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Objective To examine whether GPs’ communication styles have changed since the introduction and implementation of clinical guidelines for psychosocial problems in Dutch general practice in the 1990s. Methods From a database of 5184 consultations videotaped between 1977 and 2008, 512 consultations assessed by GPs as ‘completely psychosocial’ were coded with RIAS (Roter Interaction Analysis System). The 121 consultations prior to and 391 consultations after implementation of guidelines were analyzed whether communication styles have changed over time. Results We found that GPs were more likely to consider consultations to be mainly (17%) or completely (12%) psychosocial after the implementation of guidelines. They gave more biomedical and psychosocial information and advice in the second period compared to the first period. We also found that empathy decreased over time (frequency of empathic statements by GPs changed from 2.9–3.2 to 1.4–1.6 between periods). Conclusion Communication in psychosocial consultations has changed; GPs have become more focused on task-oriented communication (asking questions, giving information and advice) and less on showing empathy. Practice implications GPs face the challenge of integrating an evidence-based approach of applying guidelines that promote active symptom exploration with understanding patients’ personal contexts and giving room to their emotions.

Major depressive disorder has a large impact on patients and society and is projected to be the second greatest global burden of disease by 2020. The brain-derived neurotrophic factor (BDNF) gene is considered to be one of the important factors in the etiology of major depressive disorder. In a recent study, alpha power was found to mediate between BDNF Met and subclinical depressed mood. The current study looked at a population of patients with major depressive disorder (N = 107) to examine the association between the BDNF Val66Met polymorphism, resting state EEG alpha power, and depression severity. For this purpose, repeated-measures analysis of variance, partial correlation, and multiple linear models were used. Results indicated a negative association between parietal-occipital alpha power in the eyes open resting state and depression severity. In addition, Met/Met patients showed lower global absolute alpha power in the eyes closed condition compared with Val-carriers. These findings are in accordance with the previously uncovered pathway between BDNF Val66Met, resting state EEG alpha power, and depression severity. Additional research is needed for the clarification of this tentative pathway and its implication in personalized treatment of major depressive disorder.

Theories of eating regulation often attribute overweight to a malfunction of homeostatic regulation of body weight. With the goal conflict model of eating, we present a new perspective that attributes the difficulty of chronic dieters (i.e., restrained eaters) in regulating their food intake to a conflict between 2 incompatible goals-namely, eating enjoyment and weight control. This model explains the findings of previous research and provides novel insights into the psychological mechanism responsible for both dietary failure and success. According to this model, although chronic dieters are motivated to pursue their weight control goal, they often fail in food-rich environments because they are surrounded by palatable food cues that strongly prime the goal of eating enjoyment. Due to the incompatibility of the eating enjoyment goal and the weight control goal, such increase in the activation of the eating enjoyment goal results in (a) an inhibition of the cognitive representation of the weight control goal and (b) preferential processing of palatable food stimuli. Both these processes interfere with the effective pursuit of the weight control goal and facilitate unhealthy eating. However, there is a minority of restrained eaters for whom, most likely due to past success in exerting self-control, tasty high-calorie food has become associated with weight control thoughts. For them, exposure to palatable food increases the accessibility of the weight control goal, enabling them to control their body weight in food-rich environments. Evidence for these proposed psychological mechanisms is provided, and implications for interventions are discussed. © 2012 American Psychological Association.

Background Attention-deficit/hyperactivity disorder (ADHD) is the most common psychiatric disorder of childhood, with average worldwide prevalence of 5.3%, varying by region. Methods We assessed the relationship between the prevalence of ADHD and solar intensity (SI) (kilowatt hours/square meters/day) on the basis of multinational and cross-state studies. Prevalence data for the U.S. were based on self-report of professional diagnoses; prevalence data for the other countries were based on diagnostic assessment. The SI data were obtained from national institutes. Results In three datasets (across 49 U.S. states for 2003 and 2007, and across 9 non-U.S. countries) a relationship between SI and the prevalence of ADHD was found, explaining 34%–57% of the variance in ADHD prevalence, with high SI having an apparent preventative effect. Controlling for low birth weight, infant mortality, average income (socioeconomic status), latitude, and other relevant factors did not change these findings. Furthermore, these findings were specific to ADHD, not found for the prevalence of autism spectrum disorders or major depressive disorder. Conclusions In this study we found a lower prevalence of ADHD in areas with high SI for both U.S. and non-U.S. data. This association has not been reported before in the literature. The preventative effect of high SI might be related to an improvement of circadian clock disturbances, which have recently been associated with ADHD. These findings likely apply to a substantial subgroup of ADHD patients and have major implications in our understanding of the etiology and possibly prevention of ADHD by medical professionals, schools, parents, and manufacturers of mobile devices.

We investigated whether simultaneous colour contrast affects the synaesthetic colour experience and normal colour percept in a similar manner. We simultaneously presented a target stimulus (i.e. grapheme) and a reference stimulus (i.e. hash). Either the grapheme or the hash was presented on a saturated background of the same or opposite colour category as the synaesthetic colour and the other stimulus on a grey background. In both conditions, grapheme-colour synaesthetes were asked to colour the hash in a colour similar to the synaesthetic colour of the grapheme. Controls that were pair-matched to the synaesthetes performed the same experiment, but for them, the grapheme was presented in the colour induced by the grapheme in synaesthetes. When graphemes were presented on a grey and the hash on a coloured background, a traditional simultaneous colour-contrast effect was found for controls as well as synaesthetes. When graphemes were presented on colour and the hash on grey, the controls again showed a traditional simultaneous colour-contrast effect, whereas the synaesthetes showed the opposite effect. Our results show that synaesthetic colour experiences differ from normal colour perception; both are susceptible to different surrounding colours, but not in a comparable manner.

People often forget their long-term strivings because their environment confronts them with attractive temptations. Previous research suggests that self-control failures can be prevented by reminding people of their higher-order goal. Therefore, we hypothesized that using implementation intentions as a tool to directly re-activate people’s higher-order goal in tempting situations would effectively enhance self-control. We tested this in the domain of dieting behavior. Results demonstrated that this specific planning strategy activated the dieting goal for unsuccessful dieters when exposed to tempting food cues (Study 1) and reduced their consumption of calorically dense food across 2 weeks (Study 2) compared to those in control conditions. This suggests that preparing people to think of their higher-order goal when tempted can be used to protect ongoing goal striving. Appealing to higher-order goals potentially makes implementation intentions flexible instruments of self-regulation as this should trigger motivated behavior to reach goals and initiate various goal-instrumental actions. Copyright # 2011 John Wiley & Sons, Ltd. People often have to protect their higher-order goals that offer long-term benefits against temptations that promise immediate satisfaction. While keeping in mind one’s higher-order goal greatly facilitates this process of self-control (Shah, Friedman

The Dual Process Model of Coping with Bereavement (DPM; Stroebe & Schut, 1999) is described in this article. The rationale is given as to why this model was deemed necessary and how it was designed to overcome limitations of earlier models of adaptive coping with loss. Although building on earlier theoretical formulations, it contrasts with other models along a number of dimensions which are outlined. In addition to describing the basic parameters of the DPM, theoretical and empirical developments that have taken place since the original publication of the model are summarized. Guidelines for future research are given focusing on principles that should be followed to put the model to stringent empirical test.

In this article, we argue that when making moral decisions, unconscious thought can lead to more utilitarian moral decisions (approving of harmful actions that maximize good consequences), compared to conscious thought and immediate decision making. Therefore, we presented participants with a complex version of the well-known footbridge dilemma. In immediate decision conditions, participants made decisions what to do in this dilemma immediately. In conscious thought conditions, participants consciously thought about what to do for 3 minutes and then made their decisions. In unconscious thought conditions, participants were distracted for 3 minutes, and next made their decisions. As expected, participants who thought unconsciously about the dilemma were more willing to make utilitarian decisions than participants who thought consciously or who made an immediate decision. The current findings provide a new perspective on the social psychology of moral decision making and further insight into unconscious thinking.

This article is about how people make sense of life and focuses on one core threat that may play a pivotal role in people's lives as existential meaning makers: personal uncertainty. Personal uncertainty is defined as the aversive feeling that you experience when you feel uncertain about yourself. Drawing on an uncertainty management perspective, it is hypothesized that cultural worldviews may provide a means to cope with personal uncertainty and that this may explain why under conditions of personal uncertainty people may respond especially positively to events that bolster their cultural norms and values and particularly negatively to persons and events that violate these norms and values. Findings are reviewed that support the uncertainty management model's predictions. Furthermore, the uncertainty management model may explain why terror management theory is not always about terror, but (at least partly) about personal uncertainty. Finally, conceptual implications, conflicting findings, and loose ends ...

In this paper, I focus on two issues raised against the uncertainty management model that I proposed. The first issue has to do with the need for deeper insight into psychological processes instigated by uncertainty concerns, including the possibility of positive responses to uncertainty. The second issue revolves around the question to what extent uncertainty management is the core motive (vs. a core motive) of worldview defense and sense-making. By discussing these two issues, I hope to (a) make my view on uncertainty management processes clearer, (b) note explicitly that I was advocating a core motive of worldview defense (not the core motive), and (c) propose a research agenda for future research. I end the article with a plea for research studies that focus on moderators of worldview defense motives. These moderator studies may help to integrate the large variety of core motives proposed in the literature to underlie worldview defense strategies.

Contains fulltext : 48988.pdf (Publisher’s version ) (Open Access) CONTEXT: A lack of inhibitory control has been suggested to be the core deficit in attention-deficit/hyperactivity disorder (ADHD), especially in adults. This means that a primary deficit in inhibition mediates a cascade of secondary deficits in other executive functions, such as attention. Impaired stopping has been claimed to support the inhibition hypothesis. However, executive functions such as inhibition and attention are hard to disentangle. OBJECTIVE: To use event-related potentials in adult patients with ADHD to show that impaired stopping is associated with abnormalities of attention. DESIGN: The stop signal task was presented to 24 adults with ADHD combined subtype and 24 controls. Stop event-related potentials are distorted by overlap from event-related potentials to other stimuli in close temporal proximity, but we applied a method (Adjar level 2) to effectively remove this overlap. RESULTS: In line with an inhibitory control deficit, the stop signal reaction time was longer in adults with ADHD (F(1,46) = 7.12, P

The UK Government’s White Paper ‘No More Excuses’ (Home Office, 1997) set out plans for changing the culture of the Youth Court. This article focuses on one crucial aspect of the reform plans: the idea that magistrates need to engage with young offenders and their families. After a theoretical analysis of the foundation and justification for a special youth court, the article presents some findings concerning differences between the communication cultures of English/Welsh and Dutch Youth Courts. The article concludes by questioning the basic assumption of the White Paper, that fundamental changes could be realised without structural reform.

This study focuses on burnout and its positive antipode—engagement. A model is tested in which burnout and engagement have different predictors and different possible consequences. Structural equation modeling was used to simultaneously analyze data from four independent occupational samples (total N = 1698). Results confirm the hypothesized model indicating that: (1) burnout and engagement are negatively related, sharing between 10 per cent and 25 per cent of their variances; (2) burnout is mainly predicted by job demands but also by lack of job resources, whereas engagement is exclusively predicted by available job resources; (3) burnout is related to health problems as well as to turnover intention, whereas engagement is related only to the latter; (4) burnout mediates the relationship between job demands and health problems, whereas engagement mediates the relationship between job resources and turnover intention. The fact that burnout and engagement exhibit different patterns of possible causes and consequences implies that different intervention strategies should be used when burnout is to be reduced or engagement is to be enhanced. Copyright © 2004 John Wiley & Sons, Ltd.

Several studies suggest that conduct disorders and health endangering behaviors tend to co–occur. A recent review reported that conduct problems, such as delinquent behavior and aggression, were associated with (1) health endangering behaviors, such as risky traffic behavior, substance use (alcohol abuse, smoking, and drug use), self–medication, unsafe sex, unhealthy diet, lack of physical exercise, suicidal behavior, and (2) problems behaviors, such as gambling, truancy, and dropping out of school (Junger & Dekovic, in press). This co–occurrence suggests that, at least in part, a common etiological process is underlying these various forms of behavior (Baumeister, Heatherton, & Tice, 1994; Durlak, 1997; Durlak & Wells, 1997; Gottfredson & Hirschi, 1990; Logue, 1995; Mischel, Shoda, & Rodriguez, 1992; Repetti, Taylor, & Seeman, 2002). In this line of thinking, conduct problems, problem behavior, and health endangering behavior are all, to some extent, the product of common causal processes.

Contains fulltext : 64085.pdf (Publisher’s version ) (Closed access) Background: Siblings may support each other, but also reveal fierce rivalry and mutual aggression. Supportive sibling relationships have been linked to the development of psychosocial competence of children. In the present longitudinal study, we will focus on the development of perceived support in sibling dyads and on the influence of sibling support and sibling problem behavior on psychosocial adjustment in adolescence. Method: In a three-wave longitudinal sample of 285 Dutch families with two adolescent children (11 - to 15-year-olds), these two siblings judged the support perceived from each other. In addition, they themselves and their parents judged their internalizing and externalizing problem behaviors. The relation of sibling support and sibling problem behavior with internalizing and externalizing problem behaviors was examined while controlling for support from parents and friends and, over time, controlling for the autoregressive effects of problem behavior. Results: Support perceived from a sibling is mostly negatively related to externalizing problems; sibling problem behavior is strongly related to internalizing problems. Differential developmental trajectories of adolescents' adjustment are associated with siblings' support and problem behavior. Conclusion: The results indicate that adolescents' relationships with both older and younger siblings are characterized by modeling processes.

The job demands-resources (JD-R) model was used to examine the relationship between job characteristics, burnout, and (other-ratings of) performance (N = 146). We hypothesized that job demands (e.g., work pressure and emotional demands) would be the most important antecedents of the exhaustion component of burnout, which, in turn, would predict in-role performance (hypothesis 1). In contrast, job resources (e.g., autonomy and social support) were hypothesized to be the most important predictors of extra-role performance, through their relationship with the disengagement component of burnout (hypothesis 2). In addition, we predicted that job resources would buffer the relationship between job demands and exhaustion (hypothesis 3), and that exhaustion would be positively related to disengagement (hypothesis 4). The results of structural equation modeling analyses provided strong support for hypotheses 1, 2, and 4, but rejected hypothesis 3. These findings support the JD-R model's claim that job demands and job resources initiate two psychological processes, which eventually affect organizational outcomes. © 2004 Wiley Periodicals, Inc.

The first aim of this dissertation was to gain more insight in episodic memory. The studies in this part of the dissertation indicate that the parietal lobe most likely is involved in episodic memory due to the self-related demands of episodic memory tasks. Furthermore, a more ecological valid episodic memory test has been developed, that can detect deficits in anchoring events either in time, or in proximity to other events. A second aim of this dissertation was to study self-insight in cognitive performances after stroke. First, insight into the use of neuropsychological tests was studied in a group of healthy participants. The results indicate that laypeople have an understanding of the neuropsychological tests and domains used by the experts they interact with. However, this understanding does not implicate that lay people can give accurate self-estimates of their performances on cognitive domains. In a subsequent study healthy participants were found to have a tendency to overestimate. Overestimations were also found in a patient study where patients admitted with an acute ischemic stroke were found to estimates that were comparable to those of healthy participants while they were much poorer in cognitive performance. Even more, these overestimates of the patient group were found in the stable phase as well, where patients again estimated themselves comparably to the control group. Based on these results it appears that the image one has of oneself is a stable construct based on long term memory. This self-image does not adapt to changes, even after a major life event such as the hospitalization and rehabilitation after an ischemic stroke. Self-estimates thus most likely reflect a previous state of being or the future goal that one wants to achieve.

The first aim of this dissertation was to gain more insight in episodic memory. The studies in this part of the dissertation indicate that the parietal lobe most likely is involved in episodic memory due to the self-related demands of episodic memory tasks. Furthermore, a more ecological valid episodic memory test has been developed, that can detect deficits in anchoring events either in time, or in proximity to other events. A second aim of this dissertation was to study self-insight in cognitive performances after stroke. First, insight into the use of neuropsychological tests was studied in a group of healthy participants. The results indicate that laypeople have an understanding of the neuropsychological tests and domains used by the experts they interact with. However, this understanding does not implicate that lay people can give accurate self-estimates of their performances on cognitive domains. In a subsequent study healthy participants were found to have a tendency to overestimate. Overestimations were also found in a patient study where patients admitted with an acute ischemic stroke were found to estimates that were comparable to those of healthy participants while they were much poorer in cognitive performance. Even more, these overestimates of the patient group were found in the stable phase as well, where patients again estimated themselves comparably to the control group. Based on these results it appears that the image one has of oneself is a stable construct based on long term memory. This self-image does not adapt to changes, even after a major life event such as the hospitalization and rehabilitation after an ischemic stroke. Self-estimates thus most likely reflect a previous state of being or the future goal that one wants to achieve.

NTRODUCTION: Prospective memory is the ability to remember actions to be performed later in time or when a certain event occurs. Multiple cognitive processes are involved in prospective memory, and the degree to which automatic or effortful processes are involved may differ for different types of prospective memory tasks. This study aimed to investigate prospective memory (dys)functioning in stroke patients, and to get more insight in which cognitive processes are involved in time- versus event-based prospective memory. METHODS: We investigated 39 community-dwelling stroke survivors and 53 matched control participants. Assessment included naturalistic and experimental event- and time-based prospective memory tasks, as well as standard neuropsychological measures of (retrospective) memory, processing speed and attention/executive functioning. RESULTS: 41% of the stroke patients performed significantly worse than control participants on prospective memory tasks. Deficits in prospective memory occurred as frequently as impairments in retrospective memory (33%, χ(2)(1, N=39)=3.4, p=.066), and more often than impairments in attention/executive functioning (15%, χ(2)(1, N=39)=5.2, p=.022) and speed of processing (23%, χ(2)(1, N=39)=6.5, p=.011). Regression analyses showed that event-based ('focal') prospective memory is supported by retrospective memory, indicating that it is a relatively simple and automatic process. Time-based (non-'focal') prospective memory proved to be a more complex process, requiring active monitoring of the environment. Performance was predicted by speed of processing, attention/executive functioning and retrospective memory. Thirteen percent of the patients suffered from selective prospective memory impairment, which was associated with damage to the superior temporal gyrus. CONCLUSIONS: Impairment of prospective memory occurs frequently after stroke. Different cognitive operations are involved in distinct types of prospective memory. Results fit within the multi-process framework of prospective memory and help further specify its contents.

Neuropsychology is a rapidly growing, independent discipline with a broad work field. Neuropsychologists are working in hospitals, rehabilitation centres, nursing homes, forensic organisations and research institutes. One of the most important instruments of a neuropsychologist in assessing the behavioural expression of brain functions is the neuropsychological examination. This examination can have different purposes: 1. Diagnosis 2. Patient care 3. Treatment 4. Research The aim of this thesis is to demonstrate the diversity of the purposes of a neuropsychological examination. I will do this by presenting a series of studies that reflect these different purposes. Chapter 2 and chapter 3 will describe the neuropsychological examination as a diagnostic tool in two case studies. Chapter 4 and chapter 5 discuss different aspects of the neuropsychological examination in patient care. Chapter 6 illustrates the neuropsychological examination as a manner to evaluate treatment. Chapter 7, 8 and 9 are examples of the neuropsychological examination in research. In Chapter 10, the General Discussion, we question whether the different purposes of a neuropsychological examination should be seen as isolated aspects. As neuropsychologists, we aim the most optimal use of our neuropsychological assessment. Should we therefore not continuously keep other purposes as the one defined in the referral question in mind as well? Combining different purposes in one neuropsychological examination can be described as a multipurpose examination. A multipurpose examination makes us aware of other possible purposes of the neuropsychological examination than originally determined. The multipurpose examination, or in other words a multifaceted approach, forces us to think outside the standard boundaries of our assessment and outside the original reason for referral. In daily practice, the combination between the different purposes, or in other words between research and clinical care, is not always made. This can be the result of limited time and financial resources, but also simply because we are not used to it. First of all, in the curriculum of neuropsychologists in the Netherlands, the integration of different purposes is not consistently made. Clinical care and research are artificially separated in different stages of the education system and only in a very late stadium reunited. By combining clinical and research topics consequently in all stages of the neuropsychological educational program, neuropsychologists will be automatically more willing to integrate aspects of clinical care and research. Furthermore, in the broad profession of neuropsychology, some neuropsychologists are still working in isolation. This may have several drawbacks. The diagnosis and treatment procedures are viewed as fragmented and the results of the neuropsychological examination are therefore not always optimally used. Furthermore, interesting cases for research will be missed because neuropsychologists working in clinical settings are not in contact with those who are participating in research. Short lines between hospitals, rehabilitation centres, nursing homes and research institutes will be helpful in combining the different purposes. Finally, standards of evidence-based methods can be illustrative in combining research and clinical care (and integrating the four purposes described by Lezak). This thesis makes neuropsychologists more aware of the different purposes of a neuropsychological examination. Being aware of these different purposes can be helpful in looking outside the standard boundaries of your profession. As a result neuropsychology will rise to a higher level.

Neuropsychology is a rapidly growing, independent discipline with a broad work field. Neuropsychologists are working in hospitals, rehabilitation centres, nursing homes, forensic organisations and research institutes. One of the most important instruments of a neuropsychologist in assessing the behavioural expression of brain functions is the neuropsychological examination. This examination can have different purposes: 1. Diagnosis 2. Patient care 3. Treatment 4. Research The aim of this thesis is to demonstrate the diversity of the purposes of a neuropsychological examination. I will do this by presenting a series of studies that reflect these different purposes. Chapter 2 and chapter 3 will describe the neuropsychological examination as a diagnostic tool in two case studies. Chapter 4 and chapter 5 discuss different aspects of the neuropsychological examination in patient care. Chapter 6 illustrates the neuropsychological examination as a manner to evaluate treatment. Chapter 7, 8 and 9 are examples of the neuropsychological examination in research. In Chapter 10, the General Discussion, we question whether the different purposes of a neuropsychological examination should be seen as isolated aspects. As neuropsychologists, we aim the most optimal use of our neuropsychological assessment. Should we therefore not continuously keep other purposes as the one defined in the referral question in mind as well? Combining different purposes in one neuropsychological examination can be described as a multipurpose examination. A multipurpose examination makes us aware of other possible purposes of the neuropsychological examination than originally determined. The multipurpose examination, or in other words a multifaceted approach, forces us to think outside the standard boundaries of our assessment and outside the original reason for referral. In daily practice, the combination between the different purposes, or in other words between research and clinical care, is not always made. This can be the result of limited time and financial resources, but also simply because we are not used to it. First of all, in the curriculum of neuropsychologists in the Netherlands, the integration of different purposes is not consistently made. Clinical care and research are artificially separated in different stages of the education system and only in a very late stadium reunited. By combining clinical and research topics consequently in all stages of the neuropsychological educational program, neuropsychologists will be automatically more willing to integrate aspects of clinical care and research. Furthermore, in the broad profession of neuropsychology, some neuropsychologists are still working in isolation. This may have several drawbacks. The diagnosis and treatment procedures are viewed as fragmented and the results of the neuropsychological examination are therefore not always optimally used. Furthermore, interesting cases for research will be missed because neuropsychologists working in clinical settings are not in contact with those who are participating in research. Short lines between hospitals, rehabilitation centres, nursing homes and research institutes will be helpful in combining the different purposes. Finally, standards of evidence-based methods can be illustrative in combining research and clinical care (and integrating the four purposes described by Lezak). This thesis makes neuropsychologists more aware of the different purposes of a neuropsychological examination. Being aware of these different purposes can be helpful in looking outside the standard boundaries of your profession. As a result neuropsychology will rise to a higher level.

When the retinal images of the left and the right eye are incompatible, perception starts alternating. That is, the visual content that one is aware of alternates between the two images presented. This phenomenon is referred to as binocular rivalry. When one is aware of one of the two images, this image is referred to as dominant. The other image is then referred to as suppressed. In the current thesis, two unresolved issues that are central to understanding binocular rivalry are addressed. First, we focus on the interactions between aware and unaware visual information, a topic which is surrounded by many controversies. For example, there is evidence both in favor of and against binocular suppression as being non-selective. One of the key results of the present thesis is that suppression during binocular rivalry is feature-selective. Specifically, results indicate that suppression is not uniform across orientations: suppression was much stronger for orientations within a narrow range around the orientation of the suppressed rival grating, with a tuning similar reminiscent of orientation bandwidths found in V1 neurons. The same principle holds for spatial frequenty content. We go on to show that binocular rivalry competition not only affects suppressed selectively, but also the visual information of dominant perception. In other words, dominant images are affected by suppressed images in a very specific manner that can be related to the suppressed image’s feature content. Second, we discuss spatial interactions during rivalry. Although rivalry is a local phenomenon, spatial dependencies do exist. These dependencies reflect influences on binocular rivalry that may originate from different stage along the visual processing hierarchy. We go on to show that spatial dependencies in our experiments are primarily driven by the source (eye-of-origin) of the images. Image content (features) does affect spatial dependencies but this appears to be limited to the image’s most basic components, which are processed at early visual processing stages (i.e. primary visual cortex). These results suggest that higher-level image processing plays only a minor role in spatial dependencies during rivalry. The results presented in this thesis show strong interactions between aware and unaware visual information. These interactions are suggested to have an early, mainly monocular, locus. Likewise, the spatial dependencies seen for the outcome of rivalry competition (dominance) at multiple locations also appear to have a large early, monocular component. Moreover, our results suggest that higher-level modulation of dominance durations is rather weak. Taken together, the manipulations affecting perceptual suppression and dominance during binocular rivalry presented in this thesis will most likely affect processing at a monocular level of visual processing. In the context of the current dominant idea that rivalry is resolved at multiple stages of visual processing our studies provide evidence that the early stages are strongly involved, while higher-level areas contribute only little to resolving binocular rivalry.

When the retinal images of the left and the right eye are incompatible, perception starts alternating. That is, the visual content that one is aware of alternates between the two images presented. This phenomenon is referred to as binocular rivalry. When one is aware of one of the two images, this image is referred to as dominant. The other image is then referred to as suppressed. In the current thesis, two unresolved issues that are central to understanding binocular rivalry are addressed. First, we focus on the interactions between aware and unaware visual information, a topic which is surrounded by many controversies. For example, there is evidence both in favor of and against binocular suppression as being non-selective. One of the key results of the present thesis is that suppression during binocular rivalry is feature-selective. Specifically, results indicate that suppression is not uniform across orientations: suppression was much stronger for orientations within a narrow range around the orientation of the suppressed rival grating, with a tuning similar reminiscent of orientation bandwidths found in V1 neurons. The same principle holds for spatial frequenty content. We go on to show that binocular rivalry competition not only affects suppressed selectively, but also the visual information of dominant perception. In other words, dominant images are affected by suppressed images in a very specific manner that can be related to the suppressed image’s feature content. Second, we discuss spatial interactions during rivalry. Although rivalry is a local phenomenon, spatial dependencies do exist. These dependencies reflect influences on binocular rivalry that may originate from different stage along the visual processing hierarchy. We go on to show that spatial dependencies in our experiments are primarily driven by the source (eye-of-origin) of the images. Image content (features) does affect spatial dependencies but this appears to be limited to the image’s most basic components, which are processed at early visual processing stages (i.e. primary visual cortex). These results suggest that higher-level image processing plays only a minor role in spatial dependencies during rivalry. The results presented in this thesis show strong interactions between aware and unaware visual information. These interactions are suggested to have an early, mainly monocular, locus. Likewise, the spatial dependencies seen for the outcome of rivalry competition (dominance) at multiple locations also appear to have a large early, monocular component. Moreover, our results suggest that higher-level modulation of dominance durations is rather weak. Taken together, the manipulations affecting perceptual suppression and dominance during binocular rivalry presented in this thesis will most likely affect processing at a monocular level of visual processing. In the context of the current dominant idea that rivalry is resolved at multiple stages of visual processing our studies provide evidence that the early stages are strongly involved, while higher-level areas contribute only little to resolving binocular rivalry.

The Symptom Checklist 90–Revised (SCL-90-R) is an international, widely used, self-report questionnaire of multidimensional complaints with normative data for healthy control subjects and psychiatric patients. The questionnaire is also often used in neurological patients. Little is known about the amount and pattern of complaints in this group, and normative data are lacking. We therefore analyzed self-reported symptoms on the SCL-90-R of a neurological population (N = 600). Moreover, we compared the answer patterns of five subgroups: neurodegenerative disease, cerebrovascular disease, epilepsy, brain tumor, and traumatic brain injury. Neurological outpatients scored significantly higher in comparison with normative data from healthy control subjects, with most pronounced scores on Inadequacy of Thinking and Acting, Depression, and Somatization (p < .01, effect sizes 1.69, 0.83, and 0.83). No differences between the various pathologies were found. Although it is difficult to determine whether the complaints arise directly from the neurological disease or more indirectly from psychiatric disturbances accompanying the disease, simply comparing a neurological patient to normative data for healthy control subjects can lead to inappropriate classifications. Complaints of our patients should not be directly interpreted as psychopathology. A two-step procedure in which scores on the SCL-90-R are first compared to healthy control subjects and secondly to neurological patients can be helpful in the interpretation.

Onderwijskunde is een jonge universitaire studie, die in 1983 in ons land als zelfstandige studie is opgenomen in het Academisch Statuut. Deze studie werd geplaatst binnen de faculteit Sociale Wetenschappen, die 20 jaar eerder, in 1963, aan de Nederlandse Universiteiten werd ingericht. Algemeen wordt de Groningse hoogleraar Leon van Gelder (1913-1981) gezien als grondlegger (zie ook Van Essen, 2012, p. 222 e.v.). Deze vroege Onderwijskunde in Groningen was overigens een afsplitsing van ‘de pedagogiek in de volle omvang’. Ook in Utrecht was de studie van het onderwijs onderdeel van de door Martinus J. Langeveld (1905-1989) beklede leerstoel ‘pedagogiek in de volle omvang’ (zie Bos, 2011). Zowel van Gelder als Langeveld beschouwden de Onderwijskunde, die Langeveld liever aanduidde als Onderwijspedagogiek, als een onderdeel van de Pedagogiek. Er is veel disciplinaire strijd en onduidelijkheid geweest rond de Onderwijskunde. Restanten daarvan ziet men nog steeds: bij de Vrije Universiteit in Brussel is de Onderwijskunde onderdeel van de Psychologie, in Gent van de Pedagogiek. In Groningen treffen we de Onderwijskunde aan als afstudeerrichting binnen de Pedagogische Wetenschappen, evenals in Leiden, Nijmegen, en Twente. Waar de Onderwijskunde in 1983 begon als ‘boven-bouwstudie’, was zij weloverwogen gebaseerd op de fundamenten van de drie dominante Sociale Wetenschappen: de Psychologie, de Pedagogiek en de Sociologie...

OBJECTIVE: In the current study, we investigated the role of noradrenaline in directing (bias) and disengagement of visuospatial attention. METHODS: We assessed the effect of clonidine on event-related brain potential (ERP) reflections of bias and disengagement in a double-blind placebo-controlled crossover design. An initial dose of 200-μg clonidine was replaced by 100 μg because of marked side effects. Twenty-one healthy male participants performed the visual-spatial cueing task while an electroencephalogram (EEG) was recorded. The behavioral output is the validity effect (benefit of cueing in terms of reaction time to targets). ERP indices for bias were the cue-related early directing attention negativity and late directing attention positivity, and the target-elicited P1 and N1 modulations by validity ('validity-effect'). The ERP index for disengagement was the target-elicited 'late positive deflection' modulation by validity. Behavioral analyses were performed on 16 participants, electrophysiological analyses on a subset (n=9). RESULTS: Clonidine attenuated the N1 effect, albeit in a subsample. Neither cue-elicited ERPs nor the behavioral validity effect were affected. Clonidine-induced blood pressure reduction was correlated with the reduction of the late positive deflection effect under clonidine. CONCLUSION: Clonidine attenuated the result of bias in a subsample and may have a modulating effect on disengagement.

Onderwijskunde is een jonge universitaire studie, die in 1983 in ons land als zelfstandige studie is opgenomen in het Academisch Statuut. Deze studie werd geplaatst binnen de faculteit Sociale Wetenschappen, die 20 jaar eerder, in 1963, aan de Nederlandse Universiteiten werd ingericht. Algemeen wordt de Groningse hoogleraar Leon van Gelder (1913-1981) gezien als grondlegger (zie ook Van Essen, 2012, p. 222 e.v.). Deze vroege Onderwijskunde in Groningen was overigens een afsplitsing van ‘de pedagogiek in de volle omvang’. Ook in Utrecht was de studie van het onderwijs onderdeel van de door Martinus J. Langeveld (1905-1989) beklede leerstoel ‘pedagogiek in de volle omvang’ (zie Bos, 2011). Zowel van Gelder als Langeveld beschouwden de Onderwijskunde, die Langeveld liever aanduidde als Onderwijspedagogiek, als een onderdeel van de Pedagogiek. Er is veel disciplinaire strijd en onduidelijkheid geweest rond de Onderwijskunde. Restanten daarvan ziet men nog steeds: bij de Vrije Universiteit in Brussel is de Onderwijskunde onderdeel van de Psychologie, in Gent van de Pedagogiek. In Groningen treffen we de Onderwijskunde aan als afstudeerrichting binnen de Pedagogische Wetenschappen, evenals in Leiden, Nijmegen, en Twente. Waar de Onderwijskunde in 1983 begon als ‘boven-bouwstudie’, was zij weloverwogen gebaseerd op de fundamenten van de drie dominante Sociale Wetenschappen: de Psychologie, de Pedagogiek en de Sociologie...

Major depressive disorder has a large impact on patients and society and is projected to be the second greatest global burden of disease by 2020. The brain-derived neurotrophic factor (BDNF) gene is considered to be one of the important factors in the etiology of major depressive disorder. In a recent study, alpha power was found to mediate between BDNF Met and subclinical depressed mood. The current study looked at a population of patients with major depressive disorder (N = 107) to examine the association between the BDNF Val66Met polymorphism, resting state EEG alpha power, and depression severity. For this purpose, repeated-measures analysis of variance, partial correlation, and multiple linear models were used. Results indicated a negative association between parietal-occipital alpha power in the eyes open resting state and depression severity. In addition, Met/Met patients showed lower global absolute alpha power in the eyes closed condition compared with Val-carriers. These findings are in accordance with the previously uncovered pathway between BDNF Val66Met, resting state EEG alpha power, and depression severity. Additional research is needed for the clarification of this tentative pathway and its implication in personalized treatment of major depressive disorder.

Werk geeft ons de mogelijkheid om mensen te ontmoeten, plezier te hebben en een nuttige bijdrage aan de maatschappij te leveren. Werk kan echter ook een last worden wanneer er geen rekening wordt gehouden met de belemmeringen door fibromyalgie. Het is dus van groot belang dat het werk ‘passend’ is. Dat wil zeggen, afgestemd op de mogelijkheden en beperkingen van de persoon. Door het werk passend te maken, kan het werk goed en met plezier worden uitgevoerd. Dit paspoort helpt bij het vinden van werk dat passend is

Werk geeft ons de mogelijkheid om mensen te ontmoeten, plezier te hebben en een nuttige bijdrage aan de maatschappij te leveren. Werk kan echter ook een last worden wanneer er geen rekening wordt gehouden met de belemmeringen door fibromyalgie. Het is dus van groot belang dat het werk ‘passend’ is. Dat wil zeggen, afgestemd op de mogelijkheden en beperkingen van de persoon. Door het werk passend te maken, kan het werk goed en met plezier worden uitgevoerd. Dit paspoort helpt bij het vinden van werk dat passend is

Background. In primary care, many consultations address symptom-based complaints. Recovery from these complaints seldom exceeds placebo effects. Patient participation, because of its supposed effects on trust and patient expectancies, is assumed to benefit patients’ recovery. While the idea is theoretically promising, it is still unclear what the effects of increased patient participation are on patient outcomes. Aim. To review the effects of controlled intervention studies aiming to improve patient participation in face-to-face primary care consultations on patient-oriented and/or disease-oriented outcomes. Methods. This study is a systematic review. A systematic search was undertaken for randomized controlled trials designed to measure the effects of interventions that aimed to improve adult patients’ participation in primary care visits. The CINAHL, Cochrane, EMBASE, PsycINFO and PubMed databases were searched. Results. Seven different trials fulfilled the inclusion criteria. Three of the studies were related to symptom-based complaints. Five studies measured patient-oriented outcomes, the primary outcome of interest for this review. All studies suffered from substantial bias. Studies varied widely in their aims, types of complaints/diseases, strength of the interventions and their outcomes. The effects on patient-oriented outcomes and disease-oriented outcomes were ambiguous. Conclusion. Little research has been performed on health outcomes of interventions aiming to increase patient participation in general practice visits among patients suffering from symptom-based complaints. The results still are non-conclusive. The quality of the trials has been weak, possibly due to the complexity of the concept. This weak quality may explain the lack of conclusive results. Proposals for future research designs are offered. Keywords. Patient participation, patient-oriented outcomes, primary health care, shared decision-making, review (publication type).

Themes such as “effectiveness” and “evidence-based practice” dominate current debates about and within the professional field of youth care. The field seems to focus almost solely on the effectiveness of interventions and policy measures and there appears to be a general consensus on the objectivity and neutrality of interventions, policy measures and of the effectiveness research that follows from it. However, child rearing—including the professional re-education of children— entails more than encouraging desired behavior and correcting inappropriate behavior. It also includes normative ideas about this desired behavior and about issues like “good parenting” and “healthy development”. Although no one would argue that effectiveness issues are a mere detail, the assessment and evaluation of interventions and policy measures on effectiveness only, leaves these normative matters undiscussed. The research presented in this dissertation aims at unraveling this “hidden curriculum” of both youth care interventions and youth policy measures, by analyzing and clarifying the role values may play in this specific professional field. Five case studies have been conducted, each consisting of content analysis of relevant documents (i.e. articles about an intervention, policy reports), and of interviews and observations. The results of these case studies show that values are indeed expressed in youth care interventions and in youth policy measures. In contrast to the claims of objectivity and neutrality, interventions and policy measures convey specific value perspectives. In general protective values, such as security or achievement, are expressed in all of the five case studies. Some interventions combine these protective values with growth-oriented values, for instance self-direction or hedonistic values. Others combine them with values such as conformity, indicating a conservative value perspective. Differences were found between the values expressed in the theory of an intervention and the values expressed in the actual practice of an intervention. This may indicate that personal, professional or institutional values may play a role in executing an intervention. The results also seem to imply that cultural values may have some influence on the execution of an intervention. For youth policy, differences in values are mainly found between the social groups the policy measures intent to target. Overall, the results are indicative of values aimed at socialization and integration of children and families in existing social structures and norms. The results have important implications for the professional field of youth care and the research conducted in it. Differences between values in the theory and in the practice of an intervention imply that it may serve effectiveness research to pay attention to the subject of values: Professionals may struggle with the implicit values of an intervention and may adapt the intervention to better suit the values they believe are important. Likewise, fall out of clients during treatment may be explained by a discrepancy between the implicit values of an intervention and the personal values of parents and children. Moreover, the results of this research may foster a debate about the position of the professional field of youth care and the role they foresee for themselves within society.

Themes such as “effectiveness” and “evidence-based practice” dominate current debates about and within the professional field of youth care. The field seems to focus almost solely on the effectiveness of interventions and policy measures and there appears to be a general consensus on the objectivity and neutrality of interventions, policy measures and of the effectiveness research that follows from it. However, child rearing—including the professional re-education of children— entails more than encouraging desired behavior and correcting inappropriate behavior. It also includes normative ideas about this desired behavior and about issues like “good parenting” and “healthy development”. Although no one would argue that effectiveness issues are a mere detail, the assessment and evaluation of interventions and policy measures on effectiveness only, leaves these normative matters undiscussed. The research presented in this dissertation aims at unraveling this “hidden curriculum” of both youth care interventions and youth policy measures, by analyzing and clarifying the role values may play in this specific professional field. Five case studies have been conducted, each consisting of content analysis of relevant documents (i.e. articles about an intervention, policy reports), and of interviews and observations. The results of these case studies show that values are indeed expressed in youth care interventions and in youth policy measures. In contrast to the claims of objectivity and neutrality, interventions and policy measures convey specific value perspectives. In general protective values, such as security or achievement, are expressed in all of the five case studies. Some interventions combine these protective values with growth-oriented values, for instance self-direction or hedonistic values. Others combine them with values such as conformity, indicating a conservative value perspective. Differences were found between the values expressed in the theory of an intervention and the values expressed in the actual practice of an intervention. This may indicate that personal, professional or institutional values may play a role in executing an intervention. The results also seem to imply that cultural values may have some influence on the execution of an intervention. For youth policy, differences in values are mainly found between the social groups the policy measures intent to target. Overall, the results are indicative of values aimed at socialization and integration of children and families in existing social structures and norms. The results have important implications for the professional field of youth care and the research conducted in it. Differences between values in the theory and in the practice of an intervention imply that it may serve effectiveness research to pay attention to the subject of values: Professionals may struggle with the implicit values of an intervention and may adapt the intervention to better suit the values they believe are important. Likewise, fall out of clients during treatment may be explained by a discrepancy between the implicit values of an intervention and the personal values of parents and children. Moreover, the results of this research may foster a debate about the position of the professional field of youth care and the role they foresee for themselves within society.

The brain is organized around two complementary principles: modularity and connectivity. This PhD thesis introduces and evaluates novel methods to study both principles in the human brain in vivo. These methods are based on functional Magnetic Resonance Imaging (MRI), which is sensitive to the activation of brain regions and on diffusion MRI, which is sensitive to the structure of the connections between brain regions. We have first evaluated the usefulness of diffusion MRI in the context of effective connectivity studies. Such studies require an explicit model of how the brain is anatomically connected. We show that tractography based on diffusion MRI provides support for a large number of the connections that were proposed in eight previously published effective connectivity studies and also suggest a number of connections that were not used in these studies. However, the methods used in this study are problematic in regions where multiple pathways are crossing. Moreover they do not quantify the probability of finding a connection between regions. We have therefore developed a probabilistic formulation of Q-Ball Imaging, a diffusion MRI method which can resolve up to three different fibre pathways in each voxel. We have recasted the Q-Ball Imaging method in a Bayesian framework and have developed a Markov Chain Monte Carlo algorithm to sample from the posterior distribution on the fibre directions. This algorithm shows good performance both in simulated data and in real diffusion MRI data. The last two studies in this thesis deal with the modularity of the brain, as defined by patterns of anatomical connectivity and functional connectivity during rest. A large number of studies have shown that the resting brain shows a remarkable degree of organization. More specifically, networks that co-activate during task performance show a high degree of co-activation during rest. The third experimental chapter investigates whether we cannot only define functional networks based on resting-state data, but also functionally-defined regions. This chapter is based on the parcellation of a region on the medial wall of the frontal cortex, the SMA region. This region has been consistently parcellated into two sub-regions in a large number of studies using different modalities. We have developed a clustering method for resting-state fMRI data based on the fuzzy clustering algorithm and the Discrete Wavelet Transform. Using this method, we show that the clustering pattern of the SMA region is highly consistent between diffusion MRI and resting-state fMRI data. The resting-state fMRI signal is dynamic in nature, which potentially leads to inconsistencies in clustering patterns within subjects, which would be highly undesirable. The fourth experimental chapter shows that this is indeed the case and proposes an optimization of the Normalized cuts clustering algorithm that significantly improves the within-subject consistency of clustering patterns. This chapter also introduces a heuristic to determine the appropriate number of clusters for resting-state fMRI data. This heuristic is based on the uniqueness of the functional connectivity pattern of each cluster and stops increasing the number of clusters when the functional connectivity pattern of any two clusters has become statistically identical.

The brain is organized around two complementary principles: modularity and connectivity. This PhD thesis introduces and evaluates novel methods to study both principles in the human brain in vivo. These methods are based on functional Magnetic Resonance Imaging (MRI), which is sensitive to the activation of brain regions and on diffusion MRI, which is sensitive to the structure of the connections between brain regions. We have first evaluated the usefulness of diffusion MRI in the context of effective connectivity studies. Such studies require an explicit model of how the brain is anatomically connected. We show that tractography based on diffusion MRI provides support for a large number of the connections that were proposed in eight previously published effective connectivity studies and also suggest a number of connections that were not used in these studies. However, the methods used in this study are problematic in regions where multiple pathways are crossing. Moreover they do not quantify the probability of finding a connection between regions. We have therefore developed a probabilistic formulation of Q-Ball Imaging, a diffusion MRI method which can resolve up to three different fibre pathways in each voxel. We have recasted the Q-Ball Imaging method in a Bayesian framework and have developed a Markov Chain Monte Carlo algorithm to sample from the posterior distribution on the fibre directions. This algorithm shows good performance both in simulated data and in real diffusion MRI data. The last two studies in this thesis deal with the modularity of the brain, as defined by patterns of anatomical connectivity and functional connectivity during rest. A large number of studies have shown that the resting brain shows a remarkable degree of organization. More specifically, networks that co-activate during task performance show a high degree of co-activation during rest. The third experimental chapter investigates whether we cannot only define functional networks based on resting-state data, but also functionally-defined regions. This chapter is based on the parcellation of a region on the medial wall of the frontal cortex, the SMA region. This region has been consistently parcellated into two sub-regions in a large number of studies using different modalities. We have developed a clustering method for resting-state fMRI data based on the fuzzy clustering algorithm and the Discrete Wavelet Transform. Using this method, we show that the clustering pattern of the SMA region is highly consistent between diffusion MRI and resting-state fMRI data. The resting-state fMRI signal is dynamic in nature, which potentially leads to inconsistencies in clustering patterns within subjects, which would be highly undesirable. The fourth experimental chapter shows that this is indeed the case and proposes an optimization of the Normalized cuts clustering algorithm that significantly improves the within-subject consistency of clustering patterns. This chapter also introduces a heuristic to determine the appropriate number of clusters for resting-state fMRI data. This heuristic is based on the uniqueness of the functional connectivity pattern of each cluster and stops increasing the number of clusters when the functional connectivity pattern of any two clusters has become statistically identical.

During binocular rivalry, perception alternates between dissimilar images presented dichoptically. Although perception during rivalry is believed to originate from competition at a local level, different rivalry zones are not independent: rival targets that are spaced apart but have similar features tend to be dominant at the same time. We investigated grouping of spatially separated rival targets presented to the same or to different eyes and presented in the same or in different hemifields. We found eye-of-origin to be the strongest cue for grouping during binocular rivalry. Grouping was additionally affected by orientation: identical orientations were grouped longer than dissimilar orientations, even when presented to different eyes. Our results suggest that eye-based and orientation-based grouping is independent and additive in nature. Grouping effects were further modulated by the distribution of the targets across the visual field. That is, grouping within the same hemifield can be stronger or weaker than between hemifields, depending on the eye-of-origin of the grouped targets. We also quantified the contribution of the previous cues to grouping of two images during binocular rivalry. These quantifications can be successfully used to predict the dominance durations of different studies. Incorporating the relative contribution of different cues to grouping, and the dependency on hemifield, into future models of binocular rivalry will prove useful in our understanding of the functional and anatomical basis of the phenomenon of binocular rivalry.

Previous studies show that lesbian, gay and bisexual (LGB) individuals report more health problems than heterosexual individuals. However, several important gaps remain in the knowledge regarding the explanations for these health differences. In general, there is a lack of differentiation between subgroups in the LGB population, a lack of specific attention for older LGB individuals and LGB youth who grow up in relatively tolerant countries, and a lack of combined between-and-within-groups study designs that examine factors associated with health differences. These gaps are addressed in the current dissertation. Although some gender and sexual orientation differences were found in the associations between risk factors and health problems, the presented studies that addressed potential gender and sexual orientation differences in the association between minority stress factors and mental health, sexual health, substance use, and social wellbeing provide no reason to suspect that the usefulness of the minority stress model differs substantially for sexual minority women and men or for lesbian/gay and bisexual individuals. In addition, the minority stress model seems to be a useful model for explaining health problems of both LGB youth and ageing LGB individuals. Research combining between-and-within-groups study designs was shown to be a useful way of examining health differences between LGB and heterosexual individuals. Firstly, using a between-and-within-groups design enabled showing that feelings of loneliness as well as sexual health problems of LGB individuals can be explained by general risk factors as well as by LGB-specific factors. To be most effective, interventions aiming to decrease sexual health problems among LGB adults or loneliness among elderly LGB individuals should therefore target both types of factors. Secondly, the use of a between-and-within-groups study design clearly showed the hypothesized, additive health compromising effects of minority stress factors. These findings provide important and novel support for one of the main assumptions of the minority stress model, that minority stress is a form of additive stress that is experienced by minority groups in addition to the stressors that are also experienced by members of the social majority, and that it is this additional stress takes its toll on LGB individuals and affects their health over and above general health risk factors.

Previous studies show that lesbian, gay and bisexual (LGB) individuals report more health problems than heterosexual individuals. However, several important gaps remain in the knowledge regarding the explanations for these health differences. In general, there is a lack of differentiation between subgroups in the LGB population, a lack of specific attention for older LGB individuals and LGB youth who grow up in relatively tolerant countries, and a lack of combined between-and-within-groups study designs that examine factors associated with health differences. These gaps are addressed in the current dissertation. Although some gender and sexual orientation differences were found in the associations between risk factors and health problems, the presented studies that addressed potential gender and sexual orientation differences in the association between minority stress factors and mental health, sexual health, substance use, and social wellbeing provide no reason to suspect that the usefulness of the minority stress model differs substantially for sexual minority women and men or for lesbian/gay and bisexual individuals. In addition, the minority stress model seems to be a useful model for explaining health problems of both LGB youth and ageing LGB individuals. Research combining between-and-within-groups study designs was shown to be a useful way of examining health differences between LGB and heterosexual individuals. Firstly, using a between-and-within-groups design enabled showing that feelings of loneliness as well as sexual health problems of LGB individuals can be explained by general risk factors as well as by LGB-specific factors. To be most effective, interventions aiming to decrease sexual health problems among LGB adults or loneliness among elderly LGB individuals should therefore target both types of factors. Secondly, the use of a between-and-within-groups study design clearly showed the hypothesized, additive health compromising effects of minority stress factors. These findings provide important and novel support for one of the main assumptions of the minority stress model, that minority stress is a form of additive stress that is experienced by minority groups in addition to the stressors that are also experienced by members of the social majority, and that it is this additional stress takes its toll on LGB individuals and affects their health over and above general health risk factors.

Directing attention selectively to an expected event has already been known for a long time to recruit a network of frontal and parietal brain attentional control areas. In addition, this frontal-parietal control network has been hypothesized to signal stimulus-specific sensory (e.g. visual cortex) areas to increase preparatory (biasing) activity in an attempt to improve subsequent perceptual processing of the expected stimulus. The research presented in this thesis shows that there might actually be multiple, rather than one, frontal-parietal attentional control network, one being more medial-dorsal and the other being more lateral-dorsal in location. In addition, strong evidence was found for a frontal cortex initiation of top-down attentional control, rather than a parietal cortex initiation, as was hypothesized by some selective attention theories. Furthermore, it was found that the subsequently triggered sensory cortex biasing-related activity actually consisted of two different, coexisting, mechanisms: 1) a slow-wave baseline shift mechanism that can lower perceptual stimulus thresholds, and 2) an oscillatory alpha-frequency rhythm that can store an attentional trace (template), including both stimulus and response characteristics and their behavioral relevance. Finally, it was shown that voluntary choices in task strategies could selectively determine which frontal-parietal network would be activated (more medial-dorsal or more lateral-dorsal) and which sensory cortex mechanism would be selectively boosted. In short, an attention-for-perception based strategy recruits mostly a medial-dorsal frontal-parietal network and boosts most strongly the baseline shift mechanism, whereas an attention-for-action based strategy boosts more strongly the formation of an attentional template in sensory cortical areas. In conclusion, top-down attentional control is not a unitary mechanism, but includes multiple different processes that can be boosted selectively through voluntary choices in top-down task strategy.

Directing attention selectively to an expected event has already been known for a long time to recruit a network of frontal and parietal brain attentional control areas. In addition, this frontal-parietal control network has been hypothesized to signal stimulus-specific sensory (e.g. visual cortex) areas to increase preparatory (biasing) activity in an attempt to improve subsequent perceptual processing of the expected stimulus. The research presented in this thesis shows that there might actually be multiple, rather than one, frontal-parietal attentional control network, one being more medial-dorsal and the other being more lateral-dorsal in location. In addition, strong evidence was found for a frontal cortex initiation of top-down attentional control, rather than a parietal cortex initiation, as was hypothesized by some selective attention theories. Furthermore, it was found that the subsequently triggered sensory cortex biasing-related activity actually consisted of two different, coexisting, mechanisms: 1) a slow-wave baseline shift mechanism that can lower perceptual stimulus thresholds, and 2) an oscillatory alpha-frequency rhythm that can store an attentional trace (template), including both stimulus and response characteristics and their behavioral relevance. Finally, it was shown that voluntary choices in task strategies could selectively determine which frontal-parietal network would be activated (more medial-dorsal or more lateral-dorsal) and which sensory cortex mechanism would be selectively boosted. In short, an attention-for-perception based strategy recruits mostly a medial-dorsal frontal-parietal network and boosts most strongly the baseline shift mechanism, whereas an attention-for-action based strategy boosts more strongly the formation of an attentional template in sensory cortical areas. In conclusion, top-down attentional control is not a unitary mechanism, but includes multiple different processes that can be boosted selectively through voluntary choices in top-down task strategy.

The aim of this dissertation was to provide a systematic exploration of the nature and distribution of dysfunctional affect regulation, its associated phenomena, and retrospectively reported potentially traumatizing events in 475 patients diagnosed with borderline personality disorder (BPD), somatoform disorder (SoD), comorbid BPD+SoD, and a psychiatric comparison group (PC) to provide a baseline against which to compare the hypothesized elevations in dysfunctional self and affect regulation. Whereas some patients react to adversities with inhibited experiencing and social withdrawal, others react hyper-emotionally and tend to cling to a significant other to alleviate stress and regulate to base-line. Van Dijke described dysfunctional self and affect regulation as operating in vicious cycles that approach the long-term sequelae of trauma-by-primary-caretaker from a developmental perspective. Activation of dysfunctional regulation seems to follow trauma-by-primary-caretaker associated negatively biased cognitive-emotional information processing. However, when potentially neutral situations are processed and evaluated as threatening or potentially harmful, dysfunctional regulation is activated false positively. Consequently, this may result in interpersonal misunderstanding and disappointments, which in turn condition and uphold the insecure attachment representation/ working models eventually turning into dysfunctional regulation vicious circles. The present studies demonstrated that dysfunctional regulation presents in patients in three qualitatively different forms: Inhibitory-, Excitatory-, and combined Inhibitory & Excitatory (IE)-regulation. Symptoms include disturbances in self-regulation across several domains of functioning including affective, cognitive, somatic, relational, reflective, executive, behavioral, and psycho-physiological functioning. However, no disorder-specific form of dysfunctional affect regulation or dissociation was found. Adults who were exposed to potentially traumatizing events by primary caretaker during childhood often demonstrate complex psychological disturbances that are not fully captured by the Posttraumatic Stress Disorder (PTSD) diagnosis. In an attempt to capture the complex symptom presentation that includes not only posttraumatic stress symptoms, but also other symptoms reflecting disturbances predominantly in affective and interpersonal self-regulatory capacities, dissociation, somatization, and shattered or altered basic beliefs, Complex PTSD (CPTSD) was introduced as a clinical syndrome for adults. This disorder fundamentally involves the focus of this study: Dysfunctional affect regulation and dissociation. Childhood trauma-primary-caretaker plays a role in both over- and under-regulation of affect depending on the type and developmental epoch of the traumatization in psychiatrically-impaired adults, specifically in BPD. Also, CPTSD can be distinguished from BPD and/or SoD. By including patients of both genders and other diagnoses as well as BPD, the present study demonstrated that CPTSD is not exclusively or always found with (and therefore not synonymous with) BPD. The combined results of this dissertation suggest that further clinical and research studies are needed in order to further the development of empirically-based clinical assessment and treatment protocols for trauma-related self and affect dysregulation in adults with a range of Axis I and II psychiatric disorders. Also, disorder-specific assessment and treatment methods and guidelines for BPD, SoD and severe affective, and anxiety, may be enhanced by the addition of approaches focused on the types of dysfunctional affect- and self regulation that were identified and examined in the present studies.

The aim of this dissertation was to provide a systematic exploration of the nature and distribution of dysfunctional affect regulation, its associated phenomena, and retrospectively reported potentially traumatizing events in 475 patients diagnosed with borderline personality disorder (BPD), somatoform disorder (SoD), comorbid BPD+SoD, and a psychiatric comparison group (PC) to provide a baseline against which to compare the hypothesized elevations in dysfunctional self and affect regulation. Whereas some patients react to adversities with inhibited experiencing and social withdrawal, others react hyper-emotionally and tend to cling to a significant other to alleviate stress and regulate to base-line. Van Dijke described dysfunctional self and affect regulation as operating in vicious cycles that approach the long-term sequelae of trauma-by-primary-caretaker from a developmental perspective. Activation of dysfunctional regulation seems to follow trauma-by-primary-caretaker associated negatively biased cognitive-emotional information processing. However, when potentially neutral situations are processed and evaluated as threatening or potentially harmful, dysfunctional regulation is activated false positively. Consequently, this may result in interpersonal misunderstanding and disappointments, which in turn condition and uphold the insecure attachment representation/ working models eventually turning into dysfunctional regulation vicious circles. The present studies demonstrated that dysfunctional regulation presents in patients in three qualitatively different forms: Inhibitory-, Excitatory-, and combined Inhibitory & Excitatory (IE)-regulation. Symptoms include disturbances in self-regulation across several domains of functioning including affective, cognitive, somatic, relational, reflective, executive, behavioral, and psycho-physiological functioning. However, no disorder-specific form of dysfunctional affect regulation or dissociation was found. Adults who were exposed to potentially traumatizing events by primary caretaker during childhood often demonstrate complex psychological disturbances that are not fully captured by the Posttraumatic Stress Disorder (PTSD) diagnosis. In an attempt to capture the complex symptom presentation that includes not only posttraumatic stress symptoms, but also other symptoms reflecting disturbances predominantly in affective and interpersonal self-regulatory capacities, dissociation, somatization, and shattered or altered basic beliefs, Complex PTSD (CPTSD) was introduced as a clinical syndrome for adults. This disorder fundamentally involves the focus of this study: Dysfunctional affect regulation and dissociation. Childhood trauma-primary-caretaker plays a role in both over- and under-regulation of affect depending on the type and developmental epoch of the traumatization in psychiatrically-impaired adults, specifically in BPD. Also, CPTSD can be distinguished from BPD and/or SoD. By including patients of both genders and other diagnoses as well as BPD, the present study demonstrated that CPTSD is not exclusively or always found with (and therefore not synonymous with) BPD. The combined results of this dissertation suggest that further clinical and research studies are needed in order to further the development of empirically-based clinical assessment and treatment protocols for trauma-related self and affect dysregulation in adults with a range of Axis I and II psychiatric disorders. Also, disorder-specific assessment and treatment methods and guidelines for BPD, SoD and severe affective, and anxiety, may be enhanced by the addition of approaches focused on the types of dysfunctional affect- and self regulation that were identified and examined in the present studies.

Women who want to know whether their breast cancer or the breast cancer in their family is hereditary can request a referral for genetic counselling. Those who are the first in their family to request breast cancer genetic counselling often don’t know what to expect or have unrealistic expectations. Their initial breast cancer genetic counselling visits are mainly educational in nature, with large amounts of relatively standard information and little counselee participation. These visits might not optimally fulfil counselees’ information needs. Therefore, a pre-visit website, called E-info geneca, was developed with the aim to help counselees to prepare for their first visit and to pursue a more active role in the visit. We conducted a study of the effects of this pre-visit website E-info geneca on counselees’ expectations, communication in the visit and post-visit outcomes. 197 Counselees were randomized to receive usual care (UC) or UC plus the pre-visit website. The website provided counselees with computer-tailored information and a question prompt sheet (QPS) on which counselees could write their questions for the visit. These questions were sent to the counsellor pre-visit. All counselees completed a pre- and post-visit questionnaire and visits were videotaped. We studied effects on the communication in the visit, counselees’ information recall, knowledge about breast cancer and heredity, fulfilment of needs, risk perception accuracy, anxiety and perceived personal control, using multilevel regression analyses. After having accessed E-info geneca counselees better knew what to expect of their first visit and less often had unrealistic expectations about possibilities for DNA-testing than counselees in the UC group. In the visit, counselees in the intervention group more often shared their agenda, directed the flow of the visit and paraphrased the counsellors’ words. Counsellors consistently introduced and answered the QPS questions. As a result, counsellors provided more information about preventive options, risk of family members and inheritance if this was requested and the information provided was more specific to the individual counselee. Post-visit, counselees in the intervention group remembered more of the information provided in the visit. They also had more knowledge of breast cancer and heredity and reported better fulfilment of information needs than counselees in the UC group. The effects of the intervention were strongest for those counselees who did not receive an indication for DNA-testing, their recall scores showed more increase and their anxiety levels dropped more in the intervention compared to UC group. No intervention effects were found after the first visit on accuracy of risk perception or perceived personal control. This study shows that pre-counselling education, using tailored information technology, facilitates counselees to better prepare themselves for their first visit for breast cancer genetic counselling. This leads to more effective first visits, in particular for counselees who received no indication for DNA-testing and therefore had no indication for a second visit. Future study should focus on the effects of the website on the outcomes after a complete series of visits

Women who want to know whether their breast cancer or the breast cancer in their family is hereditary can request a referral for genetic counselling. Those who are the first in their family to request breast cancer genetic counselling often don’t know what to expect or have unrealistic expectations. Their initial breast cancer genetic counselling visits are mainly educational in nature, with large amounts of relatively standard information and little counselee participation. These visits might not optimally fulfil counselees’ information needs. Therefore, a pre-visit website, called E-info geneca, was developed with the aim to help counselees to prepare for their first visit and to pursue a more active role in the visit. We conducted a study of the effects of this pre-visit website E-info geneca on counselees’ expectations, communication in the visit and post-visit outcomes. 197 Counselees were randomized to receive usual care (UC) or UC plus the pre-visit website. The website provided counselees with computer-tailored information and a question prompt sheet (QPS) on which counselees could write their questions for the visit. These questions were sent to the counsellor pre-visit. All counselees completed a pre- and post-visit questionnaire and visits were videotaped. We studied effects on the communication in the visit, counselees’ information recall, knowledge about breast cancer and heredity, fulfilment of needs, risk perception accuracy, anxiety and perceived personal control, using multilevel regression analyses. After having accessed E-info geneca counselees better knew what to expect of their first visit and less often had unrealistic expectations about possibilities for DNA-testing than counselees in the UC group. In the visit, counselees in the intervention group more often shared their agenda, directed the flow of the visit and paraphrased the counsellors’ words. Counsellors consistently introduced and answered the QPS questions. As a result, counsellors provided more information about preventive options, risk of family members and inheritance if this was requested and the information provided was more specific to the individual counselee. Post-visit, counselees in the intervention group remembered more of the information provided in the visit. They also had more knowledge of breast cancer and heredity and reported better fulfilment of information needs than counselees in the UC group. The effects of the intervention were strongest for those counselees who did not receive an indication for DNA-testing, their recall scores showed more increase and their anxiety levels dropped more in the intervention compared to UC group. No intervention effects were found after the first visit on accuracy of risk perception or perceived personal control. This study shows that pre-counselling education, using tailored information technology, facilitates counselees to better prepare themselves for their first visit for breast cancer genetic counselling. This leads to more effective first visits, in particular for counselees who received no indication for DNA-testing and therefore had no indication for a second visit. Future study should focus on the effects of the website on the outcomes after a complete series of visits

Nightmares and insomnia are sleep disorders with serious consequences. Both sleep disorders can effectively be treated with cognitive-behavioral therapy (CBT). Because of its cost-effectiveness and promising effects, self-help CBT has been proposed as a first option within a stepped-care framework. CBT for insomnia and nightmares primarily consists of psycho-education about sleep and exercises to improve sleep-wake habits. Therefore, the use of CBT self-help manuals for sleep problems within a stepped care approach framework seems promising. This dissertation describes three large randomized controlled trials concerning self-help CBT for nightmares or insomnia. In the first nightmare RCT, 399 participants were randomized into Imagery Rehearsal Therapy - IRT (n = 103), exposure (n = 95), recording (n = 106) or waiting-list condition (n = 95). Results showed that nightmares can successfully be treated with self-help and that effectiveness is sustained in the long run. IRT alleviated nightmare frequency faster, but, unexpectedly, was equally effective to exposure. It seems thus that the desensitization to the feared image is the crucial element in nightmare treatment. In the second nightmare RCT, 278 participants were randomized into IRT (n = 70), IRT+ (with sleep hygiene; n = 76), Lucid Dreaming Therapy - LDT (n = 70), or waiting-list condition (n = 62). Results showed that in addition to IRT, sleep hygiene or lucid dreaming did not have a beneficial effect. For insomnia, a self-help CBT protocol was developed and its effectiveness was evaluated in a large RCT (N = 623) which compared Internet delivered self-help CBT to bibliotherapy and a waiting-list condition. We found that insomnia can effectively be treated with unsupported self-help CBT. Internet and bibliotherapy were equally effective at 4-week follow-up. However, the Internet condition had a higher dropout. Effects were sustained at 48-week follow-up, but surprisingly, symptoms of insomnia and secondary complaints decreased more in the Internet compared to the bibliotherapy condition. In conclusion, in this dissertation we found that unsupported self-help CBT can successfully ameliorate nightmares and insomnia. Sleep disorders can be specifically targeted and self-help treatments have an effect on primary sleep complaints. The nightmare studies demonstrated that self-help CBT decreased nightmare frequency. The insomnia study showed that CBT increased total sleep time, and decreased sleep onset latency as well as waking time after sleep onset. Moreover, indirect effects were found on affective complaints such as depression and anxiety. The effects were sustained in the long run, suggesting that not only face-to-face but also self-help CBT has better long-term effects than sleep medication. The unsupported self-help format is promising because it appears to be a cost-effective way to reach a large number of people with sleep disorders.

Nightmares and insomnia are sleep disorders with serious consequences. Both sleep disorders can effectively be treated with cognitive-behavioral therapy (CBT). Because of its cost-effectiveness and promising effects, self-help CBT has been proposed as a first option within a stepped-care framework. CBT for insomnia and nightmares primarily consists of psycho-education about sleep and exercises to improve sleep-wake habits. Therefore, the use of CBT self-help manuals for sleep problems within a stepped care approach framework seems promising. This dissertation describes three large randomized controlled trials concerning self-help CBT for nightmares or insomnia. In the first nightmare RCT, 399 participants were randomized into Imagery Rehearsal Therapy - IRT (n = 103), exposure (n = 95), recording (n = 106) or waiting-list condition (n = 95). Results showed that nightmares can successfully be treated with self-help and that effectiveness is sustained in the long run. IRT alleviated nightmare frequency faster, but, unexpectedly, was equally effective to exposure. It seems thus that the desensitization to the feared image is the crucial element in nightmare treatment. In the second nightmare RCT, 278 participants were randomized into IRT (n = 70), IRT+ (with sleep hygiene; n = 76), Lucid Dreaming Therapy - LDT (n = 70), or waiting-list condition (n = 62). Results showed that in addition to IRT, sleep hygiene or lucid dreaming did not have a beneficial effect. For insomnia, a self-help CBT protocol was developed and its effectiveness was evaluated in a large RCT (N = 623) which compared Internet delivered self-help CBT to bibliotherapy and a waiting-list condition. We found that insomnia can effectively be treated with unsupported self-help CBT. Internet and bibliotherapy were equally effective at 4-week follow-up. However, the Internet condition had a higher dropout. Effects were sustained at 48-week follow-up, but surprisingly, symptoms of insomnia and secondary complaints decreased more in the Internet compared to the bibliotherapy condition. In conclusion, in this dissertation we found that unsupported self-help CBT can successfully ameliorate nightmares and insomnia. Sleep disorders can be specifically targeted and self-help treatments have an effect on primary sleep complaints. The nightmare studies demonstrated that self-help CBT decreased nightmare frequency. The insomnia study showed that CBT increased total sleep time, and decreased sleep onset latency as well as waking time after sleep onset. Moreover, indirect effects were found on affective complaints such as depression and anxiety. The effects were sustained in the long run, suggesting that not only face-to-face but also self-help CBT has better long-term effects than sleep medication. The unsupported self-help format is promising because it appears to be a cost-effective way to reach a large number of people with sleep disorders.

In 1688 Molyneux asked the question whether a blind man who knew the difference between a sphere and a cube from touch, with his sight restored would be able to distinguish between them based on vision. One interpretation of Molyneux’s question is whether spatial representations are modality-specific. In a series of experiments the nature of spatial mental representations and the link with spatial language and imagery was studied. First the current literature on this topic was reviewed. Spatial information can be obtained through modality-specific input (such as vision, touch and audition, etc.), but also through amodal verbal input. A model is proposed in which these inputs feed into a supramodal representation of spatial information. A supramodal representation contains the purely spatial information, but maintains links with input modalities. This model explains how different sources of input can yield behaviorally similar results. In line with this, results from early blind people, without any visual memories, indicate that they perform quite well on various spatial and navigation tasks, suggesting that vision is not the only modality that can convey spatial information. Following the model described above a series of empirical studies were conducted. The first part of this thesis deals with simple spatial sentences, such as “the ball is above the shoe”, and reference frame processing. Reference frames determine the point of view for communication and are very important for successful communication. Potentially, reference frames allow for communication between different sensory modalities, as illustrated by Molyneux’s question. This part discusses how these simple spatial sentences are represented using, verbal, visual and haptic comparisons. Spatial language hardly ever occurs in isolation but should also be considered in a larger context such as talking about space and getting from one place to the other. Therefore, the second part of this thesis examined the processing of complex spatial descriptions. The reference frames that clarify how objects are located support different perspectives and possibly different representations, both behaviorally and neurally. This part describes neuroimaging studies that investigate whether the representations built up from these complex descriptions are indeed spatial, that is whether they represent metric information about the locations described. Finally, the third part of this thesis focuses on how compelling such spatial information is when understanding language. Can spatial information also be accessed through language that is not necessarily spatial at first? This question links spatial representations to the influential idea of grounded cognition that language is understood by linking it to perceptual simulations. Three chapters directly tested early blind participants. This special participant group allowed to determine the role of visual experience in representing spatial information. Together the results from this thesis support the idea the spatial information can be obtained from multiple different input modalities and is represented supramodally. This supramodal representation can be addressed using spatial language. Moreover, vision is not a prerequisite to build up these supramodal representations, as demonstrated by the highly similar results for blind and sighted participants.