somatoform and sleep disorders chapter 9. concepts of somatoform and dissociative disorders...
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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 withoutwithout 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
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