Somatoform Disorders

CRITICAL PATHWAY of Care for the Posttrauma Client

Estimated length of stay: 14 days-variations from designated pathway should be documented in progress notes.

Nursing Diagnosis and Categories	Dimension	Goals/Actions	Time Dimension	Goals/Actions	Dimensions	Discharge Outcome
Posttrauma response	Day 1	Reassurance of client safety	Ongoing	Environment is made safe for	Day 14	Client is able to carry out activities of daily living. Fewer flashbacks, nightmares.
Referrals	Day 1	Psychiatrist Psychologist Social worker Clinical nurse spe- Music therapist Occupational thera- Recreational thera- Chaplain			Day 14	Discharge with follow-up appointments as required.
3 Diagnostic studies	Day 1	Drug screen ECG EEG
	Day 2-5	MMPI Impact of event scale (IES)
Medications	Day 1	Antidepressant medication as ordered (tricyclics or MAO inhibitors) Antianxiety medication, as ordered (benzodiazepines); may be given pm because of addictive quality Clonidine or propranolol (for intrusive thoughts and hyperarousal) Sedative-hypnotics for sleep disturbances; may be given pm	Day 1-14	Assess for effectiveness and side effects of medications Administer addictive medications judiciously and taper dosage.	Day 14	Discharged with medications as ordered by MD (e.g., antidepressants, clonidine, propranolol).
Additional assessments	Day 1	VS every shift assess: Mental status Mood swings Anxiety level Social interaction Ability to carry out activities of daily living Suicide ideation Sleep disturbances Flashbacks Presence of guilt feelings	Day 2-14 Day 2-13	VS daily if stable. Ongoing assessments	Day 14	Anxiety is maintained at manageable level. Mood is appro- Interacts with Carries out activities of daily living independently. Denies suicide ideation. Sleeps without medication. Is able to interrupt flashbacks with adaptive, coping strategies. Has worked through feelings of guilt.
Diet	Day 1	Client’s choice or low-tyramine if taking MAO inhibitors	Day 2-14	Same.	Day 14	Client eats well balanced diet.
Client education	Day l	Orient to unit	Day 5-12	Stages of grief. Side effects of medications. Coping strategies. Low-tyramine diet. Community resources. Support group. Importance of not mixing drugs and alcohol.	Day 14	Client is discharged. Verbalizes understanding of information presented before discharge.
			Day 12-13	Reinforce teaching.

Main characteristic: involuntary, physical symptoms without demonstrable organic findings or identifiable physiological bases; involve psychological factors or nonspecific conflicts.

General assessment:
1. Precipitant: major emotional, interpersonal stress.
2. Occurrence of secondary gain from illness.
General analysis/nursing diagnosis:
1. Fear related to loss of dependent relationships.
2. Powerlessness related to chronic resentment over frustration of dependency needs.
3. Altered feeling states: inhibition of anger, which is discharged physiologically and is related to control of anxiety.
4. Impaired judgment related to denial of existence of any conflicts or relationship to physical symptoms
5. Altered role performance: regression related to not having dependency needs met.

Somatization Disorder

Repeated, multiple, vague or exaggerated physical complaints of several years’ duration without identifiable physical cause; clients constantly seek medical attention, undergo numerous tests; at risk for unnecessary surgery or drug abuse.

Assessment:
1. Onset and occurrence - teen years, more common in women.
2. Reports illness most of life.
  1. Neuromuscular symptoms - fainting, seizures, dysphagia, difficulty walking, back pain, urinary retention.
  2. Gastrointestinal symptoms - nausea, vomiting, flatus, food intolerance, constipation or diarrhea.
  3. Female reproductive symptoms - dysmenorrhea, hyperemesis gravidarum.
  4. Psychosexual symptoms - sexual indifference, dyspareunia.
  5. Cardiopulmonary symptoms - palpitations, shortness of breath, chest pain.
  6. Rule out: multiple sclerosis, systemic lupus erythematosus, porphyria, hyperparathyroidism.
3. Appears anxious and depressed.
Analysis/nursing diagnosis:
1. Anxiety related to threat to security, unmet dependency needs, and inability to meet role expectations.
2. Self-care deficit related to development of physical symptoms to escape stress full situations.
3. Impaired social interaction related to inability to accept that physical symptoms lack a physiological basis; preoccupation with self and physical symptoms, chronic pain; rejection by others.
4. Body-image disturbance and altered role performance related to passive acceptance of disabling symptoms.

Conversion Disorder (Hysterical Neuroses, Conversion Type)

Sudden symptoms of symbolic nature developed under extreme psychological stress (e.g., war, loss, natural disaster) that disappear through hypnosis.

Assessment:
1. Neurological symptoms - paralysis, aphonia, tunnel vision, seizures, blindness, paresthesias, anesthesias.
2. Endocrinological symptoms - pseudocyesis.
3. Hysterical, dependent personality profile: exhibitionistic dress and language; self-indulgent; suggestible; impulsive and global impressions and hunches; little capacity to concentrate, integrate, and organize thoughts or plan action or outcomes; little concern for symptoms, despite severe impairment (“La Belle Indifference”).
Analysis/nursing diagnosis:
1. Prolonged loss or alteration of physiological processes related to severe psychological stress and conflict that results in disuse, atrophy, contractures. Primary gain - internal conflict or need is kept out of awareness; there is a close relationship in time between stressor and occurrence of symbolic symptoms.
2. Impaired social interaction: chronic sick role related to attention seeking.
3. Noncompliance with expected routines related to secondary gain - avoidance of upsetting situation, with support obtained from others.
4. Impaired adjustment related to repression of feelings through somatic symptoms, regression, denial and isolation, and externalization.
5. Ineffective individual coping, e.g., day-dreaming, fantasizing, superficial warmth and seductiveness related to inability to control symptoms voluntarily or to explain them by known physical disorder.

Hypochondriasis (Hypochondriacal Neurosis)

Exaggerated concern for one’s physical health; unrealistic interpretation of signs or sensations as abnormal; preoccupation with fear of having serious disease, despite medical reassurance of no diagnosis of physical disorder.

Assessment:
1. Preoccupation with symptoms; sweating, peristalsis, heartbeat, coughing, muscular soreness, skin eruptions.
2. Occurs in both men and women in adolescence, 30s, or 40s.
3. History of long, complicated shopping for doctors and refusal of mental health care.
4. Organ neurosis may occur (e.g., cardiac neurosis).
5. Personality trait: compulsive.
6. Prevalence of anxiety and depression.
7. Controls relationships through physical complaints.
Analysis/nursing diagnosis:
1. Personal identity disturbance related to perception of self as ill in order to meet needs for dependency, attention, affection.
2. Displaced anxiety related to inability to verbalize feelings.
3. Fear related to not being believed.
4. Powerlessness related to feelings of insecurity.
5. Altered role performance: disruption in work and interpersonal relations related to regression and need gratification through preoccupation with fantasized illness; and related to control over others through physical complaints.

General nursing care plans/implementation for somatoform disorders:
1. Long-term goals:
  1. Develop interests outside of self. Introduce to new activities and people.
  2. Facilitate experiences of increased feelings of independence.
  3. Increase reality perception and problem-solving ability.
  4. Emphasize positive outlook and promote positive thinking. Reassure that symptoms are anxiety related, not a result of physical disease.
  5. Develop mature ways for meeting affection needs.
2. Short-term goals:
  1. Prevent anxiety from mounting and becoming uncontrollable by recognizing symptoms, for early intervention.
  2. Environment: warm, caring, supportive interactions; instill hope that anxiety can be mastered.
  3. Encourage client to express somatic concerns verbally. Encourage awareness of body processes.
  4. Provide diversional activities.
  5. Develop ability to relax rather than ruminate or worry. Help find palliative relief through anxiety reduction (slower breathing, exercise).
3. Health teaching:
  1. Relaxation training as self-help measures.
  2. Increase knowledge of appropriate and correct information on physiological responses that accompany anxiety.
General evaluation/outcome criteria:
1. Does not isolate self.
2. Discusses fears, concerns, conflicts that are self originated and not likely to be serious.
3. Decides which aspects of situation can be overcome and ways to meet conflicting obligations.
4. Looks for things of importance and value.
5. Deliberately engages in new activities other than ruminating or worrying.
6. Talks self out of fears.
7. Decrease in physical symptoms; is able to sleep, feels less restless.
8. Makes fewer statements of feeling helpless.
9. Can freely express angry feelings in overt way and not through symptoms.