1. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 19 Somatoform Disorders

2. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Somatization is the transference of mental experiences and states into bodily symptoms Somatoform disorders are the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis to account fully for them Somatoform Disorders Definitions

3. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 3 Central Features Physical complaints suggest major medical illness but have no demonstrable organic basis Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms Symptoms or magnified health concerns are not under the client’s conscious control

4. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Somatization disorder: multiple physical symptoms; combination of pain, GI, sexual, and pseudoneurologic symptoms Conversion disorder: unexplained deficits in sensory or motor function associated with psychological factors; attitude of “la belle indifference” (lack of concern or distress) Pain disorder: pain unrelieved by analgesics; psychological factors influence onset, severity, exacerbation, and maintenance Hypochondriasis: preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia) Body dysmorphic disorder: preoccupation with imagined or exaggerated defect in physical appearance 5 Somatoform Disorders

5. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Onset and Clinical Course Onset of symptoms usually occurs in adolescence or early adulthood All the somatoform disorders are either chronic or recurrent Clients will go from one physician or clinic to another, or they may see multiple providers at once in an effort to obtain relief of symptoms

6. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders Malingering: the intentional production of false or grossly exaggerated physical or psychological symptoms; motivated by external incentives Factitious disorder (also known as Munchausen syndrome): a person intentionally produces or feigns physical or psychological symptoms solely to gain attention In malingering and factitious disorders, people willfully control the symptoms. In somatoform disorders, clients do not voluntarily control their physical symptoms.

7. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders (cont’d) Munchausen’s by proxy occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a “hero” for saving the victim

8. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology Psychosocial theories: –Unconsciously expressing internalized stress through physical symptoms (somatization) –Primary gains are achieved when the direct external benefits of being sick provides relief of anxiety, conflict, or distress –Secondary gains are obtained when the person receives internal or personal benefits from others because one is sick Biologic theories: –Familial tendencies –Differences in the way body stimuli are regulated and interpreted

9. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Considerations Somatization disorder is rare in men in the United States but more common in Greece and Puerto Rico Men in India often have dhat, which is a hypochondriacal concern about loss of semen Koro occurs in Southeast Asia and may be related to body dysmorphic disorder Falling-out episodes, found in the southern United States and the Caribbean islands, are characterized by a sudden collapse Hwa-byung is a Korean folk syndrome attributed to the suppression of anger and includes insomnia, fatigue, panic, indigestion, and generalized aches and pains Shenjing shuariuo occurs in China and includes multiple symptoms

10. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Treatment is focused on managing symptoms, improving quality of life, and improving coping skills Antidepressants are sometimes used for accompanying depression Referral to a pain clinic is helpful in pain disorder Involvement in therapy groups to improve coping and express emotions verbally has shown some benefit

11. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Application of the Nursing Process: Somatization Assessment –Investigate the client’s physical health status thoroughly to rule out underlying pathology requiring treatment –History: client likely provides a detailed medical history; quite distressed about their health status (except the client with conversion disorder, who displays la belle indifference)

12. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –General appearance and motor behavior: normal –Mood and affect: may be labile, shifting from sad and depressed (describing physical ailments) to bright and excited (describing trips to healthcare providers) –Thought processes and content: intact; content is about physical symptoms; vague in their description but use colorful, exaggerated terms Application of the Nursing Process: Somatization (cont’d)

13. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –Sensorium and intellectual processes: alert and oriented –Judgment and insight: little or no insight; judgment may be affected by exaggerated responses to physical health concerns –Self-concept: low self-esteem, lack of confidence, difficulty coping Application of the Nursing Process: Somatization (cont’d)

14. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment (cont’d) –Roles and relationships: difficulty fulfilling family roles; few friends or social activities; may report lack of family support –Physiologic and self-care concerns: legitimate health concerns may include disturbed sleep patterns, poor nutrition, lack of exercise, overuse of prescription medications Application of the Nursing Process: Somatization (cont’d)

15. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Data analysis –Nursing diagnoses include: oIneffective coping oIneffective denial oImpaired social interaction oAnxiety oDisturbed sleep pattern oFatigue oPain Application of the Nursing Process: Somatization (cont’d)

16. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Outcomes –The client will: oIdentify the relationship between stress and physical symptoms oVerbally express emotional feelings oFollow an established daily routine oDemonstrate alternative ways to deal with stress, anxiety, and other feelings oDemonstrate healthier behavior regarding rest, activity, and nutrition Application of the Nursing Process: Somatization (cont’d)

17. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention –Provide health teaching –Assist client to express emotions –Teach coping strategies Emotion-focused coping strategies (progressive relaxation, deep breathing, guided imagery, and distractions) Problem-focused coping strategies (learning problem-solving methods, applying the process to identified problems, and role- playing interactions with others) Application of the Nursing Process: Somatization (cont’d)

18. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation –Is the client making fewer visits to physicians with physical complaints? –Is the client using less medication and more positive coping techniques? –Are the client’s functional abilities increased? –Does the client have improved family and social relationships? Application of the Nursing Process: Somatization (cont’d)

19. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care Make appropriate referrals, such as a pain clinic for clients with pain disorder Provide information about support groups in the community Encourage clients to find pleasurable activities or hobbies

20. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion Assist clients to deal with emotional issues directly Assist clients to continue gaining knowledge about themselves and their emotional needs

21. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Deal with feelings of frustration Be realistic about small successes Validate client’s feelings Deal with feeling that client “could do better if he tried”