1. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 1 Chapter 9 Somatoform and Dissociative Disorders

2. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 2 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

3. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 3 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

4. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 4 Biological Theories Related to Somatoform Disorders No direct evidence for genetic etiology –Some data support that somatization disorder runs in families Genetic factors may play role in predisposition to somatoform disorders –Low pain threshold –Impaired verbal communication –Impaired patterns of information processing

5. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 5 Other Theories Related to Somatoform Disorders Learning theories and sociocultural factors –Early learning is important in adult somatic sensitivity –Symptoms that are reinforced by parental attention recur later Psychodynamic theory –Separation-individuation phase in toddlers is essential in establishing self-esteem Inconsistent parenting in this phase leads to adult narcissistic focus on body symptoms

6. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 6 Other Theories Interpersonal theory –Childhood physical, sexual abuse linked to adult somatoform disorders Cultural considerations –Culture influences individual’s tendency to express anxiety as somatoform symptoms –DSM-IV-TR provides information about role of culture in somatoform disorders

7. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 7 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

8. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 8 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

9. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 9 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

10. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 10 Pain Disorder Typical sites for pain: head, face, lower back, and pelvis Cormorbidity –Depression, substance abuse, personality disorder

11. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 11 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

12. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 12 Body Dysmorphic Disorder (BDD) Typical characteristics –Obsessive thinking and compulsive behavior Mirror checking and camouflaging –Feelings of shame –Withdrawal from others Cormorbidity –Depression, OCD, social phobia

13. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 13 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

14. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 14 Conversion Disorder Common symptoms –Involuntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, and deafness Cormorbidity –Depression, anxiety, other somatoform disorders, personality disorders

15. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 15 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

16. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 16 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnosis assigned –Ineffective coping Outcomes identification –Overall goal: patient will live as normal life as possible

17. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 17 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

18. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 18 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

19. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 19 Nursing Communication Guidelines for Patient with Somatoform Disorder Use matter-of-fact approach to patient resistance or anger Avoid fostering dependence Teach assertive communication

20. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 20 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

21. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 21 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

22. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 22 Dissociative Disorders: General Information Altered mind-body connections associated with stress and anxiety Prevalence –Unknown: estimated from 5%-20% among psychiatric patients Comorbidity –PTSD, borderline personality disorder (BPD), childhood sexual abuse, attention deficit disorder

23. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 23 Biological Theories Related to Dissociative Disorders Research indicates: –Limbic system involvement –Hippocampus smaller than normal –Possible neurological link Genetics –Dissociative identify disorder more common in first-degree relatives of individuals with this disorder

24. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 24 Other Theories Related to Dissociative Disorders Psychosocial factors –Learned method for avoidance of stress and anxiety Cultural factors –Culturally bound disorders exist in which anxiety, trancelike states, running and fleeing with amnesia can occur

25. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 25 Depersonalization Disorder Persistent alteration in perception of self with intact reality testing –Person feels mechanical, dreamy, or detached from body Can be precipitated by: –Severe acute stress –Childhood emotional abuse

26. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 26 Dissociative Amnesia Inability to recall personal information often occurring after traumatic event Types of amnesia –Generalized: inability to recall entire lifetime –Localized: inability to remember all events in certain periods –Selective: some but not all events recalled

27. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 27 Dissociative Fugue Sudden, unexpected travel away from home and inability to recall one’s identify and information about one’s past Individual may assume new identity –Lead simple life without calling attention to self Precipitated by traumatic event

28. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 28 Dissociative Identity Disorder (DID) Presence of two or more distinct personality states that take control of behavior –Alter or subpersonality has own pattern of thinking, perceiving and relating –Principal personality (core) unaware of others

29. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 29 Dissociative Identity Disorder (DID) Precipitated by severe sexual, physical, or psychological trauma Signs of DID –Finding unfamiliar clothes in closet –Being called unfamiliar name by stranger –Periods of lost time

30. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 30 Nursing Process: Assessment Guidelines Rule out medical illness, substance abuse, and other psychiatric disorders Note signs of dissociative disorder –Changes in behavior, voice, and dress –Referring to self by another name or in third person –Partial memory or memory gaps –Disorientation to time, place, person –Presence of blackouts

31. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 31 Nursing Process: Assessment Gather information about events in patient’s life and history of injury, epilepsy, and physical, mental, or sexual abuse Note mood changes Determine history of substance use Determine effect of patient problems on family, daily functioning, and employment Determine suicide risk

32. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 32 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnosis assigned –Disturbed personal identify Common goals –Develop trust –Correct faulty perceptions –Encourage patient to remain in present

33. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 33 Nursing Process: Planning and Implementation Planning –Select implementations focused on safety and crisis interventions when patient is hospitalized Implementation –Guided by assessment data collected

34. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 34 Interventions for Patient with Dissociative Disorders Offer emotional presence during recall of painful events Teach information about –Illness –Coping skills –Stress management Provide safe environment as part of milieu treatment

35. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 35 Treatment for Dissociative Disorders Psychotherapy –Primary treatment offered, most effective –Techniques used include psychoeducation, talking through trauma, safety planning, journaling, and artwork Medications –Antidepressants and antianxiety medications for comorbid conditions

36. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 36 Nursing Process: Evaluation Identified outcomes are the basis for evaluation –Have patient’s safety needs been met? –Is patient’s anxiety decreased? –Have conflicts been explored? –Does patient use new coping skills to function better? –Is stress handled without use of dissociation?