By Mercedes A. PerezMillan MSN, ARNP

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Somatoform and Dissociative Disorders

• By Mercedes A. Perez-Millan MSN, ARNP

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Definition

• Somatoform disorders are characterized by
  physical symptoms suggesting medical disease but
  without any organic changes.
• The symptoms are not under the individuals
  voluntary control.

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Epidemiological Statistics

• Somatoform disorders are more common in women,the
  poor, non-educated and those
  living in rural communities.
• Theory of family dynamics
• - Psychosomatic families and role modeling.
• Cultural and environmental factors
• - Low socioeconomic, occupational, and
  educational status
• Genetic factors
• - Predisposition may be inherited

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Somatoform Disorders General
Considerations

• Expressing a conflict through
• the body
• Pathological ego-defense mechanism
• Primary gain (anxiety relief) secondary gain
  (special attention, relief from responsibilities)
• Reinforcement results when when the sick role
  relieves the clients need to deal with a
  stressful situation.

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Somatoform DisordersGeneral Considerations

• Significant impairment occurs in social and/or
  occupational functioning resulting in restriction
  of activities and relationship problems.
• Visits multiple health care providers and may
  undergo many unnecessary surgeries.
• Overuses prescribed and over the counter
  medication often resulting in addiction to
  narcotics and anti-anxiety medications.
• Denial and resistance to psychiatric treatment is
  common.

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AssessmentSomatization Disorder

• Chronic syndrome of multiple somatic symptoms
  that cannot be explained medically.
• Common complaints Neurological, GI, GU,
  cardiopulmonary, psychosexual, etc.
• Anxiety, depression, suicidal attempts commonly
  experienced.

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Assessment

• Pain disorder
• Chronic severe pain in one or more anatomical
  sites resulting in severe distress.
• Even when a medical condition is detected it
  plays a minor role in accounting for the pain.
• The onset of symptoms can be connected to an
  stressful situation.

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AssessmentHypochondria

• Unrealistic preoccupation with fear of having a
  serious illness.
• The individuals interpretation of body symptoms
  is without organic basis.

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Assessment Hypochondria (cont.)

• Even in the presence of medical disease, the
  symptoms are grossly disproportionate to the
  severity of illness.
• Anxiety and depression are common findings, and
  obsessive-compulsive traits frequently accompany
  the disorder.

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Assessment Conversion disorder

• A loss or change in body function resulting from
  a psychological conflict.
• The symptoms are not due to a physical illness
  and seems to be associated psychosocial
  stressors.

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AssessmentConversion disorder (cont.)

• The client often expresses a relative lack of
  concern with the severity of the impairment. La
  bella indiference
• This lack of concern provides a clue to the
  psychological nature of the disorder.

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AssessmentConversion disorder (cont.)

• Generally characterized by
• Sensory dysfunction blindness, deafness or loss
  of tactile sense, etc.
• Motor system dysfunction aphasia, paralysis,
  seizures, impaired coordination, etc.

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Assessment Body Dysmorphic Disorder

• Characterized by the exaggerated belief that the
  body is deformed or defective in some specific
  way.
• Common complaints involve imagined or slight
  flaws of face or head.
• Symptoms of depression and of OCD are common in
  people with body dysmorphic disorder.

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Nursing Diagnosis

• Ineffective individual coping
• Disturbed body image
• Denial, ineffective
• Severe/ Panic anxiety
• Coping, defensive
• Health seeking behaviors (Specific)
• Social isolation
• Knowledge deficit

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Planning and outcomes

• The client with a somatoform disorder will
• Express anxiety and conflict verbally rather than
  with physical symptoms.
• Reduce or eliminate behavior that is demanding or
  manipulative in relationship with others.
• Reduce attention and other secondary gains for
  presence of symptomatic behaviors.
• Verbalizes adaptive strategies for dealing with
  fears and anxieties.

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Planning/Implementation Somatoform
Disorders

• Report and assess new physical complaints,
  because organic disease is also a possibility for
  this client.
• Decrease reinforcement of secondary gains for
  physical symptoms
• Avoid fostering dependency, and encourage
  independent behaviors.
• Teach and encourage use of stress reducing
  measures.

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Planning/ImplementationSomatoform Disorders

• Maintain therapeutic focus on feelings, emotional
  responses, and relationship problems rather than
  somatic symptoms.
• Set limits on manipulative behaviors in matter of
  fact manner.
• Help the client identify and use positive means
  to meet emotional needs.

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Planning/ImplementationSomatoform Disorders

• Encourage maintenance of long-term relationship
  with primary health provider.
• Help identify relationship of stressful life
  events and somatic symptoms.
• Refer to appropriate support group. (ACOA,
  victims of incest, etc.)

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Client/Family Education

• Nature of the illness
• Define and describe symptoms of the disorders.
• Discuss etiologies of these disorders.
• Management of the illness
• Ways to identify onset of escalating anxiety.
• Ways to intervene to prevent exacerbation of
  physical symptom.
• Assertive techniques.

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Client/Family Education (cont.)

• Management of the illness
• Relaxation techniques.
• Physical activities.
• Ways to increase feelings of control and
  decrease feelings of powerlessness.
• Pain management.
• Family how to prevent reinforcing the illness.
• Pharmacotherapy.

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Client/Family Education (cont.)

• Support services
• Support groups.

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Individual psychotherapy.

• Biofeedback.
• Behavior therapy.

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Treatment Modalities

• Somatoform disorders
• Individual psychotherapy
• Group psychotherapy
• Behavior therapy
• Psychopharmacology

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Dissociative Disorders

• Dissociative disorders involve a sudden,
  gradual, transient or chronic disturbance in the
  integrated functions of consciousness,memory,
• identity, or perception.

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Dissociative Disorders Theory

• The actual cause of dissociative disorders (DID)
  is unknown. However, childhood sexual abuse has
  been associated with the development of the
  disorder.
• DID is linked to severe experiences of childhood
  trauma (rates reported
• from 85 to 97).

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Dissociative Disorders

• Repression of mental contents is perceived as a
  coping mechanism for protecting the client from
  emotional pain resulting from experiences.

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Dissociative DisordersDSM-IV-TV

• Four major Dissociative Disorders
• 1. Depersonalization disorder
• 2. Dissociative amnesia
• 3. Dissociative fugue
• 4. Dissociative identity disorder (DID)

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Depersonalization Disorder

• Assessment
• Characterized by a temporary change in the
  quality of self-awareness experienced as
• Feelings of unreality
• Changes in body image
• Feelings of detachment from the environment
• Sense of observing oneself from outside the body

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Depersonalization Disorder (cont.)

• Assessment
• Symptoms of depersonalization disorder are often
  accompanied by
• Anxiety
• Fear of going insane
• Depression
• Obsessive thoughts
• Somatic complaints
• Disturbance in the subjective sense of time

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Dissociative amnesia

• Assessment
• One or more episodes inability to recall
  important information- usually of a traumatic or
  stressful nature.
• Causes significant impairment in social,
  occupational, or other important areas of
  functioning.
• Localized or generalized amnesia.

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Dissociative Fugue

• Assessment
• Characteristic feature of dissociative fugue is a
  sudden, unexpected travel away from home or
  customary workplace
• A person in a fugue state unable to recall
  personal identity, and
• assumption of a new identity is common

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Dissociative Identity
Disorder (DID)

• Assessment
• Characterized by the existence of two or more
  personalities within a single individual
• Transition from one personality to another is
  usually sudden, often dramatic, and usually
  precipitated by stress

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Nursing DiagnosisDissociative Disorder

• Disturbed sensory-perception
• Anxiety (severe to panic)
• Disturbed personal identity
• Disturbed body image
• (see text for complete list)

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Nursing Diagnosis (cont)

• Risk for suicide related to unresolved grief and
  self-blame associated with child abuse
• Risk for other-directed violence related to fear
  of unknown circumstances surrounding emergence
  from fugue state
• Ineffective coping related to severe psychosocial
  stressor or substance abuse and repressed severe
  anxiety

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OutcomesDissociative Disorders

• Planning for care depends on the assessment.
• Suicidal or homicidal?
• Can function in primary role?
• Anxiety or depression?
• Perceives self and environment accurately?
• Social skills training, etc

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Implementation

• Establish a trusting relationship and provide
  support during times of depersonalization,
  amnesia, or emergence of new personalities.
• Encourage the client to disclose and discuss
  feelings in relation to painful memories becoming
  conscious.
• Teach anxiety reducing techniques.
• Document about various personalities.
• Encourage commitment to insight oriented
  psychotherapy with an experienced therapist.

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Client/Family Education

• Nature of the illness
• Define and describe the symptoms of the
  disorders.
• Discuss etiologies of the disorders.
• Discuss possibility of long-term course,
  particularly in the case of DID

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Client/Family Education (cont.)

• Management of illness
• Discuss ways to identify onset of escalating
  anxiety.
• Discuss ways to intervene to prevent exacerbation
  of symptoms.

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Client/Family Education (cont.)

• Management of illness (cont.)
• Teach relaxation techniques.
• Teach assertiveness training.
• Teach about any medications that may be used to
  treat symptoms.

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Client/Family Education (cont.)

• Support services
• Support groups
• Individual psychotherapy

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Treatment Modalities

• Dissociative amnesia
• Remove from stress
• Intravenous Amobarbital
• Supportive psychotherapy
• Dissociative fugue
• Similar to dissociative amnesia

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Treatment Modalities (cont.)

• Dissociative Identity Disorder
• Intense long-term psychotherapy
• Cognitive, psycho analytic, hypnotherapy.
• Individual, family psychotherapy
• Depersonalization disorder
• Various regimens have been tried, although none
  have proved widely successful.