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PSYCHIATRIC NURSING
(Lecture Series)
SOMATOFORM DISORDERS
DR. ARNEL MARIA SALGADO y BAÑAGA
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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
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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
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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.
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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
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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
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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
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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
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related to the onset of the Sxs
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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
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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
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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
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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
•
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Tremor
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3.
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Respiratory
•
Bronchospasm
•
Dyspnea
•
Hyperventilation
4. Integumentary
•
Pruritis
5. Genitourinary
•
Difficulties in maturation
•
Menstrual disturbances
•
Sexual dysfunction
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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
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from the sick role
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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
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functioning
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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
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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
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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
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