Cardiac modulation of startle is altered in depersonalization-/derealization disorder: Evidence for impaired brainstem representation of baro-afferent neural traffic

Patients with depersonalization-/derealization disorder (DPD) show altered heartbeat-evoked brain potentials, which are considered psychophysiological indicators of cortical representation of visceral-afferent neural signals. The aim of the current investigation was to clarify whether the impaired CNS representation of visceral-afferent neural signals in DPD is restricted to the cortical level or is also present in sub-cortical structures. We used cardiac modulation of startle (CMS) to assess baro-afferent signal transmission at brainstem level in 22 DPD and 23 healthy control individuals. The CMS paradigm involved acoustic startle stimuli (105dB(A), 50ms) elicited 0, 100, 200, 300, 400 and 500ms after a cardiac R-wave. In healthy control individuals, we observed lower startle responses at 100 and 300ms than at 0 and 400ms after an R-wave. In DPD patients, no effect of the cardiac cycle on startle response magnitude was found. We conclude that the representation of visceral-afferent neural signals at brainstem level may be deficient in DPD. This effect may be due to increased peripheral sympathetic tone or to dysregulated signal processing at brainstem level.

Pr�valenz der Urininkontinenz in der deutschen Bev�lkerung

The purpose of this study was to determine the frequency of incontinence in men and women in different age groups. In a representative survey, 883 men and 1,182 women with a mean age of 50 years (18-92 years) were studied based on standardized questionnaires on physical and psychological complaints, and quality of life. Participants suffering from involuntary loss of urine were considered "incontinent". The frequency of incontinence strongly increased with age, from 6.9% among the 18-40 year old population to 9.5% among the 41-60 year olds and 23% over the age of 60 years. Women complained more frequently of incontinence (15%) than men (9.5%; total of 12.6% in the population). The majority of the participants with incontinence also suffered from urinary urge, multiple disorders of digestion, pelvic pain and sexual dysfunction. There was also a strong increase in exhaustion, gastric pain, joint pain and cardiac complaints. The younger participants were more strongly affected by incontinence. When patients complain of incontinence, strong impairments in physical and psychological well-being, and quality of life are to be expected.

Is the end in the beginning? Child maltreatment increases the risk of non-suicidal self-injury and suicide attempts through impaired personality functioning

BACKGROUND

Child maltreatment is a risk factor for a range of mental disorders later in life, including dangerous self-harm and suicide attempts. A better understanding of the mechanisms underlying this association can inform prevention and intervention.

OBJECTIVE

To investigate personality functioning as a potential mediator of the association of childhood abuse and neglect and self-harm and suicide attempts in the general population.

PARTICIPANTS AND SETTING

Data were drawn from a representative German population sample (N = 2510).

METHODS

Participants filled out the Childhood Trauma Questionnaire (CTQ), OPD Structure Questionnaire (OPD-SQS), and items of the Self-Injurious Thoughts and Behaviors Interview (SITBI). In structural equation models, we operationalized impaired personality functioning as the mediator between childhood abuse and neglect and self-harm.

RESULTS

Individuals with a history of self-harm (combining suicide attempts, N = 47, and non-suicidal self-injury, N = 83) reported more childhood abuse and neglect (d = 1.39, p < .001) and greater impairments in personality functioning (d = 1.64, p < .001) than the rest of the population. The indirect effect via personality functioning accounted for 48.8 % of the total effect of childhood abuse and neglect on self-harm. In more differentiated analyses, emotional abuse showed the strongest association with self-harm. Only physical and sexual abuse had direct effects.

CONCLUSIONS

The results specify the relationship between child maltreatment and self-harm by demonstrating that it is partly mediated by basic functions of personality assessed using a dimensional measure. These abilities constitute modifiable risk factors that can be addressed by psychotherapy.

Distribution of Anterior Chamber Angle Width and Correlation With Age, Refraction, and Anterior Chamber Depth-The Gutenberg Health Study

PURPOSE

Scheimpflug imaging allows quantitative analysis of the width of the anterior chamber angle. We report the population-based distribution of the anterior chamber angle width using this noncontact imaging technique and investigate associated factors.

METHODS

A population-based cross-sectional study was carried out in Germany. A comprehensive ophthalmologic examination including refraction, biometry, and Scheimpflug imaging was performed. Automated measurement of the anterior chamber angle was performed in each anterior chamber quadrant. Exclusion criteria were previous ocular surgery or inadequate image quality. Association analyses were carried out to determine independently associated systemic and ocular factors for anterior chamber angle width using a generalized estimating equation model.

RESULTS

A total of 3014 subjects (48% female) with a mean age of 58.6 ± 10.4 years were included in this study. The mean anterior chamber angle width was 32.6° ± 5.5°. Statistical analysis revealed an independent association between a smaller anterior chamber angle and female sex, higher age, and more hyperopic refraction. When including biometric parameters, shallow anterior chamber depth, shorter axial length, higher central corneal thickness, and lower corneal power were independently associated with a narrower mean anterior chamber angle width.

CONCLUSIONS

These parameters are considered risk factors for angle-closure glaucoma.

New onset of depression in aging women and men: contributions of social, psychological, behavioral, and somatic predictors in the community

BACKGROUND

Based on the vulnerability-stress model, we aimed to (1) determine new onset of depression in individuals who had not shown evidence of depression at baseline (5 years earlier) and (2) identify social, psychological, behavioral, and somatic predictors.

METHODS

Longitudinal data of N = 10 036 participants (40-79 years) were evaluated who had no evidence of depression at baseline based on Patient Health Questionnaire (PHQ-9), no history of depression, or intake of antidepressants. Multivariate logistic regression models were used to predict the onset of depression.

RESULTS

Prevalence of new cases of depression was 4.4%. Higher rates of women (5.1%) than men (3.8%) were due to their excess incidence &lt;60 years of age. Regression analyses revealed significant social, psychological, behavioral, and somatic predictors: loneliness [odds ratio (OR) 2.01; 95% confidence interval (CI) 1.48-2.71], generalized anxiety (OR 2.65; 1.79-3.85), social phobia (OR 1.87; 1.34-2.57), panic (OR 1.67; 1.01-2.64), type D personality (OR 1.85; 1.47-2.32), smoking (OR 1.35; 1.05-1.71), and comorbid cancer (OR 1.58; 1.09-2.24). Protective factors were age (OR 0.88; 0.83-0.93) and social support (OR 0.93; 0.90-0.95). Stratified by sex, cancer was predictive for women; for men smoking and life events. Entered additionally, the PHQ-9 baseline score was strongly predictive (OR 1.40; 1.34-1.47), generalized anxiety became only marginally, and panic was no longer predictive. Other predictors remained significant, albeit weaker.

CONCLUSIONS

Psychobiological vulnerability, stress, and illness-related factors were predictive of new onset of depression, whereas social support was protective. Baseline subclinical depression was an additional risk weakening the relationship between anxiety and depression by taking their overlap into account. Vulnerability factors differed between men and women.

Insights Into Aspects Behind Internet-Related Disorders in Adolescents: The Interplay of Personality and Symptoms of Adjustment Disorders

PURPOSE

Problematic Internet use (PIU) that has recently been referred to as Internet-related disorder is a growing health concern. Yet, it is unclear why some adolescents are developing problematic use, whereas others sustain control. Based on previous research, we hypothesize that personality traits (low conscientiousness and high neuroticism) act as predispositions for PIU. We further hypothesize that PIU can be understood as a maladaptive reaction toward critical life events and that these maladaptive reactions are exacerbated by dysfunctional personality traits.

METHODS

The study investigates the prevalence of distinct subtypes of PIU among a sample of adolescents (n = 1,489; 10-17 years). Personality traits (Big Five Inventory-10 [BFI-10]), perceived stress (Perceived Stress Scale 4 [PSS-4]), and their relations to PIU (Scale for the Assessment of Internet and Computer Game Addiction [AICA-S]) were examined. As novel research questions, associations between PIU and adjustment disorders (Adjustment Disorder-New Module [ADNM]-6) and the mediating role of personality were investigated.

RESULTS

The prevalence of PIU was 2.5%; girls (3.0%) were more often affected than boys (1.9%). Social networking sites in girls and online games in boys were most often associated with PIU. Low conscientiousness and high neuroticism generally predicted PIU. Significantly more adolescents with PIU (70%) reported critical life events compared with those without PIU (42%). PIU was related to heightened stress and higher adjustment disorder symptoms. These associations were exacerbated by conscientiousness and neuroticism.

CONCLUSIONS

Although the overall prevalence for PIU is in line with previous studies, it appeared unexpectedly that girls were affected more often than boys. Adjustment disorders and stress showed strong associations with PIU. This bears implications for adapting etiopathological assumptions and early intervention strategies.

Prevalence, risk factors, and psychosocial adjustment of problematic gambling in adolescents: Results from two representative German samples

Background and aims Gambling disorder is a significant public health concern. Especially, male minors have been shown to gamble in a problematic way, despite legal prohibitions. Methods We examined representative samples of students aged from 12 to 18 years (N = 9,309) in two German federal states to provide prevalence data and clinical description of risk factors for problematic gambling. Results We found that about 40% of the adolescents reported engaging in gambling activities within the past 12 months and found prevalence rates of 1.7% and 2.2% for problematic gambling. Especially, use of online gambling and slot machines was found to be related to problematic gambling. Male adolescents with a migration background were of higher risk for problematic gambling and psychopathological symptoms were significantly elevated among that group. Discussion The results indicate that participation in gambling activities is common among underaged adolescents and that prevalence of problematic gambling exceeds rates of adults. Similarly, problematic gambling is associated with increased psychopathological strain. Conclusion Given that a high proportion of adult gamblers report having started gambling in adolescents, our data emphasize the need for prevention and early intervention strategies for problematic gambling.

Short-term cost-effectiveness of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: Results from the SOPHO-NET trial

BACKGROUND

To investigate the short-term cost-effectiveness of cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) compared to waiting list (WL).

METHODS

The analysis was conducted alongside the SOPHO-NET multi-center efficacy trial. Patients were randomly assigned to CBT (n=209), PDT (n=207), or WL (n=79). Resource use was assessed prior and during treatment to determine direct and absenteeism costs. Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated based on remission and response rates. To visualize statistical uncertainty, cost-effectiveness acceptability curves (CEACs) were constructed based on adjusted net-benefit regression. Different values for the society׳s willingness to pay (WTP) were assumed.

RESULTS

Both interventions were more efficacious than WL but were associated with increased direct costs besides intervention costs. Unadjusted ICERs per responder were €3615 for CBT and €4958 for PDT. Unadjusted ICERs per remitted patient were €5788 and €10,733. CEACs revealed a high degree of uncertainty: applying the 97.5% probability threshold, CBT proved cost-effective at a WTP ≥€16,100 per responder and ≥€26,605 per remitted patient. Regarding PDT cost-effectiveness only was certain for response at a WTP ≥€27,290.

LIMITATIONS

The WL condition is assumed to represent untreated patients, although the expectation to start treatment in the near future probably affects symptom severity and health care utilization.

CONCLUSIONS

At the end of treatment cost-effectiveness of CBT and PDT compared to WL is uncertain and depends on the societal WTP. The interventions may induce a more adequate utilization of other health care services - involving increased costs. Development of costs and effects in the long-run should be considered.

Prevalence and determinants of online-sex use in the German population

Introduction

The unlimited access to sexual features in the World Wide Web has raised concerns about excessive and problematic online-sex use. However, little is known about antecedents of internet-sex use of different intensity. Based on a representative German sample of 2,522 participants between the ages of 14 and 97 years, the aims of the present study were (1) to determine the prevalence rates of online-sex users with the short version (ISST_GSV) of the Internet Sex Screening Test and (2) to associate online-sex use with anxious vs. avoidant partner attachment patterns and “Big Five” personality traits as potential antecedents.

Results

The ISST is a brief, one-dimensional and reliable measure of online-sex activities (r_tt = .69). Overall, 14.7% of respondents reported occasional and 4.2% intensive online-sex use. In multivariate analysis, online-sex use was significantly positively associated with male sex, younger age, unemployment and an anxious partner attachment pattern and negatively with conscientiousness and agreeableness.

Conclusions

Arousal and satisfaction by virtual enactment of sexual phantasies may be attractive for anxiously attached persons who find it difficult to commit to a real life relationship due to fear of rejection or low self-esteem. More knowledge about the individual antecedents of intensive online-sex use may also be helpful for the development of consultation and treatment strategies for excessive and addictive online-sex use.

Mid-term effectiveness of behavioral and psychodynamic inpatient treatments of severe obesity based on a randomized study

BACKGROUND

The objective of this study was to compare the effectiveness of psychodynamic and behavioral inpatient treatments of severely obese patients regarding weight and distress.

METHODS

In a longitudinal study obese patients (body mass index, BMI >or=35) were randomly assigned to behavioral or to psychodynamic inpatient treatment. Mostly female (n = 267; 85%) obese patients with psychiatric and somatic comorbidity (age 20-64 years, BMI 35-74) were examined with standardized self-report scales on distress (SCL-90R), interpersonal problems (Inventory of Interpersonal Problems), eating behavior (Fragebogen zum Essverhalten) and body image (Fragebogen zum Korperbild).

RESULTS

During 49 days (mean) of inpatient treatment, patients lost an average of 5.6 kg (4.4%) in the behavioral (n = 130) and 5.7 kg (4.4%) in the psychodynamic setting (n = 137). In both settings, eating behavior, well-being and body image also improved significantly. One year after discharge, return rate was 73%. Forty percent had further reduced their weight (by more than 5% compared to intake), 36% had regained weight, but were still below intake level, and another 24% had increased weight above intake.

CONCLUSION

Behavioral and psychodynamic treatments were equally effective reducing weight and distress over 1 year.

Somatic Symptoms in the German General Population from 1975 to 2013

The study determines how burden and patterns of somatic symptom reporting developed over almost four decades in the general German population. Additionally, we studied how socio-demographic factors affected the degree of somatic symptoms. Population-based samples representative for West Germany between 18 and 60 years of age were analyzed comparing three cross-sectional samples of 1975 (N = 1601), 1994 (N = 1416), and 2013 (N = 1290) by conducting a three-way analysis of variance (sex, age, survey). The prevalence rates for somatic symptoms in men and women were lower in the more recent surveys; this affected women most strongly. Exhaustion and musculoskeletal complaints remained leading symptoms (affecting 25%, resp. 11% of the men and 30%, resp. 19% of the women). There was a slight increase in women’s prevalence of exhaustion from 1994 (15%) to 2013 (19%). As determined by stepwise multiple regression, somatic symptoms were consistently associated with female sex and higher age. In the 2013 survey, education became an additional negative predictor of somatic symptom load, while the impact of age and sex on somatic symptoms reporting decreased. Somatic symptoms remain a major burden in the general population. Findings are interpreted with regard to improved living and health care conditions, different cohort experiences, and more public health information.

Improving the Course of Depressive Symptoms After Inpatient Psychotherapy Using Adjunct Web-Based Self-Help: Follow-Up Results of a Randomized Controlled Trial

Background

We recently showed in a randomized controlled trial that Web-based self-help as an adjunct improved the effectiveness of multimodal inpatient psychotherapy for depression.

Objective

The aims of this study were (1) to determine whether a Web-based self-help adjunctive to multimodal inpatient psychotherapeutic treatment could also improve the course of depressive symptoms and (2) to identify predictors of residual depressive symptoms at follow-up.

Methods

Overall, 229 patients were randomized either to the Web-based self-help intervention group (Deprexis) or an active control group (Web-based information about depression and depressive symptoms) in addition to multimodal inpatient psychotherapy. Participants in both groups were able to access their respective Web-based programs for 12 weeks, which meant that they typically had access after discharge from the inpatient unit (mean hospitalization duration: 40 days, T1). Follow-up was performed 6 months after study intake (T3).

Results

At follow-up, participants of the Web-based self-help group had considerably lower symptom load regarding depressive symptoms (d=0.58) and anxiety (d=0.46) as well as a better quality of life (d=0.43) and self-esteem (d=0.31) than participants of the control group. Nearly 3 times as many participants of the intervention group compared with the control group achieved remission in accordance with less deterioration. The number needed to treat based on the Beck Depression Inventory-II (BDI-II) improved over time (T1: 7.84, T2: 7.09, and T3: 5.12). Significant outcome predictors were BDI at discharge and treatment group.

Conclusions

Web-based self-help as an add-on to multimodal inpatient psychotherapy improved the short-term course of depressive symptoms beyond termination. Residual symptoms at discharge from inpatient treatment and utilization of the Web-based self-help were the major predictors of depressive symptoms at follow-up. Challenges and barriers (eg, costs, therapists’ concerns, or technical barriers) of adding Web-based interventions to inpatient treatment have to be addressed.

Trial Registration

ClinicalTrials.gov NCT02196896; https://clinicaltrials.gov/ct2/show/NCT02196896.

Psychoanalytically-oriented inpatient psychotherapy of somatoform disorders

Somatoform disorders have been neglected in psychoanalytic publications. Unlike the descriptive approach of DSM-IV and ICD-10, sophisticated psychoanalytical models have been proposed for many years explaining the development of physical symptoms without definable medical cause. Based on a review of the psychoanalytic models of somatization and conversion, this article explores difficulties in the medical and psychotherapeutic treatments of somatoform disorders. The unique tradition of psychosomatic inpatient treatment in Germany is illustrated by the psychoanalytic treatment setting at the University of Mainz. A case report of a somatoform patient shows how childhood trauma is activated and integrated in the course of inpatient treatment. In a multimodal approach, psychoanalytic individual and group therapy may interact beneficially with body-oriented, art therapy, and other treatment elements to gain therapeutic access to chronic somatoform patients, activate and work through trauma and conflict. Regardless of the specific setting, analytic treatments need to do justice to the specific deficits (e.g., symbolization of affect, mentalization) and defences of somatoform patients.

Regulation of emotions in the community: suppression and reappraisal strategies and its psychometric properties

Objective: The German Version of the Emotion Regulation Questionnaire (ERQ) has recently been published. The questionnaire investigates two common emotion regulation strategies (10 items) on two scales (suppression, reappraisal). Major aims of the study were to assess the reliability and factor structure of the ERQ, to determine population based norms and to investigate relations of suppression and reappraisal to anxiety, depression and demographic characteristics.

Methods: In a representative community study (N=2524) we assessed emotion regulation strategies, anxiety, depression (Hospital Anxiety and Depression Scale), and demographic variables. The mean age of the participants was 49.4 (SD 18.2) years. 55.5% were female. The age-groups were represented in comparable proportions. The representativeness of the sample was ensured by drawings of ADM (Arbeitskreis Deutscher Marktforscher) samples und by comparison with the data of German Federal Statistical Office.

Results: Confirmatory factor analysis could not fully confirm the original factor structure, we kept the original scaling, except a modification regarding item 8. Internal consistencies were acceptable for the original and the modified version: reappraisal (Cronbach’s alpha = 0.82) and suppression (alpha = 0.76). Norms are presented as percentile scores for age groups and gender. Reappraisal correlated negative with anxiety and depression, whereas we could find a positive relationship of suppression with anxiety and depression. In a linear regression model suppression was predicted by depression, a lower level of education, male gender, and lower income.

Conclusions: The ERQ is a short instrument to assess emotion regulation strategies economically, e.g. in larger community based studies. We could demonstrate sufficient psychometric properties of the German version of the ERQ: reliability, factor structure and indicators for construct validity. Because of the cross sectional character of our study it remains unclear whether reappraisal is protective and suppression is unfavourable regarding mental health or whether life circumstances and psychic symptoms lead to a suppression of emotions.

Discounting delayed monetary rewards and decision making in behavioral addictions - A comparison between patients with gambling disorder and internet gaming disorder

Behavior addictions, such as Gambling Disorder and Internet Gaming Disorder, have been demonstrated to have severe negative impact. Heightened impulsivity, deficits in decision making, and cognitive biases in the preference of immediate rewards have been shown to be crucial aspects in addictive disorders. While for Gambling Disorder (GD), dysfunctional decision making has been documented before, data for Internet Gaming Disorder (IGD) are still underrepresented. In order to allow for a direct comparison of both disorders, we assessed different measures of impulsivity (trait, impulsive choice, and decision making) in a clinical sample. N = 31 patients meeting criteria for GD and n = 30 patients with IGD were recruited from an outpatient clinic and compared regarding their performance in a Delay Discounting Task (DDT), the Iowa Gambling Task (IGT), and self-report data on impulsivity (Barratt Impulsiveness Scale). Healthy controls (n = 27) were included as a reference group. In the DDT, the area under the curve was associated with the severity of GD only. No correlations were found for the impulsivity subscales and the area under the curve which, however, was similar between the two patient groups in contrast to controls. The GD-group performed poorer then the other groups in the IGT while IGD-patients performed poorer only at the beginning of the experiment. Although only few significant differences occurred, similarities between GD and IGD regarding the DDT point towards a tendency on discounting rewards faster. Likewise, both patient groups were performing worse in the IGT than healthy controls which indicates deficiencies in decision making. Interestingly, the IGD-group was able to shift towards more advantageous decision making, which might have important implications for therapeutic interventions.

Psychosocial Care Needs of Melanoma Survivors: Are They Being Met?

Patients who have survived malignant melanoma for more than five years may lack the opportunity to talk about their burden. As a consequence their psychosocial care needs remain undetected and available supportive interventions may not be utilised. Therefore, the psychosocial burden of this patient group needs to be assessed using specific screening instruments. The aim of this study was to investigate the psychosocial burden of long-term melanoma survivors, their psychosocial care needs and the determinants of these needs. We wanted to find out if the use of professional support corresponds to the care needs defined by experts. Using the cancer registry of Rhineland-Palatinate, melanoma patients diagnosed at least 5 years before the survey were contacted by physicians. N = 689 former patients completed the Hornheide Questionnaire (short form HQ-S) to identify psychosocial support need (scale cut off ≥ 16 or item-based cut-off score) and the potential psychosocial determinants of these needs. Additionally, they were asked about their utilisation of the professional support system. More than one third (36%) of them was in need for professional psychosocial support. The highest burden scores concerned worry about tumour progression. Younger age (< 50), higher general fatigue, higher symptom burden, lower general health, negative social interactions and unfulfilled information needs were significant predictors of the need for psychosocial intervention. Related to the percentage of survivors identified as 'in need', the professional support system was underused. Further studies should investigate whether using the HQ-S to routinely identify burdened melanoma patients could lead to better fulfilment of their intervention needs, ultimately enhancing health-related quality of life.

Peripapillary Retinal Nerve Fiber Layer Profile in Relation to Refractive Error and Axial Length: Results From the Gutenberg Health Study

Purpose

To investigate the retinal nerve fiber layer profile measured by optical coherence tomography and its relation to refractive error and axial length.

Methods

The Gutenberg Health Study is a population-based study in Mainz, Germany. At the five-year follow-up examination, participants underwent optical coherence tomography, objective refraction and biometry. Peripapillary retinal nerve fiber layer (pRNFL) was segmented using proprietary software. The pRNFL profiles were compared between different refraction groups and the angle between the maxima, i.e., the peaks of pRNFL thickness in the upper and lower hemisphere (angle between the maxima of pRNFL thickness [AMR]) was computed. Multivariable linear regression analysis was carried out to determine associations of pRNFL profile (AMR) including age, sex, optic disc size, and axial length in model 1 and spherical equivalent in model 2.

Results

A total of 5387 participants were included. AMR was 145.3° ± 23.4° in right eyes and 151.8° ± 26.7° in left eyes and the pRNFL profile was significant different in the upper hemisphere. The AMR decreased with increasing axial length by −5.86°/mm (95% confidence interval [CI]: [−6.44; −5.29], P < 0.001), female sex (−7.61°; 95% CI: [−8.71; −6.51], P < 0.001) and increased with higher age (0.08°/year; 95% CI: [0.03; 0.14], P = 0.002) and larger optic disc size (2.29°/mm²; 95% CI: [1.18; 3.41], P < 0.001). In phakic eyes, AMR increased with hyperopic refractive error by 2.60°/diopters (dpt) (95% CI: [2.33; 2.88], P < 0.001).

Conclusions

The pRNFL profiles are related to individual ocular and systemic parameters.

Translational Relevance

Biometric parameters should be considered when pRNFL profiles are interpreted in diagnostics, i.e., in glaucoma.

Prevalence and correlates of depersonalization in students aged 12-18 years in Germany

BACKGROUND

Depersonalization (DP) involves unpleasant experiences of detachment from one's sense of self or unreality in the environment. DP may occur in a broad range of conditions, among healthy persons due to sleep loss, drug induced, secondary to anxiety disorders or primary in depersonalization disorder. Although DP has an early age of onset, little is known about the prevalence and correlates of DP among adolescents.

METHODS

Between January and June 2011, we conducted a questionnaire-based representative survey of pupils aged 12-18 years in the federal state Rhineland-Palatinate of Germany. The final sample comprised 3,809 pupils. We analyzed the prevalence of depersonalization and its correlates regarding sociodemographic characteristics, substance abuse, global mental distress and resilience factors.

RESULTS

One-third of the sample showed severe global mental distress, and 11.9 % were in the range of clinically significant depersonalization. Depersonalized students were less often living with both parents (67.3 vs. 75.7 %), came more often from an disadvantaged socioeconomic background, had a very severe level of global mental distress (comparable to psychiatric inpatients), were more often smoking and abusing cannabis and they suffered from specific impairments regarding social insecurity, global self-efficacy and active coping abilities.

CONCLUSIONS

Experiences of depersonalization were very common among adolescents and may indicate an increased risk for poor academic achievement and mental health in the long term. Prospective studies are needed to investigate the course and clinical relevance of depersonalization for the development of the adolescents.

Fatigue in survivors of malignant melanoma and its determinants: a register-based cohort study

PURPOSE

Fatigue has found increasing attention as a debilitating and lasting condition of cancer patients. However, it has remained unclear to what degree long-term survivors of malignant melanoma suffer from fatigue. Therefore, this study aimed to determine fatigue and its link with quality of life, aftercare behavior, and mental and physical symptoms among melanoma survivors.

METHODS

A register-based sample of 684 long-term survivors an average of 8.4 (SD = 1.72; range 5.67-12.17) years after diagnosis was compared to 2049 participants from a representative survey by the Multidimensional Fatigue Inventory. In a hierarchical linear regression, statistical predictors for fatigue were ascertained.

RESULTS

Overall fatigue was not increased in melanoma survivors except for younger melanoma survivors under 40 years. As in the general population, fatigue increased with age, and it was higher in women compared to men. Fatigue was associated with decreased quality of life, reduced functioning, and increased physical and mental symptoms. Substantial predictors (30% explained variance) were higher age, additional chronic illness, self-blame, detrimental interactions and lack of social support, and also fear of recurrence. There was neither an effect of medical parameters (clinical stage, time since diagnosis) nor of participation in follow-up care.

CONCLUSIONS

Fatigue needs to be taken seriously in the aftercare of melanoma survivors as it is associated with multiple functional and quality of life impairments and heightened distress. Reduction of fatigue in melanoma patients should address younger survivors (under 40 years) and older survivors (over 60 years) with additional chronic illness and focus on illness coping and social support.

Reliability, validity and responsiveness of the EQ-5D in assessing and valuing health status in patients with social phobia

Objective

The aim of the study was to analyse the psychometric properties of the EQ-5D in patients with social phobia.

Methods

We used a sample of 445 patients with social phobia with five measurement points over a 30 month period. The discriminative ability of the EQ-5D was analysed by comparing the patients’ responses with the general population and between different disease severity levels. For test-retest reliability we assessed the level of agreement in patients’ responses over time, when there was no change in the Liebowitz Social Anxiety Scale (LSAS). Construct validity was analysed by identifying correlations of the EQ-5D with more specific instruments. For responsiveness we compared the means of EQ VAS/EQ-5D index anchored on improved (deteriorated) health status and computed effect sizes as well as a receiver operating characteristic (ROC) curve.

Results

Compared to the general population, patients with social phobia reported more problems in the dimensions “usual activities”, “pain/discomfort”, and “anxiety/depression” and less problems in “mobility” and “self-care”. The EQ-5D was able to distinguish between different disease severity levels. The test-retest reliability was moderate (intraclass correlation coefficient > 0.6). Correlations between the EQ-5D and other instruments were mostly small except for correlations with Beck Depression Inventory. The EQ-5D index seemed to be more responsive than the EQ VAS, but with only medium effect sizes (0.5 < effect size < 0.8) in the British EQ-5D index and only significant in patients with improved health status. The ROC analysis revealed no significant results.

Conclusions

The EQ-5D was moderately reliable and responsive in patients with improved health status. Construct validity was limited.

Trial registration

Current controlled trials ISRCTN53517394

Do Patient Characteristics Predict Outcome of Psychodynamic Psychotherapy for Social Anxiety Disorder?

OBJECTIVES

Little is known about patient characteristics as predictors for outcome in manualized short term psychodynamic psychotherapy (PDT). No study has addressed which patient variables predict outcome of PDT for social anxiety disorder.

RESEARCH DESIGN AND METHODS

In the largest multicenter trial on psychotherapy of social anxiety (SA) to date comparing cognitive therapy, PDT and wait list condition N = 230 patients were assigned to receive PDT, of which N = 166 completed treatment. Treatment outcome was assessed based on diverse parameters such as endstate functioning, remission, response, and drop-out. The relationship between patient characteristics (demographic variables, mental co-morbidity, personality, interpersonal problems) and outcome was analysed using logistic and linear regressions.

RESULTS

Pre-treatment SA predicted up to 39 percent of variance of outcome. Only few additional baseline characteristics predicted better treatment outcome (namely, lower comorbidity and interpersonal problems) with a limited proportion of incremental variance (5.5 to 10 percent), while, e.g., shame, self-esteem or harm avoidance did not.

CONCLUSIONS

We argue that the central importance of pre-treatment symptom severity for predicting outcomes should advocate alternative treatment strategies (e.g. longer treatments, combination of psychotherapy and medication) in those who are most disturbed. Given the relatively small amount of variance explained by the other patient characteristics, process variables and patient-therapist interaction should additionally be taken into account in future research.

TRIAL REGISTRATION

Controlled-trials.com/ISRCTN53517394.

Der chronische Beckenschmerz und seine Komorbidit�t

The diagnosis of chronic pelvic pain syndrome takes into account the fact that no clear etiology has been identified underlying chronic prostatitis and its associations with multiple somatic and psychological complaints. Based on a representative survey, this study enquires into the prevalence of pelvic pain in the community, its association with sexual dysfunction, somatic complaints and aging. Of the 770 men surveyed, 60 (7.8%) fulfilled the criteria for pelvic pain syndrome. This was assessed by a validated Giessen Prostatitis Symptom Score. Sexual dysfunction (particularly erectile dysfunction and loss of libido) were more frequently reported by men with pelvic pain than by men without a pain syndrome. The great majority of men afflicted by pelvic pain complained of additional pain symptoms (particularly back and joint pain) and fatigue. While sexual and somatic complaints were age-associated in the asymptomatic men, this was not the case for the symptomatic men. Our findings stress the fact that chronic pelvic pain syndrome is a major health problem in middle and late adulthood in men. Differentiated knowledge about comorbidity is a prerequisite for developing new interdisciplinary approaches to the diagnosis and therapy of this to date unsatisfactorily treated syndrome.

Who benefits from inpatient short-term psychotherapy in the long run? Patients' evaluations, outpatient after-care and determinants of outcome

BACKGROUND

Little work has been published on short-term inpatient treatments combining the virtues of inpatient treatments and short-term psychotherapy. The purposes of this study are to (a) determine the outcomes of short-term psychodynamic inpatient psychotherapy from patients' and therapists' perspectives, (b) assess the stability of changes, and (c) identify predictors of long-term outcome.

METHODS

83 consecutive inpatients (76% of those eligible) were assessed at intake, discharge, and 1 year follow-up by standardized questionnaires regarding symptoms (SCL-90R), interpersonal problems (IIP), object relationships (IPO), and the therapeutic relationship (HAQ). Diagnoses and functioning (GAF) were assessed by the therapists.

RESULTS

Psychological distress (effect size S = 1.14) and physical complaints (ES = 1.03) decreased strongly from intake to discharge, the majority of patients moving from the pathological to the normal range of the global severity index GSI (SCL-90R). At follow-up, average distress remained at a low level, and the majority of patients, and their therapists and physicians, regarded their well-being as improved. In a multivariate approach, a substantial proportion of variance of the distress at follow-up (42%) was explained by an infantile object relationship pattern (IPO), social avoidance (IIP), negative vocational changes, and a lack of a confidant at follow-up. A delayed start of subsequent ambulatory psychotherapy was another negative outcome predictor.

CONCLUSIONS

Attention should be given to maladaptive interpersonal relationship patterns, to vocational reintegration, and a confiding relationship as potential predictors of long-term outcome. Also, patterns of ambulatory after-care following inpatient treatment need further scrutiny.

The distribution of whole blood viscosity, its determinants and relationship with arterial blood pressure in the community: cross-sectional analysis from the Gutenberg Health Study

Background:

Blood viscosity has a role in modulating cardiovascular homeostasis; changes in this parameter have been associated with cardiovascular mortality and morbidity. However, it remains unclear whether these changes are (1) involved in the pathophysiology of disease, (2) an epiphenomenon, or (3) the expression of counterregulatory mechanisms. We report data on the normal values of blood viscosity and its association with cardiovascular risk factors, prevalent cardiovascular disease, and blood pressure in a large population-based cohort study.

Methods and results:

Viscosity was calculated using validated formulae and its associations were explored in 15,010 participants (mean 55.0, min–max: 35–74 years old; 49.5% women) from the Gutenberg Health Study as well as in a subgroup of 3223 subjects (61.1% women, mean age 49.2, min–max 35–74 years old) without risk factors or self-reported cardiovascular disease. Age- and gender-adjusted mean values for viscosity were defined. Regression models showed a relationship between classical risk factors and blood viscosity measures; the overall R2 of the multiple linear regression model was however as low as 0.067 and 0.049 for high and low shear stress viscosity, respectively. After correction for cardiovascular risk factors, there was a very mild association between viscosity and prevalent coronary artery disease and heart failure. Systolic, mean and diastolic blood pressure increased with increasing blood viscosity after correction for age and gender.

Conclusions:

We provide reference values for viscosity in a population-based cohort. Blood viscosity decreases in older subjects and shows a very mild association with cardiovascular risk factors and prevalent disease in our cohort. There is a linear positive association between viscosity and blood pressure.