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Objective: A consensual definition of occupational burnout is currently lacking. We aimed to harmonize the definition of occupational burnout as a health outcome in medical research and reach a consensus on this definition within the Network on the Coordination and Harmonisation of European Occupational Cohorts (OMEGA-NET). Methods: First, we performed a systematic review in MEDLINE, PsycINFO and Embase (January 1990 to August 2018) and a semantic analysis of the available definitions. We used the definitions of burnout and burnout-related concepts from the Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) to formulate a consistent harmonized definition of the concept. Second, we sought to obtain the Delphi consensus on the proposed definition. Results: We identified 88 unique definitions of burnout and assigned each of them to 1 of the 11 original definitions. The semantic analysis yielded a first proposal, further reformulated according to SNOMED-CT and the panelists` comments as follows: "In a worker, occupational burnout or occupational physical AND emotional exhaustion state is an exhaustion due to prolonged exposure to work-related problems". A panel of 50 experts (researchers and healthcare professionals with an interest for occupational burnout) reached consensus on this proposal at the second round of the Delphi, with 82% of experts agreeing on it. Conclusion: This study resulted in a harmonized definition of occupational burnout approved by experts from 29 countries within OMEGA-NET. Future research should address the reproducibility of the Delphi consensus in a larger panel of experts, representing more countries, and examine the practicability of the definition. This study was supported by the University of Lausanne and European Cooperation in Science and Technology, Action CA 16216 "Network on the Coordination and Harmonisation of European Occupational Cohorts” (OMEGA-NET). info:eu-repo/semantics/publishedVersion

Soldiers regularly participate in missions abroad and subjectively adapt to this situation. However, they have an increased lifetime cardiovascular risk compared to other occupational groups. To test the hypothesis that foreign deployment results in different stress habituation patterns, we investigated long-term psychological and bio-physiological stress responses to a repeated social stress task in healthy soldiers with and without foreign deployment. Ninety-one female and male soldiers from the BEST study (German armed forces deployment and stress) participated three times in the Trier Social Stress Test for groups (TSST-G) prior to, 6–8 weeks after and 1 year after the mission abroad and were compared to a control group without foreign deployment during the study period. They completed the State-Trait-Anxiety Inventory scale (STAI), the Primary Appraisal Secondary Appraisal questionnaire (PASA) and the Multidimensional Mood State Questionnaire (MDBF). Salivary cortisol and α-amylase, blood pressure, heart rate and heart rate variability were determined. Soldiers showed mental habituation over the three times with a significant decrease after the TSST-G in anxiousness (STAI) and cognitive stress appraisal (PASA), they were calmer and reported better mood (MDBF). Prior to the social stress part, the mood (MDBF) declined significantly. None of the biological and physiological markers showed any adaptation to the TSST-G. Mission abroad did not significantly influence any measured psychobiological marker when compared to soldiers without foreign deployment. Foreign deployment does not result in alterations in psychobiological social stress response patterns over 1 year after mission abroad which indicates that adaptation to acute social stress is highly maintained in healthy soldiers. The discrepancy between subjective perception and objective stress response has numerous clinical implications and should receive more attention.

Zusammenfassung Ziel der Studie Untersuchung von Erfahrungen depressiv erkrankter Väter zum Umgang mit der Erkrankung in der Familie. Methoden 17 teilstrukturierte Interviews wurden entlang der Grounded Theory Methodology durchgeführt und analysiert. Ergebnisse Väter beschreiben überwiegend Strategien im Umgang mit ihrer depressiven Erkrankung, die eine Bewältigung unabhängig von der Familie vorsehen (Selbstmanagement, [Nicht-]Sprechen über die Erkrankung). Schlussfolgerung Väter brauchen Unterstützung in der (Entscheidung zur) Offenlegung ihrer Erkrankung gegenüber der Familie sowie für die Entwicklung von Bewältigungsstrategien, die Bedarfe der Familie stärker berücksichtigen.

Aim This study aimed to identify and compare age stereotypes of registered nurses and supervisors in clinical inpatient settings. Design Generic qualitative study using half‐standardized interviews. Method Nineteen face‐to‐face interviews and five focus groups (N = 50) were conducted with nurses of varying levels at a hospital of maximum medical care in Germany between August and November 2018 and were subjected to structured qualitative content analysis. Results Reflecting the ageing process and cooperation in mixed‐age teams, nursing staff and supervisors defined similar age stereotypes towards older and younger nurses reminiscent of common generational labels ‘Baby Boomers’ and Generations X. Their evaluation created an inconsistent and contradictory pattern differing to the respective work context and goals. Age stereotypes were described as both potentially beneficial and detrimental for the individual and the cooperation in the team. If a successfully implemented diversity management focuses age stereotypes, negative assumptions can be reduced and cooperation in mixed‐age teams can be considered beneficial. Conclusion Diversity management as measures against age stereotypes and for mutual acceptance and understanding should include staff from various hierarchical levels of the inpatient setting., publishedVersion

Studies on the effectiveness of stress management interventions (SMIs) currently lack long-term evaluations. Accordingly, this article addresses questions of how workers who experience SMIs evaluate change after the intervention as well as how SMIs’ implementation can be improved. By processing 50 semi-structured interviews by a qualitative analysis, results indicate that participants perceive themselves as highly engaged and motivated at work. Attributing their engagement at work as a positive coping strategy, the in-depth qualitative analysis reveals forms of over-engagement: temporary over-engagement is considered a positive reaction to an increased work demand in the past, and it fails to work for the new cumulative stress that workers face. Additionally, identifying four different groups of SMI utilizers, we conclude that specific groups of participants benefit from individualized intervention strategies. SMI effectiveness increases, both for the individual productivity and for the corporate productivity, when focusing on the individual work engagement and providing individualized interventions.

The aim of this study was to identify and explore mediators of psychodynamic-interpersonal psychotherapy (PIT) on treatment outcome in multisomatoform disorders (MSD).Data from 164 patients with MSD who took part in a randomized control trial of PIT (Stress partially mediated the effect of PIT vs. EMC on the follow-up outcome. PIT (as compared to EMC) led to lower post-treatment stress-levels, which in turn led to higher physical quality of life at follow-up. Neither depression nor the alliance had a mediating effect.Stress mediated the outcome of PIT for MSD. Future studies are needed to extend the scope of research regarding which specific psychotherapeutic mechanisms of change are beneficial in PIT treatment of MSD patients.

Purpose An increasing prevalence of work-related stress and employees’ mental health impairments in the health care sector calls for preventive actions. A significant factor in the workplace that is thought to influence employees’ mental health is leadership behavior. Hence, effective leadership interventions to foster employees’ (leaders’ and staff members’) mental health might be an important measure to address this pressing issue. Methods We conducted a systematic review according to the PRISMA statement (Liberati et al. 2009) and systematically searched the following databases: PubMed (PMC), Web of Science, PsycINFO (EBSCOhost), EconLit (EBSCOhost), and Business Source Premier (EBSCOhost). In addition, we performed a hand search of the reference lists of relevant articles. We included studies investigating leadership interventions in the health care sector that aimed to maintain/foster employees’ mental health. Results The systematic search produced 11,221 initial search hits in relevant databases. After the screening process and additional literature search, seven studies were deemed eligible according to the inclusion criteria. All studies showed at least a moderate global validity and four of the included studies showed statistically significant improvements of mental health as a result of the leadership interventions. Conclusions Based on the findings, leadership interventions with reflective and interactive parts in group settings at several seminar days seem to be the most promising strategy to address mental health in health care employees. As the available evidence is limited, efforts to design and scientifically evaluate such interventions should be extended.

Psychological stress caused by epidemics among health care workers and implications for coping with the corona crisis: a literature review Objectives: COVID-19 has significantly changed the working and living conditions within a short period. Despite the milder course of the disease in comparison to other countries, employees in the German health care system are particularly affected by the massive impact of the disease on their professional and private lives. From a scientific point of view, summarized empirical evidence made during other epidemics and at the beginning of the COVID-19-pandemic is largely missing. Methods: Narrative review article, literature search on PubMed database. Results: A total of 56 studies were included, 35 of them on the SARS epidemic and seven on COVID-19; included studies reported overall increased stress levels, anxiety and PTSD symptoms due to health care work during various epidemics. Direct contact with patients, quarantine experiences and perceived health risks were further stress factors in epidemics. Participation in intervention studies enabled better management of epidemic-related situations. Conclusions: Healthcare workers are exposed to high workloads because of epidemics, which can have a variety of adverse effects. Recommendations are made for dealing with periods of high exposure during the COVID-19-pandemic.

Zusammenfassung Am Arbeitsplatz Krankenhaus besteht eine besonders hohe Stressbelastung, was ein Risiko für die Entstehung psychischer Erkrankungen sein kann. Da Führungskräfte die Gesundheit der Beschäftigten beeinflussen können, kann eine Führungskräftefortbildung verhältnispräventiv wirken. Dieser Beitrag beschreibt gesundheitsförderliche Führungsstile und stellt dann exemplarisch eine entsprechende Führungskräftefortbildung aus einem Teilprojekt eines BMBF geförderten Verbundprojektes vor.

Research indicates that managers’ active support is essential for the successful implementation of mental health-related organizational interventions. However, there is currently little insight into what subjective beliefs and perceptions (=mental models) make leaders support such interventions. To our knowledge, this is the first qualitative systematic review of this specific topic, and it considers 17 qualitative studies of managers’ perspective. Based on the theory of planned behavior, this review provides an overview of three action-guiding factors (attitudes, organizational norms and behavioral control) that can serve as starting points for engaging managers in the implementation of mental health-related measures and ensuring their success. Our results provide evidence that supportive organizational norms may particularly help to create a common sense of responsibility among managers and foster their perceived controllability with respect to changing working conditions. Our study thus contributes to a more differentiated understanding of managers’ mental models of health-related organizational interventions., publishedVersion

Zusammenfassung Ziel der Studie Befragung von Mitarbeitern im Krankenhaus zu arbeitsbedingten Fehlbelastungen und Stressfolgen sowie Konsequenzen für Interventionen zur Stressreduktion am Arbeitsplatz. Methodik Es wurden 6 Fokusgruppen und 7 semistrukturierte Interviews mit 34 Krankenhausmitarbeitern durchgeführt, welche inhaltsanalytisch ausgewertet wurden. Ergebnisse Mitarbeiter berichteten von Stressfolgen durch Personalmangel, hohes Arbeitsaufkommen, fehlende Rückzugs- und Versorgungsmöglichkeiten, fehlende Absprachen, intransparente Arbeitsabläufe, Teamkonflikte und fehlende Wertschätzung. Berichtete Faktoren, die zur Reduktion von Stressfolgen führten, waren soziale Unterstützung, Arbeitszeitreduktion, Sport und Entscheidungskompetenzen. Schlussfolgerung Interventionen zur Reduktion arbeitsbedingter Fehlbelastungen im Krankenhaus sollten sowohl berufsgruppenspezifische Interventionsangebote sowie organisationale Normen und strukturelle Rahmenbedingungen berücksichtigen.

Aims and objectives To test a mediating effect of compassion satisfaction on the relationship between personality traits (Big Five) and intent to leave. Background Nursing professionals work in high-stress environments and exhibit more emotional distress and mental health disorders than other hospital professionals. This translates to increased intention to leave their profession. Evidence suggests that compassion satisfaction reduces intention to leave. Research also indicates that personality factors are associated with compassion satisfaction and intent to leave. Design Using a cross-sectional design, we collected data from 536 nurses in a maximum-care hospital in Germany via questionnaires; the analyses included 518 participants. Method We applied the structural equation model and followed the STROBE checklist. Results 30% of our study participants reported high intent to leave. Compassion satisfaction mediated the relationship between agreeableness and intent to leave. Openness to experience and neuroticism had positive direct effects on intent to leave. Conclusions The results suggest that high compassion satisfaction levels may decrease intention to leave levels. Personality traits impact compassion satisfaction and intention to leave. Relevance to clinical practice Nursing professionals' compassion satisfaction needs to be improved, for example by resilience training. As personality factors remain relatively stable over time, caregivers need to consider them when identifying appropriate areas of work and responsibility.

Healthcare professionals’ exposure to work-family conflict negatively affects the health and well-being of the whole family and organizational outcomes. Specified workplace interventions are lacking. Therefore, the aim of the study was to evaluate the feasibility of a two-day group-treatment specifically designed for the needs of healthcare professionals with family responsibilities concerning participation, satisfaction with the intervention and family- and individual-related outcome variables. 24 mostly female (85.7%) participants of a community hospital in southern Germany attended the treatment. Data were collected at baseline (T0), directly after the treatment (T1) and two months later (T2). A two-factor analysis of variance with repeated measures showed a statistically significant time x group effect for self-efficacy (F = 5.29, p = 0.011). Contrasts displayed substantial pre-post (T1-T0, T2-T0) increases of self-efficacy in the intervention group as compared with the control group. Non-parametric Mann-Whitney-U tests are in line with these findings. The results indicate that the group-treatment adapted to the needs of healthcare professionals has the potential to boost self-efficacy among healthcare professionals and that participants were predominantly satisfied. Perspectives for future research and practical implications are discussed in the light of the manifest lack of healthcare professionals.

Background Adverse childhood experiences (ACEs) increase the risk for mental health problems. However, there is a lack of data targeting the role of ACEs for one of the most prevalent mental health problems in health-care professionals: burnout. Objective We aimed to assess the relationship between ACEs and the core burnout dimension ‘emotional exhaustion’ (EE). As health-care professionals have been facing particular challenges during the COVID-19 pandemic, we furthermore aimed to assess the role of COVID-19 associated burden in the interplay between ACEs and EE. Methods During the first lockdown in Germany, a total of 2500 medical healthcare professionals were questioned in a cross-sectional online survey. Questions targeted, among others, sociodemographics, ACEs, COVID-19-associated problems (e.g. increase of workload, worries about relatives and patients) and emotional exhaustion, measured by the respective dimension of the Maslach Burnout Inventory (MBI). Results In German health-care professionals, ACEs were associated with a higher EE score. The number of experienced ACEs was associated with the majority of assessed COVID-19-associated problems. An increasing number of ACEs predicted higher EE scores, controlling for gender. The association between ACEs and EE was mediated significantly by COVID-19-associated problems. These included maladaptive coping strategies such as increased smoking, drinking and use of antidepressants/tranquilizers, feeling less protected by measures of the employee or the state, a greater feeling of being burdened by COVID-19-associated problems and greater exhaustion and sleep problems. Conclusion Our findings suggest ACEs as significant risk factor for EE in German health-care professionals. The current pandemic means a significant burden that further pronounces this risk., HIGHLIGHTS Adverse childhood experiences (ACEs) predicted higher scores of emotional exhaustion (EE) in German healthcare professionals during the COVID-19 pandemic.COVID-19 associated problems mediated the association between ACEs and EE.COVID-19 and ACEs add to the risk of EE in healthcare professionals.

Why the concept of distinct psychotherapeutic approaches is indispensable - and why the tool box concept of psychotherapy cannot work Background: In Germany, the official psychotherapy guidelines are oriented towards the model of distinct psychotherapeutic approaches. Within the German health care system this also applies to the training in psychotherapy. Some critics, however, are presently pleading in favour of abolishing the model of distinct psychotherapeutic approaches, which also implies to abolish the concept of the so called "Richtlinienverfahren" in Germany - approaches of psychotherapy which proved to be efficacious and whose costs are reimbursed by the insurance companies. Objective: The arguments put forward such as the heterogeneity of the approaches as well as the proposed alternatives, for example, an "integrative" model of both mental disorders and psychotherapeutic treatment are critically discussed. Results: Both the arguments and proposed alternatives are found to be not convincing, neither from a scientific nor from a psychotherapeutic perspective. From a scientific perspective, there is no evidence for efficacy of a "general" or "integrative" model of psychotherapy - which is in contrast to the Richtlinienverfahren for which evidence for efficacy exists. From a psychotherapeutic perspective psychotherapy cannot be taught, learnt and applied by use of tools or modules without a theoretical orientation. Conclusions: The concept of distinct psychotherapeutic approaches proves to be an in dispensable principal for orientation in psychotherapy, for both therapists and patients.

ZusammenfassungArbeit und psychische Gesundheit stehen in einer engen wechselseitigen Beziehung zueinander. Psychisch bedingte Arbeitsunfähigkeitszahlen steigen seit Jahren an, sodass die Thematik für viele Betriebe, aber auch gesamtgesellschaftlich an Bedeutung gewonnen hat.Dieser Artikel gibt zunächst einen Überblick über verschiedene Arbeitsstressmodelle sowie über die Abbildung arbeitsbezogener psychischer Störungen in den Klassifikationssystemen ICD und DSM. Der Begriff Burnout wird erläutert, die Begriffsätiologie dargestellt und ein sinnvoller Einsatz des Begriffs in der klinischen Praxis beschrieben. Darüber hinaus wird die Einteilung arbeitsbezogener psychischer Störungen der Internationalen Arbeitsorganisation (engl. International Labour Organization, ILO) vorgestellt. Anschließend wird auf mögliche Interventionsmodelle zur Prävention und Therapie arbeitsbezogener psychischer Erkrankungen sowie auf die wesentlichen Bestandteile einer arbeitsbezogenen Psychotherapie eingegangen. Schließlich werden Handlungsempfehlungen im internationalen Vergleich dargestellt.

Background: Many studies indicate that men are more reluctant to seek help for mental health problems than women. Traditional ideas of masculinity are often seen as a cause of this phenomenon. However, little is known about the diversity of experiences during the processes of help-seeking and service use among men with depression who have already utilized mental health services. This study aims to explore men's experiences and attitudes toward depression, help-seeking, and service use in order to develop gender-sensitive services. Methods: Narrative-biographical interviews were conducted with men treated for depression (n = 12). Interview topics included individual experience with depression, help-seeking behavior, and mental health service use. Transcripts were analyzed using qualitative content analysis. Results: Before seeking treatment, men's help-seeking behavior was negatively affected by internalized masculine norms. However, findings indicate a change of attitudes toward depression after mental health service use. Men with depression emphasized a salutogenic perspective toward mental health problems and critically reflected on masculine norms. The positive function of men-only groups were described as key for successful service use. Conclusions: Men with depression reported experiences toward help-seeking and service use on four different levels: (i) attitudes toward depression, (ii) perception of societal views on depression, (iii) experiences within the family context and (iv) experiences with mental health services. Interventions to reduce the stigma of being “unmanly” and to improve men's capacity to cope with being unable to work should be developed. Peer-led men-only groups may increase participants' self-esteem and assist in disclosing weaknesses. In the context of GPs' mediating role, training for health professionals concerning the impact of masculine norms on mental health is recommended., publishedVersion

Working conditions in hospitals are characterized by occupational stressors, which lead to potentially harmful psychosocial stress reactions for medical and nursing staff. Representative surveys showed that almost every second hospital physician or nurse is affected by burnout and that there is a strong association between leadership behavior and employee health. Workplace health promotion programs can only be successful and sustainable if managers support them. However, it is still unclear whether hospital managers are aware of the working conditions and perceive them as an influence on the health of their employees. Therefore, the aim of this qualitative study was to explore the hospital medical and nursing managers&rsquo, perspective on the mental stress of their employees. Semi-standardized interviews with 37 chief physicians (CP), senior physicians (SP) and senior nurses (SN) in total were carried out in one German hospital. The interviews were content-analyzed based on the guideline for the mental risk assessment of the &lsquo, Gemeinsame Deutsche Arbeitsschutzstrategie&rsquo, (GDA). Most reported work characteristics related to work organization, work task, and social factors. Staff shortage could be identified as an underlying stressor for several other burdens. Social support by managers and among colleagues was mentioned as main resource. The findings indicate that managers strive to reduce the burden on their staff, especially through their personal support. Nevertheless, it seemed that managers need additional resources to counteract stressors.

Purpose Common mental disorders (CMDs) are becoming increasingly relevant in the working world. Numbers of risk factors have been confirmed by mostly correlative cross-sectional studies. Comprehensive and effective prevention is urgently needed. There is little knowledge about employees’ own perceptions on causes of CMDs and prevention measures. Therefore, a survey was conducted in 2016. Methods A standardised instrument was developed for an online survey in a commercial access panel, targeted employees in different job types. We assessed two outcomes: perceived relevance of (1) work-related demands to the development of CMDs, and (2) prevention approaches in the workplace and on individual and societal levels. Possible predictive aspects were analysed exploratively by multivariate linear regression analysis. Results The response rate was 75% (n = 610). Job types were categorised as “blue”, “grey” and “white-collar” workers (n = 193, 169, 248). The majority of respondents rated both outcomes consistently as “quite” or “very relevant”; societal prevention strategies were more relevant for non-white-collar workers. Perceived relevance of individual predisposition to develop a CMD was the strongest predictor for both outcomes, indicating the perception that people with higher personal vulnerability might suffer a higher strain from work-related risk factors than others. Conclusion We assume that participants in our survey judged the relevance of work-related causes of CMDs independently of their own workload. The perceived relevance of prevention measures in different areas is consistent with official guidelines. A possible selection bias due to characteristics of access panel collectives and own direct or indirect experiences with CMD should be critically questioned. Electronic supplementary material The online version of this article (10.1007/s00420-019-01414-7) contains supplementary material, which is available to authorized users.

Purpose A traditional male role orientation is considered to increase the risk of depression and preventing men from disclosing symptoms of mental illness and seeking professional help. Less is known about the variance of masculinity orientations in men already treated for depression and their role in the treatment process. In this study, patterns of masculinity norms and work role orientations will be identified among men treated for depression. Associations of these patterns with depressive symptoms, stigma and delay in professional help-seeking will be investigated. Methods In a cross-sectional study, male role orientations (MRNS), work-related attitudes (AVEM), symptoms of mental disorders (PHQ), and attitudes related to stigma of mental illness (DSS) were assessed by standardized methods in a sample of 250 men treated for depression in general medical, psychiatric and psychotherapeutic services. Data were analyzed by means of latent profile analysis (LPA), by multinomial and linear regression models, and by path analysis. Results The results of LPA revealed three latent classes of men treated for depression. Men assigned to class one reported a less traditional male role orientation, low professional ambitions and low coping capacities; men assigned to class two reported a traditional masculinity orientation, high professional ambitions but low coping capacities; men assigned to class three reported less traditional masculinity tended orientations, medium professional ambitions and high coping capacities. Men assigned to classes one and two to have more stigmatizing attitudes, longer periods of untreated illness and more severe symptoms of mental disorders, in comparison to men assigned to class three. Conclusions Overall, this study reveals that traditional masculinity norms and work-role orientations in men treated for depression are associated with a worse mental health status. Our study results also suggest that a slackening of traditional masculinity norms is associated with improved psychological well-being if it does not coincide with a complete distancing from professional ambitions and a lack of ability to cope with professional stress.

Selective optimization with compensation (SOC) is regarded as a powerful action strategy to cope with age-related changes in resources. Occupational interventions based on SOC might therefore make an important contribution to successful aging at work. However, SOC interventions at work are scarce. Against this background we investigated (a) whether employees can be trained with SOC, (b) whether job characteristics (job autonomy, job demands) and individual resources (job experience, self-efficacy), and chronological age moderate the effects of the intervention on SOC. We conducted 3 randomized controlled interventions among 253 nurses (chronological age 22-64 years). One hundred twenty-nine nurses were randomized to trainings that involved exercise of SOC-behaviors (intervention group, IG) and 124 were randomized to the control group (CG). Results: (a) The interventions showed a significant overall positive effect on SOC. (b) There was a significant positive effect of the intervention on SOC when job demands are low. There were no such moderating effects of job autonomy, job experience, self-efficacy, and chronological age. Our findings indicate that employees can be trained to use SOC-strategies at work. High job demands can impair the training effects, which indicate that the initial acquisition of SOC requires resources.

Experiencing maltreatment during childhood can have long-lasting consequences for both mental and physical health. Immune cell telomere length (TL) shortening might be one link between child maltreatment (CM) experiences and adverse health outcomes later in life. While the stress hormone cortisol has been associated with TL attrition, the attachment-related hormone oxytocin may promote resilience. In 15 mothers with and 15 age- and body mass index-matched mothers without CM, we assessed TL in peripheral blood mononuclear cells and selected immune cell subsets (monocytes, naive, and memory cytotoxic T cells) by quantitative fluorescence in situ hybridization, as well as peripheral cortisol and oxytocin levels. Memory cytotoxic T cells showed significantly shorter TL in association with CM, whereas TL in monocytes and naive cytotoxic T cells did not significantly differ between the two groups. Across both groups, cortisol was negatively associated with TL, while oxytocin was positively associated with TL in memory cytotoxic T cells. These results indicate that long-lived memory cytotoxic T cells are most affected by the increased biological stress state associated with CM. Keeping in mind the correlational and preliminary nature of the results, the data suggest that cortisol may have a damaging and oxytocin a protective function on TL.

Psycho-mental stressors and increased perceived stress in workplace settings may determine the onset and course of stress-related mental and psychosomatic disorders. For the description of psycho-mental stressors three distinct models have widely been used in the analyses of the matter: the Demand-Control-Model by Karasek and Theorell, the Effort-Reward-Imbalance Model by Siegrist, and the Model of Organisational Justice.The interactional or social dimension in work-place settings can be seen as a cross-sectional dimension to the above mentioned models. Here, social conflicts and mobbing, as specific forms of interactional problems, are of importance.Besides measures of primary prevention which can be derived from applying the above mentioned models, attention is paid increasingly to secondary and tertiary preventive measures in work-place settings. Concepts such as the psychosomatic consultation-hour within the context of workplace showed to be effective measures for the early detection of people at risk or early stages of e. g. stress-related psychosomatic disorders.Furthermore, step-wise reintegration of members of the work-force play an important role within the effort to retain the ability to work and the workplace of individuals who suffered from stress-related mental disorders, as it has to be stressed that working and social interactions at the workplace may well be a resource that enhances and stipulates psycho-mental well-being and mental health.This CME-Article describes the above mentioned models and discusses selected perspectives of preventive measures to avoid stress-related mental disorders in members of the work-force.

Zusammenfassung Ziel der Studie Analyse der Bedeutung von männlichkeits- und berufsrollenbezogenen Orientierungsmustern für Krankheitstheorien und Bewältigung bei depressiv erkrankten Männern. Methodik Rekonstruktive Auswertung biografisch-narrativer Interviews von 12 Männern mit depressiver Erkrankung. Ergebnisse Die berufsrollenbezogene Orientierung wird generell als Ursache der depressiven Erkrankung genannt. Gleichzeitig zeigen sich Unterschiede im Verständnis sowie in der Bewältigung der depressiven Erkrankung. Während ein Teil der Befragten trotz der berufsbedingten Krisenerfahrung an der beruflichen Orientierung festhält, nutzen andere die Depression als Chance zur Veränderung gesundheitsschädlicher Lebens- und Arbeitsentwürfe. Schlussfolgerung Prioritäten in Bezug auf Arbeits- und Lebensentwürfe und deren Bedeutung für die Krankheitsbewältigung sollten in der Behandlung thematisiert werden.

Introduction: A good relationship quality between leaders and staff members promotes mental health and prevents stress. To improve the relationship quality, it is important to identify variables which determine relationship quality at the workplace. Therefore, this study aims to identify specific leadership characteristics which support the development of a positive relationship between hospital leaders and staff members. Methods: A cross-sectional study design was applied. A total number of 1,137 leaders (n = 315) and staff members (n = 822) of different professions (physicians, nursing staff, therapeutic professionals, administration staff, IT staff, clinical services, office assistants, scientists, others) working at a tertiary hospital in Germany assessed transformational leadership style as a staff-oriented leadership style and leader–member relationship quality by self-report questionnaires [integrative leadership questionnaire (FIF), leader–member exchange (LMX-7) questionnaire]. The data were statistically analyzed by mean comparisons and a multiple linear regression analysis. Results: Leaders rated their own transformational leadership style (M = 3.98, SD = 0.43) systematically higher than staff members assessed their leader (M = 2.86, SD = 1.04). Evaluation of relationship quality showed similar results: leaders evaluated their relationship quality to one exemplary staff member higher (M = 4.06, SD = 0.41) than staff members rated their relationship quality to their direct leader (M = 3.15, SD = 0.97). From the staff members’ perspective, four sub-dimensions of transformational leadership, that is, “individuality focus,” “being a role model,” “fostering innovations,” and “providing a vision” showed large effect sizes in the regression analysis of relationship quality (R 2 = 0.79, F (14,690) = 189.26, p < 0.001, f = 1.94). Discussion: The results of our study are in line with previous investigations in other working contexts and point to a profession-independent association as the professional group of participants did not contribute to the variance explanation of the regression analysis. The exploration of potential determinants of relationship quality at work can, for example, support the development of leadership training programs with a focus on transformational leadership style. This might be an opportunity to foster high relationship quality between leaders and staff members and consequently might represent one strategy to prevent stress in the health care sector.

While biological alterations associated with childhood maltreatment (CM) have been found in affected individuals, it remains unknown to what degree these alterations are biologically transmitted to the next generation. We investigated intergenerational effects of maternal CM on DNA methylation and gene expression in N = 113 mother-infant dyads shortly after parturition, additionally accounting for the role of the FKBP5 rs1360780 genotype. Using mass array spectrometry, we assessed the DNA methylation of selected stress-response-associated genes (FK506 binding protein 51 [FKBP5], glucocorticoid receptor [NR3C1], corticotropin-releasing hormone receptor 1 [CRHR1]) in isolated immune cells from maternal blood and neonatal umbilical cord blood. In mothers, CM was associated with decreased levels of DNA methylation of FKBP5 and CRHR1 and increased NR3C1 methylation, but not with changes in gene expression profiles. Rs1360780 moderated the FKBP5 epigenetic CMassociated regulation profiles in a gene �� environment interaction. In newborns, we found no evidence for any intergenerational transmission of CM-related methylation profiles for any of the investigated epigenetic sites. These findings support the hypothesis of a long-lasting impact of CM on the biological epigenetic regulation of stress-response mediators and suggest for the first time that these specific epigenetic patterns might not be directly transmitted to the next generation., publishedVersion

IntroductionEpidemics lead to an increase in occupational stress and psychological strain among medical staff (cf. Mulfinger et al. 2020). However, there are no validated questionnaires to measure stress caused by an epidemic such as Covid-19, instead self-constructed questions are used frequently.ObjectivesThe aim was to develop items for the assessment of specific workload in epidemics which can be used to obtain longitudinal data.MethodsA sample of N=8078 persons working in the health care sector in Germany participated in the VOICE, EviPan online survey addressing the burden of Covid-19 pandemic during the 2nd quarter of 2020. We used 15 self-constructed items to examine whether these items can represent Covid-19 specific topics. A total of N=7549 (24% males) had complete data to run a confirmatory factor analysis using SEM procedure in Stata 14.2.ResultsFive factors were identified a priory: Factor (F) 1: Workload due to Covid-19 pandemic (4 items; Cronbachs’ alpha (α))=0.740); F 2: Fear, uncertainty of SarsCoV-2infection (self and others) (3 items; α= 0.741); F 3: Patient safety (3 items; α=0.533; F 4: Perception of protection concepts (2 items; α=0.590); F 5: Dysfunctional coping strategies (3 items; α=0.447). Fit-Indices: χ²(73)= 1373.849, pConclusionsWe identified 5 factors associated with problems occurring during the Covid-19 pandemic with acceptable to good internal consistency. Most of the constructed items could therefore be used in further surveys to monitor stress, as a basis for recommendations in the area of stress prevention and interventions for medical staff during epidemics.

OBJECTIVE: This study aimed to examine prospectively the influence of exposure to job insecurity during working life on subjective well-being (SWB) after retirement, an association which has not been studied to date. METHOD: Data were derived from the prospective population-based MONICA/KORA study conducted in southern Germany. Participants were recruited and data were collected during three independent surveys between 1984-1995 (T1) and followed up in 2009 (T2). The study sample consisted of 1801 employed participants (1146 male/ 655 female) aged 41-72 years at T1 and ≥65 years at T2, without missing data. Self-administered questionnaires and clinical examinations were used to assess job insecurity and risk factors at T1 and SWB at T2. Mean follow-up was 19.6 years. Logistic regression analyses were performed to determine the association of job insecurity with SWB after retirement. We accounted for an extensive set of sociodemographic, lifestyle-, health- and work-related risk factors. RESULTS: At T1, 39.5% of the participants reported job insecurity, which was associated with a 1.40-fold [95% confidence interval (95% CI) 1.08-1.82] risk of low SWB at T2 in models adjusted for sociodemographic and lifestyle- and health-related conditions at T1. Additional adjustment for a set of work-related risk factors at T1 had little effect on this association. CONCLUSIONS: Exposure to job insecurity at midlife was associated with low SWB in retirement, even after controlling for an extensive set of risk factors. This shows that the negative effects of unstable working conditions might persist well into retirement, long after cessation of employment.

Cardiovascular disorders (CVD) and posttraumatic stress disorder (PTSD) are highly comorbid, but the underlying mechanisms are not fully understood. Chronic psychosocial stress was induced in male mice by chronic subordinate colony housing (CSC), a pre-clinically validated mouse model for PTSD. Cardiac structure and function were assessed on day 20 of the CSC paradigm. Following CSC, mice were kept in different sensory contact modalities to the last aggressor for 30 days, and development of cardiac function and behavioral aspects were determined. Here we show that psychosocial trauma affects heart structure by disturbing cell-to-cell integrity of cardiomyocytes, causes tachycardia, disturbance of diurnal heart rate rhythmicity and behavioral deficits in a mouse model for PTSD. Structural and functional alterations were also found in cardiomyocytes upon in vitro treatment with pro-inflammatory cytokines typically increased after psychosocial trauma. Interestingly, sensory contact to the aggressor subsequent to psychosocial trauma prohibits functional and structural heart recovery, while isolation was beneficial for cardiac but detrimental for mental health. These findings contribute to our understanding of potential mechanisms underlying the high comorbidity of CVD and PTSD.

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 proposed 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 such as expectation are assigned a role, not only in the later amplification of bodily signals but also 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 such as virtual reality techniques combining exteroceptive and interoceptive information. ispartof: Psychosomatic Medicine vol:80 issue:5 pages:422-431 ispartof: location:United States status: published

Introduction Many studies investigate the possible positive and negative effects of work-related factors on mental health of employees, but only little is known about the attitudes of the persons involved. Therefore we aimed to assess the perceptions of occupational health physicians (OHP), primary care physicians (PCP), psychotherapists (PT), human resources managers (HRM), and employees (EMP) with regard to work-related risk factors and possibilities for prevention of common mental disorders (CMD) at the workplace. Methods A standardised questionnaire was developed to assess the individuals´ attitudes with regard to different aspects of prevention of CMD in employees. The survey assessing the estimates concerning work-related and individual risk factors, cooperation of persons involved, and engagement of specific institutions first was developed for a postal survey among OHPs, PCPs, PTs, and HRMs in 2014. 1 Second, the content was slightly adapted to perform an online survey among employees addressing an online access panel in 2016. Besides descriptive measures or explorative bivariate methods, multivariate logistic regression analysis with IBM SPSS 22 was computed. Results Data were gathered from 133 OHPs (response rate 30%), 136 PCPs (14%), 186 PTs (27%), 172 HRMs (12%) and 610 EMPs (stipulated number of participants). The significance of several work-related factors (e.g. work-related demands, work organisation) for the development of CMD in employees was judged rather similarly by the health professionals but lower by HRM. The employees´ perception often led between both. Individual predisposition for CMD was rated less important by HRM and EMP than by health professionals. The potential of work-related aspects for prevention of CMD was assess similarly high by health professionals and EMP, but slightly lower by HRM. Discussion The multiperspective survey revealed different answering patterns of the five groups indicating possibilities as well as need for further actions with regard to work-related prevention of CMD in employees. Reference . Michaelis, et al. Mental Health & Prevention 2016;4:88–95.

Background Relatives of patients in intensive care units (ICU) have important supportive care needs which are often unrecognized and rarely satisfactorily met. Objectives Description of stress factors and strains as well as supportive care needs, assessment of care needs, empirical evidence for care needs, satisfaction of care needs, options and efficacy of psychosocial support and communication recommendations for this special situation. Material and methods Evaluation of literature review articles, discussion of basic qualitative and quantitative research findings, meta-analyses and expert recommendations. Results Relatives of ICU patients report a number of cognitive, emotional, social and pragmatic support needs. Important needs, such as maintenance of hope and security as well as sincere and needs-adjusted communication often remain unrecognized and are rarely satisfactorily met. The weighting and prioritization of support needs are modulated by sociodemographic and cultural factors. Psychoeducative interventions reduce the psychosocial distress of family members. Communicative strategies of healthcare professionals reduce the risk of posttraumatic stress disorders for family members, reduce anxiety and depression and improve participative decision making. Conclusion Healthcare professionals in ICUs should be sensitized to the specific characteristics of these special situations. For healthcare professionals it is equally important to improve self-awareness regarding their own defense mechanisms and to refine communicative competence on accessibility and adequately address the reality of subjective experiences of family members. Psychosocial support services should be recommended and utilization should be encouraged.

Background: Child maltreatment (CM) and attachment experiences are closely linked to alterations in the human oxytocin (OXT) system. However, human data about oxytocin receptor (OXTR) protein levels are lacking. Therefore, we investigated oxytocin receptor (OXTR) protein levels in circulating immune cells and related them to circulating levels of OXT in peripheral blood. We hypothesized reduced OXTR protein levels, associated with both, experiences of CM and an insecure attachment representation. Methods: OXTR protein expressions were analyzed by western blot analyses in peripheral blood mononuclear cells (PBMC) and plasma OXT levels were determined by radioimmunoassay (RIA) in 49 mothers. We used the Childhood Trauma Questionnaire (CTQ) to assess adverse childhood experiences. Attachment representations (secure vs. insecure) were classified using the Adult Attachment Projective Picture System (AAP) and levels of anxiety and depression were assessed with the German version of the Hospital Depression and Anxiety scale (HADS-D). Results: CM-affected women showed significantly lower OXTR protein expression with significantly negative correlations between the OXTR protein expression and the CTQ sum score, whereas plasma OXT levels showed no significant differences in association with CM. Lower OXTR protein expression in PBMC were particularly pronounced in the group of insecurely attached mothers compared to the securely attached group. Anxiety levels were significantly higher in CM-affected women. Conclusion: This study demonstrated a significant association between CM and an alteration of OXTR protein expression in human blood cells as a sign for chronic, long-lasting alterations in this attachment-related neurobiological system.

Objective This multicentre, randomised controlled trial (RCT) aimed to evaluate the efficacy of a small-group intervention promoting successful ageing at work in older nurses (aged 45). Method A sample of 115 nurses aged 45 from 4 trial sites in Germany were randomly assigned to either the intervention group (IG), that received a small-group intervention of seven weekly sessions of 120 min with a booster session after six weeks or to a wait-list control condition (WLC). Outcomes were measured via validated self-report questionnaires at baseline (T1) and at post-treatment (T2). Primary outcomes were mental health-related well-being and mental health-related quality of life (QOL). The secondary outcomes included mental health-related and work-related measures. Results The intention to treat (ITT) analysis showed significant positive effects of the intervention on mental health. A significant small effect (d = 0.3) in favour of the IG was found for psychological health-related quality of life. Positive small effects (d = 0.24 to d = 0.31) were also found for work related mental strain. Conclusions Our small-group intervention based on a theory of successful ageing for nurses aged 45 was found to be effective with regard to improvements of psychological health related quality of life and other mental health-related outcomes. Thus, our study shows that the ageing workforce can be reached through specifically designed preventive interventions. The components of our intervention could be easily adapted to the belongings of other professions. Our results suggest that these components should be evaluated in various settings outside the healthcare sector. OA gold - CA extern

Background 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. Aim To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods 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. Results 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 questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area inmental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

Adult attachment representations have been considered to play a role in the development and treatment of somatizing behavior. In this study, the associations between the two attachment dimensions avoidance and anxiety and dimensions of psychopathology (somatization, depression, and general anxiety) were explored. The sample consists of 202 outpatients diagnosed with a somatoform disorder. Data were collected via self-report measures. A path analysis shows that the two attachment dimensions are not directly associated with somatization. There are, however, significant indirect associations between attachment and somatization mediated by depression and general anxiety, which are more pronounced for attachment anxiety than for attachment avoidance. The findings reveal that a low level of attachment security in romantic relationships, especially an anxious stance toward the partner, comes along with poor mental health, which in turn is related to a preoccupation with somatic complaints. Implications for the treatment of somatizing patients are discussed.

Prolonged work stress, as indicated by the effort-reward imbalance (ERI) model, jeopardizes health. Cortisol represents a candidate mechanism connecting stress to ill health. However, previous findings appear inconclusive, and recommendations were made to assess work stress at multiple time points and also to investigate ERI (sub-)components. This study therefore examines the effects of two single time points, as well as the mean and change scores between time points of ERI and its components on hair cortisol concentration (HCC), a long-term cortisol measurement. Participants were 66 male factory workers (age: 40.68 ± 6.74 years; HCC: 9.00 ± 7.11 pg/mg), who were followed up after a stress management intervention (2006-2008). In 2008 (T1) and 2015 (T2), participants completed a 23-item ERI questionnaire, assessing effort, the three reward components (esteem, job security, job promotion) and over-commitment. In 2015, participants also provided a 3-cm hair segment close to the scalp for HCC analysis, as well as information on relevant confounders (i.e. medication intake, age, work characteristics, socioeconomic and lifestyle factors, number of stressful life events). Linear regressions revealed hardly any cross-sectional or longitudinal effect of ERI and its components on HCC. Only the change scores between T1 and T2 of job security were negatively associated with lower HCC in unadjusted (β = -.320; p = .009) and adjusted (β = -.288; p = .044) models. In this study, only a decrease of perceived job security over time was significantly associated with higher HCC, and other predictors were not related to this outcome. Especially after correction for multiple testing, this study revealed just a weak association of different psychosocial work measurements with HCC. Lay summary This study showed that an increase in perceived job insecurity is correlated with higher levels of the stress hormone cortisol. The higher levels of cortisol might represent a biological explanation for the negative health effects of job insecurity. The association was, however, relatively low, and more and more voices are questioning whether cortisol in hair is a reliable marker for perceived work stress.

This study aimed to investigate long-term stability and variability of diurnal cortisol and alpha-amylase patterns. Diurnal cortisol and alpha-amylase secretion patterns were assessed on a single workday with three waves of measurement across a total time period of 24months in 189 participants. Separate hierarchical linear models were analyzed, with and without a number of potential predictor variables (age, BMI, smoking, chronic stress, stress reactivity). While low long-term stability was found in diurnal cortisol, the stability of diurnal alpha-amylase was moderate across the time period of 24months. Several predictor variables had a positive impact on diurnal cortisol and alpha-amylase secretion patterns averaged across waves. Our findings underpin the notion that long-term stability is not necessarily warranted in longitudinal studies. It is important to choose an appropriate study design when attempting to disentangle clinically and biologically relevant changes from naturally occurring variations in diurnal cortisol and alpha-amylase.

Objective Common mental disorders like mood and anxiety disorders and somatoform disorders have high costs, yet under-treatment is still frequent. Many people with common mental disorders are employed, so the workplace is potentially a suitable context in which to provide early treatment. Our study investigates whether a change of setting (workplace versus standard care) improves access to treatment for common mental disorders. Methods Conditional latent profile analysis was applied to identify user profiles for work ability (WAI), clinical symptoms like depression (patient health questionnaire depression, PHQ-9), health-related quality of life (QoL, SF-12), and work-related stress (Maslach Burnout Inventory, irritation scale). Patients were recruited consecutively, via psychotherapeutic consultation in the workplace (n = 174) or psychotherapeutic consultation in outpatient care (n = 193). Results We identified four user profiles in our model: ‘severe’ (n = 99), ‘moderate I—low QoL’ (n = 88), ‘moderate II—low work ability’ (n = 83), and ‘at risk’ (n = 97). The ‘at risk’ profile encompassed individuals with reduced work ability (36.0, 34.73 to 37.37), only mild clinical symptoms (PHQ-9 5.7, 4.92 to 6.53), no signs of work-related stress and good quality of life. A higher proportion of the ‘at risk’ group than of the ‘severe’ group sought help via the psychotherapeutic consultation in the workplace (OR 0.287, P < 0.01); this effect remained after controlling for gender. Conclusions Offering secondary mental health care in the workplace is feasible and accepted by users. Offering treatment in the workplace as an alternative to standard outpatient settings is a viable strategy for improving access to treatment for common mental disorders.

Oxytocin, a small neuropeptide of nine amino acids, has been characterized as the “hormone of affiliation” and is stimulated, for instance, in mothers when interacting with their offspring. Variations in maternal oxytocin levels were reported to predict differences in the quality of care provided by mothers. In this study, the Adult Attachment Projective Picture System (AAP) as a valid measure to assess attachment representations was used as an activating attachment-related stimulus. We investigated whether the AAP induces a release of oxytocin in mothers with a secure attachment representation and a stress-related cortisol response in mothers with an insecure attachment representation. Therefore, pre-post effects of AAP administration on plasma oxytocin and serum cortisol levels were investigated in n = 44 mothers 3 months after parturition. Oxytocin levels increased from pre to post by the significant majority of 73% participants (p = .004) and cortisol decreased by the significant majority of 73% participants (p = .004). Interestingly, no association between alterations in oxytocin and cortisol were found; this suggests taking a model of two independent processes into considerations. These results show that the AAP test procedure induces an oxytocin response. Concerning the results within the four AAP representation subgroups, our hypothesis of a particularly strong increase in oxytocin in secure mothers was not confirmed; however, in secure mothers we observed a particularly strong decrease in cortisol, consistent with our hypotheses. Effect sizes are reported, allowing the replication of results in a larger study with sufficient sample size to draw final conclusions with respect to differences in OT and cortisol alterations depending on attachment representation. When interpreting the results, one should keep in mind that this study investigated lactating mothers. Thus, the generalizability of results is limited and future studies should investigate non-lactating healthy females as well as males and include a control stimulus condition.

The etiopathology of somatoform disorders can only be understood against the background of an integrated biopsychosocial model. Cultural and historical influences must be taken into account as well as contemporary settings of scientific or medical priorities. In this context the emphasis on neurobiological findings can be interpreted as the non-accidental struggle for legitimacy of both patients and physicians. Altogether the available data on factors influencing the formation and maintenance of somatoform symptoms has to be described as both diverse and unspecific and thus points to a challenging research program in the coming years.

The article presents an operationalized and manualized approach for the assessment of the capability of performance. This manual has been conceptualized and tested empirically by a multicentric and interdisciplinary workgroup. It is basically oriented to the “International Classification of Functioning” (ICF; WHO), which is well accepted for assessing the course of chronic diseases and the consequences for the individual. It is especially widely applied in the context of rehabilitation. The different diagnostic levels of the manual and their operationalization are outlined. Furthermore, the first results concerning reliability, content validity, applicability and practicability are described and questions on the areas of application of the instrument are discussed.