Question

For each of the disorders listed below, briefly describe: What it is, symptoms/observable evidence, what the client may report feeling, general treatment, nursing implications, and a priority nursing diagnosis

    •    Somatic Symptom Disorder

    •    Illness Anxiety Disorder

    •    Conversion Disorder

    •    Factitious Disorder (Self/Other)

    •    Malingering

Answer 1

•    Somatic Symptom Disorder

What it is?

Somatic symptom disorders or somatoform disorders are a group of disorders in which people persistently worry or complain regarding significant physical symptoms for which there is no apparent organic cause.

· Symptoms are often inconsistent with possible physiological processes

· People do not consciously produce or control the symptoms but truly experience the symptoms and they tend to increase with increase in psycho social stressors.

· Symptoms pass (improve) only when the psychological factors that led to the symptoms are resolved

Symptoms/observable evidence:

Observable symptoms of somatic symptom disorders may be- anxiety, depression,

What the client may report feeling:

Specific sensations/ feelings - such as pain (most common symptom), headache, abdominal discomfort, loss of sleep, or shortness of breath, fatigue or weakness. They are may not be unrelated to any identifiable medical cause or may be related to a medical condition, but more significant than what's usually expected

Patient may experience a single symptom or multiple symptoms

Symptoms may also vary in severity from mild or moderate to severe

Accompanying behaviour may include few or many or many like

constant worry about potential illness,

viewing normal physical sensations also as a sign of severe physical illness,

thinking that physical sensations are threatening or harmful,

feeling that medical evaluation and treatment have not been adequate repeatedly checking your body for abnormalities,

frequent health care visits, being unresponsive to medical treatment or

unusually sensitive to medication side effects or having a more severe impairment than is usually expected from a medical condition

General treatment:

· Trusting relationship between the physician and patient

· Scheduled out patient visits every 4 or 6 weeks and performance of at least partial physical examination during each visit directed at the organ system of complaint.

· Avoid more diagnostic tests, laboratory evaluations and operative procedures unless clearly indicated

· Treatment of underlying depression and anxiety.

· Potentially addicting medications should be avoided

· Psychotherapy, both individual and group to cope with their symptoms and to express underlying emotions and to use alternative strategies for expressing their feelings

· Cognitive behavioural therapy

Nursing implications:

· Explain to the patient and family relationship between psych and somatic

· Empathic attitude

· Increased Activity Involvement to combats stress, improve mood and provides distraction from somatic

· Regular exercise program, muscle relaxation program, diaphragmatic breathing, yoga and so on has physiological effects that combat somatization and stress.

· Establish consistent sleep patterns (same bedtime and waketime every day), comfortable sleep environment, avoid alcohol/caffeine during 6 hours before bedtime, exercise regularly, but not within 4 hours of bedtime

A priority nursing diagnosis

Chronic pain related to severe level of anxiety, repressed.

•    Illness Anxiety Disorder

What it is?

Illness anxiety disorder is a persistent fear of having a grave medical illness. A person with this disorder pays excessive attention to health, and gets easily alarmed by anything that might be interpreted as a sign of illness, including normal sensations, bodily functions and mild symptoms. For them, such experiences may signal an illness with a severe outcome.

For example, a person may fear that the normal mark on the skin may be indicators of a life-threatening skin cancer.

Symptoms/observable evidence:

Symptoms of illness anxiety disorder include:

· Preoccupation with having or developing a serious illness

· Absence of physical symptoms or, if present, symptoms are mild

· Behaviour indicating health anxiety, such as checking for signs of illness

· persistent fear despite medical reassurance

· Patient may not accept being told that there is "nothing wrong." In severe forms of this disorder, a person may go from doctor to doctor

· Overuse or underuse medical care.

· Absence of delusions or psychosis

· Absence of delusions or psychosis

General treatment:

· The symptoms of illness anxiety disorder may be relieved by antidepressant even when no other psychiatric illness is present.

· Due to similarity of this disorder to obsessive-compulsive disorder (OCD) drugs used for OCD treatments, such as serotonin specific reuptake inhibitors (SSRIs) like fluoxetine or serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine can also be beneficial.

· A number of therapies like cognitive behaviour therapy and stress management can help people with illness anxiety disorder: Therapists teach distraction and relaxation techniques and help patients focus less on their symptoms and talk instead about how stress, anxiety and depression increase their psychological discomfort.

Nursing implications:

· One common perspective on this disorder is that health anxiety is so great that reassurance is only temporarily helpful at best.

· Maintaining an attentive and respectful attitude toward the symptoms complained by patient.

· Minimize the ordering of unnecessary tests, but do so when required, do not ignore carrying test simply because patients is experiencing illness anxiety disorders.

A priority nursing diagnosis

Anxiety related to lack of knowledge regarding symptoms, progression of condition, and treatment regimen as evidenced by feelings of discomfort, apprehension or helplessness, restlessness and decreased span

Conversion Disorder

What it is?

Conversion Disorder is a physical symptom or deficit suggesting loss of a part or altered body function related to psychological conflict or neurological. They appear suddenly and are related to marked stress. Conversion disorder causes patients to suffer apparently neurological symptoms, such as numbness, blindness, paralysis, or fits, but without a neurological cause.

Symptoms/observable evidence:

· Falls

· Non response to verbal communication

· Inability to move or lift body parts

What the client may report feeling:

· Impaired vision, double vision, Blindness

· Loss of hearing

· Paralysis

· Inability to talk

· Loss of touch or painsensation

General treatment:

· Psychotherapy

· Other treatments such as cognitive behavioural therapy - involves pointing out selective attention to physical sensations and discouraging the client from seeking medical assistance

· Hypnosis, EMDR, and psychodynamic psychotherapy, EEG brain biofeedback may be helpful.

· Treatment may also include the following:

Physiotherapy where appropriate

Occupational Therapy to maintain autonomy in activities of daily living

Treatment of comorbid depression or anxiety if present.

Nursing implications:

· Reassurance/appropriate rehabilitation

· Assess patients limitation/ disability

· Do not reinforce sick role

· Discuss the symptoms with the patient, convey your understanding of physical symptoms

· Encourage diversional activities

· Provide positive feed back

A priority nursing diagnosis

Factitious Disorder (Self/Other)

What is it?

Factitious disorder is a condition in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms Unlike malingerers who have material goals, such as monetary gain or avoidance of duties, patients with factitious disorder undertake these tribulations primarily to gain the emotional care and attention that comes with playing the role of the patient. While doing so, they practice artifice and art, creating hospital drama that often causes frustration and dismay.

Symptoms/observable evidence:

Presentations in Factitious Disorder with Predominantly Psychological Signs and Symptoms • Bereavement

• Depression

• Posttraumatic stress disorder

• Pain disorder • Psychosis

• Hypersomnia

• Bipolar I disorder

• Eating disorder

• Amnesia • Substance-related disorder

• Trans-sexualism

• Paraphilias

• Dissociative identity disorder

Chronic Factitious Disorder (Self/Others) patients presents with pre dominant physical signs and symptoms so well that they can gain admission to and stay in a hospital.

To support their history, these patients may feign symptoms suggesting a disorder involving any organ system.

They are familiar with the diagnosis of most disorders that usually require hospital admission or medication and can give excellent histories capable of deceiving even experienced clinicians. Even they demand treatment with specific medications.

So disease also called as professional patient syndrome

General treatment:

Observe for clinical indicators that may suggest factitious disorder by proxy

• the symptoms and pattern of illness are extremely unusual, or inexplicable physiologically.

• repeated hospitalizations and workups by numerous care givers fail to reveal a conclusive diagnosis or cause.

• physiological parameters are consistent with induced illness;

• the patient fails to respond to appropriate treatments.

• the vitality of the patient is inconsistent with the laboratory findings.

• specific person is the only witness to the onset of signs and symptoms the signs and symptoms abate when he is not there.

Major goals are to reduce the risk of morbidity and mortality, address the underlying emotional needs or psychiatric diagnosis underlying while considering legal and ethical issues. Treatment consist of:

· Efforts to arrive at a prompt diagnosis can minimize the risk of morbidity and mortality and to minimize harm.

· Avoid unnecessary tests and procedures, especially if invasive and treat according to clinical judgment, keeping in mind that subjective complaints may be deceptive.

· Interdisciplinary team to treat including members of ethical committee.

· Consider facilitating healing by using the double-bind technique or face- saving behavioural strategies, such as self-hypnosis or biofeedback.

· Treat underlying psychiatric disturbances.in psychotherapy, address coping strategies and emotional conflicts.

Nursing implications:

· Consider appointing a guardian for medical and psychiatric decisions.

· Prompt recording and reporting of patient symptoms and treatment

Malingering

What is it?

Malingering is intentional production of false or grossly exaggerated physical or psychologic symptoms motivated by external incentives. It may be pure malingering, false malingering or false imputation.

Symptoms/observable evidence:

Unusual/atypical symptoms

Currently asymptomatic

Exaggeration of symptoms

Symptoms incongruent with course of illness

Bizarre/absurd symptomatology

Unusual response to treatment

Atypical fluctuation

Voluntary control over symptoms

COMMONLY MALINGERED SYMPTOMS

They are -

• Memory deficits

• Seizure

• Sleep disorders

• Altered identity

• Mood symptoms

• Suicidal ideations

• Hallucinations

Amnesia (forgetfulness) most common as easy to feign

Suspect malingering when

Marked discrepancy- claimed disability and objective findings

Medico-legal context of presentation

Lack of cooperation in evaluation

Antisocial personality disorder

Treatment

Understanding the disorder, identifying true symptoms and their treatment

Stress coping strategies

Minimise unnecessary medication and expenditure

Nursing implications:

· Assess for history of substance abuse, psychiatric illness or involvement in antisocial activities

· Evidence of claimed disability

· Long and detailed interview with asking for clarification not confronting and observation for hesitation, pauses, body gestures

Nursing diagnosis

Attentionseeking disorder