From expectation to experience
The role of symptom expectations in time-dynamic symptom perception and the factors influencing symptom expectations in patients with somatic symptom disorder
Translated title
Von Erwartung zum Erleben : die Rolle symptombezogener Erwartung bei der zeitdynamischen Wahrnehmung von somatischer Symptombelastung und Einflussfaktoren auf die symptombezogene Erwartung bei Patient:innen mit Somatischer Belastungsstörung
Publication date
2026-06-02
Document type
Dissertation
Cumulative Thesis
✅
Author
Advisor
Referee
Löwe, Bernd
Granting institution
Helmut-Schmidt-Universität/Universität der Bundeswehr Hamburg
Exam date
2026-05-26
Organisational unit
Project
SOMA.SSD
Publisher
Universitätsbibliothek der HSU/UniBw H
Part of the university bibliography
✅
File(s)
Language
English
DDC Class
150 Psychologie
Keyword
Persistent somatic symptoms
Expectation
Somatic symptom disorder
Ambulatory assessment
Abstract
Persistent somatic symptoms are common in both general and clinical populations and impose a substantial socioeconomic burden, considerable strain on healthcare systems, and marked psychological distress and functional impairment among affected individuals. Contemporary theoretical models, including cognitive and predictive-processing accounts, have highlighted symptom expectations as central mechanisms in the development and maintenance of persistent somatic symptoms. However, it remains unclear whether expectations are prospectively associated with symptom trajectories in everyday life and which factors are associated with the formation of negative expectations in clinical populations, particularly in patients with somatic symptom disorder, who experience chronic and distressing bodily complaints.
This dissertation addresses these gaps by examining the associations between expectations and the course of somatic symptoms, by experimentally manipulating symptom expectations using expectation framing strategies in (1) a healthy student sample and (2) patients with somatic symptom disorder. Furthermore, factors associated with the development of negative expectations in patients with somatic symptom disorder are investigated. In studies I and II, symptom expectations and momentary symptom severity were assessed using smartphone-based ecological momentary assessment (EMA), allowing real-time, ecologically valid insights into symptom dynamics. In Study III, cross-sectional data were analysed to examine the characteristics of symptom-related expectations and the factors associated with their formation in patients with somatic symptom disorder.
Study I, a 7-day micro-longitudinal EMA study with n = 104 university students (three assessments/day), examined the association between momentary symptom expectations, self-management experiences and experimentally induced expectation framing on somatic symptom severity. Participants were randomized to either positive or negative expectation framing conditions. Results revealed robust concurrent associations between symptom expectations and somatic symptom severity, as well as higher somatic symptom severity in participants exposed to negative framing. Time-lagged analysis showed that higher symptom expectations predicted subsequent increases in somatic symptom severity levels, indicating small-to-moderate temporal effects.
Study II investigated patients with somatic symptom disorder (N = 217) over 10 days (three assessments/day), comparing positive framing to standard information. Symptom expectations and symptom severity showed strong concurrent associations, and symptoms decreased slightly over time. More positive initial expectations were associated with faster improvements in symptom severity. In contrast to Study I, expectation framing did not significantly affect subsequent expectations or symptom trajectories, suggesting that simple framing interventions may be insufficient to alter entrenched expectations in clinical populations.
Study III, a cross-sectional investigation of N = 241 patients with somatic symptom disorder, examined the nature and determinants of symptom expectations Most patients reported negative short-term symptom expectations. Patients with more negative symptom expectations were found to experience greater somatic symptom severity, higher depression and anxiety severity, increased symptom-related distress, and higher symptom-related disability. Symptom-related disability, symptom-related distress, depression severity, somatic symptom severity, and somatic comorbidity emerged as key factors associated with the development of negative symptom expectations.
Taken together, the results support the central relevance of symptom expectations for momentary and short-term fluctuations in somatic symptom severity and identify important factors associated with the formation of negative expectations in somatic symptom disorder. While the manipulation of symptom expectations proved feasible, its effectiveness appears limited in clinical populations and likely requires more intensive or personalized intervention approaches. A key strength of this dissertation lies in the integration of experimental, micro-longitudinal, and cross-sectional designs, providing a comprehensive examination of expectations in daily life. Limitations include the cross-sectional design of Study III, precluding causal conclusions about expectation formation; sampling constraints (student population, monocentric recruitment, limited sociodemographic diversity), and potential unmeasured confounding (e.g., mood, medication), which may restrict generalizability. Nonetheless, the findings offer valuable implications for future research on persistent somatic symptoms and the development of expectation-focused treatment approaches aimed at improving clinical outcomes in future care for patients with persistent somatic symptoms.
This dissertation addresses these gaps by examining the associations between expectations and the course of somatic symptoms, by experimentally manipulating symptom expectations using expectation framing strategies in (1) a healthy student sample and (2) patients with somatic symptom disorder. Furthermore, factors associated with the development of negative expectations in patients with somatic symptom disorder are investigated. In studies I and II, symptom expectations and momentary symptom severity were assessed using smartphone-based ecological momentary assessment (EMA), allowing real-time, ecologically valid insights into symptom dynamics. In Study III, cross-sectional data were analysed to examine the characteristics of symptom-related expectations and the factors associated with their formation in patients with somatic symptom disorder.
Study I, a 7-day micro-longitudinal EMA study with n = 104 university students (three assessments/day), examined the association between momentary symptom expectations, self-management experiences and experimentally induced expectation framing on somatic symptom severity. Participants were randomized to either positive or negative expectation framing conditions. Results revealed robust concurrent associations between symptom expectations and somatic symptom severity, as well as higher somatic symptom severity in participants exposed to negative framing. Time-lagged analysis showed that higher symptom expectations predicted subsequent increases in somatic symptom severity levels, indicating small-to-moderate temporal effects.
Study II investigated patients with somatic symptom disorder (N = 217) over 10 days (three assessments/day), comparing positive framing to standard information. Symptom expectations and symptom severity showed strong concurrent associations, and symptoms decreased slightly over time. More positive initial expectations were associated with faster improvements in symptom severity. In contrast to Study I, expectation framing did not significantly affect subsequent expectations or symptom trajectories, suggesting that simple framing interventions may be insufficient to alter entrenched expectations in clinical populations.
Study III, a cross-sectional investigation of N = 241 patients with somatic symptom disorder, examined the nature and determinants of symptom expectations Most patients reported negative short-term symptom expectations. Patients with more negative symptom expectations were found to experience greater somatic symptom severity, higher depression and anxiety severity, increased symptom-related distress, and higher symptom-related disability. Symptom-related disability, symptom-related distress, depression severity, somatic symptom severity, and somatic comorbidity emerged as key factors associated with the development of negative symptom expectations.
Taken together, the results support the central relevance of symptom expectations for momentary and short-term fluctuations in somatic symptom severity and identify important factors associated with the formation of negative expectations in somatic symptom disorder. While the manipulation of symptom expectations proved feasible, its effectiveness appears limited in clinical populations and likely requires more intensive or personalized intervention approaches. A key strength of this dissertation lies in the integration of experimental, micro-longitudinal, and cross-sectional designs, providing a comprehensive examination of expectations in daily life. Limitations include the cross-sectional design of Study III, precluding causal conclusions about expectation formation; sampling constraints (student population, monocentric recruitment, limited sociodemographic diversity), and potential unmeasured confounding (e.g., mood, medication), which may restrict generalizability. Nonetheless, the findings offer valuable implications for future research on persistent somatic symptoms and the development of expectation-focused treatment approaches aimed at improving clinical outcomes in future care for patients with persistent somatic symptoms.
Version
Published version
Access right on openHSU
Open access