Somatoform and Dissociative Disorders Chapter 18 Somatoform and Dissociative Disorders

Somatoform Disorders Somatoform disorders are characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them

Dissociative Disorders Dissociative disorders are defined by a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment

Epidemiological Statistics Somatoform disorders are more commonly found in Women than in men The poorly educated Lower socioeconomic classes

Epidemiological Statistics (cont.) Dissociative disorders are thought to be rare DID and dissociative amnesia are more common in women than in men. Brief episodes of depersonalization symptoms appear to be common in young adults, particularly in times of severe stress

Application of the Nursing Process: Assessment Types of somatoform disorders Somatization disorder: chronic syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from health-care professionals

Application of the Nursing Process: Assessment (cont.) Somatization disorder (cont.) The disorder is chronic Anxiety, depression, and suicidal ideations are frequently manifested Drug abuse and dependence are not uncommon

Application of the Nursing Process: Assessment (cont.) Somatization disorder (cont.) Personality characteristics Heightened emotionality Strong dependency needs A preoccupation with symptoms and oneself

Application of the Nursing Process: Assessment (cont.) Pain disorder Predominant disturbance in pain disorder is severe and prolonged pain that causes clinically significant distress or impairment in social, occupational, or other areas of functioning

Application of the Nursing Process: Assessment (cont.) Pain disorder (cont.) Even when organic pathology is detected, the pain complaint may be evidenced by the correlation of a stressful situation with the onset of symptoms

Application of the Nursing Process: Assessment (cont.) Pain disorder (cont.) Pain disorder may be maintained by Primary gains: symptom enables the client to avoid some unpleasant activity Secondary gains: symptom promotes emotional support or attention for the client

Application of the Nursing Process: Assessment (cont.) Pain disorder (cont.) Tertiary gains: in dysfunctional families, the physical symptom may take such a position that the real issue is disregarded and remains unresolved even though some of the conflict is relieved Symptoms of depression and substance abuse are common

Application of the Nursing Process: Assessment (cont.) Hypochondriasis A preoccupation with the fear of contracting, or the belief of having, a serious disease The fear becomes disabling and persists despite reassurance that no organic pathology can be detected

Application of the Nursing Process: Assessment (cont.) Hypochondriasis (cont.) Even in the presence of disease, the symptoms are excessive in relation to the degree of pathology Anxiety and depression are common, and obsessive–compulsive traits frequently accompany the disorder

Application of the Nursing Process: Assessment (cont.) Conversion disorder A loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism

Application of the Nursing Process: Assessment (cont.) Conversion disorder (cont.) The most obvious and “classic” conversion symptoms are those that suggest neurological disease and occur following a situation that produces extreme psychological stress for the individual

Application of the Nursing Process: Assessment (cont.) Conversion disorder (cont.) Client often expresses a relative lack of concern that is out of keeping with the severity of the impairment This lack of concern is identified as la belle indifference and may be a clue to the physician that the problem is psychological rather than physical

Application of the Nursing Process: Assessment (cont.) Body dysmorphic disorder This disorder is characterized by an exaggerated belief that the body is deformed or defective in some specific way Symptoms of depression and characteristics associated with obsessive-compulsive personality are common

Etiological Implications Somatoform disorders Genetic: hereditary factors are possibly associated with somatization disorder, conversion disorder, and hypochondriasis Biochemical: decreased levels of serotonin and endorphins may play a role in the etiology of pain disorder

Etiological Implications (cont.) Somatoform disorders (cont.) Psychodynamic theory: this theory suggests that hypochondriasis may be an ego defense mechanism; physical complaints become the expression of low self-esteem, because it is easier to feel something is wrong with the body than to feel something is wrong with the self S. Freud

Etiological Implications (cont.) Somatoform disorders (cont.) Psychodynamic theory (cont.) Conversion disorder may represent emotions associated with a traumatic event that are too unacceptable to express and so are acceptably “converted” into physical symptoms S. Freud

Etiological Implications (cont.) Somatoform 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 in an open manner Somatization brings some stability to the family and positive reinforcement to the child

Etiological Implications (cont.) Somatoform 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)

Etiological Implications (cont.) Somatoform disorders (cont.) Learning theory (cont.) Becomes prominent focus of attention because of the illness (secondary gain) Relieves conflict within family as concern is shifted to the ill person and away from the real issue (tertiary gain)

Etiological Implications (cont.) Somatoform disorders (cont.) Learning theory (cont.) Hypochondriasis: past experience with serious or life-threatening physical illness, either personal or that of close relatives, can predispose to hypochondriasis

Nursing Diagnosis/Outcome Ineffective coping Chronic pain Fear Disturbed sensory perception Disturbed body image

Outcomes 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 Verbalizes realistic perception of appearance and expresses positive body image

Planning/Implementation Nursing care of the individual with a somatoform disorder is aimed at relief of discomfort from the physical symptoms Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than preoccupation with physical symptoms

Evaluation Based on accomplishment of previously established outcome criteria

Medical Treatment Modalities Somatoform disorders Individual psychotherapy Group psychotherapy Behavior therapy Psychopharmacology

Assessment Dissociative disorders Dissociative amnesia involves An inability to recall important personal data that is too extensive to be explained by ordinary forgetfulness Not due to the direct effects of substance use or a general medical condition

Assessment (cont.) Five types of disturbance in recall Localized amnesia: inability to recall all incidents associated with the traumatic event for a specific period following the event Selective amnesia: inability to recall only certain incidents associated with a traumatic event for a specific period following the event

Assessment (cont.) Five types of disturbance in recall (cont.) Continuous amnesia: inability to recall events occurring after a specific time up to and including the present Generalized amnesia: inability to recall anything that has happened during the individual’s entire lifetime, including personal identity Systematized amnesia: inability to recall events relating to a specific category of information, such as one’s family or one particular person or event

Assessment (cont.) Dissociative fugue A sudden, unexpected travel away from home or customary workplace The individual is unable to recall personal identity and assumption of a new identity is common

Assessment (cont.) Dissociative identity disorder (DID) Characterized by 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

Assessment (cont.) Depersonalization disorder Characterized by persisten feelings of Unreality Detachment from oneself or one’s body Observing oneself from outside the body

Assessment (cont.) Depersonalization 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

Assessment (cont.) Depersonalization disorder (cont.) Symptoms of depersonalization disorder are often accompanied by Anxiety and depression Fear of going insane Obsessive thoughts Somatic complaints Disturbance in the subjective sense of time

Etiological Implications Genetics: possible hereditary factors are associated with DID Neurobiological: dissociative amnesia and dissociative fugue may be related to neurophysio- logical dysfunction; EEG abnormalities have been observed in some clients with DID

Etiological Implications (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 S. Freud

Etiological Implications (cont.) Psychological trauma A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelms the individual’s capacity to cope by any means other than dissociation

Etiological Implications (cont.) Psychological trauma (cont.) These experiences usually take the form of severe physical, sexual, or psychological abuse by a parent or significant other in the child’s life

Nursing Process: Diagnosis/Outcome Disturbed thought processes Ineffective coping Disturbed personal identity Disturbed sensory perception

Outcomes The client Can recall events associated with stressful situation Can recall all 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

Planning/Implementation Nursing care 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

Evaluation Based on accomplishment of previously established outcome criteria

Medical Treatment Modalities Individual psychotherapy Hypnosis Supportive care Integration therapy (DID)