NEUROTIC, STRESS RELATED & SOMATIZATION DISORDER.pptx

Many individuals keep running to the doctor even though there is nothing wrong
with them. These individuals may be preoccupied with their health and body and
in some cases the preoccupation maybe so excessive that it becomes maladaptive
in their daily lives. Soma means body and the common problem associated with
somatic disorders and related symptoms seems to be initially, physical disorders.
However, there is usually no identifiable physical cause for the condition. DSM-
5 lists five basic somatic symptoms and related disorders. They are somatic
symptom disorder, illness anxiety disorder, psychological factors affecting
medical condition, conversion disorder, and factitious disorder. In each, the
individual has an excessive and maladaptive preoccupation with the functioning
of his/her body. In this Unit, we will learn the clinical features, causal factors
and treatment for the five basic somatic symptoms and related disorders.

1. AMRITANSHU CHANCHAL NURSING TUTOR SLMGNC NURSING MANAGEMENT OF PATIENT WITH NEUROTIC, STRESS RELATED & SOMATIZATION DISORDER

2. Introduction Neurotic disorder is a less severe form of psychiatric disorder where, patients show either excessive or prolonged emotional reaction to any given stress. These disorders are not caused by organic disease of the brain and, however severe , do not involve hallucinations and delusion.

3. Definition A mental condition that is not caused by organic disease, involving symptoms of stress (depression, anxiety, obsessive behavior, hypochondria) but not a radical loss of touch with reality.

4. Classification (ICD 10)

5. Difference between psychotic disorder & neurotic disorder Psychosis Neurosis Etiology Genetic Factor More important Less important Stressful life events Less important More important Clinical features Disturbance in cognitive function Common Rare Behavior Markedly affected Not affected Judgment Impaired Intact Insight Lost Present Reality testing Lost Present Treatment Drugs Major Tranquilizer used Minor tranquilizer used ECT Very useful Not useful Psychotherapy Not much useful Very useful

6. Phobic Anxiety Disorder Anxiety is a normal phenomenon, which is characterized by a state of apprehension or uneasiness arising out of anticipation of danger. Normal anxiety becomes pathological when it causes significant subject distress and impairment of functioning of the individual. Anxiety disorder are abnormal states in which the most striking features are mental and physical symptoms of anxiety, which are not caused by organic brain disease or any other psychiatric disorder.

7. Types of Phobia Simple Phobia Social Phobia Agoraphobia It is an irrational fear of a specific object or stimulus. Simple phobia are common in childhood. By early teenage, most of these fear are lost, but a few persist till adult life. Sometimes they may reappear after a after symptom-free period. Exposure to the phobic object often result in panic attack. Sign & Symptoms Irrational & persistent Immediate anxiety on contact with featured object or situation. Loss of control, fainting or panic response. It is an irrational fear of performing activities in the presence of other people or interacting with others. The patient is afraid of his own actions being viewed by others critically, resulting in embarrassment or humiliation. Sign & Symptoms Hyperventilation Sweating cold & Clammy hands Blushing Palpitation Confusion GI symptoms Muscle tension It is characterized by an irrational fear of being in places away from the familiar setting of home, in crowds, or in situation that the patient cannot leave easily. Sign & Symptoms Overriding fear of open or public spaces Deep concern that help might not reach Avoiding public places or confinement at home

8. Etiology Psychodynamic theory Learning Theory Cognitive Theory According to this theory, anxiety is usually dealt with repression fails to function adequately, other secondary defense mechanism of ego come into action. In phobia, this secondary defense mechanism is displacement anxiety is transferred from really dangerous or frightening objects to a neutral object. These two objects are connected by symbolic association. The neutral object chosen unconsciously is the one that can be easily avoided in day to day activities in contrast to the frightening object. According to classical conditioning a stressful stimulus produces an unconditioned response-fear. When the stressful stimulus is repeatedly paired with a harmless object, eventually the harmless object, eventually the harmless object alone produces the fear, which is now a conditioned response. If the person avoids the harmless object to avoid fear, the fear becomes phobia. Anxiety is the product of faulty cognition or cognition or anxiety-inducing self instructions. Cognitive theorists believe that some individual engage in negative and irrational thinking that produce anxiety reaction. The individual begins to seek out avoidance behavior to prevent the anxiety reaction and phobias result.

9. Course : The phobias are more common in women with an onset in late second decade or early third decade. Onset is sudden without any cause. The course is usually chronic. Sometimes phobias are spontaneous remitting. Diagnosis : 1) No specific diagnostic test, diagnosis confirmed if ICD 10 criteria met 2) History of anxiety when exposed to or anticipating entity or situation

10. Treatment

11. Behavior Therapy

12. Systematic Desensitization: Deep muscle relaxation techniques: In the first stage of the treatment, people with anxiety and fears are taught breathing exercises and muscle relaxation techniques. Relaxation techniques are generally these types: Autogenic relaxation: You repeat words, phrases, or suggestions in your mind that create a feeling of relaxation and calm. The repetition in the mind leads to the muscles of your body getting more and more relaxed.   ‌Progressive muscle relaxation: You learn to slowly tense and relax each muscle group. You normally start from your toes and work your way up to your neck and head muscles. ‌Visualization: You imagine a journey to a peaceful and calm situation, place, or setting, like a seashore or a garden. This aids muscle relaxation and feelings of relaxation.

13. Virtual Reality Exposure Therapy Virtual reality (VR) uses technology to swap real-life environments with made-up ones that look real. That’s called simulation. Exposure therapy helps you face your fears in a safe environment. It’s used to treat: Phobias Panic disorder Social anxiety disorder Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD) Generalized anxiety disorder Traumatic brain injury

14. EMDR Eye movement desensitization and reprocessing therapy, commonly known as EMDR, is a mental health therapy method. EMDR treats mental health conditions that happen because of memories from traumatic events in your past. It’s best known for its role in treating post-traumatic stress disorder (PTSD), but its use is expanding to include treatment of many other conditions.

15. Acceptance & Commitment act therapy Acceptance and commitment therapy (ACT) is an action-oriented approach to psychotherapy that stems from traditional behavior therapy and cognitive behavioral therapy. Clients learn to stop avoiding, denying, and struggling with their inner emotions and, instead, accept that these deeper feelings are appropriate responses to certain situations that should not prevent them from moving forward in their lives. With this understanding, clients begin to accept their hardships and commit to making necessary changes in their behavior, regardless of what is going on in their lives and how they feel about it.

16. Exposure Therapy

17. Nursing Management Assess the intensity of anxiety Determine the triggers for anxiety Assess how the patient responds to anxiety Administer medications to relieve anxiety Educate the patient about anxiety Encourage patient to develop support groups Encourage patient to seek mental health counseling Educate patient on self-care

18. Provide means of support Interact with the patient in a calm and gentle manner Converse in simple language Allow the patient to talk about distressing emotions and feelings Assess patient for suicidal ideations Help strengthen patient's problem-solving abilities Tell the patient to limit alcohol and caffeinated beverages Encourage patient to participate in social functions

19. Generalized Anxiety Disorder (GAD): Restlessness, irritability, and difficulty concentrating. Muscle tension, fatigue, and sleep disturbances. Panic Disorder: Rapid heart rate, chest pain, shortness of breath , and trembling/shaking. Fear of future panic attacks, leading to avoidance behaviors. Social Anxiety Disorder (Social Phobia): Avoidance of social interactions, public speaking, or performing in front of others. Excessive self-consciousness, blushing, sweating, and trembling.

20. Assess following in the patient Specific Phobias: Immediate anxiety response when exposed to the feared object or situation. Avoidance behaviors or extreme distress when encountering the phobic stimulus. Obsessive-Compulsive Disorder (OCD): Anxiety caused by obsessions and relief sought through compulsive behaviors. Examples include excessive  handwashing , checking, or counting rituals. Post-Traumatic Stress Disorder (PTSD): Intrusive memories, flashbacks, nightmares, or distressing thoughts related to the trauma. Avoidance of reminders, emotional numbness, hypervigilance , and heightened arousal.

21. Panic Disorder Panic disorder is characterized by anxiety, which is intermittent and unrelated to particular circumstances . The central features is the occurrence of panic attacks i.e. sudden attacks of anxiety in which physical symptoms predominate and are accompanied by fear of a serious consequence such as heart attack. The lifetime prevalence of panic disorder is 1.5 to 2 percent. It is seen 2 to 3 times more often in females.

22. Classification of ICD 10 F41.0 Panic Disorder F41.1 Generalized Anxiety Disorder F41.2 Mixed Anxiety Disorder F41.9 Other Specific Anxiety Disorder

23. Etiology

24. Biochemical Factors

25. Psychodynamic Theory According to this theory, anxiety is usually dealt with repression. When repression fails to function adequately, other secondary defense mechanism of ego come into action. In anxiety repression fails to function to function adequately and the secondary defense mechanism are not activated. Hence anxiety comes to the forefront.

26. Behavioral theory: Anxiety is viewed as an unconditional inherent response of the individual to a painful stimulus. Cognitive Theory: According to this theory anxiety is related to cognitive distortions and negative automatic thoughts.

27. Clinical features Shortness of breathe and smothering sensation Heart beat rapid & Pounding Choking, chest discomfort or pain Palpitation Sweating, Dizziness, Unsteady feeling or faintness Nausea or abdominal discomfort Depersonalization or derealization Numbness or tingling sensation Flushes or chills Trembling or shaking Fear of dying or heart attack Agoraphobia ,Depression

28. Course The onset is usually in early third decade with often a chronic course. It occurs recurrently every few days. The episode is usually sudden in onset and the lasts for a few minutes. More than 95% of those diagnosed with agoraphobia have an accompanying diagnosis of panic disorder. Up to two thirds of those with this disorder also experience depression in substance abuse to cope with anxiety.

29. Diagnosis Do a physical exam to look for signs that your anxiety might be linked to medications or an underlying medical condition Order blood or urine tests or other tests, if a medical condition is suspected Ask detailed questions about your symptoms and medical history Use psychological questionnaires to help determine a diagnosis Use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

30. Treatment modalities

31. Behavioral Therapies Relaxation techniques to help the patient cope with a panic attack by easing physical symptoms and directing attention elsewhere. Deep breathing exercise, which also reduce the risk of hyperventilation Progressive relaxation, which involves conscious tightening and relaxation of the skeletal muscles in sequential fashion. Positive verbalization or guided imagery in which the patient elicit peaceful mental images or some other purposeful thought or action prompting feeling of relaxation, renewed hope, and a sense of being in control of stressful situation Listening to calming music

32. Cognitive therapy

33. Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness.

34. Introduction Obsessions are unwelcome thoughts, images, urges, worries or doubts that repeatedly appear in your mind. They can make you feel very anxious (although some people describe it as mental discomfort rather than anxiety). You can read more about obsessions here. Compulsions are repetitive activities that you do to reduce the anxiety caused by the obsession. It could be something like repeatedly checking a door is locked, repeating a specific phrase in your head or checking how your body feels. You can read more about compulsions here.

35. Types of OCD Washers are afraid of contamination. They usually have cleaning or hand-washing compulsions. Checkers repeatedly check things (oven turned off, door locked, etc.) that they associate with harm or danger. Doubters and sinners are afraid that if everything isn’t perfect or done just right something terrible will happen, or they will be punished. Counters and arrangers are obsessed with order and symmetry. They may have superstitions about certain numbers, colors, or arrangements. Hoarders fear that something bad will happen if they throw anything away. They compulsively hoard things that they don’t need or use.

36. Classification (ICD 10) F42 Obsessive compulsive disorder F42 Predominantly obsessive thoughts or rumination F42.1 Predominantly compulsive acts F42.2 Mixed obsessional thoughts F42.8 Other obsessive compulsive disorder F42.9 Obsessive compulsive disorder, unspecified

37. Etiology Genetic factor Twin studies have consistently found a significantly higher concordance rate for monozygotic twins than for dizygotic twins. 35% of first degree relatives are affected. Biochemical factor A number of studies suggest that the neurotransmitter serotonin may be abnormal in individual with OCD Psychoanalytical theory The psychoanalytical concept views patient with OCD as having regressed to developmentally earlier stages of infantile superego. Specific ego defense mechanism like isolation, undoing, displacement may lead to OCD Behavior theory The behavioral explanation of obsessive-compulsive disorder focuses on the explanation of compulsions rather than obsessions. Behaviorists believe that these compulsions begin with and are maintained by the classical conditioning .

38. Clinical features Obsessional thoughts Word, Ideas and Belief that intrude in patient mind. They are usually unpleasant and shocking to the patient, obscene or blasphemous. Obsessional Images These are vividly imagined scenes, often of a violent or disgusting kind involving abnormal sexual practice. Obsessional Rumination These involves internal debates in which arguments for and against even the simplest everyday action are reviewed endlessly. Obsessional doubts This occurs when realistic information is dismissed in favor of irrelevant information. In other words, realistic information is available and is perceived. Obsessional Impulses recurrent and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety, fear or disgust Obsessive slowness Denotes a rare condition of disablingly slow motor performance

39. Course & Prognosis Usually two-third of the patient improve by end of the year. A good prognosis is indicated by good social & occupational adjustment, the presence of a precipitating event and an episodic nature of symptoms. Prognosis appears to be worse when the onset is in childhood, the personality is obsessional, symptoms are severe , compulsion are bizarre, or there is co-existing major depressive disorder.

40. Diagnosis MRI and CT scan shows enlarged basal ganglia in some patient Positron emission tomography scanning shows increased glucose metabolism in part of basal ganglia Psychological evaluation.  This includes talking about your thoughts, feelings, symptoms and behavior patterns to find out if you have obsessions or compulsive behaviors that get in the way of your quality of life. With your permission, this may include talking to your family or friends. Physical exam.  This may be done to rule out other issues that could cause your symptoms and check for any related complications.

41. Treatment Antidepressants approved by the Food and Drug Administration (FDA) to treat OCD include: Fluoxetine , (Prozac) for adults and children 7 years and older. Fluvoxamine , ( Luvox ) for adults and children 8 years and older. Paroxetine ,(Paxil) for adults only. Sertraline (Zoloft) for adults and children 6 years and older. Clomipramine , ( Anafranil ) for adults and children 10 years and older.

42. SSRI (selective serotonin reuptake inhibitor) Celexa ( Citalopram ) Lexapro ( Escitalopram ) Prozac ( Fluoxetine ) Luvox ( Fluvoxamine ) Paxil/ Pexeva ( Paroxetine ) Zoloft ( Sertraline )

43. Popular benzodiazepines to treat OCD include Xanax ( Alprazolam ) Ativan ( Lorazepam ) Valium (Diazepam) Klonopin ( Clonazepam )

44. Exposure Therapy The psychotherapy of choice for the treatment of OCD is exposure and response prevention (ERP), which is a form of CBT. In ERP therapy, people who have OCD are placed in situations where they are gradually exposed to their obsessions and asked not to perform the compulsions that usually ease their anxiety and distress. This is done at your pace; your therapist should never force you to do anything that you do not want to do. The first step is for you to describe all of your obsessions and compulsions. Then you and the therapist will arrange them in a list, ordering them from things that don’t bother you much to things that are the most frightening. Next, the therapist will ask you to face your fear of something on your list, starting with the easiest.

45. Example Let’s say you have an obsessive fear of germs in public places, and that fear is pretty low in how much it scares you. Your therapist will design a task for you that exposes you to that fear. Your task might for you to touch a public doorknob. Here’s where the response-prevention part comes in. If your usual response is to wash your hands immediately after touching the doorknob, the therapist would ask you to wait before you wash your hands. As you repeat this exposure task, the therapist will ask you to wait longer and longer before washing your hands. Over time, this gradual exposure and delayed response would help you learn to control your fear of germs in public places without washing your hands.

46. Imaginal Exposure For those who may be resistant to jumping right into real world situations, imaginal exposure (IE), sometimes referred to as visualization, can be a helpful way to alleviate enough anxiety to move willingly to ERP. With visualization, the therapist helps create a scenario that elicits the anxiety someone might experience in a routine situation. For someone who fears walking down a hallway in a way that diverts from their “perfect” pattern, the therapist may have them picture themselves walking in that divergent manner for several minutes every day and record their level of anxiety. As they habituates to the discomfort, with decreased anxiety over time, they are gradually desensitized to the feared situation, making them more willing to move the process to real life, and engage in the next step, ERP.

47. Relaxation technique Slowly take five deep breaths. Apply muscle tension to a specific part of the body, such as your left foot. Squeeze the muscles in that area as hard as possible without hurting yourself for about five seconds as you take a slow, deep breath. Relax the tensed muscle, letting go of all the tension as you exhale. Systematic desensitization is an evidence-based therapy approach that combines relaxation techniques with gradual exposure to help you slowly overcome a phobia. During systematic desensitization , also called graduated exposure therapy, you work your way up through levels of fear, starting with the least fearful exposure. This approach also involves the use of relaxation techniques. Both of these features make it different from other desensitization techniques, such as flooding.

48. Aversion therapy also called aversive conditioning, or counter conditioning is a type of behavioral therapy. It is a psychological treatment that pairs a negative behavior or habit with a negative stimulus. For example, a dog owner may spray a bitter liquid on objects the dog should not chew.

49. Supportive psychotherapy Supportive psychotherapy is a type of therapy that primarily focuses on providing emotional support, encouragement, and validation during difficult life circumstances or psychological challenges. Your therapist will encourage you to talk about your feelings, concerns, and problems in a safe, nonjudgmental environment. They may also offer practical advice or guidance on how to address specific issues. Supportive psychotherapy is mostly focused on helping you work through present and immediate concerns, including relationship issues, family conflicts, or work-related stress. If you have a history of trauma that feels overwhelming to try to approach head-on ― this therapeutic technique can help you improve your overall mental health before doing so. Electroconvulsive Therapy

50. Nursing management Obsessive ideas might consist of the following:  Fear of germs or illness Anxiety about death or harm to loved ones Aggressive or intrusive thoughts Needing things to look a certain way Obsessive thoughts result in compulsive behaviors like:  Completing things in a predetermined order or number of times  Counting objects, such as steps or bottles Fear of shaking hands, using public restrooms, or touching doorknobs Checking and rechecking locked doors, light switches, etc. OCD is a mental health disorder found in the Diagnostic and Statistical Manual of Mental Disorders. A thorough psychological evaluation is necessary to diagnose OCD. A physical examination can rule out other causes of the patient’s symptoms.

51. Anxiety related to obsessive-compulsive disorder can be caused by distress from repetitive, persistent, involuntary, and unwanted thoughts and behaviors. Related to: Conflicting beliefs Unwanted thoughts (obsessions) Illogical urges  Repetitive behaviors (compulsive behaviors) Stressors or triggers Role performance conflicts Embarrassment

52. As evidenced by: Distressed appearance Verbalized feelings of insecurity  Extreme fear Helplessness Powerlessness Irritable mood Palpitations Tachypnea Hypertension Focused breathing Hypersensitive body sensations Frequent blinking

53. Expected outcomes: Patient will express understanding about OCD and how it relates to their anxiety. Patient will demonstrate interventions to reduce stress without turning to obsessive-compulsive behaviors.

54. Assessment Assess the patient’s level of anxiety. Anxiety worsens the unwanted thoughts and repetitive behaviors of a patient with OCD. Have the patient rate their anxiety on a 0-10 scale. Monitor for physical symptoms. Anxiety can cause the following:  Palpitations Rapid breathing Hypertension Hand-wringing Restlessness Observe the rituals. Observe for indications of OCD. Patients with OCD are unlikely to seek treatment early. They may feel ashamed of their fixation and compulsions. Note unusual behaviors or rituals.

55. Interventions Provide safety. Patients with OCD may have violent and intrusive thoughts of harming someone or themselves. The nurse may need to remove objects that could be used to cause injury, or the patient may need 1:1 supervision. Start cognitive-behavioral therapy.  Cognitive behavioral therapy (CBT) is recommended as the first-line treatment for OCD. Talk therapy focuses on thoughts, feelings, and behaviors and can be beneficial for both OCD and anxiety or other mental health comorbidities . Encourage relaxation.  Symptoms can be stressful to a patient with OCD. Stress can be relieved by activities like yoga, meditation, and massage.

56. Administer SSRIs as ordered.  Selective serotonin reuptake inhibitors are medications prescribed to manage obsessions and compulsions and reduce anxiety. Consider other treatment options.  If OCD is uncontrolled by psychotherapy or medications, newer treatments may be considered. Deep Transcranial Magnetic Stimulation non-invasively stimulates nerve cells using magnetic fields to alleviate symptoms of OCD.

57. Ineffective coping related to obsessive-compulsive disorder can be caused by irrational beliefs and practices resulting in maladaptive coping mechanisms.

58. Related to: Inadequate confidence in dealing with a situation Inadequate sense of control Ineffective tension release strategies Inadequate social support Stressors Situational crises Ritualistic behaviors Anxiety

59. As evidenced by: Altered attention Poor concentration Obsessive-compulsive behaviors Ritualistic behaviors Destructive behaviors Poor problem-solving abilities Inability to cope with stressors Expected outcomes: Patient will eliminate or lessen the practice of ritualistic behaviors. Patient will be able to develop healthy coping strategies to manage their distress.

60. Assessment: Assess the patient’s history. Attempt to uncover triggers or causes of the patient’s obsessions, such as a history of trauma or abuse. Inquire about a family history of mental illness. Evaluate coping mechanisms. Evaluate if the patient uses maladaptive coping behaviors such as using alcohol or drugs to calm them or prevent ritualistic behaviors. Harmful coping methods may need further intervention. Identify OCD triggers. Certain events or thoughts often trigger ritualistic behaviors. Recognition of triggers can help reduce ritualistic behaviors. Interventions: 1. Keep track of OCD behaviors. An OCD diary tracks the patient’s triggers and how often they employ compulsions. It evaluates the severity of the OCD and monitors progress.

61. Exposure therapy. Exposure Response Prevention Therapy exposes a person to a trigger causing an obsession. Controlled exposure to a triggering situation teaches the patient how to respond and cope effectively. Slow down the rituals. Advise facing the triggers and wait 10 seconds before acting on the compulsion. It increases the length of time before employing the ritual. This can potentially lessen the compulsive behavior and its interference. Encourage self-help techniques. Encourage the patient to try deep breathing, meditation, and progressive muscle relaxation to reduce tension and release fears.  Provide positive feedback. Coping with OCD is challenging. Provide positive feedback and acknowledge minor successes .

62. Social isolation related to obsessive-compulsive disorder can be caused by withdrawal from society due to unacceptable thoughts and behaviors contradicting the norms of society.

63. PTSD (Post Traumatic Stress Disorder) Post-traumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances. An individual may experience this as emotionally or physically harmful or life-threatening and may affect mental, physical, social, and/or spiritual well-being. Examples include natural disasters, serious accidents, terrorist acts, war/combat, rape/sexual assault, historical trauma, intimate partner violence and bullying.

64. People with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.

65. Adjustment Disorder It is characterized by predominant disturbance of emotions and conduct. This disorder usually occurs within one month of a significant life change. Adjustment disorder are one of the common psychiatric disorder seen in clinical practice. They are most frequent seen in adolescence and women. This disorder usually occurs in those individuals who are vulnerable due to poor coping skills or personality factors. The duration of the disorder is usually less than 6 months.

66. Treatment for stress and adjustment Anti-Depressant Benzodiazepenes citalopram ( Cipramil ) dapoxetine ( Priligy ) escitalopram ( Cipralex ) fluoxetine (Prozac or Oxactin ) fluvoxamine ( Faverin ) paroxetine ( Seroxat ) sertraline ( Lustral ) vortioxetine ( Brintellix ) Valium, Xanax Halcion Ativan Klonopin

67. Psychological Therapies Supportive psychotherapy is a type of therapy that primarily focuses on providing emotional support, encouragement, and validation during difficult life circumstances or psychological challenges. Your therapist will encourage you to talk about your feelings, concerns, and problems in a safe, nonjudgmental environment. They may also offer practical advice or guidance on how to address specific issues. Supportive psychotherapy is mostly focused on helping you work through present and immediate concerns, including relationship issues, family conflicts, or work-related stress. If you have a history of trauma that feels overwhelming to try to approach head-on ― this therapeutic technique can help you improve your overall mental health before doing so.

68. Do’s & Don’t for supportive psychotherapy

69. Nursing Intervention

70. Conversion Disorder

71. Conversion Disorder Conversion Disorder is characterized by the presence of one or more symptoms suggesting the presence of a neurological disorder that cannot be explained by any known neurological and medical disorder. Instead psychological factors like stress and conflicts are associated with onset or exacerbation of the symptoms . Patient are unaware of the psychological basis and are not able to control their symptoms. In ICD 10, conversion disorder is subsumed under “dissociative disorder of movements and sensation,” a subtype under dissociate disorders. It is further, dissociative anesthesia and sensory loss and dissociative convulsion.

72. Conversion disorder were formerly called as “hysteria”. The term is now changed because the word hysteria is used in everyday speech when referring to any extravagant behavior., and it is confusing to use the same word for a different phenomena that falls under this syndrome.

73. Dissociative Motor Disorder Dissociative disorders are mental health conditions that involve experiencing a loss of connection between thoughts, memories, feelings, surroundings, behavior and identity. These conditions include escape from reality in ways that are not wanted and not healthy. This causes problems in managing everyday life. Dissociative disorders usually arise as a reaction to shocking, distressing or painful events and help push away difficult memories. Symptoms depend in part on the type of dissociative disorder and can range from memory loss to disconnected identities. Times of stress can worsen symptoms for a while, making them easier to see.

74. Sign & Symptoms Feeling disconnected from yourself Problems with handling intense emotions Sudden and unexpected shifts in mood – for example, feeling very sad for no reason Depression or anxiety problems, or both Feeling as though the world is distorted or not real (called ‘ derealisation ’) Memory problems that aren’t linked to physical injury or medical conditions Other cognitive (thought-related) problems such as concentration problems Significant memory lapses such as forgetting important personal information Feeling compelled to behave in a certain way Identity confusion – for example, behaving in a way that the person would normally find offensive or abhorrent.

75. Dissociative Convulsion (Hysterical fits or Pseudo-seizures) It is characterized by convulsive movements and partial loss of consciousness. Differential diagnosis with true seizures is important. This is a band of sensory loss with normal sensation below the area. Decussating fibers located along the central canal (pain and temperature) are impaired, resulting in a decrease or a loss of pain or temperature sensation. Position, touch, and vibratory sensations are not impaired.

76. This is a band of sensory loss with normal sensation below the area. Decussating fibers located along the central canal (pain and temperature) are impaired, resulting in a decrease or a loss of pain or temperature sensation. Position, touch, and vibratory sensations are not impaired. The disturbance is usually based on patient’s knowledge of that particular illness whose symptoms are produced. A detailed examination does not reveal any abnormalities.

77. Dissociative Disorder Dissociative Amnesia Dissociative amnesia is when your mind blocks out important information about yourself, causing “gaps” in your memory. One of the most common reasons your mind blocks out things is to protect you from unpleasant, distressing or traumatic experiences. It's not the same as simply forgetting something. Dissociative Fugue A dissociative fugue is a temporary state where a person has memory loss (amnesia) and ends up in an unexpected place. People with this symptom can't remember who they are or details about their past. Other names for this include a "fugue” or a “fugue state.” Dissociative Identity Disorder Dissociative Identity Disorder (Multiple Personality Disorder) Dissociative identity disorder (DID) is a mental health condition where you have two or more separate personalities that control your behavior at different times. Trance & Possession Trance and possession disorder (TPD) is a rare and complex psychiatric condition characterized by episodes of altered consciousness, during which individuals may exhibit behavior, speech, or actions inconsistent with their usual personality

78. Etiology of Conversion & Dissociative Disorder According to psychodynamic theory, conversion symptoms develop to defend against unacceptable impulses. The primary gain, that is to say the unconscious purpose of a conversion symptom is to bind anxiety and keep a conflict internal. Trouble with senses of vision, hearing, smell, taste and touch are all possible with conversion disorder. Some examples include double or tunnel vision, hearing loss or numbness, and the inability to feel something touching your skin.

79. Behavior theory According to this theory the symptoms are learnt from the surrounding environment. These symptoms bring about psychological relief by avoidance of stress. Conversion disorder is more common in people with histrionic personality traits.

80. Diagnosis Physical exam.  Your health care professional examines you, talks about your symptoms and reviews your personal history. Certain tests may rule out physical conditions that can cause symptoms such as memory loss and feeling separate from reality. Examples include head injury, certain brain diseases, a severe lack of sleep, and drug or alcohol use. Mental health exam.  Your mental health professional talks with you about your thoughts, feelings and behavior, and your symptoms. With your permission, information from family members or others may be helpful.

81. Treatment modalities Free Association Hypnosis Abreaction theory Supportive therapy Behavior therapy Drug Therapy

82. Nursing Management Nursing Assessment Assessment of the client includes: Psychiatric interview.  The psychiatric interview must contain a description of the client’s mental status with a thorough description of behavior, the flow of thought and speech, affect, thought processes and mental content, sensorium and intellectual resources, cognitive status, insight, and judgement . Nursing Diagnosis Nursing diagnosis for patients with dissociative disorders include: Ineffective coping  related to inadequate coping skills. Disturbed thought processes  related to childhood trauma or abuse. Disturbed personal identity  related to severe level of anxiety. Disturbed sensory perception  (kinesthetic) related to threat to self-concept.

83. Nursing Care Planning and Goals The major nursing care plan goals for dissociative disorders are:  Client will verbalize understanding that he or she is employing dissociative behaviors in times of psychosocial stress. Client will verbalize more adaptive ways of coping in stressful situations than resorting to dissociation. Client will verbalize understanding that loss of memory is related to stressful situation and begin discussing stressful situation with nurse or therapist. Client will recover deficits in memory and develop more adaptive coping mechanisms to deal with stressful situations. Client will verbalize adaptive ways of coping with stress. Nursing Interventions

84. The nursing interventions for dissociative disorders are:  Promote client safety.  Reassure client of safety and security by your presence; dissociative behaviors may be frightening to the client. Assess for stressors.  Identify stressor that precipitated severe anxiety; this information is necessary to the development of an effective plan of client care and problem resolution. Explore client’s feelings.  Explore feelings that client experienced in response to the stressor; help client understand that the disequilibrium felt is acceptable-indeed, even expected-in times of severe stress. Encourage methods for coping.  Have client identify methods of coping with stress in the past and determine whether the response was adaptive or maladaptive. Enhance client’s self-esteem.  Provide positive reinforcement for client’s attempts to change; positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.

85. Evaluation Outcome goals include : Client was able to verbalize understanding that he or she is employing dissociative behaviors in times of psychosocial stress. Client was able to verbalize more adaptive ways of coping in stressful situations than resorting to dissociation. Client was able to verbalize understanding that loss of memory is related to stressful situation and begin discussing stressful situation with nurse or therapist. Client was able to recover deficits in memory and develop more adaptive coping mechanisms to deal with stressful situations. Client was able to verbalize adaptive ways of coping with stress.

86. Somatoform disorder Somatic symptom disorder (SSD formerly known as " somatization disorder" or "somatoform disorder") is a form of mental illness that causes one or more bodily symptoms, including pain. The symptoms may or may not be traceable to a physical cause including general medical conditions, other mental illnesses, or substance abuse. But regardless, they cause excessive and disproportionate levels of distress. Pain Neurologic problems Gastrointestinal complaints Sexual symptoms

87. These disorders are classified in following categories Somatization Disorder It is characterized by chronic multiple somatic symptoms in the absence. The symptoms are vague presented in a dramatic manner and involve multiple organ system Hypochondriasis It is defined as persistent preoccupation with a fear or belief of having a serious disease despite repeated medical reassurance. Somatoform autonomic dysfunction In this disorder, the symptoms are predominantly under autonomic control, as if they were due to a physical disorder. Example : Palpitation, Hiccup, Hyperventilation Persistent Somatoform Pain The main features of this disorder is severe, persistent pain without any physical basis. It may be of sufficient severity so as to cause social or occupational impairment. Preoccupation with the pain is common.

88. Diagnoses Physical workup to rule out medical and neurologic condition Complete patient history with emphasis on current psychological stressor Test to rule out underlying organic disease Treatment modalities Drug therapy: Anti depressant, Benzodiazepenes Psychological Treatment: Supportive Psychotherapy Relaxation Therapy

89. Nursing Intervention Ineffective Coping related to maladaptive responses to stressors, as evidenced by the use of physical symptoms to express emotional distress and impaired daily functioning. Disturbed Body Image related to a preoccupation with physical symptoms and excessive focus on bodily sensations, as evidenced by the patient’s expressed concerns about their appearance and somatic complaints. Anxiety related to the uncertainty surrounding the cause of physical symptoms and emotional distress, as evidenced by restlessness, increased heart rate, and difficulty concentrating. Impaired Social Interaction related to reluctance to participate in social activities due to somatic symptoms, as evidenced by the patient’s withdrawal from social interactions and avoidance of social situations. Risk for Depression related to the chronic and distressing nature of somatic symptoms, as evidenced by feelings of sadness, hopelessness, and loss of interest in previously enjoyed activities

90. Chronic Pain is related to the persistence of physical symptoms despite the absence of organic pathology, as evidenced by the patient’s reports of pain and discomfort. Self-Care Deficit related to the impact of somatic symptoms on daily functioning, as evidenced by difficulty performing activities of daily living and self-neglect. Impaired Coping is related to inadequate coping mechanisms to manage emotional distress, as evidenced by the patient’s reliance on somatic symptoms to express psychological distress. Deficient Knowledge about the somatoform disorder and its management, as evidenced by the patient’s lack of understanding about the condition and available treatment options.

91. Follow up care The people with anxiety disorder, somatoform disorders and dissociative disorders are often treated in the community clinics, physician office and psychiatric OPDs. For people with anxiety disorders the goal is effective management management of stress and anxiety, not the total elimination of anxiety. Follow up intervention are especially helpful for anxiety disorder patient. During follow up meet with patient and family members to discuss realistic expectation for the patient. Teach the patient stress management techniques such as relaxation, guided imagery and meditation, encourage him to practice regularly. Encouraging the patient to express his feeling through laughing crying etc.