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Psychosomatic Therapy is a holistic approach to the prevention and management of human disease based on the
bilateral relationship between the mind (psyche) and body (soma).
It involves the systematic analysis of the bodys physiology in terms of its shape, size and structure, which have
been determined by an individuals genetics, environment and emotional state. Face and body analysis techniques
enable practitioners to readily identify imbalances in the body, which provide an indication of the clients repetitive
emotional and cognitive behaviours.
All aspects of the physiology are assessed including biomechanical function, quality of muscular tissue, muscle-tofat ratio, weight distribution, structural symmetry and the particulars of facial features.
How does Psychosomatic Therapy work?
Once areas of stress, tension and discomfort are apparent, the aim of the therapist is to restore mental, emotional
and physical balance. A combination of techniques is applied including emotional-release bodywork, counselling,
postural alignment, breathing techniques and detailed body-mind analysis and reporting. The practitioner explores
the mental, emotional, physical and biological aspects of clients overall health and provides them with detailed
assessments with practical exercises so they can understand and participate in their own healing process.
What are the benefits of Psychosomatic Therapy?
Psychosomatic Therapy offers holistic healing benefits to clients as it addresses the emotional and physical factors
that contribute to overall health and happiness. Clients may include individuals who are experiencing physical
ailments, emotional issues or postural problems. Psychosomatics empowers individuals with a deeper
understanding of their innate tendencies and the subtle but powerful changes required to achieve greater
satisfaction in all aspects of life, including their relationships, occupation and health.

Different countries tend to concentrate on different aspects of research or praxis based largely on their
compatibility with cultural or social assumptions of illness. The psychotherapies, behavioral medicine, social
therapies and biological approaches are underscored in a given country and even within the same country
competing therapies strive for hegemony. Problems and limitations of the reductionistic versus the holistic
approaches in psychosomatic research are highlighted.

Against the background of the holistic concept of illness trends of psychosomatic therapy and research are
identified in major countries. Different countries tend to concentrate on different aspects of research or praxis
based largely on their compatibility with cultural or social assumptions of illness. The psychotherapies, behavioral
medicine, social therapies and biological approaches are underscored in a given country and even within the same
country competing therapies strive for hegemony. Problems and limitations of the reductionistic versus the holistic
approaches in psychosomatic research are highlighted.

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Investigations into psychosomatic illness have focused on the relationships between emotional life and bodily
processesboth normal and pathologicaland not on the isolated problems of the diseased mind or the diseased
body. The mind-body dichotomy is eliminated through the thesis that there is no duality of mind and body, mental
and physical, but only a unity of the total being. It is assumed that the physiology of mood, instinct, and intellect
differs from other physiology in degree of complexity but not in quality. Hence, while divisions of medical disciplines
such as physiology, internal medicine, and psychiatry may be convenient for academic administration, biologically
and philosophically these divisions have no validity. Psychic and somatic phenomena take place in the same
biological system and are two aspects of the same process.
The ever-increasing flow of observations concerning the relation of psychological and physiological processes in the
human organism supports this orientation. The influence of specific emotional tensions upon biochemical,
endocrinological, and physiological changes has been studied both clinically and experimentally, as has the
influence of physiological changes upon the emotional life of man.
Modern endocrinology and biochemistry may well be the progeny of the earlier humoral theory that medicine
sought to refute or disregard. The whole man, not just his cells, tissues, and organs, becomes the subject of study
for the modern psychosomatic researcher. Facts are seen as elements of the whole. The gestalt of man is studied
with the appreciation that the whole is more than the sum of the parts; but these parts, nonetheless, are
integrated in such fashion as to contribute to the whole. Personality is the expression of the unity of the organism.
Neurology, neurophysiology, general physiology, endocrinology, biochemistry, pharmacology, and genetics
contribute to our knowledge of the structure and function of the body. Psychology, psychiatry, and psychoanalysis
contribute knowledge of the subjective phenomena which are reflections of physiological processes but are also the
products of past social, cultural, and interpersonal relationships that have become internalized and thus are part of
the integrity of the organism. Franz Alexander observed:
The body, that complicated machine, carries out the most complex and refined motor activities under the influence
of such psychological phenomena as ideas and wishes. The most specifically human of all bodily functions, speech
is nothing but the expression of ideas through a refined musical instrument, the vocal apparatus. All our emotions
we express through physiological processes; sorrow, by weeping; amusement, by laughter; and shame, by
blushing. All emotions are accompanied by physiological changes: fear by palpitation of the heart; anger by
increased heart activity, elevation of blood pressure and changes in carbohydrate metabolism; despair by a deep
inspiration and expiration called sighing. All these physiological phenomena are the results of complex muscular
interaction under the influence of nervous impulses, carried to the expressive muscles of the face and to the
diaphragm in laughter, to the lacrimal glands in weeping, to the heart in fear, and to the adrenal glands and to the
vascular system in rage. The nervous impulses arise in certain emotional situations which in turn originate from our
interaction with other people. The originating psychological situations can only be understood as total responses
of the organism to its environment. (1950, pp. 38-39)
Various somatic manifestations may accompany different transitory emotional states in the normal organism. Thus,
disturbances of the stomach, bowels, cardiovascular system, or respiratory system may be expressions of anxiety.
These upsets are usually reversible, and in such cases morphological changes of the cells, tissues, or organs
involved are nonspecific. The anatomical structure is not permanently or grossly altered; only the function is
disturbed. Since these functional disturbances are triggered by emotional factors, the psychological understanding
of the diseased patient is necessary if one is to assist him fully. This may not require formal psychotherapy, since
the removal of the emotionally stressing external situation may by itself re-establish a level of equilibrium. When
external rearrangements are not possible, the understanding of the anatomical and physiological mechanisms
involved may allow for biochemical and pharmacological interventions that can temporarily interfere with abnormal
pathways of discharge and thus alleviate symptoms during the period of equilibrium re-establishment.
Often an emotionally disturbing situation triggers a conflict which exacerbates a previous conflict constellation that
has been rendered unconscious and largely inactive. In such cases, the functional distress may not be easily
reversed, and chronic symptomatology results. Thus, a functional disturbance of long duration or of overwhelming
intensity may lead to definite and demonstrable anatomical changes and to the clinical picture of severe organic
illness. Research in such diseases as duodenal ulcer, ulcerative colitis, bronchial asthma, neurodermatitis, essential
hypertension, rheumatoid arthritis, thyrotoxicosis, diabetes mel-litus, glaucoma, migraine, and anorexia
nervosa indicates the probability of particular personality constellations having particular vulnerability to specific
conflict situations.
The particular conflicts associated with the individual disorders have been detailed in Studies in Psychosomatic
Medicine (Alexander et al. 1948). In peptic ulcer, for example, it has been found that the individual has a basic core
of infantile oral dependency, which he copes with in various ways, such as overcompensation, aggression, or
assertiveness. When such an individuals coping mechanisms are impaired, or his oral-dependent cravings increase,
he may no longer manage the internal conflict at a psychological level. Increased gastric secretion and/or gastric
vasoconstriction may give rise to symptoms of gastric distress. If there is a decrease in stress on the organism, or
a bolstering of the internal or organic system, strain may be diminished without symptomatic progression and with
symptom remission. If psychic stress continues, what was originally dysfunction may result in an actual organic

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lesion, the peptic ulcer. The oral-dependent characteristics can be detected in dreams, behavior, and general
character structure.
Other conflicts have been linked with particular diseases: repressed hostility with essential hypertension, fear of
separation with bronchial asthma, and fear of destruction of the self with thyrotoxicosis. These conflicts have been
described in detail in Psychosomatic Specificity (1968).
For the present, the functional theory of organic disorders associated with the psychosomatic concept includes the
recognition of three etiological components acting together. Certainexternal causative factors can act as
precipitators of imbalance and give rise to functional or structural disruption. These external factors have their
effect upon underlying internal systems of equilibrium and integration. Thus many chronic disturbances are not
caused by external, mechanical, chemical, or infectious agents, but by the stresses of the struggle for existence.
These emotional conflicts arise during daily living, in the social interchange with signifi cant figures in the
environment that have symbolic as well as actual significance. Finally, one must bear in mind the predispositions to
disequilibrium which reflect constitutional and experiential influences upon the organism. These include genetic
factors, the influence of intrauterine and extrauterine physiological and pathological agents, the crucial parentsibling relationships during critical personality developmental periods of the first decade of life, especially as they
relate to mental functioning, and the impact of personal, social, and cultural influences in child-care and childrearing practices. These predisposing factors constitute the underlying matrix of vulnerability to certain situations
occurring later in life. Continuous and repressed fears, aggressions, and libidinal wishes can, for susceptible
individuals, result in permanent chronic emotional tensions which disturb the functions of various organ systems.
In this way such activities as digestion, respiration, and circulation may at first show signs and evoke symptoms of
functional distress; later, if nothing is done to alleviate the disturbed situation, organic disease may follow.
Many researchers are concerned with the study of specific emotional conflicts and personality organizations as they
relate to particular organic syndromes. For example, the cardiovascular responses intimately linked with rage seem
to be related to essential hypertension, in which inhibited expression of rage is found to be a crucial conflict
(Alexander 1939a; 1939b; Saul 1939). Dependent help-seeking tendencies seem to have a close relationship to
gastrointestinal activity, as is found in many duodenal ulcer patients (Alexander 1947; Alexander et al. 1934; Van
der Heide 1940).
The psychosomatic concept. Although the clinical and experimental study of the mind-body relationship is a
comparatively recent development in medicine, the concept is one that dates back to antiquity. The term
psychosomaticwas first used by Johann Christian August Heinroth (1818, part 2, paragraph 313, p. 49), who
regarded the body and soul as one, and madness as a disease of the entire being. Christian Friedrich Nasse stated
in 1838: The business of recognizing, preventing, and treating conditions of mental disorder rests upon the
fundamental investigation of the simultaneously psychic and somatic activity of man. Here it finds its scientific
support, from here on it gains light and learns the road(in Overholser 1948, p. 231). This statement, echoing an
ancient principle of the organism-as-a-whole, is still accepted as an operational concept.
For clarification, one must differentiate the psychosomatic approach, process, disorders, and illnesses. Many
reactions, disorders, or illnesses cannot be fully understood unless the investigator can understand the individuals
total situation. The psychosomatic approach includes both the philosophical orientation to the whole individual and
the methodological means of getting data in order to assess reactions to present and past stresses. It attempts to
obtain the datagenetic, physical, psychological, and socioculturalnecessary to interpret the forces affecting the
life of the individual. The investigator uses varied techniques of data gathering, including interviews, tests, clinical
examinations, and laboratory studies.
The psychosomatic process refers to that temporal sequential chain of events which occurs in the individual. The
end result may be a transitory functional, physiological, and emotional response(psychosomatic disorder) that does
not result in alteration of the basic organic structure of the individual, or the end result may be a particular
syndrome that shows temporary or permanent organic changes (psychosomatic illness or disease).
Psychosomatic medicine has come into general clinical use with the reintroduction of the word psychosomaticby
Felix Deutsch, Viktor von Weiz-sacker, Helen Flanders Dunbar, Franz Alexander, and others, all of whom stressed
the necessity for considering the individual in his totality, and not just as a composite of separate entities and
organs (e.g., mind-body).
Deutsch introduced the psychosomatic concept into psychoanalysis by recognizing the influence of repressed
emotional conflicts and the unconscious on the functioning of an organ. Deutsch explained that psychosomatic
symptoms are the end products of long-existing psychic dynamic processes that always have their origins in past
disorders. He demonstrated that the dysfunction of the organic process disappears when unconscious conflicts are
made conscious. He defined psychosomatic medicine as the systematized knowledge of how to study and treat
organ processes that are associated and amalgamated with the emotional processes.Deutsch (1964) postulated
that the dissolution of psychosomatic symptoms always requires treatment not of the symptoms but of the
underlying illness, including the unconscious psychic conflict associated with it.

In the instance of psychosomatic disorders, the notion of a single cause for each disturbance is no longer tenable;
in each patient many factorsacting singly or in combinationplay significant roles. The psychosomatic approach
seeks to identify and understand these variables, their relationships, and their specific contributions toward
upsetting the state of equilibrium.
Homeostasis. The essential feature of homeostasis is the tendency to maintain a steady state or a state of
equilibrium at a given time. Homeostasis is a property of psychological, emotional, and physiological processes,
and involves the interplay of various mechanisms. The organism has a constant internal environment, first
conceptualized by Claude Bernard, as well as an external environment. Since organisms are functionally indivisible,
they cannot be split into the conventional compartments that reflect categories of specialization. Organism and
environment form an inseparable pair in dynamic equilibrium. The biological internal environment is the result of
natural selection and evolutionary processes. The psychological internal environment, aside from its biological
substratum, is the product of the individuals personality development and reflects the socio-cultural milieu in which
he lives. Although the psychological predisposition to particular patterns of stress reactions may result in part from
this psychogenetic developmental process, adaptation may allow various forms of stress and tension to be handled
by means of different defense or coping mechanisms and with different pathological results.
W. B. Cannons concept of homeostasis (1932) clearly emphasized the features of the organization of living
systems whereby they tend to maintain themselves as functioning, complete organisms. His pioneering work on
the relation of emotions to bodily changes set the theoretical and experimental stage for many of the later clinical
and experimental studies in the field of psychosomatic medicine. [SeeHomeostasis; and the biography ofCannon.]
Stress, strain, and stimulus. Harold Wolff (1953) has considered stress as the internal or resisting force brought
into action by external forces or loads. The change in size or shape of an entity as a result of the application of
external force is called strain or deformation. Stimuli or external environmental agents are loads; they may be
static and sustained, repeated or of brief impact with high intensity. The interaction between external environment
and organism is stress. Strain is the alteration or deformation in the organism that ensues. The magnitude of the
deformation and the capacity of the organism to withstand the strain determine whether or not there will be reestablishment of homeostasis or a breakdown, with disruption, disorder, disease, and finally death.
Unlike Cannon, Wolff views affect and bodily changes not as being causally connected but as being separate
manifestations of response to stimulus, tempered by previous experience. Bernard saw disease as the outcome of
attempts at homeostasis in which adaptive responses to noxious forces, although appropriate in kind, are
nonetheless deficient. Wolff suggests that as man is confronted by threats, especially those which involve his
values and goals, he initiates responses inappropriate in kind as well as in magnitude. Such reactions, appropriate
to one protective purpose, may be inappropriately used for another and can, when inappropriate, be damaging or
destructive to the individual.
Threats and symbols of danger may call forth emotional and physiological reactions which in vulnerable individuals
differ little from the responses to actual physical assault. Freud first called attention to the signal function of
anxiety as an internal reaction to such internal or external dangers. Thus, the stress response resulting from a
situation (load) is based in part on the way the affected person perceives the stimulus and the conflict it then sets
in motion. Perception and the subsequent interpretation of what is perceived may be dependent upon many
factors, including genetically determined responsivity, basic needs and longings, conditioning experiences during
formative years, parental and sibling relationships, and identification patterns, as well as other experiences having
familial and sociocultural determinants. [SeeAnxiety.]
Stress disorders can be expressed psychologically and physiologically. The human organism reacts actively to
stress in life situations. The proneness to stress response, the sensitivity and level of threshold, and the specific
mode of response are the end products of many factors. Freud described this continuum of factors from the
biological to the emotional and sociocultural as a complementary series.The group of illnesses in which stress
seems to be a principal factor has been called stress disorders, in order to avoid using the term
psychosomatic.The form of mental and bodily response is determined by the biological diathesis, the personality
pattern, and the character of the situation. When the source of the stress is outside of conscious awareness, or
when action is blocked by inner censorship or outward restraints, disharmony or a nonhomeostatic state results,
and symptoms of illness appear. It must be noted that stress is the reaction inside the organism, not the force
acting on it from the outside. Thus, the inner psychological and physiological dynamics and economics of the
individual, as well as the prior and current social and cultural factors, seem to be significant. There are complex
intrapsychic phenomena behind every illness, as well as metabolic, physiological, and even anatomical alterations.
These may relate to underlying unconscious fantasies as well as to the emotional significance that different parts of
the body and their functions have for the patient. They may be regressions under stress to earlier modes of
operation or reflective of earlier fixations. [SeeStress.]
While clinical impressions suggest that there is a specific relation between the psychological stress and the physical
disorder that follows, it is not clear how this transformation occurs. The World Health Organization report on
psychosomatic disorders (1964, p. 9) summarizes the prevailing ideas on the sequence of involvement as follows:

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(a) constitutional predisposition based on heredity;
(b) constitutional predisposition laid down as a result of early experience and development (both physiological and
psychological experience, and the prenatal period as well as infancy, are included here);
(c) personality changes of later life that affect organ systems;
(d) the weakening of an organ, as by an injury or infection;
(e) the fact that an organ is in action at the moment of strain or emotional upheaval;
(f) the symbolic meaning of the organ in the personality system of the individual;
(g) organ-fixation as a result of arrested psychological development.
Empirical, clinical, demographic, and laboratory experimental research involving man and other animals has
investigated the effects of psychological stress in symptom-free subjects, as well as in patients suffering from such
diseases as duodenal ulcer, ulcerative colitis, bronchial asthma, neuro-dermatitis, thyrotoxicosis, essential
hypertension, rheumatoid arthritis, diabetes mellitus,glaucoma, migraine, and coronary heart disease. Clinical
studies of human patients have revealed the temporal relation between the onset and the exacerbation of the
patients disease with characteristic emotional upsets. When such patients were treated intensively, e.g., with
psychoanalysis, and over a long period of time, much information was obtained, and higher-level abstractions could
be formulated for the psychological patterns observed. Some of these empirical clinical studies were published in a
volume by Alexander and his associates (1948).
The differentiability of the formulations for seven of these diseases is discussed in Psychosomatic
Specificity (1968). In one such study, two matched teams of psychoanalysts and internists studied identical
interview protocols obtained from patients having one of seven diseases (peptic ulcer, ulcerative colitis, bronchial
asthma, neurodermatitis, essential hypertension, rheumatoid arthritis, or thyrotoxicosis). These interviews,
carefully edited to remove all possible references or cues to the disease of the patient, were evaluated by the two
groups from the point of view of formulation and diagnosis of the disease. From the primary clinical information,
formulations were prepared which were to explain how psychosocial and emotional conditions predisposed,
precipitated, and perpetuated the disease. These comparative diagnoses (by analysts and internists) were
statistically evaluated and compared. The results indicate that by and large it was possible to distinguish most of
the seven diseases correctly on the basis of psychological abstractions. These abstractions had earlier been derived
from the empirical observations of patients seen diagnostically or for therapeutic purposes. These formulations are
now being tested by additional studies of families of patients who have psychosomatic diseases, by studying
children who have psychosomatic diseases, by detailed investigation of the therapeutic interactions of patients with
these illnesses, and by newer laboratory and experimental researches utilizing artificial stresses, such as films, and
recording physiological and psychological data following exposure to the conflict situations.
Experimental studies of patients and control groups have been able to reproduce and verify some aspects of the
relation between emotional stimuli and the pathophysiological changes of particular diseases. Such studies do not,
however, demonstrate pathogenesis in the total etiological sense. What they do show is that particular emotional
stresses in sensitive, vulnerable, and predisposed individuals may activate pathophysiological mechanisms which
can eventually give rise to anatomical alteration and, thence, to characteristic patterns of disease syndromes. (See
Alexander 1950 for discussion of such specific studies.) The precipitating or aggravating situations have specific
emotional meaning for the patient because of their connection to his earlier life experiences, his personality
development and structure, and his unresolved conflicts that may have been compensatorily handled in various
ways until the external situation resulted in too great a stress, with a resulting internal disequilibrium. In this
regard, one must recognize that decompensation of adaptive mechanisms may result from too great external
demands that cannot be successfully mediated internally, or from a breakdown or weakening of internal control or
integrating mechanisms, making the individual more susceptible to disequilibrium effects.
Major developments
Three major developments occurred early in the twentieth century: the monumental discoveries and theories of
Sigmund Freud; the classic and basic physiological and neurophysiological experiments and theories of Walter
Cannon; and Ivan Pavlovs research and studies of conditioned reflexes. Contributions were made to the
psychosomatic field at two theoretical levels: the first sought to construct general theories and to derive universal
principles and concepts, while the second dealt with theories related to studies of particular diseases in which
psychosomatic stress is of major significance. Research has continued in both areas. The second level of somewhat
limited theory formation offers an opportunity for testing the explanatory aspects of more general and universal
theories of psychosomatic functioning. The psychoanalytic and physiological contributions will be discussed here in
fuller detail. [SeeLearning, article onClassical Conditioning; and the biography ofPavlov.]
Psychoanalysis
Psychoanalysis contributed to the understanding of psychosomatic relationships by providing a procedurefree
associationwhich made it possible to study sequences connecting psychological and physiological phenomena. It
included the previously undiscovered linkage of unconscious ideas. In addition to improved observation and data
gathering, psychoanalytic theory provided a plausible means of reasoning and of understanding previously
unintelligible and irrational phenomena, such as dreams and neurotic symptoms. The psychoanalytic method not
only permitted the reconstruction of unconscious motivational links and conflicts, but also allowed them to be
brought to consciousness and, thus, to be used therapeutically.

Freuds discovery of unconscious mental phenomena and the process of repression threw new light on many bodily
expressions of mental phenomena. These mental tensions can be discharged somatically into (1) muscular
activities leading to a change of the body in relation to its environment; (2) laughter, crying, screaming, or speech;
(3) respiratory, cardiovascular, and other visceral systems. The end effects of these modes of discharge are
subjectively experienced as feelings, affects, or emotions. Affects and emotions can be repressed and then are no
longer experienced as such, although the processes discharging them into specific somatic systems can still occur.
In his study of the unconscious, Freud discovered that strongly charged but repressed fantasies, conflicts, and
memories found distorted expression in somatic symptoms and in impairments of somatic functions. It was
discovered that these symptoms were expressions, in symbolic body language, of psychological conflicts. They
were called conversion symptoms: the conflict was convertedfrom a purely psychological one into a disorder
manifesting itself primarily through somatic symptoms which had no organic pathological correlate. Thus one could
see hysterical paralysis, hysterical amnesia, hysterical vomiting, etc. [SeeHysteria.]
According to Freud, the physiological manifestations of anxiety have a psychological meaning. In his early works he
wrote that they consist of a repetition of the physiological manifestations which occurred at the time of the
individuals birth. In later writings Freud likened anxiety to a signal used to alert the individual to danger from
either internal or external sources. Thus, later threats to survival would evoke physiological responses which
occurred in the earliest stress situation, the birth process. [See the biography ofRank.]
Hysterical conversion symptoms should not be called psychosomatic disorders, for they do not result in pathological
organic processes or lesions, even though they involve the body. They can, however, result in secondary organic
disturbances. For example, if a hysterical paralysis of the arms or legs persists, there will be progressive atrophy of
the involved limbs because of muscular inactivity.
At its outset psychoanalysis had only a single aim, that of understanding something of the nature of what were
then known as the functionalnervous diseases. The neurologists, with their high respect for physiochemical and
anatomical-pathological facts, sought further to establish an intimate and possibly exclusive connection between
certain functions and particular parts of the brain. They were puzzled by the psychical factor and did not seem to
understand it. In fact, it was believed unscientific to consider these phenomena without neurological explorations.
As late as 1885, when Freud was studying at the Salpetriere, he found that hysterical paralyses were explained by
slight functional disturbances of the same parts of the brain which, when severely damaged, led to the
corresponding organic paralyses.
In the 1880s, hypnotism provided convincing proof that striking somatic changes could be brought about solely by
mental influences which had been set in motion by the patient and were unconsciousprocesses. Hypnosis played
an important role in Freuds study of hysteria. Charcots experiments greatly impressed him, especially when
Charcot, by suggesting a trauma under hypnosis, was able artificially to induce paralyses. Charcots pupil Pierre
Janet was able to show, with the help of hypnosis, that the symptoms of hysteria depended on certain unconscious
thoughts (idees fixes). Janet attributed to hysteria a supposed constitutional incapacity for holding mental
processes togetheran incapacity which led to a disintegration (dissociation) of mental life. [ SeeHypnosis; and the
biographies ofChakcotandJanet.]
Josef Breuer was the first to study and treat hysteria with hypnosis. His work with a young woman patient made it
possible for the first time to obtain a more complete view of a case of hysteria, see the meanings of the symptoms,
and note that these symptoms arose in a situation of mental conflict: an impulse toward action had been
suppressed because of contrary moral prohibitions, and symptoms appeared in place of the suppressed action. The
patients emotions, involved in a psychic conflict, precipitated the illness, although the traumatic precipitating
causes and all the mental impulses relating to them were lost to the patients memory. Under hypnosis, memories
were recovered and, with the subsequent catharsis of affect, the symptoms disappeared.
Breuer and Freud (1893-1895) stated that in hysteria, blocked affect was changed into an unusual somatic
innervation (conversion) and resulted in symptoms. Soon after this publication, Breuer and Freud parted, and
Freud went on to develop psychoanalysis. He gave up hypnosis for free association and developed his theories of
resistance, transference, repression, mental conflict, unconscious mental functioning, and the nature and
development of sexual and aggressive drives, including the importance of infantile sexuality.
Freud also suggested that hypochondria and somatic delusions, and their relationship to the pathological return
(regression) to an earlier state of psychological organization, are other clinical entities related to psychosomatic
syndromes, even though no demonstrable organic pathology is noted in these disorders, as it is in the conversion
hysterias. His descriptions and theories of pain and pleasure, and their relationship to feelings and emotions,
provide us with an understanding of states of tension. His writings on anxiety and psychic trauma permit us to
understand psychic disorganization, its manifestations, and its signal functions. Thus, from the nosological point of
view, Freud introduced, described, and explained three clinical categories that are still important: conversion
hysteria, anxiety states, and hypochondria and somatic delusions. His concept of the actual neuroses is also of
importance, since it states that the buildup of tension and toxic products without discharge can affect the

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organism. Freud noted (1910) that not all somatic changes caused by psychological forces were conversions, just
as not all physical symptoms were expressions of specific fantasies or conflict compromises. He pointed out that
unconscious attitudes may influence organic functions in a physiological way, without the changes having any
definite psychic meaning.
Although Freud did not directly address himself to the somatic aspect of affect, his student Karl Abraham wrote
about various anatomical zonal correlates of personality (oral and anal stages), and Sandor Ferenczi dealt more
directly with the relationship of emotion and mental functioning to organically demonstrable disease. Ferenczi
described (1916) pathoneuroses that supervene as a consequence of actual organic illness or injury. Unlike
hypochondria, where demonstrable changes in the organ are absent and have never been present at all,
pathoneuroses are found in states of actual insult to bodily integrity. In 1922, Hollos and Ferenczis Psychoanalysis
and the Psychic Disorder of General Paresis described psychological reactions following central nervous system
syphilis. This diagnosis of pathoneurosis is now more generally used to describe the psychic reactions to organic
diseases. Ferenczi also described transference manifestations, having psychosomatic implications, that clearly
demonstrate Freuds initial idea of fixation and temporary regression to an earlier state of physiological functioning
induced by a current situation. [See the biographies ofAlexander;Ferenczi.]
Ferenczi also differentiated organ neuroses from conversion hysteria (1926). In the latter there are mainly
symbolic and subjective disturbances involving the body, while in the former initially there are mainly objective and
demonstrable difficulties affecting organ functioning. Ferenczi described nervous asthma, upper gastric
disturbances, intestinal difficulties, cardiac disorders, headaches, fainting, and seasickness as organ neuroses. He
noted that purely organic complaints may leave organ-neurotic disturbances behind after they have healed. These
may be considered as secondary gainphenomena, a situation in which there are psychological advantages of a
neurotic variety secondarily connected with the previously present but now absent organic disease.
Among other early psychoanalysts who pioneered in the psychosomatic field, Georg Groddeck (1923) saw
purposive activity in all morbid afflictions. Thus, a cold was seen as the wish to avoid smelling, and gynecological
disorders as the unconscious wish for chastity. Groddecks theory is perhaps the most extreme representative of a
panpsychological orientation. He introduced the term Es (idor it) as the unconscious formative principle of all
normal and abnormal bodily processes. The early writings of Deutsch also indicate the application of Freuds
concept of conversion to all dysfunctions of the body. Smith Ely Jelliffe in the United States also attempted to
explain all psychosomatic phenomena as direct expressions of highly specific repressed ideas or fantasies (1939).
His work, based on careful clinical studies, began as early as 1916, when he first published a paper on psoriasis.
Subsequently he and his associates wrote about psychological aspects of tuberculosis, multiple sclerosis, epilepsy,
bone disease, postencephalic disorders, endocrinopathics, and eye disorders. Jelliffe was the first American
scientist to apply psychoanalytic concepts to organic diseases.
Physiological contributions
Early investigators did not distinguish between (a) hysterical conversions based on changes in sensory organs or
organs under voluntary nervous control (Freuds view) and (b) changes in internal vegetative organs which are
involved with basic visceral functions and are not involved in expressing details of psychological content and in the
communication of ideas, thoughts, and feelings. The vocal apparatus, facial expressions, weeping, laughter,
blushing, and motor actions discharge and express specific emotional tensions. The internal organs are involved
with various bodily processes involving digestion, respiration, circulation, endocrinology, integration, etc. The heart
can only beat, the stomach secrete, the bowels contract, the blood vessels constrict or dilate. Although these
internal organs respond to emotions, the range of their reactions is limited. Internal organs do not react to specific
repressed ideas such as those which underlie hysterical symptoms, but to general emotional states. Neither do
these processes, as is true of conversion symptoms, discharge tensions; instead, they are sustained by them.
Alexander made the important distinction between hysterical conversion symptoms and adaptive changes in
vegetative functions stimulated by emotional tensions. His ideas followed the concepts of Cannon, who related
emotional states, such as fear and rage, to consequent activated physiological functions involving the digestive,
endocrine, and cardiovascular systems.
Interest in psychological factors in organic disease became noticeable in Germany after World War i; the work of
Leopold Alkan (1930) is especially noteworthy. He indicated that psychogenic disturbances within the autonomic
nervous system may result finally in organic changes, the morphological mechanisms of which form the last link of
an intricate causal chain. He postulated that intrapsychic conflicts may be expressed somatically and can result in
organic disease which is not reversible.
Karl Fahrenkamp demonstrated the influence of emotions on fluctuations of blood pressure and presented a strong
case for the psychogenic origin of essential hypertension (1926). Viktor von Weiz-sacker, strongly influenced by
Freudian views, emphasized the influence of emotions upon bodily disturbances and of bodily disease upon the
psyche (1925; 1925/1926; 1926; 1933). His clinical presentations demonstrated the emotional components and
antecedents of bodily disease. Bergmann (1913a; 1913b) and Westphal (1914) suggested the neurotic origin of
duodenal ulcers.
Conditioning studies

8
Much research in psychosomatic phenomena has also been carried out within the framework of conditioning theory.
Animal studies of psychosomatic disturbances are now on the increase, and there has been considerable study of
conditioning of biological functions in humans (e.g., Hofer & Hinkle 1964; Moutsos etal. 1964).
Much interest has been shown in patterns of autonomic responses in normal persons and in patients suffering from
psychosomatic disorders, at rest and under stress. Stress can be induced through hypnotic suggestion, interviews,
stagedsituations, various test situationsincluding movies and by total or partial perceptual isolation. Its
effects can be assessed. Physiological variables studied include skin potential, skin temperature, finger pulse
volume, cardiac and respiratory rates, blood pressure, and muscle activity. Individual differences in various
emotional states, and differences between various psychosomatic disorders, have been reported.
Conditioning experiments demonstrating the effects of anxiety have been carried out on humans and animals (see
Dykman et al. 1962; Edwards & Acker 1962; Moss & Edwards 1964; Porter et al. 1958). Predictive studies on the
relationship between ovarian activity and psychological processes have been made by Benedek and Rubenstein
(1942); on the relationship between emotional states and thyroid function by Dongier and his colleagues (1956);
on the etiology of peptic ulcer by Mirsky and his colleagues (1952) and Weiner and his colleagues (1957); and on
the appearance of bronchial asthmatic symptoms by Knapp (1963).
Cultural studies indicate that with the extension of Western civilization into rural areas little touched by such
acculturation, there is a rising frequency of psychosomatic disturbances (e.g., Collomb 1964; Yap 1951). Contrary
evidence has appeared about the existence of culture-specific factors determining the choice of symptoms and of
disease.
George H. Pollock
[Directly related are the entriesHysteria; Mental Disorders, article onBiological Aspects; Pain;Stress. Other relevant
material may be found inEmotion; Gestalt Theory; Illness; Psychiatry;Psychoanalysis; and in the biographies
ofAlexander; Freud.]
BIBLIOGRAPHY
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Alexander, Franz et al. 1948 Studies in Psychosomatic Medicine: An Approach to the Cause and Treatment of
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10
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Mental Science 97:313-327

International Encyclopedia of Rehabilitation Copyright 2010 by the Center for International


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-- [ Page 1 ] -International Encyclopedia of Rehabilitation
Copyright 2010 by the Center for International Rehabilitation Research Information
and Exchange (CIRRIE).
All rights reserved. No part of this publication may be reproduced or distributed in any
form or by any means, or stored in a database or retrieval system without the prior written
permission of the publisher, except as permitted under the United States Copyright Act of
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Center for International Rehabilitation Research Information and Exchange (CIRRIE) 515 Kimball Tower
University at Buffalo, The State University of New York Buffalo, NY 14214 E-mail: ub-cirrie@buffalo.edu Web:
http://cirrie.buffalo.edu This publication of the Center for International Rehabilitation Research Information and
Exchange is supported by funds received from the National Institute on Disability and Rehabilitation Research of
the U.S. Department of Education under grant number H133A050008. The opinions contained in this publication
are those of the authors and do not necessarily reflect those of CIRRIE or the Department of Education.

11
Inpatient Psychosomatic Rehabilitation including the aspects of the International Classification of
Functioning, Disability, and Health (ICF) Gerhard Schmid-Ott, M.D.
Berolina Clinic, Germany Loehne and Saale Rehabilitation-Clinic Bad Ksen Clinic I, Germany Institute of
Innovative Rehabilitation, Hospital Management and Stress Medicine (IREHA), Loehne at Bad Oeynhausen,
Germany gerhard.schmidott@googlemail.com Christian Stock, M.D.
Berolina Clinic, Germany Loehne and Saale Rehabilitation-Clinic Bad Ksen Clinic I, Germany Dipl.-Psych.
Dana Bhm Institute of Innovative Rehabilitation, Hospital Management and Stress Medicine (IREHA), Loehne at
Bad Oeynhausen, Germany Iris Tatjana Calliess, M.D.
Klinik fr Psychiatrie, Sozialpsychiatrie und Psychotherapie, Hanover Medical School, Hanover, Germany
Institut fr Standardisiertes und Angewandtes Krankenhausmanagement (ISAK), Hanover Medical School, Hanover,
Germany Axel Kobelt, Ph.D.
Deutsche Rentenversicherung Braunschweig-Hannover, Hanover, Germany Overview of inpatient
psychosomatic rehabilitation with a special focus on inpatient psychosomatic rehabilitation in Germany
Rehabilitation medicine is a medical speciality for the treatment, compensation, and prophylaxis of chronic illnesses
that last more than six months. This review focuses on inpatient psychosomatic rehabilitation as a specialization
within rehabilitation medicine.
Although it is to a certain extent an integral part of psychiatric rehabilitation, psychosomatic rehabilitation
is becoming increasingly important as a field in its own right. For a shorter survey on this topic published in
German see Schmid-Ott and Stock (2008).
"When significant segments of the population are excluded from participating in work, numerous
subsequent problems are to be expected with considerable impact on the health status of the general population in
the sense of secondary damage and impairment. Psychological damage, loss of self-esteem, social isolation,
existential crisis, limitation in physical activities, and dependencies pose significant risk factors for the health and
functioning of the population in the sense of the ICF, which are accompanied by a corresponding need for support"
(Seger et al., 2008).
-1Psychosomatic rehabilitation is mainly a German institution. For detailed information about hospitals,
beds, patient spectrum, system of admission, structure of hospitals, reimbursement, history, effects, and outcomes
in psychosomatic rehabilitation, see Schauenburg et al. (2006) and Schmid-Ott et al. (2008). - A search on Medline
(16030210) with the keywords "psychosomatic and rehabilitation" returned only a limited number of English titles
(Shapiro and Surwit 1974, Murray 1980, Dracup et al. 1984, Aitken 1987, Corbellini and Maisano 1988, Mayou
1990, Shapiro 1996, Drake et al. 2003, Rashbaum and Sarno 2003, Lash et al.
2003, Linden et al. 2003, Linden 2004, Linden et al. 2004, Fava and Sonino 2005, Petrak et al. 2005,
Linden 2006, Mitchell and Selmes 2007, Sonino and Fava 2007, Beutel et al. 2008, Kallert 2008, Fava 2009, Petrak
and Herpertz 2009). Indeed, psychosomatic medicine generally has been perceived only in Germany as a field
distinct from psychiatry. However, psychosomatic medicine is now starting to be regarded more often -- at least by
some experts in Germany and in the USA -- as a new psychiatric subspecialty that focuses on the interface
between psychiatry and medicine (e.g., Lipsitt 2001, Lyketsos et al. 2006).
Individuals with psychological or psychosomatic illnesses in adulthood frequently suffer from a chronic
course of disease, relapsing deterioration, and often exhibit a vast spectrum of comorbidity. Medical rehabilitation
often becomes necessary when illness-related damage has led to long-term disability or impairs participation in
important areas of daily life. Medical rehabilitation requires a comprehensive, holistic, and interdisciplinary
approach, according to the bio-psycho-social model. This model allows health care professionals to take the entire
background of affected persons into account, including the interactions of the individual components of functional
health and their impairment, as well as the interactions between individual health problems and contextual factors
(environmental or personal). Furthermore, those who suffer from and who are treated for psychological or
psychosomatic disorders come from diverse cultural backgrounds (see Schmid-Ott et al. 2003, Ditte et al 2006,

12
Calliess et al. 2007). Despite its somewhat out-dated institutional label "spa," inpatient psychosomatic
rehabilitation offers easy access to a suitable, specific therapy.
In summary, we can state the following conclusions about psychosomatic rehabilitation in the context of
the International Classification of Functioning, Disability, and Health (ICF) (see Baron and Linden, 2008):
Psychosomatic rehabilitation diagnoses and treats patient and their chronic illness or disability on the
somatic and psychological level as well as in their social environment, meaning that close attention is paid to the
functional and psycho-social impact of the illness or disability. In this way, the narrow focus on the physical
symptoms and the use of specific somatic treatments, frequently preferred by these patients in light of their
somatic illness, is expanded upon. As a result, the daily routine of patients is given more comprehensive attention.
However, in this context, one has to be careful not to confront the patient with a psychosomatic diagnosis
without adequate preparation. The diagnosis must rather develop slowly based on a somatic-psychological disorder.
In this context, psychosomatic rehabilitation refers to the person-related and interdisciplinary management of
impairment of functional health.
The concept of functional health is central to the International Classification of Functioning, Disability, and
Health (ICF) which was ratified by the World Health Organization (WHO) in 2001. In the ICF, functional health
refers to the mutual interactions of a patients impairment of health (listed in the ICF-10), their environmental
factors, person-related factors and contextual factors. Functional health is classified on several levels: anatomicalstructural aspects of the physical diagnosis, the functional impact of these disorders and their (Gutenbrunner et al.
2002, stn et al. 2003, World Health Organization 2000). The ICIDH (International Classification of Impairments,
Disabilities and Health) from 1980 (Jochheim and Matthesius 1995) describes the following aspects of a disorder:
impairment, disability, and handicap (social impairment, difficulty with integration). The ICIDH provides the basis
for a theory of disability and makes it possible to represent the impact of disorders within the context of three
different consequences of diseases: impairments, disabilities, and handicaps (Jochheim and Matthesius 1995,
Masala and Petretto 2010, Schuntermann 1998, World Health Organization 1980). This perspective is, however,
mono-directional, causing it to be criticized. The present ICF version emerged in response to this criticism.
The present International Classification of Functioning, Disability, and Health adds the following aspects to
the model of the ICID: the interaction of illness and disabilities and their functional effects. At the level of the
individual, they are called "activities"; in the context of social interactions they are termed "participation." The
following contextual factors are taken into account: environmental factors; individual, person-related
characteristics; attitudes; and abilities. Differentiating between supporting factors and barriers facilitates the
expansion of the patho-genetically oriented approach to encompass the saluto-genetic perspective (SchmidOtt et
al. 2007). This allows us to capture a more adequate picture of the daily life of individuals and patients.
The goal of using the ICF for the multidisciplinary and interdisciplinary management of the functional
health of an individual during inpatient psychosomatic rehabilitation is primarily to operationalize symptoms and
disabilities as close to the patient's reality as possible so as to minimize them more effectively.
The ICF defines functioning and disability as multi-dimensional concepts, within an overarching context of
a particular health condition, that relate to an individual's bodily functions and structures, their activities, the life
areas in which they participate, and the factors in their environment that affect these experiences. Disability is
used as an umbrella term for any or all of: an impairment of body structure or function, a limitation in activities, or
a restriction in participation. Environmental factors and personal factors are contextual factors. Environmental
factors consist of all the physical, social, and attitudinal features that together characterize the environment in
which a person lives -- from climate and terrain to architectural characteristics and legal and social structures.
Personal factors are defined as gender, age, coping styles, social background, education, profession, past and
current experiences, overall behavior pattern, character, and other factors that influence how a disability is
experienced by the individual. Personal factors are not classified in ICF at the moment. Environmental factors can
be either barriers to or facilitators of the person's functioning (United Nations ESCAP 2010).
Several efficient strategies for inpatient psychosomatic rehabilitation can be derived from the ICF:

13
1. A curative strategy for treating damaged body parts and body functions 2. A rehabilitative
strategy for compensating orovercoming impairment of body functions, activities, or participation 3. A
preventative strategy to avoid further impairment of body functions, activities, curative, secondary preventive,
compensatory, and tertiary preventive strategies alike.
As a rule, inpatient psychosomatic rehabilitation is used to treat chronic, often incurable health disorders
in the narrow sense. Nonetheless, rehabilitation is able to minimize the impairment of functional health by fostering
positive, health-promoting behavior and by identifying and thus activating individual salutogenetic environmental
factors. The ICF can be used to identify resources as well as deficits. This is why the contextual factors, such as
environmental factors and individual aspects of a patients personality, take on an immanently important position in
the process of rehabilitation. Achieving success is predicated upon, first, the use of multi-disciplinary diagnostics by
physicians trained in psychotherapy, psychologists, occupational and physical therapists, dieticians, nurses, and
social service specialists (social workers, rehabilitation consultants), and second, possibly also upon prior
medication and somatic treatment, among other factors. This is defined as assessment (Stucki et al. 2003). The
rehabilitation team comprehensively diagnoses impairment or disorder of physiological functions and structures,
activities and participation as well as contextual factors. This analysis is repeated at regular intervals in order to
improve the outcome of treatment. This process yields treatment indications, treatment goals, and prognoses as to
the need for rehabilitation, ability to be rehabilitated and prognosis for rehabilitation.
Assignment to a rehabilitation center for presscribed treatment is performed by pension insurance or
health insurance employees, who examine the case records of patients and determine who receives inpatient
rehabilitation. These institutions also select the specific rehabilitation center, using their own competency criteria.
Within the framework of the assignment decision, the patient, the health care provider, and the insurance carrier
are informed of the medical indication and of the goals of rehabilitation. The subsequent intervention encompasses
the rehabilitation plan and goals based on the health problems as determined in the assignment.
Inpatient psychosomatic rehabilitation regards itself as a continuing process, which means that in the
course of treatment, the patient's situation is repeatedly re-assessed and reviewed and then re-evaluated in view
of the intended goals of treatment. The results of re-assessment are ultimately discussed with the patient. This is
defined as evaluation (Gutenbrunner et al.
2002, Stucki et al. 2003).
Psychosomatic patients usually respond well to group therapy (Janssen et al. 2006). This form of health
training serves less to convey information than to impart practical knowledge for strengthening personal
responsibility (Schmid-Ott et al. 2000), encouraging individuals potential for self-help as well as improving
adherence in the sense of patients active collaboration (Korsukwitz 2003). For patients with a somatopsychological disorder, taking part in sessions of a disorder-specific self-help group is frequently useful for boosting
their self-help potential. This can already be initiated, if desired, during inpatient treatment, for instance by
providing information about the work of similar self-help organizations or contact information in the patient's place
of residence.
At the start of inpatient psychotherapy, rehabilitation goals are devised as realistic objectives attuned to
the patients daily life (assignment measures), taking into account any specific individual limitations for
participation. Patients can strive for goals on various levels: somatic, psychological, educational, activity-related,
participation-related or contextual. The following goals of therapy can be established in inpatient psychosomatic
rehabilitation within the context of the International Classification of Functioning, Disability, and Health (ICF, cf.
also Schuntermann 2008):
Psychological rehabilitation goals 1. Increasing adherence 2. Realistic assessment of the illness 3.
Improving patients ability to cope with the illness, their responsibility for themselves and their motivation to
implement the psychotherapeutic and medical treatment 4. Improving self-control 5. Encouraging the
understanding of connections between somatic and psychological influences (so-called somatic vulnerability, also in
somatoform disorders).

14
6. Learning and the application of new knowledge (e.g. improved sensory perception,
elementary learning skills, and various techniques of linking knowledge acquisition and knowledge use 7.
General issues of task resolution and coping with demands (e.g., accepting tasks, dealing with daily routines,
reducing, and balancing demands on one's psychological well-being) 8. Communication (e.g., communication as a
receiver, communication as a sender, conversation, and the use of communications technologies and techniques) 9.
Interpersonal interaction and relationships (e.g., general interpersonal interaction, specific forms of interpersonal
relationships) Social rehabilitation goals 1. Improved integration in the workplace (see Hrdel et al 2006) 2.
Improved social integration 3. Improved social competence 4. Increased involvement in community activities (e.g.,
civic engagement, recreation, religion, and spirituality) 5. Increased involvement in other important areas of life
(e.g., parenting, education, independent forms of economic production) Educational rehabilitation goals 1.
Information about risk factors and the course of mental disorders 2. Improved mechanisms for coping with stress
by learning systematic relaxation techniques The following contextual factors comprise what we regard as the
entire background of an individual central to inpatient rehabilitation based on the International Classification of
Functioning, Disability, and Health (ICF):
1. Risk factors such as abuse of stimulants, tobacco, and alcohol 2. Poor nutrition 3. Lack of
physical activity 4. Inadequate styles of coping with illness (Ermann 1997; such as denial, depressive
withdrawal, blaming others) or 5. Personality factors such as the presence of a personality disorder The
development of the International Classification of Functioning, Disability, and Health provides rehabilitative
medicine with a broad scientific foundation. The ICF operationalizes the concepts of illness, disability, and health in
a clear manner, taking (somatic) illnesses together with psychosocial stress, individual patient factors, and
environmental conditions psychotherapy because it characterizes the chronicity of numerous psychological
disorders in terms of psycho-social stress (Schmid-Ott et al. 2003, Schmid-Ott and Jger 2005, Ditte et al.
2006, Calliess et al. 2007). Disorders can be defined and documented through the ICF and in ways
appropriate to their multifaceted genesis.
It is important to point out in this context that those suffering from mental illness or undergoing
treatment are often stigmatized. Psychosomatic or psychological disorders and their professional treatment are in
contrast to most somatic illnesses and their treatments plagued by a widespread stigma on communication.
Patients usually only confide in a few trusted individuals.
The holistic approach of medical rehabilitation Medical rehabilitation takes a holistic approach. Beyond
recognizing, treating, and healing an illness, medical rehabilitation considers the interaction between a persons
health problems described in terms of damage, impairment of activity, and reduction of participation and their
context in order to achieve the best possible recovery in the sense of taking part in social life and work life.
Contextual factors can exert a positive, supportive influence (resources) as well as a negative, debilitating influence
(risk factors) on all components of functional health.
The holistic rehabilitation approach requires the application of complex measures in medical, educational,
occupational, and social arenas, differing on a case by-case basis. It also entails a tightly woven collaboration
between medical, psychotherapeutic, and nursing care with physical therapy, occupational therapy, and dietary
care. The holistic approach also helps patients to learn how to cope with the consequences of their illness and to
change their behavior with the goal of reducing negative influences on their health. In addition to its curative
effects, medical rehabilitation calls for a multi-dimensional and interdisciplinary approach.
Indications Inpatient psychosomatic rehabilitation refers to comprehensive, twenty-four hour
rehabilitation. General indications for inpatient rehabilitation are present especially in the following circumstances.
Work performance is jeopardized due to psychosomatic and psychological disorders Continuous
support and structuring through the inpatient setting becomes necessary because of reduced psycho-physical
resilience It has become necessary to remove a patient from their stressful psychological environs because of
specific professional and family conflict constellations; in other words, treatment in a protected therapeutic space,
usually removed from the area of residence, has become necessary The improvement of social competence and
relationships can only be achieved through the integration into a complete inpatient setting wherin the therapeutic

15
community functions as a learning and experimental environment for the patient The therapeutic measures are
expected to lead to emotional destabilization which surpasses the patients coping abilities Adequate adherence in
taking medicine and a constructive cooperation can only be assured through inpatient instruction and supervision
The symptoms or behavioral disorders are so grave that close supervision, treatment, and continual availability of
crisis intervention are essential prerequisite.
Indications and counter-indications for inpatient psychosomatic Indications for inpatient psychosomatic
treatment include in their majority illnesses of chapter F of ICD-10, above all the following mental and behavioral
disorders: mood (affective) disorders (F30-F39), neurotic, stress-related and somatoform disorders (F40-F48),
behavioral syndromes associated with physiological disturbances and physical factors (F50-F59) including
psychological and behavioral factors associated with disorders or diseases classified elsewhere (F54) and obesity
(E66), as well as disorders of adult personality and behavior (F60-F69). Patients with other mental illnesses can be
treated in other specialized, but not psychosomatic, rehabilitation centers, provided they are not exacerbated by an
acute somatic disorder, schizophrenia, schizoid and delusional disorders in remission (F20-F29) or metabolic and
non-metabolic dependencies (F10-F19, F55, F63).
The following disorders are absolutely counter-indicated: acute suicidal tendencies, florid psychoses,
deterioration of intelligence with severe impairment of cognitive and emotional comprehension and introspection,
and, in addition, patients with a need for urgent care with exacerbating somatic conditions or need for long-term
care.
A central goal of medical rehabilitation is to eliminate or reduce the impending or existing impairment of
participation in work and social life and to prevent deterioration or alleviate its consequences. Through
rehabilitation, the person undergoing rehabilitation should be enabled to carry out a job (again) and specific
activities of daily life in a manner and to an extent considered to be normal for that individual (in the sense of
having been typical for his or her life).
These goals can be achieved during inpatient rehabilitation for psychological and psychosomatic disorders
using the following strategies.
eliminating or reducing damage (including mental functions) reducing the severity of the impairment of
activity or reversing disabilities compensation of impairment and disability developing adequate adaptation or
coping mechanisms Rehabilitation goals relating to bodily functioning (including mental functioning) include, for
instance, mental stabilization, reducing negative affects such as depression and anxiety, improving self-perception,
improving patients acceptance of themselves and personal selfconfidence, correcting dysfunctional cognitive
patterns, reducing physical symptoms, and improving the ability to handle functional disorders.
Further rehabilitation goals related to activity include expanding the individuals repertoire of behaviors,
improving communication skills, building up social skills, improving interpersonal skills, employment skills and
problem-solving skills, optimizing coping strategies, improving the ability to structure leisure time and improving
how stress situations are handled.
Goals aimed at participation include maintaining or improving psychological independence, physical
independence, mobility and social integration or re-integration in the area of involved in as many areas of the
patient's life as is feasible. In concrete terms, this might mean training relatives through educational programs or
individual counseling or, if appropriate, establishing contact with the employer or company physician.
The type and extent of functioning problems can be exacerbated or diminished by contextual factors
(either environmental or specificallyindividual) such that they must be taken into account when determining
rehabilitation goals and when designing the diagnostic and therapeutic measures. This can take place, for instance,
by adjusting the workplace environment, changing the organization of workflow, planning and introducing
measures for participating in work life, undertaking occupational re-integration, offering instruction on healthy
nutrition and motivating changes in lifestyle (including reduction of risky behavior), instruction on how to reduce or
cope with stress, adjusting the domestic environment, and introducing appropriate leisure activities. Patients
undergoing rehabilitation receive support in how to live and cope with the consequences of their illness or handicap

16
and how to avoid negative influences or reduce their effects. Rehabilitation goals in this sense include improving
knowledge about the illness, developing strategies to reduce risky behaviors (such as smoking, alcohol and drug
abuse, poor nutrition, lack of exercise, inadequate use of leisure time, physical and mental exhaustion), and
instruction in techniques of self-control and relaxation.
Specific rehabilitation goals for somatoform and pain disorders, depression, or anxiety disorders are
established cooperatively with the patient, with the goal of making improvements in the areas of damage or
functional disorders, disabilities, impairment, risk factors, and contextual factors. These goals are also monitored
with the patient over the course of the rehabilitation process.
Psychological diagnostics in psychosomatic rehabilitation Before the start of psychosomatic rehabilitation,
an illness-related somatic and psychological diagnosis or differential diagnosis of the underlying illness and possible
concomitant illnesses should be completed. A careful, detailed diagnostic assessment must be conducted at the
beginning of the rehabilitation process within the framework of a comprehensive clinical examination, including a
psychological diagnosis and social-medical assessment. On the other hand, further diagnostic results are to be
gathered according to classification systems specific to the rehabilitation, whereby the ICF is especially relevant,
particularly the psychological and the social rehabilitation goals described above. Psychological rehabilitation
diagnostics are largely characterized by the fact that they not only make use of classical measures and instruments
(psychometric measures of anxiety, depression and pain, etc.) but also understand the health or disease condition
as a resulting from the interaction of bodily functions and structures, activities and participation factors that are
in turn impacted by social and environmental factors as described in the ICF (see Baron and Linden 2008, Fricke
2010) Psychological diagnostics are based on previous medical findings, a detailed initial interview that yields a
picture of the patients life history, and psychological testing. Patient and physician determine priorities in
treatment for the stay at the clinic. The psychological diagnostics help as do the physical diagnostics to define
the goals of rehabilitation for the patient, develop the rehabilitation plan and confirm the assessment in the
psycho-social dimension on the basis of diagnostic findings that aspire to be as objective as possible.
The psychological diagnostic instruments and techniques utilized include: depthpsychological exploration,
analysis of behaviors and conditions, observation of behavior, clinical observation of the course of treatment, and
possible counter-transference. In addition, recognized psychometric tests are conducted that are validated for the
respective language and culture and are appropriate for psychosomatic rehabilitation. These tests assess on
standardized scales the extent of somatoform or pain disorders, depressive disorders, and anxiety disorders.
Therapy during inpatient psychosomatic rehabilitation The explicit goal of inpatient psychosomatic
rehabilitation is to restore or ensure the ongoing participation of the patient in work life; this naturally includes
improvement in psychological symptoms and the successful treatment of mental and behavioral disorders from the
specific perspective of the ICF. Therefore, the focus in this section is on these aspects rather than on the treatment
of individual mental and behavioral disorders.
An essential characteristic of integrated medical rehabilitation congruent with the principles governing
good medical practice is the comprehensive evaluation of all diagnostic findings gathered by all professionals
taking part in the treatment (participating professionals, mainly medical doctors, psychologists, social workers,
physical therapists, sport therapists, occupational therapists, art therapists or music therapists and dieticians). This
approach facilitates a continuous reassessment and possible correction of the rehabilitation goals and rehabilitation
plan especially regarding social-medical problems by including multi-method treatments and job-related measures
during inpatient psychosomatic treatment. This forms the basis of the social-medical assessment. The patients are
actively integrated into this process (see Table 1.) Table 1: Implementation of the concepts of the ICF in applied
rehabilitation (modified according to Schuntermann 2008) Concept of including the patients The attending
physician and/or psychologist defines the subjective experience of parti- goals of inpatient rehabilitation by
evaluating several cipation related areas of patient well-being: contentment, healthrelated life quality, and the
amount of personal recognition Concept of bodily functions and 1. To prevent deterioration of functional disorders
and structures including psychology structural damage Concept of activities To restore or improve performance in
terms of the Concept of contextual factors: 1. To remove barriers that prevent or hinder performenvironmental
factors, personal ance or participation In psychosomatic rehabilitation, the following organizational and treatment
principles are of elementary importance (Paar and Grohmann 2008): the principle of the care-giver therapist, group
treatment, multiple methods, multiple professionals, team work, patient information, psychological education and

17
self-management, the activation of job-related and social resources, and cooperation and follow-up care. In this
context, group treatment is central for psychosomatic rehabilitation because of its lower cost and high potential for
contributing toward the goals of psychosomatic rehabilitation, e.g. activating and supporting social and jobrelated
resources. Concrete treatment elements encompass: psychotherapy, medical care and medication, socialtherapeutic care, social counseling, assistance forreintegrating into daily life and the workplace, job-related
training, training of routine skills, creative or occupational therapies, sport and exercise therapies, physiotherapy,
relaxation training, nutritional counseling, health education, social-medical assessment and initiation of ongoing
measures and adequate follow-up care (Paar and Grohmann 2008).
Cost-benefit ratio and return of investment (ROI) and long-term outcomes of inpatient psychosomatic
rehabilitation Zielke (2008) calculates the cost-benefit ratio of psychosomatic rehabilitation from the
healtheconomics perspective as follows. All cost factors together with disease-related expenditures during the two
years prior to inpatient rehabilitation were calculated to amount to 5,676 on average. The cost savings related to
successful treatment in the two-year follow-up period total an estimated 21,554. The comparison yields a costbenefit ratio of 1:3.79. This means that an investment of 1 towards inpatient psychosomatic treatment and
rehabilitation reduces the cost of disease treatment and follow-up by 3.79. Concerning the return of investment
(ROI), Zielke calculates, on the basis of various economic and business analyses, an expected standard deviation in
productivity of 0.7. Furthermore, one can expect a median effect size of the psychosomatic rehabilitation under
consideration of multiple outcome criteria of d=0. (Stapel 2005). Given annual operational costs for salary and
ancillary costs of 55,000, the standard deviation of productivity can be set at 38,500. Given a two-year period to
research the effects of the therapy, an effect size of d=0.7, and inpatient treatment costs of 5,676 per patient, we
get a net effect of 48,224 per case using Brodgens 1949 formula for evaluating the economic effect of
interventions (see Wittmann and Stapel 2005).
Steffanowski et al. (2007) evaluated eight studies with complete data on the occupational status both at
the time of admission and at follow-up in the MESTA study on the effects of inpatient psychosomatic treatment on
the continuation of work life.. One year after discharge (the first timepointof follow-up), 67.4% of all patients were
able to remain in or re-enter work. This shows a slight reduction in employment rates of 4.3% compared to the
time of admission (71.7% employed patients). In contrast, the number of retired patients rose from 2.4% at the
time of admission to 5.6% at the time of follow-up. Yet, none of these changes shows any statistical significance.
Thus, further studies will have to focus on rehabilitatory medicine's mandate to avert a potential or already
manifest threat to the patient's employment status.
Steffanowski et al. (2007) and Lschmann et al. (2006; see Zielke 2008) evaluated outcome studies with
approximately 25,000 patients in a systematic meta-analysis with respect to treatment outcome at the time of
discharge and the course of illness at follow-up points varying between one and two years. With the following effect
sizes between evaluation upon admission and discharge from the rehabilitation clinic [r ES (A/K)] on one hand and
between admission to the clinic and the changes found at follow-up [r ES (A/K)] on the other hand, they found that
the following factors influence inpatient treatment results as moderator variables. Age; in years; had a negative
effect on the outcome of treatment at follow-up [r ES (A/K) = 0.23; r ES (A/K) = 0.38, p = 5.0%]. Gender and
duration of illness, contrary to expectations, had no significant effect [r ES (A/K) = 0.10 and 0.05; r ES (A/K) =
0.10 and 0.05]. High level of education had a positive impact on the outcome with r ES (A/K) = 0.40 (p = 1.0%)
and r ES (A/K) = 0.36 (p=5.0%). Duration of treatment at the clinic also showed positive effects with r ES (A/K) =
0.27 (p = 5.0%) and r ES (A/K) = 0.42 [p = 1.0%; multiple R = 0.60 and 0.68 (p = each 5.0%)]. These results
are of particular relevance because the studies included in the meta-analysis integrate several age-groups with
treatment periods of analyses limited to a single homogenous age-group with a low variation in the duration of
inpatient therapy (see Zielke 2008).
In order to determine the efficiency of psychosomatic rehabilitation, Steffanowski et al.
(2007) used the effect size metric proposed by Wittmann et al. (2002) in the MESTA study. A total of 32
of the 65 studies included in the meta-analysis contain measurements at three time points: upon admission, at
discharge, and follow-up. Thus it was possible to assess the stability of the success of treatment. The weighted
overall effect size at the time of discharge was d=0.57 and d=0.49 at the time of follow-up. According to Cohen
(1992), this is a mediumintensity effect that drops only slightly at the time of the follow-up. Given a linear decline
of this effect of 0.08 points per year, the mean effect size for the first year after treatment is d=0.53, for the

18
second year it is d=0.45, for the third year d=0.37, the fourth year d=0.29, the fifth year d=0.21, the sixth year
d=0.13 and the seventh year d=0.05.
The Federal Statistical Office of Germany put the gross wealth creation of the German economy at a total
of 2.02 trillion in 2005. Divided by 38.8 million wage earners in that year, this corresponds to 52,126 euro on
average per year and patient. For each year the gross effect has to be determined separately by setting the mean
effect size at T=1 year and N=1 patient. Subsequently the gross effect can be added up over the seven-year period
assumed in this case.
In order to calculate net effect, the costs for the rehabilitation measures have to be deducted.
Given a treatment duration of 40 days on average (Federal Statistical Office Germany, 2005) and a daily
care per diem of 110 in psychosomatic rehabilitation, the direct costs of treatment are 4,400. The indirect
treatment costs that result from the loss of productivity for the time of the inpatient treatment are calculated as
(40 days/365 days x 52,126). Total costs are calculated by adding direct and indirect costs, which amount to
10,112. The net effect is 32,214 per patient. Multiplied by 93,658 cases of treatment absenteeism per year, this
amounts to an effect of 3.0 billion for the society as a whole for each year of overall patient treatment. Cautiously
estimated, the cost-effect ratio is 10.112:42.326 or 1:4.19. The breakeven point, where the effect equals the
costs, is already achieved before the one-year followup has passed. And after 2 years, the ratio is 1 : 2.02.
These results supply solid evidence that psychosomatic rehabilitation compares favorably with other areas
of health care. Indeed, there is reason to believe that the monetary effects of psychological and rehabilitative
treatment programs are heavily underestimated socially and politically. Psychosomatic rehabilitation is not only
effective but also efficient. For this reason, too, the current and future significance of this branch of healthcare
should receive more attention.
The influence of patient satisfaction (cf. Richter et al. 2010A and Richter et al. 2010B) on the cost-effect
ratio of inpatient psychosomatic rehabilitation has not, to our knowledge, been investigated.
Kobelt and Schmid-Ott (2010, page 101) offer the following observation.
Follow-up studies longer than one year "have only rarely been presented in psychiatric-psychosomatics
until now (e.g. Nbling psychotherapeutic care unit, Nbling et al. (1999) were able to reach 46.8% of the
patients, whereby this study forewent the use results showed above all that the mental state of the patients
undergoing rehabilitation continued to improve significantly over the five-year period compared to the one-year
follow-up; in addition, Nbling et al. (1999) found a distinct increase in unemployment and a decrease in the
number of patients who were employed full-time. In contrast, there was a continuous decrease in the number of
days patients were unable to work across the three measurement time points. At the one-year follow-up, 6.7% of
patients were retired, which rose to 12.6% after five years.
After five years, 55% of the rehabilitated individuals reported stable improvement in the outcome of
treatment; 17.2% a distinctly improved outcome, 11% a worsened outcome and 17% an unchanged outcome of
treatment. Huber et al. (2009) published another study, which focused on long-term follow-up.
Here the stability of symptomatic and interpersonal changes was investigated within three to five years
after inpatient psychodynamic psychotherapy. The patients in this study improved on symptomatic and
interpersonal levels. However, in this study the authors did not consider therapeutic aftercare. Even rarer are
follow-up studies on outpatient group therapy.
Tschuschke (2007) determined in a broad study that group therapy demonstrates better outcomes the
longer the patients take part in the group; Tschuschke also showed in his study that the symptoms, the
interpersonal problems and the general level of mental functioning improved markedly over the course of group
therapy (Tschuschke, 2007). The work group surrounding Conway, Audin, Barkham, Mellor-Clark and Russel (2003)
likewise verified that group therapy whose length is limited in time can help patients achieve better mental health.
The lengthy time period of a five-year follow-up not only presents a logistic challenge if one wants to achieve the

19
highest possible response rate. At the same time, it must be understood that the findings can only be partially
attributed to the effects of an intervention which took place five years previous and was low-threshold at that, such
as is the case with outpatient psychotherapeutic aftercare."
Kobelt and Schmid-Ott (2010) utilized a post-treatment design and compared two groups. The treatment
group included 52 participants who had concluded inpatient treatment and then started outpatient
psychotherapeutic aftercare. The 43 persons of the control group had only undergone the inpatient treatment. The
participants of the treatment group were able to improve or stabilize their depression better then the participants
of the control group (p< 0.01).
The participants dependence on pensions and/or insurance benefits showed a trend toward reduction (p<
0.1). Nevertheless, no significant differences arose between participants and the comparison group during the
periods of paying into insurance. Further studies should examine long-term follow-up studies of inpatient
psychotherapy.
We would like to thank the reviewer Prof. Dr. M. Linden Michael Linden, MD, PhD, Research Group
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