Somatoform Disorders

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Somatoform Disorders Nursing Care Management (FT)

Somatoform disorders are characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them. Learn about the nursing management for somatoform disorders in this nursing care plan guide.

Types of Somatoform Disorders

  • Somatization disorder. Somatization disorder is a chronic syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from health-care professionals.
  • Pain disorder. The essential feature of pain disorder is severe and prolonged pain that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Hypochondriasis. Hypochondriasis is an unrealistic preoccupation with the fear of having a serious illness.
  • Conversion disorder. Conversion disorder is a loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism.
  • Body dysmorphic disorder. This disorder, formerly called dysmorphophobia, is characterized by the exaggerated belief that the body is deformed or defective in some specific way.

Pathophysiology

The pathophysiology of somatoform disorders is unknown.

  • Primary somatoform disorders may be associated with a heightened awareness of normal bodily sensations.
  • This heightened awareness may be paired with a cognitive bias to interpret any physical symptom as indicative of medical illness.
  • Autonomic arousal may be high in some patients with somatoform disorders.
  • This autonomic arousal may be associated with physiologic effects of endogenous noradrenergic compounds such as tachycardia or gastric hypermotility.
  • Heightened arousal also may induce muscle tension and pain associated with muscular hyperactivity, as is seen with muscle tension headaches.

Statistics and Incidences

Prevalence rates for the most restrictive previous diagnosis of somatoform disorder appear low in community samples (0.1%).

  • One review estimates that the prevalence of somatoform disorder in the general population is approximately 5%-7%.
  • A study in Belgium reported that somatoform disorder is the third highest psychiatric disorder, with a prevalence rate of 8.9%
  • Females tend to present with somatoform disorder more frequently than males, with an estimated F:M ratio of 10:1.
  • Somatoform disorders may begin in childhood, adolescence, or early adulthood

Causes of Somatoform Disorders

Predisposing factors to somatoform disorders include:

  • Genetic. Studies have shown an increased incidence of somatization disorder, conversion disorder, and hypochondriasis in first-degree relatives, implying a possible inheritable disposition.
  • Biochemical. Decreased levels of serotonin and endorphins may play a role in the etiology of pain disorder.
  • Psychodynamic. Some psychodynamics view hypochondriasis as an ego defense mechanism; the psychodynamic theory of conversion disorder proposes that emotions associated with a traumatic event that the individual cannot express because of moral or ethical unacceptability are “converted” into physical symptoms.
  • Family dynamics. Some families have difficulty expressing emotions openly and resolving conflicts verbally; when this occurs, the child may become ill, and a shift in focus is made  from the open conflict to the child’s illness, leaving unresolved the underlying issues that the family cannot confront openly.
  • Sociocultural/familial factors. Somatic complaints are often reinforced when the sick role relieves the individual from the need to deal with a stressful situation, whether it be within the society or within the family.
  • Past experience with physical illness. Personal experience, or the experience of close family members with serious or life-threatening illness can predispose an individual  to hypochondriasis.
  • Cultural and environmental factors. Some cultures and religions carry implicit sanctions against verbalizing or directly expressing emotional states, thereby indirectly encouraging “more acceptable” somatic behaviors.

Clinical Manifestations

Symptoms of somatoform disorder include:

  • Pain symptoms. Complaints of headache, pain in the abdomen, head, joints, back, chest, rectum; pain during urination, menstruation, or sexual intercourse.
  • Gastrointestinal symptoms. There is 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, and vomiting through pregnancy.
  • Pseudoneurologic symptoms. Conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, and seizures.

Assessment and Diagnostic Findings

If indicated, specific studies used to rule out somatization due to general medical conditions include the following:

  • Thyroid function studies. Thyroid stimulating hormone (TSH) at 0.4-10 mIU/L and thyroxine at 5.0-12.5 ng/dL.
  • Pheochromocytoma screen. Urine catecholamines, homovanillic acid (HVA) 2-12 mg per 24 hours, vanillylmandelic acid (VMA) 2-7 mg per 24 hours, metanephrines less than 1.6 mg per 24 hours, and norepinephrine plus epinephrine less than 100 mcg per 24 hours.
  • Urine drug screen. Including cannabis, amphetamine, hallucinogens, cocaine, opioids, and benzodiazepines.
  • Blood studies. To screen for occult alcoholism.
  • Psychological testing. Minnesota Multiphasic Personality Inventory (MMPI) may provide insight into the likelihood of a somatic symptom disorder.

Medical Management of Somatoform Disorders

Randomized trials have demonstrated the value of physician education in the management of the patient with somatoform disorder.

  • Cognitive-behavioral psychotherapy. Cognitive-behavioral psychotherapy strategies may be specifically helpful in reducing distress and high medical use.
  • Psychosocial therapies. Psychosocial interventions directed by phsyicians form the basis for successful treatment; a strong relationship between the patient and the primary care physician can assist in long-term management.
  • Psychoeducation. Psychoeducation can be helpful by letting the patient know that physical symptoms may be exacerbated by anxiety or other emotional problems; however, be careful because patients are likely to resist suggestions that their condition is due to emotional rather than physical problems.

Pharmacologic Management

Based on studies of somatoform disorder, medication approaches rarely are successful for this condition.

  • Antidepressants. SSRIs are greatly preferred over the other classes of antidepressants; because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted.

Nursing Management of Somatoform Disorders

Nursing management of a patient with somatoform disorders include the following:

Nursing Assessment

The nurse must investigate physical health status thoroughly to ensure there is no underlying pathology requiring treatment.

  • History. Clients usually provide a lengthy and detailed account of previous physical problems, numerous diagnostic tests, and perhaps even a number of surgical procedures.
  • General appearance and motor behavior. 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.
  • 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.

Nursing Diagnosis for Somatoform Disorders

Based on the assessment data, the major nursing diagnosis are:

  • Chronic pain related to severe level of anxiety, repressed.
  • Ineffective coping related to inadequate coping skills.
  • Disturbed body image related to low self-esteem, severe level of anxiety.
  • Disturbed sensory perception related to regression to, or fixation in, an earlier level of development.
  • Self-care deficit related to paralysis of body part, pain, discomfort.
  • Deficient knowledge related to lack of interest in learning, severe anxiety.

Nursing Care Planning and Goals

The major nursing care plan goals for patients with somatoform disorders are:

  • The client will identify the relationship between stress and physical symptoms.
  • The 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.

Nursing Interventions

The nursing interventions for somatoform disorders are:

  • Providing health teaching. The nurse must help the client establish a daily routine that includes improved health behaviors.
  • Assisting the client to express emotions. 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. Emotion-focused strategies include progressive relaxation, deep breathing, guided imagery, and distractions such as music or other activities; problem-focused coping strategies include problem-solving methods, applying the process to identified problems, and role-playing interactions with others.

Evaluation

Treatment outcomes include:

  • The client was able to identify the relationship between stress and physical symptoms.
  • The client was able to verbally express emotional feelings.
  • The client was able to follow an established daily routine.
  • The client was able to demonstrate alternative ways to deal with stress, anxiety, and other feelings.
  • The client was able to demonstrate healthier behaviors regarding rest, activity, and nutritional intake.

Documentation Guidelines

Documentation in a client with somatoform disorders include the following:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward the desired outcome.

Practice Quiz: Somatoform Disorders

Nursing practice questions for Somatoform Disorders from our nursing test bank. For more practice questions, visit our NCLEX practice questions page.

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1. During a community visit, volunteer nurses teach stress management to the participants. The nurses will most likely advocate which belief as a method of coping with stressful life events?

A. Avoidance of stress is an important goal for living.
B. Control over one’s response to stress is possible.
C. Most people have no control over their level of stress.
D. Significant others are important to provide care and concern.

1. Answer: B. Control over one’s response to stress is possible.

  • Option B: When learning to manage stress, clients find it helpful to believe that they have the ability to control their response to it. It is impossible to avoid stress, which is a normal life experience.
  • Option A: Stress can be positive and growth-enhancing as well as harmful.
  • Option C: The belief that one has some control is the significant factor in minimizing stress response.

2. The nurse evaluates the treatment of Mrs. Montez with somatoform disorder as successful if:

A. Mrs. Montez practices self-medication rather than changing health care providers.
B. Mrs. Montez recognizes that physical symptoms increase anxiety level.
C. Mrs. Montez researches treatment protocols for various illnesses.
D. Mrs. Montez verbalizes anxiety directly rather than displacing it.

2. Answer: D. Mrs. Montez verbalizes anxiety directly rather than displacing it.

  • Option D: Mrs. Montez with somatoform disorder unconsciously displaces anxiety onto physical symptoms. The ability to recognize and verbalize anxious feelings directly rather than displacing them is a criterion of treatment success.
  • Options A & C: These may indicate the continuation of the problem.

3. David is preoccupied with numerous bodily complaints even after a careful diagnostic workup reveals no physiologic problems. Which nursing intervention would be therapeutic for him?

A. Acknowledge that the complaints are real to the client, and refocus the client on other concerns and problems.
B. Challenge the physical complaints by confronting the client with the normal diagnostic findings.
C. Ignore the client’s complaints, but request that the client keeps a list of all symptoms.
D. Listen to the client’s complaints carefully, and question him about specific symptoms.

3. Answer: A. Acknowledge that the complaints are real to the client, and refocus the client on other concerns and problems.

  • Option A: After physical factors are ruled out, somatic complaints are thought to be expressions of anxiety.
  • Option B: The complaints are real to the client, but the nurse should not focus on them.
  • Options C & D: Prompting the client about other concerns will encourage the expression of anxiety and dependency needs.

4. Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders?

A. Conversion disorder.
B. Depersonalization.
C. Hypochondriasis.
D. Somatization disorder.

4. Answer: C. Hypochondriasis.

  • Option C: Hypochondriasis, in this case, is shown by the client’s belief that she has a serious illness, although pathologic causes have been eliminated. The disturbance usually lasts at least 6 with identifiable life stressor such as, in this case, course examinations.
  • Option A: Conversion disorders are characterized by one or more neurologic symptoms.
  • Option B: Depersonalization refers to persistent recurrent episodes of feeling detached from one’s self or body.
  • Option D: Somatoform disorders generally have a chronic course with few remissions.

5. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statement refers to a secondary gain?

A. It brings some stability to the family.
B. It decreases the preoccupation with the physical illness.
C. It enables the client to avoid some unpleasant activity.
D. It promotes emotional support or attention for the client.

5. Answer: D. It promotes emotional support or attention for the client.

  • Option D: Secondary gain refers to the benefits of the illness that allow the client to receive emotional support or attention.
  • Option C: Primary gain enables the client to avoid some unpleasant activity.
  • Option A: A dysfunctional family may disregard the real issue, although some conflict is relieved.
  • Option B: Somatoform pain disorder is a preoccupation with pain in the absence of physical disease.

References and Sources

Interesting resources for further reading about somatoform disorders:

  • Boyd, M. A. (Ed.). (2008). Psychiatric nursing: Contemporary practice. lippincott Williams & wilkins.
  • Escalada-Hernández, P., Muñoz-Hermoso, P., González–Fraile, E., Santos, B., González-Vargas, J. A., Feria-Raposo, I., … & CUISAM GROUP. (2015). A retrospective study of nursing diagnoses, outcomes, and interventions for patients with mental disorders. Applied Nursing Research28(2), 92-98. [Link]
  • Keltner, N. L. (2013). Psychiatric nursing. Elsevier Health Sciences.
  • Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins.

As the nurse interviews Matthew, she notices that he is calm and speaks of his inability to see in a matter-of-fact manner, demonstrating no distress at his blindness. Matthew seems to have the usual interests of a 13-year old, describing his activities at school and with his friends. However, the nurse finds that Matthew has little to say about his parents, his younger brother, or activities at home.

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