An Integrative Psychosomatic Approach

to the Treatment of Patients 26

with Cardiovascular Diseases: Concepts
and Experiences of a Dedicated
Psychocardiology Ward at the University
of Göttingen Medical Center

Marvin Olewinski, Anne-Maria Paschke, Anahit Mohebbi,

Christoph Herrmann-Lingen, and Christina Kleiber

Contents
26.1 Introduction 494
26.1.1 Psychosomatic Medicine in the German Healthcare System 494
26.1.2 Outpatient and Inpatient Psychotherapy in Germany 495
26.1.3 Barriers to Integrating Psychosomatic Medicine and Cardiology 496
26.1.4 The Psychocardiology Ward at University of Göttingen Medical Center 497
26.2 Case Vignettes 500
26.2.1 Case 1: Cardiac Arrhythmias, Anxiety, and Depression 500
26.2.2 Case 2: Recurrent Ventricular Tachycardia with ICD Shocks 501
26.2.3 Case 3: Coronary Heart Disease, Myocardial Infarction,
Depression, and Anxiety 502
26.2.4 Summary 503
26.3 What Makes Clinical Psychocardiology So Challenging? 504
26.4 The Importance of an Integrative, Multi-professional Approach 504
Conclusions 506
References 506

Abstract
Mental comorbidity adversely affects quality of life, health behavior, and prog-
nosis in cardiac patients. While this comorbidity goes untreated in many patients,
others typically receive outpatient treatment with psychotherapy, antidepressant
medication, or collaborative care. However, severity of heart disease or the

M. Olewinski • A.-M. Paschke • A. Mohebbi • C. Herrmann-Lingen (*) • C. Kleiber

Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen
Medical Center, Von-Siebold-Str. 5, 37075 Gottingen, Germany
e-mail: marvin.olewinski@posteo.de; cherrma@gwdg.de

© Springer International Publishing Switzerland 2016 493

B.T. Baune, P.J. Tully (eds.), Cardiovascular Diseases and Depression,
DOI 10.1007/978-3-319-32480-7_26
494 M. Olewinski et al.

mental disorders sometimes interferes with continuous outpatient treatment. For

severely ill patients, simultaneous inpatient treatment of heart disease and mental
comorbidity may become necessary. In the German healthcare system, statutory
health insurance covers inpatient psychosomatic treatment if medically indi-
cated. This chapter describes a model of integrated inpatient psychocardiology
treatment as implemented on a dedicated ward at University of Göttingen
Medical Center. The different components of the therapeutic program are out-
lined and vignettes of typical cases are presented. Clinical impressions and first
evaluation results suggest that the psychocardiology ward closes an important
gap in the care of patients with severe comorbid heart disease and mental disor-
ders or cardiac somatization.

26.1 Introduction

Psychocardiology is a young interdisciplinary area of research and patient care.

Although the epidemiological relevance of the interrelation between cardiovascular
diseases and mental stress or disorders is well known, treatment attempts are often
either purely somatic (as in most cardiology departments), or in some cases psychi-
atric/psychotherapeutic. Therefore, whole-patient care in psychocardiology still
poses a challenge, even in the German healthcare system offering broad health
insurance coverage for psychiatry and psychotherapy as well as for specialized psy-
chosomatic medicine. A quick look at historical and structural backgrounds might
be helpful to understand the reasons for this difficulty.

26.1.1 Psychosomatic Medicine in the German Healthcare

System

Since the early twentieth century, psychotherapy wards were established in

Germany, mostly in psychiatric hospitals. This development was interrupted dur-
ing the Nazi regime in Germany from 1933 to 1945, when many leading
psychotherapists were forced to exile. After the end of World War II, in 1950 the
first German inpatient department of psychosomatic medicine was founded in
Heidelberg and chaired by the psychoanalyst Alexander Mitscherlich (Hoffmann
et al. 1999). This event marked the beginning of a clinical separation between
psychosomatic and psychiatric institutions. Psychiatry on the one side often had a
rather neurobiological view of the patients’ diseases, while psychosomatic medicine,
on the other side, often identified itself with psychotherapy rather than somatic
medicine. In the early 1970s, courses in psychosomatic medicine and psychotherapy
became mandatory for medical students. In the 1990s the field of psychosomatic
medicine and psychotherapy (formerly called psychotherapeutic medicine) was
acknowledged as a distinct medical specialty, requiring training in internal medi-
cine, psychiatry, and psychosomatic medicine itself (Hoffmann et al. 1999).
26 An Integrative Psychosomatic Approach to the Treatment of Patients 495

Junior physicians are trained on specialized psychosomatic wards, in dedicated

outpatient clinics, and consultation-liaison services and acquire profound skills
and knowledge in psychotherapy with either a psychodynamic or cognitive-behav-
ioral focus.

26.1.2 Outpatient and Inpatient Psychotherapy in Germany

The public healthcare system in Germany offers payment by statutory health insur-
ance companies for both outpatient and inpatient psychotherapy, if patients suffer
from a disorder that can effectively be treated by psychotherapy according to the
available evidence. The most frequent diagnoses of patients receiving psychother-
apy are anxiety disorders and depression. The classical forms of outpatient psycho-
therapy paid by health insurance are psychodynamic psychotherapy (both
short-term psychodynamic psychotherapy and classical psychoanalysis) and (cog-
nitive) behavioral therapy. Providers are both psychologists and physicians with a
special training and board approval in psychotherapy. The choice of treatment
method depends on the patient’s diagnosis, on the nature of underlying personality
or psychosocial problems, and also on patient preferences and the availability of
therapists trained in a specific method. After up to five initial (“probatory”) ses-
sions, the indication for outpatient psychotherapy has to be confirmed by a blinded
assessor at the base of an anonymized case report and treatment plan written by the
therapist.
Inpatient psychotherapy is only indicated if severity and complexity of the indi-
vidual case make the success of outpatient therapy unlikely at a given point of time
or if outpatient treatment has already failed. Inpatient psychotherapy is typically
provided in a structured format on specialized wards located in general or psychiat-
ric hospitals or in hospitals or rehabilitation centers entirely dedicated to psychoso-
matic medicine (Schauenburg and Hildenbrand 2011). The decision for inpatient
psychotherapy is typically made after referral of a patient by his or her GP or by
another specialist (including community-based psychiatrists or psychotherapists)
and an initial ambulatory encounter between the patient and hospital psychothera-
pist. Case conferences are often used to discuss and confirm the indication for hos-
pital admission.
Inpatient psychotherapy is typically offered by multidisciplinary teams and com-
bines different psychotherapeutic and medical approaches in an individualized
manner. Its effects and cost-effectiveness have repeatedly been documented
(Schauenburg and Hildenbrand 2011). In patients with complex disorders often
seen in psychocardiology, such a multimodal and interdisciplinary approach appears
essential for therapeutic progress. This can be more easily initiated in an inpatient
setting, where the patient can benefit from synergies of medical, psychological, and
complementary therapies. Typical weekly schedules include 20 h or more of differ-
ent therapies and the typical length of stay varies between 4 and 10 weeks, which is
considered necessary for initiating sustainable behavior change and symptom
improvement in these severely ill patients.
496 M. Olewinski et al.

After discharge from the hospital, an additional series of outpatient psychother-

apy sessions is often recommended to stabilize the achieved changes and help
patients back into daily life and work.
Example: A physically healthy patient suffering from a mild depressive disorder
and asking for psychotherapeutic support would be treated in an outpatient setting
by his or her GP and possibly a psychotherapist working in private practice. In con-
trast, a patient with major depression after a myocardial infarction persisting after
several weeks of primary care, with several relevant comorbidities, unhealthy
behavior patterns, little insight into psychosomatic aspects of his heart disease, and
low motivation for psychotherapy would benefit from an integrative, multimodal
inpatient treatment before eventually utilizing additional outpatient psychotherapy
to complement cardiological treatment.

26.1.3 Barriers to Integrating Psychosomatic Medicine

and Cardiology

At the same time when psychosomatic aspects of heart diseases started being recog-
nized more systematically, technical developments in cardiology such as cardiac
catheterization and stenting or implantable devices provided exciting and often life-
saving new therapeutic options, which strengthened a technically orientated self-
image in cardiology.
For a long time, this seemed to widen the gap between the disciplines of cardiol-
ogy and psychosomatic medicine. This often went – and still goes – along with
mutual misunderstanding and distrust. While cardiologists often look at psycho-
therapists as poorly skilled mystics, psychotherapists sometimes see cardiologists
as inhumane technicians.
While basic training in psychosomatic medicine has long been a mandatory part
of specialty training in German gynecology and family medicine, no such training
is required for internists or cardiologists. On the other hand, as mentioned above,
many psychotherapists have little knowledge of heart diseases and their
treatment.
Additionally, clinical work in cardiology happens under ever-increasing time
pressure, and physicians or hospitals receive far better payments for technical pro-
cedures than for personal attention and verbal interventions. Under these adverse
circumstances, only few physicians specialized in psychosomatic medicine or psy-
chologists trained in psychotherapy as well as somatically trained physicians have
attempted to overcome the traditional gap between mind and body in cardiology.
The way to establish psychocardiology in Germany was therefore long and some-
times complicated (Herrmann-Lingen 2011a), but it finally resulted in several inter-
disciplinary projects such as development of medical guidelines and training courses
in basic psychocardiology for cardiologists and psychologists/psychiatrists
(Herrmann-Lingen 2011b) and also in the formation of interdisciplinary treatment
models. One of these models is the psychocardiology ward at our university hospi-
tal, which opened in 2009.
26 An Integrative Psychosomatic Approach to the Treatment of Patients 497

26.1.4 The Psychocardiology Ward at University of Göttingen

Medical Center

The Department of Psychosomatic Medicine and Psychotherapy at University of

Göttingen Medical Center understands itself as complementary to the biomedical
hi-tech medicine offered in the university hospitals’ heart center. With its focus on
psychocardiology, it is actively involved in numerous research projects and clinical
work on psychosomatic aspects of cardiovascular diseases (Herrmann-Lingen
2011a, b).
The psychocardiology ward provides integrated medical care and multimodal
psychotherapy (Kleiber and Herrmann-Lingen 2011, 2015). On the one hand, and
in contrast to most psychosomatic hospitals or wards in Germany, all human and
technical resources of the biomedical heart center are available and actively
involved in the treatment wherever needed. Patients can be transferred directly
from cardiology wards during treatment of acute heart diseases, e.g., post-MI, or
referred by external hospitals or physicians in the more chronic phase of heart
disease, such as chronic heart failure. Besides treatment for their cardiac condi-
tions, patients receive up to 6 weeks of intense psychotherapy as outlined below.
Patients are admitted for inpatient treatment when severity and complexity of the
biomedical and psychosocial situation do not allow sufficient outpatient treatment.
Frequent indications for treatment on this ward are, for example, severe anxiety
and depression after myocardial infarction, supportive treatment in emotionally
distressed patients with severe heart failure before and after heart transplant, or
panic disorder/post-traumatic stress disorder in patients with malignant cardiac
arrhythmias after multiple shocks delivered by an implanted defibrillator. Other
indications include repeated emergency admissions for cardiac somatization or
hypertensive crises and maladaptive behavior patterns interfering with the treat-
ment of heart diseases.
The ward is jointly led by the departments of psychosomatic medicine and
cardiology and senior physicians from both departments share final responsibility
for patient care. The team consists of physicians trained in psychosomatic medi-
cine and psychotherapy, one physician in training for cardiology, and one or two
psychologists. Furthermore, two part-time physiotherapists, one art therapist, and
one part-time social worker belong to the team. Nine full-time posts for nurses
guarantee continuous availability of support. While most patients are more or less
mobile and able to perform basic self-care activities, nurses play an important part
both in the medical and psychotherapeutic treatment process by arranging medi-
cal diagnostics, offering crisis intervention, and leading patient groups and relax-
ation training.
The psychosomatic treatment program comprises on the one hand biomedical
diagnostics and treatment as needed. While some patients are too frightened to
undergo medically indicated and prognostically important procedures and need
much reassurance or even personal company by a familiar team member in order to
consent to an invasive procedure or magnetic resonance scan, others demand medi-
cally useless repeated diagnostics for reassurance, which is often short-lived. On the
498 M. Olewinski et al.

other hand, the program consists of an intensive psychotherapy regime integrating

psychodynamic, cognitive-behavioral, bio-psychological, and complementary ele-
ments. It is based on detailed biopsychosocial assessment including a thorough case
history, from which a detailed behavior analysis or psychodynamic hypothesis is
generated, serving as a prerequisite for agreeing with the patient on individual ther-
apeutic goals. Diagnoses are made by diagnostic interview according to ICD-10. In
addition, patients fill in validated psychometric questionnaires at admission and
before discharge. The instruments used include the German version of the Brief
Symptom Inventory (BSI; Franke 2000) covering a variety of psychological symp-
toms such as anxiety and depressive symptoms, the short version of the Gießen
symptom checklist (GBB; Brähler et al. 2000) assessing bodily symptoms, the
European Quality of Life Questionnaire (EQ-5D; Greiner et al. 2005) as a global
measure of health-related quality of life, and the General Self-Efficacy Scale (GSE-
6; Romppel et al. 2013). Individual and group psychotherapy is offered with either
a cognitive-behavioral or a psychodynamic focus. Psychoeducation provides infor-
mation about relevant topics such as stress, sleep, depression, anxiety, and cardio-
vascular diseases. Complementary therapies such as art therapy and body therapy
help to express and modify emotions by mainly nonverbal methods. These therapies
are combined with relaxation training such as progressive muscle relaxation and
biofeedback. The latter are used for altering individual cardiovascular stress
responses to emotional stressors. Physical activation and training and – if individu-
ally indicated – physiotherapy are used to help patients regain confidence into the
regular functioning of their bodies. Based on patients’ and therapists’ experiences
during the different treatment modules, the team and patient develop a common
understanding of individual problems, resources, and realistic solutions. For this
purpose, continuous and reliable communication among all team members and with
the patient is essential. Regular team conferences, patient groups, and ward rounds
are useful for this purpose.
A typical weekly therapy schedule for a particular patient is shown in Table 26.1
(medical treatments and procedures are often difficult to schedule and typically take
place during blank time slots or sometimes instead of a scheduled therapeutic
session):
The combination of different therapies and the simultaneous and equal consider-
ation of both physical and psychosocial aspects of health and disease often help the
patient to gain better cognitive and emotional insight into his or her individual situ-
ation, reinforcing sense of coherence and feelings of self-efficacy. It helps to
improve emotional awareness and competence in dealing with the heart disease.
Maladaptive behavior or interaction patterns can be observed and often reshaped
immediately. Long-lasting behaviors such as smoking or overwork can be discussed
and motivation for sustainable change can be built up. Before discharge, achieve-
ment of initial goals and next steps are discussed with the patient. In addition, symp-
tomatic improvement can be quantified by the psychometric scales completed again
before discharge.
Table 26.1 Example of a 1-week patient schedule
Example for patient schedule Group A Slot A5
Time Monday Tuesday Wednesday Thursday Friday
7:45–8:45 Morning meeting Meeting with physician Morning meeting Meeting with physician Morning meeting Walking
Walking group Walking group Walking group Walking group group
09:00–10:00 Ward round 9–9:30 Ward round with Ward round 9:40–10:10
(vice) Med. Dir.
9–9:30
10:00–11:00 Exercise training
11:00–12:00 Group psychotherapy Individual Group psychoeducation Group psychotherapy
psychotherapy
12:00–13:00 Lunch break Lunch break Lunch break Lunch break Lunch break
13:00–14:00 Individual art therapy
14:00–15:00 Group body therapy Individual psychotherapy
14:00–15:15 Group art therapy
15:00–16:00 14:30–16:10
16:00–17:00
17:00–17:30 Evening meeting Evening meeting Evening meeting Evening meeting Evening meeting
26 An Integrative Psychosomatic Approach to the Treatment of Patients

17:30–18:00 Relaxation training Relaxation training Relaxation training Relaxation training Relaxation training
18:30–19:00 Supper break Supper break Supper break Supper break Supper break
19:15–19:45 Walking group Walking group Walking group Walking group Walking group
499
500 M. Olewinski et al.

26.2 Case Vignettes

The following case vignettes are intended to illustrate individually different clinical
approaches to psychocardiological problems.

26.2.1 Case 1: Cardiac Arrhythmias, Anxiety, and Depression

Mrs. B., a 45-year-old patient with complete situs inversus, suffers from sick
sinus syndrome with symptomatic bradycardia and paroxysmal tachyarrhythmic
atrial fibrillation. A cardiac pacemaker had been implanted 2 years ago. Her
recent cardiac and general medical status has been stable. She was referred by
her outpatient cardiologist due to unclear vertigo attacks, drowsiness, nausea,
and subjective cardiac irregularity going along with a feeling of pressure in her
throat. Recently, she had consulted several physicians, especially cardiologists.
The possibility of an ablation therapy was discussed but, due to her situs inver-
sus and an inconsistency of clinical complaints and objective arrhythmia, not
realized. Mrs. B. had developed increased anxiety related to her symptoms and
had become unable to continue working as a committed nurse. Social with-
drawal and avoidance behavior furthermore led to significant depressive
symptoms.
In a first contact, she appears graceful, friendly, and insecure. Her social situa-
tion reveals that she is divorced and has not had a close partnership for many
years. Her grown-up daughter recently moved out to pursue her academic studies.
There is only little contact with her family members, especially no contact to her
mother. Her brothers and sisters are reported to have alcohol-related problems.
The patients’ father is unknown. The ex-husband refuses to support the patient
and her daughter adequately. Biography reveals that the patient grew up in Eastern
Europe and came to Germany at age 25. Her mother was single, appears to have
had emotionally unstable personality traits, and showed little affection for the
patient.
During the therapeutic process, it was possible to discuss relations between Mrs.
B.’s psychosocial situation, her biography, and her current medical illness. It
appeared that the patient had developed a high altruistic motivation with a lack of
capabilities to recognize her own individual limits and needs. The lack of apprecia-
tion for her altruism in the context of reduced capacities due to her medical situation
and the recent move-out of her daughter have led to destabilization with increased
somatic symptoms, anxiety, and depression.
Mrs. B. was diagnosed with a secondary somatoform disorder of the cardiovas-
cular system and major depression. Psychotherapy included individual and group
therapy with psychodynamic and cognitive-behavioral elements. Together with
complementary therapies such as art therapy and body psychotherapy, this helped
the patient to improve her emotional self-perception and pay more attention to her
needs. Parallel cardiac diagnostics were completed and a cardiac CT showed no
signs of coronary alterations, which was very relieving for the patient.
26 An Integrative Psychosomatic Approach to the Treatment of Patients 501

At discharge her symptoms (vertigo, drowsiness, low mood) had significantly

improved, and she could relate remaining symptoms to underlying emotions (such
as suppressed anger) rather than the heart disease. The complexity of the case made
an initial inpatient therapy necessary and helpful. In the course of inpatient treat-
ment, she could be motivated to look for additional outpatient psychotherapy after
discharge.

26.2.2 Case 2: Recurrent Ventricular Tachycardia with ICD Shocks

Mr. A., a 50-year-old man, had experienced repeated ventricular tachycardias after
myocarditis. He had been implanted with a cardioverter defibrillator (ICD) that
sometimes succeeded in terminating tachycardias by antitachycardic pacing (ATP).
However, after ATP failure the patient had also received several DC shocks from the
device. These shocks were perceived as traumatic events by the patient. He had
frequent ventricular extrasystoles which he experienced as quite frightening, since
he interpreted them as harbingers of new tachycardias and ICD shocks. Finally, he
had been unable to leave his home, avoided any physical activity, and completely
withdrew from his social contacts. Quality of life was perceived as maximally
reduced. Before the arrhythmic events, the patient had led an active life, and even
after the myocarditis, he had loved traveling. However, he had given up traveling
after he had been frightened by an arrhythmic episode occurring in a foreign coun-
try and by the subsequent hospitalization far from home.
His main treatment goals were to reduce his anxiety, increase his mobility, and
resume his physical activities and social contacts. For this purpose, stabilizing inter-
ventions and education were used as a first step to induce a feeling of security in the
patient. The hospital environment and the availability of medical emergency care
around the clock contributed to relieving the patients’ anxiety and hyperarousal. He
was better able to distinguish harmless bodily sensations such as extrasystoles from
possibly dangerous arrhythmias and started regaining better confidence in his body.
In the next step, graded exposure therapy was started. Unlike typical exposure
therapy with physically healthy patients, Mr. A. had to live with the possibility that
indeed new tachycardias might be triggered by activity. Nevertheless, it was possi-
ble to develop with the patient an individual model of his anxiety, in which he could
develop a personal understanding of his thoughts, feelings, and physical symptoms
and their interdependencies. In a process of balancing possible (real) risks of induc-
ing new arrhythmias against the benefits of a more active life, the patient became
motivated to undertake first steps toward more activity. Given the real risk of cardiac
complications, it was important to move ahead slowly during exposure therapy in
order to not overburden the patient and trigger malignant arrhythmias. Exposure
was prepared by psychoeducational group sessions on anxiety and anxiety manage-
ment. It began on the lowest level of the patient’s hierarchy of anxieties, namely, by
walking alone in the hospital park.
For Mr. A. it was important to feel his anxiety rise during exposure and at the
same time realize that no ICD shock was triggered by the situation. He could learn
502 M. Olewinski et al.

that anxiety increases but can be tolerated and abates after a while without further
adverse consequences, such as defibrillator shocks. Developing tolerance to
hardly tolerable anxiety is a key element of exposure. Many patients (and in case
of cardiac comorbidity even therapists) avoid correct exposure by fighting down
anxiety or leaving the frightening situation prematurely. Given the real risks
involved, this is understandable, especially if no medical emergency care is easily
available. However, this turns exposure ineffective and cannot induce habituation,
because patients cannot make the experience that anxiety decreases by itself. In
these cases, anxiety tends to persist and flare up as soon as external security pro-
vided by a safe environment is no longer available or internal mechanisms of
anxiety control fail.
Once Mr. A. had understood this principle, he was able to practice on his own
and increase the demand of situations to which he exposed himself. However, good
preparation of exposure and discussion of experiences from the exposure with the
therapist was important for guiding the process. With increasing physical activity, it
also became important to discuss with a cardiologist his current cardiac status,
which was re-assessed during the inpatient treatment and showed that usual physi-
cal activity was not dangerous from a somatic point of view – although no cardiolo-
gist could ever assure the patient that he would never again experience new
ventricular tachycardias. The patient practiced several times per week and experi-
enced a decline in anxiety with repeated exposure to similar situations, encouraging
him to increase the difficulty of situations.
At the end of treatment, Mr. A. felt stabilized and able to perform moderate
physical activities. He identified a personally appropriate limit of his physical
capacity and felt confident to resume daily activities after returning home.

26.2.3 Case 3: Coronary Heart Disease, Myocardial Infarction,

Depression, and Anxiety

Mr. S., a 60-year-old teacher with known three-vessel coronary heart disease who
had suffered from myocardial infarction (MI) 4 years ago, was admitted for recur-
rent angina pectoris-like complaints combined with an intense fear of suffering
another MI. The complaints did not respond to nitroglycerine. He had already
undergone 12 coronary angiographies within 4 years. All invasive diagnostics
showed an acceptable coronary status and no further progression of coronary ath-
erosclerosis. The patient suffered from severe exhaustion, high inner tension, and
feelings of “burnout” and guilt toward his colleagues. He felt unable to recover on
weekends or during vacations and felt insufficient at work, where he was frequently
confronted with children with conduct disorders. He additionally suffered from a
fear of getting a malignancy or other severe disease and permanently experienced an
icy cold feeling on his tongue and in his throat. Comprehensive diagnostics had not
shown any evidence of a somatic cause for these symptoms. On admission he
appeared slowed down and showed a tendency to ruminate. His affect was depressed
with a sense of despair. Affective modulation and energy were reduced.
26 An Integrative Psychosomatic Approach to the Treatment of Patients 503

Treatment focused on the appropriate investigation of his medical status on the

one hand and on exploring the psychosocial situation as well as individual devel-
opmental circumstances on the other hand. It was noticed that he experienced a
decrease of his “heartache” immediately after admission. With this initial improve-
ment, he tended to get into a helping position for his ward mates and showed little
sense for his emotional and physical limits and exhaustion. He also could not
easily show feelings of sadness and unfulfilled needs. When confronted with his
strong striving for achievement, his low self-perception and self-care and feelings
of shame and guilt became visible, and his heartache increased again without a
somatic correlate. After spending a weekend at home for therapeutic reasons, he
found several inner and outer factors that triggered his symptoms. The awareness
of his lifelong pattern to ignore his personal needs and demands gave him a
glimpse into the reason for his deep unhappiness and depression. He became
aware of the buried parts of his self that obviously led to a chronic sense of insuf-
ficiency and depression, expressing themselves in an overly altruistic behavior,
which finally resulted in severe exhaustion and may have contributed to his coro-
nary disease. The confrontation with his inner conflicts and emotional states only
became possible when the patient could find a safe environment allowing him to
face his life-threatening fears and his biographically shaped essential need for
security.
Consequently, he could let go of his suspicious attention to his inner bodily sen-
sations. When he was discharged, he had gained a more meaningful life perspective,
dedicating more time to his inner needs. His recurrent heartache had decreased con-
siderably. He applied for our outpatient group therapy and began regular individual
psychotherapy.

26.2.4 Summary

These vignettes illustrate typical psychocardiological cases. While outpatient treat-

ment such as collaborative care, combining expertise from cardiology and psycho-
therapy or psychiatry, is very helpful for many patients, other patients do not benefit
sufficiently from outpatient care but can improve markedly with interdisciplinary inpa-
tient treatment, addressing physical and psychosocial dimensions in an integrative
treatment concept and providing a safe environment, including facilities for arrhythmia
monitoring, immediate cardiopulmonary resuscitation, or other cardiac interventions.
Patients admitted to our ward typically have undertaken several attempts to overcome
their problems. Many have had repeated hospitalizations or emergency admissions
before but still the subjective burden had not diminished or even increased. Cost-
effectiveness analyses studying psychosomatic inpatient treatments in other German
patient groups have shown that the high cost of inpatient treatment is more than offset
by future savings in both direct medical and indirect costs, such as absence from work
or early retirement (Schauenburg and Hildenbrand 2011). In our own evaluation study
of the psychocardiology inpatient treatment, physical symptoms (measured by the
GBB) and psychological distress (measured by the BSI) decreased, while overall
504 M. Olewinski et al.

quality of life on the EQ-5D improved substantially during the 5–6 weeks of treatment.
The improvement was widely maintained over 1–2 years of follow-up (Herrmann-
Lingen et al. 2015). In detail, cardiac symptoms decreased by d = 0.84 for pre-post and
d = 0.59 for baseline vs. 1.5-year follow-up. Effect sizes on the global severity index of
the BSI were d = 0.65 for pre-post and d = 0.45 for baseline vs. follow-up. Global qual-
ity of life increased by d = 0.57 during inpatient treatment and was still improved by
d = 0.46 18 months later (all p < 0.001). Improvement during inpatient treatment signifi-
cantly predicted follow-up well-being.

26.3 What Makes Clinical Psychocardiology So Challenging?

Cardiovascular patients coming to our ward often tend to have a somatically orien-
tated concept of their disease. And they often were not told anything else by their
physicians for years or even decades. A crucial part of our work therefore is to help
the patients to develop a comprehensive concept of their disease and give them back
the experience of self-efficacy.
In many other psychosomatic hospitals, patients come with some basic – though
often ambivalent – ideas of psychosomatic processes affecting their current illness.
In contrast, patients in psychocardiology often show an extensive ambivalence. In
the delicate early stages, the treating therapist must “contain” this high level of
ambivalence and resulting tensions, especially in patients with structural personality
deficits and somatic or somatoform disorders.
Most people suffering from “heart disease” initially expect a treatment in which
they can stay passive and do not need to contribute much more than taking a medica-
tion and wait for its effect without making a conscious effort. Even medication adher-
ence is often low (Chowdhury et al. 2013), and the demand to change one’s lifestyle,
especially when it goes beyond increasing levels of exercise or dietary change, often
leads to resistance or frank refusal, as long as patients do not get a deeper understand-
ing of the inner benefit they can derive from living a more health-conscious life.

26.4 The Importance of an Integrative, Multi-professional

Approach

In this context, the multi-professional approach appears most helpful and important
(Perk et al. 2012). Many cardiac patients have a profound though sometimes denied
fear of dying and little access to their inner world. Reliable medical care and nurse
support create a safe environment enabling patients to face their fears. Nonverbal
therapies such as art therapy, relaxation training, and body awareness therapy open
avenues for better self-perception and self-expression and help with adaptive ways
of emotion regulation. Physical therapy, based on the individual goals of each
patient, offers the opportunity for recovering physical strength, cardiovascular fit-
ness, increased self-confidence, and better perception of the body as an “indicator”
of feelings and emotional states. Exercise and relaxation can also be used to
26 An Integrative Psychosomatic Approach to the Treatment of Patients 505

demonstrate cardiovascular effects of daily life situations. Psychophysiological

assessment offers the opportunity to visualize effects of emotional arousal or relax-
ation on heart rate, blood pressure, and autonomic balance. Art therapy allows
access to hidden emotions on a nonverbal level. It can also help to (re-)discover
creative potential, to imagine and depict symbolic solutions (such as healing the
wounded heart), and to find inner stability against traumatic intrusions. The social
worker can help with putting necessary changes to the working or housing situation
into practice (Bjarnason-Wehrens et al. 2007). All these elements can be reflected
upon during verbal psychotherapy sessions to create a comprehensive understand-
ing of heart-mind associations and healthy ways to deal with them.
Psychosomatic medicine in our understanding typically works as relationship
medicine – both by illustrating the relationship between emotions, behavior, and
bodily processes as indicated above and by building on the therapeutic relationship
as a powerful therapeutic agent. In practice, the first contact may take place through
the psychosomatic consultation-liaison service, often providing the first experience
of a professional explicitly acknowledging the patient’s suffering and distress,
which is often missed in today’s somatic departments because of structural factors,
insufficient training of physicians, and lack of time.
This experience can encourage patients to overcome withdrawal or aggressive
ways of coping and develop a sense of validation and new hope. At the same time,
the perspective to have both partners for reliable communication and immediate
access to diagnostic and interventional facilities whenever needed is often very
much appreciated in patients feeling emotionally and physically unstable. Typical
psychiatric or psychosomatic departments usually cannot provide the intensity of
medical care needed for treating these subjectively and often also objectively criti-
cally ill patients. On the other hand, cardiologists often lack the skills and time to
get a deeper understanding of the patients’ individuality, their “non-somatic” symp-
toms, and available treatment options.
Effective delivery of treatment therefore requires a competent and appreciative
multidisciplinary team willing to reflect their collaboration with each other and their
countertransference toward their patients. Specific factors of high importance
include an interdisciplinary biopsychosocial understanding between the somatic
and psychosomatic clinicians as well as psychologists, nurses, and other therapists.
The nursing team plays a key role as the first contact persons and sources of support
for the patients. In this function, nurses often have to buffer frequent expressions of
negative affect and medical urgencies. A good perception and first appraisal of criti-
cal somatic or affective events is therefore expected from the nursing team, and they
are held responsible for maintaining a helpful working environment on the ward.
Shaping the relationship between patients and the nursing team represents a signifi-
cant diagnostic and therapeutic element, which needs regular super- and inter-vision
with the team of physicians and therapists including daily opportunities for
exchange, weekly team conferences discussing each individual patient, detailed
case conferences for difficult or demanding patients, external supervision, etc.
With such a competent multidisciplinary team, which is often acknowledged by
patients as a core factor for their symptomatic improvement, also severe emotional
506 M. Olewinski et al.

and physical instability can be absorbed and transformed into new learning oppor-
tunities for both patients and individual team members.

Conclusions
Integrated cardiac care and psychotherapy can successfully be implemented and
delivered at a tertiary care center to treat severely ill patients with cardiac and
mental comorbidity. However, treating this group of patients requires a highly
competent multi-professional team. It needs sufficient funding to pay for treat-
ments lasting several weeks. While cost-effectiveness of this concept still needs
to be demonstrated, studies of psychosomatic inpatient treatments in general
show promising clinical results and possibly even cost savings on the long run.

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