1. Somatoform and Sleep Disorders
Chapter 9
Introduction
A. The somatoform disorders are characterized by physical symptoms
B. Somatization refers to all those mechanisms by which anxiety is translated
known pathophysiological mechanism to account for them.
suggesting medical disease, but without demonstrable organic pathology or
C. Disordered sleep is a problem for many people. The cause may be
into physical illness or bodily complaints.
A. Historical Aspects
II. Somatoform Disorders
temporarily caused by stress or anxiety; or the cause may be physiological.
1. The concept of hysteria, which is characterized by recurrent, multiple
2. Witchcraft, demonology, and sorcery were associated with hysteria in the
old and probably originated in Egypt.
somatic complaints often described dramatically, is at least 4,000 years
3. In the 19th century, the French physician Paul Briquet attributed the
Middle Ages.
expressed can be “converted” into physical symptoms.
4. Out of his work with hypnosis, Freud proposed that emotion which is not
disorder to dysfunction in the nervous system.
B. Epidemiological Statistics
socioeconomic classes.
are more common in the poorly educated and people from the lower
1. Somatoform disorders are more common in women than in men. They
1. Somatization Disorder: Background Assessment Data
C. Application of the Nursing Process to Somatoform Disorders
and long-term seeking of assistance from health care professionals.
explained medically and are associated with psychosocial distress
a. A chronic syndrome of multiple somatic symptoms that cannot be
the neurological, gastrointestinal, psychosexual, or cardiopulmonary
b. Any organ system may be affected, but common complaints involve
attempts and threats are not uncommon.
c. Anxiety and depression are frequently manifested, and suicidal
systems.
(1) Theory of family dynamics. In dysfunctional families, when a
d. Predisposing factors to somatization disorder
that the family is unable to confront in an open manner.
to the child’s illness, leaving unresolved the underlying issues
child becomes ill, a shift in focus is made from the open conflict
Somatization brings some stability to the family, and positive
physical symptoms in different ways. Cognitive or emotional
(2) Cultural and environmental factors. Various cultures deal with
reinforcement to the child.
societies. In Middle Eastern and Asian cultures, depression is
symptoms such as guilt are predominantly seen in Western
(3) Genetic factors. Studies have shown a 10- to 20-fold increased
symptoms.
almost exclusively manifested by somatic or vegetative
incidence in female first-degree relatives of persons with the
(4) Transactional Model of Stress-Adaptation. The etiology of
predisposition.
disorder. These statistics may imply a possible inheritable
factors.
somatization disorder is most likely influenced by multiple
include:
(1) Nursing diagnoses for the client with somatization disorder
e. Diagnosis/Outcome Identification
(a) Ineffective coping
nursing care.
(2) Outcome criteria are identified for measuring effectiveness of
(b) Deficient knowledge
(1) Nursing intervention for the client with somatization disorder is
f. Planning/Implementation
(2) The nurse also works to help the client correlate appearance of
other than preoccupation with physical symptoms.
aimed at assisting the client to learn to cope with stress by means
g. Evaluation is based on accomplishment of previously established
the physical symptoms with times of stress.
a. The predominant disturbance in pain disorder is severe and
2. Pain Disorder: Background Assessment Data
outcome criteria.
impairment in social, occupational, or other areas of functioning.
prolonged pain that causes clinically significant distress or
of the symptom.
be evidenced by the correlation of stressful situation with the onset
b. Even when organic pathology is detected, the pain complaint may
c. The disorder may be maintained by:
(2) Secondary gains: The symptom promotes emotional support or
unpleasant activity.
(1) Primary gains: The symptom enables the client to avoid some
(3) Tertiary gains: In dysfunctional families, the physical symptom
attention for the client.
relieved.
remains unresolved, even though some of the conflict is
may take such a position that the real issue is disregarded and
(1) Psychodynamic theory. Theorizes that pain for some clients
d. Predisposing factors to pain disorder
emotions verbally may express feelings and emotions with
wrongdoing. Individuals who have difficulty expressing
serves the purposes of punishment and atonement for perceived
(2) Behavioral theory. In behavioral terminology, psychogenic
bodily sensations.
positive or negatively reinforced.
and classical conditioning. Occurs when pain behaviors are
pain is explained as a response that is learned through operant
(3) Theory of family dynamics. “Pain games” may be played in
relationships. Tertiary gain may also be influential.
manipulating and gaining the advantage in interpersonal
families burdened by conflict. Pain may be used for
and medulla are involved in inhibiting the firing of afferent pain
(4) Neurophysiological theory. Postulates that the cerebral cortex
the central modulation of pain.
serotonin and endorphins, which are thought to play a role in
fibers. These individuals may have decreased levels of
disorder is most likely influenced by multiple factors.
(5) Transactional Model of Stress-Adaptation. The etiology of pain
(b) Social isolation
(a) Chronic pain
(1) Nursing diagnoses for the client with pain disorder include:
of nursing care.
(2) Outcome criteria are identified for measuring the effectiveness
at relief from pain.
(1) Nursing intervention for the client with pain disorder is aimed
(2) Emphasis is placed on learning more adaptive coping
times when the client is not focusing on pain.
strategies for dealing with stress. Reinforcement is given at
a. Unrealistic preoccupation with fear of having a serious illness
3. Hypochondriasis: Background Assessment Data
b. Even in the presence of medical disease, the symptoms are
grossly disproportionate to the degree of pathology.
(a) One view suggests that hypochondriasis is an ego defense
(1) Psychodynamic theory
c. Predisposing factors to hypochondriasis
mechanism. Physical complaints are the expression of
feel something is wrong with the self.
easier to feel something is wrong with the body than to
low self-esteem and feelings of worthlessness, as it is
the transformation of aggressive and hostile wishes
(b) Another psychodynamic view explains hypochondriasis as
hypochondriasis as a defense against guilt and a need to
(c) Still other psychodynamicists have viewed
toward others into physical complaints to others.
atone for past misconduct.
(3) Social learning theory. Somatic complaints are often
as arising out of perceptual and cognitive abnormalities.
(2) Cognitive theory. Cognitive theorists view hypochondriasis
from the need to deal with a stressful situation, whether it be
reinforced when the sick role serves to relieve the individual
the experience of close family members, with serious or lifethreatening
(4) Past experience with physical illness. Personal experience, or
within society or within the family constellation.
illness can predispose an individual to
influences with hypochondriasis, some evidence indicates an
(5) Genetic influences. Although little is known about hereditary
hypochondriasis.
twins and other first-degree relatives.
increased prevalence of hypochondriasis among identical
d. Diagnosis/Outcome Identification
hypochondriasis is most likely influenced by multiple factors.
(6) Transactional Model of Stress/Adaptation. The etiology of
(1) Nursing diagnoses for hypochondriasis include:
e. Planning/Implementation
(b) Chronic low self-esteem
(a) Fear
aimed at relieving the fear of serious illness.
(1) Nursing intervention for the client with hypochondriasis is
(3) The nurse also works to help the client increase feelings of
unrealistic interpretation of bodily signs and sensations.
(2) The focus is on decreasing the preoccupation with and
self-worth and resolve internalized anger.
4. Conversion Disorder: Background Assessment Data
established outcome criteria.
f. Evaluation is based on accomplishment of previously
psychological conflict, the physical symptoms of which cannot
a. A loss of or change in bodily functioning resulting from a
b. The most obvious and “classic” conversion symptoms are those
pathophysiological mechanism.
be explained by any known medical disorder or
that suggest neurological disease, and occur following a
c. The person often expresses a relative lack of concern that is out
individual.
situation that produces extreme psychological stress for the
concern is identified as la belle indifference and may be a clue
of keeping with the severity of the impairment. This lack of
d. Predisposing factors to conversion disorder
physical.
to the physician that the problem is psychological rather than
traumatic event that the individual cannot express because of
(1) Psychoanalytical Theory. Emotions associated with a
of the original emotional trauma
physical symptoms. The symptom is symbolic in some way
moral or ethical unacceptability are “converted” into
individuals with the disorder. Nongenetic familial factors,
(2) Familial factors. Occurs more often in relatives of
(3) Neurophysiological theory. Suggests that some clients with
associated with an increased risk for conversion disorder.
such as incestuous sexual abuse in childhood, also may be
conversion disorder have a disturbance in central nervous
learned through positive reinforcement from cultural, social,
(4) Behavioral theory. Suggests that conversion symptoms are
system arousal.
(5) Transactional Model of Stress/Adaptation. The etiology of
and interpersonal influences.
conversion disorder is most likely influenced by multiple
(1) Nursing diagnoses for the client with conversion disorder
(b) Self-care deficit
(a) Disturbed sensory-perception
effectiveness of nursing care.
(2) Outcome criteria are identified for measuring the
(2) Emphasis is given to assisting the client with activities of
is aimed at recovery of the lost or altered function.
(1) Nursing intervention for the client with conversion disorder
g. Evaluation is based on accomplishment of previously
to reinforce the physical limitation.
daily living until the function is regained. Care is given not
5. Body Dysmorphic Disorder: Background Assessment Data
b. Symptoms of depression and characteristics associated with
deformed or defective in some specific way.
a. Characterized by the exaggerated belief that the body is
c. Has been closely associated with delusional thinking. Traits
obsessive–compulsive personality are common.
d. Predisposing factors to body dysmorphic disorder
narcissistic personality disorders are not uncommon.
associated with schizoid, obsessive–compulsive, and
with hypochondriasis or phobias.
(1) Etiology is unknown, but presumed to be psychological(2) Predisposing factors may be similar to those associated
(4) It is most likely that multiple factors are involved in the
underlying factor.
(3) Repression of morbid anxiety is thought to be an
predisposition to body dysmorphic disorder.
(1) Nursing diagnoses for the client with body dysmorphic
(2) Outcome criteria are identified for measuring effectiveness
(a) Disturbed body image
disorder include:
disorder is aimed at development of a realistic perception
(1) Nursing intervention for the client with body dysmorphic
that contribute to altered body image.
(2) A focus is on resolution of repressed fears and anxieties
of body appearance.
unrelated to physical appearance.
(3) Positive reinforcement is given for accomplishments
A. Sleep Disorders: Background Assessment Data
III. Sleep Disorders
1. Insomnia: Difficulty with initiating or maintaining sleep.
2. Hypersomnia (somnolence): excessive sleepiness or seeking excessive
asleep, even in the middle of a task or a sentence.
3. Narcolepsy: Sleep attacks. The individual cannot prevent falling
amounts of sleep
4. Parasomnias: Unusual to undesirable behaviors that occur during
awakenings from sleep and are sufficiently severe to interfere
a. Nightmare disorder: Frightening dreams that lead to
sleep. Examples include:
with social or occupational functioning.
comfort, and if wakefulness does occur, the individual is
piercing scream or cry. The individual is difficult to awaken or
b. Sleep terror disorder: Abrupt arousal from sleep with a
cannot recall the dream episode.
usually disoriented, expresses a sense of intense fear, but
walk about, dress, go to the bathroom, talk, scream, or even
during sleep in which the individual may leave the bed and
c. Sleepwalking: the performance of motor activity initiated
5. Circadian rhythm sleep disorders: a misalignment between sleep and
drive. Episodes may last from a few minutes to a half hour.
(a) Shift work type
its usual circadian rhythm. Categories include:
wake behaviors. The normal sleep-wake schedule is disrupted from
(c) Delayed sleep phase type
(b) Jet lag type
primary insomnia, primary hypersomnia, narcolepsy, sleep terror
a. Genetic or familial patterns: thought to play a contributing role in
6. Predisposing factors to sleep disorders
disorder, and sleepwalking.
from substances, endocrine or metabolic disorders, infectious or
sleep apnea syndrome, restless leg syndrome, use of or withdrawal
b. Medical conditions implicated in the etiology of insomnia: pain,
with hypersomnia include metabolic and encephalitic conditions,
other diseases, and CNS lesions. Medical conditions associated
c. Psychiatric or environmental conditions: anxiety, depression,
stimulants, sleep apneas, and hypoventilation syndromes.
the use of alcohol or other CNS depressants, withdrawal from
posttraumatic stress disorder, and schizophrenia.
environmental changes, circadian rhythm sleep disturbances,
e. Extreme fatigue and sleep deprivation may contribute to episodes
contribute to night terrors.
d. Neurological abnormalities, such as temporal lobe epilepsy, may
7. Diagnosis/Outcome Identification
of sleepwalking.
(2) Risk for injury
(1) Disturbed sleep pattern
a. Nursing diagnoses for the client with sleep disorders include:
b. Outcome criteria are identified for measuring the effectiveness of
at determining the cause of the disturbance and performing actions
a. Nursing intervention for the client with a sleep disorder is aimed
8. Planning/Implementation
9. Evaluation is based on accomplishment of previously established
that promote sleep and rest for the client.
1. Individual psychotherapy
A. Somatoform Disorders
IV. Treatment Modalities
3. Behavior therapy
2. Group psychotherapy
1. Relaxation therapy
B. Sleep Disorders
4. Psychopharmacology
3. Pharmacotherapy
2. Biofeedback
4. Phototherapy

2. Concepts of Somatoform and Dissociative Disorders
Somatoform disorders
Physical symptoms in absence of physiological cause
Associated with increased health care use
May progress to chronic illness (sick role) behaviors
Dissociative disorders
Disturbances in integration of consciousness, memory, identify, and perception
Dissociation is unconscious mechanism to protect against overwhelming anxiety

3. characterized
physical symptoms suggesting medical disease but without a demonstrable organic
pathological condition or a known pathophysiological mechanism to account for them.
Somatoform disorders are more common
In women than in men
In those who are poorly educated
In those who live in rural communities
In those who are poor

4. Somatoform Disorders: General Information
Prevalence
Rate unknown; estimated that 38% of primary care patients have symptoms with no medical basis
55% of all frequent users of medical care have psychiatric problems
Comorbidity
Depressive disorders, anxiety disorders, substance use, and personality disorders common

5. Somatization Disorder
Diagnosis requires certain number of symptoms accompanied by functional impairment
Pain: head, chest, back, joints, pelvis
GI symptoms: dysphagia, nausea, bloating, constipation
Cardiovascular symptoms: palpitations, shortness of breath, dizziness
Comorbidity
Anxiety and depression

6. Hypochondriasis Widespread phenomenon
1 out of 20 patients seek medical care
Misinterpreting physical sensations as evidence of serious illness
Negative physical findings does not affect patient’s belief that they have serious illness
Cormorbidity
Depression, substance abuse, personality disorder

7. Pain Disorder
Diagnosed when testing rules out organic cause for symptom of pain
Evidence of significant functional impairment
Suicide becomes serious risk for patients with chronic pain
Typical sites for pain: head, face, lower back, and pelvis
Cormorbidity
Depression, substance abuse, personality disorder

8. Body Dysmorphic Disorder (BDD
Patient has normal appearance or minor defect but is preoccupied with imagined defective body part
Presence of significant impairment in function
Typical characteristics
Obsessive thinking and compulsive behavior
Mirror checking and camouflaging
Feelings of shame
Withdrawal from others
Cormorbidity
Depression, OCD, social phobia

9. Conversion Disorder
Symptoms that affect voluntary motor or sensory function suggesting a physical condition
Dysfunction not congruent with functioning of the nervous system
Patient attitude toward symptoms
Lack of concern (la belle indifférence) or marked distress

10. Common symptoms Cormorbidity
Involuntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, and deafness
Cormorbidity
Depression, anxiety, other somatoform disorders, personality disorders

11. Nursing Process: Assessment Guidelines
Collect data about nature, location, onset, characteristics and duration of symptoms
Determine if symptoms under voluntary control
Identify ability to meet basic needs
Identify any secondary gains (benefits of sick role)
Identify ability to communicate emotional needs (often lacking)
Determine medication/substance use

12. Nursing Process: Diagnosis and Outcomes Identification
Common nursing diagnosis assigned
Ineffective coping
Outcomes identification
Overall goal: patient will live as normal life as possible

13. Nursing Process: Planning and Implementation
Long-term treatment/interventions usually on outpatient basis
Focus interventions on establishing relationship
Address ways to help patient get needs met other than by somatization
Collaborate with family

14. Nursing Communication Guidelines for Patient with Somatoform Disorder
Take symptoms seriously
After physical complaint investigated, avoid further reinforcement
Spend time with patient other than when complaints occur
Shift focus from somatic complaints to feelings

15. Use matter-of-fact approach to patient resistance or anger
Avoid fostering dependence
Teach assertive communication

16. Treatment for Somatoform Disorders
Case management
Useful to limit health care costs
Psychotherapy
Cognitive and behavioral therapy
Group therapy helpful
Medications
Antidepressants (SSRIs)
Short-term use of antianxiety medications
Dependence risk

17. Nursing Process: Evaluation
Important to establish measurable behavioral outcomes as part of planning process
Common for goals to be partially met
Patients with somatoform disorder have strong resistance to change

18. Sleep Disorders: Introduction
About 75 percent of adult Americans suffer from a sleep problem.
69% of all children experience sleep problems
The prevalence of sleep disorders increases with advancing age
Sleep disorders add an estimated $28 billion to the national health care bill.
Common types of sleep disorders include insomnia, hypersomnia, parasomnias, and circadian rhythm sleep disorders

19. Sleep Disorders: Assessment
Insomnia
Difficulty falling or staying sleep
Hypersomnia (somnolence)
Excessive sleepiness or seeking excessive amounts of sleep
Narcolepsy: Similar to hypersomnia
Characteristic manifestation: Sleep attacks; the person cannot prevent falling asleep
Parasomnias
Nightmares, sleep terrors, sleep walking

20. Circadian rhythm sleep disorders Shift-work type
Sleep terror disorder
Manifestations include abrupt arousal from
sleep with a piercing scream or cry
Circadian rhythm sleep disorders
Shift-work type
Jet-lag type
Delayed sleep phase type

21. Nursing Process Nursing Diagnosis Planning/Implementation Outcomes
Evaluation

22. Predisposing Factors
Genetic or familial patterns are thought to play a
contributing role in primary insomnia, primary
hypersomnia, narcolepsy, sleep terror disorder, and sleepwalking.
Various medical conditions, as well as aging, have been implicated in the etiology of insomnia.
Psychiatric or environmental conditions can contribute to insomnia or hypersomnia.
Activities that interfere with the 24-hour circadian rhythm
hormonal and neurotransmitter functioning within the body
predispose people to sleep-wake schedule disturbances.

23. Treatment Modalities Somatoform disorders Individual psychotherapy
Group psychotherapy
Behavior therapy
Psychopharmacology
Sleep disorders
Relaxation therapy
Biofeedback
Pharmacotherapy

24. Primary hypersomnia/narcolepsy
Pharmacotherapy
CNS stimulants such as amphetamines
Parasomnias
Centers around measures to relieve obvious stress within the family
Individual or family therapy
Interventions to prevent injury