CASE STUDY

SOMATOFORM DISODER IN THIS ARTICLE

A.INTRODUCTION

Somatic symptom disorder (SSD formerly known as "somatization disorder “a form of mental
illness that causes one or more bodily symptoms, including pain. The symptoms may or may not
be traceable to a physical cause including general medical conditions, other mental illnesses, or
substance abuse. But regardless, they cause excessive and disproportionate levels of distress.

HISTORY COLLECTION
I. IDENTIFICATION
Name: J M

Sex: Male

Age: 30 years old

Marital status: Single

Place of birth: South Province

Nyanza District

Cyahinda Sector

Mukoni Cell

Gasharu village

Sibling’s position: 2nd in 4 children

Profession: veterinarian's assistant.

Religion: Catholic

Nationality: Rwandese

Admission date:

II. CHIEF COMPLAINT

“I took an overdose of some pills but I'm fine now.” total insomnia, logorrhea,Pain
Neurologic problems, gastrointestinal complaints and
Sexual symptoms
III. ANTECEDENT/PEVIOUS MENTAL HISTORY
This is the first psychiatric hospital admission 1st crisis.
IV. FAMILY HISTORY:
The patient's immediate family consists of his father (age 51), his mother (age 49), one older
brother (age 26), one young brother (age 22) and one younger sister (age 19). His father suffers
from alcohol dependence. Family history is otherwise negative for psychiatric disorders, medical
disease, dementia, addiction, suicide attempts, and violence.
Genogram:

                           

V. MEDICAL AND SURGICAL: None

VI. GYNECOLOGICAL HISTORY: She is still single with no gynecological problems.
VII. JUDICIAL HISTORY: None
VIII. PERSONAL HISTORY
The patient grew up in a medium-size city. His relationships with family members have always
been difficult. While he often got into physical fights with his brother and his father, there is no
history of physical, verbal, or sexual abuse.
In school, he had difficulty controlling his behavior, getting into fights and cursing a great deal.
He was a good student when he worked, receiving and honors in middle school and in the ninth
grade. He failed all of his classes and needed to repeat the year.
He attributed this to ignoring school and partying too much. During his last year of high school,
he attended a special arts school, studying drama and jazz. He graduated from high school after 5
years. He had trouble making friends. He had a girlfriend for 2½ years in high school, but they
broke up because they argued too much. He met his first girlfriend at age 17, but this boy cheated
on her, precipitating the previous suicide attempt. In the past 2 or 3 years, the patient has found
himself primarily attracted to men but still considers him bisexual.
There is a significant history of substance abuse. During his second and third years in high
school, he smoked marijuana two to three times each week. He stopped after graduation and has
since smoked marijuana only two or three times. He used cocaine once in high school and only
occasionally in the past 2 years, snorting a few lines each time.
IX. PHYSICAL EXAMINATIONS

i) General appearance: he has reddish eyes due to drugs and alcohol consumption with dirtiness
of clothes.

ii) HEENT: Patient does not have any problem of ears, nose with dry mouth; pink tongue with
no sore throat neck is flexed, dirty hairs.
iii) Respiratory system: no any problem in respiration presented or observed to the client.
iv) Cardiovascular system: no problem indicated to the heart with normal heart sounds.

v) Nervous system: normal sensation, shaking due to use of drugs and alcohol for long time
when he is still young, pupils is reacting to light, with GCS of 13/15.

vi) GI: No abdominal tenderness or distended.

vii) Urinary system: no complaints of urination.

viii) Integumentary system: he has scars on the left leg due to accident and head due to
wounding during alcohol consumption.

ix. Vital signs: Blood pressure: 128/70mmHg

 Pulse: 76 bpm

Temperature: 37.40c

Respiration rate: 18 bpm                 

X. PSYCHIATRIC CONDITIONS

General appearance: he is medium in size with dirty dressing with agitation, hyperactivity and
logorrhea.

Affect and mood: he is talkative and answers the nurse with unrelated words.

Perception: he has hallucinations, illusion and delusion.

Thought and speech: Has a high flow of speech with incomplete and unrelated words. His
thoughts full of hopelessness and low self-esteem but no delusions.

Orientation: he is oriented to time, place and to person.

Memory and concentration: he has the ability to recall past and recent history of her life but
mixing with his desire.

Judgment and impulse control: he has ability to plan for his future with unachievable

Insight: he has negative insight

Vegetative symptoms: normal level of energy, loss of appetite, nausea due to toxic drugs.

MULTIAXIAL DIAGNOSIS
Axis I: Schizophrenia

Axis II: no mental retardation or personality disorder.

Axis III: NONE

AXIS IV: Family and jobless stressing

XI. COMPLEMENTARY EXAMS

-Full blood count (FBC): NORMAL RESULTS

-HIV Test: Negative

XIV. TREATMENT:

-Tegretol tab 200mg BID

- Haldol tab 5mg. BID

-Nozinan tab 100mg OD

SOMATOFORM DISORDER

Somatoform disorders cause physical symptoms to appear even though there isn't a medical
condition to cause them. The psychological nature of the pains and symptoms can cause people
to continually seek treatment even when there is nothing medically wrong with them. Symptoms
include insisting on getting medical tests, and real or imagined pain that has no obvious source.
Online therapy which can help with the symptoms of somatoform disorders is available from
highly skilled therapists with Go Mentor 24/7.

Symptoms of Somatoform Disorders

 Insistence on testing
 Unexplained medical symptoms
 Chronic complaints about pain or other symptoms
 Extreme fear of having a medical illness that lasts more than six months
 Loss of voluntary motor abilities or a sensory function that is not due to medical
illness
 Constant pain in one or more anatomical spots
 Preoccupation with an imagined defect
 Pain
 Neurologic problems
 Gastrointestinal complaints
  Sexual symptoms

Dangers of Somatoform Disorders

One of the dangers that come with somatoform disorders is the possibility of financial problems
due to numerous unnecessary medical tests. Another risk associated with these disorders is that a
person will try to make their illness or pain more real by mutilating or harming themselves to
mimic symptoms of various diseases or medical conditions. There are various other physical and
psychological risks depending on the particular type of somatoform disorder that is diagnosed.
They can be minimized, however, when treatment is sought

Treatment for Somatoform Disorders

With Go Mentor 24/7 you can get help from trained therapists who specialize in somatoform
disorders. They can help give the guidance and support needed to effectively deal with these
types of disorders. This combination of psychotherapy and the Internet makes it easier than ever
to get help with all the symptoms of somatoform disorder

NURSING MANAGEMENT

I. List of patient problem

1. Disturbed Thought Processes

2. Sustained maladaptive response

3. Disturbed Sensory Perceptions

II.Priority

1. Disturbed Thought Processes

2. Sustained maladaptive response

 3. Disturbed Sensory Perceptions

Assessment Nursing Goals Intervention Rationale Implimentation Evaluation

Diagnosis
Subjective data Disturbed Short-Term Assess the level of Will facilitate care Patient thinking Patient’s state
He says” zana inzoga Thought Goal thinking. provider for was assessed. after nursing
twinkwere mureke Processes r/t proper interventions
abo basinzi, ibyo ni repressed Client will Encourage same intervention. improving
ibicucu kandi fears develop staff to work with Staff encouraged compared to the
mundeke nitahire Evidenced by trust in at client as much as To promote working with admission day.
nsange amatungo Inability to least one possible. development of patient. Continue create a
yange” meet basic staff trusting trust and check if
needs, member Avoid laughing, relationship. has swallow drugs
Objective data Alteration in within 1 whispering, or Avoided because
Patient sitting on societal week. talking quietly Suspicious clients laughing, sometimes reject
chair hands clasped participation. where client can often believe whispering, or it and show that
together, shake when Long-Term see but not hear others are talking quietly has swallow.
moved, reduced Goal what is being said. discussing them, while patient is
emotional expression, and secretive not involved.
social isolation, no Client will Be honest and behaviors
eye contact when demonstrate keep all promises. reinforce the Honest was kept
conversed with. use of more paranoid feelings. to the patient.
adaptive
Vital signs coping Mouth checks Honesty and Mouth checked
Bp= 122/74 mmHg skills, as may be necessary dependability after medication
Pl=76 Bpm evidenced after medication promote a trusting administration.
T0= 37.00C by administration. relationship.
RR= 19 Bpm appropriaten To verify that Verbalization to
ess of Encourage client client is the patient
interactions to verbalize true swallowing the encouraged.
and feelings. The tablets or capsules.
willingness nurse should avoid Suspicious clients
to becoming may believe they
participate defensive when are being poisoned
in the angry feelings are with their
therapeutic directed at him or medication and
community. her. attempt to discard
the pills.
Verbalization of
feelings in a
nonthreatening
environment may
help client come
to terms with
long-unresolved
issues.
Assessment Nursing Objectives Planning Rationale Evaluation
diagnosis
Objective: Sustained After 3 days -Encourage the - After the
-Flashbacks maladaptive of nursing client to express Identification nursing
or re- response to a intervention his or her feelings and intervention
experiencing traumatic, the client through talking, expression of the client
the overwhelming will have writing, crying, feelings are had
traumatic event as minimized or other ways in central to minimized
event(s) evidenced by dissociative which the client grieving the
-Nightmares Flashbacks episodes is comfortable. process. dissociative
or recurrent or re- or flashbacks episodes
dreams of experiencing through -Encourage the -Retelling or flashbacks
the event the traumatic grounding client to talk the through
or another event techniques about his or experience grounding
trauma event and reality her experience(s); can help the techniques
-Sleep orientation. be accepting and client to and reality
disturbances nonjudgmental of identify the orientation.
-depression- the client’s reality of
denial accounts and what has
of feelings perception. happened
or emotional and help to
numbness identify and
work through
related
feelings.