Transcript Psychopharmacology and Other Biologic Treatments

Somatoform and Related
Disorders
Chapter 21
Key Terms
• Psychosomatic
– Psychological state that contributes to the
development of a physical illness
– Mental diagnoses characterized by unexplained
medical disabilities
• Somatization
– Manifestation of physical symptoms from
psychological distress
– Primary symptom of somatoform and factitious
disorders
Definition of Disorders
• Somatoform disorders
– Patient suffers physical symptoms as a
result of psychological stress.
• Factitious disorders
– Patient self-inflicts injury as a result of
psychological stress to seek outside
treatment.
Somatoform Disorders
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Somatization Disorder
Undifferentiated Somatization Disorder
Conversion Disorder
Pain Disorder
Hypochondriasis
Body Dysmorphic Disorder
Somatization
• Culture
• Physical sensations are experienced according
to culturally defined expectations.
• Gender
• Women more than men?
– Social acceptance
– Boys taught not to cry
– Higher incidence of depression (somatic
problems)
– Women can express problems in relationships.
• Mexican American vs. non-Hispanic
• Older, separated, widowed or divorced
Somatization Disorder
• Polysymptoms that begin before the age of 30
• Involve many body systems
• Prevalence 13% of population (estimated 4-5/1000)
• Rarely seen by mental health provider
• In medical office, two or three out of every 50 patients
are undiagnosed.
• More prevalent in women (90 to 95%)
Clinical Course
• Recurring, multiple and clinically
significant somatic problems involving
several body systems (GI, neuro and
musculoskeletal)
• Episode of physical illness may last six
to nine months.
• “Sicker than the sick”
Somatization Disorder in Special
Populations
• Children
– Not diagnosed in childhood, typically begins in
adolescents
– Menstrual problems usually one of first symptoms
• Elderly
– Occurs, but is little research
– Need to differentiate disorder from medical
problems
• Occurs in all populations and cultures
Epidemiology
• 0.2 to 2% of general population, but could be as
many as two to three of every 50 patients seen in
primary care. Real prevalence may be 4-5/1000.
• Before age 30 (by definition)
• Occurs primarily in women
• Inversely related to SES
• Worldwide, may be higher in South Americans,
Mexican Americans, Puerto Ricans
• Often co-exists with medical problems
Etiology: Unknown
• Biologic
– Responsive to relevant and irrelevant stimuli
– Increased risk in first-degree relatives
– Numerous menstrual problems
• Psychological
– A patterned way of communicating
• Social
– ASP, alcoholism in family members
– Cultural expressions of other disorders
Risk Factors
• Women from families with multiple,
unexplained somatic complaints
• Abuse
• For men, not yet identified
Interdisciplinary Treatment
• Providing long-term general
management of the chronic condition
• Conservatively treating comorbid
psychiatric and physical problems
• Providing care in special settings,
including group treatment
Nursing Management:
Biologic Domain
• Assessment:
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Review of systems
Assessment of pain
Physical functioning
Pharmacologic
• Usually taking a large number of meds
• Self-medicate and provider shop
– Health attitude survey
– Review clinical vignette
• Nursing Diagnoses
– Fatigue, pain, disturbed sleep
Biologic Nursing Interventions
• Spend time with physical complaints
• Help patient establish a daily routine
• Continually monitor medication
• Pain management – need multiple approaches
• Activity enhancement
• Nutrition regulation
• Relaxation
Pharmacologic Interventions
• There is no medication for somatization
disorder.
• Treat the comorbid disorders.
– Depression: antidepressants - MOAI
– Anxiety: Avoid benzodiazepines.
• Monitor closely.
• Observe for drug-drug interactions.
Nursing Management:
Psychological Domain
Assessment
Nursing Diagnoses
• Mental status usually normal
• Anxiety
• Appearance may be
flamboyant, exaggerated
• Ineffective sexuality patterns
• Preoccupied with personal
illness (may keep a copy of
record), series of personal
crisis.
• Emotional reactions to life
stressors
• Labile mood
• Impaired social interactions
• Ineffective coping
• Ineffective management of
therapeutic regimen
Psychological Nursing
Interventions
• Maintaining nurse-patient relationship
• Counseling
• Problem solving
• Health teaching
Nursing Management:
Social Domain
Assessment
• How much time seeking
medical care and treating
illnesses?
• Extent of disability?
• Employment status?
• Social network? Do they
see their friends as
providers?
• Family members
– Tired of all the complaints?
– Alcoholism is common.
Nursing Diagnosis
• Caregiver role strain, risk
• Ineffective community coping
• Disable family coping
• Social isolation
Nursing Diagnosis
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Fatigue
Pain
Sleep pattern disturbance
Altered sexuality patterns, anxiety
Ineffective coping
Impaired social interactions
Ineffective management of therapeutic
regimen
Social Nursing Interventions
• Problem-solving groups
• Assertiveness groups
• Family interventions
Continuum of Care
• Inpatient care – very rare
• Emergency care – mostly for physical
problems, except when depressed
• Community treatment
– Spend lifetime in health care system
– Most care delivered as outpatient
Factitious Disorders
• Factitious disorder (Munchausen’s syndrome)
– Different than malingering (has other motivations)
– Injure themselves covertly
– Produce physical symptoms
• Factitious disorder NOS (by proxy)
– Injure others in order to gain attention (mother
hurting child)
Nursing Management
Assessment
• Chronology of
medical/psychological
illnesses
• Early childhood
experiences (abuse,
neglect, role of selfinjury)
• Family assessment
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• Nursing Diagnosis
Risk for trauma
Risk for selfmutilation
Ineffective individual
coping
Low self-esteem
Nursing Intervention
• Goal: To replace dysfunctional, attentionseeking behaviors with positive behaviors
• Accept and value patient.
• Encourage long-term psychotherapy.
• Confrontation is effective if patient feels
supported.