Psychosomatics referred to in the medicine a holistic approach and pathology . It looks at the psychological abilities and ways of reacting people in health and illness in their peculiarities and interrelationship with physical processes and social living conditions. The term psychosomatic is a combination of the ancient Greek words ψυχή psyché (breath, breath and soul ) and σῶμα soma (body and body).
As a pathology, psychosomatics takes into account psychological influences on somatic (physical) processes. The theoretical models for explaining the relationships established have varied since the establishment of scientific medicine by Hippocrates of Kos around 400 BC. Chr. Due to time and knowledge considerably. Because of Friedrich Schiller's influence on medium power, he is sometimes made a pioneer of psychosomatic medicine. The complementary counterpart to psychosomatics is somatopsychology : It deals with the inversion, i.e. H. with the effects of physical illnesses on emotional and cognitive processes, is not always differentiated conceptually from psychosomatics.
Psychosomatic medicine represents the practical implementation of psychosomatics in the treatment of illnesses. It deals with illnesses and states of suffering that are caused by psychosocial and psychosomatic factors (including the resulting physical-emotional interactions). Your task is the detection , treatment ( somatotherapeutic , psychosomatic-medical as well as psychotherapeutic ), prevention and rehabilitation of these diseases.
The clinical application areas of psychosomatic medicine include:
- Physical illnesses with their biopsychosocial aspects (e.g. cancer and how to cope with them; see also psycho-oncology )
- Physiological and functional disorders (as side effects of emotions and conflicts as well as as a direct or indirect reaction to psychological or physical trauma; see also post-traumatic stress disorder and adjustment disorders ).
- dissociative disorders (conversion disorders): physical symptoms that can be traced back to unconscious conflicts
- Hypochondria : the belief that you are suffering from an illness and a pathological interest in health and ailments
- Mental disorders associated with physical abnormalities: depression, anxiety disorders, personality disorders .
- mental illnesses that have physical effects: eating disorders .
- Consequences of irresponsible treatment of one's own health (e.g. consumption of harmful, addictive luxury foods and drugs )
Psychosomatic medicine also deals with somatoform disorders as special forms of psychosomatic events in which no organic findings can be proven and psychological factors play an important role in the development and maintenance of symptoms. Frequently occurring complaints that are assigned to this group include pain and functional complaints of the cardiovascular system , the gastrointestinal area and the skeletal and muscular system.
Psychosomatic urology is a stepchild in psychosomatic medicine. In the area of the urogenital organs with their simultaneous function as excretory and sexual organs, there is a complex network of possible functional disorders, and there are starting points for psychosomatic disorders and pain syndromes. Only relatively few specialists deal with this matter. In the misunderstanding of the psychosomatic connections, prostatitis is one of the most common misdiagnoses in urology.
An example of a psychophysiological connection: Fear causes the adrenal glands to secrete adrenaline , which inhibits gastrointestinal peristalsis via the autonomic nervous system , which can lead to digestive disorders if it is exposed for a long time . Many everyday expressions are based on this connection: something is “heavy in the stomach”, one thing is “hard on your kidneys”, the shock “gets into your limbs”, someone has “got a louse down your liver ”. In addition, the word hypochondriac is derived from the hypochondrium , the abdominal region below the costal arches on both sides of the pit of the stomach . Extraordinary emotional stress can cause stress cardiomyopathy in some people . The limbic system , the thalamus as the sensory center, the vegetative nervous system and the endocrine glands , which receive impulses from the vegetative nervous system for the release of neurotransmitters and hormones , play an important role as mediators and neurobiological interfaces between mental and physical processes . These relationships and their mechanisms of action belong to the research areas of psychoneuroimmunology and psychoneuroendocrinology .
History and theoretical concepts
The origins of psychosomatic medicine can be traced back to the beginnings of medicine (cf. the history of medicine ). In the history of philosophy, the debate about the mind-body problem has been a central question since ancient times; Schipperges referred to the origins of this dispute in the Mesopotamian civilizations. Psychosomatics is also briefly mentioned in the Book of Proverbs of Solomon in the Old Testament: "A happy heart brings you speed improvement, but a broken spirit dries up the bones." (Prov. 17, 22; Elberfeld Bible 1871). According to the records of his secretary Dschuzdschani also diagnosed Avicenna in the 11th century in Kurganag in Bukhara psychological reasons for somatic complaints of his patients.
Georg Ernst Stahl is considered to be the pioneer of psychosomatic medicine in medicine .
The word psychosomatic was coined in 1818 by Johann Christian August Heinroth (1773–1843). As a " psychic ", Heinroth tried to understand every illness in its overall psychological, somatic and life-historical context. With his moralistic interpretation of illness (he described every “disturbance of the soul” as an apostasy from God and “holy reason”, as the evil and devilish par excellence), however, he was close to medieval religious concepts of illness . More modern ideas were published by Erich Stern , for example . Pierre Janet's research on hysteria exerted a strong influence in Germany (1853–1947). Janet laid cognitive foundations that are corroborated in today's psychoneuroimmunology (PNI).
A century later, Georg Groddeck was similarly zealous in missionary terms, but with a completely opposite tendency . In a sanatorium he founded in Baden-Baden, he supplemented the body massages with "relaxation of tension in the soul" with the help of psychoanalysis . In his most popular work, the 1923 released "Book of the It", he understood the physical symptoms of disease as symbols with which the displaced of public morality and suppressed power of life which it gives expression. Groddeck radicalized the approach of Sigmund Freud in his studies on hysteria in 1895: "Psychological excitement that cannot be adequately processed or discharged, 'jumps' into a part of the body, is therefore converted ( conversion )". In this conception, physical suffering is a symbol of unconscious conflict or trauma.
A student of Sigmund Freud was Wilhelm Reich , who was looking for the physical forces that should be a reflection of Freud's instinctual model. His work later led to the development of bioenergetics and the modern body psychotherapy schools specializing in the treatment of psychosomatic ailments. The psychoanalytic explanatory model became decisive for a branch of psychosomatic medicine that is still widespread today (with later, in some cases considerable modifications, including by Felix Deutsch , Otto Fenichel , Harald Schultz-Hencke , Franz Alexander , Max Schur , Arthur Jores and Alexander Mitscherlich ).
A wealth of other impulses came out
- the other depth psychology schools
- philosophical-anthropological approaches (e.g. Ludolf von Krehl : "Unity of Personality", Viktor von Weizsäcker : "Introduction of the Subject into Medicine", Wolfgang Jacob : "Illness and Illness", Medard Boss : "Daseinsanalyse"),
- psychobiological (e.g. Flanders Dunbar ) and psychophysiological drafts (e.g. Walter Cannon : affects as a trigger for vegetative changes; Iwan Petrowitsch Pawlow : conditioned reflexes , Hans Selye : psychophysiological stress model ),
- systems theory (e.g. Thure von Uexküll and Wolfgang Wesiak : "dynamic bio-psycho-social model", Herbert Weiner : "integrative (salutogenic) model of health, illness and illness", George L. Engel : "biopsychosocial model" ).
The term functional syndromes , which is often used in psychosomatics, has led to a rethink in medicine and to the practical application of various new and older disease concepts.
This multitude of theoretical concepts can be seen as an expression of the questions, which for a long time have not been answered consistently, about the mechanisms by which the psychological and the somatic are causally linked. The newer models based on system theory dispense with the search for simple cause-effect chains. This gives up the idea from the pioneering days that certain “psychosomatic diseases” or “psychosomatoses” should be differentiated from other diseases.
Axel Schweickhardt defined in 2005:
“Psychosomatics means that body and soul are two inextricably linked aspects of the human being that are only differentiated for methodological reasons or for better understanding. This does not imply a "linear" causality in the sense that mental disorders cause physical illness. Such a thing would lead to a dualism in which there would be diseases with a psychic origin and diseases with a somatic origin. (…) There is no uniform model for the interactions between the body, psychological processes and the environment. Mostly, partial aspects are described that are taken up by different theories. "
Conversion model : This was developed by Sigmund Freud , who described it in his studies on hysteria . The basic assumption is that the arousal sum of an idea that gives us pleasure is converted into the physical in order to render it harmless.
De- and resomatization : This model was developed by Schur in 1955. It relates to the physical and mental, topical and genetic progressions and regressions described in psychoanalysis . Here it is assumed that psychological problems are expressed through the body (resomatization). It is also believed that this also happens in early childhood when the child has no way of dealing with mental health problems.
Biographical medicine opens up a further approach to psychosomatics. It focuses on the temporal relationship between the symptoms and an unresolved, repressed, and updated conflict. She assumes that in the anamnesis, which is based on the subjective biographical calendar of the patient ( Karl Friedrich Masuhr ), there are memory traces ( Sigmund Freud ) that show exactly the first manifestation of physical and psychological symptoms. Because in the context of life history ( Viktor von Weizsäcker : Why now? ) The phenomena appear against the background of personally important dates (anniversaries). From the point of view of biographical medicine, if one looks not only at the cross-section of symptoms (the what ), but also at the intersection of personal biography and medical history (the when ), then becoming ill shows itself in the biographical situation, which in turn depends strongly on an external one Crisis can be influenced. The three-dimensional view of a crisis is the view of the intersection of medical history, life history and contemporary history.
The neurophysiological model : its foundations were laid by Matthews and Mathews after 2005. They say that there is a neurological area in which a changed perception of one's own body is reflected, the so-called body map. Changes to this map are essential for common eating disorders and disorders of self-perception ( dissociations ).
The research of Ronald Grossarth-Maticek deal with the interactions between physical, biographical and psychological factors and possible synergies. Comprehensive knowledge and advances in the field of psychosomatic medicine are also due to the neurobiologist and doctor Joachim Bauer .
Psychosomatic medicine is a relatively young field. The decision to establish a specialist field of psychotherapeutic medicine was made by the 92nd German Medical Association in Cologne in 1992. In May 2003, the specialist field was renamed Psychosomatic Medicine and Psychotherapy at the Medical Association .
Psychosomatic medicine has existed as a separate subject with systematic scientific research since around 1935. In 1942 the American Psychosomatic Society was founded. In 1950, Germany established the first department for psychosomatic medicine in Heidelberg with financial support from the Rockefeller Foundation (under the direction of Alexander Mitscherlich ). In 1951 Johannes Cremerius founded the psychosomatic counseling centers in the medical and pediatric polyclinic of the Ludwig Maximilians University in Munich . In 1953 a department for inpatient psychotherapy and psychosomatics was founded at the University of Leipzig . A psychoanalytical group around Therese Benedek had already formed there in the 1920s . Little is known that in its pioneering days in the 1920s, the Mitteldeutsche Leipziger Rundfunk broadcast the world's first popular science program on psychoanalysis and psychosomatics, which was designed by Therese Benedek.
In 1962, Horst-Eberhard Richter was appointed to the newly established chair for psychosomatics at the University of Giessen . Richter built the Psychosomatic University Center, of which he became director.
Initial and continuing education
In the Federal Republic of Germany, the medical license to practice medicine of 1970 anchored psychosomatic medicine and psychotherapy for the first time as compulsory subjects in medical teaching. Thereafter, departments for psychosomatic medicine were set up at almost all medical faculties in the Federal Republic. In 1978 the "Specialist for Psychotherapy" was created in the GDR. In 1992, in addition to the neurologist and the specialist in psychiatry and psychotherapy, the field designation “doctor for psychotherapeutic medicine” was introduced in the Federal Republic of Germany and the guidelines for training laid down: “Health and illness must be understood as a complex, often interwoven structure , in which biological, psychological and social elements of health and illness are to be understood as equal conditions of human existence. “In 2003 the German Medical Association changed this name to specialist in psychosomatic medicine and psychotherapy .
According to the model further training regulations of the German Medical Association, the area includes "the detection, psychotherapeutic treatment, prevention and rehabilitation of diseases and states of suffering, in the cause of which psychosocial and psychosomatic factors, including the resulting physical and mental interactions, are significantly involved". There is wide overlap with the training regulations for psychological psychotherapists on the one hand and specialists in psychiatry and psychotherapy on the other.
“Basic psychosomatic care” is also a compulsory component of further training in the other specialist training courses (although with a small number of mandatory hours). All resident doctors who want to bill the services of basic psychosomatic care (psychodiagnostic discussion, psychotherapeutic intervention, relaxation procedures ) for patients with statutory health insurance must provide evidence of a qualification that can be acquired in an 80-hour course. The Balint groups based on a concept by Michael Balint are a widespread method of further training in psychosomatics .
The psychosomatic approach meets a medical system that follows the causality principle of the Cartesian worldview in many areas and tries to assign a certain cause to a disease. Accordingly, the term “psychosomatic” is often not understood in its original meaning by laypeople as well as by representatives of medicine, but is equated with “ psychogenic ”. Patients who suffer from physical symptoms then feel misunderstood and often stigmatized as "conceited sick" or simulators .
It often takes a long time for somatoform disorders to be recognized as such. Studies have shown that some patients had over a hundred medical contacts and around seven years of patient careers before they were referred to a psychotherapist for the first time . This is due, among other things, to the fact that the patients themselves do not want to and cannot accept the psychological components of their complaints - also because the nature of their complaints sometimes only seems to indicate physical "malfunctions".
On the other hand, in exceptional cases, in the case of inadequate examinations and incomplete diagnoses, in the case of physical damage that is difficult to identify (e.g. instability of the cervical spine after a capsular rupture in a facet joint or diffuse symptoms after an injury to the wing ligaments ), the chronic symptoms are interpreted as a psychosomatic problem. This danger arises especially when the suffering from chronic pain leads to depression , which is then mistakenly regarded as a cause rather than a consequence.
Many doctors lack the appropriate training or experience to correctly classify the patient's directional signals. For these reasons, a physical clarification of the complaints must always be carried out in case of doubt. In addition, psychosomatic illnesses must always be treated on a physical level.
There is broad consensus today that most diseases are multi-causal. Regarding the weighting of psychological and physical factors in different clinical pictures, however, there are always different positions between physically oriented physicians and representatives of clinical psychosomatics. New research results lead to shifts in weighting. One example of this is gastric and duodenal ulcers , which used to be one of the " holy seven " of psychosomatic diseases. Since the pathogen (the bacterium Helicobacter pylori ) was discovered in the diseased gastric mucosa in the first half of the 1980s, physical factors have played a major role in the assessment of this disease. A one-week treatment with antibiotics in combination with a two-week administration of a proton pump inhibitor leads to an eradication of the pathogen and a cure in more than 90% of cases. A special significance of the “pronounced nasolabial folds ”, which was previously interpreted as an “infallible characteristic” of the ulcer patient, can neither be observed for the diagnosis of the disease nor the healing success .
Critics of the various psychosomatic ideas point out that these are often not at all or only insufficiently backed up by empirical studies . However, proponents of these models or theories made it appear that they were facts.
The basic work on psychosomatic medicine by Thure von Uexküll "compiles various research results and also tries to achieve more support in terms of professional policy in the sense of shortening long patient careers.
German treatment system
In addition to outpatient treatment by specialists in psychosomatic medicine and psychotherapy, specialists in psychiatry and psychotherapy, appropriately trained doctors or psychological psychotherapists and practitioners qualified in body psychotherapy, inpatient treatment takes place in psychosomatic acute hospitals and psychosomatic rehabilitation clinics.
In 2012, the inpatient acute clinic had a total of 21 psychosomatic university departments, as well as a large number of psychosomatic departments at other acute hospitals with different sponsorships.
The range of psychosomatic rehabilitation offers 175 specialist departments and approx. 16,000 beds in the rehabilitation clinics (occupancy according to § 111 SGB V) as well as around 2,500 beds in the acute psychosomatic facilities (occupancy according to § 108 SGB V). Around 125,000 inpatient measures are carried out in these facilities every year, and the trend is rising.
The main target group of the psychosomatic rehabilitation offer goes beyond the classic psychosomatic indications . Patients with mental disorders such as depression , anxiety disorders or “ burnout syndromes ” are even more frequently represented in the facilities. What is specific about psychosomatic rehabilitation is rather a therapeutic offer that is based on the holistic and function- oriented international classification of functionality, disability and health . In this sense, treatment in psychosomatic rehabilitation facilities can be understood “as a special form of medical rehabilitation in which psychotherapeutic measures are of particular importance as part of a holistic rehabilitation concept”.
- On January 1, 2001, 3,638 psychotherapeutic doctors were registered, of which 2,737 were practicing. 120 of them did not do any medical work.
- At the end of 2000, 1,046 doctors in Austria had the PSY diploma II for psychosomatic medicine, 929 had the PSY diploma III for psychotherapeutic medicine
Literature before 1980
- Franz Alexander : Psychosomatic Medicine: Basics and Areas of Application. 4th edition. De Gruyter, Berlin / New York 1985, ISBN 3-11-010192-0 (reprint from 1951).
- Gustav von Bergmann : Functional Pathology. A clinical collection of results and views of one direction of work. J. Springer, Berlin 1932.
- Flanders Dunbar: Emotions and Bodily Changes. A Survey of Literature on Psychosomatic Interrelationships 1910–1945. 3. Edition. Columbia University Press, New York 1949.
- Flanders Dunbar: Psychosomatic Diagnosis. 5th Pr. Hoeber, New York 1948.
- Flanders Dunbar: Your Soul, Your Body: Psychosomatic Medicine. The Golden Fleece, Frankfurt am Main 1955.
- Georg Groddeck : The Book of It. Boarding school Psychoanalyst. Publishing house, Leipzig 1923.
- Alexander Mitscherlich : Illness as Conflict: Studies on Psychosomatic Medicine. 2. Vol. Suhrkamp, Frankfurt am Main 1966/1967.
- Josef Rattner : Psychosomatic Medicine Today. Mental causes of physical illness. Fischer TB, Frankfurt am Main 1977, ISBN 3-596-26369-7 .
- Ernst Stern: Conflicts in life as causes of illness. An introduction to psychosomatic medicine. Rascher, Zurich 1952.
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- Hans Jörg Weitbrecht : Critique of Psychosomatics , Thieme, Stuttgart, 1955
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- Rolf H. Adler: Introduction to biopsychosocial medicine. Schattauer, Stuttgart / New York 2005, ISBN 3-7945-2423-3 .
- Rolf H. Adler, Wolfgang Herzog, Peter Joraschky, Karl Köhle, Wolf Langewitz, Wolfgang Söllner, Wolfgang Wesiack (eds.): Uexküll Psychosomatic Medicine. Theoretical models and clinical practice. 7th edition. Elsevier, Munich 2011, ISBN 978-3-437-21831-6 .
- Dieter Beck : Illness as self-healing: How physical illnesses can be an attempt at mental healing. Insel, Frankfurt am Main 1981.
- Walter Groom , Paul Christian, Michael von Rad: Psychosomatic Medicine. A concise textbook. 6th edition. Thieme, Stuttgart a. a. 1997, ISBN 3-13-498305-2 .
- Claus Buddeberg: Psychosocial Medicine, Psychosomatics and Psychotherapy in Switzerland. Lines of development over the past 50 years. In: Journal for Psychosomatic Medicine and Psychotherapy . Volume 50, Issue 4, pp. 346-354.
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- Michael Ermann : Psychotherapeutic and psychosomatic medicine. A textbook on a psychoanalytic basis. 5th edition. Kohlhammer, Stuttgart 2007, ISBN 978-3-17-019664-3 .
- Peter Hahn: On the history of psychosomatics. The development of psychosomatic medicine. In: Heinrich Balmer (Ed.): History of Psychology. Vol. 2: Lines of development towards scientific psychology. Beltz, Weinheim u. a. 1982, ISBN 3-407-83046-7 , pp. 248-268.
- Reinhold Haux, Axel W. Bauer , Wolfgang Eich, Wolfgang Herzog , Johann Caspar Rüegg , Jürgen Windeler (Eds.): Scientificity in Medicine, 2: Physiology and Psychosomatics. Attempts to get closer. Frankfurt am Main 1998, pp. 82-130.
- Paul L. Janssen, Peter Joraschky , Wolfgang Tress (Eds.): Guide to Psychosomatic Medicine and Psychotherapy. Oriented towards the further training guidelines of the German Medical Association. Deutscher Ärzte-Verlag, Cologne 2005, ISBN 3-7691-0452-8 .
- Rudolf Klußmann: Psychosomatic Medicine. A compendium for all medical sub-areas. 5th edition. Springer, Berlin a. a. 2002, ISBN 3-540-41717-6 .
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- Johann Caspar Rüegg: Brain, Psyche and Body: Neurobiology of Psychosomatics and Psychotherapy. 4th edition. Schattauer, Stuttgart / New York 2007, ISBN 3-7945-2573-6 .
- Wolfgang Schmidbauer: The secret language of illness. Meaning and interpretation of psychosomatic suffering. Rowohlt, Reinbek near Hamburg 1998, ISBN 3-499-60708-5 .
- Walter Schmidt: Thick neck and cold feet. What sayings reveal about body and soul. A cheerful introduction to psychosomatics. Gütersloher Verlagshaus, Gütersloh 2011, ISBN 978-3-579-06745-2 .
- Manfred Velden: Psychosomatics. V & R Unipress, Göttingen 2007, ISBN 978-3-89971-318-3 . ( Review )
- Thure von Uexküll: Psychosomatic Medicine . 7th edition, Urban & Fischer, Munich 2011, ISBN 978-3-437-21831-6
- Herbert Weiner: The history of psychosomatic medicine and the mind-body problem in medicine. In: Psychotherapy and Medical Psychology. Vol. 36, 1986, pp. 361-391.
- Michael Wirsching: Psychosomatic Medicine. Beck, Munich 1996, ISBN 3-406-40327-1 .
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- Advances in Psychosomatic Medicine. Karger, Basel,
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Professional associations and specialist societies:
- BDPM - Federal Association of Psychosomatic Medicine and Medical Psychotherapy e. V.
- BPM - Professional Association of Specialists in Psychosomatic Medicine in Germany V. (with doctor search engine)
- DGPFG - German Society for Psychosomatic Gynecology and Obstetrics V.
- DGPM - German Society for Psychosomatic Medicine and Medical Psychotherapy e. V. - with list of doctors
- DGPPN - German Society for Psychiatry, Psychotherapy and Neurology
- DKPM - German College for Psychosomatic Medicine
- Basic psychosomatic care courses - Die Deutsche Balintgesellschaft e. V.
- ÖGPPM - Austrian Society for Psychosomatics and Psychotherapeutic Medicine
- Network Psychosomatics Austria
- Swiss Academy for Psychosomatic and Psychosocial Medicine (SAPPM)
- Klemens Dieckhöfer: Psychosomatics. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , pp. 1197 f .; here: p. 1197.
- Federal Medical Association (Working Group of the German Medical Associations): (Sample) Further Education Regulations 2003 (in the version of June 25, 2010). Pp. 126–128 , archived from the original on January 21, 2012 ; accessed on January 3, 2018 .
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- U. Koch and H. Schulz: Further development in psychosomatic rehabilitation . In: G. Schmid-Ott, S. Wiegand-Grefe, C. Jacobi, G. Paar, R. Meermann, F. Lamprech (eds.): Rehabilitation in psychosomatics . Schattauer, Stuttgart 2008, p. 434
- Framework recommendations for outpatient rehabilitation for mental and psychosomatic illnesses. The Federal Working Group for Rehabilitation (BAR). 2004. Frankfurt am Main: self-published.
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