Transcript Somatic Symptom and Dissociative Disorders

Chapter 29
Somatic Symptom and Dissociative
Disorders
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Introduction
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.
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Introduction (cont.)
Dissociative disorders are defined by
a disruption in the usually integrated
functions of consciousness, memory,
and identity.
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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.
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Epidemiological Statistics
• Somatic symptom disorders are more
commonly found in:
– Women more than men
– Less educated persons
– Rural areas
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Epidemiological Statistics (cont.)
• Individuals with factitious disorder
comprise about 0.8 to 1.0 percent of
psychiatry consultation clients.
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Epidemiological Statistics (cont.)
• Dissociative disorders (DID) are
statistically quite rare.
• DID is more prevalent in women than in
men.
• Brief episodes of depersonalization
symptoms appear to be common in
young adults, particularly in times of
severe stress.
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Application of the Nursing Process:
Assessment
• Types of Somatic Symptom Disorders
– Somatic symptom disorder
• A syndrome of multiple somatic symptoms that cannot be
explained medically and are associated with psychosocial
distress and long-term seeking of assistance from healthcare professionals.
• The disorder is chronic, and anxiety, depression, and
suicidal ideation are frequently manifested.
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Types of Somatic Symptom
Disorders (cont.)
• Somatic Symptom Disorder (cont.)
– Drug abuse and dependence are common
complications of somatic symptom disorder.
– Personality characteristics are heightened
emotionality, strong dependency needs, and a
preoccupation with symptoms and oneself.
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Types of Somatic Symptom
Disorders (cont.)
• Illness Anxiety Disorder
– Unrealistic or inaccurate interpretation of
physical symptoms or sensations leading to
preoccupation and fear of having a serious
disease.
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Types of Somatic Symptom
Disorders (cont.)
• Illness Anxiety Disorder (cont.)
– Their behavioral response to even the slightest
changes in feeling or sensation is unrealistic and
exaggerated.
– Anxiety and depression are common, and
obsessive-compulsive traits frequently
accompany the disorder.
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Types of Somatic Symptom
Disorders (cont.)
• Conversion Disorder
– 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.
– Some instances of conversion disorder may be
precipitated by psychological stress.
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Types of Somatic Symptom
Disorders (cont.)
• Psychological Factors Affecting Medical
Condition
– 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.
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Types of Somatic Symptom
Disorders (cont.)
• Factitious Disorder
– Conscious, intentional feigning of physical
and/or psychological symptoms.
– Individual pretends to be ill in order to receive
emotional care and support commonly
associated with the role of “patient.”
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Types of Somatic Symptom
Disorders (cont.)
• Factitious Disorder (cont.)
– The disorder may also be identified as
Munchausen syndrome.
– The disorder may be imposed on another
person under the care of the perpetrator
(formerly called Factitious Disorder by Proxy).
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Types of Somatic Symptom
Disorders (cont.)
1. A client, experiencing lower extremity
paralysis, is admitted to a medical unit.
Extensive tests confirm disability but rule out
any underlying organic pathology. The nurse
concludes that this is most suggestive of
which disorder?
A.
B.
C.
D.
Conversion disorder
Illness anxiety disorder
Malingering
Somatic symptom disorder
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Application of the Nursing
Process: Assessment (cont.)
• Correct answer: A
– Conversion disorder is a loss or change in body
function resulting from a psychological conflict,
the physical symptoms of which cannot be
explained by any known medical disorder. The
situation presented in the question describes a
conversion disorder.
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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.
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Predisposing Factors Associated with
Somatic Symptom Disorders (cont.)
• Neuroanatomical
– Brain dysfunction (impairment in information
processing) has been implicated as a factor in
factitious disorder.
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Predisposing Factors Associated with
Somatic Symptom Disorders (cont.)
• Psychodynamic Theory
– This theory suggests that illness
anxiety disorder is an ego defense
mechanism. Physical complaints are
the expression of low self-esteem
and feelings of worthlessness.
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S. Freud
Predisposing Factors Associated with
Somatic Symptom Disorders (cont.)
• Psychodynamic Theory
– Conversion disorder may
represent emotions associated
with a traumatic event that
are too unacceptable to express
and so are acceptably “converted”
into physical symptoms.
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S. Freud
Predisposing Factors Associated with
Somatic Symptom 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 openly.
– Somatization brings some stability to the family
and positive reinforcement to the child (called
tertiary gain).
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Predisposing Factors Associated with
Somatic Symptom 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)
• May become the prominent focus of attention
because of the illness (secondary gain)
• May relieve conflict within the family as concern is
shifted to the ill person and away from the real issue
(tertiary gain)
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Predisposing Factors Associated with
Somatic Symptom Disorders (cont.)
• Learning Theory (cont.)
– Illness anxiety disorder
• Past experience with serious
or life-threatening physical
illness, either personal or
that of close relatives, can
predispose the person to
illness anxiety disorder
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Predisposing Factors Associated with
Somatic Symptom Disorders (cont.)
• Transactional Model of Stress/Adaptation
– The etiology of somatic symptom disorders is
most likely influenced by multiple factors.
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Somatic Symptom Disorder
2. A client is experiencing pain that has no organic
etiology. This pain allows the client to avoid
going to work at a job he hates. What best
describes what this client is experiencing?
A. The client is experiencing altered social
interaction.
B. The client is experiencing disturbed thought
processes.
C. The client is experiencing primary gain.
D. The client is experiencing secondary gain.
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Somatic Symptom Disorder
• Correct answer: C
– Primary gain describes the benefit to the client of
avoidance of some unpleasant activity due to
experiencing psychologically based pain. This
avoidance directly decreases the client’s anxiety.
The situation presented in the question describes
primary gain.
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Application of the Nursing
Process: Assessment
• Types of Dissociative Disorders
– Dissociative amnesia
• Defined as an inability to recall important personal
information that is too extensive to be explained by
ordinary forgetfulness and which is not due to the direct
effects of substance use or a neurological or other
medical condition.
• Onset usually follows severe psychosocial stress.
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Dissociative Amnesia
• Types of Disturbance in Recall
– Localized amnesia
• The inability to recall all incidents associated with the
traumatic event for a specific period following the
event
– Selective amnesia
• The inability to recall only certain incidents associated
with a traumatic event for a specific period following
the event
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Dissociative Amnesia (cont.)
• Types of Disturbance in Recall (cont.)
– Generalized amnesia
• The inability to recall anything that has happened during
the individual’s entire lifetime, including personal identity
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Dissociative Amnesia (cont.)
• A specific subtype of dissociative amnesia is
with dissociative fugue in which there is
sudden, unexpected travel away from home
with the inability to recall some or all of
one’s past.
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Types of Dissociative Disorders (cont.)
• Dissociative Identity Disorder (DID)
– 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
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Types of Dissociative Disorders (cont.)
• Depersonalization-Derealization Disorder
– Characterized by a temporary change in the quality
of self-awareness that 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
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Depersonalization-Derealization
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.
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Depersonalization-Derealization
Disorder (cont.)
– Symptoms of this disorder are often accompanied
by:
•
•
•
•
•
Anxiety and depression
Fear of going insane
Obsessive thoughts
Somatic complaints
Disturbance in the subjective sense of time
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Predisposing Factors to Dissociative
Disorders
• Genetics
– Possible hereditary factors are associated with
DID.
– Neurobiological
• Dissociative amnesia may be related to
neurophysiological dysfunction.
• EEG abnormalities have been observed in some clients
with DID.
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Predisposing Factors to Dissociative
Disorders (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.
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Predisposing Factors to Dissociative
Disorders (cont.)
• Psychological Trauma
– A growing body of evidence points to the etiology
of DID as a set of traumatic experiences that
overwhelm the individual’s capacity to cope by any
means other than dissociation.
– These experiences usually take the form 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.
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Predisposing Factors to Dissociative
Disorders (cont.)
• Transactional Model of Stress/Adaptation
– The etiology of dissociative disorders is most likely
influenced by multiple factors.
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Dissociative Disorders
3. According to psychodynamic theory, which
primary defense mechanism would the nurse
expect to find in a client with dissociative
amnesia?
A.
B.
C.
D.
Suppression
Sublimation
Displacement
Repression
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Dissociative Disorders
• Correct answer: D
– Repression, which is the involuntary blocking of
unpleasant feelings and experiences from one's
awareness, is the defense mechanism most used
by clients experiencing amnesia. Freud believed
that dissociative behaviors, including amnesia,
occurred when individuals repressed distressing
mental contents from conscious awareness. He
believed that this mechanism protected the
client from emotional pain.
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Nursing Process: Diagnosis/Outcome
• Common nursing diagnoses for clients with
somatic symptom disorders include:
– 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)
– Fear (of having a serious disease [illness anxiety disorder])
– Disturbed sensory perception (conversion disorder)
– Self-care deficit (conversion disorder)
– Deficient knowledge (psychological factors affecting medical condition)
– Ineffective coping (factitious disorder)
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Nursing Process: Diagnosis/Outcome
(cont.)
• Common nursing diagnoses for clients with
dissociative disorders include:
–
–
–
–
–
Impaired memory (dissociative amnesia)
Powerlessness (dissociative amnesia)
Risk for suicide (DID)
Disturbed personal identity (DID)
Disturbed sensory perception (visual/kinesthetic
[depersonalization-derealization disorder])
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Outcomes (Somatic Symptom
Disorders)
• 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
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Outcomes (Dissociative Disorders)
• 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
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Nursing Process: Planning and
Implementation
• Nursing care of the individual with a
somatic symptom disorder is aimed at relief
of discomfort from the physical symptom.
• Assistance is provided to the client in an
effort to determine strategies for coping
with stress by means other than
preoccupation with physical symptoms.
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Nursing Process: Planning and
Implementation (cont.)
• Nursing care for the client with a dissociative
disorder 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.
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Nursing Process: Planning and
Implementation (cont.)
4. When working with a client diagnosed with a
somatic symptom disorder, which is the most
appropriate nursing action?
A. Avoid discussing social and personal
problems.
B. Focus on the physical symptoms.
C. Always meet the client’s dependency needs.
D. Gradually minimize time focusing on physical
symptoms.
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Nursing Process: Planning and
Implementation (cont.)
• Correct answer: D
– The nurse’s attention should be on the client’s
social and personal problems, which are the
underlying cause of the somatic symptom
disorder. Time focused on physical symptoms
should be minimized to avoid reinforcement.
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Nursing Process: Evaluation
• Based on accomplishment of
previously established outcome
criteria
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Medical Treatment Modalities for
Somatic Symptom Disorders
•
•
•
•
Individual Psychotherapy
Group Psychotherapy
Behavior Therapy
Psychopharmacology
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Medical Treatment Modalities for
Dissociative Disorders
•
•
•
•
•
•
•
Individual Psychotherapy
Hypnosis
Supportive Care
Cognitive Therapy
Group Therapy
Integration Therapy (DID)
Psychopharmacology
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