Somatoform and Dissociative Disorders

9. Somatization disorders are most often linked with which emotion? A) Euphoria B) Guilt C) Anger D) Anxiety

D) Anxiety

39. Clients diagnosed with illness anxiety disorder often "doctor shop." Which defense mechanism is at the root of this behavior? 1) Suppression 2) Denial 3) Projection 4) Rationalization

2) Denial Denial that fears of illness are rooted in psychological factors rather than physical illness may result in "doctor shopping" and the client's generalized belief that he or she is not receiving adequate care.

49. The psychologist who is treating Candace reports in a multidisciplinary team meeting that Candace experienced personality switches after a stressful meeting with her family. These symptoms are characteristic of which diagnosis? 1) Depersonalization-derealization disorder 2) Dissociative identity disorder 3) Narcissistic personality disorder 4) Somatic symptom disorder

2) Dissociative identity disorder The psychologist is describing a symptom characteristic of dissociative identity disorder, in which the person's different personalities emerge or switch.

41. Martha, a 93-year-old woman who is being cared for by her daughter, is hospitalized for the third time in a month with complaints of nausea and vomiting. Medical tests have been unable to identify a physical cause. When the daughter is witnessed putting syrup of ipecac in her mother's coffee, which of the following diagnoses is likely to be made? 1) Factitious disorder 2) Factitious disorder by proxy 3) Malingering 4) Conversion disorder

2) Factitious disorder by proxy Symptoms of illness that are being imposed on one by another is called factitious disorder by proxy.

45. A client has a long history of dissociative identity disorder and has 22 known personalities. Which assessment finding would the nurse expect? 1) History of alcohol abuse 2) History of physical, psychological, or sexual abuse 3) Frequent backaches 4) Electrocardiogram (EKG) abnormalities

2) History of physical, psychological, or sexual abuse Freud believed that dissociative behaviors occurred when individuals repressed distressing mental contents from conscious awareness. He believed that this mechanism protected the client from emotional pain. It is typical for clients diagnosed with dissociative identity disorder to have histories of physical, psychological, and/or sexual abuse.

37. A client has been diagnosed with major depression, borderline personality disorder, and most recently, dissociative identity disorder. One of the client's personalities attempted suicide, leading to the current hospitalization. Which is the priority nursing diagnosis for this client? 1) Altered Social Interactions 2) Risk for Suicide 3) Social Isolation 4) Altered Self-esteem

2) Risk for Suicide Because of the client's recent suicide attempt, there is a high risk for self-harm and, therefore, risk for suicide must be prioritized. At this time, safety is the primary concern.

40. When a nurse is working with a client diagnosed with a somatic symptom disorder, which is the most appropriate nursing action? 1) Avoid discussing social and personal problems. 2) Focus on the physical symptoms. 3) Always meet the client's dependency needs. 4) Gradually minimize time spent focusing on physical symptoms.

4) Gradually minimize time spent focusing on physical symptoms. The nurse's attention should be on the client's social and personal problems, which are the underlying cause of the somatic symptom disorder. Time focused on physical symptoms should be minimized to avoid reinforcement.

20. Symptoms associated with a fugue state usually occur in response to which conditions? Select all that apply. A) Severe psychological stress B) Excessive alcohol use C) Psychogenic amnesia D) Localized amnesia

A) Severe psychological stress B) Excessive alcohol use

3. When conducting an assessment of a client with suspected somatization disorder, a nurse may also expect to identify characteristics of which personality disorder? A) Borderline personality disorder B) Antisocial personality disorder C) Histrionic personality disorder D) Avoidant personality disorder

C) Histrionic personality disorder

13. A nurse is performing a thorough health history on a client suspected of having hypochondriasis. Which information, elicited by the nurse, should enable a physician to distinguish between hypochondriasis and somatization disorder? A) Pain B) Gender distribution C) Persistent fear D) Impaired functioning

C) Persistent fear

4. When working with a client with a somatization disorder, which is the most appropriate nursing intervention? A) Avoiding discussion of physical symptoms B) Allowing the client to freely explore the meaning of the physical symptoms C) Confronting the client on the validity of the physical symptoms D) Gradually limiting the focus on physical symptoms

D) Gradually limiting the focus on physical symptoms

1. A psychiatric nurse often cares for clients with somatoform disorders. Which characteristic is common to all somatoform disorders? A) Delusions B) Pain C) Paranoia D) Physical symptoms

D) Physical symptoms

48. Which of the following are categorized in the DSM-5 as somatic symptom and related disorders? Select all that apply. 1) Somatic symptom disorder 2) Conversion disorder 3) Illness anxiety disorder 4) Migraine headache 5) Peptic ulcer

Feedback 1: Somatic symptom disorder is a primary disorder in this DSM-5 chapter. It is characterized by the experience of somatic symptoms that are distressing or result in significant disruption of daily life. The client experiences excessive thoughts, feelings, or behaviors about somatic symptoms. Feedback 2: Conversion disorder is 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 is categorized as a related disorder in the DSM-5 chapter on somatic symptom and related disorders. Feedback 3: Illness anxiety disorder is a preoccupation with having or acquiring a serious illness. Somatic symptoms are not present, or if present, they are only mild.

36. One of the long-term intervention strategies for people with dissociative identity disorder is a process of recalling and mentally re-experiencing past traumas in detail. This process is called____________.

abreaction Abreaction is described as a process of "remembering with feeling." It entails bringing into conscious awareness painful events and the feelings associated with those events so that corrective reprocessing can occur.

26. A nurse is taking a history from a client with dissociative identity disorder. The nurse should expect the client to report that: Select all that apply. A) No one else in her family has ever had similar problems. B) She was abused during her childhood. C) Her family was isolated from the community. D) Her family was inconsistent in their religious beliefs. E) Mixed messages about feelings were common.

B) She was abused during her childhood. C) Her family was isolated from the community. E) Mixed messages about feelings were common.

50. A client is experiencing pain that has no organic etiology. This pain allows the client to avoid an unpleasant activity. What best describes what this client is experiencing? 1) The client is experiencing altered social interaction. 2) The client is experiencing disturbed thought processes. 3) The client is experiencing secondary gain. 4) The client is experiencing primary gain.

4) The client is experiencing primary gain. Primary gain describes the benefit to the client of avoidance of some unpleasant activity due to experiencing psychologically based pain. This avoidance directly decreases the client's anxiety. The situation presented in the question describes primary gain.

30. Which characteristic does the nurse understand is central in somatic symptom disorders? 1) The presence of delusions 2) The presence of pain 3) The presence of paranoia 4) The presence of physical symptoms

4) The presence of physical symptoms Somatic symptom disorder is characterized by physical symptoms, suggesting medical disease but without demonstrable organic pathology.

18. A new nurse is working with a client who is experiencing amnesia. The new nurse recalls that according to psychodynamic theory which defense mechanism is primarily used by those experiencing amnesia? A) Suppression B) Sublimation C) Displacement D) Repression

D) Repression

35. The ideal goal in treatment of a patient with dissociative identity disorder is that the patient achieves a blending of all the personalities into one. This process is called____________.

integration Accomplishing integration of fragmented personalities into one whole personality requires a lengthy process of therapy. For patients who do not choose that process, an alternative goal would be to facilitate smooth collaboration among the subpersonalities.

51. Disruption in identity and disruption in memory that are rooted in psychological traumas are examples of dissociative responses. Psychodynamic theory would describe these responses in which of the following ways? 1) An ego defense in the face of overwhelming anxiety 2) A cognitive distortion 3) A learned behavior 4) Factitious

1) An ego defense in the face of overwhelming anxiety Psychodynamic theory views dissociative responses as defense mechanisms used by the ego to protect oneself from overwhelming anxiety.

5. A nurse is caring for a client with a somatoform disorder. Which statement regarding somatoform disorders is most accurate? A) Women are 5 to 20 times more likely than men to have the disorder. B) Tendencies toward somatization are apparently more common in those who are highly educated. C) Somatoform disorders are most common in the middle socioeconomic class. D) Elderly people are most likely to have somatization disorders.

A) Women are 5 to 20 times more likely than men to have the disorder.

34. A client experiencing lower extremity paralysis is admitted to a medical unit. Extensive tests confirm disability but rule out any underlying organic pathology. The nurse concludes that this is most suggestive of which disorder? 1) Conversion disorder 2) Factitious disorder 3) Illness anxiety disorder 4) Somatic symptom disorder

1) Conversion disorder Conversion disorder is a loss or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder.

43. Gertrude has been admitted to the hospital for depression and concurrent alcohol abuse. During the assessment, Gertrude gives the nurse detailed accounts about several somatic symptoms she has had that "they've never been able to find a medical reason for." Based on the data provided, which of the following would be an appropriate nursing diagnosis? 1) Ineffective coping 2) Knowledge deficit 3) Impaired memory 4) Risk for suicide

1) Ineffective coping The excessive focus on somatic symptoms in the absence of physical illness suggests ineffective coping with stressors.

33. A client has a history of multiple somatic complaints involving several organ systems. Diagnostic studies revealed no physiological cause. Which diagnosis would the nurse expect the physician to assign this client? 1) Thought disorder 2) Bipolar disorder 3) Somatic symptom disorder 4) Depersonalization-derealization disorder

3) Somatic symptom disorder Somatic symptom disorder is characterized by multiple physical complaints with no organic cause. The state of being symptomatic is typically persistent for more than 6 months. Anxiety, depression, substance use, and addiction are common comorbidities with this disorder.

46. Which is the best description of dissociative fugue? 1) Inability to recall personal identity and anything occurring in lifetime 2) The existence of two or more personalities in a single individual 3) Sudden, unexpected travel under a new identity, with inability to recall the past 4) A feeling of detachment or estrangement from self

3) Sudden, unexpected travel under a new identity, with inability to recall the past A dissociative fugue is a sudden, unplanned event in which the individual travels away from normal routines. It is usually accompanied by amnesia.

31. It has been determined that Susan, who thought she was pregnant, is experiencing a conversion disorder. The nurse correctly documents this conversion symptom as which of the following? 1) Aphonia 2) Anosognosia 3) Anosmia 4) Pseudocyesis

4) Pseudocyesis Pseudocyesis is a conversion symptom in which the patient has nearly all the signs and symptoms of pregnancy but is not pregnant. It may represent a strong desire to be pregnant.

47. According to psychodynamic theory, which primary defense mechanism would the nurse expect to find in an amnesic client? 1) Suppression 2) Sublimation 3) Displacement 4) Repression

4) Repression Repression, which is the involuntary blocking of unpleasant feelings and experiences from one's awareness, is the defense mechanism most often used by clients experiencing amnesia. Freud believed that dissociative behaviors, including amnesia, occurred when individuals repressed distressing mental contents from conscious awareness. He believed that this mechanism protected them from emotional pain.

8. How should a nurse psychotherapist who is operating from a psychoanalytic paradigm explain the presence of hypochondriasis to a client? A) "Physical complaints are the expression of low self-esteem and feelings of worthlessness because it is easier to believe that something is wrong with the body than to believe that something is wrong with the self." B) "Somatic complaints are often reinforced when the sick role relieves the individual from the need to deal with a stressful situation, whether it is within society or within the family." C) "When emotional arousal precipitates somatic symptoms, the symptoms are incorrectly assessed and misinterpreted and negative cognitive meanings are attached to them." D) "Evidence indicates an increased prevalence of hypochondriasis among identical twins and other first-degree relatives."

A) "Physical complaints are the expression of low self-esteem and feelings of worthlessness because it is easier to believe that something is wrong with the body than to believe that something is wrong with the self."

27. A nurse is caring for four clients. Which client is most likely to have generalized amnesia? A) A client who has no memory of his entire lifetime, including his personal identity. B) A client who knows that her mother beat her as a child but cannot remember the details of any of the beatings. C) A client who was driving the car in which her best friend was killed but cannot recall the accident or events since the accident. D) A client whose home was destroyed in a tornado, but only remembers hearing the tornado hit, the ambulance siren, and waking up in the hospital.

A) A client who has no memory of his entire lifetime, including his personal identity.

6. Which criteria would be present in a client with somatization disorder? Select all that apply. A) At least four pain symptoms in varying locations or during various functions B) Two gastrointestinal disturbances C) Perceived disturbance in body image or appearance D) One pseudoneurological symptom, such as weakness or double vision

A) At least four pain symptoms in varying locations or during various functions B) Two gastrointestinal disturbances D) One pseudoneurological symptom, such as weakness or double vision

2. A client complaining of leg paralysis is admitted to a medical unit. Extensive tests and workups confirm the client's disability but fail to indicate any underlying organic pathological condition. This is most suggestive of which disorder? A) Conversion disorder B) Hypochondriasis C) Malingering D) Somatization disorder

A) Conversion disorder

23. A 27-year-old client has major depression, borderline personality disorder, and antisocial personality disorder. Recently, the client also received a diagnosis of dissociative identity disorder. The client has been hospitalized because one of her personalities attempted suicide. What should be a nurse's primary consideration when planning care for this client? A) Promoting safety B) Establishing trust C) Facilitating an awareness of all personalities D) Recognizing events that trigger transition between personalities

A) Promoting safety

19. A female client with dissociative identity disorder asks a nurse about how she will receive treatment. Which is the most appropriate nursing response? A) "In group therapy on an inpatient basis." B) "In individual therapy on an outpatient basis." C) "In a support group." D) "In family therapy."

B) "In individual therapy on an outpatient basis."

22. A nurse is caring for four clients. Which client is most likely to have systematized amnesia? A) A client who has no memory of his entire lifetime, including his personal identity. B) A client who knows that her mother beat her as a child, but she cannot remember the details of any of the beatings. C) A client who was driving the car in which her best friend was killed but cannot recall the accident or events since the accident. D) A client whose home was destroyed in a tornado but only remembers hearing the tornado hit, the ambulance siren, and waking up in the hospital.

B) A client who knows that her mother beat her as a child, but she cannot remember the details of any of the beatings.

11. A client has just moved to a new city and visits a nurse practitioner (NP) because of gastrointestinal distress. When the NP takes the client's history, the NP suspects some type of somatoform disorder. What is the next step necessary to confirm a diagnosis in this category? A) Conduct a mental status examination. B) Conduct a thorough physical examination. C) Review the client's old medical records. D) Refer the client to a psychiatrist.

B) Conduct a thorough physical examination.

14. A 32-year-old client suffers from dissociative identity disorder. The client has 22 known personalities. What should a nurse expect to find during the assessment of this client? A) History of alcohol abuse B) History of physical, psychological, or sexual abuse C) Frequent backaches D) ECG abnormalities

B) History of physical, psychological, or sexual abuse

17. A client is experiencing a loss of memory regarding events related to the client's wedding day. Which condition should a nurse suspect when working with this client? A) Selective amnesia B) Systematized amnesia C) Localized amnesia D) Generalized amnesia

B) Systematized amnesia

7. What is an appropriate outcome for clients experiencing somatization disorders? A) Will admit to feigning physical symptoms to gain benefits such as attention or absence from role responsibilities B) Will effectively use adaptive coping strategies during stressful situations without resorting to physical symptoms C) Will comply with medical treatments for physical symptoms D) Will seek assistance from multiple care providers or specialists to decrease the burden on any given person

B) Will effectively use adaptive coping strategies during stressful situations without resorting to physical symptoms

28. A nurse is caring for four clients. Which client is most likely to have continuous amnesia? A) A client who has no memory of his entire lifetime, including his personal identity. B) A client who knows that her mother beat her as a child but cannot remember the details of any of the beatings. C) A client who was driving the car in which her best friend was killed but cannot recall the accident or events since the accident. D) A client whose home was destroyed in a tornado but only remembers hearing the tornado hit, the ambulance siren, and waking up in the hospital.

C) A client who was driving the car in which her best friend was killed but cannot recall the accident or events since the accident.

15. A 32-year-old client suffers from dissociative identity disorder. The client has 22 known personalities. What is the most appropriate initial nursing intervention for this client? A) Encouraging exploration of trauma B) Discouraging exploration of trauma C) Establishing trust and rapport D) Administering anti-anxiety medication

C) Establishing trust and rapport

10. A 25-year-old law school graduate has worked in his first job with a private law firm for 1 year. He sees his primary care practitioner because of weakness in his right hand and arm that was present when he awoke yesterday morning. He is unable to hold a pen or to use his computer. He denies recent injury. Other extremities are normal and the client shows no other evidence of neurological impairment. The client is scheduled to take the bar examination, for the second time, in 10 days but seems philosophical about his inability to use his hand. Which information, taken together, would form the basis for a diagnosis of conversion disorder? I. Sudden onset II. Specific functional loss III. Negative neurological findings IV. Upcoming bar examination V. Philosophical attitude A) I and II B) I, II, and III C) I, II, III, and IV D) IV only

C) I, II, III, and IV

21. Anxiety is the behavioral response associated with the problem of dissociative amnesia. What defense mechanism should a nurse caring for a client with dissociative amnesia expect to see? A) Suppression B) Denial C) Repression D) Rationalization

C) Repression

25. A client receives a diagnosis of dissociative fugue. Which behavior best illustrates this diagnosis? A) Seeking privacy in his office B) Driving a long distance to visit a friend C) Sudden unexpected travel away from home D) Vacationing in a place he would usually avoid

C) Sudden unexpected travel away from home

16. A 32-year-old client suffers from dissociative identity disorder. The client has 22 known personalities. A nurse recognizes that dissociation appears to serve which function for this client? A) Dissociation is a means of attention-seeking behavior. B) Dissociation serves to decrease depression and anxiety caused by feelings of excessive and inappropriate guilt. C) The mental partitions created during episodes of dissociation serve to isolate painful events so that the primary self can escape. D) Dissociation is speculative at best, and the motivations of these clients should be questioned.

C) The mental partitions created during episodes of dissociation serve to isolate painful events so that the primary self can escape.

12. Which psychodynamic theory describes the underlying symptoms of conversion disorder? A) Relief from despair B) Repression of anger C) Unconscious resolution of internal conflicts D) Cognitive deficit

C) Unconscious resolution of internal conflicts

38. Sally was admitted to the hospital with paralysis of her right arm. Medical tests reveal the absence of physiological explanations for her symptom. Her family reports that Sally struck her infant son last week, shortly before the symptom developed, but that she sees no connection between the two events. Which of the following would be appropriate nursing interventions in Sally's plan of care? Select all that apply. 1) Ensure that children's services agencies are involved to evaluate the child's safety in the home. 2) Assist Sally with all activities of daily living, since the paralysis is real to her. 3) Encourage Sally to discuss her fears and anxieties. 4) Monitor ongoing physical assessment to ensure that organic pathology is clearly ruled out. 5) Confront Sally with the evidence that she is intentionally feigning her paralysis.

Correct 1: Nurses have a duty to ensure that potential or suspected child abuse is reported, so this would be a priority intervention. Feedback 2: It is recommended that physical assistance only be provided when it is absolutely necessary. To do otherwise might reinforce patient dependency, and independent function is the goal. Correct 3: Conversion disorder symptoms are believed to be rooted in psychological distress, so helping the client explore fears and anxieties is an appropriate intervention. Correct 4: Conversion symptoms are not identified as intentional feigning of symptoms. This would be an inappropriate intervention. Feedback 5: There is no evidence presented that suggests the patient is intentionally feigning symptoms so this would be an inappropriate or premature confrontation.

44. Helen has been diagnosed with dissociative identity disorder and the nurse documents that she switched personalities during a meeting with the psychiatrist. Which of the following symptoms that the nurse observed are consistent with her determination that Helen switched personalities? Select all that apply. 1) Helen appeared to have a sudden disruption of thought. 2) Helen abruptly sat down in a chair. 3) Helen's eyes were rapidly blinking. 4) Helen's voice and facial expression changed markedly. 5) Helen's behavior changed from her normally reserved behavior to provocative behavior.

Correct 1: Sudden shift in thoughts or disruption in thoughts is a common indication of personality switches. Feedback 2: This behavior is not significant in identifying personality switches. Correct 3: Although only a small minority of patients show observable signs of alternating identities, rapid eye blinking can be an indication of this switch. Correct 4: Marked changes in voice and/or facial expression are indicators of personality switches. Correct 5: A common indication of personality switching is a dramatic change in attitude, outlook, and preferences.

32. Flo has been seeing the nurse at the mental health center because she has been struggling with intense fear of becoming ill. She spends much of her day checking her temperature and palpating lymph nodes for signs of a lump even though there have never been positive findings of illness. Which of the following are appropriate nursing interventions in response to Flo's concerns? Select all that apply. 1) Refer all new physical complaints to the physician. 2) Help the client explore thoughts and feelings associated with her excessive fears. 3) Gently but firmly tell the client from the outset that you will not permit discussion of illnesses. 4) Help the client identify coping strategies she thinks will be useful during times when anxiety and fear are exacerbated.

Correct 1: To ignore new physical complaints could put the patient's safety in jeopardy, so this is an appropriate intervention. Correct 2: Helping the client to explore thoughts and feelings associated with her fears will lay the foundation for exploring alternative coping strategies. Feedback 3: It is recommended that some discussion of illness and illness anxiety be permitted initially, since prohibiting this discussion would likely increase the individual's anxiety and create a block to effective communication. Correct 4: Helping the client to identify alternative strategies for managing fear and anxiety is the primary goal of treatment. Patient-centered care approaches dictate that it is the client who must decide which strategies will be most helpful in accomplishing that goal.

42. A 30-year-old law school graduate is to take the bar examination tomorrow and is suddenly paralyzed but expresses no distress. History reveals no recent injury or neurological impairment. What data presented in the question reflect a conversion disorder? Select all that apply. 1) Sudden onset 2) Age of the graduate 3) Negative neurological findings 4) Upcoming bar examination 5) Lack of concern

Correct 1: Typically, symptoms of a conversion disorder appear suddenly. Feedback 2: Conversion disorder can occur at any age, so the age of the graduate would not specifically reflect this diagnosis. Correct 3: The physical symptoms present in conversion disorders cannot be explained by any known medical disorder or pathophysiological mechanism. Negative neurological findings support the diagnosis of conversion disorder. Correct 4: Conversion disorder typically results from psychological conflict, although the DSM-5 notes that the diagnosis should not be withheld simply because a stressor or trauma could not be found. In this case, the stress of the upcoming bar examination could precipitate a conversion disorder. Correct 5: Individuals experiencing conversion disorders express 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 is often a clue to the physician that the problem may be psychological rather than physical.

29. A nurse is caring for four clients. Which client is most likely to be diagnosed with selective amnesia? A) A client who has no memory of his entire lifetime, including his personal identity. B) A client who knows that her mother beat her as a child but cannot remember the details of any of the beatings. C) A client who was driving the car in which her best friend was killed but cannot recall the accident or events since the accident. D) A client whose home was destroyed in a tornado but only remembers hearing the tornado hit, the ambulance siren, and waking up in the hospital.

D) A client whose home was destroyed in a tornado but only remembers hearing the tornado hit, the ambulance siren, and waking up in the hospital.

24. A 27-year-old client has major depression, borderline personality disorder, and antisocial personality disorder. Recently, the client also received a diagnosis of dissociative identity disorder. The client has been hospitalized because one of her personalities attempted suicide. The primary nursing diagnosis during this hospitalization should be: A) Disturbed personal identity. B) Disturbed sensory perception. C) Disturbed thought processes. D) Risk for suicide.

D) Risk for suicide.