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Abstract Background Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss. Methods 228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10). Results Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms. Conclusion The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions. Trial registration Not applicable.

Abstract Background Eye contact is a fundamental part of social interaction. In clinical studies, it has been observed that patients suffering from depression make less eye contact during interviews than healthy individuals, which could be a factor contributing to their social functioning impairments. Similarly, results from mood induction studies with healthy persons indicate that attention to the eyes diminishes as a function of sad mood. The present screen-based eye-tracking study examined whether depressive symptoms in healthy individuals are associated with reduced visual attention to other persons’ direct gaze during free viewing. Methods Gaze behavior of 44 individuals with depressive symptoms and 49 individuals with no depressive symptoms was analyzed in a free viewing task. Grouping was based on the Beck Depression Inventory using the cut-off proposed by Hautzinger et al. (2006). Participants saw pairs of faces with direct gaze showing emotional or neutral expressions. One-half of the face pairs was shown without face masks, whereas the other half was presented with face masks. Participants’ dwell times and first fixation durations were analyzed. Results In case of unmasked facial expressions, participants with depressive symptoms looked shorter at the eyes compared to individuals without symptoms across all expression conditions. No group difference in first fixation duration on the eyes of masked and unmasked faces was observed. Individuals with depressive symptoms dwelled longer on the mouth region of unmasked faces. For masked faces, no significant group differences in dwell time on the eyes were found. Moreover, when specifically examining dwell time on the eyes of faces with an emotional expression there were also no significant differences between groups. Overall, participants gazed significantly longer at the eyes in masked compared to unmasked faces. Conclusions For faces without mask, our results suggest that depressiveness in healthy individuals goes along with less visual attention to other persons’ eyes but not with less visual attention to others’ faces. When factors come into play that generally amplify the attention directed to the eyes such as face masks or emotions then no relationship between depressiveness and visual attention to the eyes can be established.

Alexithymia, a multifaceted personality construct, is known to be related to difficulties in the decoding of emotional facial expressions, especially in case of suboptimal stimuli. The present study investigated whether and which facets of alexithymia are related to impairments in the recognition of emotions in faces with face masks. Accuracy and speed of emotion recognition were examined in a block of faces with and a block of faces without face masks in a sample of 102 healthy individuals. The order of blocks varied between participants. Emotions were recognized better and faster in unmasked than in masked faces. Recognition performance was worst and slowest for participants starting the task with masked faces. In the whole sample, there were no correlations of alexithymia facets with accuracy and speed of emotion recognition for masked and unmasked faces. In participants starting the task with masked faces, the facet externally oriented thinking was positively correlated with reaction latencies of correct responses for masked faces. Our findings indicate that an externally oriented thinking style could be linked to a less efficient identification of emotions from faces wearing masks when task difficulty is high and support the utility of a facet approach in alexithymia research.

BackgroundAlexithymia is a risk factor for emotional disorders and is characterized by differences in automatic and controlled emotion processing. The multi-stimulus free-viewing task has been used to detect increased negative and reduced positive attentional biases in depression and anxiety. In the present eye-tracking study, we examined whether lexical emotional priming directs attention toward emotion-congruent facial expressions and whether alexithymia is related to impairments in lexical priming and spontaneous attention deployment during multiple face perception.Materials and methodsA free-viewing task with happy, fearful, angry, and neutral faces shown simultaneously was administered to 32 alexithymic and 46 non-alexithymic individuals along with measures of negative affect and intelligence. Face presentation was preceded by masked emotion words. Indices of initial orienting and maintenance of attention were analyzed as a function of prime or target category and study group.ResultsTime to first fixation was not affected by prime category or study group. Analysis of fixation duration yielded a three-way interaction. Alexithymic individuals exhibited no prime or target category effect, whereas non-alexithymic individuals showed a main effect of target condition, fixating happy faces longer than neutral and angry faces and fearful faces longer than angry faces.DiscussionOur results show evidence of attentional biases for positive and fearful social information in non-alexithymic individuals, but not in alexithymic individuals. The lack of spontaneous attentional preference for these social stimuli in alexithymia might contribute to a vulnerability for developing emotional disorders. Our data also suggest that briefly presented emotion words may not facilitate gaze orientation toward emotion-congruent stimuli.

IntroductionMigration is often accompanied by interpersonal, material and abstract losses and can be associated with migratory grief. The correlates of migratory grief have not yet been sufficiently addressed in research. This review aims to systematically investigate the relationship between migratory grief and psychopathology, to map the current state of research on this highly relevant topic and to derive relevant implications for the target group.MethodA systematic literature search of electronic databases (PubMed/Medline, PsycINFO, Web of Science) was conducted up until January 2023. Primary empirical quantitative and qualitative studies with migrants were included that assessed the association between migratory grief and psychopathology, using a specific instrument for migratory grief (quantitative) or named migratory grief as relevant topic (qualitative). Studies that only captured aspects of migratory grief, were not written in English, or were descriptive/non-peer-reviewed publications, were excluded. A quality assessment of all studies included was performed using the Mixed Methods Appraisal Tool. The results were synthesized using a narrative synthesis approach.ResultsAll studies (quan. = 4; qual. = 1) were cross-sectional and used convenience samples. The studies had a mean number of 83 participants with a total of N = 487 participants included in the current review. All included studies reported a significant relationship between migratory grief and psychological distress.DiscussionDespite the quality of the included studies being limited, our results show that there is a link between migratory grief and depression among refugees and migrants. However, there are only few studies in this currently and certainly also in the future relevant field of research, which is why further studies on factors influencing migratory grief as well as associations with other disorders would be desirable.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42023403448.

BackgroundProlonged grief disorder (PGD) was recently included as a disorder in the ICD-11 and DSM-5-TR. Although both classification systems use the same name, the criteria content, and diagnostic approach vary. This study aimed to estimate the respective prevalence of PGDICD-11 and PGDDSM-5-TR and examine the diagnostic agreement while varying the diagnostic algorithm of PGDICD-11 (bereavement vs. symptom period; varying number of accessory symptoms).MethodsA representative sample of the German general population (N = 2,509) was investigated, of which n=1,071 reported the loss of a close person. PGD symptoms were assessed with the Traumatic Grief Inventory - Self Report Plus (TGI-SR+).ResultsThe point prevalence of PGD among the bereaved varied between 4.7%-6.8%, depending on the criteria and diagnostic algorithm. The prevalence of PGDDSM-5-TR was significantly lower than the prevalence of PGDICD-11. The diagnostic agreement between both criteria sets was substantial and increased after the number of accessory symptoms for PGDICD-11 was increased from one to three. The most common symptoms were intrusive thoughts/images related to the deceased person, longing for the deceased person, and difficulty accepting the loss.ConclusionThe results demonstrate that the prevalence of PGD significantly varies depending on the application of the diagnostic algorithm and criteria. PGD affects a substantial proportion of the general population and should be addressed by healthcare providers. However, applying the minimum ICD-11 criteria could lead overestimating the prevalence. Therefore, further harmonizing the ICD-11 and DSM-5-TR criteria and diagnostic algorithm for PGD seems appropriate.

Abstract Background Alexithymia refers to a multidimensional personality trait with the facets difficulties identifying feelings (DIF), difficulties describing feelings (DDF), and externally orientated thinking (EOT). Alexithymia is a risk factor for mental and somatic disorders. Previous research with patients suffering from various disorders showed positive relationships between alexithymia and interpersonal problems. Only one study analyzed the link between alexithymic features and interpersonal difficulties in healthy individuals but yielded inconclusive findings because participants’ negative affects were not controlled. A widely accepted conceptualization of interpersonal problems relies on the interpersonal circumplex, which is defined by two orthogonal dimensions, agency and communion. In the present study, we analyzed which facets of alexithymia are associated with the two interpersonal problem dimensions and the global severity of interpersonal distress, after adjusting for negative affect. Methods Two-hundred healthy young individuals (100 women) participated in the study. Alexithymic features were assessed using the 20-Item Toronto Alexithymia Scale (TAS-20). Interpersonal problems were measured with the Inventory of Interpersonal Problems (IIP-D). Participants’ state and trait anxiety, depressive symptoms, and verbal intelligence were also assessed. Results All alexithymia scales were positively correlated with general interpersonal distress. Regression results suggested that the TAS-20 subscale DIF was the primary predictor of general interpersonal distress after controlling for negative affectivity. The scale DDF correlated negatively with the IIP-D dimension agency. According to our regression analysis, DDF was a predictor of (low) agency controlling for negative affects. Moreover, DDF correlated negatively with the IIP-D dimension communion. Our regression results indicate that DDF was a predictor of (low) communion independent of negative affect. Correlations between alexithymia facets and IIP-D subscales did not differ between genders. Conclusions Difficulties identifying feelings seem to be linked to a high level of general interpersonal distress. Difficulties in recognizing one’s feelings may disrupt emotion regulation, which could heighten the general risk of interpersonal problems. Difficulties describing feelings could be a central factor contributing to interpersonal problems related to low communion as well as low agency, since emotion expression and communication are crucial in establishing experiences of social closeness and directing other people’s behavior.

Abstract Background Trait anxiety refers to a stable tendency to experience fears and worries across many situations. High trait anxiety is a vulnerability factor for the development of psychopathologies. Self-reported trait anxiety appears to be associated with an automatic processing advantage for threat-related information. Self-report measures assess aspects of the explicit self-concept of anxiety. Indirect measures can tap into the implicit self-concept of anxiety. Methods We examined automatic brain responsiveness to non-conscious threat as a function of trait anxiety using functional magnetic resonance imaging. Besides a self-report instrument, we administered the Implicit Association Test (IAT) to assess anxiety. We used a gender-decision paradigm presenting brief (17 ms) and backward-masked facial expressions depicting disgust and fear. Results Explicit trait anxiety was not associated with brain responsiveness to non-conscious threat. However, a relation of the implicit self-concept of anxiety with masked fear processing in the thalamus, precentral gyrus, and lateral prefrontal cortex was observed. Conclusions We provide evidence that a measure of the implicit self-concept of anxiety is a valuable predictor of automatic neural responses to threat in cortical and subcortical areas. Hence, implicit anxiety measures could be a useful addition to explicit instruments. Our data support the notion that the thalamus may constitute an important neural substrate in biased non-conscious processing in anxiety.

Alexithymia is a clinically relevant personality construct characterized by difficulties identifying and communicating one’s emotions and externally oriented thinking. Alexithymia has been found to be related to poor emotion decoding and diminished attention to the eyes. The present eye tracking study investigated whether high levels of alexithymia are related to impairments in recognizing emotions in masked faces and reduced attentional preference for the eyes. An emotion recognition task with happy, fearful, disgusted, and neutral faces with face masks was administered to high-alexithymic and non-alexithymic individuals. Hit rates, latencies of correct responses, and fixation duration on eyes and face mask were analyzed as a function of group and sex. Alexithymia had no effects on accuracy and speed of emotion recognition. However, alexithymic men showed less attentional preference for the eyes relative to the mask than non-alexithymic men, which was due to their increased attention to face masks. No fixation duration differences were observed between alexithymic and non-alexithymic women. Our data indicate that high levels of alexithymia might not have adverse effects on the efficiency of emotion recognition from faces wearing masks. Future research on gaze behavior during facial emotion recognition in high alexithymia should consider sex as a moderating variable.

Abstract Emotional intelligence and, in particular, the component emotion regulation may increase well-being and improve mood and coping with negative emotions. In the present eye-tracking study, we examined whether attention allocation to positive stimuli mediates the relationship between emotion regulation abilities and trait affect. Gaze behavior of 104 healthy adults was analyzed in a free-viewing task, in which happy, sad, angry, and neutral faces were shown simultaneously for ten seconds. Dwell time on facial expressions was used as indicator of attention allocation. Trait emotional intelligence was assessed using the Self-Rated Emotional Intelligence Scale. Self-report measures of state and trait positive and negative affect, trait anxiety, and depression were administered. In general, participants viewed longer at happy than at negative or neutral faces. The results of mediation analyses indicated that intrapersonal and interpersonal emotion regulation abilities were indirectly related to trait positive affect through attention to happy faces. Moreover, dwell time on happy faces had a mediating effect on the relationship between interpersonal emotion regulation ability and trait anxiety. Preference for positive social signals might form one attentional pathway through which emotion regulation abilities promote positive mood and buffer the development of anxiety reactions in everyday life.

Abstract Background During pregnancy, women`s bodies undergo rapid changes in body weight and body size within a relatively short period of time. Pregnancy may therefore be associated with an increased vulnerability for the development of body image dissatisfaction that has been linked to adverse health outcomes for mother and child. The present study aims to examine changes in body image during pregnancy as well as predictors of body image dissatisfaction. This is the first study using a tailored, multidimensional measure of body image especially developed for the pregnant population. Methods A prospective longitudinal design with a quantitative approach was applied. Healthy pregnant women (N = 222) were assessed using standardized instruments at two time points (T1: 18th-22th week of gestation, T2: 33th-37th week of gestation). The impact of demographic, weight- and health-related, behavioral, and psychological factors assessed at T1 on body image dissatisfaction at T1 and T2 was examined using stepwise linear regression analyses. Results T-tests for paired samples revealed that dissatisfaction with strength-related aspects of body image, dissatisfaction with body parts, and concerns about sexual attractiveness increased significantly from the middle to the end of pregnancy. In contrast, preoccupation with appearance, dissatisfaction with complexion, and prioritization of appearance over function were significantly reduced over time. Stepwise linear regression analyses revealed that factors influencing body image depend on the component of body image investigated. Overall, a low level of self-esteem and a high level of pregnancy-specific worries were risk factors for several components of body image dissatisfaction. Besides these, poor sleep quality, low levels of physical activity, disturbed eating behavior, and higher levels of BMI and weight gain were significant predictors. Conclusions The results highlight the multidimensional nature of body image and show positive as well as negative changes during pregnancy. Overall, modifiable psychological, behavioral, and weight-related factors appear relevant to the extent of body image dissatisfaction.

IntroductionAnger is a basic emotion helping people to achieve goals by preparing the body for action and prompting others to change their behavior but is also associated with health issues and risks. Trait anger, the disposition to experience angry feelings, goes along with an attribution of hostile traits to others. Negative distortions in the interpretation of social information have also been observed in anxiety and depression. The present study examined the associations between components of anger and negative interpretation tendencies in the perception of ambiguous and neutral schematic faces controlling for anxiety, depressed mood, and other variables.MethodsA sample of 150 young adults performed a computer-based perception of facial expressions task and completed the State–Trait Anger Expression Inventory (STAXI-2) along with other self-report measures and tests.ResultsTrait anger and anger expression correlated with the perception of negative affects in neutral but not in ambiguous faces. More specifically, trait anger was linked to the attribution of anger, sadness, and anxiety to neutral faces. Trait anger predicted perceived negative affects in neutral faces when adjusting for anxiety, depression, and state anger.DiscussionFor neutral schematic faces, the present data support an association between trait anger and negatively biased interpretation of facial expression, which is independent of anxiety and depressed mood. The negative interpretation of neutral schematic faces in trait angry individuals seems not only to comprise the attribution of anger but also of negative emotions signaling weakness. Neutral schematic facial expressions might be useful stimuli in the future study of anger-related interpretation biases.

BackgroundRecognition of emotions in faces is important for successful social interaction. Results from previous research based on clinical samples suggest that difficulties in identifying threat-related or negative emotions can go along with interpersonal problems. The present study examined whether associations between interpersonal difficulties and emotion decoding ability can be found in healthy individuals. Our analysis was focused on two main dimensions of interpersonal problems: agency (social dominance) and communion (social closeness).Materials and methodsWe constructed an emotion recognition task with facial expressions depicting six basic emotions (happiness, surprise, anger, disgust, sadness, and fear) in frontal and profile view, which was administered to 190 healthy adults (95 women) with a mean age of 23.9 years (SD = 3.8) along with the Inventory of Interpersonal Problems, measures of negative affect and verbal intelligence. The majority of participants were university students (80%). Emotion recognition accuracy was assessed using unbiased hit rates.ResultsNegative correlations were observed between interpersonal agency and recognition of facial anger and disgust that were independent of participants’ gender and negative affect. Interpersonal communion was not related to recognition of facial emotions.DiscussionPoor identification of other people’s facial signals of anger and disgust might be a factor contributing to interpersonal problems with social dominance and intrusiveness. Anger expressions signal goal obstruction and proneness to engage in conflict whereas facial disgust indicates a request to increase social distance. The interpersonal problem dimension of communion appears not to be linked to the ability to recognize emotions from facial expressions.

Abstract Using reaction-time measures, research on the relationship between childhood maltreatment and biased attention to emotional stimuli in adults has obtained inconsistent results. To help clarify this issue, we conducted an eye-tracking study on the link between childhood maltreatment and allocation of attention to facial emotions analyzing gaze behavior in addition to manual reactions. In contrast to prior investigations, we excluded individuals with tendencies to minimize maltreatment experiences from analyses. Gaze behavior and manual response time of 58 healthy women were examined in a dot-probe task in which pairs of emotional (happy, sad, or disgusted) and neutral faces were presented. In our analyses, participants’ affectivity, level of alexithymia, and intelligence were controlled. Entry time and dwell time on facial expressions were used as indicators of attention allocation. Childhood maltreatment showed no effect on response latencies but was associated with shorter entry times on emotional faces and shorter dwell time on disgusted faces. Experiences of childhood maltreatment seem to be linked to an increased early vigilance to emotional social signals and to an attentional avoidance of hostile facial expressions at a later stage of perception. The present results suggest a vigilance-avoidance pattern of attention allocation associated with childhood maltreatment.

Abstract Background Sleep disturbances are an underestimated risk factor for suicidal ideation and behavior. Previous research provided preliminary support of a temporal relationship between sleep disturbances and suicidal ideation. The present study therefore sought to investigate the prospective association between sleep disturbances, passive and active suicidal ideation, and further psychological risk factors, such as state impulsivity and depression. Methods Seventy-three psychiatric inpatients (71% female) with unipolar depressive disorder and current or lifetime suicidal ideation took part in an ecological momentary assessment (EMA). Participants filled out a baseline assessment and data were collected via smartphones over a 6-days period. Multilevel analyses with sleep disturbance as predictor for active and passive suicidal ideation, state impulsivity, and depression were carried out. Results Patients with sleep disturbance experienced more active suicidal ideation, but no passive suicidal ideation, the following day. Of the four state impulsivity items, one item was significantly associated with sleep disturbance. Sleep disturbance had no effect on next-day depression. Limiting factors are the small and homogeneous sample along with the rather short observation period in an inpatient setting. Conclusions The micro-longitudinal study provides preliminary support for sleep disturbance as a proximal risk factor for next-day active suicidal ideation. Clinically, results indicate to consider the evaluation and treatment of sleep disturbances for an improved risk assessment and prevention of suicide.

ObjectiveAchalasia is associated with reduced quality of life in affected patients but research regarding the psychological burden of achalasia in terms of depression and anxiety is scarce. The current study therefore aims to investigate rates of depression and anxiety in patients with achalasia in relation to prevalence rates in the general population and to examine the extent to which achalasia-related characteristics (time since diagnosis, symptom load, achalasia-related quality of life, treatment history) predict symptoms of depression and anxiety.MethodsUsing validated screening instruments, rates of depression and anxiety were assessed in a cross-sectional survey of a sample of 993 patients with achalasia and compared to population controls stratified by age and sex. Associations between depression and anxiety and achalasia-related factors were explored using linear regression.ResultsCompared to population controls, screening rates of female patients with achalasia were between 3.04 (p = .004) and 7.87 (p < .001) times higher for depression and 3.10 (p < .001) times higher for anxiety, respectively. No significant differences were found for male patients with achalasia. Both achalasia-related quality of life and symptom load were independently related to impaired mental health.ConclusionWomen appear to be specifically affected by the psychological burden of achalasia, pointing to sex-specific or gendered experiences of the disease. In addition to symptom reduction, psychological support may prove beneficial for improving the well-being of patients with achalasia.

COVID-19-related stigmatization of affected people or people at risk of infection has been shown to enhance the reluctance of affected individuals to use health services and reduce their mental health. It is thus highly important to gain a thorough understanding of COVID-19-related stigmatization. The present study's first aim was to explore stigmatization profiles of experienced stigmatization (anticipated stigmatization, internalized stigmatization, enacted stigmatization, disclosure concerns) and stigmatization practices in 371 German people at high risk of infection using latent class analyses. The second aim was to investigate the relationship between stigmatization profiles and psychological distress via multiple regression analysis taking into account other possible negative and positive risk factors. Our results showed two stigmatization profiles: "high stigmatization group" and "low stigmatization group". Belonging to the "high stigmatization group" was significantly correlated with higher levels of psychological distress. Other risk factors significantly related to psychological distress were mental health disorders in the past, exposure to COVID-19, fear related to COVID-19, perceived risk of being infected, lower perceived self-efficacy, and lower subjective knowledge about COVID-19.

Attention to emotions and emotional clarity are core dimensions of individual differences in emotion awareness. Findings from prior research based on self-report indicate that attention to and recognition of one’s own emotions are related to attention to and recognition of other people’s emotions. In the present experimental study, we examined the relations of attention to and clarity of emotions with the efficiency of facial affect perception. Moreover, it was explored whether attention to and clarity of emotions are linked to negative interpretations of facial expressions. A perception of facial expressions (PFE) task based on schematic faces with neutral, ambiguous, or unambiguous emotional expressions and a gender decision task were administered to healthy individuals along with measures of emotion awareness, state and trait anxiety, depression, and verbal intelligence. Participants had to decide how much the faces express six basic affects. Evaluative ratings and decision latencies were analyzed. Attention to feelings was negatively correlated with evaluative decision latency, whereas clarity of feelings was not related to decision latency in the PFE task. Attention to feelings was positively correlated with the perception of negative affects in ambiguous faces. Attention to feelings and emotional clarity were not related to gender decision latency. According to our results, dispositional attention to feelings goes along with an enhanced efficiency of facial affect perception. Habitually paying attention to one’s own emotions may facilitate processing of external emotional information. Preliminary evidence was obtained suggesting a relationship of dispositional attention to feelings with negative interpretations of facial expressions.

BackgroundProlonged Grief Disorder (PGD) is now included in Section II of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR). To understand the health burden and then allocate economic and professional resources, it is necessary to provide epidemiological data for this new disorder. This is especially relevant since the new diagnostic criteria differ from its predecessors, which may affect the generalizability of previous findings. More information on the characteristics of people suffering from PGD is also beneficial to better identify individuals at risk. This study, therefore, aimed to estimate the prevalence of the new PGD criteria in a representative population-based sample, evaluate the factor structure, sociodemographic, and loss-related correlates of PGD caseness and explore possible predictors.MethodsOut of a representative sample of the German general population (N = 2,531), n = 1,371 (54.2%) reported to have experienced a significant loss throughout lifetime. Participants provided sociodemographic data and loss-related characteristics. PGD symptoms were measured using items from the German versions of the Prolonged Grief Scale (PG-13) and the Inventory of Complicated Grief (ICG), which could be matched to the DSM-5-TR criteria for PGD.ResultsThe conditional prevalence of PGD was 3.4% (n = 47). The most frequently reported symptoms were intense emotional pain and intense yearning or longing for the deceased. The confirmatory factor analysis confirmed a unidimensional model of PGD. Regression analysis demonstrated that time since the death, the relationship to the deceased, and unpreparedness for the death were significant predictors of PGD.ConclusionAlthough the prevalence of 3.4% using the new diagnostic criteria is lower than the prevalence previously suggested by a meta-analysis, PGD remains a substantial disorder in the general population. In particular, the loss of a partner or child increases the risk for PGD, as does unpreparedness for the death of a loved one. Clinicians should pay particular attention to these high-risk groups. Further clinical implications are discussed.

Abstract Background The primary health care setting is considered a major starting point in successful obesity management. However, research indicates insufficient quality of weight counseling in primary care. Aim of the present study was to implement and evaluate a 5A online tutorial aimed at improving weight management and provider-patient-interaction in primary health care. The online tutorial is a stand-alone low-threshold minimal e-health intervention for general practitioners based on the 5As guidance for obesity management by the Canadian Obesity Network. Methods In a cluster-randomized controlled trial, 50 primary care practices included 160 patients aged 18 to 60 years with obesity (BMI ≥ 30). The intervention practices had continuous access to the 5A online tutorial for the general practitioner. Patients of control practices were treated as usual. Primary outcome was the patients’ perspective of the doctor-patient-interaction regarding obesity management, assessed with the Patient Assessment of Chronic Illness Care before and after (6/12 months) the training. Treatment effects over time (intention-to-treat) were evaluated using mixed-effects linear regression models. Results More than half of the physicians (57%) wished for more training offers on obesity counseling. The 5A online tutorial was completed by 76% of the physicians in the intervention practices. Results of the mixed-effects regression analysis showed no treatment effect at 6 months and 12 months’ follow-up for the PACIC 5A sum score. Patients with obesity in the intervention group scored lower on self-stigma and readiness for weight management compared to participants in the control group at 6 months’ follow-up. However, there were no significant group differences for weight, quality of life, readiness to engage in weight management, self-stigma and depression at 12 months’ follow-up. Conclusion To our knowledge, the present study provides the first long-term results for a 5A-based intervention in the context of the German primary care setting. The results suggest that a stand-alone low-threshold minimal e-health intervention for general practitioners does not improve weight management in the long term. To improve weight management in primary care, more comprehensive strategies are needed. However, due to recruitment difficulties the final sample was smaller than intended. This may have contributed to the null results. Trial registration The study has been registered at the German Clinical Trials Register (Identifier: DRKS00009241 , Registered 3 February 2016).

Abstract Background Major depressive disorder has been associated with specific attentional biases in processing emotional facial expressions: heightened attention for negative and decreased attention for positive faces. However, using visual search paradigms, previous reaction-time-based research failed, in general, to find evidence for increased spatial attention toward negative facial expressions and reduced spatial attention toward positive facial expressions in depressed individuals. Eye-tracking analyses allow for a more detailed examination of visual search processes over time during the perception of multiple stimuli and can provide more specific insights into the attentional processing of multiple emotional stimuli. Methods Gaze behavior of 38 clinically depressed individuals and 38 gender matched healthy controls was compared in a face-in-the-crowd task. Pictures of happy, angry, and neutral facial expressions were utilized as target and distractor stimuli. Four distinct measures of eye gaze served as dependent variables: (a) latency to the target face, (b) number of distractor faces fixated prior to fixating the target, (c) mean fixation time per distractor face before fixating the target and (d) mean fixation time on the target. Results Depressed and healthy individuals did not differ in their manual response times. Our eye-tracking data revealed no differences between study groups in attention guidance to emotional target faces as well as in the duration of attention allocation to emotional distractor and target faces. However, depressed individuals fixated fewer distractor faces before fixating the target than controls, regardless of valence of expressions. Conclusions Depressed individuals seem to process angry and happy expressions in crowds of faces mainly in the same way as healthy individuals. Our data indicate no biased attention guidance to emotional targets and no biased processing of angry and happy distractors and targets in depression during visual search. Under conditions of clear task demand depressed individuals seem to be able to allocate and guide their attention in crowds of angry and happy faces as efficiently as healthy individuals.

Cognitive coping strategies to deal with anxiety-provoking events have an impact on mental and physical health. Dispositional vigilance is characterized by an increased analysis of the threatening environment, whereas cognitive avoidance comprises strategies to inhibit threat processing. To date, functional neuroimaging studies on the neural underpinnings of these coping styles are scarce and have revealed discrepant findings. In the present study, we examined automatic brain responsiveness as a function of coping styles using functional magnetic resonance imaging. We administered a perceptual load paradigm with contemptuous and fearful faces as distractor stimuli in a sample of N = 43 healthy participants. The Mainz Coping Inventory was used to assess cognitive avoidance and vigilance. An association of cognitive avoidance with reduced contempt and fear processing under high perceptual load was observed in a widespread network including the amygdala, thalamus, cingulate gyrus, insula, and frontal, parietal, temporal, and occipital areas. Our findings indicate that the dispositional tendency to divert one’s attention away from distressing stimuli is a valuable predictor of diminished automatic neural responses to threat in several cortical and subcortical areas. A reduced processing in brain regions involved in emotion perception and attention might indicate a potential threat resilience associated with cognitive avoidance.

Introduction: Individuals suffering from overweight or obesity frequently experience weight-based stigmatization. The widespread belief that weight is a matter of personal will and self-control results in various weight-based stereotypes (e.g., laziness, lack of self-discipline, or neglect). Objective: Based on the modified version of the Weight Bias Internalization Scale (WBIS-M), a short form for the economic assessment of weight bias internalization in the general population was compiled and validated. Methods: A three-item short form (WBIS-3) was derived based on data from a representative sample of the German population (n = 1,092). This new short form was validated in a second representative population sample (n = 2,513). Item characteristics and internal consistency were obtained. Measurement invariance was tested. Construct validity was established via the correlation with theoretically related constructs (depression, anxiety, eating behavior, discrimination, weight status). To establish scale validity, all analyses were performed for the whole sample as well as for the subsample of individuals with overweight. Age- and gender-specific population norms were provided. Results: The WBIS-3 exhibited excellent psychometric properties. Internal consistency was α = 0.92. Strong measurement invariance was confirmed regarding age, gender, discrimination, and weight status in both the whole sample as well as the overweight subsample. Conclusions: The WBIS-3 constitutes a valid and economical tool for the assessment of weight bias internalization in epidemiological contexts. Measurement invariance allows for an unbiased comparison of means, correlation coefficients, and path coefficients within structural equation modeling across groups.

BackgroundIndividuals differ in their dispositional coping behavior when they are confronted with anxiety-provoking situations. Cognitive avoidance is characterized by a withdrawal from threatening information, whereas vigilance denotes the intensive search for threat-related information. Functional neuroimaging studies indicate alterations in brain responsivity to emotional stimuli as a function of cognitive avoidant and vigilant coping, but findings are partially discrepant. Studies on structural correlates of coping styles are scarce.Materials and MethodsBy using structural magnetic resonance imaging, the present study examined the relationship between brain gray matter volume and coping strategies in 114 healthy individuals. Individual differences in vigilance and cognitive avoidance were measured by the Mainz Coping Inventory.ResultsExploratory whole-brain analyses were conducted. Cognitive avoidant coping significantly predicted reduced gray matter volume in the bilateral thalamus, whereas vigilant coping was associated with volumetric increases in the bilateral thalamus. These relationships remained significant when controlling for a potential influence of age, sex, depressive symptoms, and trait anxiety.DiscussionOur findings indicate that dispositional strategies to deal with anxiety-provoking situations are related to volumetric alterations in the thalamus, a brain structure that has been implicated in the mediation of attentional processes and alertness, and the anticipation of harm. The dispositional tendency to monitor the environment for potential threats (i.e., vigilance), appears to be associated with volumetric increases in the thalamus, whereas the dispositional inclination to divert one’s attention away from distressing stimuli (i.e., cognitive avoidance) seems to go along with reductions in thalamic gray matter density.

BackgroundBereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce. ObjectiveThe aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement. MethodsThe intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures. ResultsA total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P

Abstract Background Obesity is one of the most common and relevant health problems in need of urgent action in Germany. General practitioners (GPs) are the initial contact and thus one of the most important starting points for the successful treatment of overweight and obesity. The aim of the study was to assess the treatment practice and attitudes towards patients with obesity in primary health care in Germany. Methods Analyses were based on baseline data of the INTERACT trial of 47 GPs in central Germany. Stigmatizing attitudes were identified using the Fat Phobia Scale (FPS). In addition, questionnaires including sociodemographic information, attribution of causes of obesity, referral behavior and clinical activities were completed. Statistical investigations include descriptive analysis, principal component analysis, inference statistics and linear regression models. Results GPs rated the quality of medical care for patients with obesity in Germany as below average. The FPS score revealed a value of 3.70, showing that GPs’ attitudes towards patients with obesity are stigmatizing. Younger GP age, male gender and a lower number of referrals to specialists were associated with higher levels of stigmatizing attitudes. Conclusion Weight-related stigmatization has an impact on medical treatment. Obesity management guides would help to increase knowledge and reduce weight-related stigmatization in primary care, thereby improving medical care for obese and overweight patients.

Abstract Background Alexithymia is a personality trait characterized by difficulties identifying and describing feelings, an externally oriented style of thinking, and a reduced inclination to imagination. Previous research has shown deficits in the recognition of emotional facial expressions in alexithymia and reductions of brain responsivity to emotional stimuli. Using an affective priming paradigm, we investigated automatic perception of facial emotions as a function of alexithymia at the behavioral and neural level. In addition to self-report scales, we applied an interview to assess alexithymic tendencies. Results During 3 T fMRI scanning, 49 healthy individuals judged valence of neutral faces preceded by briefly shown happy, angry, fearful, and neutral facial expressions. Alexithymia was assessed using the 20-Item Toronto Alexithymia Scale (TAS-20), the Bermond-Vorst Alexithymia Questionnaire (BVAQ) and the Toronto Structured Interview for Alexithymia (TSIA). As expected, only negative correlations were found between alexithymic features and affective priming. The global level of self-reported alexithymia (as assessed by the TAS-20 and the BVAQ) was found to be related to less affective priming owing to angry faces. At the facet level, difficulties identifying feelings, difficulties analyzing feelings, and impoverished fantasy (as measured by the BVAQ) were correlated with reduced affective priming due to angry faces. Difficulties identifying feelings (BVAQ) correlated also with reduced affective priming due to fearful faces and reduced imagination (TSIA) was related to decreased affective priming due to happy faces. There was only one significant correlation between alexithymia dimensions and automatic brain response to masked facial emotions: TAS-20 alexithymia correlated with heightened brain response to masked happy faces in superior and medial frontal areas. Conclusions Our behavioral results provide evidence that alexithymic features are related in particular to less sensitivity for covert facial expressions of anger. The perceptual alterations could reflect impaired automatic recognition or integration of social anger signals into judgemental processes and might contribute to the problems in interpersonal relationships associated with alexithymia. Our findings suggest that self-report measures of alexithymia may have an advantage over interview-based tests as research tools in the field of emotion perception at least in samples of healthy individuals characterized by rather low levels of alexithymia.

ObjectivesBefore the loss of a loved one to cancer, relatives have time to adapt to the impending death. However, due to the current COVID-19 pandemic, adjustment to an imminent death may be more difficult. This study investigates factors related to pre-loss grief and preparedness during the COVID-19 pandemic and their relationship with COVID-19 related fears.MethodsData of 299 participants from a cross-sectional study was used. Participants were included if they were relatives of people with cancer, spoke German and were at least 18 years. Multivariate linear regression analyses were conducted to measure the relationship between predictors (dysfunctional coping, emotion-focused coping, problem-focused coping, attachment anxiety, attachment avoidance, COVID-19 related fears, prognosis, perceived depth of the relationship, perceived conflict in the relationship, health status) and pre-loss grief, preparedness for caregiving and preparedness for death as the dependent variables.ResultsPerceived depth (β = .365, p < .001), COVID-19 related fears (β = .141, p = .002), prognosis for death (β = .241, p < .001), dysfunctional coping strategies (β = .281, p < .001) and emotion-focused coping strategies (β = -.320, p < .001) significantly predicted pre-loss grief. Prognosis for death (β = .347, p < .001), dysfunctional coping strategies (β = -.229, p < .001), emotion-focused coping strategies (β = .242, p < .001), COVID-19 related fears (β = -.112, p = .037) and health status (β = .123, p = .025) significantly predicted preparedness for death. Dysfunctional coping (β = -.147, p = .009), problem-focused coping (β = .162, p = .009), emotion-focused coping (β = .148, p = .017), COVID-19 related fears (β = -.151, p = .006), attachment anxiety (β = -.169, p = .003), perceived conflict in the relationship with the patient with cancer (β = -.164, p = .004), perceived depth in the relationship (β = .116, p = .048) and health status (β = .157, p = .003) significantly predicted preparedness for caregiving.ConclusionsThis study shows COVID-19 pandemic impacts on the grieving process of relatives of patients with cancer. Consequently, screening for pre-loss grief, preparedness and their associated factors may help provide early support for relatives of people with cancer at need. However, further research is needed to help understand the stability of pre-loss grief and preparedness.

Abstract Background Clinical depression is characterized by high levels of negative affect (NA) and attenuated positive affect (PA). Psychological and pharmacological treatments have been shown to reduce NA and to enhance PA in depressed patients. Following dual-process models, two types of affect can be distinguished: explicit (or self-reported) affect, which is formed by conscious reflections, and implicit affect, which relates to automatic affective reactions. The present study was conducted to examine, for the first time, both implicit and explicit affectivity in patients suffering from acute depression. Moreover, changes in patients’ implicit and explicit affectivity were investigated over the course of inpatient treatment. Methods Thirty-nine patients suffering from major depression and 39 healthy individuals participated in the study. Implicit affectivity was assessed using the Implicit Positive and Negative Affect Test. The explicit state and trait affectivity were measured by the Positive and Negative Affect Schedule. The level of depressive symptoms was assessed with the Beck Depression Inventory. Tests were administered to patients after admission and after 7 weeks of therapy, whereas healthy controls were investigated only once. We examined whether either comorbidity or antidepressant medication has an effect on affectivity. Results Patients with acute depression had lower implicit and explicit PA scores and higher implicit and explicit NA scores than the healthy controls. After treatment, patients’ level of depression decreased significantly. At posttreatment, patients exhibited heightened implicit and explicit PA and diminished explicit trait NA. Independent of antidepressant medication and comorbidity, no significant change in implicit NA was observed over the course of treatment. Implicit NA was correlated with explicit NA in acute depression but not during recovery. Conclusions Acute depression appears to be characterized by decreased implicit and explicit PA and increased implicit and explicit NA. After 7 weeks of treatment, depressed patients’ implicit and explicit PA increased, and explicit trait NA decreased. No decrease in implicit NA and explicit state NA occurred over the course of treatment. Finally, it seems that in the state of acute depression, the interplay between the automatic and reflective systems could be increased for negative affectivity.

This study focused on the criterion-related validity of the Implicit Positive and Negative Affect Test (IPANAT). The IPANAT is thought to be a measure of automatic activation of cognitive representations of affects. In this study, it was investigated whether implicit affect scores differentially predict ratings of facial emotions over and above explicit affectivity. Ninety-six young female participants completed the IPANAT, the Positive and Negative Affect Schedule (PANAS) as an explicit measure of state and trait affectivity, and a task for the perception of facial emotions. Implicit negative affect predicted the perception of negative but not positive facial emotions, whereas implicit positive affect predicted the perception of positive but not negative facial emotions. The observed double-dissociation in the correlational pattern strongly supports the validity of the IPANAT as a measure of implicit affectivity and is indicative of the orthogonality and thus functional distinctness of the two affect dimensions of the IPANAT. Moreover, such affect-congruent correlations were absent for explicit affect scales, which additionally supports the incremental validity of the IPANAT.

Background: The high prevalence of mental disorders related to posttraumatic stress among Syrian refugees is often in contrast with their low utilization of mental health care in the host countries. Mental health self-stigma, i.e., internalized stigma of having a mental disorder, could prevent individuals from seeking mental health care. Therefore, we aimed to provide evidence on different aspects of mental health self-stigmatization among adult Syrian refugees with posttraumatic stress symptoms residing in Germany. Moreover, we investigated associations with sociodemographic and psychopathological variables in order to identify those at higher risk of self-stigmatization.Material and Methods: Overall, 133 participants with mild to moderate posttraumatic stress symptoms were recruited in the metropolitan areas of Leipzig, Dresden and Halle, Germany, using a multimodal approach. Mental health self-stigma was assessed using the Self-Stigma of Mental Illness Scale – Short Form (SSMIS-SF), consisting of four subscales (Stereotype awareness, Stereotype agreement, Application to self , Harm to self-esteem), each scoring from 5 (low) to 45 (high) points. Linear regression analysis was used to test associations of sociodemographic and psychopathological variables with self-stigma subscales.Results: On average, self-stigma ratings ranged from 16.5 (SD = 6.6) points on Application to self to 28.3 (SD = 7.5) points on Stereotype awareness. Results showed higher scores on Application to self for individuals who were younger (t = 2.65, p = 0.009) and single (F = 5.70, p = 0.004). Regression analyses yielded statistically significant associations between having multiple comorbidities and a higher Application to self stigma (β = 0.18, p = 0.044), controlling for sociodemographic covariates.Discussion: Mental health self-stigma was increased among Syrian refugees in Germany. Correlates of increased self-stigma could inform efforts to improve access to mental health care among Syrian refugees with mental ill-health. Longitudinal studies following an intersectional approach by concurrently examining multiple forms of public and internalized stigma could provide helpful insights for developing tailored stigma reduction efforts in this context.

Alexithymia is a clinically relevant personality trait characterized by deficits in recognizing and verbalizing one's emotions. It has been shown that alexithymia is related to an impaired perception of external emotional stimuli, but previous research focused on emotion perception from faces and voices. Since sensory modalities represent rather distinct input channels it is important to know whether alexithymia also affects emotion perception in other modalities and expressive domains. The objective of our review was to summarize and systematically assess the literature on the impact of alexithymia on the perception of emotional (or hedonic) stimuli in music, odor, taste, and touch. Eleven relevant studies were identified. On the basis of the reviewed research, it can be preliminary concluded that alexithymia might be associated with deficits in the perception of primarily negative but also positive emotions in music and a reduced perception of aversive taste. The data available on olfaction and touch are inconsistent or ambiguous and do not allow to draw conclusions. Future investigations would benefit from a multimethod assessment of alexithymia and control of negative affect. Multimodal research seems necessary to advance our understanding of emotion perception deficits in alexithymia and clarify the contribution of modality-specific and supramodal processing impairments.

Background: The concept of alexithymia is characterized by difficulties identifying and describing one's emotions. Alexithymic individuals are impaired in the recognition of others' emotional facial expressions. Alexithymia is quite common in patients suffering from major depressive disorder. The face-in-the-crowd task is a visual search paradigm that assesses processing of multiple facial emotions. In the present eye-tracking study, the relationship between alexithymia and visual processing of facial emotions was examined in clinical depression.Materials and Methods: Gaze behavior and manual response times of 20 alexithymic and 19 non-alexithymic depressed patients were compared in a face-in-the-crowd task. Alexithymia was empirically measured via the 20-item Toronto Alexithymia-Scale. Angry, happy, and neutral facial expressions of different individuals were shown as target and distractor stimuli. Our analyses of gaze behavior focused on latency to the target face, number of distractor faces fixated before fixating the target, number of target fixations, and number of distractor faces fixated after fixating the target.Results: Alexithymic patients exhibited in general slower decision latencies compared to non-alexithymic patients in the face-in-the-crowd task. Patient groups did not differ in latency to target, number of target fixations, and number of distractors fixated prior to target fixation. However, after having looked at the target, alexithymic patients fixated more distractors than non-alexithymic patients, regardless of expression condition.Discussion: According to our results, alexithymia goes along with impairments in visual processing of multiple facial emotions in clinical depression. Alexithymia appears to be associated with delayed manual reaction times and prolonged scanning after the first target fixation in depression, but it might have no impact on the early search phase. The observed deficits could indicate difficulties in target identification and/or decision-making when processing multiple emotional facial expressions. Impairments of alexithymic depressed patients in processing emotions in crowds of faces seem not limited to a specific affective valence. In group situations, alexithymic depressed patients might be slowed in processing interindividual differences in emotional expressions compared with non-alexithymic depressed patients. This could represent a disadvantage in understanding non-verbal communication in groups.

Abstract Background After delivery, some women experience impairment of their mother-infant bonding (MIB), which can lead to long-term disturbances of the mother-child relationship and the child’s social-emotional development. Little is known about the association between early maternal bonding problems and mothers’ own adverse childhood experiences, even though the hypothesis of the intergenerational transmission of caregiving indicates continuity in parenting quality across generations. Therefore, the current study aimed at examining the relationship between maternal childhood maltreatment and postpartum MIB, controlling for the role of postpartum mental health. Methods From February 2014 to March 2015, 725 women completed self-report measures 2 months postpartum. Maternal childhood maltreatment was assessed with the Childhood Trauma Questionnaire, postpartum depression with the Revised Beck Depression Inventory, postpartum anxiety with the Symptom Checklist-90-Revised, and postpartum MIB with the abridged version of the Postpartum Bonding Questionnaire. Data were analysed using a hierarchical regression analysis. Results Almost 46% of the included women reported at least one type of childhood maltreatment with emotional neglect being most prevalent. 13% displayed at least mild postpartum depressive symptomatology and 20% scored above the 75th percentile for postpartum anxiety. In the final regression model, which explained 29% of variance, higher severity of maternal emotional neglect in childhood, higher levels of postpartum depression and higher education were significantly related to more postpartum MIB impairment. In contrast, higher severity of maternal physical neglect was significantly associated with less postpartum MIB impairment. Conclusions This study is the first to explore the relationship between diverse types of maternal childhood maltreatment and postpartum MIB, adjusting for postpartum mental health. Maternal experiences of emotional neglect and postpartum depressive symptoms could serve as indicators to identify and support mothers with heightened risk for bonding problems, but results need to be validated in longitudinal studies.

Abstract Background This study aimed to provide a German translation of the Body Image in Pregnancy Scale (BIPS) – a measure tailored to pregnancy-specific aspects of body image while being consistent to the multifaceted theoretical framework of body image – and to test its psychometric properties and validity. Methods The English-language original version of the BIPS was translated into German language using a forward-backward translation rationale. Face validity of the items was tested in cognitive interviews (n = 5). An online survey was conducted among 291 pregnant women. After conducting standard item analyses, factorial validity was tested using principal-axis factor analysis (PAF). Convergent and incremental validity with measures of body dissatisfaction (FFB), depression (EPDS), anxiety (GAD-7), self-esteem (RSE), and eating disorder psychopathology (EDE-Q) was tested by bivariate correlations and multiple linear hierarchical regression analyses. Results The PFA revealed a 32 item and 6-factor solution resembling the dimensions preoccupation with appearance, dissatisfaction with strength-related aspects, dissatisfaction with body parts, dissatisfaction with complexion, prioritization of appearance over function, and concerns about sexual attractiveness. Internal consistency on a subscale level was good to excellent (.79 ≤ Cronbach’s α ≤ .91). Consistent with theoretical assumptions, we found significant positive correlations of BIPS-G subscales with depression, anxiety and eating disorder psychopathology and negative correlations of BIPS-G subscales with self-esteem. BIPS-G subscales substantially improved the prediction of depression, anxiety, self-esteem and eating disorder psychopathology over demographic factors and body dissatisfaction (.03 ≤ ΔR2 ≤ .15, all p-values

Abstract Background Syrians represent the largest group among refugees in Germany. Many of them were exposed to sequential traumatizing events including war, escape and post-migration stressors, which significantly increase the risk to develop symptoms of posttraumatic stress and other mental disorders. However, there is a lack of adequate treatment options for traumatized refugees in Germany. Moreover, their access to psychosocial care is often restricted due to legal regulation, language barriers, and unclear cost coverage. We therefore aim to develop a low-threshold supportive self-help app for Syrian refugees with posttraumatic stress symptoms. By conducting a randomized controlled trial, we further aim to evaluate the apps’ efficacy, usability, acceptance, and economic health benefit/cost-effectiveness. Methods We will develop a modular, interactive self-help app in Arabic, which will be grounded on cognitive-behavioral models for the treatment of posttraumatic stress. Subsequently, screened positive (i.e., Syrian refugees, 18–65 years old, mild to moderate posttraumatic stress symptomatology as quantified by the Posttraumatic Stress Diagnostic Scale for DSM-5/PDS-5) participants (ideally up to n = 234) will be randomly allocated to an intervention (IG) and control group (CG), respectively. Participants in the IG will gain access to the self-help app for one month, while participants in the CG will receive psychoeducational reading material in form of a comprehensive brochure on traumatization and posttraumatic stress. Measurements are scheduled before the intervention (T0), directly after the intervention (T1, one month later) and three months after the intervention (T2). Using linear mixed effect models, we will investigate change in posttraumatic symptomatology. We will also test for changes in secondary outcomes such as depression, anxiety, and quality of life. Moreover, we will inspect the usability and user acceptance of the app. To evaluate the app in terms of its economic health benefit, the incremental cost-effectiveness ratio will be calculated. Discussion We plan to make the app freely available to the general public after evaluation. Thus, the app can help to add-on to routine care, which currently lacks sufficient and appropriate treatment options for Syrian refugees. Trial registration German Clinical Trials Register/Deutsches Register Klinischer Studien (DRKS). Registration ID: DRKS00013782. Registered: 06th of July 2018.

Abstract Background The Patient Assessment of Chronic Illness Care (PACIC-5A) was developed to assess the satisfaction with patient-provider interaction based on the Chronic Care Model. The additional 5A approach (assess, advise, agree, assist, arrange) allows to score behavioral counseling. The aim of the study was to assess the psychometric properties of the German adaptation of the PACIC-5A questionnaire in a sample of general practitioners (GP) patients with obesity. Methods Analyses were based on data from the study “Five A’s counseling in weight management of obese patients in primary care: a cluster randomized controlled trial (INTERACT)”. Data were collected via standardized questionnaires containing the 26-item version of the PACIC-5A questionnaire. A total of 117 patients with obesity were included in the analyses. Statistical procedures comprised descriptive analyses, the calculation of Cronbach’s alpha, test-retest analyses and factor analyses in order to assess the psychometric properties including reliability and validity of the PACIC-5A. Results The patient’s mean age was 43.4 years and the sample was mostly female (59%). Middle educational level was found for the majority (78%) and the mean Body Mass Index was 38.9 kg/m2. Descriptive analyses revealed a mean PACIC score of 2.33 and 5A sum score of 2.29. Notable floor effects were found. PACIC-5A showed high level of internal consistency (Cronbach’s alphas > 0.9) and exploratory factor analyses resulted in a unidimensional structure. Conclusion The results of this study provide evidence regarding the psychometric properties of the German version of the PACIC-5A used in a sample of GP patients with obesity and make an important contribution to the reliable and valid assessment of the patient-GP interaction with regard to obesity counseling in primary care.

Objectives: Identifying the underlying pathways between obesity and depression and which individuals with obesity are at risk for developing depressive symptoms is important for improving prevention and treatment efforts. The current study investigated appearance evaluation as a potential mediator of the relationship between obesity and depression. Methods: A total of 1,000 participants with a self-reported BMI greater than 30 kg/m2 were interviewed about their experiences with an elevated body weight and completed measures on appearance evaluation and depression. Results: A negative relationship between satisfaction with appearance and BMI and a negative association between satisfaction with appearance and depression was found in men and women. Men reported less depressive symptoms and higher satisfaction with appearance compared to women. While no mediation effect could be determined in women, satisfaction with appearance mediated the obesity-depression relationship in men. Conclusions: Efforts to reduce adverse effects of either obesity or depression need to take the reciprocal relationship between the two conditions into account. The current findings underscore the importance of appearance evaluation for treatment efforts in individuals with obesity. Interventions addressing body image might improve both, psychological distress and weight management efforts in general.

Present-centered therapy (PCT) was originally developed as a strong comparator for the non-specific effects of psychotherapy in the treatment of posttraumatic stress disorder. PCT qualifies as a not strictly supportive treatment as it is structured and homework is assigned between sessions. It does not focus on cognitive restructuring or exposure. A growing body of literature supports its beneficial effects. For example, it demonstrated only slightly inferior effect sizes and lower dropout rates compared to that of trauma-focused cognitive behavioral therapy in several trials with patients suffering from posttraumatic stress disorder. The current study is the first to evaluate the feasibility and the treatment effects of PCT in adults with prolonged grief disorder (PGD). Meta-analyses on psychotherapy for PGD have yielded moderate effect sizes. N = 20 individuals suffering from PGD were treated with PCT by novice therapists as part of a preparation phase for an upcoming RCT in an outpatient setting. Treatment consisted of 20–24 sessions á 50 min. All outcomes were assessed before treatment, at post-treatment, and at the 3-month follow-up. The primary outcome, PGD symptom severity, was assessed using the Interview for Prolonged Grief-13. Secondary outcomes were self-reported PGD severity, depression, general psychological distress, and somatic symptom severity. Furthermore, therapists evaluated their experiences with their first PCT patient and the treatment manual. In intent-to-treat analyses of all patients we found a significant decrease in interview-based PGD symptom severity at post-treatment (d = 1.26). Decreases were maintained up to the 3-month follow-up assessment (d = 1.25). There were also significant decreases in self-reported PGD symptoms, depression, and general psychological distress. No changes were observed for somatic symptoms. The completion rate was 85%. Therapists deemed PCT to be a learnable treatment program that can be adapted to the patient's individual needs. The preliminary results of PCT as a treatment for PGD demonstrate large effects and indicate good feasibility in outpatient settings. The treatment effects were larger than those reported in meta-analyses. Thus, PCT is a promising treatment for PGD. Possible future research directions are discussed.

Syria has been the main country of citizenship of refugees in Germany since 2013. Syrians face numerous human rights violations in their country that can be accompanied by the experience of potentially traumatic events, loss and displacement. Along the migration process, refugees are exposed to various factors that can have an impact on mental health. The aim of this study is to investigate sociodemographic, war- and flight-related as well as post-migration factors as predictors of posttraumatic stress, depression, somatization and anxiety in Syrian refugees with posttraumatic stress symptoms based in Germany. Data were based on the baseline sample of the “Sanadak” randomized-controlled trial. A total of 133 adult Syrian refugees participated in the study. A questionnaire covered sociodemographic and flight-related questions as well as standardized instruments for symptoms of PTSD (PDS-5), depression (PHQ-9), somatization (PHQ-15), anxiety (GAD-7), generalized self-efficacy (GSE), religiousness (Z-Scale), social support (ESSI) and mental health stigma (SSMIS-SF). Linear regression models were executed to predict mental health outcomes. Sociodemographic predictors (i.e., female sex, higher education) and flight-related predicting factors (i.e., variability of traumatic events) have a negative impact on mental health in Syrian refugees with posttraumatic stress symptoms in Germany. Mental health stigma predicts worse mental health outcomes. Post-migration factors have a major impact on mental health, such as low income, lack of social support, low life satisfaction or a strongly felt connection to Syria. Somatization is an important manifestation of mental distress in Syrian refugees with posttraumatic stress symptoms. Our study showed a range of factors predicting the mental health of Syrian refugees with posttraumatic stress symptoms. Measures to foster mental health could be securing financial security, promoting gender equality and tailored psychosocial programs addressing mental health stigma, loss and social support networks.

The Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ) was developed to measure depressive and anxious avoidance behaviors, which, according to cognitive-behavioral models, are supposed to play an important role in the development and maintenance of prolonged grief. The present study aimed to develop a German version of the DAAPGQ and evaluate its psychometric properties and validity within a representative sample of the German general population (N = 2531). The German-language DAAPGQ was developed using a forward-backward translation procedure. Then, a subsample of individuals who reported having lost a significant other (N = 1371) of a representative sample was assessed with the German DAAPGQ, along with information on sociodemographic characteristics, prolonged grief symptom severity (PG-13), general anxiety (GAD-2) and depression (PHQ-2). The factor structure of the DAAPGQ was evaluated using confirmatory factor analyses, reliability by calculating internal consistency on subscale level and convergent validity by correlations between DAAPQG subscale sores with PG-13, GAD-2 and PHQ-2 sum scores. As expected, a two-factor model with correlated latent variables showed good fit to the data, replicating findings from the original version. Internal consistency was high for both subscales (Cronbach’s α .86 and .95, respectively). Convergent validity was established by theoretically expected and statistically significant positive correlations of DAAPGQ subscales with symptom severity of prolonged grief, depression, and anxiety and negative correlations with time since loss. Furthermore, the addition of depressive and anxious avoidance significantly improved the prediction of prolonged grief symptom severity over sociodemographic and loss-related information. In sum, our results suggest that the German-language DAAPGQ is a reliable and valid measure of depressive and anxious avoidance and a useful tool to improve our knowledge on the role of avoidance in prolonged grief. We also provide descriptive data to improve the applicability of the DAAPGQ for individual diagnostics.

Background: The loss of a loved one due to suicide can be a traumatic event associated with prolonged grief and psychological distress. Objective: This study examined the efficacy of an Internet-based cognitive-behavioural grief therapy (ICBGT) specifically for people bereaved by suicide. Methods: In a randomized controlled trial, 58 participants with prolonged grief disorder (PGD) symptoms who had lost a close person to suicide were randomly allocated either to the intervention group (IG) or waitlist-control group (WCG). The 5-week intervention comprised ten writing assignments in three phases: self-confrontation, cognitive restructuring, and social sharing. Symptoms of PGD, common grief reactions after suicide, depression, and general psychopathology were assessed at pre-, post-test and follow-up. Results: Between-group effect sizes were large for the improvement of PGD symptoms in treatment completers (dppc2 = 1.03) and the intent-to-treat analysis (dppc2 = 0.97). Common grief reactions after suicide and depressive symptoms also decreased in the IG compared to the WCG (moderate to large effects). The results are stable over time. Only for general psychopathology, there was no significant time by group interaction effect found. Conclusions: The ICBGT represents an effective treatment approach for people suffering from PGD symptoms after bereavement by suicide. Considering the effect sizes, the small treatment dose, duration, and the stability of the results, the ICBGT constitutes an appropriate alternative to face-to-face grief interventions.

Background: Prolonged grief disorder (PGD) will be newly included in the ICD-11, while a clinically similar diagnosis, persistent complex bereavement disorder (PCBD), has already been added to the DSM-5. Only few studies have evaluated these criteria-sets for prolonged grief. Objective: The aim of this study was to evaluate the ICD-11 accessory symptom threshold and compare the diagnostic performance of the two criteria-sets in treatment-seeking bereaved persons. Method: 113 grief treatment-seeking bereaved persons completed the Interview for Prolonged Grief-13. We used receiver operator characteristic analysis to determine an optimum ICD-11 accessory symptom threshold. We calculated diagnostic rates for PGD and PCBD and examined associations of PGD and PCBD caseness with concurrently assessed psychopathology and prolonged grief symptoms assessed one month later. Results: An ICD-11 threshold of six accessory symptoms distinguished optimally between interview-diagnosed participants with and without prolonged grief. The prevalence of PGD (69%) was significantly higher than that of PCBD (48%) and of PGD with a 6-symptom threshold (47%). PGD caseness was associated with the relation to the deceased, 6-symptom threshold PGD and PCBD caseness with the time since loss. All criteria-sets were linked to concurrent prolonged grief, depression, and general mental distress. PCBD and 6-symptom threshold PGD but not PGD were associated with prolonged grief severity one month later. Conclusions: The results support the validity of PGD and PCBD but, at the same time, they provide further support for differing prevalence rates. Using an empirically determined ICD-11 accessory symptom threshold could prevent the pathologisation of grief reactions.

BackgroundLate-life depression is a major public health concern, driving the development of complementary treatment options. This study investigates the effectiveness and acceptability of internet-based Cognitive Behavioral Therapy (iCBT) in older individuals (60+ years) compared to younger age groups.Materials and MethodsSecondary analysis of a cluster-randomized controlled trial with 647 (18–82 years; mean 43.9) mild to moderately severe depressed primary care patients receiving either iCBT + treatment as usual (TAU) or TAU alone. Severity of depression was measured by the Beck Depression Inventory (BDI-II) at baseline, 6 weeks and 6 months. Intention-to-treat analysis in three age groups (18–39 years, n = 264; 40–59 years, n = 300; 60+ years, n = 83) was performed, using mixed-effects regression models to quantify treatment effect.ResultsNo age differences in the effectiveness of iCBT were found. Patients in the intervention group consistently showed a greater reduction in depression severity than controls in all three age groups and at both follow-ups. Effect sizes ranged from d = 0.30 (40–59 years, 6 weeks) to d = 1.91 (60+ years, 6 months). Uptake of the intervention was banded around 70% with no differences between age groups (χ² = 0.18, p = .915). The mean number of completed modules increased with age (χ² = 18.99, p = .040).DiscussioniCBT is equally effective in both younger and older individuals, thus providing a valuable complementary element of routine late-life depression care.Clinical Trial RegistrationDRKS-ID: DRKS00005075 https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005075

Background: Although the relationship of trait impulsivity and suicidal behavior is well established, its relationship with suicidal ideation and its fluctuation still remains unclear. Our aim is to examine (1) the relationship of trait impulsivity and suicidal ideation and behavior in the context of the Interpersonal Psychological Theory of Suicide (IPTS) and (2) the association of trait impulsivity with the fluctuation of suicidal ideation in an inpatient sample with unipolar depression. Method: Eighty-four inpatients with unipolar depression and current and/or lifetime suicidal ideation were assessed with a baseline assessment including trait impulsivity, suicidal ideation, suicidal behavior and the constructs of the IPTS. Seventy-four of these patients underwent a 6-day ecological momentary assessment (EMA) with 10 assessments per day across six days assessing passive and active suicidal ideation. Mean squared successive differences (MSSD) across EMA assessments of suicidal ideation were calculated to test fluctuation as an indicator of temporal variability. Correlation analyses were conducted to test the associations. Results: There were no associations of trait impulsivity with suicidal ideation, thwarted belongingness and perceived burdensomeness, except the rather low but significant association between thwarted belongingness and the attention subdomain of trait impulsivity (r = 0.23*, p ≤ 0.05). Moreover, trait impulsivity showed a significant positive correlation with capability for suicide but not with the two subdomains of capability for suicide. The only significant but rather low correlation was identified between the motor aspect of trait impulsivity and fearlessness about death (r = 0.26, p ≤ 0.01). Suicidal behavior showed a positive correlation with trait impulsivity, but not with the different subdomains of trait impulsivity. Trait impulsivity showed a significant correlation with the MSSD of passive suicidal ideation (r = 0.26, p ≤ 0.05), but not with active suicidal ideation. Furthermore, the motor aspect of trait impulsivity (BIS motor) showed a significant correlation (r = 0.32, p ≤ 0.01) with the MSSD of passive suicidal ideation, but not with active suicidal ideation or the MSSD total score. Conclusion: Overall the findings are in line with our assumptions and the IPTS and underline that trait impulsivity is related to suicidal behavior and the fluctuation of suicidal ideation, but not to suicidal ideation itself. Thus, trait impulsivity seems to act as a distal risk factor via capability for suicide and it seems to play a role for the dynamics of suicidal ideation. The results have to be investigated in larger samples, with a higher risk of suicide and in prospective studies. Moreover, the role of the fluctuation of suicidal ideation for the prediction of suicide risk should be investigated in future studies. Keywords: Trait impulsivity, Interpersonal Psychological Theory of Suicide, Perceived burdensomeness, Thwarted belongingness, Suicidal behaviour, Suicidal ideation

Trait anxiety refers to the stable tendency to attend to threats and experience fears and worries across many situations. According to the widely noticed, pioneering investigation by Etkin et al. (2004) trait anxiety is strongly associated with reactivity in the right basolateral amygdala to non-conscious threat. Although this observation was based on a sample of only 17 individuals, no replication effort has been reported yet. We reexamined automatic amygdala responsiveness as a function of anxiety in a large sample of 107 participants. Besides self-report instruments, we administered an indirect test to assess implicit anxiety. To assess early, automatic stages of emotion processing, we used a color-decision paradigm presenting brief (33 ms) and backward-masked fearful facial expressions. N = 56 participants were unaware of the presence of masked faces. In this subset of unaware participants, the relationship between trait anxiety and basolateral amygdala activation by fearful faces was successfully replicated in region of interest analyses. Additionally, a relation of implicit anxiety with masked fear processing in the amygdala and temporal gyrus was observed. We provide evidence that implicit measures of affect can be valuable predictors of automatic brain responsiveness and may represent useful additions to explicit measures. Our findings support a central role of amygdala reactivity to non-consciously perceived threat in understanding and predicting dispositional anxiety, i.e. the frequency of spontaneously occurring anxiety in everyday life.

Abstract Background Obesity is one of the most prevalent health problems in western societies. However, it seems not effectively managed in the healthcare system at present. Originating from smoking cessation a tool called the 5As for obesity management has been drafted and adapted by the Canadian Obesity Network (CON) to improve weight counseling and provider-patient-interaction. This paper describes the rationale and design of the INTERACT study. The objective of the INTERACT study is to evaluate the effectiveness and intervention costs of a 5As eLearning program for obesity management aimed specifically at general practitioners (GPs). Methods The INTERACT study is a cluster randomized controlled trial aimed at implementing and evaluating an online-tutorial for obesity management based on the 5As approach in cooperating primary health care practices. Effectiveness of the 5As intervention will be evaluated by assessing patients and doctors perspectives on obesity management in primary care before and after the training. GPs in the intervention group will get access to the 5As obesity management online-tutorial while GPs in the control group will be assigned to a waiting list. Outcome measures for patients and GPs will be compared between the intervention group (treatment as usual + training of the GP) and the control group (treatment as usual). Hierarchical regression models will be used to analyze effects over time pre- and post-intervention. Discussion The 5As present physicians with a simple mnemonic for patient counseling in the primary care context. While the use of the 5As in weight counseling seems to be associated with improved doctor-patient interaction and motivation to lose weight, intervention studies assessing the effectiveness of a short 5A eLearning tutorial for physicians on secondary outcomes, such as weight development, are lacking. Trial registration The study has been registered at the German Clinical Trials Register (DRKS00009241; date of registration: 03.02.2016).

Abstract Background Approximately 10% of the individuals experiencing the death of a loved one develop prolonged grief disorder (PGD) after bereavement. Family members of haematological cancer patients might be particularly burdened since their loss experience is preceded by a very strenuous time of disease and aggressive treatment. However, support needs of relatives of cancer patients often remain unmet, also after the death of the patient. Therapeutic possibilities are enhanced by providing easily available and accessible Internet-based therapies. This study will adapt and evaluate an Internet-based grief therapy for bereaved individuals after the loss of a significant other due to haematological cancer. Methods The efficacy of the Internet-based grief therapy is evaluated in a randomized controlled trial with a wait-list control group. Inclusion criteria are bereavement due to hematological cancer and meeting the diagnostic criteria for PGD. Exclusion criteria are severe depression, suicidality, dissociative tendency, psychosis, posttraumatic stress disorder, substance use disorder, and current psychotherapeutic or psychopharmacological treatment. The main outcome is PGD severity. Secondary outcomes are depression, anxiety, somatization, posttraumatic stress, quality of life, sleep quality, and posttraumatic growth. Data is collected pre- and posttreatment. Follow-up assessments will be conducted 3, 6, and 12 months after completion of the intervention. The Internet-based grief therapy is assumed to have at least moderate effects regarding PGD and other bereavement-related mental health outcomes. Predictors and moderators of the treatment outcome and PGD will be determined. Discussion Individuals bereaved due to haematological cancer are at high risk for psychological distress. Tailored treatment for this particularly burdened target group is missing. Our study results will contribute to a closing of this healthcare gap. Trial registration German Clinical Trial Register UTN: U1111–1186-6255. Registered 1 December 2016.

Abstract Background Pre-pregnancy obesity and postpartum mental disorders are prevalent health risks to both the mother and the offspring. The objective of our study was to examine whether a history of childhood maltreatment is associated with pre-pregnancy obesity and postpartum mental health and whether childhood maltreatment and pre-pregnancy BMI independently predict postpartum mental health. Methods We obtained self-reported data from 741 postpartum women before 16 weeks after delivery (M = 8.1 weeks, SD = 3.2). Childhood sexual, physical, and emotional abuse and physical and emotional neglect were assessed with the Childhood Trauma Questionnaire. Depression and anxiety were assessed using the BDI and SCL-90-R. We conducted logistic regression models adjusted for demographic covariates and co-occurrence of different types of maltreatment. Results 7.6% of the included women entered pregnancy with obesity. Forty-six percent reported any type of childhood maltreatment. 6.4% displayed at least moderate postnatal depressive symptomatology and 20.5% scored above the 75th percentile for postpartum anxiety. Severe physical abuse, moderate emotional abuse and severe physical and emotional neglect were associated with pre-pregnancy obesity. After controlling for the presence of all other types of childhood maltreatment, only severe physical abuse was still predictive for pre-pregnancy obesity (adj.OR = 5.24, 95% CI = 1.15-23.75). Pre-pregnancy obesity was associated with an increased risk of postpartum depression (adj.OR = 2.55, 95% CI = 1.08-6.00) but not with elevated anxiety. Pre-pregnancy obesity and severe childhood sexual abuse independently predicted postpartum depression. After controlling for histories of different types of childhood maltreatment, the association between pre-pregnancy obesity and postpartum depression attenuated to non-significance. Conclusions To our knowledge, this is the first study examining empirical relations between childhood maltreatment, pre-pregnancy BMI and postpartum mental health controlling for the co-occurrence of other maltreatment types. Childhood maltreatment has been found being associated with both pre-pregnancy obesity and impaired postpartum mental health and may at least partly account for the association between pre-pregnancy obesity and postpartum depression. Therefore childhood maltreatment is related to two common risk conditions during pregnancy and postpartum which bear several health risks for the mother and the child, and routine screening for histories of childhood maltreatment among pregnant women is warranted.