Somatic Symptom Illnesses
distress and anxiety about their health.
The term psychosomatic began to be used to
convey the connection between the mind
(psyche) and the body (soma) in states of health
and illness. Essentially, the mind can cause the
body either to create physical symptoms or to
worsen physical illnesses. Real symptoms can
begin, continue, or be worsened as a result of
emotional factors. Examples include diabetes,
hypertension, and colitis, all of which are medical
illnesses influenced by stress and emotions.
The term hysteria refers to multiple physical
complaints with no organic basis; the complaints are
usually described dramatically.
Somatic symptom illnesses
Sigmund Freud, working with Charcot, observed that
people with hysteria improved with hypnosis and
experienced relief from their physical symptoms when
they recalled memories and expressed emotions. This
development led Freud to propose that people can
convert unexpressed emotions into physical
symptoms, a process now referred to as somatization
OVERVIEW OF SOMATIC SYMPTOM ILLNESSES
Somatization is defined as the transference of mental
experiences and states into bodily symptoms. Somatic
symptom illnesses can be chasracterized as the
presence of physical symptoms that suggest a medical
condition without a demonstrable organic basis to
account fully for them.
The three central features of somatic symptom
illnesses are as follows:
• 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.
SOMATIC SYMPTOM DISORDER
Somatic symptom disorder is characterized by one or
more physical symptoms that have no organic basis.
Individuals spend a lot of time and energy focused on
health concerns, often believe symptoms to be
indicative of serious illness, and experience significant
• Conversion disorder, sometimes called conversion
reaction, involves unexplained, usually sudden deficits
in sensory or motor function (e.g., blindness,
paralysis).
• Pain disorder has the primary physical symptom of
pain, which is generally unrelieved by analgesics and
greatly affected by psychological factors in terms of
onset, severity, exacerbation, and maintenance.
• Illness anxiety disorder, formerly hypochondriasis,
is preoccupation with the fear that one has a serious
disease (disease conviction) or will get a serious
disease (disease phobia). It is thought that clients with
this disorder misinterpret bodily sensations or
functions.
Illness anxiety disorder, formerly hypochondriasis, is
preoccupation with the fear that one has a serious
disease (disease conviction) or will get a serious
disease (disease phobia). It is thought that clients
with this disorder misinterpret bodily sensations or
functions.
Somatic symptom illnesses are more common in
women than in men; they may represent about 5% to
7% of the general population, but estimates can vary
greatly.
Onset and Clinical Course
Clients with somatic symptom disorder often
experience symptoms in adolescence, though these
diagnoses may not be made until early adulthood
(about 25 years of age). Conversion disorder usually
occurs between the ages of 10 and 35 years. Pain
disorder and illness anxiety disorder can occur at any
age.
Related Disorders
Somatic symptom illnesses need to be distinguished
from other body-related mental disorders such as
malingering and factitious disorders, also known as
fabricated or induced illness, in which people feign or
intentionally produce symptoms for some purpose or
gain. In malingering and factitious disorders, people
willfully control the symptoms. In somatic symptom
illnesses, clients do not voluntarily control their
physical symptoms.
 Malingering is the intentional production of false or
grossly exaggerated physical or psychological
Cultural Concepts of Distress
symptoms; it is motivated by external incentives such
as avoiding work, evading criminal prosecution, [Syndrome- Culture- Characteristics]
obtaining financial compensation, or obtaining drugs.
Dhat- India - Hypochondriacal concern about semen
People who malinger have no real physical symptoms
loss
or grossly exaggerate relatively minor symptoms.
Koro - Southeast Asia - Belief that penis is shrinking
Factitious disorder, imposed on self, occurs when a
and will disappear into abdomen, resulting in death
person intentionally produces or feigns physical or
psychological symptoms solely to gain attention. Falling-out episodes - Southern United States,
People with factitious disorder may even inflict injury Caribbean islands - Sudden collapse; person cannot
on themselves to receive attention. The common term see or move
for factitious disorder imposed on self is Munchausen
Hwa-Byung -Korea -Suppressed anger causes
syndrome A variation of factitious disorder, imposed
insomnia, fatigue, panic, indigestion, and generalized
on others, is commonly called Munchausen
aches and pains
syndrome by proxy, and occurs when a person inflicts
illness or injury on someone else to gain the attention Sangue dormido (sleeping blood) - Portuguese Cape
of emergency medical personnel or to be a “hero” for Verde Islands - Pain, numbness, tremors, paralysis,
saving the victim. seizures, blindness, heart attack, miscarriage
Medically unexplained symptoms (MUS) and Shenjing shuairuo – China - Physical and mental
functional somatic syndromes are terms used more fatigue, dizziness, headache, pain, sleep disturbance,
frequently in general medical setting. They refer to memory loss, gastrointestinal problems, sexual
physical symptoms and limitations of function that dysfunction
has no medical diagnoses to explain their existence.
TREATMENT
ETIOLOGY
Treatment focuses on managing symptoms and
Psychosocial Theories improving quality of life. The health care provider
must show empathy and sensitivity to the client’s
Psychosocial theorists believe that people with
physical complaints. A trusting relationship helps
somatic symptom illnesses keep stress, anxiety, or
ensure clients stay with and receive care from one
frustration inside rather than expressing them
provider instead of “doctor shopping.” For many
outwardly. This is called internalization. Clients
clients, depression and anxiety may accompany or
express these internalized feelings and stress through
result from somatic symptom illnesses. Thus,
physical symptoms (somatization). Both
antidepressants help in some cases. Selective
internalization and somatization are unconscious
serotonin reuptake inhibitors such as fluoxetine
defense mechanisms. Clients are not consciously
(Prozac), sertraline (Zoloft), and paroxetine (Paxil)
aware of the process, and they do not voluntarily
are most commonly used
control it.

Biologic Theories

Research has shown differences in the way clients

with somatoform disorders regulate and interpret
stimuli. These clients cannot sort relevant from
irrelevant stimuli and respond equally to both types.
In other words, they may experience a normal body
sensation such as peristalsis and attach a pathologic
rather than a normal meaning to it.

APPLICATION OF THE NURSING PROCESS
The underlying mechanism of somatization is
consistent for clients with somatoform disorders of all
types.
Assessment for Somatic Symptom Severity
For the past 4 weeks, each of the following symptoms
is rated as: Not bothered at all Bothered a little
Bothered a lot
 Stomach pain
 Back pain
 Pain in arms, legs, and joints
 Menstrual cramps or other problems with
periods (females only)
 Headaches
 Chest pain
 Dizziness
 Fainting spells
 Feeling your heart race or pound
 Shortness of breath
History
Clients usually provide a lengthy and detailed
account of previous physical problems, numerous
diagnostic tests, and perhaps even a number of
surgical procedures. It is likely that they have
seen multiple health care providers over several
years. Clients may express dismay or anger at the
medical community with comments such as
“They just can’t find out what’s wrong with me”
or “They’re all incompetent, and they’re trying to
tell me I’m crazy!”
General Appearance and Motor Behavior
Overall appearance is usually not remarkable.
Often, clients walk slowly or with an unusual gait
because of the pain or disability caused by the
symptoms. They may exhibit a facial expression
of discomfort or physical distress.
Mood and Affect
Mood is often labile, shifting from seeming
depressed and sad when describing physical
problems to looking bright and excited when
talking about how they had to go to the hospital
in the middle of the night by ambulance.
Emotions are often exaggerated, as are reports of
physical symptoms
Thought Process and Content
Clients who somatize do not experience
disordered thought processes. The content of
their thinking is primarily about often
exaggerated physical concerns; for example,
when they have a simple cold, they may be
convinced it is pneumonia. They may even talk
about dying and what music they want played at
their funeral.
Sensorium and Intellectual Processes
Clients are alert and oriented. Intellectual functions
are unimpaired.
Judgment and Insight
Exaggerated responses to their physical health may
affect clients’ judgment. They have little or no insight
into their behavior. They are firmly convinced their
problem is entirely physical and often believe others
don’t understand.
Self-Concept
Clients focus only on the physical part of themselves.
They are unlikely to think about personal
characteristics or strengths and are uncomfortable
when asked to do so. Clients who somatize have low
self-esteem and seem to deal with it by totally
focusing on physical concerns.
Roles and Relationships
Clients are unlikely to be employed, though they may
have a past work history. They often lose jobs because
of excessive absenteeism or inability to perform work;
clients may have quit working voluntarily because of
poor physical health. Consumed with seeking medical
care, they have difficulty fulfilling family roles. It is
likely that these clients have few friends and spend
little time in social activities.
Physiological and Self-Care Concerns
In addition to the multitude of physical complaints,
these clients often have legitimate needs in terms of
their health practices (Box 21.2). Clients who somatize
often have sleep pattern disturbances, lack basic
nutrition, and get no exercise.

Clinical Nurse Alert
Just because a client has been diagnosed with a
somatic symptom illness, do not automatically dismiss
all future complaints. He or she should be completely
assessed because the client could at any time develop
a physical condition requiring medical attention.
Data Analysis
Nursing diagnoses commonly used when working with
clients who somatize include:
 Ineffective coping
 Ineffective denial
 Impaired social interaction
 Anxiety
 Disturbed sleep pattern
 Fatigue
 Pain
Outcome Identification Treatment outcomes for
clients with a somatic symptom illness may include: •
The client will identify the relationship between stress
and physical symptoms. • Th
e client will verbally express emotional feelings.
• The client will follow an established daily routine.
• The client will demonstrate alternative ways to deal
with stress, anxiety, and other feelings.
• The client will demonstrate healthier behaviors
regarding rest, activity, and nutritional intake.
Intervention
Providing Health Teaching
The nurse must help the client learn how to establish
a daily routine that includes improved health
behaviors. Adequate nutritional intake, improved
sleep patterns, and a realistic balance of activity and
rest are all areas with which the client may need
assistance.
Assisting the Client in Expressing Emotions
Teaching about the relationship between stress and
physical symptoms is a useful way to help clients
begin to see the mind–body relationship. Clients may
keep a detailed journal of their physical symptoms.
The nurse might ask them to describe the situation at
the time such as whether they were alone or with
others, whether any disagreements were occurring,
and so forth.
Teaching Coping Strategies
Two categories of coping strategies are important for
clients to learn and to practice: emotion-focused
coping strategies, which help clients relax and reduce
feelings of stress, and problem-focused coping
strategies, which help resolve or change a client’s
behavior or situation or manage life stressors.
Emotion-focused strategies include progressive
relaxation, deep breathing, guided imagery, and
distractions such as music or other activities.
CLIENT AND FAMILY EDUCATION
For Somatic Symptom Illnesses
• Establish daily health routine, including adequate
rest, exercise, and nutrition.
• Teach about relationship of stress and physical
symptoms and mind– body relationship
• Educate about proper nutrition, rest, and exercise.
• Educate client in relaxation techniques: progressive
relaxation, deep breathing, guided imagery, and
distraction such as music or other activities.
NURSING INTERVENTIONS
For Somatic Symptom Illnesses
• Health teaching
 Establish a daily routine.
 Promote adequate nutrition and sleep.
• Expression of emotional feelings
 Recognize relationship between stress/coping
and physical symptoms.
 Keep a journal.
 Limit time spent on physical complaints.
 Limit primary and secondary gains.
• Coping strategies
 Emotion-focused coping strategies such as
relaxation techniques, deep breathing, guided
imagery, and distraction
  Problem-focused coping strategies such as
problem-solving strategies and role-playing
MENTAL HEALTH PROMOTION A common theme in
somatic symptom illnesses is their occurrence in
people who do not express conflicts, stress, and
emotions verbally. They express themselves through
physical symptoms; the resulting attention and focus
on their physical ailments somewhat meet their needs
Interestingly, there are others who credit the internet
accessibility with feeding some peoples’ fears about
their health—called cyberchondria. Cyberchondria
refers to excessive or repeated online searches for
health-related information that is distressing or
anxiety-provoking for the person
Points to Consider When Working with Clients with
Somatoform Disorders
• Carefully assess the client’s physical complaints.
Even when a client has a history of a somatoform
disorder, the nurse must not dismiss physical
complaints or assume they are psychological. The
client may indeed have a medical condition.
• Validate the client’s feelings while trying to engage
him or her in treatment; for example, use a reflective
yet engaging comment, such as “I know you’re not
feeling well, but it is important to get some exercise
each day.”
• Remember that the somatic complaints are not
under the client’s voluntary control. The client will
have fewer somatic complaints when he or she
improves coping skills and interpersonal relationships.
KEY POINTS
► Somatization means transforming mental
experiences and states into bodily symptoms.
► The three central features of somatic symptom
illnesses are physical complaints that suggest major
medical illness but have no demonstrable organic
basis; psychological factors and conflicts that seem
important in initiating, exacerbating, and maintaining
the symptoms; and symptoms or magnified health
concerns that are not under the client’s conscious
control.
► Somatic symptom illnesses include somatic
symptom disorder, conversion disorder, illness anxiety
disorder, and pain disorder.
► Malingering means feigning physical symptoms for
some external gain, such as avoiding work.
► Factitious disorders are characterized by physical
symptoms that are feigned or inflicted for the sole
purpose of drawing attention to oneself and gaining
the emotional benefits of assuming the sick role.
► MUS and functional somatic syndromes are terms
used in general medical practice settings when
patients have physical symptoms and/or limitations
unexplained by a medical diagnosis.
► Internalization and somatization are the chief
defense mechanisms seen in clients with somatoform
disorders.
► Clients with somatic symptom disorder and
conversion reactions eventually may be treated in
mental health settings. Clients with other somatic
symptom illnesses are typically seen in medical
settings.
► Clients who cope with stress through somatizing
are reluctant or unable to identify emotional feelings
and interpersonal issues and have few coping abilities
unrelated to physical symptoms.
► Nursing interventions that may be effective with
clients who somatize involve providing health
teaching, identifying emotional feelings and stress,
and using alternative coping strategies.
► Coping strategies that are helpful to clients with
somatic symptom illnesses include relaxation
techniques such as guided imagery and deep
breathing; distractions such as music; and problem-
solving strategies such as identifying stressful
situations, learning new methods of managing them,
and role-playing social interactions.
► Clients with somatic symptom disorder actually
experience symptoms and the associated discomfort
and pain. The nurse should never try to confront the
client about the origin of these symptoms until the
client has learned other coping strategies.
► Somatic symptom illnesses are chronic or
recurrent, so progress toward treatment outcomes
can be slow and difficult.
► Nurses caring for clients with somatic symptom
illnesses must show patience and understanding
toward them as they struggle through years of
recurrent somatic complaints and attempts to learn
new emotion- and problem-focused coping strategies.