Somatoform and Sleep Disorders Chapter 9 Introduction A. The somatoform disorders are characterized by physical symptoms B. Somatization refers to all those mechanisms by which anxiety is translated known pathophysiological mechanism to account for them. suggesting medical disease, but without demonstrable organic pathology or C. Disordered sleep is a problem for many people. The cause may be into physical illness or bodily complaints. A. Historical Aspects II. Somatoform Disorders temporarily caused by stress or anxiety; or the cause may be physiological. 1. The concept of hysteria, which is characterized by recurrent, multiple 2. Witchcraft, demonology, and sorcery were associated with hysteria in the old and probably originated in Egypt. somatic complaints often described dramatically, is at least 4,000 years 3. In the 19th century, the French physician Paul Briquet attributed the Middle Ages. expressed can be “converted” into physical symptoms. 4. Out of his work with hypnosis, Freud proposed that emotion which is not disorder to dysfunction in the nervous system. B. Epidemiological Statistics socioeconomic classes. are more common in the poorly educated and people from the lower 1. Somatoform disorders are more common in women than in men. They 1. Somatization Disorder: Background Assessment Data C. Application of the Nursing Process to Somatoform Disorders and long-term seeking of assistance from health care professionals. explained medically and are associated with psychosocial distress a. A chronic syndrome of multiple somatic symptoms that cannot be the neurological, gastrointestinal, psychosexual, or cardiopulmonary b. Any organ system may be affected, but common complaints involve attempts and threats are not uncommon. c. Anxiety and depression are frequently manifested, and suicidal systems. (1) Theory of family dynamics. In dysfunctional families, when a d. Predisposing factors to somatization disorder that the family is unable to confront in an open manner. to the child’s illness, leaving unresolved the underlying issues child becomes ill, a shift in focus is made from the open conflict Somatization brings some stability to the family, and positive physical symptoms in different ways. Cognitive or emotional (2) Cultural and environmental factors. Various cultures deal with reinforcement to the child. societies. In Middle Eastern and Asian cultures, depression is symptoms such as guilt are predominantly seen in Western (3) Genetic factors. Studies have shown a 10- to 20-fold increased symptoms. almost exclusively manifested by somatic or vegetative incidence in female first-degree relatives of persons with the (4) Transactional Model of Stress-Adaptation. The etiology of predisposition. disorder. These statistics may imply a possible inheritable factors. somatization disorder is most likely influenced by multiple include: (1) Nursing diagnoses for the client with somatization disorder e. Diagnosis/Outcome Identification (a) Ineffective coping nursing care. (2) Outcome criteria are identified for measuring effectiveness of (b) Deficient knowledge (1) Nursing intervention for the client with somatization disorder is f. Planning/Implementation (2) The nurse also works to help the client correlate appearance of other than preoccupation with physical symptoms. aimed at assisting the client to learn to cope with stress by means g. Evaluation is based on accomplishment of previously established the physical symptoms with times of stress. a. The predominant disturbance in pain disorder is severe and 2. Pain Disorder: Background Assessment Data outcome criteria. impairment in social, occupational, or other areas of functioning. prolonged pain that causes clinically significant distress or of the symptom. be evidenced by the correlation of stressful situation with the onset b. Even when organic pathology is detected, the pain complaint may c. The disorder may be maintained by: (2) Secondary gains: The symptom promotes emotional support or unpleasant activity. (1) Primary gains: The symptom enables the client to avoid some (3) Tertiary gains: In dysfunctional families, the physical symptom attention for the client. relieved. remains unresolved, even though some of the conflict is may take such a position that the real issue is disregarded and (1) Psychodynamic theory. Theorizes that pain for some clients d. Predisposing factors to pain disorder emotions verbally may express feelings and emotions with wrongdoing. Individuals who have difficulty expressing serves the purposes of punishment and atonement for perceived (2) Behavioral theory. In behavioral terminology, psychogenic bodily sensations. positive or negatively reinforced. and classical conditioning. Occurs when pain behaviors are pain is explained as a response that is learned through operant (3) Theory of family dynamics. “Pain games” may be played in relationships. Tertiary gain may also be influential. manipulating and gaining the advantage in interpersonal families burdened by conflict. Pain may be used for and medulla are involved in inhibiting the firing of afferent pain (4) Neurophysiological theory. Postulates that the cerebral cortex the central modulation of pain. serotonin and endorphins, which are thought to play a role in fibers. These individuals may have decreased levels of disorder is most likely influenced by multiple factors. (5) Transactional Model of Stress-Adaptation. The etiology of pain (b) Social isolation (a) Chronic pain (1) Nursing diagnoses for the client with pain disorder include: of nursing care. (2) Outcome criteria are identified for measuring the effectiveness at relief from pain. (1) Nursing intervention for the client with pain disorder is aimed (2) Emphasis is placed on learning more adaptive coping times when the client is not focusing on pain. strategies for dealing with stress. Reinforcement is given at a. Unrealistic preoccupation with fear of having a serious illness 3. Hypochondriasis: Background Assessment Data b. Even in the presence of medical disease, the symptoms are grossly disproportionate to the degree of pathology. (a) One view suggests that hypochondriasis is an ego defense (1) Psychodynamic theory c. Predisposing factors to hypochondriasis mechanism. Physical complaints are the expression of feel something is wrong with the self. easier to feel something is wrong with the body than to low self-esteem and feelings of worthlessness, as it is the transformation of aggressive and hostile wishes (b) Another psychodynamic view explains hypochondriasis as hypochondriasis as a defense against guilt and a need to (c) Still other psychodynamicists have viewed toward others into physical complaints to others. atone for past misconduct. (3) Social learning theory. Somatic complaints are often as arising out of perceptual and cognitive abnormalities. (2) Cognitive theory. Cognitive theorists view hypochondriasis from the need to deal with a stressful situation, whether it be reinforced when the sick role serves to relieve the individual the experience of close family members, with serious or lifethreatening (4) Past experience with physical illness. Personal experience, or within society or within the family constellation. illness can predispose an individual to influences with hypochondriasis, some evidence indicates an (5) Genetic influences. Although little is known about hereditary hypochondriasis. twins and other first-degree relatives. increased prevalence of hypochondriasis among identical d. Diagnosis/Outcome Identification hypochondriasis is most likely influenced by multiple factors. (6) Transactional Model of Stress/Adaptation. The etiology of (1) Nursing diagnoses for hypochondriasis include: e. Planning/Implementation (b) Chronic low self-esteem (a) Fear aimed at relieving the fear of serious illness. (1) Nursing intervention for the client with hypochondriasis is (3) The nurse also works to help the client increase feelings of unrealistic interpretation of bodily signs and sensations. (2) The focus is on decreasing the preoccupation with and self-worth and resolve internalized anger. 4. Conversion Disorder: Background Assessment Data established outcome criteria. f. Evaluation is based on accomplishment of previously psychological conflict, the physical symptoms of which cannot a. A loss of or change in bodily functioning resulting from a b. The most obvious and “classic” conversion symptoms are those pathophysiological mechanism. be explained by any known medical disorder or that suggest neurological disease, and occur following a c. The person often expresses a relative lack of concern that is out individual. situation that produces extreme psychological stress for the concern is identified as la belle indifference and may be a clue of keeping with the severity of the impairment. This lack of d. Predisposing factors to conversion disorder physical. to the physician that the problem is psychological rather than traumatic event that the individual cannot express because of (1) Psychoanalytical Theory. Emotions associated with a of the original emotional trauma physical symptoms. The symptom is symbolic in some way moral or ethical unacceptability are “converted” into individuals with the disorder. Nongenetic familial factors, (2) Familial factors. Occurs more often in relatives of (3) Neurophysiological theory. Suggests that some clients with associated with an increased risk for conversion disorder. such as incestuous sexual abuse in childhood, also may be conversion disorder have a disturbance in central nervous learned through positive reinforcement from cultural, social, (4) Behavioral theory. Suggests that conversion symptoms are system arousal. (5) Transactional Model of Stress/Adaptation. The etiology of and interpersonal influences. conversion disorder is most likely influenced by multiple (1) Nursing diagnoses for the client with conversion disorder (b) Self-care deficit (a) Disturbed sensory-perception effectiveness of nursing care. (2) Outcome criteria are identified for measuring the (2) Emphasis is given to assisting the client with activities of is aimed at recovery of the lost or altered function. (1) Nursing intervention for the client with conversion disorder g. Evaluation is based on accomplishment of previously to reinforce the physical limitation. daily living until the function is regained. Care is given not 5. Body Dysmorphic Disorder: Background Assessment Data b. Symptoms of depression and characteristics associated with deformed or defective in some specific way. a. Characterized by the exaggerated belief that the body is c. Has been closely associated with delusional thinking. Traits obsessive–compulsive personality are common. d. Predisposing factors to body dysmorphic disorder narcissistic personality disorders are not uncommon. associated with schizoid, obsessive–compulsive, and with hypochondriasis or phobias. (1) Etiology is unknown, but presumed to be psychological(2) Predisposing factors may be similar to those associated (4) It is most likely that multiple factors are involved in the underlying factor. (3) Repression of morbid anxiety is thought to be an predisposition to body dysmorphic disorder. (1) Nursing diagnoses for the client with body dysmorphic (2) Outcome criteria are identified for measuring effectiveness (a) Disturbed body image disorder include: disorder is aimed at development of a realistic perception (1) Nursing intervention for the client with body dysmorphic that contribute to altered body image. (2) A focus is on resolution of repressed fears and anxieties of body appearance. unrelated to physical appearance. (3) Positive reinforcement is given for accomplishments A. Sleep Disorders: Background Assessment Data III. Sleep Disorders 1. Insomnia: Difficulty with initiating or maintaining sleep. 2. Hypersomnia (somnolence): excessive sleepiness or seeking excessive asleep, even in the middle of a task or a sentence. 3. Narcolepsy: Sleep attacks. The individual cannot prevent falling amounts of sleep 4. Parasomnias: Unusual to undesirable behaviors that occur during awakenings from sleep and are sufficiently severe to interfere a. Nightmare disorder: Frightening dreams that lead to sleep. Examples include: with social or occupational functioning. comfort, and if wakefulness does occur, the individual is piercing scream or cry. The individual is difficult to awaken or b. Sleep terror disorder: Abrupt arousal from sleep with a cannot recall the dream episode. usually disoriented, expresses a sense of intense fear, but walk about, dress, go to the bathroom, talk, scream, or even during sleep in which the individual may leave the bed and c. Sleepwalking: the performance of motor activity initiated 5. Circadian rhythm sleep disorders: a misalignment between sleep and drive. Episodes may last from a few minutes to a half hour. (a) Shift work type its usual circadian rhythm. Categories include: wake behaviors. The normal sleep-wake schedule is disrupted from (c) Delayed sleep phase type (b) Jet lag type primary insomnia, primary hypersomnia, narcolepsy, sleep terror a. Genetic or familial patterns: thought to play a contributing role in 6. Predisposing factors to sleep disorders disorder, and sleepwalking. from substances, endocrine or metabolic disorders, infectious or sleep apnea syndrome, restless leg syndrome, use of or withdrawal b. Medical conditions implicated in the etiology of insomnia: pain, with hypersomnia include metabolic and encephalitic conditions, other diseases, and CNS lesions. Medical conditions associated c. Psychiatric or environmental conditions: anxiety, depression, stimulants, sleep apneas, and hypoventilation syndromes. the use of alcohol or other CNS depressants, withdrawal from posttraumatic stress disorder, and schizophrenia. environmental changes, circadian rhythm sleep disturbances, e. Extreme fatigue and sleep deprivation may contribute to episodes contribute to night terrors. d. Neurological abnormalities, such as temporal lobe epilepsy, may 7. Diagnosis/Outcome Identification of sleepwalking. (2) Risk for injury (1) Disturbed sleep pattern a. Nursing diagnoses for the client with sleep disorders include: b. Outcome criteria are identified for measuring the effectiveness of at determining the cause of the disturbance and performing actions a. Nursing intervention for the client with a sleep disorder is aimed 8. Planning/Implementation 9. Evaluation is based on accomplishment of previously established that promote sleep and rest for the client. 1. Individual psychotherapy A. Somatoform Disorders IV. Treatment Modalities 3. Behavior therapy 2. Group psychotherapy 1. Relaxation therapy B. Sleep Disorders 4. Psychopharmacology 3. Pharmacotherapy 2. Biofeedback 4. Phototherapy

Concepts of Somatoform and Dissociative Disorders Somatoform disorders Physical symptoms in absence of physiological cause Associated with increased health care use May progress to chronic illness (sick role) behaviors Dissociative disorders Disturbances in integration of consciousness, memory, identify, and perception Dissociation is unconscious mechanism to protect against overwhelming anxiety

characterized physical symptoms suggesting medical disease but without a demonstrable organic pathological condition or a known pathophysiological mechanism to account for them. Somatoform disorders are more common In women than in men In those who are poorly educated In those who live in rural communities In those who are poor

Somatoform Disorders: General Information Prevalence Rate unknown; estimated that 38% of primary care patients have symptoms with no medical basis 55% of all frequent users of medical care have psychiatric problems Comorbidity Depressive disorders, anxiety disorders, substance use, and personality disorders common

Somatization Disorder Diagnosis requires certain number of symptoms accompanied by functional impairment Pain: head, chest, back, joints, pelvis GI symptoms: dysphagia, nausea, bloating, constipation Cardiovascular symptoms: palpitations, shortness of breath, dizziness Comorbidity Anxiety and depression

Hypochondriasis Widespread phenomenon 1 out of 20 patients seek medical care Misinterpreting physical sensations as evidence of serious illness Negative physical findings does not affect patient’s belief that they have serious illness Cormorbidity Depression, substance abuse, personality disorder

Pain Disorder Diagnosed when testing rules out organic cause for symptom of pain Evidence of significant functional impairment Suicide becomes serious risk for patients with chronic pain Typical sites for pain: head, face, lower back, and pelvis Cormorbidity Depression, substance abuse, personality disorder

Body Dysmorphic Disorder (BDD Patient has normal appearance or minor defect but is preoccupied with imagined defective body part Presence of significant impairment in function Typical characteristics Obsessive thinking and compulsive behavior Mirror checking and camouflaging Feelings of shame Withdrawal from others Cormorbidity Depression, OCD, social phobia

Conversion Disorder Symptoms that affect voluntary motor or sensory function suggesting a physical condition Dysfunction not congruent with functioning of the nervous system Patient attitude toward symptoms Lack of concern (la belle indifférence) or marked distress

Common symptoms Cormorbidity Involuntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, and deafness Cormorbidity Depression, anxiety, other somatoform disorders, personality disorders

Nursing Process: Assessment Guidelines Collect data about nature, location, onset, characteristics and duration of symptoms Determine if symptoms under voluntary control Identify ability to meet basic needs Identify any secondary gains (benefits of sick role) Identify ability to communicate emotional needs (often lacking) Determine medication/substance use

Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnosis assigned Ineffective coping Outcomes identification Overall goal: patient will live as normal life as possible

Nursing Process: Planning and Implementation Long-term treatment/interventions usually on outpatient basis Focus interventions on establishing relationship Address ways to help patient get needs met other than by somatization Collaborate with family

Nursing Communication Guidelines for Patient with Somatoform Disorder Take symptoms seriously After physical complaint investigated, avoid further reinforcement Spend time with patient other than when complaints occur Shift focus from somatic complaints to feelings

Use matter-of-fact approach to patient resistance or anger Avoid fostering dependence Teach assertive communication

Treatment for Somatoform Disorders Case management Useful to limit health care costs Psychotherapy Cognitive and behavioral therapy Group therapy helpful Medications Antidepressants (SSRIs) Short-term use of antianxiety medications Dependence risk

Nursing Process: Evaluation Important to establish measurable behavioral outcomes as part of planning process Common for goals to be partially met Patients with somatoform disorder have strong resistance to change

Sleep Disorders: Introduction About 75 percent of adult Americans suffer from a sleep problem. 69% of all children experience sleep problems The prevalence of sleep disorders increases with advancing age Sleep disorders add an estimated $28 billion to the national health care bill. Common types of sleep disorders include insomnia, hypersomnia, parasomnias, and circadian rhythm sleep disorders

Sleep Disorders: Assessment Insomnia Difficulty falling or staying sleep Hypersomnia (somnolence) Excessive sleepiness or seeking excessive amounts of sleep Narcolepsy: Similar to hypersomnia Characteristic manifestation: Sleep attacks; the person cannot prevent falling asleep Parasomnias Nightmares, sleep terrors, sleep walking

Circadian rhythm sleep disorders Shift-work type Sleep terror disorder Manifestations include abrupt arousal from sleep with a piercing scream or cry Circadian rhythm sleep disorders Shift-work type Jet-lag type Delayed sleep phase type

Nursing Process Nursing Diagnosis Planning/Implementation Outcomes Evaluation

Predisposing Factors Genetic or familial patterns are thought to play a contributing role in primary insomnia, primary hypersomnia, narcolepsy, sleep terror disorder, and sleepwalking. Various medical conditions, as well as aging, have been implicated in the etiology of insomnia. Psychiatric or environmental conditions can contribute to insomnia or hypersomnia. Activities that interfere with the 24-hour circadian rhythm hormonal and neurotransmitter functioning within the body predispose people to sleep-wake schedule disturbances.

Treatment Modalities Somatoform disorders Individual psychotherapy Group psychotherapy Behavior therapy Psychopharmacology Sleep disorders Relaxation therapy Biofeedback Pharmacotherapy

Primary hypersomnia/narcolepsy Pharmacotherapy CNS stimulants such as amphetamines Parasomnias Centers around measures to relieve obvious stress within the family Individual or family therapy Interventions to prevent injury