Somatic and Dissociative Disorders

A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of healthcare providers D. Depressive disorder

A nurse is assessing a client who has illness anxiety disorder. Which of the following are expected findings for this disorder? (SATA) A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of healthcare providers D. Depressive disorder E. Narcissistic personality

C. "I needed to make my child sick to that someone else would take care of them for a while"

A nurse is counseling several clients. Which of the following client statements should the nurse identify as expected for factitious disorder imposed on another? A. "I had to pretend I was injured in order to get my disability benefits" B. "I know that my abdominal pain is caused by a malignant tumor" C. "I needed to make my child sick to that someone else would take care of them for a while" D. "I became deaf when I heard that my partner was having an affair with my best friend"

D. Discuss alternative coping strategies with the client

A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. Encourage the client to spend time alone in their room B. Monitor the client for self-harm once per day C. Allow the client unlimited time to discuss physical manifestations D. Discuss alternative coping strategies with the client

B. Anxiety disorder C. Childhood trauma

A nurse is discussing the factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (SATA) A. Age older than 65 years B. Anxiety disorder C. Childhood trauma D. Coronary artery disease E. Obesity

A. Death of a client 2 months age

A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? A. Death of a client 2 months age B. Recent weight loss of 30lb C. Retirement 1 year ago D. History of migraine headaches

D. Risk for suicide related to unresolved grief

Ellen has a history of childhood physical and sexual abuse. She was diagnosed with dissociative identity disorder 6 years ago and has been admitted to the psychiatric unit following a suicide attempt. Which is the primary nursing diagnosis for Ellen? A. Disturbed personal identity related to childhood abuse B. Disturbed sensory perception related to repressed anxiety C. Impaired memory related to disturbed thought process D. Risk for suicide related to unresolved grief

B. Listen nonjudgmentally and respond empathically when Ellen transitions to different personality states

In establishing trust for Ellen, a client with a diagnosis of dissociative identity disorder, the nurse must: A. Try to relate to Ellen as though she did not have multiple personalities B. Listen nonjudgmentally and respond empathically when Ellen transitions to different personality states C. Ignore behaviors that Ellen attributes to other subpersonalities D. Explain to Ellen that he or she will work with her only if the primary personality is maintained

Promote safety

Interventions for Dissociative Amnesia & Depersonalization/Derealization Disorders: · ___________. Individuals may be frightened because they don't remember things, they don't' understanding who people are or what things do. They may react violently to this because they don't understand who they are or what they are doing. · Assess for stressors. Explore what they can do about the stress · Explore client's feelings. Are they anxious? Depressed? · Teach coping mechanisms. What coping do they currently have? Is it maladaptive/adaptive? What can we do to make coping adaptive? · Promote self-esteem

· Build rapport. Establish a trusting relationship · Therapeutic communication · Assist client to identify needs of subpersonalities. Each personality is a piece of the individual and has a unique meaning to the individual. · Identify stressors that precede splitting (the heart of the trauma) · Safety of all personalities. Each personality has a role. One is usually predominant, but all provide a relief of stress for the individual. One personality may take over when there is something stressful that the current personality can't handle. Nurses must make sure each personality is taken care of and integrated into care to become one personality. -One may be suicidal -> initiate suicide precautions

Interventions for Dissociative Identity Disorder:_____

A. Multiple somatic symptoms in several body systems

Lauren has been diagnosed with somatic symptom disorder. Which of the following symptom profiles would you expect when assessing her? A. Multiple somatic symptoms in several body systems B. Fear of having a serious disease C. Loss or alteration in sensorimotor functioning D. Beliefs that her body is deformed or defective in some way

B. She does not understand the correlation between symptoms and stress

Lauren, a client diagnosed with somatic symptom disorder, states, "my doctor thinks I should see a psychiatrist. I can't imagine why he would make that suggestion." What is the most common basis for Lauren's statement? A. She thinks her doctor wants to get rid of her as a client B. She does not understand the correlation between symptoms and stress C. She thinks psychiatrists are only for "crazy" people D. She thinks her doctor has made an error in diagnosis

C. "I will report this pain to your physician. In the meantime, group therapy starts in 5 minutes."

Lauren, a client diagnosed with somatic symptom disorder, tells the nurse about a pain in her side. She says she has not experienced it before. Which is the most appropriate response by the nurse? A. "I don't want to her about another physical complaint. You know they are all in your head. It's time for group therapy now." B. "Let's sit down here together and you can tell me about this new pain you are experiencing. You'll just have to miss group therapy today." C. "I will report this pain to your physician. In the meantime, group therapy starts in 5 minutes." D. "I will call your physician and see if he will order a new pain medication for your side. The one you have now doesn't seem to provide you with relief. Why don't you get some rest for now?"

D. Expresses persistent fears of having a life-threatening disease

Lucille has a diagnosis of illness anxiety disorder. Which of the following symptoms would be consistent with this diagnosis? A. Complaints of a multitube of incapacitating physical symptoms B. Manifests wish pseudo-seizures or pseudocyesis C. Takes substances to induce vomiting in order to convince the nurse that she needs treatment D. Expresses persistent fears of having a life-threatening disease E. All of the above

Therapy

Medication Management for Somatic Disorders · Medications may be used to target underlying depression/anxiety/trauma, but when antidepressants are needed, SSRIs are preferred. Long term use of benzodiazepines for anxiety should be avoided (potential for addiction). Conversion disorders may be treated with lorazepam to help reveal historical information related to trauma. · _______ is main tx

D. Learn more adaptive coping strategies

Nursing care for a client with somatic symptom disorder would focus on helping them to: A. Eliminate stress in their life B. Discontinue their numerous physical complaints C. Take their medication only as prescribed D. Learn more adaptive coping strategies

Coping involves both cognitive and behavioral responses that individuals use in an attempt to manage internal/external stressors perceived to exceed their personal resources

Predisposing Factors to Dissociative Disorders · Genetics: Preliminary research does not show evidence of significant genetic contribution, BUT many individuals do have a history of sexual or physical abuse · Neurobiological: Dissociative amnesia may be related to neurophysiological dysfunction. (not the same as amnesia induced by a brain injury) § Electroencephalogram abnormalities have been observed in some clients with DID (temporal lobe epilepsy, severe migraine headages, marijuana use § Areas of brain associated with impaired memory: hippocampus, amygdala, fornix, mammillary bodies, thalamus, and frontal cortex · Psychodynamic Theory: Freud believed dissociative disorders occurred with repressed distressing mental contents from unconscious awareness (attempts to protect self from extreme emotional pain triggered by stress) · Psychological trauma § A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelm the individual's capacity to cope by any means other than dissociation. § These experiences usually take the form of severe physical, sexual, or psychological abuse by a significant other in the child's life. § DID is thought to serve as a survival strategy for the child in this traumatic environment. · Transactional model of stress/adaptation: _____________

Dissociative amnesia may be related to neurophysiological dysfunction. (not the same as amnesia induced by a brain injury) § Electroencephalogram abnormalities have been observed in some clients with DID (temporal lobe epilepsy, severe migraine headages, marijuana use § Areas of brain associated with impaired memory: hippocampus, amygdala, fornix, mammillary bodies, thalamus, and frontal cortex

Predisposing Factors to Dissociative Disorders · Genetics: Preliminary research does not show evidence of significant genetic contribution, BUT many individuals do have a history of sexual or physical abuse · Neurobiological: _________________________________ · Psychodynamic Theory: Freud believed dissociative disorders occurred with repressed distressing mental contents from unconscious awareness (attempts to protect self from extreme emotional pain triggered by stress) · Psychological trauma § A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelm the individual's capacity to cope by any means other than dissociation. § These experiences usually take the form of severe physical, sexual, or psychological abuse by a significant other in the child's life. § DID is thought to serve as a survival strategy for the child in this traumatic environment. · Transactional model of stress/adaptation: Coping involves both cognitive and behavioral responses that individuals use in an attempt to manage internal/external stressors perceived to exceed their personal resources

decreased serotonin and endorphins, tryptophan catabolism

Risk Factors for Somatization, Somatic Symptom and Related Disorders · Genetic: First-degree relative with somatic disorder more likely to have the disorder · NT imbalances: ______________ · Hypometabolism in dominant hemisphere and hypermetabolism in the nondominant hemisphere. Impaired communication between hemispheres. Reduced volume of amygdala · Anxiety, depression, or personality disorder · Childhood trauma, abuse, neglect · Female gender (especially 16 to 25) Men may not report as frequently??? · Learned helplessness: learning to associate your inability to help yourself and the physical symptoms become your way of helping yourself

B. Psychotherapy and hypnosis

The ultimate goal of therapy for a client with dissociative identity disorder is most likely achieved through: A. Crisis intervention and directed association B. Psychotherapy and hypnosis C. Psychoanalysis and free association D. Insight psychotherapy and dextroamphetamines

resolve on their own (especially with children, younger adults)

Treatment for Somatic Disorders · 95% may achieve remission without intervention per ATI p.109 · Individuals with conversion disorder: if they can acknowledge their disorder, sometimes the disorder will _______

A. Integration of the personalities into one

What is the ultimate goal of therapy for a client with dissociative identity disorder A. Integration of the personalities into one B. The ability to switch from one personality to another voluntarily C. The ability to select one personality as the dominant self D. Recognition that multiple personalities exist

B. Repression of anxiety

Which of the following ego defense mechanisms describes the underlying psychodynamics of somatic symptom disorder? A. Denial of depression B. Repression of anxiety C. Suppression of grief D. Displacement of anger

Somatization

· DSM-5 definition of Somatic Symptoms and related disorders as a mental disorder is when the excessive focus on somatic symptoms is beyond any medical explanation and it causes significant distress and impairment in one's functioning. § Somatic symptom disorder, illness anxiety disorder, conversion disorder, factitious disorder · ________ is the expression of psychological stress through physical manifestations. Individua's often have long term history and overuse of healthcare services. Symptoms may wax and wane, and the condition is often chronic. They are hyper focused on symptoms, and usually seen in primary care setting

Somatic Symptoms Disorder

· Diagnostic Criteria for _____: § One or more somatic symptoms that are distressing or result in disruption of daily life § Excessive thoughts, feelings, behaviors related to somatic symptoms manifested by at least 1 of the following symptoms: · Disproportionate and persistent thoughts about seriousness of symptoms · Persistently high level of anxiety about health/symptoms · Excessive time/energy devoted to these symptoms/concerns § Although any symptom may not be continuously present, the state of being symptomatic is persistent, usually longer than 6 months § Mild: only 1 symptom § Moderate: two or more symptoms § Severe: two or more symptoms plus multiple somatic complaints § Specify if predominant pain § Specify if persistent: more than 6 months

Dissociative Identity Disorder

· Diagnostic Criteria for ______: § Disruption of identity characterized by 2 or more distinct personality states. The disruption in identity involves discontinuity in the sense of self accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, or sensory-motor functioning. Symptoms may be observed by others or reported by the individual. § Recurrent gaps in recall of everyday events, important personal info, or traumatic events. All are inconsistent with normal forgetting § Symptoms cause distress or impairment in social/occupational functioning § The disturbance is not a normal part of cultural or religious practice, and symptoms are not explained by effects of a substance or medical condition

Illness anxiety disorder

· Diagnostic Criteria for _______: § Preoccupation with having or acquiring a serious illness § Somatic symptoms are not present, (or if present are only mild). If a medical condition is present, the preoccupation is excessive/disproportionate § High level of anxiety about health; easily alarmed about health status § Performs excessive health-related behaviors (checking body) or exhibits maladaptive avoidance (avoids appointments/hospitals) § Illness has been present for at least 6 months (feared illness may change anytime) § Illness-preoccupation is not explained by another mental disorder, somatic symptom disorder, panic disorder, GAD, body dysmorphic disorder, ODC, or delusional disorder § Specify if Care-Seeking Type: healthcare frequently utilized § Specify if Care-Avoidant type: healthcare rarely used or avoided

Depersonalization-Derealization Disorder

· Diagnostic Criteria for _________: § The presence of persistent/recurrent depersonalization, derealization, or both · Depersonalization: experiences of unreality, detachment, being an outside observer with respect to one's thoughts, feelings, sensations, body, or actions (perception alterations, altered sense of time, physical numbing) · Derealization: experiences of unreality or detachment with respect to surroundings (individuals/objects are unreal, dreamlike, foggy, lifeless) § During the depersonalization/derealization, reality testing remains intact § The symptoms cause distress or impairment in social/occupational functioning § Disturbance is not explained by effects of a substance, medical/mental condition

Dissociative Amnesia

· Diagnostic Criteria for __________: § Inability to recall important autobiographical information, usually of traumatic/stressful nature, that is inconsistent with ordinary forgetting. § Symptoms cause distress or impairment in social/occupational functioning § Disturbance is not attributable to the physiological effects or a substance or medical condition; or dissociative identity disorder, acute distress disorder, PTSD, somatic symptom disorder, or a neurocognitive disorder § Specifier: with dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for important autobiographical information

Factitious disorder

· Diagnostic criteria for _______: § Factitious disorder imposed on self: · Falsification of physical or psychological symptoms, induction of injury, or disease · Presents self as ill, injured, or impaired to others · Deceit is present even in the absence of external rewards · Behaviors is not better explained by another mental disorder § Factitious disorder imposed on another: all other symptoms, but they present another individual (sometimes mother presenting child) as ill, impaired, or injured

Conversion disorder

· Diagnostic criteria for _______: § One or more symptoms of altered voluntary motor or sensory functions § Clinical findings provide evidence of incompatibility between symptoms and neurological/medical conditions § Symptom/deficit is not better explained by another medical/mental disorder § Symptom/deficit causes significant distress or impairment in social, occupational functioning and warrants medical evaluation § Specify symptom type: with weakness/paralysis, abnormal movement (jerking, tremors, gait problem), swallowing symptoms, attacks/seizures, anesthesia/sensory loss, speech symptom, special sensory symptom (loss of vision or smell), mixed symptom § Specify if Acute (less than 6 months) or persistent (more than 6 months) § Specify if related to psychological stressor or not

Dissociative amnesia with dissociative fugue

· Dissociative Amnesia is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too excessive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or medical condition § Amnesia: partial or total, permanent or transient loss of memory. · Localized amnesia: Unable to recall all incidents associated with a stressful event, such as inability to remember months or years of child abuse · Selective amnesia: Can recall only certain incidents associated with a stressful event for a specific period · Generalized amnesia: Amnesia for identity and total life story § Clients are often brought into ED after being found wandering by police § Onset usually follows severe stress; termination is often abrupt and followed by complete recovery § _________________: sudden, unexpected travel away from customary places or by bewildered wandering, with the inability to recall some/all of one's past. May resume a new identity during the episode

Generalized amnesia

· Dissociative Amnesia is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too excessive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or medical condition § Amnesia: partial or total, permanent or transient loss of memory. · Localized amnesia: Unable to recall all incidents associated with a stressful event, such as inability to remember months or years of child abuse · Selective amnesia: Can recall only certain incidents associated with a stressful event for a specific period · ___________: Amnesia for identity and total life story § Clients are often brought into ED after being found wandering by police § Onset usually follows severe stress; termination is often abrupt and followed by complete recovery § Dissociative amnesia with dissociative fugue: sudden, unexpected travel away from customary places or by bewildered wandering, with the inability to recall some/all of one's past. May resume a new identity during the episode

Selective amnesia

· Dissociative Amnesia is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too excessive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or medical condition § Amnesia: partial or total, permanent or transient loss of memory. · Localized amnesia: Unable to recall all incidents associated with a stressful event, such as inability to remember months or years of child abuse · ____________: Can recall only certain incidents associated with a stressful event for a specific period · Generalized amnesia: Amnesia for identity and total life story § Clients are often brought into ED after being found wandering by police § Onset usually follows severe stress; termination is often abrupt and followed by complete recovery § Dissociative amnesia with dissociative fugue: sudden, unexpected travel away from customary places or by bewildered wandering, with the inability to recall some/all of one's past. May resume a new identity during the episode

Localized amnesia

· Dissociative Amnesia is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too excessive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or medical condition § Amnesia: partial or total, permanent or transient loss of memory. · _________: Unable to recall all incidents associated with a stressful event, such as inability to remember months or years of child abuse · Selective amnesia: Can recall only certain incidents associated with a stressful event for a specific period · Generalized amnesia: Amnesia for identity and total life story § Clients are often brought into ED after being found wandering by police § Onset usually follows severe stress; termination is often abrupt and followed by complete recovery § Dissociative amnesia with dissociative fugue: sudden, unexpected travel away from customary places or by bewildered wandering, with the inability to recall some/all of one's past. May resume a new identity during the episode

Dissociation

· Dissociative disorders are defined by a disturbance of or alteration in the usually integrated functions of consciousness, memory, and identity. It occurs when anxiety becomes overwhelming and the personality becomes disorganized. § EX: Depersonalization derealization disorder, dissociative amnesia, dissociative identity disorder § Frequently found in aftermath of trauma · ____________: Unconscious defense mechanism in which there is separation of identity, memory, and cognition from affect; segregation of ideas and memories about oneself from their emotional and historical underpinnings § Freud viewed as an active defense mechanism to remove unacceptable or threatening mental contents from conscious awareness (ego-splitting)

§ Build rapport and trust § Ensure safety § Encourage verbalization of feelings. Help client identify the trigger of the manifestations. Sudden blindness may occur if client has stress in seeing their partner with someone else § Education on adaptive coping and stress management § Understand the incidence of remissions and recurrence § Administer medications as ordered: antidepressants, anxiolytics § Educate client to participate in individual and group therapy, community support groups, and medications

· Nursing Care for Conversion disorder:______

§ Perform a self-assessment prior to care § Avoid confrontation. Accept that symptoms are real to the client. Build rapport and trust § Ensure safety of client and persons affected by client. They may be suicidal or convinced that their life is at risk. § Assess for secondary gain. What are they gaining as a result of this condition? § Report new manifestations to the provider. Ensure safety. § Educate clients on assertiveness training § Educate on alternative coping mechanisms, stress management, individual cognitive behavioral therapy, support groups, any medications prescribed § Limit time allowed to discuss somatic symptoms. § Promote self-care. They need to perform healthy ADLs (having a physical every year, teeth cleaning, OBG check-ups for women) § Communicate openly with the health care team any suspicions of factitious disorder (or imposed on another). This can help reduce medical costs and unnecessary treatments/surgeries § Encourage verbalization of feelings

· Nursing Care for Factitious disorder:_______

§ Build rapport and trust § Encourage independence in self-care § Administer meds as ordered: antidepressants, anxiolytics § Educate client on group therapy and individual therapy § Attend community support groups § Medication education § Verbalize feelings § Use appropriate coping mechanisms and perform stress management techniques

· Nursing Care for Illness anxiety disorder:_____

§ Accept somatic symptoms as being real to the client § Assess for suicidal ideation and self-harm § Identify cultural impact of client's view of health and illness § Identify secondary gains from somatic manifestations (attention, distraction from goals, obligations, or problems) § Report new physical manifestations to the provider § Limit time allowed to discuss somatic manifestations § Encourage independence in self-care, verbalizations of feelings, physical exercise § Educate client on alternative coping mechanisms, assertiveness techniques § Administer medications PRN: analgesics, antidepressants, anxiolytics § Educate client on group/individual therapy, medications § Arrange with case management for follow-ups every 4-6 weeks. This decreases need for unscheduled health care and medical costs of labs

· Nursing Care for Somatic Symptoms Disorder:

Hypnosis Cognitive Behavioral Therapy

· Treatment for Depersonalization-Derealization Disorder § Medications not typically effective § _______ can be beneficial for individuals with Depersonalization-Derealization Disorder § _________ can be beneficial for individuals with Depersonalization-Derealization Disorder

Hypnosis § Group therapy for dissociative amnesia is used once memories have returned to help the client integrate memories into their conscious state § Cognitive therapy for dissociative amnesia can help clients recall details about traumatic events when they begin to correct cognitive distortions about trauma

· Treatment for Dissociative Amnesia § Amobarbital can be used to retrieve lost memories for refractory conditions § Many cases of dissociative amnesia resolve once removed from stressor § Psychotherapy for dissociative amnesia can be used to reinforce adjustment to the psychological impact of the retrieved memories. Techniques of persuasion and free or directed associated may help client remember things. § ________ can be used for dissociative amnesia to mobilize memories (may be facilitated by drugs like Amobarbital). § Group therapy for dissociative amnesia is used once memories have returned to help the client integrate memories into their conscious state § Cognitive therapy for dissociative amnesia can help clients recall details about traumatic events when they begin to correct cognitive distortions about trauma

Amobarbital

· Treatment for Dissociative Amnesia § _________ can be used to retrieve lost memories for refractory conditions § Many cases of dissociative amnesia resolve once removed from stressor § Psychotherapy for dissociative amnesia can be used to reinforce adjustment to the psychological impact of the retrieved memories. Techniques of persuasion and free or directed associated may help client remember things. § Hypnosis can be used for dissociative amnesia to mobilize memories (may be facilitated by drugs like Amobarbital). § Group therapy for dissociative amnesia is used once memories have returned to help the client integrate memories into their conscious state § Cognitive therapy for dissociative amnesia can help clients recall details about traumatic events when they begin to correct cognitive distortions about trauma

Intensive long-term therapy

· Treatment for Dissociative Identity Disorder § Optimizing client's functioning is goal of therapy for Dissociative Identity Disorder § Integration is used for Dissociative Identity Disorder to blend all of the personalities into one. It is a lengthy therapeutic regimen. When this process is achieved, the individual is able to integrate all feelings, experiences, memories, skills, and talents that were previously in command of separate personalities. § ____________ for Dissociative Identity Disorder is directed towards uncovering the underlying psychological conflicts, helping them gain insight into conflicts, and striving to synthesize the various personalities into one integrated personality. It involves insight-oriented psychotherapy, cognitive therapy, and trauma-informed/PTSD treatment approaches. Clients are assisted to recall traumas in detail through abreaction (mentally reexperience the abused that caused their illness; "remembering with feeling"). Clients may cry, scream, or feeling the pain they felt during the trauma/abuse. § Trauma informed care: getting the individual to recognize and deal with the traumatic event that caused the disorder

Integration

· Treatment for Dissociative Identity Disorder § Optimizing client's functioning is goal of therapy for Dissociative Identity Disorder § ___________ is used for Dissociative Identity Disorder to blend all of the personalities into one. It is a lengthy therapeutic regimen. When this process is achieved, the individual is able to integrate all feelings, experiences, memories, skills, and talents that were previously in command of separate personalities. § Intensive long-term therapy for Dissociative Identity Disorder is directed towards uncovering the underlying psychological conflicts, helping them gain insight into conflicts, and striving to synthesize the various personalities into one integrated personality. It involves insight-oriented psychotherapy, cognitive therapy, and trauma-informed/PTSD treatment approaches. Clients are assisted to recall traumas in detail through abreaction (mentally reexperience the abused that caused their illness; "remembering with feeling"). Clients may cry, scream, or feeling the pain they felt during the trauma/abuse. § Trauma informed care: getting the individual to recognize and deal with the traumatic event that caused the disorder

Impaired memory

· ______(dissociative amnesia): nursing diagnosis for loss of memory § Obtain as much info as possible from family/significant others. Consider likes, dislikes, important people, activities, music, and pets. § Do not confront client with information they don't remember. Exposure to painful information for person's with amnesia may stress the client more or send them into a psychotic state § Expose the client to stimuli that represent pleasant experiences from the past, like smells associated with enjoyable activities, beloved pets, and music they enjoy. As memory comes back, gradually engage the client in activities that may provide additional information. § Listen empathetically when the client discusses situations that have been stressful and explore those feelings with the client. Encourage verbalization of feelings in a nonthreatening environment to help the client come to terms with unresolved issues that contribute to dissociation § Identify conflicts that remain unresolved and help the client with possible solutions. Provide instruction regarding more adaptive ways to respond to anxiety. § Provide positive feedback for decisions made. Respect the client's right to make decisions independently and refrain from attempting to influence them toward decisions that may seem more logical. Independent choice provides a feeling of control, decreases powerlessness, and increases self-esteem

Individual psychotherapy

· _______ for somatic symptom disorders: the goal of this therapy is to help clients develop healthy/adaptive behaviors and encourage them to move beyond somatization and manage lives more effectively. Focuses on personal/social difficulties that the client has in daily life and achievement of practical solutions for these problems. § Treatment starts with a complete physical exam (may help client if done in a medical setting). Frequent exams are recommended to reassure client that their concerns are being heard.

Group psychotherapy/support groups

· _______ for somatic symptom disorders: this therapy provides a setting where clients can share feelings of illness, learn to verbalize thoughts, and be confronted by group members when they reject responsibility for maladaptive behaviors. It is the treatment of choice for somatic symptom disorder and illness anxiety disorder because it provides social support and anxiety reduction.

Dissociative Identity Disorder

· _______ is characterized by the existence of two or more personality states in a single individual (alter identities). Only one personality is present in one moment, and one personality is dominant over the course of the disorder. Each personality has different memories, behaviors, and social relationships. § Transition from one personality to another can be sudden or gradual. They may experience "gaps", "lost time", or "blackouts" during personality transitions § Many are victims of childhood abuse § Can manifest with other symptoms like amnesia, fugue states, depersonalization, and derealization § May wake up in unfamiliar situations with no idea where they are, how they got there, or the identities of those around them. § May be misdiagnosed with depression, borderline personality disorder, schizophrenia, or bipolar disorder

Disturbed personality identity

· ________ (dissociative identity disorder): presence of more than one personality within the individual § Develop a trusting, therapeutic relationship with the client. Listen nonjudgmentally when the client transitions from one personality to another. Help the client understand the existence of subpersonalities because the client may be unaware of the dissociative response. Knowledge of the needs the disorder fulfills is the first step in the integration process and the client's ability to face unresolved issues without dissociation § Help the client identify stressful situations that precipitate transition in personalities. Observe and record these transitions. Identifying stressors will help the client respond adaptively in the future § Use nursing interventions necessary to deal with maladaptive behaviors associated with each personality. For example, if one personality is suicidal, take suicide precautions (prevent harm; safety first!). If another personality is physically hostile, take precautions to protect others § Help personalities understand that their "being" will not be destroyed, but rather integrated into a unified identity within the individual. The idea of total elimination of a personality is distressing. § Provide support during disclosure of painful experiences and reassurance when the client becomes discouraged with lengthy treatment

Fear of having a serious disease

· ________ (illness anxiety disorder): preoccupation with and unrealistic interpretation of bodily signs and sensations § Monitor ongoing assessments/labs to make sure physical conditions are ruled out. Refer all new physical complaints to the physician; ignoring complaints could jeopardize client safety § Assess that the function of the client's illness is fulfilling dependency, nurturing, caring, attention, or control needs. § Identify times when the preoccupation with physical symptoms worsens to see if they correlate with anxiety/stress. § Convey empathy and let the client know you understand how a symptoms can conjure fears of illness. (unconditional acceptance = therapeutic relationship) § Allow the client a limited time to discuss physical symptoms. The client's preoccupation with illness has been a maladaptive coping mechanism, so completely preventing this activity could raise stress level/make symptoms worse § Help the client determine adaptive coping mechanisms (relaxation techniques, mental imagery, thought-stopping, exercising) to relive anxiety and help get a discussion of honest feelings § Gradually increase the limit on amount of time each hour spent discussing physical symptoms. If the client violates limits, withdrawal attention. Lack of positive reinforcement of maladaptive behaviors can help prevent them § Encourage feelings associated with fear of physical illness. § Role-play the client's plan for dealing with the fear the next time they experience it to control and prevent disabling anxiety.

Deficient knowledge

· ________ (somatic symptom disorder): history of "doctor shopping" for evidence of organic pathology to explain physical symptoms; statements of "I don't know why the doctor put me on the psychiatric unit. I have a physical problem." § Assess the client's level of knowledge regarding the effects of psych problems on the body. Assess the client's level of anxiety and readiness to learn (learning does not occur beyond a moderate level of anxiety) § Discuss physical exams and laboratory test results and explain the purpose/results of each. Fear on unknown results can contribute to anxiety. § Explore the client's feelings/fears as they demonstrate readiness to learn. Feelings may be suppressed/repressed for so long that their disclosure could be very painful/stressful. Be supportive. § Have the client keep a diary of appearance, duration, and intensity of physical symptoms and a separate record of stressful situations. Compare the records to observe a relationship between stress and physical symptoms § Help the client understand that needs are being met through the sick ("patient") role. Together, formulate more adaptive means for fulfilling these needs. Practice with role-playing to reduce discomfort in real-life situations § Provide instruction in assertiveness techniques (explain passive, passive-aggressive, and aggressive behaviors). This will promote self-esteem and improve social relationships § Discuss adaptive methods of stress management (relaxation techniques, physical exercise, meditation, breathing exercises) to decrease appearance of physical symptoms in response to stress

Conversion disorder

· ________ is a loss of or change in body function that cannot be explained by any known medical disorder or pathophysiological mechanism. There is likely a psychological component involved in the initiation, exacerbation, or perpetuation of the symptom (may not be identifiable) § Symptoms may affect voluntary motor or sensory function, such as paralysis, aphonia (inability to produce voice), seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia (inability to smell), loss of pain sensation, and hallucinations § Abnormal limb shaking with impaired/loss of consciousness that resembles seizures is referred to as psuedoseizures, psychogenic, or nonepileptic seizures § Pseudocyesis, or false pregnancy, is a common symptom of conversion disorder (may represent desire to be pregnant) § THERE MUST BE CLEAR INCOMPATIBILITY WITH NEUROLOGICAL DISEASE · EX: client appears to be having a seizure, but eyes are closed and resist opening, and there is no urinary incontinence, conversion disorder may be considered · Risk factors for ______: first degree relative, childhood abuse, depression, anxiety, PTSD, personality disorder, somatic disorder, medical/neuro condition, recent stressful event, female, adolescent, low socioeconomic status

Depersonalization-Derealization Disorder

· ________ is characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, feelings of detachment from the environment, or a sense of observing oneself from outside the body. Persistent, recurrent episodes of depersonalization, derealization, or both that cause distress and impairment in functioning § EX: a soldier in recalling experience in combat describes observing himself from a distance and wondering what he would do if he were in that position § Depersonalization: a disturbance in perception of one's self § Derealization: an alteration in the perception of the external environment § Many people experience these symptoms, and it also occurs in many illnesses such as depression, anxiety, or schizophrenia. § May be mechanical or dreamlike feeling/disbelief that the body's physical characteristics have changed. People in environment may seem automated § Often accompanied by fear of going insane, obsessive thoughts, somatic complaints, anxiety, depression, altered sense of time § Age of onset is usually adolescence. More common in women

Illness anxiety disorder

· ________ is defined as an unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation about fear of having a serious disease. The fear becomes disabling and persists despite reassurance that no organic pathology can be detected. Symptoms can be minimal or absent, but the individual is highly anxious/about suspicious of an undiagnosed serious medical illness. § They're extremely conscious about bodily sensations and changes and may become convinced that a rapid heart rate indicates heart disease, or that a small skin lesion is skin cancer § The response to these changes is unrealistic and exaggerated § Some have a history of "doctor shopping"; convinced they aren't receiving care. Others avoid doctors because it would exacerbate their anxiety § Depression and OCD are common comorbidities § May interfere with social/occupational functioning, some can function appropriately on job § Fearful, alarmed at slighted intimation of serious illness. Reading about or hearing of someone with a serious disease is alarming § FOCUSED ON FEAR OF ILLNESS · Risk factors for ________: first-degree relative with the disorder, previous losses or disappointments, childhood trauma/abuse/neglect, MDD, anxiety disorder, major life stressor, low self-esteem

Mindfulness

· _________ for somatic symptom disorders: this technique is teaching the client to be present and in the moment. They tend to not think ahead, so we convince them to be grateful for the current things/resources around them that they may have forgotten to recognize or alienated.

Ineffective coping

· _________: verbalization of numerous physical complaints in absence of pathophysiological evidence. Focusing on the self and physical symptoms(somatic symptom disorder). Feigning of physical/psychological symptoms to gain attention (factitious disorder) § Monitor ongoing assessments/labs to make sure physical conditions are ruled out. § Recognize/accept that physical complaint is real to the client despite no physical evidence of medical condition. Don't deny client's feelings § Provide pain medications as ordered PRN. Safety and Comfort are priorities § Identify gains that the symptoms are providing for the client, like increased dependency ,attention, distraction. § Initially, fulfill the client's most urgent dependency needs. Gradually withdraw attention to physical symptoms. Gradual withdrawal of positive reinforcement of dependency will discourage repeating maladaptive behaviors § Explain to the client that any new physical complaints will be communicated to the doctor, and give no further attention to the complaints. Always follow up on physician's assessment to rule out pathological condition § Encourage client to verbalize fears and anxieties. Explain that attention will be withdrawn if rumination about physical complaints begins. Set consistent limits to encourage change § Help the client understand that physical symptoms can occur due to stress and discuss coping strategies (relaxation exercises, physical activities, assertiveness) § Have the client keep a diary of appearance, duration, and intensity of physical symptoms and a separate record of stressful situations. Compare the records to observe a relationship between stress and physical symptoms

Factitious disorder

· __________ involves conscious, intentional feigning of physical or psychological symptoms. Individuals pretend to be ill in order to receive emotional care and support associated with the role of "patient". § They gain secondary attention (gains) by being "sick" or in the patient role § Individuals become skilled at presenting "symptoms" so that they successfully gain admission to hospitals and treatment centers § They may aggravate existing symptoms, induce new ones, or inflict painful injuries on themselves § Disorder may be imposed on oneself or another person § Mothers may deceive medical personnel by lying about medical history, manipulating laboratory results, or inducing injury/illness in the child through use of substances or physical assaults § AKA Munchausen syndrome · Risk factors for _______: history of emotional physical distress, childhood abuse, chronic/frequent illnesses needing hospitalization, impaired neuro ability for information processing, dependent personality, borderline personality disorder

Disturbed sensory perception

· __________: loss/alteration in physical functioning without evidence of organic pathology (conversion disorder); alteration in perception or experience of the self/environment (depersonalization-derealization disorder) § Monitor ongoing assessments/labs to make sure physical conditions are ruled out. Refer all new physical complaints to the physician; ignoring complaints could jeopardize client safety § Assess that the function of the client's illness is fulfilling dependency needs or protection from experiencing a stressful event. § Do not focus on the disability. Encourage the client to be independent. Intervene only when client needs assistance. Don't provide positive reinforcement of maladaptive behaviors § Maintain a nonjudgmental attitude when providing assistance with self-care activities § Don't reinforce the client's use of the disability as a manipulative tool to avoid participating in therapeutic activities. Withdraw attention if the client continues to focus on physical limitation § Encourage the client to verbalize fears and anxieties and help identify the physical symptom as a maladaptive coping mechanism used for extreme stress § Help the client identify adaptive coping mechanisms that they can use for extreme stress § Give positive reinforcement for identifying maladaptive coping strategies and demonstrating adaptive coping strategies § Discuss ways the client can adaptively respond to stress. Use role-play to practice. § For clients with depersonalization, provide support, security, and encouragement during times of depersonalization. Explain the depersonalization behaviors and the purpose they serve for the client to help minimize fears/anxieties associated with the disorder.

Reattribution treatment

· ___________: this treatment is commonly used for somatic symptom disorder. It works by assisting clients to identify the link between physical manifestations and psychological factors while promoting a sense of caring/understanding · Stage 1: Feeling understood: therapeutic communication, active listening, and empathy to obtain a history of manifestations while focusing on the client's perception of symptoms and their case (and brief physical assessment) · Stage 2: Broadening the agenda: Acknowledge concerns and provide feedback of assessment findings. "We are so concerned, that we have tried the best that medicine has to offer and we have found that you are the picture of health." · Stage 3: Making the link: use therapeutic communication to educate on the lack of findings without damaging client's self-esteem · Stage 4: Negotiating further treatment: work with client and provider in developing a treatment plan that allows for regular follow-ups

Cognitive behavioral therapy

· ____________ for somatic symptom disorders: this therapy helps reduce depressive symptoms in clients with somatic diseases. Psychoeducation involves teaching the patient that symptoms may be related to anxiety/stress.

Somatic Symptoms Disorder

· ____________ is a syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychological distress and frequent visits to health-care professionals to seek assistance. § Symptoms may be vague, dramatized, or exaggerated in presentation and excessive time/energy is devoted to worry and concern about symptoms § Individuals are convinced symptoms are related to organic pathology. They often reject or are irritated that stress may play a role in their condition § Chronic, symptoms usually begin before age 30 § Fluctuating with exacerbations and remissions. Commonly seen with depression and anxiety § DANGER of being treated by several physicians and having treatment interactions § Drug/alcohol abuse and dependence are common complications § PQ-15 is a screening tool to assess presence of somatic symptoms § FOCUSED ON PERCIEVED SYMPTOMS

Dissociative Amnesia

· _______________ is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too excessive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or medical condition § Amnesia: partial or total, permanent or transient loss of memory. · Localized amnesia: Unable to recall all incidents associated with a stressful event, such as inability to remember months or years of child abuse · Selective amnesia: Can recall only certain incidents associated with a stressful event for a specific period · Generalized amnesia: Amnesia for identity and total life story § Clients are often brought into ED after being found wandering by police § Onset usually follows severe stress; termination is often abrupt and followed by complete recovery § Dissociative amnesia with dissociative fugue: sudden, unexpected travel away from customary places or by bewildered wandering, with the inability to recall some/all of one's past. May resume a new identity during the episode