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Chapter 20: Somatic symptom and Dissociative Disorders; slides and book notes

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Somatic Symptom disorders characterized by
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by physical symptoms suggesting medical disease but without demonstratbale organic pathology or a known pathophysiological mechanism to account for them ~physical symptoms are major cause of symptoms ~psychosocial effect ~ not understandable by existing lab procedure; ~pt does not perceive themselves as having a psychiatric problem; and do not seek treatment from psychiatrists
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Dissociative Disorders are defined by
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disruption in the usually integrated functions of consciousness, memory, identiy, or perception of the environment ~defense mechanism that normaly govern consciousness, identity, and memory break down and behavior occurs with little or no participation on part o the conscious personality ~occur when anxiety becomes overwhelming and personality becomes disorganized
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Types of dissociative disorders in DSM5
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1. depersonalization-derealization disorder 2. dissociative amnesia 3. dissociative identity disorder (DID) 4. Other specified and unspecified dissociative disorders
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Epidemiological Statistics: SOMATIC SYMPTOMS DISORDERS ARE MORE COMMONLY FOUND IN
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~ WOMEN THAN IN MEN ~ poorly educated ~ lower socioeconomical classes
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Epidemiological Statistics: DISSOCIATIVE DISORDERS
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~thought to be rare ~ DID and dissociative amnesia are more common in women thatn in men ~brief episodes of depersonalization symptoms appear to e common in young aduts, particulary in times of severe stress: example 2 ore more personality in one person, effects life, quick shifts of personalities; defense mechanism of traumatic event
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Assessment: types of somatic symptom disorders: SOMATIC SYMPTOM DISORDERS IS DEFINED
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chronic syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychsocial distress and long term seeking of assistance from health care professionals ~symptoms may be vague, dramatized, or exaggerated in their presentation, excessive amount of time and energy is devoted to worry and concern about symptoms ~pt is convienced their symptoms are related to organic pathology that they adamantly reject and are irritated by any implication that stress or psycholosical factors play any role in condition Disorder is : ~chronic ~anxiety, depression, and suicidal ideations are frequently manifested ~drug abuse and dependence are common ~fluctuating course: periods of remission and exacerbation ~often receive medical care from several physicians leading to dangerous combos of treatments: seek relief through overmedicating with analgesics or antianxiety agents ~drug abuse and dependence are common complications ~when suicide results: usually associated with substance abuse ~doctors believe the pt is faking symptoms which is traumatizing to the pt
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Assessment of Somatic symptoms disorder: PERSONALITY CHARACTERISTICS
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~heightened emotionality ~strong dependency needs ~preoccupation with symptoms and oneself (seek attention and strong dependency) ~some overlapping of personality characteristics and features associated with histrionic personality disorder ~impressionistic thought and speech ~seductiveness
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Assessment: ILLNESS ANXIETY DISORDER
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~preoccupation with the fear of contracting or the belief of having A SEROUS ILLNESS ~fear becomes disabling and persists despite reassurance that no organic pathology can be detected Example: pt does not have anything ut knows they will get it ~even in the presence of disease, symptoms are excessive in relation to the degree of pathology, Example: wil have px but they exaggerate px level ~Anxiety and depression are common and obsessive compulsive traits frequently accompany the disorder Book notes: ~defined as unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease ~syptoms may be minimal or absent ~person is extremely conscious of bodily sensations and changes; become convinced that a rapid heart rate indicates they have heart disease; small sore = skin cancer ~preoccupied with their body, note even smallest change in feeling or sensation = unrealistic and exaggerated ~some of these pts have a long history of doctor shopping and believe they not receiving proper care ~some avoid seeking medical assistance because increases anxiety to intolerable levels ~may interfere with social or occupational functioning
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Diagnostic Criteria for : ILLNESS ANXIETY DISORDER
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1. Preoccupation with having or acquiring a serious illness 2. somatic symptoms are not present or if present = only mild in intensity; if another medical condition is present or there is a high risk for developing a medical condition (strong family history is present) = the preoccupation is clearly excessive or disproportionate 3. high level of anxiety about health; individual is easily alarmed about personal health status 4. performs excessive health related behaviors (repeatedly checks his/her body for signs of illness ) or exhibits maladaptive avoidance (avoids dr’s apptointments and hospitals 5. illness preoccupation has been present for at least 6 months, but specific illness that is feared may change over a period of time 6. illness related preoccupation is not etter explained by another mental disorder, such as somatic symptom disorder, panjc disorder, generalized anxiety disorder, body dysmorphic disorder, OCD, or delusional disorder, somatic type 2 types: A. care seeking type B. care avoidant type
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Assessment: CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER)
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~ a loss of or change in the body function resulting from a psychological conflict ~ phsycial symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism ~ most obvious and “classic” conversion symptoms are those that suggest neurological disease and occur following a situation that produces extreme psychological stress for the individual ~EXAMPLES: lost of a spouse, they have no perception of legs, cant feel cold/hot, ~go through deafness, unknown reasoning, but comes back after the traumatic event Book notes: ~most likely a psychological component involved in initiation, exacerbation, or perpetuationof symptom; may not be obvious or id
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Assessment: CONVERSION DISORDER
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~ expresses a relative lack of concern that is out of keeping with severity of impairments ~problem is psychological rather than physical EXAMPLE: focus on what am I going to do? after a traumatic event What just happened? ~appear to have a lack of concern, lasts weeks to 2 months
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Coversion symptoms affect
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voluntary motor or sensory functioning suggestive of neurological disease EXAMPLES: 1. paralysis 2. APHONIA: inability to produce voice 3. Seizures 4. coordination disturbance, 5. difficulty swallowing 6. urinary retention 7. akinesia 8. blindness 9. deafness, 9. double vision 10. ANOSMIA: inability to perceive smell 11. loss of pain sensation 12. hallucinations
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A conversion symptom that may represent a strong desire to be pregnant is called
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PSEUDOCYESIS: false pregnancy
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DSM5 Diagnostic criteria for conversion disorder (Functional neurological symptom disorder)
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A. one or more symptoms of altered voluntary motor or sensory function B. clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions C. symptom or deficit is not better explained by another medical or mental disorder D. symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation Specify Symptom type: weakness or paralysis abnormal movement swallowing symptoms speech symptom attacks or seizures anesthesia/sensory loss special sensory symptom mixed symptoms specify if: acute episode or persistent specify if: with psychological stressor or without psychological stressor *most symptoms of conversation disorder resolve within a few weeks * 20% of have a relapse within a year *favorable outcome is generally associated with acute onset, precipitating stressful event, good premorbid adjustment, and absence of medical or neurological comorbidity
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Etiological Implications: SOMATIC SYMPTOM DISORDERS
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1. GENETIC: hereditary factors are possibly associated with somatic disorder, conversion disorder, and illness anxiety disorder in first degree relatives 2. BIOCHEMICAL: decreased levels of serotonin and endorphins may play a role in etiology of PAIN DISORDER 3. PSYCHOLDYNAMIC THEORY: theory suggests that hypochondriasis may e an ego defense mechanism, physical complaints become the expression of low self esteem: beuase it is easier to feel is wrong with body than to feel something is wrong with the self ~ conversion disorder may resprent emotionals associated with traumatic events that too unacceptable to express and so are acceptaily “converted” into physical symptoms 4. FAMILY DYNAMIC: in dysfunctional families, when a child becomes ill, focus shifts from open conflict to the child’s illness and leaves unresolved underlying issues the family is unable to confront in an open manner: psotive reinformcent to the child 5. Learning theory (see next slide)
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LEARNING THEORY:
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~ somatic complaints are often reinforced when the sick person learns that he or she may avoid stressful obligations or be excused from u nwanted duties: PRIMARY GAIN ~ becomes prominent focus of attention because of the illness: SECONDARY GAIN ~relieves conflict within family as concern is shifted to the ill person away from the real issues: TERITIARY GAIN Book notes: ~somatic complaints are often reinforced when the sick role relieves the individual from the need to deal with stressful situation ~sick person learns they can avoid can avoid stressful obligations, postpone unwelcome challenges, and is excused from troublemsome duties: PRIMARY GAIN ~ THESE POSITIVE REINFORCEMENTS (PRIMARY, SECONDARY, TERITIARY) GUARANTEE REPETITION OF THE RESPONSE ~ past experience with serious or life-threatening physical illness, either personal or that of close family members can predispose an individual to illness anxiety disorder, Example: cancer recovery pt: feel they have a big disease or because family member had it they will as well ~Feaer of recurring illness generates an exaggerated response to minor physical changes: leading to excessive anxiety and health concerns
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Nursing Diagnosis/Ourcomes with Somatic symptom disorders
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Ineffective coping Chronic pain: multiple symptoms of px Fear Disturbed sensory perception Disturbed Body image: conversion disorders Book Notes: Somatic symptom disorders effectively uses adaptive coping strategies during stressful situations without resorting to pgysical symptoms ~Verbalized relief from pain and demonstrates adaptive coping strategies during stressful situations to prevent the onset of pain ILLNESS ANXIETY DISORDER OUTCOMES: ~interprets bodily sensations rationally, verbalizes understanding of the significance the irrational fear held for them, has decreased the number and frequency of physical complaints CONVERSATION DISORDER: ~free of physical disability and is able to veralize understanding of the possible correlation between the loss of or alteration in function and extreme emotional stress
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Planning/Implementation of SOMATIC SYMPTOM DISORDERS
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~Nursing care of individual with somatic symptom disorders are aimed at RELIEF OF DISCOMFORT from the physical symptoms ~Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than preoccupation with physical symptoms Reasons for relief of discomfort: because there is nothing pathologicially wrong with pt
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Evaluation: of SOMATIC SYMPTOM DISORDERS
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~ based on accomplishment of previously established outcome criteria
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Medical Treatment Modalities: SOMATIC SYMPTOM DISORDERS
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1. INDIVIDUAL PSYCHOTHERAPY: help pt develop healthy and adaptive behaviors, encourage them to move beyond their somatization, and manage their lives more effectively; focus is on personal and social difficulties and achievement of practical solutions 2. GROUP PSYCHOTHERAPY: group illness, talk/share together of illness; provides a setting where pt can share their experiences of illness, learn to verbalize thoughts and feelings, and be confronted by group members and leaders when they reject responsibility for maladaptive behaviors; TREATMENT OF CHOICE FOR SOMATIC SYMPTOM DISORDER AND ILLNESS ANXIETY DISORDER 3. BEAHVIOR THERAPY: more successful in secondary gain involves working with pt’s family or significant others who perpetuate the physical symptoms by rewarding passivity and dependency; focuses on teaching pt’s to reward pt’s autonomy, self sufficiency, and independence 4. PSYCHOPHARMACOLOGY: antidepressants often used with somatic symptom disorder when predominant symptom is PAIN; effective in relieving pain, independence of influences on mood = TCA’S (TRICYCLIC) due to efficacy in relieving px ~SSRI’s not widely used due to non relief of pain ~anticonvulsants (phenytoin (Dilantin) carbamazepine (Tegregol) and clonazepam (Klonopin) = effective in treating neuropathic and neuralgic pain: for short periods
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Assessment: dissociative disorders: DISSOCIATIVE AMNESIA
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~ an inability to recall important personal data, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgethfulness ~not due to the direct effects of substance use or a general medical condition
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Assessment: Dissociative disorders: THREE TYPES OF DISTURANCE IN RECALL IN DISSOCIATIVE AMNESIA
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1. LOCALIZED AMNESIA: inability to recall all incidents associated with the traumatic event for a specific period following the event; related to a specific stressful event that has occurred; unable to recall all incidents associated with a stressful event, may be broader than just a single event EXAMPLE: car accident; person doesn’t recall details of events for hours or days 2. SSELECTIVE AMNESIA: inability to recall only certain incidents associated with traumatic event for a specific period following the event; EXAMPLE: person only remembers bits and pieces of event or certain parts 3. GENERALIZED AMNESIA: inability to recall anything that has happened during the person’s entire lifetime, including personal identity EXAMPLE: forgets everything and all identity, no memory
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Define dissociative fugue
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subtype of dissociative amnesia is with dissociative fugue ~ a sudden, unexpected travel away from home or customary workplace ~ individual is unable to recall personal identity and assumption of a new identity is common EXAMPLE: they forget who they are and pick up a new identity and believe who they are and do not shift back
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Assessment: DISSOCIATIVE IDENTITY DISORDER (DID)
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~characterized by 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 ~Shifts from dominate ~therapy is to shift personalities together Book Notes: ~ formerly called multiple personality disorder ~only one personality is evident at any given moment, and one of them is dominat most of the time over the course of the disorder ~each personality is unique and composed of a complex set of memories, behavior patterns, and social relationships that surface during the dominate interval ~other personalities that are not dominate called: ALTERS
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Assessment: DEPERSONALIZATION-DEREALIZATION DISORDER
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~ characterized by persistent feelings of 1. unreality 2. detachment from oneself or one’s body 3. observing oneself from outside the body ~reality testing remains intact ~symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning ~ disturbance is not attributable to the physiological effects of a substance (example a drug of abuse, medication) or another medical condition (seizures) ~ disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another disccoiative disorder
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Define depersonalization
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a disturbance in perception of oneself
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define derealization
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describes an alteration in the perception of the external environment
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depersonalization-Derealization disorder: SYMPTOMS OF DEPERSOANLIZATION-DEREALIZATION DISORDER ARE OFTEN ACCOMPANIED BY:
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~ anxiety and depression ~fear of going insane ~ obsessive thoughts ~somatic complaints ~disturbance in the subjective sense of time *can watch themselves outside of body, impaired functioning
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Etiological implications of DISSOCIATIVE DISORDERS
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1. GENETICS: possible hereditary factors are associated with DID 2. NEUROBIOLOGICAL: dissociative amnesia and dissociative fugue may be realted to neurophysiological dysfunction; EEG abnormalities have been observed in some clients with DID 3. 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 Example: sexual abuse/rape/abuse = trauma; then psychodynamic theory becomes a defense mechanism 4. PSYCHOLOGICAL TRAUMA: growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelms the individuals’s capacity to cope by any means other than dissociaition ~these experiences usually take the form of severe physical, sexual, or psychological abuse by a parent or significant other in the child’s life
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Diagnosis/Outcome: Dissociation
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Distured thought process ineffective coping disturbed personal identity disturbed sensory perception
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Outcomes: Dissociation
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THE CLIENT: 1. can recall events associated with stressful situations 2. can recall all events of past life 3. can verbalize anxiety that precipitated the dissociation 4. can demonstrate coping methods to avert dissociative behaviors 5. Verbalize existence of mulitiple personalities 6. able to maintain a sense of reality during stressful situations *all are tailored to the individual
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Planning/Implementation: dissociation
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~ nursing care is aimed to restoring normal throught processes ~ assistance is provided to the client in an effort to determine strategies for coping with stress y means other than dissociation from the environment *recognize bad childhood, then shift to another personality to deal with it (or not deal with it)
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Evaluation: Dissociation
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based on accomplishment of previously established outcome criteria 1. Has client’s memory been restored? 2. can the client connect occurrence of psychological stress to loss of memory? 3. Can the client discuss the presence of various personalities within the self? 4. can verbalize why these personalities exist? 5. Can client demonstrate more adaptive coping strategies for dealing with stress without resorting to dissociation