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Chapter 12

Somatic Symptom Disorders

and Dissociative Disorders

Somatize

Somatize is the tendency to experience and communicate physical symptoms in response to psychologic distress. Although medical tests repeatedly demonstrate no medical basis, people continue to seek relief from their somatic symptoms.

Discuss artwork as it relates to somatic symptoms.

Dissociation

Daydreaming, fantasizing, and “zoning out” are all examples of healthy dissociation. However, severe traumatic dissociation comes from major trauma, and an individual may develop a disorder such as dissociative identity disorder (DID).

Discuss artwork

as it relates to

dissociation and DID.

Comparison

Somatic Symptom Disorders

Characterized by the presence of multiple, real, and/or physical symptoms for which no evidence of medical illness is revealed

Accompanied by abnormal thoughts, feelings and reactions to these symptoms

Dissociative Disorders

Characterized by mental detachment from conscious awareness in reaction to abuse

Involve a disruption in the consciousness with a significant impairment in memory, identity, social functioning, or perceptions of self

Somatic Symptom Disorder

Persistent preoccupation with and distress over physical symptoms.

Client experiences symptoms of significant anxiety and life impairment.

Associated with increased health care use, functional impairment, provider dissatisfaction, psychiatric co-morbidity, and failed treatment response.

May be exacerbated by comorbidity of other physical disorders.

Somatic Symptom Disorder: Theory

Genetic Factors: Presents in 20% of first-degree female relatives of female patients; may be higher in monozygotic twins and females

Environmental: Environmental learning, early trauma, societal devaluing of psychologic distress, school stressors

Psychologic Theory: Maladaptive/anxious attachment; perceived rejection from significant others; difficulty expressing distress verbally

Interpersonal Model: Parental somatization; early abuse; early exposure to illness

Clinical Picture

Somatic Symptom Disorder

Multiple physical symptoms; significant distress; impaired functioning; obsession with health concerns; actively seek medical relief

Pain as predominant symptom; cause not always identifiable

Persistent (> 6 months); mild, moderate, or severe

Illness Anxiety Disorder

Illness preoccupation with or without mild symptoms

Persistent (> 6 months) high anxiety over health; alarmed by body sensations; may or may not seek help

Clinical Picture (Cont.)

Conversion Disorder

Presents with impaired motor or sensory function complaint

Findings inconsistent with known neurologic conditions

Symptoms are not voluntarily controlled or created

Exhibits either la belle indifference (lack of concern) or high distress

Current theories dispute a purely psychologic origin: patients have smaller hippocampal volume

Co-morbidities: childhood abuse, depression, anxiety, personality disorder

Factitious Disorder

Imposed on self

Imposed on another

Clinical Picture (Cont.)

Factitious Disorder Imposed on Self

Deliberate symptom fabrication or self-injury without obvious potential reward (attention assumed to be possible motivation—but not clear)

Patient identifies self deceptively as impaired or ill

Single or recurrent episodes

Different from malingering: faking injury for obvious (usually monetary) gain

Factitious Disorder Imposed on Another

Perpetrator/patient is usually parent or caregiver; motivation is attention or nurturing for self at expense of a dependent victim

Objective 1: Differentiate the significant differences between somatic symptom disorders and factitious disorders.

Somatic symptom disorders

General medical conditions affected by stress or psychologic factors

Factitious disorders

Fabrication of symptoms or self-inflicted injury to assume the sick role

Objective 2: Identify factors that can make it difficult to identify somatic symptom disorders.

Individuals with somatic symptom disorders are often seen in medical clinics and not psychiatric settings because the distressing symptoms present as primarily physical in nature.

Actual diagnosed medical issues and somatic syndrome disorders can be present concurrently, which can make diagnosis difficult.

Nursing Process for Somatic Symptom Disorders

Nursing assessment: History and course of past symptoms; current physical and mental status

No voluntary control over their symptoms, with the exception of factitious disorders

Assess for secondary gains (benefits derived from symptoms)

Cognitive style: Misinterpretation of physical stimuli; reality distortion regarding symptoms

Ability to communicate emotional needs

Dependence on medications (anxiolytics such as benzodiazepines; “rebound anxiety” on withdrawal)

Dependence on Medication

Patients with many somatic complaints often become dependent on pain, anxiety, and sleep medications.

Physicians prescribe anxiolytic agents for patients concerned about symptoms.

Patients often return to a physician for prescription renewal and seek treatment from many physicians.

Nurse assessment of the medications used is important.

Nursing Diagnoses for Somatic Symptom Disorders

“Ineffective coping” (most common)

Frequent causal statements:

Distorted perceptions of symptoms

Distorted perceptions of body functions

Chronic pain of psychologic origin

Dependence on pain relievers or anxiolytics

Nursing Diagnoses for Somatic Symptom Disorders (Cont.)

Other NANDA diagnoses:

Ineffective Coping

Ineffective Role Performance

Impaired Social Interaction

Ineffective Relationship

Powerlessness

Disturbed Body Image

Pain (Acute or Chronic)

Interrupted Family Processes

Impaired Parenting

Outcome Criteria

Examples of potential outcome criteria

Patient will:

Articulate feelings such as anger, shame, guilt, and remorse.

Resume work role behaviors.

Identify ineffective coping patterns.

Make realistic appraisal of strengths and weaknesses.

Allow family involvement in decision making.

Treatment: Primarily psychosocial interventions

Physical and medical tests

Nature, location, onset, and characteristics of symptoms

Assessing the patient’s ability to meet basic needs

Assessing the risks to safety and security needs

Determining whether symptoms are under the patient’s control

Identifying secondary gains the patient is experiencing

Exploring the patient’s ability to state feelings and needs

Type and amount of medication patient is using

Implementation

Case Study

June, a 57-year-old accountant, has complained of chronic, severe lower back pain for the last 15 years. Numerous and expensive diagnostic tests reveal mild degenerative joint disease. When June arrives at the office on Monday mornings, she is “grumpy” and takes most of the morning to accomplish small tasks. Co-workers feel obligated to listen to June’s complaints but are growing weary. June is scheduled for a magnetic resonance imaging (MRI) study on Wednesday. She will be out of the office that day; however, when she returns to work on Thursday and Friday, she accomplishes little.

(Continued)

Audience Response Question

Based on June’s complaints, and considering that diagnostic tests have not revealed anything that would account for her severe pain, which of the following might be an appropriate DSM-5 diagnosis?

Factitious disorder

Conversion disorder

Illness anxiety disorder

Somatic symptom disorder with pain

Answer

Based on June’s complaints and considering that diagnostic tests have not revealed anything that would account for her severe pain, which of the following might be an appropriate DSM-5 diagnosis?

A. Factitious disorder

B. Conversion disorder

C. Illness anxiety disorder

*D. Somatic symptom disorder with pain

Case Study (Cont.)

June is told by her physician that nothing was found on the MRI that would indicate that she should be in any high degree of pain. The physician recommends duloxetine HCl (Cymbalta). June states, “That medicine is an antidepressant, and I am NOT depressed. This pain is not just all in my head!”

Later in the evening, June is brought to the emergency department by rescue. Her husband states she was severely agitated and drove to the lake. He found her staring out at the water. She was combative and screaming at him. He called 9-1-1.

Critical Thinking Question

June is now your patient. She frantically asks you, “Do you think I don’t have real pain and that I’m just imagining all this?” You have reviewed her medical history and the recent results of the MRI. Based on your knowledge of pain disorders, what is your most therapeutic response?

“I believe that you have pain, but your MRI does not show that your pain should be this severe.”

“I believe that you have pain, but you shouldn’t have pain this severe.”

“I believe that you have pain, but for now we need to focus on making certain that you are stable and comfortable.”

“I absolutely believe you, and I will speak with your physician to make certain you get the appropriate pain medication.”

(Continued)

Critical Thinking Answer

A. “I believe that you have pain, but your MRI does not show that your pain should be this severe.”

B. “I believe that you have pain, but you shouldn’t have pain this severe.”

*C. “I believe that you have pain, but for now we need to focus on making certain that you are stable and comfortable.”

D. “I absolutely believe you, and I will speak with your physician to make certain you get the appropriate pain medication.”

Critical Thinking Question and Rationales

A. “I believe that you have pain, but your MRI does not show that your pain should be this severe.”

June is in the emergency department in a crisis and not ready to discuss the MRI.

B. “I believe that you have pain, but you shouldn’t have pain this severe.”

June would probably consider this response argumentative or judgmental.

*C. “I believe that you have pain, but for now we need to focus on making certain that you are stable and comfortable.”

This answer is best and prioritizes the first intervention, stabilizing the patient. More long-term treatment goals can turn to helping the patient meet needs without somatization, but in an initial crisis, focus on comfort.

D. “I absolutely believe you, and I will speak with your physician to make certain you get the appropriate pain medication.”

This response negates the possibility that the the pain might have a psychologic origin.

Discussion Question

Consider the following answer (from the previous slide) to June’s question regarding whether you believe she is in pain. When, if ever, would this answer be appropriate? If so, what makes it appropriate?

A. “I believe that you have pain, but your MRI does not show that your pain should be this severe.”

June is in the emergency department in a crisis and not ready to discuss the MRI.

Case Study Discussion: Conversion Disorder

Frederic is a sales representative for a jet corporation. His sales have been lagging, and his boss tells him, “In 3 weeks, I want you to make a presentation to 200 buyers. If you succeed in making sales, then you can keep your job.”

Frederic works day and night and prepares an excellent presentation using the latest media technology. The day arrives, and Frederic is ready. When he begins the presentation, he is unable to see. No medical reason can explain his blindness.

Discuss what has probably happened to Frederic related to a conversion disorder. What is the likely outcome? Frederic is taken to the emergency department, where he tells you, “I’m having a nervous breakdown!” What is your best response?

Dissociative Disorders

Depersonalization/Derealization Disorder

Dissociative Amnesia

Dissociative Amnesia with Fugue

Dissociative Identity Disorder (DID)

Dissociative Disorders Hallmark Characteristics

Disturbances in a normally well-integrated continuum of consciousness, memory, identity, and perception.

Dissociation—is the unconscious defense mechanism to protect an individual against overwhelming anxiety.

Intact reality testing—is not delusional and not hallucinating.

Includes amnesiac states.

Objective 3: Describe and elaborate on the central components of three of the following dissociative disorders.

Depersonalization disorder

Derealization disorder

Dissociative amnesia

Dissociative fugue

Dissociative identity

Depersonalization/Derealization Disorder

Recurrent periods of feeling unreal, detached, outside the body, dreamlike, numb, or with a distorted sense of time or visual perception

Reality testing remains intact

Symptoms are not related to medical condition or substance use

Scenario: Janet is admitted to the ED with a sensation of “floating” and “not feeling very real.” Her ex-husband is with her and says “they were arguing over the deaths of their infant twins in a car accident last year, in which Janet was the driver at fault. This whole thing has led to our divorce,” he says.

Objective 4: Giving clinical examples, compare and contrast dissociative amnesia and dissociative fugue.

Dissociative Amnesia

Psychologically induced memory loss and inability to recall important personal information after severe stressor

Scenario: Bob’s vehicle hits an improvised explosive device (IED). He and his friend are thrown onto the sand. Bob’s friend dies. A convoy passes 2 hours later. Bob is sitting by his friend, staring into space, and is unable to state who or where he is. Bob states that he does not remember the explosion.

(Continued)

Objective 5: Giving clinical examples, compare and contrast dissociative amnesia and dissociative fugue. (Cont.)

Dissociative Amnesia with Fugue

Sudden, unexpected travel from a customary locale, and the inability to recall one’s identity after a traumatic event

Scenario: Lin, 19 years old, is admitted to the psychiatric unit after police found her wandering in a Louisiana shopping mall parking lot. Lin does not recall who she is or where she lives. It is later found that Lin lives in Oregon, where her fiancé had cancelled their wedding 2 weeks earlier.

Dissociative Identity Disorder (DID)

Formerly known as multiple personality disorder, which is the presence of two or more personality states that control behavior.

Each alternate personality (alter) has its own pattern of perceiving, affect, cognition, behavior, and memories.

Severe sexual, physical, and/or psychologic trauma in childhood predisposes an individual to DID.

Scenario: The psychiatric nurse practitioner who visits a women’s free health center notices that Taylor, 23, dresses, acts, writes, and speaks in extremely different ways at each visit and has lapses of memory in time, unable to remember the previous visits.

Objective 6: Compare and contrast etiologies and basic symptoms of somatic and dissociative disorders.

Essential Characteristics	Etiology	Consciousness	Memory	Identity	Physical Symptoms
Somatic symptom disorders
Dissociative disorders

Assessment: Dissociative Disorders

Patient History: Recent injuries, seizure history, early trauma, memory/identity questions; history of similar episodes

Mood: Depressed, anxious, unconcerned? Suicidal? Frequent shifts in mood and erratic behaviors?

Use of alcohol or other drugs

Effect on patient and family

Outcomes: Dissociative Disorders

Patient will verbalize clear sense of personal identity.

Patient will report decrease in stress (using a scale of 1 to 10).

Patient will report comfort with role expectations.

Patient will plan coping strategies for stressful situations.

Patient will refrain from injuring self.

Implementation: Dissociative Disorders

Communication Guidelines: Gentle, supportive, build rapport

Health Teaching and Health Promotion: Coping skills, stress management; techniques to interrupt a dissociative episode; journal to identify triggers

Milieu Therapy: safe; quiet, structured, supportive

Psychotherapy: most effective treatment (special training required)

Pharmacologic, Biological, and Integrative: Mostly for co-morbid symptoms

Objective 7: Compare and contrast etiologies and basic symptoms of somatic and dissociative disorders

Evaluation: Dissociative Disorders

Patient safety has been maintained.

Anxiety has been reduced and the patient has returned to a functional state.

Conflicts have been explored.

New coping strategies have permitted the patient to function at a better level.

Stress is handled adaptively, without the use of dissociation.

Therapeutic alliances have been fostered.

Audience Response Question

Which of the following is an appropriate expected outcome when working with a patient with DID?

Patient will verbalize clear sense of personal identity.

Patient will express feelings verbally rather than through the development of physical symptoms.

Patient will experience no symptoms as a result of psychologic distress.

Patient will understand the distinction between true physical pain and imagined pain.

Answer

*A. Patient will verbalize clear sense of personal identity. (Recovery from DID can take long-term therapy to address the abuse, dissolve the amnesic barriers between alter personalities leading to integration, and develop healthier coping skills.)

B. Patient will express feelings verbally rather than through the development of physical symptoms. (This is an appropriate goal for a somatization disorder, rather than a dissociative disorder.)

C. Patient will experience no symptoms as a result of psychologic distress. (Some symptoms will probably always exist.)

D. Patient will understand the distinction between true physical pain and imagined pain. (No clear distinction exists for the patient or health care provider.)