Begutachtung von somatoformen Störungen

As a result of their prevalence somatoform disorders represent a substantial burden not only for health care systems but also for social security and pension programs around the world. In fact, in recent years there has been a steady increase in the number of applicants filing for disability pensions due to such disorders. Recent studies focus on the relationship between biological, psychological and social factors and the subjective experience of somatoform symptoms and their concomitant impairments. Despite this progress, diagnostic work in general remains a challenge. The purpose of this paper is first to discuss a dimensional diagnostic system for somatoform disorders. Secondly based on the dimensions of this diagnostic system, considerations regarding the differentiation of the diagnosis “pain disorder” will be made. Furthermore, considerations concerning the severity and prognosis of somatoform disorders are presented. These considerations should help to assess vocational disability.     

Einschränkungen der Willensfreiheit bei somatoformen Störungen

Etiopathogenetic models of somatoform disorders and philosophical concepts of free will refer to theories of affect processing: affective dysregulation can promote psychosomatic ailments as well as problems in decision making. This observation brings forth the question if freedom of will is impaired in persons with somatoform disorders. By compiling, analyzing and contextualizing relevant models of current neuroscience, psychosomatic medicine and philosophy the psychodynamic construct of alexithymia as an etiologic factor of somatoform disorders and the conceptual integration of affective factors in a model of free will are developed on the basis of a common concept of affect. The synthesis of the discussed results and considerations, the multidimensional impairment of the ability to decide freely and self-determinedly due to somatoform disorders, is critically reflected; however, a blanket assumption is not admissible.     

Zur Inanspruchnahme medizinischer Leistungen bei Patienten mit somatoformen Störungen

Zusammenfassung Somatoforme Störungen sind für das Gesundheitssystem sowohl wegen ihrer hohen Prävalenz und auch wegen der intensiven Inanspruchnahme medizinischer Leistungen von großer Bedeutung. Auch bei psychotherapeutischen Interventionen muss dies berücksichtigt werden, da eine Normalisierung des Inanspruchnahmeverhaltens ein zentrales Behandlungsziel sein sollte. In der vorliegenden Studie wurden Häufigkeit ambulanter Arztbesuche und Variablen des Inanspruchnahmeverhaltens untersucht. Insgesamt wurden 295 Allgemeinarztpatienten mit mindestens zwei organisch nicht hinreichend begründbaren Beschwerden in die Studie aufgenommen. Psychische Störungen und die Inanspruchnahme des Versorgungssystems wurden mit einem strukturierten Interview erhoben; daneben wurden zahlreiche Fragebögen eingesetzt. Die Mehrheit (82%) der untersuchten Patienten erfüllte die Kriterien von mindestens einer somatoformen Störung. Die Anzahl der Arztbesuche in den letzten 6 Monaten belief sich im Mittel auf 15 Kontakte. Sie korrelierten mit der Anzahl somatoformer Symptome, dem Alter, Gesundheitsängsten, genereller Angst und Depressivität. Die Regressionsanalyse bestätigt nur die Symptomanzahl und das Alter als signifikante Prädiktoren des Inanspruchnahmeverhaltens. Implikationen für die Therapie dieser Patientengruppe unter besonderer Berücksichtigung des Hausarztes werden diskutiert.     

Die Beurteilung der Steuerungsfähigkeit bei psychischen Störungen

Psychiatric assessment of culpability is conducted in two steps: firstly, the psychiatric diagnosis is to be made and attributed to one of the legal terms that entail the requirements for diminished or lack of legal responsibility. Secondly, one has to assess from a psychiatric perspective whether the mentally disturbed suspect who was aware of the unlawfulness of the actions was also able to act in accordance with awareness and to refrain from unlawful actions. The latter is called the capacity for self-control. The ultimately legal normative term of capacity for self-control corresponds to psychobiological concepts of executive and motivational self-control as well as to the psychological models of intentional control of actions (Goschke) and ”disactualization” (Janzarik). These concepts and models are outlined and discussed, particularly with regards to paraphilia and behavioral disorders. In the context of these conditions we sometimes find free-floating considerations about the capacity for self-control without even addressing the question whether the severity of the disorder has crossed the threshold for diminished legal responsibility. The author argues the case for an overall view of the suspect’s personality and abilities, weaknesses and decisions as displayed in the history of the criminal act.     

Frühe Störungen aus der Sicht zunehmender Mentalisierung

The term “mentalization” describes the capacity to judge other humans in terms of their mental activities such as wishes, hopes, beliefs and intentions, as well as the ability to think about one’s own thinking. Mentalization and reflective function are equivalent to each other. They play an important role in selforganization, impulse control, and affect regulation. Mentalization develops during approximately the first five years of life on the basis of attachment in Bowlby’s sense. Around the 9th month of life the child begins to understand her mother as an intentional agent. Mirroring by the mother, in a way of reproducing the child’s state of mind but in a slightly different “marked” manner, enables the child to establish a second “objectified” representation of her condition besides her primary unreflected one. Consequences of lacking, unmarked, or distorted mirroring for later narcissistic or borderline personality are discussed. The child begins now thinking, i.e. playing with representations, but the state of brain development allows to conceive of only one reality. Internal world and external reality appear undistinguishably identical. This is called the “equivalence mode” of psychic functioning. As-if-games open, in a further developmental step, the possibility of including a second reality, namely a pretended one. This is called the “pretend mode” of psychic functioning. At age four to five the child has reached the capacity to take multiple realities into consideration, to take the perspective of an other and to decentrate. She now has a “theory of mind”. Patients with early disturbances have reached this stage only partially. They may also regress to one of the earlier modes of psychic functioning as a consequence of stress or trauma. The knowledge of these early mechanisms helps to identify and understand them when they appear in our clinical practice.     

Somatoforme Störungen

The therapy of somatoform disorders should focus on the reduction of physical symptoms. A constant improvement of these symptoms is not possible without the development of the body-self and the body-image, because serious somatoform disorders are always connected with problems of the self-structure, especially of the body-self and the body-image. A treatment approach is presented in a case study.     

Dissoziative Störungen (Konversionsstörungen)

The ICD-10 diagnostic category of dissociative disorders encompasses very different clinical pictures. The so called dissociative disorders of consciousness are characterized by functional disturbances to the psychic domains of consciousness, identity, autobiographic memory and experience of self and the world. The core features of conversion disorders are functional alterations in the sensorimotor systems. The phenomenological heterogeneity is reflected by prevalence rates ranging from very rare to 30% in clinical populations. Traumatic experiences play a crucial role in the etiology and pathogenesis of these disorders. High rates of comorbid disorders, a tendency to a chronic course and a somatic illness concept in patients with conversion disorders complicate the psychotherapeutic approach. Depending on the therapeutic goals, both psychodynamic and cognitive-behavioral treatment forms are suitable.     

Die pharmakologische Behandlung der Bipolaren Störung

Da die Bipolare St?rung eine Erkrankung ist, die jahrelange Therapie erfordert, wird die Akuttherapie der manischen und depressiven Episode einer Bipolaren St?rung gemeinsam mit der Phasenprophylaxe besprochen. Bei der Phasenprophylaxe sollte generell jene Medikation gew?hlt werden, die schon in der Akuttherapie wirksam war. Dabei müssen individuelle substanzspezifische Nebenwirkungen beachtet werden.     

Videotherapie bei postpartalen Störungen

Video recording is currently part of in- and out-patient therapy programs for parents with infants. The observation and analysis of video sequences allow the patient to gain an extraordinary insight with respect to its own experience and behaviour. Video Microanalytical Therapy (VMT) looks for the mother’s positive qualities in her relationship to the child and employs these qualities in order to support successful interactions. VMT is well-suited to the treatment of mothers with postpartal affective or psychotic disorders, because the typical cognitive distortions and reduced perception shown by these mothers can be avoided to a large extent through the use of pictures. In this study, a video microanalytical therapy concept will be presented, that was developed for the treatment of postpartally disordered mothers at the Psychiatric Centre Nordbaden in Wiesloch, Germany.     

Somatoforme Störungen und Bindungstheorie

Somatoform disorders are not only marked by somatic symptoms, but also by significant disturbances in interpersonal relationships. Interpersonal difficulties – including the maladaptive pattern of illness behavior and the resulting difficult doctor-patient-relationship – are an important field of therapeutic intervention (Nickel u. Egle 1999). The interpersonal problems which are characteristic in patients with somatoform disorders draw attention to the developmental aspects of these conditions. Attachment theory provides a promising framework for understanding these developmental features. In the paper presented we therefore apply concepts and observations from attachment theory to somatoform disorders. After a brief review of attachment theory we specifically discuss the developmental aspects of representation formation in somatization. As next, empirical evidence is reviewed that link attachment insecurity to the development of somatoform disorders. Finally a vulnerability model of somatoform disorders is outlined.