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Chapter 9
Somatoform and
Dissociative Disorders
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
1
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
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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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
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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
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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
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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
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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
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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
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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
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Pain Disorder
• Typical sites for pain: head, face, lower
back, and pelvis
• Cormorbidity
– Depression, substance abuse, personality
disorder
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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
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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
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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
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Conversion Disorder
• Common symptoms
– Involuntary movements, seizures, paralysis,
abnormal gait, anesthesia, blindness, and
deafness
• Cormorbidity
– Depression, anxiety, other somatoform
disorders, personality disorders
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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
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Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnosis assigned
– Ineffective coping
• Outcomes identification
– Overall goal: patient will live as normal life as
possible
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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
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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
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Nursing Communication Guidelines for
Patient with Somatoform Disorder
• Use matter-of-fact approach to patient
resistance or anger
• Avoid fostering dependence
• Teach assertive communication
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Nursing Process:
Planning and Implementation
• Planning
– Select implementations focused on safety and
crisis interventions when patient is
hospitalized
• Implementation
– Guided by assessment data collected
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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
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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
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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?
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