bewertende Schlussfolgerungen fur die Praxis gezogen. Komorbide psychosoziale Parameter im Kontext der koronaren Herzerkrankung (KHK) erreichten die groste Aufmerksamkeit mit I-A-Empfehlungen fur ein Depressionsscreening im Vorfeld und Verlauf der KHK; der Notwendigkeit zur Einbeziehung psychosozialer Konzepte in Strategien zur Verkurzung der Prahospitalzeit sowie fur die Empfehlung einer routinemasigen (Mit-)Behandlung psychosozialer Belastungsfaktoren in der Sekundarpravention der KHK. Eine weitere I-A-Empfehlung konnte fur die Einbeziehung psychologischer Belastungsfaktoren in die Bewertung von Therapieverlaufen von ICD-Patienten ausgesprochen werden. Weitere relevante Aufgabenfelder beziehen sich auf die Herzinsuffizienz und das Verhalten bei Herzoperationen. Insgesamt ist die Evidenzbasierung fur die therapeutische Umsetzung schwacher als fur Diagnostik und Fruherkennung. Das Positionspapier formuliert eine Reihe von konkreten Anwendungsfeldern mit hoher Prioritat fur die Einbeziehung psychosozialer Faktoren in die kardiologische Praxis, die eine leitlinienkonforme Evidenz aufweisen. Forschungsdefizite existieren weiterhin fur die Bewertung der Wirksamkeit von psychotherapeutischen Konzepten bei kardialen Patienten. Curricula fur die Vermittlung von (psycho)diagnostischer, kommunikativer und differenzialdiagnostischer Kompetenz mussen rasch entwickelt werden, um eine Transmission des aktuellen Wissensstandes in die Alltagspraxis zu ermoglichen.

Type D (distressed personality) comprises the joint tendency to experience negative emotions (negative affectivity) and to inhibit these emotions in social situations (social inhibition). The distressed personality can be assessed by the Type D scale (DS14). In the present study, the German version of the DS14 was to be validated especially with regard to its interrelation with anger, aggression and hostility. The study included a clinical sample of 90 patients with coronary heart disease and a nonclinical sample of 86 participants. The two-factor structure of the DS14 could be confirmed in both samples. As expected, the subscale negative affectivity correlates highly with neuroticism; the subscale social inhibition correlates highly with extraversion. Negative affectivity also relates to almost every anger and aggression scale applied in this study. Participants classified as Type D report higher anger experience than non-Type D-classified persons. They show both heightened anger-in and anger-out and encounter others with more cynicism and hostility. It seems promising to provide special psychological treatment for these patients.

Live kidney donation is increasing rapidly. Increases of blood pressure and proteinuria but no accelerated loss of renal function in kidney donors have been described. The credibility of this research is hampered by retrieval rates of only 50-70% of donors. We studied renal function, blood pressure, proteinuria, parathyroid hormone, 1,25(OH)2 cholecalciferol and calcium and phosphate excretion in a live kidney donor cohort with a 93% retrieval rate. A comprehensive physical and laboratory examination including 24-h urine collection was conducted. None of the 152 donors had renal failure. Mean time after uninephrectomy was 11 +/- 7 (range: 1-28) years. GFR had declined by 25%. Blood pressure had increased from 125 +/- 15/79 +/- 11 to 134 +/- 19/81 +/- 9 mmHg (p0.01) but remained significantly below normal. Fifty six percent of donors developed proteinuria (150 mg/day), but only 10% had albuminuria. Nineteen percent had increased PTH, 30% had a decreased tubular reabsorption rate of phosphate. Regarding risk factors for a higher loss of GFR, greater increases in blood pressure or proteinuria no consistent picture emerged. Because of the high incidence of proteinuria and possible changes in bone metabolism inclusion of kidney donors in registries appears worthwhile.

Der Myokardinfarkt ist ein plotzlich eintretendes lebensbedrohliches Ereignis (Mortalitat = 50% innerhalb der ersten 28 Tage). Fast immer sind die akuten Infarktbeschwerden so stark und bedrohlich, dass den Betroffenen die Gefahr ihrer Situation wenigstens teilweise bewusst wird. Mit dem Eintreffen des Notarztwagens beginnen heute Diagnostik und Therapie. Die Fortschritte der interventionellen Kardiologie fuhren zu einer hoch effektiven Behandlung (Angiographie mit anschliesender Dilatation/Bypassoperation und/oder medikamentoser Behandlung) und Rehabilitation. In den ersten 6 Wochen haben die Betroffenen bedrohliche und viele Lebensbereiche betreffende Informationen zu verarbeiten und mussen sich (oft erstmals im Leben) mit der Angst vor dem Tod auseinander setzen. Schon fruh wurde in der wissenschaftlichen Literatur das Infarktereignis als ein psychisch schwer belastendes und bei einigen Menschen traumatisches Geschehen angesehen. Nachfolgend wird auf der Basis einer systematischen Literaturrecherche der Stand des Wissens zu der Frage einer posttraumatischen Belastungsstorung (PTSD) nach Infarkt referiert: Es muss damit gerechnet werden, dass ca. 11% der Betroffenen eine PTSD entwickeln. Es werden die psychotherapeutischen Implikationen diskutiert.

The Type D personality pattern, consisting of negative affectivity and social inhibition, has been shown by Denollet et al. to predict adverse prognosis in patients with coronary heart disease. For measuring the Type D characteristics, Denollet has devised the 14 item Type D scale (DS14). In the present study, this instrument was translated into German. The validity, reliability and adequacy of the German DS14 were then tested in 2421 persons, including cardiological and psychosomatic patients as well as healthy factory workers. The results document sound psychometric properties of the scale. Cronbach's alpha was 0.87 for the negative affectivity subscale and 0.86 for social inhibition. The two-factor structure of the original instrument could be clearly replicated. The prevalence rates of the Type D pattern were lowest in cardiological patients (25 %) and highest in psychosomatic patients (62 %). The prevalence in this German sample of cardiology patients was also lower than the one observed in healthy factory workers (32.5 %) and in CHD samples reported in the literature. These group differences could not be accounted for by differences in age and sex distribution. In conclusion, the DS14 is a valid and reliable instrument that can be used for an economic evaluation of the Type D characteristics in patients and healthy persons. The possible meaningfulness of the low Type D prevalence in cardiac patients and the prognostic relevance of this pattern require further study.

Functional heart symptoms, especially chest pain, are very widespread and, according to the International Classification of Diseases (ICD-10), are described as "somatoform autonomous functional disorders of the cardiovascular system". Although they are very often accompanied by considerable anxiety about having a heart attack, for example, they are initially not recognizable as such and have to be distinguished from somatic complaints. The most prevalent of these symptoms (Table 2) are chest pains, followed by feelings of weakness, a tendency to become easily fatigued and breathing difficulties. The perception of changes in cardiac activity, such as tachycardia, heart palpitations, irregular heartbeat or arrhythmias, is also extremely unsettling and thus anxiety-provoking. Therefore, although a responsible cardiac diagnosis is the basis for every further step taken, it is advisable to carry out a brief anamnesis immediately, if possible, to determine the prior history (Table 1). For example, previously conducted clarification of somatic causes, consultations with more than one physician in parallel or repeated medical emergency calls can be helpful for orientation. Moreover, in the interview during the diagnostic measures, the possibility of functional causes should always be pointed out in order to counteract a somatic fixation early on. The health-care policy role that lies in early diagnosis of functional cardiac complaints has to be regarded as highly relevant. Following exclusionary diagnosis, the patients should not be discharged as "healthy" from the cardiological practice without a more in-depth anamnesis of their complaints, because differentiated questioning of the patient not only about typical physical and psychic symptoms, but also about behavior patterns (Table 3) that can accompany functional cardiac complaints, works in favor of a doctor-patient relationship that is based on trust. Since, in addition to anxiety disorders, above all depressive states accompany functional heart complaints, and can also cause them in the sense of a comorbidity, a knowledge of characteristics related to depression (Table 4), such as a depressed mood, loss of interest or low motivation, is very helpful for a better understanding of the patients. The "vicious circle" that rapidly develops precisely in the case of this group of patients, consisting of physical symptoms, avoidance behavior and psychological as well as interpersonal difficulties, is described and possible solutions are pointed up. In summary, the following recommendations can be formulated for day-to-day clinical practice: 1. From the very beginning, a holistic approach should be conveyed in the interview by addressing psychological and social aspects as well, and taking them into account as possible causes. 2. The somatic diagnosis should, if possible, not go beyond that which is urgently necessary from a cardiological standpoint and presented in guidelines. One should, above all, not give in to pressure from the patients if it is a matter of repeated examinations within a short period of time. 3. A differentiated and focused anamnesis helps the patients to feel understood and taken seriously. 4. A relationship based on trust enhances the chances for a successful transfer to psychosomatic examination and treatment.

Psychosocial risk factors like low socio-economic status, chronic family or work stress, social isolation, negative emotions (e.g., chronic depression or acute anxiety), and negative personality patterns such as Type-D-pattern or hostility, may contribute significantly to the development and adverse outcome of coronary heart disease. Therefore, systematic screening for psychosocial risk factors in cardiological practice is recommended in order to initiate adequate intervention strategies, e.g., to involve additional psychosocial counselling or treatment. Reliable methods to assess psychosocial risk factors are: (1) standardized, structured interviews; (2) standardized questionnaires, and (3) 'single-item' questions to be included into the cardiologists' clinical interviews. While structured interviews should be restricted to trained professionals, questionnaires are easily to administer, and have frequently been used in the field of cardiology. 'Single item' questions are sufficiently reliable and the most timesaving way to screen for psychosocial factors. For clinical practice, a two-step evaluation is recommended: firstly, cardiologists should include 'single-item' questions into their routine interview and/or use questionnaires in order to screen for a potential problem. Secondly, if problems are indicated, patients should be passed to qualified professionals for structured clinical interview. Instruments of all three methods are briefly presented, and implications for further treatment are discussed.

OBJECTIVES: This multi-methodical single case study examines how relationship, resistance and insight, the important therapeutic factors, are conveyed in a therapeutic process. METHODS: For depicting interaction the textual parameters - direct speech, acknowledgement tokens, activity of speech and personal pronouns - of Formal Psycholinguistic Text Analysis (Overbeck et al., 1996) are applied. The activity of the unconscious theme is measured by the Interferenzindex (Argelander, 1984). The link of emotional experiences with words is depicted by the Computerized Referential Activity method (Mergenthaler and Bucci, 1999). The attainment of emotional insight in the Model of the Therapeutic Cycle is perceived via the Emotion-/Abstraction-Patterns (Mergenthaler, 1997). RESULTS: Three phases are discriminated accordingly: Resistance, characterised by defensive intellectualization, symbolic representation on the basis of the secure relationship and emotional insight and detachment. CONCLUSIONS: The validity of the results in this single case study is guaranteed by the multi-methodical strategy.

In this article the results of a research with the CCRT-method on the psychotherapies of three in-patients suffering from eating disorders are presented. The CCRT describes recurrent internal and interpersonal relationship patterns in narratives. Each therapy session was recorded on tape and transcribed. The CCRT components were identified from the verbatim transcripts. All three patients clearly showed a negative self-perception and despite a more graded attitude regarding other people they felt rejected by the community throughout the entire therapy. The CCRT of each patient was different: patient 1. had conflicts between dependence and independence with increasing autonomy; patient 2. had great symbiotic desires, which at the beginning of the therapy were warded off with a performance ideal; patient 3. showed self-assertion and an increasing level of openness against the community, despite a high level of fear and self-isolation at the onset of therapy. Despite methodological deficiencies the CCRT method proved to be sensitive enough to show similarities and differences among the individual courses of treatment.

In Auseinandersetzung mit neueren Forschungsergebnissen wird gezeigt, das viele gangige Konzepte der psychosomatischen Medizin einer empirischen Uberprufung nicht standhalten konnen. Dieses betrifft sowohl die Spezifitatsmodelle wie auch den Dualismus zwischen Korper und Psyche oder zwischen Krankheit und Gesundheit. Die monokausal-psychogenetische Betrachtungsweise wurde abgelost durch ein komplexes Zusammenspiel von gestuften somatopsychischen Zirkeln, die in einem biosemiotischen Modell zu integrieren sind. In dem Bezugssystem Selbst-Objekt-Korper bekommen Affekte eine grosere kommunikative Bedeutung und Handeln erhalt eine wichtige interaktive Funktion. Die Wirkung der veranderten theoretischen Positionen auf neue Therapieansatze wird diskutiert.

Depersonalization (DP), i.e., feelings of being detached from one's own mental processes or body, can be considered as a form of mental escape from the full experience of reality. This mental escape is thought to be etiologically linked with maltreatment during childhood. The detached state of consciousness in DP contrasts with certain aspects of mindfulness, a state of consciousness characterized by being in touch with the present moment. Against this background, the present article investigates potential connections between DP severity, mindfulness, and childhood trauma in a mixed sample of nonpatients and chronic nonmalignant pain patients. We found a strong inverse correlation between DP severity and mindfulness in both samples, which persisted after partialing out general psychological distress. In the nonpatient sample, we additionally found significant correlations between emotional maltreatment on the one hand and DP severity (positive) and mindfulness (negative) on the other. We conclude that the results first argue for an antithetical relationship between DP and certain aspects of mindfulness and thus encourage future studies on mindfulness-based interventions for DP and second throw light on potential developmental factors contributing to mindfulness.

Type D (distressed personality) comprises the joint tendency to experience negative emotions (negative affectivity) and to inhibit these emotions in social situations (social inhibition). The distressed personality can be assessed by the Type D scale (DS14). In the present study, the German version of the DS14 was to be validated especially with regard to its interrelation with anger, aggression and hostility. The study included a clinical sample of 90 patients with coronary heart disease and a nonclinical sample of 86 participants. The two-factor structure of the DS14 could be confirmed in both samples. As expected, the subscale negative affectivity correlates highly with neuroticism; the subscale social inhibition correlates highly with extraversion. Negative affectivity also relates to almost every anger and aggression scale applied in this study. Participants classified as Type D report higher anger experience than non-Type D-classified persons. They show both heightened anger-in and anger-out and encounter others with more cynicism and hostility. It seems promising to provide special psychological treatment for these patients.

Drawing on interviews conducted with victims of New Zealand serial rapist, Malcolm Rewa, this article highlights the limitations of the terms resistance and survival as they are typically applied to women’s responses to rape attacks. Although acknowledging that formulations that stress women’s abilities to resist and their capacities to survive have been critically important in challenging popular notions of women as passive victims, the women’s accounts presented here suggest a need to question whether such formulations are adequate to reflect the complexity and diversity of women’s responses to sexual assaults. A preliminary attempt is also made to explore the implications associated with embracing expanded understandings of what resistance and survival might mean.

Functional heart symptoms, especially chest pain, are very widespread and, according to the International Classification of Diseases (ICD-10), are described as "somatoform autonomous functional disorders of the cardiovascular system". Although they are very often accompanied by considerable anxiety about having a heart attack, for example, they are initially not recognizable as such and have to be distinguished from somatic complaints. The most prevalent of these symptoms (Table 2) are chest pains, followed by feelings of weakness, a tendency to become easily fatigued and breathing difficulties. The perception of changes in cardiac activity, such as tachycardia, heart palpitations, irregular heartbeat or arrhythmias, is also extremely unsettling and thus anxiety-provoking. Therefore, although a responsible cardiac diagnosis is the basis for every further step taken, it is advisable to carry out a brief anamnesis immediately, if possible, to determine the prior history (Table 1). For example, previously conducted clarification of somatic causes, consultations with more than one physician in parallel or repeated medical emergency calls can be helpful for orientation. Moreover, in the interview during the diagnostic measures, the possibility of functional causes should always be pointed out in order to counteract a somatic fixation early on. The health-care policy role that lies in early diagnosis of functional cardiac complaints has to be regarded as highly relevant. Following exclusionary diagnosis, the patients should not be discharged as "healthy" from the cardiological practice without a more in-depth anamnesis of their complaints, because differentiated questioning of the patient not only about typical physical and psychic symptoms, but also about behavior patterns (Table 3) that can accompany functional cardiac complaints, works in favor of a doctor-patient relationship that is based on trust. Since, in addition to anxiety disorders, above all depressive states accompany functional heart complaints, and can also cause them in the sense of a comorbidity, a knowledge of characteristics related to depression (Table 4), such as a depressed mood, loss of interest or low motivation, is very helpful for a better understanding of the patients. The "vicious circle" that rapidly develops precisely in the case of this group of patients, consisting of physical symptoms, avoidance behavior and psychological as well as interpersonal difficulties, is described and possible solutions are pointed up. In summary, the following recommendations can be formulated for day-to-day clinical practice: 1. From the very beginning, a holistic approach should be conveyed in the interview by addressing psychological and social aspects as well, and taking them into account as possible causes. 2. The somatic diagnosis should, if possible, not go beyond that which is urgently necessary from a cardiological standpoint and presented in guidelines. One should, above all, not give in to pressure from the patients if it is a matter of repeated examinations within a short period of time. 3. A differentiated and focused anamnesis helps the patients to feel understood and taken seriously. 4. A relationship based on trust enhances the chances for a successful transfer to psychosomatic examination and treatment.

The aim of the study was a comprehensive psychological evaluation of living kidney donors. Existing studies indicate a high donor satisfaction with the decision to donate and good donor quality of life in short-term, as well as in long-term follow-up periods. In many studies, questionnaires with only a few items have been used to assess psychological health or well-being; however, most studies exclusively measured quality of life. Therefore, our retrospective single center study applied a broad assessment of psychological variables. We evaluated whether standardized, differentiated and specific psychological research instruments confirmed the positive, long-term condition of kidney donors as reported in the scientific literature, albeit based on a limited set of variables.From 1973 to 2001, 152 nephrectomies were performed in Frankfurt. In the context of a detailed medical follow-up examination, a psychological study was implemented using a semi-structured interview and a set of four standardized, well-established questionnaires. Overall, data from 145 donors was included in the medical follow-up and 112 donors participated in the psychological investigation.The mean age of donors was 55.9 (+/- 10.7) yrs at follow-up, and the time-since-donation was 11.2 (+/- 7.5) yrs. Donors scored better on a wide range of the psychological scales such as psychological symptoms, health behavior and health consciousness that was to be expected in comparison with data from representative German population samples. Nearly all donors (97%) would choose to donate again, and 91% remain entirely satisfied with their decision.The study demonstrates that existing results, reporting positive long-term psychological donor well-being, could be confirmed by a set of comprehensive, standardized and multi-methodological psychological instruments.

The Type D personality pattern, consisting of negative affectivity and social inhibition, has been shown by Denollet et al. to predict adverse prognosis in patients with coronary heart disease. For measuring the Type D characteristics, Denollet has devised the 14 item Type D scale (DS14). In the present study, this instrument was translated into German. The validity, reliability and adequacy of the German DS14 were then tested in 2421 persons, including cardiological and psychosomatic patients as well as healthy factory workers. The results document sound psychometric properties of the scale. Cronbach's alpha was 0.87 for the negative affectivity subscale and 0.86 for social inhibition. The two-factor structure of the original instrument could be clearly replicated. The prevalence rates of the Type D pattern were lowest in cardiological patients (25 %) and highest in psychosomatic patients (62 %). The prevalence in this German sample of cardiology patients was also lower than the one observed in healthy factory workers (32.5 %) and in CHD samples reported in the literature. These group differences could not be accounted for by differences in age and sex distribution. In conclusion, the DS14 is a valid and reliable instrument that can be used for an economic evaluation of the Type D characteristics in patients and healthy persons. The possible meaningfulness of the low Type D prevalence in cardiac patients and the prognostic relevance of this pattern require further study.

Im folgenden wird uber einen Aspekt von Copingmechanismen berichtet, der empirisch besonders schwierig zu untersuchen ist und daher in den meisten vorliegenden Studien ausgeklammert wurde, der meist auch vielfache Kontroversen auslost. Institutionelle Bedingungen der medizinischen Diagnostik und Therapie beeinflussen nach unseren Erfahrungen wesentlich die beobachtbaren individuellen Copingmechanismen. Auch das Verhalten der Patienten gegenuber den meist von ausen kommenden psychosozialen Forschern wird durch die strukturellen Gegebenheiten wesentlich mitbestimmt. Aber erst die systematische Beobachtung und Reflexion dieser Dimension ermoglicht eine kritische Einschatzung der gewonnenen Ergebnisse und beeinflust daher auch die Formulierung von Vorschlagen fur die zukunftige psychosoziale Betreuung der Patienten, die ja Ziel von Copingforschungen sein sollte. Die fur diesen Beitrag gewahlte Schwerpunktsetzung soll nicht suggerieren, das andere Determinanten des Copingprozesses — wie sie in den ubrigen Beitragen des vorliegenden Buches zu finden sind — weniger bedeutsam sind. Auch wir haben die derzeit ublichen methodischen Instrumente in unserer Untersuchung verwandt. Es soll lediglich gezeigt werden, wie sehr die instutionellen Strukturen den Forschungsprozes und die gewonnenen Ergebnisse beeinflussenm und es sollen dadurch andere Untersucher ermutigt werden, in ihren Veroffentlichungen diesem Aspekt groseren Raum zu widmen.