Chapter 20: Somatic Symptom and Dissociative Disorders (PDF)

**Chapter 20: Somatic Symptom and Dissociative Disorders (510-535)** **Somatic Symptom Disorders** - **Somatic symptom disorders** are characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to accou...

**Chapter 20: Somatic Symptom and Dissociative Disorders (510-535)** **Somatic Symptom Disorders** - **Somatic symptom disorders** are characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them. - **Dissociative disorders** are defined by a disruption in the usually integrated functions of consciousness, memory, identity, perception, behavior, emotion, body representation, & motor control. - Historical aspects: - Somatic symptom disorders have been identified as hysterical neuroses and were thought to occur in response to repressed severe anxiety. - Freud viewed dissociation as a type of repression, an active defense mechanism used to remove threatening or unacceptable mental contents from conscious awareness. - Epidemiological statistics: - **Somatic symptom disorders:** Originally thought to be more prevalent in females; however, this may be attributable to the fact that females tend to report somatic symptoms more often than males - **Conversion disorders:** are more commonly found in women than in men, adolescents and young adults - **Dissociative disorders (DID) are statistically quite rare:** - Brief episodes of depersonalization symptoms appear to be common in young adults, particularly in times of severe stress, sleep deprivation, travel to unfamiliar places, or when under the influence of substances. - Their common focus is distress and impairment secondary to somatic symptoms - Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder, Factitious Disorder - Theories for predisposing factors - Genetic, Biochemical, Neuroanatomical - Psychodynamic theory - Views illness associated with anxiety disorder is an ego defense mechanism - Family dynamics - Dysfunctional families have difficulty expressing emotions & resolving conflicts verbally - Learning theory: Somatic complaints are often reinforced **Somatic symptom disorder \[pg. 536\]: Somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder "SICF"** - Psychological factors affecting medical conditions: - Psychological factors may play a role in virtually any medical condition. - With this diagnosis, there is evidence of a general medical condition that has been precipitated by or is being perpetuated by psychological or behavioral circumstances. - **The focus is on the symptom & not the diagnosis** - **Somatic Symptom Disorder (Somatoform)** - A syndrome of multiple somatic symptoms that cannot be explained medically and is associated with psychosocial distress and long-term seeking of assistance from health-care professionals - **Individuals with somatic symptom disorder are so convinced that their symptoms are related to organic pathology that they adamantly reject, and are often irritated by any implication that stress or psychosocial factors play any role in their condition** - This disorder usually runs a fluctuating course with periods of remission and exacerbation - **The disorder is chronic, and anxiety, depression, and suicidal ideation are frequently manifested** - **Symptoms:** - **Personality characteristics: Heightened emotionality, strong dependency needs**, and a preoccupation with symptoms and oneself - Disproportionate & persistent thoughts about seriousness of symptoms - Persistent high level of anxiety about health or symptoms - Excessive time or energy devoted to these symptoms - **Drug abuse/dependence are common complications of somatic symptom disorder.** - These pts tend to seek relief through overmedicating with prescribed analgesic or antianxiety agents - **Illness Anxiety Disorder (Hypochondriasis) \[pg. 536\]** - - - - - - - Individuals with illness anxiety disorder are extremely conscious of bodily sensations and changes and may become **convinced that a rapid heart rate indicates they have heart disease or that a small sore is skin cancer.** - The distinguishing feature between illness anxiety disorder and somatic symptom disorder is that in somatic symptom disorder the primary symptom is significant somatic sensations and in illness anxiety disorder there are few to no somatic symptoms but anxiety or fear about having or acquiring an illness is a primary concern. - **Functional neurological symptom disorder (Conversion disorder) \[pg. 537\]** - A loss of or change in body function that cannot be explained by any known medical disorder or pathophysiological mechanism. - **The most obvious and "classic" conversion symptoms are those that suggest neurological disease.** - **Their s/s are REAL and these patients are experiencing these symptoms (lecture)** - Conversion s/s affect voluntary motor or sensory functioning - **S/s: paralysis, aphonia (inability to produce voice), seizures, difficulty swallowing, urinary retention, blindness, deafness, double vision.** - Some instances of conversion disorder may be precipitated by psychological stress. - Abnormal limb shaking with impaired or loss of consciousness that resembles epileptic seizures (psychogenic or nonepileptic seizures) - Pseudocyesis (false pregnancy) is a conversion symptom and may represent a strong desire to be pregnant. - **Factitious Disorder (Munchausen Syndrome & Munchausen syndrome by proxy) \[pg. 538\]** - Conscious, intentional simulation of physical and/or psychological symptoms - **Individuals pretend to be ill to receive emotional care and support commonly associated with the role of "patient."** - If imposed on another person under the care of the perpetrator - May involve legal charges or involvement of protective services - Make sure to get the possible victim alone if suspecting abuse **Psychological factors affecting medical condition** - Psychological factors may play a role in virtually any medical condition. - General medical condition that has been precipitated by or is being perpetuated by psychological or behavioral circumstances. **Predisposing factors associated with somatic symptom disorders:** - **Genetic**: Hereditary factors are possibly associated with somatic symptom disorder, conversion disorder, and illness anxiety disorder. - **Biochemical**: Decreased levels of serotonin and endorphins may play a role in the etiology of somatic symptom disorder, predominantly pain. - **Neuroanatomical**: Brain dysfunction (impaired information processing) has been implicated as a factor in factitious disorder. **Psychodynamic theory:** - Suggests that illness anxiety disorder is an ego defense mechanism. - Physical complaints are the expression of low self-esteem and feelings of worthlessness. - Conversion disorder may represent emotions associated with a traumatic event that are too unacceptable to express and so are acceptably "converted" into physical symptoms. **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 that the family is unable to confront openly. - Somatization, a focus on physical symptoms, becomes reinforced as a way to shift the focus away from family issues and discord (called tertiary gain). **Learning theory:** - Somatic complaints are often reinforced when the sick person learns that they: - May avoid stressful obligations or be excused from troublesome duties (primary gain) - May become the prominent focus of attention because of the illness (secondary gain) - Children in dysfunctional families have pseudoseizures to diverge attention & once attention is achieved, the seizure goes away. This behavior is then reinforced leading to type of conversion disorder. - May relieve conflict within the family because concern is shifted to the ill person and away from the real issue (tertiary gain) - Illness anxiety disorder - Experience with serious or life-threatening physical illness, either personal or that of close relatives, can predispose the person to illness anxiety disorder. **Somatic Disorders: Diagnosis** - Ineffective coping evidenced by numerous physical complaints (somatic symptom disorder) - Deficient knowledge \[psychological causes for physical symptoms\] (somatic symptom disorder) - Chronic pain (somatic symptom disorder) - Self-care deficit (conversion disorder) - Deficient knowledge (psychological factors affecting medical condition) - Fear (Illness anxiety disorder) - Disturbed sensory perception (conversion disorder) **Somatic Disorders: Outcomes** - Copes effectively without resorting to physical symptoms - Verbalizes relief from pain - Decreased frequency of physical complaints and interprets bodily sensations rationally - Is free of physical disability **Somatic Disorders: Planning & implementation** - Nursing care of the individual with a somatic symptom 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. **Somatic Disorders: Evaluation (based on accomplishment of previously established outcome criteria)** - Can the client identify escalating anxiety symptoms? - Can the client use coping strategies to halt anxiety before it worsens physically? - Can the client grasp the link between physical symptoms and rising anxiety? - Does the client have a stress management plan to prevent physical symptoms from worsening? - Is the client thinking less about physical symptoms? - Are fears of serious illness reduced? - Has the client fully recovered from a prior physical issue? **Somatic Disorders: Treatment modalities** - Individual psychotherapy, Group psychotherapy, Cognitive behavior therapy, Psychoeducation (includes teaching patients that their symptoms may be related to or exacerbated by stress and anxiety), Psychopharmacology **Dissociative Disorders** - Disruption in the usually integrated functions of consciousness, memory, and identity. - Defense mechanisms occur with little or no participation of the conscious personality - Dissociative response occur when anxiety is overwhelming - Dissociative Identity Disorder, Dissociative Amnesia, Depersonalization-Derealization Disorder - Epidemiology - Quite rare, more prevalent in women than in men, hx of abuse - Brief episodes of depersonalization symptoms appear to be common in young adults, particularly in times of severe stress. - Theories for Predisposing factors - Genetics, Neurobiological - 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. - Psychological trauma **Depersonalization-Derealization disorder pg. 541 \[KNOW THE DIFFERENCE\]** - Characterized by a temporary change in the quality of self-awareness, which often takes the form of: - Feelings of unreality - Changes in body image - Feelings of detachment from the environment - A sense of observing oneself from outside the body - **KNOW Depersonalization**: disturbance in the perception of oneself - Described as a feeling of unreality or detachment from one's body - **KNOW Derealization**: alteration in the perception of the external environment - Is an experience of unreality or detachment with respect to one's surroundings. - Symptoms - Anxiety and depression, Fear of going insane, Obsessive thoughts, Somatic complaints, Disturbance in the subjective sense of time, Sense of being in a dream - **An example of this disorder would be:** a soldier in recalling an experience in combat describes that he saw himself observing himself from a distance and wondered what he would do if he were in that situation. **Dissociative Identity Disorder (Multiple personality disorder) \[pg. 542\]** - Characterized by the 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 - Psychological trauma: - Evidence points to the etiology of DID as traumatic experience(s) that overwhelm the capacity to cope by any means other than dissociation. - Most often identified experiences of severe physical, sexual, or psychological abuse by a significant other in the child's life. - DID is thought to serve as a survival strategy for the child in this traumatic environment. - The achievement of **integration** (a blending of all the personality states into one) is usually considered desirable - Clients are assisted to recall past traumas in detail. They must mentally reexperience the abuse that caused their illness. - This process, called **abreaction**, or "remembering with feeling," is so painful that clients may actually cry, scream, and feel the pain that they felt at the time of the abuse. **Dissociative Amnesia \[pg. 540\]** - Defined as an **inability to recall important personal information,** usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or a neurological or other medical condition - Onset usually follows severe psychosocial stress. - **Types of disturbance in recall "uhhh kinda know ehhh, she said"** - **Localized amnesia:** is unable to recall all incidents associated with a stressful event. It may be broader than just a single event, however, such as being unable to remember months or years of child abuse - **Selective amnesia:** the individual can recall only certain incidents associated with a stressful event for a specific period after the event. - **Generalized amnesia:** the individual has amnesia for both identity and total life history. **Predisposing factors to dissociative disorders:** - **Genetics:** Preliminary research does not show evidence of significant genetic contribution. - **Neurobiological** - Dissociative amnesia may be related to neurophysiological dysfunction. - EEG abnormalities have been observed in some clients with DID - **Psychodynamic theory (Freud)** - **Dissociation is the repression of distressing mental contents from conscious awareness.** - Current stance is that dissociative behaviors are a defense against unresolved painful issues. **Dissociative Disorders: Diagnosis** - Impaired memory (dissociative amnesia) - Powerlessness (dissociative amnesia) - Risk for suicide (DID) - Disturbed personal identity (DID) - Disturbed sensory perception \[visual/kinesthetic\] (depersonalization-derealization disorder) **Dissociative Disorders: Outcomes** - 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 **Dissociative Disorders: Planning & Implementation** - Nursing care for the client with a dissociative disorder is aimed at restoring normal thought processes. - Assistance is provided to the client to determine strategies for coping with stress by means other than dissociation from the environment. **Dissociative Disorders: Evaluation (based on accomplishment of previously established outcome criteria)** - Is the client\'s memory restored? Can the client link stress to memory loss? - Does the client openly discuss fears and anxieties with staff for resolution? - Can the client acknowledge multiple self-identities? Can they explain why these identities exist? - Can the client identify triggers for transitioning between identities? - Does the client maintain a grip on reality during stress? - Can the client connect stressful situations to depersonalization? - Can the client show improved coping skills to manage stress without dissociation? **Dissociative Disorders: Treatment modalities** - Individual psychotherapy, Hypnosis, Supportive care, Cognitive therapy - Group therapy, Integration therapy (D I D), Psychopharmacology **Application of the nursing process: assessment** - Medical history: "doctor shopping" - Current s/s: appraisal of symptoms - Psychiatric history: recent stressors and/or long-term stressors; thorough mental status exam **Clicker 1:** A client experiencing lower extremity paralysis is admitted to a medical unit. Extensive tests confirm disability but rule out any underlying organic pathology. What is it? - Conversion disorder **Clicker 2:** According to psychodynamic theory, which primary defense mechanism would the nurse expect found in a client with dissociative amnesia? - Repression **Clicker 3:** When working with a client dx with somatic symptom disorder, which is the most appropriate nursing action? - Gradually minimize time focusing on physical symptoms.