chapter 17Comprehensive Study Guide: Somatic Symptom and Factitious Disorders

Overview of Somatic Symptom Disorders

  • Somatic symptom disorders involve the expression of stress through physical symptoms, which can also include psychological or emotional components.
  • Patients often exhibit:
    • Anxiety.
    • Depression.
    • Irritability.
  • Patient behaviors regarding care can vary; some may not usually seek care, while others seek it excessively.
  • Cultural Considerations:
    • Different cultures exhibit varying frequencies and types of somatic symptoms.
    • Some traditions may view these symptoms as being "spellbound."
    • Traditional healers play a significant role in certain cultures; patients may not believe they are recovered until their healer confirms it.
    • It is essential to ask patients about their cultural beliefs regarding their symptoms.

Classifications of Control in Disorders

  • Somatic disorders are categorized by whether the symptoms are under conscious or unconscious control.
  • Under Conscious Control:
    • Factitious Disorder: Fabrication of symptoms for emotional gain; this is a highly important topic for study.
    • Malingering: Conscious fabrication of physical or psychological symptoms motivated by an external incentive.
  • External Incentives for Malingering include:
    • Housing.
    • Worker’s compensation.
    • Avoiding military service.
    • Financial or personal gain.

Somatic Symptom Disorder (SSD)

  • Characterized by one or more distressing symptoms that cause a high level of functional impairment.
  • Key Features:
    • Symptoms may exist without significant physical findings or medical diagnoses.
    • The suffering experienced by the patient is authentic.
    • Individuals tend to be hard on themselves and exhibit limited self-compassion.
  • Diagnostic Aids:
    • Self-compassion scale: Found on page 315315 of the textbook.
    • DSM-5 Criteria: While students do not need to memorize all 1010 criteria, having a general idea is helpful.
  • Epidemiology and Risk Factors:
    • More common in adults.
    • Genetic factors may be involved.
    • Personality traits: High negative affect.
    • Environmental risks: Stressful events are often related to anxiety.
    • Socioeconomic factors: High risk among patients with a lack of education or low socioeconomic status.
  • Nursing Guidelines:
    • Establish a therapeutic relationship with constant reassurance.
    • Support the family and assess the patient’s support system.
    • Promote a healthy lifestyle (nutrition, hydration, sleep, outdoor activity, and consistent schedules).
    • Focus on developing positive coping mechanisms.
  • Treatment Modalities:
    • Hypnotherapy.
    • Positive behavioral therapy.
    • Pharmacotherapy: Tricyclic antidepressants and SSRIs have been used successfully.
    • Treatment is most effective when therapy and pharmacotherapy are used in conjunction; it is rare to use only one.

Illness Anxiety Disorder

  • Characterized by a fierce preoccupation with having or acquiring a serious illness.
  • Features:
    • Extreme worry or fear about the possibility of disease.
    • The disorder is chronic and relapsing.
    • Patients can be "care-seeking" or "care-avoidant."
  • Impacts on Healthcare:
    • Care-seeking patients undergo unnecessary testing, clinic visits, and ER visits.
    • Results in the consumption of significant time and expensive resources (unnecessary testing is not cheap).
  • Epidemiology and Comorbidities:
    • One to two year prevalence: Estimated at 1−2%1-2\%.
    • Comorbidities include generalized anxiety disorder and panic disorders.
  • Treatment and Outreach:
    • Electroconvulsive therapy (ECT) may be used but must be performed by specifically trained personnel (advanced practice level, not standard RN level).
    • Telehealth appointments: Referred to as ICBT (Internet Cognitive Behavioral Therapy).
    • Mental health outreach: Example includes the "Valley Wide" mobile behavioral health bus, which is an RV that provides resources to various locations.
  • Counseling Guidelines:
    • Allow time for the patient to discuss their illnesses.
    • Provide reassurance that medical care will be supplemented, not replaced.
    • Utilize "uncomfortable silence": Patients may need a moment of silence to process before they are ready to talk. Rushing with questions can overwhelm the patient and lead to shutdown or aggression.

Conversion Disorder

  • Formerly known as "hysteria."
  • Symptoms mimic neurological disease (e.g., blindness, deafness, paralysis) but lack a neurological basis.
  • Onset usually follows a physiological conflict or intense stressor.
  • La Belle Indiffrence (The Grand Indifference): Patients show a surprising lack of emotional concern about dramatic symptoms like sudden blindness.
  • Neurobiology:
    • MRI findings: Abnormal patterns of cerebral activation.
    • Increased cortisol levels: This may increase the risk for infection.
  • Examples:
    • A woman hears her husband is unfaithful and suddenly goes deaf because she "cannot hear this."
    • Someone sees a traumatic event and suddenly goes blind.
  • Comorbidities and Risks:
    • Depressive disorders.
    • History of environmental abuse (sexual or physical abuse) is a very common factor.
  • Nursing Guidelines:
    • Avoid direct confrontation (e.g., do not say, "You’re crazy, you can still see").
    • Offer reassurance and support for the patient's reported feelings.
    • Troubleshooting: Ensure there is no physical cause, such as high intraocular pressure, retinal hemorrhage, or trauma from a car accident.
  • Treatment Modalities:
    • Body-oriented physiological therapy (linking emotions to body awareness).
    • Psychodrama: The use of role play (must be used carefully depending on the patient).
    • DBT (Dialectical Behavioral Therapy).
    • Physical Therapy (PT): Helps with function and safety (e.g., helping a "blind" patient walk).

Psychological Factors Affecting Medical Conditions

  • Stress can negatively affect medical conditions and vital signs (Page 319319 lists common conditions).
  • MND: Refers to Mild to Moderate Depression.
  • Epidemiology and Risk Factors:
    • Loneliness and weak personal connections.
    • ACEs (Adverse Childhood Events): Childhood trauma is linked to mental health disorders later in life.
  • Resilience:
    • The "bounce back" method from adversity.
    • Goal: Patients show less distress and fewer physical symptoms despite childhood trauma.
    • Anecdote: One patient who experienced sexual assault in a war-torn country remained resilient by volunteering at a women’s shelter, while another with similar trauma turned to meth and alcohol.

Professional Nursing Assessment and Process

  • Assessment Guidelines:
    • Thorough medical and psychological history.
    • Personal history and use of substances.
    • Appearance.
    • Over-the-counter supplements.
    • Nutrition and Hydration: Dehydration and malabsorption are common in mental health crises as nutrition is often neglected.
    • GI Function: Assess for diarrhea, constipation, anorexia, and intentional or nonintentional weight loss.
    • Ability to meet basic needs: Hygiene, housing, and cooking (Maslow's Hierarchy).
  • Voluntary Control:
    • Determine if symptoms are voluntary. Often, somatization symptoms are not under voluntary control (Box at the bottom of page 322322).
  • Implementation:
    • Share decision-making with the patient (Page 323323).
    • Progress is measured in small increments; documentation should reflect these trends.
    • Assertiveness training: Helping patients find direct means to meet their needs.
    • Exercise regimens: Regular walks.
    • Case Management: Crucial for patients who "doctor shop" (going from provider to provider or clinic to clinic across state lines, such as New Mexico). This prevents repeated radiation exposure from unnecessary CT scans and manages resource utilization. The case manager (e.g., "Sherry") becomes the single point of contact.
  • Therapeutic Communication:
    • Avoid saying "Your symptoms are all in your head."
    • Maintain a nonjudgmental approach, even if you identify a personal bias.
    • Use "meaningful rounds": Have actual conversations and document them (e.g., "Sat with patient, offered snack, discussed x, y, and z").

Factitious Disorder and Munchausen Syndrome

  • Patients are compulsive and pretend to be ill to have emotional needs met.
  • Formerly known as Munchausen Syndrome.
  • Types:
    • Factitious Disorder Imposed on Self:
      • Dramatic presentation of illness.
      • Extensive use of correct medical terminology.
      • Reluctant to speak to providers but demands specific treatments.
      • Negative tests often lead to the "discovery" of new symptoms.
    • Factitious Disorder Imposed on Another:
      • Formerly "Munchausen by Proxy" or medical abuse.
      • A caregiver falsifies illness in a vulnerable person (child, elderly, mentally disabled, foster kids, ESL patients, or those with cognitive impairments).
      • Often perpetrated by a mother.
      • Frequently involves reports of stomach pain, headaches, or back pain.
      • The caregiver may interject when the child tries to speak or change the symptoms.
      • Anecdote: A child was repeatedly brought in for stomach pain, but the caregiver (a healthcare worker) was eventually found to be drug-seeking through the child.
  • Profile of Perpetrator:
    • Often have high IQs and extensive knowledge of the healthcare system.
    • Frequently employed in the healthcare field.
    • Personal Anecdote: The instructor notes she is the opposite; she let her child sit with an ear infection for 55 days, treating with Benadryl and Ibuprofen before going to the doctor, to avoid unnecessary ER visits.

Questions & Discussion

  • Question: Has anyone seen events where patients have been resilient or not in clinicals?
    • Response: The class indicated they had not encountered this yet in clinical rotations.
  • Question: What should be included in a physical assessment for these patients?
    • Student Answer: Personal history.
    • Student Answer: Appearance.
    • Further Details: The instructor added over-the-counter supplements, nutrition, GI distress, and the ability to meet basic needs (safety/security).
  • Question: Who qualifies as a vulnerable population for Factitious Disorder Imposed on Another?
    • Student Answer: Children.
    • Student Answer: Older and younger people.
    • Student Answer: Mentally disabled.
    • Student Answer: Foster kids.
    • Further Details: The instructor added English as a second language (ESL) and those with cognitive impairments.
  • Question (Case Study/Question): A man injures his foot to avoid military service. What is this?
    • Student Answer (Sheila): Malingering.
    • Teacher Note: This is correct because it involves an external incentive (avoiding service).