DEVELOPMENT AND VALIDATION OF A VULNERABILITY QUESTIONNAIRE (VFB) FOR PREDICTING MENTAL DISORDERS

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1 DEVELOPMENT AND VALIDATION OF A VULNERABILITY QUESTIONNAIRE (VFB) FOR PREDICTING MENTAL DISORDERS Ulrich Wesemann, Antje Bühler, Peter Zimmermann, Zafarullah Ahmad, Gerd Willmund Department of Psychiatry, Psychotherapy and Psychotraumatology, German Armed Forces Hospital, Berlin, Germany Keywords: questionnaire, test development, vulnerability, mental health, prediction, mental disorder Abstract Background:The mental health problems have increased in recent decades. A vulnerability questionnaire(vulnerabilitätsfragebogen VFB)has been developed in order to identify at-risk personnel. Methods: The questionnaire was validated on a sample of 179 male and female soldiers who served in combat units in Afghanistan and who completed the VFB before deployment. A cut-off value was determined prior to deployment and assessed in comparison to the presence of mental disorders that were identified after deployment on the basis of a clinical interview (Mini-DIPS). Results: The internal consistency of the questionnaire was acceptable (Cronbach s alpha =.73). The VFB had a sensitivity of 33.3% and a specificity of 79.5% for predicting mental disorders. Discussion: In the pre-deployment setting, the VFB on the basis of the cut-off value identified one third of the soldiers who developed a post-deployment mental disorder. A total of 20.5% of the soldiers who returned from combat duty and did not experience a mental disorder had been assessed as vulnerable prior to deployment.it is a brief instrument that enables to obtain useful information for an initial assessment of an individual s vulnerability to mental disorders. Introduction Deployments abroad have led to changes in psychological response patterns among German soldiers [1 3]. As a result, the role of mental disorders has considerably increased in military medical health care systems. Mental disorders not only cause immense personal suffering but also result in enormous economic costs related to sick leave, loss of productivity, and unfitness for service. That is a common problem, not just in the military. During the past six years, an average of more than 340 new cases of deployment-related mental conditions that classify as a disorder have been reported annually among German armed forces personnel and entered into a central database on military operations. The number of unreported cases, however, is likely to be seven times higher [4]. Different approaches have been used in order to address this problem and to predict post-deployment mental disorders [3, 5, 6]. All approaches, however, were based on characteristics that are sensitive to change, such as symptoms of depression or anxiety, sleep or quality of life before deployment. The most commonly used predictors with low sensitivity to change were age, gender, level of education, marital status, rank, number of deployments abroad, and number of days spent on deployments. Since then, no useful predictors have been identified. There are currently no studies that include more stable predictors such as personality factors or fundamental beliefs. Against this background, the objective of this study was to develop an instrument that allows vulnerability to mental disorders to be identified in the pre-deployment setting. When military personnel undergo a medical examination for fitness for foreign assignment, the instrument may help unit physicians identify vulnerable soldiers who can then receive appropriate training, education or health support. Self-report instruments have a long tradition in the military setting [7]. The VFB has been developed on the basis of current psychotherapy research with a focus on well-established aetiological behaviour therapy models [8 13]. Models that claim to be generally valid should allow users to identify both retrospectively and prospectively the [8]

2 reason why a patient develops a particular disorder at a particular time point. For this reason, the questions were designed in such a way that they do not focus on a person's current mental health conditions but assess vulnerability traits that are not restricted to specific time periods or situations. These vulnerability traits are believed to make a person either predisposed or resilient to mental disorders. Materials and Methods Test development The focus was placed on disorders with the highest prevalence in Germany and in the German armed forces, i.e. anxiety disorders, affective disorders, somatoform disorders, and substance use disorders [14]. Predictors were identified for each of these disorders and were used to formulate questions, the responses to which were coded into dichotomous items. In a retrospective preparatory study, a version with 81 questions was tested on 41 pilots and pilot cadets with symptoms of a mental or behavioural disorder or airsickness. A confirmatory factor analysis did not reveal the consistency of the four dimensions. The screeplot of an exploratory factor analysis confirmed one component of this questionnaire. A binary logistic regression analysis was performed and identified 15 questions that provided good predictors of fitness to fly [15]. These 15 questions have been isolated and are part of the new questionnaire, the VFB. The purpose of this study was to assess whether these items are also useful in a prospective study. Validation The VFB was validated on a sample of 179 combat-deployed soldiers who served with the Northern Reaction Unit (NRU) in Afghanistan from January to June The soldiers completed the VFB on a voluntary basis after having given informed consent. Data were collected for the first time approximately one week before deployment during pre-deployment training and for the second time three to six months post-deployment. The VFB, as a predictive instrument, was used only at the first time point. After their deployment abroad, the soldiers were assessed for mental disorders by experienced unit psychologists on the basis of the short version of the Diagnostic Interview for Mental Disorders (Mini-DIPS). Prior to the interview, the unit psychologists had been trained for one week by experienced and licensed clinical psychologists. After training, interrater reliability of the interview was 95%. At the second time point, the soldiers completed a number of questionnaires described below. Pre-deployment VFB scores (higher or lower than the cut-off) were compared with the results obtained on the basis of the post-deployment interview (presence or absence of mental disorders). Furthermore, we assessed whether the VFB can predict the results of the other questionnaires. Questionnaires Depression: Depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 corresponds to the depression module of the Patient Health Questionnaire (PHQ-D) developed by Spitzer, Kroenke and Williams [16]. The questionnaire uses the nine diagnostic criteria for depression laid out in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV), which are rated by respondents on a 4-point scale. Possible scores are 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day). Sensitivity ranges from 78% to 88%, specificity from 88% to 98% [17, 18]. Stress: Stress was assessed using the stress module of the PHQ-D. This questionnaire is a psychodiagnostic instrument that measures psychosocial stress factors on the basis of ten questions. Possible responses are "not bothered at all" (a score of 0), "bothered a little" (a score of 1) and "bothered a lot" (a score of 2) [19]. Somatic symptoms: The severity of somatic symptoms was measured by the Patient Health Questionnaire-15 (PHQ-15), which too is part of the PHQ-D. The PHQ-15 comprises 15 somatic symptoms corresponding to the most common somatic complaints of outpatients and the most important DSM-IV criteria for somatoform disorders. The questionnaire asks respondents to rate how much they have been bothered by each somatic symptom during the past four weeks. Possible responses are "not bothered" (0), "bothered a little" (1) and "bothered a lot" (2). The internal reliability of the PHQ-15 is.80 (Cronbach s alpha) [20]. The questionnaire has a sensitivity of 78% and a specificity of 71% for a DSM-IV somatoform diagnosis [21]. [9]

3 Quality of life: Quality of life was assessed using the World Health Organization Quality of Life (WHOQOL- BREF) questionnaire. The WHOQOL-BREF is an abbreviated 26-item version of the WHOQOL-100 and is an internationally accepted instrument for assessing subjective quality of life. It is used for persons with physical or mental diseases as well as for healthy persons. Respondents are asked to rate the 26 items on a 5-point Likert scale. The questionnaire consists of four domains, i.e. physical quality of life, psychological quality of life, social relationships, and environment. Cronbach's alphas for the subscales of the WHOQOL-BREF range between.57 and.88. The questionnaire discriminates well between persons with health impairments and healthy persons and between persons with mental and physical diseases [22]. Resilience: Resilience was assessed using the Resilience Scale (RS) developed by Wagnild and Young [23]. The abbreviated 11-item German version of the RS (RS-11) was used to quantify the resilience of the soldiers who took part in this study. Cronbach's alpha is.92. Correlation between the RS-11 and the longer 25-item version was reported to be high (r =.94) [24]. Interview The short version of the Diagnostic Interview for Mental Disorders (Mini-DIPS) was used for clinical diagnosis [25]. The Mini-DIPS is a structured clinical interview that was designed in accordance with DSM-IV and ICD-10 criteria. It is an economical instrument and was used in this study as the gold standard for the detection of mental disorders. The sensitivity of the Mini-DIPS has been reported as good and its reliability and validity as sufficiently good [26]. The unit psychologists who conducted the interviews had been trained by experienced and licensed clinical psychologists. After training, interrater reliability was 95%. Sample The sample consisted of 179 male and female combat-deployed soldiers. The participants were between 18 and 48 years of age. Their mean age was 26.3 years (median: 20 years, standard deviation: 5.11). There were 12 (7%) officers, 41 (24%) non-commissioned officers and 123 (71%) other ranks. Three participants did not indicate their military rank. Since only one female soldier took part in the study, a gender-specific analysis was not performed. This sample is not representative of the German armed forces but of combat forces that are deployed to operational settings. [4] Statistical analysis Cronbach's alpha was used to evaluate internal consistency and an exploratory factor analysis (EFA) with factor rotation was used to examine the structure of the VFB. A cut-off value was identified on the basis of a receiver operating characteristic (ROC) curve in order to assess predictive validity. The sensitivity and specificity of the VFB for predicting mental disorders was calculated. External validity: A linear regression analysis was performed in order to investigate whether a pre-deployment VFB can predict the results of the aforementioned questionnaires. An alpha error adjustment was performed using the Bonferroni correction. All analyses were performed with SPSS, version 21. Results The drop-out rate was 16.8% (n = 30). Cronbach's alpha was.73 and the structure could be confirmed by EFA. VFB total scores ranged from 0 to 13, with a mean of 5.0 and a standard deviation of The cut-off that was determined on the basis of the ROC curve was 8 and corresponds to the mean plus one standard deviation. The area under the curve (AUC) was The VFB had a sensitivity of 33.3% and a specificity of 79.5% for predicting mental disorders (Mini-DIPS). [10]

4 Figure 1: ROC curve to predict the sensitivity and specificity of mental disorders Sensi tivity 1-Specificity A linear regression analysis was performed in order to determine external validity. The (pre-deployment) VFB total score was the regressor (independent variable), the other (post-deployment) questionnaire scores were the regressands (dependent variables). Table 1: Linear regression analysis of pre-deployment VFB scores on post-deployment PHQ subscale scores Adjusted R² df numerator df denominator F Level of significance PHQ depression <.001*** PHQ somatic <.001*** PHQ stress <.001*** Bonferroni-adjusted p-value: *** p<.001 The VFB was found to explain between 23.3% (somatic symptoms) and 28.2% (stress) of the variance in PHQ scores after a deployment abroad. A further linear regression analysis was conducted in order to assess whether a pre-deployment VFB can predict post-deployment resilience. The VFB explained 11% of the variance, with F(1, 142) = 18.6, p <.001 and adjusted R² =.11. A linear regression analysis was also performed in order to investigate whether a pre-deployment VFB can predict post-deployment quality of life. [11]

5 Table 2: Linear regression analysis of pre-deployment VFB total scores on post-deployment WHOQOL subscale scores Adjusted df df denominator F Level of R² numerator significance WHOQOL physical <.001*** WHOQOL psychological <.001*** WHOQOL social <.001*** WHOQOL environment <.001** WHOQOL total <.001*** Bonferroni-adjusted p-value: ** p<.01; *** p<.001 Discussion Internal reliability was assessed using Cronbach's alpha and can be described as acceptable on the basis of commonly accepted rules (Cronbach's alpha =.73). In the pre-deployment setting, the VFB identified one third of soldiers who had a post-deployment mental disorder and who had undergone a pre-deployment medical examination for fitness for foreign assignment that had not suggested the presence of a health impairment. At the same time, 20.5% of the soldiers who did not experience a post-deployment mental disorder had been assessed as vulnerable prior to deployment. Particular attention was paid to obtaining as high a specificity as possible in order to minimise concerns about possible stigmatisation. Specificity was very good since vulnerable soldiers do not necessarily develop a disorder within a short period of time. Furthermore, vulnerability does not always lead to the development of a disorder later in life. Many soldiers are vulnerable but are able to cope successfully with stressful events during deployment or even experience personal growth. For this reason, the VFB is not intended for use as a tool to select soldiers for deployments abroad. It can, however, help vulnerable soldiers receive appropriate training more rapidly. In spite of its even lower predictive sensitivity, the VFB is the first questionnaire that can measure vulnerability to mental disorders. The long intervals between the first and the second measurement (6 12 months) and the results obtained suggest that the VFB assesses personality traits. The VFB is a brief instrument that, combined with other screening tools, enables unit physicians to obtain useful information for an initial assessment of an individual s vulnerability to mental disorders prior to a comprehensive health assessment. The ability of the VFB to predict the clinical scales of the PHQ was very good (p <.001). The VFB explained more than 20% of the variance in the different PHQ scores and thus confirmed external validity at least in the subclinical setting. The VFB, however, explained only 11% of the variance in resilience scores. This may be explained by the fact that the resilience questionnaire assesses protective factors. The VFB focuses on vulnerability and addresses protective factors only rudimentarily. Accordingly, the VFB explained 15 25% of the variance in the quality of life questionnaire, which includes both deficits and resources. The drop-out rate at the second time of measurement was unusually low [3] and reflects the high motivation of the soldiers. A similar questionnaire is not available in other armed forces. In the United States, heart rate variability has been described as the best predictor of post-traumatic stress disorders [27]. For the German armed forces, only Zimmermann et al. (unpublished study) have thus far been able to develop a value-based index that can predict the development of depressive symptoms after a deployment abroad. Limitations: The questionnaire was tested on a sample that was not representative of the German armed forces in terms of age, rank and gender. Since the VFB was completed only in the pre-deployment setting, test-retest reliability was not assessed. In addition, any conclusions on mental changes in the soldiers must be drawn with caution since no explicit pre-deployment diagnostic assessments of mental disorders were made. It should be noted, however, that soldiers are deployed only if they meet all necessary health requirements including mental stability. [12]

6 Conclusion The VFB is a brief and effective instrument for unit physicians who conduct fitness for foreign assignment medical evaluations. It provides useful information for an initial assessment of an individual s potential vulnerability to mental disorders on the basis of personality traits. Soldiers who are identified as being potentially vulnerable can be assessed more specifically and can receive appropriate pre-deployment training. A five-point Likert scale (1 = very rarely, 2 = occasionally, 3 = about half the time, 4 = often, 5 = almost always) may be used instead of dichotomous responses in order to improve the predictive validity of the VFB. The responses to the item 'family member with a substance use disorder' should, however, remain dichotomous. Further studies should then investigate the effect of these changes on statistical measures. A revised version of the VFB is already available and is being tested. This new version is designed to improve not only the prediction of vulnerability but also internal consistency. In a next step, the VFB will also be tested for civilians. References 1. Wesemann U, Zimmermann P, Bühler A, Willmund G: Gender Differences in Hostility and Aggression Among Military Healthcare Personnel after Deployment. J Womens Health 2017; 26(10): Wesemann U, Kowalski JT, Jacobsen T, et al.: Evaluation of a technology-based adaptive learning and prevention program for stress response a randomized controlled trial. MilMed 2016; 181(8): Wesemann U, Schura R, Kowalski JT, et al.: Context of deployment and tobacco dependence among soldiers; Gesu 2015; 511: Wittchen HU, Schönfeld S, Kirschbaum C, et al.: Traumatic experiences and posttraumatic stress disorder in soldiers following deployment abroad: how big is the hidden problem? Deutsches Ärzteblatt International 2012; 109 (35 36): Danker-Hopfe H, Sauter C, Kowalski JT, et al.: Sleep quality of German soldiers before, during and after deployment in Afghanistan a prospective study. JSleepRes 2017; 26(3): Wesemann U, Zimmermann PL, Mahnke M, Butler O, Polk S, Willmund GD: Burdens of operational forces after a terrorist attack in Berlin. Occup Med 2017; in print 7. Woodworth RS: Examination of emotional fitness for warfare. Psychological Bulletin 1919; 16: Fuhr K, Hautzinger M, Meyer TD: Implicit motives and cognitive variables: specific links to vulnerability for unipolar or bipolar disorder. Psychiatry Res. 2014; 215(1): Ehlers A, Margraf J: Etiological models of panic medical and biological aspects. In Baker R (Ed.) Panic Disorder: Research and Therapy. London: Wiley, Dyck IR, Phillips KA, Warshaw MG, et al.: Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia. J Pers Disord. 2001; 15: Hiller W, Rief W, Elefant S, et al.: Dysfunktionale Kognitionen bei Patienten mit Somatisierungssyndrom. Z Klin Psychol. 1997; 26: Rief W, Hiller W, Margraf J: Cognitive Aspects of Hypochondriasis and the Somatization Syndrome. J Abnorm Psychol. 1998; 107: Lindenmeyer J: Lieber schlau als blau. Informationen zur Entstehung und Behandlung von Alkohol- und Medikamentenabhängigkeit. 6. Aufl. Weinheim: Psychologie Verlags Union, Trautmann S, Goodwin L, Höfler M, Jacobi F, Strehle J, Zimmermann P, Wittchen HU: Prevalence and severity of mental disorders in military personnel: a standardised comparison with civilians. Epidemiol Psychiatr Sci. 2017; 26(2): Wesemann U: Development of a questionnaire for vulnerability detection and the application of health promoting measures. 2 nd Annual International Conference on Cognitive and Behavioral Psychology 2013; 2: 5, Singapore 16. Kroenke K, Spitzer RL, Williams J: The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine 2002; 64: Henkel V, Mergl R, Kohnen R et al.: Identifying depression in primary care: A comparison of different methods. British Medical Journal 2003; 326: Kroenke K, Spitzer RL, Williams JB: The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine 2001; 16: [13]

7 19. Löwe B, Spitzer RL, Zipfel S: PHQ-D. Gesundheitsfragebogen für Patienten (PHQ-D). Manual Komplettversion und Kurzform. 2. Auflage; Kroenke K, Spitzer RL, Williams JB: The PHQ-15: Validity of a New Measure for Evaluating the Severity of Somatic Symptoms. Psychosom Med 2002; 64: van Ravesteijn H, Wittkampf K, Lucassen P, et al.: Detecting somatoform disorders in primary care with the PHQ-15. Ann Fam Med 2009; 7(3): Angermeyer MC, Kilian A, Matschinger H: (2000). WHOQOL. World Health Organization Quality of Life. Göttingen: Hogrefe. 23. Wagnild GM, Young HM: Development and Psychometric Evaluation of the Resilience Scale. Journal of Nursing Measurement; 1993: 1(2); Schumacher J, Leppert K, Gunzelmann T, Strauß B, Brähler E: Die Resilienzskala Ein Fragebogen zur Erfassung der psychischen Widerstandsfähigkeit als Personmerkmal. Zeitschrift für Klinische Psychologie, Psychiatrie und Psychotherapie 2005; 53: Margraf J: Mini-DIPS. Diagnostisches Kurz-Interview bei psychischen Störungen [Testmappe mit Handbuch und Interviewleitfaden]. Berlin: Springer Brickenkamp R: Handbuch psychologischer und pädagogischer Tests. Elmar Brähler, Heinz Holling, Detlev Leutner, Franz Petermann (Hrsg.). 2002: Pyne JM, Constans JI, Wiederhold MD, Gibson DP et al.: Heart rate variability: Pre-deployment predictor of post-deployment PTSD symptoms. Biol Psychol; 2016: 121(Pt A): [14]

8 Author Bibliography Dr. Ulrich Wesemann Dr. Ulrich Wesemann is a Clinical Psychologist and a Clinical Flight Psychologist. He has been Deputy Head of the Research Section for the Center for Psychiatry and Psychotraumatology at the Bundeswehr Hospital Berlin, Germany since His research interests are in the area of Occupational Mental Health, airsickness, the consequences of terrorist attacks, rampage and calamities, as well as risk and resilience factors for mental health. He does special trainings and therapies for pilots (aviators) with airsickness (kinetosis, motion sickness or travel sickness) and somatoform autonomic dysfunction. uw@ptzbw.org; info@airsickness.de Dr. Antje Bühler Dr. Antje Bühler is a Clinical and Social Psychologist. She has worked as a Military Psychologist with the German Military Police and as a Human Rights Officer with the UNDPKO/UNHCR. Since 2014 Psychologist in the Research Section for the Center for Psychiatry and Psychotraumatology at the Bundeswehr. Her current research focus is on the topics of interrogation and justice, psychology and law. anb@ptzbw.org Dr. Peter Zimmermann Dr. Peter Zimmermann is a psychiatrist. Since 2009 he is director of the Center for Psychotraumatology in the Military Hospital of the Bundeswehr in Berlin, Germany. His research interests include value-orientation, post-traumatic stress disorder, military mental health, and moral injury from armed conflict. peterzimmermann@bundeswehr.org Mr. Zafarullah Ahmad Mr. Zafarullah Ahmad is a prospective doctor. He is doing his doctorate at the Charité Berlin; his topic are test characteristic values and predictive possibilities of the above described vulnerability questionnaire (VFB). Zafarullah.Ahmad@med.uni-giessen.de [15]

9 Dr. Gerd Willmund Dr. Gerd Willmund is a psychiatrist. He is the Head of the Research Section- Psychiatry and Psychotherapy at the Bundeswehr Hospital Berlin. His research interests are in the area of biomarkers for early diagnosis of PTSD and other trauma related disorders, suicide prevention, the consequences of terrorist attacks, rampage and calamities. He coaches emergency responders and operational forces. gw@ptzbw.org [16]