Patient Mr. S. has been feeling pain in the left half of his chest. He goes to his GP – who explains roughly: none of the medical results stick out. Mr. S. gets a pain killer. The pains get stronger. The internist also ascertains no pathological finding. Mr. S. is sent to a hospital for a more precise examination. Again, everything remains negative after extensive investigations. Physically everything is in order. Nevertheless the discomfort increases. Mr. S. can no longer sleep, not much later he can’t even work. He suffers from somatoform disorder. The victims experience symptoms akin to a physical ailment, however no such ailment exists.
The symptoms are conveyed exclusively through the nervous system and can be expressed diversely: most common are backache or headaches, exhaustion and fatigue and nausea, irritable bowel or shortness of breath. Doctors however find no adequate organic explanation. “Rather more crucial are psychological or social factors”, says Professor Dr. Wolfgang Herzog, Medical Director of the Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg.
Sick without finding
Dr. Mark Stelzig, specialist in psychiatry and neurology and psychotherapist in psychoanalysis and psychodrama, has also addressed the issue. He calls his book which appeared in March 2013, titled Krank ohne Befund (i.e. Sick without finding), an indictment, because for decades the volume of literature that deals with this very issue has been growing. The factual arguments presented and already existing for years were indeed accepted politely, with interest and quite approvingly noted – regardless, the retracted system for the treatment of organic diseases still gets stubbornly held onto. And not just to the chagrin of the patients. The social security institutions have also been dealt enormous costs, because somatoform disorders are not a niche issue.
A third of all patients affected
“30 per cent of patients go to a family GP with mental health problems where they encounter a system that primarily provides somatic care”, says Dr. Matthias Burkard, specialist in psychosomatic medicine, psychoanalysis and psychotherapy at the DRK Clinic Berlin Westend, “whereby the number rises significantly, i.e. up to 50 per cent, if one does not measure the number of patients, but rather the number of examinations undertaken. Depending on the field of specialisation, the prevalence varies between 37 per cent in dentistry and 66 per cent in gynaecology”, writes Stelzig.
Patients with a somatisation disorder belong to the so-called “high utiliser group” in the health care system, which weighs on the social systems, making up nine times as much as the average patient load. Multiple diagnosis process, frequent hospitalisation and sick days produce enormous costs. The “ill without finding” patients according to Stelzig create in the area of outpatient care 14-fold higher median costs than the average per capita expenditure. The inpatient costs amount to six times as much. “Our health care system funds any physical examinations whatsoever, yet doctors mostly lack time and financial incentive for discussion”, criticises Herzog. Why does nobody fight against this?
Focus on somatic disorders too strong
The biggest problem is the affected person’s own lack of knowledge. Stelzig summarises the matter as follows: “The person suffering wants an operation, a bandage, a drug. This is how he or she grew up. This is what he or she has learned. And unfortunately, most doctors have also become used to it.” He adds further: a collective outcry is precluded, because it is not always clear to most people that their mind gets adversely affected in response to a variety of exceed demands and also that physical symptoms can be associated with this. The decades-old thinking pattern passed along, believing that pain or other physical symptoms must have an organic cause, is too strong.
Possible backgrounds however include, among others, somatised depression, anxiety disorder, physical sequelae of psychological trauma, or somatoform or functional abnormalities – yielding a complex interplay of factors such as genetic predisposition, social problems and psychological pressures. Yet these diagnoses would not be made for more than half of those affected, according to Stelzig, adding that this is sad for the patients and shameful for our health system.
Thick medical records, long paths of suffering
“Being physically ill is socially accepted”, says Stelzig; being “psychologically burdened, to suffer stress, is also acknowledged”. However suffering emotionally in such a way that a mental or physical illness develops is not only not recognised, but stigmatised and devalued. It brings about fear and punishment by its tendency toward causing ejection from society. This is one possible reason why these “sick without findings” patients often have years of medical odysseys behind them before they are properly treated. “Patients with somatoform disorders usually end up first coming to us after seven years carrying a thick medical file”, says Dr. Burkard. Somatoform disorders have since 1992 also been included in the ICD European index of diseases (International Statistical Classification of Diseases and Related Health Problems).
So where does the problem lie?
“We can name the phenomena, make a diagnosis and offer a meaningful treatment plan”, writes the disgruntled lecturer – as he describes himself – Stelzig, who is contracted with the Paracelsus Private Medical University Salzburg, Danube University Krems and the University of Innsbruck. The only problem is that the knowledge of these facts has procured far too small a place in the minds of physicians, but also in the mind of those affected. But enough whining: how could we make it better?
First, a relationship of trust of the doctor with his patients is important. “It is essential to spend sufficient time explaining to the patient the mechanisms involved, so as to promote his or her understanding and to build a foundation of trust. If the pressure coming from a crowded waiting room in the background makes itself perceptible, it will hardly be possible for the doctor to provide enough time”, writes Stelzig. In this case, he recommends, even if the financial incentive is low, making an extra appointment and/or referring the patient to a specialist in psychiatry or psychotherapeutic medicine.
Also, communication between doctor and patient is important. The worst message to hear is: “You have nothing.” Similarly counterproductive are statements such as: “Physically you are healthy, then it must surely be a psychological or psychosomatic matter.” Even well-meaning advice such as relaxing, adopting a change of pace or going on vacation would draw the patient’s resistance and would not solve the problem, according to Stelzig.
The inclusion of so-called psychosomatic primary care in ambulatory care (psychotherapy agreements involving the National German Association of Statutory Health Insurance Physicians and German health insurance providers in 1987) and in the residency training system developed by the German Federal Medical Association (1992) has made a significant contribution to the training of domestic and other specialists. Herein doctors are able to qualify in psychosomatic basic care in academies and institutions.
speziALL breaks new ground
Because treatment by GP and psychosomatic specialists is recommended in the specific instance where progress of cases encounters difficulties, a team in Heidelberg has developed a collaborative therapy model called “speziALL”. This stands for specific medical-psychosomatic short group intervention. “What makes speziALL particularly different here is that primary care physician and psychosomatic specialists together offer group therapy, indeed in the family doctor’s practice”, says Dr. Rainer Schäfert, the responsible study physician at the Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg. This is because many patients want to be treated by their GP and reject psychotherapy at first. “With speziALL the resistant threshold is significantly lower among the patients”, adds Dr. HumSc Dipl. Psych. Claudia Kaufmann, the study psychologist responsible.
In ten weekly group sessions, patients receive information on the biological, social and mental factors which trigger their discomforts. They exchange information on their complaints, the causes and possible coping strategies and they learn to relax.
Significant improvements ascertainable
The speziALL group therapy seems to be successful: it was found that the psychological quality of life of patients in the speziALL group improved to a greater extent in comparison with other patients; they felt their vitality to be less restricted, and that their social contact and work efficiency was less limited. In addition, their physical symptoms declined. The number of GP visits decreased significantly among these patients after therapy. “In economic health terms speziALL has a good cost-benefit ratio”, says Schäfert. It is an approach that gives us hope, and possibly could be a trend-setting one.
Time for a rethink?
“In our Western society, physical diseases are strongly over-emphasised,” says Dr. Burkard. An estimated 90 per cent of the physicians would be dealing exclusively with somatic diseases. Dr. Stelzig urges: “Let’s finally give the power of the soul more space – in textbook medicine”.