Nursing Notes: Neurotic, Stress-Related, and Somatization Disorders
Comprehensive, visual aids and key clinical guidance for nursing students.
Introduction
Neurotic, stress-related, and somatization disorders are a major group of psychiatric illnesses characterized by symptoms of anxiety, stress, functional neurological disturbances, and physical complaints without organic basis. They are common, affecting all age groups and impacting individuals’ quality of life. Nursing professionals play a critical role in identifying, assessing, and managing these disorders with a holistic, empathetic approach.
- Neurotic disorders: Anxiety and phobia-based illnesses where reality testing remains intact.
- Stress-related disorders: Caused or aggravated by stressful life events.
- Somatization disorders: Physical symptoms arise from psychological origins, often unintentionally.
Often, these disorders are underdiagnosed or misunderstood due to their overlapping presentations and lack of organic pathology.
Mnemonic: “ANXIETY DISORDERS” — Always Nurture eXcellent Insight, Empathy, and Teamwork Year-round To Deliver Individual Support, Observe Responses, Diagnose, Empathize, Reassure, Support
Prevalence & Incidence
Neurotic, stress-related, and somatization disorders have a high prevalence globally. They are among the leading causes of disability-adjusted life years (DALYs) for psychiatric illnesses.
Key Statistics
- Lifetime prevalence of any anxiety disorder: 14–29% in the general population.
- Generalized Anxiety Disorder (GAD): 3–6% lifetime prevalence.
- Somatization disorders: 0.2–2% in the general population, up to 10% in primary care settings.
- Phobic disorders: ~10% of population.
- Dissociative disorders: < 1%, but underreported.
* Data from WHO, DSM-5, and various epidemiological studies.
Classifications
The major neurotic, stress-related, and somatization disorders (ICD-10 and DSM-5) include:
| Category | Disorders |
|---|---|
| Anxiety Disorders |
Generalized Anxiety Disorder (GAD), Panic Disorder, Agoraphobia, Social Anxiety Disorder, Selective Mutism, Separation Anxiety Disorder |
| Phobic Disorders | Specific Phobia, Social Phobia, Agoraphobia |
| Obsessive-Compulsive & Related Disorders | Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania |
| Stress-Related Disorders |
Acute Stress Reaction, Post-Traumatic Stress Disorder (PTSD), Adjustment Disorders |
| Somatoform Disorders |
Somatization Disorder, Hypochondriasis, Conversion Disorder, Pain Disorder |
| Dissociative (Conversion) Disorders |
Dissociative Amnesia, Dissociative Fugue, Depersonalization/Derealization Disorder, Dissociative Identity Disorder |
Mnemonic: “ANXIOUS PHOBIC OBSESSIONS STRESS SOMATIC DISSOCIATION”
A → Anxiety
P → Phobic
O → Obsessions/OCD
S → Stress
S → Somatic
D → Dissociation
A → Anxiety
P → Phobic
O → Obsessions/OCD
S → Stress
S → Somatic
D → Dissociation
Anxiety Disorders
Anxiety is a feeling of apprehension, uneasiness, or dread—often without a clear external threat. When excessive, persistent, and impairing, it becomes pathologic and forms the primary symptom cluster for several disorders.
Types of Anxiety Disorders:
- Generalized Anxiety Disorder (GAD): Excessive, uncontrollable worry about multiple issues for at least 6 months.
- Panic Disorder: Recurrent panic attacks—sudden onset of intense fear, physical symptoms, fear of losing control or dying.
- Social Anxiety Disorder: Intense fear of social situations, leading to avoidance or marked distress.
- Agoraphobia: Fear of being in places where escape may be difficult (e.g., crowds, open spaces).
- Selective Mutism & Separation Anxiety Disorder: Usually first seen in children, marked by refusal to speak or excessive fear of separation.
| Disorder | Core Features | Duration |
|---|---|---|
| GAD | Worry over multiple domains, muscle tension, irritability, sleep issues | >6 months |
| Panic Disorder | Panic attacks, anticipatory anxiety | 1+ month with recurrent attacks |
| Social Anxiety | Marked fear in social situations | >6 months |
| Agoraphobia | Avoids public spaces, fear of no escape | >6 months |
Mnemonic: “PAGES” for Anxiety Disorders
Panic, Agoraphobia, GAD, (social) phobia, Separation/Selective mutism
Panic, Agoraphobia, GAD, (social) phobia, Separation/Selective mutism
Phobic Disorders
Phobias are marked, persistent, and excessive fears triggered by a specific object or situation, with recognition that the fear is irrational. Exposure triggers immediate anxiety.
| Type | Description & Triggers |
|---|---|
| Specific phobia | Restricted to particular objects (e.g. animals, heights, blood) |
| Social phobia | Fear of embarrassment or scrutiny in social situations |
| Agoraphobia | Fear of places/situations where escape may be difficult |
Mnemonic: “SASS”
Social, Agoraphobia, Specific Situations = SASSy Phobias!
Social, Agoraphobia, Specific Situations = SASSy Phobias!
Clinical features: Sudden onset of fear, panic symptoms (palpitations, trembling), recognition that fear is excessive, strong avoidance behavior.
Dissociative & Conversion Disorders
Dissociative Disorders:
These involve disruptions in the normal integration of consciousness, memory, identity, emotion, perception, body representation, and behavior.
- Dissociative Amnesia: Inability to recall autobiographical information.
- Dissociative Fugue: Apparent purposeful travel/wandering with amnesia for identity.
- Dissociative Identity Disorder: Presence of 2+ distinct identities/personality states.
- Depersonalization/Derealization: Feeling detached from self/environment.
Conversion Disorder:
Also known as Functional Neurological Symptom Disorder. Involves voluntary motor or sensory dysfunction that cannot be fully explained by medical conditions, usually following psychological stress.
Classic symptoms: Weakness, paralysis, seizures, blindness, aphonia, anesthesia.
Mnemonic: “PAIR”
Paralysis, Amnesia, Identity, Realization (to recall main Dissociative/Conversion features)
Paralysis, Amnesia, Identity, Realization (to recall main Dissociative/Conversion features)
Etiology & Psychodynamics
Biological Factors
- Genetics: Family history increases risk.
- Neurotransmitter imbalance: Low GABA, serotonin (5-HT), and noradrenaline linked to anxiety.
- Abnormal brain circuits: Amygdala, prefrontal cortex dysfunction (fear and worry circuits).
- Medical conditions: Hyperthyroidism, vitamin B12 deficiency, cardiac arrhythmias.
Psychological & Social Factors
- Stressful life events: Trauma, abuse, bereavement, major life transitions.
- Personality traits: High neuroticism, anxious/avoidant, perfectionistic.
- Childhood adversity: Neglect, overprotection, insecure attachment.
- Learned behaviors: Modeling from parents, reinforcement of sick role.
| Psychodynamic Explanations | Summary |
|---|---|
| Freud: Anxiety Neurosis | Unconscious conflict between id, ego, superego → anxiety, conversion symptoms as defense |
| Learning Theory | Symptoms learned through conditioning (classical/operant) and maintained by reinforcement |
| Cognitive Theory | Maladaptive thought patterns like catastrophizing increase anxiety/somatic focus |
Mnemonic: “BIOPSY”
Biological, Interpersonal, Others (social), Psychological, Stress, Your history
Biological, Interpersonal, Others (social), Psychological, Stress, Your history
Clinical Manifestations
| Disorder | Emotional Symptoms | Physical Symptoms | Behavioral Symptoms |
|---|---|---|---|
| Generalized Anxiety | Restlessness, irritability, excessive worry | Headache, muscle tension, GI upset, sleep disturbance | Procrastination, reassurance seeking |
| Panic Attack | Sudden terror, depersonalization, fear of dying | Palpitations, chest pain, choking, diaphoresis | Avoids triggering situations |
| Phobias | Fear, anxiety on exposure | Palpitations, tremors, dizziness | Avoidance |
| Somatization Disorder | Anxiety, preoccupation with illness | Pain, GI complaints, sexual symptoms, pseudoneurological symptoms | Frequent doctor visits, high health care use |
| Dissociative Conversion | Indifference to deficits (“La belle indifférence”), emotional numbness | Paralysis, blindness, pseudoseizures | Maintains sick role |
Mnemonic: “WISE”
Worry, Insomnia, Somatic, Emotional (GAD, Panic, Phobia, Somatization and Conversion)
Worry, Insomnia, Somatic, Emotional (GAD, Panic, Phobia, Somatization and Conversion)
* Clinical features may overlap and present with both psychological and medical complaints.
Diagnostic Criteria
Diagnosis is based on structured clinical interviews following DSM-5 or ICD-10/ICD-11 criteria.
| Disorder | Key Criteria | Duration |
|---|---|---|
| Generalized Anxiety Disorder (GAD) | Excessive, uncontrollable anxiety for most days over domains + 3 or more somatic symptoms (restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance) | ≥ 6 months |
| Panic Disorder | Recurrent unexpected panic attacks + persistent concern/behavior change | ≥ 1 month |
| Phobia | Unreasonable fear out of proportion; recognition; avoidance | ≥ 6 months |
| Somatization Disorder | Multiple somatic complaints with onset before age 30, significant impairment | Several years |
| Dissociative/Conversion | Loss/alteration of function unexplained by organic cause; temporal link to stressor | Varies |
Mnemonic: “6-1-6-Years-Stress”
GAD: 6m,
Panic: 1m,
Phobia: 6m,
Somatization: Years,
Conversion: with Stress event
GAD: 6m,
Panic: 1m,
Phobia: 6m,
Somatization: Years,
Conversion: with Stress event
Investigations:
- Rule out medical/organic causes (CBC, TSH, B12, ECG, EEG).
- Use validated scales: Hamilton Anxiety Rating, GAD-7, PHQ-15, Dissociative Experiences Scale.
Nursing Assessment
1. History Taking
- Presenting complaints: onset, duration, course, detail on triggers and symptoms.
- Past psychiatric, medical, surgical history.
- Drug/alcohol/tobacco use.
- Family and personal history (including abuse, longstanding stressors).
- Social, occupational and developmental history.
2. Physical Assessment
- Comprehensive physical exam to exclude organic causes.
- Vital signs, neuro exam for soft signs (giveaway weakness, Hoover’s sign in conversion).
- Identify signs of concurrent physical disorders.
3. Mental Status Examination (MSE)
- Appearance, behavior, speech, mood & affect.
- Thought content: preoccupations, obsessions, phobias, dissociation.
- Perceptual disturbances.
- Cognition and insight.
- Assess for suicidal ideation.
Mnemonic: “HISTORY – PHYSICAL – MSE” — History, Inspection, Speech, Thought, Orientation, Review, Yield exam, Physical, Head-to-toe, Insight, Speech, Cognitive, Mood, Sensation, Exam
Treatment Modalities
1. Psychotherapy
- Cognitive Behavioral Therapy (CBT): Core for anxiety, phobias, somatization, dissociative, and conversion disorders.
- Exposure therapy: For phobic and trauma-related disorders.
- Psychoeducation & counseling: For patients and families.
- Relaxation training, mindfulness, biofeedback.
- Supportive therapy, family therapy, interpersonal therapy.
Mnemonic: “COPE”
CBT, Open dialogue, Psychoeducation, Exposure
CBT, Open dialogue, Psychoeducation, Exposure
2. Pharmacotherapy
- SSRIs (e.g., sertraline, escitalopram): First-line for anxiety, phobias, OCD, PTSD.
- SNRIs (e.g., venlafaxine): For GAD.
- Benzodiazepines: Short-term for acute anxiety, not for long-term due to dependence.
- TCAs & others: Clomipramine for OCD, amitriptyline for somatoform pain.
- Adjuncts: Beta-blockers (propranolol) for social phobia, antipsychotics if needed.
Mnemonic: “SSNRI BB”
SSRIs, SNRIs, Non-benzodiazepines, Relaxants, Inhibitors, Beta-blockers, Benzos (for short term use only)
SSRIs, SNRIs, Non-benzodiazepines, Relaxants, Inhibitors, Beta-blockers, Benzos (for short term use only)
3. Other Modalities
- Electroconvulsive Therapy (ECT): Severe depression, catatonia, resistant anxiety.
- Physical therapy: For conversion disorder motor symptoms.
- Occupational therapy, social skills training.
Mnemonic: “MOPS”
Medication, Occupational therapy, Physical therapy, Support therapy
Medication, Occupational therapy, Physical therapy, Support therapy
Nursing Management
Principles of Care
- Provide a safe, supportive environment; foster trust and rapport.
- Validate the patient’s symptoms and distress — never dismiss complaints as “imagined.”
- Help patient identify triggers, understand illness, and participate in care planning.
- Promote routine (sleep, activity, self-care); minimize secondary gain by not reinforcing sick behavior.
- In conversion disorder, avoid confrontation; symptoms are unconscious and real to the patient.
- Monitor for self-injury, substance use, withdrawal symptoms, medication side-effects.
- Family education and support are vital.
- Encourage skills development (relaxation, coping, problem-solving).
| Nursing Interventions | Rationale |
|---|---|
| Conduct frequent, brief nurse-patient interactions | Reduces anxiety & builds trust |
| Reinforce healthy coping & discourage avoidance | Promotes adaptive behavior |
| Involve the patient in goal setting | Enhances sense of control, self-efficacy |
| Teach relaxation, breathing exercises | Reduces physiologic arousal |
| Encourage expression of feelings | Promotes insight, emotional catharsis |
| Regular assessment for suicidal/self-harm risk | Ensures safety |
Mnemonic: “CARE”
Communicate, Assess needs, Reassure, Educate (the patient and family)
Communicate, Assess needs, Reassure, Educate (the patient and family)
Health Education Tips
- Teach that symptoms are common, treatable, and not a sign of weakness.
- Promote stress management, adequate sleep, healthy eating, physical activity.
- Encourage regular follow-up and medication adherence as prescribed.
- Provide resources: Support groups, help lines, and self-help materials.
Summary Table
| Disorder | Age/Onset | Key Features | Treatment |
|---|---|---|---|
| GAD | Late teens–Adult | Persistent worry, restlessness, muscle tension | CBT, SSRIs |
| Panic Disorder | 20–30 years | Panic attacks, fear of losing control | CBT, SSRIs, short-term benzodiazepines |
| Phobias | Childhood, early adulthood | Irrational fears, strong avoidance | CBT, exposure therapy, beta-blockers |
| Somatization | Before 30 | Multiple, shifting physical complaints | Supportive therapy, antidepressants |
| Dissociative/Conversion | Any age (often adolescence/young adult) | Loss of function (motor/sensory, amnesia), association with stress | Psychotherapy, physical rehab |
| PTSD/Acute Stress | Any age post-trauma | Re-experiencing, avoidance, hyperarousal | CBT, SSRIs |
References
- WHO Mental Disorders Fact Sheet
- DSM-5 Diagnostic and Statistical Manual
- Epidemiology of Anxiety Disorders
- Varcarolis, E. M. (2021). Essentials of Psychiatric Mental Health Nursing. 5th Ed.
- Sadock BJ, Sadock VA, Ruiz P. (2017). Kaplan & Sadock’s Synopsis of Psychiatry. 11th Ed.
- Townsend, M. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice. 10th Ed.
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Nursing Notes: Geriatric & Special Populations in Neurotic, Stress-Related, and Somatization Disorders
Comprehensive, visually engaging reference for nursing students and practicing nurses. Focus: geriatric care, special populations, follow-up, home care, and rehabilitation.
Table of Contents
Introduction
Neurotic, stress-related, and somatization disorders (as per ICD-11 and DSM-5) represent a spectrum of psychiatric conditions where individuals experience chronic distress, anxiety, dissociation, or bodily symptoms with minimal or no structural pathology. These disorders require a nuanced, compassionate, and tailored approach—especially relevant for older adults and vulnerable or special populations. Optimized nursing care involves recognizing unique presentations, adapting management strategies, and holistically supporting patients beyond acute episodes.
Psychiatric symptoms often present atypically in geriatrics and special populations—early identification makes a critical difference in outcomes.
Scope: Special Populations
Special populations encompass individuals in whom standard symptomatology and management may differ due to age, gender, disability, cultural background, or social context. For neurotic/stress disorders, these include:
- Geriatric patients: Older adults with comorbidities, polypharmacy, cognitive decline
- Children & Adolescents: Developmental considerations, evolving symptom patterns
- Pregnant or postpartum women: Hormonal impacts, dual patient context
- Culturally diverse individuals: Varying beliefs, idioms, and stigma
- Patients with disabilities: Intellectual, sensory, or physical impairments affecting communication and care
Geriatric Considerations
1. Unique Features in Geriatric Patients
- Atypical Presentations: Somatization and anxiety may mimic or worsen chronic medical diseases (e.g., heart disease, diabetes).
- Cognitive Decline: Dementia or delirium may overlap with anxiety or dissociative presentations.
- Polypharmacy: Increased risk for drug-drug and drug-disease interactions when treating psychiatric symptoms.
- Social Factors: Loss, bereavement, and social isolation compound psychological distress.
2. Common Neurotic/Stress Disorders in Geriatrics
| Disorder | Typical Presentation in Elderly | Special Risk Factors |
|---|---|---|
| Generalized Anxiety Disorder | Persistent worry, poor sleep, somatic complaints (aches, GI symptoms) | Chronic illnesses, financial stress |
| Phobic Disorders | Avoidance, falls (agoraphobia), reluctance to engage socially | Mobility limitations, loss of independence |
| Somatization Disorders | Multiple unexplained symptoms, excessive medical consultations | Loneliness, focus on body due to loss of roles |
| Dissociative/Conversion Disorders | Gait disturbances, “pseudoseizures”, sudden blindness/aphonia | Bereavement, trauma, neurodegeneration |
Age-Specific Assessment Pearls:
- Prioritize collateral history (family/caregivers)
- Assess cognitive status (MMSE/MoCA)
- Be alert for polypharmacy and its impacts
- Physical exam: Look for functional decline and neglect
- Screen for elder abuse and neglect
Common Triggers & Stressors:
- Bereavement, loss of spouse
- Transition to institutional care
- Chronic pain or medical conditions
- Social isolation or financial stress
Mnemonic:
“AGEING” for key factors in geriatric anxiety/somatization:
Alone (isolation) – Grief – Eloss of function – Illness/chronic disease – Neglect/abuse – Geriatric syndromes
Alone (isolation) – Grief – Eloss of function – Illness/chronic disease – Neglect/abuse – Geriatric syndromes
Considerations for Special Populations
Children & Adolescents
- Poor recognition: Symptoms may be misattributed to “normal” developmental behavior
- Somatization common: Headaches, stomachaches, school refusal rather than direct complaints of anxiety
- Etiological importance: Bullying, family dysfunction, academic pressures
- Interview: Engage both child and caregivers; use age-appropriate communication
Screening Tools:
- Screen for Child Anxiety Related Disorders (SCARED)
- Children’s Somatization Inventory
Women & Pregnancy
- Perinatal hormonal fluctuations may unmask or exacerbate neurotic symptoms
- Higher risk of somatization and anxiety in peripartum; must distinguish from physiological pregnancy symptoms
- Medication safety: Many psychotropics have fetal/neonatal risks; prefer psychotherapy and supportive management when possible
“PPP”: Pregnancy, Postpartum, Psychological Support!
Remember the 3 P’s for comprehensive peripartum care in neurotic disorders: Monitor psychological status, Prefer non-pharmacological interventions, Provide social support.
Remember the 3 P’s for comprehensive peripartum care in neurotic disorders: Monitor psychological status, Prefer non-pharmacological interventions, Provide social support.
Cultural and Ethnic Issues
- Symptom Expression: Some cultures manifest emotional distress primarily through somatic complaints
- Stigma: Mental health stigma can delay recognition and care
- Language Barriers: May impede symptom reporting (use interpreters)
- Culturally adapted interventions: Integrate cultural healers, community liaisons, and consider religious beliefs and idioms of distress
Patients with Disabilities
- Communication may be limited (e.g., non-verbal, hearing impaired)
- Somatic symptoms misattributed or overlooked due to baseline disability
- Higher rates of abuse, neglect, or social isolation
- Multidisciplinary input crucial (therapy, social work, medical, and psych)
Tip: Use AAC (Augmentative and Alternative Communication) and adaptive techniques for assessment!
Follow-Up and Home Care
Principles of Ongoing Care
- Continuity: Regular, structured follow-up (in-person, telemedicine, or community visits)
- Psychoeducation: For patients and caregivers on symptom recognition and management
- Medication Adherence: Monitor compliance, side effects, and drug interactions
- Social Support: Engage family, neighbors, and social services to reduce isolation
- Home Environment: Safe, reassuring, and structured; mitigate triggers (e.g., clutter, noise, unfamiliar settings)
| Nursing Intervention | Goal | Rationale |
|---|---|---|
| Routine check-ins (calls/visits) | Early detection of relapse | Promotes safety; reinforces coping skills |
| Symptom diary (patient/caregiver) | Track symptoms/triggers | Early intervention, empowers patient engagement |
| Medication management | Optimize adherence and safety | Prevents adverse events, enhances outcomes |
| Home hazard assessment | Reduce fall/stress risks | Minimizes injury, increases security |
“CARES” for Home Follow-Up:
Check-ins – Adjust meds – Record symptoms – Educate – Support system
Check-ins – Adjust meds – Record symptoms – Educate – Support system
Rehabilitation
Psychosocial Rehabilitation
- Psychoeducation for patient & family
- Occupational therapy for skills acquisition
- Supportive psychotherapy, CBT (group or individual)
- Social skills training to reduce isolation
- Facilitating community engagement (senior centers, hobby groups, volunteer work)
Medical and Physical Rehabilitation
- Management of comorbid illnesses (pain, mobility, sensory deficits)
- Physiotherapy to enhance function, prevent deconditioning
- Adaptive equipment for activities of daily living (ADLs)
- Speech/language therapy (when relevant: aphonia, mutism)
Discharge Planning & Multidisciplinary Approach
- Prepare safe transition: to home or supported facility; ensure clear instructions
- Involve psychiatrist, GP, social worker, physiotherapist, occupational therapist, and caregivers
- Schedule structured follow-up: coordinate appointments and community resources
- Monitor rehabilitation goals: restore autonomy, maximize function, maintain well-being
Mnemonics & Clinical Tips
“OLD AGE”: Common Elderly Stressors
Organic illness
Losses (spouse, independence)
Depression, disability
Abuse, anxiety
Grief
Environmental change
Organic illness
Losses (spouse, independence)
Depression, disability
Abuse, anxiety
Grief
Environmental change
“SOAP” for holistic home visit:
Subjective (patient’s story)
Objective (exam, observations)
Assessment (safety, cognition, mood)
Plan (referrals, education, support)
Subjective (patient’s story)
Objective (exam, observations)
Assessment (safety, cognition, mood)
Plan (referrals, education, support)
Clinical Tip: In older adults, a “medical” complaint could be psychiatric; always consider both axes in your holistic assessment!
Visual Summary: Infographics & Charts
Figure: Estimated Prevalence of Neurotic/Stress Disorders in Age Groups.
Figure: Integrated Care for Neurotic Disorders (Source: Osmosis illustration).
References & Further Reading
- American Psychiatric Association. (2022). DSM-5-TR: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision.
- World Health Organization. (2023). ICD-11 for Mortality and Morbidity Statistics. https://icd.who.int/en
- Osmosis.org. Neurotic, anxiety, and somatoform disorders. Nursing Notes
- Sadock BJ, Sadock VA, Ruiz P. (2015). Kaplan & Sadock’s Synopsis of Psychiatry. 11th edition.
- Saunders, J. C. & Jeste, D. V. (2022). Psychiatry in the Elderly. In: Comprehensive Geriatric Psychiatry. [Elsevier]
- National Institute for Health and Care Excellence (NICE). (2023). Older people: mental wellbeing. NICE guidance