SOMATOFORM

DISORDERS
OVERVIEW OF SOMATOFORM
DISORDERS

The terminology is unsatisfactory. Many

terms have been used, including
psychiatric terms such as hysteria and
hypochondriasis (historical words now
used with more precise definitions) and
more general terms including functional
symptoms, somatization, somatoform
symptoms, functional overlay.
Somatization is the most widely used
general term.

The term psychosomatic began

to be used to convey the connection between the mind
(psyche) and the body (soma) in states of health
and illness. Essentially the mind can cause the body
to create physical symptoms or to worsen physical
illnesses. Real symptoms can begin, continue, or be
worsened as a result of emotional factors. Examples
include diabetes, hypertension, and colitis, all of
which are medical illnesses influenced by stress and
emotions. When a person is under a lot of stress or
is not coping well with stress, symptoms of these
medical illnesses worsen.

Causes of bodily sensations

Major pathology
Minor pathology
Physiological processes:
Sinus tachycardia, effect of fatigue,
effect of overeating, effects of prolonged
inactivity,
Autonomic effects of anxiety
Luck of sleep.

Illness experience which may affect the interpretation of bodily

sensations and concern

Childhood illness.
Family illness and consultation in
childhood.
Childhood consultation and school
absence
Physical illness in adult life
Experience and satisfaction with medical
consultation

Illness in family and friends

Publicity in television, newspapers
Knowledge of illness and its treatmen

The association with psychiatric

disorder

The majority of medically unexplained

symptoms in general populations are not
associated with psychiatric disorder, but
such an association is more likely in
those that are persistent and those that
are multiple. The type of psychiatric
disorder is frequently one of the
standard categories of anxiety or
affective disorder, and this is true for all
cultures.

There is now considerable evidence from

smaller local studies and major international
collaborative research, that the more severe
and disabling unexplained symptoms are
associated with anxiety and depressive
disorder and that the association is strongest
for those who have the greatest number of
unexplained symptoms. The association is
generally similar for all cultures that have
been studied. There are also associations with
the somatoform disorders

Categories of somatoform disorders

in ICD-10 and DSM-IV

ICD-10

DSM1V

Somatization disorder

Somatization disorder

Undifferentiated
somatoform disorder

Undifferentiated
somatoform disorder

Hypochondriacal
disorder

hypochondriasis

Somatoform autonomic
dysfunction

------------

Persistent pain disorder

Pain disorder associated

with psychological
factors (and a general
medical condition)

Other somatoform
disorders

Somatoform disorders
not otherwise specified

------

Body dysmorphic
disorder

-------

Conversion disorder

Neurasthenia

OVERVIEW OF SOMATOFORM
DISORDERS

Somatization is defined as the

transference of mental experiences
and states into bodily symptoms.
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:

1- Physical complaints suggest major medical

illness but have no demonstrable organic
basis.
2- Psychological factors and conflicts seem
important in initiating, exacerbating, and
maintaining the symptoms.
3- Symptoms or magnified health concerns are
not under the clients conscious control
(Guggenheim, 2000).

Diagnostic criteria of somatoform

disorders

A- a history of many physical complains

beginning before the age 30 that
occurred over a period of several years
and results in treatment being sought or
significant impairment in social,
occupational, or other important area of
functioning

B. each of the following criteria must have

been met with individual symptoms
occure at any time during the course of
disturbance :
1- four pain symptoms: a history of pain
related to at least four different sites or
functions ( head, abdomen, back ,joint,
extremities, chest , rectum, during
menstruation, during sexual intercourse
or during urination

2- two gastrointestinal symptoms: A history

of at least two gastrointestinal symptoms
other than pain ( nausea, bloating,
vomiting other than during pregnancy,
diarrhoea, or intolerance of food.
3- one sexual symptom: a history of at
least one sexual or reproductive symptom
other than pain ( erectile dysfunction,
irregular menses, excessive menstrual
bleeding

4- one pseudoneurological symptom: A

history of at least one symptom or deficit
suggesting a neurological condition not
limited to pain (conversion symptoms
such as impaired coordination or
balance, paralysis or localized weakness,
difficulty swallowing, urinary retention,
blindness, deafness, seizures, amnesia
or loss of consciousness.

C. either 1 or 2
1- After appropriate investigation, each of
the symptoms in criterion B cant be
explained be fully explained by a known
general medical condition or the direct
effect of a substance (eg. A drug of abuse).
2- when there is a related general medical
condition, the physical complains or
resulting social or occupational impairment
are in excess from the history

The five specific somatoform disorders are

Somatization disorder is
characterized
by multiple physical symptoms. It begins
by
30 years of age, extends over several
years,
and includes a combination of pain and
gastrointestinal, sexual, and
pseudoneurologic
symptoms.

Pain disorder
has the primary physical symptom of
pain, which generally is unrelieved by
analgesics and greatly affected by
psychological factors in terms of onset,
severity, exacerbation, and
maintenance.

Hypochondriasis
is preoccupation with the fear that
one has a serious disease (disease
conviction) or will get a serious
disease (disease phobia). It is
thought that clients with this disorder
misinterpret bodily sensations or
functions.

Body dysmorphic disorder

is preoccupation with an imagined or
exaggerated defect in physical
appearance such as thinking ones nose
is too large or teeth are crooked and
unattractive.

ONSET AND CLINICAL COURSE

Clients with somatization disorder and

body dysmorphic disorder often
experience symptoms in adolescence,
although these diagnoses may not be
made until early adulthood (about 25
years of age). conversion disorder
usually occurs between 10 and 35 years
of age. Pain disorder and
hypochondriasis can occur at any age
(APA, 2000).

ETIOLOGY
Psychosocial Theories

Psychosocial theorists believe that

people with somatoform disorders keep
stress, anxiety, or frustration inside
rather than expressing them outwardly.
This is called internalization. Clients
express these
internalized feelings and stress through
physical symptoms (somatization).

Biologic Theories

Research has shown differences in the way

that clients with somatoform disorders regulate
and interpret stimuli. These clients cannot sort
relevant from irrelevant stimuli and respond
equally to both types. In other words, they may
experience a normal body sensation such as
peristalsis and attach a pathologic
rather than a normal meaning to it
(Guggenheim,
2000).

CULTURAL CONSIDERATIONS

The type and frequency of somatic

symptoms and their meaning may vary
across cultures. Pseudoneurologic
symptoms of somatization disorder in
Africa and South Asia include burning
hands and feet and the nondelusional
sensation of worms in the head or ants
under the skin.

TREATMENT

Treatment focuses on managing symptoms and

improving
quality of life. The health care provider must
show empathy and sensitivity to the clients
physical
complaints (Margo & Margo, 2000). A trusting
relationship
will help to ensure that clients stay with and
receive care from one provider instead of doctor
shopping.

For many clients, depression may

accompany or result from somatoform
disorders. Thus antidepressants help in
some cases. Selective serotonin
reuptake inhibitors, such as fluoxetine
(Prozac), sertraline (Zoloft), and
paroxetine (Paxil), are used most
commonly

For clients with pain disorder, referral to a chronic

pain clinic may be useful. Clients learn methods of
pain management such as visual imaging and
relaxation.
Services such as physical therapy to maintain
and build muscle tone help to improve functional
abilities. Providers should avoid prescribing and
administering
narcotic analgesics to these clients because
of the risk of dependence or abuse.

In terms of prognosis, somatoform disorders tend

to be chronic or recurrent. Conversion disorder often
remits in a few weeks with treatment but recurs in
25% of clients. Somatization disorder,
hypochondriasis,
and pain disorder often last for many years, and
clients report being in poor health. People with body
dysmorphic disorder may be preoccupied with the
same or a different perceived body flaw throughout
their lives (APA, 2000).

Nursing Intervention

PROVIDING HEALTH TEACHING

The nurse must help the client to establish a daily routine
that includes improved health behaviors. Adequate
nutritional intake, improved sleep patterns,
and a realistic balance of activity and rest are all areas
with which the client may need assistance. The nurse
should expect resistance including protests from the
client that she or he does not feel well enough to do
these things. The challenge for the nurse is to validate
the clients feelings while encouraging her or him to
participate in activities.

ASSISTING THE CLIENT TO

EXPRESS EMOTIONS

Teaching about the relationship between

stress and physical symptoms is a useful
way to help clients begin to see the
mindbody relationship. Clients may
keep a detailed journal of their physical
symptoms.

TEACHING COPING STRATEGIES

Two categories of coping strategies are important

for
clients to learn and to practice: emotion-focused
coping strategies, which help clients relax
and reduce
feelings of stress; and problem-focused coping
strategies, which help to resolve or change
a
clients behavior or situation or manage life
stressors.

Emotion-focused strategies include progressive

relaxation,
deep breathing, guided imagery, and distractions
such as music or other activities. Many
approaches
to stress relief are available for clients to try.
The nurse should help clients to learn and practice
these techniques, emphasizing that their
effectiveness
usually improves with routine use.