1/22/2015. Contemporary Psychiatric-Mental Health Nursing Third Edition. Theories: Dissociative Disorders. Theories: Dissociative Disorders (cont'd)

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1 Contemporary Psychiatric-Mental Health Nursing Third Edition CHAPTER 19 Dissociative, Somatoform, and Factitious Disorders Theories: Dissociative Disorders Biological factors Serotonin Limbic system Physical illnesses and certain drugs Various personality states in dissociative identity disorder have different activity in frontal and temporal lobes. Theories: Dissociative Disorders (cont'd) Genetic theories: Dissociative disorder occurs more often in first-degree biologic relatives 1

2 Theories: Dissociative Disorders (cont'd) Psychosocial theories: Current explanations are based on Freud s dynamic concepts. Repression of ideas leads to amnesia, to protect oneself from emotional pain. Dissociative identity disorder is a result of childhood chronic trauma. Theories: Dissociative Disorders (cont'd) Behavioral theories: Dissociative disorders are learned behaviors that provide protection from a painful experience. Theories: Dissociative Disorders (cont'd) Humanistic theories: The person is a composite of life experiences, psychobiological factors, and interpersonal interactions. 2

3 Question #2 The nurse knows that the belief that decreased amounts of endorphins and serotonin may cause some people to experience pain more intensely is related to a: Question #2 1.Psychoanalytic approach 2.Humanistic approach 3.Biologic approach 4.Genetic approach Dissociative Disorders Dissociative Disorder Types Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder Depersonalization Disorder 3

4 Care of Clients with Dissociative Disorders Dissociation is a defense against trauma that separates emotions from behaviors. Dissociation is a response to extreme childhood trauma. Consciousness, memory, identity, or perception of environment can be impaired. Care of Clients with Dissociative Disorders (cont'd) Most clients with dissociative disorder seen in community rather than inpatient settings Obtain subjective and objective data Complete psychosocial and physical assessment Biopsychosocial Characteristics of of Somatoform Disorders Unconscious transformation of emotions into physical symptoms to deal with stress Conversion disorder impaired physical function related to expression of a psychic conflict Pain disorder pain experienced for no physiologic basis and accompanied by psychological factors 4

5 Biopsychosocial Characteristics - continued (cont'd) Hypochondriasis preoccupation with fear/belief of having a serious illness that is not present on physical exam Body dysmorphic disorder preoccupation with an imagined defect in physical appearance that is exaggerated and out of proportion xl1uv9vh0 Biopsychosocial Characteristics - continued (cont'd) Malingering conscious falsification of illness, not considered a psychiatric disorder Factitious disorder psychological need to assume the sick role kwby0dok Munchausen by proxy 4 min Question #4 A client is admitted to the hospital with suspected hypochondriasis. During the assessment, the nurse could expect the client to: 5

6 Question #4 1.Have pain in one or more anatomical areas. 2.Have a voluntary motor or sensory function symptom or deficit. 3.Be preoccupied with fears of having a serious illness. 4.Be preoccupied with an imagined physical defect in appearance. Theories Theories Biologic, genetic, and psychosocial theories Biochemical brain imbalances that cause pain to be experienced more intensely Theories Theories - continued (cont'd) Adoption and twin studies show both genetic and environmental contributing factors. Communication theorists see symptoms as nonverbal body language intended to communicate a message to significant others. 6

7 Theories Theories - continued (cont'd) Humanistic theorists view the client in context to what is happening at the time. Life stressors like marital or work issues are precipitants for somatic symptoms. Somatoform Somatoform Disorders Disorders Not under voluntary control Have unconscious motivation Primary gain is reduction of anxiety Factitious Factitious Disorders Disorders Deliberately produced Motivation: to assume the sick role in order to gain attention and/or obtain medical treatment No obvious secondary gain 7

8 MalingeringMalingering Symptoms are consciously produced or feigned Have various motivations, including financial gain, relief of work duties, or obtaining illicit drugs Obvious secondary gain(s) Importance of of Comprehensive Assessment Assessment Client will present with multiple complex problems. Utilize nursing process to systematically assess and deliver care. Remain cognizant of your own values, beliefs, feelings, and nonverbal behaviors. Importance of of Comprehensive Assessment Assessment - continued (cont'd) Clients will report physical symptoms for which there is no evidence of physiologic cause. Always rule out physical causes for symptoms. 8

9 Comprehensive Assessment Obtain subjective and objective data. Consider psychobiologic factors and utilize critical thinking. Be alert to responses indicative of the client who is overly dramatic and emotional when symptoms are discussed. Comprehensive Assessment - continued (cont'd) Careful interviewing reveals a stressful life event with which the client is not coping. Suggests that preoccupation with somatic disorder is way of avoiding underlying conflict Comprehensive Assessment - continued (cont'd) Gathering objective data includes thorough physical exam, lab work, and radiologic or other studies 9

10 Personal Personal Challenges Challenges to to Professional Professional Practice Practice Focus on your feelings and be cognizant of your reactions. Monitor your own feelings of defensiveness, impatience, frustration, or anger toward the client. Practice increased self-awareness. Personal Personal Challenges Challenges to to Professional Practice - (cont'd) continued Don t judge, criticize, or make assumptions. Pain is determined and defined by the client. Pain of psychic origin is as hurtful as pain of biologic origin. Personal Challenges - continued (cont'd) Avoid reinforcing negative behaviors. Address client with a matter-of-fact approach. Reinforce adaptive vs. maladaptive behaviors. 10

11 Question #8 The nurse is finding it difficult to listen to a client s expression of pain, fear, anger, and other feelings. The nurse must focus on: Question #8 1.Listening attentively and with concern. 2.Providing quick and ready answers. 3.Giving advice. 4.Changing the subject to a more positive one. Resources Resources Hypochondriasis The highlight of this informational link on hypochondriasis is the assessment section by physicians. 11

12 Resources Resources (cont'd) International Society for the Study of Trauma and Dissociation The International Society for the Study of Trauma and Dissociation is a professional association organized to develop and promote comprehensive, clinically effective, and empirically based resources and responses to trauma and dissociation. Resources Resources - continued (cont'd) PSYweb The PSYweb site offers information on mental illnesses such as anxiety, depression, and somatoform disorders as well as information and resources for caregivers. 12