Introduction: Globally, around 2.6 billion people have consumed alcohol in 2017. In the same year, nearly 3 million or 5% of all deaths were attributable to alcohol consumption, the majority of which were non-communicable diseases, such as cancer, digestive and cardiovascular diseases. Chronic heavy alcohol consumption in particular causes harm to the cardiovascular system and is linked to an elevated risk on the occurrence of ischemic heart diseases and cardiomyopathies. The latter constitutes a heterogeneous group of cardiovascular diseases, which can generally be characterized by a weakened heart muscle. The causal link between chronic heavy alcohol consumption and cardiomyopathy has long been recognized, with the Tenth Revision of the International Classification of Diseases (ICD-10) listing alcoholic cardiomyopathy (ACM) as a fully alcohol-attributable diagnosis. For a few, predominately high-income countries, civil registries provide valuable information of ACM mortality. However, for the majority of countries and global population, the cardiomyopathy burden attributable to alcohol consumption needs to estimated. Established methods for estimating alcohol-attributable fractions (AAF), i.e. proportion of an outcome which could be avoided in a scenario of zero alcohol consumption, could not be applied for cardiomyopathy as the link between alcohol consumption levels and risk of cardiomyopathy could not be specified. Accordingly, a global assessment of the contribution of alcohol consumption to the disease burden from cardiomyopathy was lacking. Aims and objectives: First, to develop methods for estimating the contribution of alcohol consumption to cardiomyopathy that can be used globally (study I). Second, to apply the method developed in study I to estimate the global mortality from ACM (study II). Third, to assess differences between this method and an alternative method for estimating the contribution of alcohol consumption to cardiomyopathy proposed during pursuit of these aims (study III). Design: Statistical modelling study with country-level data as unit of analyses. Study I. Based on mortality data from civil registries, the proportion of deaths from ACM among deaths from any cardiomyopathy (=AAF) was used as proxy for the link between alcohol consumption and cardiomyopathy. To generalize this link to countries without available civil registry data, associations of population alcohol exposure and registered AAF were established. Cardiomyopathy deaths that are attributable to alcohol use were quantified in those countries with available registry data. Study II. For countries without available civil registry data, ACM mortality was estimated using population alcohol exposure data based on the methods from study I. As a result, national, regional and global estimates of the mortality attributable to ACM were obtained for the year 2015. Study III. In the alternative method developed by the Global Burden of Disease (GBD) study team, the contribution of alcohol consumption to cardiomyopathy was estimated taking into account that actual ACM deaths may be incorrectly coded as so-called garbage codes (disease codes that do not accurately describe the underlying cause of death). In the alternative method, garbage codes were redistributed to both cardiomyopathy and ACM using statistical procedures. The underlying assumptions for the redistribution of garbage codes were examined by comparing registered and estimated ACM mortality data taking into account the distribution of alcohol exposure. Data sources: Data on population alcohol exposure (alcohol per capita consumption, prevalence of heavy episodic drinking, prevalence of alcohol use disorders) were sourced from publicly available World Health Organization (WHO) data bases. As outcome data, sex-specific mortality counts from different disease groups (ACM, any cardiomyopathy, and selected garbage codes) were obtained at the country level from three different sources: First, WHO mortality data base, which provide civil registry mortality data on nearly half of all member states, coded according to the ICD-10. Second and third, ‘Global Health Estimates’ and ‘GBD Results Tool’ data bases, which provide complete and consistent mortality estimates aggregated into larger disease groups for all WHO member states. Data on covariates were obtained from the United Nations and the World Bank. Statistical analyses: In study I, the dependent variable – AAF for cardiomyopathy – was calculated by dividing deaths from ACM by deaths from any cardiomyopathy, based on civil registry data from N=52 countries. Taking into account country-specific crude mortality rates of ACM, AAF were modeled in two-step sex-specific regression analyses using population alcohol exposure as covariate. AAF were estimated for the same set of N=52 countries, in addition to N=43 countries without civil registry data. Estimated AAF were compared to registered AAF available for N=52 countries. In study II, the global mortality of ACM was estimated by combining civil registry ACM mortality data for N=91 countries and estimated ACM mortality for N=99 countries without available civil registry data. For the latter set of countries, ACM mortality data were calculated by estimating AAF based on the methodology outlined in the first study and subsequently applied to all cardiomyopathy deaths. As a proxy for under-reporting of ACM in civil registries, estimated ACM deaths were compared to registered ACM deaths for N=91 countries. In study III, ACM mortality estimates from the GBD study were compared against registered ACM mortality data for N=77 countries, aiming to test underlying assumptions for redistribution of garbage-coded deaths in the alternative method. For this purpose, descriptive statistics and Pearson correlations were used to assess the association of estimated and registered deaths and to examine consistency of estimates with population alcohol exposure. Results: In study I, population alcohol exposure and ACM mortality were closely linked (spearman correlation=0.7), supporting the proposed modelling strategy. For N=95 countries, the AAF for cardiomyopathy was estimated at 6.9% (95% confidence interval (CI): 5.4-8.4%), indicating that one in 14 of all cardiomyopathy deaths were attributable to alcohol in the year 2013 or the last available year. The findings were robust, with 78% of all estimated AAF deviating less than 5% from registered AAF. In study II, it was estimated that 25,997 (95% CI: 17,385-49,096) persons died from ACM in 2015 globally, with 76.0% of ACM deaths being located in Russia. Globally, 6.3% (95% CI: 4.2-11.9%) of all deaths from cardiomyopathy were estimated to be caused by alcohol. Furthermore, indications of underreporting in civil registration mortality data were found, with two out of three global ACM deaths being possibly misclassified. In study III, findings suggested that only one in six ACM deaths were correctly coded in civil registries of N=77 countries. However, the algorithm accounting for misclassifications in the GBD study was not aligned with population alcohol exposure, which has led to implausibly high ACM mortality estimates for people aged 65 years or older. Specifically, registered and estimated ACM mortality rates diverged in the elderly, which was corroborated with decreasing correlations in these age groups. Conclusions: For countries without civil registry data, the contribution of alcohol consumption to mortality from cardiomyopathy could be quantified using population alcohol exposure and estimated mortality data for any cardiomyopathy. The proposed method was adapted by the WHO in 2018, allowing for a more complete picture of the alcohol-attributable global disease burden for nearly 200 countries. Notably, ACM mortality was hardly present in countries with low to moderate alcohol consumption levels, corroborating that ACM is the result of sustained and very high alcohol consumption levels. In civil registries, at least two out of three ACM deaths are misclassified, thus, presented mortality figures are likely underestimated. As with other alcohol-attributable diseases, misclassification of ACM mortality is a systematic phenomenon, which may be caused by low resources, lacking standards and severe stigma associated with alcohol use disorders. With transition from ICD-10 to ICD-11, new methods will be required as ACM will not remain a unique diagnosis in the new classificatory system. Future methods should account for mortality misclassifications by redistributing garbage codes while taking into consideration the distribution of alcohol exposure. Further, measures to reduce stigma may improve diagnostic accuracy for ACM and other alcohol-attributable diseases. This will not only improve public health statistics but also – and more importantly – improve health prospects of persons with heavy alcohol consumption.:Statement for a publication-based dissertation I Contents II List of tables IV List of figures V Abbreviations VI Abstract VII 1 Introduction 10 1.1 Global extent of alcohol use 10 1.2 Alcohol-attributable disease burden 11 1.3 Estimating the alcohol-attributable burden 12 1.4 Cardiomyopathy 18 1.5 Alcohol and cardiomyopathy 19 2 Aims and objectives 21 3 Study design and methodology 21 3.1 Study design 21 3.2 Data sources 22 4 Study I - Quantifying the global contribution of alcohol consumption to cardiomyopathy 25 4.1 Background 26 4.2 Methods 27 4.3 Results 32 4.4 Discussion 38 4.5 Conclusion 41 5 Study II - National, regional and global mortality due to alcoholic cardiomyopathy in 2015 42 5.1 Introduction 43 5.2 Methods 44 5.3 Results 45 5.4 Discussion 51 6 Study III - Mortality from alcoholic cardiomyopathy: Exploring the gap between estimated and civil registry data 57 6.1 Introduction 58 6.2 Experimental section 59 6.3 Results 62 6.4 Discussion 67 7 General discussion 72 7.1 Summary of the findings 72 7.2 Strengths and limitations 72 7.3 Implications for future research 75 7.4 Implications for alcohol policy 79 7.5 Outlook 80 7.6 Conclusion 81 8 References 83 9 Appendix A (study I) 97 10 Appendix B (study II) 99 10.1 Methods 99 10.2 Results 103 11 Appendix C (study III) 119 11.1 Methods 119 11.2 Results 124 12 Erklärung gemäß § 5 der Promotionsordnung 128

Introduction: Alcohol is a major contributor to the burden of disease globally. In Europe, there is a long-standing tradition of drinking alcohol, with per capita consumption being the highest in the world, even if it has been declining in recent decades. Changes in per capita consumption are likely to be related to factors operating at societal level, of which globalisation has been one of the most important factors. Since early 2020, the global pandemic of the Coronavirus Disease 2019 (COVID-19) has caused serious disruptions to day-to-day and community life. As a consequence of the pandemic and the measures taken to contain the spread of the virus, patterns and levels of alcohol consumption are expected to change due to reduced alcohol availability, and according to income levels and distress experiences. Surveys are used to assess such short-term trends, but also to identify drinking patterns that cannot be derived from other sources such as alcohol purchases. However, general population surveys usually fail to capture the entire amount of alcohol consumed within a population. This inherently limiting factor of surveys is called underreporting and not well understood to date. Aims and Objectives: The overall aim of this dissertation was to provide a comprehensive and up-to-date assessment of alcohol consumption in Europe using survey data, as well as to compare survey-based annual consumption estimates with per capita consumption data, i.e., sales and other data derived. For this purpose, the following three objectives were of interest: First, to determine and to compare European drinking practices across 19 countries using survey data from 2015 (study I). Second, to examine changes in alcohol consumption during the first months of the COVID-19 pandemic in 21 European countries and whether these changes were associated with income and pandemic-related distress experiences (study II). Third, to estimate the degree of under-reporting of alcohol consumption in surveys and to study possible factors related to under-reporting based on 39 surveys from 23 European countries (study III). Design: All studies are based on individual-level data from cross-sectional pan-European surveys covering the general adult population. In study I, European drinking practices were determined by the means of latent class analysis using key indicators of alcohol consumption (past-year drinking frequency and quantity, risky single-occasion drinking, and preferred alcoholic beverage) derived from nationally representative data from 2015. In a second step, the identified drinking practices were compared across countries. In study II, self-reported changes in drinking frequency, drinking quantity, and the frequency of heavy episodic drinking over the past month were assessed in a large convenience sample collected between April and July 2020. Additionally, past-year alcohol consumption was recorded using the consumption items of the Alcohol Use Disorder Identification Test in order to obtain an estimate of alcohol consumption during the pre-pandemic period. Income and distress experiences were recorded as factors hypothesised to be associated with self-reported changes in consumption. In Study III, nationally representative surveys conducted between 2008 to 2015 were combined and compared with alcohol per capita consumption estimates for the same years and countries, in order to estimate survey-based under-reporting of alcohol consumption at the national level. Per capita consumption estimates were retrieved from sales statistics and corrected for unrecorded and tourist consumption. Data sources: Survey data were obtained from large-scale alcohol surveys covering the majority of European Union countries plus some non-European Union countries. Statistical analyses: To identify European drinking practices (study I), survey-weighted latent class models of key indicators of alcohol consumption, adjusted for respondent’s location, were conducted. The resulting class prevalence estimates were then contrasted across locations, and fractional response regression models were calculated for membership probabilities of each class (dependent variable) in explorative analysis, with sociodemographic data and individual alcohol harm experiences serving as independent variables. To identify changes in overall alcohol consumption over the past month during the COVID-19 pandemic (study II), a consumption-change score was calculated by combining the single change indicators (i.e., drinking frequency, drinking quantity, and frequency of heavy episodic drinking; range: -1 to +1). Multilevel linear regressions with the random intercept country of residence were used to test for statistical significance of the consumption-change score (dependent variable), adjusting for sample weights and past-year alcohol consumption, as well as for associations with income group and pandemic-related distress experiences. To quantify the extent to which national surveys assess alcohol per capita consumption (study III), coverage rates were calculated. Coverage is defined by dividing the survey-based annual alcohol consumption estimates by per capita consumption estimates. Using fractional response regressions, differences in coverage rates (dependent variable) across transnational regions, as well as the relative importance of heavy episodic drinking prevalence and indicators of survey methodology were tested. Results: Three latent classes of drinking practices were identified: a ‘light to moderate drinking without risky single-occasion drinking’ class (prevalence: 68.0%, 95% Confidence interval [CI]: 66.7, 69.3), a ‘infrequent heavy drinking’ class (prevalence: 12.6%, 95% CI: 11.5, 13.7), and a ‘regular drinking with at least monthly risk single-occasion drinking’ class (prevalence: 19.4%, 95% CI: 18.1, 20.9). In contrast to the former drinking practice of light to moderate drinking, the latter two were characterised by a high average amount of alcohol consumed per drink day, exceeding 100 grams pure alcohol and 60 grams pure alcohol per drink day, respectively. Regional variations in the distribution of drinking practices were observed, with the ‘light to moderate drinking without risky single-occasion drinking’ class prevailing particularly in southern European countries. In study II, an average decrease in overall alcohol consumption during the first months of the COVID-19 pandemic indicated by a negative consumption-change score was observed (-0.14, 95% CI: -0.18, -0.10). This average decline according to the consumption-change indicator was observed in all countries studied, except Ireland (no change) and the United Kingdom (increase). The most marked decrease was reported in the frequency of heavy episodic drinking (-0.17, 95% CI: -0.20, -0.14). Respondents with low- or average income, as well as those experiencing distress were more likely to increase their alcohol consumption than to decrease it. In study III, the average total alcohol consumption coverage was 36.5% (95% CI: 33.2, 39.8), with large variations in coverage rates between countries. While the prevalence of heavy episodic drinking explained up to 10% of the variance in coverage, there were no systematic variations across European regions or the survey methodologies studied, such as non-response rates. Conclusions: In many European countries, a combination of a light to moderate and risky drinking practices prevailed. With a combined prevalence of 32.0%, almost every third respondent engaged in some form of risky drinking. During the first months of the COVID-19 pandemic, overall alcohol consumption, and particularly heavy episodic drinking, appeared to have declined on average in the countries studied. On the other hand, people with low- or average incomes and those suffering from pandemic-related distress were at increased risk of escalating their alcohol consumption during this period. The results contribute both to an up-to-date assessment of alcohol consumption in Europe, including the identification of populations at increased risk of alcohol-related harm, and to the body of evidence on reducing alcohol availability as an effective measure to lower population-level consumption. Beyond consequences for alcohol policy, benefits and limitations of surveys in the field of alcohol epidemiology are discussed. In light of the substantial and apparently unsystematic under-reporting of alcohol consumption in surveys, a rethinking of this methodology is required. Presenting survey-based data and its limitations in an upfront manner, as well as applying sophisticated statistical methods are two options to address current challenges.:Statement for a publication-based dissertation I Table of contents III List of tables V List of figures VII Abbreviations IX Synopsis XI 1 Introduction 1 1.1 Determinants of alcohol consumption and alcohol-related harm 3 1.1.1 Individual vulnerability factors 4 1.1.2 Societal vulnerability factors 5 1.2 The impact of the COVID-19 pandemic on alcohol consumption 8 1.3 Strengths and limitations of survey research 11 2 Aims and objectives 13 3 Study design and methodology 14 3.1 The Standardised European Alcohol Survey 15 3.1.1 The RARHA SEAS questionnaire 15 3.1.2 Sampling procedure and data pre-processing 16 3.1.3 Calculation of annual alcohol consumption 17 3.1.4 Research ethics 17 3.2 Harmonising Alcohol-related Measures in European Surveys 17 3.2.1 Questionnaires 18 3.2.2 Sampling procedures and harmonising of the questionnaires 18 3.2.3 Research ethics 19 3.3 The Alcohol Use and COVID-19 Survey 19 3.3.1 Survey development and design 19 3.3.2 Survey dissemination 21 3.3.3 Calculation of survey and population weights 22 3.3.4 Research ethics 24 4 Study I – A new perspective on the European drinking culture: a model-based approach to determine variations in drinking practices across 19 European countries 25 4.1 Abstract 25 4.2 Introduction 26 4.3 Methods 27 4.4 Results 30 4.5 Discussion 35 5 Study II – Alcohol consumption during the COVID-19 pandemic in Europe: a large-scale cross-sectional study in 21 countries 38 5.1 Abstract 38 5.2 Introduction 39 5.3 Methods 40 5.4 Results 42 5.5 Discussion 49 6 Study III – Why is per capita consumption underestimated in alcohol surveys? Results from 39 surveys in 23 European countries 53 6.1 Abstract 53 6.2 Introduction 54 6.3 Methods 56 6.4 Results 62 6.5 Discussion 64 7 General discussion 69 7.1 Summary of findings 69 7.2 Strengths and limitations 70 7.3 Implications for future research 72 7.3.1 New impulses for drinking culture research 72 7.3.2 The realisation of multi-country online surveys 73 7.3.3 Consequences of low alcohol consumption coverage in alcohol surveys 74 7.4 Implications for alcohol policy 75 7.4.1 Altered availability of alcohol as a secondary outcome of the COVID-19 pandemic 76 7.4.2 Towards a comprehensive alcohol control policy for Europe 78 7.4.3 Alcohol screening and access to health care in high-risk drinking populations 7.5 Outlook 81 7.6 Conclusion 83 8 References 85 9 Appendix 106 9.1 Appendix A (study I) 106 9.2 Appendix B (study II) 126 9.3 Appendix C (study III) 152 10 Erklärung gemäß §5 der Promotionsordnung 160

Der Konsum psychoaktiver Substanzen stellt einen der wichtigsten vermeidbaren Risikofaktoren für Krankheit und frühzeitige Sterblichkeit dar. Die Weltgesundheitsorganisation (WHO, 2009) berichtet im Rahmen ihrer Schätzungen zur weltweiten Morbiditäts-und Mortalitätsbelastung, dass die legalen Substanzen Tabak und Alkohol zwei der fünf wichtigsten gesundheitlichen Risikofaktoren darstellen. ...

Anorexia nervosa (AN) is an eating disorder characterized by severely low bodyweight, fear of weight-gain, and a subjective believe to be “fat”. An elevated need for control and fear of losing control are considered core aspects in the development and maintenance of AN and restricting food intake is thought to function as a means to gain feelings of control (Fairburn, Shafran, & Cooper, 1999; Schmidt & Treasure, 2006). Feelings of inefficiency (i.e. lack of control regarding personal goals) have been found to predict longer duration of treatment and worse treatment outcome, underlining the relevance of the need for control in AN (Olatunji, Levinson, & Calebs, 2018; Pinto, Heinberg, Coughlin, Fava, & Guarda, 2008; Surgenor, Maguire, Russell, & Touyz, 2007). The constant striving for control could lead to rumination and negative affect – two further important symptoms associated with AN. The Goal Progress Theory of rumination (GPT; Carver & Scheier, 1990; Martin & Tesser, 1996) proposes that perceived discrepancies between desired goals (in the case of AN e.g. goals regarding lowest possible calorie intake, weight, etc.) and the current state (in the case of AN e.g. the subjective conviction of having eaten or weighing too much) trigger ruminative thoughts, which subsequently lead to negative affect. Following this theory, it could be suggested that gaining feelings of goal-progress and control could lessen the burdening repetitive thoughts and negative affect and that individuals with AN try to achieve this by restricting food intake. This dietary restriction requires self-control. However, previous research has shown that patients with AN typically not only show such elevated self-control, but also display rigid habitual behaviours and routines, struggle with set-shifting, and often display comorbid obsessive-compulsive symptoms (Treasure & Schmidt, 2013; Halmi et al., 2003). This raises the question of whether food restriction in AN is indeed an act of self-control or rather a habit. Recent scientific development has challenged the traditional dichotomy between controlled and automatic processes (Shiffrin & Schneider, 1977), instead suggesting that they are intertwined in such a way that often self-control works via the establishment of goal-serving habits and routines (Gillebaart & de Ridder, 2015; Galla & Duckworth, 2015). These theoretical considerations can generally draw support from previous research, but have not been investigated explicitly in the context of AN. It was the main goal of this thesis to analyse associations between feelings of inefficiency, rumination and negative affect, controlled and habitual behaviour, and eating behaviour to establish an empirical foundation for the proposed relationships between these aspects of AN. Study 1 (Fürtjes, Seidel, et al., 2020) employed ecological momentary assessment (EMA; data collection several times a day over a period of several days in the natural environment of the participants) to investigate associations between feelings of inefficiency, rumination, and affect in a sample of individuals with a history of AN who had recovered from the disorder in terms of eating behaviour and bodyweight and age-matched healthy control participants (HC). AN participants displayed elevated rumination about bodyweight/figure (but not food) and negative affect compared to HC, suggesting that these cognitive-affective symptoms are persistent even after recovery. Analyses investigating associations with inefficiency showed that inefficiency was associated with heightened rumination and negative affect, which is in line with the GPT. Furthermore, AN participants showed higher levels of inefficiency than HC and stronger associations between rumination and negative affect. These findings indicate that feelings of lack of goal-progress and control are a central aspect of AN, likely contributing to maintenance of the disorder by triggering dysfunctional cognitive-affective processes. The fact that these associations were still present in a sample of recovered individuals underlines the persistence of these processes, suggesting that they might not only maintain the disorder but could also present a vulnerability factor or contribute to risk of relapse. Study 2 (Fürtjes et al., 2018) made use of EMA and leptin, an endocrinological marker of undernutrition, to further investigate associations between rumination and affect in a sample of patients with acute AN, once at the beginning of treatment and again after weight-restoration. In line with Study 1, results confirmed that rumination about bodyweight/figure and negative affect are closely linked in AN and that this association persists even after weight-gain. Thoughts about food on the other hand were associated with leptin levels, declined with weight-gain, and showed weaker associations with affect. This suggests that thoughts about food may reflect a physiological symptom of the disorder, connected to undernourishment, whereas thoughts about bodyweight/figure might present a cognitive-affective symptom which could be involved in maintenance of the disorder (as suggested by Study 1). To test supporting evidence for the interaction of self-control and habits in the regulation of eating behaviour, Study 3 (Fürtjes, King, et al., 2020) employed task-based measures of controlled and automatic processing as well as self-report measures of self-control, habitual behaviour, and eating behaviour in a large female sample representative of the general population through an online study design. Results obtained via structural equation modelling (SEM) revealed that eating behaviour appears to be largely guided by habits and automatic behavioural tendencies, whereas controlled aspects have an indirect influence via this association. These findings could be interpreted as support for the proposal that self-control might work via the establishment of goal-serving habits and routines, which outlines the possibility that the restrictive eating behaviour in AN might be achieved and maintained via a combination of self-control and rigid routines and habits. Taken together, the research presented in this thesis was able to demonstrate how striving for control as a core aspect of AN might play a role in triggering dysfunctional cognitive-affective processes, likely contributing to development and maintenance of the disorder, and that self-control and habitual behaviour interact inguiding human eating behaviour, carrying implications for the mechanisms behind restrictive eating in AN. Clinical implications that can be derived from this research include addressing need for control and feelings of inefficiency in therapy to enable improvement of dysfunctional cognitive-affective processes as well as eating behaviour.

Die seit März 2020, mit strengen Schutzmaßnahmen in Form von Kontaktreduzierungen und Einschränkungen im öffentlichen Leben, in Deutschland einhergehende Covid-19-Pandemie löste bei vielen Menschen individuell ausgeprägte Sorgen und Ängste innerhalb diversen Lebensbereichen aus. Ein, den Kriegszeiten ähnlicher, Zustand trat ein und nach Worten der Politikvertreter/innen ging es um Leben oder Tod, Arbeitsplatzsicherheit oder Arbeitsplatzlosigkeit sowie Geborgenheit oder Isolation. Gegenwärtige Schlagzeilen wie „Die Corona-Krise führt immer häufiger zu psychischen Problemen (Haas, C., Kunz, A. 2020: www.welt.de)“, „Eine Herausforderung für Menschen mit Depression (Moghimi, J. 2020: www.rnd.de)“ oder „Menschen mit psychischen Erkrankungen leiden am meisten (Pingel, S. 2020: www.msn.com)“ lassen auf eine starke Betroffenheit von psychisch erkrankten Menschen im Kontext der COVID-19-Pandemie schließen. Ziel dieser Arbeit ist es, die individuelle Betroffenheit von depressiv erkrankten Menschen zu untersuchen. Findet die Annahme, einer steigenden Tendenz psychischer Belastungen, fortwährend Bestätigung, ist eine unmittelbare Reaktion professionellen Handelns durch die Soziale Arbeit notwendig, um mögliche soziale Folgen aufzufangen und gleichzeitig präventiv für Betroffene Unterstützung anzubieten. Insbesondere Menschen mit einer Depression sind, aufgrund von (Vor-)Erfahrungen hinsichtlich ihres Krankheitsbildes, Experten im Umgang mit Isolationserlebnissen. Gelten sie demnach als Meister der Isolation im Umgang mit der Covid-19-Pandemie?:Inhaltsverzeichnis Abkürzungsverzeichnis 1 Einleitung 2 Die COVID-19-Pandemie 2.1 Das SARS-CoV-2-Virus 2.2 Die COVID-19-Chronik und die Maßnahmen zum Eindämmung des Virus 2.3 Die gesamtgesellschaftliche Situation 3 Die Auswirkungen der Pandemie auf das psychische Wohlbefinden 4 Depressionen während einer Pandemie 4.1 Betroffenheit der Menschen mit der psychischen Krankheit Depression während der COVID-19-Pandemie 4.2 Die Krankheit Depression 4.2.1 Krankheitsbild 4.2.2 Ursachen 4.2.3 Behandlungsmöglichkeiten 4.3 Forschungsstand 4.3.1 Historische Epi-/Pandemien 4.3.2 COVID-19-Pandemie 5 Die subjektive Wahrnehmung von Betroffenen mit einer Depression 5.1 Methodisches Vorgehen 5.1.1 Qualitativer Forschungsansatz 5.1.2 Erhebungsmethode 5.1.3 Zugang zum Feld 5.1.4 Durchführung der Erhebung 5.1.5 Auswertungsmethode 5.2 Darstellung der Ergebnisse 5.3 Diskussion mit der Gegenüberstellung eigener Forschungsergebnisse und externen Erhebungen 6 Der Umgang mit Lebenskrisen 6.1 Psychosoziale Krisen 6.2 Lebensbewältigung 6.3 Resilienz 6.4 Eine konstruktive Bewältigung psychischer Folgen der Pandemie 7 Handlungsempfehlungen im Umgang mit der COVID-19-Pandemie 7.1 Psychosoziale Notfallversorgung durch Intervention 7.2 Bewältigung im privaten Kontext 7.3 Adaption des Versorgungssystems 7.3.1 Fortbestehen von Angeboten 7.3.2 Entwicklung und Anpassung neuer Angebote 7.4 Öffentlichkeitsarbeit 8 Professionalisierungsdiskurs für die Soziale Arbeit 9 Schlussfolgerung Quellenverzeichnis Anhang

Der Konsum psychoaktiver Substanzen stellt einen der wichtigsten vermeidbaren Risikofaktoren für Krankheit und frühzeitige Sterblichkeit dar. Die Weltgesundheitsorganisation (WHO, 2009) berichtet im Rahmen ihrer Schätzungen zur weltweiten Morbiditäts-und Mortalitätsbelastung, dass die legalen Substanzen Tabak und Alkohol zwei der fünf wichtigsten gesundheitlichen Risikofaktoren darstellen. ...

Alkoholkonsum beginnt häufig bereits im Jugendalter. Allerdings fehlen bisher Erkenntnisse darüber, ob, wie häufig und aufgrund welcher Merkmale Jugendlichen und junge Erwachsene auch bereits klinisch definierte Mißbrauchs- und Abhängigkeitsdiagnosen entwickeln. In der vorliegenden Arbeit werden Ergebnisse einer repräsentativen Untersuchung an 3021 Jugendlichen im Alter von 14-24 Jahren vorgestellt. Neben der Prävalenz von Alkoholmißbrauch und -abhängigkeit nach DSM-IV werden Daten zur Häufigkeit und Menge des Alkoholkonsums berichtet sowie erste Symptome beschrieben. 9,7% der befragten Jugendlichen erhielten aufgrund von DSM-IV-Kriterien eine Mißbrauchsdiagnose, 6,2% eine Abhängigkeitsdiagnose. Bei männlichen Jugendlichen war die Prävalenz wesentlich höher als bei weiblichen. Die Prävalenz war in den älteren Geburtskohorten höher. Als erstes Missbrauchssymptom trat am häufigsten "Gebrauch mit körperlicher Gefährdung" (91,9%), als erstes Abhängigkeitssymptom "Toleranzentwicklung" (34,3%) auf. Erste diagnostische Kriterien einer Alkoholstörung traten zumeist deutlich vor dem 18. Lebensjahr auf. Diese Daten unterstreichen, daß Alkoholmißbrauch und -abhängigkeit bereits im Jugend- und frühen Erwachsenenalter häufig sind. / Alcohol use frequently begins in adolescence. However, only few studies have reported the prevalence of alcohol abuse disorders in adolescents. This paper reports results from a representative study in a sample of 3021 adolescents, aged 14-24 years. The Prevalence of alcohol abuse and dependence according to DSM-IV criteria, as well as the prevalence, frequency and quantity of alcohol abuse and a description of the first occuring symptoms, are presented here. Alcohol abuse was reported by 9.7% of respondents and alcohol dependence by 6.2%. Males were more likely to report an alcohol disorder than females, and the prevalence also increased in the older age cohorts. The most frequent initial symptoms were "hazardous use" (91.9%) for abuse and "tolerance" (34.3%) for dependence. First symptoms have been shown to occur long before the age of 18. These results show that even in adolescents and young adults alcohol abuse and dependence are frequent disorders.

Alcohol use disorder (AUD) is a widespread mental disease denoted by chronic alcohol use despite significant negative consequences for a person’s life. It affected more than 14 million persons in Europe alone and accounted for more than 5% of deaths worldwide in 2011-2012. Understanding the psychological and neurobiological mechanisms driving the development and maintenance of pathological alcohol use is key to conceptualizing new programs for prevention and therapy of AUD. There has been a variety of etiological models trying to describe and relate these mechanisms. Lately, the view of AUD as a disorder of learning and decision making has received much support proposing dual systems to be at work in AUD – one system being deliberate, forward-planning, and goal-directed and the other one reflexive, automatic, and habitual. Both systems supposedly work in parallel in a framework of value-based decision making and their balance can be flexibly adjusted in healthy agents, while a progressive imbalance favoring habitual over goal-directed choice strategies is assumed in AUD. This imbalance has been theoretically associated to neural adaptations to chronic alcohol use in corticostriatal pathways involved in reward processing, especially in ventral striatum. However, these theoretical models are grounded strongly on animal research while empirical research in the human domain remains rather sparse and inconclusive. Furthermore, alterations in value-based decision-making processes and their neural implementation might not only result from prolonged alcohol misuse but may also represent premorbid interindividual differences posing a risk factor for the development of AUD. Therefore, I here present three studies investigating the relation of alcohol use with the balance between goal-directed and habitual decision systems and with parameters modulating option valuation processes of these systems, namely delay, risk, and valence of option outcomes. To separate the investigation of these decision processes as predisposing risk for or consequence of alcohol use, two samples were examined: one sample of 201 eighteen-year-old men being neither abstinent from nor dependent on alcohol as well as one sample of 114 AUD patients in detoxification treatment and 98 control participants matched for age, sex, educational background, and smoking status. Both samples had a baseline assessment of several behavioral tasks, questionnaires, and neuropsychological testing and were followed-up over one year to examine drinking trajectories in the sample of young men and relapse in detoxified patients. The behavioral tasks included a sequential choice task using model-free and model-based reinforcement learning as operationalization of habitual and goal-directed decision making, respectively, during functional magnetic resonance imaging and four tasks probing participants’ delay discounting, probability discounting for gains and losses, and loss aversion. Study 1 presents the cross-sectional analysis of the sequential choice task in relation to baseline drinking behavior of the young-adult sample. These analyses did not reveal an association between non-pathological alcohol use and habitual and goal-directed control on neither a behavioral nor neural level except for one exploratory finding of increased BOLD responses to model-free habitual learning signals in participants with earlier onset of drinking. Study 2 examined the same task in AUD patients compared to control participants showing no difference in behavioral control or neural correlates between those groups. However, prospectively relapsing AUD patients showed lower BOLD responses associated to model-based goal-directed control than abstaining patients and control participants. Additionally, the interaction of goal-directed control and positive expectancies of alcohol effects discriminated subsequently relapsing and abstaining patients revealing an increased risk of relapse for those patients who showed higher levels of goal-directed control and low alcohol expectancies or low levels of goal-directedness and high expectancies. Study 3 examined modulating features of goal-directed and habitual option valuation – delay, risk, and valence of options – in association to alcohol use in the young-adult sample and AUD status in the sample of patients and matched control participants on a cross-sectional as well as longitudinal level. This study revealed no relation of delay, risk, and loss aversion with current alcohol use and consumption one year later in the young men. In contrast, AUD patients showed systematically more impulsive choice behavior than control participants in all four tasks: a higher preference for immediate rewards, more risky choices when facing gains and less when facing losses, and lower loss aversion. Furthermore, a general tendency to overestimate the probability of uncertain losses could predict relapse risk over the following year in AUD patients. Taken together, these results do not support the hypothesis that mechanisms of value-based decision making might be predisposing risk factors for alcohol consumption. The findings for patients already suffering from AUD are mixed: while choice biases regarding delays, risks, and valence of option outcomes seem to be altered systematically in AUD, there was no indication of an imbalance of habitual and goal-directed control. These findings challenge the assumption of a generalized outcome-unspecific shift of behavioral control from goal-directed to habitual strategies during the development of AUD and point towards several possible future avenues of research to modify or extend the theoretical model.:Table of Contents List of Figures List of Tables List of Abbreviations Abstract Chapter 1. Perspectives on alcohol use disorder 1.1 The size of alcohol use disorder 1.1.1 Terminology of alcohol-use related disorders 1.1.2 Size and burden of alcohol consumption and alcohol use disorders 1.2 Cognitive psychological perspectives on alcohol use disorder 1.2.1 A unified framework for addiction 1.2.2 Value-based decision making 1.2.3 Goal-directed and habitual systems 1.3 Neurobiological perspectives on alcohol use disorders 1.3.1 Neural underpinnings of the reward circuit 1.3.2 Neural underpinning of goal-directed and habitual decision making 1.3.3 Striatal adaptations associated with chronic alcohol consumption 1.4 Synopsis and research questions Chapter 2. Study 1 2.1 Abstract 2.2 Introduction 2.3 Material and methods 2.3.1 Participants and procedure 2.3.2 Measures of goal-directed and habitual behavioral control 2.3.3 Measure of alcohol consumption 2.3.4 Behavioral statistical analyses 2.3.5 Functional magnetic resonance imaging data acquisition and analysis 2.4 Results 2.4.1 Sample characteristics 2.4.2 Behavioral results 2.4.3 Functional magnetic resonance imaging results 2.5 Discussion Chapter 3. Study 2 3.1 Abstract 3.2 Introduction 3.3 Methods and materials 3.3.1 Participants 3.3.2 Procedure 3.3.3 Alcohol Expectancy Questionnaire 3.3.4 Task 3.3.5 Magnetic Resonance Imaging 3.3.6 Follow-up procedure 3.3.7 Data analysis 3.3.8 fMRI analysis 3.4 Results 3.4.1 Sample characteristics 3.4.2 Task-related group differences 3.4.3 Interaction between alcohol expectancies and model-based control 3.4.4 fMRI results 3.5 Discussion Chapter 4. Study 3 4.1 Abstract 4.2 Introduction 4.3 Study 3.1 4.3.1 Material and methods 4.3.2 Results 4.4 Study 3.2 4.4.1 Material and methods 4.4.2 Results 4.5 Discussion Chapter 5. General discussion 5.1 Summary of findings and discussion 5.1.1 Goal-directed and habitual decision making and alcohol use (disorder) 5.1.2 Neuroimaging correlates of goal-directed and habitual control 5.1.3 Modulators of the valuation systems and alcohol use (disorders) 5.1.4 Integration of findings 5.2 Limitations 5.2.1 Methodological critique of the Two-Step task 5.3 Outlook for future studies 5.3.1 Tentative framework for future studies 5.4 Conclusions References Appendix A Supplementary Information of Study 1 A.1 Supplementary Methods 1 - behavioral A.2 Supplementary Methods 2 - fMRI A.3 Supplementary Results - behavioral A.4 Supplementary results - fMRI B Supplementary Information of Study 2 B.1 Computational fits B.2 Preprocessing of the functional imaging data B.3 Exclusion criteria for different analyses B.4 First level analysis of the functional imaging analysis B.5 Voxel-based morphometry B.6 Drinking Motives Questionnaire B.7 Model-free comparisons B.8 Association with time to relapse B.9 Number of detoxifications and model-based control: behavioral and neuroimaging analyses C Supplementary Information of Study 3 C.1 Differences between VBDM version used in this study compared to the VBDM version reported in Pooseh et al. (under review) C.2 Additional correlational analyses D Supplementary Information for additional analyses

Anhand einer prospektiven epidemiologischen Verlaufsstudie an einer repräsentativen Bevölkerungsstichprobe von ursprünglich 14- bis 17jährigen Jugendlichen (N=1395) werden die Häufigkeit und die Verlaufsmuster des Konsums, des Mißbrauchs und der Abhängigkeit von Cannabis untersucht. Die Jugendlichen wurden persönlich mit Hilfe eines Interviews befragt, wobei als diagnostisches Instrument das M-CIDI mit seinen DSM-IV Algorithmen verwendet wurde. Die Ergebnisse aus der Basiserhebung ergaben, daß 1995 etwa 20% aller 14- bis 17jährigen - in der Mehrzahl wiederholt - Cannabis probiert hatten und 6% der Population einen regelmäßigen Gebrauch aufweisen. Die Einjahres-Inzidenz (= Auftreten neuer Fälle) für den Cannabisgebrauch der nun 15- bis 19jährigen betrug zum Zeitpunkt der Nachuntersuchung 20,1% für die Männer und 16,3% für die Frauen. Für den regelmäßigen Gebrauch wurden Inzidenzraen von 12% (Männer) und 8,4% (Frauen) ermittelt. Die Stabilität des Konsumverhaltens zwischen der Basis- und der Nachuntersuchung war relativ hoch un stieg mit höherem Initialkonsum an. Angesichts der hohen Gebrauchsrate von 32,4% bei den 15- bis 19jährigen bei der Nachuntersuchung ergab sich im Vergleich zu anderen psychotropen Substanzen eine relativ niedrige Prävalenz für Mißbrauch und Abhängigkeit (4%). Das Vorliegen einer Diagnose bei der Erstuntersuchung weist allerdings eine relativ hohe Stabilität über die Nachuntersuchungskette auf. / The paper examines the prevalence, incidence and stability patterns of cannabis use and dependence in a prospective epidemiological study of a random community sample of adolescents, aged 14 to 17 years (N=1395) at time 1. Assesments are based on personal interviews by trained clinical psychologists using the computerized DSM-IV lifetime and 12-month change version of the M-CIDI. Results indicate that in 1995 every fifth person aged 14 to 17 years had used cannabis at least once and 6% reported regular use. The 12-month incidence rates (i.e. proportion of the sample reporting first cannabis use in the last year) among subjects, 15 to 19 years of age at time 2, was high, with 20,1% of males and 16,3% of females reporting first use. The incidence of regular use was 12,0% (males) and 8,4% (females). The stability of consumption patterns from time 1 to time 2 was high. Increasing with higher initial consumption. Given the reexamined samples overall high cannabis consumption rates of 32,4%, the prevalence of clinically manifest DSM-IV abuse and dependence was low in comparison to other psychologic drugs (4%). However there was remarkable diagnostic stability over time in this age group of those with an initial diagnosis at time 1 receiving a diagnosis again at time 2.

Die Arbeit gibt einen methodenkritischen Überblick über die in Deutschland vorliegenden Ergebnisse zur Prävalenz sowie Risikofaktoren von Substanzmißbrauch und -abhängigkeit (SMA). Es wird gezeigt, daß die vorliegenden epidemiologischen Studien unvollständig und methodisch unbefriedigend sind. Vor allem die fehlende Erfassung spezifischer diagnostischer Kriterien zur Ableitung klinisch relevanter Mißbrauchs- und Abhängigkeitsstörungen erschwert eine Interpretation der Ergebnisse der vorliegenden Repräsentativerhebungen. Diese geben zwar aussagekräftige populationsbezogene Informationen über die Häufigkeit und Verteilungsmuster von legalen und illegalen Substanzen, klinisch relevante Beurteilungsaspekte wie z.B. zu Schweregrad, Toleranz und Abstinenzproblemen sowie zu Einstieg und Verlauf der "Sucht"-Problematik fehlen jedoch vollständig. Dies trifft auch für Untersuchungen zu Risikofaktoren zu. Als ein durchgängiger Mangel wird ferner die Erfassungsmethodologie angesehen, die sich bislang fast ausschließlich auf Fragebögen oder Interviews stützt, über deren Reliabilität und Validität nur unzureichende psychometrische Daten vorliegen. / A critical review of prevalence and risk factor studies of substance abuse and dependence in Germany is presented. It is shown that currently available epidemiological data are incomplete due to the failure of instruments to allow for a detailed assessment of specific substance use disorders. The neglect of diagnostic criteria for clinically significant abuse and dependence disorders makes it especially difficult to draw conclusions about the results of representative surveys. Although the give clear population-related information about frequency and distribution patterns of legal and illegal substancees, relevant clinical data regarding aspects such as severity, tolerance, problems of abstinence, onset and course of abuse and dependence are completely lacking. This is also true of studies on risk factors. An additional problem is diagnostic assessment based almost exclusively on questionnaires and interviews whose reliability and validity have not been sufficiently established.