Somatoform and Sleep Disorders

1. Somatoform and Sleep Disorders Chapter 9

2. 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

3. characterized • physical symptoms suggesting medical disease but without 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Common symptoms • Involuntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, and deafness • Cormorbidity • Depression, anxiety, other somatoform disorders, personality disorders

11. 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

12. Nursing Process: Diagnosis and Outcomes Identification • Common nursing diagnosis assigned • Ineffective coping • Outcomes identification • Overall goal: patient will live as normal life as possible

13. 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

14. 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

15. Use matter-of-fact approach to patient resistance or anger • Avoid fostering dependence • Teach assertive communication

16. 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

17. 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

18. 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 disordersinclude insomnia, hypersomnia, parasomnias, and circadian rhythm sleep disorders

19. 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

20. 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

21. Nursing Process • Nursing Diagnosis • Planning/Implementation • Outcomes • Evaluation

22. 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.

23. Treatment Modalities • Somatoform disorders • Individual psychotherapy • Group psychotherapy • Behavior therapy • Psychopharmacology Sleep disorders • Relaxation therapy • Biofeedback • Pharmacotherapy

24. 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