Somatic disorders
Which would be considered an appropriate outcome when planning care for an inpatient client diagnosed with somatic symptom disorder? A. The client will admit to fabricating physical symptoms to gain benefits by day 3. B. The client will list three potential adaptive coping strategies to deal with stress by day 2. C. The client will comply with medical treatments for physical symptoms by day 3. D. The client will openly discuss physical symptoms with staff by day 4.
B. The client will list three potential adaptive coping strategies to deal with stress by day 2.
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. Carly's mother reports that someone from the family stays with Carly each night because the physical symptoms are incapacitating. ANS: C 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
A client diagnosed with somatic symptom disorder is most likely to exhibit which personality disorder characteristics? A. Uses "splitting" and manipulation in relationships B. Is socially irresponsible, exploitative, and guiltless and disregards rights of others C. Expresses heightened emotionality, seductiveness, and strong dependency needs D. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange
C. Expresses heightened emotionality, seductiveness, and strong dependency needs
Risk factors Biopsychosocial Phenomenon
increased sensitivity to negativity, less resilient prone to catastrophic thinking negative interpretation of life events
Factitious Disorder Imposed on Another: (Munchausen syndrome by proxy)
Caregiver deliberately falsifies illness in a vulnerable dependent Attention and excitement
Factitious Disorders
Consciously pretend to be ill to get emotional needs met and attain status of patient.
The family of a client diagnosed with conversion disorder asks the nurse, "Will his paralysis ever go away?" Which of these responses by the nurse is evidence-based? A. "Most symptoms of conversion disorder resolve within a few weeks." B. "Typically people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives." C. "The only people who recover are those that develop conversion disorder symptoms without a precipitating stressful event." D. "Technically, he could walk now since he is intentionally feigning paralysis."
A. "Most symptoms of conversion disorder resolve within a few weeks." 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.
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. Deal with physical symptoms in a detached manner.
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. Disproportionate and persistent thoughts about the seriousness of one's symptoms The primary focus in somatic symptom disorder is on physical symptoms that suggest medical disease but which have no basis in organic pathology.
A client is diagnosed with illness anxiety disorder. Which of the following symptoms is the client most likely to exhibit? Select all that apply. A. Obsessive-compulsive traits B. Pseudocyesis C. Disabling fear of having a serious illness D. Multiple pronounced physical symptoms E. Depression
A. Obsessive-compulsive traits C. Disabling fear of having a serious illness E. Depression
Malingering: consciously motivated act of fabricating an illness or exaggerating symptoms
Done for secondary gains Reported pains vague, hard to diagnose
Factitious Disorder Imposed on Self
Dramatic description of illness, admitted to hospital Negative test results Accuse staff of incompetence Serious complications may result
Illness Anxiety Disorder
Extreme worry and fear about the possibility of having a disease. • Actual symptom and complain of symptom of mild or absent • Previously known as hypochondriasis • Obsessive, intrusive, hard to dismiss even if patient realizes that fears are unrealistic • Chronic and relapsing, increases with stress Depression may play a role Uses 41%-78% more health care services per year than patients with a well-defined medical condition Need to address patient's health concerns at early stage to avoid excess medical costs and patient fear Elaborately described
Goals of Assuming Sick Role in patients with Factitious Disorders
Factitious Disorder Imposed on Self Factitious Disorder Imposed on Another: (Munchausen syndrome by proxy) Malingering: consciously motivated act of fabricating an illness or exaggerating symptoms
Somatic Disorder
Focus on somatic (physical) symptoms (pain, fatigue) to point of excessive concern, preoccupation and fear Combination of distressing symptoms and an excessive or maladaptive response. ** or associated health concern without significant physical findings and medical diagnosis. Female, ages 16-25 > male Comorbid psychiatric disorders: depression anxiety personality disorder
Psychological Factors
Interrelationships exist between psychiatric and medical comorbidities • Major depressive disorder and CHD • Essential hypertension • Depression and cancer • Peptic ulcer • Tension headache vStress—fight or flight response; Selye's general adaption syndrome • HIV affected by stress · Abnormalities in the brain may misunderstand a stimulus, ie: minor gas pain as a serious abdominal injury
Link between somatization and traumatic experiences
More common in women 20%-25% children (HA, abdominal pain, muscle pain) Childhood maltreatment and increase C-Reactive protein
A patient who experienced a myocardial infarction was transferred from critical care to a step-down unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient's needs. When the nurse manager intervenes directly with this patient, which comment is most therapeutic? a. "I'm wondering if you are feeling anxious about your illness and being left alone." b. "The staff are concerned that you are not satisfied with the care you are receiving." c. "Let's talk about why you use your call light so frequently. It is a problem." d. "You frustrate the staff by calling them so often. Why are you doing that?"
a. "I'm wondering if you are feeling anxious about your illness and being left alone." Blaming someone else and rationalizing one's failure to exercise are not adaptive coping strategies. Seeing the glass as half full, using social and religious supports, and confronting one's situation are seen as more effective strategies. The distracters demonstrate effective coping associated with a serious medical condition.
Which comment by a patient who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies? a. "My employer should have paid for a health club membership for me." b. "My family will see me through this. It won't be easy, but I will never be alone." c. "My heart attack was no fun, but it showed me up the importance of a good diet and more exercise." d. "I accept that I have heart disease. Now I need to decide if I will be able to continue my work daily."
a. "My employer should have paid for a health club membership for me."
A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."
a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." Patients with conversion (functional neurological) disorder demonstrate a lack of concern regarding the seriousness of symptoms.
Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder? a. "What are you unable to do now but were previously able to do?" b. "How many doctors have you seen in the last year?" c. "Who do you talk to when you're upset?" d. "Did you experience abuse as a child?"
a. "What are you unable to do now but were previously able to do?"
A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient support the suspected diagnosis? Select all that apply. a. Female b. Reports frequent syncope c. Rates pain as "1" on a scale of "10" d. First diagnosed with psoriasis at age 12 e. Reports insomnia often results from back pain
a. Female b. Reports frequent syncope e. Reports insomnia often results from back pain
Which presentations suggest the possibility of a factitious disorder, self-directed type? Select all that apply. a. History of multiple hospitalizations without findings of physical illness b. History of multiple medical procedures or exploratory surgeries c. Going from one doctor to another seeking the desired response d. Claims illness to obtain financial benefit or other incentive e. Difficulty describing symptoms
a. History of multiple hospitalizations without findings of physical illness b. History of multiple medical procedures or exploratory surgeries Persons with factitious disorders, self-directed type, typically have a history of multiple hospitalizations and medical workups, with negative findings from workups. Sometimes they have even had multiple surgeries seeking the origin of the physical complaints. I
A patient diagnosed with a somatic symptom disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance
a. Spiritual distress e. Ineffective role performance
A nurse's neighbor says, "I saw a news story about a man without any known illness who died suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be fatal?" The nurse should respond by noting that some serious medical conditions may be complicated by emotional stress, including: (select all that apply) a. cancer. b. hip fractures. c. hypertension. d. immune disorders. e. cardiovascular disease.
a. cancer. c. hypertension. d. immune disorders. e. cardiovascular disease.
Nursing
To the patient, the symptoms feels real. Clinicians should avoid unnecessary, repetitive, or extensive testing in an attempt to demonstrate to the patient and/or family that the presenting complaint is of somatic origin
A patient says, "I know I have a brain tumor despite the results of the MRI. The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive reframing? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your belief." b. "Let's see if there are any other possible explanations for your vomiting." c. "You seem so worried. Let's talk about how you're feeling." d. "We need to talk about something else."
b. "Let's see if there are any other possible explanations for your vomiting."
Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder? a. Narcotic analgesics for use as needed for acute pain b. Antidepressant medications to treat underlying depression c. Long-term use of benzodiazepines to support coping with anxiety d. Conventional antipsychotic medications to correct cognitive distortions
b. Antidepressant medications to treat underlying depression
A patient with blindness related to conversion (functional neurological) disorder says, "All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don't find me as interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance
b. Chronic low self-esteem
A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results were normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Conversion (functional neurological) disorder b. Illness anxiety disorder (hypochondriasis) c. Somatic symptom disorder d. Factitious disorder
b. Illness anxiety disorder (hypochondriasis)
A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder by proxy is suspected. Which nursing interventions are appropriate? Select all that apply. a. Increase private visiting time for the parents to improve bonding. b. Keep careful, detailed records of visitation and untoward events. c. Place mittens on the child to reduce access to ports and incisions. d. Encourage family members to visit in groups of two or three. e. Interact with the patient frequently during visiting hours.
b. Keep careful, detailed records of visitation and untoward events. d. Encourage family members to visit in groups of two or three. e. Interact with the patient frequently during visiting hours.
Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)? a. Voluntary control of symptoms b. Patient's style of presentation c. Results of diagnostic testing d. The role of secondary gains
b. Patient's style of presentation
A patient has blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? a. The patient is suppressing accurate feelings regarding the problem. b. The patient's anxiety is relieved through the physical symptom. c. The patient's optic nerve transmission has been impaired. d. The patient will not disclose genuine fears.
b. The patient's anxiety is relieved through the physical symptom.
A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder. Care planning is facilitated by understanding that the patient will probably: a. readily seek psychiatric counseling. b. be resistant to accepting psychiatric help. c. attend psychotherapy sessions without encouragement. d. be eager to discover the true reasons for physical symptoms.
b. be resistant to accepting psychiatric help.
A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. assume roles and functions of other family members. b. demonstrate performance of former roles and tasks. c. focus energy on problems occurring in the family. d. rely on family members to meet personal needs.
b. demonstrate performance of former roles and tasks.
A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed self after explaining arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self. d. address needs of other patients in the dining room, then feed this patient.
b. expect the patient to feed self after explaining arrangement of the food on the tray.
Which treatment modality should a nurse recommend to help a patient diagnosed with a somatic symptom disorder to cope more effectively? a. Flooding b. Response prevention c. Relaxation techniques d. Systematic desensitization
c. Relaxation techniques
A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as: a. marginally successful. b. minimally successful. c. partially successful. d. totally achieved.
c. partially successful. Decreased preoccupation with symptoms and increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance.
A patient diagnosed with a somatic symptom disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess: a. mood. b. cognitive style. c. secondary gains. d. identity and memory.
c. secondary gains.
To assist patients diagnosed with somatic symptom disorders, nursing interventions of high priority: a. explain the pathophysiology of symptoms. b. help these patients suppress feelings of anger. c. shift focus from somatic symptoms to feelings. d. investigate each physical symptom as it is reported.
c. shift focus from somatic symptoms to feelings.
What are the symptoms of Somatic Disorders?
chest pain, SOB, headache insomnia, numbness, swelling fatigue, back pain, and abdominal pain Patients feel discounted and misunderstood; HCP feels frustrated 40% of all visits to PCP. Less pt centered communication Described elaborately, likely depressed
What is an essential difference between somatic symptom disorders and factitious disorders? a. Somatic symptom disorders are under voluntary control, whereas factitious disorders are unconscious and automatic. b. Factitious disorders are precipitated by psychological factors, whereas somatic symptom disorders are related to stress. c. Factitious disorders are individually determined and related to childhood sexual abuse, whereas somatic symptom disorders are culture bound. d. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization.
d. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization.
Conversion Disorder
Also known as functional neurological disorder Neurological symptoms in the absence of a neurological diagnosis. Channeling of emotional conflicts or stressors into physical symptoms Deficits in voluntary motor or sensory functions (paralysis, blindness, movement disorder, gait disorder, numbness, paresthesia (tingling or burning sensations), loss of vision or hearing, or episodes resembling epilepsy. Lack of personal concern or ***la belle indifference or the grand indifference" ***Childhood physical or sexual abuse is common finding Comorbid psych diagnosis: Depression Anxiety PTSD Personality disorders (learned helplessness) other somatic disorders With acute onset during stressful events, remission rate high; gradual onset not as readily treated Always r/o medical or neurological condition first Patient says: Very matter of fact, I stepped on the step and now I can't walk
A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, "My chest is tight, and my heart misses beats. I'm often absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Somatic symptom disorder c. Antisocial personality disorder d. Illness anxiety disorder (hypochondriasis)
d. Illness anxiety disorder (hypochondriasis) Illness anxiety disorder (hypochondriasis) involves preoccupation with fears of having a serious disease even when evidence to the contrary is available.
A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that the patient: a. sees a relationship between symptoms and interpersonal conflicts b. has little difficulty communicating emotional needs to others. c. rarely derives personal benefit from the symptoms. d. has altered comfort and activity needs.
d. has altered comfort and activity needs. Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the patient as a person rather than as a condition
To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a. are generally chronic. b. have a physiological basis. c. can be voluntarily controlled. d. provide relief from health anxiety.
d. provide relief from health anxiety.
