Relaxation - Induced by Vibroacoustic Stimulation via a Body Monochord and via Relaxation Music - Is Associated with a Decrease in Tonic Electrodermal Activity and an Increase of the Salivary Cortisol Level in Patients with Psychosomatic Disorders.

Vibroacoustic stimulation by a Body Monochord can induce relaxation states of various emotional valence. The skin conductance level (SCL) of the tonic electrodermal activity is an indicator of sympathetic arousal of the autonomic nervous system and thus an indicator of the relaxation response. Salivary cortisol is considered to be a stress indicator of the HPA-axis. The effects of the treatment with a Body Monochord and listening to relaxation music (randomized chronological presentation) on SCL and salivary cortisol in relation to the emotional valence of the experience were examined in patients with psychosomatic disorders (N = 42). Salivary cortisol samples were collected immediately before and after the expositions. Subjective experience was measured via self-rating scales. Overall, both the exposure to the Body Monochord as well as the exposure to the relaxation music induced an improvement of patients' mood and caused a highly significant reduction of SCL. A more emotionally positive experience of relaxation correlated with a slightly stronger reduction of the SCL. Both treatment conditions caused a slight increase in salivary cortisol, which was significant after exposure to the first treatment. The increase of salivary cortisol during a relaxation state is contrary to previous findings. It is possible that the relaxation state was experienced as an emotional challenge, due to inner images and uncommon sensations that might have occurred.

Phoenixin is negatively associated with anxiety in obese men.

Phoenixin was recently identified in the rat hypothalamus and initially implicated in reproductive functions. A subsequent study described an anxiolytic effect of the peptide. The aim of the study was to investigate a possible association of circulating phoenixin with anxiety in humans. We therefore enrolled 68 inpatients with a broad spectrum of psychometrically measured anxiety (GAD-7). We investigated men since a menstrual cycle dependency of phoenixin has been assumed. Obese subjects were enrolled since they often report psychological comorbidities. In addition, we also assessed depressiveness (PHQ-9) and perceived stress (PSQ-20). Plasma phoenixin levels were measured using a commercial ELISA. First, we validated the ELISA kit performing a spike-and-recovery experiment showing a variance of 6.7±8.8% compared to the expected concentrations over the whole range of concentrations assessed, while a lower variation of 1.6±0.8% was observed in the linear range of the assay (0.07-2.1ng/ml). We detected phoenixin in the circulation of obese men at levels of 0.68±0.50ng/ml. These levels showed a negative association with anxiety scores (r=-0.259, p=0.043), while no additional associations with other psychometric parameters were observed. In summary, phoenixin is present in the human circulation and negatively associated with anxiety in obese men, a population often to report comorbid anxiety.

Cerebral Processing of Emotionally Loaded Acoustic Signals by Tinnitus Patients.

This exploratory study determined the activation pattern in nonauditory brain areas in response to acoustic, emotionally positive, negative or neutral stimuli presented to tinnitus patients and control subjects. Ten patients with chronic tinnitus and without measurable hearing loss and 13 matched control subjects were included in the study and subjected to fMRI with a 1.5-tesla scanner. During the scanning procedure, acoustic stimuli of different emotional value were presented to the subjects. Statistical analyses were performed using statistical parametric mapping (SPM 99). The activation pattern induced by emotionally loaded acoustic stimuli differed significantly within and between both groups tested, depending on the kind of stimuli used. Within-group differences included the limbic system, prefrontal regions, temporal association cortices and striatal regions. Tinnitus patients had a pronounced involvement of limbic regions involved in the processing of chimes (positive stimulus) and neutral words (neutral stimulus), strongly suggesting improperly functioning inhibitory mechanisms that were functioning well in the control subjects. This study supports the hypothesis about the existence of a tinnitus-specific brain network. Such a network could respond to any acoustic stimuli by activating limbic areas involved in stress reactivity and emotional processing and by reducing activation of areas responsible for attention and acoustic filtering (thalamus, frontal regions), possibly reinforcing negative effects of tinnitus.

Introduction of DRG-based reimbursement in inpatient psychosomatics--an examination of cost homogeneity and cost predictors in the treatment of patients with eating disorders.

OBJECTIVE: Various western countries are focusing on the introduction of reimbursement based on diagnosis-related groups (DRG) in inpatient mental health. The aim of this study was to analyze if psychosomatic inpatients treated for eating disorders could be reimbursed by a common per diem rate. METHODS: Inclusion criteria for patient selection (n=256) were (1) a main diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder-related obesity (OB), (2) minimum length of hospital stay of 2 days, (3) and treatment at Charité Universitaetsmedizin Berlin, Germany during the years 2006-2009. Cost calculation was executed from the hospital's perspective, mainly using micro-costing. Generalized linear models with Gamma error distribution and log link function were estimated with per diem costs as dependent variable, clinical and patient variables as well as treatment year as independent variables. RESULTS: Mean costs/case for AN amounted to 5,251€, 95% CI [4407-6095], for BN to 3,265€, 95% CI [2921-3610] and for OB to 3,722€, 95% CI [4407-6095]. Mean costs/day over all patients amounted to 208€, 95% CI [198-218]. The diagnosis AN predicted higher costs in comparison to OB (p=.0009). A co-morbid personality disorder (p=.0442), every one-unit increase in BMI in OB patients (p=.0256), every one-unit decrease in BMI in AN patients (p=.0002) and every additional life year in BN patients (p=.0455) predicted increased costs. CONCLUSION: We see a need for refinements to take into account considerable variations in treatment costs between patients with eating disorders due to diagnosis, BMI, co-morbid personality disorder and age.

Sulfated cholecystokinin-8 activates phospho-mTOR immunoreactive neurons of the paraventricular nucleus in rats.

The serin/threonin-kinase, mammalian target of rapamycin (mTOR) was detected in the arcuate nucleus (ARC) and paraventricular nucleus of the hypothalamus (PVN) and suggested to play a role in the integration of satiety signals. Since cholecystokinin (CCK) plays a role in the short-term inhibition of food intake and induces c-Fos in PVN neurons, the aim was to determine whether intraperitoneally injected CCK-8S affects the neuronal activity in cells immunoreactive for phospho-mTOR in the PVN. Ad libitum fed male Sprague-Dawley rats received 6 or 10 µg/kg CCK-8S or 0.15M NaCl ip (n=4/group). The number of c-Fos-immunoreactive (ir) neurons was assessed in the PVN, ARC and in the nucleus of the solitary tract (NTS). CCK-8S increased the number of c-Fos-ir neurons in the PVN (6 µg: 103 ± 13 vs. 10 µg: 165 ± 14 neurons/section; p<0.05) compared to vehicle treated rats (4 ± 1, p<0.05), but not in the ARC. CCK-8S also dose-dependently increased the number of c-Fos neurons in the NTS. Staining for phospho-mTOR and c-Fos in the PVN showed a dose-dependent increase of activated phospho-mTOR neurons (17 ± 3 vs. 38 ± 2 neurons/section; p<0.05), while no activated phospho-mTOR neurons were observed in the vehicle group. Triple staining in the PVN showed activation of phospho-mTOR neurons co-localized with oxytocin, corresponding to 9.8 ± 3.6% and 19.5 ± 3.3% of oxytocin neurons respectively. Our observations indicate that peripheral CCK-8S activates phospho-mTOR neurons in the PVN and suggest that phospho-mTOR plays a role in the mediation of CCK-8S's anorexigenic effects.

Depression, mood, stress, and Th1/Th2 immune balance in primary breast cancer patients undergoing classical massage therapy.

PURPOSE: Cancer patients frequently suffer from psychological comorbidities such as depression and elevated stress. Previous studies could demonstrate that cancer patients benefit from massage therapy on the physical and psychological level. This pilot study investigates the effects of massage on depression, mood, perceived stress, and the Th1/Th2 ratio in breast cancer patients. METHODS: Thirty-four breast cancer patients were randomly assigned to a massage group (n=17) and a control group (n=17). Patients of the massage group received two 30-min classical massages per week for 5 weeks. At baseline, at the end of the intervention period, and 6 weeks after the end of intervention, patients of both groups completed the Perceived Stress Questionnaire (PSQ), the Patient Health Questionnaire (PHQ), and the Berlin Mood Questionnaire (BFS) and blood was withdrawn for determining cytokine concentrations and the Th1/Th2 ratio. RESULTS: Twenty-nine patients were included in the statistical analysis. Depression (PHQ) and anxious depression (BSF) were significantly reduced immediately after massage compared to the control group. Stress (PSQ) and elevated mood (BSF) did not show significant alterations after massage therapy. Changes of cytokine concentrations and Th1/Th2 ratio were insignificant as well, although there was a slight shift towards Th1 in the massage group over time. CONCLUSIONS: Massage therapy is an efficient treatment for reducing depression in breast cancer patients. Insignificant results concerning immunological parameters, stress, and mood indicate that further research is needed to determine psychological and immunological changes under massage therapy.

The efficacy of classical massage on stress perception and cortisol following primary treatment of breast cancer.

To investigate the efficacy of classical massage on stress perception and mood disturbances, 34 women diagnosed with primary breast cancer were randomized into an intervention or control group. For a period of 5 weeks, the intervention group (n = 17) received biweekly 30-min classical massages. The control group (n = 17) received no additional treatment to their routine health care. The Perceived Stress Questionnaire (PSQ) and the Berlin Mood Questionnaire (BSF) were used and the patients' blood was collected at baseline (T1), at the end of the intervention period (T2), and 6 weeks after T2 (T3). Compared with control group, women in the intervention group reported significantly lower mood disturbances, especially for anger (p = 0.048), anxious depression (p = 0.03) at T2, and tiredness at T3 (p = 0.01). No group differences were found in PSQ scales, cortisol and serotonin concentrations at T2 and T3. However, perceived stress and cortisol serum levels (p = 0.03) were significantly reduced after massage therapy (T2) compared with baseline in the intervention group. Further research is needed to validate our findings.

Long-term improvement in tinnitus after modified tinnitus retraining therapy enhanced by a variety of psychological approaches.

This work evaluates an enhanced tinnitus retraining therapy (TRT) for patients with chronic tinnitus based on different group therapeutic interventions in a day hospital setting. Therapy for chronic tinnitus is intended to improve the way patients cope with tinnitus by learning how to reduce tinnitus-induced impairments. Short-term and long-term changes in stress variables and tinnitus-related distress were investigated using 3 psychometric instruments. Patients received 7 consecutive days of a multidisciplinary therapy at the Charité University Hospital in Berlin. The data were assessed before and after therapy, either immediately or after 3, 6 or 12 months. As a control, we used scores of tinnitus patients from the waiting list, and compared these to the scores of the therapy group 3 months after the end of treatment. The main factors of the modified TRT were Jacobson's progressive muscle relaxation, physiotherapy, education via lectures and training of selective attention, as well as changes of appraisal, mental attitude and behavior towards tinnitus. The therapy resulted in a significant reduction in both short-term and long-term tinnitus-related distress and psychometric stress variables, with the latter being more reduced in patients with higher initial scores. Moreover, our study revealed differences in psychometric parameters concerning duration of tinnitus, age and gender, which may explain the different outcomes of therapy. The outpatient setting enables the patients to test, practice and transfer strategies into their everyday life.

Axis I comorbidity and psychopathologic correlates of autodestructive syndromes.

OBJECTIVE: Nonsuicidal deliberate self-harm and factitious disorders have been proposed as subtypes within the autodestructive behavior spectrum, basically differing in the issue of concealment. Aims are to determine Axis I diagnoses and psychopathologic correlates of open self-harmers and patients diagnosed with factitious disorders. METHODS: One hundred ninety-four psychosomatic medicine inpatients participated. Assessment included the structured World Health Organization Composite International Diagnostic Interview (computerized version) and self-report questionnaires for anxiety, depression, perceived stress, and personal coping resources. RESULTS: Thirty-seven patients identified with self-destructive behavior were matched with 37 patients without such behavior. Overt self-harmers (n = 18) were more frequently diagnosed with anxiety, depressive, substance abuse/dependence, or eating disorders and reported more stress than factitious disorder patients (n = 19) or those without self-destructive behavior. Patients with factitious disorder exhibited lower Axis I comorbidity and less psychopathology than patients without self-harm behavior. CONCLUSIONS: Regarding psychopathologic assessment, contrary to open self-harmers, factitious disorder patients appear strikingly inconspicuous.

Is desacyl ghrelin a modulator of food intake?

Desacyl ghrelin is produced in the gastric mucosa and plasma by deacylation of ghrelin. It occurs in considerably larger amounts than ghrelin in various regions in the organisms of rats and mice. It exerts biological activities in vitro as different as stimulating adipogenesis or inhibiting glucose output in hepatocytes. In fasted rats, desacyl ghrelin levels decreased under catabolic metabolic conditions and in mice, high desacyl ghrelin concentrations went along with decreased food intake. These observations suggest an influence of the peptide on food intake and energy homeostasis. Behavioral studies led to controversial results, but several suggest an anorexigenic effect. Studies on desacyl ghrelin-induced modulation of food intake indicate the involvement of central nervous pathways, since it is said to cross the blood-brain barrier and to induce increased neuronal activity hypothalamic nuclei. It is likely to be involved in the regulation of the synthesis of anorexigenic hypothalamic mediators. Quite possibly, there might be means of interaction between desacyl ghrelin and its supposable precursor ghrelin.

Massage therapy reduces physical discomfort and improves mood disturbances in women with breast cancer.

BACKGROUND. A randomized controlled trial was conducted to investigate the efficacy of classical massage treatment in reducing breast cancer-related symptoms and in improving mood disturbances. METHODS. Women diagnosed with primary breast cancer were randomized into an intervention group and a control group. For a period of 5 weeks, the intervention group received bi-weekly 30-min classical massages in the back and head-neck areas. The control group received no additional treatment to their routine healthcare. To evaluate treatment efficacy, the following validated questionnaires were administrated at baseline (T1), at the end of the intervention (T2), and at a followup at 11 weeks (T3): the Short Form-8 Health Survey, the European Organization of Research and Treatment of Cancer quality of life questionnaire breast module (EORTC QLQ-BR23), the Giessen Complaints Inventory (GBB), and the Berlin Mood Questionnaire (BSF). RESULTS. Eighty-six eligible women (mean age: 59 years) were enrolled in the study. A significantly higher reduction of physical discomfort was found in the intervention group compared with the control group at T2 (p=0.001) and at T3 (p=0.038). A decrease in fatigue was also observed. Women in the intervention group reported significantly lower mood disturbances at T2 (p<0.01) but not at T3. The effect of treatment on mood disturbances was significantly higher if a patient was treated continuously by the same masseur. CONCLUSION. Classical massage seems to be an effective adjuvant treatment for reducing physical discomfort and fatigue, and improving mood disturbances in women with early stage breast cancer.

Functioning and validity of a Computerized Adaptive Test to measure anxiety (A-CAT).

BACKGROUND: The aim of this study was to evaluate the Computerized Adaptive Test to measure anxiety (A-CAT), a patient-reported outcome questionnaire that uses computerized adaptive testing to measure anxiety. METHODS: The A-CAT builds on an item bank of 50 items that has been built using conventional item analyses and item response theory analyses. The A-CAT was administered on Personal Digital Assistants to n=357 patients diagnosed and treated at the department of Psychosomatic Medicine and Psychotherapy, Charité Berlin, Germany. For validation purposes, two subgroups of patients (n=110 and 125) answered the A-CAT along with established anxiety and depression questionnaires. RESULTS: The A-CAT was fast to complete (on average in 2 min, 38 s) and a precise item response theory based CAT score (reliability>.9) could be estimated after 4-41 items. On average, the CAT displayed 6 items (SD=4.2). Convergent validity of the A-CAT was supported by correlations to existing tools (Hospital Anxiety and Depression Scale-A, Beck Anxiety Inventory, Berliner Stimmungs-Fragebogen A/D, and State Trait Anxiety Inventory: r=.56-.66); discriminant validity between diagnostic groups was higher for the A-CAT than for other anxiety measures. CONCLUSIONS: The German A-CAT is an efficient, reliable, and valid tool for assessing anxiety in patients suffering from anxiety disorders and other conditions with significant potential for initial assessment and long-term treatment monitoring. Future research directions are to explore content balancing of the item selection algorithm of the CAT, to norm the tool to a healthy sample, and to develop practical cutoff scores.

Peripheral obestatin has no effect on feeding behavior and brain Fos expression in rodents.

Obestatin is produced in the stomach from proghrelin by post-translational cleavage. The initial report claimed anorexigenic effects of obestatin in mice. Contrasting studies indicated no effect of obestatin on food intake (FI). We investigated influences of metabolic state (fed/fasted), environmental factors (dark/light phase) and brain Fos response to intraperitoneal (ip) obestatin in rats, and used the protocol from the original study assessing obestatin effects in mice. FI was determined in male rats injected ip before onset of dark or light phase, with obestatin (1 or 5 micromol/kg), CCK8S (3.5 nmol/kg) or 0.15 M NaCl, after fasting (16 h, n=8/group) or ad libitum (n=10-14/group) food intake. Fos expression in hypothalamic and brainstem nuclei was examined in freely fed rats 90 min after obestatin (5 micromol/kg), CCK8S (1.75 nmol/kg) or 0.15 M NaCl (n=4/group). Additionally, fasted mice were injected ip with obestatin (1 micromol/kg) or urocortin 1 (2 nmol/kg) 15 min before food presentation. No effect on FI was observed after obestatin administration during the light and dark phase under both metabolic conditions while CCK8S reduced FI irrespectively of the conditions. The number of Fos positive neurons was not modified by obestatin while CCK8S increased Fos expression in selective brain nuclei. Obestatin did not influence the refeeding response to a fast in mice, while urocortin was effective. Therefore, peripheral obestatin has no effect on FI under various experimental conditions and did not induce Fos in relevant central neuronal circuitries modulating feeding in rodents.

[DRGs and daily rates of pay in psychosomatics: 2002-2005]. / DRGs und Pflegesätze in der Psychosomatik: 2002-2005.

OBJECTIVES: Over the last years the use of diagnosis-related groups (G-DRG) was introduced into most areas of the German health care system, which led to changed compensation for departments outside the G-DRG system as well. We evaluated the development of revenues in 17 different psychosomatic departments over the last three years. METHODS: Our analyses were based on official daily rates for each of the clinics included. If daily rates changed within one year, we used the average daily rate for that year. RESULTS: Together all departments provided 547 in-patient beds for the treatment of acute psychosomatic patients. With 85% occupancy all departments would achieve a revenue of 62.5 million euro in 2005, two million euro less than three years previously. Due to the introduction of the German DRG system their average income was reduced by approx. 3%. The loss was greater for psychosomatic departments at larger hospitals, which have a higher percentage of departments included in the G-DRG system. CONCLUSIONS: The introduction of the G-DRG system leads to reduced revenues for departments outside the G-DRG system, while performance was expected to remain at the same level and costs have increased. Thus, to ensure the spectrum of psychosomatic medicine as it is today, it has become increasingly important to demonstrate the real costs of treatment to political decision makers.

Antonovsky's Sense of Coherence in psychosomatic patients - a contribution to construct validation.

OBJECTIVE: The objective of the present study is to contribute towards the validation of the SOC (Sense of Coherence) construct on the basis of data from psychosomatic patients. METHOD: The study included a total of 1403 patients treated as out-patients or in consultations in the Clinic for Psychosomatic Medicine at the Charité University of Medicine, Berlin, between July 2002 and October 2005. Correlations were tested between the sense of coherence (SOC-L9), sociodemographic variables and the following psychometric instruments: Patient Health Questionnaire (PHQ), Brief COPE, Questionnaire on Self-Efficacy, Optimism and Pessimism (SWOP-K9) and Perceived Stress Questionnaire (PSQ-20). RESULTS: Associations were found between sense of coherence and age, but not with gender. In addition, high sense of coherence was correlated with high self-efficacy, optimism, subjective physical well-being and favourable coping strategies as well as with low perceived stress. CONCLUSION: The results contribute to the validation of the SOC construct. Future investigations should include longitudinal studies of the precise association between sense of coherence and other psychological variables.

Upregulation of tumor necrosis factor-alpha by stress and substance p in a murine model of allergic airway inflammation.

OBJECTIVE: Clinical observation has suggested that stress and asthma morbidity are associated, though underlying mechanisms are not clearly understood. After having established a mouse model of stress-exacerbated allergic airway inflammation, we demonstrated a stress-mediating role for neurokinin-1 receptor, the main substance P (SP) receptor. Here, our aim was to investigate the influence of stress or exogenously applied SP on airway inflammation and on the local cytokine production of immune cells. METHODS: BALB/c mice were systemically sensitized to ovalbumin (OVA) and repeatedly challenged with OVA aerosol. Sound stress was applied to the animals for 24 h, starting with the first airway challenge. Alternatively, one group of non-stressed mice received intranasal SP before airway challenges. Cell numbers were determined in bronchoalveolar lavage (BAL) fluid. Leukocytes from mediastinal lymph nodes were analyzed by flow cytometry to determine the percentages of T cells producing interleukin-4, interferon-gamma and tumor necrosis factor-alpha. RESULTS: In BAL fluids of stressed or SP-treated animals, significantly higher total cell counts were found compared to non-stressed mice. In lymph nodes, the percentage of TNF-alpha-positive T cells was higher in stressed mice and mice after application of SP. In contrast, the influence of stress did not increase the percentages of interferon-gamma-positive CD3+ cells, meanwhile the application of SP increased the percentages of T cells positive for this cytokine. CONCLUSION: Our data provide further evidence for a stress-mediating neuroimmunological pathway that, putatively via SP, is able to influence the composition of immune cells in different compartments of allergic airway inflammation.

Cerebral processing of auditory stimuli in patients with irritable bowel syndrome.

AIM: To determine by brain functional magnetic resonance imaging (fMRI) whether cerebral processing of non-visceral stimuli is altered in irritable bowel syndrome (IBS) patients compared with healthy subjects. To circumvent spinal viscerosomatic convergence mechanisms, we used auditory stimulation, and to identify a possible influence of psychological factors the stimuli differed in their emotional quality. METHODS: In 8 IBS patients and 8 controls, fMRI measurements were performed using a block design of 4 auditory stimuli of different emotional quality (pleasant sounds of chimes, unpleasant peep (2000 Hz), neutral words, and emotional words). A gradient echo T2*-weighted sequence was used for the functional scans. Statistical maps were constructed using the general linear model. RESULTS: To emotional auditory stimuli, IBS patients relative to controls responded with stronger deactivations in a greater variety of emotional processing regions, while the response patterns, unlike in controls, did not differentiate between distressing or pleasant sounds. To neutral auditory stimuli, by contrast, only IBS patients responded with large significant activations. CONCLUSION: Altered cerebral response patterns to auditory stimuli in emotional stimulus-processing regions suggest that altered sensory processing in IBS may not be specific for visceral sensation, but might reflect generalized changes in emotional sensitivity and affective reactivity, possibly associated with the psychological comorbidity often found in IBS patients.

[Standardized diagnosing: computer-assisted (CIDI) diagnoses compared to clinically-judged diagnoses in a psychosomatic setting]. / Standardisierte Diagnosefindung: Computergestützte (CIDI)--versus klinische Diagnosestellungen an einer psychosomatischen Stichprobe.

BACKGROUND: Within the past two decades, there has been an increasing trend towards the use of empirically-based, standardized instruments to diagnose mental disorders. The purpose of this study was to investigate the congruence between clinically-derived and standardized computerized diagnoses using the Composite International Diagnostic Interview (CIDI) in a psychosomatic setting. PATIENTS AND METHODS: N = 230 inpatients treated at the Department of Psychosomatic Medicine, Charité Berlin, were diagnosed for mental disorders by experienced clinicians and by the CIDI according to the diagnostic criteria of ICD-10 and DSM-IV. RESULTS: Congruence between computerized and clinically-derived diagnoses for all mental disorders was fair to poor (kappa = 0.0 - 0.33). The diagnostic congruence of somatoform (F45), anxiety (F40 - 41), depressive (F32 - 34), eating (F50) and dissociative disorders (F44) and disorders due to psychoactive substance use (F10 - 19) was fairly low (kappa = 0.19 - 0.33). Diagnostic congruence of diagnoses of reactions to severe stress (F43) and obsessive compulsive disorders (F42) was particularly poor (kappa = 0.0 - 0.01). CONCLUSION: Overall diagnostic congruence between computerized and clinical diagnostics was unsatisfactory. Thus, the validity of computer-assisted standardized interviews - like the CIDI - is questionable in a psychosomatic setting.

The Perceived Stress Questionnaire (PSQ) reconsidered: validation and reference values from different clinical and healthy adult samples.

OBJECTIVE: The aim was to translate, revise, and standardize the Perceived Stress Questionnaire (PSQ) by Levenstein et al. (1993) in German. The instrument assesses subjectively experienced stress independent of a specific and objective occasion. METHODS: Exploratory factor analyses and a revision of the scale content were carried out on a sample of 650 subjects (Psychosomatic Medicine patients, women after delivery, women after miscarriage, and students). Confirmatory analyses and examination of structural stability across subgroups were carried out on a second sample of 1,808 subjects (psychosomatic, tinnitus, inflammatory bowel disease patients, pregnant women, healthy adults) using linear structural equation modeling and multisample analyses. External validation included immunological measures in women who had suffered a miscarriage. RESULTS: Four factors (worries, tension, joy, demands) emerged, with 5 items each, as compared with the 30 items of the original PSQ. The factor structure was confirmed on the second sample. Multisample analyses yielded a fair structural stability across groups. Reliability values were satisfactory. Findings suggest that three scales represent internal stress reactions, whereas the scale "demands" relates to perceived external stressors. Significant and meaningful differences between groups indicate differential validity. A higher degree of certain immunological imbalances after miscarriage (presumably linked to pregnancy loss) was found in those women who had a higher stress score. Sensitivity to change was demonstrated in two different treatment samples. CONCLUSION: We propose the revised PSQ as a valid and economic tool for stress research. The overall score permits comparison with results from earlier studies using the original instrument.