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Somatoform and Related Disorders
Chapter 21
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
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.
Somatoform Disorders
• Somatization Disorder
• Undifferentiated Somatization Disorder
• Conversion Disorder
• Pain Disorder
• Hypochondriasis
• Body Dysmorphic Disorder
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
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%)
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”
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
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
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
Risk Factors
• Women from families with multiple, unexplained somatic complaints
• Abuse
• For men, not yet identified
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
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
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
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.
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
Psychological Nursing Interventions
• Maintaining nurse-patient relationship
• Counseling
• Problem solving
• Health teaching
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
Nursing Diagnosis
• Fatigue• Pain• Sleep pattern disturbance• Altered sexuality patterns, anxiety • Ineffective coping • Impaired social interactions• Ineffective management of therapeutic
regimen
Social Nursing Interventions
• Problem-solving groups
• Assertiveness groups
• Family interventions
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
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)
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
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.