1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 21 Somatic Symptom Illnesses

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Somatic Symptom Illnesses Psychosomatic: connection between mind (psyche) and body (soma) Hysteria: multiple physical complaints with no organic basis –Proposal by Freud that people can convert unexpressed emotions into physical symptoms Somatization: transference of mental experiences, states into body symptoms

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Somatic Symptom Illnesses (cont.) Three central features –Physical complaints suggest major medical illness but have no demonstrable organic basis –Psychological factors and conflicts seem important in initiating, exacerbating, maintaining symptoms –Symptoms or magnified health concerns are not under patient’s conscious control

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Somatic Symptom Illnesses Somatic symptom illness: multiple physical symptoms— combination of pain, GI, sexual, pseudoneurologic symptoms Conversion disorder: unexplained sensory or motor deficits associated with psychological factors; typically involves significant functional impairment; “la belle indifference”

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Somatic Symptom Illnesses (cont.) Pain disorder: pain unrelieved by analgesics; psychological factors influencing onset, severity, exacerbation, maintenance Illness anxiety disorder (hypochondriasis): disease conviction or disease phobia

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Onset and Clinical Course Symptoms usually onset in adolescence or early adulthood All either chronic or recurrent Patients go from one physician or clinic to another, or see multiple providers at once, to obtain relief of symptoms

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A patient with a somatic symptom illness is able to voluntarily control the symptoms.

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: The symptoms of somatic symptom illness are not under the patient’s voluntary control.

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders Malingering: intentional false or grossly exaggerated symptoms; external incentives as motivation Factitious disorder: intentional symptoms to gain attention (Munchausen’s syndrome = imposed upon self) –Munchausen’s syndrome by proxy = imposed upon others

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders (cont.) Malingering and factitious disorders: willful control of symptoms; somatic symptom illnesses—no voluntary control over symptoms

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology Psychosocial theories –Internalization –Primary gains: direct external benefits of being sick provide relief of anxiety, conflict, distress –Secondary gains: person receives internal or personal benefits from others because one is sick.

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology (cont.) Biologic theories: –Differences in regulation, interpretation of stimuli

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Considerations Variable in frequency, meaning across cultures (see Table 21.1) –Dhat (men in India) –Koro (Southeast Asia) –Falling-out episodes –Hwa-byung (Korean folk syndrome) –Shenjing shuariuo (China)

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Symptom management, improvement in quality of life Antidepressants for accompanying depression: SSRIs (see Table 21.2) Pain clinic referral for disorder Involvement in therapy groups

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Somatic Symptom Illnesses and Nursing Process Application Assessment –Investigation of physical health status; screening (se Box 21.1) –History: usually detailed medical history; distress about health status (except patient with conversion disorder who displays la belle indifference) –General appearance, motor behavior –Mood, affect: labile; exaggerated emotions

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A patient with a factitious disorder develops symptoms primarily for attention.

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Factitious disorder occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention.

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Somatic Symptom Illnesses and Nursing Process Application (cont.) Assessment (cont.) –Thought process, content: focus on symptoms –Sensorium, intellectual processes –Judgment, insight –Self-concept: focus on physical self –Roles, relationships: problems –Physiologic, self-care concerns (Box 21.2)

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Somatic Symptom Illnesses and Nursing Process Application (cont.) Data analysis/nursing diagnoses Outcome identification –Identify relationship between stress and physical symptoms –Verbally express emotions/feelings –Establish and follow a daily routine –Demonstrate alternate ways to deal with stress, anxiety, and other feelings –Demonstrate healthy behaviors regarding rest, activity, and nutritional intake

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Somatic Symptom Illnesses and Nursing Process Application (cont.) Intervention –Provide health teaching: improved health behaviors –Help express emotions: journaling; limiting time spent on physical complaints –Teach coping strategies Emotion-focused coping strategies Problem-focused coping strategies Evaluation

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care Appropriate referrals, such as pain clinic for patients with pain disorder Information about community support groups Pleasurable activities or hobbies

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following would be an example of a problem-focused coping strategy? –A. Progressive relaxation –B. Deep breathing –C. Interaction role-playing –D. Guided imagery

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Interaction role-playing Rationale: Interaction role-playing is an example of a problem-focused coping strategy. –Progressive relaxation, deep breathing, and guided imagery are emotion-focused coping strategies.

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion Assist patients to deal directly with emotional issues Assist patients to continue gaining knowledge about themselves, their emotional needs

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Deal with feelings of frustration. Be realistic about small successes. Validate patient’s feelings. Deal with feeling that patient “could do better if he tried.”