Chapter 18

Somatoform and Dissociative

Disorders
Somatoform Disorders

• Somatoform disorders are

characterized by physical
symptoms suggesting medical
disease but without
demonstrable organic pathology
or a known pathophysiological
mechanism to account for them
Dissociative Disorders

• Dissociative disorders are

defined by a disruption in the
usually integrated functions of
consciousness, memory,
identity, or perception of the
environment
Epidemiological Statistics

Somatoform disorders are more

commonly found in
– Women than in men
– The poorly educated
– Lower socioeconomic classes
Epidemiological Statistics (cont.)

• Dissociative disorders are thought to

be rare
• DID and dissociative amnesia are
more common in women than in men.
• Brief episodes of depersonalization
symptoms appear to be common in
young adults, particularly in times of
severe stress
Application of the Nursing Process:
Assessment

Types of somatoform
disorders
• Somatization disorder: chronic
syndrome of multiple somatic
symptoms that cannot be explained
medically and are associated with
psychosocial distress and long-term
seeking of assistance from health-
care professionals
• Somatization disorder
(cont.)
– The disorder is chronic
– Anxiety, depression, and suicidal
ideations are frequently
manifested
– Drug abuse and dependence
are not uncommon
• Somatization disorder (cont.)
– Personality characteristics
• Heightened emotionality
• Strong dependency needs
• A preoccupation with symptoms and
oneself
Pain disorder
• Predominant disturbance in pain disorder is
severe and prolonged pain that causes clinically
significant distress or impairment in social,
occupational, or other areas of functioning
Pain disorder (cont.)
• Even when organic pathology is detected, the
pain complaint may be evidenced by the
correlation of a stressful situation with the onset
of symptoms
Pain disorder (cont.)
– Pain disorder may be maintained by
• Primary gains: symptom enables the client to
avoid some unpleasant activity
• Secondary gains: symptom promotes
emotional support or attention
for the client
Pain disorder (cont.)
• Tertiary gains: in dysfunctional
families, the physical symptom
may take such a position that the
real issue is disregarded and
remains unresolved even though
some of the conflict is relieved
• Symptoms of depression and
substance abuse are common
Hypochondriasis
• A preoccupation with the fear of
contracting, or the belief of having,
a serious disease
• The fear becomes disabling and
persists despite reassurance that
no organic pathology can be
detected
Hypochondriasis (cont.)
• Even in the presence of disease, the
symptoms are excessive in relation to
the degree of pathology
• Anxiety and depression are common,
and obsessive–compulsive traits
frequently accompany the disorder
Conversion disorder
• A loss of or change in body function
resulting from a psychological conflict,
the physical symptoms of which cannot
be explained by any known medical
disorder or pathophysiological
mechanism
Conversion disorder (cont.)
• The 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
Conversion disorder (cont.)
• Client often expresses a relative lack of concern
that is out of keeping with the severity of the
impairment
• This lack of concern is identified as la belle
indifference and may be a clue
to the physician that the
problem is psychological rather
than physical
Body dysmorphic disorder
• This disorder is characterized by an
exaggerated belief that the body is deformed or
defective in some specific way
• Symptoms of depression and
characteristics associated with
obsessive-compulsive
personality are common
Etiological Implications

Somatoform disorders
• Genetic: hereditary factors are
possibly associated with
somatization disorder, conversion
disorder, and hypochondriasis
• Biochemical: decreased levels
of serotonin and endorphins may
play a role in the etiology of pain
disorder
Etiological Implications (cont.)

Somatoform disorders (cont.)

• Psychodynamic theory: this theory
suggests that hypochondriasis may be
an ego defense mechanism; physical
complaints become the expression of
S. Freud
low self-esteem, because it is easier to
feel something is wrong with the body
than to feel something is wrong with
the self
Etiological Implications (cont.)

Somatoform disorders (cont.)

• Psychodynamic theory (cont.)
• Conversion disorder may represent
emotions associated with a traumatic
event that are too unacceptable to
express and so are acceptably S. Freud
“converted” into physical symptoms
Etiological Implications (cont.)

Somatoform disorders (cont.)

• Family dynamics: in dysfunctional families,
when a child becomes ill, focus shifts from the
open conflict to the child’s illness and leaves
unresolved underlying issues the family is
unable to confront in an open manner
• Somatization brings some stability to the family
and positive reinforcement to the child
Etiological Implications (cont.)

Somatoform disorders (cont.)

• Learning theory: Somatic complaints are often
reinforced when the sick person learns that he
or she may avoid stressful obligations or be
excused from unwanted duties (primary gain)
Etiological Implications (cont.)

Somatoform disorders (cont.)

• Learning theory (cont.)
– Becomes prominent focus of attention because
of the illness (secondary gain)
– Relieves conflict within family as
concern is shifted to the ill person
and away from the real issue
(tertiary gain)
Etiological Implications (cont.)

Somatoform disorders (cont.)

– Learning theory (cont.)
• Hypochondriasis: past experience with serious
or life-threatening physical illness, either
personal or that of close relatives, can
predispose to hypochondriasis
Nursing Diagnosis/Outcome

• Ineffective coping
• Chronic pain
• Fear
• Disturbed sensory perception
• Disturbed body image
Outcomes

The client
– Copes effectively without resorting to physical
symptoms
– Verbalizes relief from pain
– Has decreased frequency of physical complaints and
interprets bodily
sensations rationally
– Is free of physical disability
– Verbalizes realistic perception of
appearance and expresses positive
body image
Planning/Implementation

• Nursing care of the individual with a somatoform

disorder is 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
Evaluation

• Based on accomplishment of previously

established outcome criteria
Medical Treatment Modalities

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

Dissociative disorders
• Dissociative amnesia involves
– An inability to recall important
personal data that is too extensive to
be explained by ordinary
forgetfulness
– Not due to the direct effects of
substance use or a general medical
condition
Assessment (cont.)

Five types of disturbance in recall

• Localized amnesia: inability to
recall all incidents associated with
the traumatic event for a specific
period following the event
• Selective amnesia: inability to
recall only certain incidents
associated with a traumatic event
for a specific period following the
event
Assessment (cont.)

Five types of disturbance in recall

(cont.)
 Continuous amnesia: inability to recall
events occurring after a specific time up to
and including the present
 Generalized amnesia: inability to recall
anything that has happened during the
individual’s entire lifetime, including
personal identity
 Systematized amnesia: inability to recall
events relating to a specific category of
information, such as one’s family or one
particular person or event
Assessment (cont.)

Dissociative fugue
– A sudden, unexpected travel away from
home or customary workplace
– The individual is unable to recall
personal identity and assumption
of a new identity is common
Assessment (cont.)

Dissociative identity disorder (DID)

– 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
Assessment (cont.)

• Depersonalization disorder
– Characterized by persisten
feelings of
• Unreality
• Detachment from oneself or
one’s body
• Observing oneself from outside
the body
Assessment (cont.)

• Depersonalization disorder (cont.)

– Depersonalization is defined as a
disturbance in the perception of oneself
– Derealization is described as an
alteration in the perception of
the external environment
Assessment (cont.)
• Depersonalization disorder (cont.)
– Symptoms of depersonalization disorder
are often accompanied by
• Anxiety and depression
• Fear of going insane
• Obsessive thoughts
• Somatic complaints
• Disturbance in the subjective sense of time
Etiological Implications

• Genetics: possible hereditary factors are

associated with DID
• Neurobiological: dissociative
amnesia and dissociative fugue
may be related to neurophysio-
logical dysfunction; EEG
abnormalities have been observed in some
clients with DID
Etiological Implications (cont.)

• 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 S. Freud
unresolved painful issues
Etiological Implications (cont.)

• Psychological trauma
– A growing body of evidence points to the
etiology of DID as a set of traumatic
experiences that overwhelms the individual’s
capacity to cope by any means other than
dissociation
Etiological Implications (cont.)

Psychological trauma (cont.)

• These experiences usually take the form of
severe physical, sexual, or psychological abuse
by a parent or significant other in the child’s life
Nursing Process: Diagnosis/Outcome

• Disturbed thought processes

• Ineffective coping
• Disturbed personal identity
• Disturbed sensory perception
Outcomes

The client
– Can recall events associated with stressful situation
– Can recall all events of past life
– Can verbalize anxiety that precipitated the dissociation
– Can demonstrate coping methods to avert
dissociative behaviors
– Verbalizes existence of multiple
personalities
– Is able to maintain a sense of reality
during stressful situations
Planning/Implementation

• Nursing care is aimed at restoring normal

thought processes
• Assistance is provided to the client in an
effort to determine strategies for coping
with stress by means other than
dissociation from the
environment
Evaluation

• Based on accomplishment of previously

established outcome criteria
Medical Treatment Modalities

• Individual psychotherapy
• Hypnosis
• Supportive care
• Integration therapy (DID)