1 SOMATOFORM DISORDERS (PSYCHOPHYSICAL PROBLEMS)

OUTLINE PRESENTATION 29-Mar-13 © INTRODUCTION CHARACTERISTICS CLASSIFICATION a. Somatization disorder b. Conversion c. Hypochondriasis d. Body dysmorphic disorder e. Pain disorder MALINGERING FACTITIOUS NURSING INTERVENTIONS

INTRODUCTION 29-Mar-13 © Soma means “body,” and somatoform disorders involve patterns in which individuals complain of body symptoms that suggest the presence of physical problems, but for which no organic basis can be found that satisfactorily explains the symptoms. That is, somatoform disorders are characterized by persistent requests for medical attention because of physical complaints that cannot be sufficiently explained by medical causes.

INTRODUCTION – Cont’d 29-Mar-13 © The symptoms are associated with psychological stressors but are not intentionally produced. Somatoform disorders probably occur through some mechanism that allows unconscious conflict to manifest as physical symptoms.

CHARACTERISTICS 29-Mar-13 © The somatoform disorders are characterized by: 1. Physical symptoms without medical cause; 2. Symptoms are not intentionally produced; 3. Psychological factors are associated with symptoms; and 4. Persistent requests for medical attention. 5. Identity disturbance 6. Perceptual disturbance, e.g., depersonalisation, derealisation

CLASSIFICATION 29-Mar-13 © There are five (5) somatoform disorders: 1. Somatization Disorder 2. Conversion (hysteria) 3. Hypochondriasis 4. Body Dysmorphic Disorder 5. Somatoform Pain disorder

Somatization Disorder 29-Mar-13 © Historically referred to as Briquette’s syndrome, or hysteria. It is a syndrome of multiple symptoms where anxiety is translated into physical illness or bodily complaints by the client without sufficient medical cause and is associated with psychosocial distress, and long term seeking of medical treatment from healthcare professionals at the same time. It begins before 30 years of age, sometimes as early as adolescence or childhood.

Symptoms of Somatization Disorder 29-Mar-13 © It is characterized by the following symptoms: a. Four pain symptoms – e.g., abdomen, head, back, joints, extremities, chest, rectum, menstruation, sexual intercourse, or during urination. b. Two gastrointestinal symptoms – e.g., nausea, vomiting, bloating, diarrhoea, or intolerance of several different foods.

Symptoms of Somatization Disorder – cont’d 29-Mar-13 © c. One sexual symptom – e.g., irregular menses, excessive menstrual bleeding, erectile or ejaculatory dysfunction, sexual indifference, vomiting throughout pregnancy. d. One neurological symptom – e.g., paralysis, localized weakness, lump in throat, difficulty swallowing, aphonia, urinary retention, hallucinations, pain sensation or loss of touch, double vision, blindness, deafness, seizures, loss of consciousness, or amnesia.

Differentiating Somatization Disorder from Medical Problem 29-Mar-13 © Three features may help health professionals to differentiate a somatization disorder from a medical problem: 1. The involvement of multiple organ systems; 2. The disorder is characterized by an early onset and chronic condition in which no physical changes occur over time; and 3. The absence of any significant laboratory values indicates that the underlying problems may be emotionally based.

Treatment of Somatization Disorder 29-Mar-13 © Psychotherapy Relaxation techniques Hypnosis Antianxiety drugs Antidepressants Regular physical examination

Conversion Disorder 29-Mar-13 © This is a loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism. It is characterized by neurological symptoms that usually involve sensory or voluntary motor functioning such as functional blindness or paralysis. Patients are unaware of the psychological basis and are therefore unable to control their symptoms.

Conversion Disorder – Cont’d 29-Mar-13 © Symptom usually occurs after a situation that produces extreme psychological stress for the individual. It appears suddenly, and often the person expresses a relative lack of concern for the impairment. This lack of concern is identified as la belle indifference. The symptom promotes secondary gain as a way to obtain attention or support that might not otherwise be forthcoming.

Conversion Disorder – Cont’d Thus, Conversion disorder is a somatoform disorder in which an intrapsychic conflict or anxiety provoking impulse is unconsciously converted into physiological or somatic signs and symptoms 29-Mar-13 ©

Causes – Conversion Disorder Cont’d Anxiety Depression Personality disorder, e.g., borderline, antisocial Hereditary 29-Mar-13 ©

Risk Factors – Conversion Disorder 29-Mar-13 © Conversion disorder risk factors include: Recent significant stress or emotional trauma Being female — women are much more likely to get conversion disorder Being an adolescent or young adult — conversion disorder can occur at any age, but it’s most common during adolescence or early adulthood Having a mental health condition, such as mood and anxiety disorders, dissociative disorder and certain personality disorders Having a family member with conversion disorder A history of physical or sexual abuse Financial problems

Symptoms– Conversion Disorder 29-Mar-13 © Common symptoms can include: Poor coordination or balance (Ataxia) Paralysis in an arm or leg Difficulty swallowing or “a lump in the throat”/Globus hystericus Inability to speak (Aphonia/Mutism) Vision problems, including double vision and blindness Deafness Seizures or convulsions, i.e., hysterical fits Loss of smell (Anosmia)

Symptoms– Conversion Disorder (cont’d) 29-Mar-13 © Other conversion disorder symptoms include: Loss of balance Numbness or loss of the touch sensation (Tingling) Inability to feel pain (Anaesthesia/Paraesthesia) Hallucinations Difficulty with walking (Akinesia-loss of muscle tone) Urinary retention Tremors Pseudocyesis diarrhoea/constipation/profuse sweating

Treatment - Conversion Disorder 29-Mar-13 © Psychotherapy Cognitive-Behavioural Therapy (CBT) Relaxation techniques Biofeedback techniques Hypnosis Antianxiety drugs Antidepressants

Hypochondriasis 29-Mar-13 © This is defined as a person’s preoccupation with the fear of contracting, or the belief of having, a serious disease that no medical cause serves as a basis for the disease onset. The individual always and constantly keep thinking of and believes of having a serious disease. The fear becomes disabling and persists despite the appropriate reassurance that no medical cause has been detected. The fear is based on a misinterpretation or inaccurate interpretation of the client’s physical symptoms.

Hypochondriasis – Cont’d 29-Mar-13 © Symptoms occur for at least six (6) months to convince patients that they have a disease. Transient state of hypochondriasis may exist following a true illness or the death of a loved one. They often have a long history of “doctor shopping” who move from one doctor to another for the same examinations and treatment, because they are convinced that they are not receiving proper treatment.

Hypochondriasis – Cont’d 29-Mar-13 © They reject, and often irritated by the idea that stress or psychosocial factors play a role in their condition. Even reading or hearing that someone they know has been diagnosed with an illness precipitates alarm on their part. It is associated with depressive or anxiety disorder. It equally affects men and women, and one’s socioeconomic status is not a factor.

Precipitating Factors – Hypochondriasis 29-Mar-13 © Disease outbreaks Anxiety Depression Media, e.g., adverts of serious illness Genetic

Treatment – Hypochondriasis 29-Mar-13 © Psychotherapy Relaxation techniques Hypnosis Antianxiety drugs Antidepressants, e.g., SSRIs Regular physical examination

Body Dysmorphic Disorder 29-Mar-13 © Formerly called dysmorphophobia, is characterized by the exaggerated belief that the body is deformed or defective in some specific way. The most common complaints involve imagined or slight flaws of the face or head, such as thinning hair, acne, wrinkles, scars, vascular markings, facial swelling or asymmetry, or excessive facial hair. Other complaints may have to do with some aspect of the nose, ears, eyes, mouth, lips, or teeth.

Body Dysmorphic Disorder – Cont’d 29-Mar-13 © The distress may be so severe that client refuses to leave the house, avoid work, social or public gatherings for fear of being ridiculed. The client’s social, occupational, or other important areas of functioning are impaired as a result of the anxiety associated with the imagined body defect. His or her medical history may reflect numerous visits to plastic surgeons and dermatologists for correction of the imagined defect. He or she may undergo unnecessary surgical procedures towards this effort.

Aetiology – Body Dysmorphic Disorder 29-Mar-13 © The actual cause is unknown Serotonin dysregulation in the brain Endorphin deficiency Schizophrenia Family history of major mood or anxiety disorders, such as depression or obsessive- compulsive disorder

Treatment – Body Dysmorphic Disorder 29-Mar-13 © Psychotherapy Relaxation techniques Antianxiety drugs Antidepressants, e.g., SSRIs Cosmetic treatment, such as dental, surgical, or dermatological repairs.

Somatoform Pain Disorder 29-Mar-13 © Somatoform Pain Disorder is a severe and prolonged pain that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning that cannot be fully explained by medical condition.

Diagnostic Criteria for Pain Disorder 29-Mar-13 © Pain in one or more body sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Psychological factors are judged to have an important role in the onset, severity, intensity, or maintenance of the pain. The symptom is not intentionally produced or feigned

Aetiology – Pain Disorder 29-Mar-13 © Endorphin deficiency has been implicated as one of the causes of pain disorder. Psychological factors

Treatment – Pain Disorder 29-Mar-13 © Psychotherapy Biofeedback training Relaxation techniques Antidepressant medication, e.g., Amitriptyline (Elavil) NB: Analgesics may not be useful to reduce the pain, and for that matter their use is ineffective.

Malingering and factitious disorders differ from somatoform disorders in that signs and symptoms are intentionally (deliberately) produced or feigned. Both psychological and physical signs and symptoms are expressed by individuals who fake illnesses. © MALINGERING & FACTITIOUS DISORDERS 29-Mar-13

MALINGERING 29-Mar-13 © People who are malingering willfully produce the symptoms of a physical illness for some form of external or secondary gain to meet a recognizable goal. That is, the symptoms are produce to satisfy an external motivation. The goal, however, in malingering is often to avoid difficulties or dangerous situations, responsibilities, punishment, or perhaps the police; or to receive compensation, free room and board, or a source of drug.

MALINGERING 29-Mar-13 © For instance, a student who fakes a stomachache to be excused from school duties is a common example of malingering. Some security officers may produce symptoms of a serious physical illness to the extent of being hospitalized just to avoid being assigned to dangerous missions. Another possible motivation is retaliation (e.g., for guilt, financial loss, legal penalty, job loss). However, once people get to know their motive, symptoms usually disappear because they no longer serve a purpose.

MALINGERING 29-Mar-13 © Symptoms such as low-back pain, headache, neck pain, vague abdominal or chest pain, dizziness, amnesia, and anxiety are typically complaint about because they are difficult to disprove. Patients are more interested in compensation, avoidance of responsibility, or drugs than a cure and may become angry if given a clean bill of health. In an inpatient setting, symptoms may wax and wane depending on whether or not the patient is being observed (Brochert, 2002).

FACTITIOUS DISORDER 29-Mar-13 © Factitious disorder, also called Munchausen’s syndrome, is the deliberate production of signs and symptoms of a physical illness in another person just to assume the sick role. In other words, factitious occurs when a person pretends to be ill in order to assume the sick role.

FACTITIOUS DISORDER 29-Mar-13 © Persons with factitious disorders may take medications to produce dramatic side effects or pretend to have seizure with no actual history of epilepsy. These individuals may give dramatic and colourful medical history; but when probed and questioned further, they are inconsistent with their complaints. It is slightly common in males. The aetiology may be related to childhood abuse, childhood hospitalisation, and/or rejecting parents.

FACTITIOUS DISORDER 29-Mar-13 © The hallmark of this disorder is that the individual’s only goal in faking illness is to assume the role of a patient (i.e., the sick role). There is no financial or other secondary gain (e.g., disability, time off from work, avoiding jail), which if present would change the diagnosis to malingering. Patients often have a history of repeated visits to different hospitals or clinicians in different areas, to avoid detection. Some patients may also undergo painful procedures and even major surgery. Affected individuals often have normal intelligence and lack a formal thought disorder (Brochert, 2002).

PREPARED & PRESENTED BY RICHARD OPOKU ASARE MPhil, B.ed (Hons) (health Sciences), RN (Dip)-RMN, Cert. Ed KEY NURSING INTERVENTIONS FOR CLIENTS WITH PSYCHOPHYSICAL PROBLEMS © Mar-13

NURSING INTERVENTION 29-Mar-13 © Early recognition of the disorders to help prevent potentially dangerous treatments from being given. Convey an attitude of acceptance and understanding. Conduct a thorough evaluation of patient’s complaints. Meet all physical needs of the client during acute feelings of illness. Minimize secondary gains once the acute phase of the illness is resolved. Avoid direct confrontation.

NURSING INTERVENTION – Cont’d Use the client’s level of anxiety as a gauge to determine the amount and type of health teaching. Acknowledge the client as a responsible adult while indirectly addressing dependency needs. Encourage the client to talk about his or her feelings. Expose the patient’s motivation, at least initially, because this approach often causes him or her to leave the hospital. Assist the client and family to enlarge their social network. 29-Mar-13 ©

NURSING INTERVENTION – Cont’d Orient client to reality, where necessary Educate client on condition Introduce client to Counselling Teach client effective coping mechanism 29-Mar-13 ©