[Bio-Psycho-Social Therapy for Stress-Induced Chronic Pain]. / Bio-psycho-soziale Therapie bei stressinduzierten Schmerzzuständen.

Bio-Psycho-Social Therapy for Stress-Induced Chronic Pain Abstract. Against the background of latest neurobiological and epigenetic findings the bio-psycho-social model of disease is outlined often misinterpreted in the context of chronic pain. It represents the basic principle for a personalized treatment of stress-induced chronic pain. Consequences for diagnostic procedures are delineated to detect this pathogenetic subgroup of chronic pain patients (e.g. fibromyalgia, back pain, temporomandibular dysfunction, tension headache). Finally, the principles of a bio-psycho-social treatment program with high efficiency are presented.

[Health-related long-term effects of adverse childhood experiences - an update]. / Gesundheitliche Langzeitfolgen psychosozialer Belastungen in der Kindheit - ein Update.

In the last decade strong empirical evidence from several long-term studies supports the conclusion that physical and sexual abuse as well as emotional deprivation in childhood make people significantly more vulnerable to mental and functional disorders across their lifetime. Additionally, an increased vulnerability to several somatic disorders (cardiovascular disorders, type-2-diabetes, hepatitis, chronic obstructive pulmonary disease (COPD), immunological and pain disorders, pharynx and lung cancer) was demonstrated - most of them with a reduced life expectancy. A review of the current research will be presented that outlines the underlying developmental neurobiological and psychological mechanisms mediating these long-term effects. There is now sufficient evidence about familial risk constellations that demonstrates the well-documented impact of specific prevention strategies by several model projects. Only by establishing these strategies, future enormous health-related burdens and high economic costs (unfitness to work, early retirement) can presumably be limited.

Manualized psychodynamic-interactional group therapy for the treatment of somatoform pain disorders.

Medically unexplained and clinically significant symptoms of pain are highly prevalent in the general population. More than one third of all patients in general practices and various departments of hospitals suffer from somatoform disorders with pain being the main complaint of 70% of these patients. This treatment manual is the first disorder-specific, psychodynamically oriented treatment for these patients. Based on psychodynamic-interactional group psychotherapy, it focuses on disorder-specific aspects as well as on psychic and interpersonal problems which have resulted from adverse childhood experiences and insecure attachment. In three treatment phases comprising an "information and motivational phase" followed by "work" and ultimately "transfer" phase spread over a period of 6 to 7 months, between seven and nine patients were treated in 40 group therapy sessions. The group started with psychoeducational elements intended to inform them about their illness. Through the discussion and formulation of individual treatment goals, the patients are drawn into the work phase of the group therapy, in which the relationship of the patients in the group and their behavior is the main focus of the therapeutic interventions.

[Determinants of quality of life in patients with somatoform disorders with pain as main symptom - the case for differentiating subgroups]. / Determinanten der Lebensqualität bei somatoformen Störungen mit Leitsymptom Schmerz - Plädoyer für eine Subgruppen-Differenzierung im ICD-11.

OBJECTIVES: What impact do the degree of somatization and the presence of a comorbid psychological disorder have on health-related quality of life in patients with pain-dominated somatoform disorders? METHODS: 282 consecutive patients (57.6 %) from a total population of N=490 patients fulfilling the criteria of somatoform pain disorders were included in the study following a thorough interdisciplinary diagnostic process at a German university hospital. Structured interviews (SKIDI and SKID-II) to assess comorbid psychological disorders as well as a structured biographical interview to assess chronification factors were conducted. We employed the Screening for Somatoform Disorders form (SOMS) to discover the extent and distribution of somatic symptoms and the SF-36 to determine the health-related quality of life. RESULTS: The patients exhibited a multiplicity of further somatic complaints apart from pain. 69 % had a comorbid psychological disorder. The health-related physical and psychological quality of life was clearly impaired in patients with "small", "substantial" and "pronounced" somatization. Regression analysis explained 48 % of the variance of the body-related and 35 % of the variance of the psychological quality of life: Besides the extent of somatization, older age, duration of pain-associated hospitalizations and the subjective amount of occupational impairment proved to be important. With regard to the psychological (but not the somatic) health-related quality of life, the presence of a current comorbid psychological disorder was also relevant. CONCLUSION: Patients with pain-dominated somatoform disorders are substantially impaired in their quality of life. Because 31 % of the patients with such disorders have no additional comorbid psychic disorder and the existence of a comorbid psychic disorder impacts only the psychological domain of their health-related quality of life, the results appear to strongly support maintaining the diagnostic category of somatoform disorders in ICD-11 and DSM-V. They also support the grading of the severity of the somatization similar to the grading of depressive disorders.

[The symptom checklist-27 in Germany]. / Die Symptom-Checkliste-27 in Deutschland.

The symptom-checklist SCL-27 is a short, multidimensional screening instrument for mental health problems. It contains six subscales, i. e. depressive, dysthymic, vegetative, agoraphobic, sociophobic symptoms, symptoms of mistrust and a global severity index (GSI-27). A survey is presented in two representative samples with overall more than 4500 subjects. The scales of the SCL-27 show satisfying reliability (Cronbach's alpha > 0.70 for all subscales and alpha > 0.90 for global severity) throughout, as well as a largely congruent six factor structure (Comparative Fit Index CFI = 0.91, Standardisized Root Mean square Residual SRMR = 0.04). While women presented with higher scores in the year 1996 on almost all subscales, this was no longer observed in 2003. Additionally, age-effects were less pronounced in 2003 than in 1996.

[Somatoform disorders--an update]. / Hilfe fir Patienten mit somatoformen Störungen. Sagen Sie bloss nicht: "lhnen fehlt nichts!"

Somatoform disorders occur frequently. The patients complain about numerous physical problems and/or pain for which, as a rule, an organic pathological cause cannot be not found. They are not willing to or cannot accept psychosomatic explanations. The real cause is faulty stress processing due to earlier biographical factors, for example, an early attachment disorder. A behavioral therapy could help the patient cope with the everyday routine; it influences the symptoms and signs, but does not fundamentally change them. Psychodynamic approaches are very promising. For comorbidity with anxiety or a depressive disorder as well as certain forms of fibromyalgia, psychopharmaceutical drugs should be additionally given.

Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together.

Fibromyalgia (FM) is a controversial syndrome, characterised by persistent widespread pain, abnormal pain sensitivity and additional symptoms such as fatigue and sleep disturbance. The syndrome largely overlaps with other functional somatic disorders, particularly chronic fatigue syndrome (CFS). Although the exact aetiology and pathogenesis of FM are still unknown, it has been suggested that stress may play a key role in the syndrome. This article first reviews the function of the stress response system, placing special emphasis on the relationships between adverse life experiences, stress regulation and pain-processing mechanisms, and summarising the evidence for a possible aetiopathogenetic role of stress in FM. Finally, an integrative biopsychosocial model that conceptualizes FM as a stress disorder is proposed, and the clinical and research implications of the model are discussed.

[Funded research in psychosomatic medicine, medical psychology, and psychotherapy]. / Drittmittelforschung im Bereich der Psychosomatischen Medizin, Medizinischen Psychologie und Psychotherapie. Bestandsaufnahme, Fördermöglichkeiten und Empfehlungen.

This paper, summarizing the activities of the research task force of the German College of Psychosomatic Medicine (DKPM), reviews how research in psychosomatic medicine, medical psychology and psychotherapy has been funded by different institutions. The review reveals that psychosocial research has received considerable grants especially by the German Research Council and the Federal Ministry of Education and Research but also from other funding institutions. Besides an overview of potential sources for funding in the psychosocial disciplines, recommendations are formulated that might be helpful for raising research funds in the future.

[Symptom Checklist SCL-27]. / Die Symptom-Checkliste SCL-27 - Ergebnisse einer deutschen Repräsentativbefragung.

The Symptom-Checklist-27 (SCL-27) forms a modification of the widely used Symptom-Checklist-90-R, with the latter demonstrating considerable shortcomings in psychometric properties. The SCL-27 is designed to screen for psychiatric symptoms in patients presenting somatic complaints. It contains the six subscales depressive, dysthymic, vegetative, agoraphobic, sociophobic symptoms and symptoms of mistrust. Additionally, a global severity index (GSI-27), similar to the GSI in the SCL-90-R is available. The subscales are short, the number of items varies between four and six. Psychometric properties and reference values based on a representative German sample of more than 2000 subjects are presented for the various subscales. All subscales show sufficient internal consistency with Cronbach's alpha > or = 0.70 and for the GSI-27 alpha is = 0.93. The correlation between GSI-27 and GSI is r = 0.93. Sex-specific cut-offs are presented to identify those patients, who need further examination.

[Fibromyalgia as a dysfunction of the central pain and stress response]. / Fibromyalgie als Störung der zentralen Schmerz- und Stressverarbeitung - Ein neues biopsychosoziales Krankheitsmodell -

Fibromyalgia is often understood as a syndrome mainly characterised by widespread pain and tenderness and "unexplained" etiology and pathogenesis. In the last years evidence is growing that biological as well as psychosocial stress play a pathogenetic key-role. Beginning with the general function and development of the stress response system the actual knowledge of its relationship with central pain-processing mechanisms is reviewed. Early adverse childhood experiences can impair the function of the stress system all over the lifespan. Subsequently, research evidence for the role of stress in the etiopathogenesis of fibromyalgia is summarised. Psychological as well as psychobiological consequences are outlined. Finally, an integrative model of fibromyalgia is proposed, which may put several pieces of a biopsychosocial puzzle together. This model offers an approach for the differentiation of subgroups and a clinical orientation for developing an adequate therapy for the individual patient.

[Predictors of quality of life after orthopedic treatment of lower back pain due to lumbar intervertebral disc disorders]. / Prädiktoren der Lebensqualität nach orthopädischer Behandlung lumbaler "bandscheibenbedingter" Rückenschmerzen.

OBJECTIVES: To investigate the relevance of somatic, psychic and psychosocial factors on the health-related quality of life at the one year follow-up of patients with lower back pain. METHODS: Prospective cohort study of 109 patients recruited consecutively. At baseline and at one year follow-up self-report instruments were administered to evaluate health-related quality of life (SF-36), psychic or psychological distress (SF-36), and coping strategies (FKV-LIS). RESULTS: In regards to the physical and mental dimensions of the quality of life at follow-up, psychosocial factors evaluated at baseline were far more relevant. Using a multiple regression analysis we were able to account for 38 % of the variance in the physical dimension of the quality of life and 45 % of the variance in the mental dimension. In these two dimensions the factors "psychic distress" (GSI, SCL-90-R) and "sick leave" were significant predictors, in the mental dimension additionally "doctor shopping". Beyond that, impaired health-related quality of life at baseline as well as at follow-up was related to depressive coping (FKV-LIS). CONCLUSIONS: The study shows the high impact of psychic and psychosocial factors on health-related quality of life in patients with chronic lower back pain.

Childhood adversities in patients with fibromyalgia and somatoform pain disorder.

Primary fibromyalgia is regarded as disorder with a complex symptomatology, and no morphological alterations. Findings increasingly point to a dysfunction of the central nervous pain processing. The study aims to discuss vulnerability for fibromyalgia from a developmental psychopathological perspective. We investigated the presence of psychosocial adversities affecting the childhood of adult fibromyalgia patients (FM) and compared them to those of patients with somatoform pain disorders (SOM) and a control group (CG) with medically explained chronic pain. Using the structured biographical interview for pain patients (SBI-P), 38 FM patients, 71 SOM patients, and 44 CG patients were compared on the basis of 14 childhood adversities verified as relevant regarding longterm effects for adult health by prospective studies. The FM patients show the highest score of childhood adversities. In addition to sexual and physical maltreatment, the FM patients more frequently reported a poor emotional relationship with both parents, a lack of physical affection, experiences of the parents' physical quarrels, as well as alcohol or other problems of addiction in the mother, separation, and a poor financial situation before the age of 7. These experiences were found to a similar extent in the SOM patients, but distinctly less frequently in the CG. The results point to early psychosocial adversities as holding a similar etiological meaning in fibromyalgia as well as in somatoform pain disorders. The potential role of these factors as increasing the vulnerability for fibromyalgia is discussed.

[Diagnostic subgroups and psychosocial characteristics in chronic non-malignant pain patients referred to an out-patient pain center]. / Diagnostische Subgruppen und psychosoziale Charakterisierung von Patienten einer universitären Schmerzambulanz.

The purpose of this study is to describe an out-patient Pain Center population on the basis of IASP Classification of Chronic Pain. Furthermore, the study investigates the relationship between diagnostic subgroups of chronic non-malignant pain patients and psychosocial parameters. The average age of the patients was 42 and the mean age at the onset of pain was 34.2. In the present study about x of all the patients had severe pain with a duration of 48 months (median value), patients with dysfunctional pain, one of three diagnostic subgroups, had a significantly longer pain duration (80 months). Nearly (1/3) of all patients are not able to work regularly and 85 % felt impaired in their daily work activities. Nearly (1/3) of the patients without any somatic pathological findings had at least one invasive intervention, just like the patients in the other diagnostic subgroups, and the need-controlled pain medication reached its highest level in this group (45 %). Only 19 % of the 323 patients investigated had nociceptive-neuropathic pain complaint, whereas 53 % were suffering from dysfunctional, and 28 % had a somatoform pain disorder. So, in patients suffering from chronic pain, simultaneous somatic and psychic or psychosomatic diagnostics are indispensable due to the relevance of psychic and psychosocial factors to pain genesis, modulation and persistence. For patients in each of the described subgroups additional psychological factors such as attitudes, beliefs, self-efficacy, fear-avoidance beliefs and motivational factors always have a significant influence on the persistence of chronic pain syndromes. So, as a rule, to make a reliable diagnosis and to give a profound prognosis for the course of treatment, a close interdisciplinary cooperation is required.

Psychosocial factors in subjects with thyroid-associated ophthalmopathy.

General agreement has emerged that the perceptions of patients of how they are feeling and how they are able to function in daily life should be included in the evaluation and monitoring of the effects of disease and treatment. Thyroid-associated orbitopathy (TAO), an inflammatory autoimmune eye disease, affects 50%-60% of patients with Graves' hyperthyroidism. Having blurred vision and/or diplopia has a detectable and significant impact on functional status and well-being, especially in role limitations caused by physical health problems. Therefore, to assess the impact of TAO on quality of life, we performed a descriptive study on consecutive ophthalmopathy patients with varying degrees of severity of TAO. General quality of life was assessed using a brief, internationally accepted, and standardized general questionnaire: the Medical Outcomes Study (MOS-36). In comparison to a large German reference group, low scores on the MOS-36 were found. Marked and significant differences from the control group were especially observed for the following items: vitality, social functioning, mental health, health perceptions, and body pain. MOS-36 did not correlate with the duration or severity of the ophthalmopathy. These results demonstrate the impact of a common visual symptom on health status and well-being, as measured by the MOS-36. In addition, comparison of the impact of various symptoms and conditions provides important and potentially clinically relevant information. In conclusion, we have shown that TAO has a large influence on the quality of life of these patients. The negative impact on well-being seems not to be related to the usual clinical assessment. These findings underscore the need for quality of-life measurements in prospective and controlled clinical trials.

The relevance of anxiety, depression, and coping in patients after liver transplantation.

The aim of this study is to investigate the effects of anxiety, depression, and coping on quality of life in patients after liver transplantation. Patients were asked to fill out a postal survey. Two hundred thirty-six of 375 patients (63%) who entered the study returned the questionnaires, and 186 of these patients could be included in the assessment. Anxiety and depression were surveyed using the Hospital Anxiety and Depression Scale; health-related quality of life, using the 36-Item Short-Form Health Survey; and coping strategies, using the Freiburg Questionnaire on Coping With Illness. In terms of physical and mental dimensions of health-related quality of life, psychosocial factors are far more relevant in liver transplant recipients than purely somatic factors, such as the number of posttransplantation complications or length of hospital stay. Through multiple regression analysis, we were able to account for 51% of the variance in the physical dimension of health-related quality of life and 58% of the variance in the mental dimension. Physical factors of depression, age, and employment and mental factors of anxiety and depression were significant for predicting health-related quality of life after liver transplantation. Depressive coping, anxiety, and depression, as well as aspects of the social environment, contribute considerably to determine well-being and health-related quality of life of patients after liver transplantation.