Chapter 15 Somatoform and Dissociative Disorders Somatoform Disorders

Chapter 15 Somatoform and Dissociative Disorders

Somatoform Disorders • Physical symptoms suggest a physical disorder. • Medical evaluation and diagnostic tests are negative. • Symptoms are linked to psychobiological factors. • Symptoms are not intentional or under conscious control. – In contrast to malingering and factitious disorder

Dissociative Disorders • Disturbances in the normally wellintegrated continuum of consciousness, memory, identity, and perception

Differentiation of Somatoform Disorders • Malingering – Intentionally producing symptoms to achieve an environmental goal • Factitious disorder – Fabrication of symptoms or self-inflicted injury to assume the sick role • Psychosomatic illness – A real medical condition affected by stress or psychological factors

Somatoform Disorders • Somatization disorder • Hypochondriasis • Pain disorder • Body dysmorphic disorder • Conversion disorder

Theories • Biological factors – Abnormal brain structure or neurotransmitter function • Genetic factors – Run in families • Cultural factors – Variability across cultures • Psychosocial factors – Psychoanalytic theory • Repression of conflict – Behavioral theory • Learned helplessness – Cognitive theory • Misinterpretation of body sensations

Somatization Disorder • Most frequent symptoms – Pain, dysphagia, nausea, bloating, constipation, palpitations, dizziness, shortness of breath • Significant functional impairment • Course of illness chronic and relapsing • Suicide threats and gestures common – Depression and anxiety common

Hypochondriasis • Misinterpretation of real physical sensations • Diagnostic tests are negative • Depression or anxiety disorders common • Chronic and relapsing, worse during periods of stress

Pain Disorder • Diagnostic testing rules out organic cause • Discomfort leads to impairment • Suicide a serious risk factor – Rate nine times higher • Usual sites of pain: head, face, lower back, pelvis • Depression, personality disorders, substance abuse common

Body Dysmorphic Disorder • Preoccupation with an imagined defective body part • Obsessional thinking and compulsive behavior • Impaired social, academic, or occupational functioning • Major depression, OCD, and social phobia common

Conversion Disorder • Deficits in voluntary motor or sensory functions • Common symptoms: involuntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, deafness • "La belle indifférence" versus distress • Comorbid conditions: depression, anxiety, other somatoform disorders, personality disorders • The most common somatoform disorder

Assessment • Symptoms and unmet needs • Voluntary control of symptoms – Symptoms not under voluntary control • Secondary gains • Cognitive style – Misinterpretation of stimuli • Ability to communicate feelings and emotional needs • Dependence on medication

Assessment Guidelines • Assess nature, location, onset, characteristics, and duration of symptoms • Assess ability to meet basic needs • Assess risks to safety • Determine if symptoms under voluntary control

Assessment Guidelines • Identify secondary gains • Assess cognitive style and ability to communicate feelings and needs • Assess type and amount of medications

Nursing Diagnosis • Ineffective coping, disturbed body image, chronic low self-esteem, selfcare deficits, pain – See table 15 -3 on page 261 entitled “Potential Nursing Diagnoses for Somatoform Disorders. ”

Outcome Criteria • Realistic and attainable • Structure outcomes in small steps to give the client hope for success.

Basic Level Nursing Interventions • Promotion of self-care activities • Health teaching – Assertiveness training • Case management – Brief, regular PCP appointments • Psychobiological interventions – SSRIs, short-term antianxiety agents – Relaxation techniques

Advanced Practice Interventions • Psychotherapy • Consultation with PCP

Dissociative Disorders • Depersonalization disorder • Dissociative amnesia • Dissociative fugue • Dissociative identity disorder – Formerly multiple personality disorder

Theory • Biological factors – Impaired limbic system and neurotransmitters (serotonin) • Genetic factors – Dissociative Identity Disorder (DID) • Cultural factors • Psychosocial factors – Learning theory: a learned method to survive overwhelming stress

Depersonalization Disorder • Alteration in perception of self • Disturbing experiences of – Feeling a sense of deadness of the body – Seeing oneself from a distance – Perceiving limbs to be larger or smaller than normal • Reality testing remains intact

Dissociative Amnesia • Inability to recall important personal information often of a traumatic nature – Generalized amnesia • No recall of entire life – Localized amnesia • No recall of a specific period – Selective amnesia • Recall some but not all events of a specific period

Dissociative Fugue • Sudden unexpected travel away from the customary locale • Precipitated by traumatic event • Inability to recall one's identity and some or all of the past • During fugue state tend to live simple, quiet lives • When remember former identity, become amnesic for time spent in fugue state

Dissociative Identity Disorder • Presence of two or more distinct personality states • Primary personality (host) usually not aware of alters • Alternate personalities (alters) or subpersonalities take control of behavior • Alters often aware of each other • Each alter thinks and behaves as a separate individual

Assessment • Self-identity and memory • Client history – Head injury, seizure disorder, abuse • Moods – Mood swings with DID • Use of alcohol and other drugs • Impact on client and family • Suicide risk – Self-harm

Basic Level Nursing Interventions • Milieu therapy – Safe environment • Health teaching – Stress management, coping strategies • Psychobiological interventions – Antidepressants, antianxiety agents

Advanced Practice Interventions • Cognitive-behavioral therapy • Psychodynamic psychotherapy

Evaluation: Successful Treatment • Client safety maintained • Anxiety reduced • Client functions at a higher level • Conflicts explored • Effective use of new coping strategies