All medicine is ultimately "psychosomatic"

Psychiatric-psychosomatic disorders are frequently encountered. Therefore, they should be included in the differential diagnosis. The core of the treatment is psychotherapeutic. Intensive multidisciplinary approaches are offered in clinics.

Psychosomatic complaints are extremely common in family practice and often cause high treatment costs and chronic suffering.
The term “psychosomatic” focuses on the fact that almost all mental disorders (e.g., anxiety disorders, depression, somatoform disorders) have numerous psychovegetative symptoms that initially lead the sufferer to suspect a primarily physical ailment. Mental disorders also result in behavioral patterns that promote physical sequelae (e.g., eating disorders, addictive behavior, or malcompliance with somatic comorbidities). Conversely, primarily physical illnesses can trigger secondary psychological disorders in the course of their development (e.g., adjustment disorders in cancer or other chronic conditions that severely impair quality of life).

Complicating factors are personality traits or psychosocial circumstances that reduce a person’s coping ability in certain constellations to the point of decompensation.

Psychosomatics in medicine and society

Basically, it can be stated that actually all medicine is a “psychosomatic” one, not forgetting the social, cultural and life history aspects of each person. It is also essential to observe that, despite all the awareness campaigns, mental phenomena are still subject to stigmatization (both socially and intrapsychically, i.e. subjective feelings of guilt and shame in the face of mental health problems) and are therefore not spontaneously reported in many cases. There is also a primary lack of knowledge about psychovegetative functional circuits, so that patients often suspect anxiety-related physical illnesses and consider psychological connections unlikely.

It is not always easy to make a clear medical decision as to how much somatic-diagnostic clarification is useful and appropriate.

Communication

A very essential competence in (general) medical practice is the ability to communicate appropriately to the situation. A helpful, easily understandable and learnable concept is offered, for example, by the so-called “motivational interviewing” according to Miller and Rollnick. This is based on the fundamental attitude of a respectful, eye-level, i.e. equal doctor-patient relationship. It is essential for physicians not to be too quick to interpret and present possible solutions, but to take more time (relatively speaking) for open listening and to grasp the patient’s motives, goals and own resources. Open questions and non-judgmental commenting are elements that can change a conversation atmosphere decisively and demonstrably do not cost more time in everyday life. A patient who may feel less pressured in this way gains more confidence, reports crucial details, and develops initiative for action on his or her own.

Treatment approaches

Patients who eventually seek “psychosomatic” treatment are often still self-conscious, skeptical, and anxious-worried about the unfamiliar psychotherapeutic approach. This is the central focus of the treatment: It is again essential to precisely identify as many internal and external factors, stresses and resources as possible. In addition, a precise diagnostic assessment is carried out by a specialist doctor or psychologist, since many profound mental disorders (such as psychoses or dementias) begin insidiously with non-specific symptoms and therefore need to be evaluated precisely. At the beginning of treatment, the focus is on building trust and communicating an understandable model of the disorder. The patient is encouraged to observe symptoms, behaviors, and conditioning factors so that they can be gradually classified. The goal of behavioral therapy approaches, for example, is to achieve a gradual modification of inner guiding principles, mental evaluations, and non-reflective behaviors through situation analyses in which thoughts, feelings, physical symptoms, and behavioral aspects are presented in detail. This should result in greater room for maneuver, a more differentiated behavioral repertoire, and more inner freedom – an essential pillar of psychological stability.

Psychosomatic clinics

Psychosomatic clinics offer multimodal treatment concepts that include many movement- and body-centered offerings in addition to medical and psychological psychotherapy. Many patients also find the art therapy services very effective, including design and painting therapy, music therapy, and movement and dance therapy. Artistic, not primarily language-based expression can often trigger intense emotional processes and provide very significant impulses for psychotherapy. Clinics offer the decisive advantage of coordinated therapy as a team with regular interdisciplinary exchange.

The medical history is explored in detail, necessary further somatic clarifications are organized. Psychiatric-psychological an accurate differential diagnosis of psychopathology is worked out, then a treatment plan with the appropriate psychotherapeutic interventions is prepared. As mentioned, a sufficiently long period of time is often required for motivation building and psychoeducation (information about the context of the mental disorder). Parallel to this, units begin in physiotherapy, occupational therapy and activation therapy that promote movement, action and relaxation and, individually tailored to the patient’s starting level, contribute as continuously as possible to a small sense of achievement. Art therapy is also customized. Among other things, there are very good approaches here for the treatment of psychological traumatization, which precedes many disturbance patterns. In addition, depending on the situation, nutritional counseling (combined with balanced and specialized cuisine) and social counseling are offered.

It is also important to plan the procedure well in advance after the patient leaves the hospital, so that the successes of the inpatient treatment do not disappear again immediately in everyday life. The involvement of the social environment, the employer and other important reference persons should always be sought. Further therapies (e.g. also occupational therapy at the patient’s home, psychiatric Spitex, job coaching, outpatient psychotherapy) are ideally fixed at the first appointment upon discharge. The continuation of art therapy is also very valuable in some cases and possible for patients with supplementary insurance or upon application to the health insurance company. It is essential, whenever possible, to discuss the staged career re-entry together with the employer in advance.

The range of psychosomatic clinics is not congruent in every location. It is often worthwhile, especially in complex cases, to contact the clinic directly (by telephone). In many cases, preliminary outpatient consultations are also offered for treatment planning.

Political and economic aspects

The field of “psychosomatics” is in a state of flux: the illnesses that fall under it, or mental disorders in general, are increasingly being identified as ailments that cause enormous medical costs, work absences and retirements among mostly young people. Naturally, however, there are no treatments that can be completely standardized and (cost-)calculated.

In recent years, psychosomatic treatment programs are increasingly being offered by the large psychiatric hospitals as well, and the traditional offering of inpatient psychosomatic rehabilitation is being challenged to some extent. Among other things, this also results in unattractive competition and lobbying. The legislator has the idea of clearly assigning disease patterns to treatment pathways. However, the exact differentiation between psychiatric and psychosomatic disorders is actually not possible from a technical point of view; in fact, in many countries of the world, such a distinction is not made at all, but the term mental disorders (WHO, ICD-10) is used in general. References by payers such as “the patient suffers from a mental disorder and must therefore be treated in a psychiatric clinic” are an expression of the desire for standardization, but very often fail to meet the needs of those affected.

In the last few years, the social insurances (e.g. the IV) have also been acting in a seemingly judgmental manner for those affected (in expert opinions, through pension revisions and cancellations) and have primarily triggered a lack of understanding and even despair, which often leads to increased effort on the part of those treating the patient.

Overall, it can be stated that psychiatric-psychosomatic disorders are very common and are of great importance in terms of both health and social policy due to their high costs (treatment, loss of working hours, disability). Often, patients are already significantly chronic at diagnosis or when they agree to specialized treatment, and therapy becomes more complicated. There are clear, well-evaluated treatment guidelines, but they are difficult to standardize in the time dimension of treatment and expected goal attainment. Health and sociopolitical currents do not always contribute to simplifying access to treatment. Well-designed health services research in this area would be desirable. What is needed are sustainable and professional therapy offers with sufficient variation, since the same setting cannot be used for all patients, especially in psychotherapy.

Take-Home Messages

Psychiatric-psychosomatic disorders are very common in practice and should always be included in the differential diagnosis.
In the case of numerous somatic examinations “without findings”, psychodiagnostics should be sought.
Further training in the field of communication (e.g. motivational interviewing, also for teams) can be very useful for all medical professionals in their daily work.
Intensive and multidisciplinary treatments with a focus on psychotherapy are offered in clinics; in complex cases, it is worthwhile to contact them directly and discuss the case (possibly with a preliminary interview).
The health and socio-political approach to mental illness is currently inconsistent and does not facilitate treatment.