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SOMATOFORM DISORDERS
• formerly called as psychosomatic disorders
• group of psychiatric disorders in which the
patient has persistent somatic (physical)
complaints that can't be explained by a
physical disorder, substance use, or another
mental disorder
CAUSES
• in the view of psychodynamic theorists, these
conditions result from repression of emotions,
such as after a traumatic event
PSYCHOBIOLOGICAL MECHANISMS
• heightened body sensations
• increased autonomic arousal
• identification of the "patient" within a family
• perceived need to be sick
STRESS-RELATED DISORDERS IN CHILDREN
Stuttering
• speech rhythms are abnormal, with
repetitions and hesitations at the beginning of
words
• sometimes abnormalities are accompanied by
movements of the face, shoulders, and
respiratory muscles
Sleepwalking and sleep terrors
• sleepwalking - child calmly rises from bed in
an altered state of consciousness and walks
about, with no subsequent recollection of
dream content
• sleep terrors - child awakes terrified, in a state
of clouded consciousness, often unable to
recognize parents and familiar surroundings.
Visual hallucinations may occur, too
Functional enuresis/bed-wetting
• characterized by intentional or involuntary
voiding of urine, usually at night
Functional encopresis
• evacuation of feces into the child's clothes or
inappropriate receptacles
THERAPEUTIC APPROACHES
Family therapy
• may be recommended for children or
adolescents with somatoform disorders,
particularly if the parents seem to be using
the child to divert attention from other
difficulties
• for patients with pain disorder, family therapy
can help avoid reinforcement of dependency
among family members
Alternative therapies
• may relieve stress, pain, and other symptoms,
not just on a physical level but also on a
mental, emotional, and spiritual level
• these therapies include acupuncture,
hydrotherapy, therapeutic massage,
meditation, botanical medicine, and
homeopathic treatment
BODY DYSMORPHIC DISORDER
• patient is preoccupied with an imagined or
slight defect in physical appearance
• preoccupation can lead to severe distress and
impaired functioning. In extreme cases, it
results in psychiatric hospitalization, suicidal
ideation, or suicide attempts
CAUSES
Biological theory
• some people may have a genetic
predisposition to psychiatric dis-orders,
making them more likely to develop BDD
• certain stresses or life events, especially
during adolescence, may precipitate onset of
the disorder
• BDD also may be associated with an
imbalance of serotonin or other brain
chemicals
Psychological theory
• low self-esteem and a tendency to judge
oneself almost exclusively by appearance may
contribute to BDD
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• sufferers may be perfectionists striving for an
impossible ideal and not liking what they see
in the mirror
SIGNS AND SYMPTOMS
• often checks her reflection in the mirror, or
avoids mirrors
• frequently compares her appearance with
others' or examines others' appearance
• tries to cover the perceived defect with
clothing, makeup, or a hat or by changing her
posture
• seeks corrective treatment, such as surgery or
dermatologic therapy, to eradicate the
perceived defect (even though doctors, family,
and friends think such measures aren't
necessary)
• constantly seeks reassurance from others
about the perceived flaw or, conversely, tries
to convince others of its repulsiveness
• performs long grooming rituals, such as
repeatedly combing or cutting the hair or
applying makeup or cover-up creams
• picks at her skin or squeezes pimples or
blackheads for hours
• frequently touches the perceived problem
area
• measures the body part she thinks is repulsive
• is anxious and self-conscious around peers
• feels acute distress over her appearance,
causing functional impairment
• avoids social situations where the perceived
defect may be exposed
• has difficulty maintaining relationships with
peers, family, and spouses
• performs poorly in school or work, or takes
frequent sick days
• has low self-esteem
• has suicidal thoughts or behaviors
DIAGNOSIS
• may be misdiagnosed as anorexia nervosa,
social phobia, agoraphobia, panic disorder,
trichotillomania, OCD, or depression
• doctor may use such diagnostic instruments as
Yale-Brown Obsessive-Compulsive Scale
modified for BDD, National Institute of Health
Body Dysmorphic Disorder (BDD) Scale,
Psychiatric Status Rating Scale for BDD, Global
Assessment of Functioning Scale, Schneier
Disability Profile, Fixity of Beliefs
Questionnaire, and Hamilton Depression
Rating Scale
• diagnosis of BDD is confirmed if the patient
meets the criteria in the Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR)
TREATMENT
• group therapy - may reduce the patient's
sense of helplessness and help her to
communicate her thoughts, feelings, and
desires directly
• cognitive-behavioral therapy - specific
techniques include:
1. forbidding the patient from performing
behaviors that heighten discomfort and
worsen the disorder
2. teaching her to resist compulsive
behaviors
3. decreasing the time she spends on
obsessive thoughts and compulsive
behavior
4. helping her to face the situations she's
been avoiding
• aversion therapy - a painful stimulus is applied
to the patient to create an aversion to her
obsession with the perceived defect
• antidepressant drugs called selective
serotonin reuptake inhibitors (SSRIs), including
the relatively new agent fluvoxamine (Luvox) -
effectively diminish preoccupation, distress,
depression, and anxiety. The tricyclic
antidepressant clomipramine (Anafranil) also
has proven effective
DIAGNOSTIC CRITERIA
• The patient is preoccupied with an imagined
defect in appearance. If a slight physical
abnormality actually is present, her concern
over it is markedly excessive.
• The preoccupation causes clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
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• The preoccupation isn't better explained by • blindness

another mental disorder (such as anorexia • tunnel vision
nervosa).
Motor symptoms
NURSING INTERVENTIONS
• abnormal movements
• Approach the patient unhurriedly. Provide an • gait disturbances
accepting, nonjudgmental atmosphere. Don't • weakness
express shock, amusement, or criticism of her • paralysis
behavior. • tremors
• Keep the patient's physical health in mind. • tics
(For ex-ample, constantly picking at the skin • jerks
may cause infection or skin breakdown.) If she
becomes involved in ritualistic thoughts and Neurologic symptoms
behaviors to the point of self-neglect, provide
• seizure-like symptoms
for basic needs, such as rest, nutrition, and
• symptoms that mimic those of degenerative
grooming.
neuro-logic disorders
• Let the patient know you're aware of her
behavior. Help her explore feelings associated Other findings
with the behavior. You might ask her, "What
• abnormal focus on bodily functions and
do you think about while you perform this
sensations
behavior?"
• anger, frustration, and depression
HYPOCHONDRIASIS • frequent doctor visits despite assurance from
health care providers that the patient is
• marked by the persistent conviction that one healthy
has or is likely to get a serious disease -
• intensified symptoms when around
despite medical evidence and reassurance to
sympathetic people
the contrary
• rejection of the notion that symptoms are
• patient bases her conviction on bodily
stress related
sensations or symptoms that she has
• use of symptoms to avoid difficult situations
misinterpreted
DIAGNOSIS
CAUSES
• projective psychological tests (such as inkblot
• exact cause isn't known, but some experts
interpretation and sentence completion tests)
believe it involves biologically based
- may show a preoccupation with somatic
hypersensitivity to internal stimuli
concerns
CONTRIBUTING FACTORS • tests - to rule out underlying organic disease,
although invasive procedures should be
• death of a loved one minimized
• family member or friend with a serious illness
• a history of serious illness DIAGNOSTIC CRITERIA
• in elderly people, hypochondriasis may be • The patient is preoccupied with fears of
associated with depression or grief having a serious disease based on
SIGNS AND SYMPTOMS misinterpretation of signs or symptoms.
• The preoccupation persists despite
Sensory symptoms appropriate medical evaluation and
• anesthesia reassurance.
• paresthesia • The patient's belief lacks delusional intensity
• deafness and isn't restricted to a circumscribed concern
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about appearance (as in body dysmorphic dis-
order).
• The preoccupation causes clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
• The disturbance lasts at least 6 months.
• The preoccupation isn't better explained by
generalized anxiety disorder, obsessive-
compulsive disorder, panic disorder, a major
depressive episode, separation anxiety, or
another somatoform disorder.
Other features
• The patient is deemed to have poor insight it,
for most of the time during the current
episode, she doesn't recognize that the
concern about having a serious illness is
excessive or unreasonable.
TREATMENT
Follow-up care
• can help the patient deal with symptoms
which is important because up to 30% of
patients with hypochondriasis later develop
organic disease
Psychotherapy
• individual psychotherapy - uses
psychodynamic principles to help the patient
understand unconscious conflicts
• group therapy - provides support to help her
learn to cope with symptoms and to improve
her social skills
• family therapy - focuses on improving family
members' awareness of their interaction
patterns and on enhancing their
communication with each other
Cognitive and behavioral therapy
• provides incentives, motivation, and rewards
to control symptoms
Pharmacologic therapy
• benzodiazepines, such as lorazepam (Ativan)
or alprazolam (Xanax)
• SSRIS
• tricyclic antidepressants, such as amitriptyline
(Elavil) or imipramine (Tofranil)
• can be especially helpful for patients with
overlapping psychiatric conditions, such as
depression or anxiety disorders
NURSING INTERVENTIONS
• Help the patient deal with ineffective
individual coping and altered health
maintenance.
• Assess her level of knowledge about the
effects of emotions and stress on physiologic
functioning. Provide appropriate teaching.
• Encourage her to express her feelings to deter
emotional re-pression, which can have
physical consequences.
PAIN DISORDER
• patient complains of persistent pain, which
results predominantly or exclusively from
psychological factors
• pain becomes the patient's main focus of
attention and causes significant distress
CAUSES
Psychological theories
• a patient with pain disorder converts
unconscious conflicts to pain symptoms or
expresses an intrapsychic conflict through pain
Life events
• recent history of a traumatic, stressful, or
humiliating experience may be a contributing
factor for pain disorder
SIGNS AND SYMPTOMS
• acute or chronic pain not explained by a
physiologic cause
• pain whose severity, duration, or resulting
disability isn't explained by an underlying
physical disorder
• insomnia
• anger, frustration, and depression
• anger directed at health care professionals
(because they have failed to relieve her pain)
• drug-seeking behavior in an attempt to relieve
pain
• frequent visits to multiple doctors to seek pain
relief
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• pain often involves the back, head, abdomen,
and chest
DIAGNOSTIC CRITERIA
Pain features
• The patient's chief complaint is pain in one or
more anatomic sites that's severe enough to
warrant clinical attention.
• The pain causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.
• Psychological factors are judged to play an
important part in the onset, severity,
exacerbation, or maintenance of the pain.
• The patient doesn't intentionally produce or
feign the pain.
• The pain isn't better explained by a mood,
anxiety, or psychotic disorder and doesn't
meet the criteria for dyspareunia (painful
sexual intercourse).
Subtypes of pain disorder
• In pain disorder associated with psychological
factors, psychological factors are judged to
play a major role in pain onset, severity,
exacerbation, or maintenance. (However, this
type of pain disorder isn't diagnosed if the
patient also meets the criteria for
somatization disorder.)
• In pain disorder associated with a general
medical condition, a general medical condition
plays a major role in the onset, severity,
exacerbation, or maintenance of the pain.
• In pain disorder associated with both
psychological factors and a general medical
condition, psychological factors and a general
medical condition are both judged to play
important roles in pain onset, severity,
exacerbation, or maintenance.
TREATMENT
Supportive measures
• include hot or cold packs, physical therapy,
distraction techniques, hypnotherapy, and
cutaneous stimulation with massage or
transcutaneous electrical nerve stimulation
Pharmacologic therapy
• doctor is likely to prescribe analgesics for a
patient with pain disorder and also reduce the
patient's anxiety about asking for pain
medication and eliminate unnecessary
confrontations
• two other types of drugs may be prescribed as
well, including anxiolytics (benzodiazepines),
such as lorazepam and alprazolam, and
tricyclic antidepressants, such as amitriptyline,
imipramine, or doxepin (Sinequan) (rarely
used as first-choice drugs)
NURSING INTERVENTIONS
• Assess and record characteristics of the
patient's pain, including its severity, duration,
any precipitating or alleviating factors, and any
resulting disabilities.
• Provide assistance in relieving the patient's
pain and reducing her anxiety.
• Ensure a safe, accepting environment to
promote therapeutic communication.
CONVERSION DISORDER
• marked by the loss of or change in voluntary
motor or sensory functioning (for instance,
blindness, paralysis, or anesthesia) that
suggests a physical illness but has no
demonstrable physiologic basis
• symptom has a psychological basis, as
suggested by:
1. exacerbation during times of emotional
stress
2. relief of stress or inner conflict provided
by the symptom
3. attention, support, or avoidance of
responsibilities provided by the symptom
CAUSES
Biological factors
• more conversion symptoms occur on the left
side of the body than the right which suggests
that the brain's left hemisphere, where verbal
capacities are centralized, somehow blocks
impulses carrying painful emotional content
from the right hemisphere
Psychological factors
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• psychodynamic theory explains conversion
disorder as a defense mechanism that absorbs
and neutralizes the anxiety evoked by an
unacceptable impulse or wish
• patient represses unconscious intrapsychic
conflicts and converts her anxiety into a
physical symptom
RISK FACTORS
• history of histrionic personality disorder
(marked by excessive emotionality and
attention seeking)
• family history of the disorder or are seriously
ill or in chronic pain
• physical or sexual abuse within the family
SIGNS AND SYMPTOMS
• pseudoseizures (seizure-like attacks that are
thought to be psychogenically produced)
• loss of a special sense, such as vision
(blindness or double vision), hearing
(deafness), or touch
• aphonia (inability to use the voice)
• dysphagia (difficulty swallowing)
• impaired balance or coordination
• sensation of a lump in the throat
• urinary retention
• patient may report that the symptom began
after a traumatic event
DIAGNOSTIC CRITERIA
• The patient exhibits the loss of or a change in
voluntary motor or sensory function that
suggests a physical disorder.
• Psychological factors seem to be associated
with the symptom or deficit, because its onset
or exacerbation follows a psychological
conflict or other stressor.
• The patient isn't intentionally producing or
feigning the symptom or deficit.
• The symptom or deficit can't be explained by a
general medical condition, direct physiologic
effects of a substance, or culturally sanctioned
behavior.
• The symptom or deficit causes clinically
significant distress or impairment of social,
occupational, or other important areas of
functioning.
• The symptom or deficit isn't limited to pain or
sexual dysfunction.
• The symptom or deficit isn't better explained
by another mental disorder.
Other features
• The symptom or deficit is specified as a motor
symptom or deficit, sensory symptom or
deficit, seizures or convulsions, and mixed
presentation.
TREATMENT
• psychotherapy, family therapy, relaxation
training, behavior modification, biofeedback
training, or hypnosis - may be used alone or in
combination to treat conversion disorder
• pharmacologic therapy - benzodiazepines,
such as lorazepam and alprazolam, have
proven useful in treating some patients with
conversion disorder
NURSING INTERVENTIONS
• Establish a supportive relationship that
communicates acceptance of the patient but
keeps the focus away from her symptoms.
Doing this helps her learn to recognize and
express anxiety.
• Don't force the patient to talk, but convey a
caring attitude that encourages her to share
feelings.
• Encourage her to seek psychiatric care if she
isn't already receiving it.
SOMATIZATION DISORDER
• characterized by multiple and often vague
physical complaints that suggest a physical
disorder but have no physical basis
• symptoms are recurrent
• complaints may involve any body system and
often persist for years and may begin or get
worse after a job loss, death of a close relative
or friend, or some other loss as stress tends to
intensify the symptoms
CAUSES
Biological theories
• patients with somatization disorder may
perceive and process pain differently than
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others and may also have a lower pain
threshold, which increases their sensitivity to
physical sensations
Genetic factors
• disorder may run in families and is seen in
10% to 20% of primary female relatives of
patients with somatization disorder
• primary male relatives of these patients have
an increased incidence of alcoholism, drug
abuse, and antisocial personality disorder
Other factors
• underlying feelings of depression, anxiety, or
other distress, which the patient doesn't
recognize, child abuse, and particularly sexual
abuse
SIGNS AND SYMPTOMS
• may involve any body system but most
commonly involve the GI, neurologic,
cardiopulmonary, or reproductive systems
COMMON ASSESSMENT FINDINGS
Cardiopulmonary symptoms
• Chest pain
• Dizziness
• Palpitations
• Shortness of breath (without exertion)
Female reproductive signs and symptoms
• Excessive menstrual bleeding
• Irregular menses
• Vomiting throughout pregnancy
GI signs and symptoms
• Abdominal pain (excluding menstruation)
• Diarrhea
• Flatulence
• Intolerance to foods
• Nausea and vomiting (excluding motion
sickness
Pain
• In extremities
• In the back
• During urination
Pseudoneurologic signs and symptoms
• Amnesia
• Blindness
• Difficulty walking, paralysis, or weakness
• Double or blurred vision
• Dysphagia
• Dysuria or urinary retention
• Fainting or loss of consciousness
• Loss of voice or hearing
• Seizures
Sexual signs and symptoms
• Burning sensation in sexual organs or rectum
(except during intercourse)
• Dyspareunia or lack of pleasure during sex
• Impotence
• Sexual indifference
DIAGNOSIS
• patient should undergo a physical examination
and limited diagnostic tests to rule out
physical conditions that may produce vague,
confusing symptoms (such as multiple
sclerosis, hypothyroidism,
hyperparathyroidism, systemic lupus
erythematosus, and porphyria)
• psychological evaluation can rule out related
psychiatric disorders, including depression,
schizophrenia with somatic delusions,
hypochondriasis, and malingering
• diagnosis is confirmed if the patient meets the
criteria in the DSM-IV-TR
DIAGNOSTIC CRITERIA
History of complaints
• The patient has a history of many physical
complaints, beginning before age 30 and
persisting for several years, that cause her to
seek medical treatment or that impair
important areas of functioning.
Symptom features
• The patient reports all of these symptoms at
some time during the disturbance:
1. two Gl signs or symptoms: vomiting (other
than during pregnancy), abdominal pain
(other than during menstruation), nausea
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(other than motion sickness), bloating, of diagnostic test results and their
diarrhea, or intolerance of different foods implications.
2. four pain symptoms: pain in the • Negotiate a plan of care with input from the
extremities, back, joints or rectum; patient and, if possible, her family. Encourage
menstrual pain; pain during urination; and help them to understand her need for
pain during sexual intercourse; or other troublesome symptoms.
pain (excluding headache)
3. one conversion or pseudoneurologic
symptom: amnesia, difficulty swallowing,
loss of voice, deafness, double or blurred
vision, blindness, fainting or loss of
consciousness, seizures, difficulty walking,
paralysis or muscle weakness, urinary
retention, or difficulty urinating
4. one sexual symptom: burning sensation in
the sexual organs or rectum (other than
during intercourse, sexual indifference,
pain during intercourse, impotence,
painful menstruation, irregular menstrual
periods, excessive menstrual bleeding,
vomiting throughout pregnancy.

Other features

• The patient's symptoms aren't explained by a

known general medical condition or the direct
effects of a substance. Or, if a related general
medical condition is present, the complaint or
resulting social or occupational impairment
exceeds what would be expected from the
history, physical examination, or laboratory
findings.
• The symptoms aren't feigned or intentionally
produced.

TREATMENT

• no definitive therapy for somatization disorder

exists
• pharmacologic treatment - patient with a
coexisting depressive or anxiety disorder may
benefit from antidepressant drugs, such as
SSRIs or monoamine oxidase inhibitors, to
ease her preoccupation with symptoms

NURSING INTERVENTIONS

• Acknowledge the patient's symptoms and

support her efforts to function and cope
despite distress. Don't tell her that her
symptoms are imaginary - but do inform her