1. Somatoform Disorders NUR 444 Fall 2015

2. 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

3. 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.

4. 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.

5. 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

6. Predisposing factors
Family Dynamics
Defense against anxiety
Cultural

7. 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).

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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.

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

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

25. 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

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

27. 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

28. 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

29. Nursing Diagnosis
Disturbed body image related to repressed severe anxiety

30. 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

31. 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”

32. 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

33. 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?

34. 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.”

35. 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?

36. 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”

37. 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.