The Experts below are selected from a list of 1476 Experts worldwide ranked by ideXlab platform
Rohit Varman - One of the best experts on this subject based on the ideXlab platform.
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dispossessing vulnerable consumers Derealization desubjectification and violence
Marketing Theory, 2018Co-Authors: Rohit Varman, Devi VijayAbstract:This article draws upon the work of Judith Butler to explain how violence is deployed against vulnerable consumers. It examines a site in which a commercial complex including a shopping mall is to be constructed in Ejipura, Bangalore (India), by displacing the poor from their slums. It offers insights into the mechanisms of violent dispossession that inhere liberal modes of governance of consumers. Moreover, this study attends to Derealization that desubjectifies vulnerable consumers. It further helps to comprehend why violence remains in the zone of ellipsis without any popular revulsion against it.
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Supplemental Material, Appendixfinal - Dispossessing vulnerable consumers: Derealization, desubjectification, and violence
2018Co-Authors: Rohit Varman, Devi VijayAbstract:Supplemental Material, Appendixfinal for Dispossessing vulnerable consumers: Derealization, desubjectification, and violence by Rohit Varman, and Devi Vijay in Marketing Theory
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Accumulation through Derealization: How corporate violence remains unchecked
Human Relations, 2016Co-Authors: Rohit Varman, Ismael Al-amoudiAbstract:This study examines the alleged organization of violence by Coca-Cola through a field study conducted in a village in India. It draws on the works of Judith Butler to show how subaltern groups are derealized and made into ungrievable lives through specific, yet recurrent, practices that keep violence unchecked. Many participants attempt to resist Derealization through protest activities that showcase their vulnerability. However, the firm appropriates their claims to vulnerability through a paternalistic discourse that justifies intensified violence and Derealization. This research offers insights into accumulation through Derealization and on the effects of resistance to it.
Ruth A Lanius - One of the best experts on this subject based on the ideXlab platform.
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structural brain aberrations associated with the dissociative subtype of post traumatic stress disorder
Acta Psychiatrica Scandinavica, 2016Co-Authors: Judith K Daniels, Paul Frewen, Jean Theberge, Ruth A LaniusAbstract:ObjectiveOne factor potentially contributing to the heterogeneity of previous results on structural grey matter alterations in adult participants suffering from post-traumatic stress disorder (PTSD) is the varying levels of dissociative symptomatology. The aim of this study was therefore to test whether the recently defined dissociative subtype of PTSD characterized by symptoms of depersonalization and Derealization is characterized by specific differences in volumetric brain morphology. MethodWhole-brain MRI data were acquired for 59 patients with PTSD. Voxel-based morphometry was carried out to test for group differences between patients classified as belonging (n=15) vs. not belonging (n=44) to the dissociative subtype of PTSD. The correlation between dissociation (depersonalization/Derealization) severity and grey matter volume was computed. ResultsPatients with PTSD classified as belonging to the dissociative subtype exhibited greater grey matter volume in the right precentral and fusiform gyri as well as less volume in the right inferior temporal gyrus. Greater dissociation severity was associated with greater volume in the right middle frontal gyrus. ConclusionThe results of this first whole-brain investigation of specific grey matter volume in dissociative subtype PTSD indentified structural aberrations in regions subserving the processing and regulation of emotional arousal. These might constitute characteristic biomarkers for the dissociative subtype PTSD.
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latent profile analysis and principal axis factoring of the dsm 5 dissociative subtype
European Journal of Psychotraumatology, 2015Co-Authors: Paul Frewen, Carolin Steuwe, Matthew F D Brown, Ruth A LaniusAbstract:Objective : A dissociative subtype has been recognized based on the presence of experiences of depersonalization and Derealization in relation to DSM-IV posttraumatic stress disorder (PTSD). However, the dissociative subtype has not been assessed in a community sample in relation to the revised DSM-5 PTSD criteria. Moreover, the 20-item PTSD Checklist for DSM-5 (PCL-5) currently does not assess depersonalization and Derealization. Method : We therefore evaluated two items for assessing depersonalization and Derealization in 557 participants recruited online who endorsed PTSD symptoms of at least moderate severity on the PCL-5. Results : A five-class solution identified two PTSD classes who endorsed dissociative experiences associated with either 1) severe or 2) moderate PTSD symptom severity (D-PTSD classes). Those in the severe dissociative class were particularly likely to endorse histories of childhood physical and sexual abuse. A principal axis factor analysis of the symptom list identified six latent variables: 1) Reexperiencing, 2) Emotional Numbing/Anhedonia, 3) Dissociation, 4) Negative Alterations in Cognition & Mood, 5) Avoidance, and 6) Hyperarousal. Conclusions : The present results further support the presence of a dissociative subtype within the DSM-5 criteria for PTSD. Keywords: Posttraumatic stress disorder; dissociative subtype; dissociation; trauma-related altered states of consciousness; psychological trauma Responsible Editor: Julian D. Ford, University of Connecticut Health Center, United States. For the abstract or full text in other languages, please see Supplementary files in the column to the right (under ‘Article Tools’) (Published: 1 April 2015) Citation: European Journal of Psychotraumatology 2015, 6 : 26406 - http://dx.doi.org/10.3402/ejpt.v6.26406
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dissociative disorders in dsm 5
Annual Review of Clinical Psychology, 2013Co-Authors: David Spiegel, Daphne Simeon, Eric Vermetten, Ruth A Lanius, Roberto Lewisfernandez, Matthew J FriedmanAbstract:The rationale, research literature, and proposed changes to the dissociative disorders and conversion disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are presented. Dissociative identity disorder will include reference to possession as well as identity fragmentation, to make the disorder more applicable to culturally diverse situations. Dissociative amnesia will include dissociative fugue as a subtype, since fugue is a rare disorder that always involves amnesia but does not always include confused wandering or loss of personality identity. Depersonalization disorder will include Derealization as well, since the two often co-occur. A dissociative subtype of posttraumatic stress disorder (PTSD), defined by the presence of depersonalization or Derealization in addition to other PTSD symptoms, is being recommended, based upon new epidemiological and neuroimaging evidence linking it to an early life history of adversity and a combination of frontal activation and limbic inhibition. Conversion disorder (functional neurological symptom disorder) will likely remain with the somatic symptom disorders, despite considerable dissociative comorbidity.
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evidence for a dissociative subtype of ptsd by latent profile and confirmatory factor analyses in a civilian sample
Depression and Anxiety, 2012Co-Authors: Carolin Steuwe, Ruth A Lanius, Paul A FrewenAbstract:BACKGROUND: Dissociative symptoms are increasingly recognized in individuals with posttraumatic stress disorder (PTSD). The aim of this study was to investigate the prevalence of Derealization and depersonalization symptoms via latent profile analyses (LPAs) in a civilian PTSD sample and examine the relationship between PTSD and dissociative symptoms via factor analytic methods. METHODS: A civilian sample of individuals with PTSD predominantly related to childhood abuse (n = 134) completed a diagnostic interview for PTSD and comorbid psychiatric disorders. LPAs and confirmatory factor analyses (CFAs) were performed on the severity scores for PTSD, Derealization, and depersonalization symptoms. RESULTS: LPAs extracted three groups, one of which was uniquely characterized by high Derealization and depersonalization symptoms, and accounted for 25% of the sample. Individuals in the dissociative subgroup also showed a higher number of comorbid Axis I disorders and a more significant history of childhood abuse and neglect. CFAs suggested the acceptance of a five factor solution in which dissociative symptoms are distinct from but correlate significantly with the core PTSD symptom clusters. CONCLUSIONS: The results from LPAs and CFAs are concordant with the concept of a dissociative subtype in patients with PTSD and suggest that symptoms of Derealization-depersonalization and the core symptoms of PTSD are positively correlated. Thought should be given to including a dissociative subtype of PTSD in the DSM-5. Language: en
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the dissociative subtype of posttraumatic stress disorder rationale clinical and neurobiological evidence and implications
Depression and Anxiety, 2012Co-Authors: Ruth A Lanius, Eric Vermetten, Paul A Frewen, Bethany L Brand, David SpiegelAbstract:BACKGROUND: Clinical and neurobiological evidence for a dissociative subtype of posttraumatic stress disorder (PTSD) has recently been documented. A dissociative subtype of PTSD is being considered for inclusion in the forthcoming Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) to address the symptoms of depersonalization and Derealization found among a subset of patients with PTSD. This article reviews research related to the dissociative subtype including antecedent, concurrent, and predictive validators as well as the rationale for recommending the dissociative subtype. METHODS: The relevant literature pertaining to the dissociative subtype of PTSD was reviewed. RESULTS: Latent class analyses point toward a specific subtype of PTSD consisting of symptoms of depersonalization and Derealization in both veteran and civilian samples of PTSD. Compared to individuals with PTSD, those with the dissociative subtype of PTSD also exhibit a different pattern of neurobiological response to symptom provocation as well as a differential response to current cognitive behavioral treatment designed for PTSD. CONCLUSIONS: We recommend that consideration be given to adding a dissociative subtype of PTSD in the revision of the DSM. This facilitates more accurate analysis of different phenotypes of PTSD, assist in treatment planning that is informed by considering the degree of patients' dissociativity, will improve treatment outcome, and will lead to much-needed research about the prevalence, symptomatology, neurobiology, and treatment of individuals with the dissociative subtype of PTSD. Language: en
Clemens Kirschbaum - One of the best experts on this subject based on the ideXlab platform.
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depersonalization Derealization during acute social stress in social phobia
Journal of Anxiety Disorders, 2013Co-Authors: Juergen Hoyer, David Braeuer, Stephen Crawcour, Elisabeth Klumbies, Clemens KirschbaumAbstract:The present study aimed at investigating how frequently and intensely depersonalization/Derealization symptoms occur during a stressful performance situation in social phobia patients vs. healthy controls, as well as testing hypotheses about the psychological predictors and consequences of such symptoms. N=54 patients with social phobia and N=34 control participants without mental disorders were examined prior to, during, and after a standardized social performance situation (Trier Social Stress Test, TSST). An adapted version of the Cambridge Depersonalization Scale was applied along with measures of social anxiety, depression, personality, participants' subjective appraisal, safety behaviours, and post-event processing. Depersonalization symptoms were more frequent in social phobia patients (92%) than in controls (52%). Specifically in patients, they were highly positively correlated with safety behaviours and post-event-processing, even after controlling for social anxiety. The role of depersonalization/Derealization in the maintenance of social anxiety should be more thoroughly recognized and explored.
Matthias Michal - One of the best experts on this subject based on the ideXlab platform.
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Emotion regulation strategies moderate the relationship of fatigue with depersonalization and Derealization symptoms.
Journal of Affective Disorders, 2018Co-Authors: Ana N. Tibubos, Jennifer Grammes, Manfred E. Beutel, Matthias Michal, Gabriele Schmutzer, Elmar BrählerAbstract:Abstract Background The aim of the present study was to investigate the relationships of common emotion regulation strategies (suppression and reappraisal) to self-reported fatigue and depersonalization/Derealization symptoms. Specifically, we tested the moderating effect of suppression and reappraisal on the link of fatigue with depersonalization and Derealization symptoms. Opposite effects were expected for both emotion regulation strategies assuming that cognitive reappraisal has an adaptive buffering effect, while suppression intensifies the association of fatigue and depersonalization/Derealization experiences. Methods In a representative study (N = 2524) we assessed emotion regulation strategies, fatigue, depersonalization/Derealization, distress, and demographic variables via questionnaires. 55.5% of the participants were female, mean age was 49.4 (SD = 18.2) years with age groups represented in comparable proportions. Results In line with the assumptions, moderated regression analyses revealed an interaction effect of emotion regulation strategies and fatigue. Simple slope analyses indicated a buffering effect of cognitive reappraisal on the positive relation of fatigue with depersonalization and Derealization symptoms. In contrast, suppression fosters the positive correlation of fatigue and depersonalization and Derealization experiences. Limitations Our study is limited to these two habitual emotion regulation strategies employing a cross sectional design. Conclusion Our findings provide comprehensive empirical data investigating depersonalization/Derealization symptoms from the perspective of emotion regulation research. Cognitive reappraisal might help people suffering from fatigue to prevent depersonalization and Derealization tendencies.
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a case series of 223 patients with depersonalization Derealization syndrome
BMC Psychiatry, 2016Co-Authors: Matthias Michal, Julia Adler, Jorg Wiltink, Iris Reiner, Regine Tschan, Klaus Wolfling, Sabine Weimert, Inka Tuin, Claudia Subicwrana, Manfred E. BeutelAbstract:Depersonalization-Derealization syndrome (DDS) is an underdiagnosed and underresearched clinical phenomenon. In Germany, its administrative prevalence is far below the threshold for orphan diseases, although according to epidemiological surveys the diagnosis should be comparable frequent as anorexia nervosa for instance. Against this background, we carried out a large comprehensive survey of a DDS series in a tertiary mental health center with a specialized depersonalization-Derealization clinic. To reveal differential characteristics, we compared the DDS patients, who consulted the specialized depersonalization-Derealization clinic, with a group of patients with depressive disorders without comorbid DDS from the regular outpatient clinic of the mental health center. The sample comprised 223 patients with a diagnosis of depersonalization-Derealization-syndrome and 1129 patients with a depressive disorder but without a comorbid diagnosis of DDS. DDS patients were described and compared with depressive outpatients in terms of sociodemographic characteristics, treatment history, treatment wishes, clinical symptomatology, prevailing psychosocial stressors, family history of common mental disorders and history of childhood trauma. Despite the high comorbidity of DDS patients with depressive disorders and comparable burden with symptoms of depression and anxiety, the clinical picture and course of both patient groups differed strongly. DDS patients were younger, had a significant preponderance of male sex, longer disease duration and an earlier age of onset, a higher education but were more often unemployed. They tended to show more severe functional impairment. They had higher rates of previous or current mental health care utilization. Nearly all DDS patients endorsed the wish for a symptom specific counseling and 70.7 % were interested in the internet-based treatment of their problems. DDS patients had lower levels of self-rated traumatic childhood experiences and current psychosocial stressors. However, they reported a family history of anxiety disorders more often. In consideration of the selection bias of this study, this case series supports the view that the course of the DDS tends to be long-lasting. DDS patients are severely impaired, utilizing mental health care to a high degree, which nevertheless might not meet their treatment needs, as patients strongly opt for obtaining disorder specific counseling. In view of the size of the problem, more research on the disorder, its course and its optimal treatment is urgently required.
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altered patterns of heartbeat evoked potentials in depersonalization Derealization disorder neurophysiological evidence for impaired cortical representation of bodily signals
Psychosomatic Medicine, 2015Co-Authors: Andre Schulz, Manfred E. Beutel, S Koster, Hartmut Schachinger, Claus Vogele, Silke Rost, Manfred Rauh, Matthias MichalAbstract:ABSTRACTObjectiveCore features of depersonalization/Derealization disorder (DPD) are emotional numbing and feelings of disembodiment. Although there are several neurophysiological findings supporting subjective emotional numbing, the psychobiology of disembodiment remains unclear.MethodsHeartbeat-ev
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depersonalisation Derealization clinical picture diagnostics and therapy
Zeitschrift Fur Psychosomatische Medizin Und Psychotherapie, 2009Co-Authors: Matthias Michal, Manfred E. BeutelAbstract:The present state of knowledge about depersonalization (DP) and Derealization (DR) is reviewed with respect to classification, epidemiology, etiology, and therapy. Mild and transient DP-DR are considered to be common phenomena. The prevalence of depersonalization-Derealization disorder (DP-DR-D) is estimated to be approx. 1-2% of the general population in the Western hemisphere. DP-DR-D is probably severely underdiagnosed. DP-DR-D is strongly associated with depression and anxiety disorders. It is suggested that symptoms of DP-DR indicate disease severity and negatively predict therapy outcome. Neurobiological and psychological models have shown that a disordered body schema and emotional and autonomic blunting are essential components of the disorder. Despite the frequency of DPDR and its clinical relevance, there is a considerable lack of empirical research on DP-DR with respect to the health-care situation of depersonalized patients and with regard to treatment options.
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depersonalization Derealization in the psychosomatic outpatient and consultation liaison service
Zeitschrift Fur Psychosomatische Medizin Und Psychotherapie, 2009Co-Authors: Matthias Michal, Jorg Wiltink, Claudia Subicwrana, Rudiger Zwerenz, Achim Knebel, Anke Schafer, Cornelia Nehring, Manfred E. BeutelAbstract:OBJECTIVES First, to determine the prevalence of symptoms of depersonalization (DP) and Derealization (DR) in psychosomatic consultation-liaison patients and psychosomatic outpatients; second, to examine how DP-DR contributes to differences among patients with respect to the spectrum of other diagnoses, disease severity, history of psychotherapeutic outpatient treatment and psychiatric/psychosomatic inpatient treatments as well as to self-rated distress. METHODS The sample comprises n=825 patients. In order to analyze the effects of DP-DR, the sample was divided into three subgroups of DP-DR severity: patients without symptoms of DP-DR, patients with mild DP-DR, and patients with clinical significant DP-DR. RESULTS 34.8% patients had no symptoms of DP-DR, 48.2% mild DP-DR, and 17.0% scored clinical significant DP-DR. The severity of DP-DR was associated with other indicators of self- and observer-rated disease severity as well as with greater psychosomatic and psychiatric health care use. However, after adjustment for indicators of disease severity, the significant association between the use of psychotherapeutic outpatient treatment and psychiatric or psychosomatic inpatient treatment in the medical history disappeared. CONCLUSIONS Symptoms of DP-DR are very common in psychosomatic patients. They represent an indicator of disease severity, which however is paradoxically not associated with increased use of psychotherapeutic health care.
Manfred E. Beutel - One of the best experts on this subject based on the ideXlab platform.
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Emotion regulation strategies moderate the relationship of fatigue with depersonalization and Derealization symptoms.
Journal of Affective Disorders, 2018Co-Authors: Ana N. Tibubos, Jennifer Grammes, Manfred E. Beutel, Matthias Michal, Gabriele Schmutzer, Elmar BrählerAbstract:Abstract Background The aim of the present study was to investigate the relationships of common emotion regulation strategies (suppression and reappraisal) to self-reported fatigue and depersonalization/Derealization symptoms. Specifically, we tested the moderating effect of suppression and reappraisal on the link of fatigue with depersonalization and Derealization symptoms. Opposite effects were expected for both emotion regulation strategies assuming that cognitive reappraisal has an adaptive buffering effect, while suppression intensifies the association of fatigue and depersonalization/Derealization experiences. Methods In a representative study (N = 2524) we assessed emotion regulation strategies, fatigue, depersonalization/Derealization, distress, and demographic variables via questionnaires. 55.5% of the participants were female, mean age was 49.4 (SD = 18.2) years with age groups represented in comparable proportions. Results In line with the assumptions, moderated regression analyses revealed an interaction effect of emotion regulation strategies and fatigue. Simple slope analyses indicated a buffering effect of cognitive reappraisal on the positive relation of fatigue with depersonalization and Derealization symptoms. In contrast, suppression fosters the positive correlation of fatigue and depersonalization and Derealization experiences. Limitations Our study is limited to these two habitual emotion regulation strategies employing a cross sectional design. Conclusion Our findings provide comprehensive empirical data investigating depersonalization/Derealization symptoms from the perspective of emotion regulation research. Cognitive reappraisal might help people suffering from fatigue to prevent depersonalization and Derealization tendencies.
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a case series of 223 patients with depersonalization Derealization syndrome
BMC Psychiatry, 2016Co-Authors: Matthias Michal, Julia Adler, Jorg Wiltink, Iris Reiner, Regine Tschan, Klaus Wolfling, Sabine Weimert, Inka Tuin, Claudia Subicwrana, Manfred E. BeutelAbstract:Depersonalization-Derealization syndrome (DDS) is an underdiagnosed and underresearched clinical phenomenon. In Germany, its administrative prevalence is far below the threshold for orphan diseases, although according to epidemiological surveys the diagnosis should be comparable frequent as anorexia nervosa for instance. Against this background, we carried out a large comprehensive survey of a DDS series in a tertiary mental health center with a specialized depersonalization-Derealization clinic. To reveal differential characteristics, we compared the DDS patients, who consulted the specialized depersonalization-Derealization clinic, with a group of patients with depressive disorders without comorbid DDS from the regular outpatient clinic of the mental health center. The sample comprised 223 patients with a diagnosis of depersonalization-Derealization-syndrome and 1129 patients with a depressive disorder but without a comorbid diagnosis of DDS. DDS patients were described and compared with depressive outpatients in terms of sociodemographic characteristics, treatment history, treatment wishes, clinical symptomatology, prevailing psychosocial stressors, family history of common mental disorders and history of childhood trauma. Despite the high comorbidity of DDS patients with depressive disorders and comparable burden with symptoms of depression and anxiety, the clinical picture and course of both patient groups differed strongly. DDS patients were younger, had a significant preponderance of male sex, longer disease duration and an earlier age of onset, a higher education but were more often unemployed. They tended to show more severe functional impairment. They had higher rates of previous or current mental health care utilization. Nearly all DDS patients endorsed the wish for a symptom specific counseling and 70.7 % were interested in the internet-based treatment of their problems. DDS patients had lower levels of self-rated traumatic childhood experiences and current psychosocial stressors. However, they reported a family history of anxiety disorders more often. In consideration of the selection bias of this study, this case series supports the view that the course of the DDS tends to be long-lasting. DDS patients are severely impaired, utilizing mental health care to a high degree, which nevertheless might not meet their treatment needs, as patients strongly opt for obtaining disorder specific counseling. In view of the size of the problem, more research on the disorder, its course and its optimal treatment is urgently required.
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altered patterns of heartbeat evoked potentials in depersonalization Derealization disorder neurophysiological evidence for impaired cortical representation of bodily signals
Psychosomatic Medicine, 2015Co-Authors: Andre Schulz, Manfred E. Beutel, S Koster, Hartmut Schachinger, Claus Vogele, Silke Rost, Manfred Rauh, Matthias MichalAbstract:ABSTRACTObjectiveCore features of depersonalization/Derealization disorder (DPD) are emotional numbing and feelings of disembodiment. Although there are several neurophysiological findings supporting subjective emotional numbing, the psychobiology of disembodiment remains unclear.MethodsHeartbeat-ev
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depersonalisation Derealization clinical picture diagnostics and therapy
Zeitschrift Fur Psychosomatische Medizin Und Psychotherapie, 2009Co-Authors: Matthias Michal, Manfred E. BeutelAbstract:The present state of knowledge about depersonalization (DP) and Derealization (DR) is reviewed with respect to classification, epidemiology, etiology, and therapy. Mild and transient DP-DR are considered to be common phenomena. The prevalence of depersonalization-Derealization disorder (DP-DR-D) is estimated to be approx. 1-2% of the general population in the Western hemisphere. DP-DR-D is probably severely underdiagnosed. DP-DR-D is strongly associated with depression and anxiety disorders. It is suggested that symptoms of DP-DR indicate disease severity and negatively predict therapy outcome. Neurobiological and psychological models have shown that a disordered body schema and emotional and autonomic blunting are essential components of the disorder. Despite the frequency of DPDR and its clinical relevance, there is a considerable lack of empirical research on DP-DR with respect to the health-care situation of depersonalized patients and with regard to treatment options.
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depersonalization Derealization in the psychosomatic outpatient and consultation liaison service
Zeitschrift Fur Psychosomatische Medizin Und Psychotherapie, 2009Co-Authors: Matthias Michal, Jorg Wiltink, Claudia Subicwrana, Rudiger Zwerenz, Achim Knebel, Anke Schafer, Cornelia Nehring, Manfred E. BeutelAbstract:OBJECTIVES First, to determine the prevalence of symptoms of depersonalization (DP) and Derealization (DR) in psychosomatic consultation-liaison patients and psychosomatic outpatients; second, to examine how DP-DR contributes to differences among patients with respect to the spectrum of other diagnoses, disease severity, history of psychotherapeutic outpatient treatment and psychiatric/psychosomatic inpatient treatments as well as to self-rated distress. METHODS The sample comprises n=825 patients. In order to analyze the effects of DP-DR, the sample was divided into three subgroups of DP-DR severity: patients without symptoms of DP-DR, patients with mild DP-DR, and patients with clinical significant DP-DR. RESULTS 34.8% patients had no symptoms of DP-DR, 48.2% mild DP-DR, and 17.0% scored clinical significant DP-DR. The severity of DP-DR was associated with other indicators of self- and observer-rated disease severity as well as with greater psychosomatic and psychiatric health care use. However, after adjustment for indicators of disease severity, the significant association between the use of psychotherapeutic outpatient treatment and psychiatric or psychosomatic inpatient treatment in the medical history disappeared. CONCLUSIONS Symptoms of DP-DR are very common in psychosomatic patients. They represent an indicator of disease severity, which however is paradoxically not associated with increased use of psychotherapeutic health care.