Chapter 30

Anxiety-Related, Somatoform, and Dissociative Disorders

Psychiatric-Mental Health Nurses Association of the Philippines, Inc. (PMHNAP)

Learning Objectives
Recognize the special terms related to anxiety disorders, somatoform disorders, and dissociative disorders. Describe the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for these disorders (APA, 2000). Describe objective and subjective symptoms of these disorders.

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Learning Objectives
Develop nursing care plans for individuals with these disorders. Evaluate the effectiveness of nursing interventions for individuals with these disorders. Recognize issues related to the care of individuals with these disorders.

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I. Anxiety-Related Disorders
Generalized Anxiety Disorder: The anxiety or worry is chronic, excessive, or unreasonable and may concern everyday events, such as work or school.

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DSM-IV-TR Criteria for Generalized Anxiety Disorder

1. Excessive worry and anxiety 2. Difficulty in controlling the worry 3. Anxiety and worry are evident in three or more of the following: Restlessness Fatigue Irritability Decreased ability to concentrate Muscle tension Disturbed sleep
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2. Panic Disorder with or without Agoraphobia

Patients with panic disorder experience recurrent panic attacks and are worried about having more attacks.

DSM-IV-TR CRITERIA for Panic Disorder: 1. Recurrent, unexpected panic attacks 2. Panic attacks followed by a month or more of worry about having additional attacks, worry about the results of the attacks, and behavior changes related to the attacks 3. Panic disorder possibly accompanied by agoraphobia
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Psychotherapeutic Management
Reduce anxiety Nursepatient relationship Psychopharmacology Milieu management Psychotherapy (cognitive behavioral therapy)

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Anxiety Related Disorders: Phobia

3. Agoraphobia without panic disorder 4. Specific phobia 5. Social phobia

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Phobic Disorders
Phobic disorders are intense, irrational fear responses to an external object, activity, or situation. 1. Agoraphobia without history of panic disorder: A fear of being in public or open spaces, places, or situations in which escape might be difficult or help might not be availablefor example, if the person faints.

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Phobic Disorders
2. Social phobia: Fear of being humiliated, scrutinized, or embarrassed in publicfor example, choking while eating in front of others or stumbling while dancing in view of others. 3. Specific phobia: Fear of a specific object or situation that is neither of the abovefor example, fear of animals, flying, or heights.

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Psychotherapeutic Management
Nurse-patient relationship Psychopharmacology Milieu management

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6. Obsessive-Compulsive Disorder
Obsessions are recurrent and persistent thoughts, ideas, impulses, or images that are experienced as intrusive and senseless.

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DSM-IV-TR Criteria for Obsessive-Compulsive Disorders

A. Obsessions 1. Intrusive, inappropriate, recurrent, and persistent thoughts, impulses, or images that are distressful or produce anxiety. 2. Unsuccessful attempts to ignore or neutralize thoughts or impulses by other thoughts or actions. 3. Recognition that obsessions are produced by own thoughts. 4. Not simply excessive worry about real-life problems.
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DSM-IV-TR Criteria for Obsessive-Compulsive Disorders

B. Compulsions 1. Repetitive behaviors, such as hand washing, or mental acts, such as counting, performed in response to an obsession. 2. Excessive behaviors or mental acts used to reduce distress or prevent dreaded events. C. Recognition that obsessions or compulsions are unreasonable or excessive. D. Obsessions or compulsions cause distress, are time-consuming, and interfere with usual daily functioning.
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Psychotherapeutic Management
Nurse-patient relationship Psychopharmacology Milieu management

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Anxiety Disorder
7. Acute stress disorder (ASD) 8. Posttraumatic stress disorder (PTSD) ASD and PTSD are disorders that can develop after exposure to a clearly identifiable traumatic event that threatens the self, others, resources, and/or sense of control or hope. 9. Anxiety disorder due to a general medical condition

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Psychotherapeutic Management
Nurse-patient relationship Evidence-based therapies to treat the symptoms of PTSD are trauma-focused CBT, prolonged exposure therapy, and eye movement desensitization and reprocessing Psychopharmacology (benzodiazepines, clonidine, propranolol, and atypical antipsychotics) Milieu management

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Adjustment Disorders
The diagnosis of adjustment disorder might be made when symptoms develop within 3 months after an identifiable life event, and the reaction is not severe enough to fit the criteria of ASD or PTSD. Common events or circumstances that might precipitate an adjustment disorder are divorce, moving, marriage, retirement, illness or disability, financial problems, or difficulties in child rearing.

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II. Somatoform Disorders

Somatization disorder Pain disorder Hypochondriasis Conversion disorder

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DSM-IV-TR Criteria for Somatoform Disorders

Somatization disorder: Many physical complaints over several years, resulting in treatment being sought or impairment in functioning. It is characterized by four pain, two gastrointestinal, one sexual, and one pseudoneurologic symptoms. Pain disorder: Pain in one or more areas of the body that is severe enough to seek treatment; causes impairment in functioning or significant distress.

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DSM-IV-TR Criteria for Somatoform Disorders

Conversion disorder: One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or general medical condition. Hypochondriasis: Preoccupation with fear of having, or the idea that one has, a serious disease; includes misinterpretation of bodily symptoms; preoccupation persists despite medical evaluation and reassurance.

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Psychotherapeutic Management
Nurse-patient relationship Psychopharmacology Milieu management (relaxation exercises, meditation, and CBT are used to treat somatoform disorders)

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Dissociative Disorders
Dissociative amnesia Dissociative fugue Depersonalization disorder Dissociative identity disorder (multiple-personality disorder)

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DSM-IV-TR Criteria for Dissociative Disorders

Dissociative amnesia: Loss of memory of important personal events that were traumatic or stressful in nature. Dissociative fugue: Sudden, unexpected travel away from home or work with a loss of memory about the past; confusion about identity or assumption of partial or completely new identity is present.

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DSM-IV-TR Criteria for Dissociative Disorders

Depersonalization: Experiences of feeling detached from, or an outside observer of, ones body or mental processes; reality testing is intact. Dissociative identity disorder: Presence of two or more identities or personalities that take control of the persons behavior; loss of memory for important personal information.

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Psychotherapeutic Management
Nurse-patient relationship
establish trust and support

Psychopharmacology for anxiety or depression if present Milieu management Psychotherapy

Individual therapy Occupational therapy Art therapy

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