Alexandra Martin - Academia.edu (original) (raw)

Papers by Alexandra Martin

Research paper thumbnail of Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image: a control group comparison of psychological characteristics prior to surgical correction

European Journal of Cardio-Thoracic Surgery, 2011

The aim of this study was to evaluate the effects of anterior chest-wall deformities on disease-s... more The aim of this study was to evaluate the effects of anterior chest-wall deformities on disease-specific and health-related quality of life, body image, and psychiatric comorbidity prior to surgical correction. Methods: A total of 90 patients (71 with pectus excavatum, 19 with pectus carinatum) presenting themselves for pectus repair and 82 control subjects were recruited for this study. The objective severity of the deformity was determined through the funnel-chest index by Hümmer and the Haller index. Disease-specific quality of life was measured with the Nuss Questionnaire modified for Adults (NQ-mA) and health-related quality of life was determined by the Short-Form-36 Health Survey (SF-36). Body image was assessed via the Body Image Questionnaire (FKB-20), the Dysmorphic Concern Questionnaire (DCQ), and a self-evaluation of the subjective impairment of the appearance. The Diagnostic Interview for Mental Disorders-Short Version (Mini-DIPS), the General Depression Scale (Allgemeine Depressionsskala, ADS), and a self-rating of self-esteem were used to evaluate general psychological impairment. Results: Compared with control group results, physical quality of life was reduced in patients with pectus excavatum, while mental quality of life was decreased in patients with pectus carinatum (p < 0.05). Body image was highly disturbed in all the patients and differed significantly from the control group (p < 0.01). Patients with pectus carinatum appeared to be less satisfied with their appearance than those with pectus excavatum (p = 0.07). Body image distress was multivariately associated with both reduced mental quality of life and low self-esteem (p < 0.001). Body image did not influence physical quality of life. Patients displayed no elevated rates of mental disorders according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. Conclusion: Since self-perception is a major contributor to therapeutic decision making, a systematic evaluation of body image should be included in the assessment of patients with chest deformities. Body image concerns may be even more relevant to the decision-making process than physical restrictions. Exaggerated dysmorphic concerns should be prospectively investigated in their ability to influence the extent of satisfaction with the surgical outcome.

Research paper thumbnail of Körperbild und Körperbildstörungen

Research paper thumbnail of Efficacy of biofeedback for migraine: A meta-analysis

Pain, 2007

In this article, we meta-analytically examined the efficacy of biofeedback (BFB) in treating migr... more In this article, we meta-analytically examined the efficacy of biofeedback (BFB) in treating migraine. A computerized literature search of the databases Medline, PsycInfo, Psyndex and the Cochrane library, enhanced by a hand search, identified 86 outcome studies. A total of 55 studies, including randomized controlled trials as well as pre-post trials, met our inclusion criteria and were integrated. A medium effect size ( d ¼ 0:58, 95% CI = 0.52, 0.64) resulted for all BFB interventions and proved stable over an average follow-up phase of 17 months. Also, BFB was more effective than control conditions. Frequency of migraine attacks and perceived self-efficacy demonstrated the strongest improvements. Blood-volume-pulse feedback yielded higher effect sizes than peripheral skin temperature feedback and electromyography feedback. Moderator analyses revealed BFB in combination with home training to be more effective than therapies without home training. The influence of the meta-analytical methods on the effect sizes was systematically explored and the results proved to be robust across different methods of effect size calculation. Furthermore, there was no substantial relation between the validity of the integrated studies and the direct treatment effects. Finally, an intention-to-treat analysis showed that the treatment effects remained stable, even when drop-outs were considered as nonresponders. Ó

Research paper thumbnail of Association between Obesity and Adult Attention-Deficit/Hyperactivity Disorder in a German Community-Based Sample

Obesity Facts, 2011

The goal of the present study was to examine the association between attention-deficit/hyperactiv... more The goal of the present study was to examine the association between attention-deficit/hyperactivity disorder (ADHD) and obesity in a representative community based sample of the German population. Participants were 1,633 German residents (53.6% female) aged 18-64 years. A retrospective assessment of childhood ADHD and a self-report assessment of adult ADHD were administered for diagnosis of adult ADHD. In addition, binge eating and purging behaviors as well as depression and anxiety were assessed using self-rating instruments. The estimated prevalence of ADHD in obese participants was 9.7% compared to 3.8% in overweight and 4.3% in under-/normal-weight participants. The prevalence of obesity was 22.1% among adults with ADHD and 10.2% among persons without ADHD. Adult ADHD was significantly associated with a greater likelihood of being obese but not overweight even after adjusting for sociodemographic characteristics. Results were similar when adjusting for depression and anxiety symptoms and for purging behaviors. Odds ratios decreased after adjusting for binge eating; however, the results were still significant which shows that the relationship between obesity and ADHD in adulthood is not fully explained by binge eating. Overall, the results indicate that adult ADHD is associated with obesity in a community-based sample of the adult German population.

Research paper thumbnail of Patients with medically unexplained symptoms and their significant others: Illness attributions and behaviors as predictors of patient functioning over time

Journal of Psychosomatic Research, 2010

Previous research suggests that medically unexplained symptoms (MUS) are maintained in an interpe... more Previous research suggests that medically unexplained symptoms (MUS) are maintained in an interpersonal context. The current study examined MUS concurrently and prospectively by measuring specific interpersonal predictors of symptom severity and health care use. A total of 127 patients with MUS and their significant others were recruited through primary care offices and assessed with self-report questionnaires and structured interviews about illness attributions, illness behavior and responses, relationship quality, symptom severity, and health care use at baseline and 6-month follow-up. Illness attributions and interpersonal illness behaviors of patients with MUS were cross-sectionally associated with illness attributions and responses of the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; significant others. Relationship quality was related to specific illness behaviors and responses. Symptom severity at baseline was predicted by patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; somatic illness attributions. Symptom severity at 6-month follow-up was predicted by somatic illness attributions of patients and withdrawal of patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; significant others at baseline, but these predictors became insignificant when correcting for baseline symptomatology. Health care use at baseline was predicted by a greater amount of coping behavior and higher anxiety scores of patients, and health care use at 6-month follow-up was predicted by more attention-seeking behaviors and health care use of patients at baseline. The results document the interpersonal influences on the maintenance of MUS. The perspective of significant others should be considered for enhancement of psychological approaches to the treatment of patients with MUS.

Research paper thumbnail of The relationship between chronic fatigue and somatization syndrome: A general population survey

Journal of Psychosomatic Research, 2007

Objective: The objective of this study was to assess the prevalence of chronic fatigue (CF) and i... more Objective: The objective of this study was to assess the prevalence of chronic fatigue (CF) and its association with somatization syndrome [Somatization Syndrome Index (SSI) 4/6: z4 somatoform symptoms in men, 6 in women] in the general population. Methods: A representative sample of the German population (N=2412) completed a fatigue questionnaire and a screening instrument for current somatoform symptoms (Screening for Somatoform Symptoms 7). Results: The prevalence rate of CF was 6.1% (n=147). Females were affected significantly more often as compared with males (7% vs. 5.1%). The mean number of somatoform symptoms was higher in CF cases than in control subjects without CF (11 vs. 2; Pb.001). Seventy-two percent of the subjects with CF fulfilled the SSI4/6 criterion for somatization syndrome. Quality of life (EUROHIS-QOL and 8-item Short-Form Health Survey) and well-being (5-item WHO Well-Being Index) were markedly decreased in CF and SSI4/6. The results of regression analyses suggest that fatigue and somatization severity had a similar impact on quality of life. Conclusions: The results suggest that CF is relevant in the general population. Its substantial overlap with somatization syndrome supports the hypothesis that the two syndromes are only partially different manifestations of the same underlying processes. D

Research paper thumbnail of Body image, emotions and thought control strategies in body dysmorphic disorder compared to eating disorders and healthy controls

Journal of Psychosomatic Research, 2012

A disordered body image, emotions such as shame and disgust, and intrusive thoughts are described... more A disordered body image, emotions such as shame and disgust, and intrusive thoughts are described as important and interdependent features of body dysmorphic disorder (BDD). However, research in this field is scarce and knowledge is often based on clinical observation. The present study examined body image dimensions, emotions, and thought control strategies in individuals with: BDD (n=31), anorexia nervosa (n=32), bulimia nervosa (n=34), and healthy controls (n=33). Assessment was based on structured diagnostic interviews and self-report questionnaires. Individuals with BDD scored higher on psychosocial and appearance manipulation dimensions of body image compared to healthy controls. Furthermore, they reported higher psychosocial impairment due to appearance than both eating disorder groups. In terms of emotions, BDD subjects reported a higher degree of negative emotions compared to healthy controls, whereas no differences were found in comparison to eating-disordered patients. Individuals with BDD reported using maladaptive strategies such as worrying and confrontation more often than healthy controls, when encountering intrusive and unwanted thoughts. The results indicate that individuals with BDD experience substantial psychosocial impairment due to appearance, high levels of various negative emotions and frequently use maladaptive thought control strategies.

Research paper thumbnail of Memory bias for health-related information in somatoform disorders

Journal of Psychosomatic Research, 2007

Cognitive processes are considered to be relevant to the etiology and maintenance of somatoform d... more Cognitive processes are considered to be relevant to the etiology and maintenance of somatoform disorders (SFDs). The aim of this study was to assess explicit and implicit information-processing bias for disorder-congruent information in SFDs. A clinical sample of 33 patients suffering from multiple somatoform symptoms (SSI-3/5) and 25 healthy controls performed an encoding task with computer-presented word lists (illness related, negative, positive, neutral content), subsequently followed by explicit memory tests (free recall and recognition) and an implicit test (word-stem completion). The somatoform group showed a memory bias for illness-related stimuli in the word-stem completion task, whereas the two groups did not differ in explicit memory tests. This effect could not be explained by comorbid depression. These results provide some support for current theories on SFDs.

Research paper thumbnail of Lifetime Traumatic Experiences and Posttraumatic Stress Disorder in the German Population

The Journal of Nervous and Mental Disease, 2011

Only a few European population-based studies on the epidemiology of posttraumatic stress disorder... more Only a few European population-based studies on the epidemiology of posttraumatic stress disorder (PTSD) are available to date. This study aims to broaden the epidemiological knowledge of traumatic experiences (TEs), PTSD, and comorbid mental conditions in a representative German sample (N = 2510). The Composite International Diagnostic Interview list of traumatic events, the Posttraumatic Diagnostic Scale, and Patient Health Questionnaire (PHQ)-9 as well as PHQ-15 were used in this survey. Main results were low frequencies of TEs (24%) and PTSD (2.9%). Older participants (960 years) reported significantly more TEs and more posttraumatic symptoms, whereas there was no significant difference in PTSD prevalence. A third of the subjects diagnosed with PTSD were found positive for depressive syndromes, and 27% were found positive for somatization syndrome. The results show that TEs and posttraumatic symptoms are frequent in senior citizens and thus have to be considered when treating older patients with mental health conditions.

Research paper thumbnail of Meta-analysis of biofeedback for tension-type headache: Efficacy, specificity, and treatment moderators

Journal of Consulting and Clinical Psychology, 2008

The aims of the present meta-analysis were to investigate the short-and long-term efficacy, multi... more The aims of the present meta-analysis were to investigate the short-and long-term efficacy, multidimensional outcome, and treatment moderators of biofeedback as a behavioral treatment option for tension-type headache. A literature search identified 74 outcome studies, of which 53 were selected according to predefined inclusion criteria. Meta-analytic integration resulted in a significant mediumto-large effect size (d ϭ 0.73; 95% confidence interval ϭ 0.61, 0.84) that proved stable over an average follow-up phase of 15 months. Biofeedback was more effective than headache monitoring, placebo, and relaxation therapies. The strongest improvements resulted for frequency of headache episodes. Further significant effects were observed for muscle tension, self-efficacy, symptoms of anxiety, depression, and analgesic medication. Moderator analyses revealed biofeedback in combination with relaxation to be the most effective treatment modality; effects were particularly large in children and adolescents. In intention-to-treat and publication-bias analyses, the consistency of these findings was demonstrated. It is concluded that biofeedback constitutes an evidence-based treatment option for tension-type headache.

Research paper thumbnail of Implicit affective evaluation of somatosensory sensations in patients with noncardiac chest pain

Journal of Behavior Therapy and Experimental Psychiatry, 2014

Etiological models of noncardiac chest pain (NCCP) stress the importance of abnormal implicit aff... more Etiological models of noncardiac chest pain (NCCP) stress the importance of abnormal implicit affective evaluations of somatosensory sensations, but this has never been studied empirically. The aim was therefore to assess implicit affective evaluations of somatosensory stimuli in NCCP using an experimental design. A total of 34 patients with NCCP, 24 patients with cardiac chest pain, and 46 healthy controls, took part in the study. Participants completed a tactile modification of the Affect Misattribution Procedure (tAMP) and answered self-report measures on anxiety sensitivity, somatosensory amplification, and somatic symptom distress. A 3 × 3-ANOVA revealed that most negative judgments were found in the aversive condition, but this effect was not specific to patients with NCCP. Anxiety sensitivity was positively associated with negative implicit evaluations of aversive tactile stimuli in the tAMP. The task seemed to be too difficult for older participants. Also, future studies should apply clinically more relevant, e.g., heart related, stimuli that are more ecologically valid than the electrical stimulation of the finger used as a proxy for aversive somatosensory sensations here. Against theoretical assumptions, patients with NCCP do not seem to show a stronger implicit negative interpretation bias concerning somatosensory sensations in comparison to patients either with cardiac chest pain, or without chest pain. Nevertheless, anxiety sensitivity seems to contribute significantly to implicit affective interpretations of somatic sensations. Further studies are required investigating the relevance of implicit interpretative processes for the course of NCCP and distressing somatic symptoms in general.

Research paper thumbnail of Body-related cognitions, affect and post-event processing in body dysmorphic disorder

Journal of Behavior Therapy and Experimental Psychiatry, 2014

Cognitive behavioural models postulate that individuals with BDD engage in negative appearance-re... more Cognitive behavioural models postulate that individuals with BDD engage in negative appearance-related appraisals and affect. External representations of one&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s appearance are thought to activate a specific mode of processing characterized by increased self-focused attention and an activation of negative appraisals and affect. The present study used a think-aloud approach including an in vivo body exposure to examine body-related cognitions and affect in individuals with BDD (n = 30), as compared to individuals with major depression (n = 30) and healthy controls (n = 30). Participants were instructed to think aloud during baseline, exposure and follow-up trials. Individuals with BDD verbalized more body-related and more negative body-related cognitions during all trials and reported higher degrees of negative affect than both control groups. A weaker increase of positive body-related cognitions during exposure, a stronger increase of sadness and anger after exposure and higher levels of post-event processing, were specific processes in individuals with BDD. Individuals with major depression were not excluded from the BDD group. This is associated with a reduction of internal validity, as the two clinical groups are somewhat interwoven. Key findings need to be replicated. The findings indicate that outcomes such as negative appearance-related cognitions and affect are specific to individuals with BDD. An external representation of one&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s appearance activates a specific mode of processing in BDD, manifesting itself in the absence of positive body-related cognitions, increased anger and sadness, and high levels of post-event processing. These specific processes may contribute toward maintenance of BDD psychopathology.

Research paper thumbnail of Gender Differences in Healthcare Utilization: The Mediating Effect of Utilization Propensity

Journal of Applied Social Psychology, 2012

To evaluate the mediating effect of utilization propensity (UP) on gender differences in healthca... more To evaluate the mediating effect of utilization propensity (UP) on gender differences in healthcare utilization (HCU), a representative sample of the German general population (N= 2,510) was assessed with questionnaires. Gender differences in HCU, UP, and the ...

Research paper thumbnail of Health care utilization among first and second generation immigrants and native-born Germans: a population-based study in Germany

International Journal of Public Health, 2011

Objectives There are contradictory findings on health care utilization (HCU) of immigrants compar... more Objectives There are contradictory findings on health care utilization (HCU) of immigrants compared to nativeborn populations. Our study focuses on this topic using a population-based approach and differentiates generational cohorts of immigrants. Methods In a representative population survey in Germany (N = 2,510), immigrant background/generational cohort and HCU in the preceding 12 months were screened by means of self-rating instruments. Results 11.1% (7.0% first and 4.1% second generation) of the sample are immigrants. No differences have been detect with regard to subjective state of health, satisfaction with life and with health and functional disabilities. First generation immigrants contacted a medical specialist less likely, but they more frequently use general practitioners (GPs) than the native-born Germans and the second generation immigrants. Conclusions First generation immigrants show remarkable differences in HCU compared to the native-born Germans and the second generation immigrants. Their HCU seems to be focused on primary care, and access to secondary care might be complicated. It seems relevant to especially pay attention to HCU of first generation immigrants and to support equal access to care for this subgroup.

Research paper thumbnail of Disagreement in Doctor's and Patient's Rating About Medically Unexplained Symptoms and Health Care Use

International Journal of Behavioral Medicine, 2013

Background Medically unexplained (somatoform) symptoms (MUS) are highly prevalent in primary care... more Background Medically unexplained (somatoform) symptoms (MUS) are highly prevalent in primary care. It remains unclear to what extent patients and their general practitioners (GPs) agree upon the etiology of physical symptoms as well as on the number of visits to the GP. Purpose The purpose of this study is to determine patientphysician agreement on reported symptoms. Method A sample of 103 persons provided information on MUS and health care utilization (HCU) during the previous 12 months. The persons' GPs (n0103) were asked for the same information. By determining patient-physician agreement on reported symptoms, the sample was subdivided into a concordance group (high agreement: Pt0GP) and two discordance groups (substantial disagreement: Pt>GP, Pt<GP). Results Patients and their GPs showed substantial disagreement concerning physical symptom reports for the prior 12 months. On means, patients named 3.26 (SD03.23; range 0-21) physical complaints of which 71.6% were considered to be medically unexplained (MUS), whereas GPs only determined 1.77 (SD01.94; range 0-11) symptoms of which 57.5% were MUS. Substantial patient-physician agreement regarding the number of reported MUS was detected in 29.1% of the cases (Pt0GP). Patients of all groups underestimated their HCU. Conclusion Since patients' and GPs' reports differ substantially concerning the etiology of symptoms and concerning HCU, both sources of data gathering should be treated carefully in primary care research.

Research paper thumbnail of Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population

General Hospital Psychiatry, 2006

Objective: The aim of this study was to assess the validity of the Patient Health Questionnaire d... more Objective: The aim of this study was to assess the validity of the Patient Health Questionnaire depression module (PHQ-9). It has been subject to studies in medical settings, but its validity as a screening for depression in the general population is unknown. Method: A representative population sample (2066 subjects, 14-93 years) filled in the PHQ-9 for diagnosis [major depressive disorder, other depressive disorder, depression screen-positive (DS+) and depression screen-negative (DSÀ)] and other measures for distress (GHQ-12), depression (Brief-BDI) and subjective health perception (EuroQOL; SF-36). Results: A prevalence rate of 9.2% of a current PHQ depressive disorder (major depression 3.8%, subthreshold other depressive disorder 5.4%) was identified. The two depression groups had higher Brief-BDI and GHQ-12 scores, and reported lower health status (EuroQOL) and health-related quality of life (SF-36) than did the DSÀ group ( P's b .001). Strong associations between PHQ-9 depression severity and convergent variables were found (with BDI r = .73, with GHQ-12 r = .59). Conclusion: The results support the construct validity of the PHQ depression scale, which seems to be a useful tool to recognize not only major depression but also subthreshold depressive disorder in the general population. D

Research paper thumbnail of Lower decision threshold for doctor visits as a predictor of health care use in somatoform disorders and in the general population

General Hospital Psychiatry, 2008

More than half of all outpatient visits are trigged by physical symptoms which, in turn, are not ... more More than half of all outpatient visits are trigged by physical symptoms which, in turn, are not adequately explained by medical disorders at least half of the time. Further, the presence and severity of somatic symptoms often correlate more strongly with psychological, cognitive and behavioral factors than with physiological or biological findings. Finally, our understanding of the etiology, evaluation, and management of somatic symptoms and functional syndromes is less advanced than our knowledge of many defined medical and psychiatric disorders. This special section, edited by Kurt Kroenke, M.D., will highlight original studies that advance the science and clinical care of somatic symptoms.

Research paper thumbnail of The estimated prevalence and correlates of adult ADHD in a German community sample

European Archives of Psychiatry and Clinical Neuroscience, 2012

Little research on the prevalence and correlates of adult ADHD has been conducted outside the Uni... more Little research on the prevalence and correlates of adult ADHD has been conducted outside the United States. The aim of the present study was to estimate the prevalence and correlates of adult ADHD in a large representative sample of the German population aged 18-64 years (n = 1,655). Two self-rating screening instruments to assess childhood and adult ADHD symptomatology were used to estimate the prevalence of ADHD. A 4-item screening tool was used to assess probable cases of current depression and anxiety (Patient Health Questionnaire). The estimated crude prevalence rate of current ADHD was 4.7%. Adult ADHD was significantly associated with lower age, low educational level, unemployment, marital status (never married and divorced), and rural residency. No association was found with gender. Adult ADHD was strongly associated with positive screening results for depression and anxiety. ADHD is a common disorder of adulthood, is associated with significant social impairment and psychiatric co-morbidity, and should receive further research attention.

Research paper thumbnail of Sind Vergleiche im Depressions- und Somatisierungsausmaß zwischen Migranten und Deutschen möglich?

Diagnostica, 2010

Zusammenfassung: Zur Erfassung der psychischen Gesundheit von Migranten im Vergleich zu Deutschen... more Zusammenfassung: Zur Erfassung der psychischen Gesundheit von Migranten im Vergleich zu Deutschen sind Untersuchungen in der Allgemeinbevölkerung zentral. Für diesen Ansatz hat sich die Verwendung des Depressivitäts-und des Somatisierungsmoduls des Patient Health Questionnaire (PHQ-9, PHQ-15) bewährt. Es ist jedoch unklar, ob diese Module bei Migranten das Gleiche messen wie bei Deutschen (Messäquivalenz). Dadurch bleibt es fraglich, ob die Ergebnisse vergleichender Studien richtig interpretierbar sind.

Research paper thumbnail of Dispositional emotion coping styles and physiological responses to expressive writing

British Journal of Health Psychology, 2013

The purpose of these two studies was to assess how repressors and defensive, high-anxious individ... more The purpose of these two studies was to assess how repressors and defensive, high-anxious individuals exhibit their psychological and health characteristics subjectively through self-reports and objectively through physiological markers and ratings of emotional expression. Cross-sectional descriptive design (study one) and randomized controlled design (study two). In the first descriptive study, repressors, defensive, high-anxious individuals and low-anxious individuals were identified from a pool of 748 undergraduates. Participants were asked to complete questionnaires assessing psychological and health characteristics. In the second experimental study, the three groups were randomized into either emotional or non-emotional writing conditions. Participants were asked to write three essays on either an emotional or a non-emotional topic in a single day. In the first study, defensive, high-anxious individuals reported significantly more distress, symptoms, sickness behaviours and difficulty expressing anger relative to repressors. In the second study, there was a significant difference in salivary cortisol concentrations between the two writing conditions regardless of the emotional coping grouping. Analysis of the writing showed no significant differences among repressors, defensive, high-anxious and low-anxious individuals in their cognitive and affective expression. Whereas self-reports of health outcomes and psychological traits clearly distinguish repressors and defensive, high-anxious individuals, more objective indices of emotional expressiveness and physiology do not appear to do so. The results also indicate that expressive writing may be helpful to reduce physiological arousal towards emotionally charged memories.

Research paper thumbnail of Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image: a control group comparison of psychological characteristics prior to surgical correction

European Journal of Cardio-Thoracic Surgery, 2011

The aim of this study was to evaluate the effects of anterior chest-wall deformities on disease-s... more The aim of this study was to evaluate the effects of anterior chest-wall deformities on disease-specific and health-related quality of life, body image, and psychiatric comorbidity prior to surgical correction. Methods: A total of 90 patients (71 with pectus excavatum, 19 with pectus carinatum) presenting themselves for pectus repair and 82 control subjects were recruited for this study. The objective severity of the deformity was determined through the funnel-chest index by Hümmer and the Haller index. Disease-specific quality of life was measured with the Nuss Questionnaire modified for Adults (NQ-mA) and health-related quality of life was determined by the Short-Form-36 Health Survey (SF-36). Body image was assessed via the Body Image Questionnaire (FKB-20), the Dysmorphic Concern Questionnaire (DCQ), and a self-evaluation of the subjective impairment of the appearance. The Diagnostic Interview for Mental Disorders-Short Version (Mini-DIPS), the General Depression Scale (Allgemeine Depressionsskala, ADS), and a self-rating of self-esteem were used to evaluate general psychological impairment. Results: Compared with control group results, physical quality of life was reduced in patients with pectus excavatum, while mental quality of life was decreased in patients with pectus carinatum (p < 0.05). Body image was highly disturbed in all the patients and differed significantly from the control group (p < 0.01). Patients with pectus carinatum appeared to be less satisfied with their appearance than those with pectus excavatum (p = 0.07). Body image distress was multivariately associated with both reduced mental quality of life and low self-esteem (p < 0.001). Body image did not influence physical quality of life. Patients displayed no elevated rates of mental disorders according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. Conclusion: Since self-perception is a major contributor to therapeutic decision making, a systematic evaluation of body image should be included in the assessment of patients with chest deformities. Body image concerns may be even more relevant to the decision-making process than physical restrictions. Exaggerated dysmorphic concerns should be prospectively investigated in their ability to influence the extent of satisfaction with the surgical outcome.

Research paper thumbnail of Körperbild und Körperbildstörungen

Research paper thumbnail of Efficacy of biofeedback for migraine: A meta-analysis

Pain, 2007

In this article, we meta-analytically examined the efficacy of biofeedback (BFB) in treating migr... more In this article, we meta-analytically examined the efficacy of biofeedback (BFB) in treating migraine. A computerized literature search of the databases Medline, PsycInfo, Psyndex and the Cochrane library, enhanced by a hand search, identified 86 outcome studies. A total of 55 studies, including randomized controlled trials as well as pre-post trials, met our inclusion criteria and were integrated. A medium effect size ( d ¼ 0:58, 95% CI = 0.52, 0.64) resulted for all BFB interventions and proved stable over an average follow-up phase of 17 months. Also, BFB was more effective than control conditions. Frequency of migraine attacks and perceived self-efficacy demonstrated the strongest improvements. Blood-volume-pulse feedback yielded higher effect sizes than peripheral skin temperature feedback and electromyography feedback. Moderator analyses revealed BFB in combination with home training to be more effective than therapies without home training. The influence of the meta-analytical methods on the effect sizes was systematically explored and the results proved to be robust across different methods of effect size calculation. Furthermore, there was no substantial relation between the validity of the integrated studies and the direct treatment effects. Finally, an intention-to-treat analysis showed that the treatment effects remained stable, even when drop-outs were considered as nonresponders. Ó

Research paper thumbnail of Association between Obesity and Adult Attention-Deficit/Hyperactivity Disorder in a German Community-Based Sample

Obesity Facts, 2011

The goal of the present study was to examine the association between attention-deficit/hyperactiv... more The goal of the present study was to examine the association between attention-deficit/hyperactivity disorder (ADHD) and obesity in a representative community based sample of the German population. Participants were 1,633 German residents (53.6% female) aged 18-64 years. A retrospective assessment of childhood ADHD and a self-report assessment of adult ADHD were administered for diagnosis of adult ADHD. In addition, binge eating and purging behaviors as well as depression and anxiety were assessed using self-rating instruments. The estimated prevalence of ADHD in obese participants was 9.7% compared to 3.8% in overweight and 4.3% in under-/normal-weight participants. The prevalence of obesity was 22.1% among adults with ADHD and 10.2% among persons without ADHD. Adult ADHD was significantly associated with a greater likelihood of being obese but not overweight even after adjusting for sociodemographic characteristics. Results were similar when adjusting for depression and anxiety symptoms and for purging behaviors. Odds ratios decreased after adjusting for binge eating; however, the results were still significant which shows that the relationship between obesity and ADHD in adulthood is not fully explained by binge eating. Overall, the results indicate that adult ADHD is associated with obesity in a community-based sample of the adult German population.

Research paper thumbnail of Patients with medically unexplained symptoms and their significant others: Illness attributions and behaviors as predictors of patient functioning over time

Journal of Psychosomatic Research, 2010

Previous research suggests that medically unexplained symptoms (MUS) are maintained in an interpe... more Previous research suggests that medically unexplained symptoms (MUS) are maintained in an interpersonal context. The current study examined MUS concurrently and prospectively by measuring specific interpersonal predictors of symptom severity and health care use. A total of 127 patients with MUS and their significant others were recruited through primary care offices and assessed with self-report questionnaires and structured interviews about illness attributions, illness behavior and responses, relationship quality, symptom severity, and health care use at baseline and 6-month follow-up. Illness attributions and interpersonal illness behaviors of patients with MUS were cross-sectionally associated with illness attributions and responses of the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; significant others. Relationship quality was related to specific illness behaviors and responses. Symptom severity at baseline was predicted by patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; somatic illness attributions. Symptom severity at 6-month follow-up was predicted by somatic illness attributions of patients and withdrawal of patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; significant others at baseline, but these predictors became insignificant when correcting for baseline symptomatology. Health care use at baseline was predicted by a greater amount of coping behavior and higher anxiety scores of patients, and health care use at 6-month follow-up was predicted by more attention-seeking behaviors and health care use of patients at baseline. The results document the interpersonal influences on the maintenance of MUS. The perspective of significant others should be considered for enhancement of psychological approaches to the treatment of patients with MUS.

Research paper thumbnail of The relationship between chronic fatigue and somatization syndrome: A general population survey

Journal of Psychosomatic Research, 2007

Objective: The objective of this study was to assess the prevalence of chronic fatigue (CF) and i... more Objective: The objective of this study was to assess the prevalence of chronic fatigue (CF) and its association with somatization syndrome [Somatization Syndrome Index (SSI) 4/6: z4 somatoform symptoms in men, 6 in women] in the general population. Methods: A representative sample of the German population (N=2412) completed a fatigue questionnaire and a screening instrument for current somatoform symptoms (Screening for Somatoform Symptoms 7). Results: The prevalence rate of CF was 6.1% (n=147). Females were affected significantly more often as compared with males (7% vs. 5.1%). The mean number of somatoform symptoms was higher in CF cases than in control subjects without CF (11 vs. 2; Pb.001). Seventy-two percent of the subjects with CF fulfilled the SSI4/6 criterion for somatization syndrome. Quality of life (EUROHIS-QOL and 8-item Short-Form Health Survey) and well-being (5-item WHO Well-Being Index) were markedly decreased in CF and SSI4/6. The results of regression analyses suggest that fatigue and somatization severity had a similar impact on quality of life. Conclusions: The results suggest that CF is relevant in the general population. Its substantial overlap with somatization syndrome supports the hypothesis that the two syndromes are only partially different manifestations of the same underlying processes. D

Research paper thumbnail of Body image, emotions and thought control strategies in body dysmorphic disorder compared to eating disorders and healthy controls

Journal of Psychosomatic Research, 2012

A disordered body image, emotions such as shame and disgust, and intrusive thoughts are described... more A disordered body image, emotions such as shame and disgust, and intrusive thoughts are described as important and interdependent features of body dysmorphic disorder (BDD). However, research in this field is scarce and knowledge is often based on clinical observation. The present study examined body image dimensions, emotions, and thought control strategies in individuals with: BDD (n=31), anorexia nervosa (n=32), bulimia nervosa (n=34), and healthy controls (n=33). Assessment was based on structured diagnostic interviews and self-report questionnaires. Individuals with BDD scored higher on psychosocial and appearance manipulation dimensions of body image compared to healthy controls. Furthermore, they reported higher psychosocial impairment due to appearance than both eating disorder groups. In terms of emotions, BDD subjects reported a higher degree of negative emotions compared to healthy controls, whereas no differences were found in comparison to eating-disordered patients. Individuals with BDD reported using maladaptive strategies such as worrying and confrontation more often than healthy controls, when encountering intrusive and unwanted thoughts. The results indicate that individuals with BDD experience substantial psychosocial impairment due to appearance, high levels of various negative emotions and frequently use maladaptive thought control strategies.

Research paper thumbnail of Memory bias for health-related information in somatoform disorders

Journal of Psychosomatic Research, 2007

Cognitive processes are considered to be relevant to the etiology and maintenance of somatoform d... more Cognitive processes are considered to be relevant to the etiology and maintenance of somatoform disorders (SFDs). The aim of this study was to assess explicit and implicit information-processing bias for disorder-congruent information in SFDs. A clinical sample of 33 patients suffering from multiple somatoform symptoms (SSI-3/5) and 25 healthy controls performed an encoding task with computer-presented word lists (illness related, negative, positive, neutral content), subsequently followed by explicit memory tests (free recall and recognition) and an implicit test (word-stem completion). The somatoform group showed a memory bias for illness-related stimuli in the word-stem completion task, whereas the two groups did not differ in explicit memory tests. This effect could not be explained by comorbid depression. These results provide some support for current theories on SFDs.

Research paper thumbnail of Lifetime Traumatic Experiences and Posttraumatic Stress Disorder in the German Population

The Journal of Nervous and Mental Disease, 2011

Only a few European population-based studies on the epidemiology of posttraumatic stress disorder... more Only a few European population-based studies on the epidemiology of posttraumatic stress disorder (PTSD) are available to date. This study aims to broaden the epidemiological knowledge of traumatic experiences (TEs), PTSD, and comorbid mental conditions in a representative German sample (N = 2510). The Composite International Diagnostic Interview list of traumatic events, the Posttraumatic Diagnostic Scale, and Patient Health Questionnaire (PHQ)-9 as well as PHQ-15 were used in this survey. Main results were low frequencies of TEs (24%) and PTSD (2.9%). Older participants (960 years) reported significantly more TEs and more posttraumatic symptoms, whereas there was no significant difference in PTSD prevalence. A third of the subjects diagnosed with PTSD were found positive for depressive syndromes, and 27% were found positive for somatization syndrome. The results show that TEs and posttraumatic symptoms are frequent in senior citizens and thus have to be considered when treating older patients with mental health conditions.

Research paper thumbnail of Meta-analysis of biofeedback for tension-type headache: Efficacy, specificity, and treatment moderators

Journal of Consulting and Clinical Psychology, 2008

The aims of the present meta-analysis were to investigate the short-and long-term efficacy, multi... more The aims of the present meta-analysis were to investigate the short-and long-term efficacy, multidimensional outcome, and treatment moderators of biofeedback as a behavioral treatment option for tension-type headache. A literature search identified 74 outcome studies, of which 53 were selected according to predefined inclusion criteria. Meta-analytic integration resulted in a significant mediumto-large effect size (d ϭ 0.73; 95% confidence interval ϭ 0.61, 0.84) that proved stable over an average follow-up phase of 15 months. Biofeedback was more effective than headache monitoring, placebo, and relaxation therapies. The strongest improvements resulted for frequency of headache episodes. Further significant effects were observed for muscle tension, self-efficacy, symptoms of anxiety, depression, and analgesic medication. Moderator analyses revealed biofeedback in combination with relaxation to be the most effective treatment modality; effects were particularly large in children and adolescents. In intention-to-treat and publication-bias analyses, the consistency of these findings was demonstrated. It is concluded that biofeedback constitutes an evidence-based treatment option for tension-type headache.

Research paper thumbnail of Implicit affective evaluation of somatosensory sensations in patients with noncardiac chest pain

Journal of Behavior Therapy and Experimental Psychiatry, 2014

Etiological models of noncardiac chest pain (NCCP) stress the importance of abnormal implicit aff... more Etiological models of noncardiac chest pain (NCCP) stress the importance of abnormal implicit affective evaluations of somatosensory sensations, but this has never been studied empirically. The aim was therefore to assess implicit affective evaluations of somatosensory stimuli in NCCP using an experimental design. A total of 34 patients with NCCP, 24 patients with cardiac chest pain, and 46 healthy controls, took part in the study. Participants completed a tactile modification of the Affect Misattribution Procedure (tAMP) and answered self-report measures on anxiety sensitivity, somatosensory amplification, and somatic symptom distress. A 3 × 3-ANOVA revealed that most negative judgments were found in the aversive condition, but this effect was not specific to patients with NCCP. Anxiety sensitivity was positively associated with negative implicit evaluations of aversive tactile stimuli in the tAMP. The task seemed to be too difficult for older participants. Also, future studies should apply clinically more relevant, e.g., heart related, stimuli that are more ecologically valid than the electrical stimulation of the finger used as a proxy for aversive somatosensory sensations here. Against theoretical assumptions, patients with NCCP do not seem to show a stronger implicit negative interpretation bias concerning somatosensory sensations in comparison to patients either with cardiac chest pain, or without chest pain. Nevertheless, anxiety sensitivity seems to contribute significantly to implicit affective interpretations of somatic sensations. Further studies are required investigating the relevance of implicit interpretative processes for the course of NCCP and distressing somatic symptoms in general.

Research paper thumbnail of Body-related cognitions, affect and post-event processing in body dysmorphic disorder

Journal of Behavior Therapy and Experimental Psychiatry, 2014

Cognitive behavioural models postulate that individuals with BDD engage in negative appearance-re... more Cognitive behavioural models postulate that individuals with BDD engage in negative appearance-related appraisals and affect. External representations of one&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s appearance are thought to activate a specific mode of processing characterized by increased self-focused attention and an activation of negative appraisals and affect. The present study used a think-aloud approach including an in vivo body exposure to examine body-related cognitions and affect in individuals with BDD (n = 30), as compared to individuals with major depression (n = 30) and healthy controls (n = 30). Participants were instructed to think aloud during baseline, exposure and follow-up trials. Individuals with BDD verbalized more body-related and more negative body-related cognitions during all trials and reported higher degrees of negative affect than both control groups. A weaker increase of positive body-related cognitions during exposure, a stronger increase of sadness and anger after exposure and higher levels of post-event processing, were specific processes in individuals with BDD. Individuals with major depression were not excluded from the BDD group. This is associated with a reduction of internal validity, as the two clinical groups are somewhat interwoven. Key findings need to be replicated. The findings indicate that outcomes such as negative appearance-related cognitions and affect are specific to individuals with BDD. An external representation of one&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s appearance activates a specific mode of processing in BDD, manifesting itself in the absence of positive body-related cognitions, increased anger and sadness, and high levels of post-event processing. These specific processes may contribute toward maintenance of BDD psychopathology.

Research paper thumbnail of Gender Differences in Healthcare Utilization: The Mediating Effect of Utilization Propensity

Journal of Applied Social Psychology, 2012

To evaluate the mediating effect of utilization propensity (UP) on gender differences in healthca... more To evaluate the mediating effect of utilization propensity (UP) on gender differences in healthcare utilization (HCU), a representative sample of the German general population (N= 2,510) was assessed with questionnaires. Gender differences in HCU, UP, and the ...

Research paper thumbnail of Health care utilization among first and second generation immigrants and native-born Germans: a population-based study in Germany

International Journal of Public Health, 2011

Objectives There are contradictory findings on health care utilization (HCU) of immigrants compar... more Objectives There are contradictory findings on health care utilization (HCU) of immigrants compared to nativeborn populations. Our study focuses on this topic using a population-based approach and differentiates generational cohorts of immigrants. Methods In a representative population survey in Germany (N = 2,510), immigrant background/generational cohort and HCU in the preceding 12 months were screened by means of self-rating instruments. Results 11.1% (7.0% first and 4.1% second generation) of the sample are immigrants. No differences have been detect with regard to subjective state of health, satisfaction with life and with health and functional disabilities. First generation immigrants contacted a medical specialist less likely, but they more frequently use general practitioners (GPs) than the native-born Germans and the second generation immigrants. Conclusions First generation immigrants show remarkable differences in HCU compared to the native-born Germans and the second generation immigrants. Their HCU seems to be focused on primary care, and access to secondary care might be complicated. It seems relevant to especially pay attention to HCU of first generation immigrants and to support equal access to care for this subgroup.

Research paper thumbnail of Disagreement in Doctor's and Patient's Rating About Medically Unexplained Symptoms and Health Care Use

International Journal of Behavioral Medicine, 2013

Background Medically unexplained (somatoform) symptoms (MUS) are highly prevalent in primary care... more Background Medically unexplained (somatoform) symptoms (MUS) are highly prevalent in primary care. It remains unclear to what extent patients and their general practitioners (GPs) agree upon the etiology of physical symptoms as well as on the number of visits to the GP. Purpose The purpose of this study is to determine patientphysician agreement on reported symptoms. Method A sample of 103 persons provided information on MUS and health care utilization (HCU) during the previous 12 months. The persons' GPs (n0103) were asked for the same information. By determining patient-physician agreement on reported symptoms, the sample was subdivided into a concordance group (high agreement: Pt0GP) and two discordance groups (substantial disagreement: Pt>GP, Pt<GP). Results Patients and their GPs showed substantial disagreement concerning physical symptom reports for the prior 12 months. On means, patients named 3.26 (SD03.23; range 0-21) physical complaints of which 71.6% were considered to be medically unexplained (MUS), whereas GPs only determined 1.77 (SD01.94; range 0-11) symptoms of which 57.5% were MUS. Substantial patient-physician agreement regarding the number of reported MUS was detected in 29.1% of the cases (Pt0GP). Patients of all groups underestimated their HCU. Conclusion Since patients' and GPs' reports differ substantially concerning the etiology of symptoms and concerning HCU, both sources of data gathering should be treated carefully in primary care research.

Research paper thumbnail of Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population

General Hospital Psychiatry, 2006

Objective: The aim of this study was to assess the validity of the Patient Health Questionnaire d... more Objective: The aim of this study was to assess the validity of the Patient Health Questionnaire depression module (PHQ-9). It has been subject to studies in medical settings, but its validity as a screening for depression in the general population is unknown. Method: A representative population sample (2066 subjects, 14-93 years) filled in the PHQ-9 for diagnosis [major depressive disorder, other depressive disorder, depression screen-positive (DS+) and depression screen-negative (DSÀ)] and other measures for distress (GHQ-12), depression (Brief-BDI) and subjective health perception (EuroQOL; SF-36). Results: A prevalence rate of 9.2% of a current PHQ depressive disorder (major depression 3.8%, subthreshold other depressive disorder 5.4%) was identified. The two depression groups had higher Brief-BDI and GHQ-12 scores, and reported lower health status (EuroQOL) and health-related quality of life (SF-36) than did the DSÀ group ( P's b .001). Strong associations between PHQ-9 depression severity and convergent variables were found (with BDI r = .73, with GHQ-12 r = .59). Conclusion: The results support the construct validity of the PHQ depression scale, which seems to be a useful tool to recognize not only major depression but also subthreshold depressive disorder in the general population. D

Research paper thumbnail of Lower decision threshold for doctor visits as a predictor of health care use in somatoform disorders and in the general population

General Hospital Psychiatry, 2008

More than half of all outpatient visits are trigged by physical symptoms which, in turn, are not ... more More than half of all outpatient visits are trigged by physical symptoms which, in turn, are not adequately explained by medical disorders at least half of the time. Further, the presence and severity of somatic symptoms often correlate more strongly with psychological, cognitive and behavioral factors than with physiological or biological findings. Finally, our understanding of the etiology, evaluation, and management of somatic symptoms and functional syndromes is less advanced than our knowledge of many defined medical and psychiatric disorders. This special section, edited by Kurt Kroenke, M.D., will highlight original studies that advance the science and clinical care of somatic symptoms.

Research paper thumbnail of The estimated prevalence and correlates of adult ADHD in a German community sample

European Archives of Psychiatry and Clinical Neuroscience, 2012

Little research on the prevalence and correlates of adult ADHD has been conducted outside the Uni... more Little research on the prevalence and correlates of adult ADHD has been conducted outside the United States. The aim of the present study was to estimate the prevalence and correlates of adult ADHD in a large representative sample of the German population aged 18-64 years (n = 1,655). Two self-rating screening instruments to assess childhood and adult ADHD symptomatology were used to estimate the prevalence of ADHD. A 4-item screening tool was used to assess probable cases of current depression and anxiety (Patient Health Questionnaire). The estimated crude prevalence rate of current ADHD was 4.7%. Adult ADHD was significantly associated with lower age, low educational level, unemployment, marital status (never married and divorced), and rural residency. No association was found with gender. Adult ADHD was strongly associated with positive screening results for depression and anxiety. ADHD is a common disorder of adulthood, is associated with significant social impairment and psychiatric co-morbidity, and should receive further research attention.

Research paper thumbnail of Sind Vergleiche im Depressions- und Somatisierungsausmaß zwischen Migranten und Deutschen möglich?

Diagnostica, 2010

Zusammenfassung: Zur Erfassung der psychischen Gesundheit von Migranten im Vergleich zu Deutschen... more Zusammenfassung: Zur Erfassung der psychischen Gesundheit von Migranten im Vergleich zu Deutschen sind Untersuchungen in der Allgemeinbevölkerung zentral. Für diesen Ansatz hat sich die Verwendung des Depressivitäts-und des Somatisierungsmoduls des Patient Health Questionnaire (PHQ-9, PHQ-15) bewährt. Es ist jedoch unklar, ob diese Module bei Migranten das Gleiche messen wie bei Deutschen (Messäquivalenz). Dadurch bleibt es fraglich, ob die Ergebnisse vergleichender Studien richtig interpretierbar sind.

Research paper thumbnail of Dispositional emotion coping styles and physiological responses to expressive writing

British Journal of Health Psychology, 2013

The purpose of these two studies was to assess how repressors and defensive, high-anxious individ... more The purpose of these two studies was to assess how repressors and defensive, high-anxious individuals exhibit their psychological and health characteristics subjectively through self-reports and objectively through physiological markers and ratings of emotional expression. Cross-sectional descriptive design (study one) and randomized controlled design (study two). In the first descriptive study, repressors, defensive, high-anxious individuals and low-anxious individuals were identified from a pool of 748 undergraduates. Participants were asked to complete questionnaires assessing psychological and health characteristics. In the second experimental study, the three groups were randomized into either emotional or non-emotional writing conditions. Participants were asked to write three essays on either an emotional or a non-emotional topic in a single day. In the first study, defensive, high-anxious individuals reported significantly more distress, symptoms, sickness behaviours and difficulty expressing anger relative to repressors. In the second study, there was a significant difference in salivary cortisol concentrations between the two writing conditions regardless of the emotional coping grouping. Analysis of the writing showed no significant differences among repressors, defensive, high-anxious and low-anxious individuals in their cognitive and affective expression. Whereas self-reports of health outcomes and psychological traits clearly distinguish repressors and defensive, high-anxious individuals, more objective indices of emotional expressiveness and physiology do not appear to do so. The results also indicate that expressive writing may be helpful to reduce physiological arousal towards emotionally charged memories.