Care of Patients with Somatoform Disorders (In

DSMV called Somatic Symptom and Related

Disorders)

“Doctor shopping”
““Always Sick””

Prepared by
Dr/ Safaa Abdelazem Osman
Lecturer of psychiatric & mental health nursing faculty of
nursing/ Suez Canal University
2018/1440
 Out line
• Definition of Somatoform Disorders
• Common Characteristics of Somatoform
Disorders
• Classifications of Somatoform Disorders
• Epidemiology of Somatoform Disorders
• Etiology of Somatoform Disorders
• Nursing Management of somatoform
disorder
 Introduction

Anxiety exerts a powerful influence on the lives of individuals.

People vary in their ability to cope with anxiety. Some cope successfully,
other cope dysfunctional. One of maladaptive way to cope with anxiety is
somatoform disorders. Somatoform disorders encompass several mental
health disorders in which individual report physical symptoms or concerns are
not explained by a physical disorder. These symptoms or concerns cause
significant distress or interfere with daily functioning. Group of disorders
demonstrate the interaction between mind and body, in which people have
subjective feelings of illness that are seemingly untreatable by medical means.
Common Characteristics of “Somatoform”
Somatic Symptom and Related Disorders
 Related terms

Primary gains: are benefits that being sick provides

such as relief of anxiety, conflict, or distress.

Secondary gains: are the personal benefits received

from others because one is sick such as attention
from family members and comfort measures (e.g.,
being brought tea, receiving a back rub ….…..).
Classifications of Somatoform
5 specific disorders“DSM iv”

1- Somatization disorder

2- Conversion disorder

3- Hypochondriasis

4- Pain disorder

5- Body dimorphic disorder

 1- Somatization disorder

 Chronic multiple physical complaints

for which medical attention is sought
but with no apparent medical cause.

 Common criteria includes

Pain in four different body sites or
involving four different body
functions
Tow gastrointestinal symptoms
One sexual symptom
One pseudo neurological symptoms.
Symptoms of somatization disorder

Gastrointestinal symptoms: Nausea, bloating, vomiting (other

than during pregnancy), diarrhea, or intolerance of several foods.

Sexual symptoms: Sexual indifference, erectile or ejaculatory

dysfunction, irregular menses, excessive menstrual bleeding.

Pseudo neurologic symptoms: Such as impaired coordination or

balance, weakness, difficulty swallowing or lump in throat,
urinary retention.
 The disorder requires a history of several
years duration beginning before age 30) and is
associated with significant psychological
distress, impairment in social and occupational
functioning.

 Patients have a tendency to seek relief

through over medicating with prescribed
analgesics or antianxiety agents. Drug abuse &
dependency are common complication.

 Now in DSM-V iS called Illness Anxiety

Disorder.
 It involves one or more neurological symptoms
2- Conversion “sensory” (numbness, blindness, deafness and
disorder: anaesthesia) or “motor” function (Such as
paralysis, a phonia, ataxia, Falling, and paresis)
that are not caused by neurological dysfunction.

The patient has no muscle atrophy and

electromyography findings are normal but
symptoms are associated with psychological
factors.
The patient is abnormally calm despite the
seriousness of symptoms (la belle indifference)
& lack of concern.
Clients with conversion disorder may be at risk
for disuse syndrome from having pseudo
neurologic paralysis symptoms. In other words,
if clients do not use a limb for a long time, the
muscles may weaken or atrophy from lack of
use.
- The patient learns the sick role that is
reinforced through social gratification.
The sick role then becomes a mean of
receiving attention from others.

- Easily suggestibility “(placebo effect) ”.

- The symptoms are unconsciously

produced to alleviate the anxiety caused
by the stress and to gain sympathy,
attention, or relief from responsibility.

- It was previously called Hysteria. And

now in DSM-V is called “ Functional
Neurologic Symptom Disorder”.

- Stress may make the symptoms worse.

3- Hypochondriasis
Hypochondriasis represents an
underlying depressive disorder,
generalized anxiety disorder or
obsessive compulsive disorder.

Clients do not seek help from

mental health professionals.

Now in DSM-V called “Somatic

Symptom Disorder”
4- Pain disorder  The primary symptom of pain disorder is the
presence of pain in one site that cannot be
explained by medical or neurological tests, e.g.
low back pain, headache, facial pain, chronic
pelvic pain, pain in the abdomen, joints, chest,
rectum; pain during urination, menstruation,
or sexual intercourse.

 Primary physical symptom of pain, which is

generally unrelieved by analgesics and is
generally affected by psychological factors in
terms of onset, severity, exacerbation, and
maintenance.

 If medical cause is present, psychological

factors have a major role in mediating the
expression and impact of pain.
5- Body dysmorphic disorder “ Dysmorphogia, Imagined ugliness”
 Related disorders

1- Malingering: “professional patients”

 It is the intentional production of false physical or

psychological symptoms

 It is motivated by external incentives such as avoiding

work, escaping from criminal punishment, insurance
payments, avoidance of jail term, obtaining financial
reward, or obtaining drugs.

 Malinger have no real physical symptoms. They can stop

the physical symptoms as soon as they have gained what
they wanted.
 2-Factitious disorder “Hospital Addiction, Hospital Hoboes”

 Characterized by physical symptoms that are feigned for

purpose of drawing attention to oneself and gaining the
emotional benefits of assuming the sick role.

 People with factitious disorder may even cause injury to

themselves to receive attention.
 The common term for factitious disorder is Munchausen’s
syndrome.

 Hospitalization is often a primary objective and a way of life

 Epidemiology of Somatoform Disorders

 Somatization disorder exists in 0.2% to 2% of the general

population.
 Conversion disorder occurs in less than 1% of the population.
 In general medical clinic populations, prevalence of
hypochondriasis is 4 to 6 %.
 Pain disorder is commonly seen in medical practice with 10% to
15% of people reporting work disability related to back pain
alone.
 Somatization disorder, conversion disorder, and pain disorder are
more common in women than in men; hypochondriasis and
body dysmorphic disorder are distributed equally by gender.
 Etiological factors of Somatoform Disorders”
 Freud propose that people can convert unexpressed emotions
into physical symptoms. Aggressive, sexual and hostile wishes
toward others are transferred into physical complaints (through
repression, conversion and displacement “past disappointments,
rejections, and losses”)
 Low thresholds and low tolerance of physical discomfort.
 Parental abuse or rejection.
 The symptoms may be caused by an excessive cortical arousal
 Deficiency in serotonin and endorphins lead the person to
perceive incoming pain stimuli as being more intense.
 Genetic theory: indicate that somatoform disorders run in families
 Behavioral theory suggest that somatoform disorders are learned
ways of communicating helplessnes. Through positive
reinforcement from families.
Management of somatoform disorder “Difficult patients”
Nursing process for patients with somatoform disorders
1- Assessment
Assess General appearance and motor behavior:
 Patients walk slowly or with an unusual gait because of the pain or
disability caused by the symptoms.

Assess 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.
Assessing the ability to communicate
emotional needs
---- patients have difficulty verbalizing
feeling, especially those related to anger,
guilt and dependence.

Assessing dependence on medication:

---- Individuals experiencing many
somatic complaints often become
dependent on medication to relieve pain
or anxiety or to induced sleep.
Nursing diagnosis for clients with somatoform disorders
 Points to Consider When Working With Clients with
Somatoform Disorders.

 A trusting relationship will help to ensure that clients stay with

and receive care from one provider instead of “doctor
shopping.”
 Avoid describing the physical symptoms as "in the client's
head“ “Do not arguing”.
 Nurses caring for clients with somatoform disorders must show
patience and understanding and should expect patient
resistance
 Nurses must remember that these clients really experience the
symptoms they describe and cannot voluntarily control them.
 Focus on patients’ strengths.
 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.”
 Nursing intervention A- Patient Health teaching
 Establish a daily routine to improve healthy behaviors (eating
more nutritious foods, getting up and dressed at a certain time
every morning, and setting a regular bedtime).
 Promote adequate nutrition and sleep.
 Expression of emotional feelings, life events, and stressors.
 Recognize relationship between stress/coping and physical
symptoms.
 Keep a journal.
 Limit time spent on physical complaints.
 psycho-pharmaco education related to any prescribed
psychotropic medication.
 Teach patients Coping strategies
Coping strategies
 2- Problem-focused coping strategies:

 Include learning problem-solving methods which

help to resolve or change a client’s behavior or situation
such as problem-solving techniques and role-playing.

 Identify the problem, examine alternatives,

weigh the pros and cons of each alternative,

select and implement an approach, and evaluate
its success),
 Apply role-playing in interactions with others.
 B- Family teaching:

 Explain to the family about primary and secondary gains.

 The nurse can encourage the family to stop reinforcing the
sick role.
For example, The family provide attention to patients when
they are feeling better or fulfilling responsibilities, patient isn’t
more likely to continue doing so.
 Family members have covered attention on patient when
they have physical complaints,
 Specific nursing intervention
S&S :physical complaint -Absence of pathophysiology -Focus on self

Nursing Diagnosis: Ineffective coping

Nursing Actions
- Accept that the symptoms is real to the client.
- Fulfill client's needs.
- Do not give positive reinforcement to symptoms.
- Teach adaptive coping strategies.

Outcomes
- Client recognizes signs of escalating anxiety.
- Client is able to intervene before the exacerbation of physical
symptoms.
 S&S: Preoccupation with symptoms of pain.

Nursing Diagnosis: Chronic Pain

Nursing Actions
- Accept that pain is real to the client.
- Provide comfort measures.
- Distract clients with activities.
- Identify adaptive coping strategies.

Outcomes
- Client connects pain to onset of anxiety.
- Client is able to cope adaptively without experiencing pain.
 S&S: Preoccupation with illness.

Nursing Diagnosis: Fear (of having a serious disease)

Nursing Actions
- Refer all new physical complaints to physician.
- Limit amount of time client discusses symptoms.
- Encourage verbalization of fears associated with illness.

Outcomes
-Fear of serious illness has diminished.
-Client uses adaptive coping mechanisms
.
 S&S:-Repressed severe anxiety.

Nursing Actions
- Assess level of disability .
- Encourage performance at level of ability.
- Assist client as required with self-care deficit.
- Give positive reinforcement for independent performance.

Outcomes
- Performs self-care independently.
- Demonstrate more adaptive coping strategies.
- Discuss feeling associated with the stressful event.
 Evaluation:

 The client identify the relationship between stress and

physical symptoms.

 The client verbally express emotional feelings.

 The client demonstrate alternative ways to deal with stress,
anxiety, and other feelings without resorting to physical
symptoms.

 The client demonstrate healthier behaviors regarding rest,

activity, and nutritional intake.