SLEEP DISTURBANCE IN SOMATOFORM PAIN DISORDERAl bukhariEdho Biondi Joris

IntroductionA. The somatoform disorders are characterized by physical symptomssuggesting medical disease, but without demonstrable organic pathology orknown pathophysiological mechanism to account for them.B. Somatization refers to all those mechanisms by which anxiety is translatedinto physical illness or bodily complaints.C. Disordered sleep is a problem for many people. The cause may betemporarily caused by stress or anxiety; or the cause may be physiological.II. Somatoform DisordersA. Historical Aspects1. The concept of hysteria, which is characterized by recurrent, multiplesomatic complaints often described dramatically, is at least 4,000 yearsold and probably originated in Egypt.2. Witchcraft, demonology, and sorcery were associated with hysteria in theMiddle Ages.3. In the 19th century, the French physician Paul Briquet attributed thedisorder to dysfunction in the nervous system.4. Out of his work with hypnosis, Freud proposed that emotion which is notexpressed can be converted into physical symptoms.B. Epidemiological Statistics1. Somatoform disorders are more common in women than in men. Theyare more common in the poorly educated and people from the lowersocioeconomic classes.C. Application of the Nursing Process to Somatoform Disorders1. Somatization Disorder: Background Assessment Dataa. A chronic syndrome of multiple somatic symptoms that cannot beexplained medically and are associated with psychosocial distressand long-term seeking of assistance from health care professionals.b. Any organ system may be affected, but common complaints involvethe neurological, gastrointestinal, psychosexual, or cardiopulmonarysystems.c. Anxiety and depression are frequently manifested, and suicidalattempts and threats are not uncommon.d. Predisposing factors to somatization disorder(1) Theory of family dynamics. In dysfunctional families, when achild becomes ill, a shift in focus is made from the open conflictto the childs illness, leaving unresolved the underlying issuesthat the family is unable to confront in an open manner.Somatization brings some stability to the family, and positivereinforcement to the child.(2) Cultural and environmental factors. Various cultures deal withphysical symptoms in different ways. Cognitive or emotionalsymptoms such as guilt are predominantly seen in Westernsocieties. In Middle Eastern and Asian cultures, depression isalmost exclusively manifested by somatic or vegetativesymptoms.(3) Genetic factors. Studies have shown a 10- to 20-fold increasedincidence in female first-degree relatives of persons with thedisorder. These statistics may imply a possible inheritablepredisposition.(4) Transactional Model of Stress-Adaptation. The etiology ofsomatization disorder is most likely influenced by multiplefactors.e. Diagnosis/Outcome Identification(1) Nursing diagnoses for the client with somatization disorderinclude:(a) Ineffective coping(b) Deficient knowledge(2) Outcome criteria are identified for measuring effectiveness ofnursing care.f. Planning/Implementation(1) Nursing intervention for the client with somatization disorder isaimed at assisting the client to learn to cope with stress by meansother than preoccupation with physical symptoms.(2) The nurse also works to help the client correlate appearance ofthe physical symptoms with times of stress.g. Evaluation is based on accomplishment of previously establishedoutcome criteria.2. Pain Disorder: Background Assessment Dataa. The predominant disturbance in pain disorder is severe andprolonged pain that causes clinically significant distress orimpairment in social, occupational, or other areas of functioning.b. Even when organic pathology is detected, the pain complaint maybe evidenced by the correlation of stressful situation with the onsetof the symptom.c. The disorder may be maintained by:(1) Primary gains: The symptom enables the client to avoid someunpleasant activity.(2) Secondary gains: The symptom promotes emotional support orattention for the client.(3) Tertiary gains: In dysfunctional families, the physical symptommay take such a position that the real issue is disregarded andremains unresolved, even though some of the conflict isrelieved.d. Predisposing factors to pain disorder(1) Psychodynamic theory. Theorizes that pain for some clientsserves the purposes of punishment and atonement for perceivedwrongdoing. Individuals who have difficulty expressingemotions verbally may express feelings and emotions withbodily sensations.(2) Behavioral theory. In behavioral terminology, psychogenicpain is explained as a response that is learned through operantand classical conditioning. Occurs when pain behaviors arepositive or negatively reinforced.(3) Theory of family dynamics. Pain games may be played infamilies burdened by conflict. Pain may be used formanipulating and gaining the advantage in interpersonalrelationships. Tertiary gain may also be influential.(4) Neurophysiological theory. Postulates that the cerebral cortexand medulla are involved in inhibiting the firing of afferent painfibers. These individuals may have decreased levels ofserotonin and endorphins, which are thought to play a role inthe central modulation of pain.(5) Transactional Model of Stress-Adaptation. The etiology of paindisorder is most likely influenced by multiple factors.e. Diagnosis/Outcome Identification(1) Nursing diagnoses for the client with pain disorder include:(a) Chronic pain(b) Social isolation(2) Outcome criteria are identified for measuring the effectivenessof nursing care.f. Planning/Implementation(1) Nursing intervention for the client with pain disorder is aimedat relief from pain.(2) Emphasis is placed on learning more adaptive copingstrategies for dealing with stress. Reinforcement is given attimes when the client is not focusing on pain.g. Evaluation is based on accomplishment of previously establishedoutcome criteria.3. Hypochondriasis: Background Assessment Dataa. Unrealistic preoccupation with fear of having a serious illnessb. Even in the presence of medical disease, the symptoms aregrossly disproportionate to the degree of pathology.c. Predisposing factors to hypochondriasis(1) Psychodynamic theory(a) One view suggests that hypochondriasis is an ego defensemechanism. Physical complaints are the expression oflow self-esteem and feelings of worthlessness, as it iseasier to feel something is wrong with the body than tofeel something is wrong with the self.(b) Another psychodynamic view explains hypochondriasis asthe transformation of aggressive and hostile wishestoward others into physical complaints to others.(c) Still other psychodynamicists have viewedhypochondriasis as a defense against guilt and a need toatone for past misconduct.(2) Cognitive theory. Cognitive theorists view hypochondriasisas arising out of perceptual and cognitive abnormalities.(3) Social learning theory. Somatic complaints are oftenreinforced when the sick role serves to relieve the individualfrom the need to deal with a stressful situation, whether it bewithin society or within the family constellation.(4) Past experience with physical illness. Personal experience, orthe experience of close family members, with serious or lifethreateningillness can predispose an individual tohypochondriasis.(5) Genetic influences. Although little is known about hereditaryinfluences with hypochondriasis, some evidence indicates anincreased prevalence of hypochondriasis among identicaltwins and other first-degree relatives.(6) Transactional Model of Stress/Adaptation. The etiology ofhypochondriasis is most likely influenced by multiple factors.d. Diagnosis/Outcome Identification(1) Nursing diagnoses for hypochondriasis include:(a) Fear(b) Chronic low self-esteeme. Planning/Implementation(1) Nursing intervention for the client with hypochondriasis isaimed at relieving the fear of serious illness.(2) The focus is on decreasing the preoccupation with andunrealistic interpretation of bodily signs and sensations.(3) The nurse also works to help the client increase feelings ofself-worth and resolve internalized anger.f. Evaluation is based on accomplishment of previouslyestablished outcome criteria.4. Conversion Disorder: Background Assessment Dataa. A loss of or change in bodily functioning resulting from apsychological conflict, the physical symptoms of which cannotbe explained by any known medical disorder orpathophysiological mechanism.b. The most obvious and classic conversion symptoms are thosethat suggest neurological disease, and occur following asituation that produces extreme psychological stress for theindividual.c. The person often expresses a relative lack of concern that is outof keeping with the severity of the impairment. This lack ofconcern is identified as la belle indifference and may be a clueto the physician that the problem is psychological rather thanphysical.d. Predisposing factors to conversion disorder(1) Psychoanalytical Theory. Emotions associated with atraumatic event that the individual cannot express because ofmoral or ethical unacceptability are converted intophysical symptoms. The symptom is symbolic in some wayof the original emotional trauma(2) Familial factors. Occurs more often in relatives ofindividuals with the disorder. Nongenetic familial factors,such as incestuous sexual abuse in childhood, also may beassociated with an increased risk for conversion disorder.(3) Neurophysiological theory. Suggests that some clients withconversion disorder have a disturbance in central nervoussystem arousal.(4) Behavioral theory. Suggests that conversion symptoms arelearned through positive reinforcement from cultural, social,and interpersonal influences.(5) Transactional Model of Stress/Adaptation. The etiology ofconversion disorder is most likely influenced by multiplefactors.e. Diagnosis/Outcome Identification(1) Nursing diagnoses for the client with conversion disorderinclude:(a) Disturbed sensory-perception(b) Self-care deficit(2) Outcome criteria are identified for measuring theeffectiveness of nursing care.f. Planning/Implementation(1) Nursing intervention for the client with conversion disorderis aimed at recovery of the lost or altered function.(2) Emphasis is given to assisting the client with activities ofdaily living until the function is regained. Care is given notto reinforce the physical limitation.g. Evaluation is based on accomplishment of previouslyestablished outcome criteria.5. Body Dysmorphic Disorder: Background Assessment Dataa. Characterized by the exaggerated belief that the body isdeformed or defective in some specific way.b. Symptoms of depression and characteristics associated withobsessivecompulsive personality are common.c. Has been closely associated with delusional thinking. Traitsassociated with schizoid, obsessivecompulsive, andnarcissistic personality disorders are not uncommon.d. Predisposing factors to body dysmorphic disorder(1) Etiology is unknown, but presumed to be psychological(2) Predisposing factors may be similar to those associatedwith hypochondriasis or phobias.(3) Repression of morbid anxiety is thought to be anunderlying factor.(4) It is most likely that multiple factors are involved in thepredisposition to body dysmorphic disorder.e. Diagnosis/Outcome Identification(1) Nursing diagnoses for the client with body dysmorphicdisorder include:(a) Disturbed body image(2) Outcome criteria are identified for measuring effectivenessof nursing care.f. Planning/Implementation(1) Nursing intervention for the client with body dysmorphicdisorder is aimed at development of a realistic perceptionof body appearance.(2) A focus is on resolution of repressed fears and anxietiesthat contribute to altered body image.(3) Positive reinforcement is given for accomplishmentsunrelated to physical appearance.g. Evaluation is based on accomplishment of previouslyestablished outcome criteria.III. Sleep DisordersA. Sleep Disorders: Background Assessment Data1. Insomnia: Difficulty with initiating or maintaining sleep.2. Hypersomnia (somnolence): excessive sleepiness or seeking excessiveamounts of sleep3. Narcolepsy: Sleep attacks. The individual cannot prevent fallingasleep, even in the middle of a task or a sentence.4. Parasomnias: Unusual to undesirable behaviors that occur duringsleep. Examples include:a. Nightmare disorder: Frightening dreams that lead toawakenings from sleep and are sufficiently severe to interferewith social or occupational functioning.b. Sleep terror disorder: Abrupt arousal from sleep with apiercing scream or cry. The individual is difficult to awaken orcomfort, and if wakefulness does occur, the individual isusually disoriented, expresses a sense of intense fear, butcannot recall the dream episode.c. Sleepwalking: the performance of motor activity initiatedduring sleep in which the individual may leave the bed andwalk about, dress, go to the bathroom, talk, scream, or evendrive. Episodes may last from a few minutes to a half hour.5. Circadian rhythm sleep disorders: a misalignment between sleep andwake behaviors. The normal sleep-wake schedule is disrupted fromits usual circadian rhythm. Categories include:(a) Shift work type(b) Jet lag type(c) Delayed sleep phase type6. Predisposing factors to sleep disordersa. Genetic or familial patterns: thought to play a contributing role inprimary insomnia, primary hypersomnia, narcolepsy, sleep terrordisorder, and sleepwalking.b. Medical conditions implicated in the etiology of insomnia: pain,sleep apnea syndrome, restless leg syndrome, use of or withdrawalfrom substances, endocrine or metabolic disorders, infectious orother diseases, and CNS lesions. Medical conditions associatedwith hypersomnia include metabolic and encephalitic conditions,the use of alcohol or other CNS depressants, withdrawal fromstimulants, sleep apneas, and hypoventilation syndromes.c. Psychiatric or environmental conditions: anxiety, depression,environmental changes, circadian rhythm sleep disturbances,posttraumatic stress disorder, and schizophrenia.d. Neurological abnormalities, such as temporal lobe epilepsy, maycontribute to night terrors.e. Extreme fatigue and sleep deprivation may contribute to episodesof sleepwalking.7. Diagnosis/Outcome Identificationa. Nursing diagnoses for the client with sleep disorders include:(1) Disturbed sleep pattern(2) Risk for injuryb. Outcome criteria are identified for measuring the effectiveness ofnursing care.8. Planning/Implementationa. Nursing intervention for the client with a sleep disorder is aimedat determining the cause of the disturbance and performing actionsthat promote sleep and rest for the client.9. Evaluation is based on accomplishment of previously establishedoutcome criteria.IV. Treatment ModalitiesA. Somatoform Disorders1. Individual psychotherapy2. Group psychotherapy3. Behavior therapy4. PsychopharmacologyB. Sleep Disorders1. Relaxation therapy2. Biofeedback3. Pharmacotherapy4. Phototherapy*

Concepts of Somatoform and Dissociative DisordersSomatoform disordersPhysical symptoms in absence of physiological causeAssociated with increased health care useMay progress to chronic illness (sick role) behaviorsDissociative disordersDisturbances in integration of consciousness, memory, identify, and perceptionDissociation is unconscious mechanism to protect against overwhelming anxiety

characterizedphysical 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

Somatoform Disorders: General InformationPrevalenceRate unknown; estimated that 38% of primary care patients have symptoms with no medical basis55% of all frequent users of medical care have psychiatric problemsComorbidityDepressive disorders, anxiety disorders, substance use, and personality disorders common

Somatization DisorderDiagnosis requires certain number of symptoms accompanied by functional impairmentPain: head, chest, back, joints, pelvisGI symptoms: dysphagia, nausea, bloating, constipationCardiovascular symptoms: palpitations, shortness of breath, dizzinessComorbidityAnxiety and depression

HypochondriasisWidespread phenomenon1 out of 20 patients seek medical careMisinterpreting physical sensations as evidence of serious illnessNegative physical findings does not affect patients belief that they have serious illnessCormorbidityDepression, substance abuse, personality disorder

Pain DisorderDiagnosed when testing rules out organic cause for symptom of painEvidence of significant functional impairmentSuicide becomes serious risk for patients with chronic painTypical sites for pain: head, face, lower back, and pelvisCormorbidityDepression, substance abuse, personality disorder

Body Dysmorphic Disorder (BDDPatient has normal appearance or minor defect but is preoccupied with imagined defective body partPresence of significant impairment in functionTypical characteristicsObsessive thinking and compulsive behaviorMirror checking and camouflagingFeelings of shameWithdrawal from othersCormorbidityDepression, OCD, social phobia

Conversion DisorderSymptoms that affect voluntary motor or sensory function suggesting a physical conditionDysfunction not congruent with functioning of the nervous systemPatient attitude toward symptomsLack of concern (la belle indiffrence) or marked distress

Common symptomsInvoluntary movements, seizures, paralysis, abnormal gait, anesthesia, blindness, and deafnessCormorbidityDepression, anxiety, other somatoform disorders, personality disorders

Sleep Disorders: Introduction

Females is more often with somatiform and sleep disorder, 71%38,7 % with sleep disorder and 13% without sleep disorderThe prevalence of sleep disorders increases with advancing ageCommon types of sleep disorders include insomnia, hypersomnia, parasomnias, and circadian rhythm sleep disorders

Sleep Disorders: AssessmentInsomnia Difficulty falling or staying sleep Hypersomnia (somnolence) Excessive sleepiness or seeking excessive amounts of sleepNarcolepsy: Similar to hypersomniaCharacteristic manifestation: Sleep attacks; the person cannot prevent falling asleepParasomnias Nightmares, sleep terrors, sleep walking

Sleep terror disorder Manifestations include abrupt arousal from

sleep with a piercing scream or cryCircadian rhythm sleep disorders Shift-work type Jet-lag type Delayed sleep phase type

Nursing Process

Nursing DiagnosisPlanning/ImplementationOutcomesEvaluation

Predisposing FactorsGenetic 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.

Treatment ModalitiesSomatoform disorders Individual psychotherapy Group psychotherapy Behavior therapy Psychopharmacology

Sleep disordersRelaxation therapyBiofeedbackPharmacotherapy

Primary hypersomnia/narcolepsyPharmacotherapyCNS stimulants such as amphetaminesParasomniasCenters around measures to relieve obvious stress within the familyIndividual or family therapyInterventions to prevent injury

Thanks

IntroductionA. The somatoform disorders are characterized by physical symptomssuggesting medical disease, but without demonstrable organic pathology orknown pathophysiological mechanism to account for them.B. Somatization refers to all those mechanisms by which anxiety is translatedinto physical illness or bodily complaints.C. Disordered sleep is a problem for many people. The cause may betemporarily caused by stress or anxiety; or the cause may be physiological.II. Somatoform DisordersA. Historical Aspects1. The concept of hysteria, which is characterized by recurrent, multiplesomatic complaints often described dramatically, is at least 4,000 yearsold and probably originated in Egypt.2. Witchcraft, demonology, and sorcery were associated with hysteria in theMiddle Ages.3. In the 19th century, the French physician Paul Briquet attributed thedisorder to dysfunction in the nervous system.4. Out of his work with hypnosis, Freud proposed that emotion which is notexpressed can be converted into physical symptoms.B. Epidemiological Statistics1. Somatoform disorders are more common in women than in men. Theyare more common in the poorly educated and people from the lowersocioeconomic classes.C. Application of the Nursing Process to Somatoform Disorders1. Somatization Disorder: Background Assessment Dataa. A chronic syndrome of multiple somatic symptoms that cannot beexplained medically and are associated with psychosocial distressand long-term seeking of assistance from health care professionals.b. Any organ system may be affected, but common complaints involvethe neurological, gastrointestinal, psychosexual, or cardiopulmonarysystems.c. Anxiety and depression are frequently manifested, and suicidalattempts and threats are not uncommon.d. Predisposing factors to somatization disorder(1) Theory of family dynamics. In dysfunctional families, when achild becomes ill, a shift in focus is made from the open conflictto the childs illness, leaving unresolved the underlying issuesthat the family is unable to confront in an open manner.Somatization brings some stability to the family, and positivereinforcement to the child.(2) Cultural and environmental factors. Various cultures deal withphysical symptoms in different ways. Cognitive or emotionalsymptoms such as guilt are predominantly seen in Westernsocieties. In Middle Eastern and Asian cultures, depression isalmost exclusively manifested by somatic or vegetativesymptoms.(3) Genetic factors. Studies have shown a 10- to 20-fold increasedincidence in female first-degree relatives of persons with thedisorder. These statistics may imply a possible inheritablepredisposition.(4) Transactional Model of Stress-Adaptation. The etiology ofsomatization disorder is most likely influenced by multiplefactors.e. Diagnosis/Outcome Identification(1) Nursing diagnoses for the client with somatization disorderinclude:(a) Ineffective coping(b) Deficient knowledge(2) Outcome criteria are identified for measuring effectiveness ofnursing care.f. Planning/Implementation(1) Nursing intervention for the client with somatization disorder isaimed at assisting the client to learn to cope with stress by meansother than preoccupation with physical symptoms.(2) The nurse also works to help the client correlate appearance ofthe physical symptoms with times of stress.g. Evaluation is based on accomplishment of previously establishedoutcome criteria.2. Pain Disorder: Background Assessment Dataa. The predominant disturbance in pain disorder is severe andprolonged pain that causes clinically significant distress orimpairment in social, occupational, or other areas of functioning.b. Even when organic pathology is detected, the pain complaint maybe evidenced by the correlation of stressful situation with the onsetof the symptom.c. The disorder may be maintained by:(1) Primary gains: The symptom enables the client to avoid someunpleasant activity.(2) Secondary gains: The symptom promotes emotional support orattention for the client.(3) Tertiary gains: In dysfunctional families, the physical symptommay take such a position that the real issue is disregarded andremains unresolved, even though some of the conflict isrelieved.d. Predisposing factors to pain disorder(1) Psychodynamic theory. Theorizes that pain for some clientsserves the purposes of punishment and atonement for perceivedwrongdoing. Individuals who have difficulty expressingemotions verbally may express feelings and emotions withbodily sensations.(2) Behavioral theory. In behavioral terminology, psychogenicpain is explained as a response that is learned through operantand classical conditioning. Occurs when pain behaviors arepositive or negatively reinforced.(3) Theory of family dynamics. Pain games may be played infamilies burdened by conflict. Pain may be used formanipulating and gaining the advantage in interpersonalrelationships. Tertiary gain may also be influential.(4) Neurophysiological theory. Postulates that the cerebral cortexand medulla are involved in inhibiting the firing of afferent painfibers. These individuals may have decreased levels ofserotonin and endorphins, which are thought to play a role inthe central modulation of pain.(5) Transactional Model of Stress-Adaptation. The etiology of paindisorder is most likely influenced by multiple factors.e. Diagnosis/Outcome Identification(1) Nursing diagnoses for the client with pain disorder include:(a) Chronic pain(b) Social isolation(2) Outcome criteria are identified for measuring the effectivenessof nursing care.f. Planning/Implementation(1) Nursing intervention for the client with pain disorder is aimedat relief from pain.(2) Emphasis is placed on learning more adaptive copingstrategies for dealing with stress. Reinforcement is given attimes when the client is not focusing on pain.g. Evaluation is based on accomplishment of previously establishedoutcome criteria.3. Hypochondriasis: Background Assessment Dataa. Unrealistic preoccupation with fear of having a serious illnessb. Even in the presence of medical disease, the symptoms aregrossly disproportionate to the degree of pathology.c. Predisposing factors to hypochondriasis(1) Psychodynamic theory(a) One view suggests that hypochondriasis is an ego defensemechanism. Physical complaints are the expression oflow self-esteem and feelings of worthlessness, as it iseasier to feel something is wrong with the body than tofeel something is wrong with the self.(b) Another psychodynamic view explains hypochondriasis asthe transformation of aggressive and hostile wishestoward others into physical complaints to others.(c) Still other psychodynamicists have viewedhypochondriasis as a defense against guilt and a need toatone for past misconduct.(2) Cognitive theory. Cognitive theorists view hypochondriasisas arising out of perceptual and cognitive abnormalities.(3) Social learning theory. Somatic complaints are oftenreinforced when the sick role serves to relieve the individualfrom the need to deal with a stressful situation, whether it bewithin society or within the family constellation.(4) Past experience with physical illness. Personal experience, orthe experience of close family members, with serious or lifethreateningillness can predispose an individual tohypochondriasis.(5) Genetic influences. Although little is known about hereditaryinfluences with hypochondriasis, some evidence indicates anincreased prevalence of hypochondriasis among identicaltwins and other first-degree relatives.(6) Transactional Model of Stress/Adaptation. The etiology ofhypochondriasis is most likely influenced by multiple factors.d. Diagnosis/Outcome Identification(1) Nursing diagnoses for hypochondriasis include:(a) Fear(b) Chronic low self-esteeme. Planning/Implementation(1) Nursing intervention for the client with hypochondriasis isaimed at relieving the fear of serious illness.(2) The focus is on decreasing the preoccupation with andunrealistic interpretation of bodily signs and sensations.(3) The nurse also works to help the client increase feelings ofself-worth and resolve internalized anger.f. Evaluation is based on accomplishment of previouslyestablished outcome criteria.4. Conversion Disorder: Background Assessment Dataa. A loss of or change in bodily functioning resulting from apsychological conflict, the physical symptoms of which cannotbe explained by any known medical disorder orpathophysiological mechanism.b. The most obvious and classic conversion symptoms are thosethat suggest neurological disease, and occur following asituation that produces extreme psychological stress for theindividual.c. The person often expresses a relative lack of concern that is outof keeping with the severity of the impairment. This lack ofconcern is identified as la belle indifference and may be a clueto the physician that the problem is psychological rather thanphysical.d. Predisposing factors to conversion disorder(1) Psychoanalytical Theory. Emotions associated with atraumatic event that the individual cannot express because ofmoral or ethical unacceptability are converted intophysical symptoms. The symptom is symbolic in some wayof the original emotional trauma(2) Familial factors. Occurs more often in relatives ofindividuals with the disorder. Nongenetic familial factors,such as incestuous sexual abuse in childhood, also may beassociated with an increased risk for conversion disorder.(3) Neurophysiological theory. Suggests that some clients withconversion disorder have a disturbance in central nervoussystem arousal.(4) Behavioral theory. Suggests that conversion symptoms arelearned through positive reinforcement from cultural, social,and interpersonal influences.(5) Transactional Model of Stress/Adaptation. The etiology ofconversion disorder is most likely influenced by multiplefactors.e. Diagnosis/Outcome Identification(1) Nursing diagnoses for the client with conversion disorderinclude:(a) Disturbed sensory-perception(b) Self-care deficit(2) Outcome criteria are identified for measuring theeffectiveness of nursing care.f. Planning/Implementation(1) Nursing intervention for the client with conversion disorderis aimed at recovery of the lost or altered function.(2) Emphasis is given to assisting the client with activities ofdaily living until the function is regained. Care is given notto reinforce the physical limitation.g. Evaluation is based on accomplishment of previouslyestablished outcome criteria.5. Body Dysmorphic Disorder: Background Assessment Dataa. Characterized by the exaggerated belief that the body isdeformed or defective in some specific way.b. Symptoms of depression and characteristics associated withobsessivecompulsive personality are common.c. Has been closely associated with delusional thinking. Traitsassociated with schizoid, obsessivecompulsive, andnarcissistic personality disorders are not uncommon.d. Predisposing factors to body dysmorphic disorder(1) Etiology is unknown, but presumed to be psychological(2) Predisposing factors may be similar to those associatedwith hypochondriasis or phobias.(3) Repression of morbid anxiety is thought to be anunderlying factor.(4) It is most likely that multiple factors are involved in thepredisposition to body dysmorphic disorder.e. Diagnosis/Outcome Identification(1) Nursing diagnoses for the client with body dysmorphicdisorder include:(a) Disturbed body image(2) Outcome criteria are identified for measuring effectivenessof nursing care.f. Planning/Implementation(1) Nursing intervention for the client with body dysmorphicdisorder is aimed at development of a realistic perceptionof body appearance.(2) A focus is on resolution of repressed fears and anxietiesthat contribute to altered body image.(3) Positive reinforcement is given for accomplishmentsunrelated to physical appearance.g. Evaluation is based on accomplishment of previouslyestablished outcome criteria.III. Sleep DisordersA. Sleep Disorders: Background Assessment Data1. Insomnia: Difficulty with initiating or maintaining sleep.2. Hypersomnia (somnolence): excessive sleepiness or seeking excessiveamounts of sleep3. Narcolepsy: Sleep attacks. The individual cannot prevent fallingasleep, even in the middle of a task or a sentence.4. Parasomnias: Unusual to undesirable behaviors that occur duringsleep. Examples include:a. Nightmare disorder: Frightening dreams that lead toawakenings from sleep and are sufficiently severe to interferewith social or occupational functioning.b. Sleep terror disorder: Abrupt arousal from sleep with apiercing scream or cry. The individual is difficult to awaken orcomfort, and if wakefulness does occur, the individual isusually disoriented, expresses a sense of intense fear, butcannot recall the dream episode.c. Sleepwalking: the performance of motor activity initiatedduring sleep in which the individual may leave the bed andwalk about, dress, go to the bathroom, talk, scream, or evendrive. Episodes may last from a few minutes to a half hour.5. Circadian rhythm sleep disorders: a misalignment between sleep andwake behaviors. The normal sleep-wake schedule is disrupted fromits usual circadian rhythm. Categories include:(a) Shift work type(b) Jet lag type(c) Delayed sleep phase type6. Predisposing factors to sleep disordersa. Genetic or familial patterns: thought to play a contributing role inprimary insomnia, primary hypersomnia, narcolepsy, sleep terrordisorder, and sleepwalking.b. Medical conditions implicated in the etiology of insomnia: pain,sleep apnea syndrome, restless leg syndrome, use of or withdrawalfrom substances, endocrine or metabolic disorders, infectious orother diseases, and CNS lesions. Medical conditions associatedwith hypersomnia include metabolic and encephalitic conditions,the use of alcohol or other CNS depressants, withdrawal fromstimulants, sleep apneas, and hypoventilation syndromes.c. Psychiatric or environmental conditions: anxiety, depression,environmental changes, circadian rhythm sleep disturbances,posttraumatic stress disorder, and schizophrenia.d. Neurological abnormalities, such as temporal lobe epilepsy, maycontribute to night terrors.e. Extreme fatigue and sleep deprivation may contribute to episodesof sleepwalking.7. Diagnosis/Outcome Identificationa. Nursing diagnoses for the client with sleep disorders include:(1) Disturbed sleep pattern(2) Risk for injuryb. Outcome criteria are identified for measuring the effectiveness ofnursing care.8. Planning/Implementationa. Nursing intervention for the client with a sleep disorder is aimedat determining the cause of the disturbance and performing actionsthat promote sleep and rest for the client.9. Evaluation is based on accomplishment of previously establishedoutcome criteria.IV. Treatment ModalitiesA. Somatoform Disorders1. Individual psychotherapy2. Group psychotherapy3. Behavior therapy4. PsychopharmacologyB. Sleep Disorders1. Relaxation therapy2. Biofeedback3. Pharmacotherapy4. Phototherapy*