Somatoform and Related Disorders

Chapter 21

Key Terms

• Psychosomatic – Psychological state that contributes to the

development of a physical illness– Mental diagnoses characterized by unexplained

medical disabilities

• Somatization– Manifestation of physical symptoms from

psychological distress– Primary symptom of somatoform and factitious

disorders

Definition of Disorders

• Somatoform disorders– Patient suffers physical symptoms as a

result of psychological stress.

• Factitious disorders– Patient self-inflicts injury as a result of

psychological stress to seek outside treatment.

Somatoform Disorders

• Somatization Disorder

• Undifferentiated Somatization Disorder

• Conversion Disorder

• Pain Disorder

• Hypochondriasis

• Body Dysmorphic Disorder

Somatization

• Culture • Physical sensations are experienced according

to culturally defined expectations.

• Gender• Women more than men?

– Social acceptance – Boys taught not to cry– Higher incidence of depression (somatic

problems)– Women can express problems in relationships.

• Mexican American vs. non-Hispanic• Older, separated, widowed or divorced

Somatization Disorder

• Polysymptoms that begin before the age of 30

• Involve many body systems

• Prevalence 13% of population (estimated 4-5/1000)

• Rarely seen by mental health provider

• In medical office, two or three out of every 50 patients are undiagnosed.

• More prevalent in women (90 to 95%)

Clinical Course

• Recurring, multiple and clinically significant somatic problems involving several body systems (GI, neuro and musculoskeletal)

• Episode of physical illness may last six to nine months.

• “Sicker than the sick”

Somatization Disorder in Special Populations

• Children

– Not diagnosed in childhood, typically begins in adolescents

– Menstrual problems usually one of first symptoms

• Elderly

– Occurs, but is little research

– Need to differentiate disorder from medical problems

• Occurs in all populations and cultures

Epidemiology• 0.2 to 2% of general population, but could be as

many as two to three of every 50 patients seen in primary care. Real prevalence may be 4-5/1000.

• Before age 30 (by definition)

• Occurs primarily in women

• Inversely related to SES

• Worldwide, may be higher in South Americans, Mexican Americans, Puerto Ricans

• Often co-exists with medical problems

Etiology: Unknown• Biologic

– Responsive to relevant and irrelevant stimuli– Increased risk in first-degree relatives– Numerous menstrual problems

• Psychological– A patterned way of communicating

• Social– ASP, alcoholism in family members– Cultural expressions of other disorders

Risk Factors

• Women from families with multiple, unexplained somatic complaints

• Abuse

• For men, not yet identified

Interdisciplinary Treatment

• Providing long-term general management of the chronic condition

• Conservatively treating comorbid psychiatric and physical problems

• Providing care in special settings, including group treatment

Nursing Management:Biologic Domain

• Assessment: – Review of systems– Assessment of pain– Physical functioning– Pharmacologic

• Usually taking a large number of meds• Self-medicate and provider shop

– Health attitude survey – Review clinical vignette

• Nursing Diagnoses– Fatigue, pain, disturbed sleep

Biologic Nursing Interventions

• Spend time with physical complaints

• Help patient establish a daily routine

• Continually monitor medication

• Pain management – need multiple approaches

• Activity enhancement

• Nutrition regulation

• Relaxation

Pharmacologic Interventions• There is no medication for somatization

disorder.

• Treat the comorbid disorders.

– Depression: antidepressants - MOAI

– Anxiety: Avoid benzodiazepines.

• Monitor closely.

• Observe for drug-drug interactions.

Nursing Management: Psychological Domain

Assessment • Mental status usually normal

• Appearance may be flamboyant, exaggerated

• Preoccupied with personal illness (may keep a copy of record), series of personal crisis.

• Emotional reactions to life stressors

• Labile mood

Nursing Diagnoses

• Anxiety

• Ineffective sexuality patterns

• Impaired social interactions

• Ineffective coping

• Ineffective management of therapeutic regimen

Psychological Nursing Interventions

• Maintaining nurse-patient relationship

• Counseling

• Problem solving

• Health teaching

Nursing Management: Social Domain

Assessment • How much time seeking

medical care and treating illnesses?

• Extent of disability?

• Employment status?

• Social network? Do they see their friends as providers?

• Family members

– Tired of all the complaints?

– Alcoholism is common.

Nursing Diagnosis

• Caregiver role strain, risk

• Ineffective community coping

• Disable family coping

• Social isolation

Nursing Diagnosis

• Fatigue• Pain• Sleep pattern disturbance• Altered sexuality patterns, anxiety • Ineffective coping • Impaired social interactions• Ineffective management of therapeutic

regimen

Social Nursing Interventions

• Problem-solving groups

• Assertiveness groups

• Family interventions

Continuum of Care

• Inpatient care – very rare

• Emergency care – mostly for physical problems, except when depressed

• Community treatment– Spend lifetime in health care system– Most care delivered as outpatient

Factitious Disorders• Factitious disorder (Munchausen’s syndrome)

– Different than malingering (has other motivations)

– Injure themselves covertly

– Produce physical symptoms

• Factitious disorder NOS (by proxy)

– Injure others in order to gain attention (mother hurting child)

Nursing Management

Assessment • Chronology of

medical/psychological illnesses

• Early childhood experiences (abuse, neglect, role of self-injury)

• Family assessment

• Nursing Diagnosis • Risk for trauma• Risk for self-

mutilation• Ineffective individual

coping• Low self-esteem

Nursing Intervention

• Goal: To replace dysfunctional, attention-seeking behaviors with positive behaviors

• Accept and value patient.

• Encourage long-term psychotherapy.

• Confrontation is effective if patient feels supported.