Diagnostik der funktionellen Herzbeschwerden aus psychosomatischer Sicht

Zusammenfassung

Störungen des kardiovaskulären Systems sind weit verbreitet. Obwohl psychologische Auffälligkeiten bei Patienten mit funktionellen Herzbeschwerden lange bekannt sind, werden diese-wenn überhaupt-erst spät diagnostiziert. Es wird auf die deskriptive Diagnostik funktioneller Herzbeschwerden nach ICD-10 (Kapitel V) eingegangen. Nach Ausschluß einer körperlichen Ursache muß geprüft werden, ob die funktionellen Herzbeschwerden im Rahmen einer psychischen Grunderkrankung aufgetreten sind. Wichtig sind in diesem Zusammenhang die Gruppe der Angststörungen (von allem Panikstörungen und Agoraphobie) und die Gruppe der depressiven Erkrankungen. Kann eine solche psychische Erkrankung im engeren Sinne nicht nachgewiesen werden, kommt eine Diagnose aus der Gruppe der somatoformen Störungen in Betracht, wobei hier somatoforme autonome Funktionsstörungen, die hypochondrische Störung und die eigentlichen Somatisierungsstörungen unterschieden werden.

Für die Frage der Indikation einer psychotherapeutischen Behandlung ist neben der deskriptiven Einordnung eine weitere Störungsanalyse notwendig. Hierbei sind Informationen, die den Kontext der Beschwerden sowohl auf der biologischphysiologischen als auch auf der intrapsychischen und interpersonellen Ebene betreffen, bedeutsam. Dabei ist die psychosomatische Diagnostik auf eine enge Kooperation mit den behandelnden Hausärzten und Internisten angewiesen.

Abstract

Disorders of the cardiovascular system are common. Heart pain is one of the most frequent complaints leading patients to seek medical help. Although psychologically conspicuous behavior in patients with functional cardiac complaints are well known, they are — if at all — diagnosed quite late. Descriptive diagnostics of functional cardiac complaints according to the International Classification of Diseases (ICD-10, Chapter 5) are discussed (Figure 1). Possible physical causes of the disease must first be excluded. In a second step it must be clarified whether the complaints even those non-verbally conveyed are due to psychic illness in a narrower sense. Anxiety and depressive disorders must be taken into consideration here. If the patient demonstrates an avoidance behavior in the case of anxiety, then an agoraphobia can be assumed: in episodic paroxysmal fear one can assume panic attacks in which vegetative anxiety equivalents such as shortness of breath, numbness, palpitation of the heart, tachycardia and chest pain are prominent often accompanied by trembling, perspiration, nausea and dizziness. The different depressive disorders are characterized by a dejected mood, loss of interest, loss of enthusiasm and drive reduction; the disorders are divided up according to intensity and course. Within the scope of depressive physical symptoms, frequently unpleasant sensations and pain in the chest area are described along with concern, despair, and an increase in self-observation.

If no psychic disturbance in a narrower sense can be diagnosed. then the diagnosis of a somatoform disorder allows for this behavior. It is characteristic for this category of illnesses that the repeated presentation of physical symptoms in connection with the persistent demand for medical treatment may be observed although no physical causes can be demonstrated. The patients insist that their complaints are of a physical origin despite the doctor’s assertion that this is not the case. If the symptoms are related to vegetative innervated organs then one speaks of somatoform autonomous functional disorders (F45.3, Table 1). Cardiovascular disorders fall within this scope. Further diagnoses within the spectrum of somatoform disorders are hypochondric and somatization disorders which demonstrate a variety of symptoms and inconsistent and frequently changing complaints.

If a descriptive diagnosis can correspondingly be made then further analysis of the disorder must be carried out in order to reach an indication for psychotherapeutic treatment. From a psychodynamic point of view, the personality- and comflict-related background of the disturbance is relevant. Quite often unconscious ambivalent separation conflicts-be they real or phantasized situations of being left or being left alone-may be observed to trigger cardiovascular symptoms. In the cognitive-behavioral therapeutic tradition an exact analysis of the patient’s symptomatology is carried out in which prior and actual causal factors of the symptoms are looked for.

Irrespective of the different approaches, information on the context of the complaints both on a biological, intrapsychic and interpersonal level is necessary for psychosomatic diagnostics. The better the causal conditions are known on the basis of which functional cardiovascular complaints have arisen, the easier it is to recognize those factors that will influence a change and allow a therapeutic approach. This is best done in cooperation with practitioners and internists who still have a key position in the diagnosis and treatment of patients with functional cardiac disorders. The ways and means in which they conduct the anamnesis is decisive in leading their patients to regard psychosomatic diagnostics as being either stuck in the so-called “psycho corner” or as a helpful relationship which they can accept.