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Giesmann M, Flatten-Whitehead I, Specht L, Fegert JM, Schellong J, Rassenhofer M, Schäfer I. [Rapid assistance for victims of acute violence-Current treatment in outpatient trauma clinics in Germany]. DER NERVENARZT 2024; 95:597-606. [PMID: 38832956 PMCID: PMC11222281 DOI: 10.1007/s00115-024-01676-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Assistance following acute violence was previously regulated by the Victim Compensation Act (OEG). At the beginning of the current year it was replaced by the Social Code XIV (SGB XIV). The SGB XIV defines new groups of beneficiaries, outpatient trauma clinics must be provided nationwide and binding criteria for the quality of care were established. The aim of this study was to map the current status of care in outpatient trauma clinics in accordance with the requirements of the new SGB XIV. With respect to new beneficiaries, the status of services for victims of human trafficking was recorded as an example. METHODS Outpatient clinics that provide rapid assistance under the OEG or SGB XIV were surveyed on structural and content-related aspects of their work. An online survey consisting of 10 thematic modules was used. Data were obtained from a total of N = 110 outpatient clinics (response rate 50%). RESULTS The participating outpatient clinics reported a wide range in terms of the number of staff and the number of people seeking counselling. Some of the outpatient clinics reported deficits with respect to structural aspects, such as the waiting time for the initial consultation and specific training in trauma treatment for staff. The majority of outpatient clinics were uncertain about how to deal with victims of human trafficking. DISCUSSION Outpatient trauma clinics appear to reach their target population and provide appropriate services for their care; however, a significant number of outpatient clinics need to make improvements in order to fulfil the quality criteria of SGB XIV and provide adequate care to new groups of beneficiaries.
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Affiliation(s)
- Marc Giesmann
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | | | - Lina Specht
- Klinik und Poliklinik für Psychotherapie und Psychosomatik, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - Jörg M Fegert
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Julia Schellong
- Klinik und Poliklinik für Psychotherapie und Psychosomatik, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - Miriam Rassenhofer
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Ingo Schäfer
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Fernandez A, Askenazy F, Zeghari R, Auby P, Robert P, Thümmler S, Gindt M. Somatic and Posttraumatic Stress Symptoms in Children and Adolescents in France. JAMA Netw Open 2024; 7:e247193. [PMID: 38635269 DOI: 10.1001/jamanetworkopen.2024.7193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Importance Somatic symptoms are a major concern among the pediatric population because of frequency and burden. The association between adverse childhood experiences and somatic symptoms in adults is well established but less is known concerning somatic symptoms in young people. Objective To explore the frequency and intensity of somatic symptoms in children and adolescents exposed to traumatic events. Design, Setting, and Participants This cross-sectional study was conducted from January 1 to December 31, 2021, at the Nice Pediatric Psychotrauma Referral Center in Nice, France. Participants included pediatric outpatients, aged 7 to 17 years, who were referred to the center. Statistical analysis was performed in January 2022. Exposure All participants experienced at least 1 traumatic event during life. Main Outcome and Measure Somatic and posttraumatic stress symptoms were assessed using the Patient Health Questionnaire-13 (PHQ-13) and Child PTSD Checklist (CPC). Posttraumatic stress disorder (PTSD) and non-PTSD groups were defined based on CPC symptoms severity score. In the hypothesized association between somatic symptoms and posttraumatic stress symptoms (PTSS), PTSD and non-PTSD groups were compared, correlations between PTSS and severity of CPC were analyzed, and a regression model was performed. Results There were 363 participants included (mean [SD] age, 13.58 [0.25] years; 174 [47.9%] female, 189 [52.1%] male). Compared with the non-PTSD group, the PTSD group presented with a higher mean (SD) number of somatic symptoms (7.0 [2.5] vs 4.0 [2.5] symptoms; t360 = 11.7; P < .001), and higher mean (SD) intensity (10.4 [4.6] vs 4.8 [3.7] points; t360 = 12.6; P < .001). Most of the explored somatic symptoms positively correlated with the intensity of PTSS and their functional alterations (eg, PTSS intensity correlated with stomach pain symptoms [r = .30; P < .001]; and with headaches symptoms [r = .44; P < .001]). In the regression model, the combination of migraines, palpitation, nausea, tiredness, and sleep disorders explained 6.5% of the variance in the PTSD group. (F1,341 = 22.651; P < .001). Conclusions and Relevance In this cross-sectional study, somatic symptoms were positively correlated with PTSS both in frequency and intensity among youths. These results suggest that the systematic screening for somatic symptoms in youths with traumatic exposure should be a routine evaluation procedure.
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Affiliation(s)
- Arnaud Fernandez
- Nice Pediatric Psychotrauma Center, University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France
- CoBTek, Université Côte d'Azur, Nice, France
- Centre Régional du Psychotraumatisme PACA, Nice, France
| | - Florence Askenazy
- Nice Pediatric Psychotrauma Center, University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France
- CoBTek, Université Côte d'Azur, Nice, France
- Centre Régional du Psychotraumatisme PACA, Nice, France
| | - Radia Zeghari
- Nice Pediatric Psychotrauma Center, University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France
- CoBTek, Université Côte d'Azur, Nice, France
| | - Philippe Auby
- Nice Pediatric Psychotrauma Center, University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France
- CoBTek, Université Côte d'Azur, Nice, France
| | - Philippe Robert
- Nice Pediatric Psychotrauma Center, University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France
- CoBTek, Université Côte d'Azur, Nice, France
| | - Susanne Thümmler
- Nice Pediatric Psychotrauma Center, University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France
- CoBTek, Université Côte d'Azur, Nice, France
| | - Morgane Gindt
- Nice Pediatric Psychotrauma Center, University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France
- CoBTek, Université Côte d'Azur, Nice, France
- Centre Régional du Psychotraumatisme PACA, Nice, France
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Zeghari R, Gindt M, Guivarch J, Auby P, Robert P, Rolling J, Schröder C, Valo P, Askenazy F, Fernandez A. July 14th 2016 Nice Terrorist Attack Court Trial: A Protocol on Sleep Quality and Somatic Symptoms as Markers of Risk for Traumatic Reactivation in Adolescents Exposed to This Attack. Healthcare (Basel) 2023; 11:2953. [PMID: 37998445 PMCID: PMC10671086 DOI: 10.3390/healthcare11222953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/05/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023] Open
Abstract
The court trial of the 14th of July 2016 terrorist attack in Nice (France) opened in September 2022 and ended in December 2022. Engaging in court proceedings, whether as a victim or a witness, can lead to a significant risk of traumatic reactivation (i.e., the re-emergence of post-traumatic stress symptoms). The present protocol aimed to improve knowledge of the pathophysiology of traumatic reactivation due to the media coverage of the trial by assessing sleep disturbances and somatic symptoms that could reappear if there is a traumatic reactivation. Method and Analysis: This is a monocentric longitudinal study, with recruitment solely planned at the Nice Pediatric Psychotrauma Center (NPPC). We intended to include 100 adolescents aged 12 to 17 years who were directly or indirectly exposed to the attack and included in the "14-7" program). Assessments began one month before the trial, in August 2022, and were scheduled once a month until the end of the trial. A smartwatch recorded sleep activity. Somatic and PTSD symptoms and sleep were assessed through validated questionnaires. The main analyses comprised the variance and regression analyses of predictors of clinical evolution over time. Ethics and Dissemination: The National Ethics Committee "NORD OUEST III" approved the "14-7" program protocol (number 2017-A02212-51). The specific amendment for this research was approved in April 2022 by the same national ethical committee. Inclusions started in August 2022.
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Affiliation(s)
- Radia Zeghari
- Nice Pediatric Psychotrauma Center (NPPC), Child and Adolescent Psychiatry Department, Hôpitaux Pédiatriques Universitaires Lenval, 06200 Nice, France
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Morgane Gindt
- Nice Pediatric Psychotrauma Center (NPPC), Child and Adolescent Psychiatry Department, Hôpitaux Pédiatriques Universitaires Lenval, 06200 Nice, France
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Jokthan Guivarch
- Department of Child Psychiatry, APHM, 13009 Marseille, France;
- CANOP Institut de Neurosciences de la Timone, UMR 7289, CNRS, Aix Marseille University, 13005 Marseille, France
- Faculty of Medicine, Aix-Marseille University, 13005 Marseille, France
| | - Philippe Auby
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Philippe Robert
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Julie Rolling
- Regional Center for Psychotraumatism Great East, Strasbourg University Hospital, 67000 Strasbourg, France
- Department of Child and Adolescent Psychiatry, Strasbourg University Hospitals, 67000 Strasbourg, France
- CNRS UPR3212-Research Team “Light, Circadian Rhythms, Sleep Homeostasis and Neuropsychiatry”, Institute of Cellular and Integrative Neurosciences, 67000 Strasbourg, France
- Excellence Centre for Autism and Neurodevelopmental Disorders STRAS&ND, 67091 Strasbourg, France
- Sleep Disorders Centre & International Research Centre for ChronoSomnology (Circsom), University Hospitals Strasbourg, 67091 Strasbourg, France
| | - Carmen Schröder
- Department of Child and Adolescent Psychiatry, Strasbourg University Hospitals, 67000 Strasbourg, France
- CNRS UPR3212-Research Team “Light, Circadian Rhythms, Sleep Homeostasis and Neuropsychiatry”, Institute of Cellular and Integrative Neurosciences, 67000 Strasbourg, France
- Excellence Centre for Autism and Neurodevelopmental Disorders STRAS&ND, 67091 Strasbourg, France
- Sleep Disorders Centre & International Research Centre for ChronoSomnology (Circsom), University Hospitals Strasbourg, 67091 Strasbourg, France
- Expert Centre for High-Functioning Autism, Fondation FondaMental, 67000 Strasbourg, France
| | - Petri Valo
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Florence Askenazy
- Nice Pediatric Psychotrauma Center (NPPC), Child and Adolescent Psychiatry Department, Hôpitaux Pédiatriques Universitaires Lenval, 06200 Nice, France
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Arnaud Fernandez
- Nice Pediatric Psychotrauma Center (NPPC), Child and Adolescent Psychiatry Department, Hôpitaux Pédiatriques Universitaires Lenval, 06200 Nice, France
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
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Hauber D, Zank S. WWII trauma impacts physical and mental health in the oldest old: results from a German population-based study. Aging Ment Health 2022; 26:834-842. [PMID: 33554646 DOI: 10.1080/13607863.2021.1876637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Epidemiological studies in different traumatised samples indicate an increased risk for numerous physical and mental diseases. It is suspected that this is due to chronic changes in fundamental processes in the immune, nervous, and endocrine systems, which take years to manifest pathologically. Previous studies have considered intervals of a few decades. However, little is known about whether a link between trauma and physical and mental health can be established over very long periods of time and in the oldest old population. MATERIALS AND METHODS A total of 1,299 German citizens aged 80 and above were interviewed about on-going suffering from the effects of traumatic World War II (WWII) events as well as about physical and mental health. Multiple linear and logistic regression models were used to assess the impact of suffering from the effects of traumatic events on general health, several medical conditions, multimorbidity, pain, and depression. RESULTS 43.94% of the oldest old were still suffering from the effects of traumatic events in connection with WWII. Participants who were still suffering from the effects of traumatic events were more likely to be treated for heart failure, blood diseases, bladder problems, back pain, respiratory or lung diseases, and sleep disorders. They also had poorer general health, higher multimorbidity, more pain, and higher depression scores. DISCUSSION Findings suggest that chronic psychological suffering from the effects of traumatic events in early life is associated with impaired physical and mental health even seven decades after the events.
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Affiliation(s)
- Daniel Hauber
- Department of Special Education and Rehabilitation Sciences, University of Cologne, Cologne, Germany
| | - Susanne Zank
- Department of Special Education and Rehabilitation Sciences, University of Cologne, Cologne, Germany.,Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health, University of Cologne, Cologne, Germany
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Gensichen J, Schultz S, Adrion C, Schmidt K, Schauer M, Lindemann D, Unruh N, Kosilek RP, Schneider A, Scherer M, Bergmann A, Heintze C, Joos S, Briegel J, Scherag A, König HH, Brettschneider C, Schulze TG, Mansmann U, Linde K, Lühmann D, Voigt K, Gehrke-Beck S, Koch R, Zwissler B, Schneider G, Gerlach H, Kluge S, Koch T, Walther A, Atmann O, Oltrogge J, Sauer M, Schnurr J, Elbert T. Effect of a combined brief narrative exposure therapy with case management versus treatment as usual in primary care for patients with traumatic stress sequelae following intensive care medicine: study protocol for a multicenter randomized controlled trial (PICTURE). Trials 2018; 19:480. [PMID: 30201053 PMCID: PMC6131807 DOI: 10.1186/s13063-018-2853-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic events like critical illness and intensive care are threats to life and bodily integrity and pose a risk factor for posttraumatic stress disorder (PTSD). PTSD affects the quality of life and morbidity and may increase health-care costs. Limited access to specialist care results in PTSD patients being treated in primary care settings. Narrative exposure therapy (NET) is based on the principles of cognitive behavioral therapy and has shown positive effects when delivered by health-care professionals other than psychologists. The primary aims of the PICTURE trial (from "PTSD after ICU survival") are to investigate the effectiveness and applicability of NET adapted for primary care with case management in adults diagnosed with PTSD after intensive care. METHODS/DESIGN This is an investigator-initiated, multi-center, primary care-based, randomized controlled two-arm parallel group, observer-blinded superiority trial conducted throughout Germany. In total, 340 adult patients with a total score of at least 20 points on the posttraumatic diagnostic scale (PDS-5) 3 months after receiving intensive care treatment will be equally randomized to two groups: NET combined with case management and improved treatment as usual (iTAU). All primary care physicians (PCPs) involved will be instructed in the diagnosis and treatment of PTSD according to current German guidelines. PCPs in the iTAU group will deliver usual care during three consultations. In the experimental group, PCPs will additionally be trained to deliver an adapted version of NET (three sessions) supported by phone-based case management by a medical assistant. At 6 and 12 months after randomization, structured blinded telephone interviews will assess patient-reported outcomes. The primary composite endpoint is the absolute change from baseline at month 6 in PTSD symptom severity measured by the PDS-5 total score, which also incorporates the death of any study patients. Secondary outcomes cover the domains depression, anxiety, disability, health-related quality-of-life, and cost-effectiveness. The principal analysis is by intention to treat. DISCUSSION If the superiority of the experimental intervention over usual care can be demonstrated, the combination of brief NET and case management could be a treatment option to relieve PTSD-related symptoms and to improve primary care after intensive care. TRIAL REGISTRATION ClinicalTrials.gov, NCT03315390 . Registered on 10 October 2017. German Clinical Trials Register, DRKS00012589 . Registered on 17 October 2017.
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Affiliation(s)
- Jochen Gensichen
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Pettenkoferstr. 8a, 80336, Munich, Germany.
| | - Susanne Schultz
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Christine Adrion
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Konrad Schmidt
- Institute of General Practice of the Charité, Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany.,Institute of General Practice and Family Medicine, Jena University Hospital, Bachstr. 18, 07743, Jena, Germany
| | - Maggie Schauer
- Clinical Psychology, University of Konstanz, 78457, Konstanz, Germany
| | - Daniela Lindemann
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Natalia Unruh
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Robert P Kosilek
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Antonius Schneider
- Institute of General Practice, Technical University of Munich, Klinikum rechts der Isar, Orleansstr. 47, 81667, Munich, Germany
| | - Martin Scherer
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Haus West 37, Martinistr. 52, 20246, Hamburg, Germany
| | - Antje Bergmann
- Department of General Practice/Clinic of General Medicine - Medical clinic III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Christoph Heintze
- Institute of General Practice of the Charité, Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Stefanie Joos
- Institute for General Practice and Interprofessional Health Care, University Clinic Tübingen, Osianderstr. 5, 72076, Tübingen, Germany
| | - Josef Briegel
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Andre Scherag
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Bachstr. 18, 07743, Jena, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian Brettschneider
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Thomas G Schulze
- Institute of Psychiatric Phenomics and Genomics, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Klaus Linde
- Institute of General Practice, Technical University of Munich, Klinikum rechts der Isar, Orleansstr. 47, 81667, Munich, Germany
| | - Dagmar Lühmann
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Haus West 37, Martinistr. 52, 20246, Hamburg, Germany
| | - Karen Voigt
- Department of General Practice/Clinic of General Medicine - Medical clinic III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Sabine Gehrke-Beck
- Institute of General Practice of the Charité, Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Roland Koch
- Institute for General Practice and Interprofessional Health Care, University Clinic Tübingen, Osianderstr. 5, 72076, Tübingen, Germany
| | - Bernhard Zwissler
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Gerhard Schneider
- Clinic for Anesthesiology, Technical University of Munich, Klinikum rechts der Isar, Orleansstr. 47, 81667, Munich, Germany
| | - Herwig Gerlach
- Clinic for Anesthesiology, Operative Intensive Care and Pain Management, Vivantes Klinikum Neukölln, Rudower Str. 49, 12351, Berlin, Germany
| | - Stefan Kluge
- Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Thea Koch
- Clinic of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Andreas Walther
- Clinic for Anesthesiology and Operative Intensive Care, Klinikum Stuttgart - Katharinenhospital, Kriegsbergerstr. 60, 70174, Stuttgart, Germany
| | - Oxana Atmann
- Institute of General Practice, Technical University of Munich, Klinikum rechts der Isar, Orleansstr. 47, 81667, Munich, Germany
| | - Jan Oltrogge
- Department of General Practice / Primary Care, University Medical Center Hamburg-Eppendorf, Haus West 37, Martinistr. 52, 20246, Hamburg, Germany
| | - Maik Sauer
- Department of General Practice/Clinic of General Medicine - Medical clinic III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Julia Schnurr
- Institute for General Practice and Interprofessional Health Care, University Clinic Tübingen, Osianderstr. 5, 72076, Tübingen, Germany
| | - Thomas Elbert
- Clinical Psychology, University of Konstanz, 78457, Konstanz, Germany
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