Somatic Symptoms and Related Disorders

What to know about somatic symptom disorder?

• Previously called somatoform disorder

• Complex somatic symptom disorder

  • Illness anxiety disorder

  • Conversion disorder (Functional neurologic symptom disorder)

  • Factitious disorder 

    • Factitious disorder imposed on another (previously Münchausen’s by proxy)

What is psychosomatic?

• Used to describe, explain, and predict the psychological origins of illness and disease (it’s all in your head).

• These symptoms are actual physical symptoms, not imaginary

What is somatization?

• Manifestation of psychological distress as physical symptoms that may result in functional changes, or both.

• Historically linked to a woman’s body (uterus), mind, or soul.

• The term hysteria was used to describe a woman’s symptoms that had no apparent underlying cause

What is somatic symptoms disorder (SSD)?

• Symptoms changeable, diffuse and complex; variable, moving from one body system to another

• Being “sicker than the sick”; multiple visits to health care providers; “provider shop”; they avoid mental health providers

What is the diagnostic criteria for SSD?

• Many physical complaints for at least 6 months & excessive thoughts about the illness

• Causes significant disruption in one’s life

• Symptoms may or may not be supported by any physiological alterations  or medical evidence

What is the etiology of SSD?

• Biologic:

  • Biologic dysfunction common in depression and chronic fatigue syndrome

  • Genetic: Runs in families, first degree relative

• Psychological

  • Somatization as a form of social or emotional communication

  • Interaction of cognitive (negative views) with physical factors (pain, discomfort)

  • Personality trait of alexithymia

  • Difficulty expressing emotions

• Social: cultural expressions

What is included in teamwork and collaboration?

• Three approaches to care

  • Providing long-term general management of the chronic condition

  • Seeing same provider at every visit to establish a trusting relationship; conservatively treating comorbid psychiatric and physical problems; avoiding invasive procedures

  • Providing care in special settings: individual & group; complimentary medicine; cognitive behavioral therapy

  • Safety issues

What is included in the evidence-based mental health nursing care of the person with SSD?

• Mental Health Assessment

  • Review of systems

  • Pain (most common symptom)*

  • Physical functioning:

    • problems with sleep, fatigue, sexual functioning

  • Pharmacologic assessment

    • Use several drugs

    • Self-medicate and provider shop

• PSYCHOSOCIAL ASSESSMENT

  • Cognitive and behavioral responses

  • Self-concept

  • Stress and coping patterns

  • Social network

  • Family issues

• QUALITY OF LIFE

• STRENGTHS ASSESSMENT

What is included in clinical judgement?

• The physical issues dominate the individual’s concern and should not be dismissed.

• They may have a variety of health issues to discuss including:

  • Fatigue

  • Pain

  • Insomnia

  • Depression

  • Suicidal behavior

  • Social isolation

What is included in the therapeutic relationship?

• The most difficult but most crucial is developing a sound, positive, nonjudgmental nurse–patient relationship

• Requires time and patience

• Therapeutic communication techniques

  • Used to refocus the patient on psychosocial problems related to the physical manifestations

• During periods when symptoms of other psychiatric disorders surface, additional interventions are needed

What are the mental health nursing interventions for SSD?

• ESTABLISHING RECOVERY and WELLNESS GOALS

• PHYSICAL HEALTH INTERVENTIONS

  • Pain management

  • Activity enhancement

  • Nutrition regulation

  • Relaxation

• WELLNESS CHALLENGES

• MEDICATION INTERVENTIONS

  • No specific medications recommended

    • Comorbid conditions treated as needed

    • Duloxetine (Cymbalta)

  • Administering and monitoring medications (SSRI’s) usually at higher doses than for depression.

  • Managing side effects

  • Management of complications

• PSYCHOSOCIAL INTERVENTIONS

  • Therapeutic interactions

  • Cognitive behavioral interventions***

  • Counseling

    • Psychoeducation***

      • Teaching about symptoms 

      • Wellness strategies

      • Social relationships

        • Family education***

• PROMPTING SAFETY

• GROUP INTERVENTIONS

• EVALUATION and TREATMENT OUTCOMES

• CONTINUUM of CARE

  • Emergency Care

  • Inpatient Care

  • Community Care

  • Virtual Mental Health Care

• INTEGRATION with PRIMARY CARE

What is illness anxiety disorder?

• Previously, the term hypochondriasis (or hypochondria) was used

• either do not have somatic symptoms or have only very mild symptoms, but who remain preoccupied with having or developing a medical illness

• Fear of having an illness continues despite medical reassurance and interferes with psychosocial functioning

• Sometimes appears if the person had had a serious childhood illness or if a family member has a serious illness

What is conversion disorder?

• Functional neurologic symptom disorder

• Neurologic symptoms and sensory problems but test result is negative; symptoms “real” for the patient

• Symptoms follow the person’s own perceived conceptualization of the problem

• Etiology: possible neurologic changes in the brain or childhood trauma

• Nursing management: acknowledgment of symptoms, development of trusting therapeutic relationship, development of problem-solving approaches

• Conversion disorder is a “psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms.”

• Impaired coordination, paralysis, inability to produce sound, lump in throat)

• These conditions are very real to the patient.

What is factitious disorder?

• FACTITIOUS DISORDER Formerly called Munchausen’s syndrome

  • Intentional injury (covertly) or illness to receive attention of health care workers

  • Motivation by desire to be a patient and develop dependent relationship

    • Different from malingering

  • Clinical Course and Diagnosis Criteria

    • Pseudologia fantastica

  • Epidemiology and Risk Factors

  • Etiology

What is factitious disorder by proxy?

• Factitious disorder Imposed on another to gain attention of health care provider

• Most severe form of child abuse

• Seizures, smothering, poisoning

What is included in the nursing management of factitious disorder?

• Assessment

  • History of medical or psychological illnesses

    • Early childhood experiences (abuse, neglect, role of self-injury)

    • Family Assessment; how is family coping? What are the major family issues?

  • Mental Health Nursing Interventions

  • Establish trusting therapeutic relationship***

  • Must develop self-awareness of one’s own feelings &emotions

  • Goal: replace dysfunctional, attention-seeking behaviors with positive behaviors; Clear interdisciplinary communication

  • Behavioral techniques

When assessing a patient with SSD, the nurse would mostly expect the patient to complain of what?

Pain

Is the following statement true or false?

A patient with somatic symptom disorder often displays an altered mental status.

False

Is the following statement true or false?

A patient with factitious disorder intentionally produces symptoms of illness and is motivated by being classified as disabled or avoiding work.

True