Somatoform and Dissociative

Disorders
Somatoform Disorders

 The common focus of somatoform disorders is

physical sx in the absence of clinically significant
organic disease
 Includes:
– Body dysmorphic disorder
– Pain disorder
– Somatization disorder
– Conversion disorder
– Hypochondriasis
Body Dysmorphic Disorder

 Characterized by a preoccupation with an

imagined defect in appearance
– If the individual has a slight physical anomaly, the
person’s concern is markedly excessive
 The preoccupation causes clinically significant
distress or impairment in social or occupational
functioning
 The preoccupation is not better accounted for by
another mental d/o
Body Dysmorphic Disorder
(cont)
 Typical concerns focus on imagined or minor
flaws of the face or head—wrinkles, complexion
tone, markings such as scars or freckles,
excessive or thinning hair, or asymmetry of the
face, eyes, ears, or nose
 These individuals spend inordinate amounts of
time checking their “defect” in mirrors
 Often extreme grooming rituals are present
Pain Disorder

The predominant clinical focus is pain in

one or more anatomic sites
The pain is of sufficient severity to warrant
clinical attention and cause impairment in
1 or more areas of functioning
Psychological factors are judged to have an
important role in the onset, severity,
exacerbation, or maintenance of pain
Somatization Disorders

 These clients frequently seek and obtain medical

treatment for multiple, clinically significant
somatic complaints
 The c/o must begin before age 30
 The c/o cannot be adequately explained by any
general medical d/o or the direct effects of a
substance
 If there is a medical condition present, the c/o or
impairment in functioning are in excess of what
would be expected from the Health assessment
&Physical examination or lab findings
Somatization Disorders (cont)

 Each of the following criteria must have been

met:
– 4 pain sx: a hx of pain r/t at least 4 different sites of
function (head, back, abdomen, joints, extremities,
chest, rectum, during menstruation, during sex, or
during urination)
– 2 GI sx: nausea, bloating, vomiting, diarrhea, or
intolerance to several different foods
– 1 sexual sx: sexual indifference, erectile or ejaculatory
dysfunction, irregular menses, excessive menstrual
bleeding
Somatization Disorders (cont)

Each of the following criteria must have

been met:
– 1 pseudoneurological sx
• Conversion sx such as impaired coordination or
balance, paralysis or localized weakness, difficulty
swallowing or lum in the throat urinary retention,
hallucinations, loss of touch or pain sensation,
double vision, blindness, deafness, seizures
__ Autonomic Nervous Symptoms
Conversion Disorder

 The term conversion comes from the idea that the

individual uses the somatic sx in an unconscious manner
to reduce or repress a psychological conflict that creates
anxiety
 The most common sx is a d/o of movement—inability to
walk, stand, or move an arm
– Researchers have found that 71% of clients present
with CNS sx
 Other sx may take the form of blindness, deafness, or
difficulty swallowing
 The client often seems unconcerned about this serious,
sudden incapacitation (la belle indifference)
Conversion Disorder (cont)

 Clients exhibit 1 or more sx or deficits affecting

voluntary motor or sensory function that suggests
a neurological or other general medical condition
 Psychological factors are judged to be associated
with the sx or deficit
 The sx or deficit is not intentionally produced or
feigned
 The sx or deficit impairs functioning or warrants
medical evaluation
 The sx or deficit is not limited to pain or sexual
dysfunction
Hypochondriasis

 Individual is preoccupied with fears of having—

or the idea of having—a serious medical d/o
based on the individual’s misinterpretation of
bodily sx
 The misinterpretation of sx persists despite
appropriate medical evaluation and reassurance
 The individual’s preoccupation is not as intense
or distorted as in delusional d/o nor is it as
restricted as in body dysmorphic d/o
Dissociative Disorders

Dissociation refers to feeling detached

form usual experiences, “cut off”, in a
dream like state, or unable to remember
things
Includes:
– Dissociative amnesia
– Dissociative fugue
– Dissociative identity disorder
Dissociative Amnesia
 Clients have difficulty remembering past periods
of time
 The memory loss goes beyond usual
forgetfulness
 There may be defined gaps in the memory for
years or for self-destructive, violent , or suicidal
episodes
 Traumatic events such as physical or sexual
abuse frequently account for the memory
impairment
 An example is an individual who has no memory
of childhood
Dissociative Fugue

Relatively uncommon
Characterized by travel away from one’s
home or one’s customary place of work
with an inability to recall one’s past
The individual demonstrates confusion
about personal identity
Dissociative Identity Disorder

Individual must demonstrate 2 or

more distinct identities or personality
states
At least 2 of these personality states
take control of the person’s behavior
Individuals with this d/o describe very
different personalities, with distinct
histories, ages, gender, names, and mood
styles such as angry depressed or
domineering
Most individuals with this dx have
histories of severe childhood abuse
Depersonalization disorder

Persistent or recurrent feeling of being

detached from one’s mental process or
body
Person may describe feelings as though
they are in a dream state that they are
outside observer of their lives.
Nursing intervention

1. Recognize the client use of relieving behaviors

2. Limit caffeine, nicotine and NCS stimulants
3. Teach client to differentiate between
identifiable and non-identifiable anxiety
4. Use anxiety –reducing techniques.
5. Help client to build effective coping methods.
6. Help client identify supportive persons who can
help
7. Help client to control of overwhelming feelings
and impulses.
8. Construct client’s environment to be less noisy
and less stimulus
Interdisciplinary Treatment
Providing long-term general
management of the chronic condition
Conservatively treating comorbid
psychiatric and physical problems
Providing care in special settings,
including group treatment
Nursing Management:
Biologic Domain
 Assessment:
– Review of systems
– Assessment of pain
– Physical functioning
– Pharmacologic
• Usually taking a large number of meds
• Self-medicate and provider shop
– Health attitude survey
– Review clinical vignette

 Nursing Diagnoses
– Fatigue, pain, disturbed sleep
Biologic Nursing Interventions

 Spend time with physical complaints

 Help patient establish a daily routine
 Continually monitor medication
 Pain management – need multiple approaches
 Activity enhancement
 Nutrition regulation
 Relaxation
Pharmacologic Interventions
 There is no medication for somatization
disorder.
 Treat the comorbid disorders.
– Depression: antidepressants - MOAI
– Anxiety: Avoid benzodiazepines.

 Monitor closely.
 Observe for drug-drug interactions.
Nursing Management:
Psychological Domain
Assessment Nursing Diagnoses
 Mental status usually  Anxiety
normal
 Appearance may be  Ineffective sexuality
flamboyant, exaggerated patterns
 Preoccupied with personal  Impaired social interactions
illness (may keep a copy of
 Ineffective coping
record), series of personal
crisis.  Ineffective management of
 Emotional reactions to life therapeutic regimen
stressors
 Labile mood
Psychological Nursing
Interventions
Maintaining nurse-patient relationship
Counseling
Problem solving
Health teaching
Nursing Management:
Social Domain
Assessment Nursing Diagnosis
 How much time seeking  Caregiver role strain, risk
medical care and treating
illnesses?  Ineffective community
 Extent of disability?
coping
 Employment status?
 Disable family coping
 Social network? Do they
see their friends as  Social isolation
providers?
 Family members
– Tired of all the complaints?
– Alcoholism is common.
Nursing Diagnosis
Fatigue
Pain
Sleep pattern disturbance
Altered sexuality patterns, anxiety
Ineffective coping
Impaired social interactions
Ineffective management of therapeutic
regimen
 Social Nursing Interventions

Problem-solving groups
Assertiveness groups
• Family interventions
Factitious Disorders
 Factitious disorder (Munchausen’s
syndrome)
– Different than malingering (has other motivations)
– Injure themselves covertly
– Produce physical symptoms

 Factitious disorder NOS (by proxy)

– Injure others in order to gain attention (mother
hurting child)
Nursing Management

Assessment  Nursing Diagnosis

 Chronology of  Risk for trauma
medical/psychological  Risk for self-
illnesses mutilation
 Early childhood  Ineffective individual
experiences (abuse, coping
neglect, role of self-  Low self-esteem
injury)
 Family assessment
Nursing Intervention

Goal: To replace dysfunctional, attention-

seeking behaviors with positive behaviors
Accept and value patient.
Encourage long-term psychotherapy.
Confrontation is effective if patient feels
supported.