Chapter 20: Somatic Symptom and Related Disorders (Week 7)

Chapter 20: Somatic Symptom and Related Disorders

Common in primary care settings

Nurses must be familiar with:

• Disorders themselves

• Their role in caring for clients

Included Disorders

• Somatic Symptom Disorder (physical symptoms without full medical explanation)

• Illness Anxiety Disorder (preoccupation with having/getting a serious illness)

• Functional Neurological Symptom Disorder (neurological symptoms incompatible with medical conditions; formerly conversion disorder)

• Factitious Disorder (intentional falsification/induction of symptoms for attention/assumption of sick role)

• Psychological Factors Affecting Other Medical Conditions (mental state negatively impacts medical illness)

Somatic Symptom Disorder

Expression of psychological stress through physical symptoms

Symptoms cannot be explained by underlying pathology

Key Features

• Physical symptoms → cause distress and long-term healthcare use

• Symptoms may be vague/exaggerated; course may be acute or chronic with remissions/exacerbations

• Clients often:

  • Worry excessively about symptoms

  • Allow symptoms to dominate life and relationships

  • Reject psychological explanation for symptoms

  • Seek multiple providers → higher medical costs

• Typically seen in primary/medical care, not mental health settings

• Common comorbidities: anxiety, depression

Somatic Symptom Disorder Risk Factors / Expected Findings

Risk Factors

• First-degree relative with somatic symptom disorder

• Decreased neurotransmitters: serotonin, endorphins

• Comorbidities: depressive disorder, personality disorder, anxiety disorder

• Low socioeconomic status

• Adverse childhood experiences

• Learned helplessness

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Expected Findings

• Somatic symptoms that disrupt daily life

• Excessive preoccupation with symptoms

• High anxiety about health

• Symptoms present > 6 months (though they may vary)

• Remissions and exacerbations of symptoms

• Possible alcohol or substance use

• Overuse of analgesics/antianxiety meds

• Frequent healthcare use with multiple providers

Somatic Symptom Disorder Laboratory and Diagnostic Tests

Laboratory and Diagnostic Tests

• CT scans, MRIs, etc. → used to rule out underlying pathology

Assessment Tools

Patient Health Questionnaire-15 (PHQ-15): screens for 15 common somatic symptoms:

• Abdominal pain

• Back pain

• Extremity/joint pain

• Menstrual problems/cramps

• Headaches

• Chest pain

• Dizziness

• Fainting

• Palpitations (heart racing/pounding)

• Dyspnea (shortness of breath)

• Pain with intercourse

• Bowel elimination issues (constipation/diarrhea)

• Nausea, indigestion, or gas

• Lethargy (low energy)

• Sleep problems

Somatic Symptom Disorder Nursing Care

Accept client’s symptoms as real to them

Assess for suicidal ideation/self-harm

Consider cultural impact on health/illness views

Identify secondary gains (attention, escape from obligations)

Report new symptoms to provider

Limit time spent on discussing somatic complaints

Encourage independence in self-care

Promote verbalization of feelings

Teach alternative coping mechanisms

Teach assertiveness techniques

Encourage daily physical exercise

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Reattribution Treatment

• Goal: Help client connect physical symptoms with psychological factors while providing empathy and support

Four Stages of Reattribution Treatment:

1. Feeling understood – Use therapeutic communication, empathy, and active listening; gather history & brief physical assessment

2. Broadening the agenda – Validate client concerns, provide feedback about assessment findings

3. Making the link – Acknowledge lack of physical cause; promote self-esteem

4. Negotiating further treatment – Collaborate on a treatment plan; allow regular follow-up visits

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Client Education

• Participate in individual and group therapy

• Take prescribed medications as directed

• Work with case manager to set regular follow-up schedule (every 4–6 weeks)

  • Reduces unscheduled healthcare use

  • Lowers medical costs (fewer unnecessary tests and visits)

Somatic Symptom Disorder Medications (AAA)

Administer as prescribed:

• Analgesics (pain relief)

• Antidepressants (mood regulation)

  • STAMiNA

• Anxiolytics (anxiety reduction)

Illness Anxiety Disorder

Misinterpretation of physical sensations as signs of a serious illness

Formerly called hypochondriasis

Leads to obsessive thoughts and fear of illness

Physical symptoms may be minimal or absent

Key Features

• Clients are overly aware of bodily sensations → attribute to serious illness

• Excessive researching and self-examination (e.g., checking throat in mirror)

• May seek numerous opinions or avoid care altogether to reduce anxiety

• Anxiety persists despite negative diagnostic tests and reassurance

Illness Anxiety Disorder Risk Factors / Expected Findings

Risk Factors

• Family history (first-degree relative with disorder)

• Past losses/disappointments → guilt, anger, hostility

• Childhood trauma, neglect, or maltreatment

• Comorbid depressive or anxiety disorder

• Major life stressors

• Low self-esteem

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Expected Findings

• Excessive anxiety about serious illness (present >6 months, focus may shift)

• Preoccupation with health behaviors (e.g., frequent breast self-exams)

• Two types:

  • Health-seeking type → frequent medical care & diagnostic tests

  • Care-avoidant type → avoids providers due to anxiety

Illness Anxiety Disorder Laboratory and Diagnostic Tests

CT scans, MRIs, etc. → performed only to rule out medical causes

A nurse is discussing the factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include?

Select all that apply.

a

Age older than 65 years

b

Anxiety disorder

c

Childhood trauma

d

Coronary artery disease

e

Obesity

b Anxiety disorder

c Childhood trauma

A nurse is reviewing the medical record of a client who has functional neurological symptom disorder. Which of the following findings should the nurse identify as placing the client at risk for functional neurological symptom disorder?

a

Death of a child 2 months ago

b

Recent weight loss of 30 lb

c

Retirement 1 year ago

d

History of migraine headaches

a Death of a child 2 months ago

A nurse is assessing a client who has illness anxiety disorder. Which of the following are expected for this disorder?

Select all that apply.

a

Obsessive thoughts about disease

b

History of childhood maltreatment

c

Avoidance of health care providers

d

Depressive disorder

e

Narcissistic personality

a Obsessive thoughts about disease

b History of childhood maltreatment

c Avoidance of health care providers

d Depressive disorder

Avoidance of health care providers is an expected finding in clients who have illness anxiety disorder of the care-avoidant type.

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Low self-esteem is an expected finding in a client who has illness anxiety disorder.

Illness Anxiety Disorder Nursing Care

Build rapport and trust with client

Encourage independence in self-care

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Client Education

• Participate in individual and group therapy

• Attend community support groups

• Take prescribed medications consistently

• Collaborate with provider for brief, frequent office visits

• Verbalize feelings

• Use alternative coping mechanisms

• Practice stress management techniques

Illness Anxiety Disorder & Functional Neurological Symptom Disorder Medications (AA)

Administer as prescribed:

• Antidepressants

  • STAMiNA

• Anxiolytics

Functional Neurological Symptom Disorder

(Previously Conversion Disorder)

Neurologic symptoms without a neurologic diagnosis

Emotional/psychological stressors converted into physical symptoms

Key Features

• Symptoms can cause extreme anxiety/distress OR a lack of emotional concern (la belle indifférence)

• Causes significant impairment in daily functioning

• Deficits in voluntary motor or sensory function

  • Blindness, paralysis, seizures, gait disorder, hearing loss

Functional Neurological Symptom Disorder Risk Factors / Expected Findings

Risk Factors

• First-degree relative with disorder

• Childhood physical/sexual abuse

• Comorbid psychiatric disorders:

  • Depressive disorder

  • Anxiety disorder

  • PTSD

  • Personality disorder

  • Other somatic disorders

• Comorbid medical/neurologic condition

• Recent acute stressful event

• Female sex

• Adolescent/young adult age group

• Low socioeconomic status, low education

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Expected Findings

• Motor deficits: paralysis, abnormal movements/gait, seizure-like movements

• Sensory deficits: blindness, aphonia (loss of speech), anosmia (loss of smell), deafness, numbness, tingling/burning sensations

• Pseudocyesis: false pregnancy in clients with extreme desire to conceive

Functional Neurological Symptom Disorder Laboratory & Diagnostic Tests

CT, MRI, etc. → performed to rule out underlying pathology

Functional Neurological Symptom Disorder Nursing Care

Build rapport and trust with clients

Ensure safety of clients

Encourage verbalization of feelings and help identify psychological triggers

• Example: sudden blindness after witnessing partner’s infidelity

Teach alternative coping mechanisms

Teach stress management techniques

Recognize remission and recurrence patterns:

• 95% remission without intervention (especially if triggered by acute stress)

• 20% relapse within 1 year of initial diagnosis

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Client Education

• Participate in individual and group therapy

• Attend community support groups

• Take prescribed medications as directed

A nurse is developing a plan of care for a client who has functional neurological symptom disorder. Which of the following actions should the nurse include?

a

Encourage the client to spend time alone in their room.

b

Monitor the client for self-harm once per day.

c

Allow the client unlimited time to discuss physical manifestations.

d

Discuss alternative coping strategies with the client.

d Discuss alternative coping strategies with the client.

Psychological Factors Affecting Other Medical Conditions

Psychological/behavioral factors can cause, worsen, or perpetuate medical conditions

Examples: depression and anxiety linked to heart disease, cancer

Mind-body connection influences illness progression and recovery

Psychological Factors Affecting Other Medical Conditions Risk Factors / Expected Findings

Risk Factors

• Chronic stressors

• Depressive disorder or anxiety disorder

• Neurotransmitter malfunction

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Expected Findings

• Confirmed medical diagnosis + psychological factor that:

  • Contributes to development/exacerbation/delayed recovery of illness

  • Interferes with adherence to treatment

  • Increases client’s risk for additional health problems

  • Worsens physical manifestations or increases need for medical treatment

Psychological Factors Affecting Other Medical Conditions Nursing Care

Nursing Care

• Discuss exam findings with client

• Assess for suicidal ideation/self-harm

• Explore client’s feelings and fears

• Allow time to express feelings

• Educate on coping mechanisms and assertiveness techniques

• Address both physical and psychological needs

• Administer prescribed medications

• Provide holistic care (physical + psychological)

Client Education

• Participate in treatment plan

• Use prescribed medications

Factitious Disorder

(Previously Munchausen Syndrome)

Conscious decision to falsify or induce symptoms (physical or psychological)

No external gain (not malingering) → motivation is emotional need for attention

May involve self-inflicted injury or injury to others (factitious disorder imposed on another / Munchausen by proxy)

Clients often dramatic, knowledgeable about medical terminology, resistant to provider contact with family/previous providers

Often report new symptoms after negative test results

Distinction: Factitious disorder is a mental illness, malingering is intentional for personal gain (e.g., disability benefits, avoiding military service)

Factitious Disorder Risk Factors / Expected Findings

Risk Factors

• History of emotional/physical distress, child maltreatment, or frequent childhood hospitalizations

• Impaired neurologic information processing

• Dependent personality

• Borderline personality disorder

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Expected Findings

• False reports of symptoms (physical & psychological)

• Possible self-injury (factitious disorder)

• Possible injury to others (factitious disorder imposed on another)

Factitious Disorder Laboratory/Diagnostic Tests

CT scans, MRIs → used to rule out pathology

Factitious Disorder Nursing Care

Perform self-assessment before care

Avoid confrontation

Build rapport and trust

Ensure safety of client and others (if imposed on another)

Teach alternative coping & stress management

Communicate openly with healthcare team about suspicions → prevents unnecessary tests/surgeries, reduces costs

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Client Education

• Participate in individual/group therapy

• Attend community support groups

• Use prescribed medications

• Encourage verbalization of feelings

A nurse is counseling several clients. Which of the following client statements should the nurse identify as expected for factitious disorder imposed on another?

a

“I had to pretend I was injured in order to get disability benefits.”

b

“I know that my abdominal pain is caused by a malignant tumor.”

c

“I needed to make my child sick so that someone else would take care of them for a while.”

d

“I became deaf when I heard that my partner was having an affair with my best friend.”

c “I needed to make my child sick so that someone else would take care of them for a while.”

A client who has factitious disorder imposed on another often consciously injures another person or causes them to be sick due to a personal need for attention or relief of responsibility.

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A client’s falsification of an illness or injury for the purpose of personal gain is malingering.

Although clients who have factitious disorder often use proper medical terminology, a client’s fear of a serious illness is expected with illness anxiety disorder.

Developing a sensory impairment due to an acute stressor is an expected finding of functional neurological symptom disorder.