Ch. 20 Somatic Symptom/Dissociative Disorders

Question 1

Somatic Symptom Disorders are…

Answer 1

Disorders with primarily somatic symptoms are characterized by physical symptoms, suggesting medical disease, but without demonstrable organic pathology.

Question 2

Characteristics (Diagnostic Criteria) of Somatic Symptom Disorders

Answer 2

1. One or more somatic symptoms that are distressing or result in significant disruption in daily life.
2. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
   - Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
   - Persistently high level of anxiety about health or symptoms
   - Excessive time and energy devoted to these symptoms or health concerns.
3. Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
   Specify if…
   - With predominant pain (the somatic symptoms predominantly involve pain)
   - Persistent (a persistent course is characterized by severe symptoms, marked impairment, and long duration [more than 6 months])
   Specify if…
   - Mild (only one of the symptoms specified in Criterion 2 is fulfilled)
   - Moderate (two or more of the symptoms specified in Criterion 2 are fulfilled)
   - Severe (two or more of the symptoms specified in Criterion 2 are fulfilled, plus there are multiple somatic complaints [or one very severe somatic symptom])

Question 3

Age of onset and comorbidities for Somatic Symptom Disorders

Answer 3

The disorder is chronic, with symptoms beginning before age 30.
Anxiety and depression are frequent comorbidities, and, consequently, the disorder is associated with an increased risk for suicide attempts.

Question 4

Complications of Somatic Symptom Disorder

Answer 4

Drug abuse and dependence

Question 5

Illness Anxiety Disorder is…
Comorbidities

Answer 5

An unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease
Psychiatric comorbidities are common, including generalized anxiety disorder, depression, somatization disorder, and panic disorder; in addition, patients with illness anxiety disorder are three times more likely to have a concurrent personality disorder

Question 6

Characteristics (Diagnostic Criteria) of Illness Anxiety Disorder

Answer 6

1. Preoccupation with having or acquiring a serious illness.
2. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate.
3. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
4. The individual performs excessive health-related behaviors (repeatedly checks his/her body for signs of illness) or exhibits maladaptive behaviors (avoids doctor’s appointments and hospitals).
5. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
6. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
   Specify whether…
   - Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used.
   - Care-avoidant type: Medical care is rarely used.

Question 7

Conversion Disorder is…

Answer 7

A loss of or change in body function that cannot be explained by any known medical disorder or pathophysiological mechanism.

Question 8

Characteristics (Diagnostic Criteria) of Conversion Disorder

Answer 8

1. One or more symptoms of altered voluntary motor or sensory function.
2. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
3. The symptom or deficit is not better explained by another medical or mental disorder.
4. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
   Specify symptom type:
   - With weakness or paralysis
   - With abnormal movement
   - With swallowing symptoms
   - With speech symptom
   Specify if:
   - Acute episode
   - Persistent
   Specify:
   - With or without psychological stressor

Question 9

Examples of Conversion Disorder symptoms include…

Answer 9

• Paralysis
• Aphonia (inability to speak)
• Seizures
• Coordination disturbance
• Difficulty swallowing
• Urinary retentions
• Akinesia (absence of movement)
• Blindness
• Deafness
• Double vision
• Anosmia (inability to perceive smell)
• Loss of pain sensation
• Hallucination
• Abnormal limb shaking with impaired of LOC that resembles epileptic seizures known as psychogenic or nonepileptic seizures
• Pseudocyesis (false pregnancy) may represent a strong desire to be pregnant

Question 10

La belle indifference

Answer 10

Client’s indifference to symptoms that seem very serious to other individuals.
Although not diagnostic of a conversion disorder, it is an associated symptom

Question 11

Factitious disorder is…

Answer 11

Disorder that involves conscious, intentional feigning of physical or psychological symptoms.

Question 12

Characteristics of factitious disorder

Answer 12

• Individuals with factitious disorder pretend to be ill to receive emotional care and support commonly associated with the role of patient.
• To accomplish this, they may aggravate existing symptoms, induce new ones, or even inflict painful injuries on themselves
• The disorder has also been identified as Munchausen syndrome, and symptoms may be psychological or physical, or a combination of both.
• The disorder may be imposed on oneself or on another person (previously called factitious disorder by proxy). In the latter case, physical symptoms are intentionally imposed on a person who is under the care of the perpetrator.

Question 13

Genetic predisposing factor of Somatic Symptom and Related Disorders

Answer 13

Hereditary factors are possibly associated with somatic symptom disorder, conversion disorder, and illness anxiety disorder.
Somatic symptom and related disorders should be conceptualized as a complex interaction of genetic vulnerabilities; history of trauma; learning; environmental, psychological, and behavioral influences

Question 14

Biochemical predisposing factors of Somatic Symptom and Related Disorders

Answer 14

Decreased levels of serotonin and endorphins may play a role in the sensation of pain. Serotonin is the main neurotransmitter in inhibiting the firing of afferent pain fibers.

Question 15

Neuroanatomical predisposing factors of Somatic Symptom and Related Disorders

Answer 15

• Brain dysfunction has been proposed by some researchers as a factor in factitious disorders.
• The hypothesis is that impairment in information processing contributes to the aberrant behaviors associated with the disorder.

Question 16

Psychodynamic Theory of Somatic Symptom and Related Disorders

Answer 16

• Some psychodynamicists view illness anxiety disorder as an ego defense mechanism.
• Physical complaints are the expression of low self-esteem and feelings of worthlessness because it is easier to feel that something is wrong with the body than to feel that something is wrong with the self.
• The psychodynamic theory of conversion disorder proposes that emotions associated with a traumatic event that the individual cannot express because of moral or ethical unacceptability are “converted” into physical symptoms.
• Another view suggests that individuals with factitious disorders were victims of child abuse or neglect.

Question 17

Family Dynamics associated with Somatic Symptom and Related Disorders

Answer 17

In families who have difficulty resolving conflicts, a child’s illness creates a shift in focus from the unresolved conflicts to the child’s illness.
Somatization becomes reinforced as a way to shift the focus away from family issues and discord.
The stabilization of the family achieved by somatizing is referred to as a tertiary gain.

Question 18

Learning Theory behind Somatic Symptom and Related Disorders

Answer 18

• Somatic complaints are often reinforced when the sick role relieves the individual from the need to deal with a stressful situation, whether it be within society or within the family.
• The sick person learns that he or she may avoid stressful obligations; may postpone unwelcome challenges; is excused from troublesome duties (primary gain); becomes the prominent focus of attention because of the illness (secondary gain); or relieves conflict within the family as concern is shifted to the ill person and away from the real issue (tertiary gain).
• Past experience with serious or life-threatening physical illness, either personal or that of close family members, can predispose an individual to illness anxiety disorder.
• Once an individual has experienced a threat to biological integrity, he or she may develop a fear of recurrence.
• The fear of recurring illness generates an exaggerated response to minor physical changes, leading to excessive anxiety and health concerns.

Question 19

Behaviors associated with nursing diagnosis: Ineffective Coping; Chronic Pain

Answer 19

Verbalization of numerous physical complaints in the absence of any pathophysiological evidence; focus on the self and physical symptoms (somatic symptom disorder)

Question 20

Behaviors associated with nursing diagnosis: Deficient Knowledge (psychological causes for physical symptoms)

Answer 20

History of “doctor shopping” for evidence of organic pathology to substantiate physical symptoms; statements such as, “I don’t know why the doctor put me on the psychiatric unit. I have a physical problem” (somatic symptom disorder)

Question 21

Behaviors associated with nursing diagnosis: Disturbed Sensory Perception

Answer 21

Loss or alteration in physical functioning without evidence of organic pathology (conversion disorder)
Alterations in perception or experience of self or environment (depersonalization-derealization disorder)

Question 22

Behaviors associated with nursing diagnosis: Self-Care Deficit

Answer 22

Need for assistance to carry out self-care activities such as eating, dressing, maintaining hygiene, and toileting due to alteration in physical functioning (conversion disorder)

Question 23

Behaviors associated with nursing diagnosis: Deficient Knowledge (psychological factors affecting medical condition); Denial

Answer 23

History of numerous exacerbations of physical illness; inappropriate or exaggerated behaviors; denial of emotional problems (psychological factors affecting other medical conditions)

Question 24

Behaviors associated with nursing diagnosis: Ineffective Coping

Answer 24

Feigning of physical or psychological symptoms to gain attention (factitious disorder)

Question 25

Behaviors associated with nursing diagnosis: Fear (Of Having A Serious Disease)

Answer 25

Preoccupation with and unrealistic interpretation of bodily signs and sensations (illness anxiety disorder)

Question 26

Outcome criteria for Somatic Symptom and Related Disorders

Answer 26

• Effectively uses adaptive coping strategies during stressful situations without resorting to physical symptoms (Somatic Symptom Disorder).
• Interprets bodily sensations rationally, verbalizes understanding of the significance the irrational fear held for him or her, and has decreased the number and frequency of physical complaints (Illness Anxiety Disorder and Somatic Symptom Disorder).
• Is free of physical disability and verbalizes understanding of the possible correlation between the loss of or alteration in function and extreme emotional stress (Conversion Disorder).

Question 27

Ineffective Coping; Chronic Pain
Goals for Patient

Answer 27

• Within (specified time), patient will verbalize understanding of correlation between physical symptoms and psychological problems.
• By time of discharge from treatment, patient will demonstrate ability to cope with stress by means other than preoccupation with physical symptoms.

Question 28

Ineffective Coping; Chronic Pain
Interventions and Rationales for them

Answer 28

1. Monitor physician’s ongoing assessments, lab reports, etc. to maintain assurance that possibility of organic pathology is ruled out. Review with pt.
   - Accurate medical assessment is vital for the provision of appropriate care. Honest explanation may help patient understand psychological implications.
2. Recognize and accept that the physical complaint is real to the patient.
   - Denial of the patient’s feelings is nontherapeutic and interferes with establishment of a trusting relationship.
3. Provide pain meds as prescribed by physician.
   - Patient comfort and safety are nursing priorities.
4. Identify gains that the physical symptoms are providing: increased dependency, attention, distraction from other problems.
   - Identification of underlying motivation is important in assisting the patient with problem resolution.
5. Initially, fulfill the pt’s most urgent dependency needs, but gradually withdraw attention to physical symptoms. Minimize time given in response to physical complaints.
   - Anxiety and maladaptive behaviors will increase if dependency needs are ignored initially. Gradual lack of positive reinforcement will discourage repetition of maladaptive behaviors.
6. Encourage pt to verbalize fears and anxieties. Explain that attention will be withdrawn if rumination about physical complaints begins. Follow through.
   - The possibility of organic pathology must always be considered. Failure to do so could jeopardize pt safety.
7. Discuss possible alternative coping strategies pt may use in response to stress (relaxation exercises; physical activities; assertiveness skills). Give positive reinforcement for use of these alternatives.
   - Without consistency of limit setting, change will not occur.
8. Help pt identify ways to achieve recognition from others without resorting to physical symptoms.
   - Pt may need help with problem-solving. Positive reinforcement encourages repetition.
   Positive recognition from others enhances self-esteem and minimizes the need for attention through maladaptive behaviors.

Question 29

Fear (Of Having A Serious Disease) Goals for Patient

Answer 29

Patient will verbalize that fears associated with bodily sensations are irrational (within time limit deemed appropriate for specific individual).
Patient will interpret bodily sensations correctly.

Question 30

Fear (Of Having A Serious Disease) Interventions and Rationales for them

Answer 30

1. Monitor physician’s ongoing assessments and lab reports.
   - Organic pathology must be clearly ruled out.
2. Refer all new physical complaints to physician.
   - To ignore all physical complaints could place pt’s safety in jeopardy.
3. Assess the function that pt’s excessive concern is fulfilling for him or her (unfulfilled needs for dependency, nurturing, caring, attention, or control).
   - This info may provide insight into reasons for maladaptive behavior and provide direction for planning client care.
4. Identify times during which preoccupation with physical symptoms is worse. Determine extent of correlation of physical complaints with times of increased anxiety.
   - Pt may be unaware of the psychosocial implications of the physical complaints. Knowledge of the relationship is the first step in the process for creating change.
5. Convey empathy. Let pt know that you understand how a specific symptom may conjure up fears of previous life-threatening illness.
   - Unconditional acceptance and empathy promote a therapeutic nurse/client relationship.
6. Initially provide patient a limited amount of time to discuss physical concerns.
   - Because this has been his/her primary method of coping for so long, complete prohibition of this activity would likely raise pt’s anxiety level significantly, further exacerbating the behavior.
7. Help pt determine what techniques may be most useful for him or her to implement when fear and anxiety are exacerbated (relaxation techniques, mental imagery, thought-stopping techniques, physical exercise).
   - All of these techniques are effective to reduce anxiety and may assist pt in the transition from focusing on fear of physical illness to the discussion of honest feelings.
8. Gradually increase the limit on amount of time spent each hour in discussing physical concerns. If pt violates the limits, withdraw attention.
   - Lack of positive reinforcement may help to extinguish maladaptive behavior.
9. Facilitate patient discussion of feelings associated with fear of serious illness.
   - Verbalization of feelings in a nonthreatening environment facilitates expression and resolution of disturbing emotional issues. When the pt can express feelings directly, there is less need to express them through physical symptoms.
10. Role-play the patient’s plan for dealing with the fear the next time it assumes control and before anxiety becomes disabling.
    - Anxiety and fears are minimized when patient has achieved a degree of comfort through practicing a plan for dealing with stressful situations in the future.

Question 31

Disturbed Sensory Perception Goals for Patient

Answer 31

Patient will verbalize understanding of emotional problems as a contributing factor to the alteration in physical functioning (within time limit appropriate for specific individual).
Patient will demonstrate recovery of lost or altered function.

Question 32

Disturbed Sensory Perception
Interventions and Rationales for them

Answer 32

1. Monitor physician’s ongoing assessments, lab reports, and other data to ensure that organic pathology is ruled out.
   - Failure to do so may jeopardize pt safety.
2. Identify primary or secondary gains that the physical symptom may be providing (e.g., increased dependency, attention, protection from experiencing a stressful event).
   - Primary and secondary gains are often etiological factors and may be used to assist in problem resolution.
3. Do not focus on the disability and encourage pt to be as independent as possible. Intervene only when pt requires assistance.
   - Positive reinforcement would encourage continual use of the maladaptive response for secondary gains, such as dependency.
4. Maintain nonjudgmental attitude when providing assistance to the pt. The physical symptom is not within the pt’s conscious control and is very real to him or her.
   - A judgmental attitude interferes with the nurse’s ability to establish trust and provide therapeutic care for the patient.
5. Identify the expectation and importance of pt attending therapeutic activities. Withdraw attention if pt continues to focus on physical limitations as a reason to avoid participation.
   - Somatization may be used to avoid addressing issues. Clarifying expectations facilitates follow-through. Lack of reinforcement may help to extinguish the maladaptive response.
6. Encourage the pt to verbalize fears and anxieties. Help identify physical symptoms as a coping mechanism that is used in times of extreme stress.
   - Pts with conversion disorder are usually unaware of the psychological implications of their illness.
7. Help pt identify coping mechanisms that he/she could use when faced with stressful situations, rather than retreating from reality with a physical disability.
   - Educating and engaging the pt in identifying alternative coping strategies helps diminish the need for maladaptive responses.
8. Give positive reinforcement for identification or demonstration of alternative, more adaptive coping strategies.
   - Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors.

Question 33

Deficient Knowledge (psychological factors affecting medical condition)
Goals for Patient

Answer 33

Patient will cooperate with plan for teaching provided by primary nurse.
By time of discharge from treatment, patient will be able to verbalize psychological factors affecting his or her physical condition.

Question 34

Deficient Knowledge (psychological factors affecting medical condition)
Interventions and Rationales for them

Answer 34

1. Assess level of knowledge regarding effects of psychological problems on the body.
   - An adequate database is necessary for the development of an effective teaching plan.
2. Assess level of anxiety and readiness to learn.
   - Learning does not occur beyond the moderate level of anxiety.
3. Discuss physical examinations and lab tests that have been conducted. Explain purpose and results of each.
   - Fear of the unknown may contribute to elevated level of anxiety. Pt has the right to know about and accept or refuse any medical treatment.
4. Explore feelings and fears. Go slowly. These feelings may have been suppressed or repressed for so long that their disclosure may be a very painful experience. Be supportive.
   - Expression of feelings in the presence of a trusted individual and in a nonthreatening environment may encourage the individual to confront unresolved issues.
5. Have pt keep a diary of appearance, duration, and intensity of physical symptoms. A separate record of situations that the pt finds especially stressful should also be kept.
   - Comparison of these records may provide objective data from which to observe the relationship between physical symptoms and stress.
6. Help pt identify needs that are being met through the sick role. Together, formulate more adaptive means for fulfilling these needs. Practice by role-playing.
   - Repetition through practice serves to reduce discomfort in the actual situation.
7. Provide instruction in assertiveness techniques, especially the ability to recognize the differences among passive, assertive, and aggressive behaviors and the importance of respecting the rights of others while protecting one’s own basic rights.
   - These skills will preserve pt’s self-esteem while also improving his or her ability to form satisfactory interpersonal relationships.
8. Discuss adaptive methods of stress management, such as relaxation techniques, physical exercise, meditation, breathing exercises, and autogenics.
   - Use of these adaptive techniques may decrease appearance of physical symptoms in response to stress.

Question 35

Evaluation of the nursing actions for the patient with a somatic symptom disorder may be facilitated by gathering information using the following types of questions: Does the patient:

Answer 35

• Recognize signs and symptoms of escalating anxiety?
• Intervene with adaptive coping strategies to interrupt the escalating anxiety before physical symptoms are exacerbated?
• Verbalize an understanding of the correlation between physical symptoms and times of escalating anxiety?
• Have a plan for dealing with increased stress to prevent exacerbation of physical symptoms?
• Demonstrate a decrease in ruminations about physical symptoms?
• Express that fears of serious illness have diminished?
• Demonstrate full recovery from previous loss or alteration of physical functioning?

Question 36

Individual Psychotherapy
How is it used for Somatic Symptom and Related Disorders?

Answer 36

• The goal of psychotherapy is to help clients develop healthy and adaptive behaviors and to encourage them to move beyond their somatization and manage their lives more effectively.
• Treatment is initiated with a complete physical examination to rule out organic pathology.
• Clients may be more amenable to psychotherapeutic treatment, particularly stress management, when it is conducted in a medical setting.

Question 37

Group Psychotherapy
How is it used for Somatic Symptom and Related Disorders?

Answer 37

Group therapy may be helpful for somatic symptom disorders because it provides a setting where clients can share their experiences of illness, can learn to verbalize thoughts and feelings, and can be confronted by group members and leaders when they reject responsibility for maladaptive behaviors.

Question 38

Cognitive behavior therapy and psychoeducation
How is it used for Somatic Symptom and Related Disorders?

Answer 38

• Cognitive behavior therapy is an effective strategy for reducing symptoms in clients with somatic diseases.
• Psychoeducation has also been identified as beneficial and includes teaching the patient that the symptoms may be related to or exacerbated by stress and anxiety.
• This teaching should be done in the context of a trusting relationship between the healthcare provider and the client because the client may resist the suggestion that physical symptoms could have a psychological foundation.
• Psychoeducation for family members/other support systems focuses on teaching these individuals to reward the client’s autonomy, self-sufficiency, and independence while being careful not to reinforce passivity and dependence associated with the sick role.

Question 39

Psychopharmacology
How is it used for Somatic Symptom and Related Disorders?

Answer 39

Medication is not effective unless it is being used to treat underlying depression or anxiety.
- Short term treatment of anxiety (benzodiazepines)
- Long term treatment use of benzodiazepines should be avoided because of the potential for addiction
- When antidepressant therapy is warranted, SSRIs are generally preferred.

Question 40

Dissociative Disorders are…

Answer 40

Dissociative disorders are defined by a disruption in psychobiological functions that would otherwise be integrated aspects of experience and cognition including memory, identity, consciousness, perception, behavior, emotion, body representation, and motor control.

Question 41

Dissociative Amnesia is…

Answer 41

The inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or a neurological or other medical condition
Onset of an amnestic episode usually follows severe psychosocial stress.

Question 42

Characteristics (Diagnostic Criteria) of Dissociative Amnesia
What is dissociative fugue?

Answer 42

1. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. Most often consists of localized (Unable to recall all incidents associated with a stressful event) or selective amnesia (The individual can recall only certain incidents associated with a stressful event for a specific period after the event), or generalized amnesia (The individual has amnesia for his or her identity and total life history.)
2. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition).
4. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
   - Specify if: With Dissociative fugue (Purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information).

Question 43

Dissociative Identity Disorder is…
Comorbidities

Answer 43

This disorder is characterized by the existence of two or more personality states in a single individual. These different personality states are sometimes referred to as alter identities or just alters.
It is not uncommon for clients with DID to also manifest with symptoms of other dissociative disorders, such as amnesia, fugue states, depersonalization, and derealization

Question 44

Characteristics (Diagnostic Criteria) of DID

Answer 44

1. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
2. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
5. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Question 45

Depersonalization-Derealization Disorder is…
Age of onset
Comorbidities

Answer 45

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.
The age of onset is typically late adolescence or early adulthood, and it is two to four times more common in women than in men
Often accompanied by anxiety, depression, fear of going insane, obsessive thoughts, somatic complaints, and an alteration in the subjective sense of time.

Question 46

Characteristics (Diagnostic Criteria) of Depersonalization-Derealization Disorder

Answer 46

1. The presence of persistent or recurrent depersonalization, derealization, or both
   - Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing).
   - Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
2. During the depersonalization or derealization experiences, reality testing remains intact.
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).
5. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, PTSD, or another dissociative disorder.

Question 47

Predisposing Factors Associated with Dissociative Disorders
Genetics

Answer 47

The overwhelming majority of adults with DID have a history of physical and sexual abuse, and although genetic factors are being studied, preliminary research does not show evidence of a significant genetic contribution

Question 48

Predisposing Factors Associated with Dissociative Disorders
Neurobiological

Answer 48

• Some clinicians have suggested a possible correlation between neurological alterations and dissociative disorders.
• Although available information is inadequate, it is possible that dissociative amnesia may be related to neurophysiological dysfunction.
• Depersonalization has been associated with migraines and with marijuana use; responds to selective serotonin reuptake inhibitors (SSRIs); and is seen in cases where L-tryptophan, a serotonin precursor, is depleted—these facts all suggest some level of serotonergic involvement in this dissociative symptom

Question 49

Predisposing Factors Associated with Dissociative Disorders
Psychodynamic Theory

Answer 49

• Freud believed that dissociative behaviors occurred when individuals repressed distressing mental contents from conscious awareness.
• Current psychodynamic explanations of dissociation are based on Freud’s concepts.
• The repression of mental contents is believed to protect the client from extreme emotional pain triggered by either disturbing external circumstances or anxiety-provoking internal urges and feelings.

Question 50

Predisposing Factors Associated with Dissociative Disorders
Psychological Trauma

Answer 50

• A growing body of evidence points to the etiology of dissociative disorders as a response to traumatic experiences that overwhelm the individual’s capacity to cope by any means other than dissociation.
• In DID, these experiences are most often physical, sexual, or psychological abuse by a parent or significant other in the child’s life.
• The most widely accepted explanation for DID is that it begins as a survival strategy that serves to help children cope with the horrifying sexual, physical, or psychological abuse and evolves into a fragmented identity as the victim struggles to meld conflicting aspects of personality into an integrated whole
• Dissociative amnesia is frequently related to acute and extreme trauma but may also develop in the clinical presentation of DID.
• Dissociative amnesia is also often noted in response to combat trauma during wartimes.

Question 51

Disturbed sensory perception [visual/kinesthetic]
Behaviors

Answer 51

Alteration in the perception or experience of the self or the environment (depersonalization-derealization disorder)

Question 52

Impaired Memory
Behaviors

Answer 52

Loss of memory (dissociative amnesia)

Question 53

Powerlessness
Behaviors

Answer 53

Verbalizations of frustration over lack of control and dependence on others (dissociative amnesia)

Question 54

Risk for suicide
Behaviors

Answer 54

Unresolved grief; depression; self-blame associated with childhood abuse (DID)

Question 55

Disturbed personal identity
Behaviors

Answer 55

Presence of more than one personality within the individual (DID)

Question 56

Ineffective coping
Behaviors

Answer 56

Feigning of physical or psychological symptoms to gain attention (factitious disorder)

Question 57

Impaired Memory
Goals for Patient

Answer 57

Patient will verbalize understanding that loss of memory is related to a stressful situation and begin discussing the stressful situation with nurse or therapist.
Patient will recover deficits in memory and develop more adaptive coping mechanisms to deal with stressful situations.

Question 58

Impaired Memory
Interventions and Rationales for them

Answer 58

1. Obtain as much information as possible about the pt from fam and SOs if possible. Consider likes, dislikes, important people, activities, music, and pets.
   - A comprehensive baseline assessment is important for the development of an effective plan of care.
2. Do not flood pt with data regarding his/her past life.
   - Individuals who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state.
3. Instead, expose pt to stimuli that represent pleasant experiences from the past, such as smells associated with enjoyable activities, beloved pets, and music. As memory begins to return, engage pt in activities that may provide additional stimulation.
   - Recall may occur during activities that simulate life experiences.
4. Encourage pt to discuss situations that have been especially stressful and to explore the feelings associated with those times.
   - Verbalization of feelings in a nonthreatening environment may help pt come to terms with unresolved issues that may be contributing to the dissociative process.
5. Identify specific conflicts that remain unresolved and assist pt to identify possible solutions. Provide instruction regarding more adaptive ways to respond to anxiety.
   - Unless these underlying conflicts are resolved, any improvement in coping behaviors must be viewed as only temporary.

Question 59

Disturbed Personal Identity
Goals for Patient

Answer 59

■ Patient will verbalize understanding about the existence of multiple identities within the self.
■ Patient will be able to recognize stressful situations that precipitate transition from one identity to another.
■ Patient will verbalize understanding of the reason for existence of each personality and the role each plays for the individual.
■ Patient will enter into and cooperate with long-term therapy, the ultimate goal being integration into one personality.

Question 60

Disturbed Personal Identity
Interventions and Rationales for them

Answer 60

1. The nurse must develop a trusting relationship with the pt regardless of which identities are being manifested.
   - Trust is the basis of a therapeutic relationship. Each of the identities views itself as a separate entity and must initially be treated as such.
2. Help pt understand the existence of the subpersonalities and the need each serves in the personal identity of the individual.
   - Pt may initially be unaware of the dissociative response. Knowledge of the needs each identity fulfills is the first step in the integration process.
3. Help pt identify stressful situations that precipitate transition from one identity to another. Carefully observe and record these transitions.
   - Identification of stressors is required to assist pt in responding more adaptively and to eliminate the need for transition to other identities.
4. Use nursing interventions necessary to deal with maladaptive behaviors associated with individual subpersonalities. Note: It may be possible to seek assistance from one of the identities.
   - The safety of patient and others is a nursing priority.
5. Help the pt recognize that intervention is intended to promote an integrated, unified identity within the individual.
   - Because subpersonalities function as separate entities, the idea of total elimination generates fear and defensiveness.
6. Provide support during disclosure of painful experiences and reassurance when patient becomes discouraged with lengthy treatment.
   - Positive reinforcement may encourage repetition of desirable behaviors.

Question 61

Disturbed Sensory Perception (Visual/Kinesthetic)
Goals for Patient

Answer 61

Patient will verbalize adaptive ways of coping with stress.
Patient will demonstrate the ability to perceive stimuli correctly and maintain a sense of reality during stressful situations.

Question 62

Disturbed Sensory Perception (Visual/Kinesthetic)
Interventions and Rationales for them

Answer 62

1. Provide support and encouragement during times of depersonalization.
   - Pts manifesting these symptoms may express fear and anxiety at experiencing such behaviors. They don’t understand the response and may express a fear of going insane. Support and encouragement provide a feeling of security when fears and anxieties are manifested.
2. Explain the depersonalization behaviors and the purpose they usually serve for the pt.
   - This knowledge may help to minimize fears and anxieties associated with their occurrence.
3. Explain the relationship between severe anxiety and depersonalization behaviors. Help relate these behaviors to times of severe psychological stress that pt has experienced.
   - The pt may be unaware that the occurrence of depersonalization behaviors is related to severe anxiety. Knowledge of this relationship is the first step in the process of behavioral change.
4. Explore past experiences and possibly repressed painful situations, such as trauma or abuse, as the pt demonstrates readiness.
   - Prompting pts to recall traumatic events and experiences before they are ready can be retraumatizing, and premature recounting of traumatic experiences may predispose individuals to dissociative disorders.
5. Discuss these painful experiences with pt and encourage him or her to deal with the feelings associated with these situations. Work to resolve the conflicts these repressed feelings have nurtured.
   - Conflict resolution will serve to decrease the need for the dissociative response to anxiety.
6. Discuss ways the pt may more adaptively respond to stress and use role-play to practice using these new methods.
   - Role-play helps to prepare the pt to face stressful situations by using these new behaviors when they occur in real life.

Question 63

The following criteria may be used for the measurement of outcomes in the care of the client with dissociative disorders.
The client:

Answer 63

■ Recalls events associated with a traumatic or stressful situation (dissociative amnesia).
■ Verbalizes the extreme anxiety that precipitated the dissociation (depersonalization- derealization disorder).
■ Demonstrates more adaptive coping strategies to avert dissociative behaviors in the face of severe anxiety (depersonalization-derealization disorder).
■ Verbalizes understanding of the existence of multiple personality states and the purposes they serve (dissociative identity disorder).
■ Maintains a sense of reality during stressful situations (depersonalization-derealization disorder).

Question 64

Evaluation of the nursing actions for the patient with a dissociative disorder may be facilitated by gathering information using the following types of questions:
Does the patient:

Answer 64

• Recall memories accurately?
• Connect occurrence of psychological stress to loss of memory?
• Discuss fears and anxieties with members of the staff in an effort toward resolution?
• Discuss the presence of various identities within the self?
• Verbalize situations that precipitate transition from one identity to another?
• Maintain a sense of reality during stressful situations?
• Verbalize a correlation between stressful situations and the onset of depersonalization behaviors?
• Demonstrate more adaptive coping strategies for dealing with stress without resorting to dissociation?

Question 65

Individual Psychotherapy
How is it used in Dissociative Disorders?

Answer 65

Dissociative Amnesia
- Most clinicians recommend supportive psychotherapy to reinforce adjustment to the psychological impact of the retrieved memories and the emotions associated with them.
- Techniques of persuasion and free or directed association are used to help the client remember.
DID
- Clients are assisted to recall past traumas in detail. They must mentally reexperience the abuse that caused their illness. This process, called abreaction, or “remembering with feeling,” is so painful that clients may cry, scream, and feel the pain that they felt at the time of the abuse.

Question 66

Hypnosis
How is it used for Dissociative Disorders?

Answer 66

Dissociative Amnesia
- Hypnosis may be required to mobilize the memories
- Hypnosis is sometimes facilitated using pharmacological agents, such as sodium amobarbital.
- Once the memories have been obtained through hypnosis, supportive psychotherapy, group psychotherapy, and cognitive therapy may be employed to help the client integrate the memories into his or her conscious state.

Question 67

Cognitive Therapy
How is it used for Dissociative Disorders?

Answer 67

Dissociative Amnesia
- Cognitive therapy has an added benefit that when the client begins to correct cognitive distortions about the associated trauma, he or she may develop better recall of details about traumatic events

Question 68

Group Therapy
How is it used for Dissociative Disorders?

Answer 68

Once the memories have been obtained through hypnosis, supportive psychotherapy, group psychotherapy, and cognitive therapy may be employed to help the client integrate the memories into his or her conscious state.

Question 69

Integration Therapy
How is it used for Dissociative Disorders?

Answer 69

• The goal of therapy for the client with DID is to optimize the client’s function and potential.
• The achievement of integration (a blending of all the personality states into one) is usually considered desirable, but some clients choose not to pursue this lengthy therapeutic regimen.
• In these cases, resolution, or a smooth collaboration among the subpersonalities, may be all that is realistic.

Question 70

Psychopharmacology
How is it used for Dissociative Disorders?

Answer 70

• Many cases of dissociative amnesia resolve spontaneously when the individual is removed from the stressful situation. For more refractory conditions, IV administration of amobarbital is useful in the retrieval of lost memories.
• Info about the treatment of depersonalization-derealization disorder is sparse and inconclusive. Various psychiatric medications have been tried, both singly and in combination: antidepressants, mood stabilizers, anticonvulsants, and antipsychotics. Results are sporadic at best
• If other psychiatric disorders, such as schizophrenia, are evident, they too may be treated pharmacologically.