[Transdisciplinary treatment of functional movement disorders: integration instead of dissociation]. / Die transdisziplinäre Behandlung funktioneller Bewegungsstörungen: Integration statt Dissoziation.

Successful treatment of patients with functional motor disorders is integrative in several ways: the primary treatment goal is the (re)integration of sensorimotor, cognitive and social functioning. The prerequisites for this are an integrated biopsychosocial model of everyone involved as well as close transdisciplinary cooperation. Instead of a simple addition of treatment components, all care providers and patients act in concert.

Functional Somatic Disorders, Their Subtypes, and Their Association With Self-Rated Health in the German General Population.

OBJECTIVE: The heterogeneous conceptualizations and classifications of persistent and troublesome physical symptoms impede their adequate clinical management. Functional somatic disorder (FSD) is a recently suggested interface concept that is etiologically neutral and allows for dysfunctional psychobehavioral characteristics as well as somatic comorbidity. However, its prevalence and impact are not yet known. METHODS: We analyzed 2379 participants (mean age = 48.3 years, 52.5% female) from a representative German community survey using operationalized FSD criteria. These criteria defined FSD types based on somatic symptom count, type, and severity assessed by the Bodily Distress Syndrome Checklist. In addition, the associations of those types with health concerns, comorbidity, psychological distress, and self-rated health were determined. RESULTS: There were four clearly demarcated groups with no relevant bothering symptoms, with one or with few bothering symptoms from one organ system, and with multiple bothering symptoms from at least two organ systems. Psychological distress, health concerns, and comorbidity steadily increased, and self-rated health decreased according to the number and severity of symptoms. Somatic symptom burden, health concerns, and comorbidity independently predicted self-rated health, with no interaction effect between the latter two. CONCLUSIONS: Our data support an FSD concept with two severity grades according to persistent and troublesome symptoms in one versus more organ systems. The delimitation of subtypes with psychobehavioral characteristics and/or with somatic comorbidity seems useful, while still allowing the demarcation of a group of participants with high symptom burden but without those additional characteristics.

Migraine in the context of chronic primary pain, chronic overlapping pain disorders, and functional somatic disorders: A narrative review.

OBJECTIVE: To contextualize migraine as the most common primary headache disorder in relation to other chronic primary pain and non-pain functional somatic and mental conditions. BACKGROUND: Migraine is increasingly understood as a sensory processing disorder within a broader spectrum of symptom disorders. This has implications for diagnosis and treatment. METHOD: Narrative review based on a search of the literature of the last 15 years on the overlap of migraine with other symptom disorders. RESULTS: Migraine as the prototypical primary headache disorder not only comprises many non-headache symptoms in itself, it also shows high comorbidity with other chronic pain and non-pain conditions (e.g., fibromyalgia syndrome, irritable bowel syndrome, functional non-epileptic seizures, depression, anxiety, and posttraumatic stress disorder). Such "symptom disorders" share several etiological factors (e.g., female preponderance, psychological vulnerability) and psychophysiological mechanisms (e.g., altered sensory processing, pain expectancy). These facts are acknowledged by several recent integrative conceptualizations such as chronic primary pain, chronic overlapping pain conditions, or functional somatic disorders. Accordingly, migraine management increasingly addresses the total symptom burden and individual contributors to symptom experience, and thus incorporates centrally acting pharmacological and non-pharmacological, that is, psychological and behavioral, treatment approaches. CONCLUSIONS: Migraine and also other primary headache disorders should be seen as particular phenotypes within a broader spectrum of symptom perception and processing disorders that require integrative diagnostics and treatment. A harmonization of classifications and better interdisciplinary collaboration are desirable.

Let's Get Personal, Let's Get Physical: Approaching the Bodily Self in Clinical Interactions.

Medicine usually looks at the body as a biochemical and physical apparatus - from a distant third-person perspective, with fragmented, reductionist positions, unidirectional causal models, and highly selective foci. Even psychiatrists and psychotherapists focus more and more on the brain as an organ, look at genes and colourful pictures. And just as biomedical medicine stares at physical and chemical facts and ignores the person, one could say that psychotherapy stares at personality, cognition, and behaviour and ignores the body. But the lowlands where being-a-person and having-a-body meetmatter a lot for becoming ill, staying, and getting well. What attitudes and what approaches can help us understand the bodily self? After very briefly summarizing current understandings of embodiment and enactivism, we will suggest some practical consequences for everyday clinical diagnostics.

[Body Experience and Body Interaction in Psychotherapeutic Diagnostics]. / Körpererfahrung und Körperinteraktion in der psychotherapeutischen Anamnese- und Befunderhebung.

Since they are core features of many mental and psychosomatic disorders, disturbances of body experience and body interaction are relevant to understand and treat a particular patient. There are several body-related constructs, standardized psychometric instruments and experiments, focusing on single facets and following categorized evaluation. However, there is a lack of terminology and methods to individually and situationally understand and use body experience and body interaction in everyday clinical psychotherapeutic diagnostics. Based on clinical experience and a broad, topic-focused literature research, this discussion agenda delineates their core dimensions - bodily perception, body language, bodily changes, body-related narratives and actions, bodily resonance - and how to approach them by observation, mentalization, and relatedness.

[Chronic pain syndromes and other persistent functional somatic symptoms]. / Chronische Schmerzsyndrome und andere persistierende funktionelle Körperbeschwerden.

Somatic symptoms including pain are everyday human experiences. They usually result from a complex interaction of stimuli, interpretation and reaction, and are not necessarily proportional to structural damage. Persistent functional somatic symptoms can be associated with a significant impairment of quality of life and functioning, even without mental or somatic comorbidity. Dysfunctional experiences, expectancies and behavior, not only by patients but also by physicians, can increase the risk of chronification. From the outset, management should be graded with respect to the severity and biopsychosocial aspects, with thorough but cautious diagnostics and with psychoeducative, active and coping-oriented treatment.

[The Somatic Symptoms Experiences Questionnaire (SSEQ): a new self-report instrument for the assessment of psychological characteristics of patients with somatoform disorder]. / Der Fragebogen zum Erleben von Körperbeschwerden (SSEQ): Ein neues Selbstbeurteilungsinstrument zur Erfassung der psychischen Merkmale somatoformer Störungen.

Psychological symptoms of somatoform disorders will be part of their new definition in DSM-5. We developed the Somatic Symptoms Experiences Questionnaire (SSEQ) as a self-report questionnaire to assess important psychological characteristics of patients with somatoform disorders. Item selection and identification of factor structure, as well as reliability and validity have been checked in a sample of N=453 psychsomatic outpatients. Results of a principal components analysis with Promax-rotation suggested 4 factors (health worries, illness experience, difficulties in interaction with doctors, impact of illness). Validity analyses confirmed associations between the SSEQ-Scores and the physical disability of patients. Although further assessments of psychometric qualities are needed, the questionnaire appears to be well-suited for future assessment of relevant psychological features of somatoform disorders.

Patients with "organically unexplained symptoms" presenting to a borreliosis clinic: clinical and psychobehavioral characteristics and quality of life.

OBJECTIVE: This study explores the prevalence of patients with "organically unexplained symptoms" presenting to a Lyme borreliosis clinic and describes their clinical and psychobehavioral characteristics as well as health-related quality of life. METHODS: Study instruments consisted of a set of self-rating questionnaires and an organicity rating of presenting symptoms by an acknowledged expert. Participants included 125 patients presenting with symptoms attributed to borreliosis. Clinical and psychobehavioral characteristics as well as health-related quality of life for patients whose symptoms were rated as "organically unexplained" were compared with those of patients whose symptoms were rated as "organically explained." RESULTS: Symptoms of 37 (30%) patients were rated as "organically unexplained" (ORG-) and symptoms of 88 (70%) patients were rated as "organically explained" (ORG+). ORG- differed from ORG+ in various clinical and psychobehavioral characteristics and in health-related quality of life. For example, ORG- reported a higher number of symptoms, more illness consequences and negative emotional illness representations, and felt less reassured in the medical context, more dissatisfied with medical care, and more convinced of having a serious illness. CONCLUSIONS: Our results suggest that patients with "organically unexplained symptoms" inadequately attributed to Lyme borreliosis reveal many clinical and psychobehavioral characteristics that indicate significant somatic and mental distress. An early focus on all of the patients' mental and bodily symptoms, as well as on subjective illness perceptions and consequences allows for a more specific plan.

[Conflict coping strategies in patients with somatoform disorders]. / Konfliktbewältigungsstrategien bei Patienten mit somatoformen Störungen.

245 patients presenting with allergic complaints were interviewed with SCID for the diagnosis of a somatoform disorder and filled in the "ques-tionnaire of conflict coping strategies (FKBS)" 55 patients with insect allergy and 100 depressed patients served as controls. Only depressed patients diverged from the FKBS reference scores, particularly with respect to "turning against self".

[New guidelines on functional and somatoform disorders]. / Neue Leitlinien zu funktionellen und somatoformen Störungen.

The S3 guideline "Dealing with patients with non-specific, functional and somatoform bodily symptoms" emphasizes the similarities in the management of the manifold manifestations of so called "medically unexplained symptoms" and gives recommendations for a stepped and collaborative diagnostic and therapeutic approach in all subspecialties and all levels of health care. It has a special focus on recommendations regarding attitude, physician-patient-relationship, communication, the parallelization of somatic and psychosocial diagnostics and a stepped therapeutic approach. The "Evidence-based guideline psychotherapy in somatoform disorders and associated syndromes" provides a differentiated analysis of the current evidence regarding the effectiveness of various psychotherapeutic interventions for the most relevant manifestations of functional and somatoform disorders. In combination, both guidelines pose important advances for treatment quality in Germany, but also illustrate remarkable structural and research deficits.

[Fibromyalgia syndrome as a psychosomatic disorder - diagnosis and therapy according to current evidence-based guidelines]. / Das Fibromyalgiesyndrom als psychosomatische Erkrankung - empfehlungen Aktueller Evidenzbasierter Leitlinien zu Diagnostik und Therapie.

OBJECTIVES: The classification and therapy of patients with chronic widespread pain without evidence of somatic factors as an explanation is currently a matter of debate. The diagnostic label "fibromyalgia syndrome"(FMS) has been rejected by some representatives of general and psychosomatic medicine. METHODS: A summary is given of the main recommendations from current evidence-based guidelines on FMS and nonspecific/functional/somatoform bodily complaints. RESULTS: The criteria of FMS and of persistent somatoform pain disorder or chronic pain disorder with somatic and psychological factors partly overlap. They include differential clinical characteristics of persons with chronic widespread pain but without sufficiently explaining somatic factors. Not all patients diagnosed with FMS meet the criteria of a persistent somatoform pain disorder. FMS is a functional disorder, in which in most patients psychosocial factors play an important role in both the etiology and course of illness. FMS can be diagnosed by looking at the history of a typical symptom cluster and excluding somatic differential diagnoses (without a tender point examination) using the modified 2010 diagnostic criteria of the American College of Rheumatology. Various levels of severity of FMS can be distinguished from a psychosomatic point of view, ranging from slight (single functional syndrome) to severe (meeting the criteria of multiple functional syndromes) forms of chronic pain disorder with somatic and psychological factors, of persistent somatoform pain disorder or of a somatization disorder. The diagnosis of FMS as a functional syndrome/stress-associated disorder should be explicitly communicated to the patient. A therapy within collaborative care adapted to the severity should be provided. For long-term management, nonpharmacological therapies such as aerobic exercise are recommended. In more severe cases, psychotherapy of comorbid mental disorders should be conducted. CONCLUSIONS: The coordinated recommendations of both guidelines can synthesize general medical, somatic, and psychosocial perspectives, and can promote graduated care of patients diagnosed with FMS.

[Functional somatic symptoms: Clinical varieties, diagnostic challenges, therapeutic principles]. / Funktionelle Körperbeschwerden: Klinische Vielfalt, diagnostische Herausforderungen, therapeutische Prinzipien.

Functional somatic symptoms are common and multiform. They occur in all genders and age groups, with and without somatic or mental comorbidity. Dysfunctional illness behaviour on the patients' (e. g., excessive attention or anxiety) and also on the caregivers' side (e. g., nocebo messages, redundant investigations or risky treatments) can promote chronification. Empathy, well balanced diagnostics, comprehensible information within individual multifactorial explanatory models, refocussing, activation, and - in more severe forms - additional measures such as psychotherapy are recommended.

Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome.

BACKGROUND: Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system. METHODS: Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS. RESULTS: Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence. CONCLUSION: Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.

Gender specific somatic symptom burden and mortality risk in the general population.

Gender specific all-cause mortality risk associated with a high somatic symptom burden (SSB) in a population-based cohort was investigated. The study population included 5679 women and 5861 men aged 25-74 years from the population-based MONICA/KORA Cohort. SSB was assessed following the Somatic Symptom Scale-8 and categorized as very high (≥ 95th percentile), high (60-95th percentile), moderate (30-60th percentile), and low (≤ 30th percentile). The impact of SSB on all-cause mortality risk within a mean follow-up period of 22.6 years (SD 7.1; 267,278 person years) was estimated by gender-specific Cox regression models adjusted for sociodemographic, lifestyle, somatic and psychosocial risk factors, as well as pre-existing medical conditions. Approximately 5.7% of men and 7.3% of women had very high SSB. During follow-up, 3638 (30.6%) mortality cases were observed. Men with a very-high SSB had 48% increased relative risk of mortality in comparison to men with a low SSB after adjustment for concurrent risk factors (1.48, 95% CI 1.20-1.81, p < .0001), corresponding to 2% increased risk of mortality for each 1-point increment in SSB (1.02; 95% CI 1.01-1.03; p = 0.03). In contrast, women with a very high SSB had a 22% lower risk of mortality (0.78, 95% CI 0.61-1.00, p = 0.05) and women with high SSB had an 18% lower risk of mortality (0.82; 95% CI 0.68-0.98, p = 0.03) following adjustment for concurrent risk factors. The current findings indicate that an increasing SSB is an independent risk factor for mortality in men but not in women, pointing in the direction of critical gender differences in the management of SSB, including women's earlier health care utilization than men.

Stability and predictors of somatic symptoms in men and women over 10 years: A real-world perspective from the prospective MONICA/KORA study.

OBJECTIVE: To assess the stability of somatic symptoms in community-dwelling participants. METHODS: The study included 2472 participants (1190 men, 1282 women; mean age 44.3 ± 10.9) from the prospective population-based MONICA-S3 cohort (1994/95) and the 10-year follow-up KORA-F3 cohort. Somatic symptoms were assessed by an adapted version of the Somatic Symptom Scale-8 (SSS-8a) with scores ranging from 0 to 24. Somatic symptom stability was assessed by weighted kappa values (κ). Generalized Estimating Equation models assessing symptom stability were adjusted for sociodemographic, lifestyle, clinical and psychosocial risk factors, as well as pre-existing medical conditions. RESULTS: The mean (±SD) SSS-8a was lower in men (S3: 6.88 ± 3.87, F3: 6.60 ± 3.86) than women (S3: 8.43 ± 4.0, F3: 8.31 ± 4.2) at both time points. However, somatic symptoms remained moderately stable in both genders over 10 years (κ =0.42 in men and κ = 0.48 in women), with the largest stability observed in trouble sleeping for men (κ =0.41) and pain in the joints for women (κ =0.41). Pre-existing somatic symptoms were significantly associated with increasing symptoms at follow-up [men: ß = 0.82 (SE 0.12), women: ß = 0.85 (SE 0.12)], followed by age and psychosocial factors, whereas higher education and recent health care utilization were inversely associated with increasing symptoms. Although hypertension and obesity were associated with increasing somatic symptoms in men, pre-existing medical conditions were not associated with increasing somatic symptoms in men nor women. CONCLUSIONS: The current findings indicate that somatic symptoms remain moderately stable in the general population during 10 years of follow-up, mainly driven by sociodemographic and psychosocial factors.

Patient-doctor interaction, psychobehavioural characteristics and mental disorders in patients with suspected allergies: do they predict "medically unexplained symptoms"?

In approximately 20% of patients with suspected allergies, no organic symptom explanation can be found. Limited knowledge about patients with "medically unexplained symptoms (MUS)" contributes to them being perceived as "difficult" and being treated inadequately. This study examined the psychobehavioural characteristics of patients presenting for a diagnostic allergy work-up. Patients were interviewed and completed various self-rating questionnaires. Patient-Doctor interaction was evaluated, and the organic explicability of the patients' symptoms was rated by allergists. Patients with vs. those without MUS differed in several respects. Mental comorbidity, female sex, dissatisfaction with care, and a problematic countertransference (the interviewer's feelings towards the patient) independently predicted MUS. Patients whose symptoms could be explained organically reported more psychobehavioural problems than a control group of immuno-therapy patients. There were no differences in patient-doctor interaction. In patients with suspected allergies, recognition of psychological burden and concurrent mental disorders is important. Mental comorbidity and a difficult patient-doctor interaction may predict MUS.

Factitious Disorders in Everyday Clinical Practice.

BACKGROUND: The pathological feigning of disease can be seen in all medical disciplines. It is associated with variegated symptom presentations, self-inflicted injuries, forced but unnecessary interventions, unusual and protracted recoveries, and frequent changes of treating physician. Factitious illness is often difficult to distinguish from functional or dissociative disorders on the one hand, and from malingering on the other. Many cases, even fatal ones, probably go unrecognized. The suspicion that a patient's problem may be, at least in part, factitious is subject to a strong taboo and generally rests on supportive rather than conclusive evidence. The danger of misdiagnosis and inappropriate treatment is high. METHODS: On the basis of a selective review of current literature, we summarize the phenomenology of factitious disorders and present concrete strategies for dealing with suspected factitious disorders. RESULTS: Through the early recognition and assessment of clues and warning signs, the clinician will be able to judge whether a factitious disorder should be considered as a differential diagnosis, as a comorbid disturbance, or as the suspected main diagnosis. A stepwise, supportive confrontation of the patient with the facts, in which continued therapeutic contact is offered and no proofs or confessions are demanded, can help the patient set aside the sick role in favor of more functional objectives, while still saving face. In contrast, a tough confrontation without empathy may provoke even more elaborate manipulations or precipitate the abrupt discontinuation of care-seeking. CONCLUSION: Even in the absence of systematic studies, which will probably remain difficult to carry out, it is clearly the case that feigned, falsified, and induced disorders are underappreciated and potentially dangerous differential diagnoses. If the entire treating team successfully maintains an alert, transparent, empathic, and coping-oriented therapeutic approach, the patient will, in the best case, be able to shed the pretense of disease. Above all, the timely recognition of the nature of the problem by the treating team can prevent further iatrogenic harm.