1. Somatoform and Dissociative Disorders
Chapter 18
Somatoform and Dissociative Disorders

2. 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

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

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

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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)

24. 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)

25. 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

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

27. 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

28. 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

29. Evaluation
Based on accomplishment of previously established outcome criteria

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

31. 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

32. 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

33. 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

34. 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

35. 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

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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

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

44. 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

45. 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

46. Evaluation
Based on accomplishment of previously established outcome criteria

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