Jörg Wiltink

Dizziness: Anxiety, health care utilization and health behavior—: Results from a representative German community survey

BACKGROUND Due to the lack of epidemiological data on the relation of dizziness and anxiety, we investigated the prevalence of dizziness and anxiety in a representative sample of the German population. We explored the consequences of comorbid anxiety for emotional distress, functional impairment, health care utilization, and health behavior in dizziness. METHODS By the end of 2006, we surveyed a total of 1287 persons between 14 and 90 years of age in their homes by trained interviewers with standardized self-rating questionnaires on anxiety (Patient Health Questionnaire, Generalized Anxiety Disorder Scale, Mini-Social Phobia Inventory) and dizziness (Vertigo Symptom Scale). The sample was representative for the German population in terms of age, sex, and education. RESULTS Symptoms of dizziness were reported by 15.8% of the participants. Of the participants with dizziness, 28.3% reported symptoms of at least one anxiety disorder (generalized anxiety, social phobia, panic). Persons with dizziness reported more somatic problems such as hypertension, migraine, diabetes, etc. Comorbid anxiety was associated with increased health care use and impairment. CONCLUSION Dizziness is a highly prevalent symptom in the general population. A subgroup with comorbid anxiety is characterized by an increased subjective impairment and health care utilization due to their dizziness. Because treatment options for distinct neurotologic disorders are also known to reduce psychological symptoms, and in order to avoid unnecessary medical treatment, early neurologic and psychiatric/psychotherapeutic referral may be indicated.

Type D personality is independently associated with major psychosocial stressors and increased health care utilization in the general population

BACKGROUND Type D is considered as a non pathological personality trait and propensity for mental distress. Its relationship with mental distress has been mainly studied in cardiovascular patients and with respect to depression. The knowledge about the relationship of Type D with mental disorders, psychosocial stressors and health care utilization in the general population is insufficient. Therefore the present study sought to determine the associations of Type D with mental distress, major psychosocial stressors, health status, and health care utilization in the general population. METHODS Cross-sectional analysis in a representative population based sample of n = 2495 subjects (mean age 49 years, range 14-92 years) of whom 33.1% had Type D personality. RESULTS Individuals with Type D had an increased risk for clinically significant depression, panic disorder, somatization and alcohol abuse. After adjustment for these mental disorders Type D was still robustly associated with all major psychosocial stressors. The strongest associations emerged for feelings of social isolation and for traumatic events. After comprehensive adjustment Type D still remained associated with increased help seeking behavior and utilization of health care, especially of mental health care. LIMITATIONS The main limitation is the reliance on self-report measures and the lack of information about the medical history and clinical diagnosis of the participants. CONCLUSION Type D identifies persons with severely increased risk for mental distress, major psychosocial stressors and increased health care utilization. As a frequent disposition, Type D is assumed to be of high relevance for health care.

Profile of the Immune and Inflammatory Response in Individuals With Prediabetes and Type 2 Diabetes

OBJECTIVE The inflammatory and immune systems are altered in type 2 diabetes. Here, the aim was to profile the immune and inflammatory response in subjects with prediabetes and diabetes in a large population-representative sample. RESEARCH DESIGN AND METHODS In total, 15,010 individuals were analyzed from the population-based Gutenberg Health Study. Glucose status was classified according to HbA1c concentration and history of diagnosis. All samples were analyzed for white blood cells (WBCs), granulocytes, lymphocytes, monocytes, platelets, C-reactive protein (CRP), albumin, fibrinogen, and hematocrit. Interleukin-18 (IL-18), IL-1 receptor antagonist (IL-1RA), and neopterin concentrations were determined in a subcohort. RESULTS In total, 7,584 men and 7,426 women were analyzed (range 35–74 years), with 1,425 and 1,299 having prediabetes and diabetes, respectively. Biomarkers showed varying dynamics from normoglycemic via subjects with prediabetes to subjects with diabetes: 1) gradual increase (WBCs, granulocytes, monocytes, IL-1RA, IL-18, and fibrinogen), 2) increase with subclinical disease only (lymphocytes and CRP), 3) increase from prediabetes to diabetes only (neopterin), and 4) no variation with glucose status (hematocrit). The strongest relative differences were found for CRP, IL-1RA, and fibrinogen concentrations. Several inflammatory and immune markers were associated with the glucose status independent from cardiovascular risk factors and comorbidities, varied with disease severity and the presence of disease-specific complications in the diabetes subcohort. CONCLUSIONS The inflammatory and immune biomarker profile varies with the development and progression of type 2 diabetes. Markers of inflammation and immunity enable differentiation between the early preclinical and clinical phases of the disease, disease complications, and progression.

The Social Phobia Psychotherapy Research Network : The First Multicenter Randomized Controlled Trial of Psychotherapy for Social Phobia: Rationale, Methods and Patient Characteristics

This paper presents the Social Phobia Psychotherapy Research Network. The research program encompasses a coordinated group of studies adopting a standard protocol and an agreed-on set of standardized measures for the assessment and treatment of social phobia (SP). In the central project (study A), a multicenter randomized controlled trial, refined models of manualized cognitive-behavioral therapy and manualized short-term psychodynamic psychotherapy are compared in the treatment of SP. A sample of 512 outpatients will be randomized to either cognitive-behavioral therapy, short-term psychodynamic psychotherapy or waiting list. Assessments will be made at baseline, at the end of treatment and 6 and 12 months after the end of treatment. For quality assurance and treatment integrity, a specific project using highly elaborated measures has been established (project Q). Study A is complemented by 4 interrelated add-on projects focusing on attachment style (study B1), on cost-effectiveness (study B2), on variation in the serotonin transporter gene in SP (study C1) and on structural and functional deviations of the hippocampus and amygdala (study C2). Thus, the Social Phobia Psychotherapy Research Network program enables a highly interdisciplinary research into SP. The unique sample size achieved by the multicenter approach allows for studies of subgroups (e.g. comorbid disorders, isolated vs. generalized SP), of responders and nonresponders of each treatment approach, for generalization of results and for a sufficient power to detect differences between treatments. Psychological and biological parameters will be related to treatment outcome, and variables for differential treatment indication will be gained. Thus, the results provided by the network may have an important impact on the treatment of SP and on the development of treatment guidelines for SP.

Type D personality as a cardiovascular risk marker in the general population: results from the Gutenberg health study.

Background: Type D personality is considered as an independent risk factor for morbidity and mortality in cardiovascular patients and a vulnerability factor for distress in the general population. Because representative community studies are rare, we sought to determine the prevalence of type D personality and its relationship with demographic characteristics, different features of mental disorders, cardiovascular risk factors, health behavior, endothelial function and cardiovascular biomarkers in the general population. Methods: The prevalence of type D personality and its correlates were analyzed cross-sectionally in a population-based sample of 5,000 Mid-Europeans aged 35–74 years from the Gutenberg Health Study. Results: The prevalence of type D personality was 22.2% without remarkable differences in sex distribution. Type D subjects were characterized by lower socioeconomic status, lack of a partnership, increased depression, anxiety, depersonalization and health care utilization. Despite its strong association with mental disorders, type D personality emerged as psychometrically distinct. Although type D personality was independently associated with coronary heart disease (OR = 1.54, p = 0.044), no associations with traditional cardiovascular risk factors were found independently from depression or anxiety. Conclusions: Although type D personality is strongly associated with depression, anxiety, impaired mental and somatic health status, and increased health care utilization, the type D construct seems to comprise dysfunctional personality patterns not covered by depression and anxiety scales. Beyond these associations, the pathways of the cardiotoxic impact of type D personality remain to be elucidated. There is a need for prospective population studies on potential links between type D personality and cardiac disease.

Prevalence, correlates, and predictors of depersonalization experiences in the German general population.

The survey aimed to investigate the prevalence of depersonalization (DP) experiences, its sociodemographic characteristics and its associations with medical conditions, illness behavior, and potential etiologic factors. A representative face-to-face household survey was conducted. The sample consists of n = 1,287 participants aged 14 to 90 years. Sociodemographic variables, medical conditions, current mental disorders, health care utilization, and childhood adversities were assessed. A total of 1.9% participants scored in the range of clinically significant DP (DP-C) and 9.7% reported at least some impairment through DP (DP-I). DP-C/DP-I were strongly associated with depression and anxiety. After adjustment for depression and anxiety, DP-C and DP-I were independently associated with hypertension, diabetes mellitus, chronic pulmonary disease, severe pain, and childhood adversities. We conclude that DP is common, it can not be reduced to a negligible variant of depression or anxiety and that more awareness about DP with respect to detection and research is urgently required.

Validation of the German version of the Vertigo Symptom Scale (VSS) in patients with organic or somatoform dizziness and healthy controls

ObjectiveThe objective of this study was to validate the German version of the Vertigo Symptom Scale (VSS) and to determine its ability to differentiate the type, frequency, and severity of balance disorders. The scale (34 items) was designed by Yardley and coworkers and has been already validated in its English and Spanish versions.Methods98 patients with organic vertigo syndromes, 90 patients with somatoform (psychogenic) dizziness and 56 healthy controls were evaluated with the VSS and additional standardized questionnaires regarding distress (SCL-90R), quality of life (SF-36), anxiety and depression (HADS). In order to differentiate organic from somatoform dizziness all patients underwent detailed clinical neurological and vestibular neurophysiological testing.ResultsThe two identified subscales ‘vertigo and related symptoms’ (VER) and ‘somatic anxiety and autonomic arousal’ (AA) had good internal consistencies (Cronbach’s alpha: VER 0.79; AA 0.89). Test-retest correlations were r = 0.75 for VER and r = 0.75 for AA. VER could discriminate well between dizziness patients and healthy controls. AA discriminated moderately between somatoform and organic dizziness. We found close relations between the AA scale and different measures of emotional distress. Correlations between VER and measures of emotional distress were weaker.ConclusionThe German version of the VSS has good reliability and validity in the detection of different vertigo syndromes. Measurement of anxiety symptoms can be helpful to identify patients with somatoform dizziness.

Life satisfaction, anxiety, depression and resilience across the life span of men

Objective. To determine (a) the relationship between life satisfaction, anxiety, depression and ageing in the male community and (b) to identify the impact of vulnerability factors, personal and social resources on life satisfaction and distress. Design. A stratified random sample of the German male population (N = 2144) was investigated by standardized questionnaires of life satisfaction (FLZM), depression, anxiety (PHQ), resilience (RS-11) and self-esteem (RSS). Results. No age-related change was found regarding overall life satisfaction. Satisfaction with health decreased in midlife (51–60 years), while the importance of health increased. Importance of and satisfaction with partnership and sexuality were only reduced in the oldest group (70+). Anxiety was highest around midlife (51–60 years), accompanied by reduced resilience and self-esteem. No clear age-related change was found regarding depression. Life satisfaction was strongly associated with resilience, lack of unemployment, the presence of a partnership, positive self-esteem, a good household income, the absence of anxiety and depression and living in the Eastern states. Conclusions. Personal and social resources and the absence of anxiety and depression are of crucial importance for the maintenance of life satisfaction in ageing men. There is also evidence for a crisis around midlife manifested by health concerns, anxiety and reduced resilience.

Associations between depression and different measures of obesity (BMI, WC, WHtR, WHR)

BackgroundGrowing evidence suggests that abdominal obesity is a more important risk factor for the prognosis of cardiovascular and metabolic diseases than BMI. Somatic-affective symptoms of depression have also been linked to cardiovascular risk. The relationship between obesity and depression, however, has remained contradictory. Our aim was therefore to relate body mass index (BMI) and different measures for abdominal obesity (waist circumference, WC, waist-to-hip ratio, WHR, waist-to-height ratio, WHtR) to somatic vs. cognitive-affective symptoms of depression.MethodsIn a cross-sectional population based study, data on the first N = 5000 participants enrolled in the Gutenberg Health Study (GHS) are reported. To analyze the relationship between depression and obesity, we computed linear regression models with the anthropometric measure (BMI, WC, WHR, WHtR) as the dependent variable and life style factors, cardiovascular risk factors and psychotropic medications as potential confounders of obesity/depression.ResultsWe found that only the somatic, but not the cognitive-affective symptoms of depression are consistently positively associated with anthropometric measures of obesity.ConclusionsWe could demonstrate that the somatic-affective symptoms of depression rather than the cognitive-affective symptoms are strongly related to anthropometric measures. This is also true for younger obese starting at the age of 35 years. Our results are in line with previous studies indicating that visceral adipose tissue plays a key role in the relationship between obesity, depression and cardiovascular disease.

Implementing Panic-Focused Psychodynamic Psychotherapy into Clinical Practice

Objective: To determine the effectiveness of manualized panic-focused psychodynamic psychotherapy (PFPP) in routine care in Germany. Method: German psychoanalysts were trained according to the PFPP manual. Fifty-four consecutive outpatients with panic disorder (with or without agoraphobia) were randomly assigned in a 2:1 ratio to PFPP or cognitive-behavioural therapy (CBT) plus exposure therapy. Subjects (female 57.4%; mean age 36.2 years) had high rates of psychiatric (68.5%) and somatic (64.8%) comorbidity, and previous psychiatric treatments (57.4%). Assessments were performed pre- and posttreatment and at 6-month follow-up. The primary outcome measure was the Panic Disorder Severity Scale. Results: Both treatments were highly effective. In patients randomized to PFPP, remission was achieved in 44.4% at termination and by 50% at follow-up (CBT 61.1 % and 55.6%, respectively). No significant differences were found. Emotional awareness, a posited moderator of good outcome in psychotherapies, was significantly higher in the CBT group at baseline. It was found to be a strong moderator of treatment effectiveness in both treatments. After adjusting for initial Levels of Emotional Awareness Scale (LEAS) scores, effect sizes (ESs) for the primary outcome were Cohen d = 1.28, from pre- to posttreatment, and d = 1.03, from pretreatment to follow-up, for PFPP, and d = 1.81 and 1.28 for CBT, respectively. Conclusions: PFPP was implemented effectively into clinical practice by psychoanalysts in the community in a sample with severe mental illness with large ESs. Assessment of LEAS may facilitate the identification of patients suitable for short-term psychotherapy. (Clinical Trial Registration Number: German Clinical Trials Register, DRKS00000245; Universal Trial Number, U1111-1112-4245)