The multicenter effectiveness study of inpatient and day hospital treatment in departments of psychosomatic medicine and psychotherapy in Germany.

Background: Reliable outcome data of psychosomatic inpatient and day hospital treatment with a focus on psychotherapy are important to strengthen ecological validity by assessing the reality of mental health care in the field. This study aims to evaluate the effectiveness of inpatient and day hospital treatment in German university departments of Psychosomatic Medicine and Psychotherapy in a prospective, naturalistic, multicenter design including structured assessments. Methods: Structured interviews were used to diagnose mental disorders according to ICD-10 and DSM-IV at baseline. Depression, anxiety, somatization, eating disorder and posttraumatic stress disorder (PTSD) symptoms, as well as personality functioning were assessed by means of questionnaires on admission and at discharge. Results: 2,094 patients recruited by 19 participating university hospitals consented to participation in the study. Effect sizes for each of the outcome criteria were calculated for 4-5 sub-groups per outcome domain with differing severity at baseline. Pre-post effect sizes for patients with moderate and high symptom severity at baseline ranged from d = 0.78 to d = 3.61 with symptoms of PTSD, depression, and anxiety showing the largest and somatization as well as personality functioning showing somewhat smaller effects. Conclusions: Inpatient and day hospital treatment in German university departments of Psychosomatic Medicine and Psychotherapy is effective under field conditions. Clinical trial registration: https://drks.de/search/de/trial/DRKS00016412, identifier: DRKS00016412.

What Kind of Patients Receive Inpatient and Day-Hospital Treatment in Departments of Psychosomatic Medicine and Psychotherapy in Germany?

INTRODUCTION: Germany is one of the few countries with a medical specialty of psychosomatic medicine and psychotherapy and many treatment resources of this kind. OBJECTIVE: This observational study describes the psychosomatic treatment programs as well as a large sample of day-hospital and inpatients in great detail using structured diagnostic interviews. METHODS: Mental disorders were diagnosed according to ICD-10 and DSM-IV by means of Mini-DIPS and SCID-II. In addition to the case records, a modified version of the CSSRI was employed to collect demographic data and service use. The PHQ-D was used to assess depression, anxiety, and somatization. RESULTS: 2,094 patients from 19 departments participated in the study after giving informed consent. The sample consisted of a high proportion of "complex patients" with high comorbidity of mental and somatic diseases, severe psychopathology, and considerable social and occupational dysfunction including more than 50 days of sick leave per year in half of the sample. The most frequent diagnoses were depression, somatoform and anxiety disorders, eating disorders, personality disorders, and somato-psychic conditions. CONCLUSIONS: Inpatient and day-hospital treatment in German university departments of psychosomatic medicine and psychotherapy is an intensive multimodal treatment for complex patients with high comorbidity and social as well as occupational dysfunction.

[Mental health research opportunities in the MONICA-KORA study]. / Seelische Gesundheit als Forschungsgegenstand in der MONICA-KORA-Studie.

Mental health research opportunities in the MONICA-KORA study Goal: Initially, part of the worldwide MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Project of the World Health Organization (WHO), the project was pursued 1996 as KORA (Cooperative Health Research in the Region Augsburg) Study, which now substantially expands the former focus on cardiovascular medicine. Major research questions within the mental health focus emphasize the prognostic impact of psychosocial stress on the incidence of somatic endpoints and the gender-driven crosstalk of psycho-neuro- immunological conditions with somatic diseases. Methods: Three independent representative population-based MONICA/KORA surveys (S1 to S3) starting in 1984/85 and performed in 5-years intervals, constitute the backbone of the psychosocial MONICA sub study. An extensive set of psychosocial baseline data captured in the S1 to S3 surveys are available for a total of approximately 13000 participants in the age range of 25 to 75 years. Here, data allow estimates of work-stress conditions, social isolation, social network, life satisfaction and the Type A Behavior Pattern. The Follow-up studies (F3, F4, FFF4) allow for prospective, time-dependent analyses. In the follow-up (F) surveys, psychosomatic research was strengthened with the inclusion of standardized assessments of depression, anxiety, Type D personality and (in F4) for Posttraumatic Stress Disorder (PTSD), psychosocial stress and life satisfaction. Combined analyses with genetic, epigenetic and metabolomic datasets are feasible. Results: The initial S1 to S3 surveys provided psychosocial baseline data for approximately 13000 participants in the age range of 25 to75 years. The Follow-up studies (F3, F4, FFF4) each included approximately 3000 participants with validated datasets with a median of 9 to 15 years of follow-up period from baseline. An increasing number of co-operations dealing with sophisticated basic research tools are currently ongoing. Conclusions: Prospective assessments of psychosocial stress conditions on the onset of somatic disease conditions and research on the interaction with autonomic, endocrine and inflammatory pathways result in new insights of established disease conditions and may contribute as a game-changer in the current disease understanding.

Functional somatic disorders: discussion paper for a new common classification for research and clinical use.

BACKGROUND: Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients' quality of life and healthcare costs. MAIN BODY: We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose 'functional somatic disorders' (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrum - and also within organ system-specific chapters of a classification - they should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD). CONCLUSION: We propose a new classification, 'functional somatic disorder', which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders.

Management of Functional Somatic Syndromes and Bodily Distress.

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

A Comparison of Dual Attention, Eye Movements, and Exposure Only during Eye Movement Desensitization and Reprocessing for Posttraumatic Stress Disorder: Results from a Randomized Clinical Trial.

BACKGROUND: Currently, there is controversy on the possible benefits of dual-attention tasks during eye movement desensitization and reprocessing (EMDR) for patients with posttraumatic stress disorder (PTSD). METHODS: A total of 139 consecutive patients (including 85 females) suffering from PTSD were allocated randomly among 3 different treatment conditions: exposure with eyes moving while fixating on the therapist's moving hand (EM), exposure with eyes fixating on the therapist's nonmoving hand (EF), and exposure without explicit visual focus of attention as control condition (EC). Except for the variation in stimulation, treatment strictly followed the standard EMDR manual. Symptom changes from pre- to posttreatment were measured with the Clinician-Administered PTSD Scale (CAPS) by an investigator blinded to treatment allocation. RESULTS: In total, 116 patients completed the treatment, with an average of 4.6 sessions applied. Intention-to-treat analysis revealed a significant improvement in PTSD symptoms with a high overall effect size (Cohen's d = 1.96, 95% CI: 1.67-2.24) and a high remission rate of PTSD diagnosis (79.8%). In comparison to the control condition, EM and EF were associated with significantly larger pre-post symptom decrease (ΔCAPS: EM = 35.8, EF = 40.5, EC = 31.0) and significantly larger effect sizes (EM: d = 2.06, 95% CI: 1.55-2.57, EF: d = 2.58, 95% CI: 2.01-3.11, EC: d = 1.44, 95% CI: 0.97-1.91). No significant differences in symptom decrease and effect size were found between EM and EF. CONCLUSIONS: Exposure in combination with an explicit external focus of attention leads to larger PTSD symptom reduction than exposure alone. Eye movements have no advantage compared to visually fixating on a nonmoving hand.

[Competence-based catalogue of learning objectives for conducting medical consultations]. / Kompetenzbasierter Lernzielkatalog ¼Ärztliche Gesprächsführung« .

ISSUE: In 2012 the German medical licensure regulations (Approbationsordnung) made teaching and assessing the conduction of medical consultations a mandatory part of medical education. A catalogue of learning objectives (LO) based on existing references was developed to assist medical schools in meeting this requirement. METHODS: A body of relevant material was compiled using literature research and surveying experts. Then, in a multiphase Delphi process, this was evaluated and condensed by an interdisciplinary working group in dialogue with external (clinical) experts. Competence levels and examples of clinical application were assigned to enhance implementation. The catalogue was revised by the medical faculties, professional associations and the BVMD. RESULTS: This learning catalogue comprised 116 learning objectives for the specific skills necessary to conducting medical consultations as well as exemplary application contexts. The catalogue proved to be practical in terms of developing curricula and networking at medical schools. DISCUSSION: This catalogue of learning objectives can serve as the basis for developing a sample communication curriculum for use by medical faculties.

[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.

Classification and clinical diagnosis of fibromyalgia syndrome: recommendations of recent evidence-based interdisciplinary guidelines.

Objectives. Fibromyalgia syndrome (FMS), characterized by subjective complaints without physical or biomarker abnormality, courts controversy. Recommendations in recent guidelines addressing classification and diagnosis were examined for consistencies or differences. Methods. Systematic searches from January 2008 to February 2013 of the US-American National Guideline Clearing House, the Scottish Intercollegiate Guidelines Network, Guidelines International Network, and Medline for evidence-based guidelines for the management of FMS were conducted. Results. Three evidence-based interdisciplinary guidelines, independently developed in Canada, Germany, and Israel, recommended that FMS can be clinically diagnosed by a typical cluster of symptoms following a defined evaluation including history, physical examination, and selected laboratory tests, to exclude another somatic disease. Specialist referral is only recommended when some other physical or mental illness is reasonably suspected. The diagnosis can be based on the (modified) preliminary American College of Rheumatology (ACR) 2010 diagnostic criteria. Discussion. Guidelines from three continents showed remarkable consistency regarding the clinical concept of FMS, acknowledging that FMS is neither a distinct rheumatic nor mental disorder, but rather a cluster of symptoms, not explained by another somatic disease. While FMS remains an integral part of rheumatology, it is not an exclusive rheumatic condition and spans a broad range of medical disciplines.

Effects of verbal suggestion on coronary arteries: results of a randomized controlled experimental investigation during coronary angiography.

BACKGROUND: Decrease of chest pain perception under placebo conditions has been frequently observed. The aim of this study was to examine whether placebo-induced chest pain improvement could be the result of changes in coronary blood flow. We, therefore, performed an experiment to investigate whether a verbal suggestion (VS) integrated in a cardiologic procedure has an impact on diameters of coronary arteries. METHODS: A total of 30 chest pain patients with normal diagnostic angiograms were assigned to a VS or a control group (CG). Saline solution was administered intracoronarily to both groups. The VS group received a standardized VS, implying coronary vasodilation. The CG remained without VS. Coronary end points were the changes in percentage diameter stenosis, Minimal lumen diameter and reference diameter of the index coronary segment before and 60 seconds after the administration of saline. Furthermore, changes in hemodynamics, psychological distress, and chest pain perception were recorded. RESULTS: The VS led to coronary vasoconstriction in comparison with CG (change in mean percentage diameter stenosis ± SD 3.2% ± 6.3% vs -1.7% ± 6.8%, P = .062; change in mean minimal lumen diameter ± SD -0.18 ± 0.32 mm vs 0.06 ± 0.23 mm, P = .029, no relevant change in the reference diameter). At the same time, the degree of chest pain perception was significantly reduced in the VS group (-0.7 ± 1.3) compared with the CG (0.3 ± 1.3), P = .024. CONCLUSION: The findings of this study suggest that a VS results in a biological alteration within coronary arteries. Contrary to expectation, the VS led to vasoconstriction, whereas chest pain perception decreased.

Effects of functional relaxation and guided imagery on IgE in dust-mite allergic adult asthmatics: a randomized, controlled clinical trial.

Although relaxation and imagination techniques have repeatedly proven their effectiveness in asthma, nothing is known about the immunological effects of these complementary interventions. Therefore, the aim of this study is to investigate the effects of the brief relaxation technique of functional relaxation (FR) with guided imagery (GI) on serum IgE in adult patients with dust mite allergic asthma in a randomized, controlled trial. Sixty-four patients were treated over a 4-week period and assessed at baseline, after treatment and after 4 months for follow-up. Due to its significant role in the pathophysiology of allergic asthma, the serum IgE was employed as outcome measure in this investigation. Participation in FR, GI, and FR/GI led to decreases in serum IgE (IU/mL) of -54.7 +/- 67.1, -49.5 +/- 93.4, and -28.4 +/- 93.9 compared with an increase of 27.7 +/- 43.2 in CI. Our study confirmed a positive and clinically relevant effect of FR and GI on total serum IgE levels.

Brief relaxation versus music distraction in the treatment of dental anxiety: a randomized controlled clinical trial.

BACKGROUND: Dental anxiety is a significant cause of poor dental health. Because patients often prefer nonpharmacological interventions, the clinical effectiveness of clearly structured approaches is of particular interest. METHODS: This prospective randomized controlled study compares a brief relaxation method (BR) with music distraction (MD) and with a control group (C). The authors randomly assigned 90 patients with dental anxiety to BR, MD or C groups. They assessed the outcomes by means of the state anxiety subscale of the State-Trait Anxiety Inventory. RESULTS: Both BR and MD reduced dental anxiety significantly. In contrast, patients in the C group did not exhibit a significant change in their anxiety level. BR was significantly superior to MD. Stratification according to the patient's general level of dental anxiety revealed that BR also was particularly effective in highly anxious subjects, whereas MD did not have a clinically relevant effect on these subjects. CONCLUSIONS: BR appears to be a safe, economically sound and effective nonpharmacological approach to the short-term reduction of dental anxiety. Additional investigations are needed to validate these findings in a larger clinical trial and to determine the long-term effects of this intervention. CLINICAL IMPLICATIONS: Relaxation techniques are a pragmatic, effective and cost-saving method of facilitating dental treatment in anxious patients.

Redefining (somatoform) pain disorder in ICD-10: a compromise of different interest groups in Germany.

PURPOSE OF REVIEW: Pain is one of the most frequent reasons to visit health professionals. Many patients suffering from chronic pain conditions not only need medical treatment but also psychiatric or psychological interventions. This additional treatment need should be underlined using an ICD section F diagnosis. The current ICD-10 diagnosis of somatoform pain disorder requests psychological causation of the pain, which is frequently unclear or difficult to decide. RECENT FINDINGS: In Germany, the different interest groups, namely of psychiatry, pain research, psychosomatic medicine and clinical psychology, met to find a consensus on how to re-classify pain disorder under section F of ICD-10. This manuscript summarizes the result. SUMMARY: A diagnosis of pain disorder is necessary to underline the additional need of psychiatric/psychological interventions in chronic pain conditions. This diagnosis should include psychological features that are relevant for development or maintenance of chronic pain. In contrast to earlier attempts of redefining pain diagnoses, our attempt included representatives of the association for the study of pain.

Management of fibromyalgia syndrome--an interdisciplinary evidence-based guideline.

The prevalence of fibromyalgia syndrome (FMS) of 1-2% in the general population associated with high disease-related costs and the conflicting data on treatment effectiveness had led to the development of evidence-based guidelines designed to provide patients and physicians guidance in selecting among the alternatives. Until now no evidence-based interdisciplinary (including patients) guideline for the management of FMS was available in Europe. Therefore a guideline for the management of fibromyalgia syndrome (FMS) was developed by 13 German medical and psychological associations and two patient self-help organisations. The task was coordinated by two German scientific umbrella organisations, the Association of the Scientific Medical Societies in Germany AWMF and the German Interdisciplinary Association of Pain Therapy DIVS. A systematic search of the literature including all controlled studies, systematic reviews and meta-analyses of pharmacological and non-pharmacological treatments of FMS was performed in the Cochrane Library (1993-12/2006), Medline (1980-12/2006), PsychInfo (1966-12/2006) and Scopus (1980-12/ 2006). Levels of evidence were assigned according to the classification system of the Oxford-Centre for Evidence Based Medicine. Grading of the strengths of recommendations was done according to the German program for disease management guidelines. Standardized procedures were used to reach a consensus on recommendations. The guideline was reviewed and finally approved by the boards of the societies involved and published online by the AWMF on april 25, 2008: http://www.uni-duesseldorf.de/AWMF/ll/041-004.htm. A short version of the guideline for patients is available as well: http://www.uni-duesseldorf.de/AWMF/ll/041-004p.htm. The following procedures in the management of fms were strongly recommended: information on diagnosis and therapeutic options and patient-centered communication, aerobic exercise, cognitive and operant behavioural therapy, multicomponent treatment and amitriptyline. Based on expert opinion, a stepwise FMS-management was proposed. Step 1 comprises confirming the diagnosis and patient education and treatment of physical or mental comorbidities or aerobic exercise or cognitive behavioural therapy or amitriptyline. Step 2 includes multicomponent treatment. Step 3 comprises no further treatment or self-management (aerobic exercise, stress management) and/or booster multicomponent therapy and/or pharmacological therapy (duloxetine or fluoxetine or paroxetine or pregabalin or tramadol/aminoacetophen) and/or psychotherapy (hypnotherapy or written emotional disclosure) and/or physical therapy (balneotherapy or whole body heat therapy) and/or complementary therapies (homeopathy or vegetarian diet). The choice of treatment options should be based on informed decision-making and respect of the patients' preferences.

[Working as a clinician-scientist in psychosomatic medicine: status, skills and research productivity]. / Der klinische Forscher in der psychosomatischen Medizin: Status, Kompetenzen und Leistungen.

OBJECTIVE: Even though there is a high need of clinical research for the medical and psychotherapeutic practice in Germany, the interest in clinical research seems to be decreasing. The aim of this study was to assess the circumstances under which clinical research in psychosocial medicine is performed and to identify opportunities for improvement. METHODS: n = 53 residents of the departments for Psychosomatic Medicine of the University Hospitals of Heidelberg and Tübingen and of the Technical University of Munich were asked about their research activities, their subjective research skills, and their productivity in clinical psychosocial research. In addition, objective research knowledge was investigated using a multiple-choice test. RESULTS: Both, subjective research skills and objective research knowledge were relatively low. The percentage of correct answers in the multiple choice test was 33 %. Subjective problems were predominately stated regarding "biostatistics" and "study design". In terms of research productivity, 33 % of residents had published as first authors of an original journal article, and 12 % had submitted a successful grant proposal. DISCUSSION: Altogether, there is a high need of training in the field of clinical psychosomatic research. We are presenting a training model that is adapted to the conditions of young clinicians and that addresses both general clinical research and specific psychosocial clinical research.