Herbert Fliege

University Medical Center Hamburg - Eppendorf, Hamburg, Hamburg, Germany

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Publications (66)147.4 Total impact

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    ABSTRACT: Computerized adaptive testing (CAT) based on Item Response Theory, (IRT) offers an efficient way for accurate measurement of patient reported outcomes. The efficiency lies within a minimal response burden and a high measurement precision over a broad measurement range. The objective of the study was to evaluate and compare the responsiveness of CATs measuring anxiety, depression, and stress reaction to standard static self-assessment tools. Longitudinal data of n=595 psychosomatic inpatients were analyzed for evaluating retest-reliability and sensitivity to change of the CATs compared to static measures (GAD-7, PHQ-9, and PSQ) using correlational and ANOVA statistics. The study hypothesized that CATs are at least as retest-reliable and as sensitive to change as static tools. The three CATs show a low burden for patients, administering on average 5-7 (±2-6SD) items with similar retest-reliability compared to the static tools applied (A-CAT: r=.78 vs. GAD-7: r=.75, D-CAT: r=.71 vs. PHQ-9: r=.75, S-CAT: r=.80 vs. PSQworries scale: r=.80). The CATs were overall as sensitive to change as the static tools (Cohen׳s d ranged between .19 and .69). This is a monocenter, observational, longitudinal study without external clinical criteria; thus generalization to other settings may be limited. The tested CATs belong to the first generation of CATs being used in daily routine for more than a decade. They are as retest reliable and sensitive to change as static tools. Newer CATs may provide further practical advantages. Copyright © 2014 Elsevier B.V. All rights reserved.
    Journal of Affective Disorders 11/2014; DOI:10.1016/j.jad.2014.10.063 · 3.38 Impact Factor
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    ABSTRACT: Many questionnaires assessing depressive symptoms are available. Most of these questionnaires are constructed based on classical test theory, making comparisons of individual scores difficult. Item response theory (IRT) allows the comparison of scores from different instruments. In this study, the impact of IRT-based cross-calibration methods on the results of a treatment outcome study was evaluated using 2 instruments. Data collected during admission and discharge procedures from 1066 inpatients in 2 psychosomatic clinics using different depression measures were analyzed. To achieve comparability across the applied depression measures, we used an IRT-based conversion table to transform scores from one instrument's scale to the other. Latent trait values were also estimated using different instruments in each clinic. We compared these methods to the traditional approach of using the same instrument in both clinics and examined their effects on the statistical analyses. There was no substantial change in the interpretation of the study results when different instruments were used. However, F values, P values, and effect sizes in the analysis of variance changed significantly. This might be attributed to differences in the content or measurement properties of the instruments. Interestingly, no difference was observed between use of transformed sum scores and latent trait values. IRT cross-calibration methods are a convenient way to enhance the comparability of questionnaire data in applied clinical settings but seem not to be able to overcome differences in measurement properties of the instruments. As these differences can lead to biased results, there is a need for further research into more advanced techniques.
    Medical care 04/2012; 50(4):320-6. DOI:10.1097/MLR.0b013e31822945b4 · 3.23 Impact Factor
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    A. Riedl · J. Maass · A. Ahnis · A. Stengel · H. Mo?nnikes · B.F. Klapp · H. Fliege ·

    Current Concepts in Colonic Disorders, 01/2012; , ISBN: 978-953-307-957-8
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    ABSTRACT: The Narcissism Inventory (NI) is a frequently used German inventory for measuring narcissism in clinical settings; an additional short version (NI-90) also exists. Psychometric properties of the NI-90 scales were examined in clinical and non-clinical adolescent samples. Two adolescent samples were assessed with the NI-90: a non-clinical sample (n = 439, mean age ± SD = 15.05 ± 1.77 years) and a clinical sample (n = 235, 18.26 ± 0.77 years). Confirmatory factor analysis and principle component analysis were used to scrutinize the structure of the scales. Multiple regression analysis was used to predict the scores on two scales (helpless self; negative body self). This study revealed heterogeneity in the NI-90 scales, which in turn explains the wide range seen in Cronbach's α (from 0.53 to 0.93). The postulated 4-factor structure could not be replicated in both samples. Multiple regression analysis revealed that personality disorder did not significantly predict negative body self or helpless self scores, whereas eating, mood, as well as somatoform and conversion disorders did. One NI-90 scale (greedy for praise and reassurance) showed sufficient psychometric quality for the measurement of narcissism in both samples. Based on the results, the authors recommend revising the NI-90. Items that may be useful for measuring aspects related to affective and body image complaints are presented. The greedy for praise and reassurance scale may be valuable for measuring features of 'overt' narcissism.
    Psychopathology 01/2012; 45(1):53-60. DOI:10.1159/000328579 · 2.08 Impact Factor
  • H Felix Fischer · Karin Tritt · Burghard F Klapp · Herbert Fliege ·
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    ABSTRACT: A wide range of questionnaires for measuring depression are available. Item Response Theory models can help to evaluate the questionnaires exceeding the boundaries of Classical Test Theory and provide an opportunity to equate the questionnaires. In this study after checking for unidimensionality, a General Partial Credit Model was applied to data from two different depression scales [Patient Health Questionnaire (PHQ-9) and ICD-10-Symptom Rating (ISR)] obtained in clinical settings from a consecutive sample, including 4517 observations from a total of 2999 inpatients and outpatients of a psychosomatic clinic. The precision of each questionnaire was compared and the model was used to transform scores based on the assumed underlying latent trait. Both instruments were constructed to measure the same construct and their estimates of depression severity are highly correlated. Our analysis showed that the predicted scores provided by the conversion tables are similar to the observed scores in a validation sample. The PHQ-9 and ISR depression scales measure depression severity across a broad range with similar precision. While the PHQ-9 shows advantages in measuring low or high depression severity, the ISR is more parsimonious and also suitable for clinical purposes. Furthermore, the equation tables derived in this study enhance the comparability of studies using either one of the instruments, but due to substantial statistical spread the comparison of individual scores is imprecise.
    12/2011; 20(4):203-14. DOI:10.1002/mpr.350
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    ABSTRACT: Assessment of the retest-reliability and sensitivity to change of the ICD-10-Symptom-Rating (ISR) is provided. The ISR was filled out repeatedly by a non-clinical as well as different samples of psychosomatic patients. Between the two measurements either no or an integrated psychosomatic treatment took place. During the treatment free phase a high degree of stability of the test scores was expected, whereas a significant improvement of test scores was expected for the respective scales over the treatment phase. The retest-reliability for the individual scales ranges from 0.70 to 0.94. Between admission to a psychosomatic treatment and discharge significant differences were found for all scales. The retest-reliability showed satisfactory results comparable to similar, symptom-oriented instruments. Furthermore, the instruments reproduces symptomatic changes consistently and is - from our point of view - suitable for the assessment of change.
    PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie 03/2011; 61(3-4):162-9. · 1.02 Impact Factor

  • PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie 08/2010; 60(08):307-315. DOI:10.1055/s-0029-1214419 · 1.02 Impact Factor

  • Gastroenterology 05/2010; 138(5). DOI:10.1016/S0016-5085(10)63272-6 · 16.72 Impact Factor

  • PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie 03/2010; 60(08). DOI:10.1055/s-0030-1249683 · 1.02 Impact Factor
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    I Daig · S Burkert · H F Fischer · T Kienast · B F Klapp · H Fliege ·
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    ABSTRACT: Narcissism is seen as a normal but heterogeneously formed personality variable, ranging from 'grandiosity-exhibitionism' to 'vulnerability-sensitivity'. This article reports the development and factorial validation of a short version of a narcissism inventory. The sample includes data of 4,509 consecutive psychosomatic inpatients. The overall sample was divided in 2 equally sized randomized subsamples. One sample (n = 2,262) was used for exploratory factor analysis (principal component analysis). The other sample (n = 2,265) was used for confirmatory tests of the model fit of the newly built NI-20 version, and to analyze the model fit separately for men and women using structural equation modeling with AMOS software. The short version (NI-20) consists of 20 items, with items representing almost all of the original 18 subscales and 4 second-order dimensions. The NI-20 possesses properties similar to the NI-90, with a considerable gain in test economy. The 4-factor structure of the NI-20 was confirmed, and reaches good fit indices. The NI-20 is an economical instrument with acceptable psychometric characteristics that reflects the heterogeneous aspects of narcissism. A methodological limitation is that the interactions between sociodemographic variables were not included as potential predictors.
    Psychopathology 02/2010; 43(3):150-8. DOI:10.1159/000288636 · 2.08 Impact Factor
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    Isolde Daig · Burghard F. Klapp · Herbert Fliege ·
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    ABSTRACT: Narcissism can be seen along a continuum of adjustment with well-defended narcissism on the adjusted end, and poorly-defended narcissism on the maladjusted end. Poorly-defended narcissism is associated with negative emotions, and somatic preoccupations. The present study investigated whether aspects of poorly-defended narcissism can be changed during hospital treatment and if the change predicts therapy outcome. Data from 1442 psychosomatic in-patients (70% women, mean age 40.1years) at admission and discharge were analyzed. Narcissism, mood and quality of life were assessed with standardized instruments. Patients with somatoform, anxiety, depressive or adjustment disorders differed significantly in narcissistic aspects. During inpatient treatment, narcissistic aspects decreased, and mood and quality of life increased. Changes in threatened self were associated with an improvement on all mood dimensions. Psychosomatic hospital treatment can help patients with poorly-defended narcissism to regulate aspects of threatened self with subsequent positive impact on mood and quality of life.
    Journal of Psychopathology and Behavioral Assessment 12/2009; 31(4):368-377. DOI:10.1007/s10862-008-9122-0 · 1.55 Impact Factor
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    ABSTRACT: Patients' ideas about the nature, cause, and treatment of their illnesses are part of the complex process of coping with illness. To date, limited research on subjective theories of illness in patients with irritable bowel syndrome (IBS) has been performed. The aim of the study was to investigate patients' subjective theories of illness and how these are related to clinical and psychological outcome criteria, in particular IBS symptom severity and quality of life. Eighty-eight patients with IBS, as defined by Rome III criteria, were administered a battery of questionnaires to collect the following data: sociodemographic variables, subjective theories of illness (Subjektive Krankheitstheorien, Cause Questionnaire), anxiety (Hospital Anxiety and Depression Scale), depression (Beck Depression Inventory), quality of life (SF-12), and IBS symptoms (Questionnaire for Gastrointestinal Symptoms). Almost all patients reported theories of illness reflecting their subjective causal assumptions. The most frequently mentioned causal factors were physical illness, intrapsychic factors, and stress. Patients with mainly somatic attributions had higher IBS symptoms scores (P<.05) and reduced physical quality of life. Intrapsychic attributions were associated with reduced mental quality of life and enhanced physical quality of life (P<.01). All correlations were independent of gender, age, and irritable bowel subgroups. Subjective theories of illness can have significant implications for IBS symptom severity, as well as for physical and mental quality of life.
    Journal of psychosomatic research 11/2009; 67(5):449-55. DOI:10.1016/j.jpsychores.2009.02.001 · 2.74 Impact Factor
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    ABSTRACT: 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. 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. 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. Regarding psychopathologic assessment, contrary to open self-harmers, factitious disorder patients appear strikingly inconspicuous.
    Comprehensive psychiatry 07/2009; 50(4):327-34. DOI:10.1016/j.comppsych.2008.09.008 · 2.25 Impact Factor
  • Herbert Fliege · Jeong-Ran Lee · Anne Grimm · Burghard F Klapp ·
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    ABSTRACT: Deliberate self-harm behavior--without suicidal intent--is a serious health problem and may be studied as a clinical phenomenon in its own right. Empirical studies of sociodemographic and psychological correlates and risk factors are systematically reviewed. We searched Medline, PsycINFO, PSYNDEX (German psychological literature), and reference lists. We targeted self-induced bodily harm without conscious suicidal intent. Studies on suicidal behavior or self-poisoning were only included if they also assessed nonsuicidal self-harm. Fifty-nine original studies met the criteria. Deliberate self-harm may occur at all ages, yet adolescents and young adults are at a higher risk. Evidence on gender is complex. Only 5 studies realize a prospective design (6 months to 10 years) and test predictors. The majority use cross-sectional and retrospective methods. No longitudinal study (separately) examines new incidence. Evidence of correlates encompasses distal/proximal, person/environment, and state/trait factors. Many studies report associations between current self-harm behavior and a history of childhood sexual abuse. Adolescent and adult self-harmers experience more frequent and more negative emotions, such as anxiety, depression, and aggressiveness, than persons who do not self-harm. Two studies yield specific interactions between childhood trauma and current traits and states such as low emotional expressivity, low self-esteem, and dissociation with respect to a vulnerability to self-harm. Evidence of distal, biographical stressors is fairly strong. Proximal stressors have rarely been investigated; protective factors, hardly at all. Despite many findings of correlates, the data do not yet justify terming them risk factors. Longitudinal studies are needed.
    Journal of psychosomatic research 07/2009; 66(6):477-93. DOI:10.1016/j.jpsychores.2008.10.013 · 2.74 Impact Factor
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    ABSTRACT: The ICD-10-Symptom-Rating (ISR) is a self-rating questionnaire for patients. According to its conceptualization, the instrument was developed to closely represent the syndrome structure of the ICD-10 while assessing the extent of psychological distress an individual suffers from. The results of different factor analyses testing the postulated syndrome structure as well as item and scale characteristics are reported here. Data was collected from a consecutive sample of 1 057 psychosomatic patients of the University Hospital Charité Berlin. Evaluation of the dimensional structure of the questionnaire included exploratory and confirmatory factor analyses each computed with a randomized half of the sample. Multi-Sample-Analyses with different subgroups of the sample were performed to test the stability of the factor structure. The individual factors were constituted by the postulated syndrome units of the ICD-10 involving a high and uniform distribution of accounted variance. They also proved themselves satisfactorily stable over the different subsamples. The scales showed a high degree of internal consistency with relatively small gender and age effects, while psychological disorders had a large effect on the means of the scales. Taking a perspective of test theory, the ICD-10-Symptom-Rating is in accordance with the syndrome structure of the ICD-10 and suitable for the assessment of psychological symptoms. Other aspects pertaining to the reliability and validity of the ISR remain to be proven in future research.
    PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie 05/2009; 60(8):307-15. · 1.02 Impact Factor
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    ABSTRACT: This study aimed to develop and evaluate a first computerized adaptive test (CAT) for the measurement of stress perception (Stress-CAT), in terms of the two dimensions: exposure to stress and stress reaction. Item response theory modeling was performed using a two-parameter model (Generalized Partial Credit Model). The evaluation of the Stress-CAT comprised a simulation study and real clinical application. A total of 1,092 psychosomatic patients (N1) were studied. Two hundred simulees (N2) were generated for a simulated response data set. Then the Stress-CAT was given to n=116 inpatients, (N3) together with established stress questionnaires as validity criteria. The final banks included n=38 stress exposure items and n=31 stress reaction items. In the first simulation study, CAT scores could be estimated with a high measurement precision (SE<0.32; rho>0.90) using 7.0+/-2.3 (M+/-SD) stress reaction items and 11.6+/-1.7 stress exposure items. The second simulation study reanalyzed real patients data (N1) and showed an average use of items of 5.6+/-2.1 for the dimension stress reaction and 10.0+/-4.9 for the dimension stress exposure. Convergent validity showed significantly high correlations. The Stress-CAT is short and precise, potentially lowering the response burden of patients in clinical decision making.
    Journal of clinical epidemiology 03/2009; 62(3):278-87, 287.e1-3. DOI:10.1016/j.jclinepi.2008.03.003 · 3.42 Impact Factor
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    ABSTRACT: In the past, a German Computerized Adaptive Test, based on Item Response Theory (IRT), was developed for purposes of assessing the construct depression [Computer-adaptive test for depression (D-CAT)]. This study aims at testing the feasibility and validity of the real computer-adaptive application.The D-CAT, supplied by a bank of 64 items, was administered on personal digital assistants (PDAs) to 423 consecutive patients suffering from psychosomatic and other medical conditions (78 with depression). Items were adaptively administered until a predetermined reliability (r > or = 0.90) was attained. For validation purposes, the Hospital Anxiety and Depression Scale (HADS), the Centre for Epidemiological Studies Depression (CES-D) scale, and the Beck Depression Inventory (BDI) were administered. Another sample of 114 patients was evaluated using standardized diagnostic interviews [Composite International Diagnostic Interview (CIDI)].The D-CAT was quickly completed (mean 74 seconds), well accepted by the patients and reliable after an average administration of only six items. In 95% of the cases, 10 items or less were needed for a reliable score estimate. Correlations between the D-CAT and the HADS, CES-D, and BDI ranged between r = 0.68 and r = 0.77. The D-CAT distinguished between diagnostic groups as well as established questionnaires do.The D-CAT proved an efficient, well accepted and reliable tool. Discriminative power was comparable to other depression measures, whereby the CAT is shorter and more precise. Item usage raises questions of balancing the item selection for content in the future.
    International Journal of Methods in Psychiatric Research 03/2009; 18(1):23-36. DOI:10.1002/mpr.274 · 3.76 Impact Factor
  • F Fischer · K Tritt · H Fliege · BF Klapp ·

    PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie 02/2009; 59(02). DOI:10.1055/s-0029-1208193 · 1.02 Impact Factor
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    ABSTRACT: 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. 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. 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. 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.
    Depression and Anxiety 12/2008; 25(12):E182-94. DOI:10.1002/da.20482 · 4.41 Impact Factor
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    ABSTRACT: Asthma is a chronic disease defined by airway inflammation, increased airway hyperresponsiveness and episodes of airway obstruction. Although there are abundant clinical and experimental data showing that stress may worsen asthma, the mechanisms linking stress to asthma are not well understood. By inducing a pro-inflammatory cytokine milieu, stress might enhance airway inflammation in bronchial asthma. We therefore investigated the correlation of stress perception and the cytokine profile of circulating lymphocytes in humans. Allergic asthmatic patients and healthy controls were evaluated for perceived level of stress, demographic and lung function data. Whole blood cells were obtained and stimulated by mitogen to assess intracellular IL-4, IFN-gamma and TNF-alpha by flow cytometry. Neurotrophins nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) were measured in serum. Asthmatic patients showed significantly higher percentages of TNF-alpha-producing T cells than healthy controls. Only in asthmatic patients was stress perception correlated with percentages of TNF-alpha-producing T cells and serum BDNF levels, while forced expiratory volume in 1 s (% predicted) was negatively correlated to BDNF. The results of our study support the hypothesis that stress deteriorates bronchial asthma by inducing a pro-inflammatory cytokine profile in allergic asthmatics. Stress management might provide a supplement therapy of allergic asthma.
    Clinical & Experimental Allergy 03/2008; 38(2):283-90. DOI:10.1111/j.1365-2222.2007.02899.x · 4.77 Impact Factor

Publication Stats

1k Citations
147.40 Total Impact Points


  • 2012
    • University Medical Center Hamburg - Eppendorf
      Hamburg, Hamburg, Germany
  • 2004-2012
    • Charité Universitätsmedizin Berlin
      • Medical Department, Division of Psychosomatic Medicine
      Berlín, Berlin, Germany
  • 2006
    • Vrije Universiteit Brussel
      Bruxelles, Brussels Capital Region, Belgium
  • 2000-2005
    • Humboldt-Universität zu Berlin
      • Clinical Psychology Research Unit
      Berlín, Berlin, Germany