Ch. 21- Somatic Symptom Illnesses

Secondary Gain

*Internal or personal benefits received from others because one is sick (ex. Time off of work, people start helping you out, focus of attention, get out of obligations or problems, avoiding stressful things) -May become the prominent focus of attention because of the illness

A patient with blindness related to a functional neurological (conversion) disorder says, "All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital don't find me interesting." Which nursing diagnosis is most relevant? A. Social isolation B. Chronic low self-esteem C. Interrupted family processes D. Ineffective health maintenance

B Feedback: B—the patient is mentioning that the symptoms make her more interested, which indicates that the patient believes he or she is uninteresting and unpopular without the symptoms, thus supporting this diagnosis. Defining characteristics for the other nursing diagnoses are not present in this scenario.

Which of the following ego defense mechanisms describes the underlying psychodynamics of somatic symptom disorder? A. Denial of depression B. Repression of anxiety C. Suppression of grief D, Displacement of anger

B. Repression of anxiety

Onset and Clinical course

*Clients with somatic symptom disorder often experience symptoms in adolescence *Conversion disorder usually occurs between 10-35 *Pain disorder and hypochondriasis can occur at any age *All somatic symptom illnesses are either chronic or recurrent, and clients with these disorders typically tend to go from one physician or clinic to another *Comorbidity with anxiety and/or depression Expected Findings: symptoms disrupt the daily life, excesive preoccupation with somatic symptoms, increased level of anciety about symptoms, usually present for longer than 6 months, remissions and exacerbations, probable alcohol or other substance use, overmedication with analgesics and anti-anxiety medications

Clinical Picture of Somatic Symptom Disorder

*Common occurrences: -Disproportionate and persistent concerns about the medical seriousness of one's symptoms -High levels of health-related anxiety -Excessive time and energy devoted to the symptoms or health concerns *Usually has a long history of physician visits for complaints of multiple somatic symptoms. -One or more somatic symptoms is distressing or causes significant functional impairment. -Exaggerated and colorful descriptions of symptoms. -Often have histories of repeated surgeries, alcohol or drug abuse, marital instability, and suicide attempts. Ex. of Symptoms Expressed: pain, chest pain, back pain, joint pain, abdominal pain, pelvis pain, dysphagia, nausea, bloating, constipation, stomach stuff, dizziness, fatigue

Application of Process- Implementation and Evaluation

*Developing of effective coping and communication strategies -Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than preoccupation with physical symptoms. *Health teaching and promotion Client family education: daily routine, promote good sleep and nutrition, expression of feelings, keep a journal, limit time spent on physical complaints, limit primary and secondary gains, encourage family to provide attention and encouragement when client has fewer complaints, decrease special attention when in "sick" role Psychotherapy -Behavior—can provide incentives, motivation, and rewards to help patients control their symptoms. -Cognitive Pharmacological: usually SSRIs because they have decreased serotonin levels so are a common treatment, might have a short term us of benzos for their anxiety, risk for dependence so will only be on thee for a short time, tricyclics can be used for pain but have anticholinergic side effects Evaluation: often goals are only partially met. Won't be met right away, keep things positive, will be resistant to change, continue to reinforce their progression Symptoms do provide relief of their anxiety, will be difficult for them to start not going that, will be a work in progress, teach assertiveness, help them talk about what they are feeling, case management is helpful to provide primary person to check in with, can help decrease their anxiety if they have someone like case management they can all all the time

Identifying co-occurring/comorbid condisions

*Differentiating somatic symptom disorders from physical disorders and identifying comorbid conditions are significant issues for the provider. *Identify co-occurring/comorbid conditions. Half of the people that are using frequent medical care are having somatic disorder, depression and anxiety are the two major comorbidities that people will present with *A comprehensive physical examination with appropriate diagnostic studies is necessary to rule out medical conditions that can be confused with somatic symptom disorders.

Predisposing Factors Associated with Somatic Symptoms Disorders

*Genetic- first degree relatives *Biochemical- decreased level of serotonin *Psychodynamic- ego defense mechanism, physical complaints are complaint of low self esteem, would rather have something wrong with their body than with themselves, emotions connected to traumatic event and can't express how they feel *Family Dynamics- raised where they can't express emotions opening, bottled up inside, child grows up knowing they can bring stability into the home by being sick because mom and dad will stop fighting and will take care of me *Precipitating events/past experiences- weak ego, ego defense mechanism, feeling low self esteem or unresolved guilt, can transition to the illness anxiety disorder, repression of inexpressible emotions, traumatic experiences, history of child abuse and neglect-facticious *Learning Theory

somatic symptom illnesses

*Group of disorders characterized by physical symptoms suggesting medical disease, but without demonstrable organic pathology or known pathophysiological mechanisms to account for them. Three Central Features: 1. Physical complaints suggest major medical illness but have no demonstrable organic basis.- coming in with stomach ache, have done many major medical workup and can not find reason for why having stomach ache 2. Psychological factors and conflicts seem important initiating, exacerbating, and maintaining the symptoms. 3. Symptoms or magnified health concerns are not under the client's conscious control.- this is really important to answer, these are real and physical symptoms for them, can't argue with how much pain some is having, often back pain, stomach ache, headaches, patients are very convinced of the symptoms even if we do a whole medical workup

Conversion Disorder

*Loss of, or change in, body function that cannot be explained by any known medical disorder or pathophysiological mechanism. *Essentially functional neurological disorders. *Among the most common of the somatic symptom disorders. *Marked by symptoms or deficits that affect voluntary motor or sensory functions and that suggest a medical condition. -Common symptoms **look these up in book: blindness, paralysis, false pregnancy, often with fingers, feet, and sensory deficits -Course of the disorder is related to its acuity -Most symptoms resolve within a few weeks -About 20% have a relapse within 1 year. - often because not dealing with their stress, another stressful event happens and they they are dealing with their stress in the same way

Nursing Interventions

*Ongoing assessment -Accept that the symptoms are real to the patient *Communication -Limit amount of time client discusses symptoms -Do not given positive reinforcement to the symptoms -Gradually withdraw attention to physical symptoms- don't want to allow them to talk about their symptoms for ever and ever, don't want to reinforce this behavior, give them limits *Teach alternative coping strategies *Therapies -Individual psychotherapy -Behavior therapy

Background Assessment Data

*Symptoms may be vague, dramatized, or exaggerated in presentation *Excessive amount of time and energy is devoted to worry and concern about the symptoms *Chronic disorder, symptoms often beginning before age 30. *Fluctuating course, with periods of remission and exacerbation. *Suggested overlapping personality characteristics with histrionic personality disorder (histrionic, regina George of mean girls, heightened emotionality, labile emotions and moods, seductiveness, strong dependency- want it to be all about them, preoccupation with oneself and symptoms) Might see self medication, alcohol abuse, over medication, etc.

Acute Illness Anxiety (Hypochondriasis)

*Widespread phenomenon: patients with this disorder misinterpret innocent physical sensations as evidence of a serious illness. *Cannot be reassured by negative diagnostic test findings and they seek extensive medical care with frustrating results. *Most present with somatic symptoms as well as total preoccupation with the belief of having a devastating sickness or disease. *People experience severe distress, and their ability to function in personal, social, and occupational roles is impaired. *Highly anxious, chronic, can relapse with stressors

somatiziation

*expressions of stress through physical manifestations *Associated with? Multiple complaints, increased medical costs, can lead to functional impairment, often associated with this, provider dissatisfaction, doctor shopping, psychiatric comorbidities such as anxiety and others, failure to respond to treatment *Is a manifestation of anxiety and this is why they are considered mental illnesses -Transference of medical experiences into bodily -Everything I'm feeling is coming out through my body

Application of Nursing Process-Assessment

-Ensure that a thorough physical examination with appropriate medical tests have been completed.- can't just come in and assume it is one of these disorders -Assess for nature, location, onset, characteristics, and duration of the symptoms. -Assess the patient's ability to meet basic needs. -Assess risks to safety and security needs of the patient as a result of the symptom(s). -Determine whether the symptoms are under the patient's voluntary control. -Identify any primary or secondary gains that the patient is experiencing from symptom(s). -Explore the patient's cognitive style and ability to communicate feelings and needs. -Assess type and amount of medication the patient is using.

Diagnosis Examples

-Ineffective coping evidenced by numerous physical complaints (somatic symptom disorder) -Deficient knowledge (psychological causes for physical symptoms [somatic symptom disorder]) -Chronic pain (somatic symptom disorder) -Fear (of having a serious disease [illness anxiety disorder]) -Disturbed sensory perception (conversion disorder) -Self-care deficit (conversion disorder) -Deficient knowledge (psychological factors affecting medical condition) -Ineffective coping (factitious disorder)

Planning Examples

-Seldom admitted to psychiatric units -Long-term interventions usually take place outpatient basis or in the home -Must address ways to help the patient meet needs without resorting to somatization. -Optimal goal: not only to relieve symptoms, but to increase quality of life and independence.

Summary

-Somatic symptom disorders are associated with anxiety that occurs at the severe level. The anxiety is repressed and manifested in the forms of symptoms and behaviors. -Types of somatic symptom disorders include somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder. -Individuals with somatic symptom disorders often receive health care initially in areas other than psychiatry. -Nurses can assist clients with these disorders by helping them to understand their problem and identify and establish new, more adaptive behavior patterns.

Which of the following is an appropriate expected outcome when working with a patient with somatization disorder? A. Patient will verbally express feelings rather than through the development of physical symptoms. B. Patient will experience no symptoms as a result of psychologic distress. C. Patient will understand the distinction between true physical pain and imagined pain. D. Patient will comprehend how a patient's stress level triggers somatic pain.

A Feedback: the goal is to decrease somatization B-some symptoms might not go away C—no clear distinction between the 2 exists—pain is subjective D—it is important for the patient to recognize triggers, but this goal is poorly stated and does not address behavior change

A nurse is working with a client diagnosed with somatic symptom disorder. What predominant symptoms should a nurse expect to assess? A. Disproportionate and persistent thoughts about the seriousness of one's symptoms B. Amnestic episodes in which the client is pain free C. Excessive time spent discussing psychosocial stressors D. Lack of physical symptoms

A- The primary focus in somatic symptom disorder is on physical symptoms that suggest medical disease but which have no basis in organic pathology. Although the symptoms are associated with psychosocial distress, the individual focuses on the seriousness of the physical symptoms rather than the underlying psychosocial issues.

Neurological tests have ruled out pathology in a client's sudden lower-extremity paralysis. Which nursing care should be included for this client? A. Deal with physical symptoms in a detached manner. B. Challenge the validity of physical symptoms. C. Meet dependency needs until the physical limitations subside. D. Encourage a discussion of feelings about the lower-extremity problem.

A-The nurse should assist the client in dealing with physical symptoms in a detached manner to avoid reinforcing the symptoms by providing secondary gains. This is an example of a conversion disorder in which symptoms affect voluntary motor or sensory functioning. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations.

Diagnostic Criteria for Somatic Symptom Disorder

A. One or more somatic symptoms that are distressing or result in significant disruption in daily life. Often will have more than this. B. Excessive thoughts, feelings, or behaviors r/t the somatic symptoms or associated health concerns as manifested by at least one of the following: 1. Disproportionate and persistent thoughts about the seriousness of one's symptoms 2. Persistently high level of anxiety about health or symptoms 3. Excessive time and energy devoted to these symptoms of health concerns C. Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)

A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by 6 different doctors. The results are normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? A. Conversion disorder B. Prominent health anxiety (illness anxiety disorder) C. Pain disorder D. Dissociative fugue

B-Patients with hypochondriasis have fears of serious medical problems such as cancer or heart disease. These fears persist, despite medical evaluations, and interfere with daily functioning. No complaints of pain are made, and no evidence of dissociation or conversion exists.

To assist a patient with a somatic symptom disorder, a nursing intervention of high priority is to: A. imply that somatic symptoms are not real B. Help the patient suppress feelings of anger C. Shift the focus from somatic symptoms to feelings D. Investigate each physical symptom as it is offered

C Shifting the focus from somatic symptoms to feelings or to neutral topics conveys an interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome is that the patient expresses feelings, including anger, if it is present. Once physical symptoms have been investigated, they do not need to be reinvestigated each time the patient reports them. Want to help them learn more adaptive coping strategies.

Carly has been diagnosed with somatic symptom disorder. As the nurse is talking with Carly and her family, which of the following statements suggest primary or secondary gains that the physical symptoms are providing for the client? A. The family agrees that Carly began having physical symptoms after she lost her job. B. Carly states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor. C. Carly's mother reports that someone from the family stays with Carly each night because the physical symptoms are incapacitating. D. Carly states she noticed feeling hotter than usual the last time she had a headache.

C-Feedback: It is important for the nurse to identify gains that the symptoms might be providing for the client, since these can reinforce illness behavior. Having family attend to the patient when she is symptomatic could reinforce increased dependency and attention needs.

Somatic Symptom Disorder

Characterized by one or more physical symptoms that have no organic basis Pain disorder has moved under somatic symptoms disorder

A client is experiencing pain that has no organic etiology. This pain allows the client to avoid going to work at a job he hates. What best describes what this client is experiencing? A. The client is experiencing altered social interaction. B. The client is experiencing disturbed thought processes. C. The client is experiencing primary gain. D. The client is experiencing secondary gain.

D. The client is experiencing secondary gain.

When working with a client diagnosed with somatic symptom disorder, which is the most appropriate nursing action? A. Avoid discussing social and personal problems. B. Focus on the physical symptoms. C. Always meet the client's dependency needs. D. Gradually minimize time focusing on physical symptoms.

D: The nurse's attention should be on the client's social and personal problems, which are the underlying cause of the somatic symptom disorder. Time focused on physical symptoms should be minimized to avoid reinforcement.

Primary Gain

Direct external benefits that being sick provides- relief of their anxiety, they can focus on the physical symptoms rather than the anxiety

Outcomes Examples

Overall goal is that people with these disorders will eventually be able to live as normal a life as possible. OVERALL GOAL: CAN START TO LIVE A 'NORMAL' LIFE AND CAN DEAL WITH THEIR STRESS AND ANXIETY AND NOT MANIFEST THROUGH THEIR PHYSICAL SYMPTOMS, NOT OFTEN ADMITTED TO INPATIENT, OFTEN TREATED THROUGH OUTPATIENT SERVICES, LONG TERM, HELPING THEM WORK THROUGH THE THERAPIES AND IDENTIFITYING THEIR THOUGHTS AND WORRIES -Copes effectively without resorting to physical symptoms -Verbalizes relief from pain and demonstrates adaptive coping strategies during stressful situations to prevent the onset of pain -Has decreased frequency of physical complaints and interprets bodily sensations rationally Is free of physical disability

Hypochondriasis (now illness anxiety disorder)

Preoccupation with the fear that one has a serious disease, really starts to take over their life, becomes disabling

Conversion Disorder

Unexplained, usually sudden deficits in sensory or motor function (blindness, paralysis) can come in thinking they've had a stroke, usually tricky to diagnose

Learning Theory

learned behaviors that is of direct benefit to them, must assess for primary and secondary gains

Factitious disorder- making a diagnosis

must be ruled out to diagnosis somatic symptom disorder *deliberate fabrication of symptoms or self-injury without obvious gains, they are aware of what they are doing, say they are going to have the symptoms because they know they are going to benefit from these, ex. Self inflicted wounds, manipulating a thermometer, secret use of medications, injections -Imposed on self (Munchausen's syndrome) -Imposed on another- doing it to a child

Malingering- making a diagnosis

must be ruled out to diagnosis somatic symptom disorder *involves a conscious process of intentionally producing symptoms for an obvious benefit *People who malinger have no real physical symptoms or grossly exaggerate relatively minor symptoms. *Can stop the physical symptoms as soon as they have gained what they wanted. *Secondary gains, are aware of it, ex. I can receive pain medications if I go in and complain of pain, seeking financial gain such as work comp claims

Prevalence (don't need to know exact rates)

somatic disorders and conversion disorders-more common in women, in rural areas, and less educated people. illness anxiety- equal in men and women, common onset is early dulthood

Diagnostic Criteria for Conversion Disorder

■ A. One or more symptoms of altered voluntary motor or sensory function. ■ B. Clinical findings provide evidence of incompatibility between the symptoms and recognized neurological or medical conditions. C. Symptom or deficit is not better explained by another medical or mental disorder. D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, or warrants medical evaluation. *Usually quick onset and sudden, won't persist for 6 months or long period of time Symptoms examples: With weakness or paralysis With abnormal movement With swallowing symptoms With speech symptoms With attacks or seizures With anesthesia or sensory loss With special sensory system

Diagnostic Criteria for Illness Anxiety Disorder

■ A. Preoccupation with having or acquiring a seriousness illness. ■ B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g.- strong family history), the preoccupation is clearly excessive or out of disproportionate. ■ C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. ■ D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for sign of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals). ■ E. Illness preoccupation has been present for at least *6 months*, but the specific illness that is feared may change over that period of time. F. the illness=related preoccupation is not better explained by another medical disorder