A wide range of psychiatric conditions are associated with heightened pain prevalence, including major depressive disorder, borderline personality disorder, addictions and posttraumatic stress disorder. One of the most important challenges faced by psychiatric professionals is how to distinguish and approach physical and emotional symptoms arising in the context of pain experienced by their patients.

Further, because chronic pain is the most common concern brought to healthcare professionals and is exceedingly prevalent in psychiatric patients, psychiatrists will be faced with growing numbers of pain patients.

Besides, most pain syndromes are only partially responsive to opioids and so innovative approaches are essential.

Psychiatrists are understandably suited to recognize and treat subtle psychological processes, including expression of feelings via somatic pain concerns, defense mechanisms (denial and repression vs. lying and malingering), and conscious and unconscious motivations, such as self-reported pain with adequate analgesia owing to unwarranted anxiety about an impending opioid dose reduction (i.e., pseudo-opioid resistance) or drug craving vs. pseudo-addiction or therapeutic dependence.

Psychiatrist must know different treatment approaches to pain, bio-psycho- socio -spiritual views are crucial for all practitioners especially psychiatrists.

By the way, psychiatrists could help enhance patient compliance and participation in pain treatment plans.

Adding pain management to psychiatric training and elevating psychiatrists' new role in patient care, teaching, and research in the field of pain medicine may be a substantial clinical contribution in a domain that currently offers relatively little in terms of effective therapeutic interventions.

*Associate professor Psychiatry

  Head of psychosomatic research center

  Isfahan University of medical sciences, Isfahan, Iran

طب رفتاری حوزه ای از علم طب است که به بررسی رفتار ونقش آن در سلامت می پردازد و سعی دارد روشهای شناختی و رفتاری را با توجه به فیزیولوژی ، مداخلاتی به منظور تغییر عوامل خطرساز،سیروتاثیر بیماری های طبی بکارگیرد.درحوزه طب رفتاری به موضوعاتی همچون رابطه پزشک وبیمار،بهبود سازگاری با بیماری ها وارتقاء همکاری بیماران دردرمان ومدیریت استرس پرداخته می شود.دراین مقاله به تفصیل به هریک ازاین موارد،اجزاء آن وروش های مورد استفاده آنها می پردازد.

Dieser Vortrag soll die Wirkung der schwer überschaubaren Psychotherapie beleuchten. Dabei sollen die 4 Faktoren (nach der Metaanalyse von Klaus Grawe)

vorgestellt werden, die den Therapieerfolg bei den verschiedenen Therapieschulen und –Orientierungen unterschiedlich verantworten: Problembewältigung, motivationaler Problemklärung, Problemaktualisierung, Ressourcenaktivierung.

Patients from family-oriented societies have a different understanding of pain and other healing expectations, even in contact with the doctor, as patients in Western societies. This has not been considered enough in modern multimodal therapy. The pain experience is not limited to a part of the body, but having seen the body holistically related. The diseased body expresses the social, collective, economic, migration-history, psychological and cultural situation of the patient. For this it is necessary to understand in the treatment setting the importance of the pain sued and especially the therapist-patient relationship. Not only linguistic communication difficulties but lack culturally specific knowledge and skills hinder acceptance and effectiveness of treatment.

Patienten aus familienorientierten Gesell­schaften haben ein anderes Verständnis von Schmerz und andere Heilungsvorstellungen als Patienten aus westlichen Gesellschaften. Dies ist in den modernen multimodalen The­rapieansätzen bisher nicht ausreichend be­rücksichtigt worden. Das Schmerzerleben wird nicht auf einen Teil des Körpers beschränkt, sondern ganzheitlich körperbezogen gese­hen. Der geringe Zugang zu psychischen Beschwerden führt häufig zu körperlichen Be­schwerden. Der erkrankte Körper drückt die soziale, kollektive, ökonomische, migrations­geschichtliche, psychische und kulturelle Be­findlichkeit des Patienten aus. Hierfür ist es in der Behandlung und vor allem in der Therapeut-Patient-Beziehungsgestaltung notwendig zu verstehen, welche  Bedeutung den geklagten Schmerzen in der Gestaltung und Erleben von zwischenmenschlichen Beziehungen zukommt. Nicht nur sprachliche Verständigungsschwierigkeiten, sondern unzureichende kulturspezifische Kenntnisse und Kompetenzen behindern Akzeptanz und Wirksamkeit der Behandlung.

Participants will obtain information about definition, clinical symptoms, neurobiology and medical treatment of acute and chronic phantom limb pain. In particular recent advances concerning phantom limb pain emphasizing the importance of neuroplastic central changes for the development and maintenance of chronic pain were demonstrated supporting the idea that extensive plasticity is a possible basis for somatosensory pain memories which can be detected by noninvasive neuroimaging methods. Specifically our empirical work revealed a positive relationship between the amount of cortical reorganization and the magnitude of phantom limb pain (r=0.93). Moreover, the present data point towards altered patterns of brain functioning in other chronic pain syndromes such as low back pain and fibromyalgia. New treatment approaches like the modulation of neuroplasticity by prophylactic pharmacological, psychological and sensory training methods and the results of a placebo-controlled randomized morphine study, as well as an anaesthesiological experiment concerning preemptive analgesia for the prevention of acute and chronic phantom limb pain are discussed. It will be shown that new treatment strategies that can reverse or prevent cortical reorganization toward normal could eliminate chronic pain as well. A comprehensivemodel for the development of chronic pain syndromes that incorporates both,  psychological as well as peripheral and central factors will be demonstrated.

The lecture allows an insight into the creative and empowering approach by Dr. Danie Beaulieu, a Canadian psychologist well known as a co-developer of Impact Therapy and Eye Movement Integration Therapy. She is a specialist on innovative multi-sensory intervention and teaching methods.  

Der Vortrag vermittelt einen Einblick in den kreativen und machtvollen Ansatz von Dr. Danie Beaulieu, einer kanadischen Psychotherapeutin, die bekannt wurde als Co-Entwicklerin sowohl der Impact Therapie als auch der Eye Movement Integration Therapy. Sie ist Spezialistin für innovative multisensorische Interventions- und Lehrmethoden.

Impact-Techniken für die Psychotherapie ist ihr bekanntestes Buch. Es vermittelt die Basisprinzipien der Impact Therapie, die ursprünglich von Ed Jacobs 1992 entwickelt wurde. Impact Therapie kann als solide Brücke zwischen Theorie und Technik fungieren. Es ist ein multisensorischer Ansatz, der berücksichtigt, dass Veränderung bzw. Wirkung nicht Folge eines alleine verbalen, sondern vielmehr eines visuellen und kinästhetischen Austauschs sind. Multisensorische Interventionen garantieren die höchst mögliche Wirkkraft. Die Symbolkraft einfacher Objekte transformiert abstrakte Ideen und komplexe Probleme in klare, konkrete, leicht verständliche Metaphern. Requisiten, Zeichnungen, Analogien, Stühle und auch Bewegung bereichern die therapeutischen Interventionen. Sowohl Therapeut als auch Klient agieren im Problemlösungsprozess aktiver – mit schnellem und anhaltendem Erfolg. Impact-Therapie integriert bereits bestehende theoretische Konzepte aus der Lernforschung (Mnemotechniken), Lösungsorientierten Therapie, NLP, Rational-Emotiven-Therapie, Transaktionsanalyse, Gestalttherapie; besonders beeinflusst ist sie durch den Hypnotherapeutischen Ansatz von Milton Erickson. Es handelt sich um eine Form von Kurzzeittherapie, die den Beratungsprozess deutlich beschleunigt. Der Impact Therapeut versucht immer, zum Kern des Problems vorzustoßen; sein Augenmerk liegt auf dem kreativen Veränderungsprozess.

The psychosomatic view-manner has already one in the old Persia over 3500 year old history.

In zoroaster-writting we can find some ideas of the relationship between psyche and soma and the the use of hypnotherapeutical rituals for psychosmatic symptoms (Moshref, 1985).

Two pesian dochtors, Razi (865-925) and Avicenna (980-1037) worked already at that time on the diagnostic and treatment of bio-psycho-social system-models.

The Book of Avicenna became some of hundred years later in Europe a standard-book in the medicin-education.

Little by little changed Persia, the country experienced many heavy, deep injuries in the history with following negative political, economic and cultural changes. Already in the Ghajarih-Zeit, this type of the medicine after Razi was almost vanished. An identity-loss occurred.

While there the traditional psychosomatics of the Orient increasingly faded, the modern psychosomatics with the utilization of the traditional Oriental psychosomatics idea in german-language area was built more intensively.

In Germany, the first psychosomatics-clinic was set up in Berlin 1927 and that first University-clinic was set up in 1950 in Heidelberg.

Germany belongs to the leading countries of the world concern the psychosomatic basic-supply. Almost in each university-clinic, there is a psychosomatic clinic.

This reciprocal development-process finds in the 21. Century one for both sides integrativ-enrich- level: The project “Psychosomatics in the Iran" is not one-sidedly positioned. It is a good example for medicial-intercultural cooperation.

Die psychosomatische Sichtweise hat im alten Persien schon eine über 3500 Jahre alte Geschichte. In zoroastrischen Schriften wird häufig auf die wechselseitige Wirkung von Psyche und Soma eingegangen und hypnotherapeutische Rituale  zur Behandlung der psychosomatischen Beschwerden angeboten (Moshref, 1985).

Zwei persische Ärzte, Razi (865- 925) und Avicenna (980-1037) arbeiteten schon damals an der Diagnostik und Behandlung von Bio-Psycho-sozialen Systemmodellen.

Das Buch Kanon von Avicenna wurde mehrere hundert Jahre in Europa als Standardbuch der Medizin unterrichtet.

Nach und nach veränderte sich Persien, das Land erlebte viele schwere, tiefe Verletzungen in der Geschichte mit nachfolgenden negativen politischen, wirtschaftlichen und kulturellen Veränderungen. Schon in der Ghajarih-Zeit wurde diese Art der Medizin nach Razi nur noch selten betrieben. Es kam zu einem Identitätsverlust.

Während die traditionelle Psychosomatik des Orients dort zunehmend verblasste, wurde die moderne Psychosomatik mit der Nutzung der Schule der traditionellen orientalischen Psychosomatik   im deutschsprachigen Raum intensiver aufgebaut. In Deutschland wurde die erste Psychosomatik-Klinik in Berlin 1927 begründet und das 1. Universitätsklinikum in Heidelberg 1950 begründet. Deutschland gehört zu den führenden Ländern der Welt, was psychosomatische Grundversorgung angeht. In fast jedem Universitätsklinikum gibt es eine Psychosomatische Klinik.

The field of psychoneuroimmunology has come into existence in relatively more recent times. The term psychoneuroimmunology was first employed by Ader in 1980 to capture what had become growing evidence of the intercommunication between the brain and the immune system. Ader notes that interest in such a link can be traced back to early work by Russian investigators, who, based on Pavlov’s work, hypothesized that immune responses could be conditioned and reported preliminary positive Wndings as early as 1926. Also, the studies of Hans Selye in the

1930s demonstrating that a variety of noxious conditions (stressors) caused endocrine effects and changes in immune tissues were important in the birth of this field. Ader has further traced the emergence of psychoneuroimmunology through the work of Rasmussen (1950s) on the effect of psychological stress on susceptibility to infection, and Solomon’s work (1960s) exploring an autoimmune etiology for schizophrenia.

In the 1970s, well-designed conditioning studies, as well as a variety of animal and human studies documenting effects on the immune system by manipulations of the situation or the occurrence of life events affecting the individual’s emotional state, further underscored that a link must exist between brain activity and the cells of the immune system. Also beginning in the 1970s, endocrine and ANS connections to cells of the immune system were demonstrated, as was the 18 Introduction to Psychoneuroimmunology presence of receptors for neurotransmitters and hormones on immune cells. The early work has been summarized by Ader (1981). In addition, evidence began to accumulate that substances released by cells of the immune systems could affect brain activity and behavior. This, of course, should not be surprising because changes in behavior have always been associated with illnesses. Indeed, the fact that the immune system can affect the brain had already been discovered in the 1930s, when it was observed that vaccination against rabies could cause massive inflammation of the brain. This was because the vaccine was prepared from central nervous system tissue, which led to an immune response against the individual’s own brain. Moreover, in the late 1950s and early 1960s, investigators, including Fessel and Hirata-Hibi, Heath, and Solomon, made observations suggesting immune abnormalities in schizophrenic patients, including the possibility that schizophrenia could be an autoimmune disorder. The hypothesis that major psychiatric disorders could result from misdirected immune activity continued to receive attention. Misdirected immune activity has now been implicated in a number of disorders of the brain that affect behavior and mental processes (e.g., childhood-onset obsessive-compulsive disorder). Thus, the picture that has begun

to emerge is one wherein life circumstances, by affecting brain activity, can alter immune function, with the potential to have health consequences. Meanwhile, the immune system’s response to pathogen stimulation causes the release of substances that can affect brain activity and may even disrupt its functioning.At the  end I refereenced to the Iranian researches about this field in oral presentation.

Asthma is a chronic inflammatory disease with different phenotypes, characterized by variable, reversible airway obstruction and abnormally increased responsiveness (hyperreactivity) of the airways to various stimuli on the base of a complex network of molecular and environmental factors and immunological reactions.

Over the last few decades there has been a dramatic increase in the prevalence of asthma. Asthma is now worldwide one of the major public health problems and an enormous burden on health care resources.  Nowadays more than 300 million people were affected worldwide by asthma leading to approximately 250,000 deaths per year. WHO estimates that asthma has a 7-10% prevalence worldwide.

Asthma is caused by interaction between genes and environmental and psychological factors. These factors influence how severe asthma is and how well it responds to medication. The immunologic hallmark of allergic asthma is an increased production of IgE and T helper (Th) type 2 cell cytokines such as IL-4, IL-5, IL-9 and IL-13 by Th cells reacting to common environmental allergens.

Emotional factors may modulate processes of inflammation in asthma and, conversely, peripheral inflammatory signals influence the brain. During prolonged stress the cytokine profile of immune cells shifts toward the promotion of an allergic response and inflammation.

The results of some studies indicate that both physiological and psychological stressors activate similar neural circuitry, acting as two different routes to a bidirectional communication network between the brain and the immune system. It means that stress and emotion can regulate inflammation, and peripheral inflammatory mediators can influence mood and cognitive function. On the other hand it could be demonstrated that depressive condition has been associated with elevations in the same proinflammatory cytokines that are released during an asthmatic reaction.

Using functional magnetic resonance imaging(fMRI), Rosenkranz et al. could recently show that activity in the anterior cingulate cortex and insula to asthma-relevant emotional, compared with valence-neutral stimuli, is associated with markers of inflammation and airway obstruction in asthmatic subjects exposed to antigen. This activation suggests a neural basis for emotion-induced modulation of airway disease in asthma.

This work tries to show the relation between psychological conditions and asthma from the viewpoint of molecular and psychoneuroimmunological aspects.

BACKGROUND: Some studies have shown that acute and chronic psychological stressors are associated with acute coronary syndromes (ACSs). The aim of the present study was to assess the association between acute and chronic psychological stressors and ACS in an Iranian population.

METHOD: In an age-sex frequency-matched, case-control study, 78 hospitalized patients with ACS as the case group were compared with 146 patients with chronic stable angina (CSA) as the control group. Chronic stable angina was confirmed by positive angiographic findings. Acute stressors were examined through a semistructured interview and the acute life event checklist, regarding stressful events during 48 hours before interview. To assess chronic stress, the occurrence of 46 stressful events in a period of 6 months prior to the interview was examined using the stress inventory questionnaire.

RESULTS: The average acute stressor counts were 4.80 (SD, 2.87) and 3.97 (SD, 2.2) in ACS and CSA groups, respectively (P = .028). Chronic stressor counts were 9.91 (SD, 5.86) and 6.58 (SD, 3.16) in case and control groups (<.001), respectively. Odds ratios for acute and chronic stressor counts were 1.14 (95% confidence interval [95% CI], 1.02-1.28) and 1.84 (95% CI, 1.10-1.26), respectively; when the associations were adjusted for traditional risk factors, they become 1.12 (95% CI, 0.99-1.27) and 1.20 (95% CI, 1.10-1.30), respectively.

CONCLUSION: Acute stress did not contribute significantly in the models including chronic stress. Acute stressful events in the recent 48 hours, independent of traditional risk factors, can have a triggering effect on ACS occurrence. Nevertheless, this happens in the context of high chronic stress. In addition, chronic stress count was moderately associated with ACS even when it was adjusted for traditional risk factors.

Keywords: Acute stress, Chronic stress, Acute coronary syndrome

A common problem in consultation of the gynecologist are patients with chronic pelvic pain desease. Mostly a lot of diagnostic procedures are performed including invasive interventions such as laparoscopies, adhesiolysis and more. If the sympotoms are are going on, patients are consulting other doctors or try dubious so called  "alternative"  therapies.
After introduction of those "difficult patients" in the Balint group mostly a new sight to the chronic pain syndrome is opening, and is helping the patient and the therapist-not always to find a way to to cure, bot to a new understanding of the problem, by using psychosomatic theory and treatment.
Main topic of the presentation are some casuistics from the own ordination.

Attachment theory over the past two decades has become a central concept of psychosomatic medicine. Based on John Bowlbys theoretical framework M. Hofer and others have studied the impact of short term and long-term separation on the physiologic homöstasis and have demonstrated the differential aspects of attachment for the regulation of  various biological systems. In recent years M Meaney has shown that early deprivation in young rats has long lasting effects on the regulation of the HPA- Axis and the biological as well as the beahvioural stress response. All these findings suggest that attachment experiences has a formative effect on biologic processes in animals. In humans observation from various sources has demonstrated that attachment security is strongly depending on maternal sensitivity, that is the capacity of the primary care giver to respond promptly and adaquately to the infants needs.  Longterm studies of attachment development suggest a long term effect of early attachment experiences in terms of affect regulation and other areas of personality which are important for psychological functioning. We will relate these findings  of attachment research to clinical disorders such as pain and anxiety.

Key words: attachment, psychobiology, deprivation, physiological regulation

Psychosomatic dermatology addresses diseases in which psychogenic causes, consequences, or concomitant circumstances have an essential and therapeutically important influence. In this respect, dermatoses are viewed as an unit in a biopsychosocial model. This model enjoys broad recognition these days and serves as one of the modern approaches to a dermatosis/disease. The patient is increasingly viewed as a holistic individual in whom lifestyle, perception, interpretation of the perceived, reality testing, past experiences and psychosocial context are decisive in the development of disease.

Based on research results now available and on practical experience, classification in psychosomatic dermatology can be differentiated in the following ways:

• Dermatoses of primarily psychological/psychiatric genesis ( “psychiatric dermatoses”)

• Dermatoses with multifactorial basis, whose course is subject to emotional influences (“psychosomatic dermatoses”)

• Psychiatric disorders secondary to serious or disfiguring dermatoses (“somatopsychic dermatoses”)