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To contextualize migraine as the most common primary headache disorder in relation to other chronic primary pain and non-pain functional somatic and mental conditions.Migraine is increasingly understood as a sensory processing disorder within a broader spectrum of symptom disorders. This has implications for diagnosis and treatment.Narrative review based on a search of the literature of the last 15 years on the overlap of migraine with other symptom disorders.Migraine as the prototypical primary headache disorder not only comprises many non-headache symptoms in itself, it also shows high comorbidity with other chronic pain and non-pain conditions (e.g., fibromyalgia syndrome, irritable bowel syndrome, functional non-epileptic seizures, depression, anxiety, and posttraumatic stress disorder). Such "symptom disorders" share several etiological factors (e.g., female preponderance, psychological vulnerability) and psychophysiological mechanisms (e.g., altered sensory processing, pain expectancy). These facts are acknowledged by several recent integrative conceptualizations such as chronic primary pain, chronic overlapping pain conditions, or functional somatic disorders. Accordingly, migraine management increasingly addresses the total symptom burden and individual contributors to symptom experience, and thus incorporates centrally acting pharmacological and non-pharmacological, that is, psychological and behavioral, treatment approaches.Migraine and also other primary headache disorders should be seen as particular phenotypes within a broader spectrum of symptom perception and processing disorders that require integrative diagnostics and treatment. A harmonization of classifications and better interdisciplinary collaboration are desirable.

Every individual experiences subjective somatic symptoms that might or might not be explained by a known medical condition. Some of these symptoms disappear quickly, whereas others persist. This chapter focuses mostly on symptoms that cannot be easily understood from a solely biomedical perspective, the so-called functional somatic symptoms (FSS). The symptoms referred to as FSS are comprised of varying combinations of pain in different parts of the body, functional disturbances attributed to organs like cardiovascular or gastrointestinal dysfunctions or dizziness, and symptoms surrounding fatigue. Their main characteristics, pathophysiology, and etiology are briefly discussed. In addition, the authors discuss the relation between FSS and the current DSM classification of somatic symptom disorder and other related diagnostic categories.

Die ICD-11 wahlt einen grundlegendend neuen Zugang zu den bisherigen somatoformen Storungen und ihren verwandten Krankheitsbildern. Die neue Bezeichnung »Bodily Distress Disorder« (deutsch voraussichtlich »Somatische Belastungsstorung«) ruckt die zirkulare Dynamik von Stress und Korperbeschwerden in den Fokus: Eine Vielzahl von Belastungen kann zu Beschwerden fuhren und gleichzeitig durch Beschwerden entstehen, insbesondere bei ubermasiger Ausrichtung des Denkens und Handelns darauf. Der bisherige einseitige und zudem dualistische Fokus auf die Beschwerdeatiologie (Ausschluss organischer Ursachen; bei chronischen Schmerzstorungen mit somatischen und psychischen Faktoren Forderung organischer Ursachen und psychischer Verstarker, aber Ausschluss psychischer Ursachen; bei dissoziativen Storungen und somatoformen Schmerzstorungen Forderung psychischer Ursachen) ist verschwunden. Allerdings bleibt es bei einer Verortung der Krankheitsbilder bei den psychischen Storungen sowie bei einer Parallelklassifikation mit funktionellen gastrointestinalen und neurologischen Storungsbildern. Das neue Konzept des »chronischen primaren Schmerzes« wandert ins Symptom-Kapitel. Es gibt also nach wie vor keine verbindende Bruckenkategorie, die die enge Verwobenheit psychophysischer Mechanismen und damit die Notwendigkeit einer interdisziplinaren Herangehensweise klar macht.

Functional somatic symptoms are common and multiform. They occur in all genders and age groups, with and without somatic or mental comorbidity. Dysfunctional illness behaviour on the patients' (e. g., excessive attention or anxiety) and also on the caregivers' side (e. g., nocebo messages, redundant investigations or risky treatments) can promote chronification. Empathy, well balanced diagnostics, comprehensible information within individual multifactorial explanatory models, refocussing, activation, and - in more severe forms - additional measures such as psychotherapy are recommended.

To assess the stability of somatic symptoms in community-dwelling participants.The study included 2472 participants (1190 men, 1282 women; mean age 44.3 ± 10.9) from the prospective population-based MONICA-S3 cohort (1994/95) and the 10-year follow-up KORA-F3 cohort. Somatic symptoms were assessed by an adapted version of the Somatic Symptom Scale-8 (SSS-8a) with scores ranging from 0 to 24. Somatic symptom stability was assessed by weighted kappa values (κ). Generalized Estimating Equation models assessing symptom stability were adjusted for sociodemographic, lifestyle, clinical and psychosocial risk factors, as well as pre-existing medical conditions.The mean (±SD) SSS-8a was lower in men (S3: 6.88 ± 3.87, F3: 6.60 ± 3.86) than women (S3: 8.43 ± 4.0, F3: 8.31 ± 4.2) at both time points. However, somatic symptoms remained moderately stable in both genders over 10 years (κ =0.42 in men and κ = 0.48 in women), with the largest stability observed in trouble sleeping for men (κ =0.41) and pain in the joints for women (κ =0.41). Pre-existing somatic symptoms were significantly associated with increasing symptoms at follow-up [men: β = 0.82 (SE 0.12), women: β = 0.85 (SE 0.12)], followed by age and psychosocial factors, whereas higher education and recent health care utilization were inversely associated with increasing symptoms. Although hypertension and obesity were associated with increasing somatic symptoms in men, pre-existing medical conditions were not associated with increasing somatic symptoms in men nor women.The current findings indicate that somatic symptoms remain moderately stable in the general population during 10 years of follow-up, mainly driven by sociodemographic and psychosocial factors.

Schmerzen und andere Korperbeschwerden gehoren zum menschlichen Wahrnehmungsalltag. Sie erklaren sich aus einem komplexen Zusammenspiel aus Reizwahrnehmung, Interpretation und Reaktion und sind nicht unbedingt proportional zu strukturellen Schaden. Wenn sie persistieren, konnen sie Lebensqualitat und Leistungsfahigkeit auch ohne somatische oder psychische Komorbiditat erheblich beeintrachtigen. Das Risiko fur eine Chronifizierung steigt durch dysfunktionale Erfahrungen, Erwartungen und Verhaltensweisen seitens der Patienten, aber auch durch ungunstiges Arztverhalten. Die Behandlung sollte von Anfang an biopsychosozial und schweregradgestuft erfolgen, mit sorgfaltiger, zugleich zuruckhaltender Diagnostik und psychoedukativer, aktiver und bewaltigungsorientierter Therapie.

Since they are core features of many mental and psychosomatic disorders, disturbances of body experience and body interaction are relevant to understand and treat a particular patient. There are several body-related constructs, standardized psychometric instruments and experiments, focusing on single facets and following categorized evaluation. However, there is a lack of terminology and methods to individually and situationally understand and use body experience and body interaction in everyday clinical psychotherapeutic diagnostics. Based on clinical experience and a broad, topic-focused literature research, this discussion agenda delineates their core dimensions - bodily perception, body language, bodily changes, body-related narratives and actions, bodily resonance - and how to approach them by observation, mentalization, and relatedness.Schwierigkeiten mit Körpererfahrung und Körperinteraktion kennzeichnen viele psychische und psychosomatische Erkrankungen und sind sowohl für das Störungsverständnis als auch für die Therapie eines konkreten Patienten relevant. Für ihre Diagnostik gibt es eine Reihe von körperbezogenen Konstrukten, standardisierten Messinstrumenten und Experimenten, die sich auf Einzelaspekte konzentrieren bzw. einer kategorisierenden Auswertungslogik folgen. In der alltäglichen psychotherapeutischen Diagnostik fehlt es aber an Begriffen und Methoden, um Körpererfahrung und Körperinteraktion individuell und situativ zu verstehen und zu nutzen. Dieses Diskussionspapier beschreibt auf der Grundlage klinischer Erfahrungen und einer breiten, themengeleiteten Literaturrecherche ihre wichtigsten Dimensionen – subjektives Körpererleben, dargebotene Körpersprache, gezeigte und verborgene körperliche Befunde, körperbezogene Narrative und Handlungen, körperliche Resonanz – und wie sie in der klinischen Interaktion durch Beobachtung, Mentalisierung und Bezogenheit erfasst werden können.

Medicine usually looks at the body as a biochemical and physical apparatus – from a distant third-person perspective, with fragmented, reductionist positions, unidirectional causal models, and highly selective foci. Even psychiatrists and psychotherapists focus more and more on the brain as an organ, look at genes and colourful pictures. And just as biomedical medicine stares at physical and chemical facts and ignores the person, one could say that psychotherapy stares at personality, cognition, and behaviour and ignores the body. But the lowlands where being-a-person and having-a-body meetmatter a lot for becoming ill, staying, and getting well. What attitudes and what approaches can help us understand the bodily self? After very briefly summarizing current understandings of embodiment and enactivism, we will suggest some practical consequences for everyday clinical diagnostics.

Wann ist der Mensch krank, was hilft ihm beim Gesundwerden? Was konstituiert Krankheit, was legitimiert sie, und welche Bedeutung haben dabei subjektive Beschwerden? Eine Medizin, die sich auf das Messen und Korrigieren von Fakten konzentriert, dabei das Erleben des Kranken uberhort und den Kontext des Krankwerdens und Krankbleibens ubersieht, verschenkt diagnostisches und therapeutisches Potenzial.

Funktionelle Korperbeschwerden in der Neurologie sind haufig, vielgestaltig und werden oft als Herausforderung empfunden. Als verantwortungsbewusster Arzt verliert man sich schnell in Aktionismus, mit — dem Risiko einer zusatzlichen iatrogenen Somatisierung und Chronifizierung. Wenn die Diagnostik keinen Hinweis auf eine organische Erkrankung ergibt, werden die Patienten oft „abgehakt“ und weggeschickt. Dabei sind sie zumindest fur die Grundversorgung bei Neurologen und Nervenarzten gut aufgehoben.

BACKGROUND: Nociplastic pain has been recently introduced as a third mechanistic descriptor of pain arising primarily from alterations of neural processing, in contrast to pain due to tissue damage leading to nociceptor activation (nociceptive) or due to lesion or disease of the somatosensory nervous system (neuropathic). It is characterized by hyperalgesia and allodynia, inconsistency and reversibility, as well as dynamic cross-system interactions with biological and psychobehavioral factors. Along with this renewed understanding, functional pain disorders, also classified as chronic primary pain, are being reframed as biopsychosocial conditions that benefit from multimodal treatment. OBJECTIVE: To summarize the current understanding of nociplastic pain and functional pain disorders, with a focus on conditions that are common in neurology practice. METHODS: This was a narrative literature review. RESULTS: Chronic back pain, fibromyalgia syndrome and complex regional pain syndrome are best understood within a biopsychosocial framework of pain perception that considers structural factors (predispositions and sequelae) and psychobehavioral mechanisms. Although pain is often the primary complaint, it should not be the only focus of treatment, as accompanying symptoms such as sleep or mood problems can significantly impact quality of life and offer useful leverage points for multimodal treatment. Analgesic pharmacotherapy is rarely helpful on its own, and should always be imbedded in a multidisciplinary setting.

Somatic symptoms including pain are everyday human experiences. They usually result from a complex interaction of stimuli, interpretation and reaction, and are not necessarily proportional to structural damage. Persistent functional somatic symptoms can be associated with a significant impairment of quality of life and functioning, even without mental or somatic comorbidity. Dysfunctional experiences, expectancies and behavior, not only by patients but also by physicians, can increase the risk of chronification. From the outset, management should be graded with respect to the severity and biopsychosocial aspects, with thorough but cautious diagnostics and with psychoeducative, active and coping-oriented treatment.

Background The pathological feigning of disease can be seen in all medical disciplines. It is associated with variegated symptom presentations, self-inflicted injuries, forced but unnecessary interventions, unusual and protracted recoveries, and frequent changes of treating physician. Factitious illness is often difficult to distinguish from functional or dissociative disorders on the one hand, and from malingering on the other. Many cases, even fatal ones, probably go unrecognized. The suspicion that a patient's problem may be, at least in part, factitious is subject to a strong taboo and generally rests on supportive rather than conclusive evidence. The danger of misdiagnosis and inappropriate treatment is high. Methods On the basis of a selective review of current literature, we summarize the phenomenology of factitious disorders and present concrete strategies for dealing with suspected factitious disorders. Results Through the early recognition and assessment of clues and warning signs, the clinician will be able to judge whether a factitious disorder should be considered as a differential diagnosis, as a comorbid disturbance, or as the suspected main diagnosis. A stepwise, supportive confrontation of the patient with the facts, in which continued therapeutic contact is offered and no proofs or confessions are demanded, can help the patient set aside the sick role in favor of more functional objectives, while still saving face. In contrast, a tough confrontation without empathy may provoke even more elaborate manipulations or precipitate the abrupt discontinuation of care-seeking. Conclusion Even in the absence of systematic studies, which will probably remain difficult to carry out, it is clearly the case that feigned, falsified, and induced disorders are underappreciated and potentially dangerous differential diagnoses. If the entire treating team successfully maintains an alert, transparent, empathic, and coping-oriented therapeutic approach, the patient will, in the best case, be able to shed the pretense of disease. Above all, the timely recognition of the nature of the problem by the treating team can prevent further iatrogenic harm.

Objective To study the prevalence and clinical characteristics of Somatic Symptom Disorder (SSD), Bodily Distress Syndrome (BDS) and fibromyalgia syndrome (FMS) and their overlap in the general German population. Methods A cross-sectional nationally representative population survey was performed. 2531 participants (mean age 48.8 ± 17.85 years, 53.3% women) completed the Somatic Symptom Scale SSS-8, the Bodily Distress Syndrome (BDS) 25 checklist, the Whiteley Index 7 (WI-7), the self-administered comorbidity questionnaire and the Michigan Body Map. Case definitions of SSD, BDS and FMS were assigned using established criteria. Results 4.5% of participants met the criteria of SSD (SSS – 8 at least one item “bothered very much” and WI- 7 total score ≥ 1). 9.6% met the criteria of single-organ BDS and 1.3% of multi-organ BDS. Prevalence of FMS according to 2016 criteria was 3.4%. 82.3% of FMS cases met any BDS criteria.28.1% of FMS cases satisfied SSD criteria. 28.8% of any BDS cases met the criteria of SSD. 75.1% of SSD cases met the criteria of any BDS. FMS cases reported the highest amount of somatic and psychological symptom burden and health anxieties. There were no differences in age and gender between any BDS and SSD cases. SSD cases reported worse general health and more fibromyalgia-related variables than any BDS cases. Conclusions In the general population, there is a substantial overlap between FMS and BDS, but not of FMS and SSD, and not of SSD and any BDS. Case definitions of the three disorders partially captured different groups in the general population.

Objective The Bodily Distress Syndrome 25 (BDS 25) checklist is a self-report instrument that can be used for case finding of a BDS in both clinical practice and research. We assessed the reliability and the internal and external validity of the German version of the BDS 25 in a sample of the general German population. Methods The psychometric properties of the BDS 25 German were examined in a representative cross-sectional German population survey which included 2386 persons aged ≥14 years. Validation instruments included the Somatic Symptom Scale 8, the Giessen Subjective Complaints List 8 and the Patient Health Questionnaire 4. Participants were asked if they had been diagnosed with fibromyalgia or irritable bowel syndrome by a physician in the past. Results The acceptance was high. Only 81 (2.3%) single items were not answered. Internal consistency was sufficiently high for all four subscales and the total score (α > 0.800). Exploratory and confirmatory factor analysis revealed clear evidence for a four-factorial structure with cardiopulmonary, gastrointestinal, musculoskeletal and general symptoms. Moderate to high correlations with other measures of somatic and psychological symptom burden were found. In latent class analysis, the model featuring three classes with no, moderate and severe BDS symptoms evinced the best model fit. Participants with self-reported fibromyalgia and irritable bowel syndrome were mainly found in the moderate and severe BDS group. Conclusions The BDS 25 German has excellent psychometric properties to screen for BDS in the general population.

Ein bewusster Umgang mit unklaren (somatoformen, funktionellen) Korperbeschwerden kann Arzten wie Betroffenen neue (Be-)Handlungsspielraume eroffnen. Insbesondere Haltung und Gesprachsfuhrung stellen bei unklaren Korperbeschwerden bereits eine erste, aber wesentliche therapeutische Intervention dar. Anhand zahlreicher Beispiele werden Strategien in der Gesprachsfuhrung vorgestellt sowie diagnostische und therapeutische Aspekte behandelt. Mit genauem Hinschauen und Hinhoren kann der Patient zum aktiven Behandlungspartner werden. Auf diese Weise kann seine Selbstwirksamkeit gefordert und die Behandlungszufriedenheit auf beiden Seiten verbessert werden.

Ein Patient klagt uber Ruckenschmerzen, aber weder Anamnese noch korperliche Untersuchung ergeben Hinweise auf eine behandlungsbedurftige korperliche Erkrankung. Jetzt gilt es, den Patienten weder abzuwimmeln noch seinem (oder sogar dem eigenen) Wunsch nach mehr Diagnostik nachzugeben. Wie konnen wir Patienten mit unklaren Korperbeschwerden helfen, sodass beide Seiten mit der Behandlung zufrieden sind?

Mit der S3-Leitlinie „Umgang mit Patienten mit nicht-spezifischen, funktionellen und somatoformen Korperbeschwerden (NFS)“ (AWMF Registernr. 051–001) gibt es erstmals einen breiten, evidenzbasierten Konsens uber psychosoziale und somatische Disziplinen hinweg zu Terminologie und Versorgung dieser grosen, gerade in der Schmerzmedizin hochrelevanten Patientengruppe.

Nicht-spezifische, funktionelle und somatoforme Korperbeschwerden (NFS) sind ein haufiges und oft chronisches Phanomen in der Haus- und Facharztmedizin. Die Patienten sind erheblich in ihrer Lebensqualitat beeintrachtigt, die direkten und indirekten Folgekosten sind hoch. Fur den Arzt bedeutet ihre Behandlung eine Herausforderung, im ungunstigen Falle kann das Verhalten des Arztes den Verlauf negativ beeinflussen. Unter Federfuhrung der beiden Fachverbande fur Psychosomatische Medizin wurde kurzlich eine umfassende, evidenzbasierte und interdisziplinare S3-Leitlinie zum Umgang mit Patienten mit NFS entwickelt. Diese beschreibt die wesentlichen Elemente der arztlichen Grundhaltung und Gesprachsfuhrung sowie des diagnostischen und therapeutischen Vorgehens aufgrund der aktuellen empirischen Befundlage. Der Aufbau einer partnerschaftlichen Arbeitsbeziehung sowie eine symptom- und bewaltigungsorientierte Grundhaltung begunstigen die Behandlung von Patienten mit NFS. Die biopsychosoziale Simultandiagnostik umfasst die Erhebung der Korperbeschwerden plus organischer Basisdiagnostik und von Beginn an eine psychosoziale Basisanamnese, die bei Hinweisen auf psychosoziale Belastungen erweitert wird. Bei leichteren Verlaufen reicht meist die Behandlung durch den Hausarzt, auf der Grundlage therapeutischer Masnahmen aus der psychosomatischen Grundversorgung. Schwerere Verlaufe werden in einem starker strukturierten Setting behandelt, sie bedurfen regelmasiger und beschwerdeunabhangiger Termine und erfordern die Mitarbeit des Patienten in hoherem Mase. Erforderlich ist der koordinierte und kooperative Einsatz weiterer Elemente aus den Bereichen gestufte Aktivierung, Psychotherapie, Entspannungsverfahren sowie ggf. befristete Medikation. Besonders schwere Verlaufe bedurfen einer multimodalen Behandlung, ggf. im (teil-)stationaren Setting.

Mit der S3-Leitlinie „Nicht-spezifische, funktionelle und somatoforme Korperbeschwerden“ wurde erstmals uber psychosoziale und somatische Disziplinen hinweg ein breiter, evidenzbasierter Konsens zu Terminologie und Versorgung erreicht. Dieser Beitrag fasst die fur Psychotherapeuten wesentlichen Hintergrundinformationen und Empfehlungen zusammen. Bei leichteren Verlaufen reicht meist die Behandlung durch den Hausarzt mit Erarbeiten eines biopsychosozialen Erklarungsmodells und korperlicher/sozialer Aktivierung. Schwerere Verlaufe bedurfen eines kooperativen, koordinierten Vorgehens mit regelmasigen/beschwerdeunabhangigen Terminen beim Hausarzt, gestufter Aktivierung und Psychotherapie – v. a. kognitiv-behaviorale, daneben psychodynamisch-interpersonelle und hypnotherapeutische/imaginative. Besonders schwere Verlaufe erfordern eine multimodale, ggf. (teil-)stationare Therapie. Erganzend wird die fur Betroffene und ihre Angehorigen erarbeitete Patientenleitlinie vorgestellt.

Umweltbezogene Angste und Korperbeschwerden sind weit verbreitet. In Form so genannter Umweltsyndrome erlangen sie haufig Krankheitswert, auch wenn in der Regel kein Nachweis eines Zusammenhangs zwischen subjektiven Auslosern und Beschwerden gelingt. Die Rolle der Psychotherapie ist umstritten, v. a. da die Patienten um die Legitimitat ihrer Beschwerden furchten und eher somatisch- oder alternativ-orientierte Behandlungen suchen. Auserdem stutzt bisher nur wenig Evidenz die Wirksamkeit von Psychotherapie. Angesichts des hohen Leidensdrucks – v. a. aufgrund von antizipatorischer Erwartungsangst, ausgepragtem Vermeidungsverhalten, Ruckzug und Misstrauen – sowie der hohen psychischen Komorbiditat konnen Patienten mithilfe einer Psychotherapie jedoch haufig wieder mehr Selbstwirksamkeit, mehr Vertrauen, einen groseren Aktionsradius und damit mehr Lebensqualitat erlangen.

Psychological symptoms of somatoform disorders will be part of their new definition in DSM-5. We developed the Somatic Symptoms Experiences Questionnaire (SSEQ) as a self-report questionnaire to assess important psychological characteristics of patients with somatoform disorders. Item selection and identification of factor structure, as well as reliability and validity have been checked in a sample of N=453 psychsomatic outpatients. Results of a principal components analysis with Promax-rotation suggested 4 factors (health worries, illness experience, difficulties in interaction with doctors, impact of illness). Validity analyses confirmed associations between the SSEQ-Scores and the physical disability of patients. Although further assessments of psychometric qualities are needed, the questionnaire appears to be well-suited for future assessment of relevant psychological features of somatoform disorders.

245 patients presenting with allergic complaints were interviewed with SCID for the diagnosis of a somatoform disorder and filled in the "ques-tionnaire of conflict coping strategies (FKBS)" 55 patients with insect allergy and 100 depressed patients served as controls. Only depressed patients diverged from the FKBS reference scores, particularly with respect to "turning against self".

Zusammenfassung Fragestellung: Die Klassifikation und Therapie von Patienten mit chronischen Schmerzen in mehreren Korperregionen ohne hinreichend erklarenden somatischen Krankheitsfaktor ist umstritten. Das diagnostische Etikett "Fibromyalgiesyndrom" (FMS) wird von einigen Vertretern psychosozialer Facher und der Allgemeinmedizin abgelehnt. Methode: Zusammenfassung der wichtigsten Empfehlungen der aktuellen S3-Leitlinien zum FMS und zu nicht-spezifischen/funktionellen/somatoformen Korperbeschwerden. Ergebnisse: Das FMS ist eine funktionelle Storung, bei der psychosoziale Faktoren in Entstehung und Verlauf bei derMehrheit der Patienten eine wesentliche Rolle spielen. Die Diagnose eines FMS kann anhand des typischen Beschwerdebildes und durch Ausschluss somatischer Differenzialdiagnosen ohne Tender Point Untersuchung anhand der 2010 modifizierten diagnostischen Kriterien des American College of Rheumatology gestellt werden. Aus psychosomatischer Sicht sollte eine Einordnung nach Schweregrad vorgenommen wer...

The S3 guideline "Dealing with patients with non-specific, functional and somatoform bodily symptoms" emphasizes the similarities in the management of the manifold manifestations of so called "medically unexplained symptoms" and gives recommendations for a stepped and collaborative diagnostic and therapeutic approach in all subspecialties and all levels of health care. It has a special focus on recommendations regarding attitude, physician-patient-relationship, communication, the parallelization of somatic and psychosocial diagnostics and a stepped therapeutic approach. The "Evidence-based guideline psychotherapy in somatoform disorders and associated syndromes" provides a differentiated analysis of the current evidence regarding the effectiveness of various psychotherapeutic interventions for the most relevant manifestations of functional and somatoform disorders. In combination, both guidelines pose important advances for treatment quality in Germany, but also illustrate remarkable structural and research deficits.

Vor dem Hintergrund der zunehmenden Berucksichtigung von Geschlechterunterschieden in der Medizin in den letzten 20 Jahren sehen sich die „Psycho-Facher“ (Psychiatrie, Psychotherapie, Psychosomatik) in besonderer Weise mit den vielfaltigen Einflussen der Geschlechtszugehorigkeit sowohl von PatientInnen als auch TherapeutInnen auf Krankheits- wie auch Behandlungsprozesse befasst. Mehr noch als in den somatischen medizinischen Fachdisziplinen wirkt sich der Faktor Geschlecht – im Sinne von „Gender“ – erheblich auf Entstehung, Erkennung, Verlauf, Behandlung und psychosoziale Konsequenzen psychischer Storungen aus.

In approximately 20% of patients with suspected allergies, no organic symptom explanation can be found. Limited knowledge about patients with "medically unexplained symptoms (MUS)" contributes to them being perceived as "difficult" and being treated inadequately. This study examined the psychobehavioural characteristics of patients presenting for a diagnostic allergy work-up. Patients were interviewed and completed various self-rating questionnaires. Patient-Doctor interaction was evaluated, and the organic explicability of the patients' symptoms was rated by allergists. Patients with vs. those without MUS differed in several respects. Mental comorbidity, female sex, dissatisfaction with care, and a problematic countertransference (the interviewer's feelings towards the patient) independently predicted MUS. Patients whose symptoms could be explained organically reported more psychobeha-vioural problems than a control group of immuno-therapy patients. There were no differences in patient-doctor interaction. In patients with suspected allergies, recognition of psychological burden and concurrent mental disorders is important. Mental comorbidity and a difficult patient-doctor interaction may predict MUS.

The classification and therapy of patients with chronic widespread pain without evidence of somatic factors as an explanation is currently a matter of debate. The diagnostic label "fibromyalgia syndrome"(FMS) has been rejected by some representatives of general and psychosomatic medicine.A summary is given of the main recommendations from current evidence-based guidelines on FMS and nonspecific/functional/somatoform bodily complaints.The criteria of FMS and of persistent somatoform pain disorder or chronic pain disorder with somatic and psychological factors partly overlap. They include differential clinical characteristics of persons with chronic widespread pain but without sufficiently explaining somatic factors. Not all patients diagnosed with FMS meet the criteria of a persistent somatoform pain disorder. FMS is a functional disorder, in which in most patients psychosocial factors play an important role in both the etiology and course of illness. FMS can be diagnosed by looking at the history of a typical symptom cluster and excluding somatic differential diagnoses (without a tender point examination) using the modified 2010 diagnostic criteria of the American College of Rheumatology. Various levels of severity of FMS can be distinguished from a psychosomatic point of view, ranging from slight (single functional syndrome) to severe (meeting the criteria of multiple functional syndromes) forms of chronic pain disorder with somatic and psychological factors, of persistent somatoform pain disorder or of a somatization disorder. The diagnosis of FMS as a functional syndrome/stress-associated disorder should be explicitly communicated to the patient. A therapy within collaborative care adapted to the severity should be provided. For long-term management, nonpharmacological therapies such as aerobic exercise are recommended. In more severe cases, psychotherapy of comorbid mental disorders should be conducted.The coordinated recommendations of both guidelines can synthesize general medical, somatic, and psychosocial perspectives, and can promote graduated care of patients diagnosed with FMS.

245 patients presenting with allergic complaints were interviewed with SCID for the diagnosis of a somatoform disorder and filled in the "ques-tionnaire of conflict coping strategies (FKBS)" 55 patients with insect allergy and 100 depressed patients served as controls. Only depressed patients diverged from the FKBS reference scores, particularly with respect to "turning against self".

The S3 guideline "Dealing with patients with non-specific, functional and somatoform bodily symptoms" emphasizes the similarities in the management of the manifold manifestations of so called "medically unexplained symptoms" and gives recommendations for a stepped and collaborative diagnostic and therapeutic approach in all subspecialties and all levels of health care. It has a special focus on recommendations regarding attitude, physician-patient-relationship, communication, the parallelization of somatic and psychosocial diagnostics and a stepped therapeutic approach. The "Evidence-based guideline psychotherapy in somatoform disorders and associated syndromes" provides a differentiated analysis of the current evidence regarding the effectiveness of various psychotherapeutic interventions for the most relevant manifestations of functional and somatoform disorders. In combination, both guidelines pose important advances for treatment quality in Germany, but also illustrate remarkable structural and research deficits.