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Primary and secondary processes are the foundational axes of the Freudian mental apparatus: one horizontally as a tendency to associate, the primary process, and one vertically as the ability for perspective taking, the secondary process. Primary process mentation is not only supposed to be dominant in the unconscious but also, for example, in dreams. The present study tests the hypothesis that the mental activity during REM-sleep has more characteristics of the primary process, while during non-REM-sleep more secondary process operations take place. Because the solving of a rebus requires the ability to non-contexually condensate the literal reading of single stimuli into a new one, rebus solving is a primary process operation by excellence. In a replication of the dream-rebus study of Shevrin and Fisher (1967), a rebus, which consisted of an image of a comb (German: "Kamm") and an image of a raft (German: "Floß"), resulting in the German rebus word "kampflos" (Engl.: without a struggle), was flashed subliminally (at 1 ms) to 20 participants before going to sleep. Upon consecutive awakenings participants were asked for a dream report, free associations and an image description. Based on objective association norms, there were significantly more conceptual associations referring to Kamm and Floß indexing secondary process mentation when subjects were awakened from non-REM sleep as compared to REM-awakenings. There were not significantly more rebus associations referring to kampflos indexing primary process mentation when awakened from REM-sleep as compared to non-REM awakenings. However, when the associations were scored on the basis of each subject's individual norms, there was a rebus effect with more idiosyncratic rebus associations in awakenings after REM than after non-REM-sleep. Our results support the general idea that REM-sleep is characterized by primary process thinking, while non-REM-sleep mentation follows the rules of the secondary process.

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Obesity and depression are prevalent complications during pregnancy and associated with severe health risks for the mother and the child. The co-occurrence of both conditions may lead to a particular high-risk group. This review provides a systematic overview of the association between pre-pregnancy obesity and antenatal or postnatal depression. We conducted a systematic electronic literature search for English language articles published between January 1990 and March 2017. Inclusion criteria were (a) adult pregnant women, (b) women with pre-pregnancy obesity and normal weight controls, (c) definition of obesity according to the IOM 1990/2009 criteria, (d) established depression measure, and (e) report on the association between pre-pregnancy obesity and antenatal or postnatal depression. Fourteen (eight prospective (PS), six cross-sectional (CS)) studies were included. One study reported data from a large community-based sample, and one reported cross-national data. Of 13 studies examining pre-pregnancy obesity and antenatal depression, 9 found a higher risk or higher levels of antenatal depression among women with obesity relative to normal weight (6 PS, 3 CS), while 4 studies found no association (2 PS, 2 CS). Of four studies examining pre-pregnancy obesity and postnatal depression, two studies found a positive association (two PS), one study (CS) reported different findings for different obesity classes, and one study found none (PS). The findings suggest that women with obesity are especially vulnerable to antenatal depression. There is a need to develop appropriate screening routines and targeted interventions to mitigate negative health consequences for the mother and the child. Research addressing the association between obesity and postnatal depression is too limited to draw solid conclusions. Results are mainly based on selective samples, and there is a need for further high-quality prospective studies examining the association between pre-pregnancy obesity and antenatal and postnatal depression.

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BACKGROUND: Adaption to the loss of a loved one due to suicide can be complicated by feelings of guilt, shame, responsibility, rejection, and stigmatization. Therefore people bereaved by suicide have an increased risk for developing complicated grief which is related to negative physical and mental disorders and an increased risk for suicidal behavior. Grief interventions are needed for this vulnerable population. The aim of this systematic review was to provide an overview of the current state of evidence concerning the effectiveness of interventions that focus on grief for people bereaved by suicide. METHODS: We conducted a systematic literature search using PubMed, Web of Science, and PsycINFO for articles published up until November 2016. Relevant papers were identified and methodological quality was assessed by independent raters. A narrative synthesis was conducted. RESULTS: Seven intervention studies met the inclusion criteria. Two interventions were based on cognitive-behavioral approaches, four consisted of bereavement groups, and one utilized writing therapy. As five of the seven interventions were effective in reducing grief intensity on at least one outcome measure, there is some evidence that they are beneficial. Bereavement groups tend to be effective in lowering the intensity of uncomplicated grief, as are writing interventions in lowering suicide-specific aspects of grief. Cognitive-behavioral programs were helpful for a subpopulation of people who had high levels of suicidal ideation. LIMITATION: On average, methodological quality was low so the evidence for benefits is not robust. The stability of treatment effects could not be determined as follow-up assessments are rare. Generalizability is limited due to homogeneous enrollments of mainly female, white, middle-aged individuals. CONCLUSIONS: People bereaved by suicide are especially vulnerable to developing complicated grief. Therefore, grief therapies should be adapted to and evaluated in this population. Prevention of complicated grief may be successful in populations of high risk individuals.

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Binge-eating disorder (BED) is a prevalent health condition associated with obesity. Few people with BED receive appropriate treatment. Personal barriers include shame, fear of stigma, geographic distance to mental health services, and long wait-lists. The aims of this study were to examine the efficacy of an Internet-based cognitive-behavioral intervention for adults with threshold BED (DSM-IV) and to examine the stability of treatment effects over 12months. Participants were randomly assigned to a 16-week Internet-based cognitive-behavioral intervention (n=69) or a wait-list condition (n=70). Binge-eating frequency and eating disorder psychopathology were measured with the Eating Disorder Examination-Questionnaire and the Eating Disorder Examination administered over the telephone. Additionally, body weight and body mass index, depression, and anxiety were assessed before and immediately after treatment. Three-, 6-, and 12-month follow-up data were recorded in the treatment group. Immediately after the treatment the number of binge-eating episodes showed significant improvement (d=1.02, between group) in the treatment group relative to the wait-list condition. The treatment group had also significantly reduced symptoms of all eating psychopathology outcomes relative to the wait-list condition (0.82≤d≤1.11). In the treatment group significant improvement was still observed for all measures 1year after the intervention relative to pretreatment levels. The Internet-based intervention proved to be efficacious, significantly reducing the number of binge-eating episodes and eating disorder pathology long term. Low-threshold e-health interventions should be further evaluated to improve treatment access for patients suffering from BED.

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Pre-pregnancy overweight and obesity is associated with poor health outcomes for the mother and the child. General population studies suggest that childhood maltreatment is associated with obesity in adulthood. The aim of our study was to examine the association between pre-pregnancy overweight and obesity and a history of childhood abuse or neglect including different stages of severity of abuse and neglect. Three hundred twenty-six normal weight, overweight, or obese pregnant women reported demographic data, height and weight, and general psychological distress at 18-22 weeks of gestation. Childhood maltreatment was assessed using the Childhood Trauma Questionnaire. Associations were examined using logistic regression analyses and a reference group of normal weight women. Fifty percent reported a history of abuse or neglect. After adjusting for age, education, income, marital status, and the number of previous children, pre-pregnancy overweight and obesity were strongly associated with severe physical abuse (overweight: OR = 8.33, 95% CI 1.48-47.03; obesity: OR = 6.31, 95% CI 1.06-37.60). Women with severe physical neglect (OR = 4.25, 95% CI 1.23-14.74) were at increased risk of pregnancy overweight. We found a dose-response relationship between physical abuse and pre-pregnancy overweight and obesity. Whereas other studies report an association between childhood maltreatment and pre-pregnancy obesity, this is the first study that found an association between childhood maltreatment and pre-pregnancy overweight. Considering the severe health risks of pre-pregnancy overweight and obesity and the long-term consequences of childhood maltreatment, affected women constitute a subgroup with special needs in prenatal care. Further research is needed to improve the understanding of the underlying mechanisms.

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OBJECTIVE: This review is to provide a first overview about prevalences and associations of forms of child maltreatment in binge eating disorder (BED). METHODS: Systematic literature search in PubMed and Web of Science in December 2013. Terms considered were "binge eating disorder" AND "child* maltreatment", "child* abuse", "child* sexual abuse", "child* emotional abuse", "child* physical abuse", "child* emotional neglect" as well as "child* physical neglect". Inclusion criteria were studies published between 1990 and 2013, publications in English or German, adult patients, studies that considered patients with full DSM criteria for BED, and studies that reported prevalences of forms of child maltreatment. RESULTS: Eight studies out of 366 met criteria. Child maltreatment rates in BED were more than two times higher than in representative samples, but they were similar to psychiatric comparisons. Up to 83 % of patients with BED reported at least one form of child maltreatment. There were associations to psychiatric comorbidity, but not to gender, obesity and specific features of the eating behaviour. CONCLUSION: Child maltreatment is very prevalent among BED. Its contribution to the development and the maintenance of BED is not understood yet.

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OBJECTIVE: Findings about the association between working alliance and therapy outcome in Internet-based treatments are contradictory. Evidence for the working alliance in Internet-based treatment for Binge Eating Disorder is still missing and can help to elucidate this question. METHODS AND RESULTS: In an Internet-based cognitive-behavioral intervention, working alliance (WAI-S, mid n = 59; post n = 49) and eating disorder symptoms (EDE-Q, n = 49) as therapy outcome were assessed. A positive working alliance was reported by study participants. Working alliance had significant correlations with and EDE-Q-scales but not with binge eating episodes. CONCLUSIONS: Our study refers to the important role working alliance has for therapy outcome.

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BACKGROUND: The loss of a child during pregnancy causes significant psychological distress for many women and their partners, and may lead to long-lasting psychiatric disorders. Internet-based interventions using exposure techniques and cognitive restructuring have proved effective for posttraumatic stress disorder (PTSD) and prolonged grief. This study compared the effects of an Internet-based intervention for parents after prenatal loss with a waiting list condition (WLC). METHODS: The Impact of Event Scale - Revised assessed symptoms of PTSD; the Inventory of Complicated Grief and the Brief Symptom Inventory assessed depression, anxiety, and general mental health. The 228 participants (92% female) were randomly allocated to a treatment group (TG; n = 115) or a WLC group (n = 113). The TG received a 5-week cognitive behavioral intervention including (1) self-confrontation, (2) cognitive restructuring, and (3) social sharing. RESULTS: The TG showed significantly reduced symptoms of posttraumatic stress, prolonged grief, depression, and anxiety relative to the WLC control group. Intention-to-treat analysis revealed treatment effects of between d = 0.84 and d = 1.02 for posttraumatic stress and prolonged grief from pre- to posttreatment time points. Further significant improvement in all symptoms of PTSD and prolonged grief was found from the posttreatment evaluation to the 12-month follow-up. The attrition rate of 14% was relatively low. CONCLUSIONS: The Internet-based intervention proved to be a feasible and cost-effective treatment, reducing symptoms of posttraumatic stress, grief, depression, anxiety, and general mental health after pregnancy loss. Low-threshold e-health interventions should be further evaluated and implemented routinely to improve psychological support after pregnancy loss.

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AIMS: This study aims to investigate sleep quality and the subjective dream experience in alcohol-dependent patients during withdrawal and abstinence compared with healthy controls. METHODS: Thirty-seven patients with alcohol dependency and 35 healthy control subjects were asked to fill in several questionnaires and to give information about their subjective sleep and dream experiences. Twelve patients participated in a follow-up interview 4 weeks later. RESULTS: Sleep quality is impaired in alcohol-dependent patients during detoxication, and the subjective dream experience is more negatively toned compared with healthy controls. Both sleep quality and dream experience improves slightly after 4 weeks of abstinence. Patients with alcohol dependency during withdrawal and abstinence dream significantly more often about alcohol. However, none of the abstinent alcohol-dependent patients dreamed about alcohol during withdrawal. CONCLUSIONS: This study shows that the subjective sleep and dream quality is strongly impaired in patients with alcohol dependency. Differences in the dream experience between alcohol-dependent patients and healthy controls are in accordance with the continuity hypotheses of dreaming. The hypothesis of dreaming about alcohol as a compensatory effect, however, could not be confirmed.

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