Active coping strategies (e.g., physical exercise, positive attitude, motivation for psychotherapy) Healthy life style (enough sleep, balanced diet, exercise and relaxation) Secure relationships, social support Good work conditions Sustainable physician-patient relationship Biopsychosocial, decatastrophizing approach, avoiding unnecessary investigations and treatments Health care system that is freely accessible but emphasizes self-responsibility and prevention
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Several complaints (polysymptomatic course) Frequent or persistent complaints (complaint-free intervals non-existent or rare or brief) Dysfunctional perception of health/ illness (e.g., catastrophizing thoughts, substantial health-related anxiety) Dysfunctional health/illness behavior (high use of health services, resting and avoidance behavior) Markedly reduced ability to function; inability to work > 4 weeks, social withdrawal, physical deconditioning, possibly with physical sequelae Moderate to severe psychosocial stress (possibly biographical stressors) (e.g., low spirits, anxiety about the future, few social contacts) Psychological co-morbidity (especially depression, anxiety, post-traumatic stress disorder, substance dependence disorders, personality disorders) Physician-patient relationship experienced (by both) as “difficult” Iatrogenic “somatizing” factors (Box 1)
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Very severe complaints Occurrence of known warning signs of a somatically defined disease Indications of serious self-harming behavior Suicidality Physical sequelae (e.g., faulty posture becomes fixed, limitation of movement up to severe restricted mobility of spared joints, contractures, serious weight gain, patient stays in bed) Particularly severe psychological co-morbidity (e.g., development of severe depression; anxiety that keeps the patient confined in the home) Frequent change of treating phyisicans and therapists and frequent discontinuation of therapy Indications of severe iatrogenic damaging behavior
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