Somatic Symptom & Dissociative Disorders

Somatic symptom disorder (SSD)

- A focus on somatic or physical symptoms such as pain

- Clients report excessive concern, anxiety, fear, and preoccupation related to a condition

Somatization

When emotional distress and psychological issues are exhibited in physical manifestations that cannot be explained medically

Diagnosis of SSD

Based on the client's experience of distressing somatic symptoms (physical manifestations that may be excessive and are functionally debilitating) and disruptive/atypical thoughts, feelings, and behaviors in response to the physical symptoms

- Can be undiagnosed in older adults

Illness anxiety disorder

- When a client experiences constant thoughts about having a significant illness (hypochondriasis)

- Often the client is misinterpreting their symptoms and may seek extensive treatment as a form of relieving their anxiety

- In some cases the client's need to seek treatment and receive a medical diagnosis leads to a paradoxical reaction, causing more severe anxiety

- Older individuals often experience somatic symptoms in fear of losing memory and sensory functioning

Functional neurological symptom disorder

- A client may experience motor weakness of paralysis, tremors, reduced tactile, visual, and auditory sensations, and in some cases, syncope

- Testing for underlying biological causes of these symptoms would result in a negative finding (EEG wouldn't show signs of seizure)

- Functional neurological symptom disorder is seen across the lifespan and has a better prognosis in younger children than in adults and adolescents

Factitious disorder

- When the client falsifies their symptoms to themselves or others, even when there is no external reward for doing so

- The client may self-induce, simulate, or fabricate their symptoms

Malingering

The intentional reporting of symptoms for personal gain.

- Not factitious disorder

Dissociative Disorders

Disruption in the way that memory, consciousness, identity, emotion, motor control, and behavior interact with each other

- Can be present in a person who has experienced trauma

- Dissociation is a defense mechanism that that client engages in unconsciously to protect from anxiety or stress

Positive dissociative symptoms

Depersonalization, division of identity, or derealization

Negative dissociative symptoms

Lack of control or access to mental functions that were previously controlled or accessible (amnesia)

Depersonalization/derealization disorder

- When the client experiences a detachment from their surroundings

- May describe feeling like they are floating out of their body or that they are in a dreamlike state

- Still able to test reality

Dissociative amnesia

Unable to recall events related to their history and is not consistent with normal forgetting

- Does not affect the ability to remember future events and is largely associated with traumatic events in the client's past

Dissociative identity disorder (DID)

Two or more distinct identities that take control of client behavior

- Sudden and temporary changes in consciousness, behavior, and identity

- The client may also report recurrent gaps in memory of everyday events, and their manifestations cause significant distress or disruption in social, occupational, or other areas of functioning

Alters

An alternative personality that has its own behaviors and personality

- Present in patients with DID

First step in management of DID ..

SAFETY

- Higher risk for suicidal ideation or self-injurious behavior

SSD across the lifespan

- Can be diagnosed at any age

- Increasing in children and adolescence, higher prevalence in females

- Most common in older adults and tends to worsen with age

- Older adults have an increase in the comorbidity of depressive and anxiety disorders related to the severity of their symptoms

- Older females who have an increased diagnosis of other physical disorders have higher rates of SSD

Dissociative disorders across the lifespan

- Dissociative disorders may develop from any point in early childhood through older adulthood

- The nurse should investigate how the client attempted or plans to resolve their feelings related to a stressor, rather than the stressor itself

SSD etiology

- Biological and genetic vulnerabilities

- ACEs (neglect, sexual abuse, psychological distress, inconsistent lifestyle patterns)

- Learned behaviors

- Low socioeconomic status, limited education and academic experiences, health-related events

SSD epidemiology

- It is estimated that the prevalence of SSD is 4% to 6% of the general population

- More females live with this disorder than males (10:1), and it can occur in childhood, adolescence, and adulthood.

Dissociative disorders etiology

More than 90% of individuals who are diagnosed with a dissociative disorder report some type of early childhood abuse or trauma

- Several twin-based genetic studies of dissociative disorders have suggested that this condition has a genetic component

SSD comorbidities

- Clients diagnosed with SSD are more likely to have psychiatric comorbidities of major depression, anxiety, substance use, and personality disorders

- Suicidal ideation and a history of suicide attempts are more frequent in SSD and related disorders

Dissociative disorders comorbidities

- Posttraumatic stress disorder, substance-related disorders, antisocial personality disorder, or a depressive disorder

- After experiencing an episode of dissociative amnesia, it is common for an individual to experience symptoms of guilt, rage, dysphoria, shame, and psychological conflict (may meet criteria for persistent depressive disorder)

- Manifestations of anxiety and depression are common for individuals diagnosed with depersonalization/derealization disorder

SSD DSM-5 Criteria

- One or more somatic symptoms that are distressing or result in significant disruption of daily life.

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.

- Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than six months).

Illness anxiety disorder manifestation

- Constantly researching specific manifestations or diseases.

- Continually exaggerating manifestations (for example believing a pain in their stomach is cancer).

- Obsessing about body functions and vital signs.

- High levels of anxiety related to health status.

- Oversharing manifestations with others or constantly seeking reassurance about these manifestations

Functional neurological symptom disorder manifestations

- It is considered a psychiatric disorder where emotional stress presents in physical symptoms​​​​​​​

- Neurologic symptoms may include blindness, paralysis, inability to swallow, or impairments in walking

- Comorbidities such as depression, anxiety, and posttraumatic stress disorder are often present. A history of childhood abuse is common

Factitious disorder manifestations

- Clients who have factitious disorder assume the sick role by misrepresenting their manifestations or deliberately injuring or infecting themselves in an attempt to have their emotional needs met

- These behaviors are used to convince others that hospitalizations, procedures, or even invasive surgeries are needed

Factitious disorder imposed on another

- May be present if a family member or caregiver presents to others as sick, such as when a parent falsely claims their child is ill

- In severe cases, a parent or caregiver intentionally injures a person under their care

Dissociative amnesia disorder manifestations

Dissociative amnesia can be:

• localized – unable to remember an event or period of time (most common type)

• selective – unable to remember a specific aspect of an event or some events within a period of time

• generalized – complete loss of identity and life history (rare)

Derealization

Feel detached from their environment or that objects around them are unreal

- A client may describe feeling like they are a giant and that the chairs in the room are in are small

Depersonalization

Where they feel like they are seeing themselves from outside of their body

- Some clients report transient manifestations, while others experience manifestations that are triggered by a stressful event and then become more constant

DID manifestations

- Individuals with this disorder experience recurrent episodes that are outside of their control

- Clients who have this disorder may experience changes in perception, invasions into their conscious functioning, and changes to their sense of self

- Stress often exacerbates dissociative symptoms

SSD treatment and management

The main treatment goal is to help the client develop positive approaches to manage anxiety, decrease maladaptive behaviors, and cope with physical manifestations, rather than eliminate them

- Clients who have SSD often have a difficult time differentiating between normal body sensations and manifestations that point to something harmful

- Case management can help the client avoid unnecessary tests and procedures and decrease costs

- Only one primary care provider should be utilized with regularly scheduled visits to review symptoms and how the client is coping

Illness anxiety disorder treatment

- Reduce anxiety and improve quality of life

- Use SSRIs, such as fluoxetine, along with CBT/psychotherapy

Function neurological symptom disorder treatments

- No specific treatments for FNSD

- Physical, speech, and occupational therapy can be helpful

- CBT and psychotherapy

- Medications can be prescribed to treat pain, anxiety, depression, insomnia, or headache that may occur​​​​​​​

- Nurse should work with the client to develop positive coping skills and reduce stress and anxiety

Factitious disorder treatment

- The goal of treatment is to limit the risk of adverse events and self-harm of the patient and to reduce the number of treatments and procedures

- Psychotherapy is the first-line treatment (often involve multidisciplinary team)

- Medications such as SSRIs may be used to treat symptoms and/or any co-occurring mental health disorders, but not usually to treat factitious disorder itself

Challenges for caring with clients who have factitious disorder

- Clients will often go from one provider or hospital to another. - The client may have reluctance in allowing health care professionals to speak to family, friends, or previous health care providers who cared for the client

- Clients who have this disorder may cause significant harm to themselves (or others, in cases of factitious disorder imposed on another) and be emotionally labile or angry if hospital staff does not follow through with client requests

SSD nursing interventions

- Teach and encourage the use of relaxation techniques.

- Encourage the client to participate in cognitive behavioral therapy (CBT) and mindfulness-based interventions and therapy.

- Encourage positive thinking or assist with cognitive reframing.

- Assist the client in setting realistic goals.

- Provide symptomatic relief measures such as pain medication or digestive relief

- Always include a careful assessment and determine what has worked for the client in the past.

- Encourage self-management.

- Promote education about the disorder and the association between the symptom pathways for physical pain and emotional symptoms and their similarities. This can help clients understand the relationship between their physical and emotional symptoms.

- Establishing rapport, showing empathy, and providing education and explanations of care and disease treatment are associated with higher patient satisfaction, reduced patient complaints, and improved self-management​​​​​​​

- Provide medication education and encourage adherence.

- Focus communication on the facilitation of emotions over symptom severity.

DID treatment

- The priority goal during treatment and management of clients who have DID focuses on the safety of the client, as many clients who have this diagnosis also exhibit suicidal ideation and self-injurious behavior

- Individual psychotherapy and cognitive behavioral therapy are the most effective treatments for dissociative identity disorder

- Meds to target specific manifestations of disorder

Dissociative amnesia treatment

- The goal in treating dissociative amnesia is for the client’s memories to return and for the client to be able to safely process them

- Safety and suicide assessment should be a large part of nursing care for dissociative amnesia

- Psychotherapy, cognitive behavioral therapy, and dialectical behavioral therapy are commonly used in treatmen

- Meds to treat anxiety and depression

Depersonalization/derealization disorder treatment

The main treatment approach for depersonalization/derealization disorder is psychotherapy, which is conducted by a trained clinician and is often used in combination with cognitive behavioral therapy and/or dialectical behavioral therapy

- The priority of the nurse is client safety and reducing the client’s anxiety

SSD inpatient

- Clients who have somatic symptom and related disorders are rarely admitted to the inpatient mental health setting with this diagnosis alone

- There must be additional criteria, such as severe depression or suicidal thoughts

- The nurse will often work with clients who have this disorder in the outpatient setting

Periods of dissociation

- Provide a simple routine and assist with decision making if memory is impaired.

- Confirm the identity of the client as well as client orientation.

- Provide 1:1 therapeutic interaction and support when the client is exploring their feelings.

- Reflect on the client's feelings and use affirmations to promote a therapeutic interaction.

- Teach stress reduction.

- Provide a safe and controlled environment