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Somatoform and Sleep Disorders Chapter 9 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 – 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 • 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