 PSYCHIATRIC NURSING ANXIETY-RELATED DISORDER Chapter 19

Objectives  Discuss different types of psychophysiological, somatoform and dissociative disorders  Identify the etiology of these disorders and the treatment modalities 2

 Anxiety-related disorders Psychophysiological responses to anxiety are those in which it has been determined that psychological factors contribute to the initiation or exacerbation of the physical condition. These responses have pathophysiological evidence or presence of organic pathology. Certain psychological factors can influence the development or exacerbation of, or delayed recovery from, different medical conditions (p.368). Mental disorder (major depressive disorder) Psychological symptoms (depressed mood) Coping style (denial the need for care)

Introduction Maladaptive health behaviors (smoking, over eating) Stress-related physiological responses (tension headache )  Somatoform disorders: physical symptoms suggesting medical disease but without organic pathology or pathophysiological mechanism.  Are they classified as mental disorders???why??  What is the difference between psychophysiological responses and somatoform?? 4

What is the difference between psychosomatic and somatoform disorders?  Psychosomatic have a physical basis but are largely caused by psychological factors such as stress and anxiety  Somatoform have physical symptoms but can’t identify a physical cause 5

Anxiety-related disorders  Somatization: all those mechanisms by which anxiety is translated into physical illness or bodily complaints.  Dissociative disorders/responses: disruption in integrated functions of consciousness, memory, identity, or perception of environment; they occur when anxiety becomes overwhelming and personality becomes disorganized.  Four general types of reaction to stress (Peplau, 1963): Normal reaction (defense), Psychophysiological reaction (somatic symptoms), Neurotic reaction (neurotic symptoms), Psychotic reaction (misperception of the environment) (p. 368). 6

First: Psychophysiological disorders  Asthma was found to be associated with those who have fears and increased anxiety and depression.  Cancer was found to be spreading with those having type C personality (nice guy’s disease).  Coronary heart disease: those with type A personality are at risk of CHD  Peptic ulcer: increased gastric secretion with feeling of frustration 7

Psychophysiological disorders  Essential hypertension  Migraine headache (migraine personality) (perfectionists, inflexible) 8

Second: Somatoform disorders (SD)  SD are characterized by physical symptoms that suggest medical disease, but that do not have demonstrable organic pathology or known pathophysiological mechanism to account for them.  There is evidence or presumption that psychological factors are the major cause of the symptoms of the SD.  Somatization: those mechanisms by which anxiety is translated into physical illnesses or body complaints.  There are five types of SD 9

1. Somatization disorder  A syndrome of multiple somatic symptoms that cannot be explained medically and that that are associated with psychosocial distress and long-term seeking of assistance from health care professionals.  Symptoms are identified as recurring complain of pain (in at least four different sites), GI symptoms,sexual symptoms, pseudo-neurological symptoms.  Symptoms begins before 30 years old  Other symptoms are: anxiety, depression, suicidal threats and attempts, substance abuse and dependence. 10

Somatization disorder  Clients often receive medical care from several physicians.  Seek relief through overmedicating with prescribed analgesics or antianxiety agents. Therefore, drug abuse and dependence are common.  There is overlapping of personality characteristics and features of histrionic PD: heightened emotionality, impressionistic thought and speech, seductiveness and strong dependency needs. 11

Biopsychosocial Characteristics of Somatoform Disorders  Unconscious transformation of emotions into physical symptoms to deal with stress  Conversion disorder—impaired physical function related to expression of a psychic conflict  Pain disorder—pain experienced for no physiologic basis and accompanied by psychological factors

Biopsychosocial Characteristics - continued Biopsychosocial Characteristics (cont'd)  Hypochondriasis—preoccupation with fear/belief of having a serious illness that is not present on physical exam  Body dysmorphic disorder—preoccupation with an imagined defect in physical appearance that is exaggerated and out of proportion

Biopsychosocial Characteristics - continued Biopsychosocial Characteristics (cont'd)  Malingering—conscious falsification of illness, not considered a psychiatric disorder  Factitious disorder—psychological need to assume the sick role

Theories  Biologic, genetic, and psychosocial theories  Biochemical brain imbalances that cause pain to be experienced more intensely

Theories - continued Theories (cont'd)  Adoption and twin studies show both genetic and environmental contributing factors.  Communication theorists see symptoms as nonverbal body language intended to communicate a message to significant others.

Theories - continued Theories (cont'd)  Humanistic theorists view the client in context to what is happening at the time.  Life stressors like marital or work issues are precipitants for somatic symptoms.

Somatoform Disorders  Not under voluntary control  Have unconscious motivation  Primary gain is reduction of anxiety

2. Pain disorder  This disorder is characterized by severe and prolonged pain that causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.  Etiology of the pain may be evidenced by correlation of stressful situations with the onset of the symptoms. Primary gain Secondary gain  Characteristic behaviors include frequent visits to physicians in an attempt to obtain relief, excessive analgesic use, and requesting surgery. 19

 Primary gain: produces positive internal motivations. For example, a patient might feel guilty about being unable to perform some task. If he has a medical condition justifying his inability, he might not feel so bad. Alleviation of anxiety that results from conversion of emotional conflict into demonstrably organic illnesses.  Secondary gain can also be a component of any disease, but is an external motivator. If a patient's disease allows him/her to miss work, avoid military duty, obtain financial compensation, obtain drugs, or avoid a jail sentence, these would be examples of secondary gain. Interpersonal or social advantages gained indirectly from organic illness, such as an increase in attention from others. 20

Question?  What is the difference between somatization and pain disorder? Somatization disorder is a multiple somatic syndrome Pain disorder is most commonly linked with patient’s gain 21

3. Hypochondriasis  It is the person ’ s preoccupation with the fear/worry of contracting, or the belief of having, a serious disease. The preoccupation may be with specific organ or disease (e.g. cardiac disease), or with bodily functions (e.g. heartbeat). Their response to slight signs is usually unrealistic and exaggerated.  Occasionally, medical disease may be present but in the individual with this disorder, the symptoms are excessive compared to the pathology.  For example, those have hypochondriasis may become convinced that a rapid heart rate indicate a serous heart disease, a small sore on the skin is skin cancer, sounds in the intestine, etc. 22

Hypochondriasis  Those people have a long history of ‘’doctor shopping ’’.  They are convinced they are not receiving proper treatment.  Anxiety and depression are common and OCD frequently accompany this disorder.  Impaired social and occupational functioning.  Even reading about a disease or hearing someone they know has illness makes them distressed.  Thought for the day: a little knowledge is a dangerous thing (the nurse example). 23

4. Conversion disorder  Loss or change in body function (patient suffer from a neurological symptoms) resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism.  Affect voluntary motor or sensory functioning (called “ pseudo- neurological ” ).  Examples of conversion disorders are: paralysis, aphonia, difficulty swallowing, urinary retention, blindness, deafness, anosmia, pseudocyesis (false pregnancy) and fits. 24

Conversion disorder  They are evidenced by presence of primary or secondary gain.  Conversion symptoms serve to prevent internal conflicts or painful issues from attaining awareness.  Symptoms usually occur after a stressful situation, suddenly appear, the individual expresses lack of concern to the impairment.  Most of these symptoms resolve in days or weeks. Good prognosis of blindness, aphonia, and paralysis; poorer prognosis of seizures and tremor.  E.g. in military. 25

5. Body dysmorphic disorder/Dysmorphophobia.  Exaggerated belief that the body is deformed or defective in some specific way. is preoccupation with an imagined or exaggerated defect in physical appearance such as thinking one’s nose is too large or teeth are crooked and unattractive.  Examples: imagined or slight defects of the face or head (thinning hair, acne, wrinkles, scars, facial swelling). Sometimes complaints include nose, ears, eyes, mouth, lips, or teeth and may be other parts of the body.  Concern the body image and physical features  In some cases a true defect is present but the significance of the defect is unrealistically exaggerated and the concern is excessive 26

Body dysmorphic disorder  Symptoms of depression and obsessive-compulsive personality characteristics are common. Impairment in functioning is also common due to excessive anxiety in relation to imagined defect.  Those people have history of visiting plastic surgeons and dermatologists. They may undergo unnecessary surgeries to correct imagined defect.  Etiology is believed to be attributed to another pervasive psychiatric disorder (schizophrenia, major mood disorder, anxiety disorder) evidenced by improvement of the condition by using serotonin-specific drugs. 27

 Clinical Description Clinical Description  Preoccupation With Appearance Imagined Defect Preoccupation With Appearance Imagined Defect  “Imagined” Ugliness “Imagined” Ugliness  Mirrors (Avoidance) Mirrors (Avoidance)  Ideas of Reference Ideas of Reference  Suicidal Ideation Suicidal Ideation  Clinical Description Clinical Description  Preoccupation With Appearance Imagined Defect Preoccupation With Appearance Imagined Defect  “Imagined” Ugliness “Imagined” Ugliness  Mirrors (Avoidance) Mirrors (Avoidance)  Ideas of Reference Ideas of Reference  Suicidal Ideation Suicidal Ideation 28

 Common Locations of Defects Common Locations of Defects  Hair Hair  Nose Nose  Skin Skin  Eyes Eyes  Head / Face Head / Face  Lips Lips  Common Locations of Defects Common Locations of Defects  Hair Hair  Nose Nose  Skin Skin  Eyes Eyes  Head / Face Head / Face  Lips Lips 29

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Somatoform Disorders: True or False?  Discussion 31

Nursing Diagnoses  Ineffective coping  Chronic pain  Fear  Disturbed sensory perception 32

Third: Dissociative disorders (DS)  DS is a disruption/breakdown in consciousness, memory, identity, or perception of the environment.  Dissociative responses occur when anxiety becomes overwhelming (after a psychological trauma).  In DS, defense mechanisms that usually govern consciousness, identity, and memory break down, and behavior occurs with little or no participation on the part of the conscious personality (involuntary). 33

Dissociation  Dissociation is a continuum ranging from normal to a disorder.  Some people have the experience of driving a car and suddenly realizing that they don’t remember what happened during all or part of the trip.  Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was just said. 34

 Some people find that they have no memory for some important events in their lives (e.g. a wedding or graduation).  Some people sometimes have the experience of feeling that other people, objects, and the world around them are not real.  There are four types of DS. 35 Dissociation

1. Dissociative amnesia  Inability to recall important personal information, usually of traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness and is not related to substance abuse or medical conditions or neurological or other medical disorder.  There are five types of recall disturbance: localized, selective, continuous, generalized, systematized. Example (car accident)  Onset of amnesia usually follows a severe psychological stress, termination is abrupt and followed by complete recovery. Recurrences are unusual. 36

2. Dissociative Fugue  Sudden, unexpected travel away from home or place of daily activities, with inability to recall some or all of one ’ s past. (feels like they don’t belong)  Confusion (they cannot recall personal identity and often assume a new identity).  They can provide details of their earlier life, but cannot recall things after the fugue state.  Duration is usually brief (hours, days, rarely months).  Recovery is rapid and complete. Recurrences are unusual. 37

3. Dissociative identity (Multiple personality) disorder  The existence of two or more personalities within a single individual. Only one of the personalities is evident at any given moment, and one of them is dominant most of the time over the course of the disorder. each of them is amnesic of the other/s.  Each personality is unique and responds to stress in a different way.  Personality IQ’s, components and transitions??  Those people are misdiagnosed with borderline and antisocial personality disorders, depression, schizophrenia, epilepsy, or bipolar disorder before they are diagnosed with DID. 38

4. Depersonalization disorder  Occurrence of persistent feelings of unreality, detachment from one ’ s self or one ’ s body.  This disorder is more common in women and young people.  It is common in all psychiatric disorders.  It is estimated that half of the adults experience transient episodes. 39

Theories: Dissociative Disorders  Biological factors  Serotonin  Limbic system  Physical illnesses and certain drugs  Various personality states in dissociative identity disorder have different activity in frontal and temporal lobes.

Theories: Dissociative Disorders (cont'd)  Genetic theories:  Dissociative disorder occurs more often in first- degree biologic relatives

Theories: Dissociative Disorders (cont'd)  Psychosocial theories:  Current explanations are based on Freud’s dynamic concepts.  Repression of ideas leads to amnesia, to protect oneself from emotional pain.  Dissociative identity disorder is a result of childhood chronic trauma.

Theories: Dissociative Disorders (cont'd)  Behavioral theories:  Dissociative disorders are learned behaviors that provide protection from a painful experience.

Theories: Dissociative Disorders (cont'd)  Humanistic theories:  The person is a composite of life experiences, psychobiological factors, and interpersonal interactions.

Care of Clients with Dissociative Disorders  Dissociation is a defense against trauma that separates emotions from behaviors.  Dissociation is a response to extreme childhood trauma.  Consciousness, memory, identity, or perception of environment can be impaired.

Care of Clients with Dissociative Disorders (cont'd)  Most clients with dissociative disorder seen in community rather than inpatient settings  Obtain subjective and objective data  Complete psychosocial and physical assessment

Nursing Diagnoses  Disturbed thought processes  Ineffective coping  Disturbed personal identity  Disturbed sensory perception 47

Etiological implications for SD  Genetics: increased incidence in first degree relatives (somatization and hypochondriasis)  Biochemical: decreased levels of serotonin and endorphins  Psychodynamic (ego defense mechanism, physical complains are the expressions of low self-esteem and feeling of worthlessness) AND (moral or ethical unacceptable emotions are converted into physical symptoms)  Learning theory (the sickness relieves the individual from the need to deal with a stressful situation). 48

Etiological implications for SD  Family dynamics ( the child example, somatization by the child brings stability to the family) 49

Medical Treatment modalities  Individual psychotherapy  Group therapy  Behavioral therapy  Psychopharmacology 50

Importance of Comprehensive Assessment  Client will present with multiple complex problems.  Utilize nursing process to systematically assess and deliver care.  Remain cognizant of your own values, beliefs, feelings, and nonverbal behaviors.

Importance of Comprehensive Assessment - continued Importance of Comprehensive Assessment (cont'd)  Clients will report physical symptoms for which there is no evidence of physiologic cause.  Always rule out physical causes for symptoms.

Comprehensive Assessment  Obtain subjective and objective data.  Consider psychobiologic factors and utilize critical thinking.  Be alert to responses indicative of la belle indifference and/or the client who is overly dramatic and emotional when symptoms are discussed.

Comprehensive Assessment - continued Comprehensive Assessment (cont'd)  Careful interviewing reveals a stressful life event with which the client is not coping.  Suggests that preoccupation with somatic disorder is way of avoiding underlying conflict

Comprehensive Assessment - continued Comprehensive Assessment (cont'd)  Gathering objective data includes thorough physical exam, lab work, and radiologic or other studies

Personal Challenges to Professional Practice  Focus on your feelings and be cognizant of your reactions.  Monitor your own feelings of defensiveness, impatience, frustration, or anger toward the client.  Practice increased self-awareness.

Personal Challenges to Professional Practice - continued Personal Challenges to Professional Practice (cont'd)  Don’t judge, criticize, or make assumptions.  Pain is determined and defined by the client.  Pain of psychic origin is as hurtful as pain of biologic origin.

Personal Challenges - continued Personal Challenges (cont'd)  Be alert for signs of secondary gain.  Avoid reinforcing negative behaviors.  Address client with a matter-of-fact approach.  Reinforce adaptive vs. maladaptive behaviors.

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