Chapter 12: Somatoform Disorders and Dissociative Disorders

Question 1

1. A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably:
   a. readily seek psychiatric counseling.
   b. be resistant to accepting psychiatric help.
   c. attend psychotherapy sessions without encouragement.
   d. be eager to discover the true reasons for physical symptoms.

Answer 1

ANS: B
Patients with somatic system disorders go from physician to physician trying to establish a physical cause for their symptoms. When a psychological basis is suggested and a referral for counseling is offered, these patients reject both.

Question 2

2. A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurses planning for this patient? The patient is:
   a. suppressing accurate feelings regarding the problem.
   b. relieving anxiety through the physical symptom.
   c. meeting needs through hospitalization.
   d. refusing to disclose genuine fears.

Answer 2

ANS: B
Psychoanalytic theory suggests conversion reduces anxiety through the production of a physical symptom that is symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. The other distractors oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously).

Question 3

3. A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should:
   a. establish a buddy system with other patients who can feed the patient at each meal.
   b. expect the patient to feed himself or herself after explaining the arrangement of the food on the tray.
   c. direct the patient to locate items on the tray independently and feed himself or herself unassisted.
   d. address the needs of other patients in the dining room, and then feed this patient.

Answer 3

ANS: B
The patient is expected to maintain some level of independence by feeding himself or herself, whereas the nurse is supportive in a matter-of-fact way. The distractors support dependency or offer little support.

Question 4

4. A patient with blindness related to a functional neurological (conversion) disorder says, All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital dont find me interesting. Which nursing diagnosis is most relevant?
   a. Social isolation
   b. Chronic low self-esteem
   c. Interrupted family processes
   d. Ineffective health maintenance

Answer 4

ANS: B
The patient mentions that the symptoms make people more interested, which indicates that the patient believes he or she is uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of Chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in this scenario.

Question 5

5. To assist a patient diagnosed with a somatic system disorder, a nursing intervention of high priority is to:
   a. imply that somatic symptoms are not real.
   b. help the patient suppress feelings of anger.
   c. shift the focus from somatic symptoms to feelings.
   d. investigate each physical symptom as soon as it is reported.

Answer 5

ANS: C
Shifting the focus from somatic symptoms to feelings or to neutral topics conveys an interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome is that the patient expresses feelings, including anger, if it is present. Once physical symptoms have been investigated, they do not need to be reinvestigated each time the patient reports them.

Question 6

6. A patient who fears serious heart disease was referred to the mental health center by a cardiologist after diagnostic evaluation showed no physical illness. The patient says, My heart misses beats. Im frequently absent from work. I dont go out much because I need to rest. Which health problem is most likely?
   a. Body dysmorphic disorder
   b. Antisocial personality disorder
   c. Illness anxiety disorder (hypochondriasis)
   d. Persistent depressive disorder (dysthymia)

Answer 6

ANS: C
Illness anxiety disorder (hypochondriasis) involves a preoccupation with fears of having a serious disease, even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Body dysmorphic disorder involves a preoccupation with ones perceived defective body parts or appearance. Persistent depressive disorder (dysthymia) is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others.

Question 7

7. A nurse assessing a patient diagnosed with a somatic system disorder is most likely to note that the patient:
   a. readily sees a relationship between symptoms and interpersonal conflicts.
   b. rarely derives personal benefit from the symptoms.
   c. has little difficulty communicating emotional needs.
   d. has unmet needs related to comfort and activity.

Answer 7

ANS: D
The patient diagnosed with a somatic system disorder frequently has altered comfort and activity needs. In addition, hygiene, safety, and security needs may also be compromised. The patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients with somatic system disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others.

Question 8

8. To plan effective care for patients diagnosed with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms:
   a. are generally chronic in nature.
   b. have a physiological basis.
   c. can be voluntarily controlled.
   d. provide relief from health anxiety.

Answer 8

ANS: D
the unconscious level, the patients primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide a secondary gain, patients frequently and fiercely cling to the symptoms. The symptoms tend to be chronic; however, this does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based.

Question 9

9. A patient diagnosed with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patients disabling symptoms as evidenced by the spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will:
   a. assume roles and functions of the other family members.
   b. demonstrate a resumption of former roles and tasks.
   c. focus energy on problems occurring in the family.
   d. rely on family members to meet his or her personal needs.

Answer 9

ANS: B
The patient with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and the resumption of former roles are necessary to change this pattern. The distractors are inappropriate outcomes.

Question 10

10. A woman wears a size 7 shoe. She says, My feet are huge. Ive asked three orthopedists to surgically reduce my feet. The patient tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?
    a. Dissociative amnesia with fugue
    b. Illness anxiety disorder
    c. Body dysmorphic disorder
    d. Dissociative identity disorder

Answer 10

ANS: C
Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patients feet are proportional to the rest of her body. Dissociative amnesia with fugue is characterized by sudden, unexpected travel away from the customary locale and the inability to recall ones identity and information about some or all of the past. Illness anxiety disorder involves a belief that one has a serious, life-threatening illness when none exists. Dissociative identity disorder involves the existence of two or more personality states that take control of ones behavior.

Question 11

11. Which assessment finding best supports the diagnosis of dissociative amnesia with fugue? The patient states:
    a. I cannot recall why Im living in this town.
    b. I feel as if Im living in a fuzzy dream state.
    c. I feel like different parts of my body are at war.
    d. I feel very anxious and worried about my problems.

Answer 11

ANS: A
The patient in a fugue state frequently relocates and assumes a new identity while not recalling his or her previous identity or places previously inhabited. The distractors are more consistent with depersonalization, generalized anxiety disorder, or dissociative identity disorder.

Question 12

12. A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later, and then sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered?
    a. Functional neurological (conversion) disorder
    b. Dissociative identity disorder
    c. Dissociative amnesia
    d. Body dysmorphic disorder

Answer 12

ANS: B
Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. At least two of the subpersonalities take control of the persons behavior but leave the individual unable to remember the periods of time in which the subpersonality is in control.

Question 13

13. A nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment is most likely from this patient?
    a. Since my father died, Ive been short of breath and had sharp pains that go down my left arm, but I think its just indigestion.
    b. I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry and I think Im getting seriously dehydrated.
    c. Sexual intercourse is painful. I pretend as if Im asleep so I can avoid it. I think its starting to cause problems with my marriage.
    d. I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus.

Answer 13

ANS: A
Patients with functional neurologic (conversion) disorder often demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed la belle indiffrence. In addition, a specific cause for the development of the symptoms is identifiable; in this instance, the death of a parent precipitates the stress. The incorrect options suggest other types of somatic symptom disorders.

Question 14

14. A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care?
    a. Anxiety
    b. Risk for suicide
    c. Disturbed body image
    d. Ineffective role performance

Answer 14

ANS: B
A high risk of completed suicide exists in patients with body dysmorphic disorder. Safety is always a high priority for the nurse; in this instance, the plan of care should include an awareness of the risk for self-inflicted harm.

Question 15

15. Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder: Disturbed personal identity, related to:
    a. obsessive fears of harming self or others.
    b. poor impulse control and lack of self-confidence.
    c. depressed mood secondary to nightmares and intrusive thoughts.
    d. cognitive distortions associated with unresolved childhood abuse issues.

Answer 15

ANS: D
Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant.

Question 16

16. For a patient diagnosed with dissociative amnesia, complete this outcome: Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by:
    a. functioning independently.
    b. verbalizing feelings of safety.
    c. regularly attending diversional activities.
    d. describing previously forgotten experiences.

Answer 16

ANS: D
The ability to recall previously repressed or dissociated material is an indication that the patient is integrating identity and memory. A patient may verbalize feeling safe but may be disoriented and have memory deficits. A patient may be able to function independently on a basic level without being able to remember significant information. Attending activities is possible without being able to remember antecedent events.

Question 17

17. A person comes to the clinic reporting, I wear a scarf across my lower face when I go out but because of my ugly appearance. Assessment reveals an average appearance with no actual disfigurement. Which problem is most likely?
    a. Dissociative identity disorder
    b. Body dysmorphic disorder
    c. Pseudocyesis
    d. Malingering

Answer 17

ANS: B
Body dysmorphic disorder involves a preoccupation with an imagined defect in appearance. Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. Pseudocyesis is the false belief that one is pregnant. Malingering is intentionally producing symptoms for a personal gain.

Question 18

18. A nurse counseling a patient diagnosed with dissociative identity disorder (DID) should understand that the assessment of highest priority is:
    a. risk for self-harm
    b. cognitive functioning
    c. identification of drug abuse
    d. readiness to reestablish identity or memory

Answer 18

ANS: A
Assessments that relate to patient safety take priority. Patients diagnosed with dissociative identity disorders may be at risk for suicide or self-mutilation; therefore, the nurse must be alert for hints of hopelessness, helplessness and worthlessness, low self-esteem, and impulses to self-mutilate. The distractors are important assessments but rank beneath safety.

Question 19

19. A patient says, I feel detached and weird all the time, like Im looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study. Which term should the nurse use to document this complaint?
    a. Depersonalization
    b. Hypochondriasis
    c. Dissociation
    d. Malingering

Answer 19

ANS: A
Depersonalization involves a persistent or recurrent experience of feeling detached from and outside ones mental processes or body. Although reality testing is intact, the detached experience causes significant impairment in social or occupational functioning and distress to the individual. Malingering involves a conscious process of intentionally producing symptoms for an obvious benefit; dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety. Hypochondriasis involves the interpretation of body sensations as symptomatic of a serious illness.

Question 20

20. A patient reports fears of having cervical cancer and says to the nurse, Ive had Pap smears by six different doctors. The results are normal, but Im sure thats because of errors in the laboratory. Which disorder would the nurse suspect?
    a. Functional neurologic (conversion) disorder
    b. Illness anxiety disorder (hypochondriasis)
    c. Body dysmorphic disorder
    d. Dissociative amnesia with fugue

Answer 20

ANS: B
Patients with illness anxiety disorder (hypochondriasis) have fears of serious medical problems such as cancer or heart disease. These fears persist, despite medical evaluations, and interfere with daily functioning. No complaints of pain are made, and no evidence of dissociation or conversion exists. Body dysmorphic disorder involves a belief that ones appearance is flawed.

Question 21

21. A patient diagnosed with somatic symptom disorder says, I have pain from an undiagnosed injury. I cant take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much. It is important for the nurse to assess:
    a. mood.
    b. cognitive style.
    c. secondary gains.
    d. identity and memory.

Answer 21

ANS: C
Secondary gains should be assessed. The patients dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patients diagnosis has been established.

Question 22

22. The causes of somatic system disorders may be related to:
    a. faulty perceptions of body sensations.
    b. traumatic childhood events.
    c. culture-bound phenomena.
    d. mood instability.

Answer 22

ANS: A
Structural or functional abnormalities of the brain have been suggested to lead to the somatic system disorders, resulting in disturbed processes of perception and interpretation of bodily sensations. Furthermore, cognitive theorists believe patients misinterpret the meaning of certain bodily sensations and then become excessively alarmed by them. Traumatic childhood events are related to the dissociative disorders. Culture-bound phenomena may explain the prevalence of some symptoms but cannot explain the cause. Somatic system disorders are not a facet of mood instability; however, depression may coexist with a somatic system disorder.

Question 23

23. What is the primary difference between somatic system disorders and dissociative disorders?
    a. Somatic system disorders are under voluntary control, whereas dissociative disorders are unconscious and automatic.
    b. Dissociative disorders are precipitated by psychological factors, whereas somatic system disorders are related to stress.
    c. Dissociative disorders are individually determined and related to childhood sexual abuse, whereas somatic system disorders are culture bound.
    d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychological stress through somatic symptoms.

Answer 23

ANS: D
The correct response is the only fully accurate statement. Somatic system disorders are not under voluntary control and are not culture bound.

Question 24

24. A patient says, I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day. Which response by the nurse fosters cognitive restructuring?
    a. You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking.
    b. Lets see whether any other explanations for your vomiting are possible.
    c. You seem so worried. Lets talk about how youre feeling.
    d. We should talk about something else.

Answer 24

ANS: B
Questioning the evidence is a cognitive restructuring technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective.

Question 25

25. Which treatment modality should a nurse recommend to help a patient diagnosed with somatic symptom disorder cope more effectively?
    a. Flooding
    b. Relaxation
    c. Response prevention
    d. Systematic desensitization

Answer 25

ANS: B
Pain, a common complaint in patients diagnosed with somatic symptom disorder, increases when the patient has muscle tension. Relaxation can diminish the patients perceptions of the intensity of pain. The distractors are modalities useful in treating selected anxiety disorders.

Question 26

26. A patient diagnosed with depersonalization disorder tells the nurse, Its starting again. I feel as though Im going to float away. The nurse should help the patient by:
    a. encouraging meditation.
    b. administering an anxiolytic medication.
    c. helping the patient visualize a pleasant scene.
    d. helping the patient focus on the here and now.

Answer 26

ANS: D
Talking with someone who can help the patient focus on reality allows the patient to interrupt the stimulus to dissociate. The incorrect options foster detachment.

Question 27

27. A patient diagnosed with somatic symptom disorder has been in treatment for 4 weeks. The patient says, Although Im still having pain, I notice it less and am able to perform more activities. The nurse should evaluate the treatment plan as:
    a. unsuccessful.
    b. minimally successful.
    c. partially successful.
    d. totally achieved.

Answer 27

ANS: C
Decreased preoccupation with symptoms and an increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance.

Question 28

1. A patient diagnosed with somatic symptom disorder says, Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear. Which nursing diagnoses apply to this patient? Select all that apply.
   a. Spiritual distress
   b. Decisional conflict
   c. Adult failure to thrive
   d. Impaired social interaction
   e. Ineffective role performance

Answer 28

ANS: A, E
The patients verbalization is consistent with spiritual distress. Moreover, the patients description of being unable to provide for and burdening the family suggests ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict.

Question 29

2. A nurse assesses a patient suspected to have somatic system disorder. Which findings support the diagnosis? Select all that apply.
   a. Female
   b. Reports frequent syncope
   c. Complains of heavy menstrual bleeding
   d. First diagnosed with psoriasis at 12 years of age
   e. Reports of back pain, painful urination, frequent diarrhea, and hemorrhoids

Answer 29

ANS: A, B, C, E
No chronic disease explains the symptoms for patients with somatic system disorder. Patients report multiple symptoms; gastrointestinal, sexual, and pseudoneurological symptoms are common. This disorder is more common in women than in men.

Question 30

3. A patients roommate has observed the patient behaving in uncharacteristic ways, but the patient cannot remember the episodes. Dissociative identity disorder (DID) is suspected. Which questions are most relevant to the assessment of this patient? Select all that apply.
   a. Are you sexually promiscuous?
   b. Do you think you need an antidepressant medication?
   c. Have you ever found yourself someplace and did not know how you got there?
   d. Are your memories of childhood clear and complete, or do you have blank spots?
   e. Have you ever found new things in your belongings that you cant remember buying?

Answer 30

ANS: C, D, E
Asking, Are you sexually promiscuous? would probably produce defensiveness on the part of the patient. If a subpersonality acts out sexually, the main personality is probably not aware of the behavior. Do you think you need an antidepressant medication? is a premature question and not in the nurses scope of practice. All of the other questions are pertinent.