Study Guide for Somatoform, Factitious, and Dissociative Disorders

Overview of Somatoform, Factitious, and Dissociative Disorders

• Learning Outcomes

  • Describe anxiety disorders including Somatoform, Factitious, and Dissociative Disorders.

  • Review the prevalence and comorbidity of these disorders.

  • Discuss related theoretical frameworks.

  • Discuss collaborative management in patient care for these disorders.

• Constructs and Concepts

  • Attributes and Resources: Development, functional ability, and family dynamics.

  • Personal Preferences: Culture, spirituality, and self-management.

  • Mood and Cognition: Anxiety and cognition.

  • Nursing Attributes and Roles: Clinical judgment and patient education.

  • Care Competencies: Communication.

Somatic Symptom Disorders

• Definition:
      A group of disorders characterized by the presence of physical symptoms accompanied by abnormal thoughts, feelings, and behaviors in response to these symptoms, often in the absence of a known physical or medical illness.

• Key Characteristics:

  • Persistent preoccupation with perceived health issues.

  • Demands for unnecessary medical tests.

  • Non-compliance with physician recommendations.

  • "Doctor shopping": Visiting multiple physicians seeking medical attention.

  • Undergoing unwarranted procedures, invasive diagnostic tests, and surgeries.

  • Consciousness Level: Symptoms are involuntary and not under the conscious control of the patient.

• Prevalence and Comorbidity:

  • Approximately $30\\%$ of patients seen by primary care physicians present with unexplained symptoms diagnosed with no serious medical basis.

  • A comprehensive physical examination and diagnostic studies are required to rule out medical conditions.

  • Somatoform Disorder Point Prevalence: Approximately $2\\%$.

  • Criteria for Somatoform Disorders: Physical symptoms without demonstrable cause where anxiety is inferred, requiring at least $8$ physical complaints occurring before age $30$ (pain, gastrointestinal, sexual, and pseudoneurological issues).

• Etiology:

  • Genetic Factors: Evidence showing presence in $10 - 20\%$ of first-degree female relatives.

  • DSM-V Risk Factors:
    
    

    • Personality traits characterized by negativity.

    • Co-occurring anxiety or depression.

    • Lower educational levels and low socioeconomic status.

    • Cultural variation in the type and frequency of somatic symptoms.

Specific Somatoform and Related Disorders

• Illness Anxiety Disorder (Formerly Hypochondriasis)

  • Characterized by an exaggerated interpretation of physical signs as abnormal.

  • Involves an intense fear of having a serious disease.

  • Physician reassurance is typically ineffective.

• Conversion Disorder (Functional Neurological Symptom Disorder)

  • A somatic psychiatric disorder involving neurological-type symptoms affecting movement or sensation.

  • Symptoms cannot be explained by a neurological disorder (e.g., non-epileptic seizures or limb paralysis).

  • Rare; more common in females.

  • Symptoms are involuntary and distinct from malingering.

  • Distinguishing Features:
    
    

    • Disturbance in motor or sensory function without organic cause.

    • Symptoms permit avoidance of stress; typically triggered by a stressful situation.

    • Historically a frequent psychological diagnosis in soldiers during WWI.

    • La belle indifference: Lack of concern regarding the symptom, observed in approximately $1/3$ of cases.

• Body Dysmorphic Disorder (BDD)

  • Highly distressing and impairing disorder.

  • Average Age of Onset: < 20 years.

  • Characterized by preoccupation with an imagined "defective body part."

  • Common Areas of Concern: Face, skin, genitalia, thighs, hips, and hair.

  • Symptoms of BDD:
    
    

    • Strong belief of being deformed.

    • Belief that others notice the "flaw."

    • Constant comparisons with others.

    • Seeking reassurance.

    • Strong desire for plastic surgery and attempts to "fix" the flaw.

    • Social isolation.

Factitious Disorders and Malingering

• Differential Diagnosis Criteria

  • Unconscious Attempt: Somatic Symptom Disorder, Conversion Disorder, and Illness Anxiety Disorder.

  • Conscious Attempt: Factitious Disorder and Malingering.

• Factitious Disorder

  • Physical or psychological symptoms are intentionally produced or feigned to assume the "sick role."

  • Identified by Dr. Richard Asher (Munchausen's syndrome).

  • Motivations: Primary gain (internal), such as receiving medical attention or sympathy.

  • Characteristics: Symptoms presented with "dramatic flair," vague responses when questioned, pathological lying, extensive medical knowledge (often among nurses or healthcare workers).

  • Confrontation: Patients often discharge themselves and deny allegations to avoid treatment.

• Subtypes of Factitious Disorder

  • Factitious Disorder Imposed on Self: Deliberate symptom fabrication with no reward beyond attention.

  • Factitious Disorder Imposed on Another (Munchausen by Proxy/MSP): Perpetrator intentionally injures a victim (usually a child) to garner sympathy and attention.

• MSP Warning Signs:

  • Unexplained, prolonged illnesses unresponsive to treatment.

  • Discrepancies between clinical findings and patient history.

  • Signs only in parent's presence.

  • Parent is highly knowledgeable about the illness and treatments.

  • Parent remains very attentive, refusing to leave the hospital.

  • Other family members with similar symptoms.

• Malingering

  • Not considered a mental illness in the DSM-5.

  • Conscious and intentional production of symptoms for obvious external benefits (secondary gain), such as avoiding duties or gaining economic compensation.

Dissociative Disorders

• Definition:
      Disturbances in the normal well-integrated continuum of consciousness, memory, identity, and perception.

• Core Feature:
      Disruption in stable personality identity and alterations in conscious awareness, including forgetfulness or different personalities.

• Risk Factors and Etiology of DID:

  • Trauma and Abuse: Severe, repeated childhood trauma (physical, emotional, or sexual abuse).

  • Critical Threshold: Trauma before age $9$.

  • Splitting Off: An individual reacts to trauma by dissociating from the memory.

  • Neurodevelopmental Impact: Abuse affects the left hemisphere and limbic system, impacting mood, aggression, and memory.

• Types of Dissociative Disorders:

  1. Depersonalization/Derealization Disorder: Persistent alteration in self-perception; reality testing intact.

  2. Dissociative Amnesia: Psychologically induced memory loss; typically follows a severe stressor.
     
     

     • Localized Amnesia: Inability to recall specific events.

     • Generalized Amnesia: Loss of all autobiographical data and general knowledge.

  3. Dissociative Fugue: Sudden travel away from home with inability to recall identity.

  4. Dissociative Identity Disorder (DID): Presence of two or more distinct personality states (alters) that control behavior.

  5. DID NOS: Dissociative disorders not fitting specific criteria.

Collaborative Management and Nursing Care

• Nursing Assessment (History and Physical):

  • Mental Status Examination (MSE): Assessment of appearance, speech, motor activity, mood, affect, perceptions, thought content/process, level of consciousness, memory, insight, and suicide assessment.

  • Social Assessment: Interaction ability in work and social life; assessing for marked distress or social isolation caused by pain.

• Nursing Diagnoses:

  • Ineffective Coping, Ineffective Role Performance, Powerlessness, Disturbed Body Image.

  • Pain (Acute or Chronic), Interrupted Family Processes, Spiritual Distress, Hopelessness.

  • For Dissociative Disorders: Disturbed Personal Identity, Risk for Self-Directed or Other-Directed Violence.

• Patient Outcomes:

  • Patient will articulate feelings of anger, shame, and guilt.

  • Patient will resume performance of work role behaviors.

  • Patient will identify ineffective coping and realistic appraisals of strengths.

• Treatment Modalities for Somatic Symptom Disorder:

  • Cognitive Behavioral Therapy (CBT): Change negative thought patterns.

  • Medication: SSRIs and short-term anti-anxiety medications (caution due to dependency risk).

  • Lifestyle Changes: Exercise, sleep hygiene, stress management.

  • Support Groups: For emotional validation.

• Specific Nursing Interventions:

  • For Somatic Symptoms: Offer explanations during testing; avoid reinforcing physical complaints; shift focus from symptoms to feelings; reward non-illness behaviors.

  • For Dissociative Disorders: Ensure safety in a protected environment; provide simple routines; support the patient during exploration of stressful events; teach stress reduction.