Tag Archives: Depression

Health Locus of Control and Psychological and Somatization Disorder in Icelandic Outpatients with Cancer: A Quantitative Study

The concept Locus of Control (LOC) appeared first in Rotter´s (1966) social learning theory and later became a central concept in the field of personality psychology (Goldzweig et al, 2016). The definition of Health Locus of Control (HLC) refers to personal health and health behaviour (Wallston, 2005), a widely accepted concept in studies of individuals’ beliefs based on past experiences in controlling health issues (Kulpa et al, 2016). According to Rotter´s theory, the patients’ tendency to regard health related events is characterized and controllable by two different forces: internal locus of control (ILC) and external locus of control (ELC). Internal reinforcement occurs when one believes that one’s behaviour is in one’s own control and that he or she is in control of his or her health, while external reinforcement is present when a person believes that his or her health status is influenced by the actions of other people (Wallston et al, 1994). The Multidimensional Health Locus of Control form C (MHLC-C), developed by Wallston and colleagues in 1994, is a condition-specific LOC scale measuring LOC for people with any medical or health related condition. It measures ILC and ELC, the latter including three subgroups (having faith in doctors, having faith in other people, and believing in chance and fate).

Studies have revealed that cancer patients with a higher ELC are significantly more often using sources of information as well as being significantly more in need for additional information than those with ILC (Keinki et al, 2016). Another study (Goldzweig et al, 2016) found a significant relationship between perceived threat of illness and depression among cancer patients reporting low levels of ILC. Findings in this study also distinguish between ILC and ELC, and the authors suggest that ILC may be more appropriate and helpful to master the cognitive perception of the threat of illness than ELC. Additionally, Marton et al (2021) found that people with a lower score in ELC (having faith in other people) were more likely to prefer an active role or collaborative role in medical decision-making. The authors suggested that it may be so that people do not fully grasp the impact that other people and doctors could have on their health.

Studies on psychological distress and somatic symptoms among patients with cancer show high levels of distress with emotional and physical problems being the main problems (Chi and Demiris, 2016; Hjörleifsdóttir et al, 2019; Peters et al, 2020). Findings in previous studies suggest that there is a need for an early identification of patients with high risk for psychological distress, and factors which may contribute to the development of depression and anxiety should be considered. These may be physical and social factors,  symptoms related to cancer and its treatment, treatment setting, and type of cancer and time since diagnosis (Zhang et al, 2015). Kulpa et al (2014) support the above-mentioned results from previous studies by showing in their study on patients with cancer that confirming that the lower is the severity of anxiety and depression, the higher is the degree of ILC.

To our best knowledge, only a few studies have considered a correlation between HLC and somatic symptoms (Basinska and Andruszkiewicz, 2012). In Zhang et al’s (2015) study on patients with cancer who were receiving chemotherapy treatment it was found that more self-efficacy meant less symptoms and less interference with daily life, but anxiety and depression were positively associated with symptom distress. However, more severe symptoms were shown to be associated with age, gender, and the stage of the disease. Gogou et al (2015) found, in a study of patients who were receiving radiotherapy treatment for their cancer, that symptom complications such as fatigue, sleeplessness and pain were significantly associated with a poor quality of life (QoL) and high levels of anxiety. Furthermore, Marijanović et al (2017) compared HLC between patients with early stage, and later stage cancer and its correlation to early attendance to hospital. Their conclusion was that HLC was not a statistically significant predictor of early admittance, neither was there an indication of a relationship between depression and time of arrival to hospital. The authors emphasise that more research is needed to make any suggestions on this construct.

From a global perspective, the incidence of cancer will continue to rise, in the year 2008 an estimated 12.7 million individuals were diagnosed with cancer and this number is bound to rise substantially by 2030 (Coleman, 2013). The incidence rate of cancer among the Icelandic population has quadrupled since registration on cancer diagnosis began in 1954, with around 1,500 individuals diagnosed on a yearly basis (Jónasson and Tryggvadóttir, 2012). Overall, the studies presented above indicate that ILC can be interpreted as having a sense of mastery and control when managing one´s own health during the disease and treatment process. In contrast, ELC can be understood as being more likely to rely on others to manage one’s own health. HLCis one of the factors that can affect people’s ability to cope with cancer and its treatment. More studies are needed on the correlation of anxiety and depression with HLC so that the severity of anxiety-depressive disorders can be reduced (Kulpa et al, 2014). Lack of research, in Iceland and globally, on HLC and how it may have an impact on how patients with cancer cope with their often-severe symptoms and its consequences, prompted this study.




The aim of this study was to investigate differences in psychological distress and HLC between cancer outpatients receiving treatment for cancer. A further aim was to describe and investigate correlation between psychological distress and HLC, severity of symptoms, and its interference with daily life. Finally, we explored factors which might contribute to psychological distress.

 Study design and setting

This descriptive cross-sectional study was conducted in three oncology outpatient clinics, two in the capital Reykjavík and surrounding communities (situated in the south of the country with 236,518 inhabitants), and one in Akureyri, which is a town serving the north and surrounding communities with 19,573 inhabitants (Statistics Iceland. Inhabitant’s overview, 2017).


Questionnaires were distributed to 300 individuals who were receiving radiotherapy or chemotherapy treatment for cancer. The sample consisted of patients (N=247) with cancer. The participants were eligible for the study if they understood and could speak Icelandic, were 18 years of age or older, and were currently receiving radiotherapy, chemotherapy or palliative therapy as a treatment for cancer.

 Study procedures

Nurses at the outpatient clinics approached potential participants for recruitment and informed them of the study. Those patients who were interested were given more detailed information including a specific information letter explaining the purpose of the study, how it would be implemented, how full confidentiality would be secured, and participants’ consent consisted in answering the questionnaire. Completed questionnaires were returned anonymously to the first researcher in a prepaid envelope. Data was gathered over a one-year period during 2016- 2017.

 Ethical issues

Ethics approval was obtained from the Icelandic Bioethics Committee according to Icelandic regulations on the scientific study of patients and in accordance with the Declaration of Helsinki.



A self-administered questionnaire consisting of four parts was used for the study: The first part included socio-demographic and disease-related information (gender, age, marital status, education, frequency of diagnosis, reason for treatment, type of treatment, and stage of disease).


The second part assessed participants’ belief in control of their own health using the MHLC-C, which was adapted for patients with existing medical conditions. This form consists of 18 items divided into four LC subscales: perception of ILC (6 items); chance (6 items); other powerful, i.e., doctors and health care professionals (3 items); and other people (3 items). The instrument measures four dimensions of MHLC, ILC, ELC (believing in chances, believing in physicians, and believing in others), rated on a six-point Likert scale (strongly disagree to strongly agree). This tool has no cut-off point, and the mean or median score is used for final evaluation (Wallston, 2005).

As stated, the notion of HLC derives from social learning theory and refers to the degree of control that people believe they possess over their personal health (Rotter, 1966; Wallston, 2005). People with high ILC are likely to believe that their personal health related outcomes are mostly determined by their own choices and actions, while those who have high ELC believe that other powerful people, such as physicians, will determine their health outcome, i.e., what happens to them depends on others’ behaviour, coincidences, fate, or luck (Rotter, 1966; Wallston, 2005). The questionnaire was translated in a forward-backward procedure according to guidelines established by the European Organisation for Research and Treatment of Cancer (EORTC) quality of life group (Kuliś et al, 2017). MHLC-C has been found to be a reliable instrument in studies in different countries on people with chronic diseases and cancer showing Cronbach alpha range from 0.79 (Thege et al, 2014), 0.74 (Ubbiali et al, 2008), and 0.90 (Mirzania et al, 2019). A permission for translating and utilizing the MHLC-C instrument was granted from the late Professor Kenneth A. Wallston. Minor alterations were done from the original version of the instrument (Wallston et al, 1994). In the present study, Cronbach’s alpha coefficient for ILC was 0.62, for ELC-chance 0.86, for ELC-physician 0.61, and for ELC-other 0.58.


The third section assessed anxiety and depression using the Icelandic version of the Hospital Anxiety and Depression Scale (HADS) (Schaaber et al, 1990). HADS has been developed and tested for its reliability in studies on patients with cancer and chronic diseases showing Cronbach alpha range from 0. 83-0,85 (Ágústsdóttir et al, 2010; Smári and Valtýsdóttir, 1997). HADS consist of 2 subscales assessing the level of anxiety (HADS-A) and symptoms of depression (HADS-D). Each subscale consists of seven items rated on a four-point Likert scale indicating symptoms during the past week. Each subscale has a possible score range of 0–21. A score of 0 to 7 for either scale is considered normal (no symptoms), a score of 8 to 10 suggests possible symptoms, and a score of 11 or higher indicates probable symptoms of either anxiety or depression for the respective subscale. The Cronbach alpha coefficient in our study for the HADS-A was 0.86 and 0.80 for the HADS-D.


Lastly, the Icelandic version of the M. D. Anderson Symptom Inventory (MDASI) was used to assess the severity of symptoms and the interference with daily living caused by these symptoms. The MDASI is a useful tool to measure symptom prevalence, severity, and interference with daily life during the last 24 hours on a scale of 0-10 with 0 being “not present” and 10 being “as bad as you can imagine.” It is well liked, easy to answer and brief (13 items), and can easily be adapted for use with any medical or health related condition. It assesses both symptom severity (pain, fatigue/tiredness), nausea, disturbed sleep, being distressed, shortness of breath, difficulty remembering, lack of appetite, feeling drowsy, dry mouth, feeling sad, vomiting and numbness or tingling). It also measures how symptoms interfere with six aspects of the patient´s daily functioning (daily activity, mood, work, relations with others, walking, and enjoyment of life) (Cleeland, 2016). MDASI has been proved to be a reliable instrument in studies in various countries (Jones et al, 2014; Hu et al, 2022; Viganò et al, 2021; Piil et al, 2020), showing Cronbach alpha range from 0.82 to 0.96. The Cronbach alpha coefficient in the present study was 0.92, 0.87 and 0.89 for the MDASI total, Interference and Symptom Severity scale, respectively. The internal consistency of the scales was established through the calculation of Cronbach alpha coefficient, with the range of values being between 0.00 and 1.00 (Altman, 1991).



Data were analysed using the Statistical Package for the Social Science (SPSS 26.0) and the Statistical Software programme Jamovi 2.2. Descriptive statistics included description of sample mean, standard deviations (SD) and percentages. The data were not normally distributed, so a Mann-Whitney U-test was used to analyse significant differences between two groups in psychological distress, LOC, somatic symptoms, and its interference with daily life. Kruskal-Wallis test was used in case the groups were more than two. Mann-Whitney U-test with a reduced p-value was used as a post hoc test to prevent the risk of finding significant differences by chance (Type I error) (Pallant, 2016). Pearson r correlation coefficient was used to analyse significant correlation between psychological distress, LOC, somatic symptoms, and its interference with daily life on a scale varying from – 1 through 0 to + 1 (Altman, 1991). In our analysis we considered that according to Cleeland (2016), when calculating the subscale score on the MDSAI, seven of the 13 core symptoms severity items and four of the six interference items will represent the majority of the items for the subscales; thus, if the participant responded to fewer than half of the subscale’s items, the subscale should be considered as “missing.” Differences were taken as statistically significant with a p-value of <0.05 (Cronbach, 1951).



The response rate was 80% (N=247), with higher number of women (57.1%) than men (42.9%); most participants (32%) were in the age group 61 to 70 years old; most of them were married or cohabiting (77.7%); high school diploma was the most reported education (44.5%), while 34.8% had a university degree. Being diagnosed once was reported by the majority (72.5%), and 66.1% said that the reason for treatment was cure. Radiotherapy and chemotherapy were distributed almost equally among participants (Table 1).


Comparison of mean scores

Women scored higher on the anxiety scale than men. The age group <50 had significantly higher anxiety than the other age groups (p<0.001). Participants who belonged to the age group 61-70 years old reported significantly higher scores for faith in ELC-physicians than those who were in the age group <50 (p<0.001). Those who were in treatment for symptom control only, reported significantly higher scores for MDASI total than those in treatment aiming for cure (p<0.001); for them interference with daily life was also found to be significantly worse (p<0.001). Chemotherapy treatment had significantly the most impact on total scores for MDASI total (p<0.001), symptoms severities (p<0.001), and interference with daily life (p<0.001), compared to those receiving radiotherapy or a combination of both (Table 2).


Correlation between variables

Significant positive relationship was observed for HADS (anxiety) with HADS (depression) (r=0.56, p<0.01), MDASI-Symptom severity (r=0.42, p<0.01), and MDASI-Interference scale (r=0.41, p<0.01). The same was found between HADS (depression) with ELC-others (r=0.17, p<0.01), MDASI-Symptom severity (r=0.54, p<0.01), and with the MDASI-Interference scale (r=0.63, p<0.01). A significant positive relationship was observed for ILC and ELC-chance (r=0.39, p<0.01), ELC-physician (r=0.18, p<0.01), and with ELC-others (r=0.20, p<0.01). The same was found between ELC-chance and ELC-physician (r=0.21, p<0.01), ELC-chance and ELC-others (r=0.36, p<0.01), and ELC- physician and ELC-others (r=0.22, p<0.01). A significant positive relationship was also found for MDASI-Severity of symptoms with MDASI-Interference (r=0.78, p<0.01). A significant negative relationship was observed for HADS (anxiety) with ILC (r=-0.21, p<0.01), and for HADS (depression) and ILC (r=-0.26, p<0.01). The same results were shown for ILC and MDASI-Severity of symptoms (r=-0.18, p<0.01), and for ILC with MDASI-Interference (r=-0.23, p< 0.01) (Table 3).



The purpose of the present study was to determine HLC, anxiety and depression levels in patients with cancer during the time of chemotherapy or radiotherapy treatment. A further aim was to assess the severity of somatic symptoms and their interference with patients’ daily life. It has been suggested that a person’s health and health behaviour are important factors when people are challenged with any medical or health related condition (Goldzweig et al, 2016; Kulpa et al, 2014), characterized and controlled by two forces which have been described earlier as ILC and ELC, the latter encompassing three subscales (having faith in doctors, having faith in other people, and believing in chance and fate) (Wallston et al, 1994).

This dichotomization is prominent in the HLC literature (Wallston et al, 1994; Keinki et al, 2016; Lopez-Carrido, 2020). As has been mentioned earlier, individuals with an ILC are characterized by greater self-activity including self-control of their own life believing that the probability of success depends on their own efforts, their high aspirations and faith in their own strengths. On the contrary, individuals with ELC do not trust themselves and do not believe in the effectiveness of their own actions, therefore, they submit to others (Sacha and Gibek, 2019). Results from this study indicate that men and women do not differ regarding internal reinforcement (ILC), nor was there a difference between gender in external reinforcement (ELC) (Wallston et al, 1994). This contradicts findings in Sacha and Gibek’s (2019) and Dopelt et al’s (2022) studies on patients with cancer showing women demonstrate more external control than men, but notably only in the chance factor.

Zeilinger et al (2022) note that the prevalence of anxiety and depression is high in patients with cancer, and the most frequent comorbidities, although this is still unclear. In their study on outpatients with cancer it was found that every sixth patient was likely to have a psychiatric condition, with women being more frequently affected. These results are in accordance with numerous previous findings in studies on outpatients with cancer who found that being a woman was an important factor for both anxiety and depression (Hjörleifsdóttir et al, 2006; Hjörleifsdóttir et al, 2007; Yüce et al, 2021). The present study indicates that women may be more anxious than men, and the severity of symptoms and their interference with daily life may have more impact on women than men. These findings were not significant, but they should, however, not be overlooked. Rather, they call for further investigations to identify underlying causes for distress and experience of symptom burden amongst patients with cancer (Table 2).

It is also important to highlight the psychological distress reported by the younger patients with cancer. Results are consistent with findings in previous studies conducted on outpatients with cancer (Hjörleifsdóttir et al, 2007; Krok et al, 2013) indicating that the youngest ones, 50 years old and younger, are significantly the most vulnerable when in the situation of having cancer and receiving treatment. These findings indicate that the older generations have less psychological distress than younger patients with cancer. This does not necessarily mean that having cancer and receiving treatment affects the older individuals any less than it does the younger persons, it does, however, indicate different reasons for psychological distress related to different situations and responsibilities in life. In this context, it is noteworthy that the age groups 70 years old and older were those who reported significantly strongest belief in ELC-chance and those 61-70 had significantly strongest belief in ELC-physician (Table 2).

The results did not allow for a division between the consequences of the cancer and the side effects of treatment. Yet, the results give reason to believe that treatment given for symptom control only, the severity of symptoms and their interference with  patients’ daily life are significantly worse than amongst those who are receiving treatment for curing the disease. A significant difference in severity of symptoms between types of treatment was also found, since patients receiving chemotherapy reported higher scores of severity of symptoms and their interference with patients’ daily life than those having radiotherapy or a combination of both. This may be, to some extent, related to the side effects of radiotherapy being known to appear later in the treatment process than in chemotherapy (Table 2). These findings correlate with previous findings on side effects of cancer treatment (Pearse and Haas, 2017; Prieto-Callejero et al, 2020).

It is interesting that findings in this present study indicate that boundaries between ILC, ELC and its subscales, can be diverse and a clear distinction is not necessarily the case. Results showed a positive significant correlation between all the three subscales of ELC (belief in chance, physicians, and others) and ILC. This is in accordance with Rotter (1975) who emphasized that this should be conceptualized as a continuum between ELC and ILC, rather than it being an either/or categorization. Wallston and Wallston’s (1978) argue that in a situation of cancer, only low internal control may be possible, thus, patients are more dependent on external sources of control, such as doctors or others. Boddu et al (2021) also suggest that individuals can have both internal and external locus at the same time and the concept of internality and externality cannot be dichotomized.

The present study found that there was a positive significant correlation between believing in physicians and believing in others (Table 3), but this should not come as a surprise, insofar as these two categories are intertwined (Wallston et al, 1994; Boddu et al, 2021). Adding to the above, O´Bryan (2021) argued that human agency consists in being able to decide your actions and reactions. If the reasons are part of your own psychology, we talk about ILC, if the reasons originate in the views of knowledge, power or actions of others, we talk about ELC. These two types of loci of control do not exclude each other, and it depends on the context which one is appropriate insofar as trusting and believing in your doctor because he or she has the knowledge to possibly cure your sickness does not necessarily decrease one’s ILC. Sacha and Gibek (2019) suggest that the longer is the disease process for the patient, the stronger is the belief that his own health is a result of the actions of others. Findings in this present study are in accordance with previous studies, indicating that the lower is the degree of anxiety and depression, the higher is the degree of ILC (Kulpa et al, 2014). Additionally, findings in this present study are in line with previous findings on patients with cancer (Zhang et al, 2015; Sacha and Gibek, 2019) indicating that the longer the disease persists in oncological patients, the weaker is their ILC, and their sense of responsibility for the process weakens as well.



The primary limitation of this study is the relatively small sample size. Other factors which may be seen as possible limitations of categorisation may be the lack of information on the type of cancer, the duration of the disease, and that patients were receiving different treatments at various phases in their disease process. Furthermore, data collection, including reason for treatment and stage of disease, was solely built on information from the patients themselves and was not checked against patients’ medical files. To some extent, this may limit the accuracy of the information, but results give valuable insight into how the patients perceive their own situation and how they describe it. With respect to information revealing similar percentage between the numbers reporting treatment for curing the disease (62.3%) and those with local cancer (62.8%), and between the numbers reporting treatment for symptom control (32%) and those with metastatic disease (35.6%), there is reason to believe that this information is close to reality. It is, however, not possible to jump to any conclusion on whether this was exactly the right division between these two groups or not; it does, however, provide information on a very difficult and sensitive experience seen from patients’ perspectives. In this context, cancer patients are increasingly having treatment for a longer time where the goal is to relieve symptoms and prolong life but not to cure (Ho et al, 2011; Randén et al, 2013). Despite these limitations, the findings in the present study are similar to reports in larger studies in terms of HLC, psychological distress and somatic symptoms (Krok et al, 2013; Zeilinger et al, 2022).



The results of this study provide insights into different aspects of HLC among outpatients with cancer who are receiving chemotherapy or radiotherapy. Findings indicate that ILC may alleviate psychosocial suffering and make the life of the patient more bearable. There is reason to consider the difference between genders in future studies on this matter, because women were found to be more anxious than men and they were suffering more from physical symptoms. The results of this study call for increased attention to the younger patients with cancer, indicating that the youngest ones, 50 years old and younger, are the most vulnerable when in the situation of having cancer and receiving treatment. This does not necessarily mean that having cancer and receiving treatment affects the older individuals any less than it does the younger persons; it does, however, tell us to consider different reasons for psychological distress related to different situations and responsibilities in life. In this context, it is noteworthy that the age groups 70 years old and older were those who reported significantly strongest belief in ELC-chance and those 61-70 had significantly strongest belief in ELC-physician. The results may suggest that the longer the disease persists, the more severe impact it has on a patient’s psychosocial well-being and the more it interferes with their daily life.

Findings in this study distinguish between ILC and ELC and the authors suggest that ILC may be more appropriate and helpful to master the cognitive perception of the threat of illness than ELC. Additionally, Marton et al (2021) found that people with a lower score in ELC (having faith in other people), were more likely to prefer an active role or collaborative role in medical decision-making. The authors suggest that it may be so that people do not fully grasp the impact that other people and doctors could have on their health. Studies have revealed that cancer patients with a higher ELC are significantly more often using sources of information as well as being significantly more in need for additional information than those with ILC (Keinki et al, 2016). The authors suggest that by measuring HLC amongst patients with cancer would be helpful to make a more useful plan for the patients regarding support and care. The HLC-C  questionnaire is short and easy to answer, and it is simple to use in outpatient clinics where patients come for their treatment. Often the patients’ greatest fear is to lose control over their lives. It is, therefore, urgent to understand patients’ fear and anxiety, and help them to encounter this new reality and to master the cognitive perception of the threat of illness. One way to do so is by measuring their inner strength and work from there to assist them in building up inner strength to be able to handle the situation.



We want to thank late Professor Kenneth A. Wallston, Vanderbilt Kennedy Center, USA, for his assistance in obtaining permissions for translating the MHLC-C questionnaire into Icelandic and using it in this study. We also want to thank the staff at the University of Texas, MD Anderson Cancer Center for their permissions for translating the M.D. Anderson Symptom Inventory (MDASI) into Icelandic and use it in this study. The authors would like to express their gratitude to all the participants who contributed valuable information.



Altman, D.G. (1991). Practical statistics for medical research. (1st ed). London: Chapman and Hall/CRC.

Agustsdottir, S., Kristinsdottir, A., Jonsdottir, K., Larusdottir, S. O., Smari, J. and Valdimarsdottir, H. B. (2010). The impact of dispositional emotional expressivity and social constraints on distress among prostate cancer patients in Iceland. British Journal of Health Psychology, 15(1), p 51–61.

Basinska, M. A. and Andruszkiewicz, A. (2012). Health locus of control in patients with Graves-Basedow Disease and Hashimoto Disease and their acceptance of illness. International Journal of Endocrinology and Metabolism, 10(3): p 537–542. doi: 10.5812/ijem.3932

Boddu, V. K., Rebello, A., Chandrasekharan, S.V., Rudrabhatla, P.K., Chandran, A., Ravi, S., Unnithan, G., Menon, R. N., Cherian, A. and Radhakrishnan. A. (2021). How does “locus of control” affect persons with epilepsy? Epilepsy and Behavior, 123: 108257 p 1–6.

Chi, N. A. and Demiris, G. (2016). Family caregivers´ pain management in end-of-life care: A systematic review. American Journal of Hospice and Palliative Care, 34(5), p 470–485.

Cleeland C. S. (2016). The M.D. Anderson Symptom Inventory: User Guide, Version 1, p 1-79. Texas: University of Texas, M. D. Anderson Cancer Center. 2006

Coleman M. P. (2013). The CONCORD programme: Why we need global surveillance of cancer survival. Cancer Control. Epidemiology, p 60-65. Retrieved from: http://cancercontrol.info/wp-content/uploads/2014/08/cc2013_60-65-Michel-P-Coleman_2013.pdf

Cronbach L. J. Coefficient alpha and the internal structures of tests. Psychometrika.  1951; 16(3): p 297–334.

Dopelt, K., Bashkin, O., Asna, N. and Davidovitch, N. (2022). Health locus of control in cancer patient and oncologist decision-making: An exploratory qualitative study, PLOS ONE, 17(1), p 1–12.

Gogou, P., Tsilika, E., Parpa, E., Kouvaris, I., Damigos, D., Balafouta, M., Maureas, V. and Mystakidou, K. (2015). The Impact of Radiotherapy on Symptoms, Anxiety and QoL in Patients with Cancer.  Anticancer Research, 35: p 1771–1775.

Goldzweig, G., Hasson-Ohayon, I., Alon, S. and Shalit, E. (2016). Perceived threat and depression among patients with cancer: The moderating role of health locus of control. Psychology, Health Medicine, 21(5): p 601–607.

Hjörleifsdóttir E., Hallberg I. R., Bolmsjö I. A. and Gunnarsdóttir E. D. (2006) Distress and coping in cancer patients: feasibility of the Icelandic version of BSI 18 and the WOC-CA questionnaires. European Journal of Cancer Care 15, p 80–89.

Hjörleifsdóttir, E., Hallberg, I. R., Bolmsjö, I. Å. and Gunnarsdóttir, E. D. (2007). Icelandic cancer patients receiving chemotherapy or radiotherapy. Does distance from treatment center influence distress and coping? Cancer Nursing, 30(6), E1-10. Doi: 10.1097/01.NCC.0000300161.06016.a9[doi]

Hjörleifsdóttir, E., Einarsdóttir, A., Óskarsson, G. K. and Frímannsson, G. H. (2019). Family caregivers’ satisfaction with specialized end-of-life care provided at home. Assessment of the psychometric characteristics of the Icelandic version of the Family assessment of treatment at the end-of-life questionnaire. Journal of Hospice and Palliative Nursing 21(5), 412-421.

Ho, T. H., Barbera, L., Saskin, R., Lu, H., Neville, A. and Earle, C. C. (2011). Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. Journal of Clinical Oncology, 29(12), p 1587–1591.

Hu, Z., Gou, J., Cai, M. and Zhang, Y. (2022). Translation and validation of M.D. Anderson Symptom Inventory-Thyroid Cancer module in Chinese thyroid cancer patients: A cross-sectional and methodological study. BMC Cancer, 22(1), 2–10.

Jónasson, J. G. and Tryggvadóttir L. Krabbamein á Íslandi – Upplýsingar úr Krabbameinsskrá fyrir tímabilið 1955-2010 (Information from The Cancer Registration Statistic Iceland for 1955-2010. Reykjavík: Krabbameinsfélagið; 2012 (Reykjavík: The Icelandic Cancer Association; 2012). Retrieved from: https://www.krabb.is (in Icelandic).

Jones, D., Zhao, F., Fish, M. J., Wagner, L. I., Patric-Miller, L. J., Cleeland, C. S. and Mendoza, T. R. (2014). The validity and utility of the MD Anderson Symptom Inventory in patients with prostate cancer: Evidence from the Symptom Outcomes and Practice Patterns (SOAPP) data from the Eastern Cooperative Oncology Group. Clinical Genitourinary Cancer, 12(1), p 41–9.

Kuliś, D., Bottomley, A., Velikova, G., Greimel, E., Koller, M. On behalf of the EORTC Quality of Life Group, 2017. EORTC Quality of Life Group Translation Procedure. Fourth edition, 2017.

Krok, J. L., Baker, T. A. and McMillan, S. C. (2013). Age differences in the presence of pain and psychological distress in younger and older cancer patients. Journal of Hospice and Palliative Nursing, 15(2), 107–113.

Keinki, C., Seilacher, E., Ebel, M., Ruetters, D., Kessler, I., Stellamans, J., Rudolph, I. and Huebenr, J. (2016). Information needs of cancer patients and perception of impact of the disease, of self-efficacy, and locus of control. Journal of Cancer Education, 31(3), p 610–606.

Kulpa, M., Kosowicz, M., Stypula-Ciuba, B. J. and Kazalska, D. (2014). Anxiety and depression, cognitive coping strategies, and health locus of control in patients with digestive system cancer. Gastroenterology Review, 9(6), p 329–335.

Lopez-Garrido, G. (2020). Locus of control. Simply Psychology. Retrieved from: www.simplypsychology.org/locus-of-control.html

Marton, G., Pizzoli, S. F. M., Vergani, L., Mazzocco, K., Monzani, D., Bailo, L., Pancani, L. and Pravettoni, G. (2021). Patients’ health locus of control and preferences about the role that they want to play in the medical decision-making process. Psychology, Health and Medicine, 26(2), p 260–266.

Marijanović, I., Pavleković, G., Buhocac, T. and Martinac, M. (2017). The relationship between health locus of control, depression, and sociodemographic factors and amount of time breast cancer patients wait before seeking diagnosis and treatment. Psychiatria Danubina, 29(3) p 330–344.

Mirzania, M., Khajavi, A. and Moshki, M. (2019). Validity and reliability of form C of the Multidimensional Health Locus of Control Scale in pregnant women. Iranian Journal of Medical Sciences, 44(4) p 307–314.

O´Bryan, A. (2022). Internal vs external locus of control: 7 examples and theories. Optimism and mindset. Retrieved from: https://positivepsychology.com/

Pallant, J. (2016). SPSS survival manual. A step-by-step guide to data analysis using SPSS. 6th ed. Berkshire: Oxford University Press; 2016).

Pearse, A. and Haas, M. (2017). Incidence and severity of self-reported chemotherapy side effects in routine care: A prospective cohort study. PLOS ONE, 12(10), p 1–12.

Peters, L., Brederecke, J., Franzke, A., de Zwaan, M. and Zimmerman, T. (2020). Psychological distress in a sample of inpatients with mixed cancer. A cross-sectional study of routine clinical data. Frontiers in Psychology, 11: 591771.

Prieto-Callejero, B., Rivera, F., Fagundo-Rivera, J., Romero, A., Romero-Martín, M., Gómez-Salgado, J. and Ruiz-Frutos, C. (2020). Relationship between chemotherapy-induced adverse reactions and health-related quality of life in patients with breast cancer. Medicine, 99(33), p e21695.

Piil, K., Whisenant, M., Mendoza, T., Armstrong, T., Cleeland, C., Nordentoft, S., Williams, L. A. and Jarden, M. (2021). Psychometric validity and reliability of the Danish version of the MD Anderson Symptom Inventory Brain Tumor Module. Neuro-Oncology Practice, 8(2), p 137–147.

Randén, M., Helde-Frankling, M., Runesdotter, S. and Strang, P. (2013). Treatment decisions and discontinuation of palliative chemotherapy near the end-of-life, in relation to socioeconomic variables. Acta Oncologica, 52,6, p 1062–1066.

Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied, 80(1), p 1–28.

Rotter, J. B. (1975). Some problems and misconceptions related to the construct of internal versus external control of reinforcement. Journal of Consulting and Clinical Psychology, 43(1), p 56–67.

Sacha T. and Gibek K. (2019). Comparison of health locus of control in oncological and non-oncological patients. Contemporary Oncology, 23(2), p 115–120.

Schaaber, Ú. L., Smári, J. and Óskarsson, H. (1990). Comparison of the Hospital Anxiety and Depression Rating Scale (HAD) with other depression and anxiety rating scales. Nordisk Psykiatrisk Tidsskrift44(5), p 507–512.

Smári, J. and Valtýsdóttir, H. (1997). Dispositional coping, psychological distress and disease-control in diabetes. Personality and Individual Differences, 22(2), p 151–156.

Statistics Iceland. Inhabitant’s overview. 2017. Retrieved from: https://www.statice.is/statistics/population/inhabitants/overview/.

Thege, B. K., Rafael, B. and Rohánszky, M. (2014). Psychometric properties of the multidimensional health locus of control scale form C in a non-western culture. PLOS ONE, 9(9), e107108.

Ubbiali, A., Donati, D., Chiorri, C., Bregani, V., Cattaneo, E., Maffei, C. and Visintini, R. (2008). The usefulness of the Multidimensional Health Locus of Control form C (MHLC-C) for HIV subjects: An Italian study. AIDS Care, 20(4), p 495–502.

Vigano, A., De Felice, F., Lacovelli, N.A., Alterio, D., Facchinetti, N., Oneta, O., Bcigalupo, A … Orlandi, E. M.D. (2021). Anderson Symptom Inventory Head Neck (MDASI-HN) Questionnaire: Italian language psychometric validation in head and neck cancer patients treated with radiotherapy ± systemic therapy – A study of the Italian association of radiotherapy and clinical oncology (AIRO). Oral Oncology, 115: 105189 p 1–7.

Wallston, K. A. (2005). The validity of the Multidimensional Health Locus of Control Scales. Journal of Health Psychology, 10(5), p 623–631.

Wallston, K. A., Stein, M. J. and Smith, C. A. (1994). Form C of the MHLC scales: A condition-specific measure of locus of control. Journal of Personality Assessment, 63(3), p 534–553.

Wallston, B. S. and Wallston, K. A. (1978). Locus of control and health: A review of the literature. Health Education and Behavior, 6(1), p 107–117.

Yüce, G. E., Döner, A. and Muz, G. (2021). Psychological distress and its association with unmet needs and symptom burden in outpatient cancer patients: A cross-sectional study. Seminars in Oncology Nursing, 37(5), 1–7.

Zeilinger, E. L., Oppenauer, C., Knefel, M., Kantor, V., Schneckenreiter, C., Lubowitzki, S., Krammer, K. … and Gaiger, A. (2022). Prevalence of anxiety and depression in people with different types of cancer or haematologic malignancies: A cross-sectional study. Epidemiology and Psychiatric Sciences 31, e74, p 1–7.

Zhang, M., chunZheng, M., yanLiu, M., shanWen, Y., danWu, X. and wenLiu, Q. (2015). The influence of demographics, psychological factors, and self-efficacy on symptom distress in colorectal cancer patients undergoing post-surgical adjuvant chemotherapy. European Journal of Oncology Nursing, 19(1), 89–96.

The “Third Reich” in the German Legal, Philosophical and Political Thinking

It is much less known that Adolf Hitler (1889-1945) himself was never in full support of this expression even though it proved quite effective both before and after the NSDAP (Nationalsozialistische Deutsche Arbeiterpartei) takeover.[2] A circular letter that was issued by the Ministry of People’s Education and Propaganda of the German Empire (Reichsministerium für Volksaufklärung und Propaganda) on July 10, 1939 explicitly forbade the official use of “Third Reich”. According to this circular letter Germany’s official name is from this point on “Greater German Empire” (Großdeutsches Reich).[3] It is worth pointing out that the “Greater German Empire” (Großgermanisches Reich) used by the SS cannot be considered official either.

Years later, on March 21, 1942 the Ministry of People’s Education and Propaganda issued a circular letter with provisions for the official name of the “new Germany”. It was to be called “Empire”, quite possibly modelled after the British Empire.[4] The goal of using the expression of “Empire” was to illustrate to the world that the newly acquired lands include territories annexed or occupied by Germany without any international validity, altogether ca. 841 000 sq. km.[5] The same circular letter limits the use of the expression to Germany, emphasizing that there is only one Empire and that is Germany.[6] The use of the term “Third Reich”, however, implied a serial empire which is comparable both in deeds and leaders to the empire, an idea that was entirely incompatible with the self-conscience of the imperialistic national-socialism which fancied to be looked upon as the pinnacle of German history.

In a historical sense the First Empire was established by Otto I in 962 who was crowned emperor by Pope John XII in Rome. This empire is also known as the Holy Roman Empire (Sacrum Romanum Imperium, Heiliges Römisches Reich) which existed till August 6, 1806.[7] The “Second Empire” was founded on January 18, 1871 in Versailles after the Franco–Prussian War and remained the most influential political and military power in Europe until its dissolution in November 1918. In a sense the Weimar Republic can be considered an “intermezzo” (Zwischenreich) between the “Second Empire” and the “Third Empire”.[8]

Following the Christian doctrine of Trinitarianism the three empires can be thought of in a religious and messianic way as follows: the “First Empire” is related to the Father, the “Second Empire” to the Son, while the “Third Empire” to the Holy Spirit. According to such an interpretation the “Third Empire” would constitute the zenith of history and the perfect symbiosis between the real and ideal, satisfying the prophetic requirement of Ibsen and Lessing[9] that the contradiction between Christianity and Antiquity be dissolved. This “Third Empire” would follow a distorted era of Christianity that would be realized by the arrival of a new Messiah.

It is furthermore worth mentioning that in Ernst Krieck’s (1882-1947) Die deutsche Staatsidee (1917) the “Third Empire” appears not as a historical or political, but rather as a moral idea. Ernst Krieck alludes to Johann Gottlieb Fichte (1762-1814), the author of Reden an die deutsche Nation, a work that was highly influential in the latter’s era. Also, by 1919, Dietrich Eckart (1868-1923) uses the “Third Empire” with a clearly political and nationalistic content.[10]

Ernst Fraenkel (1898-1975) a lawyer who immigrated after the National Socialist takeover, quite rightly uses the term Doppelstaat (“Dual State”) to describe the autocratic national-socialist system, emphasizing the double nature of the national-socialist political rule. To insure the normal functioning of the economy an abstract Normenstaat is in effect in the areas of civil, trade, corporate and tax law. On the other hand only professional experience i.e. personal knowledge plays a part in securing political power (Maßnahmenstaat).[11]

In the preface of his work Arthur Moeller van den Bruck (1876-1925) emphasizes that the notion of the “Third Empire” is ideological (Weltanschauungsgedanke), hence it rises above reality. Moeller van den Bruck’s work quickly becomes widely known in Germany and has a large influence on the thinking of the young intellectual class with nationalistic feelings.[12] The disappointment felt after the very harsh political and economic terms of the Peace Treaty of Versailles that was imposed on Germany after the First World War undoubtedly helped shape the thinking of this class. The same work only very slowly becomes known outside of Germany.

The Solingen-born author, who came partly from a traditional Prussian military family, was greatly influenced by the philosophy of Nietzsche. His affinity to the Pan-German ideas is also quite strong. He is rather well acquainted with the most influential European countries, since he visited England, France, Austria, Italy and Russia between the turn of the century and the outbreak of the First World War. He was never really concerned about the unique ethnic problems of the Austro-Hungarian Monarchy. With the exception of the Dual Monarchy and Germany, he vehemently criticizes the major Western European powers, especially their political system and structure. To him the ideal “power” is Germany, his homeland, without which – according to him – no stability can or will ever exist in Europe.

Moeller van den Bruck is convinced that Germany is predestined to lead Europe for the historical ties it has with the Holy Roman Empire (Sacrum Romanum Imperium). He states that in its history the Holy Roman Empire was never able to amalgamate itself into a real political community (politische Gemeinschaft). The Holy Roman Empire is, in his view, almost exclusively dominated by the notion of territoriality (territorialitas), the result of which is centurial territorial dismemberment. This limits the development of German ethnic identity. The birth of the “Second-Empire” – despite the given of political unity – failed to change this situation. The state further remains autocratic and is viewed as a “foreign body” by its citizens.

As a truly conservative philosopher, he feels deep antipathy for Western democracies, primarily towards France and England. He introduces the democratic system of these countries in an ironic, belittling way. According to him, it is only a fiction that the nation (natio) is made up of formally equal individuals. Consistently, Moeller van den Bruck condemns Weimar Germany too, in which all political views are superficial and not reflective of what he believes actual society to be like. He strongly criticizes the Weimar constitution of 1919 as well, since in his opinion it is unable to provide a united Germany with an acceptable constitutional framework. Only with the elimination of its pseudo-values can Germany fulfil its mission of reviving Europe; something it is obligated to do with its rich ties to the Holy Roman Empire. It is the duty of the young generation to revitalize the dormant German intellectuals. They have to intuitively oppose and revolt against the deceiving values. Only as a result of such a “revolution” can the “Third Empire” come into existence.

The birth of the Third Empire, however, automatically assumes the territorial unification of the German ethnic group, which implies the termination of the system of the Treaty of Versailles. The substantial growth of the German population can provide the nation with the necessary strength to attain its goal.

It is quite interesting from the viewpoint of the “Third Reich” to briefly analyze the Article 61 of the Weimar Constitution. According to this article German-Austria after joining Germany receives proportional representation in the Imperial Council (Reichsrat). Even till the accession German-Austria (Deutsch-Österreich) is endowed with the right of consultation (later Germany was forced to declare the passage void). According to Article 80 of the Treaty of Versailles, Germany binds itself to acknowledging and respecting the independence of Austria. Austria’s independence is inviolable. Only with the consent of the League of Nations (Völkerbund) can the status of Austria be modified. This condition, however, led the peace conference to the inclusion of article 88 in the text of the third draft of the peace treaty signed with Austria on September 2, 1919. According to this article Austria’s independence is inviolable and is always dependant on the consent of the League of Nations. This article of the treaty is in unison with the decree that Austria must make a commitment to refrain from any action that could directly or indirectly threaten its independence.

It must be emphasized that this section opens the floor to a very wide range of interpretations. The expression “Jesuit section” used by John Maynard Keynes is quite telling of this section.[13] It was viewed positively by the followers of Pan-Germanism, since it left the door open for the unification with Germany (Anschluß) through a rather peculiar interpretation.

The emphasis of Moeller van den Bruck’s philosophy is on social or more specifically nationalistic demagogy. According to Moeller van den Bruck the integration of the peripheral classes into society and the German nation would be the solution to serious differences within the society of the Weimar Republic. Closely related to this idea, of course, is the goal of developing a national identity as soon as and as efficiently as possible. All this is a kind of anti-capitalist reaction and a significant contribution to the conservative and heterogeneous trend of both the conservative and the popular revolutions. The author of Das dritte Reich is an active supporter of only the first one.

Moeller van den Bruck’s idea of a “perfect” empire had already been present in Lessing’s and Ibsen’s thoughts concerning the “Third Reich”, but was influenced primarily by Gerhard von Mutius’ (1872-1934) value-ideal worldview.[14] Despite the rejection of modern liberalist ideals and the formulation of a plan for a “new European order”, the leaders of Germany’s political and ideological life refused to accept Moeller van den Bruck’s idea of the “Third Empire” that was originally trademarked by idealistic rather than politically relevant thoughts. This general hostility was further reinforced by the publication of a strong critique of Moeller van den Bruck’s views in 1939. Still, the ideas of the conservative intellectual philosopher are especially popular with the conservative German “national” intellectuals.[15] During the Great Depression of the early 30’s Moeller van den Bruck is often cited by many adherents of this group. It may also be worth mentioning that the expression “Prussian style” (Preußischer Stil) comes from Moeller van den Bruck.

Followers of the idea of conservative revolution are the writers, historians, economists, and lawyers who had close ties with the Die Tat cultural journal published by Ernst Horneffer (1871-1954) in Jena between 1909 and 1939. A majority of these people consider themselves to be the intellectual successor of Horneffer in some way.[16] After Horneffer, Eugen Diederichs (1867-1930) takes over as the magazine’s editor. During Diederich’s editorial years the paper gains a more religious, social and cultural political appearance. From April 1913 the sub-title of Die Tat becomes “Social-religiöse Monatschrift für deutsche Kultur”, well reflecting the changes in ideology of the paper. During the First World War the paper is out of print. In 1921 the sub-title of Die Tat is changed by Diederichs to “Monatschrift für die Zukunft deutscher Kultur”, implying a change in style once again. The goal of the paper is changing Germany’s political and cultural life.[17] The articles published in the Die Tat welcome the fall of the empire and follow a new socio-religious aristocratic thinking. Diederichs provides space for both the national-socialists and the liberals.[18] The “community of people” (Volksgemeinschaft) wishes to bring a halt to the social and political decline of the bourgeoisie through the simultaneous creation of a national-socialist and authoritarian state. He furthermore demands a “revolution from the top” (Revolution von oben).

It is necessary to mention Eugen Rosenstock (1888-1973) who further developed the ideas of Diederichs. His work on the European revolutions, published in the early 1930’s was quite influential. The same can be said about economist Ferdinand Fried (1898-1967), who used empirical research to demonstrate the serious crisis of capitalist production in his main work, eloquently entitled Ende des Kapitalismus (Jena, 1931). According to Rosenstock, the solution to this problem is an authoritarian economic system. He is further disturbed by the gradual impoverishment of the middle-class, and the drastic strengthening of a rather small elite in the political and cultural life of Germany. This evermore powerful group barely constitutes one-tenth percent of a 60 million large Germany, yet it seems to create an unbridgeable gap between itself and the rest of society. He believes that the only solution to this problem is not only economic expansion, but also a substantial increase in exports. In order to achieve this Germany needs to become self-sufficient economically and must switch to an authoritarian system politically.

Carl Schmitt (1888-1985), a renowned professor of law and the author of the well-known work Der Hüter der Verfassung (1931) was also a person with close ties to the Die Tat. In this greatly influential work, through closely studying the Weimar Republic, he reaches the conclusion that in historic dimensions the state becomes “overpowering”, directly leading to the rise of a totalitarian state. In many respects Carl Schmitt’s Gegenspieler is Hermann Ignatz Heller (1891-1933) who quite appropriately writes that “the need for a strong person is the bourgeoisie’s way of expressing its desperation. Through the strengthening of the working masses they feel that not only they own political and economic interests, but also the entire European culture is threatened… The only thing left for the desperate bourgeoisie is to place all their faith into a strong person.”[19]

Heller, who becomes a full professor of public law at Frankfurt am Main University in 1932, is a committed supporter of the Weimar Republic. The fact that in the same year he was the legal representative of the faction of the social democrats of the Prussian provincial diet in the so-called Preußenschlagverfahren seems to only reinforce this fact. It must be pointed out that Heller thinks that the modern state and its era are entirely incompatible with the class-stratification. As he indicated in his rather fragmented work, Staatslehre which was published after his early death, a modern state is both a social and democratic constitutional state, which by definition excludes the possibility of a strong person-led authoritarian state.[20]

Certainly worth mentioning is Hans Zehrer (1899-1966), who became the editor of the Die Tat in October 1929.[21] He is regarded as a supporter of the “conservative revolution” and the opponent of parliamentary democracy. After World War II Zehrer becomes the editor-in-chief of the Die Welt, and modifies the sub-title (“Monatsschrift zur Gestaltung neuer Wirklichkeit”) established by his predecessor Adam Kuckhoff (1888-1943). In 1932 he adds the adjective “independent” (unabhängig) to the original subtitle. The Die Tat becomes the intellectual interpretative forum for national-socialist ideas although keeping a distance of from Hitler and underestimating the dangerousness of the NSDAP. As the solution to the instable political and economic system of the Weimar Republic, Zehrer envisioned a new system, the “Third Reich”, as a fundamentally different, religion based corporate political system. This new system, which is in essence a 20th century version of Luther’s directorate, would be led by a new elite with “folk roots”. In Zehrer’s opinion only a return to the Lutheran Reformation can stop both communism and national-socialism from fulfilling their ultimate goal of establishing an authoritarian system. In accordance with Zehrer’s interpretation the “Third Reich” would have an eschatological political structure that had its foundations in the Reformation.

The intellectuals of the Die Tat, especially Giselher Wirsing (1907-1975), the person who becomes the editor of the review after the Nazi takeover in 1933, concentrate on Germany’s relations with Central Europe. Starting 1934-5 Wirsing shortens the review sub-title to “Unabhängige Monatsschrift”. This is “confirmed” or seems to be confirmed by the unique, yet already true fact that the “transformation of reality” has already taken place. From 1936 the word “independent” disappears and only “Deutsche Monatsschrift” appears on the cover of the paper. In March 1939 the publication of the Die Tat comes to an end by merging with the Das XX. Jahrhundert magazine. Despite the political, ideological changes it has gone through the years the Die Tat becomes very popular in Germany, especially during Zehrer’s editorial years. The circulation of the paper reaches a yet unprecedented 30 000 copies. In addition Tat-clubs (Tat-Kreise) are born all throughout Germany, forming intellectual debate forums. According to Wirsing, Germany’s future is primarily influenced by South-eastern Europe (Südost-Europa). He is convinced that the goal of Germany’s enemies or perceived enemies is to encircle the country. It is for this reason that Germany needs to establish a closed national “living-space” (Lebensraum). He is convinced that self-sufficient German economy should open towards South-eastern Europe instead of the increasingly hostile financial world. At the same time Wirsing, similarly to most of his colleagues of the Die Tat, does not wish to continue or renew the old policy of annexation. Wirsing essentially revives the Mitteleuropa-Plan (1848-50) which states that Germany’s expansion should be directed towards Central Europe instead of the West. This latter option has been limited, anyway, by the Locarno Treaty in 1925. The ultimate goal of the expansion is to establish the so-called Großwirtschaftsraum (Greater Economic Space). The Mitteleuropa-Plan is generally associated with Friedrich Naumann (1860-1919); however, it was the Prussian-born Karl von Bruck (representative of Trieste in 1848 in the Viennese Parliament and financial minister of Austria between 1855 and 1859) who first developed the financial aspect of the plan.[22]

Moeller van den Bruck was the intellectual centre for the other group of intellectuals who sympathized with the idea of a “conservative revolution”. These people were united under the Berlin-based Juni-Club and were led by Moeller van den Bruck’s friend Heinrich von Gleichen. There is a close relationship between the Juni-Club, organized around figures of Moeller van den Bruck, Heinrich von Gleichen and Martin Spahn from Berlin and the Deutscher Hochschulring (DHR), an organization established and actively participating at most German universities after World War I.[23] The Ring-Bewegung is primarily characterized by conservatism, a nationalistic attitude and – due to disorientation – a trend-seeking at the beginning. The ties are particularly strong in Berlin which is illustrated by the fact that the centres of the Hochschulring are in the headquarters of the Juni-Club. The Juni-Club is rather active in Berlin, in particular it exhibits educational activities of political nature. In November 1922 Martin Spahn, one of the leading figures of the Juni-Club establishes a “Political Collegium”, where he regularly organizes lectures. From 1923 the Collegium’s name changes to “Hochschule für nationale Politik”, where he holds “private university” classes. These classes are visited primarily by youth who sympathize with nationalist ideals, such as Werner Best, a lawyer and one of the most well-known national-socialists having a law degree.[24]

A prominent member of the Juni-Club is Edgar Jung (1894-1934). The Austrian economist, philosopher and sociologist, through the influence of Othmar Spann (1878-1950), propagates the rebirth and revival of the Holy Roman Empire of the German Nation.[25] This view is quite similar to Moeller van den Bruck’s call for the establishment of the “Third Reich”, since both of them reach back to the Holy Roman Empire for ideological support. Without going into an extensive analysis of the question, it must be pointed out that the linking of the Holy Roman Empire with the Germans as an ethnic group is entirely unhistorical.

Even based on this brief summary it can be ascertained that the idea of the “Third Reich” dates back a long time. In traces it is already present in Fichte’s philosophy. The idea of the “Third Reich” has quite an influence on the thinking of the conservative cultural philosophers, primarily Arthur Moeller van den Bruck. It is also present in the works of the era’s most influential literary, political and economic scholars. However, not even the often eschatological “Third Reich” is a uniformly interpreted idea. For political and philosophical reasons the national-socialist regime isolates itself from the idea of “Third Reich” already by the end of the 1930s. The “conservative revolutionary” branch of the Deutsche Bewegung (“German Movement”) – including all branches of the “conservative revolution” – becomes then unacceptable as an ideological base for the national-socialist rulers.

The “völkisch” branch of the Deutsche Bewegung is an entirely different matter. This latter one cannot be considered a uniform movement either, since it includes the Schwarze Front trend that later comes into conflict with the national-socialist ideals and the Landvolkbewegung,[26] a movement unfolding at the end of the 1920s in Schleswig-Holstein and one that wobbles between anarchy and corporatism as well. Of all these different movements, it is the Führerprinzip (“the leader’s principle”), espoused by Hans F. K. Günter (1891-1968), Richard Walter Darré (1895-1953) and Alfred Rosenberg (1893-1946), which becomes the official ideology of national-socialist Germany, in which the idea of the “Third Reich” no longer plays a role.

[1] An earlier version of this essay was published in Acta Juridica Hungarica 42(1-2), 2001, pp. 91-101.

[2] During Hitler’s official visit to Italy in May 1938, the German press repeatedly referred to the Holy Roman Empire of the German nation (Heiliges Römisches Reich Deutscher Nation). See V. Klemperer: LTI. La langue du IIIe Reich, Paris, 1996. p. 158 (In German original: LTI – Notizbuch eines Philologen. Leipzig, 1975.)

[3] In contemporary German legal textbooks the term “Greater German Empire” (Großdeutsches Reich) was used instead of Germany. See E.R. Huber: Verfassungsrecht des Großdeutschen Reiches, Hamburg, 1939.

[4] It is noteworthy that the name of the weekly paper released by Germany for foreign countries between 1940 and 1945 was Das Reich. This paper of the Nazi Germany contained a wide range of political, historical and literary information and was in print even in April 1945.

[5] According to a German official statement the territory of Germany in 1942 without Elsace, Lorraine, Luxembourg, the Czech-Moravian Protectorate (Reichsprotektorat Böhmen und Mähren) and Poland (the total size of these lands was 160 000 sq. km) was 681 000 sq. km. Previous to the Peace Treaty of Versailles the size of the “Second Reich” (which is often called “altes Reich”) was 540 000 sq. km. This substantial change is primarily due to the annexation of Austria (Anschluß), the Czech-Moravian regions following the Munich Agreement and the Polish regions (e. g. Warthegau) after the beginning of World War II. After the creation of the “Social Republic of Salò” (Repubblica Sociale di Salò) a part of Northern Italy, the so-called “Voralpenland” which includes Southern Tirol and the coastline of the Adriatic (“Adriatisches Küstenland”), became part of Germany. It is, however, difficult to decide whether these territorial acquisitions, from a legal viewpoint, were occupied or annexed.

[6] In legal terminology, primarily in administration, one comes across the euphemistic expression “Verreichlichung” quite often.

[7] For the international legal status of the Holy Roman Empire see F. Berber: Internationale Aspekte des Heiligen Römischen Reiches. In: Festschrift für Th. Maunz zum 80. Geburtstag, München, 1981, pp. 17-25. Regarding the relationship between the idea of the renovatio imperii and the Holy Roman Empire see Földi A. – Hamza G.: The History and Institutes of Roman Law, 5th revised and enlarged edition, Budapest, 2000, p. 114.

[8] For the most recent literature see R. Dufraisse: Le Troisième Reich. In: Les empires occidentaux de Rome à Berlin. Sous la direction de J. Tulard, Paris, 1997, p. 449.

[9] In his work “L’education du genre humain” (p. 86) Gotthold Ephraim Lessing foretells the “new eternal Gospel”, which means the “third era” (p. 90).

[10] It is worth pointing out that the title of Stefan George’s (1868-1933) work is “Das neue Reich” in which the expression “völkisch” occurs.

[11] See: E. Fraenkel: The Dual State, New York, 1941. (reprint: 1969). This work only appears in German translation in 1974 (Der Doppelstaat, Frankfurt am Main–Köln). For Ernst Fraenkel’s view of the state see: A. v. Brünneck: Ernst Fraenkel (1898-1975), Soziale Gerechtigkeit und pluralistische Demokratie. In: Streitbare Juristen, Eine andere Tradition, Baden-Baden, 1988, pp. 415-425.

[12] In the 3rd edition of Das dritte Reich (1931) Hans Schwarz emphasizes that national-socialism accepts the name “Third Reich” and named the federation’s paper “Oberland” based on the title of Moeller van den Bruck’s work.

[13] The decision, formulated by the Supreme Council on December 16, 1919 deals with the interpretation of the mentioned article. It was sent to Chancellor Karl Renner on the same day with a lettre d’envoi, that included the Allied Powers’ guarantee for the territorial integrity of Austria.

[14] See G. von Mutius: Die drei Reiche, Berlin, 1920, p. 226. Von Mutius writes: “One who frees himself of his own self stands in the Third Reich.” (Wer sich von seinem Selbst geschieden hat, der steht im dritten Reich.)

[15] Carlo Schmid writes in his memoirs, that in the 1930’s the members of Tübingen Wiking-Bund, a nationalistic student group, read the works of Moeller van den Bruck. See C. Schmid: Erinnerungen, Bern–München, 1979, p. 143.

[16] Essays and critiques are published in the Die Tat by distinguished writers and philosophers such as Hermann Bahr (1863-1934), Paul Ernst (1866-1933) and George Simmel (1858-1918).

[17] According to Diederichs the current leading bourgeoisie (bisher geistige Schicht des Bürgertums) cannot be the carrier of culture in the future. (Träger der Kultur nicht walten kann). See: E. Diederichs: Die neue „Tat”. In: Die Tat, Heft 7, October 1929, p. 481.

[18] K. Fritsche: Politische Romantik und Gegenrevolution. Fluchtwege in der Kriese der bürgerlichen Gesellschaft: Das Beispiel des „Tat”-Krises, Frankfurt am Main, 1976, p. 45.

[19] Hermann Heller writes: “Von grosser Wichtigkeit ist es, dass neufeudale Kraftpose und den Schrei nach dem starken Mann als den Ausdruck einer Verzweiflungsstimmung des Bürgers zu erkennen. Erschreckt durch das Avancieren der Arbeitermassen, glaubt er nicht nur seine eigenen politischen und ökonomischen Herrschaftsansprüche bedroht, sondern sieht zugleich das Ende der gesamten europäischen Kultur nahe. […] Begreiflich, dass diesem verzweifelten Bürger nur die Hoffnung auf den starken Mann übrig bleibt.” See H. I. Heller: Rechtsstaat oder Diktatur? Tübingen, 1930, pp. 17-18.

[20] For the importance of Heller’s view of the social state with respect to the German constitutional thinking see: Staatslehre in der Weimarer Republik. Hermann Heller zu ehren, Hrsg. von Ch. Müller und I. Staff, Köln, 1985.

[21] Adam Kuckhoff takes over the editing of the Die Tat from Diederichs in April 1928. Kuckhoff only works at the journal for one year. In August 1943 he gets executed by the Nazis as a member of the “Rote Kapelle”.

[22] It must be mentioned that Constantin Frantz, a political opponent of Bismarck, feels nostalgic towards the Holy Roman Empire. According to Frantz the three “Germanies” (Prussia, Austria, and the “third Germany”), which include the South and Central German states, may provide the real defence against the French and Russian expansion. Frantz’s idea is anti-Nazi and was rather popular in German circles outside of Germany. See: F. Genton: L’Europe Centrale, une idée d’Europe, Dijon, 1997, p. 362.

[23] At some universities the name of the Deutscher Hochschulring is Hochschulring Deutscher Art (HDA).

[24] See: U. Herbert: Best. Biographische Studien über Radikalismus, Weltanschauung und Vernunft. 1903-1989, 2. durchg. Aufl. Bonn, 1996, p. 55.

[25] In contrast with Adam Smith and David Ricardo’s liberal economics Othmar Spann, the founder of social economics and universalism in philosophy, develops a new view for studying the so-called Ganzheitslehre. In his opinion the construction of a “real state” (wahrer Staat) assumes the new, profession based establishment of the economy and the state (Ständestaat auf berufsständiger Grundlage). Through opposing the various trends of liberalism and Marxism Spann exerts great influence on the conservative Austrian thinkers. Following the Anschluß Spann was stripped of his professorship in Vienna. Thereafter he took an active part in the formulation of the so-called Korneuburger Eid, an oath of the Austrofascist Heimwehr.

[26] Here we point out that the trend represented by Ernst Niekisch (1889-1967) is part of the Deutsche Bewegung’s “völkisch” revolutionary branch. Ernst Niekisch is also one of Moeller van den Bruck’s students.