Somatoform and Sleep

Disorders
Chapter 9
 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
 characterized
• physical symptoms suggesting medical disease but
without a demonstrable organic
pathological condition or a known
pathophysiological mechanism to account for them.
• Somatoform disorders are more common
– In women than in men
– In those who are poorly educated
– In those who live in rural communities
– In those who are poor
 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
 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
 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
 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
• Typical sites for pain: head, face, lower back, and
pelvis
• Cormorbidity
– Depression, substance abuse, personality disorder
 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
• Typical characteristics
– Obsessive thinking and compulsive behavior
• Mirror checking and camouflaging
– Feelings of shame
– Withdrawal from others
• Cormorbidity
– Depression, OCD, social phobia
 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
• Common symptoms
– Involuntary movements, seizures, paralysis,
abnormal gait, anesthesia, blindness, and
deafness
• Cormorbidity
– Depression, anxiety, other somatoform
disorders, personality disorders
 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
 Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnosis assigned
– Ineffective coping
• Outcomes identification
– Overall goal: patient will live as normal life as
possible
 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
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
• Use matter-of-fact approach to patient
resistance or anger
• Avoid fostering dependence
• Teach assertive communication
 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
 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
 Sleep Disorders: Introduction
• About 75 percent of adult Americans suffer from a sleep
problem.
• 69% of all children experience sleep problems
• The prevalence of sleep disorders increases with advancing
age
• Sleep disorders add an estimated $28 billion to the national
health care bill.
• Common types of sleep disorders include insomnia,
hypersomnia, parasomnias, and circadian rhythm
sleep disorders
 Sleep Disorders: Assessment
• Insomnia
– Difficulty falling or staying sleep
• Hypersomnia (somnolence)
– Excessive sleepiness or seeking excessive amounts of
sleep
• Narcolepsy: Similar to hypersomnia
– Characteristic manifestation: Sleep attacks; the person
cannot prevent falling asleep
• Parasomnias
– Nightmares, sleep terrors, sleep walking
• Sleep terror disorder
– Manifestations include abrupt arousal from
sleep with a piercing scream or cry
• Circadian rhythm sleep disorders
– Shift-work type
– Jet-lag type
– Delayed sleep phase type
 Nursing Process

• Nursing Diagnosis
• Planning/Implementation
• Outcomes
• Evaluation
 Predisposing Factors
• Genetic or familial patterns are thought to play a
contributing role in primary insomnia, primary
hypersomnia, narcolepsy, sleep terror disorder, and
sleepwalking.
• Various medical conditions, as well as aging, have been
implicated in the etiology of insomnia.
• Psychiatric or environmental conditions can contribute to
insomnia or hypersomnia.
• Activities that interfere with the 24-hour circadian rhythm
hormonal and neurotransmitter functioning within the body
predispose people to sleep-wake schedule disturbances.
 Treatment Modalities
• Somatoform disorders
– Individual psychotherapy
– Group psychotherapy
– Behavior therapy
– Psychopharmacology
Sleep disorders
– Relaxation therapy
– Biofeedback
– Pharmacotherapy
• Primary hypersomnia/narcolepsy
– Pharmacotherapy
– CNS stimulants such as amphetamines
• Parasomnias
– Centers around measures to relieve obvious stress
within the family
– Individual or family therapy
– Interventions to prevent injury