The impact of music-imaginative pain treatment (MIPT) on psychophysical affect regulation - A single case study.

Music-imaginative Pain Treatment (MIPT) is part of the multi-professional treatment plan for hospitalised patients in departments for psychosomatic medicine. MIPT is an intervention that encourages the patient to create music representing pain and relief from pain and promotes active engagement and self-reflection. This single case study of a 46-year-old female patient diagnosed with chronic pain disorder with somatic and psychological factors includes narrative, demographic, psychometric, and cardiophysiological data. During the interventions, early childhood stress, which is a risk factor for developing chronic pain, turns out to be a crucial focal point in therapy and conspicuous in her handling of the music. Social trauma is considered an appropriate concept for a deeper understanding of the case.

Improvement of pain experience and changes in heart rate variability through music-imaginative pain treatment.

Music-imaginative Pain Treatment (MIPT) is a form of music therapy addressing pain experience and affective attitudes toward pain. It includes two self-composed music pieces: one dedicated to the pain experience (pain music, PM) and the other to healing imagination (healing music, HM). Our non-experimental study addresses patients with chronic somatoform pain disorders participating in MIPT. The goal is to gain insight into the direct effect mechanisms of MIPT by combining outcome measures on both the objective physiological and subjective perception levels. The research questions are directed toward changes in pain experience and heart rate variability and their correlations. Thirty-seven hospitalized patients with chronic or somatoform pain disorders receiving MIPT participated in this study. Demographic data and psychometric measures (Symptom Check List SCL90, Childhood Trauma Questionnaire CTQ) were collected to characterize the sample. Subjective pain experience was measured by McGill Pain Questionnaire (SF-MPQ), and Heart Rate Variability by 24 h-ECG. Data analysis shows a reduction of reported pain from MT1 = 19.1 (SD = 7.3) to MT2 = 10.6 (SD = 8.0) in all dimensions of the SF-MPQ. HRV analyses shows a reduced absolute power during PM and HM, while a relative shift in the autonomic system toward higher vagal activity appears during HM. Significant correlations between HRV and MPQ could not be calculated. Findings are interpreted as a physiological correlate to the psychological processes of the patients. Future studies with more participants, a control-group design, and the integration of medium- and long-term effects are recommended.

Unwillingly traumatizing: is there a psycho-traumatologic pathway from general surgery to postoperative maladaptation?

BACKGROUND: Surgery may possibly be undermined by psychologic, psychiatric and psychosomatic problems, as long as these problems interfere with a patient's capacity to cope with surgery adaptively. Recent studies have shown that interpersonal trauma, e.g. abuse or neglect, and its correlates are involved in the adaptation to surgery. This observation is heuristically coherent, given the respective traumatization is an interpersonal event occurring in a relationship. Notably, surgery inevitably leads to the violation of physical boundaries within a doctor-patient relationship. Based on the principles of psycho-traumatologic thinking, such a constellation is deemed qualified to activate posttraumatic symptoms in the traumatized. METHOD: The present topical review summarizes the respective findings which point to a subgroup of patients undergoing surgery, in whom difficulty bearing tension and confiding in others may cause adaptive problems relevant to surgery. Although this theorizing is empirically substantiated primarily with respect to total knee arthroplasty (TKA), a pubmed-research reveals psychopathologic distress to occur prior to surgery beyond TKA. Likewise, posttraumatic distress occurs in large numbers in the context of several operations, including cardiac, cancer and hernia surgery. CONCLUSION: Aspects of psychological trauma may be linked to the outcomes of general surgery, as well, e.g. biliary, hernia or appendix surgery. The mechanisms possibly involved in this process are outlined in terms of a hierarchical organization of specific anxiety and negative affect as well as in terms of psychodynamics which imply the unconscious action of psychologic defenses at their core. IMPLICATIONS: Not least, we encourage the screening for trauma and its correlates including defenses prior to general surgery in order to identify surgical candidates at risk of, e.g. chronic postoperative pain, before the operation.

[Postoperative Dissociation after Knee Replacement and its Influence on the Course of Pain]. / Postoperative Dissoziation nach Totalem Kniegelenkersatz und ihr Einfluss auf den Schmerzverlauf.

OBJECTIVE: Even after successful knee replacement, one in 5 patients complains of chronic pain. Previous studies suggest that surgical interventions trigger postoperative traumatic stress in some patients. The aim of this explorative study is to investigate whether postoperative dissociation occurs as a manifestation of postoperative traumatic stress after total knee replacement. In addition, it should be investigated whether these patients have more chronic postoperative pain 1 year postoperatively and to what extent the course of pain differs from the other patients. METHODS: 201 Patients who underwent primary knee TEP were studied. They answered questionnaires on knee pain (WOMAC) and dissociation (FDS-20) at 3 measurement points: 1 day preoperatively (T1), 10 weeks postoperatively (T2) and 1 year postoperatively (T3). RESULTS: Data from 145 patients could be analyzed. The incidence for postoperative dissociation is 8.3%. Not only do patients with postoperative dissociation report more chronic postoperative pain after 1 year (p=0,016), but also their postoperative pain levels decreases less than in the patients without postoperative dissociation (p=0,025). DISCUSSION: The findings provide evidence that postoperative dissociation occurs as a manifestation of postoperative traumatic stress after total knee replacement. Even if dissociation seems to be a defense mechanism for the regulation of overstraining affects in the short term, it is associated with more chronic postoperative pain in the long term. Furthermore, the patients with postoperative dissociation benefit less in a 1-year follow-up from total knee replacement in terms of pain reduction. CONCLUSION: Strategies to reduce dissociation could lead to better results after knee TEP implementation and should be investigated in future intervention studies.

Local glutamate in cingulate cortex subregions differentially correlates with affective network activations during face perception.

The cingulate cortex is involved in emotion recognition/perception and regulation. Rostral and caudal subregions belong to different brain networks with distinct roles in affective perception. Despite recent accounts of the relevance of cingulate cortex glutamate (Glu) on blood-oxygen-level-dependent (BOLD) responses, the specificity of the subregional Glu levels during emotional tasks remains unclear. Seventy-two healthy participants (age = 27.33 ± 6.67, 32 women) performed an affective face-matching task and underwent magnetic resonance spectroscopy (MRS) at 7 Tesla. Correlations between the BOLD response during emotion perception and Glu concentration in the pregenual anterior cingulate cortex (pgACC) and anterior midcingulate cortex (aMCC) were compared on a whole-brain level. Post hoc specificity of the association with an affect was assessed. Lower Glu in the pgACC correlated with stronger activation differences between negative and positive faces in the left inferior and superior frontal gyrus (L IFG and L SFG). In contrast, lower Glu in the aMCC correlated with BOLD contrasts in the posterior cingulate cortex (PCC). Furthermore, negative face detection was associated with prolonged response time (RT). Our results demonstrate a subregion-specific involvement of cingulate cortex Glu in interindividual differences during viewing of affective facial expressions. Glu levels in the pgACC were correlated with frontal area brain activations, whereas Glu in the salience network component aMCC modulated responses in the PCC-precuneus. We show that region-specific metabolite mapping enables specific activation of different BOLD signals in the brain underlying emotional perception.

The Pain Paradox of Borderline Personality and Total Knee Arthroplasty (TKA): Recruiting Borderline Personality Organization to Predict the One-Year Postoperative Outcome.

BACKGROUND: TKA is a common treatment for arthropathies of the knee; however, its results are compromised by psychosocial equivalents of pain: prior research suggests persistent pain and dysfunction after TKA not only to be linked to psychological symptoms such as depression or anxiety but also to psychodynamic determinants of borderline personality, namely borderline personality organization. Osteoarthritis (OA) and Rheumatoid arthritis (RA), the main indications for TKA, are themselves linked to personality factors and disorders, e.g. borderline. The present study investigates the influence of borderline personality organization (BPO) on the outcomes of TKA one year postoperatively. METHODS: We studied 144 patients scheduled for primary TKA before and after the operation using the IPO-16 and the WOMAC for the assessment of knee pain and function. RESULTS: Non-parametric correlations were found between primitive defenses and knee-pain, not function. Linear regression showed prediction of knee pain and knee function by the preoperative WOMAC scores (p<0.01), whereas there was additional prediction of knee-pain by gender (p=0.03) and primitive defenses (p=0.04). DISCUSSION: The results suggest a psychodynamic mechanism of maladaptation after TKA apparently representing the bodily manifestations of fundamental psychic defenses.

Attachment-specific speech patterns induce dysphoric mood changes in the listener as a function of individual differences in attachment characteristics and psychopathology.

OBJECTIVES: Early childhood experiences influence cognitive-emotional development, with insecure attachment predisposing to potential psychopathologies. We investigated whether narratives containing attachment-specific speech patterns shape listeners' emotional responses and social intentions. DESIGN: First, 149 healthy participants listened to three narratives characteristic for secure, insecure-preoccupied, and insecure-dismissing attachment. Following each narrative, the well-being and interpersonal reactivity as a particular aspect of emotional reactivity of the listener were assessed. Likewise, psychopathological aspects of personality were evaluated. A follow-up study compared 10 psychosomatic patients with a current depressive episode and/or personality disorder with distinct depressive symptoms and 10 age- and gender-matched healthy controls. METHODS: Effects of narratives on listeners' mental state were tested with repeated-measures AN(C)OVA. Mediating effects in the listener (attachment characteristics in the context of personality traits) were explored. Narrative effects were compared between patients and controls. RESULTS: Listening to insecure attachment narratives reduced well-being in controls. Nevertheless, tendency for social interaction was highest following the insecure-preoccupied narrative. Importantly, listeners' individual attachment characteristics mediated the relationship between well-being/interpersonal reactivity following the insecure-preoccupied narrative and levels of psychopathology. Furthermore, compared with healthy participants, patients showed higher emotional reactivity following exposure to the insecure-preoccupied narrative, represented by lower well-being and lower estimation of friendliness towards the narrator. CONCLUSIONS: Exposure to attachment-specific speech patterns can result in dysphoric mood changes. Specifically, the insecure-preoccupied narrative influenced the listeners' emotional state, which was further mediated by the individual attachment patterns and psychopathological personality characteristics. This deepens the understanding of interpersonal processes, especially in psychotherapeutic settings. PRACTITIONER POINTS: In clinical populations, insecure-preoccupied attachment has a high prevalence. In this study, listening to a narrative characteristic of insecure-preoccupied speech patterns resulted in reduced well-being in healthy listeners. Patients with depressive symptoms showed a higher emotional reactivity towards the insecure-preoccupied narrative compared to healthy controls. While working on (childhood) traumata, for example, in group therapy or inpatient settings, therapists should raise awareness to possible mood changes through discourse-conveyed attachment characteristics in listeners as a 'side effect'.

Dissociation and Pain-Catastrophizing: Absorptive Detachment as a Higher-Order Factor in Control of Pain-Related Fearful Anticipations Prior to Total Knee Arthroplasty (TKA).

Total Knee Arthroplasty (TKA) is the ultima-ratio therapy for knee-osteoarthritis (OA), which is a paradigmatic condition of chronic pain. A hierarchical organization may explain the reported covariation of pain-catastrophizing (PC) and dissociation, which is a trauma-related psychopathology. This study tests the hypotheses of an overlap and hierarchical organization of the two constructs, PC and dissociation, respectively, using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Childhood Trauma Screener (CTS), a shortened version of the Dissociative Experiences Scale (FDS-20), the Brief Symptom Inventory (BSI-18), the Pain-Catastrophizing Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK) in 93 participants with knee-OA and TKA. Non-parametric correlation, linear regression, and an exploratory factor analysis comprising the PCS and the FDS-20 in aggregate were run. The three factors: 1) PC factor, 2) absorptive detachment, and 3) conversion altogether explained 60% of the variance of the two scales. Dissociative factors were related to childhood trauma, and the PC-factor to knee-pain. The latter was predicted by absorptive detachment, i.e., disrupted perception interfering with the integration of trauma-related experiences possibly including invasive surgery. Absorptive detachment represents negative affectivity and is in control of pain-related anxieties (including PC). The clinical associations of trauma, psychopathology, and maladaptation after TKA may be reflections of this latent hierarchical organization of trauma-related dissociation and PC.

Negative Affect, Type D Personality, Quality of Life, and Dysfunctional Outcomes of Total Knee Arthroplasty.

Background: Type D personality (TDP) is a sign of tapered stress and compromises treatment outcomes including those of hip arthroplasty. The common dissatisfaction with total knee arthroplasty (TKA) is predicted by fear avoidance, pain catastrophizing and emotional lability, with poor quality of life (QoL) reflecting these strains. This study is the first to investigate the influence of TDP on TKA assuming (1) negative affect (NA) to be linked to fear avoidance and to increased dissatisfaction with TKA and (2) the expression of NA and social inhibition (SI) to not be stable over time. Method: We studied 79 participants using the brief symptom inventory-18, the pain-catastrophizing scale, the Tampa scale of kinesiophobia, the SF-36, and the WOMAC preoperatively and 12 months postoperatively. T-test and regression were used to compare the variables of interest between groups built based upon outcome severity. Result: NA at follow-up predicted knee pain (p=0.02) and knee function (p < 0.01) at follow-up. Contrarily, increased expressions of NA/SI at follow-up were predicted by NA (p=0.04) and rumination (p=0.05) at the baseline. Conclusion: The present results suggest the postoperative increase of NA to be linked to dysfunctional outcomes of TKA due to an interaction with pain catastrophizing. Baseline self-rated physical health did not connect to the dissatisfaction with TKA 1-year postoperatively.

Exposure to attachment narratives dynamically modulates cortical arousal during the resting state in the listener.

BACKGROUND: Affective stimulation entails changes in brain network patterns at rest, but it is unknown whether exogenous emotional stimulation has a prolonged effect on the temporal dynamics of endogenous cortical arousal. We therefore investigated differences in cortical arousal in the listener following stimulation with different attachment-related narratives. METHODS: Resting-state EEG was recorded from sixteen healthy subjects for ten minutes each with eyes closed: first at baseline and then after passively listening to three affective narratives from strangers about their early childhood experiences (prototypical for insecure-dismissing, insecure-preoccupied, and secure attachment). Using the VIGALL 2.1 algorithm, low or high vigilance stages in consecutive EEG segments were classified, and their dynamic profile was analyzed. Questionnaires assessed the listeners' emotional response to the content of the narrative. RESULTS: As a general effect of preceding affective stimulation, vigilance following the stimulation was significantly elevated compared to baseline rest, and carryover effects in dynamic vigilance profiles were observed. A difference between narrative conditions was revealed for the insecure-dismissing condition, in which the decrease in duration of high vigilance stages was fastest compared to the other two conditions. The behavioral data supported the observation that especially the insecure narratives induced a tendency in the listener to affectively disengage from the narrative content. DISCUSSION: This study revealed carryover effects in endogenous cortical arousal evoked by preceding affective stimulation and provides evidence for attachment-specific dynamic alterations of brain states and individual differences in emotional reactivity.

[A review on psychosomatic factors affecting the outcome after total knee-arthroplasty (TKA)]. / Übersicht zu psychosomatischen Aspekten des Kniegelenksersatzes (TKA).

A review on psychosomatic factors affecting the outcome after total knee-arthroplasty (TKA) Objectives: In today's ageing Western societies, arthroplasty is a common treatment for endstage osteoarthritis. Despite highly developed implants and surgery, however, this treatment does not always succeed in relieving pain and restoring joint function, i.e., in restoring satisfactory algofunction. Clinicians partly blame psychological factors for this discrepancy, especially in the absence of objective medical complications. METHODS: The present review summarizes previous studies on the role of psychosomatic interactions affecting the course after total knee arthroplasty (TKA). RESULTS: During the perioperative period, patients with TKA suffer from marked psychic distress that is also linked to the postoperative algofunction. CONCLUSIONS: We discuss the theoretical and clinical implications of the findings reviewed.

Changes in brain activity of somatoform disorder patients during emotional empathy after multimodal psychodynamic psychotherapy.

Somatoform disorder patients show a variety of emotional disturbances including impaired emotion recognition and increased empathic distress. In a previous paper, our group showed that several brain regions involved in emotional processing, such as the parahippocampal gyrus and other regions, were less activated in pre-treatment somatoform disorder patients (compared to healthy controls) during an empathy task. Since the parahippocampal gyrus is involved in emotional memory, its decreased activation might reflect the repression of emotional memories (which-according to psychoanalytical concepts-plays an important role in somatoform disorder). Psychodynamic psychotherapy aims at increasing the understanding of emotional conflicts as well as uncovering repressed emotions. We were interested, whether brain activity in the parahippocampal gyrus normalized after (inpatient) multimodal psychodynamic psychotherapy. Using fMRI, subjects were scanned while they shared the emotional states of presented facial stimuli expressing anger, disgust, joy, and a neutral expression; distorted stimuli with unrecognizable content served as control condition. 15 somatoform disorder patients were scanned twice, pre and post multimodal psychodynamic psychotherapy; in addition, 15 age-matched healthy control subjects were investigated. Effects of psychotherapy on hemodynamic responses were analyzed implementing two approaches: (1) an a priori region of interest approach and (2) a voxelwise whole brain analysis. Both analyses revealed increased hemodynamic responses in the left and right parahippocampal gyrus (and other regions) after multimodal psychotherapy in the contrast "empathy with anger"-"control." Our results are in line with psychoanalytical concepts about somatoform disorder. They suggest the parahippocampal gyrus is crucially involved in the neurobiological mechanisms which underly the emotional deficits of somatoform disorder patients.

Contemporary perspectives on psychosomatics in Germany: A commentary on Karen Gubb's paper, "Psychosomatics today: a review of contemporary theory and practice".

Karen Gubb's (2013) review focuses on contemporary developments in psychoanalytic theory and practice in relation to psychosomatics, starting with some historical remarks, and Paris School with the Attachment approach. This paper examines the question of how the German scene fits into the issues raised in Gubb's discussion. From a historical point of view, psychosomatic thinking had already come into existence at the beginning of the twentieth century in internal medicine, influenced not only by Freud's ideas, but also by holistic philosophical approaches, anthropology, and semiotic systems theory as well. Psychosomatics is still under the influence of psychodynamic thinking, but as a required subject for all medical students, it is currently more involved in inpatient treatment settings than in psychoanalyses in the classical couch setting. Research projects using standardized questionnaires, neuroimaging, and other empirical methods have also proved that these treatments are as effective as therapy based on psychoanalytic concepts like alexithymia or the Attachment approach. In addition, qualitative methods have been implemented to grasp the fine-grained conscious and unconscious processes in the inner life of patients and in the verbal and nonverbal interaction phenomena of therapies. To sum up: Recent developments in psychoanalytic theory, which begin to overcome the differences among psychoanalytic schools in favor of re-erecting a common psychoanalytic understanding like that demonstrated in Gubb's article, fit together in bridging the gap between insights from classical psychoanalyses and results from empirical research.

[Pregnancy experiences of women with pregnancy-induced hypertension]. / Schwangerschaftserleben von Frauen mit schwangerschaftsinduzierter Hypertonie- eine qualitative Untersuchung.

OBJECTIVES: The study assesses the experience of pregnancy of women who have pregnancy induced hypertension (PIH) compared to women with an uncomplicated course of pregnancy. METHODS: 21 women were retrospectively investigated between 5 and 13 months after giving birth via a semistandardised interview focussing on the personal experience of pregnancy. The interviews were analysed by means of qualitative content analysis. The categories "development and course," "coping with anxiety," "image of one's mother" and "relationship with partner" were determined and described. Finally, we developed data-driven, ideal-type models of pregnancies with pregnancy-induced hypertension versus normal pregnancies by detecting the similarities and contrasts between the groups. RESULTS: Interviewees with pregnancy-induced hypertension showed an ambivalence with regard to their pregnancy, which was more often than not unplanned and/or unwanted. Conflicts with significant others, especially with their partners, were also reported more often. Emotions tended to be understated. DISCUSSION: The results can be employed in the operationalisation of future projects in a hitherto unclear research field. They should also be considered in the care of patients with pregnancy-induced hypertension.

Altered brain activity during emotional empathy in somatoform disorder.

Somatoform disorder patients suffer from impaired emotion recognition and other emotional deficits. Emotional empathy refers to the understanding and sharing of emotions of others in social contexts. It is likely that the emotional deficits of somatoform disorder patients are linked to disturbed empathic abilities; however, little is known so far about empathic deficits of somatoform patients and the underlying neural mechanisms. We used fMRI and an empathy paradigm to investigate 20 somatoform disorder patients and 20 healthy controls. The empathy paradigm contained facial pictures expressing anger, joy, disgust, and a neutral emotional state; a control condition contained unrecognizable stimuli. In addition, questionnaires testing for somatization, alexithymia, depression, empathy, and emotion recognition were applied. Behavioral results confirmed impaired emotion recognition in somatoform disorder and indicated a rather distinct pattern of empathic deficits of somatoform patients with specific difficulties in "empathic distress." In addition, somatoform patients revealed brain areas with diminished activity in the contrasts "all emotions"-"control," "anger"-"control," and "joy"-"control," whereas we did not find brain areas with altered activity in the contrasts "disgust"-"control" and "neutral"-"control." Significant clusters with less activity in somatoform patients included the bilateral parahippocampal gyrus, the left amygdala, the left postcentral gyrus, the left superior temporal gyrus, the left posterior insula, and the bilateral cerebellum. These findings indicate that disturbed emotional empathy of somatoform disorder patients is linked to impaired emotion recognition and abnormal activity of brain regions responsible for emotional evaluation, emotional memory, and emotion generation.

[Surviving the initial phase: subjective theories of illness in patients suffering from acute leukaemia at the end of initial inpatient treatment]. / Das Überleben der initialen Phase: Subjektive Krankheitsvorstellungen von Patienten mit akuter Leukämie zum Ende der stationären Erstbehandlung.

OBJECTIVES: Studies concentrating on the temporal dependence of subjective concepts during oncological treatment are underrepresented. Subjective interpretation contexts develop in the course of illness. The study focuses on the ideal-typical gestalt of these contents. METHODS: In a follow-up study on coping, 12 patients with acute leukaemia (AL) were interviewed using a semistructured interview at the end of initial inpatient treatment. Using qualitative methodology, we inductively developed categories and assigned them to formal main categories. RESULTS: The following categories were developed: causal uncertainty as burden; discrepancy between subjective and objective assessment of degree of threat; knowledge of disease: conflict between information-seeking and information-avoiding behavior; dominance of medical approach to treatment; pursuit of normality; defense of emotions; orientation to workflows on the ward; adjustment as a coping strategy; positive attitude as a resource; life between hope and fear; limited future; latent fear of death. CONCLUSION: Themes of coping with the disease become visible. Some of these contents are tacit and latent, although of high subjective relevance to the patient. Their consideration could improve the patient-physician relationship.

[The usefulness of the Brief Symptom Inventory 18 (BSI-18) in psychotherapeutic patients]. / Der Einsatz des Brief Symptom Inventory 18 (BSI-18) bei Psychotherapiepatienten.

The BSI-18, an abridged version of the Brief Symptom Inventory of Derogatis, contains the 3 six items scales Somatization, Depression, Anxiety, and the Global Score (GSI). In a sample of N=638 psychotherapeutic patients, reliability and validity were proven. Reliability of the 3 scales was good: Somatization α=0.79, Depression α=0.84, Anxiety α=0.84, and GSI α=0.91. The postulated three-factor structure was proven sufficiently using confirmatory and explorative factor analyses. The questionnaire separated different patients groups. Judgments of the therapists corresponded well with the self-rating behavior of the patients. In conclusion, the psychometric evaluation of the BSI-18 resulted in persuasive evidence for its reliability and validity. The loss of information, as a result of item reduction, is acceptable analyzing large samples; in cases of individual analyses, the SCL-90-R is advised.

Multimodal psychodynamic psychotherapy induces normalization of reward related activity in somatoform disorder.

OBJECTIVES: Somatoform disorder patients demonstrate a disturbance in the balance between internal and external information processing, with a decreased focus on external stimulus processing. We investigated brain activity of somatoform disorder patients, during the processing of rewarding external events, paying particular attention to the effects of inpatient multimodal psychodynamic psychotherapy. METHODS: Using fMRI, we applied a reward task that required fast reactions to a target stimulus in order to obtain monetary rewards; a control condition contained responses without the opportunity to gain rewards. Twenty acute somatoform disorder patients were compared with twenty age-matched healthy controls. In addition, 15 patients underwent a second scanning session after participation in multimodal psychodynamic psychotherapy. RESULTS: Acute patients showed diminished hemodynamic differentiation between rewarding and non rewarding events in four regions, including the left postcentral gyrus and the right ventroposterior thalamus. After multimodal psychodynamic psychotherapy, both regions showed a significant normalization of neuronal differentiation. CONCLUSION: Our results suggest that diminished responsiveness of brain regions involved in the processing of external stimuli underlies the disturbed balance of internal and external processing of somatoform disorder patients. By providing new approaches to cope with distressing events, multimodal psychodynamic psychotherapy led to decreased symptoms and normalization of neuronal activity.