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Editorial
Psychother Psychosom 2016;85:262–269
DOI: 10.1159/000447701
Psychosomatic Medicine in Germany:
More Timely than Ever
Stephan Zipfel
a
Wolfgang Herzog
b
Johannes Kruse
c
Peter Henningsen
d
a
Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital Tübingen,
Tübingen ,
b
Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital,
Heidelberg ,
c
Department of Psychosomatic Medicine and Psychotherapy, University Hospital Giessen and Marburg,
Giessen and Marburg , and
d
Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar,
Technical University of Munich, Munich , Germany
In Germany, psychosomatic medicine is not a subspe-
cialty of psychiatry, although it has clear connections in
terms of shared models, methods, and overlapping care
for patients. At some places, most prominently in Heidel-
berg and Tübingen, departments of psychosomatic med-
icine are part of overarching departments for internal
medicine. The institutional independence of psychoso-
matic medicine in Germany is largely due to German psy-
chiatry resisting the integration of psychotherapy as a
core method. Hence, psychosomatic medicine developed
independently as an institutional and academic basis for
psychotherapy in medicine and later for integrated care
models.
The clinical core competency of German psychoso-
matic medicine is centered on integrated care for the fol-
lowing disorders: somatoform/functional disorders, eat-
ing disorders, somatopsychic disorders (including psy-
cho-oncology, psychocardiology, neuropsychosomatics,
and psychodiabetology), and psychotraumatology. An
overlap with psychiatry exists in the fields of depressive,
anxiety, and personality disorders.
The following presents a brief overview of the current
state of institutionalization, research, and teaching in the
field of German psychosomatic medicine.
Introduction
Psychosomatic medicine in Germany is not a syn-
onym for consultation-liaison psychiatry but represents a
comprehensive field
[1] as well as a specialized medical
discipline
[2] . As a consequence, psychosomatic medi-
cine in Germany has a larger institutional basis than in
any other country. Like elsewhere, the German psychoso-
matic approach was originally rooted in the tradition of
applying psychoanalysis to medicine – Franz Alexander
was probably this method’s most influential psychoana-
lyst. The fate of his primarily psychogenetic model was
tied, as it was in Germany (Alexander Mitscherlich), to
the rise and decline of psychoanalysis and psychoanalytic
concepts like the specific conflict. German psychosomat-
ic medicine, however, has another root, which was an in-
dependent forerunner of current models for bio-psycho-
social medicine
[3] . The so-called integrative psychoso-
matic medicine, as developed in internal medicine (Thure
von Uexküll) and neurology (Viktor von Weizsäcker),
conceptualized the interactions of mind, body, and envi-
ronment in a different ‘enactive and embodied’ way: body
and bodily symptoms are not mere manifestations of the
‘theatre of the soul’. The body and its sensorimotor and
other activities shape the mind as much as the other way
round
[4] .
Received: May 10, 2016
Accepted after Revision: June 16, 2016
Published online: August 11, 2016
Prof. Dr. Stephan Zipfel
Department of Psychosomatic Medicine and Psychotherapy
University Medical Hospital Tübingen
Otfried-Müller-Strasse 14, DE–72076 Tübingen (Germany)
E-Mail stephan.zipfel
@ med.uni-tuebingen.de
© 2016 S. Karger AG, Basel
0033–3190/16/0855–0262$39.50/0
www.karger.com/pps
Psychosomatic Medicine in Germany:
More Timely than Ever
Psychother Psychosom 2016;85:262–269
DOI: 10.1159/000447701
263
Psychosomatic Facilities and Structure
The first psychosomatic inpatient hospital was opened
in Berlin in 1927. Since then, numerous hospitals and de-
partments developed specifically to address psychoso-
matic issues have been established across Germany. Ac-
tual data show that there are a total of 223 institutions
covering more than 10,000 inpatient beds, with a mean
duration of stay of 40 days. Of note, the number of inpa-
tient beds in Germany nearly tripled this millennium.
There has also been a steep increase of psychosomatic
day-patient facilities in recent years.
The current types of psychosomatic hospital facilities
are as follows:
1 Hospitals for psychosomatic medicine with a superre-
gional coverage area. The hospitals often include spe-
cialized subunits (for example, eating disorders, PTSD,
and chronic pain) comprising more than 200 beds.
2 Departments of psychosomatic medicine at general
hospitals providing regional coverage. The depart-
ments administer a consultation-liaison service for the
entire hospital but have limited inpatient facilities (9–
36 beds).
3 Departments of psychosomatic medicine and psycho-
therapy as academic institutions at university hospi-
tals. These departments are responsible for patient
care (20–70 beds), teaching, and research ( fig.1 ).
4 Departments of psychosomatic medicine that are part
of a psychiatric hospital (20–30 beds).
5 Consultation-liaison services for psychosomatic med-
icine at general and university hospitals (without own
treatment unit).
Health insurance (public or private) covers treatment
costs from a budget separate from the one for psychiatry.
Costs for psychosomatic care are based on length of treat-
ment rather than on the diagnosis-related group. This re-
funding system will probably change in the next few
years.
Aside from the health insurance-covered hospital sec-
tor, there is a separate system of rehabilitation centers in
Germany, which target the clinical areas of cardiology,
oncology, neurology, orthopedics, and psychosomatic
medicine. Their particular focus is on work-related as-
pects of disability prevention. Pension insurance covers
the costs for these centers. There are 141 centers for psy-
chosomatic medicine in this system, which provide about
16,000 additional inpatient beds with average treatment
duration of 37 days [for more details, see
5 ].
Psychosomatic inpatient and day-patient treatment
programs are mostly combined multimodal therapy pro-
grams, combining psychotherapy in individual and group
formats, oriented on treatment guidelines and best prac-
tice experiences. Very often, psychodynamic and cogni-
tive-behavioral approaches are both used in a coherent
overall framework. Based on the leading diagnosis, addi-
tional therapies, for example stress reduction techniques,
physiotherapy, body psychotherapy, and creative thera-
pies (art and/or music therapy) are often part of the com-
bined treatment package. Problems in the interpersonal
and psychosocial field are the major focus of family/part-
ner-oriented treatments often supplemented by psycho-
social skills training. As part of the new reimbursement
system, the dosage of psychotherapy is monitored as a key
input factor.
Effectiveness of Integrated Care in German
Psychosomatic Medicine
Multimodal inpatient care in hospital departments for
psychosomatic medicine has been shown to be effective
in numerous naturalistic studies – RCTs are hardly pos-
sible to design to test such a complex intervention. A re-
cent systematic review and meta-analysis on these studies
[6] revealed a medium within-group effect size of g = 0.72
for symptom change and 0.35 for change of interperson-
al problems. However, there are now multisite RCTs in
Germany, investigating the setting effects of day- and in-
patient psychosomatic treatment in patients with a de-
pressive disorder
[7, 8] .
The majority of psychosomatic departments and hos-
pitals take part in stringent quality assurance programs in
order to monitor their treatment programs and to pro-
vide transparency to the patients. In addition, registries
were introduced in respective regions and states to pro-
vide outcome data on basic factors, for example duration
of treatment, leading diagnosis, and number of comorbid
disorders
[9] .
Stages of Training and Specialization
In 1993, the General Assembly of German Physicians
voted for a three-level approach and, thus, a differenti-
ated and stepped-care qualification training process for
specializing in psychosomatic medicine and psychother-
apy:
1 Psychosomatic basic care or ‘Psychosomatische
Grundversorgung’ includes an 80-hour training com-
prising theoretical and clinical instruction, communi-
Zipfel/Herzog/Kruse/Henningsen
Psychother Psychosom 2016;85:262–269
DOI: 10.1159/000447701
264
cation training with psychosomatic patients, and re-
flection of the doctor-patient relationship. All clinical-
ly practicing medical specialists can enroll in this
training. Psychosomatic basic care is also an integral
part of specialist training in general medicine and gy-
necology. About 35,000 general practitioners and
12,000 gynecologists have obtained this qualification
[10] .
2 A postgraduate degree in psychotherapy for those al-
ready holding a specialization degree (about 18,000
with an additional qualification in psychotherapy)
[11] . The training is extra-occupational and conveys
basic psychotherapeutic skills (120 h of supervised
psychotherapy, 120 h of theoretical input, and person-
al therapy).
3 A 5-year specialization in psychosomatic medicine
and psychotherapy (including 1 year each of internal
medicine and psychiatry). This training comprises
1,500 h of supervised psychotherapy, 240 h of theo-
retical input, and personal therapy in both individual
and group settings. The main emphasis is on the spe-
cialized psychotherapeutic and integrated psychoso-
matic treatment of patients with mental, psychoso-
matic, somatopsychic, and stress disorders (for more
details, see table1 ). Among physicians who practice
psychotherapy in Germany, a specialist in psychoso-
matic medicine and psychotherapy has received the
most intensive psychotherapeutic training. Thus, he or
she is the most qualified expert within the medical psy-
chotherapeutic and psychosomatic care fields (5,000
specialists of psychosomatic medicine and psycho-
therapy)
[11] . Additionally, there are about 11,000
psychiatrists and 5,600 neurologists
[12] . In the outpa-
tient sector, there are 3,058 specialists in psychoso-
matic medicine and psychotherapy as well as 3,900
specialists in psychiatry and psychotherapy, 1,972
neurologists, and 10,269 medical specialists with an
additional psychotherapy certification (out of these,
3,493 are practicing mainly psychotherapy), summa-
rizing a total of 21,312 medical trained doctors with a
certification in psychotherapy (2014)
[13] and a total
of 16,664 psychologists with a specialization in psy-
chotherapy
[10] . In Germany, only medical doctors
and psychologists are allowed to practice psychother-
apy for adults.
InpaƟent:
Oīering inpaƟent care, including
specialized seƫngs (e.g. eaƟng
disorders, trauma, somatoform
disorders)
Day-paƟent:
Stepped down aŌĞr iniƟĂů
inpaƟent care, primary day care
OutpaƟent:
DiagnosƟcs and gate-
keeping for dŝīerent
therapeuƟc opƟons
Development,
implementaƟon, and
evaluaƟon of specialized
treatment programs
C-L:
Psycho-oncology; general C-L;
specialized C-L (e.g. transplantaƟon,
bariatric surgery, pain clinics)
Research,
teaching
and
training
PSM
Fig. 1. Structure of an academic psychosomatic department (PSM) in Germany. C-L = Consultation-liaison;
PSM = psychosomatics.
Color version available online
Psychosomatic Medicine in Germany:
More Timely than Ever
Psychother Psychosom 2016;85:262–269
DOI: 10.1159/000447701
265
Psychosomatic Medicine in Academic Teaching and
Research
In 1970, psychosomatic medicine became an obliga-
tory subject in the medical school curriculum at the 37
official medical schools in Germany. Building on this ad-
vancement, the majority of the medical schools (n = 26)
then decided to establish entire departments of psycho-
somatic medicine. The curricula of these departments not
only cover the topic of psychosomatic medicine – its dis-
orders, diagnostic techniques, and treatment methods –
but department members have actively created and im-
plemented communication skills training as part of a
competency-based medical curriculum. The departments
have also been involved in the development, implementa-
tion, and evaluation of state-of-the-art teaching formats
and continue to play an active role in the international
medical education community
[14–16] .
In the first 2 decades following the nationwide intro-
duction of psychosomatic medical departments in 1970,
conducting empirical research was not a high priority.
Providing proper instruction was more pressing, and
most chairs and professors were psychotherapeutic clini-
cians and theoreticians rather than empirical researchers.
In 1986, the German Council of Science and Humanities
(the central science advisory board to the government)
criticized the state of research in the field of psychosomat-
ic medicine. Since this wake-up call, things have changed
gradually, but profoundly. Today, German psychosomat-
ic medicine plays an active role in all areas of medical in-
vestigation – funded by federal and other third parties – be
it clinical, health care, public health, or basic research.
Clinical Research
A particular strength of clinical research in psychoso-
matic medicine is the conceptualization, implementa-
tion, and evaluation of manualized disorder-oriented
brief psychotherapies tested and demonstrated in differ-
ent psychosomatic and mental disorders (e.g. the AN-
TOP study in anorexia nervosa
[17, 18] , the SPIRR-CAD
study in depressed patients with coronary heart disease
[19] and chronic heart failure [20] , the PISO and SPE-
Table 1. Synopsis of the specialization curriculum in psychosomatic medicine in Germany
Specialization in psychosomatic medicine and psychotherapy
At least 5 years of full-time clinical training [3 years in psychosomatic medicine, 1 year in psychiatry, and 1
year in an additional clinical discipline (e.g. internal medicine), including theoretical, technical, and clinical
training as well as supervision and personal therapy (see below)]
In total, 240 h of theory in psychosomatic medicine and psychotherapy [e.g. basics in psychodynamic-oriented
psychotherapy (PDT) and CBT, psychopathology, psycho-diagnostic tests]
In total, 1,500 h of psychotherapeutic treatment have to be conducted alternatively in (a) PDT or (b) CBT,
including individual or group-based supervision of at least every 4th session
PDT-oriented track
6 individual psychotherapies of 50
– 120 h/patient
6 individual psychotherapies of 25
– 50 h/patient
4 focal, short-term therapies of 5
– 25 h/patient
2 couple therapies over a minimum of 10 sessions/couple
2 family therapies of 5
– 25 sessions/family
100 h of group psychotherapy (group size 6
– 9 patients)
150 h of psychodynamic-oriented personal psychotherapy and 70 h of personal psychodynamic-oriented group
psychotherapy
CBT-oriented track
10 long-term individual CBT psychotherapies of 50 sessions/patient
10 short-term CBT-oriented psychotherapies with a total of 200 h
4 couple and/or family therapies
6 group psychotherapies
70 × 2 h of CBT-oriented personal therapy in individual or group format
In addition, each trainee has to be trained in as follows: at least 32 h of stress reduction and relaxation
techniques (e.g. autogenic training), 10 cases of psycho-education in somatically ill patients, 35 × 2 h of Balint
groups or interactional group supervision, and 20 documented consultation-liaison cases
Zipfel/Herzog/Kruse/Henningsen
Psychother Psychosom 2016;85:262–269
DOI: 10.1159/000447701
266
CIAL studies in somatoform disorders [21, 22] , the SO-
PHONET study in social phobia
[23] , the DAD study in
diabetes
[24, 25] , and RCTs in depression [7, 26] and per-
sonality disorders
[27] ). Psycho-oncology is a fast-grow-
ing field of research interest in psychosomatic medicine,
ranging from diagnostic to intervention studies
[28–30] .
While many of these therapies are psychodynamic
[31,
32]
, the scope of treatment development is much broader
and also covers CBT-oriented therapy and neuropsycho-
logically informed treatment approaches. Most of these
multisite RCTs were designed, implemented, and evalu-
ated according to stringent and robust regulatory rules
conforming to good clinical practice. In recent years, the
psychotherapy community has worked to modernize
web-based health treatments by developing and testing
approaches that apply digital media (Interbed, Base, Re-
start
[33–35] ).
Health Care and Public Health Research
Health care research in psychosomatic medicine has a
traditional, but by no means exclusive, focus on psycho-
oncology. Typical topics include developing screening in-
struments
[29] , assessing the need for psycho-oncological
support for patients and caregivers
[36] , and evaluating
naturalistic interventions
[37] . Another example of psy-
chosomatic-based health care research is a trans-sectoral
networking initiative in the large city of Hamburg, which
brought together more than 60 partners from the govern-
ment and the research, health care, and health industries
(Psychenet
[38] ). In cooperation with other academic
partners, the local university’s Department of Psychoso-
matic Medicine coordinates and evaluates screening, net-
working, and therapeutic interventions in patients with
eating and somatoform disorders
[39] .
Developing and coordinating evidence-based national
guidelines on topics relevant to psychosomatic medicine,
such as functional/somatoform or eating disorders, has
been an important undertaking in recent years
[22, 40–
44]
. Researchers of psychosomatic medicine have also
participated in several population-based cohorts in Ger-
many (e.g. the Gutenberg Health Study in Mainz
[45] , the
KORA study in Augsburg, and the ESTHER study in Hei-
delberg
[46] ). The studies provide epidemiological data
on the interaction of different psychological, social, im-
munological, and other risk factors in the etiology and
course of diabetes and cardiovascular and other chronic
diseases. In a research world increasingly dominated by
purely (systems) biological perspectives, these bio-psy-
cho-social approaches are an important antidote against
an all too strong reductionism.
Basic Science
In German psychosomatic research, there is a long tra-
dition of basic science-related research
[47] , especially in
the areas of mechanism-oriented
[48] , psychophysiologi-
cal
[49] , life event-related, and stress-related research
[49] . Contrarily, interest and expertise in animal-based or
wet laboratory-based research is relatively recent. In the
last decade, though, there has been a steep increase in the
number of institutions with expertise in the field of neu-
roscience-related research paradigms, including neuro-
cognitive
[50] and neuroimaging approaches [51] and
neuroimmunology
[52] . Psychosomatic medicine re-
search also plays a crucial role in national and interna-
tional collaborative research networks, for example on
nutrition medicine and eating disorders
[50, 53–56] , pla-
cebo and nocebo effects (DFG-funded research unit FOR
1328
[57–59] ), and neural control of intestinal functions
(NeuroGut in EU FP7
[44, 59, 60] ).
Conceptual Work
Adapting bio-psycho-social concepts to modern med-
icine requires conceptual work. German psychosomatic
medicine has contributed to two interdisciplinary Euro-
pean Union Marie Curie Training Networks (DISCOS
and TESIS), where neuroscientists, psychologists, psychi-
atrists, and philosophers worked on translating current
concepts of embodiment and enaction to clinical ap-
proaches to ‘disorders of the embodied self’
[61] .
Organizations and National Congress
There are two major psychosomatic medicine societies
in Germany, which closely collaborate and share offices
in Berlin. The first is the German College of Psychoso-
matic Medicine (DKPM) founded in 1974 by Thure von
Uexküll and associates. It is an interdisciplinary scientific
professional association for doctors, psychologists, and
other professions (e.g. art therapists) and has about 450
members. Supported by the Swiss-based Carus Founda-
tion, it runs and promotes postgraduate research-based
training and advancement in all areas of psychosomatic
medicine
[62] . It has strong ties to other European, Amer-
ican, and Asian societies in the field of psychosomatic
medicine. The second, the German Society for Psychoso-
matic Medicine and Medical Psychotherapy (DGPM),
founded in 1992, is the medical association for the field of
psychosomatic medicine and psychotherapy. It has about
1,300 members. Both organizations have their own Jour-
nal Citation Reports-listed journals (DKPM: Psychother