Culture sensitivity, health care utilization, and disability in individuals suffering from bodily complaints – a population-based approach

Different bodily complaints are very common in the general population. For many of the most frequent bodily complaints no medical explanation can be found. Consequently they are called medically unexplained or somatoform. Somatoform complaints constitute the core symptoms of somatoform disorders. These are among the most frequent mental disorders in Germany and Europe and are associated with high disability and abnormal illness behavior. In this publication-based cumulus three articles are presented. These base on three areas which are of major importance for investigations about bodily complaints or somatoform disorders. These areas are the following: 1. Culture sensitivity, 2. Health care utilization, and 3. Disability. Ad 1. The perception and presentation of bodily complaints, as well as the most frequent bodily symptoms are influenced by the cultural background. Persons with another cultural background (i. e. migrants) share approximately 19% of the German population. However, their mental health has only rarely been investigated. In the first article in this cumulus it is analysed to what extent two common questionnaires for the assessment of somatoform disorders and depression measure the same in Germans as in migrants in Germany (i. e. measurement invariance). Measurement invariance is a crucial precondition for the interpretation of studies on migrants. It was fulfilled for both questionnaires. Ad 2. Somatoform disorders are related to high health care utilization. The influence of psychological factors on health care utilization has rarely been investigated so far. Also, most studies investigating health care utilization studied selected samples. In the second article in this cumulus predictors for health care utilization are analysed. A representative sample of the German general population as well as a sub-group of persons with many somatoform complaints and a sub-group of persons with few somatoform complaints are investigated. Beside other predictors the intention to visit a doctor in the hypothetical situation of having different bodily complaints was analysed. In all three groups the same predictors for health care utilization were found. Beside the number and severity of bodily complaints, the mental health, and the employment status, the intention to visit a doctor was an important predictor. Ad 3. The disability by complaints is one of the most important criteria in diagnosing mental disorders. Thereby, disability is defined as any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human. However, it has not been investigated what the range of normal disability by bodily symptoms is. In the third article in this cumulus a questionnaire for the assessment of disability by bodily symptoms is evaluated in a representative sample of the German general population. Also, normative data for people with at least one bodily complaint are presented and the influence of disability on health care utilization is investigated. The normative data can be used to describe clinical samples. The results of the three articles are discussed and perspectives for further studies are described

Psychological pathology of eating disorders, self-efficacy, and locus of control in inpatients with anorexia nervosa and bulimia nervosa – a prospective study

Anorexia (AN) und Bulimia nervosa (BN) sind sehr ernstzunehmende psychische Erkrankungen. Das Gelingen einer stationären Behandlung setzt von Seiten der Patientinnen eine ausreichende Therapiemotivation voraus sowie die Erwartung, durch eigenes Verhalten eine Verbesserung der Symptomatik und des Wohlbefindens erreichen zu können. Dies beinhaltet zwei Aspekte: Zum einen die Überzeugung, dass wichtige Dinge im eigenen Leben durch eigenes Verhalten beeinflussbar sind (internale Kontrollüberzeugung) und nicht von anderen Personen oder dem Schicksal, Glück oder Zufall abhängen (soziale bzw. fatalistische externale Kontrollüberzeugung). Und zum anderen die Erwartung, dass man das Verhalten, dass zu einem subjektiv wichtigen Ergebnis führt, erfolgreich ausführen kann (Selbstwirksamkeitserwartung, SWE). Die wenigen Studien zu diesem Thema zeigen übereinstimmend, dass AN und BN-Patienten/innen eine niedrige Kontrollüberzeugung und eine geringe SWE haben und, dass diese Ressourcen durch eine Therapie beeinflussbar sind bzw. mit dem Therapieerfolg zusammenhängen. Vor diesem Hintergrund untersucht die vorliegende Studie in einem prospektiven Design den Verlauf und die Zusammenhänge von Essstörungssymptomatik, Lebensqualität, Kontrollüberzeugungen und Selbstwirksamkeitserwartung bei 26 BN und 24 AN-Patientinnen über ihre stationäre Behandlung. Die teilnehmenden Patientinnen (73% der geeigneten) zeigten bei Aufnahme eine vergleichbare Essstörungssymptomatik und Lebensqualität wie Essstörungsgruppen in anderen Studien. Im Vergleich zu Normpopulationen war die internale Kontrollüberzeugung geringer und die SWE wesentlich geringer, während die sozial externale Kontrollüberzeugung etwas höher war. Die Essstörungssymptomatik nahm von der Aufnahme bis zur Entlassung signifikant ab. Eine Zunahme der SWE und eine Verringerung der sozial externalen Kontrollüberzeugung über die Behandlung hingen mit einer Abnahme der Essstörungspathologie und einer Zunahme der psychischen Lebensqualität zusammen. Patientinnen, die die Behandlung vollständig durchliefen erreichten bei der Entlassung den Normbereich für die SWE, die internale und sozial externale Kontrollüberzeugung. Die Multi-level-Analyse zum Verlauf der SWE während der Behandlung zeigte, dass die Patientinnen besonders von den ersten Behandlungswochen profitieren und ihr Erreichtes dann stabilisieren können. Therapieabbrecherinnen haben eine niedrigere SWE zu Beginn der Therapie und zeigen auch eine immer geringere Zunahme der SWE über die Zeit. Die Zunahme der SWE von einer Woche zu anderen kann innerhalb einer Person sehr unterschiedlich sein. Der Typ der Essstörung hatte keinen Einfluss auf den Verlauf. Die vorliegende Studie zeigt eindrücklich, wie wichtig die Berücksichtigung von psychischen Ressourcen, besonders der Selbstwirksamkeitserwartung, für die Therapie von Patientinnen mit Anorexia und Bulimia nervosa ist.The aim of the medical doctoral thesis (Dr. rer. medic.) was to improve my expertise in psychotherapy studies, eating disorders, and psychological resources, and to add a very important aspect to the research in this field. I assumed that effective inpatient therapy for anorexia (AN) and bulimia nervosa (BN) depended on the patient’s expectation that she/he can reach symptom improvement and well-being with her/his own behavior, i.e. on the one hand the belief, that important goals in life can be reached by own behavior (internal locus of control) and do not dependent on other’s behavior or chance (external locus of control), and on the other hand the expectation that one can perform the behavior which is acquired to reach the goal (self efficacy). Despite the relevance, both concepts have been rarely investigated in inpatients with AN or BN. Consequently, I investigated the influence of locus of control and self-efficacy on eating disorder psychopathology and quality of life in a prospective study of 26 inpatients with BN and 24 inpatients with AN. Assessments took place weekly during the inpatient stay. Data was analyzed using non-parametric methods, regression analyses for the whole sample, and multi-level-analyses for the weekly assessments. The results of the study showed how important it is to account for psychological resources, especially self-efficacy, for the inpatient therapy of eating disorders

Validation of the Protect Questionnaire: A tool to detect mental health problems in asylum seekers by non-health professionals

Introduction: Prevalence rates of trauma-related mental disorders such as posttraumatic stress disorder (PTSD) or major depression (MD) are high in asylum seekers. The PROTECT Questionnaire (PQ) was designed to detect indications of those disorders in asylum seekers. Empirical data are needed to evaluate the PQ psychometrically. The objective of this study is to investigate the reliability, validity, sensitivity, and specificity of the PQ. Method: The PQ and validated questionnaires for PTSD (Posttraumatic Diagnostic Scale, PDS) and depression (Patient Health Questionnaire-9, PHQ- 9) were filled in by a sample of recently arrived asylum seekers in Germany (n=141). A sub-sample of 91 asylum seekers took part in a structured clinical interview to diagnose PTSD or MD (SCID-I). Results: The PQ showed a one-factor structure and good reliability (Cronbach’s ⍺= .82). It correlated highly with the PDS and the PHQ-9 (rs=.53-.77; ps≤.001). Diagnostic accuracy with regard to PTSD (AUC=.74; SE=.06; p<.001; 95%-CI=.63-.84) and MD (AUC=.72; SE=.06; p<.001; 95%-CI=.61- .83) was adequate, suggesting an optimal cut-off of 8 or 9. By categorizing participants into a low- and high-risk category, the PQ differentiated well between asylum seekers who fulfilled a PTSD or MD diagnosis and those who did not. Discussion: The results support the use of the PQ as a reliable and valid instrument for the purpose of detecting signs and symptoms of the two most common mental disorders in asylum seekers. Persons found to be at risk of mental disorders should be referred to a clinical diagnostic procedure

Preliminary evidence: the stress-reducing effect of listening to water sounds depends on somatic complaints. A randomized trial

Background: Listening to natural sounds is applied in health contexts in order to induce relaxation. However, it remains unclear whether this effect is equally efficacious in all individuals or whether it depends on interindividual differences. Given that individuals differ in how they are impaired by somatic complaints, we investigated whether somatic complaints moderate the stress-reducing effect of listening to water sounds. Methods: Sixty healthy women (Mage = 25 years) were randomly allocated to 3 different conditions (listening to water sounds, a relaxing piece of music, or no auditory stimulus: n = 20 per condition) for 10 minutes before they were exposed to a standardized psychosocial stress task. Salivary cortisol was assessed before, during, and after the stress task. For binary logistic regression analyses, participants were divided into 2 groups: 1 group with a high salivary cortisol release and 1 group with low cortisol release. The Freiburg Complaints Inventory was used to assess occurrence of somatic complaints. Results: A significant moderating effect of somatic complaints on cortisol secretion was found in the group listening to water sounds (χ2(1) = 5.87, P < .015) but not in the other 2 groups, explaining 35.7% of the variance and correctly classifying 78.9% of the cases. Conclusion: The stress-reducing effect of listening to water sounds appears to depend on the occurrence of somatic complaints. This effect was not found in the music or silence condition. Individuals with somatic complaints may benefit from other, potentially more powerful forms of stress-reducing interventions, that is, combinations of visual and auditory stimuli

Does childhood trauma impact daily psychobiological stress in somatic symptom disorder? An ambulatory assessment study

Objectives: Somatic symptom disorder is characterized by excessive thoughts, feelings, and behaviors dedicated to bodily symptoms, which are often medically unexplained. Although 13% of the population are affected by this disorder, its aetiopathogenesis is not fully understood. Research in medically unexplained conditions (e.g., fibromyalgia) points to increased psychosocial stress and alterations in stress-responsive bodily systems as a potential contributing factor. This pattern has often been hypothesized to originate from early life stress, such as childhood trauma. The aim of this study was to examine, for the first time, whether individuals with somatic symptom disorder exhibit elevated levels of self-reported daily stress and alterations in the autonomic nervous system and hypothalamic-pituitary-adrenal axis, both in comparison to healthy controls and individuals with depressive disorders, and whether reports of childhood trauma influence these alterations. Methods: A total of N = 78 individuals were recruited into this study. Of these, n = 27 had a somatic symptom disorder, n = 23 were healthy controls, and n = 28 had a depressive disorder. All individuals underwent a 14-day measurement period at home, with five assessments of self-reported stress, salivary alpha-amylase, and cortisol per day. Childhood trauma was assessed by the Childhood Trauma Questionnaire. Results: Individuals with somatic symptom disorder exhibited higher daily stress levels (p = 0.063) as well as a less pronounced alpha-amylase awakening response (p = 0.050), compared to healthy controls (statistical trends). Moreover, they were characterized by significantly attenuated diurnal cortisol concentrations (p &lt; 0.001). A nearly identical pattern was observed in individuals with depression. In individuals with somatic symptom disorder and depressive disorders, childhood trauma was, by trend, associated with a more pronounced alpha-amylase awakening response (b = −0.27, p = 0.077). Conclusions: This study provides preliminary evidence for elevated daily stress and blunted sympathetic and hypothalamic-pituitary-adrenal axis activity in individuals with somatic symptom disorder and depressive disorders. Further studies will help to uncover the conditions under which these dysregulations develop into medically unexplained vs. depressive symptoms

“It's That Route That Makes Us Sick”: Exploring Lay Beliefs About Causes of Post-traumatic Stress Disorder Among Sub-saharan African Asylum Seekers in Germany

Many asylum seekers have been confronted with traumatizing events, leading to high prevalence rates of post-traumatic stress disorder (PTSD). Within the diagnostic context, clinicians should take into account patients' culturally shaped presentation of symptoms. Therefore, we sought to provide insights into beliefs about causes of PTSD held by Sub-Saharan African asylum seekers living in Germany. To this aim, we used a quantitative and qualitative methodological triangulation strategy based on a vignette describing symptoms of PTSD. In the first part of the study, asylum seekers (n = 119), predominantly from Eritrea (n = 41), Somalia (n = 36), and Cameroon (n = 25), and a German comparison sample without a migration background (n = 120) completed the Revised Illness Perception Questionnaire (IPQ-R). In the second part, asylum seekers reviewed the results within eight focus group discussions (n = 26), sampled from groups of the three main countries of origin. Descriptive analyses of the first part demonstrated that asylum seekers predominantly attributed PTSD symptoms to psychological and religious causes, and rather disagreed with supernatural causes. In comparison to the German sample without a migration background, asylum seekers attributed symptoms less strongly to terrible experiences, but more strongly to religious and supernatural causes. Within the focus group discussions, six attribution categories of participants' causal beliefs were identified: (a) traumatic life experiences, (b) psychological causes, (c) social causes, (d) post-migration stressors, (e) religious causes, and (f) supernatural causes. Our findings suggest that the current Western understanding of PTSD is as relevant to migrants as to non-migrants in terms of psychological causation, but might differ regarding the religious and supernatural realm. While awareness of culture-specific belief systems of asylum seekers from Sub-Saharan Africa regarding PTSD is important, our findings do underline, at the same time, that cultural differences should not be overstated

Associations between sleep problems and posttraumatic stress symptoms, social functioning, and quality of life in refugees with posttraumatic stress disorder

Many patients with posttraumatic stress disorder (PTSD) suffer from sleep problems, leading to impairments in social functioning and quality of life. Refugees are at high risk for sleep problems due to stressful life circumstances and a high PTSD prevalence. However, limited data on the frequency of sleep problems in refugees with diagnosed PTSD exist. This study examined the frequency of sleep problems in refugees with PTSD and their associations with symptoms of PTSD. Additionally, we investigated the contribution of sleep problems to social functioning and quality of life. Participants (N = 70) were refugees from different countries of origin currently living in Germany. All participants met the criteria for PTSD and completed measures of PTSD symptom severity, subjective sleep problems, social impairment, and quality of life. There was a very high frequency of sleep problems in the sample (100%), and sleep problems were significantly associated with both clinician-rated, r = .47, and self-rated, r = .30, PTSD symptom severity after controlling for overlapping items. Contrary to expectations, sleep problems did not predict social impairment, d = 0.16, nor quality of life, d = 0.13, beyond the effect of other PTSD symptoms. The findings highlight the widespread frequency of sleep problems among refugees. Future studies should assess the causal nature of the association between sleep problems and measures of psychosocial functioning in more detail and examine its dynamic change over time

Definition and Characteristics of Behavioral Medicine, and Main Tasks and Goals of the International Society of Behavioral Medicine—an International Delphi Study

© 2020, The Author(s). Background: In the past decades, behavioral medicine has attained global recognition. Due to its global reach, a critical need has emerged to consider whether the original definition of behavioral medicine is still valid, comprehensive, and inclusive, and to reconsider the main tasks and goals of the International Society of Behavioral Medicine (ISBM), as the umbrella organization in the field. The purpose of the present study was to (i) update the definition and scope of behavioral medicine and its defining characteristics; and (ii) develop a proposal on ISBM’s main tasks and goals. Method: Our study used the Delphi method. A core group prepared a discussion paper. An international Delphi panel rated questions and provided comments. The panel intended to reach an a priori defined level of consensus (i.e., 70%). Results: The international panel reached consensus on an updated definition and scope of behavioral medicine as a field of research and practice that builds on collaboration among multiple disciplines. These disciplines are concerned with development and application of behavioral and biomedical evidence across the disease continuum in clinical and public health domains. Consensus was reached on a proposal for ISBM’s main tasks and goals focused on supporting communication and collaboration across disciplines and participating organizations; stimulating research, education, and practice; and supporting individuals and organizations in the field. Conclusion: The consensus on definition and scope of behavioral medicine and ISBM’s tasks and goals provides a foundational step toward achieving these goals

Походження права законодавчої ініціативи Державної ради Російської імперії 1906-1916 років

Демократизація державного та громадського життя в Україні висуває вимоги вивчення історичного досвіду цього процесу, перш за все, в умовах переходу від авторитарного управління до парламентаризму, а також гальмуючої ролі пережитків минулого. Це зачіпає і питання про впливи, які визначили сутність права законодавчої ініціативи Державної ради Російської імперії 1906 – 1916 рр. Воно не знайшло висвітлення, за одиночним винятком – статті російського правознавця Б.Е.Нольде (3) ні в дорадянській, ні в радянській історіографії. Мету нашого дослідження складає спроба встановити і охарактеризувати джерело виникнення права законодавчої ініціативи Державної ради Російської імперії 1906 – 1916 рр. шляхом аналізу відповідних законодавчих актів. Головним завданням дослідження є аналіз Основних державних законів 23 квітня 1906 р., Запровадження Державної ради 24 квітня 1906 р., Запроваджень Державної думи 6 серпня 1905 та 20 лютого 1906 рр., а також підготовчих матеріалів щодо цих актів