Somatoform and Sleep Disorders

Chapter 9

Concepts of Somatoform and Dissociative Disorders

• Somatoform disorders– Physical symptoms in absence of physiological cause– Associated with increased health care use

• May progress to chronic illness (sick role) behaviors

• Dissociative disorders– Disturbances in integration of consciousness,

memory, identify, and perception– Dissociation is unconscious mechanism to protect

against overwhelming anxiety

characterized

• physical symptoms suggesting medical disease but withoutwithout a demonstrable organic

pathological condition or a known pathophysiological mechanism to account for them.

• Somatoform disorders are more common – In women than in men– In those who are poorly educated– In those who live in rural communities– In those who are poor

Somatoform Disorders: General Information

• Prevalence– Rate unknown; estimated that 38% of primary

care patients have symptoms with no medical basis

– 55% of all frequent users of medical care have psychiatric problems

• Comorbidity• Depressive disorders, anxiety disorders, substance

use, and personality disorders common

Somatization Disorder• Diagnosis requires certain number of symptoms

accompanied by functional impairment– Pain: head, chest, back, joints, pelvis– GI symptoms: dysphagia, nausea, bloating,

constipation– Cardiovascular symptoms: palpitations, shortness of

breath, dizziness

• Comorbidity– Anxiety and depression

Hypochondriasis

• Widespread phenomenon– 1 out of 20 patients seek medical care

• Misinterpreting physical sensations as evidence of serious illness– Negative physical findings does not affect

patient’s belief that they have serious illness

• Cormorbidity– Depression, substance abuse, personality

disorder

Pain Disorder

• Diagnosed when testing rules out organic cause for symptom of pain– Evidence of significant functional impairment

• Suicide becomes serious risk for patients with chronic pain

• Typical sites for pain: head, face, lower back, and pelvis

• Cormorbidity– Depression, substance abuse, personality disorder

Body Dysmorphic Disorder (BDD

• Patient has normal appearance or minor defect but is preoccupied with imagined defective body part

– Presence of significant impairment in function

• Typical characteristics

– Obsessive thinking and compulsive behavior

• Mirror checking and camouflaging

– Feelings of shame

– Withdrawal from others

• Cormorbidity

– Depression, OCD, social phobia

Conversion Disorder

• Symptoms that affect voluntary motor or sensory function suggesting a physical condition– Dysfunction not congruent with functioning of

the nervous system

• Patient attitude toward symptoms– Lack of concern (la belle indifférence) or

marked distress

• Common symptoms– Involuntary movements, seizures, paralysis,

abnormal gait, anesthesia, blindness, and deafness

• Cormorbidity– Depression, anxiety, other somatoform

disorders, personality disorders

Nursing Process: Assessment Guidelines

• Collect data about nature, location, onset, characteristics and duration of symptoms– Determine if symptoms under voluntary control

• Identify ability to meet basic needs• Identify any secondary gains (benefits of

sick role)• Identify ability to communicate emotional

needs (often lacking)• Determine medication/substance use

Nursing Process: Diagnosis and Outcomes Identification

• Common nursing diagnosis assigned– Ineffective coping

• Outcomes identification– Overall goal: patient will live as normal life as

possible

Nursing Process: Planning and Implementation

• Long-term treatment/interventions usually on outpatient basis

• Focus interventions on establishing relationship– Address ways to help patient get needs met

other than by somatization

• Collaborate with family

Nursing Communication Guidelines for Patient with Somatoform Disorder

• Take symptoms seriously

– After physical complaint investigated, avoid further reinforcement

• Spend time with patient other than when complaints occur

• Shift focus from somatic complaints to feelings

• Use matter-of-fact approach to patient resistance or anger

• Avoid fostering dependence

• Teach assertive communication

Treatment for Somatoform Disorders

• Case management– Useful to limit health care costs

• Psychotherapy– Cognitive and behavioral therapy– Group therapy helpful

• Medications– Antidepressants (SSRIs)– Short-term use of antianxiety medications

• Dependence risk

Nursing Process: Evaluation

• Important to establish measurable behavioral outcomes as part of planning process

• Common for goals to be partially met– Patients with somatoform disorder have strong

resistance to change

Sleep Disorders: Introduction

• About 75 percent of adult Americans suffer from a sleep problem.

• 69% of all children experience sleep problems• The prevalence of sleep disorders increases with

advancing age• Sleep disorders add an estimated $28 billion to the

national health care bill.• Common types of sleep disorders include insomnia,

hypersomnia, parasomnias, and circadian rhythm sleep disorders

Sleep Disorders: Assessment• Insomnia

– Difficulty falling or staying sleep

• Hypersomnia (somnolence) – Excessive sleepiness or seeking excessive amounts of

sleep

• Narcolepsy: Similar to hypersomnia– Characteristic manifestation: Sleep attacks; the person

cannot prevent falling asleep

• Parasomnias – Nightmares, sleep terrors, sleep walking

• Sleep terror disorder – Manifestations include abrupt arousal from

sleep with a piercing scream or cry

• Circadian rhythm sleep disorders– Shift-work type

– Jet-lag type– Delayed sleep phase type

Nursing Process

• Nursing Diagnosis

• Planning/Implementation

• Outcomes

• Evaluation

Predisposing Factors• Genetic or familial patterns are thought to play a contributing role in primary insomnia, primary hypersomnia, narcolepsy, sleep terror disorder, and

sleepwalking.

• Various medical conditions, as well as aging, have been implicated in the etiology of insomnia.

• Psychiatric or environmental conditions can contribute to insomnia or hypersomnia.

• Activities that interfere with the 24-hour circadian rhythm hormonal and neurotransmitter functioning within the body predispose people to sleep-wake schedule disturbances.

Treatment Modalities

• Somatoform disorders– Individual psychotherapy– Group psychotherapy– Behavior therapy– Psychopharmacology Sleep disorders– Relaxation therapy– Biofeedback– Pharmacotherapy

• Primary hypersomnia/narcolepsy– Pharmacotherapy– CNS stimulants such as amphetamines

• Parasomnias– Centers around measures to relieve obvious stress

within the family– Individual or family therapy– Interventions to prevent injury