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4-Dissociation and form

4-Dissociation and form

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Published by: Armando on Jun 12, 2009
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Somatoform and Dissociative Disorders

Somatoform Disorders
 The common focus of somatoform disorders is

physical sx in the absence of clinically significant organic disease  Includes:
– – – – – Body dysmorphic disorder Pain disorder Somatization disorder Conversion disorder Hypochondriasis

Body Dysmorphic Disorder
 Characterized by a preoccupation with an

imagined defect in appearance
– If the individual has a slight physical anomaly, the person’s concern is markedly excessive

 The preoccupation causes clinically significant

distress or impairment in social or occupational functioning  The preoccupation is not better accounted for by another mental d/o

Body Dysmorphic Disorder (cont)
 Typical concerns focus on imagined or minor

flaws of the face or head—wrinkles, complexion tone, markings such as scars or freckles, excessive or thinning hair, or asymmetry of the face, eyes, ears, or nose  These individuals spend inordinate amounts of time checking their “defect” in mirrors  Often extreme grooming rituals are present

Pain Disorder
The predominant clinical focus is pain in

one or more anatomic sites The pain is of sufficient severity to warrant clinical attention and cause impairment in 1 or more areas of functioning Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of pain

Somatization Disorders
 These clients frequently seek and obtain medical

treatment for multiple, clinically significant somatic complaints  The c/o must begin before age 30  The c/o cannot be adequately explained by any general medical d/o or the direct effects of a substance  If there is a medical condition present, the c/o or impairment in functioning are in excess of what would be expected from the Health assessment &Physical examination or lab findings

Somatization Disorders (cont)
 Each of the following criteria must have been


– 4 pain sx: a hx of pain r/t at least 4 different sites of function (head, back, abdomen, joints, extremities, chest, rectum, during menstruation, during sex, or during urination) – 2 GI sx: nausea, bloating, vomiting, diarrhea, or intolerance to several different foods – 1 sexual sx: sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding

Somatization Disorders (cont)
Each of the following criteria must have

been met:
– 1 pseudoneurological sx
• Conversion sx such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lum in the throat urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures __ Autonomic Nervous Symptoms

Conversion Disorder
 The term conversion comes from the idea that the

individual uses the somatic sx in an unconscious manner to reduce or repress a psychological conflict that creates anxiety  The most common sx is a d/o of movement—inability to walk, stand, or move an arm – Researchers have found that 71% of clients present with CNS sx  Other sx may take the form of blindness, deafness, or difficulty swallowing  The client often seems unconcerned about this serious, sudden incapacitation (la belle indifference)

Conversion Disorder (cont)
 Clients exhibit 1 or more sx or deficits affecting

voluntary motor or sensory function that suggests a neurological or other general medical condition  Psychological factors are judged to be associated with the sx or deficit  The sx or deficit is not intentionally produced or feigned  The sx or deficit impairs functioning or warrants medical evaluation  The sx or deficit is not limited to pain or sexual dysfunction

 Individual is preoccupied with fears of having—

or the idea of having—a serious medical d/o based on the individual’s misinterpretation of bodily sx  The misinterpretation of sx persists despite appropriate medical evaluation and reassurance  The individual’s preoccupation is not as intense or distorted as in delusional d/o nor is it as restricted as in body dysmorphic d/o

Dissociative Disorders
Dissociation refers to feeling detached

form usual experiences, “cut off”, in a dream like state, or unable to remember things Includes:
– Dissociative amnesia – Dissociative fugue – Dissociative identity disorder

Dissociative Amnesia
 Clients have difficulty remembering past periods

of time  The memory loss goes beyond usual forgetfulness  There may be defined gaps in the memory for years or for self-destructive, violent , or suicidal episodes  Traumatic events such as physical or sexual abuse frequently account for the memory impairment  An example is an individual who has no memory of childhood

Dissociative Fugue
Relatively uncommon Characterized by travel away from one’s

home or one’s customary place of work with an inability to recall one’s past The individual demonstrates confusion about personal identity

Dissociative Identity Disorder
Individual must demonstrate 2 or

more distinct identities or personality states At least 2 of these personality states take control of the person’s behavior

Individuals with this d/o describe very

different personalities, with distinct histories, ages, gender, names, and mood styles such as angry depressed or domineering Most individuals with this dx have histories of severe childhood abuse

Depersonalization disorder
Persistent or recurrent feeling of being

detached from one’s mental process or body Person may describe feelings as though they are in a dream state that they are outside observer of their lives.

Nursing intervention
1. 2. 3. 4. 5. 6. 7. 8.

Recognize the client use of relieving behaviors Limit caffeine, nicotine and NCS stimulants Teach client to differentiate between identifiable and non-identifiable anxiety Use anxiety –reducing techniques. Help client to build effective coping methods. Help client identify supportive persons who can help Help client to control of overwhelming feelings and impulses. Construct client’s environment to be less noisy and less stimulus

Interdisciplinary Treatment
Providing long-term general

management of the chronic condition
Conservatively treating comorbid

psychiatric and physical problems
Providing care in special settings,

including group treatment

Nursing Management: Biologic Domain
 Assessment:
– – – – Review of systems Assessment of pain Physical functioning Pharmacologic
• Usually taking a large number of meds • Self-medicate and provider shop

– Health attitude survey – Review clinical vignette

 Nursing Diagnoses
– Fatigue, pain, disturbed sleep

Biologic Nursing Interventions
 Spend time with physical complaints  Help patient establish a daily routine  Continually monitor medication  Pain management – need multiple approaches  Activity enhancement  Nutrition regulation  Relaxation

Pharmacologic Interventions
 There is no medication for somatization

 Treat the comorbid disorders.
– Depression: antidepressants - MOAI – Anxiety: Avoid benzodiazepines.

 Monitor closely.  Observe for drug-drug interactions.

Nursing Management: Psychological Domain
 Mental status usually

Nursing Diagnoses
 Anxiety  Ineffective sexuality


 Appearance may be

flamboyant, exaggerated illness (may keep a copy of record), series of personal crisis. stressors

 Impaired social interactions  Ineffective coping  Ineffective management of

 Preoccupied with personal

 Emotional reactions to life  Labile mood

therapeutic regimen

Psychological Nursing Interventions
Maintaining nurse-patient relationship Counseling Problem solving Health teaching

Nursing Management: Social Domain
 How much time seeking

Nursing Diagnosis
 Caregiver role strain, risk  Ineffective community

medical care and treating illnesses?

 Extent of disability?  Employment status?  Social network? Do they

 Disable family coping  Social isolation

see their friends as providers?

 Family members
– Tired of all the complaints? – Alcoholism is common.

Nursing Diagnosis
Fatigue Pain Sleep pattern disturbance Altered sexuality patterns, anxiety Ineffective coping Impaired social interactions Ineffective management of therapeutic


Social Nursing Interventions
Problem-solving groups Assertiveness groups • Family interventions

Factitious Disorders
 Factitious disorder (Munchausen’s

– Different than malingering (has other motivations) – Injure themselves covertly – Produce physical symptoms

 Factitious disorder NOS (by proxy)
– Injure others in order to gain attention (mother hurting child)

Nursing Management
Assessment  Chronology of medical/psychological illnesses  Early childhood experiences (abuse, neglect, role of selfinjury)  Family assessment
 Nursing Diagnosis  Risk for trauma  Risk for self-

mutilation  Ineffective individual coping  Low self-esteem

Nursing Intervention
Goal: To replace dysfunctional, attention-

seeking behaviors with positive behaviors Accept and value patient. Encourage long-term psychotherapy. Confrontation is effective if patient feels supported.

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