Chapter 20: Somatic Symptoms and Dissociative Disorders

Question 1

A client diagnosed with somatic symptom disorder (SSD) is most likely to exhibit which personality disorder characteristics?

1. Experiences intense and chaotic relationships with fluctuating attitudes toward others.
2. Socially irresponsible, exploitative, guiltless, and disregards rights of others.
3. Self-dramatizing, attention seeking, overly gregarious, and seductive.
4. Uncomfortable in social situations, perceived as timid, withdrawn, cold, and strange.

Answer 1

ANS: 3
Rationale: The nurse should anticipate that a client diagnosed with SSD would be self-dramatizing, attention seeking, and overly gregarious. It has been suggested that, in somatic symptom disorder, there may be some overlapping of personality characteristics and features associated with histrionic personality disorder. These symptoms include heightened emotionality, impressionistic thought and speech, seductiveness, strong dependency needs, and a preoccupation with symptoms and oneself.

Question 2

A nurse is working with a client diagnosed with SSD. What criteria would differentiate this diagnosis from illness anxiety disorder (IAD)?

1. The client diagnosed with SSD experiences physical symptoms in various body systems, and the client diagnosed with IAD does not.
2. The client diagnosed with SSD experiences a change in the quality of self-awareness, and the client diagnosed with IAD does not.
3. The client diagnosed with SSD disorder has a perceived disturbance in body image or appearance, and the client diagnosed with IAD does not.
4. The client diagnosed with SSD only experiences anxiety about the possibility of illness, and the client diagnosed with IAD does not.

Answer 2

ANS: 1
Rationale: Individuals experiencing somatic symptoms without corroborating pathology are considered to have SSD, and those with minimal or no somatic symptoms would be diagnosed with IAD, a diagnosis new to the DSM-5. Clients diagnosed with IAD have minimal or no somatic complaints, but present with intense anxiety and suspiciousness of the presence of an undiagnosed, serious medical illness.
Cognitive Level: Analysis
Integrated Process: Assessment

Question 3

Which would be considered an appropriate outcome when planning care for an inpatient client diagnosed with SSD?

1. The client will admit to fabricating physical symptoms to gain benefits by day three.
2. The client will list three potential adaptive coping strategies to deal with stress by day two.
3. The client will comply with medical treatments for physical symptoms by day three.
4. The client will openly discuss physical symptoms with staff by day four.

Answer 3

ANS: 2
Rationale: The nurse should determine that an appropriate outcome for a client diagnosed with SSD would be for the client to list three potential adaptive coping strategies to deal with stress by day two. Because the symptoms of SSD are associated with psychosocial distress, increased coping skills may help the client reduce symptoms.

Question 4

Which are examples of primary and secondary gains that clients diagnosed with SSD: predominately pain, may experience?

1. Primary: chooses to seek a new doctor; Secondary: euphoric feeling from new medications
2. Primary: euphoric feeling from new medications; Secondary: chooses to seek a new doctor
3. Primary: receives get-well cards; Secondary: pain prevents attending stressful family reunion
4. Primary: pain prevents attending stressful family reunion; Secondary: receives get-well cards

Answer 4

ANS: 4
Rationale: The nurse should identify that primary gains are those that allow the client to avoid an unpleasant activity (stressful family reunion) and that secondary gains are those in which the client receives emotional support or attention (get-well cards).

Question 5

A nursing instructor is teaching about the etiology of IAD from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred?

1. “They tend to have a familial predisposition to this disorder.”
2. “When the sick role relieves them from stressful situations, their physical symptoms are reinforced.”
3. “They misinterpret and cognitively distort their physical symptoms.”
4. “They express personal worthlessness through physical symptoms, because physical problems are more acceptable than psychological problems.”

Answer 5

ANS: 4
Rationale: The nurse should understand that from a psychoanalytical perspective, IAD occurs because physical problems are more acceptable than psychological problems. Psychodynamicists view IAD as a defense mechanism.

Question 6

An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority?

1. Encourage exploration of sexual abuse.
2. Encourage guided imagery.
3. Establish trust and rapport.
4. Administer antianxiety medications.

Answer 6

ANS: 3
Rationale: The nurse should prioritize establishing trust and rapport when beginning to work with a client diagnosed with DID. DID was formerly called multiple personality disorder. Trust is the basis of every therapeutic relationship. Each personality views itself as a separate entity and must be treated as such to establish rapport.

Question 7

A client diagnosed with DID switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function?

1. It is a means to attain secondary gain.
2. It is a means to explore feelings of excessive and inappropriate guilt.
3. It serves to isolate painful events so that the primary self is protected.
4. It serves to establish personality boundaries and limit inappropriate impulses.

Answer 7

ANS: 3
Rationale: The nurse should anticipate that a client who switches personalities when confronted with destructive behavior is dissociating in order to isolate painful events so that the primary self is protected. The transition between personalities is usually sudden, dramatic, and precipitated by stress.

Question 8

A client is diagnosed with DID. What is the primary goal of therapy for this client?

1. To recover memories and improve thinking patterns.
2. To prevent social isolation.
3. To decrease anxiety and need for secondary gain.
4. To collaborate among sub-personalities to improve functioning.

Answer 8

ANS: 4
Rationale: The nurse should anticipate that the primary therapeutic goal for a client diagnosed with DID is to collaborate among sub-personalities to improve functioning. Some clients choose to pursue a lengthy therapeutic regimen to achieve integration, a blending of all the personalities into one. The goal is to optimize the client’s functioning and potential.

Question 9

According to the DSM-5 diagnostic criteria for dissociative amnesia (DA), what symptom would be essential to meet the criteria for the subcategory of dissociative fugue?

1. An inability to recall important autobiographical information
2. Clinically significant distress in social and occupational functioning
3. Sudden unexpected travel or bewildered wandering
4. “Blackouts” related to alcohol toxicity

Answer 9

ANS: 3
Rationale: An inability to recall important autobiographical information and clinically significant distress in social and occupational functioning are basic criteria for the diagnosis of DA. A specific subtype of dissociative amnesia is with dissociative fugue. Dissociative fugue is characterized by a sudden, unexpected travel away from customary place of daily activities, or by bewildered wandering, with the inability to recall some or all of one’s past. The DSM-5 also states that symptoms cannot be attributable to the direct physiological effects of a substance (e.g., alcohol, a drug of abuse, a medication).

Question 10

Which situation is an example of selective amnesia?

1. A client cannot relate any lifetime memories.
2. A client can describe driving to Ohio but cannot remember the car accident that occurred.
3. A client often wanders aimlessly after sunset.
4. A client cannot provide personal demographic information during admission assessment.

Answer 10

ANS: 2
Rationale: Three types of disturbance in recall are identified in the DSM-5: localized, selective, and generalized. Localized and selective amnesia are related to a specific stressful event that has occurred. In selective amnesia, the individual can recall only certain incidents associated with a stressful event for a specific period after the event. In the generalized type, the individual has amnesia for his or her identity and total life history.

Question 11

Neurological tests have ruled out pathology in a client’s sudden lower-extremity paralysis. Which nursing care should be included for this client?

1. Deal with physical symptoms in a detached manner.
2. Challenge the validity of physical symptoms.
3. Meet dependency needs until the physical limitations subside.
4. Encourage a discussion of feelings about the lower-extremity problem.

Answer 11

ANS: 1
Rationale: The nurse should assist the client in dealing with physical symptoms in a detached manner. This client should be diagnosed with a conversion disorder in which symptoms affect voluntary motor or sensory functioning with or without apparent impairment of consciousness. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations.

Question 12

Which combination of diagnoses and appropriate pharmacological treatments are correctly matched?

1. SSD: predominantly pain; treated with venlafaxine (Effexor)
2. IAD; treated with cefadroxil (Duricef)
3. Conversion disorder; treated with cyclobenzaprine (Flexeril)
4. Depersonalization-derealization disorder; treated with mometasone (Elocom)

Answer 12

ANS: 1
Rationale: The nurse should anticipate that the diagnosis of SSD: predominantly pain can be effectively treated with venlafaxine. Antidepressants are often used with somatic symptom disorder when the predominant symptom is pain. They have been shown to be effective in relieving pain, independent of influences on mood.

Question 13

A nurse is reviewing progress notes on a newly admitted client. One progress note reveals that the client purposefully inserted a contaminated catheter into urethra, leading to a urinary tract infection. The nurse recognizes this behavior as characteristic of which mental disorder?

1. Illness anxiety disorder
2. Factitious disorder
3. Functional neurological symptom disorder
4. Depersonalization-derealization disorder

Answer 13

ANS: 2
Rationale: Factitious disorders involve conscious, intentional feigning of physical or psychological symptoms. Individuals with factitious disorder pretend to be ill in order to receive emotional care and support commonly associated with the role of “patient.” Individuals become very inventive in their quest to produce symptoms. Examples include self-inflicted wounds, injection or insertion of contaminated substances, manipulating a thermometer to feign a fever, urinary tract manipulation, and surreptitious use of medications.

Question 14

A nursing instructor is teaching about the DSM-5 diagnosis of depersonalization-derealization disorder (D-DD). Which student statement indicates a need for further instruction?

1. “Clients with this disorder can experience emotional and/or physical numbing and a distorted sense of time.”
2. “Clients with this disorder can experience unreality or detachment with respect to their surroundings.”
3. “During the course of this disorder, individuals or objects are experienced as dreamlike, foggy, lifeless, or visually distorted.”
4. “During the course of this disorder, the client is out of touch with reality and is impaired in social, occupational, or other areas of functioning.”

Answer 14

ANS: 4
Rationale: D-DD 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. Depersonalization (a disturbance in the perception of oneself) is differentiated from derealization, which describes an alteration in the perception of the external environment. The DSM-5 states that during the depersonalization and/or derealization experiences, reality testing remains intact. This student statement indicates a need for further instruction.

Question 15

A client is diagnosed with IAD. Which of the following symptoms is the client most likely to exhibit? (Select all that apply.)

1. Obsessive-compulsive behaviors
2. Pseudocyesis
3. Anxiety
4. Flat affect
5. Depression

Answer 15

ANS: 1, 3, 5
Rationale: The nurse should expect that a client diagnosed with IAD would exhibit obsessive-compulsive behaviors, anxiety, and depression. Hypochondriasis involves an unrealistic or inaccurate interpretation of physical symptoms or sensations that can lead to preoccupation and fear of having a serious disease.

Question 16

A client is diagnosed with functional neurological symptom disorder (FNSD). Which of the following symptoms is the client most likely to exhibit? (Select all that apply.)

1. Anosmia
2. Anhedonia
3. Akinesia
4. Aphonia
5. Amnesia

Answer 16

ANS: 1, 3, 4
Rationale: FNSD can also be termed conversion disorder. Conversion symptoms affect voluntary motor or sensory functioning suggestive of neurological disease. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, loss of pain sensation, and hallucinations.

Question 17

A client is exhibiting symptoms of generalized amnesia. Which of the following questions should the nurse ask to confirm this diagnosis? (Select all that apply.)

1. “Have you taken any new medications recently?”
2. “Have you recently traveled away from home?”
3. “Have you recently experienced any traumatic event?”
4. “Have you ever felt detached from your environment?”
5. “Have you had any history of memory problems?”

Answer 17

ANS: 1, 3, 5
Rationale: The nurse should assess the client for possible causes of amnesia, which may include side effects of new medications, experiencing a traumatic event, or having a history of memory problems. Three types of disturbance in recall are identified in the DSM-5: localized, selective, and generalized. In the generalized type, the individual has amnesia for his or her identity and total life history.