1. Somatoform and Related Disorders Chapter 21

2. 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

3. 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.

4. Somatoform Disorders Somatization Disorder Undifferentiated Somatization Disorder Conversion Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder

5. 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

6. 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%)

7. 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”

8. 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

9. 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

10. 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

11. Risk Factors Women from families with multiple, unexplained somatic complaints Abuse For men, not yet identified

12. 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

13. 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

14. 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

15. 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.

16. 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

17. Psychological Nursing Interventions Maintaining nurse-patient relationship Counseling Problem solving Health teaching

18. 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

19. Nursing Diagnosis Fatigue Pain Sleep pattern disturbance Altered sexuality patterns, anxiety Ineffective coping Impaired social interactions Ineffective management of therapeutic regimen

20. Social Nursing Interventions Problem-solving groups Assertiveness groups Family interventions

21. 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

22. 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)

23. 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

24. 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.