Chapter 29 Somatic Symptom and Dissociative Disorders Copyright

Chapter 29 Somatic Symptom and Dissociative Disorders Copyright © 2014. F. A. Davis Company

Introduction Somatic symptom disorders are characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them. Copyright © 2014. F. A. Davis Company

Introduction (cont. ) Dissociative disorders are defined by a disruption in the usually integrated functions of consciousness, memory, and identity. Copyright © 2014. F. A. Davis Company

Historical Aspects • Somatic symptom disorders have been identified as hysterical neuroses and were thought to occur in response to repressed severe anxiety. • Freud viewed dissociation as a type of repression, an active defense mechanism used to remove threatening or unacceptable mental contents from conscious awareness. Copyright © 2014. F. A. Davis Company

Epidemiological Statistics • Somatic symptom disorders are more commonly found in: – Women more than men – Less educated persons – Rural areas Copyright © 2014. F. A. Davis Company

Epidemiological Statistics (cont. ) • Individuals with factitious disorder comprise about 0. 8 to 1. 0 percent of psychiatry consultation clients. Copyright © 2014. F. A. Davis Company

Epidemiological Statistics (cont. ) • Dissociative disorders (DID) are statistically quite rare. • DID is more prevalent in women than in men. • Brief episodes of depersonalization symptoms appear to be common in young adults, particularly in times of severe stress. Copyright © 2014. F. A. Davis Company

Application of the Nursing Process: Assessment • Types of Somatic Symptom Disorders – Somatic symptom disorder • A syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from healthcare professionals. • The disorder is chronic, and anxiety, depression, and suicidal ideation are frequently manifested. Copyright © 2014. F. A. Davis Company

Types of Somatic Symptom Disorders (cont. ) • Somatic Symptom Disorder (cont. ) – Drug abuse and dependence are common complications of somatic symptom disorder. – Personality characteristics are heightened emotionality, strong dependency needs, and a preoccupation with symptoms and oneself. Copyright © 2014. F. A. Davis Company

Types of Somatic Symptom Disorders (cont. ) • Illness Anxiety Disorder – Unrealistic or inaccurate interpretation of physical symptoms or sensations leading to preoccupation and fear of having a serious disease. Copyright © 2014. F. A. Davis Company

Types of Somatic Symptom Disorders (cont. ) • Illness Anxiety Disorder (cont. ) – Their behavioral response to even the slightest changes in feeling or sensation is unrealistic and exaggerated. – Anxiety and depression are common, and obsessive-compulsive traits frequently accompany the disorder. Copyright © 2014. F. A. Davis Company

Types of Somatic Symptom Disorders (cont. ) • Conversion Disorder – A loss of or change in body function that cannot be explained by any known medical disorder or pathophysiological mechanism. – The most obvious and “classic” conversion symptoms are those that suggest neurological disease. – Some instances of conversion disorder may be precipitated by psychological stress. Copyright © 2014. F. A. Davis Company

Types of Somatic Symptom Disorders (cont. ) • Psychological Factors Affecting Medical Condition – Psychological factors may play a role in virtually any medical condition. – With this diagnosis, there is evidence of a general medical condition that has been precipitated by or is being perpetuated by psychological or behavioral circumstances. Copyright © 2014. F. A. Davis Company

Types of Somatic Symptom Disorders (cont. ) • Factitious Disorder – Conscious, intentional feigning of physical and/or psychological symptoms. – Individual pretends to be ill in order to receive emotional care and support commonly associated with the role of “patient. ” Copyright © 2014. F. A. Davis Company

Types of Somatic Symptom Disorders (cont. ) • Factitious Disorder (cont. ) – The disorder may also be identified as Munchausen syndrome. – The disorder may be imposed on another person under the care of the perpetrator (formerly called Factitious Disorder by Proxy). Copyright © 2014. F. A. Davis Company

Types of Somatic Symptom Disorders (cont. ) 1. A client, experiencing lower extremity paralysis, is admitted to a medical unit. Extensive tests confirm disability but rule out any underlying organic pathology. The nurse concludes that this is most suggestive of which disorder? A. B. C. D. Conversion disorder Illness anxiety disorder Malingering Somatic symptom disorder Copyright © 2014. F. A. Davis Company

Application of the Nursing Process: Assessment (cont. ) • Correct answer: A – Conversion disorder is a loss or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder. The situation presented in the question describes a conversion disorder. Copyright © 2014. F. A. Davis Company

Predisposing Factors Associated with Somatic Symptom Disorders • Genetic – Hereditary factors are possibly associated with somatic symptom disorder, conversion disorder, and illness anxiety disorder. • Biochemical – Decreased levels of serotonin and endorphins may play a role in the etiology of somatic symptom disorder, predominantly pain. Copyright © 2014. F. A. Davis Company

Predisposing Factors Associated with Somatic Symptom Disorders (cont. ) • Neuroanatomical – Brain dysfunction (impairment in information processing) has been implicated as a factor in factitious disorder. Copyright © 2014. F. A. Davis Company

Predisposing Factors Associated with Somatic Symptom Disorders (cont. ) • Psychodynamic Theory – This theory suggests that illness anxiety disorder is an ego defense mechanism. Physical complaints are the expression of low self-esteem and feelings of worthlessness. Copyright © 2014. F. A. Davis Company S. Freud

Predisposing Factors Associated with Somatic Symptom Disorders (cont. ) • Psychodynamic Theory – Conversion disorder may represent emotions associated with a traumatic event that are too unacceptable to express and so are acceptably “converted” into physical symptoms. Copyright © 2014. F. A. Davis Company S. Freud

Predisposing Factors Associated with Somatic Symptom Disorders (cont. ) • Family Dynamics – In dysfunctional families, when a child becomes ill, focus shifts from the open conflict to the child’s illness and leaves unresolved underlying issues the family is unable to confront openly. – Somatization brings some stability to the family and positive reinforcement to the child (called tertiary gain). Copyright © 2014. F. A. Davis Company

Predisposing Factors Associated with Somatic Symptom Disorders (cont. ) • Learning Theory – Somatic complaints are often reinforced when the sick person learns that he or she: • May avoid stressful obligations or be excused from unwanted duties (primary gain) • May become the prominent focus of attention because of the illness (secondary gain) • May relieve conflict within the family as concern is shifted to the ill person and away from the real issue (tertiary gain) Copyright © 2014. F. A. Davis Company

Predisposing Factors Associated with Somatic Symptom Disorders (cont. ) • Learning Theory (cont. ) – Illness anxiety disorder • Past experience with serious or life-threatening physical illness, either personal or that of close relatives, can predispose the person to illness anxiety disorder Copyright © 2014. F. A. Davis Company

Predisposing Factors Associated with Somatic Symptom Disorders (cont. ) • Transactional Model of Stress/Adaptation – The etiology of somatic symptom disorders is most likely influenced by multiple factors. Copyright © 2014. F. A. Davis Company

Somatic Symptom Disorder 2. A client is experiencing pain that has no organic etiology. This pain allows the client to avoid going to work at a job he hates. What best describes what this client is experiencing? A. The client is experiencing altered social interaction. B. The client is experiencing disturbed thought processes. C. The client is experiencing primary gain. D. The client is experiencing secondary gain. Copyright © 2014. F. A. Davis Company

Somatic Symptom Disorder • Correct answer: C – Primary gain describes the benefit to the client of avoidance of some unpleasant activity due to experiencing psychologically based pain. This avoidance directly decreases the client’s anxiety. The situation presented in the question describes primary gain. Copyright © 2014. F. A. Davis Company

Application of the Nursing Process: Assessment • Types of Dissociative Disorders – Dissociative amnesia • Defined as an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness and which is not due to the direct effects of substance use or a neurological or other medical condition. • Onset usually follows severe psychosocial stress. Copyright © 2014. F. A. Davis Company

Dissociative Amnesia • Types of Disturbance in Recall – Localized amnesia • The inability to recall incidents associated with the traumatic event for a specific period following the event – Selective amnesia • The inability to recall only certain incidents associated with a traumatic event for a specific period following the event Copyright © 2014. F. A. Davis Company

Dissociative Amnesia (cont. ) • Types of Disturbance in Recall (cont. ) – Generalized amnesia • The inability to recall anything that has happened during the individual’s entire lifetime, including personal identity Copyright © 2014. F. A. Davis Company

Dissociative Amnesia (cont. ) • A specific subtype of dissociative amnesia is with dissociative fugue in which there is sudden, unexpected travel away from home with the inability to recall some or all of one’s past. Copyright © 2014. F. A. Davis Company

Types of Dissociative Disorders (cont. ) • Dissociative Identity Disorder (DID) – Characterized by the existence of two or more personalities within a single individual – Transition from one personality to another usually sudden, often dramatic, and usually precipitated by stress Copyright © 2014. F. A. Davis Company

Types of Dissociative Disorders (cont. ) • Depersonalization-Derealization Disorder – Characterized by a temporary change in the quality of self-awareness that often takes the form of: • • Feelings of unreality Changes in body image Feelings of detachment from the environment A sense of observing oneself from outside the body Copyright © 2014. F. A. Davis Company

Depersonalization-Derealization Disorder (cont. ) – Depersonalization is defined as a disturbance in the perception of oneself. – Derealization is described as an alteration in the perception of the external environment. Copyright © 2014. F. A. Davis Company

Depersonalization-Derealization Disorder (cont. ) – Symptoms of this disorder are often accompanied by: • • • Anxiety and depression Fear of going insane Obsessive thoughts Somatic complaints Disturbance in the subjective sense of time Copyright © 2014. F. A. Davis Company

Predisposing Factors to Dissociative Disorders • Genetics – Possible hereditary factors are associated with DID. – Neurobiological • Dissociative amnesia may be related to neurophysiological dysfunction. • EEG abnormalities have been observed in some clients with DID. Copyright © 2014. F. A. Davis Company

Predisposing Factors to Dissociative Disorders (cont. ) • Psychodynamic Theory – Freud described dissociation as repression of distressing mental contents from conscious awareness. Current psychodynamic explanations reflect Freud’s concepts that dissociative behaviors are a defense against unresolved painful issues. Copyright © 2014. F. A. Davis Company

Predisposing Factors to Dissociative Disorders (cont. ) • Psychological Trauma – A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelm the individual’s capacity to cope by any means other than dissociation. – These experiences usually take the form of severe physical, sexual, or psychological abuse by a significant other in the child’s life. – DID is thought to serve as a survival strategy for the child in this traumatic environment. Copyright © 2014. F. A. Davis Company

Predisposing Factors to Dissociative Disorders (cont. ) • Transactional Model of Stress/Adaptation – The etiology of dissociative disorders is most likely influenced by multiple factors. Copyright © 2014. F. A. Davis Company

Dissociative Disorders 3. According to psychodynamic theory, which primary defense mechanism would the nurse expect to find in a client with dissociative amnesia? A. B. C. D. Suppression Sublimation Displacement Repression Copyright © 2014. F. A. Davis Company

Dissociative Disorders • Correct answer: D – Repression, which is the involuntary blocking of unpleasant feelings and experiences from one's awareness, is the defense mechanism most used by clients experiencing amnesia. Freud believed that dissociative behaviors, including amnesia, occurred when individuals repressed distressing mental contents from conscious awareness. He believed that this mechanism protected the client from emotional pain. Copyright © 2014. F. A. Davis Company

Nursing Process: Diagnosis/Outcome • Common nursing diagnoses for clients with somatic symptom disorders include: – Ineffective coping evidenced by numerous physical complaints (somatic symptom disorder) – Deficient knowledge (psychological causes for physical symptoms [somatic symptom disorder]) – Chronic pain (somatic symptom disorder) – Fear (of having a serious disease [illness anxiety disorder] ) – Disturbed sensory perception (conversion disorder) – Self-care deficit (conversion disorder) – Deficient knowledge (psychological factors affecting medical condition) – Ineffective coping (factitious disorder) Copyright © 2014. F. A. Davis Company

Nursing Process: Diagnosis/Outcome (cont. ) • Common nursing diagnoses for clients with dissociative disorders include: – – – Impaired memory (dissociative amnesia) Powerlessness (dissociative amnesia) Risk for suicide (DID) Disturbed personal identity (DID) Disturbed sensory perception (visual/kinesthetic [depersonalization-derealization disorder] ) Copyright © 2014. F. A. Davis Company

Outcomes (Somatic Symptom Disorders) • The Client: – Copes effectively without resorting to physical symptoms – Verbalizes relief from pain – Has decreased frequency of physical complaints and interprets bodily sensations rationally – Is free of physical disability Copyright © 2014. F. A. Davis Company

Outcomes (Dissociative Disorders) • The Client: – Can recall events associated with stressful situation – Can recall events of past life – Can verbalize anxiety that precipitated the dissociation – Can demonstrate coping methods to avert dissociative behaviors – Verbalizes existence of multiple personalities – Is able to maintain a sense of reality during stressful situations Copyright © 2014. F. A. Davis Company

Nursing Process: Planning and Implementation • Nursing care of the individual with a somatic symptom disorder is aimed at relief of discomfort from the physical symptom. • Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than preoccupation with physical symptoms. Copyright © 2014. F. A. Davis Company

Nursing Process: Planning and Implementation (cont. ) • Nursing care for the client with a dissociative disorder is aimed at restoring normal thought processes. • Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than dissociation from the environment. Copyright © 2014. F. A. Davis Company

Nursing Process: Planning and Implementation (cont. ) 4. When working with a client diagnosed with a somatic symptom disorder, which is the most appropriate nursing action? A. B. C. D. Avoid discussing social and personal problems. Focus on the physical symptoms. Always meet the client’s dependency needs. Gradually minimize time focusing on physical symptoms. Copyright © 2014. F. A. Davis Company

Nursing Process: Planning and Implementation (cont. ) • Correct answer: D – The nurse’s attention should be on the client’s social and personal problems, which are the underlying cause of the somatic symptom disorder. Time focused on physical symptoms should be minimized to avoid reinforcement. Copyright © 2014. F. A. Davis Company

Nursing Process: Evaluation • Based on accomplishment of previously established outcome criteria Copyright © 2014. F. A. Davis Company

Medical Treatment Modalities for Somatic Symptom Disorders • • Individual Psychotherapy Group Psychotherapy Behavior Therapy Psychopharmacology Copyright © 2014. F. A. Davis Company

Medical Treatment Modalities for Dissociative Disorders • • Individual Psychotherapy Hypnosis Supportive Care Cognitive Therapy Group Therapy Integration Therapy (DID) Psychopharmacology Copyright © 2014. F. A. Davis Company