- Psychiatric and Mental Health Care





9. Somatoform disorders The primary characteristic of somatoform disorder is the presence of physical symptoms that can t be substantiated by organic findings or identified physiologic mechanisms. These physical symptoms aren t intentionally produced by the client, yet they do cause the client significant distress or impairment in social, occupational, or daily functioning.

Somatoform Disorder DSM-IV CATEGORIES 300.81 Somatization disorder 300.81 Undifferentiated somatoform disorder 300.81 Somatoform disorder NOS With somatization disorder, the client experiences the recurrence of many clinically significant somatic problems. According to the DSM-IV criteria, there's a history of physical complaints beginning before age 30 and lasting over a period of years, eventually resulting in treatment being obtained. The client has a history of pain related to at least four different sites (such as the head, chest, abdomen, back, or joints). There's also a history of at least two Gl problems exclusive of pain. Often, the gastric symptoms lead to radiologic studies and abdominal surgery that later may be evaluated as not necessary. The client has at least one reproductive or sexual symptom other than pain. There's also a history of at least one symptom that suggests a neurologic problem. (For further information, see Symptoms Associated with Somatization Disorder) After a thorough investigation of the symptoms from each of the four categories is completed, these symptoms can't be explained by a medical condition or by the direct effects of a substance. When the client has a related medical condition, the physical complaints or impairment in social or occupational functioning is greater than what would be expected from the history, physical examination, and diagnostic studies. The symptoms experienced aren't feigned or intentionally produced by the client, as occurs in malingering or a factitious disorder. The symptoms are also unlike those in the client with hypochondrias is, who has a preoccupation with the fear that a severe medical problem is present based on misinterpretation o' symptoms. Clients with somatization disorder are often inconsistent in their histories, obtain health care from several providers simultaneously, and may encounter hazards from the combination of treatments. Anxiety and depression commonly occur in this population. Often, the personal lives of these clients are as complicated as their medical histories, and frequent use of medications may lead to adverse effects or substance-related disorders. SYMPTOMS ASSOCIATED WITH SOMMIZATIOM DISORDER History of pain (In at least four different sites or functions) Head Chest Abdomen Rectum

Back Joints Extremities

Gl symptoms (at least two) Nausea Bloating Hyperemesis not associated with pregnancy Diarrhea

Severe flatulence Abdominal pain not associated with menstruation Intolerance for specific foods

Reproductive or sexual symptoms (at least one) Dyspareunia Sexual indifference Burning sensation in sexual organs or rectum Dysmenorrhea Irregular menses

Menorrhagia Vomiting throughout pregnancy Impotence Erectile dysfunction Ejaculatory dysfunction

Nenrologic symptoms (at least one) Ataxia Amnesia Fainting or loss of consciousness Dysphagia Aphonia Deafness Blindness Blurred or double vision

Seizure Muscle weakness or paralysis Urine retention Dysuria Pain in extremities Back pain Joint pain Other pain (excluding headaches)

For the client with undifferentiated somatoform disorder, one or more physical complaints exist for longer than 6 months. The most common complaints are chronic fatigue, Gl problems, and genitourinary symptoms. Somatoform disorder NOS (not otherwise specified) is a category for disorders with somatoform symptoms that don't meet the criteria for a typical somatoform disorder. An example is pseudocyesis, a false pregnancy with objective signs of being pregnant. Somatoform disorder may have a neurophysiologic basis. Its physical symptoms may be related to faulty body perceptions o' misinterpretations of body sensations. There may be an amplification of sensations or limited inhibition of sensory input to the brain, possibly related to inadequate communication between the two hemispheres.

COMMUNICATION STRATEGIES Convey sincere interest in the client rather than in physical problems. Reinforce the client's sense of self-worth as a person. Acknowledge the client's concerns, and then move the discussion away from the symptoms. Identify and discuss the client's emotions. Encourage the client to take responsibility for his own needs. Emphasize the client's ability to learn new coping skills that help alleviate the symptoms. NURSING DIAGNOSIS: ANXIETY Probable Causes

Defining Characteristics

Underlying conflict about life goals and values Personal losses in employment, physical health, or family life Overwhelming stress associated with fear of role changes Depression Experiences of abuse or neglect

Verbalization of physical complaints in vague, dramatic Inability to express emotions Over involvement with body functions Use of symptoms for secondary gain Somatic complaints that are unsubstantiated by objective data

Long-Term Goal The client will demonstrate the use of healthy coping strategies to manage anxiety rather than develop physiologic symptoms. Short-Term Goal #1:The client will practice effective coping skills. Interventions and Rationales Encourage the client to identify coping skills and build on those skills that were effective in the past. This helps the client build on skills previously used in stressful situations. Help the client identify the positive aspects of self. This action promotes self-esteem. Discuss with the client how anxiety affects the body physically. Awareness of the relation between somatic symptoms and stress is needed before the client can change methods of coping with anxiety. Teach the client health promotion techniques, such as exercise, positive self-talk, and contact with others. These techniques help the client reduce anxiety and decrease somatization. Short-Term Goal #2: The client will demonstrate less attention to physical symptoms. Interventions and Rationales Encourage the client to discuss emotions and relate them to the current situation. This discussion helps the client understand the sources of somatic symptoms. Encourage the client to focus on emotions and topics other than physical complaints. The client can experience attention anc value as a person without using physical symptoms to obtain attention. Encourage the client to focus attention on self-care and social activities. Directing the client's energy into common and purposeful activities provides a way to enhance self-esteem, decrease social isolation, and reinforce normal thought patterns and habits..

THERAPIES Individual Therapy Help the client develop appropriate coping strategies. Discuss how to develop a healthy and productive lifestyle. Work with the client to see the relation between physical problems and emotional factors. Decrease over involvement with health care providers by encouraging the client to list all current symptoms that are know to be benign and to agree to seek health care only for new or exacerbated symptoms. Teach relaxation techniques, stress management skills, self-reinforcement of normal activities, and thought-stopping techniques concerning symptoms.

MEDICATIONS Clients with somatoform disorder usually don't benefit from medication. If severe anxiety is present, antianxiety drugs may be used. If severe depression is present, antidepressants, especially the selective serotonin reuptake inhibitors, may be used. (See Appendix D for medication information.)

FAMILY CARE Discuss how the client's condition affects the family. Work with family members to decrease the attention and concern they give to the client's symptoms. This is known as secondary gain. Explore healthy ways for the client to get needs met by family members rather than by manipulating others. Help the family find ways to focus on the client's strengths and communicate messages that enhance the client's self-esteem. Teach the family strategies to reduce stress. Help family members develop their communication skills so that they can more effectively share their emotions and engage in active listening.

Conversion Disorder DSM-IV CATEGORIES 300.11 Conversion disorder (specify type: with motor symptom or deficit/with sensory symptom or deficit/with seizures or convulsions/with mixed presentation) Conversion disorder is manifested by symptoms or deficits that affect voluntary motor capacity or sensory functioning. The symptoms seem to indicate that a physical disorder is present, but on observation and evaluation, it's discovered that the initiation or exacerbation of the symptoms is preceded by conflict and judged to be an expression of a psychological conflict. Typically, the symptoms aren't consciously produced, but they can't be explained physiologically after the client has been thoroughly evaluated. The symptoms or deficits cause the person distress and alterations in social, occupational, and other areas of functioning. It's believed that conversion disorder occurs when an unconscious conflict is disguised by somatic symptoms. The voluntary motor deficit or sensory loss keeps the internal conflict out of awareness or enables the person to avoid an activity that is threatening while simultaneously facilitating support that wouldn't otherwise be available. Often, the symptoms occur when the person is under extreme emotional distress. The client may exhibit "la belle indifference," a lack of concern about the condition. Onset typically occurs in late childhood to early adulthood. Chemical and biological factors influence how the central nervous system is aroused. Scientists believe these factors play a role in the development ofpseudoneurologic symptoms, especially the loss of sensation and loss of voluntary motor function. Cytokines, messenger molecules that the immune system uses to communicate to the central nervous system, may also be involved. (For further information, see Symptoms of Conversion Disorder.) SYMPTOMS OF CONVERSION DISORDER Blindness Diplopia Tunnel vision Anosmia Paralysis Anesthesia Paresthesia Aphonia

Sensation of lump in the throat Seizures Hallucinations Lack of coordination Akinesia Dyskinesia Urine retention

COMMUNICATION STRATEGIES Encourage the client to explore emotions. Help the client identify conflicts with self and others. Encourage the client to identify and examine personal and family expectations. Discuss and validate the client's strengths. Silently accept the client's need for the sick role, but avoid focusing discussion on the symptoms. Help the client describe unmet needs and how symptoms meet these needs. Have the client develop strategies to meet needs in healthier ways. NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING Probable Causes

Defining Characteristics

Severe anxiety Family history of inadequate coping skills Low self-concept Unmet basic needs

Verbalization about physical symptoms Refusal to participate in self-care activities Verbalization of problems in social and occupational functioning Long history of health-seeking behaviors

Long-Term Goal The client will express negative emotions verbally instead of developing physical symptoms. Short-Term Goal #1:The client will identify the relation between emotional conflict and physical symptoms. Interventions and Rationales Establish a supportive relationship that accepts the client and doesn't focus on the symptoms. Focusing the therapeutic relationship on the whole person rather than on the symptoms encourages the client to relinquish preoccupation with the sick role. Review all laboratory and diagnostic study reports to ascertain whether any physical problems may be present. Physiologic problems must be ruled out to provide proper care. Encourage the client to review and assess activities, lifestyle, relationships, and environment. A review of all aspects of the client s life helps uncover strengths and weaknesses as well as underlying emotional conflicts that give rise to the symptoms. Help the client identify unmet dependency needs and devise ways to satisfy them. Problems in meeting basic needs increase anxiety and reinforce symptoms. Encourage the client to identify and discuss emotional conflicts that occurred before the onset of symptoms. This intervention helps the client make a conscious connection between the emotional conflict and the subsequent symptom. Encourage the client to perform self-care activities, and monitor the client's progress. These positive actions reduce the sick role behavior. Short-Term Goal #2: The client will develop appropriate skills for handling emotional conflicts. Interventions and Rationales Direct the interaction with the client away from physical symptoms. Setting limits on the interactions with the client helps the client avoid/housing on physical symptoms. Facilitate the client's expression of anxiety, anger, and other negative or unpleasant emotions. Expression of emotions is the first step toward identifying and managing them. Teach the client to be sensitive to and to experience the normal physiologic manifestations of emotions, such as the heart beating faster, hands perspiring, and muscles tensing. Direct experience of personal emotions relieves the client of the need to express emotions through symptoms. Discuss with the client how body symptoms may be used to avoid dealing with emotional conflict. The client must be made aware that physical symptoms occur because of intense emotional conflict. Teach the client and have the client practice appropriate methods of expressing emotions and asking that needs be met. The client needs assistance with verbalizing anxiety, anger, sadness, and other negative emotions and with obtaining nurturing and support. Have the client develop skills, such as assertive behavior, conflict resolution, and relaxation methods, for coping with stress and dealing with conflicts. The acquisition of practical coping skills helps the client relinquish the sick role as a response to stress.

THERAPIES Individual Therapy Focus on areas of distress and recent change in the client's life. Examine what secondary gains are derived from the illness, and begin to explore the underlying conflict. Work on strategies to decrease anxiety. Facilitate direct expression of emotions. Work to eliminate manipulative behavior that the client may use to get needs met and to avoid working out conflicts. Explore how pain can be psychological as well as physiologic. Build self-esteem by helping the client identify accomplishments, make positive statements about self and use problem solving and effective coping skills. Promote the client's acceptance of stress and conflict as normal parts of life.

MEDICATIONS Antianxiety medications may be used for symptomatic relief of anxiety. (See Appendix D for medication information,)

FAMILY CARE Explain to the family the nature of the illness and the therapeutic interventions used. Explore with family members how they may be promoting secondary gains by cooperating with the client's sick role behavior. Teach the family how to set limits on the client's sick role behavior while still providing support. Help family members avoid focusing on the physical symptoms thus inadvertently reinforcing them. Teach the family how to decrease daily stressors and develop appropriate expectations of the client.

Pain Disorder DSM-IV CATEGORIES 307.xx Pain disorder 307.80 Pain disorder associated with psychological factors 307.89 Pain disorder associated with both psychological factors and a general medical condition (specify if: acute chronic The primary characteristic of pain disorder associated with psychological factors is the experience of pain of sufficient severity to warrant clinical attention. The pain causes the client significant distress and impairment, yet physical findings can't completely account for it. In pain disorder associated with both psychological factors and a general medical condition; both psychological factors and a diagnosed medical condition are fudged to play a role in the client's recurrent pain experience. Among the most frequent medical conditions associated with pain disorder are musculoskeletal conditions, neuropathies, and cancers. Sometimes the treatments provided for the pain produce additional problems or can cause even more pain. Despite medical evaluations, no patho-physiologic explanation accounts for the severity, frequency, or duration of the pain. If a pathologic process is found, it's insufficient to warrant the intensity of the pain. Research suggests that pain disorder may result from a brain chemistry imbalance or from structural deviations in the limbic system. A serotonin or endorphin deficiency may alter a person 5 perception of pain, causing it to be consistently perceived as severe, Many clients with this disorder are so preoccupied with me pain experience that they lose the capacity to work or maintain normal family and social ties. Often, they're unconscious of the emotional factors that contribute to the pain experience. Its common for the pain to lead to inactivity and social isolation and progress to depression. Over time, these clients may also develop substance dependence or abuse. Pain disorder can occur at an\ age, but the typical age of onset is during the 30s and 40s. More women than men are diagnosed with pain disorder.

COMMUNICATION STRATEGIES Encourage the client to discuss emotions. Help the client identify both physical and emotional stressors that seem to affect the experience of pain. Talk about what the client is able to do for herself and encourage discussion of possible changes in work routine or persona life that may minimize the pain. Encourage the client to address depression or anxiety that may have occurred as a result of the disorder or may have been preexisting. NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING Probable Causes

Defining Characteristics

Emotional conflict Distorted perceptions of pain Psychosocial and environmental stressors Cultural issues

Pain as the primary symptom Absence of pathologic condition that accounts for r-.e pain Little or no relief obtained from analgesics Difficulty expressing emotions

Long-Term Goal The client will verbalize understanding of the relation between pain and emotional problems. Short-Term Goal #1:The client will recognize and discuss stressful situations that precipitate the onset of pain or increase its severity. Interventions and Rationales Acknowledge the pain rather than challenge or minimize it. Acceptance of the client's pain as real prevents the client from using energy to convince the nurse and facilitate the nurse-client relationship. Explore sources of anxiety and conflict in the client's life. Identification ofstressors is essential in order to develop a plan for positive coping. Encourage the client to verbalize emotions and relate the pain to the escalating anxiety. The client needs to make the connection between stress and the response of physical pain. Help the client recognize situations that precipitate pain. The client needs to gain awareness of possible causes or factors that contribute to pain. Short-Term Goal #2: The client will demonstrate the use of pain-relief measures to maintain optimal daily functioning. Interventions and Rationales Help the client identify currently used measures that alleviate pain. Background information on the client's coping skills is used to determine the most effective ways to deal with pain. Reinforce or teach the client to use stress reduction strategies, such as guided imagery, visualization techniques, massage, music, meditation, deep breathing, and progressive relaxation exercises. These strategies provide the client with alternatives for handling pain and associated stressors. Encourage the client to develop purposeful activities, such as hobbies, exercise, and recreational interests. Purposeful activity that has meaning for the client helps refocus energy away from pain. Help the client develop a repertoire of physical comfort measures, such as applying heat or ice, receiving back rubs, soaking in warm water, and using supportive devices. These methods provide physical comfort for the client. Teach the client behavior modification techniques such as self-control therapy, in which the client talks herself through an experience when pain is occurring. For example, the client will say, "My arm is beginning to hurt. Take it easy. Sit down. Rest the arm and breathe deeply ... I'm feeling calmer. My arm is feeling better." By focusing on the positive, the client feels empowered and is less likely to revert to the invalid role. Work with the client to increase involvement in relationships and activities that enhance health rather than center on suffering and the sick role. It's important for the client to participate ir. activities that promote enjoyment and life satisfaction. Encourage the client to attend a pain support group. Group interaction promotes support, self-understanding, and an exchange of ideas on how to cope with pain.

THERAPIES Individual Therapy Work with the client to develop effective coping methods. Identify self-defeating behaviors, and have the client work to eliminate them. Help the client focus on identifying and expressing repressed feelings and meeting dependency needs. Teach the client and have the client practice strategies to control the pain. Work with the client to develop strategies to facilitate interpersonal relationships in order to decrease feelings of social isolation. Help the client verbalize needs and concerns appropriately. Reinforce self-care skills, and encourage the client to maintain maximum independence. Increase opportunities to enhance self-esteem, such as helping the client relate to others without drawing attention to physical symptoms and practicing assertiveness skills.

MEDICATIONS Muscle relaxants and analgesics are used judiciously. For severe anxiety, anti-anxiety medications may be prescribed. If persistent depression occurs, antidepressant drugs are used. (See Appendix D for medication information.)

FAMILY CARE Help the family understand the client's situation and typical responses to pain. Clarify for family members that although the client suffers from real pain, the underlying medical condition isn't severe enough to explain it. Teach the family how to support the client's own efforts to handle pain. Have the family reinforce the client's positive behaviors and actions that attempt to alleviate the pain. Prevent the family from inadvertently providing the client with secondary gains from the pain. Teach family members to accept the client's limitations and support the client to continue with life.

Hypochondriasis DSM-IV CATEGORIES 300.7 Hypochondriasis (specify if: with poor insight) The major characteristic of hypochondriasis is preoccupation with the fear of having or contracting a serious illness based on the person's misinterpretation of physical symptoms. The person construes all physical sensations as indications of illness. Even after undergoing a medical evaluation that doesn't support a diagnosis or physical disorder, the fear persists. The client's preoccupation with the symptoms causes distress or impairment in social, occupational, or other areas of general functioning and is present for at least 6 months. Most clients can acknowledge the possibility that the fear is unfounded. When the client doesn't recognize that the fear about having a serious illness is excessive or unreasonable, the diagnosis of hypochondriasis includes the specifier "with poor insight." These clients have a history of being very sensitive to body functions, and minor alterations are viewed as serious disease. The health history is detailed, and many health practitioners have been involved in the client's care. Many clients with this disorder are frustrated and angry that they aren't receiving appropriate treatment. Often, they experience anxiety and depression and have obsessive-compulsive characteristics. The disorder can occur at any age, most commonly in early adulthood, and it affects women and men equally. There are no identifiable neurologic or biological mechanisms to explain hypochondriasis.

COMMUNICATION STRATEGIES After diagnostic studies have ruled out organic illness, don't reinforce symptoms or complaints. Frankly acknowledge the client's health concerns without allowing the conversation to focus on the complaints. Focus on the client's developing awareness of emotions. Talk about topics other than physical complaints. Don't challenge the client's description of symptoms. Communicate interest in healthy aspects of the client's life and support the exploration of underlying emotional conflict. NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING Probable Causes Underlying emotional conflict Unmet dependency needs Lack of coping skills Anxiety as a hindrance to learning

Defining Characteristics Preoccupation with physical concerns Difficulty listening to health care providers Verbalization of complaints about body processes and physical sensations Denial of emotional problems

Long-Term Goal The client will develop a lifestyle that focuses on establishing satisfying relationships and activities rather than being preoccupied with physical symptoms. Short-Term Goal #1:The client will identify the association between strong personal emotions and physical symptoms. Interventions and Rationales Acknowledge the client's health concerns frankly, but don't allow these concerns to dominate the conversation. If discussion of symptoms is avoided or minimized, the client may become more anxious, yet limits are needed to prevent reinforcing complaints. Assess the client's level of knowledge about how emotional issues influence physiologic functioning. Assessment of knowledge is the first step toward establishing an effective teaching plan. Teach the client how to differentiate between the emotional component and the somatic component of an experience. The client needs assistance in learning to separate emotions from body sensations. Encourage expression of all emotions, especially anger and frustration. It's important for the client to learn and practice appropriate expression of emotions rather than express them through physical symptoms. Have the client describe the physical sensations associated with emotions. The client needs to learn the connection between physical symptoms and strong emotions. Help the client label the emotions and develop an awareness of them. The client must develop an awareness of emotions to make a connection between emotional conflict and somatic symptoms. Short-Term Goal #2: The client will recognize how preoccupation with physiologic functioning impairs social and job-related interactions. Interventions and Rationales Discuss and encourage participation in hobbies, social activities, and work as appropriate substitutes for health rituals or emotional reactions to physical sensations. Normal activities serve to change the client's focus from an illness orientation to a health-promoting one. Discuss ways the client can assume personal responsibility for improving basic needs of daily living, such as exercise and nutrition. This discussion recognizes the client's strengths and decreasesthe client's dependency on illness to meet personal needs. Teach the client thought-stopping techniques, relaxation methods, and assertiveness skills. These skills assist the client in reducing obsessive thoughts and the anxiety related to the fear of illness. Talk to the client about how to become interested in the needs of others and to express concern for them. Focusing on others decreases the emphasis on self and physical problems. Encourage the client to initiate conversations with others that focus on topics other than personal physical problems. To have a successful social interaction, the client must shift the focus of discussion to topics other than the self. Encourage the client to identify opportunities to participate in employment, community service, hobbies, and social activities. This strategy expands the client's social contacts and provides opportunities for positive interactions with others.

THERAPIES Individual Therapy Acknowledge the client's physical symptoms, but don't allow them to dominate the interaction. Focus the interaction on discussion of the client's emotions, level of functioning, and lifestyle. Explore the client's level of anxiety and how the anxiety is manifested by physical symptoms. Examine the conflict present in the client's life related to such areas as occupational performance, relationships, failure, anger and disappointment. Focus on and have the client develop personal coping skills to prevent permanent adoption of the sick role. Teach the client assertiveness and relaxation techniques. Have the client develop strategies to enhance self-esteem, social interactions, and occupational functioning. Work to diminish any associated compulsive behaviors related to the client's health.

MEDICATIONS Antianxiety medication may be used for relief of anxiety. Antidepressant drugs are used if depression is present. (See Appendix D for medication information.)

FAMILY CARE Teach family members to be supportive while not reinforcing physical symptoms or the invalid role. Help family members identify and discuss unresolved anger or frustration toward the client. Work with family members to set limits on the responsibilities that they assume for the client because they're responding to the client's helplessness. Family members must be aware that the client may seek to obtain attention, sympathy, or other secondary gains from illness behaviors. Help family members acknowledge the client's strengths. Work with family members to promote the client's independence. Have the family develop comfort in expressing and accepting the emotions of each family member.

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