Somatoform and Dissociative Disorders
Somatoform Disorders The common focus of somatoform disorders is
physical sx in the absence of clinically significant organic disease Includes: – – – – –
Body dysmorphic disorder Pain disorder Somatization disorder Conversion disorder Hypochondriasis
Body Dysmorphic Disorder Characterized by a preoccupation with an
imagined defect in appearance – If the individual has a slight physical anomaly, the person’s concern is markedly excessive
The preoccupation causes clinically significant
distress or impairment in social or occupational functioning The preoccupation is not better accounted for by another mental d/o
Body Dysmorphic Disorder (cont) Typical concerns focus on imagined or minor
flaws of the face or head—wrinkles, complexion tone, markings such as scars or freckles, excessive or thinning hair, or asymmetry of the face, eyes, ears, or nose These individuals spend inordinate amounts of time checking their “defect” in mirrors Often extreme grooming rituals are present
Pain Disorder The predominant clinical focus is pain in
one or more anatomic sites The pain is of sufficient severity to warrant clinical attention and cause impairment in 1 or more areas of functioning Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of pain
Somatization Disorders These clients frequently seek and obtain medical
treatment for multiple, clinically significant somatic complaints The c/o must begin before age 30 The c/o cannot be adequately explained by any general medical d/o or the direct effects of a substance If there is a medical condition present, the c/o or impairment in functioning are in excess of what would be expected from the Health assessment &Physical examination or lab findings
Somatization Disorders (cont) Each of the following criteria must have been
met:
– 4 pain sx: a hx of pain r/t at least 4 different sites of function (head, back, abdomen, joints, extremities, chest, rectum, during menstruation, during sex, or during urination) – 2 GI sx: nausea, bloating, vomiting, diarrhea, or intolerance to several different foods – 1 sexual sx: sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding
Somatization Disorders (cont) Each of the following criteria must have
been met: – 1 pseudoneurological sx • Conversion sx such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lum in the throat urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures __ Autonomic Nervous Symptoms
Conversion Disorder The term conversion comes from the idea that the
individual uses the somatic sx in an unconscious manner to reduce or repress a psychological conflict that creates anxiety The most common sx is a d/o of movement—inability to walk, stand, or move an arm – Researchers have found that 71% of clients present with CNS sx Other sx may take the form of blindness, deafness, or difficulty swallowing The client often seems unconcerned about this serious, sudden incapacitation (la belle indifference)
Conversion Disorder (cont) Clients exhibit 1 or more sx or deficits affecting
voluntary motor or sensory function that suggests a neurological or other general medical condition Psychological factors are judged to be associated with the sx or deficit The sx or deficit is not intentionally produced or feigned The sx or deficit impairs functioning or warrants medical evaluation The sx or deficit is not limited to pain or sexual dysfunction
Hypochondriasis Individual is preoccupied with fears of having—
or the idea of having—a serious medical d/o based on the individual’s misinterpretation of bodily sx The misinterpretation of sx persists despite appropriate medical evaluation and reassurance The individual’s preoccupation is not as intense or distorted as in delusional d/o nor is it as restricted as in body dysmorphic d/o
Dissociative Disorders Dissociation refers to feeling detached
form usual experiences, “cut off”, in a dream like state, or unable to remember things Includes: – Dissociative amnesia – Dissociative fugue – Dissociative identity disorder
Dissociative Amnesia Clients have difficulty remembering past periods
of time The memory loss goes beyond usual forgetfulness There may be defined gaps in the memory for years or for self-destructive, violent , or suicidal episodes Traumatic events such as physical or sexual abuse frequently account for the memory impairment An example is an individual who has no memory of childhood
Dissociative Fugue Relatively uncommon Characterized by travel away from one’s
home or one’s customary place of work with an inability to recall one’s past The individual demonstrates confusion about personal identity
Dissociative Identity Disorder Individual must demonstrate 2 or
more distinct identities or personality states At least 2 of these personality states take control of the person’s behavior
Individuals with this d/o describe very
different personalities, with distinct histories, ages, gender, names, and mood styles such as angry depressed or domineering Most individuals with this dx have histories of severe childhood abuse
Depersonalization disorder Persistent or recurrent feeling of being
detached from one’s mental process or body Person may describe feelings as though they are in a dream state that they are outside observer of their lives.
Nursing intervention 1. 2. 3. 4. 5. 6. 7. 8.
Recognize the client use of relieving behaviors Limit caffeine, nicotine and NCS stimulants Teach client to differentiate between identifiable and non-identifiable anxiety Use anxiety –reducing techniques. Help client to build effective coping methods. Help client identify supportive persons who can help Help client to control of overwhelming feelings and impulses. Construct client’s environment to be less noisy and less stimulus
Interdisciplinary Treatment Providing long-term general
management of the chronic condition Conservatively treating comorbid
psychiatric and physical problems Providing care in special settings,
including group treatment
Nursing Management: Biologic Domain Assessment: – – – –
Review of systems Assessment of pain Physical functioning Pharmacologic • Usually taking a large number of meds • Self-medicate and provider shop
– Health attitude survey – Review clinical vignette
Nursing Diagnoses – Fatigue, pain, disturbed sleep
Biologic Nursing Interventions Spend time with physical complaints Help patient establish a daily routine Continually monitor medication Pain management – need multiple approaches Activity enhancement Nutrition regulation Relaxation
Pharmacologic Interventions There is no medication for somatization
disorder. Treat the comorbid disorders. – Depression: antidepressants - MOAI – Anxiety: Avoid benzodiazepines.
Monitor closely. Observe for drug-drug interactions.
Nursing Management: Psychological Domain Assessment
Nursing Diagnoses
Mental status usually
Anxiety
Appearance may be
Ineffective sexuality
Preoccupied with personal
Impaired social interactions
normal
flamboyant, exaggerated illness (may keep a copy of record), series of personal crisis.
Emotional reactions to life
stressors
Labile mood
patterns
Ineffective coping Ineffective management of
therapeutic regimen
Psychological Nursing Interventions Maintaining nurse-patient relationship Counseling Problem solving Health teaching
Nursing Management: Social Domain Assessment How much time seeking
medical care and treating illnesses?
Extent of disability? Employment status? Social network? Do they
see their friends as providers?
Family members – Tired of all the complaints? – Alcoholism is common.
Nursing Diagnosis Caregiver role strain, risk Ineffective community
coping Disable family coping Social isolation
Nursing Diagnosis Fatigue Pain Sleep pattern disturbance Altered sexuality patterns, anxiety Ineffective coping Impaired social interactions Ineffective management of therapeutic
regimen
Social Nursing Interventions Problem-solving groups Assertiveness groups • Family interventions
Factitious Disorders Factitious disorder (Munchausen’s
syndrome) – Different than malingering (has other motivations) – Injure themselves covertly – Produce physical symptoms
Factitious disorder NOS (by proxy) – Injure others in order to gain attention (mother hurting child)
Nursing Management Assessment Chronology of medical/psychological illnesses Early childhood experiences (abuse, neglect, role of selfinjury) Family assessment
Nursing Diagnosis Risk for trauma Risk for self-
mutilation Ineffective individual coping Low self-esteem
Nursing Intervention Goal: To replace dysfunctional, attention-
seeking behaviors with positive behaviors Accept and value patient. Encourage long-term psychotherapy. Confrontation is effective if patient feels supported.