Purpose: The Demoralization scale (DS-I) is a validated and frequently used instrument to assess existential distress in patients with cancer and other severe medical illness. The purpose of this study was to provide normative values derived from a representative German general population sample and to analyze the correlational structure of the DS-I. Methods: A representative sample of the adult German general population completed the DS-I (24 Items), the Emotion Thermometers (ET) measuring distress, anxiety, depression, anger, need for help, and the Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-fatigue). Results: The sample consists of N = 2,407 adults (mean age = 49.8; range = 18–94 years), 55.7% women). The percentages of participants above the DS-I cutoff (30) was 13.5%. The mean scores of the DS-I dimensions were as follows: (1) loss of meaning and purpose: M = 2.78 SD = 4.49; (2) disheartenment: M = 3.19 SD = 4.03; (3) dysphoria M = 4.51 SD = 3.20; (4) sense of failure: M = 6.24 SD = 3.40; and for the DS-I total score: M = 16.72 SD = 12.74. Women reported significantly higher levels of demoralization than men, with effect sizes between d = 0.09 (Loss of Meaning) and d = 0.21 (Dysphoria). Age was not associated with demoralization in our sample. DS-I reliability was excellent (a = 0.94) and DS-I subscales were interrelated (r between 0.31 and 0.87) and significantly correlated with ET, especially depression, anxiety, and need for help and fatigue (r between 0.14 and 0.69). Conclusions: In order to use the DS-I as a screening tool in clinical practice and research the normative values are essential for comparing the symptom burden of groups of patients within the health care system to the general population. Age and sex differences between groups of patients can be accounted for using the presented normative scores of the DS-I.

Objectives: Fatigue is a frequent debilitating symptom associated with cancer. However, scientific data on cancer-related fatigue is scarce in developing nations. This work examines psychometric properties of the multidimensional fatigue inventory (MFI- 20) and analyzes the level of fatigue among Ethiopian patients with cancer in comparison with data from Germany. Methods: A sample of 256 patients with cancer drawn from a hospital in Ethiopia was examined with the MFI-20 and the European Organization for Research and Treatment of Cancer Quality of Life questionnaire (EORTC QLQ-C30). A comparative sample of 780 German patients with cancer served as the control. Results: The MFI-20 scales and total score showed acceptable reliability (a = 0.60– 0.93) with a considerable convergent validity between MFI-20 and the EORTC QLQ-C30 fatigue scale (r = 0.67–0.75). The Ethiopian patients with cancer reported higher levels of fatigue than the German patients. Analyses of variance showed that Ethiopian patients with cancer who were illiterate, having advanced cancer, and those who did not receive either surgery or chemotherapy reported especially high levels of fatigue. Conclusion: The MFI-20 is a fairly reliable and valid instrument to be used with Amharic speaking patients with cancer. The high level of fatigue in these patients implies that appropriate cancer care is needed in developing countries.

Objective: Pre-hospital personnels (PHPs) who work in disasters under extreme pressure, uncertainty, and complex situations are victims of disasters themselves, and there is a link between experiencing such incidents andmental health problems. Because most studies focus on the injured and less on the psychological issues of PHPs, the present study aimed to develop a model to provide relief for PHPs in disasters from a psychological perspective. Methods: A grounded theorymethodology recommended by Corbin and Strauss (2015) was employed. PHPs (n = 24) participated in a semi-structured interview between July 2018 to May 2020. Results: In the analysis of the pre-hospital staff interviews, three main themes were extracted, namely, providing relief with struggle (complexity of incident scenes, command-organizational and occupational challenges), psychological distress (psychological regression and psychological empowerment), and consequences (resilience and job burnout). Seven categories and 22 subcategories were explored from our data via the grounded theory approach Conclusions: The PHPs managed psychological distress with two approaches: psychological self-empowerment and regression, which resulted in resilience and burnout, respectively. Due to the lack of enough support, the resilience of the PHPs was short-term, turned into burnout over time, and affected the structural factors again as a cycle.

Objectives: Having cancer in young adulthood increases the risk of adverse long-term health effects. These risks can be influenced by one’s health behavior (HB). The aim of this study is therefore to investigate the presence of health behavior in adolescents and young adults (AYAs) and to identify associated factors. Design: Young cancer patients (18–39 years old at time of diagnosis) were surveyed at baseline and 12 months later via online or as a paper-pencil version. Methods: A spectrum of indicators for HB was assessed via seven items from the Questionnaire of Multiple Health Behavior (MHB). Multiple linear regression analyses were conducted to determine factors associated with patients’ HB indicators. Results: Five-hundred and fourteen AYAs (75% women) reported the highest level of health-conscious behavior for “avoidance of consumption of nicotine,” “follow medical recommendations,” and “being considerate in road traffic.” Less health-conscious behavior was reported for “keeping an appropriate and balanced diet” and “physical activity.” Significant improvements from baseline to the follow-up were observed for “regularly attending health screening” (Hedges’ g = 0.44). The analyzed factors explained up to 10% of the HB indicators. Women reported significantly more healthconscious behavior than men in four out of seven HB indicators. Higher quality of life (QoL) was associated with more health behavior in three out of seven HB indicators. Conclusion: Findings show a predominantly health-conscious lifestyle in AYA cancer patients, though we also found harmful behavior which needs to be better approached—e.g., through improving AYAs’ health education. AYA men should be particularly targeted in specific prevention and health promotion measures. Future work should identify other factors associated with HB to evaluate targets for intervention.

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

Editorial on the Research Topic. Age-Based Stereotype Threat Effects on Performance Outcomes.

Objective: To test the psychometric properties, internal consistency, dimensional structure, and convergent validity of the German version of the Demoralization Scale- II (DS-II), and to examine the association between demoralization, sociodemographic, disease- and treatment-related variables in patients with cancer. Methods: We recruited adult patients with cancer at a Psychosocial Counseling Center and at oncological wards. Participants completed the 16-item DS-II, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Screener-2 (GAD-2), Distress Thermometer (DT), and Body Image Scale (BIS). We analyzed internal consistency of the DS-II using Cronbach‘s Alpha (a). We tested the dimensional structure of the DS-II with Confirmatory Factor Analyses (CFA). Convergent validity was expressed through correlation coefficients with established measures of psychological distress. The associations between demoralization, sociodemographic, disease- and treatmentrelated variables were examined with ANOVAs. Results: Out of 942 eligible patients, 620 participated. The average DS-II total score was M = 5.78, SD = 6.34, the Meaning and Purpose subscale M = 2.20, SD = 3.20, and the Distress and Coping Ability subscale M = 3.58, SD = 3.45. Internal consistency ranged from high to excellent with a = 0.93 for the DS-II total scale, a = 0.90 for the Meaning and Purpose subscale, and a = 0.87 for the Distress and Coping Ability subscale. The one-factor and the two-factor model yielded similar model fits, with CFI and TLI ranging between 0.910 and 0.933, SRMR < 0.05. The DS-II correlated significantly with depression (PHQ-9: r = 0.69), anxiety (GAD-2: r = 0.72), mental distress (DT: r = 0.36), and body image disturbance (BIS: r = 0.58). High levels of demoralization were reported by patients aged between 18 and 49 years (M = 7.77, SD = 6.26), patients who were divorced/separated (M = 7.64, SD = 7.29), lung cancer patients (M = 9.29, SD = 8.20), and those receiving no radiotherapy (M = 7.46, SD = 6.60). Conclusion: The DS-II has very good psychometric properties and can be recommended as a reliable tool for assessing demoralization in patients with cancer. The results support the implementation of a screening for demoralization in specific risk groups due to significantly increased demoralization scores.

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

Background: Cannabis is the third most consumed drug worldwide. Thus, healthcare providers should be able to identify users who are in need for an intervention. This study aims to explore the relationship of acute, chronic, and early exposure (AE, CE, and EE) to cannabis with cognitive and behavioral harms (CBH), as a first step toward defining risky cannabis use criteria. Methods: Adults living in Spain who used cannabis at least once during the last year answered an online survey about cannabis use and health-related harms. Cannabis use was assessed in five dimensions: quantity on use days during the last 30 days (AE), frequency of use in the last month (AE), years of regular use (YRCU) (CE), age of first use (AOf) (EE), and age of onset of regular use (AOr) (EE). CBH indicators included validated instruments and custom-made items. Pearson correlations were calculated for continuous variables, and Student’s t-tests for independent samples were calculated for categorical variables. Effect sizes were calculated for each of the five dimensions of use (Cohen’s d or r Pearson correlation) and harm outcome. Classification and Regression Trees (CART) analyses were performed for those dependent variables (harms) significantly associated with at least two dimensions of cannabis use patterns. Lastly, logistic binary analyses were conducted for each harm outcome. Results: The mean age of participants was 26.2 years old [standard deviation (SD) 8.5]. Out of 2,124 respondents, 1,606 (75.6%) reported at least one harm outcome (mean 1.8 and SD 1.5). In our sample, using cannabis on 3 out of 4 days was associated with an 8-fold probability of scoring 4+ on the Severity Dependence Scale (OR 8.33, 95% CI 4.91–14.16, p < 0.001), which is indicative of a cannabis use disorder. Also, a start of regular cannabis use before the age of 25 combined with using cannabis at least once per month was associated with a higher probability of risky alcohol use (OR 1.33, 95% CI 1.12–1.57, p = 0.001). Besides, a start of regular cannabis use before the age of 18 combined with a period of regular use of at least 7.5 years was associated with a higher probability of reporting a motor vehicle accident (OR 1.81, 95% CI 1.41–2.32, p < 0.0001). Results were ambiguous regarding the role that age of first use and milligrams of THC per day of use might play regarding cannabis-related harms. Conclusions: The relationship among AE, CE, and EE with CBH indicators is a complex phenomenon that deserves further studies. The pattern of cannabis use should be carefully and widely evaluated—(not just including frequency but also other dimensions of pattern of use)—in research (preferably in longitudinal studies) to assess cannabis-related harms.

As humans we are not stuck in an everlasting present. Instead, we can project ourselves into both our personal past and future. Remembering the past and simulating the future are strongly interrelated processes. They are both supported by largely the same brain regions including the rostral and ventral medial prefrontal cortex (mPFC) but also the hippocampus, the posterior cingulate cortex (PCC), as well as other regions in the parietal and temporal cortices. Interestingly, this core network for episodic simulation and episodic memory partially overlaps with a brain network for evaluation and value-based decision making. This is particularly the case for the mPFC. This part of the brain has been associated both with a large number of different cognitive functions ranging from the representation of memory schemas and self-referential processing to the representation of value and affect. As a consequence, a unifying account of mPFC functioning has remained elusive. The present thesis investigates the unique contribution of the mPFC to episodic simulation by highlighting its role in the representation of memory schemas and value. In a first functional MRI and pre-registered behavioral replication study, we demonstrate that the mPFC encodes representations of known people as well as of known locations from participants’ everyday life. We demonstrate that merely imagined encounters with liked vs. disliked people at these locations can change our attitude toward the locations. The magnitude of this simulation-induced attitude change was predicted by activation in the mPFC during the simulations. Specifically, locations simulated with liked people exhibited significantly larger increases in liking than those simulated with disliked people. In a second behavioral study, we examined the mechanisms of simulation-based learning more closely. To this end, participants also simulated encounters with neutral people at neutral locations. Using repeated behavioral assessments of participants’ memory representations, we reveal that simulations cause an integration of memory representations for jointly simulated people and locations. Moreover, compared to the neutral baseline condition we demonstrate a transfer of positive valence from liked and of negative valence from disliked people to their paired locations. We also provide evidence that simulations induce an affective experience that aligns with the valence of the person and that this experience can account for the observed attitude change toward the location. In a final fMRI study, we examine the structure of memory representations encoded in the mPFC. Specifically, we provide evidence for the hypothesis that the mPFC encodes schematic representations of our social and physical environment. We demonstrate that representations of individual exemplars of these environments (i.e., individual people and locations) are closely intertwined with a representation of their value. In sum, our findings show that we can learn from imagined experience much as we learn from actual past experience and that the mPFC plays a key role in simulation-based learning. The mPFC encodes information about our environment in value-weighted schematic representations. These representations can account for the overlap of mnemonic and evaluative functions in the mPFC and might play a key role in simulation-based learning. Our results are in line with a view that our memories of the past serve us in ways that are oriented toward the future. Our ability to simulate potential scenarios allows us to anticipate the future consequences of our choices and thereby fosters farsighted decision making. Thus, our findings help to better characterize the functional role of the mPFC in episodic future simulation and valuation.