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Haim-Nachum S, Kube T, Rozenkrantz L, Lazarov A, Levy-Gigi E, Michael T, Neria Y, Sopp MR. Does disconfirmatory evidence shape safety-and danger-related beliefs of trauma-exposed individuals? Eur J Psychotraumatol 2024; 15:2335788. [PMID: 38626065 PMCID: PMC11022916 DOI: 10.1080/20008066.2024.2335788] [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: 11/24/2023] [Accepted: 03/11/2024] [Indexed: 04/18/2024] Open
Abstract
Recent accounts of predictive processing in posttraumatic stress disorder (PTSD) suggest that trauma-exposed individuals struggle to update trauma-related hypotheses predicting danger, which may be involved in the etiology and maintenance of this disorder. Initial research supports this account, documenting an association between trauma-exposure, impaired expectation updating, and PTSD symptoms. Yet, no study to date has examined biased belief updating in PTSD using a scenario-based approach.Objective: Here, we examined the predictive processing account among trauma-exposed and non-trauma-exposed individuals using a modified Trauma-Related version of the Bias Against Disconfirmatory Evidence task.Method: The task presents both danger-and safety-related scenarios highly relevant for trauma-exposed individuals. For each scenario, participants viewed several explanations and rated their plausibility. Their ability to update their initial interpretation following new-contradictory information was assessed.Results: Preregistered analyses did not reveal any significant findings. Based on indications that our sample may not have been sufficiently powered, we conducted exploratory analyses in an extended sample of participants. These analyses yielded a significant association between reduced belief updating and PTSD symptoms which was evident for disconfirming both safety and danger scenarios. However, the effect sizes we found were in the small-to-medium range.Conclusion: Although preliminary, our current findings support initial evidence that individuals with higher PTSD symptoms show a higher resistance to update their beliefs upon new disconfirmatory evidence. Our results should be interpreted cautiously in light of the extended sample and the limitations of the current study.
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Affiliation(s)
- Shilat Haim-Nachum
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Tobias Kube
- Department of Clinical Psychology and Psychotherapy, RPTU University of Kaiserslautern-Landau, Landau, Germany
| | | | - Amit Lazarov
- School of Psychological Sciences, Tel-Aviv University, Tel Aviv, Israel
| | - Einat Levy-Gigi
- Faculty of Education and the Brain Science Center, Bar-Ilan University, Ramat-Gan, Israel
| | - Tanja Michael
- Division of Clinical Psychology and Psychotherapy, Saarland University, Saarbrücken, Germany
| | - Yuval Neria
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
- Department of Epidemiology, Columbia University Irving Medical Center, New York, NY, USA
| | - M. Roxanne Sopp
- Division of Clinical Psychology and Psychotherapy, Saarland University, Saarbrücken, Germany
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The relationship between multiple traumatic events and the severity of posttraumatic stress disorder symptoms – evidence for a cognitive link. Eur J Psychotraumatol 2023; 14:2165025. [PMID: 37052097 PMCID: PMC9879173 DOI: 10.1080/20008066.2023.2165025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background: Previous research has shown that multiple traumatic experiences cumulatively increase the risk for the development of severe symptoms of posttraumatic stress disorder (PTSD). Yet, little is known about the specific psychological mechanism through which this increased risk comes about.Objective: In the present study, we examined a possible cognitive link between multiple traumatic events and PTSD symptom severity through dysfunctional cognitions and expectations.Methods: A sample of patients with a diagnosed PTSD (N = 70; MAge = 42.06; 82% female) and high symptom burden (IES-R M = 79.24) was examined. On average, patients had experienced 5.31 different traumatic events. In a structural equation model, we tested the hypothesis that the relationship between multiple traumatic experiences and PTSD symptom severity is mediated through dysfunctional general cognitions and dysfunctional situation-specific expectations. General trauma-related cognitions were assessed with the Posttraumatic Cognition Inventory (PTCI) and trauma-related situational expectations were assessed with the Posttraumatic Expectations Scale (PTES).Results: The direct effect of the number of traumatic events on PTSD symptom severity was non-significant. Instead, as hypothesised, there was evidence for a significant indirect effect via dysfunctional general cognitions and situation-specific expectations.Conclusions: The current results further specify the cognitive model of PTSD by indicating that the relationship between the number of traumatic events and PTSD symptom severity is mediated through dysfunctional cognitions and expectations. These findings emphasise the importance of focused cognitive treatment approaches that seek to modify dysfunctional cognitions and expectations in people with multiple traumatic experiences.
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Herzog P, Kaiser T, Rief W, Brakemeier EL, Kube T. Assessing Dysfunctional Expectations in Posttraumatic Stress Disorder: Development and Validation of the Posttraumatic Expectations Scale (PTES). Assessment 2023; 30:1285-1301. [PMID: 35549727 DOI: 10.1177/10731911221089038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Dysfunctional expectations are a particularly important subset of cognitions that influence the development and maintenance of various mental disorders. This study aimed to develop and validate a scale to assess dysfunctional expectations in posttraumatic stress disorder (PTSD), the "Posttraumatic Expectations Scale" (PTES). In a cross-sectional study, 70 PTSD patients completed the PTES, the Posttraumatic Cognitions Inventory (PTCI), as well as measures of the severity of symptoms of PTSD and depression. The results show that the PTES has excellent internal consistency and correlates significantly with the PTCI and PTSD symptom severity. A regression analysis revealed that the PTES explained variance of PTSD symptom severity above the PTCI, supporting the incremental validity of the PTES. While the original version of the PTES comprises 81 items, short scales were constructed using the BISCUIT (best items scales that are cross-validated, unit-weighted, informative and transparent) method. The current findings provide preliminary psychometric evidence suggesting that the PTES is an internally consistent and valid novel self-report measure in patients with PTSD. However, conclusions about the psychometric properties of the PTES are limited because of the absence of criterion-related validity, factor structure evidence, variability over time/response to intervention, and test-retest reliability. Future research should use the PTES in large-scale longitudinal studies to address these aspects to further validate the scale.
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Affiliation(s)
- Philipp Herzog
- Philipps-University Marburg, Germany
- University of Greifswald, Germany
- University of Koblenz-Landau, Germany
| | | | | | | | - Tobias Kube
- Philipps-University Marburg, Germany
- University of Koblenz-Landau, Germany
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Matos L, Água J, Sinval J, Park CL, Indart MJ, Leal I. Assessing meaning violations in Syrian refugees: A mixed-methods cross-cultural adaptation of the Global Meaning Violations Scale-ArabV. J Trauma Stress 2022; 35:1201-1214. [PMID: 35362149 DOI: 10.1002/jts.22819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 11/05/2022]
Abstract
Refugees are disproportionately affected by extreme traumatic events that can violate core beliefs and life goals (i.e., global meaning) and cause significant distress. This mixed-methods study used an exploratory sequential design to assess meaning violations in a sample of Syrian refugees living in Portugal. For this purpose, we cross-culturally adapted the Global Meaning Violations Scale (GMVS) for use with Arabic-speaking refugees. In total, 43 war-affected Syrian adults participated in the two-phase study. Participants completed measures of trauma and narrated violations as they filled out the newly adapted GMVS-ArabV. GMVS-ArabV validity evidence based on response processes was investigated through Phase 1 focus groups (FGs; n = 2), whereas data from Phase 2 cognitive interviews (n = 38) were used to preliminarily explore the measure's internal structure through descriptive statistics as well as culture- and trauma-informed content evidence through thematic analysis. The results suggested highest goal (M = 3.51, SD = 1.46) and lowest belief (M = 2.38, SD = 1.59) violations of educational goals and religious beliefs, respectively. Themes related to stressors, item formulation, response scale, and the global meaning construct suggested that (a) beliefs and goals can be differentially violated by different stressors; (b) much like war trauma, including torture, daily stressors can additionally shatter pretrauma global meaning; and (c) refugees reappraise meaning and suffer violations anew throughout their migration journeys. The GMVS-ArabV offers a promising tool for exploring shattered cognitions in refugees and informs evidence-based approaches to trauma recovery and psychological adjustment in postmigration settings (the Arabic abstract and keywords are available in the Supplementary Materials).
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Affiliation(s)
- Lisa Matos
- William James Center for Research, ISPA-Instituto Universitário, Lisbon, Portugal
| | - Joana Água
- William James Center for Research, ISPA-Instituto Universitário, Lisbon, Portugal
| | - Jorge Sinval
- William James Center for Research, ISPA-Instituto Universitário, Lisbon, Portugal.,Business Research Unit, Instituto Universitário de Lisboa (ISCTE-IUL), Lisbon, Portugal
| | - Crystal L Park
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Monica J Indart
- Graduate School of Applied and Professional Psychology, Rutgers University, New Brunswick, New Jersey, USA
| | - Isabel Leal
- William James Center for Research, ISPA-Instituto Universitário, Lisbon, Portugal
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Putica A, Felmingham KL, Garrido MI, O'Donnell ML, Van Dam NT. A predictive coding account of value-based learning in PTSD: Implications for precision treatments. Neurosci Biobehav Rev 2022; 138:104704. [PMID: 35609683 DOI: 10.1016/j.neubiorev.2022.104704] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 04/05/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
While there are a number of recommended first-line interventions for posttraumatic stress disorder (PTSD), treatment efficacy has been less than ideal. Generally, PTSD treatment models explain symptom manifestation via associative learning, treating the individual as a passive organism - acted upon - rather than self as agent. At their core, predictive coding (PC) models introduce the fundamental role of self-conceptualisation and hierarchical processing of one's sensory context in safety learning. This theoretical article outlines how predictive coding models of emotion offer a parsimonious framework to explain PTSD treatment response within a value-based decision-making framework. Our model integrates the predictive coding elements of the perceived: self, world and self-in the world and how they impact upon one or more discrete stages of value-based decision-making: (1) mental representation; (2) emotional valuation; (3) action selection and (4) outcome valuation. We discuss treatment and research implications stemming from our hypotheses.
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Affiliation(s)
- Andrea Putica
- Phoenix Australia Centre for Post-traumatic Mental Health, Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia.
| | - Kim L Felmingham
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Marta I Garrido
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Meaghan L O'Donnell
- Phoenix Australia Centre for Post-traumatic Mental Health, Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Nicholas T Van Dam
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, VIC, Australia
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Nickerson A, Byrow Y, O'Donnell M, Bryant RA, Mau V, McMahon T, Benson G, Liddell BJ. Cognitive mechanisms underlying the association between trauma exposure, mental health and social engagement in refugees: A longitudinal investigation. J Affect Disord 2022; 307:20-28. [PMID: 35341811 DOI: 10.1016/j.jad.2022.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/23/2022] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUNDS Refugees and asylum-seekers are at heightened risk for developing psychological symptoms following exposure to trauma and displacement. Despite this, relatively little is known about the cognitive mechanisms that underlie common mental disorders in refugees. METHODS In this study, we investigated the associations between self-efficacy, beliefs about others (relating to benevolence and trust) and psychological and social outcomes in 1079 refugees from Arabic, Farsi, Tamil or English-speaking backgrounds who were residing in Australia. Participants completed an online survey assessing exposure to potentially traumatic events (PTEs), at baseline (T1), and self-efficacy, beliefs about others, PTSD symptoms, depression symptoms, anger and social engagement at baseline (T1) and six months later (T2). RESULTS A path analysis revealed that greater PTE exposure was associated with lower self-efficacy and lower positive beliefs about others at T1. Self-efficacy at T1 was negatively associated with depression and anger at T2, while positive beliefs about others at T1 were positively associated with social engagement and greater depression symptoms at T2. LIMITATIONS Limitations of this study included the fact that the study sample was not necessarily representative of the broader refugee population, and in particular may have overrepresented those with higher education levels. CONCLUSIONS Findings point to the critical role that cognitive variables play in the maintenance of psychological symptoms in forcibly displaced persons, and highlight the importance of targeting these in psychological interventions to promote positive posttraumatic mental health.
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Affiliation(s)
- Angela Nickerson
- School of Psychology, University of New South Wales, Sydney, NSW, Australia.
| | - Yulisha Byrow
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Meaghan O'Donnell
- Phoenix Australia, University of Melbourne, Parkville, VIC, Australia
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Vicki Mau
- Australian Red Cross, North Melbourne, VIC, Australia
| | - Tadgh McMahon
- Settlement Services International, Ashfield, NSW, Australia; Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Greg Benson
- Settlement Services International, Ashfield, NSW, Australia
| | - Belinda J Liddell
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
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Kube T, Berg M, Kleim B, Herzog P. Rethinking post-traumatic stress disorder - A predictive processing perspective. Neurosci Biobehav Rev 2020; 113:448-460. [PMID: 32315695 DOI: 10.1016/j.neubiorev.2020.04.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 12/15/2022]
Abstract
Predictive processing has become a popular framework in neuroscience and computational psychiatry, where it has provided a new understanding of various mental disorders. Here, we apply the predictive processing account to post-traumatic stress disorder (PTSD). We argue that the experience of a traumatic event in Bayesian terms can be understood as a perceptual hypothesis that is subsequently given a very high a-priori likelihood due to its (life-) threatening significance; thus, this hypothesis is re-selected although it does not fit the actual sensory input. Based on this account, we re-conceptualise the symptom clusters of PTSD through the lens of a predictive processing model. We particularly focus on re-experiencing symptoms as the hallmark symptoms of PTSD, and discuss the occurrence of flashbacks in terms of perceptual and interoceptive inference. This account provides not only a new understanding of the clinical profile of PTSD, but also a unifying framework for the corresponding pathologies at the neurobiological level. Finally, we derive directions for future research and discuss implications for psychological and pharmacological interventions.
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Affiliation(s)
- Tobias Kube
- Harvard Medical School, Program in Placebo Studies, Beth Israel Deaconess Medical Center, Brookline Avenue 330, Boston, MA, 02115, USA; University of Koblenz-Landau, Pain and Psychotherapy Research Lab, Ostbahnstr. 10, 76829 Landau, Germany.
| | - Max Berg
- Philipps-University of Marburg, Department of Psychology, Division of Clinical Psychology and Psychological Treatment Gutenbergstraße 18, D-35032, Marburg, Germany
| | - Birgit Kleim
- University of Zurich, Department of Psychology, Binzmühlestrasse 14, Box 8, CH-8050, Zurich, Switzerland; Psychiatric University Hospital (PUK), Lenggstrasse 31, CH-8032, Zurich, Switzerland
| | - Philipp Herzog
- Philipps-University of Marburg, Department of Psychology, Division of Clinical Psychology and Psychological Treatment Gutenbergstraße 18, D-35032, Marburg, Germany; University of Greifswald, Department of Psychology, Clinical Psychology and Psychotherapy, Franz-Mehring-Straße 47, D-17489, Greifswald, Germany; Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, D-23562, Lübeck, Germany
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Contextualizing Cognitions: the Relation Between Negative Post-traumatic Cognitions and Post-traumatic Stress Among Palestinian Refugees. Int J Cogn Ther 2020. [DOI: 10.1007/s41811-020-00066-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractNegative post-traumatic cognitions (PTC) are a relevant factor in the development, persistence, and treatment of post-traumatic stress disorder (PTSD). Palestinian refugees live under challenging circumstances and have negative future prospects, so negative cognitions might be expected to prevail. It is uncertain whether findings on the relation between PTC and PTSD in other (non-refugee) populations can be generalized to the Palestinian refugee context. The first objective was to examine the degree to which endorsement of PTC in this sample differed from the endorsement observed in other samples. The second objective was to investigate whether PTC explain variance in PTSD symptomatology and are predictive of PTSD diagnostic status. In Palestinian refugees (N = 85, 51.8% female), PTSD symptoms and negative cognitions were assessed. One sample t tests and multiple logistic regression analyses were performed. Total PTC scores were significantly higher in the Palestinian sample than in reference samples. Negative cognitions explained significant variance in PTSD symptoms and probable diagnostic status. Findings support the relevance of PTC for PTSD symptoms and diagnosis in a Palestinian refugee sample, in line with the cognitive model for PTSD. This is especially relevant for researchers and clinicians working with refugees in conflict areas.
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Woud ML, Kleim B, Cwik JC. Editorial for the Special Issue on Negative Appraisals in Trauma: Current Status and Future Directions for Research. COGNITIVE THERAPY AND RESEARCH 2019. [DOI: 10.1007/s10608-018-09992-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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10
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A Review of the Role of Negative Cognitions About Oneself, Others, and the World in the Treatment of PTSD. COGNITIVE THERAPY AND RESEARCH 2018. [DOI: 10.1007/s10608-018-9938-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Nickerson A, Hoffman J, Schick M, Schnyder U, Bryant RA, Morina N. A Longitudinal Investigation of Moral Injury Appraisals Amongst Treatment-Seeking Refugees. Front Psychiatry 2018; 9:667. [PMID: 30618859 PMCID: PMC6305427 DOI: 10.3389/fpsyt.2018.00667] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 11/19/2018] [Indexed: 12/03/2022] Open
Abstract
There is currently an unprecedented number of forcibly displaced people worldwide. Understanding psychological mechanisms that contribute to the mental health of refugees and asylum-seekers is important for informing the development of effective interventions for these populations. Moral injury appraisals represent an important potential cognitive mechanism that may contribute to psychological symptoms following exposure to persecution, war, and displacement. In the current study, we investigated the longitudinal association between moral injury appraisals related to one's own perceived transgressions (moral injury-self), others' perceived transgressions (moral injury-other), and PTSD and depression symptoms. Participants in this study were 134 refugees receiving treatment at two outpatient clinics in Switzerland who completed survey measures investigating these concepts. Of these, 71 were followed up 2 to 4 years later. Path analyses revealed that greater depression symptoms were associated with subsequent increases in moral injury-self appraisals (β = 0.25, SE = 0.08, 95% CI [0.11, 0.43], p = 0.002). In contrast, greater moral injury-self appraisals were associated with subsequent decreases in PTSD symptoms (β = -0.23, SE = 0.11, 95% CI = [-0.44, -0.31], p = 0.035). Findings suggest that different types of moral injury appraisals may be associated with differential psychological outcomes. These results have important potential implications for policy and treatment of refugees and asylum-seekers, highlighting the importance of targeting cognitive factors in the maintenance and treatment of psychological distress, and considering the post-migration context when working with refugees.
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Affiliation(s)
- Angela Nickerson
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Joel Hoffman
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Matthis Schick
- Department of Consultation-Liason Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ulrich Schnyder
- Department of Consultation-Liason Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Naser Morina
- Department of Consultation-Liason Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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