Medical and Surgical Nursing

1. “BODY –MIND COMPLEX AND
PSYCHOSOMATIC(SOMATOFORM)
DISORDER"
Sushila Hamal
M.Sc. Nursing 1st Year(B-2023)
BPKIHS, Dharan

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3. General objective
At the end of this session, the participant will be able to
explain about the body mind complex and Psychosomatic
disorder.
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4. Specific objectives
At the end of this session the participant will be able to:
• Review of anatomy and physiology of nervous system
• Introduction to body mind complex
• Definition of body mind complex
• Body’s response to psychological stimuli
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5. Specific objectives Contd…
• Introduction of Psychosomatic disorder
• Introduction of Somatoform Disorders
• Classify Somatoform disorder
• Causes of Somatoform disorder
• Diagnostic guidelines
• Treatment
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6. Anatomy and physiology
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8. Anatomy and physiology Contd…
The nervous system detects and responds to changes inside and
outside the body.
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9. Neuron
The nervous system consists of a vast number
of cells called neurons, supported by a special
type of connective tissue, neuroglia.
Neurons are the structural and functional
unit of nervous system that generate and
transmit nerve impulses.
Each neuron consists of a cell body,
axon and dendrites.
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10. Synapse
The point at which the nerve impulse passes from one nerve cell to
another is called synapse. There is no physical contact between these
neurons .
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11. Neurotransmitter
• Neurotransmitters: are chemical messenger that transmit signals from a
neuron to a target cell across a synapse. Target cell may be a neuron or
some other kind of cell like a muscle or gland cell. Necessary for rapid
communication in synapse.
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14. Body mind complex
Introduction
• There is a bi-directional influence between our mind and
body.
• They do not function in isolation. Our mind consisting of our
perception, thoughts, emotions, motivation etc. affect our
body's functioning, physical health; similarly our body's
capacity, health conditions affect our mind and mental health.
• Thus there is a relationship between physical health and
mental health, both affect each other.
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15. Example of body mind complex
With mind-body exercises like yoga or tai chi, you can help better
control anxiety and pain. Some mindful activities can help boost
your energy and your mood, and even help you find more happiness
and compassion to improve the overall quality of your life.
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16. Body mind complex
Definition
“Body and mind cannot be separated for purposes of treatment, for
they are one and individual. Sick minds must be healed as well as
sick bodies.”
-C.Jeff.Miller
“The brain and peripheral nervous system, the endocrine and
immune system and indeed, all emotional responses we have share a
common chemical language and are constantly communicating with
one another.”
-Dr.James Gordon
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17. Bodily conditions affecting mental functioning
• An increase in blood pressure causes mental over activity
• Sever pain reduce the concentration level.
• Constipation can cause irritability
• Chronic illness causes depression
• Hyperthyroidism causes mental restlessness and over excitability
• Hypothyroidism leads to dullness of mind or mental tiredness.
• Autonomic stimulation causes fight or flight response of the body
when a person is faced with such situation that demand
behavioral adjustment.
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18. Mental functioning affecting bodily function
• Mind motivates all physical and motor activities.
• Unpleasant emotion such as fear, anger and worry causes
headache, insomnia, indigestion and can lead to disease
condition such as peptic ulcer, ulcerative colitis, bronchitis,
asthma and migraine headache.
• Deep thinking and concentration can cause physical fatigue.
• Meditation can produce soothing effect on physical and
physiological processes.
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20. Body’s response to psychological stimuli
• Interpretation of stimuli in brain: In stress response, afferent
impulses are carried from sensory organs and internal sensors
(baro receptors and chemo receptors) to nerve centers in brain.
• Stress may be perceived by different centers from cortex to brain
stem, which relay information to hypothalamus that coordinates
the adjustments necessary for return to hypothalamus.
• Neuroendocrine system: In stress response, neural and neuro
endocrine pathways are activated which are under control of
hypothalamus.
• At first there is sympathetic nervous response followed by
sympathetic adrenal medullary response. If still stress persists
than hypothalamic pituitary system is activated.
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21. Body’s response to psychological stimuli (Contd..)
• Sympathetic nervous system: Response is rapid and short lived.
• Norepinephrine is released to cause increase in function of vital
organs and state of general body arousal.
• Sympathetic adrenal medullary response: It is fight or flight
response and has sustained effect and prolonged actions.
• Sympathetic nervous system stimulates medulla of adrenal gland
to produce epinephrine and nor-epinephrine.
• Stress and immune system: Glucocorticoids depress immune
system thus ability of person to resist infection reduces and
increases the susceptibility of person to illness.
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22. Body’s response to psychological stimuli (Contd..)
• Hypothalamic pituitary response: Hypothalamus secrets
corticotrophins releasing factor stimulate ACTH
(Adrenocorticotropic hormone).
• It stimulates adrenal cortex to produce mineralocorticoids which
inhibits glucose intake of many cells other than brain and heart.
• Antidiuretic hormones and aldosterone are released which cause
sodium and water retention.
• Epinephrine and nor-epinephrine and cortisol has important role
in response to stress.
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23. Psychosomatic disorder
Introduction
• Psychosomatic means mind and body.
• A psychosomatic disorder is a disease involving both mind
and body.
• Psychosomatic also called Psycho - physiologic disorder,
condition in which psychological stresses adversely affect
physiological (somatic) functioning to the point of distress.
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24. Psychosomatic disorder
Definition
• A group of mental ailments in which emotional stress is a
contributing factor to physical problems involving an organ
system under involuntary control.
- Bimala Kapoor, 1994
• Disorders in which psychic elements are significant in
initiating alteration in chemical, physiological or structure of
the individual resulting in physical symptoms.
- Sreevani R
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25. Somatoform Disorders
• A group of disorders in which people experience significant
physical symptoms for which there is no apparent organic
cause.
• Somatic symptom disorder is characterized by persistent
and repeated manifestation of 1 or more physical symptoms
which do not have any physical basis or medical condition.
• People do not consciously produce or control the symptoms
but truly experience the symptoms.
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26. ICD 10 Classification of Somatoform Disorder
F45 Somatoform disorders:
• F45.0 Somatization disorder
• F45.1 Undifferentiated somatoform disorder
• F45.2 Hypochondriac disorder
• F45.3 Somatoform autonomic dysfunction
• F45.4 Persistent somatoform pain disorder
• F45.5 Other somatoform disorders
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27. TYPES OF
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28. F45.0 Somatization disorder
• The main features is chronic, multiple, recurrent, and
frequently changing physical symptoms in the absence
of physical disorder, which have usually been present for
several years before the patient is referred to a psychiatrist.
• Most patients have a long and complicated history of
contact with both primary and specialist medical services.
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29. Epidemiology
• Lifetime prevalence in females varies from (0.2-2)% and
is less than 0.2% in men.
• Common in the less educated, poor, lower occupational
group.
• Coexisted with other medical disorders.
• About 2/3 of all patients with somatization disorder have
identifiable psychiatric symptoms.
• Up to half have other mental disorders.
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30. Symptoms of Somatization disorder
• Gastrointestinal sensations (pain, belching, regurgitation,
vomiting, nausea, etc.)
• abnormal skin sensations (itching, burning, tingling,
numbness, soreness, etc.) blotchiness.
• Sexual and menstrual complaints
• Marked depression and anxiety are frequently present and
may justify specific treatment
• Disruption of social, interpersonal, and family behavior.
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31. F45.1 Undifferentiated somatoform disorder
• When physical complaints are multiple, varying and
persistent, but the complete and typical clinical picture
of somatization disorder is not fulfilled, this category
should be considered.
• A somatoform disorder in which one or more physical
complaints persist for 6 months or longer and cannot be
explained by a known medical condition.
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32. F45.2 Hypochondrial disorder
• The essential feature is a persistent preoccupation with the
possibility of having one or more serious and progressive
physical disorders.
• Patients manifest persistent somatic complaints or
persistent preoccupation with their physical appearance.
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33. F45.3 Somatoform autonomic dysfunction
• The symptoms are presented by the patient as if they were
due to a physical disorder of a system or organ that is
largely or completely under autonomic innervation and
control, i.e. the cardiovascular, gastrointestinal, respiratory
system, genitourinary system .
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34. Clinical feature of Somatoform autonomic
dysfunction
• The cardiovascular system ("cardiac neurosis"), the
respiratory system (psychogenic hyperventilation and
hiccough) and the gastrointestinal system ("gastric
neurosis" and "nervous diarrhea").
• Nonspecific symptoms, such as sensations of fleeting aches
and pains, burning, heaviness, tightness, and sensations
of being bloated or distended abdomen.
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35. F45.4 Persistent somatoform pain disorder
• The predominant complaint is of persistent, severe, and
distressing pain, which cannot be explained fully by a
physiological process or a physical disorder. Pain occurs in
association with emotional conflict or psychosocial problems.
• For e.g : Muscle pain or migraine.
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36. F45.5 Other somatoform disorders
• This category includes other somatoform disorders not classified
in the previous four categories, e.g. 'globus hystericus',
psychogenic torticollis,
psychogenic pruritus, teeth grinding.
• Sensations of swelling and paraesthesis
(tingling and/or numbness).
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37. Causes of Somatoform Disorder
• Idiopathic
• Biological factors: An abnormality in brain and
function of neurotransmitter can lead to
misinterpretation of ordinary events. For eg : The brain
may misunderstand a stimulus identifying a minor pain
as a serious injury.
Decreased endorphins may play role in pain disorder.
Personality traits: tense, under pressure, attention
seeking, weak ego.
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38. Causes (Contd…)
• Genetic factor : First degree relatives has increased risk of
developing somatoform disorder.
• 29% in monozygotic twins and 20% in Dizygotic twins
• Psychodynamic factor: Emotion associated with the traumatic
event that the individual cannot express because of moral or
ethical unacceptability are converted into physical symptoms.
• Past experience
• Family History
• Substance abuse.
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39. Causes (Contd…)
• Han and colleagues (2008) studied patients meeting the
diagnostic criteria for somatoform disorder ,where patient was
treated with selective serotonin reuptake inhibitor and
antidepressant.
• Learning theory: Somatic complaints are often reinforced
when the sick role relieves the individual from the need to deal
with a stressful situation, whether it be within society or within
the family.
• The sick person learns that he or she may avoid stressful
obligations, postpone unwelcome challenges troublesome
duties and the act is repeated.
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40. Causes (Contd…)
• Vulnerable personality: anxiety, frustration, depressed,
stress can be contributing factors for physical symptoms due
to increased nerve impulse activity, adrenaline and
epinephrine releases can also trigger anxiety.
• Social environment: Poor IPR, deprived bondages, cultural
or religious factors, disharmony between family members,
low socio-economic, educational difficulties, absence of
support system.
• Poor or inadequate coping strategies
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42. Some Important Psychosomatic Disorders
1. Bronchial Asthma
2. Irritable Bowel Syndrome (IBS)
3. Ulcerative colitis
4. Migraine and tension typed headache
5. Pain disorders
6. Malingering
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43. Clinical features of Somatoform Disorder
• Gastrointestinal symptoms (e.g. abdominal pain, bowel
problems, nausea, vomiting, belching, regurgitation etc.)
• pain in the various body parts (extremities, back, joints)
• conversion symptoms (pseudo seizures, fainting,
in- coordination, loss of voice, difficulty swallowing)
• symptoms referring to cardiopulmonary system (chest pain,
palpitation)
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44. Clinical features (Contd…)
• Generalized symptoms
• Arthralgia
• Backache
• Chronic tiredness
• Headache
• Genitourinary symptoms
• Erectile dysfunction, ejaculatory disturbance, and impotence
• Decreased libido
• Dysuria
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45. Diagnosis (DSM-5 Criteria)
Criterion A: One or more somatic symptoms that are
distressing or result in significant disruption of daily life
Criterion B:
1) Excessive thoughts, feelings, or behaviors related to the
somatic symptoms or associated health
2) Concerns as manifested by at least one of the following:
• Disproportionate and persistent thoughts about the
seriousness of one's symptoms
• Persistently high level of anxiety about health or symptoms
• Excessive time and energy devoted to these symptoms or
health concerns 45

46. Diagnosis (DSM-5 Criteria) Contd…
• Criterion C: Although any one somatic symptom may not be
continuously present, the state of being symptomatic is
persistent (at least 6 months)
Severity
• Mild: Only 1 criterion B symptom
• Moderate: 2 or more criterion B symptoms
• Severe: Same as Moderate plus multiple somatic symptoms
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47. Treatment
•Non-pharmacological management
•Pharmacological management
•Nursing management
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48. Non-pharmacological management
• Jacobson’s progressive relaxation technique
• Yoga
• Fasting Therapy
• Hypnosis
• Cognitive Behavior Therapy
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50. Non-pharmacological management (Contd…)
Jacobson’s progressive relaxation technique:
• It is a type of therapy that focuses on tightening and relaxing
specific muscle groups in sequence by concentrating on specific
areas and tensing and then relaxing them while keeping the rest
of the body relaxed and then releasing the tension.
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51. Non-pharmacological management (Contd…)
Yoga:
• Yoga has a calming effect on the body and makes you more aware
and accepting of yourself and your surroundings.
• Experiments have shown yoga to be as effective as drugs when it
comes to psychosomatic disorders.
• Improve physical and mental health.
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52. Research article
Management of PCOS (Polycystic ovarian Syndrome): A
Psychosomatic Disorder by Yoga Practice
Jan 2015,International journal of innovative research and development
• There is a strong relation between obesity ,stress and PCOS.
• Approximately 50-60 % of women with PCOS are obese. Obesity and
stress shows somatic symptoms of PCOS like hirsutism, anovulation,
abnormal menstruation, sub fertility, acne and psychic symptoms like
anxiety, depression, insomnia, loss of concentration are develop.
• Daily yoga for 30 minutes with 4 Asanas, 4 Pranayama, meditation and
Shavasana helps in weight reduction and stress management which
ultimately stabilize the normal function of hypothalmo- pituitary –
ovarian axis and cure PCOS. 52

53. Non-pharmacological management (Contd…)
Fasting therapy:
• A treatment well known in Japan, fasting therapy has
successfully alleviated both physical and psychological
symptoms in psychosomatic disorder patients.
• According to this therapy, the autonomic nervous system and
endocrine system are regulated by the fasting process. As a
result, the body re-establishes its balance for both mental health
and physical health.
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54. Research article
Effects of fasting therapy on irritable bowel syndrome
• Sample size:58,experiemental group:36,control group:22
• The basic treatment consisted of pharmacotherapy and brief psychotherapy,
• Whereas the FT consisted of 10 days of starvation followed by 5 days of
refeeding.
• FT significantly improved 7 out of the 10 symptoms assessed; that is,
abdominal pain-discomfort ,abdominal distension ,diarrhea ,anorexia, nausea,
anxiety , and interference with life in general. However, the control therapy
significantly improved only 3 out of the 10 symptoms assessed; that is,
abdominal pain-discomfort , abdominal distension , and interference with life
Conclusion: Results suggest that FT may have beneficial effects on
intractable patients with IBS
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55. Non-pharmacological management (Contd…)
Hypnosis:
• Migraines, asthma, and gastrointestinal issues seen with
psychosomatic disorders are often treated with hypnosis.
• Anger, fear, pain and dependency issues have been resolved
successfully with this therapy in the past.
• Long-term hypnotherapy can work effectively to resolve the
underlying emotions and stop the psyche from affecting the
body and the symptoms from developing.
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56. Hypnosis Contd…
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57. Non-pharmacological management (Contd…)
Behavior Modification techniques
• Positive Reinforcement: Positive reinforcement is using a
reward for positive behavior to continue with the desired
behavior. For example, praise and reward.
• Negative Reinforcement: Negative reinforcement is taking
something unpleasant away to reinforce good behavior
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58. Non-pharmacological management (Contd…)
Cognitive behavioral therapy:
• Positive reframing: Turning negative messages into positive ones.
• Decatastrophizing: It involves the therapist’s use of questions to
more realistically appraise the situation. It is also called the “what
if” technique because the worst case scenario is confronted by
asking a “what if” question.
• Assertiveness training: Helps the person take more control over
life situations. These techniques help the person negotiate
interpersonal situations and foster self-assurance.
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59. Pharmacological management
Tricyclic antidepressants (TCA):
Inhibit reuptake of serotonin (5-HT), inhibit reuptake of nor
epinephrine receptor ,Block ACh receptor ,Block histamine (H1 )
receptor
Reduces depression, relief of severe pain, prevent panic attacks
For eg:Amitriptyline, amoxapine,desipramine
Serotonin and noradrenalin reuptake inhibitors (SNRI):
Potent inhibitor of serotonin and norepinephrine reuptake
Reduces depression, relieves neuropath pain, stress urine
incontinence (duloxetine), relieves anxiety (venlafaxine)
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60. Pharmacological management (Contd…)
Atypical antipsychotics:
Inhibit dopaminergic neurotransmission, noradrenergic
blocking action
Relief of psychosis (relief of anxiety, relief of acute mania)
For eg: clozapine, olanzepine, aripiprazole, quetiapine,
risperdone, ziprasidone, paliperidone, iloperidone, asenapine
Serotonin reuptake inhibitors (SRI):
Inhibit reuptake of serotonin (5-HT)
Reduces depression ,controls anxiety, controls obsessions
For eg:citalopram,fluoxetine,sertraline 60

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62. Assessment
• Level of concern regarding physical symptoms
• Level of anxiety
• Degree of impairment
• Ability to manage stressful situations
• Preoccupation with imagined physical defects
• level of understanding regarding disease process
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63. Nursing diagnosis
• Ineffective coping strategies related to anxiety and inadequate
coping methods
• Self-Care Deficit related to Physical illness and disabling anxiety.
• Anxiety related to lack of knowledge regarding symptoms,
progression of condition, and treatment regimen.
• Social isolation related to past experiences of difficulty in
interaction with others.
• Knowledge deficit related to disease condition, unfamiliarity with
medications used and potential adverse effects.
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64. Nursing interventions
1. Ineffective Coping related to anxiety and inadequate
coping methods
• Assess client’s level of anxiety.
• Initially meet the client’s dependency needs as necessary.
• Encourage independence and give positive reinforcement for
independent behaviors.
• Support and encourage client’s efforts to explore the meaning
and purpose of the behavior.
• Gradually limit the amount of time allotted for ritualistic
behavior as client becomes more involved in unit activities.
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65. Nursing interventions (Contd…)
2. Self-Care deficit related to physical illness and
disabling anxiety.
• Encourage independence.
• Offer recognition and positive reinforcement for independent
accomplishments.
• Show client how to perform activities with which he is having
difficulty.
• Keep strict records of food and fluid intake.
• Offer nutritious snacks and fluids between meals.
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66. Nursing interventions (Contd…)
3. Anxiety related to lack of knowledge regarding symptoms,
progression of condition and treatment regimen.
• Maintain a calm, non-threatening manner while working with the
client.
• Establish and maintain a trusting relationship by listening to the
client; answering questions directly.
• Remain with the client at all times when levels of anxiety are high.
• Move the client to a quiet area with minimal stimuli.
• Maintain calmness in your approach to the client.
• Provide reassurance and comfort measures.
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67. Nursing interventions (Contd…)
4. Social isolation related to past experiences of difficulty in
interaction with others.
• Convey an accepting and positive attitude by making brief,
frequent contacts.
• Be honest and keep all promises.
• Be cautious with touch. Allow client extra space and avenue for
exit if he becomes too anxious.
• Discuss with the client the signs of increasing anxiety and
techniques for interrupting the response such as breathing
exercises, thought stopping, relaxation, meditation.
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68. Nursing interventions (Contd…)
5. Knowledge deficit related to disease condition,
unfamiliarity with medications used and potential
adverse effects.
• Explain the physiologic action of SSRI in relieving anxiety.
• Assess for nausea, headache, nervousness, insomnia,
agitation, sexual dysfunction.
• Assess for fatigue, drowsiness, and cognitive impairments.
• A gradual tapering is necessary when a benzodiazepine is
discontinued.
• Teach for the follow up care.
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69. References
• Budhathoki S, Prajapati P. A Textbook of Mental Health and
Psychiatric Nursing. 1sted. Bhotahity, Kathmandu: Vidyarthi
Pustak Bhhandar; 2015.
• Townsend M.C, Essentials of Psychiatric Mental Health Nursing,
5th ed. F.A. Davis Company, 2011.
• Ahuja N. A Short Textbook of Psychiatry. 7thed. New Delhi: Jaypee Brothers
Medical Publishers PVT.LTD; 2011.
• Rai L. Nursing Concepts theories and principle.3rded. Chettrapati,
Kathmandu: Tara books and stationery; 2015.
• Verma A, Kumar S, Dei L, Dhiman K. Management of PCOS: A
psychosomatic disorder by yoga practice. Int J Innov Res Devel.
2015 Jan 31;4(1):216-9, retrieved on:18th September.
• Kanazawa M, Fukudo S. Effects of fasting therapy on irritable
bowel syndrome. International journal of behavioral medicine.
2006 Sep 1;13(3):214-20, retrieved on 18th September. 69

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