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PSYCHIATRIC NURSING (Lecture Series) SOMATOFORM DISORDERS DR. ARNEL MARIA SALGADO y BAÑAGA 2 5/24/2017 I. Overview / Theories A. Psychological Responses 1. Amplified awareness of somatic stimuli caused by impaired CNS inhibitory function 2. Deficient communication between hemispheres of brain that impairs the ability to express emotions directly B. Defense Against Anxiety 1. A person may express conflict and resultant anxiety through physical symptoms • Being physically ill is socially acceptable • Receives help and nurturance, as well as having dependency needs met www.arnelsalgado.com 3 2. 5/24/2017 Conflict does not have to be acknowledged • May consciously seek relief from physical symptoms • May unconsciously not want to give up the symptoms because they decrease anxiety C. Family Dynamics 1. Family rules may prevent direct expression of conflict 2. Family view illness as an unacceptable way to avoid meeting otherwise required developmental tasks and role demands 3. Family may provide secondary gain 4. Symptoms may serve to control others or to stabilize relationships www.arnelsalgado.com 4 5/24/2017 II. Etiology A. Physical symptoms have no organic basis – objective diagnostic tests do not reveal structural or functional changes B. Physical symptoms for which there is no organic basis allow client to meet dependency needs without admitting such needs exist. C. Clients may be admonished to be mentally strong and to not express emotional needs or problems D. Somatoform Disorders in which there is no organic basis for the physical symptoms , may or may not begin after a physical illness or injury. www.arnelsalgado.com 5 5/24/2017 E. Culture Influences Physical Expression • Cultures may expect distress to be manifested in bodily symptoms , with psychological distress viewed as unacceptable • Somatization is defined as a disorder in primarily Western societies • Some symptoms maybe culture-bound, appearing only in some groups such as the feeling of worms in the head being found only in some parts of Africa and South Asia • Many culture bound illnesses have little influence on role performance F. Somatization disorders, characterized by multiple complaints in multiple body systems, are more prevalent in women than in men www.arnelsalgado.com 6 5/24/2017 III. Specific Disorders A. Somatization Disorder • Onset prior to age 30 with symptoms of several years duration • Multiple physical complaints in multiple body systems • New symptoms often arise with increased emotional distress • Tends to run in families • Lifestyle changes evoked physical illness, affecting occupational, family and community relationships o Client is often disabled o Often a history of multiple surgeries www.arnelsalgado.com 7 • 5/24/2017 SPECIAL INTERVENTIONS o Client requires long term management, often in a medical setting o Treat physical symptoms conservatively o Antidepressant may be prescribed if there is depressive symptom www.arnelsalgado.com 8 5/24/2017 B. Conversion Disorder • A somatoform disorder in which a motor, sensory or visceral function is lost and about which the client is usually indifferent • Sxs do not have an underlying organic cause • Motor Sxs: mutism, paralysis, tremors • Sensory Sxs: blindness, deafness, numbness Visceral Sxs: urinary retention, breathing difficulties, headaches • The more medically naïve the client, the more implausible the Sxs • Clear, identifiable psychological factors (stress, conflict) are www.arnelsalgado.com related to the onset of the Sxs 9 5/24/2017 C. Pain Disorder • A somatoform disorder characterized by pain • Client seeks medical attention for severe, prolonged pain with no organic basis • Pre-occupation with pain that is not helped by analgesics • Manifestations vary: low back pain, headache, chronic pelvic pain D. HYPOCHONDRIASIS E. Body Dysmorphic Disorder www.arnelsalgado.com 10 5/24/2017 IV. Assessment A. History 1. Onset is variable , depending upon the disorder 2. Has seen multiple care providers without relief of symptoms 3. Sees the problem as physical, and denies psychological influences on symptoms 4. Primary gain: Illness allows reprieve from responsibilities 5. Secondary gain: sick role allows for dependency needs to be met 6. Over time, client is increasingly socially isolated and physically inactive 7. Family may insist on client seeking assistance due to altered role performance www.arnelsalgado.com 11 5/24/2017 B. Mental Status Variations 1. Depends upon type of disorder 2. Appearance: Ranges from deeply anguished to indifferent; may assume antalgic position 3. Mood: maybe depressed, anxious, or unaffected; mood maybe labile 4. Thought: usually preoccupied with symptoms 5. Insight: highly impaired, usually denying any stressors or minimizing reactions to stressful events; not psychologically minded www.arnelsalgado.com 12 5/24/2017 C. Physical Symptoms 1. Respectful and thoroughly evaluate physical symptoms 2. Common organ system responses: 1. 2. CV • Fainting • HPN • Migraine headache • Tachycardia MS • Back Pain • Fatigue • Tension headache • www.arnelsalgado.com Tremor 13 3. 5/24/2017 Respiratory • Bronchospasm • Dyspnea • Hyperventilation 4. Integumentary • Pruritis 5. Genitourinary • Difficulties in maturation • Menstrual disturbances • Sexual dysfunction www.arnelsalgado.com 14 5/24/2017 V. Nursing Diagnosis A. Coping, ineffective individual related to severe level of anxiety, low self-esteem, regression to earlier level of development and inadequate coping skills B. Family processes, altered related to detachment and inability to express feeling or to struggle for power and control C. Denial, ineffective related to threat to self-concept D. Social interaction, impaired related to fear of leaving neighborhood or home or to physical symptoms and disability E. Body image disturbance related to low self-esteem and unmeet dependency needs F. Self-care deficit related to paralysis of body part, inability to see, hear or speak; and pain or discomfort G. Pain, chronic related to severe level of anxiety and secondary gains www.arnelsalgado.com from the sick role 15 5/24/2017 VI. Planning and Implementation A. Specific Strategies 1. Establish trusting, therapeutic relationship a. Avoid describing the physical symptoms as in the client’s head b. Note that the symptoms are not an attempt to get attention c. Recall that the client does not create symptoms consciously or on purpose d. Accept the reality of the symptoms as client present them 2. Client Education a. Explain symptoms on a tissue level, using understandable and acceptable language b. Present current knowledge of mind body interaction, emphasizing how stress and anxiety affect physiological www.arnelsalgado.com functioning 16 5/24/2017 3. Encourage verbalization of thoughts and feelings, life events and stressors 4. Assist in problem-solving specific conflicts or situations 5. Self-care strategies Modify exercise to fit client’s needs Employ nursing measure to promote sleep and rest Promote healthy nutritional practice Teach day-to-day client management of symptoms 6. Encourage gradual assumption of normal work www.arnelsalgado.com 17 5/24/2017 B. PHARMACOLOGICAL TREATMENT 1. No specific psychotropic medications for somatoform disorders 2. Some evidence for use of antidepressants with pain and Somatization disorders 3. Co-morbid anxiety or depression treated symptomatically with anxiolytics and antidepressants C. Individual and Group Treatment 1. Cognitive-behavioral approaches 2. Groups for clients and families 3. Supportive Approaches 4. Behavior modification www.arnelsalgado.com 18 5/24/2017 VII. Evaluation and Outcomes A. Identifies the interaction of mind and body and the effects of stress B. Increase ability to verbalize thoughts and feelings C. Identifies conflicts D. Seeks to actively solve problems actions through talking and concrete E. Assumes appropriate role in work, family and community F. Employ self- help strategies www.arnelsalgado.com