Somatoform Disorders NUR 444 Fall 2015

Learning Objectives 1. Describe the common characteristics and dynamics of somatoform disorders Somatization Disorder Pain Disorder Hypochondriasis Conversion Disorder Body Dysmorphic Disorder Somatoform Disorder NOS 2. Distinguish somatoform disorders from factitious disorders and malingering 3. Identify predisposing factors in the development of somatoform disorders 4. Apply the nursing process to the care of clients with somatoform disorders 5. Describe treatment modalities relevant to somatoform disorders

Reading Reach Chapter 29 *disregard sleep d/o content Townsend, M. (2015). Psychiatric mental health nursing: Concepts of care in evidenced base practice (8th ed.). Philadelphia: F.A. Davis.

Introduction Somatoform Disorders - group of disorders characterized by physical symptoms suggesting medical disease but without a known organic cause or physiologic mechanism to account for them.

Common Characteristics of Somatoform Disorders Physical symptoms worsen during crisis Physician shopping Unwarranted exploratory and unnecessary surgical procedures Substance abuse Avoidance of work or social activities Refusal of referral to mental health Symptoms are not intentional

Predisposing factors Family Dynamics Defense against anxiety Cultural

Predisposing factors Learned Theory: a. Somatic complaints reinforced when the sick person is excused from unwanted duties (primary gain). b. The sick person becomes prominent focus of attention (secondary gain).

Somatoform-related Disorders Malingering Factitious Disorders Munchausen’s Syndrome Intentionally produce symptoms for some purpose or gain

Somatoform disorders Somatization Disorder Pain Disorder Hypochondriasis Conversion Disorder Body Dysmorphic Disorder Somatoform Disorder NOS

Somatization Disorder A syndrome of multiple somatic symptoms cannot be explained medically associated with psychosocial distress long-term seeking of assistance from health care professionals. develops during adolescence (majority women) may be connected to Antisocial personality disorder

Somatization Disorder (cont.) History of physical complaints begins before age 30 The symptoms are not intentionally produced Anxiety and depression common Substance abuse common (analgesics and antianxiety meds) Suicide risk Hx of multiple surgeries Goes from provider to provider

Somatization D/o Multiple physical complaints in multiple body systems: 4 pain symptoms 2 gastrointestinal symptoms 1 sexual symptom 1 symptom suggesting a neurological d/o fatigue

Pain Disorder The predominant disturbance in pain disorder is severe and prolonged pain that causes: Clinically significant distress Impairment in social, occupational, or other areas of functioning

Pain Disorder (cont.) Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain The pain complaint may be evidenced by correlation of a stressful situation with onset of symptoms* Pain generally unrelieved by analgesics High risk for suicide Irritability and anger

Pain Disorders associated with a general medical condition Low back pain Migraine Facial pain Joint/bone pain Chest pain Eye/ear/throat pain Pelvic pain

Hypochondriasis Unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease

Hypochondriasis (cont.) Even in the presence of medical disease, the symptoms grossly exceed extent of pathological condition. Anxiety and depression are common findings, and obsessive-compulsive traits frequently accompany the disorder.

Conversion Disorder 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

Conversion Disorder (cont.) Predominant feature: la belle indifference a relative lack of concern about the severity of the impairment. may be a clue to the physician that the problem is psychological rather than physical.

Conversion Disorder Characteristics Symptoms often suggest a neurological disorder Examples: paralysis, localized weakness, impairment in balance, urinary retention, difficulty swallowing, seizures, blindness, deafness Unconscious mechanism Onset of symptoms follows an event or experience perceived as a major stressor

Body Dysmorphic Disorder Defined as the fear of some physical defect thought to be noticeable to others although the client appears normal. Characterized by the exaggerated belief that the body is deformed or defective in some specific way Common complaints involve imagined or slight flaws of face or head

Body Dysmorphic Disorder (cont.) Symptoms of depression and characteristics associated with OCD common in people with body dysmorphic disorder Etiology unknown Often leads to social isolation Individuals usually remain single

Somatoform Disorder, NOS Used for disorders that do not meet criteria for other somatoform disorders Physical symptoms present for less than 6 months Includes: Pseudocyesis False belief that one is pregnant Unexplained physical symptoms of fatigue or body weakness

Somatoform disorders Individual psychotherapy Group psychotherapy Treatment Modalities Somatoform disorders Individual psychotherapy Group psychotherapy Behavior therapy Psychopharmacology

Nursing Diagnosis Ineffective coping related to repressed anxiety and unmet dependency needs Deficient knowledge (psychological causes for physical symptoms) related to strong denial defense system

Nursing Diagnosis Chronic pain related to repressed anxiety and learned maladaptive coping skills Social isolation related to preoccupation with self and pain

Nursing Diagnosis Fear (of having serious disease) related to past experience with life-threatening illness Chronic low self-esteem related to unfulfilled childhood needs for nurturing and caring

Disturbed sensory perception related to repressed severe anxiety Nursing Diagnosis Self-care deficit related to loss or alteration in physical functioning Disturbed sensory perception related to repressed severe anxiety

Nursing Diagnosis Disturbed body image related to repressed severe anxiety

Nursing Interventions Avoid “in the patients head” Accept the reality of the symptoms as the pt.. presents them, avoiding dispute Encourage verbalization of thoughts and feelings, life events, stressors Assist in problem-solving

Nursing Interventions Emphasize the relationship between stress and physical symptoms Focusing attention to relaxation task Challenge irrational beliefs and self statements regarding illness Convey empathy “This must be very trying for you”

Nursing Interventions Keep discussion of symptoms brief and matter-of-fact, but without dismissal Treat physical symptoms conservatively, matter-of-factly Focus on coping techniques Work on Social activities and relationships

Practice A pt.. treated for pain d/o has an upsetting phone conversation with her husband and requests an analgesic. The pt.. states, “my neck is killing me, I just need my pain pill so I can feel better.” The nurse’s best response is?

Practice A. “your neck is fine, your just angry with you husband” B. “you must try not to rely on the pain pills so much since they are addictive” C. “Go lay down for awhile and I’ll come check on you” D. “I’ll get your medication and then lets talk about what just happened.”

Practice A pt. with a somatization d/o has been attending group therapy. Which pt.. statement suggest to the nurse that the therapy has been effective?

Practice A. “I think I’d better get some pain pills. My back hurt form sitting in group” B. “the other people in group have mental problems” C. “I haven’t said much, but I get a lot out of listening” D. “I feel better physically just from getting a chance to talk”

Practice A patient who is being counseled for somatoform pain disorder states he believes his pain is the result of an undiagnosed injury. He adds that he cannot adhere to his plan for care involving performing his own activities of daily living, walking 20 minutes daily, and using pain medication only at bedtime. He states he feels “like a baby” because his wife and children must provide so much care for him. The nurse understands that it is most important to assess: a. mood. b. cognitive style. c. secondary gains. d. identity and memory.