Somatoform Disorders

                                                                                                                                                                                                    

 

INTRODUCTION

Somatoform disorders can be characterized as the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis to account fully for them. The three central features of somatoform disorders are as follows:

• Physical complaints suggest major medical   illness but have no demonstrable organic basis.

• Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms.

• Symptoms or magnified health concerns are not under the client’s conscious control

(Guggenheim, 2000)

1.      Somatization disorder

2.    Conversion disorder

3.    Hypochondriasis

4.    Psychogenic pain disorder

5.    Body dysmorphic disorder (Dysmorphophobia) .

CLASSIFICATION- ICD-10 & DSM –IV

DSM-IV                                                    ICD-10

Somatization disorder                               Somatization disorder

Conversion disorder                                 Hypochondriacal disorder

Hypochondriasis                                       Somatoform autonomic dysfunction

Pain disorder                                            Persistent somatoform pain disorder

Body dysmorphic disorder                        Other somatoform disorders

Un differantiated                                        Somatoform disorder, unspecified

somatoform disorder

Somatoform disorder NOS

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 impairment or treatment seeking, or both.

EPIDEMIOLOGY

Lifetime prevalence in females varies from 0.2-2% and is less than 0.2 % in men. The disorder is more common in the less educated, the poor and those from lower occupational groups.

ETIOLOGY

The exact etiology is not known. Probably multiple factors are at work, which include contributions by genetic and environmental factors, and some defects in neurophysiological functions like information processing.

Familial Factors

The role of familial factors is well established in the etiogenesis of somatization disorder. It has been found that the risk to develop the disorder is 10-20% in female first-degree relatives of probands with somatization disorder, whereas the male relatives show an increased risk of antisocial personality and alcoholism. However, somatization in men is probably heterogenous in character.

Biological factors

A neurophysiological dysfunction in the attention process has been demonstrated in somatization disorder, which may be explained by a reduced corticofugal inhibition in the diencephalon and the brainstem of afferent bodily stimuli, resulting in insufficient filtering of irrelevant bodily stimuli.

Sociocultural factorsFactors

Socio-cultural factors are also responsible for the somatizing tendency. It has been documented that the tendency to perceive and report distress in psychological or somatic terms is influenced by various social and cultural factors, including the degree of stigma associated with particular symptoms.

Neurophysiological basis

Some abnormalities in information processing system have also been reported, like distractibility difficulty in differentiating between target and non-target stimuli, and impaired verbal communi­cation. This leads to inability to habituate to repetitive stimuli.

CLINICAL PRESENTATION

The patients present with multiple somatic complaints of several years duration, which are recurrent and frequently changing. There is a long and complicated medical history during which numerous medical diagnoses have been entertained and many negative investigations or fruitless operations might have been carried out. Symptoms may refer to any part of the body, but common ones are

·         Gastrointestinal symptoms (e g. abdominal pain, bowel problems, nausea, vomiting, belching, regurgitation, etc.),

·         Pain in the various body parts (extremities, back, joints, . etc),

·         Conversion symptoms (pseudoseizures, fainting, incoordination, loss of voice, difficulty in swallowing, etc.),

·         Symptoms referring to cardiopulmonary system (pain chest, palpitation, etc), and

·         Sexual and menstrual disturbances.¹

·         Some patients show a lack of concern about the nature and implications of their symptoms (la belle indifference) and there may be a striking discrepancy between the patient's subjective complaints and behaviour. For example, a patient may smile, walk, and move normally when reporting severe intolerable pain in muscles and joints.⁴

Patients' medical histories are often circumstantial, vague, imprecise, inconsistent, and disorganized. Patients classically (but not always) describe their complaints in a dramatic, emotional, and exaggerated fashion, with vivid and colorful language; they may confuse temporal sequences and cannot clearly distinguish current from past symptoms. Female patients with somatization disorder may dress in an exhibitionistic manner. Patients may be perceived as dependent, self-centered, hungry for admiration or praise, and manipulative.

DIAGNOSTIC CRITERIA-ICD-10

At least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found;

Persistent refusal to accept the advice or reassurance of several doctors that there is no physical explanation for the symptoms;

Some degree of impairment of social and family functioning attributable to the nature of the symptoms and resulting behaviour.

MANAGEMENT

Management of somatization disorder patients is quite difficult because there is no definite therapy and the patients usually have very high expectations, especially about the symptoms removal and a high tendency to change their doctor frequently. Goals of treatment include reduced frequency and severity of physical complaints, improvement in social adjustment and reduction in the cost and frequency of medical treatment.

Morrison has summarized the management of somatization disorder in ABCs as follows:

 A-Accommodate initially to forge rapport

 B-Behavior modification (ignore symptoms, praise for improved behavior)

C-Confrontation later about effects of behavior style

D-Decrease drugs gradually with praise for reduction

 E-Educate about course and meaning of illness

F-Family involvement to give information and help with treatment

G-Guilt should be assuaged in physicians, who may blame themselves, when patients do not improve,

H-Hospitalize only for serious suicide risk, substance abuse or other extreme behavior, and

I-Intercurrent depression should be treated conser­vatively.

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. The symptoms or deficits of conversion disorder are not intentionally produced, are not caused by substance use, are not limited to pain or sexual symptoms, and the gain is primarily psychological and not social, monetary, or legal.

EPIDEMIOLOGY

Incidence and prevalence of conversion symptoms is uncertain, because vast majority of such symptoms remit spontaneously without treatment. Reported rates of conversion disorder have varied widely, ranging from 11/100,000 to 300/100,000 in general population samples. Life time prevalence of conversion symptoms varies from 25 to 30%, Conversion disorder is 2 to 5 times more common in women than in men and more prevalent in persons from low education, low economic and rural backgrounds.

AETIOLOGY

Psychoanalytic Factors

According to psychoanalytic theory, conversion disorder is caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptom. The conflict is between an instinctual impulse (e.g., aggression or sexuality) and the prohibitions against its expression. The symptoms allow partial expression of the forbidden wish or urge but disguise it, so that patients can avoid consciously confronting their unacceptable impulses; that is, the conversion disorder symptom has a symbolic relation to the unconscious conflict. Conversion disorder symptoms also allow patients to communicate that they need special consideration and special treatment. Such symptoms may function as a nonverbal means of controlling or manipulating others.

Learning Theory

In terms of conditioned learning theory, a 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

Preliminary brain-imaging studies have found hypometabolism of the dominant hemisphere and hypermetabolism of the nondominant hemisphere and have implicated impaired hemispheric communication in the cause of conversion disorder. The symptoms may be caused by an excessive cortical arousal that sets off negative feedback loops between the cerebral cortex and the brainstem reticular formation. Elevated levels of corticofugal output, in turn, inhibit the patient's awareness of bodily sensation, which may explain the observed sensory deficits in some patients with conversion disorder. Neuropsychological tests sometimes reveal subtle cerebral impairments in verbal communication, memory, vigilance, affective incongruity, and attention in these patients.

CLINICAL FEATURES

The most common conversion symptoms are sensory or motor symptoms suggesting a neurological illness.

Motor Symptoms

●      Involuntary movements

●      Tics

●      Blepharospasm

●      Torticollis

●      Opisthotonos

●      Seizures

●      Abnormalgait

●      Falling

●      Astasia-abasia

●      Paralysis

●      Weakness

●      Aphonia

Sensory Deficits

●      Anesthesia,especially of extremities

●      Midline anesthesia

●      Blindness

●      Tunnelvision

●      Deafness

Visceral Symptoms

●      Psychogenic vomiting

●      Pseudocyesis

●      Urinary retention

●      Diarrhoea.

MANAGEMENT

The management is in two phases:

1.           Symptom removal

2.           Recognition and coping with the psychosocial stresses provoking the symptoms

 Symptom Removal

Prompt elimination of the symptom is important to prevent the secondary gains from reinforcing it and making it chronic. The patient should not be told that there is nothing wrong, but should be reassured that the symptom is going to disappear quickly and completely. After detailed examination, a suggestion may even be made that it   has already started improving- Mild sedation, relaxation exercises, hypnosis and anxiolytics may be used at this stage and are quite effective. If there is no response, amobarbital or pentothal interview may be used, which has both diagnostic and therapeutic value.

Dealing with psychosocial stresses

If the precipitating stress is transient or is unlikely to recur and there is no significant psychopathology, this phase of treatment is brief. If the stress is persistent or there is significant psychopathology, insight-oriented psycho­therapy or dynamic therapy is to be used. In recent years, briefer and more directive forms of psychotherapies have also been used to treat conversion disorders. A non-con­frontational approach is encouraged.

In addition, secondary gain should be cut to minimum, using environmental manipulation. The family should be told to encourage the patient's autonomy self-sufficiency and independence, and to discourage the sick role.

HYPOCHONDRIASIS

The term hypochondriasis is derived from the old medical term hypochondrium, (below the ribs) and reflects the common abdominal complaints of many patients with the disorder, but they may occur in any part of the body.

Hypochondriasis is characterized by 6 months or more of a general and non delusional preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. This preoccupation causes significant distress and impairment in one's life; it is not accounted for by another psychiatric or medical disorder; and a subset of individuals with hypochondriasis has poor insight about the presence of this disorder.

Epidemiology

The prevalence of hypochondriasis in general population is not known. The prevalence in general medical setting is reported to be 4-9%. The disorder affects both sexes equally or may be slightly predominant in men. The peak age of onset is probably between 20-30, though it may occur at any age. However, it rarely presents for the first time after 50.

AETIOLOGY

There are three theories of origin of hypochondriasis, namely psychodynamic theory, sociocultural theory, and neuropsychological theory.

Psychodynamic Theory

The dynamic theory describes hypochondriasis as an alternate channel to deflect sexual, aggressive or oral drives or an ego defense against guilt and low esteem or a sign of excessive self concern. The aggressive and hostile wishes towards others are transformed into physical complaints through repression or displacement. Freud explained it as a withdrawal of sexual libido from external objects, which is reinvested as narcissistic libido and eventually overflows into actual somatic changes.

Sociocultural Theory

Hypochondriasis has also been visualized as a learned social behaviour, serving the purpose of nonverbal interpersonal communication. The behavior was learned because of its success in past in eliciting caretaking and in securing the other secondary gains of the sick role. They may have assumed the sick role initially as a result of an accident, injury or medical illness or by modeling themselves after someone, who successfully used the sick role. The sick role serves to convey about their distress and disability to others, serving nonverbal communication.

Neurophysiological theory

According to this theory, hypochondriasis is the result of an underlying perceptual or cognitive abnormality. The patients amplify and augment normal bodily sensations and perceive them as more noxious and intense than does the person, who is not hypochondriacal. They have constitutionally lower thresholds and tolerance for physical discomfort. They misinterpret normal bodily sensations, physiological functions, the trivial symptoms of everyday life and the somatic symptoms of emotional arousal by misattributing them to a serious disease process.

CLINICAL FEATURES

The most common complaints are pain and symptoms referable to gastrointestinal and cardiovascular systems. The symptoms usually run a chronic, waxing and waning course. Often the patient comes with a detailed patho­physiological model explaining his symptoms.

The hypochondriacs are profoundly preoccupied with their bodies and their health status. They keep on scrutinizing their body functioning, always preoccupied with their body appearance, functional limitations and health considerations. They often complain of abnormal body sensations, disturbed body functions or anatomical deviations suggesting disease.

MANAGEMENT

Hypochondriacs are one of the most difficult patients to treat .Since hypochondriacs are clinging, demanding and harboring unrealistic expectations, their relations with doctors are often strained and unsatis­factory. Their doctor shopping behavior also elicits negative reaction from the treating physician.

Basic principles of treatment can be outlined as:

1.            Treatment by a single physician, with whom the patient feels confident

2.            Supportive approach and regularly scheduled visits, that are not on as needed basis or based on develop­ment of new or exacerbation of existing symptoms

3.            Avoidance of hospitalizations, diagnostic procedures and medications with abuse potential

4.            Focussing on symptoms and brief examination in initial visit to facilitate rapport development and gradually concentrating on social or interpersonal problems

The physician's approach should be of care rather than of cure. The patient should be helped in learning to cope with and tolerate their symptoms and to live with them as adaptivcly as possible, rather than to remove them.

Selected patients respond to supportive psycho­therapy. Group psychotherapy has also been found useful. Good psychotherapy outcomes are associated with illness of less than 3 years duration, absence of severe personality disorder and possibly higher social class.

Drugs do not have any role in primary hypochon­driasis. But, if there are significant anxiety or depressive symptoms, corresponding drugs may be used.

PAIN DISORDER

Pain disorder (persistent somatoform pain disorder in ICD-10) is characterized by presence of severe and prolonged pain for which there is no adequate medical explanation.

Eprdemio!ogy

The exact prevalence of pain disorder is not known, because diagnostic criteria have been frequently changing. One recently done community survey puts one-year prevalence at 0.6%. However, it is quite common. The disorder is more common in women, about twice more than in men. The peak age of onset is in fourth and fifth decades.

Etiology

There are 4 ways of understanding genesis of somatoform pain disorder; psychodynamic, behavioral, interpersonal and neurophysiological.

Psychodynamic Theory

Pain in these patients serves the purpose of punishment and atonement for unconscious guilt. Their childhood histories are marked by physical abuse, use of pain as punishment and emotional distance from parents. They have also difficulties in expressing anger.

Behavioural Theory

Pain related behavior might also be learnt by operant and classical conditioning. The pain related behaviors include grimacing, complaining, lying down, taking analgesics and staying away from work. Such behaviors are learnt, when pain occurs for the first time and are reinforced by increased attention from friends and relatives, and relief from carrying out undesirable activities such as hard physical labor and sexual obligations. Pleasurable effects of analgesics, when given for pain and possibility of monetary gain from litigation or compensation, further reinforce these behaviors. Classical conditioning occurs when certain neutral objects and settings begin to evoke pain-related behavior by their association with pain, such as patient's bed room or his work place. Pain may act as a defense against emotional distress from achievement, either in academic work or in sports.

Interpersonal Theory

Pain serves as nonverbal interpersonal communication and may be used for manipulation or gaining advantage in interpersonal relationships. This phenomenon has also been referred to as pain games or painsmenship.

Neurophysiological Theory

Serotonin has been implicated in pain disorder since it has an inhibiting effect on pain perception and is probably the neurotransmitter of the descending inhibitory pathways that arise in the raphe nucleus of the medulla. Endorphins and serotonin metabolism are decreased in cerebrospinal fluid of chronic pain patients. Patients with somatoform pain syndromes have higher autonomic and muscle activity as compared to controls. There is dysfunction of corticofugal inhibitory system resulting in insufficient inhibition of the afferent stimulation, which results in amplification of heightened arousal to somatic sensory input (pain).

CLINICAL FEATURES

The patient presents with preoccupation with continuous and severe pain, which defies any medical explanation. The pain may involve anybody area.

The patients often display a lifestyle, which can be described as the disease of the D's:

1.  Dramatic display in describing the painful experience

2. Disuse and degeneration of various body functions as consequences of the pain related behavior

3. Drug misuse and doctor shopping

4.  Dependency, passivity and learned helplessness, which lead to demoralization and depression

5.Disability pain-contingent financial compensation or desire for compensation through litigation and disability claims.

Alexithymia is also reported to be common in these patients. Depressive symptoms are a very common accom­paniment. Major depression can be diagnosed in 25-30% of somatoform pain patients.

MANAGEMENT

Pharmacotherapy

Analgesic medications do not generally benefit most patients with pain disorder. In addition, substance abuse and dependence are often major problems for such patients who receive long-term analgesic treatment. Sedatives and antianxiety agents are not especially beneficial and are also subject to abuse, misuse, and adverse effects.

Antidepressants such as amitriptyline, imipramine,doxepin and phenelzine have been found effective,even when depressive symptoms are not prominent,and sometimes provide pain relief at dosage lesser than those required to treat depression. If there is no response

after 6 weeks of an adequate dose, another agent should be tried before concluding that antidepressants are not effective. Whether antidepressants reduce pain by their

antidepressant action or have independent direct analgesic effect (on serotonergic inhibitory pain pathways) remains unclear.

Anticonvulsants such as, phenytoin, carbamazepine, and clonazepam are effective in treating neuropathic and neuralgic pain, at least for short periods.

 No drug should be prescribed on 'as needed basis. Time contingent prescriptions are less likely to lead to drug misuse through conditioning.

Behavioural Interventions

A wide variety of behavioral techniques like behavior modification (using principles of operant conditioning to discourage pain related behavior, and to shape and reinforce new health related behaviors), relaxation train­ing, cognitive therapy and graduated exercise program may be used. The family and other figures important to patient may be involved in management. They should be explained the importance of normal activities of daily living and range of physical activity, which can be carried out by the patient without risk.

In recent years, biofeedback has been found modera­tely helpful in some cases, especially in migraine, myofascial pain and muscle tension states (such as tension headaches).

Psychotherapeutic intervention

Traditional psychotherapeutic interventions do not have much role in somatoform pain disorder patients. However, family therapy and group therapy along with supportive psychotherapy in combination with other treatments, bring about beneficial results.

Pain clinics and Pain control Programmes

In recent years, a number of such facilities have come up. These usually have a multi-disciplinary team consisting of physicians, psychologists, anesthesiologists, physio­therapists and occupational therapists. About 70% of patients, who go through such programs, show improve­ment.

BODY DYSMORPHIC DISORDER OR DYSMOSRPHO PHOBIA

Body dysmorphic disorder or dysmorphophobia is characterized by preoccupation with some imagined defect in appearance in a normal appearing person or a grossly excessive concern about a slight physical anomaly. The belief is not of delusional intensity.

Epidemiology

Body dysmorphic disorder is a poorly studied condition, partly because patients are more likely to go to dermatologists, internists, or plastic surgeons than to psychiatrists. One study of a group of college students found that more than 50 percent had at least some preoccupation with a particular aspect of their appearance, and in about 25 percent of the students, the concern had at least some significant effect on their feelings and functioning.

Available data indicate that the most common age of onset is between 15 and 30 years and that women are affected somewhat more often than men. Affected patients are also likely to be unmarried. Body dysmorphic disorder commonly coexists with other mental disorders. One study found that more than 90 percent of patients with body dysmorphic disorder had experienced a major depressive episode in their lifetimes; about 70 percent had experienced an anxiety disorder; and about 30 percent had experienced a psychotic disorder.

AETIOLOGY

Not much is known about the etiology of body dysmor­phic disorder. According to psychodynamic theory, these patients invest a particular body part with a high level of unconscious meaning that can be traced to an event during an earlier stage of psychosexual development. Important defense mechanisms are repression, dissociation, distor­tion, symbolization and projection. In some patients, the symptoms are a part of some other disorder such as schizo­phrenia, mood disorder, obsessive compulsive disorder or severe personality disorder.

CLINICAL FEATURES

❏      imaginary defects in their bodily appearance,mostly of nose, hair, breasts or genitalia, face

❏      excessive significance of facial wrinkles,minor scar marks,

❏       Secondary symptoms like anxiety, insomnia and depression are often present

❏      indulge in excessive and repetitive beha­viors such as mirror checking, skin picking and reassu­rance seeking

❏      consulting plastic surgeons and dermatologists, and requesting for cosmetic surgery or related treatments.

❏      The patients resist psychiatric referral

MANAGEMENT

These patients are very difficult to treat, as they refuse psychiatric referral and treatment. Symptoms have been reported to respond to pimozide, other antipsychotics, tricyclic antidepressants and monoamine oxidase inhibitors. There are some recent reports of good response to selective serotonin uptake inhibitors like clomipramine and fluoxetine.

UNDIFFERENTIATED SOMATOFORM DISORDERS

The diagnosis is made when one or more physical symptoms (e.g. fatigue, loss of appetite, urinary or gastrointestinal complaints), without an adequate medical explanation, are present for a minimum duration of 6 months (ICD-10 does not specify any duration for making a diagnosis).

Epidemiology

Undifferentiated somatoform disorder is much more common than somatization disorder, with a 30 times higher prevalence. Life-time prevalence is estimated at 4-ll% and one-year prevalence of 13.8% was reported recently from Italy. It is more common in women and in those from lower socio- economic groups.

Etiology

The etiological theories are similar to those of somatization disorder

Course and Prognosis

The course is likely to be chronic and relapsing. However, being a recently introduced diagnostic category, long term follow-up studies are lacking.

Management

The management is on similar lines as in somatization disorder.

NURSING MANAGEMENT

SOMATIZATION DISORDER

Nursing diagnosis

Ø  Ineffective coping related to repressed anxiety and unmet dependency needs

Nursing interventions

·         Recognize and accept that the physical complaint is real to the client, even though no organic aetiology can be identified

·         Identify the gains that the physical symptoms are providing for the patient

·         Initially fulfill the client’s urgent dependency needs but gradually withdraw attention to physical symptoms

·         Minimize time given in response to physical complaints

·         Explain to the client to report any new physical complaints to the physician

·         Encourage client to verbalize fears and anxieties

·         Discuss possible alternative coping strategies client may use in response to stress

·         Help client identify ways to achieve recognition from others without restoring to physical complaints

CONVERSION DISORDER

Nursing Diagnosis

Ø  Ineffective Coping related to inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

Interventions same as above

PAIN DISORDER

Chronic pain

Nursing Diagnosis

Ø  Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage  sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration of greater than 6 months related to severe level of anxiety, repressed ,low self-esteem ,unmet dependency needs,

secondary gains from the sick role

Interventions

1. Monitor physician’s ongoing assessments and laboratory reports to ascertain that organic pathology is clearly ruled out.

2. Recognize and accept that the pain is real to the individual, even though no organic cause can be identified. Denying the client’s feelings is nontherapeutic and hinders the development of a

trusting relationship.

3. Observe and record the duration and intensity of the pain. Note factors that precipitate the onset of pain. Identification of the precipitating stressor is important for assessment purposes. This information will be used to develop a plan for assisting the client to cope more adaptively.

4. Provide pain medication as prescribed by physician. Client comfort and safety are nursing priorities.

5. Assist with comfort measures, such as back rub, warm bath, and heating pad. Be careful, however, not to respond in a way that reinforces the behavior. Secondary gains from physical symptoms may prolong maladaptive behaviors.

6. Offer attention at times when client is not focusing on pain. Positive reinforcement encourages repetition of adaptive behaviors.

7. Identify activities that serve to distract client from focus on self

and pain. These distractors serve in a therapeutic manner as a transition from focus on self or physical manifestations to focus on unresolved psychological issues.

8. Encourage verbalization of feelings. Explore meaning that pain holds for client. Help client connect symptoms of pain to times of increased anxiety and to identify specific situations that cause anxiety to rise. Verbalization of feelings in a nonthreatening environment facilitates expression and resolution of disturbing emotional issues.

9. Encourage client to identify alternative methods of coping with stress. These may avert the physical pain as a maladaptive response to stress.

10. Explore ways to intervene as symptoms begin to intensify, so that pain does not become disabling. (e.g., visual or auditory distractions, mental imagery, deep-breathing exercises, application of hot or cold compresses, relaxation exercises).

11. Provide positive reinforcement for adaptive behaviors. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.

DISTURBED BODY IMAGE

Nursing diagnosis

Ø  Confusion in mental picture of one’s physical self. related to low self-esteem unmet dependency needs.

Interventions with Selected Rationales

1. Establish trusting relationship with client. Trust enhances therapeutic interactions between nurse and client.

2. If there is actual change in structure or function, encourage client to progress through stages of grieving. Assess level of knowledge and provide information regarding normal grieving process and associated feelings. Knowledge of acceptable feelings facilitates progression through the grieving process.

3. Identify misperceptions or distortions client has regarding body image. Correct inaccurate perceptions in a matter-of-fact, nonthreatening manner. Withdraw attention when preoccupation with distorted image persists. Lack of attention may encourage elimination of undesirable behaviors.

4. Help client recognize personal body boundaries. Use of touch may help him or her recognize acceptance of the individual by others and reduce fear of rejection because of changes in bodily structure or function.

5. Encourage independent self-care activities, providing assistance as required. Self-care activities accomplished independently enhance self-esteem and also create the necessity for client to confront reality of his or her bodily condition.

6. Provide positive reinforcement for client’s expressions of realistic bodily perceptions. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.

.

Ø  Knowledge deficit (Psychological Causes for Physical Symptoms)

 Absence or deficiency of cognitive information related to a specific topic.related to

lack of interest in learning,severe level of anxiety charecterized by denial ,statements such as, “I don’t know why the doctor put me on the psychiatric unit. I have a physical problem, history of “shopping” for a doctor who will substantiate symptoms as pathophysiological, noncompliance with psychiatric treatment plan.

.

Interventions

1. Assess client’s level of knowledge regarding effects of psychological problems on the body.

2. Assess client’s level of anxiety and readiness to learn.

3. Discuss physical examinations and laboratory tests that have been conducted. Explain purpose and results of each.

4. Explore feelings and fears held by client. Go slowly. These feelings may have been suppressed or repressed for a very long time and their disclosure will undoubtedly be a painful experience. Be supportive..

5. Have client keep a diary of appearance, duration, and intensity of physical symptoms. A separate record of situations that the client finds especially stressful should also be kept.

6. Help client identify needs that are being met through the sick role. Together, formulate a more adaptive means for fulfilling these needs. Practice by role-playing.

7. Explain assertiveness techniques to the client. Discuss the importance of recognizing the differences among passive, assertive, and aggressive behaviors, and of respecting the human rights of others while protecting one’s own basic human rights.

8. Discuss adaptive methods of stress management: relaxation techniques, physical exercise, meditation, breathing exercises, or mental imagery. ⁶

Conclusion

The nurse should never try to confront the client about the origin of these symptoms until the client has learned other coping strategies. Somatoform disorders are chronic or recurrent, so progress toward treatment outcome can be slow and difficult.

Nurses caring for clients with somatoform disorders must show patience and understanding toward them as they struggle through years of recurrent somatic complaints and attempts to learn new emotion and problem-focused coping strategies.

Nursing interventions that may be effective with clients who somatize involve providing health teaching, identifying emotional feelings and stress, and using alternative coping strategies. Coping strategies that are helpful to clients with somatoform disorders include relaxation techniques such as guided imagery and deep breathing, distraction such as music, and problem-solving strategies such as identifying stressful situations and new methods of managing them and role-playing social interactions.

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