Somatoform Disorder

MALADAPTIVE PATTERNS OF BEHAVIOR
C. PSYCHOPHYSIOLOGIC RESPONSE,
SOMATIC SYMPTOMS DISORDER AND
SLEEP DISORDERS
I. PSYCHOPHYSIOLOGICAL RESPONSE
Psychosomatic Response
PSYCHO PHYSIOLOGIC
Psyche – mind Soma – body
• Stress – biological reaction to an adverse stimulus (physical, mental, emotional) that

disturbs an organism’s homeostasis.
• Stressors – adverse stimulus that disturbs homeostasis
According to Hans Selye, stressful experiences have a direct effect on individual’s physical
functioning. He identified a three-stage process of response to stress known as GAS or
Generalized Adaptation Syndrome:
a. The alarm reaction – This reaction is the immediate response to a stressor in a

localized area. Adrenocortical mechanism responds, resulting in behaviors
associated with the fight-or-flight response.
b. Stage of resistance – the body makes some effort to resist the stressor. The body
adapts and functions at a lower than optimal level. This requires a greater than
usual energy for survival.
c. Stage of exhaustion – the adaptive mechanism become worn out and then fail.
The negative effect of the stressor spreads to the entire organism. If the stressor
is not removed or counteracted, death may result.
CONTINUUM OF PSYCHOPHYSIOLOGICAL RESPONSE
Adaptive Response Maladaptive Response
Alarm Resistance Exhaustion
Prepared by Prof. Amelia Z. Manaois for PLM College of Nursing to be used as Instructional Material only for the Lecture in Maladaptive
Patterns of Behavior. Refrain from reproducing this material without the consent of the preparer and the PLM-CN
The primary behaviors observed with psychophysiological responses are the physical
symptoms. These symptoms lead the person to seek health care. Psychological factors affecting
the physical condition may involve any body part
Physical Conditions Affected by Psychological Factors

Cardiovascular Gastrointestinal
Migraine Anorexia Nervosa
Essential Hypertension Peptic Ulcer
Angina Irritable Bowel Movement
Tension Headaches Colitis
Obesity
Musculoskeletal
Rhematoid Arthritis Skin
Low Back Pain (idiopathic) Neurodermatitis
Eczema
Respiratory Psoriasis
Hyperventilation Pruritus
Asthma
Endocrinological
Genitourinary Hyperthyroidism
Impotence Diabetes
Frigidity
Premenstrual Syndrome
Wear and Tear of SHOCK ORGAN
STRESS SYMPTOMS ORGANIC IMPAIRMENT
(Lifestyle, Head ache, Cardiomegaly,

Family Dizziness, Aneurysm, Myocardial
relations, Work Hypertensive Infarctions
Nature)
Or
Hypertension
*Shock Organ – weakest organ or body part or system of a person, usually recipient of the stressor
Ex. During recitation, your stomach grinds ((GIT)
During examination, you perspire a lot (Skin)
During an interview, your heart pounds loudly (Heart)
II. SOMATIC SYMPTOMS AND RELATED DISORDERS (SOMATOFORM DISORDER)
• Occurrence of physical symptoms without any organic impairment or organic cause
STRESS SYMPTOMS ORGANIC CAUSE
(Lifestyle, Head ache,

(-)
Family relations, Dizziness,
Work Nature) Hypertensive
People are often reluctant to believe that a physical problem may be related to psychological
factors. In part, this is because being physically ill is more socially acceptable than having
psychological problems
Somatoform Disorder related to SICK ROLES:
1. Seek help to get well

2. Cooperate to get well
3. Gratification of Dependency
4. Release from Responsibility
5. Call for Attention
People with somatoform disorder embraced the sick role: 3, 4, 5
Some people have physical symptoms without any organic impairment or organic cause, and
these are called Somatoform disorder. They include the following:
A. SOMATIC SYMPTOM DISORDER

B. ILLNESS ANXIETY DISORDER (HYPOCHONDRIASIS)
C. CONVERSION DISORDER
D. FACTITIOUS DISORDER
1. MUNCHAUSEN SYNDROME
2. MUNCHAUSEN SYNDROME BY PROXY
E. MALINGERING
UNCONSCIOUS ATTEMPT CONSCIOUS ATTEMPT
Involuntary Voluntary
A. SOMATIC SYMPTOM D. FACTITIOUS DISORDER

DISORDER
PRIMARY GAIN – Chief goal is internal

(for medical attention or sympathy)
B. ILLNESS ANXIETY
DISORDER MUNCHAUSEN
(HYPOCHONDRIASIS) SYNDROME
MUNCHAUSEN
SYNDROME BY
PROXY
C. CONVERSION
DISORDER
E. MALINGERING
SECONDARY GAIN – Chief goal is external

(day off from work or extra compensation)
A. SOMATIC SYMPTOM DISORDER – in which the person has many physical complaints
that are not constant and related. These symptoms are typical “call for attention”,
gratification of “dependency” or “release from responsibilities”
Somatic symptom disorder is characterized by a focus on physical (somatic) symptoms,

such as:
• PAIN or FATIGUE, causing excessive concern, preoccupation, and fear.
• Previously known as PAIN disorder * Somatization Disorder
Patients’ suffering is authentic and they typically experience a high level of functional
impairment.
The diagnostic criteria for Somatic Symptom Disorder noted in DSM 5 are:
A. One or more somatic symptoms that are distressing or result in significant
disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms
or associated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of
one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health
concerns.
C. Although any one somatic symptom may not be continuously present, the
state of being symptomatic is persistent (typically more than 6 months).
*They have the tendency for DOCTOR SHOPPING & HOSPITAL HOPPING if ever told that there
is nothing wrong with them and that signs and symptoms are not consistent with the laboratory
finding
*They have the tendency to become negativistic and hostile to health care personnel and would
prove that somatic patient is right with his signs and symptoms by going to one clinic to another
*They have the tendency to become defensive if told to seek a psychologist or a psychiatrist to
manage the physical symptoms
B. ILLNESS ANXIETY DISORDER
Formerly known as (Hypochodriasis). This term was last seen in DSRM-IV and was
replaced with the descriptive diagnosis of Illness Anxiety Disorder in DSM-5, 2013
Characterized by extreme worry and fear about the possibility of having a disease.
Illness anxiety is quite obsessive of thoughts about illness being intrusive and hard to
dismiss even when the patients realize their fears are unrealistic. This worry leads the
individual performs excessive health-related behaviors (e.g., repeatedly checks, scans his
or her body for signs of illness)
Actual symptoms and complaints of symptoms are either mild or absent.
Constantly talking about health and possible illness is common.
Some individuals with this disorder are care seekers and some are care avoiders.
o Care-seeking type: Medical care, including physician visits or undergoing tests and
procedures, is frequently used.
o Care-avoidant type: Medical care is rarely used
C. CONVERSION DISORDER
Also known as Functional Neurological Disorder
It manifests itself as neurological symptoms in the absence of a neurological diagnosis
The organic symptoms reduce the patient’s anxiety and usually gives a clue to the conflict.
These symptoms are typical “escape from an impulse”, “call for attention, form of
“manipulation” and freedom from “responsibilities. Conversion symptoms might include
the following:
• Sensory symptoms such as numbness, blindness or deafness
• Motor symptoms such as paralysis, tremors, mutism
• Visceral symptoms such as urinary retention, headaches, or DOB
D. FACTITIOUS DISORDER
Factitious (Latin word): “artificial or contrived.”
1. MUNCHAUSEN SYNDROME
A disorder imposed on Self
An older term for Factitious Disorder is Munchausen syndrome, which was named after
Baron Karl Friedrich Hieronymus von Münchausen (1720–1797). He was an 18th-century
German officer with a reputation for fabricating outrageous tales such as traveling to the
moon, riding a cannonball, or fighting a 40-foot crocodile
Patients with this disorder consciously, artificially, deliberately, and dramatically fabricate
symptoms or self-inflict injury with the goal of assuming the sick role.
Examples of manufactured illnesses include bleeding, fever, hypoglycemia, seizures,

fracture hallucinations, and even cancer.
Individuals with factitious disorder may report depression and suicidality after the death of
a spouse despite the fact that the death is not true or that he was not even married (APA,
2013)
Admission to the hospital often begins in the emergency room with a dramatic description
of an illness using unusually proper medical terminology.
The patient is often reluctant for professionals to speak with family members, friends, or
previous healthcare providers. Once admitted, the patient is frequently demanding and
requests specific treatments and interventions. Negative test results are often followed by
new or additional symptoms. If the healthcare team sets limits and does not follow through
with requests, the patient may become angry and accuse the staff of incompetence and
maltreatment. Patients go from one primary care provider or hospital to another.
Serious complications and sepsis may result from self-injections of toxins such as E. coli.
Patients may have “crisscrossed” or “railroad-track” abdomens due to scars from
numerous exploratory surgeries to investigate unexplained symptoms. In the extreme,
amputations may even result from this disorder.
2. MUNCHAUSEN SYNDROME BY PROXY
A disorder Imposed on another person
A caregiver deliberately falsifies illness in a vulnerable dependent, usually a child or

unsuspecting individual or relative
Hence, diagnosis is imposed on the perpetrator and not on the victim.

People with this disorder do it for the purpose of the attention and excitement and to
perpetuate the relationship with healthcare providers of that dependent. The parent or
guardian is frequently a healthcare worker or someone with extensive knowledge of
the healthcare system.
They desire full control of the victim
The disorder results in multiple, frequent and unnecessary medical visits and
sometimes-harmful medical procedures. Examples of this falsified problem include
inducing premature delivery by rupturing the amniotic sac with a fingernail, infant
apnea and sudden infant death, and introducing microorganisms into a child’s wound.
Falsification of illnesses results in extreme pain, surgical procedures, and even the
death of dependents.
E. MALINGERING
Malingering is a consciously motivated act of fabricating an illness or exaggerating

symptoms.
This is done for secondary gain to become eligible for such things as disability
compensation, committing fraud against insurance companies, obtaining prescription
medications, evading military service, or receiving a reduced prison sentence.
Reported pains are vague and hard for clinicians to prove or disprove (e.g., back pain,
stomach ailments, headache, or toothache).
While not a specific mental disorder, malingering is included here as a condition related
to the factitious disorders.
Malingering is associated with antisocial, narcissistic, and borderline personality

disorders.
*Body dysmorphic disorder – in which a person with a normal appearance is concerned
about having a physical defect
Formerly categorized as Somatic Symptom Disorder but are now classified as Anxiety
Disorder, DSM-5
BDD is a body-image disorder characterized by persistent and intrusive

preoccupations with an imagined or slight defect in one's appearance.
People with BDD can dislike any part of their body, although they often find fault with
their hair, skin, nose, chest, or stomach. In reality, a perceived defect may be only a
slight imperfection or nonexistent. But for someone with BDD, the flaw is significant
and prominent, often causing severe emotional distress and difficulties in daily
functioning.
III. SLEEP - WAKE DISORDER
Sleep-Wake disorders are common in the general population and among people with psychiatric
disorders. Sleep-Wake disorders can influence the development and course of mental illness as
well as addictive disorders.
Either EXCESSIVE SLEEPINESS or SLEEP DEPRIVATION: May affect mood, pain perception,
cognitive function, and memory = REDUCTION IN OVERALL QUALITY OF LIFE
MAJOR GROUPS / CLASSIFICATION OF SLEEP-WAKE DISORDER

According to ASDC, APA (2013) / ICSD-3 (2014)
A. INSOMNIA DISORDER
B. HYPERSOMNOLENCE
C. NARCOLEPSY
D. BREATHING-RELATED SLEEP DISORDERS
E. CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS
F. PARASOMNIAS
G. SLEEP RELATED MOVEMENT DISORDERS
A. INSOMNIA DISORDER
Dissatisfaction with quality or quantity of sleep (DSM-5)
Is the most prevalent sleep disorder. It is a disorder of repeated difficulty with sleep
initiation, duration, consolidation, or quality that occurs despite adequate opportunity and
circumstances for sleep and result in some form of daytime impairment (ICSD-3)
ICSD-3 Categorized Insomnia as Primary and Secondary Type:

Primary Insomnia – sleep problem not linked to any health problems or conditions
Secondary Insomnia – sleep problem caused by either medical condition, substance
induced or mental disorder
DSM-5 further describe insomnia as a disorder if:

• The sleep disturbance causes clinically significant distress or impairment in social,
occupational, educational, academic, behavioral, or other important areas of
functioning.
• The sleep difficulty occurs at least 3 nights per week.
• The sleep difficulty is present for at least 3 months.
• The sleep difficulty occurs despite adequate opportunity for sleep.
B. HYPERSOMNOLENCE DISORDER
Also known as Hypersomnia
The disorder is associated with excessive DAYTIME sleepiness
Hypersomnolence disorder is chronic (3 months or more) and begins in young adulthood.
Excessive sleepiness significantly impairs social and vocational functioning by impacting

the person’s ability to participate and enjoy relationships and function in the workplace.
Cognitive impairment is common and increased risk for accident or injury associated with
the sleepiness.
The patient with hypersomnolence reports recurrent periods of sleep or unintended lapses
into sleep, frequent napping, a prolonged main sleep period of greater than 9 hours, non-
refreshing non-restorative sleep regardless of amount of time slept, and difficulty
with full alertness during the wake period
C. NARCOLEPSY
An uncontrollable urge to sleep (Daytime, Noon or Night Time…..Anytime)
Derived from the Greek words narke (numbness or stupor) and lepsis (attack)
Narcolepsy may be accompanied by cataplexy, which refers to brief episodes of bilateral

loss of muscle tone while maintaining consciousness. This is usually triggered by a strong
emotion such as anger, frustration, or laughter. This terrifying symptom may last for up to
several minutes, and recovery is generally immediate and complete.
Two other classic symptoms of narcolepsy are:
• Hypnagogic hallucinations—false auditory, visual, and tactile sensations. They

occur at the transition from wakefulness to sleep.
• Sleep paralysis—an inability to move or speak during the transition from sleep to
wakefulness
Differentiating Hypersomnolence with Narcolepsy:
In hypersomnia:
Excessive daytime sleep

Sleep quality is non-refreshing non-restorative regardless of amount of time slept
No cataplexy hypnogogic hallucinations and sleep paralysis
In narcolepsy:
Sleep Anytime
people may experience refreshing naps but few minutes after they go back to sleep again
Accompanied with cataplexy hypnogogic hallucinations and sleep paralysis
D. BREATHING-RELATED SLEEP DISORDERS

The most common disorder of breathing and sleeping is Obstructive Sleep Apnea, and
Hypopnea Syndrome.
Associated with:
Obesity.
Upper airway collapse and obstruction that result in sleep fragmentation
Typical symptoms:
• Disruptive snoring,
• Apnea witnessed by others,
• Excessive daytime sleepiness.
ADDITIONAL BREATHING-RELATED SLEEP DISORDERS INCLUDE:

• Central sleep apnea
• Cessation of respiration during sleep due to instability of the respiratory control
system
• Common among:
• Older individuals
• Advanced cardiac or pulmonary disease,
• Neurological disorders
• Sleep-related hypoventilation.
• Associated with sustained oxygen desaturation during sleep in the absence of
apnea or respiratory events.
• Common among:
• Individuals with morbid obesity
• Lung parenchymal disease
• Pulmonary vascular pathology
E. CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS
Circadian – refers to 24 hour cycle
Characterized by normal sleep occurring at the wrong time.
The patient experience excessive daytime sleepiness, insomnia or both.

It can greatly disturb the ability to initiate or maintain sleep or to achieve a restful,
restorative sleep
TYPES:
1. Delayed sleep phase type—
A delay of more than 2 hours between desired time of sleep and actual sleep. Results
in delays in waking.
2. Advanced sleep phase type—Sleep begins several hours earlier and ends several
hours earlier than desired.
3. Irregular sleep-wake type—Sleep is sporadic and fragmented. The longest sleep

period lasts about 4 hours and tends to occur between 2:00 a.m. and 6:00 a.m. It is
associated with brain disorders such as Alzheimer’s and disruptive environments such
as hospitals.
4. Non-24-hour sleep-wake type—Characterized by a mismatch of the 24-hour

environment and the person’s internal clock. Sleep tends to occur later and later,
eventually resulting in daytime sleeping. This problem is rare in sighted people but is
a significant problem for up to 70% of blind individuals.
Medication is specifically approved for this problem—tasimelteon (Hetlioz)—which
works by increasing melatonin.
5. Shift work type—Working outside of the normal work hours (late evening and night)
results in excessive sleepiness at work and impaired sleep at home. It is estimated to
occur in up to 10% of night shift workers.
6. Jet Lag Disorder – occurs when a person travels across two or more time zones
F. PARASOMNIAS
Disorders associated with sleep-wake transition (NREM and REM)
Activation of the Autonomic Nervous System, motor system and cognitive processes at
inappropriate time (as during sleep)
Physical movement or actions are unwanted and often unsafe
Classification:
1. Arousal of NREM sleep
• A person awakens in a confused state, talks in slurred speech, and will not
remember the activities once awake
• Sleep walking (somnambulism)
• Or even jumping from third floor, having sexual activities, texting, committing a
crime
• Sleep talking (somniloquism)
• Night terrors – or Sleep terrors is different from nightmares. There is no dream
but acts very frightened and screaming, jumping out of the bed…run…goes
back to bed, return to slow wave sleep and have no recollection of the event in
the morning
• Sleep-related eating disorder – the same episode of eating while on sleep and
have no recall of the activity when awaken
2. Arousal of REM Sleep

REM sleep behavior disorder (RBD) consist of physical events or activities occurring
during REM sleep
In normal sleepers, muscle atonia occurs during REM
In RBD, muscle tone is maintained during REM sleep and the muscles may twitch or
move
• This is usually accompanied by a nightmare resulting to Isomorphism – acting out

the dreams (person likely to remember the dream)
• OTHER FORMS:
• Enuresis – bedwetting while asleep
• Encopresis - defecating while asleep
G. SLEEP RELATED MOVEMENT DISORDERS
• A class of sleep disorders characterized by simple, often repetitive movement during

sleep that can disrupt the sleep of the patient, the bed partner, or both
Common Forms:
• Restless legs syndrome
• Periodic Limb Movement
• Sleep Related Leg Cramps
• Bruxism
H. Sleep Disorders Related to Another Mental Disorder

I. Sleep Disorder Due to General Medical Condition
J. Substance Induced Sleep Disorder
IV. NURSING PROCESS
A. ASSESSMENT
Assessment Guidelines
1. Assess for nature, location, onset, characteristics, and duration of the symptom(s).
2. Explore past history of adverse childhood events.
3. Identify symptoms of anxiety, depression, and past trauma that may be contributing to
somatic symptoms and ability to meet basic physical, and safety/security needs
4. Determine current quality of life, social support, and coping skills including spirituality.
5. Identify any secondary gain that the patient is experiencing from symptom(s).
6. Explore the patient’s cognitive style and ability to communicate feelings and needs.
7. Assess current psychosocial and biological needs.
8. Screen for misuse of prescribed medication and substance use.
B. NURSING DIAGNOSIS
Somatic Symptom Disorder:

1. Impaired adjustment
2. Ineffective coping mechanism: Denial
3. Impaired Social Interaction
4. Fatigue
5. Chronic pain
6. Sleep pattern disturbance
7. Anxiety,
8. Risk for loneliness, powerlessness, hopelessness,
9. Social isolation,
10. Altered family processes,
11. Risk for suicide.
Sleep Disorder
1. Insomnia
2. Sleep deprivation
3. Disturbed sleep pattern
C. PLANNING / IMPLEMENTATION OF CARE
Somatic Symptom Disorder

Initially, nursing interventions should focus on:
1. Establishing a helping and therapeutic relationship with the patient. The therapeutic
relationship is vital to the success of the care plan given
• The patient’s resistance to the concept that no physical cause for the symptom
exists and
The patient’s tendency to go from caregiver to caregiver
2. Educate the patient regarding specific treatments and how body functions
3. Focus on a patient’s strengths and reinforcing coping skills
4. Spend time with patient at times other than when patient summons nurse to voice
physical complaint
5. Avoid unnecessary tests and procedures.
6. After physical complaints have been investigated, avoid further reinforcement (e.g., do
not take vital signs each time patient complains of palpitations).
7. Avoid making disparaging comments such as, “Your symptoms are all in your head
8. Pharmacological Interventions:
• Tricyclic antidepressants (TCAs)
• Selective serotonin reuptake inhibitors (SSRIs)
• May be helpful in somatic disorders by reducing depressive symptoms
and subsequent somatic responses
• Short-term use of benzodiazepine antianxiety medication
Because patients are seldom admitted to psychiatric care settings specifically for
treatment of somatic disorders, long-term interventions usually take place on an outpatient
basis.
The nurse may initiate short-term planning if the patient is admitted to a medical-surgical
unit. Such a stay is usually brief, and discharge will occur after the results of diagnostic
tests are negative
Patients who somatize often do not mention psychological symptoms and attribute their
symptoms to physical problems when consulting healthcare providers.
Somatization is common in primary care, but providers are not confident in managing it
and often prescribe unnecessary treatments. Because comorbidities between somatic
disorders and major depression and anxiety are common in primary care, it is essential
that an integrated model of care exist between psychiatric care providers and medical
clinicians
Sleep-Wake Disorders
1. Maintain a regular sleep-wake schedule
2. Develop a pre-sleep routine that signals the end of the day
3. Reserve the bedroom for sleep and a place for intimacy
4. Create an environment that is conducive to sleep (light, temperature, and clothing)
5. Avoid clock watching
6. Limit caffeinated beverages to one or two a day and none in the evening
7. Avoid heavy meals before bedtime
8. Avoid use of alcoholic beverages for several hours before bed
9. Avoid daytime napping
10. Exercise daily, but not right before bed
11. Pharmacological Health Teachings:
1. No more than 2 weeks intake – to avoid tolerance and withdrawal
2. Benefits, dosage, side effects, adverse effects
12. Non-pharmacological approaches: Yoga, meditation, music therapy, aromatherapy
D. EVALUATION OF CARE
Evaluation of patients with somatic symptom disorders is a straightforward process when

written measurable behavioral outcomes are clear and realistic. Though often, goals and
outcomes are only partially met as patients are likely to report the continuing presence of
somatic symptoms, but as they say they are less concerned about the symptoms is
already a big leap of success in the plan of care. Same goes with families who may report
outcomes that are satisfying to them even without total eradication of the patient’s
symptoms
Sample Outcome for Somatic Symptom Disorder
SIGNS & SYMPTOMS NURSING OUTCOMES

DIAGNOSIS
Ineffective coping strategies, Ineffective Identifies ineffective coping

insufficient access of social coping patterns, identifies alternate coping
support, insufficient problem- strategies, uses support system
solving skills, inability to meet role
expectations
Presence of secondary gains by Pain, acute Recognizes associated symptoms
adoption of sick role or chronic of pain, reports pain control
Absence of support system, Social Identifies support system, willing to

disabling condition, preoccupation Isolation call on others for assistance,
with own thoughts, friends and identifies a support group
family alienated by physical
obsessions
Nonassertive behavior, Chronic Low Verbalizes positive regard for self,
exaggerates negative feedback Self-esteem describes self as successful, strong
about self, excessive seeking of beliefs that decisions and actions
reassurance, repeatedly control health outcomes
unsuccessful in life events
Sample Outcome for Sleep Disorder
SIGNS & SYMPTOMS NURSING OUTCOMES

DIAGNOSIS
Absenteeism, changes in affect and Insomnia Successful sleep induction,

energy; reports changes in mood, appropriate hours of sleep,
quality of life, concentration, and consistent sleep pattern, minimal
sleep; reports lack of energy, sleep awakening
disturbances, early wakening
Acute confusion, agitation, anxiety, Sleep Balance between work and sleep,
apathy, fatigue, poor concentration, deprivation minimal awakening,
irritability, lethargy, malaise, feeling restored after sleep, sleeping
perceptual disorders, slowed between 7 and 9 hours on average
reaction
Changes in normal sleep pattern, Disturbed Minimal awakening, feeling restored
decreased ability to function, sleep after sleep
dissatisfaction with sleep, pattern
awakening, not feeling well rested
References:
• Margaret Jordan Halter, Varcaroli’s Foundations of Psychiatric-Mental Health Nursing, 8th
edition, 2018
• Shiela L. Videbeck, Psychiatric Mental Health Nursing 6th edition 2011.
CRITICAL THINKING EXERCISES:
1. Diane, a 63-year-old mother of three, was brought to the community psychiatric clinic. Diane
and her son had a bitter fight over finances. Ever since Diane has been complaining of “a severe
pain in my neck.” She has seen several doctors who cannot find a physical basis for the pain. The
nurse knows that:
a. Showing concern for Diane’s pain will increase her obsessional thinking.
b. Diane’s symptoms are manipulative and under conscious control.
c. Diane believes there is a physical cause for the pain and will resist a psychological explanation.
d. Diane is trying to make her son feel bad about the argument.
2. You are caring for Aaron, a 38-year-old patient diagnosed with somatic symptom disorder.
When interacting with you, Aaron continues to focus on his severe headaches. In planning care for
Aaron, which of the following interventions would be appropriate?
a. Call for a family meeting with Aaron in attendance to confront Aaron regarding his diagnosis.
b. Educate Aaron on alternative therapies to deal with pain.
c. Improve reality testing by telling Aaron that you do not believe that the headaches are real.
d. After a limited discussion of physical concerns, shift focus to feelings and effective coping skills
3. The care plan of a patient diagnosed with a somatic disorder includes the nursing diagnosis
ineffective coping. Which patient behavior demonstrates a successful outcome for that nursing
diagnosis?
a. Showers and dresses in clean clothes daily
b. Calls a friend to talk when feeling lonely
c. Spends more time talking about pain in her abdomen
d. Maintains focus and concentration
4. Which patient is at greatest risk for developing a stress- induced myocardial infarction?
a. A patient who lost a child in an accidental shooting 24 hours ago
b. A woman who has begun experiencing early signs of menopause
c. A patient who has spent years trying to sustain a successful business
d. A patient who was diagnosed with chronic depression 10 years ago
5. Melanie is a 38-year-old female admitted to the hospital to rule out a neurological disorder. The
testing was negative, yet she is reluctant to be discharged. Today she has added lower back pain
and a stabbing sensation in her abdomen. The nurse suspects a factitious disorder in which Melanie
may:
a. Consciously tries to maintain her role of a sick patient
b. Not recognize her unmet needs to be cared for
c. Protect her child from illness
d. Recognize physical symptoms as a coping mechanism
6. Which patient statement supports a diagnosis of narcolepsy?
a. “My wife tells me I snore at night.”
b. “I sleepwalk several nights a week.”
c. “I have no control over when I fall asleep.”
d. “My legs feel funny, and that keeps me awake.”
7. The following are treatments typically prescribed for primary insomnia, EXCEPT
a. Cognitive-behavioral therapy-insomnia (CBT-I)
b. Intravenous medication for sedation
c. Stimulus control
d. Sleep restriction
e. Sleep hygiene measures
8. The stage of sleep known as rapid eye movement or REM sleep is characterized by atonia and
myoclonic twitches in addition to the actual rapid movement of the eyes. Atonia is thought to be a
protective mechanism as it:
a. Limits physical movements
b. Prevents nightmares
c. Enhances the dream state
d. Regulates the autonomic nervous system
9. Many people allow life circumstances to dictate their amount of sleep instead of recognizing
sleep as a priority. Which statement will the nurse recognize as progress in the patient’s sleep
hygiene program?
a. “I go to bed even if I am not sleepy, hoping I will fall asleep.”
b. “I have one glass of red wine at bedtime each night.”
c. “I take a nap each day to ‘catch up’ on my sleep deficit.”
d. “I have removed the television from my bedroom.”
10. Light projected into the retina is believed to trigger changes in sleep patterns and quality of
sleep. Therefore, the nurse should suggest:
a. Not reading within an hour of bedtime
b. Exercising before bedtime in a darkened environment
c. Limiting use of electronic devices in the hour before bedtime
d. Dimming the screen on cellphones and computers in the evening
Critical Thinking Part 1: Answer the questions by selecting the right answer from the choices
After answering each question, compare your answer to the correct answers provided below this page.
Critical thinking part 2: Analyze what rationale supports the right answer
(1c, 2d, 3b, 4d,5a,6c,7b,8a,9d,10c)

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MALADAPTIVE PATTERNS OF BEHAVIOR

• Stress – biological reaction to an adverse stimulus (physical, mental, emotional) that

• Stressors – adverse stimulus that disturbs homeostasis

a. The alarm reaction – This reaction is the immediate response to a stressor in a

CONTINUUM OF PSYCHOPHYSIOLOGICAL RESPONSE

Adaptive Response Maladaptive Response

Alarm Resistance Exhaustion

Physical Conditions Affected by Psychological Factors

Wear and Tear of SHOCK ORGAN

STRESS SYMPTOMS ORGANIC IMPAIRMENT

(Lifestyle, Head ache, Cardiomegaly,

• Occurrence of physical symptoms without any organic impairment or organic cause

STRESS SYMPTOMS ORGANIC CAUSE

(Lifestyle, Head ache,

Somatoform Disorder related to SICK ROLES:

1. Seek help to get well

People with somatoform disorder embraced the sick role: 3, 4, 5

A. SOMATIC SYMPTOM DISORDER

A. SOMATIC SYMPTOM D. FACTITIOUS DISORDER

PRIMARY GAIN – Chief goal is internal

SECONDARY GAIN – Chief goal is external

Somatic symptom disorder is characterized by a focus on physical (somatic) symptoms,

B. ILLNESS ANXIETY DISORDER

Actual symptoms and complaints of symptoms are either mild or absent.

Constantly talking about health and possible illness is common.

It manifests itself as neurological symptoms in the absence of a neurological diagnosis

Factitious (Latin word): “artificial or contrived.”

A disorder imposed on Self

Examples of manufactured illnesses include bleeding, fever, hypoglycemia, seizures,

2. MUNCHAUSEN SYNDROME BY PROXY

A disorder Imposed on another person

A caregiver deliberately falsifies illness in a vulnerable dependent, usually a child or

Hence, diagnosis is imposed on the perpetrator and not on the victim.

They desire full control of the victim

Malingering is a consciously motivated act of fabricating an illness or exaggerating

Malingering is associated with antisocial, narcissistic, and borderline personality

BDD is a body-image disorder characterized by persistent and intrusive

III. SLEEP - WAKE DISORDER

MAJOR GROUPS / CLASSIFICATION OF SLEEP-WAKE DISORDER

Dissatisfaction with quality or quantity of sleep (DSM-5)

ICSD-3 Categorized Insomnia as Primary and Secondary Type:

DSM-5 further describe insomnia as a disorder if:

Also known as Hypersomnia

The disorder is associated with excessive DAYTIME sleepiness

Hypersomnolence disorder is chronic (3 months or more) and begins in young adulthood.

Excessive sleepiness significantly impairs social and vocational functioning by impacting

An uncontrollable urge to sleep (Daytime, Noon or Night Time…..Anytime)

Narcolepsy may be accompanied by cataplexy, which refers to brief episodes of bilateral

• Hypnagogic hallucinations—false auditory, visual, and tactile sensations. They

Differentiating Hypersomnolence with Narcolepsy:

Excessive daytime sleep

D. BREATHING-RELATED SLEEP DISORDERS

ADDITIONAL BREATHING-RELATED SLEEP DISORDERS INCLUDE:

Circadian – refers to 24 hour cycle

Characterized by normal sleep occurring at the wrong time.

The patient experience excessive daytime sleepiness, insomnia or both.

3. Irregular sleep-wake type—Sleep is sporadic and fragmented. The longest sleep