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Psychiatric-Mental Health Nursing

21.1 Psychological and Behavioral Factors in Somatic Symptom Disorders

Psychiatric-Mental Health Nursing21.1 Psychological and Behavioral Factors in Somatic Symptom Disorders

Learning Objectives

By the end of this section, you will be able to:

  • Discuss the DSM-5-TR diagnosis relative to somatic symptom disorders and their presentation
  • Identify psychosocial and behavioral risk factors for somatic symptom disorders
  • Give examples of client symptoms associated with somatic symptom disorders
  • Describe stress responses reported by clients due to somatic symptom disorders
  • Plan nursing and collaborative care for clients seeking treatment for somatic symptom disorders

Somatic symptom disorder (SSD), formerly known as somatization disorder, is a condition where individuals experience distressing physical symptoms that cannot be explained fully by an underlying medical condition. Somatic symptom disorder presents a unique challenge for health-care professionals because it involves the manifestation of physical symptoms without a clear underlying medical cause.

The nursing role goes beyond addressing physical ailments; it extends to acknowledging and addressing the psychological and emotional dimensions of health. Learning about the relationship between mind and body to understand these complexities is essential for providing compassionate care and supporting individuals with these disorders.

DSM-5 Medical Diagnosis

When a client is focused on physical symptoms to the point of significant distress and disruption of normal functioning, they are considered to have somatic symptom disorder (SSD) (American Psychiatric Association [APA], 2022). The term somatic means relating to or affecting the body. The physical symptoms experienced by the client may or may not be attributable to an actual physical problem. The defining feature of this diagnosis is the abnormal preoccupation with physical symptoms to the point that it causes distress and interferes with everyday life.

According to the DSM-5-TR (APA, 2022), there are three criteria to meet in order for an individual to be diagnosed with somatic symptom disorder:

  • one or more somatic symptoms that cause significant distress and interference with daily life
  • excessive thoughts about one’s symptoms, high-level anxiety about health or symptoms, or disproportionate time and energy spent on symptoms and illness
  • presence of symptoms for more than six months

It is estimated that 5 to 7 percent of the population meets criteria for SSD (D’Souza & Hooten, 2023), and it can occur in childhood, adolescence, or adulthood. Women are ten times as likely as men to be diagnosed with SSD. The prevalence of SSD is higher in individuals with functional disorders, including fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome.

People with SSD may be excessively negative about illness and their health and think the worst, even if there is no medical evidence, or there is medical evidence to the contrary. They may avoid physical activity. High levels of services utilization, or use of health-care services, may be part of the client’s history. This may include trips to multiple providers for the same symptoms. Some clients believe that their medical diagnoses and treatments have been and continue to be inadequate. They may demonstrate increased sensitivity to adverse effects of medication but seemingly show resistance to treatment.

Clients with somatic symptom disorder may have a single complaint, but most often have multiple symptoms contributing to their distress. The top client complaint is pain, but clients may complain of any variety of symptoms, including fatigue, heart palpitations, and more. Somatic symptom disorder frequently occurs alongside other confirmed medical diagnoses. For example, a person may undergo an uncomplicated hip replacement operation that does not result in any disability from the procedure itself, but become disabled by somatic symptom disorder afterward. Still, many individuals with SSD do not have a confirmed medical diagnosis, yet the physical complaints expressed and experienced by the individual are genuine, regardless of whether there is a medical explanation for it.

Psychosocial and Behavioral Risk Factors

Risk factors for SSD are varied and differ among life stages and cultures. These factors include psychosocial as well as behavioral elements.

Psychosocial Risk Factors

Experiencing adverse events during childhood, such as abuse, neglect, or other traumatic experiences, has been linked to an increased risk of developing somatic symptom disorder (SSD) later in life (D’Souza & Hooten, 2023). Early life stressors can have long-lasting effects on psychological well-being and may contribute to the development of somatic symptoms as a way of coping or expressing distress.

Anxiety and depression are commonly associated with SSD, as is a history of substance misuse. Additionally, certain personality traits may increase the risk of SSD. People with avoidant, paranoid, self-defeating, or obsessive thinking may be more prone to experiencing and focusing on somatic symptoms. Individuals who experience chronic stress, trauma, or have difficulty coping with emotional problems may be more susceptible to developing SSD. Dysfunctional family dynamics, including high levels of conflict, overprotection, or excessive attention to physical symptoms, can contribute to the development of SSD.

Certain cognitive factors and illness beliefs also can contribute to the development and maintenance of SSD. These may include catastrophizing (interpreting mild symptoms as indicative of severe illness), perceiving bodily sensations more intensely, and a tendency to focus on and misinterpret normal bodily sensations as abnormal or indicative of a serious medical condition. These illness beliefs can be formed by social and cultural factors that have influenced the client. Societal beliefs about the legitimacy of physical symptoms and cultural norms related to expressing distress, or the influence of cultural or religious beliefs on illness interpretations can all contribute to the development of SSD.

Cultural Context

Cultural Considerations and Somatic Symptom Disorder

Numerous studies have shown that unexpressed emotions play a notable role in somatic symptom disorder (SSD). The country of Iran has been identified as having a particularly high rate of SSD. The authors of one study found three main obstacles to the expression of emotion in Iran: genderizing of emotion (i.e., defining the expression of emotion as excessively feminine and perceived as fragile), a prohibition on expressing emotions about parents and authority figures, and problems expressing positive emotion.

The authors of the study concluded that because of these cultural barriers, SSD clients in Iran have difficulties directly expressing their emotions. Cultural considerations such as these must always be taken into account when evaluating a client with suspected or diagnosed SSD.

(Vaziri et al., 2019)

Behavioral Risk Factors

Importantly, behavioral factors can both contribute to the development of SSD and influence its persistence. Observing and learning from others’ illness behaviors can contribute to the development or reinforcement of SSD. Per Leventhal (2001), illness is experienced as a threat and a need for protection, prompting the person to seek medical care. Family members who model illness behavior, or place excessive focus on physical complaints, may inadvertently reinforce somatic symptoms in individuals. For example, if a person frequently witnesses a family member displaying exaggerated illness behaviors or utilizing excessive health care, they may learn and imitate those behaviors.

People with SSD may frequently seek reassurance from health-care professionals, family members, or friends regarding their symptoms or concerns. This behavior stems from the need for validation and confirmation that their symptoms are not indicative of a severe medical condition. Seeking reassurance repeatedly can reinforce the focus on symptoms and contribute to the maintenance of SSD. Individuals with SSD may experience secondary gain—the inadvertent advantages one receives from an illness—from adopting a sick role, such as receiving attention, sympathy, or support from others, or avoiding responsibilities or stressful situations. These reinforcements can encourage continuation of somatic symptoms.

Behaviors and Symptoms of Clients with SSD

Individuals with somatic symptom disorder (SSD) may adopt maladaptive coping strategies, such as excessive rumination about their symptoms, catastrophizing (interpreting symptoms as indicating a serious illness), or engaging in behaviors that temporarily relieve distress but reinforce the illness belief. One example of this type of behavior would be constantly checking the body for signs of illness.

Preoccupation with Health

Clients with SSD often display a heightened and persistent preoccupation with their health. They may spend excessive time researching medical information, participating in online health forums, or seeking reassurance from health-care professionals to validate their concerns. They also engage in excessive health-care-seeking behavior. They may visit multiple doctors or specialists in search of a diagnosis or treatment for their symptoms, even when medical tests and evaluations show no clear evidence of an underlying medical condition.

Clients with somatic symptom disorder often spend a significant amount of time and energy focused on their symptoms. This can involve constantly monitoring their bodies for any changes, analyzing symptoms, and engaging in excessive self-examination or self-checking behaviors. They may also exhibit exaggerated or dramatic expressions of their physical symptoms. This can involve amplifying the severity or impact of their symptoms during medical consultations or interactions with others, seeking validation or attention.

Avoidance Behaviors

Individuals with SSD may engage in avoidance behaviors that may affect their daily functioning and overall quality of life. They may refrain from physical activity or certain situations that they believe may exacerbate their symptoms. This avoidance can lead to a reduction in daily functioning, social withdrawal, and isolation. The symptoms of SSD can significantly impair an individual’s ability to carry out their daily activities and fulfill their responsibilities.

Resist Psychological Explanations

Clients with somatic symptom disorder may resist psychological explanations for their symptoms. They may reject or dismiss the idea that their symptoms have psychological or emotional roots and instead continue to seek physical explanations.

Expression of Pain

Pain is the most cited single complaint among clients with SSD. Some of the specific symptoms reported include muscle and joint pain, back pain, headaches, noncardiac chest pain, heartburn, and irritable bowel. A variety of factors may contribute to SSD-related pain. These include possible genetic and biological vulnerability, such as increased sensitivity to pain.

Expression of Fear

People with SSD may have a heightened emotional response to their physical symptoms, experiencing extreme anxiety, fear, or distress even when the symptoms are mild or temporary. Their reaction may seem excessive or out of proportion to the actual medical severity of the symptoms.

Stress Responses Reported by Clients

Individuals with SSD experience persistent physical and emotional symptoms that are distressing and disruptive to their daily lives. These symptoms may cause pain, discomfort, fatigue, or other physical sensations, resulting in functional impairment and limitations in different aspects of client life. These clients are also likely to experience anxiety, depression, frustration, or fear related to their symptoms. They may worry about the cause of their symptoms, the impact on their health, and the potential for serious underlying conditions. The symptoms may interfere with work or school attendance, social interactions, personal relationships, and recreational activities. The cycle of medical appointments, tests, and treatments brought on by frequent health-care utilization can be emotionally and financially draining. The level of impairment to the client’s daily life can vary from mild to severe, depending on the severity and frequency of the symptoms.

SSD can strain personal relationships. Loved ones may become frustrated or concerned about the persistent focus on physical symptoms, leading to tension. SSD, like many other somatic disorders, can be stigmatized, leading to further challenges for individuals affected by it. There is often a lack of awareness or understanding among the general public, friends and family, and even health-care professionals, which may result in skepticism, dismissal, or blame placed on the individual experiencing the symptoms, and can lead to feelings of isolation and invalidation.

Nursing Care for Clients with SSD

The first step in effective nursing care of a client with SSD is building trust and rapport with the client. Nurses should create a safe and nonjudgmental environment where clients feel comfortable discussing their symptoms and concerns. Demonstrate empathy and active listening skills when interacting with clients. Nurses should validate the client’s experiences, concerns, and emotions. It is important for the nurse to remember that clients with SSD are experiencing distress and this distress might not receive validation by medical tests (i.e., stomach upset with no explanation or insight gained from diagnostic testing). Nursing validation by acknowledging the client’s distress can help build trust and improve the therapeutic relationship.

Nurses are encouraged to remain aware of professional boundaries and seek clinical guidance in care of clients with SSD. Some clients may have developed dependent behaviors that may be inadvertently reinforced by the nurse. Clients are likely to benefit more from empowerment toward self-care. For example, nurses may tend to spend more time with clients who readily express needs that the nurse can fulfill, strengthening the helping relationship. Nurses should remain aware that the helping relationship also exists when the nurse encourages the client toward self-care and gives honest praise for their efforts.

The nurse should provide the client with accurate information and education about SSD to help them understand the nature of their condition. Explain that SSD is a real illness, and symptoms are not intentionally produced or under the client’s conscious control. Offer resources, such as educational materials or support groups, to assist them in learning more about their condition.

One of the more effective strategies for clients dealing with SSD is to “focus on the here and now.” By encouraging clients to focus on the present moment, nurses can assist clients in finding relief from their distress and promote a sense of calm and control. Focusing on the here and now emphasizes the present moment and encourages clients to redirect their attention away from distressing or anxious thoughts to the present experience. For example, a nurse may engage a client in grounding exercises, such as deep breathing, guided imagery, or sensory stimulation, to help them anchor themselves in the present and alleviate anxiety or pain.

Work together with the client to establish realistic and attainable goals. Involve the client in their care plan to promote a sense of ownership and engagement. Realize that insight into the condition of SSD may develop slowly or not at all; the ultimate goal should be to restore the client to their optimal level of functioning.

Nursing Assessment

Medical screening tools include client self-report rating scales, which can be combined with the interview to determine symptom burden in order to make a medical diagnosis. When performing a nursing assessment on a client with potential SSD, the nurse must gather a thorough physical and psychiatric history, paying particular attention to the client’s symptoms, their onset, duration, and any potential triggers. It is important to approach the process with sensitivity and empathy. Ask the client about their perception of their symptoms, their impact on daily functioning, and any previous medical evaluations or treatments they have undergone. Observe any inconsistencies or incongruence between the reported symptoms and medical findings. Be attentive to the client’s emotional responses and their understanding of the mind-body connection.

Assess the client’s mental health status, including any history of anxiety, depression, trauma, or other psychiatric disorders. Evaluate their emotional well-being, coping mechanisms, and stress levels. Look for any underlying psychosocial stressors that may contribute to the manifestation or exacerbation of somatic symptoms. Assess their ability to carry out activities of daily living, work, and engage in social interactions. Evaluate the impact of SSD on the client’s daily functioning, relationships, and overall quality of life; this will help determine their treatment plan.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Safety for the Client with Somatic Symptom Disorder

The nurse will:

  • discuss effective strategies for maintaining and ensuring safe environment, and provide client and family education
  • describe factors that can create the therapeutic relationship, such as focusing on the “here and now” and teaching grounding exercises and goal setting
  • demonstrate effective therapeutic communication during time with the client by building trust and rapport, and showing empathy and active listening
  • communicate observations and concerns to other members of the health-care team by seeking clinical guidance as needed for professional boundaries issues
  • value monitoring own performance for optimal therapeutic effect in client empowerment by providing nursing validation of client’s concerns
  • appreciate client’s personal limits regarding ability to manage self-care due to heightened emotional responses to stressors; goal is restoration to optimal level of functioning; insight and coping develop per individual

(Quality and Safety Education for Nurses, 2022)

Approaches to Treating Somatic Disorders

The management of SSD can be complex. Individuals may face challenges in receiving an accurate diagnosis, finding appropriate health-care providers who understand the condition, and accessing effective treatments. The involvement of various health-care professionals, such as primary care physicians, psychiatrists and advance practice providers, psychologists, and other specialists, is necessary to provide comprehensive care. The client should be treated as a partner on the health-care team, and the team should employ a client-centered care approach. As discussed by Agarwal et al. (2020), there are several ways in which the nurse can advocate for the client and assist in finding and evaluating appropriate treatments. The nurse should encourage the client to participate in CBT, an evidence-based psychotherapy that focuses on identifying and modifying the maladaptive thoughts, emotions, and behaviors associated with SSD. Reinforce the benefits of therapy and provide referrals to mental health professionals as needed. Nurses can help the client develop strategies to manage their physical symptoms effectively. Encourage healthy coping mechanisms, such as relaxation techniques, deep breathing exercises, mindfulness, or guided imagery. Collaborating with the health-care team to ensure appropriate pharmacological interventions if indicated (medication management) is a critical nursing function. This may include the use of medications, such as SSRIs to manage associated anxiety or depression that often coexist with SSD. Nurses should also schedule regular appointments to monitor the client’s progress, reassess symptoms, and adjust the treatment plan if necessary. Regular check-ins provide an opportunity to reinforce therapeutic interventions and provide ongoing support.


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