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DGPM DKPM S3 guideline on functional physical complaints

S3 guideline "Functional body complaints" - long version

S3 guideline "Functional body complaints"

AWMF reg. No. 051-001

Participating professional societies and associations

German College for Psychosomatic Medicine (DKPM) and German Society for Psychosomatic Medicine and Medical Psychotherapy (DGPM) (jointly in charge; mandate holder: Peter Henningsen)
German Society for General Medicine and Family Medicine (DEGAM) (Mandate holder: Markus Herrmann)
German Society for Internal Medicine (DGIM) (Mandate holder: Timo Specht)
German Society for Surgery (DGCH), German Society for Orthopedics and Orthopedic Surgery (DGOOC) (Mandate holder: Marcus Schiltenwolf)
German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) (Mandate holder: Hans-Peter Kapfhammer)
German Society for Urology (DGU) / Working Group on Psychosomatic Urology and Sexual Medicine (Mandate holder: Ulrike Hohenfellner)
German Pain Society (DGSS) (mandate holder: Winfried Häuser)
German Society for Psychosomatic Obstetrics and Gynecology (DGPFG) (Mandate holder: Friederike Siedentopf)
German Society for Neurology (DGN) (Mandate holder: Marianne Dieterich)
German Society for Ear, Nose and Throat Medicine, Head and Neck Surgery (DGHNO) (mandate holders: Astrid Marek and Birgit Mazurek)
Society for Phytotherapy (GPT) (Mandate holder: Jost Langhorst)
German Society for Cardiology (DGK) (Mandate holder: Karl-Heinz Ladwig)
German Society for Digestive and Metabolic Diseases (DGVS) (Mandate holder: Hubert Mönnikes)
German Society for Dentistry, Oral and Maxillofacial Medicine (DGZMK) / Working Group Psychology and Psychosomatics (Mandate holder: Anne Wolowski)
German Society for Occupational and Environmental Medicine (DGAUM) (Mandate holder: Dennis Nowak)
German Society for Allergology and Clinical Immunology (DGAKI) and German Dermatological Society (DDG) / Working Group Psychosomatic Dermatology (APD) (Mandate holder: Uwe Gieler)
German Society for Behavioral Medicine and Behavioral Modification (DGVM) (Mandate holder: Winfried Rief)
German Society for Medical Psychology (DGMP) (Mandate holder: Heide Glaesmer)
Section for Clinical Psychology and Psychotherapy of the German Society for Psychology (DGPs) (Mandate holder: Alexandra Martin)
German Psychoanalytical Association (DPV) (Mandate holder: Ulrich Schultz-Venrath)
German Society for Clinical Psychotherapy and Psychosomatic Rehabilitation (DGPPR) (Mandate holder: Stefan Schmädecke)
German Society for Rheumatology (DGRh) (Mandate holder: Wolfgang Eich)
German Society for Pediatric and Adolescent Medicine (DGKJ), Working Group Pediatric Psychosomatics (AGPPS) (Mandate holder: Torsten Lucas)
German Working Group on Self-Help Groups (DAG SHG) (Mandate holder: Jürgen Matzat)
Independent Association of Active Pain Patients in Germany (UVSD) PainLos e.V. (Mandate holder: Heike Norda)
Austrian Society for Psychiatry, Psychotherapy and Psychosomatics (Mandate holder: Hans-Peter Kapfhammer)
German Society for Neurosurgery (DGNC) (approval without mandate holder)
Society for Hygiene, Environmental Medicine and Preventive Medicine (GHUP) (approval without mandate holder)
German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP) (approval without mandate holder)
German Society for Social Medicine and Prevention (DGSMP) (approval without mandate holder)
German Society for Gynecology and Obstetrics (DGGG) (approval without mandate holder)

Steering group / editing: Casper Roenneberg, Constanze Hausteiner-Wiehle, Rainer Schäfert, Heribert Sattel and Peter Henningsen

External experts: Antonius Schneider and Bernd Löwe

Methodological advice and moderation of the consensus conference (on November 16, 2017): Monika Nothacker (AWMF)

Preliminary remark and explanation

This guideline is aimed (predominantly, but not exclusively) at doctors from all disciplines and levels of care, from primary care providers (mostly general practitioners) to specialist doctors or medical and psychological psychotherapists.

Based on a systematic literature search and a particularly broad and carefully determined expert consensus, this guideline provides recommendations for dealing with the large and heterogeneous group of adults with so-called “functional physical complaints”.

Under "functional physical complaints" we subsume a broad spectrum of symptoms and syndromes, from temporary disorders of well-being to so-called "medically unexplained (physical) symptoms (MU (P) S)" to critically pronounced somatoform disorders, the newly defined physical stress disorders (" somatic symptom disorder "," bodily distress disorder "), so-called functional syndromes (e.g. fibromyalgia syndrome (FMS), irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), craniomandibular dysfunction (temporo-mandibular joint disorder, TMJD)) or different types of unclear pain (e.g. chronic, non-specific back, facial, or myofascial pain).

This guideline is intended to set standards for the diagnosis and treatment of functional somatic complaints in German-speaking countries (Germany, Austria) across medical disciplines and levels of care; In doing so, it is based (not only, but above all) on the realities of the German pension system. It is intended to support its users in their diagnostic and therapeutic decisions in order to achieve more quality of life and functionality for those affected, more mutual treatment satisfaction, more sensible use of resources and, last but not least, better health policy framework conditions.

Please note the following special features when applying this guideline:

  • Compared to the previous version (“Dealing with patients with non-specific, functional and somatoform physical complaints”), this update speaks of “functional physical complaints” in the title and text. This term is preferred by those affected, describes a particularly broad spectrum of complaints and degrees of severity (including those without disease value) and best reflects international language usage. As a positively worded term, it also allows practitioners and patients - similar to "bodily distress" - a helpful pathogenetic understanding, namely that in the case of functional physical complaints, it is not the structure but the function of organs (including postural and locomotor organs) that is predominantly impaired.
  • This does not mean physical complaints in clearly defined organic diseases such as joint pain in rheumatism, or transitional areas such as exhaustion in cancer or multiple sclerosis - although the "physical" pathomechanism of these phenomena is often not clearly understood, there is a high comorbidity of "organic" and " functional "diseases exist, psychosocial factors demonstrably influence the course and psychological or" body-mind "therapy approaches have a demonstrable effect. (Therefore the usual classification of complaints into “explained” or “unexplained”, “physical” or “psychological” should be relativized and an “as well as” perspective should generally apply.)
  • Because functional physical complaints cannot be objectified in the same way as diseases with a defined organ pathology, the subjective experience of complaints, the individual complaint context, general coping strategies and the doctor-patient interaction are of great relevance. Many recommendations therefore relate to genuinely medical ways of thinking and behaving (which are also helpful for other diseases) and (in a broader sense) psychological interventions. Their effectiveness is scientifically proven or verifiable only to a limited extent (e.g. without blinding, with partly subjective inclusion criteria, in the form of qualitative studies), and of course there are no complete data for every aspect of every syndrome; however, they achieve a high expert consensus (strong consensus> 95%; consensus> 75 to 95%; majority agreement> 50 to 75%). Therefore, the recommendations are listed in general clinical consensus points KKP and indicated by clear evidence tables (see table) with the specification of evidence levels for individual therapeutic measures for specific disorders. In addition, there is an overview of other relevant guidelines as well as clinical decision-making aids with many illustrative examples (see DGPM DKPM S3 guideline Functional Physical Complaints - Clinical Decision-Making Aids).
  • This guideline condenses large amounts of empirical evidence, theoretical knowledge and years of clinical experience of numerous experts from different disciplines. Nevertheless, their recommendations are consciously formulated in simple, realistic language, if possible without complicated technical terms, and are aimed directly at the user. Common guideline language regulations (“should / should”) are deliberately avoided.
  • Because functional physical complaints are very heterogeneous in terms of their disease value and the medical procedure has a strong influence on the prognosis, especially in the early phase, the recommendations are broken down according to severity and treatment phases: into measures of the 1st initial basic care, the 2nd extended basic care (divided into “Simultaneous diagnostics” and “From the explanatory model to coping”) and finally 3. multimodal treatment / psychotherapy including socio-medical aspects. The recommendations build on one another, i.e. the recommendations for the initial phase also apply to more difficult processes, but require additional measures for these. Because many recommendations therefore apply to several degrees of severity, slight redundancies were accepted.
  • This guideline deliberately does not make recommendations for the treatment of children and adolescents with functional physical complaints, as recommendations for adults cannot be transferred without prior approval. The German Society for Pediatrics and Adolescent Medicine (DGKJ) and the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP) are preparing the updated development of their own guidelines on functional complaints in children and adolescents. As part of the guideline presented here, under “7. Listen carefully and ask questions “briefly dealt with transgenerational aspects and particularities of diagnostics and therapy in children and adolescents.
  • As explained at the beginning, this guideline is primarily aimed at doctors of all disciplines and psychological psychotherapists. We are pleased when representatives of other therapeutic and nursing professions find suggestions for their important work in it. In the interests of legibility, we often refer to the guideline addressees collectively as “practitioners” without listing the individual professional groups.
  • Also in the interest of legibility, we usually use the masculine form for the plural and for fixed expressions or job titles (“doctor-patient relationship”, “general practitioner”); In the background texts, we use male and female forms alternately for specific people. However, we mean all people regardless of gender.
  • In order to facilitate the connection to the international specialist literature, we use English key words (in brackets and quotation marks) for the structuring of the treatment sections and for the recommendations.
  • Medicine is subject to a continuous process of development. All information in this guideline corresponds to the current state of knowledge. Plus, every treatment is different. Despite the recommendations given here, diagnosis and therapy, especially psychotherapy, should always be individualized and therapy freedom and responsibility (in consultation with the patient) should remain with the practitioner.

We hope that this guideline represents a practical decision-making aid in everyday life for as many colleagues as possible.

Please send reader suggestions to [email protected] or as feedback in the respective section at AMBOSS.

Related guidelines (as of June 2018)

DGPM-FK table National guidelines (selection): Working Group of the Scientific Medical Societies in Germany (AWMF)

title Classification Register number
National care guideline for low back pain[1]S3nvl - 007
Chronic pain[2]S1053 - 036
Opioids, long-term use for the treatment of non-tumor pain[3]S3145 - 003
Fibromyalgia Syndrome: Definition, Pathophysiology, Diagnosis and Therapy[4]S3145 - 004
Irritable bowel syndrome: definition, pathophysiology, diagnosis and therapy[5]S3021 - 016
Dizziness, acute in the general practitioner's office[6]S3053 - 018
Chest pain[7]S3053 - 023
Chronic lower abdominal pain in women[8]S2k016 - 001
fatigue[9]S3053 - 002
Chronic tinnitus[10]S3017 - 064
Diagnosis and therapy of chronic pruritus[11]S2k013 - 048
Psychosomatic Dermatology (Psychodermatology)[12]S2013 - 024
Acute and chronic cough, diagnosis and therapy of adult patients[13]S3020 - 003
Chronic Pain: Medical Assessment of People with Chronic Pain[14]S2k094 - 003
Assessment of mental and psychosomatic illnesses[15]S2k051 - 029
General principles of medical assessment[16]S2k094-001
Unipolar Depression - National Care Guideline[17]S3nvl - 005
Anxiety disorders[18]S3051 - 028
Evidence-based guideline on psychotherapy somatoform disorders[19]
NHG guideline on medically unexplained symptoms (MUS)[20]
Medically unexplained symptoms[21]
Guidance for health professionals on medically unexplained symptoms[22]

RECOMMENDATION 1-5: INITIAL BASIC CARE Vigilance, restraint and empathy

Recommendation 1: "realize and recognize"

DGPM-FK-KKP 1.1: Functional physical complaints are frequent and varied. Therefore, consider at an early stage the possibility that the complaints presented by the patient are of a functional nature.
(strong consensus)

DGPM-FK-KKP 1.2: This is worthwhile because with vigilance, restraint and empathy you can positively influence the course of possible functional physical complaints.
(Consensus)

Recommendation 2: Carefully question and examine ("get in touch 1")

DGPM-FK-KKP 2.1: Ask patients about their main complaints, but also about other complaints or problems.
(strong consensus)

DGPM-FK-KKP 2.2: Ask how the patients feel about their complaints, how the complaints affect (in lifestyle, in the social or professional environment) and how they deal with them: Get an impression of them with what impairments the complaints are associated with, in everyday life and due to possible psychological stress.
(strong consensus)

DGPM-FK-KKP 2.3: After the announcement, carry out a careful, general physical examination in order to record any indications of further complaints, findings and restrictions (→ DGPM-FK-KE 1).
(Consensus)

DGPM-FK-KKP 2.4: Pay attention to the behavior of the patient during the conversation as well as during the physical examination (e.g. fearful avoidance of movements, dramatic expression of complaint).
(strong consensus)

DGPM-FK-KKP 2.5: After discussing the (preliminary) findings with the patient, carry out further diagnostics, graded according to severity, systematically but cautiously.
(strong consensus)

DGPM-FK-KKP 2.6: On the basis of all the information and findings collected, pay attention to any information that may be available for preventable, dangerous processes or for risk factors for a chronic course (→ DGPM-FK-KE 7).
(strong consensus)

Recommendation 3: calm down ("reassure")

DGPM-FK-KKP 3.1: If you have not found any indications of preventable, dangerous courses of known physical or mental illnesses from the anamnesis and examination results, inform the patient of this in order to reassure them.
(strong consensus)

DGPM-FK-KKP 3.2: Give the patient the feeling of being taken seriously, of care and security.
(strong consensus)

DGPM-FK-KKP 3.3: In particular, convey the credibility of the complaints without necessarily resorting to a diagnosis, but also without playing down or negating the complaints.
(strong consensus)

Recommendation 4: “advise”

DGPM-FK-KKP 4.1: Inquire / remind the patient of general measures that are suitable for influencing the complaints favorably (in the sense of a healthy, physically active lifestyle; → DGPM-FK-KE 2).
(strong consensus)

DGPM-FK-KKP 4.2: First advise patients to take such health-promoting measures that they may take.have previously had positive experiences in comparable situations (“patient preferences”).
(strong consensus)

Recommendation 5: "watchful waiting"

DGPM-FK-KKP 5.1: If necessary, offer the patient a follow-up appointment in two to four weeks.
(strong consensus)

DGPM-FK-KKP 5.2: Expressly emphasize that the symptoms are likely to improve and that there is no need to worry if they persist.
(strong consensus)

Recommendation 1: "realize and recognize"

DGPM-FK-KKP 1.1: Functional physical complaints are frequent and varied. Therefore, consider at an early stage the possibility that the complaints presented by the patient are of a functional nature.
(strong consensus)

DGPM-FK-KKP 1.2: This is worthwhile because with vigilance, restraint and empathy you can positively influence the course of possible functional physical complaints.
(Consensus)

comment

Functional body complaints are common and varied.

In a study on the prevalence of physical complaints in the general population in Germany, 82% of the surveyed participants reported complaints that had at least slightly affected them within the last week. 22% of respondents reported at least one complaint that had seriously affected them in the past seven days (Hiller et al., 2006). A study from the USA showed that out of 1,000 people every month, 800 experience physical complaints, 327 seek general medical help, 217 see a doctor (113 of them to a general practitioner and 104 to another specialist), 65 to a complementary or alternative medical practitioner visit, 21 present themselves to a hospital outpatient department, 14 receive care at home, 13 present themselves to an emergency room, and only 8 of these people are admitted to hospital (Green et al., 2001). The information on the frequency of “unexplained complaints” in the general population fluctuates massively, as organic findings can only be recorded very unreliably outside of a medical context (Hilderink et al., 2013).

In medical contexts, frequencies of between 20% and 50% in general practices and between 25% and 66% in more specific clinical contexts (e.g. rheumatism, pain or gynecological outpatient clinic) are given for functional physical complaints (Nimnuan et al., 2001, Maiden et al ., 2003; Snijders et al., 2004; de Waal et al., 2004). In general practice in particular, these complaints, for which there is very often no sufficiently explanatory, clearly identifiable physical illness with appropriate treatment consequences, are often referred to as medically unexplained symptoms. A current systematic review, in which 32 studies with 70,085 patients from 24 countries could be included, showed that 40–49% of all general practitioner patients could "diagnose" more than at least one medically unexplained complaint, with the upper confidence intervals of up to 80% were (Haller et al., 2015).

The frequency of functional and somatoform disorders, including more modern concepts such as “Bodily Distress Disorder”, is reported to be around 10% in the general population (insofar as it can be reliably recorded here, outside of a clinical context) (Hilderink et al. 2013). The 12-month prevalence of somatoform disorders in the European population was given as 6.3% in 2005 and 4.9% in 2011, making them the third most common “mental” disorders (Wittchen et al., 2011); For the general German population, the prevalence was calculated from these data to be 5.2% (Jacobi et al., 2014). In general practitioners' practices, the prevalence for at least one somatoform disorder (according to DSM-IV or ICD-10), depending on the diagnostic criteria applied, was between 26.2% and 34.8%, for a somatization disorder between 0.85% and 5.9 % (Haller et al. 2015). The frequency of “bodily distress disorder” (a new conceptualization of “somatoform” disorders) among patients in general medicine, internal medicine and neurology was around 29% (Fink et al., 2007). The prevalence of fibromyalgia in a representative German population sample was given as 2.1%; for irritable bowel syndrome it is estimated at around 7–10% (S3 guideline on fibromyalgia syndrome; Wolfe et al., 2013).

Functional physical complaints (taken together) are one of the most common reasons for advice (Reid et al. 2001; Henningsen et al. 2018b). A general practitioner with 40 patients a day sees around two patients with functional physical complaints per hour. An analysis of health insurance data (three substitute insurance companies and the German Federal Pension Insurance Association) showed that 91% of all insured persons with an F4 diagnosis according to ICD-10 were cared for exclusively by general practitioners and specialists in the somatic disciplines (Gaebel, Kowitz et al. 2013). The main burden and responsibility for detection and diagnosis rests with primary care physicians.

Excursus: Etiological assumptions on functional body complaints or "bodily distress"
The etiology of functional physical complaints or “bodily distress” is ultimately unclear. It is also unclear whether a common disturbance model can adequately depict the different disturbance patterns at all. It is currently assumed that the genesis is multifactorial, in which biological (including genetic and epigenetic), psychological and sociocultural factors interlock - individually or in the case of individual disorders. A distinction can be made between:

  • predisposing factors that precede the manifestation of the symptoms make their occurrence in the sense of a "vulnerability" more likely, but by no means predict them,
  • Triggering factors that immediately precede the manifestation of the symptoms and are probably also causally connected with it, but without being a necessary condition,
  • and sustaining factors that prevent the symptoms from disappearing again or from being ignored or overcome, and which thereby often determine their persistence, their chronification and thus their disease value;
  • although these factors cannot always be clearly separated from one another (e.g. a predisposing concomitant disease can also be a sustaining factor).

Fig. 1. Etiological model of functional somatic complaints. From: Hennigsen et al. 2018

The course of functional physical complaints is very variable, both in terms of their type and location as well as in terms of their extent, severity and their effects on quality of life and performance.

The type or localization of the complaints is extremely varied (pain, palpitations, dizziness, diarrhea, weak limbs, fatigue, etc.); some patients complain of a single, some of several physical complaints. If several complaints exist at the same time, the criteria for circumscribed functional syndromes, several functional syndromes at the same time, or somatoform disorders are often met; Here one speaks of a considerable syndrome overlap or the general tendency towards “somatization” or “bodily distress”, in which diagnosis and, above all, therapy should not only focus on one organ system or one discipline (Kanaan et al. , 2007; Fink and Schröder, 2010; Henningsen et al., 2018b). The extent ranges from slight disturbances of well-being with minor functional impairment to pronounced complaints with permanent limitations and disabilities; the symptoms can occur episodically (with or without a trigger) or persist (olde Hartman et al., 2009; Henningsen et al., 2018b).

Many functional physical complaints in the general population and in some cases also in primary medicine are initially self-limiting; they lead to no or no repeated visits to the doctor (Verhaak et al. 2006; Rosendal et al., 2017). In at least 20%, more likely 50% of patients who have multiple physical complaints and who already meet the criteria for a “somatoform disorder”, a “multisomatoform disorder” or a “bodily distress syndrome”, the symptoms are persistent (Lieb et al., 2002; Jackson and Kroenke, 2008; Steinbrecher and Hiller 2011; Budtz-Lilly et al., 2015); in patients with somatoform pain, 34% still met the criteria for such a syndrome or disorder even after 11 years (Leiknes et al., 2007). For adults with chronic fatigue syndrome, on the other hand, it was reported that only 39.5% (range 8–63%) improve over the course and only 5% (range 0–31%) regain their premorbid performance level (Cairns and Hotopf 2005). According to a systematic review, around 50–75% of patients report an improvement in their symptoms over the course of time, while 10–30% report a deterioration (Olde Hartman et al., 2009). Life expectancy appears to be normal (individual studies even report a lower mortality in this often particularly well-studied group), apart from an increased risk of suicide (S3 guideline fibromyalgia syndrome; Hatcher et al., 2011; see also excursus in DGPM-FK recommendation 7). The number of complaints and existing catastrophic interpretations are the most important predictors of a chronic course; a high number of complaints is associated with high psychiatric comorbidity, high functional impairment and high level of utilization (Kroenke et al. 1994; Jackson et al. 2006; olde Hartman et al., 2009; Escobar et al. 2010; Tomenson et al., 2013; Creed et al., 2013; Kingma et al., 2013; Woud et al., 2016; den Boeft et al., 2016; Rosendal et al., 2017). Rosendal suggest a simple prognosis assessment based on the amount, location and frequency / duration of the complaints ("multiple symptoms, multiple systems, multiple times") (Rosendal et al., 2017).

Functional physical complaints are disproportionate to the lack of or poor physical findings and often associated with impairments of quality of life and performance and thus also with high direct and indirect health costs (Hatcher et al., 2011; Konnopka et al., 2012; Mack et al., 2015; den Boeft et al. 2016; Rask et al., 2017; Henningsen et al., 2018b). Particularly noteworthy are the negative effects of somatoform disorders that are pronounced according to the criteria on working life and interpersonal relationships in younger adults (Asselmann et al., 2017).

One can roughly say that in the general medical setting about a third of all complaints are of a functional nature; again a third of these meet the criteria for a functional or somatoform disorder; The proportion is even higher in specialized settings. Another third of them take a chronic course.

Therefore, consider at an early stage the possibility that the complaints presented by the patient are of a functional nature.

Since functional physical complaints, functional and somatoform disorders initially present themselves as physical complaints for the practitioner (and also the patient), their correct diagnostic classification is often a challenge, especially during initial contact (Rask et al. 2016). Despite their high prevalence and importance for health policy, functional somatic complaints are therefore often not identified as such and therefore not diagnosed; the rate of “overlooked” functional complaints that are incorrectly classified as physical illnesses is high (Hamilton et al. 2013, Murray et al. 2016; Henningsen et al., 2018b). It is not uncommon for practitioners to hesitate to give a functional or psychosomatic diagnosis because they are afraid of overlooking an organic disease; The risk of complaints wrongly classified as “functional” is low at 0.5–8.8%, although not negligible (Stone et al., 2009; Eikelboom et al. 2016; see DGPM-FK recommendation 10). Patients with functional physical complaints are often "passed" from doctor to doctor and from discipline to discipline or they always seek out new trustworthy doctors and experts themselves ("frequent flyers", "doctor (s) hoppers", "thick folder" patients) (Mann and Wilson 2013; Evens et al. 2015; Henningsen et al., 2018b).

In a systematic review by Murray and colleagues, corresponding “hurdles” in the diagnosis of patients with functional somatic complaints were identified. As one of the potential "hurdles", specific behavior and communication styles of doctors and patients were described in the consultation: The complaints presented by patients with functional physical complaints were described as chaotic, complex, inconsistent, incomplete and implicit, among other things. Here, patients with functional physical complaints were more reluctant to provide the practitioner with psychosocial information during a conversation. In some cases, practitioners felt they were under pressure and controlled by a demanding attitude on the part of the patient. The patients often presented plastic and emotional complaints in order to convince the doctors of the extent of the complaints. Another “hurdle” in diagnosing patients with functional physical complaints was the insistence of some patients on a somatic / biomedical explanation of the physical complaints with corresponding therapy expectations (Murray et al. 2016).

Such peculiarities or contradictions often irritate practitioners ("pattern irritation"; "irritational pattern"): Due to the complaints presented, the presentation of the complaints, the previous history and other (above all subjectively experienced) deviations, patients do not and can not fit into "common patterns" are not (sufficiently) provided with common schemes; the practitioners are unsure as to which usual counseling or treatment path they should take. Doctors often experience these patients' own communicative, diagnostic and therapeutic abilities, their own feelings and the unsuitable health system for these patients as "difficult" (Heijmans et al., 2011; Jackson and Kay, 2013; Maatz et al., 2016; Rask et al., 2016). Ultimately, this is a fundamental epistemological problem, since these phenomena and clinical pictures simply do not occur in the current dualistic understanding of illness and in medical training, which is also expressed in uncertainty and lack of communication skills on the part of the doctor (Epstein et al., 2006; Heijmans et al ., 2011; Murray et al., 2016; Johansen and Risor, 2017). Such "pattern irritations" (including own feelings and reactions), "hurdles" or "identifying marks" should be perceived by the practitioner, recognized as important and incorporated into the differential diagnostic considerations (see DGPM-FK recommendations 6 and DGPM-FK recommendation 7) . They can (but do not have to be) valuable clues for the functional genesis of the complaints presented; after all, patients who are experienced as “difficult” can of course also have organically defined diseases.

This is worthwhile because with vigilance, restraint and empathy you can positively influence the course of possible functional body complaints.

For further clarification / diagnostics and therapy (or conscious "non-diagnostics" and "non-therapy") - which must be graded according to severity - it is crucial to identify physical complaints of functional origin as such as early as possible (Olde Hartman et al. 2013, Brownell et al. 2016; Murray et al. 2016, Henningsen et al., 2018b). Studies show that patients with functional physical complaints consult their physicians primarily for (emotional) support and not primarily to initiate further examinations (Peters et al. 1998; Salmon et al. 2004; Salmon et al. 2005). Since patients often worry disproportionately about their complaints, irritate the practitioner or the treatment process, or have already had negative experiences with pre-practitioners, the main goal of the first contact is that patients understand their worries and needs and at the same time provide medically safe (cared for) ) feel (Brownell et al. 2016). Therefore, both at the first contact and at later encounters, it is necessary to “switch” with a consciously broader diagnostic vigilance with simultaneous restraint with regard to technical examinations as well as a reflective, empathic attitude (which is associated with slightly more effort, time and commitment).

This is best done through

  • an empathic medical attitude with recognition of the complaints as real and legitimate (see also DGPM-FK recommendation 6 and