B. Luban-Plozza W. Poldinger F. Kroger Psychosomatic Disorders in General Practice Third, Revised and Enlarged Edition Translated and Revised from the German by G. Blythe Foreword by M. Balint With 18 Figures and 18 Tables Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona Budapest Prof. Dr. Dr. hc. BORIS LUBAN-PLOZZA Clinica Santa Croce, Psychosomatic Department 6600 Locarno, Switzerland Prof. Dr . WALTER POLDINGER Psychiatrische Universitatsklinik Wilhelm-Klein-StraBe 27, 4025 Basel, Switzerland Dr. FRIEDEBERT KROGER Rheinisch-Westfalische Technische Hochschule Aachen Klinik flir Psychosomatische Medizin W-5100 Aachen, Bundesrepublik Deutschland Translator: George Blythe, SpechtstraBe 3, 4106 Therwil, Switzerland Previous editions published by © Editiones Roche, F. Hoffmann-La Roche Ltd, Basle, Switzerland ISBN-13: 978-3-540-54556-9 e-ISBN-13: 978-3-642-76940-5 001: 10.1007/978-3-642-76940-5 Library of Congress Cataloging-in-Publication Data. Luban-Plozza, Boris. [Psychosomatisch Kranke in der Praxis. English] Psychosomatic disorders in general practice I B. Luban-Plozza, W. POIdinger, F. Kroger. - 3rd, rev., and en!. ed. p. cm. Translation of: Der psycho somatisch Kranke in der Praxis. Includes bibliographical references and index. ISBN-I3:978-3-540-54556-9 1. Medicine, Psychosomatic. I. Poldinger, W. (Walter) II. Kroger, F. (Friedebert) III. Title. RC49.L8213 1991. 616.08 - dc20. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must atways be obtained from Springer-Verlag. 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Typesetting: Best-set Typesetter Ltd., Hong Kong 1913130-543210 - Printed on acid-free paper Foreword to the First Edition This book is addressed first and foremost to the neophyte, that is to the doctor who, although properly educated in the traditional 'illness centred medicine' is ill at ease in face of the many patients whose case histories cannot be understood and whose complaints cannot be helped on the basis of what he has learned. Here, then, new ways of thinking and of acting are offered to him, not by devaluating his present knowledge and skills, but by using them as a basis upon which to extend his therapeutic resources. As the first step the authors demonstrate that, in addition to the traditional understanding of the signs and symptoms of illness in terms of pathophysiological changes of the body and its functions, various diseases can also be understood as the expression of the patient's affective state, his \lnresolved personality conflicts and his difficulties in social adaptation. They then demonstrate the usefulness of this way of thinking. They discuss in detail the fundamental difference between the traditional way of 'taking a medical history' which, in fact, is hardly more than getting the patient to answer the items of a complicated questionnaire, and the new way of 'listening' which encourages the patient to tell his doctor not only the detailed history of his illness but also all his realistic and unrealistic fantasies and fears which are either provoked by, or expressed through, his illness. It is duly emphasized that this new way amounts to an 'examination by the patient himself' in which process the doctor's task is to help the patient to a better understanding of himself by acting as a mirror. The danger that the doctor attaches too much significance to a possibly unimportant 'organic' symptom during the diagnostic period is properly emphasized. This usually leads to a situation in which all the patient's complaints are seen in terms of this symptom. Once a 'name' has been given to the patient's frightening fantasies and disquieting sensations it is most difficult to dislodge. The authors take a critical view of the habitual procedure in psychosomatic conditions: as a first step the doctor undertakes a phys ical examination; when he is convinced that no organic abnormalities can be found, he 'reassures' the patient that he is completely healthy; all of us know how questionable the results of this reassurance are. VI Foreword to the First Edition If the doctor knows the patient fairly well, he might try to 'advise' him how to live, how to behave. Such advice is always well meant but its therapeutic efficiency is rather doubtful. In addition, if he feels that still more is needed, the doctor writes a prescription according to the symptomatology presented: an anti depressant for tiredness and exhaustion, sadness and despair, or a tranquilizer for complaints such as anxiety or excitation. The authors raise the justified question, is this procedure correct? And if it is, under what conditions and in what indications should these drugs be given? This of course is not an easy question to answer, all the more so since the answer depends as much on the doctor:'s personality and convictions as on the patient's complaints. The authors therefore propose the principle that psychotherapy should never replace the traditional medical treatment, only comple ment it. Unquestionably this principle is safe and sensible, but one may ask whether it is always therapeutically efficient. In this book Luban-Plozza and Poldinger make a serious attempt to elucidate these complicated questions from as many angles as poss ible. In addition to discussing the influence of the doctor's therapeutic approach on the development of the psychosomatic complaint they also stress the repercussions of the changed atmosphere created by the Health Services in various countries. An attempt is made to discover whether the patient's personal responsibility for his illness and re covery is diminished, and whether it can be replaced by impersonal insurance or state systems. This process is further reinforced by the development of the various social services all over the Western world which try to take away still more of the patient's personal respon sibility, almost saying 'If you are so weak, here we are to help you, lean on us'. The difficulties that this changed atmosphere puts in the way of the proper treatment of psychosomatic conditions are discussed. This book will serve as a useful guide to any doctor who wishes to know more about this complex field of medicine. MICHAEL BALINT t, LONDON (1896-1970) Preface to the Third Edition Closely geared to general practice yet without neglecting basic theory, this book has retained so much appeal among readers .as to warrant a third edition. We assume that the work has retained its place among the leading publications on psychosomatics because it embodies our strong interest in the 'here and now' of medical practice. The timing of this thoroughly revised and enlarged edition appears opportune as psychosomatic basic care and the medicine of dialogue acquire more meaning in daily routine practice, and as the need for basic information increases. We conceive psychosomatics to be an integral part of medicine. When we speak of 'psychosomatic disorders' in this book, our premise is that somatic and psychosocial aspects play an important role in their pathogenesis and course. This notion constitutes the very basis of what is understood as psychosomatic medical treatment. Such a point of departure calls for a consistent spirit of cooperation with regard to the problems involved. This alone satisfies the initial requirement of simultaneously considering both the somatic and psychosocial aspects of health and illness. Understanding and action are impossible without resort to some form of theoretical framework. The German neurologist Victor von Weizsacker founded the notion that psychosomatic medicine had to be depth psychological or nothing. The development of psycho analytic theory thus is at the base of psychosomatic practice, which however is being extended by modern ideas to improve our under standing of symptoms, as for example in general-systems theory, by the stress· concept, and by basic biological and social psychiatric aspects. We prefer an approach orientated towards patients and prob lems to' one deriving exclusively from one specific, theoretical line of thought. We the authors are closely associated and have, in this as in other editions, had a complementary effect on broadening one another's knowledge and experience. Moreover, F. Kroger, a member of the younger generation, is a coauthor of this edition, further broadening our experience. As was the case with previous editions, this book is suited to the needs of all physicians in private practice, clinicians, and other hospital . staff. It has also been our intent to make the book attractive to medical VIII Foreword to the Third Edition students and to open up fresh vistas on psychosomatics, not only to all those working in the various fields of health care but also to the interested layman. An attempt has been made to retain spontaneity and frankness of dialogue when comparing the various opinions and schools of thought. We are particularly grateful to the following specialists who worked with us on this publication: Professor M. Berger (gynecological disorders), Drs. M. Fisch and E. Streich-Schlossmacher (psycho logical and psychosomatic aspects of dentistry), Dr. R. Hohmeister (musculoskeletal disorders), and Professor A. Krebs (skin diseases). Locarno/Basle/Heidelberg 1991 BORIS LUBAN-PLOZZA WALTER POLDINGER FRIEDEBERT KROGER Contents 1 Psychosomatic Groundwork .......................... . 1 1.1 Historical Introduction .............................. . 1 1.2 Psychosomatic Correlates ............................ . 9 1.2.1 Psychophysiological Connections ...................... . 10 1.2.2 Psychodynamic Concepts ............................ . 14 1.2.3 Models Based on the General-Systems Theory .......... . 20 1.2.4 Sociopsychosomatics ................................ . 21 1.2.5 Conclusion to the Precepts ........................... . 23 2 Psychosomatic Disorders ............................. . 25 2.1 Disorders of the Respiratory Organs .................. . 26 2.1.1 Bronchial Asthma .................................. . 27 2.1.2 Coughing and Singultus .............................. . 30 2.1.3 The Nervous Breathing Syndrome .................... . 30 2.1.4 The Hyperventilation Syndrome ...................... . 31 2.1.5 Pulmonary Tuberculosis ............................. . 33 2.2 Cardiovascular Disorders ............................ . 35 2.2.1 Functional Heart Disorders .......................... . 36 2.2.2 Coronary Heart Disease ............................. . 39 2.2.3 Essential Hypertension .............................. . 43 2.3 Aspects of Eating Behaviour ......................... . 46 2.3.1 Nutrition ....................................... '.' .. 46 2.3.2 Overnutrition and Obesity ........................... . 51 2.3.3 Anorexia Nervosa .................................. . 54 2.3.4 Bulimia ........................................... . 59 2.4 Gastrointestinal Disorders ........................... . 62 2.4.1 Gastric and Duodenal Ulcers ......................... . 63 2.4.2 Constipation ....................................... . 69 2.4.3 Emotional Diarrhea ................................. . 71 2.4.4 Irritable Colon ..................................... . 72 2.4.5 Ulcerative Colitis and Crohn's Disease ................. . 72 2.5 Disorders of the Endocrine System .................... . 74 2.5.1 Hyperthyroidism ................................... . 74 2.5.2 Diabetes Mellitus ................................... . 75 X Contents 2.6 Aspects of Allergy .................................. . 77 2.7 Skin Diseases ...................................... . 79 2.7.1 Urticaria .......................................... . 80 2.7.2 Pruritus ........................................... . 81 2.7.3 Atopic Dermatitis (Disseminated Neurodermatitis) ...... . 81 2.7.4 Anogenital Pruritus ................................. . 82 2.7.5 Psoriasis ........................................... . 83 2.7.6 Dermatological Artifact ............................. . 83 2.7.7 Treatment ......................................... . 83 2.8 Headache ......................................... . 84 2.9 The Sleepless Patient ................................. . 86 2.10 Gynecological Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 90 2.10.1 Dysmenorrhea...................................... 91 2.10.2 Functional Sterility.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 92 2.11 Musculoskeletal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .. 94 2.11.1 Soft Tissue Rheumatism. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 95 2.11.2 Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 97 2.11.3 Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 99 3 Psychoautonomic Syndromes .......................... 103 3.1 Basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 103 3.2 Pathogenetic Concepts ............................... 105 3.3 Triggering Factors and Personality Profile. . . . . . . . . . . . . .. 107 3.4 Types of Decompensation ............................. 108 3.5 Treatment .......................................... 109 4 Psychosexual Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 111 4.1 Basics .............................................. 111 4.2 Pathogenic and Therapeutic Concepts .................. 112 4.3 Forms of Treatment .................................. 113 4.4 Sexuality with Increasing Age ......................... 119 4.5 Personal Experience of the Consultation in Psychosexual Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 120 5 Psychological and Psychosomatic Aspects of Dentistry ..... 123 5.1 Basics .............................................. 123 5.2 The Significance of the Oral Region. . . . . . . . . . . . . . . . . . .. 125 Contents XI 5.3 Going to the Dentist 125 5.4 The Dentist-Patient Relationship. . . . . . . . . . . . . . . . . . . . . .. 126 5.5 Psychological Aspects During Treatment ................ 127 5.6 The Various Groups of Patients ........................ 128 5.7 Psychogenic Influences in the Maxillofacial Region. . . . . .. 133 5.8 Loss of Teeth ....................................... 134 5.9 The Dental Prosthesis ............................... , 135 5.10 Conclusions.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 136 6 The Psychosomatic Patient After Onset of Middle Age . . . .. 137 6.1 Crises in Middle Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 138 6.2 Psychosomatic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 142 6.3 Treatment .......................................... 145 7 The Cancer Patient with an Unfavourable Prognosis. . . . . .. 147 7.1 Basics ............................................. , 147 7.2 Informing the Patient of the Diagnosis .................. 148 7.3 Family Participation .................................. 152 7.4 Sociopsychosomatic Implications. . . . . . . . . . . . . . . . . . . . . .. 154 8 Aspects of Anxiety ................................... 157 8.1 Basics .............................................. 157 8.2 Psychopathology of Anxiety Syndromes ................. 159 8.3 Anxiety Disorders as Defined by Internati.onal Systems of Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 160 8.4 The Different Origins of Anxiety. . . . . . . . . . . . . . . . . . . . . .. 163 8.5 Coping with Anxiety ..... . . . . . . . . . . . . . . . . . . . . . . . . . . .. 164 8.6 Treatment of the Anxiety Syndrome. . . . . . . . . . . . . . . . . . .. 167 9 Masked Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 171 10 The Psychosomatic Approach to the Patient. . . . . . . . . . . . .. 175 10.1 Problems of the Psychosomatic Approach ............... 176 10.2 Various Forms of Dialogue with the Patient ............ , 179