1
|
Burback L, Yap S, Purdon SE, Abba-Aji A, O’Shea K, Brémault-Phillips S, Greenshaw AJ, Winkler O. Randomized controlled trial investigating web-based, therapist delivered eye movement desensitization and reprocessing for adults with suicidal ideation. Front Psychiatry 2024; 15:1361086. [PMID: 38435978 PMCID: PMC10904458 DOI: 10.3389/fpsyt.2024.1361086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction Promising preliminary evidence suggests that EMDR may reduce suicidal ideation (SI) when used to treat Major Depressive Disorder, Posttraumatic Stress Disorder, and trauma symptoms in the context of acute mental health crises. EMDR has never been tested specifically for treating SI, and there is a lack of data regarding the safety and effectiveness of web-based, therapist-delivered EMDR in populations with known SI. The primary objective of this study was to investigate the impact of web-based, therapist-delivered EMDR, targeting experiences associated with suicidal thinking. Secondary objectives included examining the effect of EMDR treatment on symptoms of depression, anxiety, posttraumatic stress, emotional dysregulation, and dissociation, as well as safety and attrition. Methods This randomized control trial (ClinicalTrials.gov ID number: NCT04181047) assigned adult outpatients reporting SI to either a web-based EMDR intervention or a treatment as usual (TAU) group. TAU included primary and mental health services available within the Canadian public health system. Participants in the EMDR group received up to 12 web-based EMDR desensitization sessions, delivered twice weekly during the COVID-19 pandemic (2021-2023). The Health Research Ethics Board at the University of Alberta approved the protocol prior to initiation of data collection for this study (protocol ID number: Pro00090989). Results Forty-two adult outpatients received either EMDR (n=20) or TAU (n=22). Participants reported a high prevalence of early onset and chronic SI, and there was a high rate of psychiatric comorbidity. In the EMDR group, median SI, depression, anxiety, and posttraumatic symptom scale scores decreased from baseline to the four month follow-up. In the TAU group, only the median SI and posttraumatic symptom scale scores decreased from baseline to four month follow up. Although sample size precludes direct comparison, there were numerically fewer adverse events and fewer dropouts in the EMDR group relative to the TAU group. Conclusion Study results provide promising preliminary evidence that web-based EMDR may be a viable delivery approach to address SI. In this complex population, a short treatment course was associated with reductions of SI and other symptoms across multiple diagnostic categories. Further investigation is warranted to verify and extend these results. Clinical Trial Registration https://clinicaltrials.gov/study/NCT04181047?id=NCT04181047&rank=1, identifier NCT04181047.
Collapse
Affiliation(s)
- Lisa Burback
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
| | - Sidney Yap
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Scot E. Purdon
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adam Abba-Aji
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
| | - Katie O’Shea
- Eye Movement Desensitization and Reprocessing International Association, Austin, TX, United States
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andrew J. Greenshaw
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Olga Winkler
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Hospital Edmonton, Edmonton, AB, Canada
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Edmonton, AB, Canada
| |
Collapse
|
2
|
Provencher J, Cernik R, Marin MF. Impact of Stress and Exercise on Fear Extinction. Curr Top Behav Neurosci 2023; 64:157-178. [PMID: 37498495 DOI: 10.1007/7854_2023_432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
This chapter reviews the literature on the impact of stress and exercise on fear extinction. Given that key brain regions of the fear circuitry (e.g., hippocampus, amygdala and frontal cortex) can be modulated by stress hormones, it is important to investigate how stress influences this process. Laboratory-based studies performed in healthy adults have yielded mixed results, which are most likely attributable to various methodological factors. Among these factors, inter-individual differences modulating the stress response and timing of stressor administration with respect to the task may contribute to this heterogeneity. Given that fear is a core manifestation of various psychopathologies and that exposure-based therapy relies on fear extinction principles, several studies have attempted to assess the role of stress hormones on exposure-based therapy in patients suffering from post-traumatic stress disorder or anxiety disorders. These studies tend to suggest a beneficial impact of stress hormones (through either natural endogenous variations or synthetic administration) on exposure-based therapy as assessed mostly by subjective fear measures. Similar to stress, exercise can have an impact on many physiological and biological systems in humans. Of note, exercise modulates biomarkers such as brain-derived neurotrophic factor (BDNF) and anandamide (EAE) that act on brain regions implicated in the fear circuitry, supporting the importance of studying the impact of exercise on fear extinction. Overall, the results converge and indicate that fear extinction (tested in the laboratory or via exposure-based therapy in clinical populations) can be enhanced with exercise. Further research is needed to understand the mechanisms by which stress and exercise modulate fear learning and extinction processes, as well as to maximize the applicability to clinical contexts.
Collapse
Affiliation(s)
- Jessie Provencher
- Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada
- Research Centre of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
| | - Rebecca Cernik
- Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada
- Research Centre of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
| | - Marie-France Marin
- Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada.
- Research Centre of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.
| |
Collapse
|
3
|
Wiebe A, Kannen K, Selaskowski B, Mehren A, Thöne AK, Pramme L, Blumenthal N, Li M, Asché L, Jonas S, Bey K, Schulze M, Steffens M, Pensel MC, Guth M, Rohlfsen F, Ekhlas M, Lügering H, Fileccia H, Pakos J, Lux S, Philipsen A, Braun N. Virtual reality in the diagnostic and therapy for mental disorders: A systematic review. Clin Psychol Rev 2022; 98:102213. [PMID: 36356351 DOI: 10.1016/j.cpr.2022.102213] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 08/21/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders. OBJECTIVE To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders. DATA SOURCE Systematic literature searches via PubMed (last literature update: 9th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders. ELIGIBILITY CRITERIA To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology. STUDY EVALUATION For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria. RESULTS Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder. CONCLUSION While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application. REVIEW REGISTRATION PROSPERO register CRD42020188436. FUNDING The review was funded by budgets from the University of Bonn. No third party funding was involved.
Collapse
Affiliation(s)
- Annika Wiebe
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Kyra Kannen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Benjamin Selaskowski
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Aylin Mehren
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Ann-Kathrin Thöne
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa Pramme
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Nike Blumenthal
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mengtong Li
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Laura Asché
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Stephan Jonas
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Katharina Bey
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Marcel Schulze
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Maria Steffens
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Max Christian Pensel
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Matthias Guth
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Felicia Rohlfsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mogda Ekhlas
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Lügering
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Fileccia
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Julian Pakos
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Niclas Braun
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany.
| |
Collapse
|
4
|
Pace-Schott EF, Seo J, Bottary R. The influence of sleep on fear extinction in trauma-related disorders. Neurobiol Stress 2022; 22:100500. [PMID: 36545012 PMCID: PMC9761387 DOI: 10.1016/j.ynstr.2022.100500] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/21/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
In Posttraumatic Stress Disorder (PTSD), fear and anxiety become dysregulated following psychologically traumatic events. Regulation of fear and anxiety involves both high-level cognitive processes such as cognitive reattribution and low-level, partially automatic memory processes such as fear extinction, safety learning and habituation. These latter processes are believed to be deficient in PTSD. While insomnia and nightmares are characteristic symptoms of existing PTSD, abundant recent evidence suggests that sleep disruption prior to and acute sleep disturbance following traumatic events both can predispose an individual to develop PTSD. Sleep promotes consolidation in multiple memory systems and is believed to also do so for low-level emotion-regulatory memory processes. Consequently sleep disruption may contribute to the etiology of PTSD by interfering with consolidation in low-level emotion-regulatory memory systems. During the first weeks following a traumatic event, when in the course of everyday life resilient individuals begin to acquire and consolidate these low-level emotion-regulatory memories, those who will develop PTSD symptoms may fail to do so. This deficit may, in part, result from alterations of sleep that interfere with their consolidation, such as REM fragmentation, that have also been found to presage later PTSD symptoms. Here, sleep disruption in PTSD as well as fear extinction, safety learning and habituation and their known alterations in PTSD are first briefly reviewed. Then neural processes that occur during the early post-trauma period that might impede low-level emotion regulatory processes through alterations of sleep quality and physiology will be considered. Lastly, recent neuroimaging evidence from a fear conditioning and extinction paradigm in patient groups and their controls will be considered along with one possible neural process that may contribute to a vulnerability to PTSD following trauma.
Collapse
Affiliation(s)
- Edward F. Pace-Schott
- Massachusetts General Hospital, Department of Psychiatry, Charlestown, MA, USA
- Harvard Medical School, Department of Psychiatry, Charlestown, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
- Corresponding author. Harvard Medical School, Massachusetts General Hospital - East, CNY 149 13th Street, Charlestown, MA, 02129, USA.
| | - Jeehye Seo
- Massachusetts General Hospital, Department of Psychiatry, Charlestown, MA, USA
- Harvard Medical School, Department of Psychiatry, Charlestown, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
- Korea University, Department of Brain & Cognitive Engineering, Seongbuk-gu, Seoul, South Korea
| | - Ryan Bottary
- Massachusetts General Hospital, Department of Psychiatry, Charlestown, MA, USA
- Harvard Medical School, Department of Psychiatry, Charlestown, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, MA, USA
| |
Collapse
|
5
|
Biological markers in clinical psychological research - A systematic framework applied to HPA axis regulation in PTSD. COMPREHENSIVE PSYCHONEUROENDOCRINOLOGY 2022; 11:100148. [PMID: 35967927 PMCID: PMC9363642 DOI: 10.1016/j.cpnec.2022.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/17/2022] [Accepted: 06/07/2022] [Indexed: 11/21/2022] Open
Abstract
Biological markers, particularly endocrine measurements, are increasingly being integrated into clinical psychological research. We introduce a systematic framework that classifies different functions of such biomarkers. The framework distinguishes between diagnostic biomarkers which add a biological perspective to conventional clinical assessments, prognostic biomarkers that inform about an individual’s risk to develop or maintain a mental health disorder, and intervention-related biomarkers. Regarding interventions, including prevention and treatment, it further distinguishes between prescriptive biomarkers which predict an individual’s response to an intervention, outcome biomarkers which evaluate intervention-related changes on a biological level and indicators of change mechanisms. We demonstrate how to apply the framework by exemplarily classifying and describing previously published systematic reviews and primary empirical studies on endogenous, peripheral cortisol concentrations as a biomarker for posttraumatic stress disorder (PTSD). The evidence on cortisol’s diagnostic and prognostic value is heterogeneous and still sparse regarding parameters based on multiple cortisol measurements, such as the cortisol awakening response. With regard to interventions, most research focused on trauma-focused psychotherapy and cortisol reactivity to trauma reminders. This field of research appears to be growing and very promising due to its potential to optimize PTSD-related interventions. The proposed framework can help in gaining a systematic overview of existing research. It can assist in structuring, comparing, summarizing and evaluating empirical studies, and in identifying research gaps. Iagnostic biomarkers can inform about biological alterations in mental disorders. Prognostic biomarkers can help to predict the development of a mental disorder. Biomarkers can indicate the outcome, differential effects, or mechanisms of change of clinical psychological interventions.
Collapse
|
6
|
Martín-González E, Olmedo-Córdoba M, Prados-Pardo Á, Cruz-Garzón DJ, Flores P, Mora S, Moreno M. Socioemotional deficit and HPA axis time response in high compulsive rats selected by schedule-induced polydipsia. Horm Behav 2022; 142:105170. [PMID: 35367739 DOI: 10.1016/j.yhbeh.2022.105170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 01/30/2023]
Abstract
Compulsivity is a failure to stop an ongoing behavior that has become inappropriate to the situation and is recognized as a transdiagnostic trait present in different neuropsychiatric disorders. The implication of motivation and emotion, as well as the stress response in compulsive population has not been fully understood. We assessed the motivation to reward and cues, the emotional response in different contexts and the hypothalamic-pituitary-adrenal (HPA) axis response in rats selected by a preclinical model of compulsive behavior. Firstly, high (HD) or low (LD) drinkers were selected according to their drinking behavior on schedule-induced polydipsia (SIP). Then, we assessed motivation by the propensity to attribute incentive salience to rewards on Pavlovian Conditioned Approach (PavCA) and motivation to gain reward on Progressive Ratio Schedule of Reinforcement (PRSR). Emotion was measured by Social Dominance on the Tube Test (SDTT) and emotional memory on Passive Avoidance (PA). Plasma corticosterone (CORT) levels in response to SIP were assessed. HD rats showed a socioemotional deficit by fewer victories on the SDTT, and an increased latency to enter the dark compartment on the PA. No differences were found between groups regarding to motivational assessment. Moreover, HD rats revealed a blunted time response in the increase of CORT levels at 45 min after SIP compared to LD rats. The findings show that the compulsive phenotype of HD rats exhibit less social dominance, more resistance to extinction and a differential CORT time response to SIP. These findings may contribute to highlight the relevance of assessing socioemotional behaviors and stress response for a better characterization of the vulnerability to compulsive spectrum disorders.
Collapse
Affiliation(s)
- Elena Martín-González
- Department of Psychology and Health Research Center (CEINSA), University of Almería, Spain
| | - Manuela Olmedo-Córdoba
- Department of Psychology and Health Research Center (CEINSA), University of Almería, Spain
| | - Ángeles Prados-Pardo
- Department of Psychology and Health Research Center (CEINSA), University of Almería, Spain
| | - Daniel J Cruz-Garzón
- Department of Psychology and Health Research Center (CEINSA), University of Almería, Spain
| | - Pilar Flores
- Department of Psychology and Health Research Center (CEINSA), University of Almería, Spain
| | - Santiago Mora
- Department of Psychology and Health Research Center (CEINSA), University of Almería, Spain
| | - Margarita Moreno
- Department of Psychology and Health Research Center (CEINSA), University of Almería, Spain.
| |
Collapse
|
7
|
Hummel KV, Schellong J, Trautmann S, Kummer S, Hürrig S, Klose M, Croy I, Weidner K, Kirschbaum C, Steudte-Schmiedgen S. The predictive role of hair cortisol concentrations for treatment outcome in PTSD inpatients. Psychoneuroendocrinology 2021; 131:105326. [PMID: 34182250 DOI: 10.1016/j.psyneuen.2021.105326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/30/2021] [Accepted: 06/11/2021] [Indexed: 11/18/2022]
Abstract
Psychological treatments of posttraumatic stress disorder (PTSD) are associated with non-response rates of up to 50%. This fact highlights the need to identify characteristics of poorer treatment outcome. Among others, previous evidence focused on the role of dysfunctional cortisol secretion which has been related to the development, maintenance and treatment of PTSD. Particularly, promising evidence stems from research using hair cortisol analysis which allows for a reliable assessment of cortisol secretion over several months. Another variable that has been linked to both HCC and non-response to treatment is childhood maltreatment (CM). In order to examine the predictive value of pre-treatment hair cortisol concentrations (HCC), treatment-related changes in HCC as well as CM for changes in PTSD symptomatology, we set up a prospective study in which we followed 52 female PTSD patients over the course of a trauma-focused inpatient treatment. Specifically, 3-month integrated HCC were assessed at treatment entry, at discharge and on average five months later accompanied by assessments of PTSD, overall and depressive symptomatology. CM was measured at treatment entry. Self-report indices improved following inpatient treatment. No evidence for pre-treatment HCC to be associated with changes in PTSD symptoms was revealed. However, attenuated pre-treatment HCC predicted less improvement in overall symptomatology from treatment entry to discharge. This effect lost significance after adjusting for baseline dissociative symptoms. Neither changes in HCC nor CM were predictive of treatment response. Pre-treatment cross-sectional analyses revealed no association between HCC and CM. The current hair cortisol data provided little evidence for a predictive role of lower long-term integrated cortisol secretion for poorer inpatient treatment outcome. If corroborated by further research in larger PTSD samples with much more methodological rigor, these data might be a valuable basis for future tailored research projects.
Collapse
Affiliation(s)
- Katrin V Hummel
- Faculty of Psychology, Technische Universität Dresden, Germany
| | - Julia Schellong
- Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Germany
| | | | - Sylvia Kummer
- Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Germany
| | - Sabine Hürrig
- Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Germany
| | - Michael Klose
- Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Germany
| | - Ilona Croy
- Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Germany
| | - Kerstin Weidner
- Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Germany
| | | | - Susann Steudte-Schmiedgen
- Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Germany.
| |
Collapse
|