Somatoform Disorders
Introduction
Somatoform disorders
Somatoform disorders are a group of psychiatric disturbances that
includes conditions characterized by physical symptoms that may
resemble other medical conditions, but the symptoms have no
identifiable anatomical or physiological cause.
Somatoform Disorders
• Have you ever "played sick" in order to get out of something?
How did that work out (did you get what you wanted)?-
Sick -> attention (friends, family, medical)= secondary gains
• Likely link between secondary gains and somatoform disorders-
• Some medical condition may actually exist
Type Of Somatoform Disorders
• Somatization Disorder Repeated concern with a variety of bodily complaints in the absence
of a medical reason
• Conversion Disorder An expression of psychological conflict or need that involves an
alteration or loss of physical functioning that suggests a bodily causes in the absence of a
medical reason
• Hypochondriasis* Preoccupation with having or contracting a serious disease in the absence
of a medical reason
• Body Dysmorphic Disorder Preoccupation with an imagined defect in appearance of a
normal-appearing person
• Pain Disorder Preoccupation with pain in the absence of an adequate physical basis for it
Somatization Disorder
Somatization disorder is an illness of multiple somatic complaints in
multiple organ systems that occurs over a period of several years and
results in significant impairments or treatment seeking, or both
Incidence
• Lifetime prevalence:
0.2 - 2% in women
less than 0.2% in men
Etiology
Psychosocial Factors
• The cause is unknown.
• Interpretations of the symptoms as social communication whose result
is to avoid obligations (e.g., going to a job a person does not like), to
express emotions (e.g., anger at a spouse), or to symbolize a feeling or
a belief(e.g., a pain in the gut).
Biological Factors
• Patients have characteristic attention and cognitive impairments that
result in the faulty perception and assessment of somatosensory inputs
Etiology
Genetics
• Occurs in 10 to 20 percent of the first-degree female, first-degree male
relatives are susceptible to substance abuse and antisocial personality
disorder.29 percent in monozygotic twins and 10percent in dizygotic twins.
Cytokines"
• Cytokines are messenger molecules that the immune system uses to
communicate within itself and with the nervous system, including the
brain.
• The abnormal regulation of the cytokine system may result in some of the
symptoms seen in somatoform disorders.
Diagnosis
• A history of many physical complaints beginning before age 30 years that occur
over a period of several years and result in treatment being sought or significant
impairments in social, occupational, or other importance areas of functioning
• Each of the following criteria must have been met, with individual symptoms
occurring at any time during the course of the disturbance:
Four pain symptoms: a history of pain related to at least four different sites or
functions
Two gastrointestinal symptoms: a history of at least two gastrointestinal
symptomsOther than pain
Diagnosis
one sexual symptom: a history of at least one sexual or reproductive
symptom other than pain
one pseudoneurological symptom: a history of at least one symptom or
deficit suggesting a neurological condition not limited to pain(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, seizures; dissociative symptoms)
Clinical Features
• Patients with somatization disorder have many somatic complaints and
long, complicated medical histories.
• Nausea and vomiting (other than during pregnancy ), difficulty
swallowing, pain in the arms and legs, shortness of breath unrelated to
exertion, amnesia, and complications of pregnancy and menstruation are
among the most common symptoms .
• Patients frequently believe that they have been sickly most of their lives.
• Psychological distress and interpersonal problems are prominent;
anxiety and depression are the most prevalent psychiatric conditions.-
• Suicide threats are common, but actual suicidal is rare
Clinical Features
• Somatization disorder is commonly associated with other mental
disorders, including major depressive disorder, personality disorders,
substance-related disorder’s , generalized anxiety disorder, and
phobias . The combination of these disorders and the chronic
symptoms results in an increased incidence of marital, occupational,
and social problems
Course and Prognosis
• Somatization disorder is a chronic and relapsing disorder that rarely
remits completely.
• It is unusual for the individual with somatization disorder to be free
of symptoms for greater than1 year, during which time they may see a
doctor several times.
• Research has indicated that a person diagnosed with somatization
disorder has approximately an80 percent chance of being diagnosed
with this disorder 5 years later
Treatment
• Somatization disorder is best treated when the patient has a single
identified physician as primary caretaker, When more than one
clinician is involved, patients have increased opportunities to express
somatic complaints.Psychotherapy, both individual and group therapy
Conversion Disorder
• Conversion disorder is an illness of symptoms or deficits that affect
voluntary motor or sensory functions, which suggest another medical
condition, but that is judged to be caused by psychological factors because
the illness is preceded by conflicts or other stressors.
Incidence
• Highly prevalent Female
• Predominance
• Young age
• Rural and low social class
• Little-educated and psychologically unsophisticated
Etiology
Psychoanalytic Factors
• Caused by repression of unconscious intra-psychic-conflict and conversion
of anxiety into a physical symptom.
• Learning Theory
Conversion symptom can be seen as a piece of classically conditioned
learned behavior; symptoms of illness, learned in childhood, are called
forth as a means of coping with an otherwise impossible situation.
Biological Factors
• Increasing data implicate biological and neuropsychological factors in the
development of conversion disorder symptoms
Clinical Features
• Paralysis, blindness, and mutism are the most common conversion
disorder symptoms.
• Conversion disorder may be most commonly associated with passive-
aggressive, dependent, antisocial , and histrionic personality
disorders.
• Depressive and anxiety disorder symptoms often accompany the
symptoms of conversion disorder, and affected patients are at risk for
suicide.
Symptoms
Motor Symptoms Sensory Deficits
Involuntary movements Anesthesia, especially of extremities
Tics Blindness
Torticollis Tunnel vision
Seizures Deafness
Abnormal gait
Falling Visceral Symptoms
Paralysis Psychogenic vomiting
Weakness Urinary retention
Aphonia Diarrhea
Diagnosis
• One or more symptoms or deficits affecting voluntary motor or
sensory function that suggests a neurological or other general medical
condition.
• Psychological factors are judged to be associated with the symptom
or deficit because the initiation or exacerbation of the symptoms or
deficit is preceded by conflicts or other stressors.
• The symptom or deficit is not intentionally produced .
Diagnosis
• The symptom or deficit cannot, after appropriate investigation, be
fully explained by a general medical condition, or by the direct effects
of a substance, or as a culturally sanctioned behavior or experience.
• The symptom or deficit causes clinically significant distress or
impairment in social, occupational , or other important areas of
functioning or warrants medical evaluation.
• The symptom or deficit is not limited to pain or sexual dysfunction,
does not occur exclusively during the course of somatization disorder,
and is not better accounted for by another mental disorder.
Course and Prognosis
• Symptoms or deficits are usually of short duration, and approximately
95percent of acute cases remit spontaneously, usually within 2 weeks
in hospitalized patients .
Treatment
• Insight-oriented supportive or behavior therapy.Hypnosis, anxiolytics,
and behavioral relaxation exercises are effective in some cases.
Hypochondriasis
Hypochondriasis is characterized by 6 months or more of a general and non delusions
preoccupation with fears of having, or the idea that one has, a serious disease based on
the person'smisinterpretation of bodily symptoms.
Epidemiology
• Men and women are equally affected by hypochondriasis.
• Onset of symptoms can occur at any age, the disorder most commonly appears in
persons 20 to 30 years of age.
Learning theory-
Sick role made by a person facing seemingly insolvable problems." The sick role offers an
escape that allows a patient to avoid obligations, to postpone unwelcome challenges, and
to be excused from usual duties.
Clinical Features
• Patients with hypochondriasis believe that they have a serious
disease that has not yet been detected.
• They may maintain a belief that they have a particular disease or, as
time progresses, they may transfer their belief to another disease.
• Their convictions persist despite negative laboratory results.“
• Hypochondriasis is often accompanied by symptoms of depression
and anxiety and commonly coexists with a depressive or anxiety
disorder.
Diagnosis
• Preoccupation with fears of having, or the idea that one has, a
serious disease based on the person's misinterpretation of bodily
symptoms,
• The preoccupation persists despite appropriate medical evaluation
and reassurance.
• The belief in Criterion A is not of delusional intensity (as in delusional
disorder, somatic type)and is not restricted to a circumscribed
concern about appearance (as in body dysmorphic disorder).
• The preoccupation causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
• The duration of the disturbance is at least 6months.
• The preoccupation is not better accounted forby generalized anxiety
disorder, obsessive-compulsive disorder, panic disorder, a major
depressive episode, separation anxiety, or another somatoform
disorder.
Course and Prognosis
• The course of hypochondriasis is usually episodic ; the episodes last
from months to years and are separated by equally long quiescent
periods.
• A good prognosis is associated with high socioeconomic status,
treatment-responsive anxiety or depression, sudden onset of
symptoms, the absence of a personality disorder, and the absence of
a related non psychiatric medical condition.
• Most children with hypochondriasis recover by late adolescence or
early adulthood
Treatment
• Patients with hypochondriasis usually resist psychiatric treatment.
• Group psychotherapy often benefits such patients, in part because it
provides the social support and social interaction that seem to reduce their
anxiety.
• Other forms of psychotherapy, such as individuals insight-oriented
psychotherapy.behavior therapy, cognitive therapy, and hypnosis may be
useful.
Pharmacotherapy alleviates
Hypochondriacal symptoms only when a patient has an underlying drug
responsive condition, such as an anxiety disorder or major depressive disorder
Body Dysmorphic Disorder
Body dysmorphic disorder is characterized by a preoccupation with an
imagined defect in appearance that causes clinically significant distress
or impairment in important areas of functioning.
Epidemiology
• Most common age of onset is between 15and 30 years
• Women are affected more often than men."
• Affected patients are also likely to be unmarried.
• Body dysmorphic disorder commonly coexists with other mental
disorders
Etiology
• The cause of body dysmorphic disorder is unknown .
• Some patients, the pathophysiology of the disorder may involve
serotonin and may be related to other mental disorders,
• Stereotyped concepts of beauty emphasized in certain families and
within the culture at large may significantly affect patients with body
dysmorphic disorder.
• In psychodynamic models, body dysmorphic disorder is seen as
reflecting the displacement of a sexual or emotional conflict onto a
non related body part.
Clinical Features
• The most common concerns involve facial flaws , particularly those
involving specific parts.
• Common associated symptoms include ideas of delusions of reference ,
either excessive mirror checking or avoidance of reflective surfaces, and
attempts to hide the presumed deformity (with makeup or clothing).
suicide.
• The effects on a person's life can be significant ; almost all affected patients
avoid social and occupational exposure.
• As many as one third of the patients may be housebound because of worry
about being ridiculed for the alleged deformities, and approximately one
fifth attempt suicide.
Diagnosis
• Preoccupation with an imagined defect in appearance. If a slight
physical anomaly is present, the person's concern is markedly
excessive.
• The preoccupation causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.- The
preoccupation is not better accounted for by another mental disorder
(e.g., dissatisfaction with body shape and size in anorexia nervosa).
Treatment
• Treatment of patients with body dysmorphic disorder with surgical,
dermatological, dental, and other medical procedures to address the
alleged defects is almost invariably unsuccessful.
Antidepressents
Tricyclic drugs, monoamine oxidase inhibitors (MAOIs), SSRIhave
reportedly been useful.
Pain Disorder
• A pain disorder is characterized by the presence of, and focus on, pain
in one or more body sites and is sufficiently severe to come to clinical
attention.
Epidemiology
• The prevalence of pain disorder appears to be common.
• Recent work indicates that the 6-month and lifetime prevalence is
approximately 5percent and 12 percent, respectively.
Etiology
Psychodynamic Factors
Patients who experience bodily aches and pains without identifiable and adequate
physical causes may be symbolically expressing an intra-psychic conflict through the
body.
Behavioral Factors Pain behaviors are reinforced when rewarded and are inhibited
when ignored or punished .
Interpersonal Factors
Means for manipulation and gaining advantage in interpersonal relationships.
Such secondary gain is most important to patients with pain disorder.
Biological Factors
Serotonin and endorphins play a role in pain disorders.
Diagnosis
• Pain in one or more anatomical sites is the predominant focus of the
clinical presentation and is of sufficient severity 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 have an important role in the
onset, severity, exacerbation, or maintenance of the pain.- The
symptom or deficit is not intentionally produced or feigned (as in
fictitious disorders or malingering).
Clinical Features
• Low back pain, headache, atypical facial pain , chronic pelvic pain, and
other kinds of pain .
• Patients with pain disorder often have long histories of medical and
surgical care.
• Patients often deny any other sources of emotional dysphoria and
insist that their lives are blissful except for their pain.
• Their clinical picture can be complicated by substance-related
disorders, because these patients attempt to reduce the pain through
the use of alcohol and other substances.
Course and Prognosis
• The pain in pain disorder generally begins abruptly and increases in
severity for a few weeks or months.
• The prognosis varies, although pain disorder can often be chronic,
distressful, and completely disabling.
Treatment
Pharmacotherapy
• Analgesic medications do not generally benefit most patients with pain
disorder.
• Sedatives and anti anxiety agents are note specially beneficial and are
also subject to abuse , misuse, and adverse effects
• Antidepressants, such as tricyclics and SSRIs, are the most effective
pharmacological agents
Psychotherapy
• Some outcome data indicate that psychodynamic psychotherapy benefits
patients with pain disorder.
Nursing Management of Somatoform
Disorders
• Nursing Assessment • Mood and affect. Mood is often labile,
The nurse must investigate physical health shifting from seeming depressed and sad
status thoroughly to ensure there is no when describing physical problems to looking
underlying pathology requiring treatment. bright and excited when talking about how
they had to go to the hospital in the middle of
• History. Clients usually provide a lengthy and the night by ambulance.
detailed account of previous physical problems, • Thought process and content.Clients who
numerous diagnostic tests, and perhaps even a somatize do not experience disordered thought
number of surgical procedures. processes; the content of their thinking is
• General appearance and motor primarily about often exaggerated physical
behavior. Often, clients walk slowly or with an concerns, for example, when they have a
unusual gait because of the pain or disability simple cold they may be convinced it
caused by the symptoms; they may exhibit a is pneumonia.
facial expression of discomfort or physical
distress.
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.
Prevention
Little is known about how to prevent somatic symptom disorder. However, these
recommendations may help.
• If you have problems with anxiety or depression, seek professional help as
soon as possible.
• Learn to recognize when you're stressed and how this affects your body —
and regularly practice stress management and relaxation techniques.
• If you think you have somatic symptom disorder, get treatment early to help
stop symptoms from getting worse and impairing your quality of life.
• Stick with your treatment plan to help prevent relapses or worsening of
symptoms.
