The aim of the study was to assess the association of hypertension and symptoms of depression and... more The aim of the study was to assess the association of hypertension and symptoms of depression and generalized anxiety in a large cohort of elderly people. Methods: Data were derived from the 8-year follow-up (2008-2010) of the epidemiological ESTHER-cohort study. A total of 3124 randomly chosen participants aged 57-84 were visited at their homes by trained study doctors. General practitioner based diagnosis, self-reported status of hypertension, medication, and blood pressure measurement were considered to define the existence of hypertension. Depression and general anxiety severity were assessed using validated questionnaires. Logistic regression analyses were performed to determine cross-sectional associations between hypertension and clinically significant symptoms of depression (CSD) and generalized anxiety. Well known lifestyle risk factors for hypertension such as obesity were included in multivariate cross-sectional analyses. Results: Hypertension was prevalent in 1659 participants [53.1%; 95% confidence interval (CI) ¼ (51.3; 54.9)]. CSD was detected in 163 participants [5.2%; 95%-CI ¼ (4.4; 6.0)]. Symptoms of generalized anxiety were found in 434 participants [13.9%; 95%-CI ¼ (12.7; 15.1)]. Patients with CSD showed significantly higher odds of being hypertensive [odds ratio (OR) ¼ 1.76; 95%-CI ¼ (1.14; 2.74)]. Participants with symptoms of generalized anxiety were found to have no higher odds for a hypertension diagnosis [OR ¼ 1.1; 95%-CI ¼ (0.85; 1.44)]. Overweight [OR ¼ 1.86; 95%-CI ¼ (1.53; 2.25)] as well as obesity [OR ¼ 3.58; 95%-CI ¼ (2.84; 4.52)] was significantly associated with hypertension. Conclusion: CSD appear to be related to hypertension in elderly adults. No association was found between symptoms of generalized anxiety and hypertension.
This manuscript has been accepted by the editors of Psychosomatic Medicine, but it has not yet be... more This manuscript has been accepted by the editors of Psychosomatic Medicine, but it has not yet been copy edited; information within these pages is therefore subject to change. During the copy-editing and production phases, language usage and any textual errors will be corrected, and pages will be composed into their final format. Please visit the journal's website (www.psychosomaticmedicine.org) to check for a final version of the article. When citing this article, please use the following: Psychosomatic Medicine (in press) and include the article's digital object identifier (DOI).
Background: Functional somatic symptoms and disorders are common and complex phenomena involving ... more Background: Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients' quality of life and healthcare costs. Main body: We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose 'functional somatic disorders' (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrumand also within organ system-specific chapters of a classificationthey should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD). Conclusion: We propose a new classification, 'functional somatic disorder', which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders.
Objective: The mechanisms underlying the perception and experience of persistent physical symptom... more Objective: The mechanisms underlying the perception and experience of persistent physical symptoms are not well understood, and in the models, the specific relevance of peripheral input versus central processing, or of neurobiological versus psychosocial factors in general, is not clear. In this article, we propose a model for this clinical phenomenon that is designed to be coherent with an underlying, relatively new model of the normal brain functions involved in the experience of bodily signals. Methods: Based on a review of recent literature we describe central elements of this model and its clinical implications. Results: In the model the brain is seen as an active predictive processing or inferential device rather than one that is passively waiting for sensory input. A central aspect of the model is the attempt of the brain to minimize prediction errors that result from constant comparisons of predictions and sensory input. Two possibilities exist: adaptation of the generative model underlying the predictions or alteration of the sensory input via autonomic nervous activation (in the case of interoception). Following this model, persistent physical symptoms can be described as "failures of inference" and clinically well known factors like expectation are assigned a role, not "only" in the later amplification of bodily signals, but in the very basis of symptom perception. Conclusions: We discuss therapeutic implications of such a model including new interpretations for established treatments as well as new options like virtual reality techniques combining exteroceptive and interoceptive informations.
ObjectivePrevious research suggests that patients with anorexia nervosa (AN) show an impaired cap... more ObjectivePrevious research suggests that patients with anorexia nervosa (AN) show an impaired capacity to mentalize (reflective functioning, RF). RF is discussed as a possible predictor of outcome in psychotherapeutic processes. The study aimed to explore RF in sessions of patients with AN and its association with outcome and type of treatment.MethodsA post-hoc data analysis of selected cases from a randomized trial on outpatient psychotherapy for AN was conducted. Transcripts from 84 sessions of 28 patients (early phase, middle phase, and end of treatment) were assessed using the In-Session-Reflective-Functioning-Scale [14 cognitive-behavior therapy, enhanced (CBT-E); 14 focal psychodynamic therapy (FPT); 16 with good, 12 with poor outcome after 1 year]. Relations between the level of RF, type of treatment, and outcome were investigated using mixed linear models. Additionally, associations with depressive symptoms, weight gain, and therapeutic alliance were explored.ResultsMean in-...
Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) ar... more Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on question...
BackgroundAnorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortali... more BackgroundAnorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive–behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN.MethodThe analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WT...
Letter to the Editor therapeutic alliance and have learned to deal adaptively with distress. Prev... more Letter to the Editor therapeutic alliance and have learned to deal adaptively with distress. Previous psychotherapy research has demonstrated that emotional processing particularly during mid-treatment predicts favourable treatment outcomes [4]. Our main hypothesis was that greater expression of negative emotions, particularly during midtreatment, is associated with favourable outcomes in AN treatment, independent of the psychotherapeutic approach. Data were obtained from a multicentre randomised controlled trial comparing 40 sessions of manualised focal psychodynamic therapy (FPT) and enhanced cognitive behaviour therapy (CBT-E) against optimised treatment-as-usual in adult outpatients with AN (for more details of the ANTOP study see [5]). Participants were female, ≥ 18 years, and had a DSM-IV diagnosis of full-syndrome/ subthreshold AN (BMI 15.0-18.5). Written informed consent was obtained from each participant. Independent research ethics committees approved the study. Participants were randomised to receive either FPT, CBT-E, or optimised treatment-as-usual. Sessions were recorded and stored as audio files only in the FPT and CBT-E condition. Recordings were not available in 21% of the cases because either the patient or the therapist refused to give informed consent to use the recordings, and in 23% of the cases recordings were either incomplete or of insufficient quality. The analysis is thus based on the data from 89 patients (FPT: 43; CBT-E: 46), i.e., 56% of the original samples, which corresponds to similar studies [6]. These patients did not differ from those excluded regarding BMI, illness duration, eating disorder psychopathology, proportion of restricting subtype, and comorbid disorders at baseline (all p > 0.073). Likewise, FPT and CBT-E participants in this sample did not differ in these variables at baseline, end of treatment, and follow-up (all p > 0.129), except for more common comorbid MDD among CBT-E patients at baseline, χ 2 (1) = 5.169, p = 0.023. However, patients with and without comorbid MDD did not differ regarding emotional expression in any treatment phase (all p > 0.156). FPT comprised 3 treatment phases: sessions 1-15 focused on therapeutic alliance, pro-anorectic behaviour/beliefs, and self-esteem, sessions 16-32 emphasised emotional experiencing, interpersonal relationships, and their association with problematic eating behaviour, and sessions 33-40 focused on transfer to everyday life, anticipation of treatment termination, and parting. CBT-E comprised several modules: motivation, normalisation of nutrition, creating a formulation, and relapse prevention (mandatory), and cognitive restructuring, mood regulation, social skills, shape concern, and self-esteem (optional). BMI (calculated as kilograms/metres squared) at end of treatment and at the 12-month follow-up served as the primary outcome. Secondary outcomes were self-reported (Eating Disorders
The comorbidity of somatic, anxious and depressive syndromes occurs in half of all primary care c... more The comorbidity of somatic, anxious and depressive syndromes occurs in half of all primary care cases. As research on this overlap of syndromes in the general population is scarce, the present study investigated the prevalence of the overlapping syndromes and their association with health care use. Method: A national general population survey was conducted between June and July 2012. Trained interviewers contacted participants face-to-face, during which, individuals reported their health care use in the previous 12 months. Somatic, anxious and depressive syndromes were assessed using the Somatic Symptom Scale-8 (SSS-8), Generalized Anxiety Disorder-2 (GAD-2) and Patient Health Questionnaire-2 (PHQ-2) respectively. Results: Out of 2510 participants, 236 (9.4%) reported somatic (5.9%), anxious (3.4%) or depressive (4.7%) syndromes, which were comorbid in 86 (3.4%) cases. The increase in the number of syndromes was associated with increase in health care visits (no syndrome: 3.18 visits vs. mono syndrome: 5.82 visits vs. multi syndromes: 14.16 visits, (F (2,2507) = 149.10, p b 0.00001)). Compared to each somatic (semi-partial r 2 = 3.4%), anxious (semi-partial r 2 = 0.82%) or depressive (semi-partial r 2 = 0.002%) syndrome, the syndrome overlap (semi-partial r 2 = 6.6%) explained the greatest part of variance of health care use (change_in R 2= 11.2%, change_in F (3,2499) = 112.81, p b 0.001.) Conclusions: The overlap of somatic, anxious and depressive syndromes is frequent in the general population but appears to be less common compared to primary care populations. To estimate health care use in the general population the overlap of somatic, anxious and depressive syndromes should be considered.
International journal of methods in psychiatric research, Dec 16, 2016
To investigate differential item functioning (DIF) of PROMIS Depression items between US and Germ... more To investigate differential item functioning (DIF) of PROMIS Depression items between US and German samples we compared data from the US PROMIS calibration sample (n = 780), a German general population survey (n = 2,500) and a German clinical sample (n = 621). DIF was assessed in an ordinal logistic regression framework, with 0.02 as criterion for R(2) -change and 0.096 for Raju's non-compensatory DIF. Item parameters were initially fixed to the PROMIS Depression metric; we used plausible values to account for uncertainty in depression estimates. Only four items showed DIF. Accounting for DIF led to negligible effects for the full item bank as well as a post hoc simulated computer-adaptive test (< 0.1 point on the PROMIS metric [mean = 50, standard deviation =10]), while the effect on the short forms was small (< 1 point). The mean depression severity (43.6) in the German general population sample was considerably lower compared to the US reference value of 50. Overall, we...
In approximately 20% of patients with suspected allergies, no organic symptom explanation can be ... more In approximately 20% of patients with suspected allergies, no organic symptom explanation can be found. Limited knowledge about patients with "medically unexplained symptoms (MUS)" contributes to them being perceived as "difficult" and being treated inadequately. This study examined the psychobehavioural characteristics of patients presenting for a diagnostic allergy work-up. Patients were interviewed and completed various self-rating questionnaires. Patient-Doctor interaction was evaluated, and the organic explicability of the patients' symptoms was rated by allergists. Patients with vs. those without MUS differed in several respects. Mental comorbidity, female sex, dissatisfaction with care, and a problematic countertransference (the interviewer's feelings towards the patient) independently predicted MUS. Patients whose symptoms could be explained organically reported more psychobehavioural problems than a control group of immuno-therapy patients. There...
are the core features of many medical diseases, and they are used to evaluate the severity and co... more are the core features of many medical diseases, and they are used to evaluate the severity and course of illness. The 8-item Somatic Symptom Scale (SSS-8) was recently developed as a brief, patient-reported outcome measure of somatic symptom burden, but its reliability, validity, and usefulness have not yet been tested. OBJECTIVE To investigate the reliability, validity, and severity categories as well as the reference scores of the SSS-8. DESIGN, SETTING, AND PARTICIPANTS A national, representative general-population survey was performed between June 15, 2012, and July 15, 2012, in Germany, including 2510 individuals older than 13 years. MAIN OUTCOMES AND MEASURES The SSS-8 mean (SD), item-total correlations, Cronbach α, factor structure, associations with measures of construct validity (Patient Health Questionnaire-2 depression scale, Generalized Anxiety Disorder-2 scale, visual analog scale for general health status, 12-month health care use), severity categories, and percentile rank reference scores. RESULTS The SSS-8 had excellent item characteristics and good reliability (Cronbach α = 0.81). The factor structure reflects gastrointestinal, pain, fatigue, and cardiopulmonary aspects of the general somatic symptom burden. Somatic symptom burden as measured by the SSS-8 was significantly associated with depression (r = 0.57 [95% CI, 0.54 to 0.60]), anxiety (r = 0.55 [95% CI, 0.52 to 0.58]), general health status (r = −0.24 [95% CI, −0.28 to −0.20]), and health care use (incidence rate ratio, 1.12 [95% CI, 1.10 to 1.14]). The SSS-8 severity categories were calculated in accordance with percentile ranks: no to minimal (0-3 points), low (4-7 points), medium (8-11 points), high (12-15 points), and very high (16-32 points) somatic symptom burden. For every SSS-8 severity category increase, there was a 53% (95% CI, 44% to 63%) increase in health care visits. CONCLUSIONS AND RELEVANCE The SSS-8 is a reliable and valid self-report measure of somatic symptom burden. Cutoff scores identify individuals with low, medium, high, and very high somatic symptom burden.
The American Journal of Geriatric Psychiatry, 2014
The aim of this study was to evaluate the validity of the seven-item Generalized Anxiety Disorder... more The aim of this study was to evaluate the validity of the seven-item Generalized Anxiety Disorder scale (GAD-7) and its two core items (GAD-2) for detecting GAD in elderly people. A criterion-standard study was performed between May and December of 2010 on a general elderly population living at home. A subsample of 438 elderly persons (ages 58-82) of the large population-based German ESTHER study was included in the study. The GAD-7 was administered to participants as part of a home visit. A telephone-administered structured clinical interview was subsequently conducted by a blinded interviewer. The structured clinical (SCID) interview diagnosis of GAD constituted the criterion standard to determine sensitivity and specificity of the GAD-7 and the GAD-2 scales. Twenty-seven participants met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for current GAD according to the SCID interview (6.2%; 95% confidence interval [CI]: 3.9%-8.2%). For the GAD-7, a cut point of five or greater appeared to be optimal for detecting GAD. At this cut point the sensitivity of the GAD-7 was 0.63 and the specificity was 0.9. Correspondingly, the optimal cut point for the GAD-2 was two or greater with a sensitivity of 0.67 and a specificity of 0.90. The areas under the curve were 0.88 (95% CI: 0.83-0.93) for the GAD-7 and 0.87 (95% CI: 0.80-0.94) for the GAD-2. The increased scores on both GAD scales were strongly associated with mental health related quality of life (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). Our results establish the validity of both the GAD-7 and the GAD-2 in elderly persons. Results of this study show that the recommended cut points of the GAD-7 and the GAD-2 for detecting GAD should be lowered for the elderly general population.
This is the first study that investigates the prevalence and actual treatment of anxiety, depress... more This is the first study that investigates the prevalence and actual treatment of anxiety, depression, and other mental disorders in patients with pulmonary hypertension (PH). The prevalence of mental disorders in patients with PH was compared with parallel groups of primary care patients and patients with inflammatory rheumatic diseases, and the relationship between functional status and prevalence of mental disorders was determined. The patient group with PH (70.1% female; mean age, 47.8 +/- 12.7 years) and the two comparison groups, which were matched by age and sex, consisted of 164 patients each. Patients completed self-administered instruments, including the Patient Health Questionnaire for the diagnosis of mental disorders. New York Heart Association (NYHA) functional class was assessed in all patients with PH. Thirty-five percent of the patients with PH suffered from mental disorders, with the most common being major depressive disorder (15.9%) and panic disorder (10.4%). Both panic disorder and panic attacks were significantly more prevalent in patients with PH than in either patients with inflammatory rheumatic diseases or primary care patients. The prevalence of mental disorders in patients with PH increased significantly with functional impairment, from 17.7% (NYHA class I) to 61.9% (NYHA class IV). Only 24.1% of the patients with PH with mental disorders were receiving psychopharmacological or psychotherapeutic treatment. Anxiety and depression are frequent in patients with PH and increase as the severity of disease progresses. Given the fact that safe and efficacious treatments of mental disorders are available, greater importance should be attached to the diagnosis and treatment of these conditions in patients with PH.
Even though there is a high need of clinical research for the medical and psychotherapeutic pract... more Even though there is a high need of clinical research for the medical and psychotherapeutic practice in Germany, the interest in clinical research seems to be decreasing. The aim of this study was to assess the circumstances under which clinical research in psychosocial medicine is performed and to identify opportunities for improvement. n = 53 residents of the departments for Psychosomatic Medicine of the University Hospitals of Heidelberg and Tübingen and of the Technical University of Munich were asked about their research activities, their subjective research skills, and their productivity in clinical psychosocial research. In addition, objective research knowledge was investigated using a multiple-choice test. Both, subjective research skills and objective research knowledge were relatively low. The percentage of correct answers in the multiple choice test was 33 %. Subjective problems were predominately stated regarding &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;biostatistics&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;study design&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;. In terms of research productivity, 33 % of residents had published as first authors of an original journal article, and 12 % had submitted a successful grant proposal. Altogether, there is a high need of training in the field of clinical psychosomatic research. We are presenting a training model that is adapted to the conditions of young clinicians and that addresses both general clinical research and specific psychosocial clinical research.
The aim of the study was to assess the association of hypertension and symptoms of depression and... more The aim of the study was to assess the association of hypertension and symptoms of depression and generalized anxiety in a large cohort of elderly people. Methods: Data were derived from the 8-year follow-up (2008-2010) of the epidemiological ESTHER-cohort study. A total of 3124 randomly chosen participants aged 57-84 were visited at their homes by trained study doctors. General practitioner based diagnosis, self-reported status of hypertension, medication, and blood pressure measurement were considered to define the existence of hypertension. Depression and general anxiety severity were assessed using validated questionnaires. Logistic regression analyses were performed to determine cross-sectional associations between hypertension and clinically significant symptoms of depression (CSD) and generalized anxiety. Well known lifestyle risk factors for hypertension such as obesity were included in multivariate cross-sectional analyses. Results: Hypertension was prevalent in 1659 participants [53.1%; 95% confidence interval (CI) ¼ (51.3; 54.9)]. CSD was detected in 163 participants [5.2%; 95%-CI ¼ (4.4; 6.0)]. Symptoms of generalized anxiety were found in 434 participants [13.9%; 95%-CI ¼ (12.7; 15.1)]. Patients with CSD showed significantly higher odds of being hypertensive [odds ratio (OR) ¼ 1.76; 95%-CI ¼ (1.14; 2.74)]. Participants with symptoms of generalized anxiety were found to have no higher odds for a hypertension diagnosis [OR ¼ 1.1; 95%-CI ¼ (0.85; 1.44)]. Overweight [OR ¼ 1.86; 95%-CI ¼ (1.53; 2.25)] as well as obesity [OR ¼ 3.58; 95%-CI ¼ (2.84; 4.52)] was significantly associated with hypertension. Conclusion: CSD appear to be related to hypertension in elderly adults. No association was found between symptoms of generalized anxiety and hypertension.
This manuscript has been accepted by the editors of Psychosomatic Medicine, but it has not yet be... more This manuscript has been accepted by the editors of Psychosomatic Medicine, but it has not yet been copy edited; information within these pages is therefore subject to change. During the copy-editing and production phases, language usage and any textual errors will be corrected, and pages will be composed into their final format. Please visit the journal's website (www.psychosomaticmedicine.org) to check for a final version of the article. When citing this article, please use the following: Psychosomatic Medicine (in press) and include the article's digital object identifier (DOI).
Background: Functional somatic symptoms and disorders are common and complex phenomena involving ... more Background: Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients' quality of life and healthcare costs. Main body: We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose 'functional somatic disorders' (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrumand also within organ system-specific chapters of a classificationthey should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD). Conclusion: We propose a new classification, 'functional somatic disorder', which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders.
Objective: The mechanisms underlying the perception and experience of persistent physical symptom... more Objective: The mechanisms underlying the perception and experience of persistent physical symptoms are not well understood, and in the models, the specific relevance of peripheral input versus central processing, or of neurobiological versus psychosocial factors in general, is not clear. In this article, we propose a model for this clinical phenomenon that is designed to be coherent with an underlying, relatively new model of the normal brain functions involved in the experience of bodily signals. Methods: Based on a review of recent literature we describe central elements of this model and its clinical implications. Results: In the model the brain is seen as an active predictive processing or inferential device rather than one that is passively waiting for sensory input. A central aspect of the model is the attempt of the brain to minimize prediction errors that result from constant comparisons of predictions and sensory input. Two possibilities exist: adaptation of the generative model underlying the predictions or alteration of the sensory input via autonomic nervous activation (in the case of interoception). Following this model, persistent physical symptoms can be described as "failures of inference" and clinically well known factors like expectation are assigned a role, not "only" in the later amplification of bodily signals, but in the very basis of symptom perception. Conclusions: We discuss therapeutic implications of such a model including new interpretations for established treatments as well as new options like virtual reality techniques combining exteroceptive and interoceptive informations.
ObjectivePrevious research suggests that patients with anorexia nervosa (AN) show an impaired cap... more ObjectivePrevious research suggests that patients with anorexia nervosa (AN) show an impaired capacity to mentalize (reflective functioning, RF). RF is discussed as a possible predictor of outcome in psychotherapeutic processes. The study aimed to explore RF in sessions of patients with AN and its association with outcome and type of treatment.MethodsA post-hoc data analysis of selected cases from a randomized trial on outpatient psychotherapy for AN was conducted. Transcripts from 84 sessions of 28 patients (early phase, middle phase, and end of treatment) were assessed using the In-Session-Reflective-Functioning-Scale [14 cognitive-behavior therapy, enhanced (CBT-E); 14 focal psychodynamic therapy (FPT); 16 with good, 12 with poor outcome after 1 year]. Relations between the level of RF, type of treatment, and outcome were investigated using mixed linear models. Additionally, associations with depressive symptoms, weight gain, and therapeutic alliance were explored.ResultsMean in-...
Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) ar... more Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on question...
BackgroundAnorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortali... more BackgroundAnorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive–behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN.MethodThe analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WT...
Letter to the Editor therapeutic alliance and have learned to deal adaptively with distress. Prev... more Letter to the Editor therapeutic alliance and have learned to deal adaptively with distress. Previous psychotherapy research has demonstrated that emotional processing particularly during mid-treatment predicts favourable treatment outcomes [4]. Our main hypothesis was that greater expression of negative emotions, particularly during midtreatment, is associated with favourable outcomes in AN treatment, independent of the psychotherapeutic approach. Data were obtained from a multicentre randomised controlled trial comparing 40 sessions of manualised focal psychodynamic therapy (FPT) and enhanced cognitive behaviour therapy (CBT-E) against optimised treatment-as-usual in adult outpatients with AN (for more details of the ANTOP study see [5]). Participants were female, ≥ 18 years, and had a DSM-IV diagnosis of full-syndrome/ subthreshold AN (BMI 15.0-18.5). Written informed consent was obtained from each participant. Independent research ethics committees approved the study. Participants were randomised to receive either FPT, CBT-E, or optimised treatment-as-usual. Sessions were recorded and stored as audio files only in the FPT and CBT-E condition. Recordings were not available in 21% of the cases because either the patient or the therapist refused to give informed consent to use the recordings, and in 23% of the cases recordings were either incomplete or of insufficient quality. The analysis is thus based on the data from 89 patients (FPT: 43; CBT-E: 46), i.e., 56% of the original samples, which corresponds to similar studies [6]. These patients did not differ from those excluded regarding BMI, illness duration, eating disorder psychopathology, proportion of restricting subtype, and comorbid disorders at baseline (all p > 0.073). Likewise, FPT and CBT-E participants in this sample did not differ in these variables at baseline, end of treatment, and follow-up (all p > 0.129), except for more common comorbid MDD among CBT-E patients at baseline, χ 2 (1) = 5.169, p = 0.023. However, patients with and without comorbid MDD did not differ regarding emotional expression in any treatment phase (all p > 0.156). FPT comprised 3 treatment phases: sessions 1-15 focused on therapeutic alliance, pro-anorectic behaviour/beliefs, and self-esteem, sessions 16-32 emphasised emotional experiencing, interpersonal relationships, and their association with problematic eating behaviour, and sessions 33-40 focused on transfer to everyday life, anticipation of treatment termination, and parting. CBT-E comprised several modules: motivation, normalisation of nutrition, creating a formulation, and relapse prevention (mandatory), and cognitive restructuring, mood regulation, social skills, shape concern, and self-esteem (optional). BMI (calculated as kilograms/metres squared) at end of treatment and at the 12-month follow-up served as the primary outcome. Secondary outcomes were self-reported (Eating Disorders
The comorbidity of somatic, anxious and depressive syndromes occurs in half of all primary care c... more The comorbidity of somatic, anxious and depressive syndromes occurs in half of all primary care cases. As research on this overlap of syndromes in the general population is scarce, the present study investigated the prevalence of the overlapping syndromes and their association with health care use. Method: A national general population survey was conducted between June and July 2012. Trained interviewers contacted participants face-to-face, during which, individuals reported their health care use in the previous 12 months. Somatic, anxious and depressive syndromes were assessed using the Somatic Symptom Scale-8 (SSS-8), Generalized Anxiety Disorder-2 (GAD-2) and Patient Health Questionnaire-2 (PHQ-2) respectively. Results: Out of 2510 participants, 236 (9.4%) reported somatic (5.9%), anxious (3.4%) or depressive (4.7%) syndromes, which were comorbid in 86 (3.4%) cases. The increase in the number of syndromes was associated with increase in health care visits (no syndrome: 3.18 visits vs. mono syndrome: 5.82 visits vs. multi syndromes: 14.16 visits, (F (2,2507) = 149.10, p b 0.00001)). Compared to each somatic (semi-partial r 2 = 3.4%), anxious (semi-partial r 2 = 0.82%) or depressive (semi-partial r 2 = 0.002%) syndrome, the syndrome overlap (semi-partial r 2 = 6.6%) explained the greatest part of variance of health care use (change_in R 2= 11.2%, change_in F (3,2499) = 112.81, p b 0.001.) Conclusions: The overlap of somatic, anxious and depressive syndromes is frequent in the general population but appears to be less common compared to primary care populations. To estimate health care use in the general population the overlap of somatic, anxious and depressive syndromes should be considered.
International journal of methods in psychiatric research, Dec 16, 2016
To investigate differential item functioning (DIF) of PROMIS Depression items between US and Germ... more To investigate differential item functioning (DIF) of PROMIS Depression items between US and German samples we compared data from the US PROMIS calibration sample (n = 780), a German general population survey (n = 2,500) and a German clinical sample (n = 621). DIF was assessed in an ordinal logistic regression framework, with 0.02 as criterion for R(2) -change and 0.096 for Raju's non-compensatory DIF. Item parameters were initially fixed to the PROMIS Depression metric; we used plausible values to account for uncertainty in depression estimates. Only four items showed DIF. Accounting for DIF led to negligible effects for the full item bank as well as a post hoc simulated computer-adaptive test (< 0.1 point on the PROMIS metric [mean = 50, standard deviation =10]), while the effect on the short forms was small (< 1 point). The mean depression severity (43.6) in the German general population sample was considerably lower compared to the US reference value of 50. Overall, we...
In approximately 20% of patients with suspected allergies, no organic symptom explanation can be ... more In approximately 20% of patients with suspected allergies, no organic symptom explanation can be found. Limited knowledge about patients with "medically unexplained symptoms (MUS)" contributes to them being perceived as "difficult" and being treated inadequately. This study examined the psychobehavioural characteristics of patients presenting for a diagnostic allergy work-up. Patients were interviewed and completed various self-rating questionnaires. Patient-Doctor interaction was evaluated, and the organic explicability of the patients' symptoms was rated by allergists. Patients with vs. those without MUS differed in several respects. Mental comorbidity, female sex, dissatisfaction with care, and a problematic countertransference (the interviewer's feelings towards the patient) independently predicted MUS. Patients whose symptoms could be explained organically reported more psychobehavioural problems than a control group of immuno-therapy patients. There...
are the core features of many medical diseases, and they are used to evaluate the severity and co... more are the core features of many medical diseases, and they are used to evaluate the severity and course of illness. The 8-item Somatic Symptom Scale (SSS-8) was recently developed as a brief, patient-reported outcome measure of somatic symptom burden, but its reliability, validity, and usefulness have not yet been tested. OBJECTIVE To investigate the reliability, validity, and severity categories as well as the reference scores of the SSS-8. DESIGN, SETTING, AND PARTICIPANTS A national, representative general-population survey was performed between June 15, 2012, and July 15, 2012, in Germany, including 2510 individuals older than 13 years. MAIN OUTCOMES AND MEASURES The SSS-8 mean (SD), item-total correlations, Cronbach α, factor structure, associations with measures of construct validity (Patient Health Questionnaire-2 depression scale, Generalized Anxiety Disorder-2 scale, visual analog scale for general health status, 12-month health care use), severity categories, and percentile rank reference scores. RESULTS The SSS-8 had excellent item characteristics and good reliability (Cronbach α = 0.81). The factor structure reflects gastrointestinal, pain, fatigue, and cardiopulmonary aspects of the general somatic symptom burden. Somatic symptom burden as measured by the SSS-8 was significantly associated with depression (r = 0.57 [95% CI, 0.54 to 0.60]), anxiety (r = 0.55 [95% CI, 0.52 to 0.58]), general health status (r = −0.24 [95% CI, −0.28 to −0.20]), and health care use (incidence rate ratio, 1.12 [95% CI, 1.10 to 1.14]). The SSS-8 severity categories were calculated in accordance with percentile ranks: no to minimal (0-3 points), low (4-7 points), medium (8-11 points), high (12-15 points), and very high (16-32 points) somatic symptom burden. For every SSS-8 severity category increase, there was a 53% (95% CI, 44% to 63%) increase in health care visits. CONCLUSIONS AND RELEVANCE The SSS-8 is a reliable and valid self-report measure of somatic symptom burden. Cutoff scores identify individuals with low, medium, high, and very high somatic symptom burden.
The American Journal of Geriatric Psychiatry, 2014
The aim of this study was to evaluate the validity of the seven-item Generalized Anxiety Disorder... more The aim of this study was to evaluate the validity of the seven-item Generalized Anxiety Disorder scale (GAD-7) and its two core items (GAD-2) for detecting GAD in elderly people. A criterion-standard study was performed between May and December of 2010 on a general elderly population living at home. A subsample of 438 elderly persons (ages 58-82) of the large population-based German ESTHER study was included in the study. The GAD-7 was administered to participants as part of a home visit. A telephone-administered structured clinical interview was subsequently conducted by a blinded interviewer. The structured clinical (SCID) interview diagnosis of GAD constituted the criterion standard to determine sensitivity and specificity of the GAD-7 and the GAD-2 scales. Twenty-seven participants met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for current GAD according to the SCID interview (6.2%; 95% confidence interval [CI]: 3.9%-8.2%). For the GAD-7, a cut point of five or greater appeared to be optimal for detecting GAD. At this cut point the sensitivity of the GAD-7 was 0.63 and the specificity was 0.9. Correspondingly, the optimal cut point for the GAD-2 was two or greater with a sensitivity of 0.67 and a specificity of 0.90. The areas under the curve were 0.88 (95% CI: 0.83-0.93) for the GAD-7 and 0.87 (95% CI: 0.80-0.94) for the GAD-2. The increased scores on both GAD scales were strongly associated with mental health related quality of life (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.0001). Our results establish the validity of both the GAD-7 and the GAD-2 in elderly persons. Results of this study show that the recommended cut points of the GAD-7 and the GAD-2 for detecting GAD should be lowered for the elderly general population.
This is the first study that investigates the prevalence and actual treatment of anxiety, depress... more This is the first study that investigates the prevalence and actual treatment of anxiety, depression, and other mental disorders in patients with pulmonary hypertension (PH). The prevalence of mental disorders in patients with PH was compared with parallel groups of primary care patients and patients with inflammatory rheumatic diseases, and the relationship between functional status and prevalence of mental disorders was determined. The patient group with PH (70.1% female; mean age, 47.8 +/- 12.7 years) and the two comparison groups, which were matched by age and sex, consisted of 164 patients each. Patients completed self-administered instruments, including the Patient Health Questionnaire for the diagnosis of mental disorders. New York Heart Association (NYHA) functional class was assessed in all patients with PH. Thirty-five percent of the patients with PH suffered from mental disorders, with the most common being major depressive disorder (15.9%) and panic disorder (10.4%). Both panic disorder and panic attacks were significantly more prevalent in patients with PH than in either patients with inflammatory rheumatic diseases or primary care patients. The prevalence of mental disorders in patients with PH increased significantly with functional impairment, from 17.7% (NYHA class I) to 61.9% (NYHA class IV). Only 24.1% of the patients with PH with mental disorders were receiving psychopharmacological or psychotherapeutic treatment. Anxiety and depression are frequent in patients with PH and increase as the severity of disease progresses. Given the fact that safe and efficacious treatments of mental disorders are available, greater importance should be attached to the diagnosis and treatment of these conditions in patients with PH.
Even though there is a high need of clinical research for the medical and psychotherapeutic pract... more Even though there is a high need of clinical research for the medical and psychotherapeutic practice in Germany, the interest in clinical research seems to be decreasing. The aim of this study was to assess the circumstances under which clinical research in psychosocial medicine is performed and to identify opportunities for improvement. n = 53 residents of the departments for Psychosomatic Medicine of the University Hospitals of Heidelberg and Tübingen and of the Technical University of Munich were asked about their research activities, their subjective research skills, and their productivity in clinical psychosocial research. In addition, objective research knowledge was investigated using a multiple-choice test. Both, subjective research skills and objective research knowledge were relatively low. The percentage of correct answers in the multiple choice test was 33 %. Subjective problems were predominately stated regarding &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;biostatistics&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;study design&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;. In terms of research productivity, 33 % of residents had published as first authors of an original journal article, and 12 % had submitted a successful grant proposal. Altogether, there is a high need of training in the field of clinical psychosomatic research. We are presenting a training model that is adapted to the conditions of young clinicians and that addresses both general clinical research and specific psychosocial clinical research.
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Papers by Bernd Löwe