Fluent Essays

Hello, this is a psychiatry assignment. Please read Chapter 12 of the PowerPoint attached below and answer the questions separately.  Somatic & Dissociative Disorder Activity After completing your reading assignment (Chapter 12) engage in the following activity: Which somatic or dissociative disorder/ condition piqued your interest the most and why?  Include at least two medications commonly used in its management.  List at least two important medications teaching a nurse could be engaged in related to side effects and/or food and dietary restrictions. Chapter 12 Somatic Symptom Disorders and Dissociative Disorders Copyright © 2017, Elsevier Inc. All Rights Reserved. Somatize Somatize is the tendency to experience and communicate physical symptoms in response to psychologic distress. Although medical tests repeatedly demonstrate no medical basis, people continue to seek relief from their somatic symptoms.   Copyright © 2017, Elsevier Inc. All Rights Reserved. 2 Discuss artwork as it relates to somatic symptoms. 2 Dissociation Daydreaming, fantasizing, and “zoning out” are all examples of healthy dissociation. However, severe traumatic dissociation comes from major trauma, and an individual may develop a disorder such as dissociative identity disorder (DID). Copyright © 2017, Elsevier Inc. All Rights Reserved. 3 Discuss artwork as it relates to dissociation and DID. Comparison Somatic Symptom Disorders Characterized by the presence of multiple, real, and/or physical symptoms for which no evidence of medical illness is revealed Accompanied by abnormal thoughts, feelings and reactions to these symptoms Dissociative Disorders Characterized by mental detachment from conscious awareness in reaction to abuse Involve a disruption in the consciousness with a significant impairment in memory, identity, social functioning, or perceptions of self Copyright © 2017, Elsevier Inc. All Rights Reserved. 4 Somatic Symptom Disorder Persistent preoccupation with and distress over physical symptoms. Client experiences symptoms of significant anxiety and life impairment. Associated with increased health care use, functional impairment, provider dissatisfaction, psychiatric co-morbidity, and failed treatment response. May be exacerbated by comorbidity of other physical disorders. Copyright © 2017, Elsevier Inc. All Rights Reserved. 5 Somatic Symptom Disorder: Theory Genetic Factors: Presents in 20\% of first-degree female relatives of female patients; may be higher in monozygotic twins and females Environmental: Environmental learning, early trauma, societal devaluing of psychologic distress, school stressors Psychologic Theory: Maladaptive/anxious attachment; perceived rejection from significant others; difficulty expressing distress verbally Interpersonal Model: Parental somatization; early abuse; early exposure to illness Copyright © 2017, Elsevier Inc. All Rights Reserved. 6 Clinical Picture Somatic Symptom Disorder Multiple physical symptoms; significant distress; impaired functioning; obsession with health concerns; actively seek medical relief Pain as predominant symptom; cause not always identifiable Persistent (> 6 months); mild, moderate, or severe Illness Anxiety Disorder Illness preoccupation with or without mild symptoms Persistent (> 6 months) high anxiety over health; alarmed by body sensations; may or may not seek help Copyright © 2017, Elsevier Inc. All Rights Reserved. 7 Clinical Picture (Cont.) Conversion Disorder Presents with impaired motor or sensory function complaint Findings inconsistent with known neurologic conditions Symptoms are not voluntarily controlled or created Exhibits either la belle indifference (lack of concern) or high distress Current theories dispute a purely psychologic origin: patients have smaller hippocampal volume Co-morbidities: childhood abuse, depression, anxiety, personality disorder Factitious Disorder Imposed on self Imposed on another Copyright © 2017, Elsevier Inc. All Rights Reserved. 8 Clinical Picture (Cont.) Factitious Disorder Imposed on Self Deliberate symptom fabrication or self-injury without obvious potential reward (attention assumed to be possible motivation—but not clear) Patient identifies self deceptively as impaired or ill Single or recurrent episodes Different from malingering: faking injury for obvious (usually monetary) gain Factitious Disorder Imposed on Another Perpetrator/patient is usually parent or caregiver; motivation is attention or nurturing for self at expense of a dependent victim Copyright © 2017, Elsevier Inc. All Rights Reserved. 9 Objective 1: Differentiate the significant differences between somatic symptom disorders and factitious disorders. Somatic symptom disorders General medical conditions affected by stress or psychologic factors Factitious disorders Fabrication of symptoms or self-inflicted injury to assume the sick role Copyright © 2017, Elsevier Inc. All Rights Reserved. 10 Objective 2: Identify factors that can make it difficult to identify somatic symptom disorders. Individuals with somatic symptom disorders are often seen in medical clinics and not psychiatric settings because the distressing symptoms present as primarily physical in nature. Actual diagnosed medical issues and somatic syndrome disorders can be present concurrently, which can make diagnosis difficult. Copyright © 2017, Elsevier Inc. All Rights Reserved. 11 Nursing Process for Somatic Symptom Disorders Nursing assessment: History and course of past symptoms; current physical and mental status No voluntary control over their symptoms, with the exception of factitious disorders Assess for secondary gains (benefits derived from symptoms) Cognitive style: Misinterpretation of physical stimuli; reality distortion regarding symptoms Ability to communicate emotional needs Dependence on medications (anxiolytics such as benzodiazepines; “rebound anxiety” on withdrawal) Copyright © 2017, Elsevier Inc. All Rights Reserved. 12 Dependence on Medication Patients with many somatic complaints often become dependent on pain, anxiety, and sleep medications. Physicians prescribe anxiolytic agents for patients concerned about symptoms. Patients often return to a physician for prescription renewal and seek treatment from many physicians. Nurse assessment of the medications used is important. Copyright © 2017, Elsevier Inc. All Rights Reserved. 13 Nursing Diagnoses for Somatic Symptom Disorders “Ineffective coping” (most common) Frequent causal statements: Distorted perceptions of symptoms Distorted perceptions of body functions Chronic pain of psychologic origin Dependence on pain relievers or anxiolytics Copyright © 2017, Elsevier Inc. All Rights Reserved. 14 Nursing Diagnoses for Somatic Symptom Disorders (Cont.) Other NANDA diagnoses: Ineffective Coping Ineffective Role Performance Impaired Social Interaction Ineffective Relationship Powerlessness Disturbed Body Image Pain (Acute or Chronic) Interrupted Family Processes Impaired Parenting Copyright © 2017, Elsevier Inc. All Rights Reserved. 15 Outcome Criteria Examples of potential outcome criteria Patient will: Articulate feelings such as anger, shame, guilt, and remorse. Resume work role behaviors. Identify ineffective coping patterns. Make realistic appraisal of strengths and weaknesses. Allow family involvement in decision making. Copyright © 2017, Elsevier Inc. All Rights Reserved. 16 Treatment: Primarily psychosocial interventions Physical and medical tests Nature, location, onset, and characteristics of symptoms Assessing the patient’s ability to meet basic needs Assessing the risks to safety and security needs Determining whether symptoms are under the patient’s control Identifying secondary gains the patient is experiencing Exploring the patient’s ability to state feelings and needs Type and amount of medication patient is using Copyright © 2017, Elsevier Inc. All Rights Reserved. 17 Implementation Case Study June, a 57-year-old accountant, has complained of chronic, severe lower back pain for the last 15 years. Numerous and expensive diagnostic tests reveal mild degenerative joint disease. When June arrives at the office on Monday mornings, she is “grumpy” and takes most of the morning to accomplish small tasks. Co-workers feel obligated to listen to June’s complaints but are growing weary. June is scheduled for a magnetic resonance imaging (MRI) study on Wednesday. She will be out of the office that day; however, when she returns to work on Thursday and Friday, she accomplishes little. (Continued) Copyright © 2017, Elsevier Inc. All Rights Reserved. 18 Audience Response Question Based on June’s complaints, and considering that diagnostic tests have not revealed anything that would account for her severe pain, which of the following might be an appropriate DSM-5 diagnosis? Factitious disorder Conversion disorder Illness anxiety disorder Somatic symptom disorder with pain Copyright © 2017, Elsevier Inc. All Rights Reserved. 19 Answer Based on June’s complaints and considering that diagnostic tests have not revealed anything that would account for her severe pain, which of the following might be an appropriate DSM-5 diagnosis? A. Factitious disorder B. Conversion disorder C. Illness anxiety disorder *D. Somatic symptom disorder with pain Copyright © 2017, Elsevier Inc. All Rights Reserved. 20 Case Study (Cont.) June is told by her physician that nothing was found on the MRI that would indicate that she should be in any high degree of pain. The physician recommends duloxetine HCl (Cymbalta). June states, “That medicine is an antidepressant, and I am NOT depressed. This pain is not just all in my head!” Later in the evening, June is brought to the emergency department by rescue. Her husband states she was severely agitated and drove to the lake. He found her staring out at the water. She was combative and screaming at him. He called 9-1-1. Copyright © 2017, Elsevier Inc. All Rights Reserved. 21 Critical Thinking Question June is now your patient. She frantically asks you, “Do you think I don’t have real pain and that I’m just imagining all this?” You have reviewed her medical history and the recent results of the MRI. Based on your knowledge of pain disorders, what is your most therapeutic response? “I believe that you have pain, but your MRI does not show that your pain should be this severe.” “I believe that you have pain, but you shouldn’t have pain this severe.” “I believe that you have pain, but for now we need to focus on making certain that you are stable and comfortable.” “I absolutely believe you, and I will speak with your physician to make certain you get the appropriate pain medication.” (Continued) Copyright © 2017, Elsevier Inc. All Rights Reserved. 22 Critical Thinking Answer A. “I believe that you have pain, but your MRI does not show that your pain should be this severe.” B. “I believe that you have pain, but you shouldn’t have pain this severe.” *C. “I believe that you have pain, but for now we need to focus on making certain that you are stable and comfortable.” D. “I absolutely believe you, and I will speak with your physician to make certain you get the appropriate pain medication.” Copyright © 2017, Elsevier Inc. All Rights Reserved. 23 Critical Thinking Question and Rationales A. “I believe that you have pain, but your MRI does not show that your pain should be this severe.” June is in the emergency department in a crisis and not ready to discuss the MRI. B. “I believe that you have pain, but you shouldn’t have pain this severe.” June would probably consider this response argumentative or judgmental. *C. “I believe that you have pain, but for now we need to focus on making certain that you are stable and comfortable.” This answer is best and prioritizes the first intervention, stabilizing the patient. More long-term treatment goals can turn to helping the patient meet needs without somatization, but in an initial crisis, focus on comfort. D. “I absolutely believe you, and I will speak with your physician to make certain you get the appropriate pain medication.” This response negates the possibility that the the pain might have a psychologic origin. Copyright © 2017, Elsevier Inc. All Rights Reserved. 24 Discussion Question Consider the following answer (from the previous slide) to June’s question regarding whether you believe she is in pain. When, if ever, would this answer be appropriate? If so, what makes it appropriate? A. “I believe that you have pain, but your MRI does not show that your pain should be this severe.” June is in the emergency department in a crisis and not ready to discuss the MRI. Copyright © 2017, Elsevier Inc. All Rights Reserved. 25 Case Study Discussion: Conversion Disorder Frederic is a sales representative for a jet corporation. His sales have been lagging, and his boss tells him, “In 3 weeks, I want you to make a presentation to 200 buyers. If you succeed in making sales, then you can keep your job.” Frederic works day and night and prepares an excellent presentation using the latest media technology. The day arrives, and Frederic is ready. When he begins the presentation, he is unable to see. No medical reason can explain his blindness. Discuss what has probably happened to Frederic related to a conversion disorder. What is the likely outcome? Frederic is taken to the emergency department, where he tells you, “I’m having a nervous breakdown!” What is your best response? Copyright © 2017, Elsevier Inc. All Rights Reserved. 26 Dissociative Disorders Depersonalization/Derealization Disorder Dissociative Amnesia Dissociative Amnesia with Fugue Dissociative Identity Disorder (DID) Copyright © 2017, Elsevier Inc. All Rights Reserved. 27 Dissociative Disorders Hallmark Characteristics Disturbances in a normally well-integrated continuum of consciousness, memory, identity, and perception. Dissociation—is the unconscious defense mechanism to protect an individual against overwhelming anxiety. Intact reality testing—is not delusional and not hallucinating. Includes amnesiac states. Copyright © 2017, Elsevier Inc. All Rights Reserved. 28 Objective 3: Describe and elaborate on the central components of three of the following dissociative disorders. Depersonalization disorder Derealization disorder Dissociative amnesia Dissociative fugue Dissociative identity Copyright © 2017, Elsevier Inc. All Rights Reserved. 29 Depersonalization/Derealization Disorder Recurrent periods of feeling unreal, detached, outside the body, dreamlike, numb, or with a distorted sense of time or visual perception Reality testing remains intact Symptoms are not related to medical condition or substance use Scenario: Janet is admitted to the ED with a sensation of “floating” and “not feeling very real.” Her ex-husband is with her and says “they were arguing over the deaths of their infant twins in a car accident last year, in which Janet was the driver at fault. This whole thing has led to our divorce,” he says. Copyright © 2017, Elsevier Inc. All Rights Reserved. 30 Objective 4: Giving clinical examples, compare and contrast dissociative amnesia and dissociative fugue. Dissociative Amnesia Psychologically induced memory loss and inability to recall important personal information after severe stressor Scenario: Bob’s vehicle hits an improvised explosive device (IED). He and his friend are thrown onto the sand. Bob’s friend dies. A convoy passes 2 hours later. Bob is sitting by his friend, staring into space, and is unable to state who or where he is. Bob states that he does not remember the explosion. (Continued) Copyright © 2017, Elsevier Inc. All Rights Reserved. 31 Objective 5: Giving clinical examples, compare and contrast dissociative amnesia and dissociative fugue. (Cont.) Dissociative Amnesia with Fugue Sudden, unexpected travel from a customary locale, and the inability to recall one’s identity after a traumatic event Scenario: Lin, 19 years old, is admitted to the psychiatric unit after police found her wandering in a Louisiana shopping mall parking lot. Lin does not recall who she is or where she lives. It is later found that Lin lives in Oregon, where her fiancé had cancelled their wedding 2 weeks earlier. Copyright © 2017, Elsevier Inc. All Rights Reserved. 32 Dissociative Identity Disorder (DID) Formerly known as multiple personality disorder, which is the presence of two or more personality states that control behavior. Each alternate personality (alter) has its own pattern of perceiving, affect, cognition, behavior, and memories. Severe sexual, physical, and/or psychologic trauma in childhood predisposes an individual to DID. Scenario: The psychiatric nurse practitioner who visits a women’s free health center notices that Taylor, 23, dresses, acts, writes, and speaks in extremely different ways at each visit and has lapses of memory in time, unable to remember the previous visits. Copyright © 2017, Elsevier Inc. All Rights Reserved. 33 Objective 6: Compare and contrast etiologies and basic symptoms of somatic and dissociative disorders. Essential Characteristics Etiology Consciousness Memory Identity Physical Symptoms Somatic symptom disorders Dissociative disorders Copyright © 2017, Elsevier Inc. All Rights Reserved. 34 Assessment: Dissociative Disorders Patient History: Recent injuries, seizure history, early trauma, memory/identity questions; history of similar episodes Mood: Depressed, anxious, unconcerned? Suicidal? Frequent shifts in mood and erratic behaviors? Use of alcohol or other drugs Effect on patient and family Copyright © 2017, Elsevier Inc. All Rights Reserved. 35 Outcomes: Dissociative Disorders Patient will verbalize clear sense of personal identity. Patient will report decrease in stress (using a scale of 1 to 10). Patient will report comfort with role expectations. Patient will plan coping strategies for stressful situations. Patient will refrain from injuring self. Copyright © 2017, Elsevier Inc. All Rights Reserved. 36 Implementation: Dissociative Disorders Communication Guidelines: Gentle, supportive, build rapport Health Teaching and Health Promotion: Coping skills, stress management; techniques to interrupt a dissociative episode; journal to identify triggers Milieu Therapy: safe; quiet, structured, supportive Psychotherapy: most effective treatment (special training required) Pharmacologic, Biological, and Integrative: Mostly for co-morbid symptoms Copyright © 2017, Elsevier Inc. All Rights Reserved. 37 Objective 7: Compare and contrast etiologies and basic symptoms of somatic and dissociative disorders Evaluation: Dissociative Disorders Patient safety has been maintained. Anxiety has been reduced and the patient has returned to a functional state. Conflicts have been explored. New coping strategies have permitted the patient to function at a better level. Stress is handled adaptively, without the use of dissociation. Therapeutic alliances have been fostered. Copyright © 2017, Elsevier Inc. All Rights Reserved. 38 Audience Response Question Which of the following is an appropriate expected outcome when working with a patient with DID? Patient will verbalize clear sense of personal identity. Patient will express feelings verbally rather than through the development of physical symptoms. Patient will experience no symptoms as a result of psychologic distress. Patient will understand the distinction between true physical pain and imagined pain. Copyright © 2017, Elsevier Inc. All Rights Reserved. 39 Answer *A. Patient will verbalize clear sense of personal identity. (Recovery from DID can take long-term therapy to address the abuse, dissolve the amnesic barriers between alter personalities leading to integration, and develop healthier coping skills.) B. Patient will express feelings verbally rather than through the development of physical symptoms. (This is an appropriate goal for a somatization disorder, rather than a dissociative disorder.) C. Patient will experience no symptoms as a result of psychologic distress. (Some symptoms will probably always exist.) D. Patient will understand the distinction between true physical pain and imagined pain. (No clear distinction exists for the patient or health care provider.) Copyright © 2017, Elsevier Inc. All Rights Reserved. 40 40