NCP Somatoform Disorders

SOMATOFORM DISORDERS

DSM-IV

300.81 Somatization disorder
300.11 Conversion disorder
300.7 Hypochondriasis
300.7 Body dysmorphic disorder
307.xx Pain disorder
307.80 Associated with psychological factors
307.89 Associated with both psychological factors and a general medical condition
300.82 Undifferentiated somatoform disorder
300.82 Somatoform disorder NOS

Somatization refers to all those mechanisms by which anxiety is translated into physical illness or bodily complaints. The expression of physical symptoms suggests the presence of physiological disorder, but there are no demonstrable organic findings/known pathological mechanisms, or the symptoms are not fully explained by any physical disorder. That is, the symptoms are in excess of what would be expected from the history, physical examination, or laboratory findings. There does exist, however, positive evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts. These disorders are more common in women than in men, with somatization disorder rare in men.

ETIOLOGICAL THEORIES

Psychodynamics

This disorder may represent an unconscious transformation of internal conflicts into physical symptoms that can be explained in terms of the ego’s ability to control the sensory and motor apparatus, which may have specific meaning for the client.

Dependency is common in individuals with somatoform disorders, and fixation in an earlier level of development may be evident. Repression is the primary defense mechanism, as severe anxiety is repressed and manifested by the presence of physical symptoms.

Biological

Although biological and neurophysiological influences in the etiology of anxiety have been investigated, no relationship has yet been established. However, there does seem to be a genetic influence with a high family incidence.

The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety. These manifestations of anxiety may be related to physiological abnormalities.

Family Dynamics

The family contributes to these conditions by initiating, reinforcing, and perpetuating the behavior patterns. The children learn (overtly or covertly) that physical complaints are acceptable ways of coping with stress and obtaining attention, care, and gratification of dependency needs. The client may gain attention and meet these needs by overdramatization of the symptoms, resulting in overinvolvement of other family members in enmeshed behavior patterns. In the beginning, the client may exaggerate minor symptoms to prove she or he is really ill when others ignore reports of illness.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Fatigue

General weakness

Circulation

Heart rate may be elevated if symptoms mimic those of cardiopulmonary disease (similar to those experienced during panic attack)

Ego Integrity

Preoccupation with imagined defect in appearance or markedly excessive concern with slight physical anomaly not better accounted for by another mental disorder (e.g., dissatisfaction with body shape/size in anorexia nervosa [body dysmorphic disorder])

Evidence of severe psychological stress preceding onset/exacerbation of the physical symptoms (e.g., death of a loved one [conversion])

Preoccupation with fear of having a serious disease (hypochondriasis)

Use of denial; evidence that presence of the symptoms alleviates or promotes avoidance of the psychological conflict

Feelings of anger, helplessness, powerlessness

Report of issues suggesting unconscious secondary gain (e.g., attention of others, financial reimbursement, change in role expectations/responsibilities)

Elimination

Urinary retention

Constipation, diarrhea

Food/Fluid

Two or more GI symptoms (e.g., nausea, vomiting, bloating, intolerance of several different foods, difficulty swallowing [somatization])

Changes in eating patterns (loss of appetite/excessive intake)

Weight loss/gain

Hygiene

May neglect and/or report inability to perform basic ADLs

Excessive concern/preoccupation with/or more imagined defects in appearance (body dysmorphic disorder)

Neurosensory

Mental Status Exam:

  Fearfulness; preoccupation with belief of having serious disease; anxiety (symptoms associated with moderate to severe level) or la belle indifférence (lack of concern about loss of physical functioning)

  Depressed mood

  Amnesia

  Communication patterns: ruminating about physical symptoms

May display loss of consciousness other than fainting (somatization)

Apparent loss of or alteration in voluntary motor or sensory functioning that suggests neurological disease (e.g., blindness, double vision, deafness, paralysis, anosmia, aphonia, episodic seizure activity, and coordination disturbances [especially common in conversion disorder])

Pain/Discomfort

Pain in 1 or more anatomical sites of at least 6 months’ duration and of sufficient severity to warrant clinical attention (pain disorder); involving 4 different sites of function (e.g., head, abdomen, back, joints, chest, during urination/menstruation/sexual intercourse [somatization])

Excessive use of analgesics with minimal relief of pain

Respiration

Respiratory rate may be increased

Shortness of breath without exertion

Safety

May report suicidal ideations, inability to continue in current situation

Social Interactions

Observed/reported impairment in social, occupational, or other areas of functioning

Acute withdrawal from life activities, fear of being seen/scrutinized by others in public setting (body dysmorphic disorder)

Sexuality

One or more sexual/reproductive symptoms other than pain, e.g., decreased libido/sexual indifference, irregular menses/excessive menstrual bleeding, erectile/ejaculatory difficulties, pseudocyesis (false pregnancy), somatization

Teaching/Learning

Reports of physical symptoms of several years’ duration beginning before the age of 30 (somatization)

History of a past experience with true serious organic disease, in self or close family member (hypochondriasis)

History of frequent visits to physicians (doctor shopping) to obtain relief/requests for surgery despite medical reassurance of absence of organic pathology or need for plastic surgery (e.g., facelift, liposuction)

Failure to improve despite multiple approaches/therapies

Expression of anger and frustration toward physicians for “inability to determine cause of physical symptoms”

DIAGNOSTIC STUDIES

Virtually any diagnostic procedure (including exploratory surgery) may be performed as deemed appropriate to rule out organic pathology in light of the physical symptom(s) presented by the client.

Urine and/or Serum Toxicology Screen: Determines evidence of substance use/abuse

NURSING PRIORITIES

1. Alleviate or minimize physical symptoms/chronic pain.
2. Promote client safety.
3. Resolve potentially dysfunctional areas of client/family dynamics.
4. Promote independence in self-care activities.
5. Provide information and support for lifestyle changes.

DISCHARGE GOALS

1. Relief obtained from admitting physical symptom(s).
2. Client/family recognizes relationship between psychological stressors and onset/exacerbation of physical symptoms(s).
3. Stress management techniques used appropriately to prevent the occurrence/exacerbation of the physical symptom(s).
4. Level of function/independence increased.
5. Plan in place to meet needs after discharge.