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Causal attributions for somatic symptom disorder
Journal of Psychosomatic Research 129 (2020) 109910
Contents lists available at ScienceDirect
Journal of Psychosomatic Research journal homepage: www.elsevier.com/locate/jpsychores
Causal attributions for somatic symptom disorder a,⁎
b
b
Olaf von dem Knesebeck , Marco Lehmann , Bernd Löwe , Daniel Lüdecke a b
T a
Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20146 Hamburg, Germany Institute and Outpatients Clinic for Psychosomatic Medicine and Psychotherapy, Martinistr. 52, 20146 Hamburg, Germany
A R T I C LE I N FO
A B S T R A C T
Keywords: Somatic symptom disorder Public beliefs Causal attribution Stigma Psychotherapy
Objectives: Two research questions will be addressed: (1) What does the German public think about possible causes of somatic symptom disorder (SSD) and are there differences in causal attributions according to symptom and course of SSD? (2) Are causal attributions associated with beliefs about treatment and stigmatizing attitudes? Methods: Two vignettes with symptoms of SSD were used in a national telephone survey in Germany (N = 1004). Vignettes differed regarding main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Respondents were asked about their agreement with five causal beliefs (broken home, heredity, lack of willpower, work stress, and misinterpretation of body signals). Results: About 90% of the respondents agreed that work stress is a possible cause of the SSD symptoms. Agreement was significantly more pronounced in case of a person with fatigue and an earlier severe somatic disease. A quarter endorsed lack of willpower as a possible cause. Lack of willpower was associated with a significant increase of desire for social distance in both vignettes. Work stress was associated with a significantly increased likelihood of positively evaluating the effectiveness of psychotherapy in both cases of SSD. Conclusions: Public beliefs about causes of SSD are associated with stigma and treatment beliefs. Emphasising work stress as a cause may promote the belief that psychotherapy is effective for treatment of SSD.
1. Introduction Public beliefs about causes of mental illness are a central illness representation and have been found to be associated with stigma, treatment beliefs, and help seeking behaviour [1,2]. Attribution theory [3,4] can help to predict the consequences of causal attributions. According to this approach, causes that are beyond the responsibility and control of the afflicted individual (e.g., genetics, childhood adversities) are expected to be associated with reduced mental illness stigma while causes that are considered controllable (e.g., lack of willpower) are expected to increase social rejection [4]. Moreover, causal attributions that are viewed as stable, unchangeable and not amenable to treatment are likely to increase social distance and affect beliefs about treatability and effectiveness of therapeutic measures [4,5]. Empirical studies investigating public causal beliefs about mental illnesses largely focus on depression, schizophrenia, and substance abuse and differentiate between biogenetic and psychosocial causes [2,5,6]. In terms of biogenetic causes, results show that mental disorders are increasingly attributed to brain diseases, chemical imbalances in the brain or genetic causes [7–9]. Contrary to the above mentioned assumptions, biogenetic causal attributions are not ⁎
associated with more tolerant attitudes; some studies even found such beliefs to be related with increased stigma, for example in case of schizophrenia [5,6,8]. A German population survey found strong associations between biogenetic causal attributions and the recommendation of psychotropic drugs for treatment of schizophrenia, major depression and alcohol dependence [10]. Psychosocial causal attributions are consistently endorsed by the majority of respondents in population studies [9]. Associations of psychosocial causal beliefs (stress, childhood adversities) with stigmatizing attitudes were found to be inconsistent. The same holds true for associations with beliefs about the effectiveness of psychotherapy [10]. Research has repeatedly shown that public causal beliefs are illnessspecific, and, to our knowledge, there is no study analysing different public beliefs about causes of somatic symptom disorder (SSD) [11,12]. SSD is characterized by one or more distressing bodily symptoms (A criterion), symptom- or health-related concern, anxiety or behaviour (B criterion), and symptom persistence of typically more than six months (C criterion) [13]. In DSM-5, SSD replaces somatoform disorders and the necessity of medically unexplained symptoms as a basis for the diagnosis has been omitted. Although more recent approaches based on scientific evidence attempt to resolve the rigid dichotomy between
Corresponding author. E-mail address: [email protected] (O. von dem Knesebeck).
https://doi.org/10.1016/j.jpsychores.2019.109910 Received 8 August 2019; Received in revised form 16 December 2019; Accepted 20 December 2019 0022-3999/ © 2019 Elsevier Inc. All rights reserved.
Journal of Psychosomatic Research 129 (2020) 109910
O. von dem Knesebeck, et al.
childhood adversities, personal responsibility, stress, somatosensory amplification, and biogenetic aspects. On a four-point Likert scale, respondents were asked to indicate to what extent they think the following statements are true: “A possible cause of these symptoms is …” “…to be raised in a broken home”, “…a lack of willpower”, “…work stress”, “…a misinterpretation of body signals”, “…heredity”. Items were coded from 1 (not true at all) to 4 (completely true). In terms of beliefs about treatment, the respondents were asked how effective psychotherapy is for the treatment of the symptoms. We decided to use this item because psychotherapy is the treatment with the best-proven effectiveness in case of SSD [19]. The scale was ranging from 1 (not at all effective) to 4 (very effective). Desire for social distance was used as an indicator of public stigma. It was measured by a scale developed by Link et al. [20] and includes seven items addressing various social relationships (tenant, co-worker, neighbour, child carer, in-law, and person one would recommend for a job or person of the same social circle). Respondents were asked to specify whether they would accept the described person in the vignette for each social relationship on a four-point Likert scale (ranging from 1 ‘totally agree’ to 4 ‘totally disagree’). A sum score (ranging from 7 to 28) was computed to assess the respondents' overall desire for social distance. Cronbach's Alpha of the Desire for Social Distance scale is 0.83 [17]. For the analyses, the five indicators of causal attributions were dichotomized by combining the first two (not at all/rather not true) and the last two response options (rather/completely true). Differences in causal attributions between the vignettes were analysed using Chi2 tests. Associations of causal attributions with the continuous variable “desire for social distance” were examined by multiple linear regression analyses. Preparatory analyses showed that requirements for linear regression models (i.e. absence of multicollinearity, normally distributed residuals and homoscedasticity) were met. Unstandardized (b) and standardized (beta) regression coefficients, 95%-confidence intervals, and p-values are documented. Associations of causal attributions with the belief about effectiveness of psychotherapy were examined using logistic regression analyses. Belief about effectiveness was dichotomized (not at all/rather not effective = 0, rather/very effective = 1). Odds ratios, 95% confidence intervals, and significances are displayed. We decided to use logistic regression models in this case for the sake of clearness and because preconditions of linear regressions were violated. Age, gender, and education (highest educational degree) were introduced as control variables in all regression analyses. Sampling weights were used for all descriptive and multivariate analyses. Analyses were conducted with the R statistical package [21].
mental and biomedical disorders and to describe SSD as an interface disorder, in the diagnostic manual DSM-5 [13] and ICD-11 [14] SSD is classified in the chapter on mental disorders. Current aetiological models explain the bodily symptoms associated with SSD as a dysregulation of bodily perception [15]. A comparable conceptualisation of the diagnosis based on distressing physical symptoms and health worries is characterized as bodily stress disorder within the framework of the ICD-11 [14]. Since the coding of diseases according to these diagnostic manuals will eventually reach the public in near future, it is relevant to know, which possible causes the public associates with SSD. Against this background, in this study, the following research questions will be addressed: (1) What does the German public think about possible causes of SSD and are there differences in causal attributions according to the main symptom of SSD and presence/absence of an earlier somatic disease? (2) Are causal attributions associated with beliefs about treatment and stigmatizing attitudes? 2. Methods Data stem from a national telephone survey among adults conducted in winter 2017 in Germany. Random sample consisted of registered and ex-directory landline numbers (about 70%) and generated mobile phone numbers (Random Digit Dialling, about 30%). We used the Kish-Selection Grid [16] to randomly select participants in the households. Selected individuals were informed that participation in the study is voluntary and that withdrawal from the study is possible at any time. 1004 respondents gave verbal consent, reflecting a response rate of about 48.3%. Data collection procedure was approved by the Ethics Commission of the Medical Association in Hamburg (No. PV3707). Comparison of sociodemographic characteristics of the sample with official statistics indicates that distribution of age, gender, and education is similar to the general adult population in Germany [17]. In the beginning of the interview, a vignette with signs and symptoms suggestive of a SSD was presented to the respondents. Two different vignettes were developed with the input of clinicians (see Appendix A). Both vignettes show cases of a SSD according to DSM-5 [13]. In both vignettes, the first sentence gives information about the A criterion (burdensome somatic symptom) and the C criterion (persistence of symptom burden) of SSD. The subsequent sentences are related to the B criterion, i.e. excessive thoughts about the severity of the symptoms, severe anxiety about one's health and the symptoms, and excessive symptom related behaviour. In vignette A, fatigue is the main symptom involving an earlier severe somatic disease, while vignette B shows a case of a SSD with pain as the main symptom without a comorbid somatic disease. Thus, the two SSD vignettes differ in terms of main type of symptom and existence of an earlier somatic disease. Vignettes were additionally varied according to gender (female vs. male) and age (32 years vs. 62 years), resulting in eight different vignettes that each were randomly assigned to about 125 respondents (i.e. about 12.5% of the sample). The same dataset was used in two previous analyses. In a first paper [12], we analysed knowledge and beliefs about SSD and associations with socio-demographic factors and experiences with the disorder. The second paper [17] focused on the magnitude and predictors of public stigma towards individuals with SSD and differences in public stigma between SSD and depression. Thus, this is the first analysis on different public beliefs about causes of SSD. To assess causal attributions, a list of 15 questions about possible causes of the symptoms presented in the vignette was derived from instruments measuring public causal beliefs about mental illnesses [5,18]. A principal component analysis yielded a four-factor solution with a total variance explanation of 47.5%. However, factor loadings were ambiguous and internal consistency (Cronbach's Alpha) of three sub-scales was lower than 0.5. Therefore, for the present analyses, we selected five single items reflecting the following possible causes:
3. Results 3.1. Descriptive results Mean age of the respondents was 51 years (ranging from 18 to 91 years, standard deviation 18.9) and 51.9% were female. About one third (36%) of the respondents were unmarried, while 43% were married, 10% were divorced, and 11% were widowed. In terms of education, 35% had a low degree (< 10 years) and 34% had a high degree (12 years or more). Table 1 shows the distribution of the five causal beliefs for the total sample and for the subsamples of the two vignettes. About 90% of the respondents agreed that work stress is a possible cause of the presented symptoms. Agreement was more pronounced in case of vignette A. Two thirds thought that misinterpretation of body signals is a possible cause and 57% expressed their agreement with heredity. About 40% agreed that the symptoms can be caused by a broken home. About a quarter endorsed lack of willpower as a possible cause. Additional analyses (not shown in detail) revealed that about 85% (vignette B) to 90% (vignette A) of the respondents endorsed more than one cause.
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Journal of Psychosomatic Research 129 (2020) 109910
O. von dem Knesebeck, et al.
Table 1 Causal attributions according to symptoms (% rather true/completely true). Causes
Table 3 Associations of causal attributions with belief about effectiveness of psychotherapy (rather/very effective, logistic regression analyses).
p⁎
Vignette A
Vignette B
Total
Fatigue with previous somatic disease (n = 505)
Pain without somatic disease (n = 499)
N = 1004
44.0 57.3 25.0 92.7 65.5
39.8 57.1 22.9 87.9 67.3
41.9 57.2 24.0 90.3 66.4
Causes
Broken home Heredity Lack of willpower Work stress Misinterpretation of body signals
0.20 0.98 0.47 0.015 0.59
Broken home Heredity Lack of will power Work stress Misinterpretation of body signals
p values < 0.05 are bold. ⁎ Significance of Chi2 test.
Vignette A
Vignette B
Fatigue with previous somatic disease (n = 505)
Pain without somatic disease (n = 499)
OR
CI
p
OR
CI
p
1.44 0.80 2.73 2.27 1.16
0.88–2.34 0.49–1.29 1.36–5.46 1.04–4.95 0.70–1.91
0.15 0.36 0.005 0.040 0.56
1.35 0.52 1.76 2.55 1.96
0.81–2.24 0.30–0.87 0.92–3.36 1.34–4.85 1.19–3.24
0.25 0.015 0.09 0.004 0.009
Adjusted for gender, age, and education; OR: Odds Ratio; CI: 95% Confidence Intervals; p: significance, p values < 0.05 are bold.
3.2. Associations with social distance
one specific item addressing somatosensory amplification as an important perceptual mechanism [12,15]. About two thirds of the respondents endorsed misinterpretation of body signals as a possible cause, with no difference between the two vignettes used. Thus, stress and somatosensory amplification are the causes with highest agreement, which largely supports the current conceptualisation of “bodily distress” [15]. Similar to other mental illnesses, we found that public causal beliefs about SSD were associated with stigmatizing attitudes. In this respect, causal attribution to a lack of willpower was associated with a significant increase of desire for social distance in case of both SSD vignettes. Work stress, heredity, and misinterpretation of body signals were not significantly associated with social distance. While this is the first study exploring somatosensory amplification, previous studies analysing the belief in stress as a cause for depression also did not find significant associations with social distance [5]. Thus, this finding does not seem to be specific for SSD. Biogenetic causes like heredity were found to be associated with reduced social distance in case of depression [5]. In terms of broken home, there were differences between the vignettes: This causal attribution was significantly associated with more desire for social distance in case of a person with fatigue and a previous somatic disease, but not in case of pain as the main symptom without a comorbid somatic disease. When interpreting this difference, it is important to mention that the magnitude of desire for social distance does not differ between the two SSD vignettes [17]. Thus, our results only partly comply with attribution theory [3,4]. On the one hand and in accordance with this approach, weakness of will as a controllable cause was consistently associated with increased stigma. On the other hand, one cause that is beyond the responsibility and control of the afflicted individual (childhood adversities) was also associated with increased social distance, at least in case of one of the two vignettes. These findings are in line with previous studies focusing on other mental illnesses and raise the question on what other factors may help to understand the consequence of causal attributions. An analysis of the
Associations between the five causal beliefs and desire for social distance for the two SSD vignettes are shown in Table 2. In case of the person with fatigue and a previous somatic disease (vignette A), belief that a broken home or a lack of willpower is a cause is significantly related to more social distance. In terms of vignette B (pain without somatic disease), only the attribution to lack of willpower significantly increases the desire for social distance. 3.3. Associations with effectiveness belief Results of logistic regressions show that respondents who agree that symptoms of vignette A may be caused by a lack of willpower or work stress have a significantly increased likelihood to believe that psychotherapy is effective (Table 3). In case of vignette B, beliefs in work stress and misinterpretation of body signals as causes are associated with a significantly higher effectiveness rating, while this rating is significantly reduced when heredity is endorsed. 4. Discussion In this study, we analysed causal attributions for SSD in the German public, using two vignettes with different symptoms. The vast majority (about 90%) of the respondents agreed that work stress is a possible cause of the SSD symptoms presented, while only a quarter endorsed lack of willpower as a possible cause. More than half of the respondents endorsed a biogenetic cause (heredity). Other German studies addressing public causal beliefs about depression also showed that work stress is endorsed by the large majority while biogenetic causes and unfavourable traits like weakness of will find less agreement [22,23]. Thus, overall public causal attributions for SSD and depression seem similar, while for schizophrenia, biogenetic causes are considered more important. There are some studies investigating causal attributions among patients with somatoform disorders [24,25]. However, none of them referred to causal beliefs of the public. In this regard, we analysed
Table 2 Associations of causal attributions with desire for social distance (linear regression analyses). Causes
Broken home Heredity Lack of will power Work stress Misinterpretation of body signals
Vignette A
Vignette B
Fatigue with previous somatic disease (n = 505)
Pain without somatic disease (n = 499)
B
Beta
CI
p
B
Beta
CI
p
1.25 −0.05 1.81 −0.15 −0.57
0.18 −0.01 0.23 −0.01 −0.08
0.10–0.27 −0.10 - 0.08 0.14–0.31 −0.11–0.08 −0.17–0.01
< 0.001 0.88 < 0.001 0.80 0.07
0.37 −0.39 1.14 0.13 0.55
0.06 -0.06 0.15 0.01 0.08
−0.03–0.14 −0.15 - 0.03 0.06–0.24 −0.08–0.11 −0.01–0.17
0.22 0.18 0.001 0.77 0.08
Adjusted for gender, age, and education; CI: 95% confidence intervals; p: significance, p values < 0.05 are bold. 3
Journal of Psychosomatic Research 129 (2020) 109910
O. von dem Knesebeck, et al.
to a current medical examination, her heart is in a good condition. She still has intense fear regarding her health and her complaints. Mrs. E. is investing a lot of time and energy on her health concerns.
pathways between causal beliefs and desire for social distance in case of depression revealed that notions of dangerousness and differentness may be even more important than responsibility [5]. In terms of treatment beliefs, our results show that work stress is the only causal attribution that was associated with a significantly increased likelihood of positively evaluating the effectiveness of psychotherapy in both cases of SSD. On the other hand, broken home is the only cause that was not significantly related to the effectiveness evaluation in both vignettes. Two causal beliefs (lack of will power and misinterpretation of body signals) were associated with a positive evaluation of psychotherapy in one case of SSD but not in the other. In this regard, it is interesting that there is no significant difference in this treatment belief between the two SSD vignettes: In case of vignette A, 79% of the respondents considered psychotherapy as a rather or very effective measure, respective rate for vignette B was 82% [12]. In view of these numbers, it is remarkable that only 25% of affected patients undergo psychotherapy [19]. Belief in heredity as a cause was negatively associated with effectiveness evaluation, especially in case of pain as the main symptom without a comorbid somatic disease. This indicates that this biogenetic cause is viewed as stable, unchangeable and not amenable to treatment. In terms of methodological limitations, it has to be considered that we used short audio-vignettes (see Appendix A) that were applicable in a telephone survey. It is debatable whether such vignettes adequately represent a complex and polymorphic disorder like SSD. For example, a scenario with unknown or (uncured) somatic morbidity is missing. Secondly, about 52% of the selected eligible persons refused to participate or were not available. Thus, a selection bias cannot be ruled out, although distribution of socio-demographic characteristics of the sample is similar to data provided by official statistics. Thirdly, we selected five single items to analyse causal attributions. While most of these items were used in previous studies [5,18], they do not cover all possible causes. Finally, we cannot rule out that social desirability may play a role when answering questions about stigma. Our results show that public beliefs about causes of SSD are associated with stigmatizing attitudes and treatment beliefs. However, it is not easy to draw clear conclusions about practical implications, because causal attributions (weakness of will) can have negative consequences for stigma but positive consequences for treatment beliefs. On the other hand, emphasising work stress as a cause may promote the belief that psychotherapy is effective for treatment of SSD and possibly even the willingness to utilize psychotherapy. The missing association between childhood adversities (broken home) and the positive evaluation of psychotherapy suggests that it is reasonable to educate the public about the possibility to successfully address the psychological consequences of such adversities in psychotherapy.
A.2. Vignette B (pain without somatic disease) Since one year, 32 years old/62 years* old Anja/Anton* S. has been suffering from constant piercing pain in the left side of her body, in her hand, arm, leg, and in her feet. She feels very restricted in her daily life. Medical examinations have provided no explanation for her complaints. Mrs. S has an intense fear for her health and is thinking about her complaints all the time. She is constantly surfing the internet to learn more about her troubles. *Gender and age of the person in the vignettes were systematically varied. References [1] H. Leventhal, E.A. Leventhal, R.J. Contrada, Self-regulation, health, and behavior: a perceptual-cognitive approach, Psychol. Health 13 (1998) 717–733. [2] B.G. Link, J.C. Phelan, M. Bresnahan, et al., Public conceptions of mentl illness: labels, causes, dangerousness, and social distance, Am. J. Public Health 89 (1999) 1328–1333. [3] B. Weiner, Judgements of Responsibility: A Foundation for the Theory of Social Conduct, Guilford Press, New York, 1995. [4] P.W. Corrigan, Mental health stigma as social attribution: implications for research methods and attitude change, Clin. Psychol. Sci. Pract. 7 (2000) 48–67. [5] G. Schomerus, H. Matschinger, M.C. Angermeyer, Causal beliefs of the public and social acceptance of persons with mental illness: a comparative analysis of schizophrenia, depression and alcohol dependence, Psychol. Med. 44 (2014) 303–314. [6] M.C. Angermeyer, A. Daubmann, Wegscheider et al. the relationship between biogenetic attributions and desire for social distance from persons with schizophrenia and major depression revisited, Epidemiol. Psychiatr. Sci. 24 (2015) 335–341. [7] M.C. Angermeyer, H. Matschinger, Causal beliefs and attitudes to people with schizophrenia, Br. J. Psychiatry 186 (2005) 331–334. [8] M.C. Angermeyer, A. Holzinger, M.G. Carta, G. Schomerus, Biogenetic explanations and public acceptance of mental illness: systematic review of population studies, Br. J. Psychiatry 199 (2011) 367–372. [9] G. Schomerus, C. Schwahn, A. Holzinger, et al., Evolution of public attitudes about mental illness: a systematic review and meta-analysis, Acta Psychiatr. Scand. 125 (2012) 440–452. [10] S. Speerforck, G. Schomerus, H. Matschinger, M.C. Angermeyer, Treatment recommendations for schizophrenia, major depression and alcohol dependence and stigmatizing attitudes of the public: results from a German population survey, Eur. Arch. Psychiatry Clin. Neurosci. 267 (2017) 341–350. [11] J.E. Dimsdale, F. Creed, J. Escobar, et al., Somatic symptom disorder: an important change in DSM, J. Psychosom. Res. 75 (2013) 223–228. [12] L.B. Knesebeck Ovd, M. Lehmann, A. Makowski, Public beliefs about somatic symptom disorders, Front. Psychiatry 9 (2018) 616. [13] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, DSM-5, ed 5 American Psychiatric Publishing, Arlington, 2013. [14] World Health Organization, ICD-11 for Mortality and Morbidity Statistics, Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity %2f767044268, (2019) , Accessed date: 1 November 2019. [15] P. Henningsen, H. Gündel, W.J. Kop, et al., Persistent physical symptoms as perceptual dysregulation: a neuropsychobehavioral model and its clinical implications, Psychosom. Med. 80 (2018) 422–431. [16] L. Kish, A procedure for objective respondent selection within the household, J. Am. Stat. Assoc. 44 (1949) 380–387. [17] L.M. Knesebeck Ovd, B. Löwe, A. Makowski, Public stigma towards individuals with somatic symptom disorders – survey results from Germany, J. Psychosom. Res. 115 (2018) 71–75. [18] E. Mnich, A.C. Makowski, M. Lambert, et al., Beliefs about depression - do affliction and treatment experience matter? Results of a population survey from Germany, J. Affect. Disord. 164 (2014) 28–32. [19] B. Löwe, K. Piontek, A. Daubmann, et al., Effectiveness of a stepped, collaborative, and coordinated health care network for somatoform disorders (Sofu-net): a controlled cluster cohort study, Psychosom. Med. 79 (2017) 1016–1024. [20] B.G. Link, F.T. Cullen, J. Frank, et al., The social rejection of former mental patients: understanding why labels matter, Am. J. Sociol. 92 (1987) 1461–1500. [21] R Core Team, R: A Language and Environment for Statistical Computing, R Foundation for Statistical Computing, Vienna, Austria, 2018https://www.R-project.org/. [22] M.E. Knesebeck Ovd, A. Daubmann, et al., Socioeconomic status and beliefs about depression, schizophrenia and eating disorders, Soc. Psychiatry Psychiatr. Epidemiol. 48 (2013) 775–782. [23] U. von Lersner, J. Gerb, S. Hizli, et al., Stigma of mental illness in Germans and Turkish immigrants in Germany: the effect of causal beliefs, Front. Psychiatry 10 (2019) 46. [24] W. Rief, A. Nanke, J. Emmerich, et al., Causal illness attributions in somatoform disorders. Associations with comorbidity and illness behaviour, J. Psychosom. Res. 57 (2004) 367–371. [25] S. Groben, C. Hausteiner, Somatoform disorders and causal attributions in patients with suspected allergies: do somatic causal attributions matter? J. Psychosom. Res. 70 (2011) 229–238.
Declarations of Competing Interest None. Acknowledgement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no competing interests to report. Appendix A. Appendix A.1. Vignette A (fatigue with cured somatic disease) For more than six months, 32 years old/62 years old* Monika/ Martin* E. has been suffering from total exhaustion, accompanied by chest pain, pain in her muscles and her shoulder. After a fully cured inflammation of the heart muscle eight months ago, she is continuously thinking that her complaints indicate a severe heart disease. According 4
Contents lists available at ScienceDirect
Journal of Psychosomatic Research journal homepage: www.elsevier.com/locate/jpsychores
Causal attributions for somatic symptom disorder a,⁎
b
b
Olaf von dem Knesebeck , Marco Lehmann , Bernd Löwe , Daniel Lüdecke a b
T a
Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20146 Hamburg, Germany Institute and Outpatients Clinic for Psychosomatic Medicine and Psychotherapy, Martinistr. 52, 20146 Hamburg, Germany
A R T I C LE I N FO
A B S T R A C T
Keywords: Somatic symptom disorder Public beliefs Causal attribution Stigma Psychotherapy
Objectives: Two research questions will be addressed: (1) What does the German public think about possible causes of somatic symptom disorder (SSD) and are there differences in causal attributions according to symptom and course of SSD? (2) Are causal attributions associated with beliefs about treatment and stigmatizing attitudes? Methods: Two vignettes with symptoms of SSD were used in a national telephone survey in Germany (N = 1004). Vignettes differed regarding main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Respondents were asked about their agreement with five causal beliefs (broken home, heredity, lack of willpower, work stress, and misinterpretation of body signals). Results: About 90% of the respondents agreed that work stress is a possible cause of the SSD symptoms. Agreement was significantly more pronounced in case of a person with fatigue and an earlier severe somatic disease. A quarter endorsed lack of willpower as a possible cause. Lack of willpower was associated with a significant increase of desire for social distance in both vignettes. Work stress was associated with a significantly increased likelihood of positively evaluating the effectiveness of psychotherapy in both cases of SSD. Conclusions: Public beliefs about causes of SSD are associated with stigma and treatment beliefs. Emphasising work stress as a cause may promote the belief that psychotherapy is effective for treatment of SSD.
1. Introduction Public beliefs about causes of mental illness are a central illness representation and have been found to be associated with stigma, treatment beliefs, and help seeking behaviour [1,2]. Attribution theory [3,4] can help to predict the consequences of causal attributions. According to this approach, causes that are beyond the responsibility and control of the afflicted individual (e.g., genetics, childhood adversities) are expected to be associated with reduced mental illness stigma while causes that are considered controllable (e.g., lack of willpower) are expected to increase social rejection [4]. Moreover, causal attributions that are viewed as stable, unchangeable and not amenable to treatment are likely to increase social distance and affect beliefs about treatability and effectiveness of therapeutic measures [4,5]. Empirical studies investigating public causal beliefs about mental illnesses largely focus on depression, schizophrenia, and substance abuse and differentiate between biogenetic and psychosocial causes [2,5,6]. In terms of biogenetic causes, results show that mental disorders are increasingly attributed to brain diseases, chemical imbalances in the brain or genetic causes [7–9]. Contrary to the above mentioned assumptions, biogenetic causal attributions are not ⁎
associated with more tolerant attitudes; some studies even found such beliefs to be related with increased stigma, for example in case of schizophrenia [5,6,8]. A German population survey found strong associations between biogenetic causal attributions and the recommendation of psychotropic drugs for treatment of schizophrenia, major depression and alcohol dependence [10]. Psychosocial causal attributions are consistently endorsed by the majority of respondents in population studies [9]. Associations of psychosocial causal beliefs (stress, childhood adversities) with stigmatizing attitudes were found to be inconsistent. The same holds true for associations with beliefs about the effectiveness of psychotherapy [10]. Research has repeatedly shown that public causal beliefs are illnessspecific, and, to our knowledge, there is no study analysing different public beliefs about causes of somatic symptom disorder (SSD) [11,12]. SSD is characterized by one or more distressing bodily symptoms (A criterion), symptom- or health-related concern, anxiety or behaviour (B criterion), and symptom persistence of typically more than six months (C criterion) [13]. In DSM-5, SSD replaces somatoform disorders and the necessity of medically unexplained symptoms as a basis for the diagnosis has been omitted. Although more recent approaches based on scientific evidence attempt to resolve the rigid dichotomy between
Corresponding author. E-mail address: [email protected] (O. von dem Knesebeck).
https://doi.org/10.1016/j.jpsychores.2019.109910 Received 8 August 2019; Received in revised form 16 December 2019; Accepted 20 December 2019 0022-3999/ © 2019 Elsevier Inc. All rights reserved.
Journal of Psychosomatic Research 129 (2020) 109910
O. von dem Knesebeck, et al.
childhood adversities, personal responsibility, stress, somatosensory amplification, and biogenetic aspects. On a four-point Likert scale, respondents were asked to indicate to what extent they think the following statements are true: “A possible cause of these symptoms is …” “…to be raised in a broken home”, “…a lack of willpower”, “…work stress”, “…a misinterpretation of body signals”, “…heredity”. Items were coded from 1 (not true at all) to 4 (completely true). In terms of beliefs about treatment, the respondents were asked how effective psychotherapy is for the treatment of the symptoms. We decided to use this item because psychotherapy is the treatment with the best-proven effectiveness in case of SSD [19]. The scale was ranging from 1 (not at all effective) to 4 (very effective). Desire for social distance was used as an indicator of public stigma. It was measured by a scale developed by Link et al. [20] and includes seven items addressing various social relationships (tenant, co-worker, neighbour, child carer, in-law, and person one would recommend for a job or person of the same social circle). Respondents were asked to specify whether they would accept the described person in the vignette for each social relationship on a four-point Likert scale (ranging from 1 ‘totally agree’ to 4 ‘totally disagree’). A sum score (ranging from 7 to 28) was computed to assess the respondents' overall desire for social distance. Cronbach's Alpha of the Desire for Social Distance scale is 0.83 [17]. For the analyses, the five indicators of causal attributions were dichotomized by combining the first two (not at all/rather not true) and the last two response options (rather/completely true). Differences in causal attributions between the vignettes were analysed using Chi2 tests. Associations of causal attributions with the continuous variable “desire for social distance” were examined by multiple linear regression analyses. Preparatory analyses showed that requirements for linear regression models (i.e. absence of multicollinearity, normally distributed residuals and homoscedasticity) were met. Unstandardized (b) and standardized (beta) regression coefficients, 95%-confidence intervals, and p-values are documented. Associations of causal attributions with the belief about effectiveness of psychotherapy were examined using logistic regression analyses. Belief about effectiveness was dichotomized (not at all/rather not effective = 0, rather/very effective = 1). Odds ratios, 95% confidence intervals, and significances are displayed. We decided to use logistic regression models in this case for the sake of clearness and because preconditions of linear regressions were violated. Age, gender, and education (highest educational degree) were introduced as control variables in all regression analyses. Sampling weights were used for all descriptive and multivariate analyses. Analyses were conducted with the R statistical package [21].
mental and biomedical disorders and to describe SSD as an interface disorder, in the diagnostic manual DSM-5 [13] and ICD-11 [14] SSD is classified in the chapter on mental disorders. Current aetiological models explain the bodily symptoms associated with SSD as a dysregulation of bodily perception [15]. A comparable conceptualisation of the diagnosis based on distressing physical symptoms and health worries is characterized as bodily stress disorder within the framework of the ICD-11 [14]. Since the coding of diseases according to these diagnostic manuals will eventually reach the public in near future, it is relevant to know, which possible causes the public associates with SSD. Against this background, in this study, the following research questions will be addressed: (1) What does the German public think about possible causes of SSD and are there differences in causal attributions according to the main symptom of SSD and presence/absence of an earlier somatic disease? (2) Are causal attributions associated with beliefs about treatment and stigmatizing attitudes? 2. Methods Data stem from a national telephone survey among adults conducted in winter 2017 in Germany. Random sample consisted of registered and ex-directory landline numbers (about 70%) and generated mobile phone numbers (Random Digit Dialling, about 30%). We used the Kish-Selection Grid [16] to randomly select participants in the households. Selected individuals were informed that participation in the study is voluntary and that withdrawal from the study is possible at any time. 1004 respondents gave verbal consent, reflecting a response rate of about 48.3%. Data collection procedure was approved by the Ethics Commission of the Medical Association in Hamburg (No. PV3707). Comparison of sociodemographic characteristics of the sample with official statistics indicates that distribution of age, gender, and education is similar to the general adult population in Germany [17]. In the beginning of the interview, a vignette with signs and symptoms suggestive of a SSD was presented to the respondents. Two different vignettes were developed with the input of clinicians (see Appendix A). Both vignettes show cases of a SSD according to DSM-5 [13]. In both vignettes, the first sentence gives information about the A criterion (burdensome somatic symptom) and the C criterion (persistence of symptom burden) of SSD. The subsequent sentences are related to the B criterion, i.e. excessive thoughts about the severity of the symptoms, severe anxiety about one's health and the symptoms, and excessive symptom related behaviour. In vignette A, fatigue is the main symptom involving an earlier severe somatic disease, while vignette B shows a case of a SSD with pain as the main symptom without a comorbid somatic disease. Thus, the two SSD vignettes differ in terms of main type of symptom and existence of an earlier somatic disease. Vignettes were additionally varied according to gender (female vs. male) and age (32 years vs. 62 years), resulting in eight different vignettes that each were randomly assigned to about 125 respondents (i.e. about 12.5% of the sample). The same dataset was used in two previous analyses. In a first paper [12], we analysed knowledge and beliefs about SSD and associations with socio-demographic factors and experiences with the disorder. The second paper [17] focused on the magnitude and predictors of public stigma towards individuals with SSD and differences in public stigma between SSD and depression. Thus, this is the first analysis on different public beliefs about causes of SSD. To assess causal attributions, a list of 15 questions about possible causes of the symptoms presented in the vignette was derived from instruments measuring public causal beliefs about mental illnesses [5,18]. A principal component analysis yielded a four-factor solution with a total variance explanation of 47.5%. However, factor loadings were ambiguous and internal consistency (Cronbach's Alpha) of three sub-scales was lower than 0.5. Therefore, for the present analyses, we selected five single items reflecting the following possible causes:
3. Results 3.1. Descriptive results Mean age of the respondents was 51 years (ranging from 18 to 91 years, standard deviation 18.9) and 51.9% were female. About one third (36%) of the respondents were unmarried, while 43% were married, 10% were divorced, and 11% were widowed. In terms of education, 35% had a low degree (< 10 years) and 34% had a high degree (12 years or more). Table 1 shows the distribution of the five causal beliefs for the total sample and for the subsamples of the two vignettes. About 90% of the respondents agreed that work stress is a possible cause of the presented symptoms. Agreement was more pronounced in case of vignette A. Two thirds thought that misinterpretation of body signals is a possible cause and 57% expressed their agreement with heredity. About 40% agreed that the symptoms can be caused by a broken home. About a quarter endorsed lack of willpower as a possible cause. Additional analyses (not shown in detail) revealed that about 85% (vignette B) to 90% (vignette A) of the respondents endorsed more than one cause.
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Table 1 Causal attributions according to symptoms (% rather true/completely true). Causes
Table 3 Associations of causal attributions with belief about effectiveness of psychotherapy (rather/very effective, logistic regression analyses).
p⁎
Vignette A
Vignette B
Total
Fatigue with previous somatic disease (n = 505)
Pain without somatic disease (n = 499)
N = 1004
44.0 57.3 25.0 92.7 65.5
39.8 57.1 22.9 87.9 67.3
41.9 57.2 24.0 90.3 66.4
Causes
Broken home Heredity Lack of willpower Work stress Misinterpretation of body signals
0.20 0.98 0.47 0.015 0.59
Broken home Heredity Lack of will power Work stress Misinterpretation of body signals
p values < 0.05 are bold. ⁎ Significance of Chi2 test.
Vignette A
Vignette B
Fatigue with previous somatic disease (n = 505)
Pain without somatic disease (n = 499)
OR
CI
p
OR
CI
p
1.44 0.80 2.73 2.27 1.16
0.88–2.34 0.49–1.29 1.36–5.46 1.04–4.95 0.70–1.91
0.15 0.36 0.005 0.040 0.56
1.35 0.52 1.76 2.55 1.96
0.81–2.24 0.30–0.87 0.92–3.36 1.34–4.85 1.19–3.24
0.25 0.015 0.09 0.004 0.009
Adjusted for gender, age, and education; OR: Odds Ratio; CI: 95% Confidence Intervals; p: significance, p values < 0.05 are bold.
3.2. Associations with social distance
one specific item addressing somatosensory amplification as an important perceptual mechanism [12,15]. About two thirds of the respondents endorsed misinterpretation of body signals as a possible cause, with no difference between the two vignettes used. Thus, stress and somatosensory amplification are the causes with highest agreement, which largely supports the current conceptualisation of “bodily distress” [15]. Similar to other mental illnesses, we found that public causal beliefs about SSD were associated with stigmatizing attitudes. In this respect, causal attribution to a lack of willpower was associated with a significant increase of desire for social distance in case of both SSD vignettes. Work stress, heredity, and misinterpretation of body signals were not significantly associated with social distance. While this is the first study exploring somatosensory amplification, previous studies analysing the belief in stress as a cause for depression also did not find significant associations with social distance [5]. Thus, this finding does not seem to be specific for SSD. Biogenetic causes like heredity were found to be associated with reduced social distance in case of depression [5]. In terms of broken home, there were differences between the vignettes: This causal attribution was significantly associated with more desire for social distance in case of a person with fatigue and a previous somatic disease, but not in case of pain as the main symptom without a comorbid somatic disease. When interpreting this difference, it is important to mention that the magnitude of desire for social distance does not differ between the two SSD vignettes [17]. Thus, our results only partly comply with attribution theory [3,4]. On the one hand and in accordance with this approach, weakness of will as a controllable cause was consistently associated with increased stigma. On the other hand, one cause that is beyond the responsibility and control of the afflicted individual (childhood adversities) was also associated with increased social distance, at least in case of one of the two vignettes. These findings are in line with previous studies focusing on other mental illnesses and raise the question on what other factors may help to understand the consequence of causal attributions. An analysis of the
Associations between the five causal beliefs and desire for social distance for the two SSD vignettes are shown in Table 2. In case of the person with fatigue and a previous somatic disease (vignette A), belief that a broken home or a lack of willpower is a cause is significantly related to more social distance. In terms of vignette B (pain without somatic disease), only the attribution to lack of willpower significantly increases the desire for social distance. 3.3. Associations with effectiveness belief Results of logistic regressions show that respondents who agree that symptoms of vignette A may be caused by a lack of willpower or work stress have a significantly increased likelihood to believe that psychotherapy is effective (Table 3). In case of vignette B, beliefs in work stress and misinterpretation of body signals as causes are associated with a significantly higher effectiveness rating, while this rating is significantly reduced when heredity is endorsed. 4. Discussion In this study, we analysed causal attributions for SSD in the German public, using two vignettes with different symptoms. The vast majority (about 90%) of the respondents agreed that work stress is a possible cause of the SSD symptoms presented, while only a quarter endorsed lack of willpower as a possible cause. More than half of the respondents endorsed a biogenetic cause (heredity). Other German studies addressing public causal beliefs about depression also showed that work stress is endorsed by the large majority while biogenetic causes and unfavourable traits like weakness of will find less agreement [22,23]. Thus, overall public causal attributions for SSD and depression seem similar, while for schizophrenia, biogenetic causes are considered more important. There are some studies investigating causal attributions among patients with somatoform disorders [24,25]. However, none of them referred to causal beliefs of the public. In this regard, we analysed
Table 2 Associations of causal attributions with desire for social distance (linear regression analyses). Causes
Broken home Heredity Lack of will power Work stress Misinterpretation of body signals
Vignette A
Vignette B
Fatigue with previous somatic disease (n = 505)
Pain without somatic disease (n = 499)
B
Beta
CI
p
B
Beta
CI
p
1.25 −0.05 1.81 −0.15 −0.57
0.18 −0.01 0.23 −0.01 −0.08
0.10–0.27 −0.10 - 0.08 0.14–0.31 −0.11–0.08 −0.17–0.01
< 0.001 0.88 < 0.001 0.80 0.07
0.37 −0.39 1.14 0.13 0.55
0.06 -0.06 0.15 0.01 0.08
−0.03–0.14 −0.15 - 0.03 0.06–0.24 −0.08–0.11 −0.01–0.17
0.22 0.18 0.001 0.77 0.08
Adjusted for gender, age, and education; CI: 95% confidence intervals; p: significance, p values < 0.05 are bold. 3
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to a current medical examination, her heart is in a good condition. She still has intense fear regarding her health and her complaints. Mrs. E. is investing a lot of time and energy on her health concerns.
pathways between causal beliefs and desire for social distance in case of depression revealed that notions of dangerousness and differentness may be even more important than responsibility [5]. In terms of treatment beliefs, our results show that work stress is the only causal attribution that was associated with a significantly increased likelihood of positively evaluating the effectiveness of psychotherapy in both cases of SSD. On the other hand, broken home is the only cause that was not significantly related to the effectiveness evaluation in both vignettes. Two causal beliefs (lack of will power and misinterpretation of body signals) were associated with a positive evaluation of psychotherapy in one case of SSD but not in the other. In this regard, it is interesting that there is no significant difference in this treatment belief between the two SSD vignettes: In case of vignette A, 79% of the respondents considered psychotherapy as a rather or very effective measure, respective rate for vignette B was 82% [12]. In view of these numbers, it is remarkable that only 25% of affected patients undergo psychotherapy [19]. Belief in heredity as a cause was negatively associated with effectiveness evaluation, especially in case of pain as the main symptom without a comorbid somatic disease. This indicates that this biogenetic cause is viewed as stable, unchangeable and not amenable to treatment. In terms of methodological limitations, it has to be considered that we used short audio-vignettes (see Appendix A) that were applicable in a telephone survey. It is debatable whether such vignettes adequately represent a complex and polymorphic disorder like SSD. For example, a scenario with unknown or (uncured) somatic morbidity is missing. Secondly, about 52% of the selected eligible persons refused to participate or were not available. Thus, a selection bias cannot be ruled out, although distribution of socio-demographic characteristics of the sample is similar to data provided by official statistics. Thirdly, we selected five single items to analyse causal attributions. While most of these items were used in previous studies [5,18], they do not cover all possible causes. Finally, we cannot rule out that social desirability may play a role when answering questions about stigma. Our results show that public beliefs about causes of SSD are associated with stigmatizing attitudes and treatment beliefs. However, it is not easy to draw clear conclusions about practical implications, because causal attributions (weakness of will) can have negative consequences for stigma but positive consequences for treatment beliefs. On the other hand, emphasising work stress as a cause may promote the belief that psychotherapy is effective for treatment of SSD and possibly even the willingness to utilize psychotherapy. The missing association between childhood adversities (broken home) and the positive evaluation of psychotherapy suggests that it is reasonable to educate the public about the possibility to successfully address the psychological consequences of such adversities in psychotherapy.
A.2. Vignette B (pain without somatic disease) Since one year, 32 years old/62 years* old Anja/Anton* S. has been suffering from constant piercing pain in the left side of her body, in her hand, arm, leg, and in her feet. She feels very restricted in her daily life. Medical examinations have provided no explanation for her complaints. Mrs. S has an intense fear for her health and is thinking about her complaints all the time. She is constantly surfing the internet to learn more about her troubles. *Gender and age of the person in the vignettes were systematically varied. References [1] H. Leventhal, E.A. Leventhal, R.J. Contrada, Self-regulation, health, and behavior: a perceptual-cognitive approach, Psychol. Health 13 (1998) 717–733. [2] B.G. Link, J.C. Phelan, M. Bresnahan, et al., Public conceptions of mentl illness: labels, causes, dangerousness, and social distance, Am. J. Public Health 89 (1999) 1328–1333. [3] B. Weiner, Judgements of Responsibility: A Foundation for the Theory of Social Conduct, Guilford Press, New York, 1995. [4] P.W. Corrigan, Mental health stigma as social attribution: implications for research methods and attitude change, Clin. Psychol. Sci. Pract. 7 (2000) 48–67. [5] G. Schomerus, H. Matschinger, M.C. Angermeyer, Causal beliefs of the public and social acceptance of persons with mental illness: a comparative analysis of schizophrenia, depression and alcohol dependence, Psychol. Med. 44 (2014) 303–314. [6] M.C. Angermeyer, A. Daubmann, Wegscheider et al. the relationship between biogenetic attributions and desire for social distance from persons with schizophrenia and major depression revisited, Epidemiol. Psychiatr. Sci. 24 (2015) 335–341. [7] M.C. Angermeyer, H. Matschinger, Causal beliefs and attitudes to people with schizophrenia, Br. J. Psychiatry 186 (2005) 331–334. [8] M.C. Angermeyer, A. Holzinger, M.G. Carta, G. Schomerus, Biogenetic explanations and public acceptance of mental illness: systematic review of population studies, Br. J. Psychiatry 199 (2011) 367–372. [9] G. Schomerus, C. Schwahn, A. Holzinger, et al., Evolution of public attitudes about mental illness: a systematic review and meta-analysis, Acta Psychiatr. Scand. 125 (2012) 440–452. [10] S. Speerforck, G. Schomerus, H. Matschinger, M.C. Angermeyer, Treatment recommendations for schizophrenia, major depression and alcohol dependence and stigmatizing attitudes of the public: results from a German population survey, Eur. Arch. Psychiatry Clin. Neurosci. 267 (2017) 341–350. [11] J.E. Dimsdale, F. Creed, J. Escobar, et al., Somatic symptom disorder: an important change in DSM, J. Psychosom. Res. 75 (2013) 223–228. [12] L.B. Knesebeck Ovd, M. Lehmann, A. Makowski, Public beliefs about somatic symptom disorders, Front. Psychiatry 9 (2018) 616. [13] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, DSM-5, ed 5 American Psychiatric Publishing, Arlington, 2013. [14] World Health Organization, ICD-11 for Mortality and Morbidity Statistics, Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity %2f767044268, (2019) , Accessed date: 1 November 2019. [15] P. Henningsen, H. Gündel, W.J. Kop, et al., Persistent physical symptoms as perceptual dysregulation: a neuropsychobehavioral model and its clinical implications, Psychosom. Med. 80 (2018) 422–431. [16] L. Kish, A procedure for objective respondent selection within the household, J. Am. Stat. Assoc. 44 (1949) 380–387. [17] L.M. Knesebeck Ovd, B. Löwe, A. Makowski, Public stigma towards individuals with somatic symptom disorders – survey results from Germany, J. Psychosom. Res. 115 (2018) 71–75. [18] E. Mnich, A.C. Makowski, M. Lambert, et al., Beliefs about depression - do affliction and treatment experience matter? Results of a population survey from Germany, J. Affect. Disord. 164 (2014) 28–32. [19] B. Löwe, K. Piontek, A. Daubmann, et al., Effectiveness of a stepped, collaborative, and coordinated health care network for somatoform disorders (Sofu-net): a controlled cluster cohort study, Psychosom. Med. 79 (2017) 1016–1024. [20] B.G. Link, F.T. Cullen, J. Frank, et al., The social rejection of former mental patients: understanding why labels matter, Am. J. Sociol. 92 (1987) 1461–1500. [21] R Core Team, R: A Language and Environment for Statistical Computing, R Foundation for Statistical Computing, Vienna, Austria, 2018https://www.R-project.org/. [22] M.E. Knesebeck Ovd, A. Daubmann, et al., Socioeconomic status and beliefs about depression, schizophrenia and eating disorders, Soc. Psychiatry Psychiatr. Epidemiol. 48 (2013) 775–782. [23] U. von Lersner, J. Gerb, S. Hizli, et al., Stigma of mental illness in Germans and Turkish immigrants in Germany: the effect of causal beliefs, Front. Psychiatry 10 (2019) 46. [24] W. Rief, A. Nanke, J. Emmerich, et al., Causal illness attributions in somatoform disorders. Associations with comorbidity and illness behaviour, J. Psychosom. Res. 57 (2004) 367–371. [25] S. Groben, C. Hausteiner, Somatoform disorders and causal attributions in patients with suspected allergies: do somatic causal attributions matter? J. Psychosom. Res. 70 (2011) 229–238.
Declarations of Competing Interest None. Acknowledgement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no competing interests to report. Appendix A. Appendix A.1. Vignette A (fatigue with cured somatic disease) For more than six months, 32 years old/62 years old* Monika/ Martin* E. has been suffering from total exhaustion, accompanied by chest pain, pain in her muscles and her shoulder. After a fully cured inflammation of the heart muscle eight months ago, she is continuously thinking that her complaints indicate a severe heart disease. According 4