Chapter 19 Somatoform Disorders

1. Chapter 19Somatoform Disorders

2. Psychosomatic • Psychosomatic was a term first used to convey the connection between the mind and body in states of health and illness. Somatization is defined as the transference of mental experiences into bodily symptoms. • The client ask the nurse, “What does having a psychosomatic symptoms mean?” Stress and or emotions are causing your symptoms.

3. Somatoform disorders are characterized by the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis to account fully for the symptoms. Three central features of somatoform disorders: • Physical complaints that suggest medical illness but have no demonstrable organic basis • The primary gain associated with developing physical symptoms in response to stress is to “Decrease anxiety”.

4. Psychological factors and conflicts that seem important in initiating, exacerbating, and maintaining the symptoms • Symptoms or magnified health concerns that are not under the client’s conscious control

5. Somatoform disorders cont’ • Clients are convinced they have serious medical problems, despite negative test results. They actually experience the physical symptoms, as well as the accompanying distress and functional limitations. They seek help from health care professionals but often are told “it’s all in your head.” It is important to remember that their symptoms and distress are real. “the pain in their head is very real!!”

6. Five specific somatoform disorders: • Somatization disorder: multiple physical symptoms; combination of pain, GI, sexual, and pseudoneurologic symptoms • Conversion disorder: unexplained deficits in sensory or motor function such as blindness or paralysis associated with psychological factors; attitude of “la belle indifference” (lack of concern or distress about physical symptom) EX: graduate nurse to take NCLEx exam in 3 days woke up today could not see anything at all but tells classmates “Oh don’t worry it will work out • Primary gain for a client with conversion disorder “relief from emotional conflict”

7. Pain disorder: pain unrelieved by analgesics; psychological factors influence onset, severity, exacerbation, and maintenance • Hypochondriasis: persistant preoccupation with fear that one has or will get a serious disease; they may interpret normal body functions as signs of disease • Body dysmorphic disorder: preoccupation with imagined or exaggerated defect in physical appearance. Ex: nose is too big for their face; “My hair is so thin that I always wear a hat.”

8. Somatization disorder cont’ • Somatization disorder, conversion disorder, and pain disorder are more common in women. Hypochondriasis and body dysmorphic disorders occur equally in men and women. All somatoform disorders are either chronic or recurrent, lasting for decades. • Onset: somatization and body dysmorphic disorder, 25 years; conversion disorder, 10 to –35 years; pain disorder and hypochondriasis occur at any age.

9. Related Disorders • Malingering • Intentional production of false or grossly exaggerated physical or psychological symptoms motivated by avoiding work, evading criminal prosecution, or obtaining financial compensation or drugs. Client has no real symptoms. “Once gain what they want-physical symptoms disappear-such as receiving compensation from a law suit settlement • Factitious Disorder-is an example of Malingering • Occurs when a person intentionally causes or feigns symptoms to gain attention; commonly called Munchausen’s syndrome • A variation is inflicting injury or causing symptoms in someone else, thereby gaining attention from medical personnel or for “saving” the person’s life. Munchausen’s by proxy: rare; most commonly seen when parents injure their children or medical personnel injure patients; these people are usually prosecuted for criminal behavior.

10. Etiology • Psychosocial theories: anxiety, frustration; feelings are expressed through physical symptoms rather than verbally internalization; primary gain(relief of anxiety—EX: piano recital client hand becomes numb so no unable to play at recital(anxiety/stress) and secondary gains-client becomes ill now the family has to do all the chores, cook, etc. • Biologic theories: familial tendencies; differences in the way body stimuli are regulated and interpreted

11. Cultural Considerations • There are many culture-bound syndromes associated with physical symptoms; the meaning of physical symptoms varies greatly from one culture to another. • Table 19-1

12. Treatment • Treatment is focused on managing symptoms, improving quality of life, and improving coping skills. The client who indicates understanding-will say “How the client handles the stress and emotions can affect their physical health.” • Long term outcome-the client will develop alternative methods of coping mechanism. • Antidepressants are sometimes used for accompanying depression. Check side effects. Table 19-2 • Referral to a pain clinic is helpful in pain disorder. • Involvement in therapy groups to improve coping and express emotions verbally has shown some benefit just by talking/expressing self to others.

13. Application of the Nursing Process: Somatization Assessment • It is important to investigate the client’s physical health status thoroughly to rule out underlying pathology requiring treatment. • History: Client likely provides a detailed medical history; may state, “they can’t find out what’s wrong”; most clients are quite distressed about their health status, except the client with conversion disorder, who seems indifferent to the symptoms

14. Assessment (cont’d) • General appearance and motor behavior: overall appearance not remarkable; client may walk slowly or have distressed facial expression

15. Assessment (cont’d) • Mood and affect: Mood may be labile, shifting from sad and depressed (when describing physical ailments) to bright and excited (describing trips to the hospital by ambulance). Clients often brighten and look “better” while they have the nurse’s undivided attention

16. Assessment (cont’d) • Thought processes and content: Clients with somatization disorder may be vague in their description but use colorful, exaggerated terms. Thought process is intact; majority of content is about physical symptoms. When asked about feelings, clients respond in physical, not emotional terms. Clients with hypochondriasis also voice concerns that they are gravely ill and worry about dying. • Sensorium and intellectual processes: alert and oriented

17. Assessment (cont’d) • Judgment and insight: intellectual functions intact, little or no insight into their behavior; judgment may be affected by exaggerated responses to physical health concerns • Self-concept: low self-esteem but likely to focus only on the physical self, lack of confidence, difficulty coping, not likely to be employed (due to poor health)

18. Assessment (cont’d) • Roles and relationships: difficulty fulfilling family roles (too sick); probably few friends or social activities, may report lack of family support; family may be very tired and frustrated with client • Physiologic and self-care concerns: Clients who somatize may have legitimate health concerns, such as disturbed sleep patterns, poor nutrition, lack of exercise, overuse of prescription medications.

19. Data Analysis Nursing diagnoses include: • Ineffective Coping • Ineffective Denial • Impaired Social Interaction • Anxiety • Disturbed Sleep Pattern • Fatigue • Pain

20. Outcomes The client will: • Identify the relationship between stress and physical symptoms • Verbally express emotional feelings • Follow an established daily routine • Demonstrate alternative ways to deal with stress, anxiety, and other feelings • Demonstrate healthier behavior regarding rest, activity, and nutrition

21. Intervention • Providing health teaching-effective when you hear “I will feel better when I begin handling stress more effectively.” • Emotion-focused coping strategies-designed-helping the client manage the intensity of symptoms • Assisting client to express emotions-the client feels better physically just from getting a chance to talk.” • Teaching coping strategies

22. Evaluation • Changes are likely to occur slowly. • Using fewer medications, making fewer visits to physicians, improved coping skills, increased functional abilities would be indicators of treatment success.

23. Self-Awareness Issues • Deal with feelings of frustration • Be realistic about small successes • Validate client’s feelings • Deal with feeling that client “could do better if he tried”