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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. 2 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 3 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 4 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 5 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 6 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 7 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 8 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 9 Pain Disorder • Typical sites for pain: head, face, lower back, and pelvis • Cormorbidity – Depression, substance abuse, personality disorder Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 10 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 11 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 12 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 13 Conversion Disorder • Common symptoms – Involuntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, and deafness • Cormorbidity – Depression, anxiety, other somatoform disorders, personality disorders Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 14 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 15 Nursing Process: Diagnosis and Outcomes Identification • Common nursing diagnosis assigned – Ineffective coping • Outcomes identification – Overall goal: patient will live as normal life as possible Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 16 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 17 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 18 Nursing Communication Guidelines for Patient with Somatoform Disorder • Use matter-of-fact approach to patient resistance or anger • Avoid fostering dependence • Teach assertive communication Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 19 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 20 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 21 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 22 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 23 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 24 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 25 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 26 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 27 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 28 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 29 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 30 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 31 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 32 Nursing Process: Planning and Implementation • Planning – Select implementations focused on safety and crisis interventions when patient is hospitalized • Implementation – Guided by assessment data collected Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 33 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 34 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 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 35 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? Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 36