Psychophysiological Responses and Somatoform and Sleep Disorders



Psychophysiological Responses and Somatoform and Sleep Disorders


Gail W. Stuart




Learning Objectives



1. Describe the continuum of adaptive and maladaptive psychophysiological responses.


2. Identify behaviors associated with psychophysiological responses.


3. Analyze predisposing factors, precipitating stressors, and appraisal of stressors related to psychophysiological responses.


4. Describe coping resources and coping mechanisms related to psychophysiological responses.


5. Formulate nursing diagnoses related to psychophysiological responses.


6. Examine the relationship between nursing diagnoses and medical diagnoses related to psychophysiological responses.


7. Identify expected outcomes and short-term nursing goals related to psychophysiological responses.


8. Develop a patient education plan to teach adaptive strategies to cope with stress.


9. Analyze nursing interventions related to psychophysiological responses.


10. Evaluate nursing care related to psychophysiological responses.



Throughout history, philosophers and scientists have debated the nature of the relationship between the mind (psyche) and the body (soma). There is now great interest in holistic health practices, and research is identifying the links among thoughts, feelings, and body functioning. It is now recognized that physical disorders have a psychological component and psychological disorders have a physical one.



Continuum of Psychophysiological Responses


Current thinking about psychophysiological responses is related to an increased understanding of the role of stress in human life. In 1956 stress theory was advanced when Hans Selye published The Stress of Life, in which he described the stress response and the effect of stressful experiences on physical functioning. He identified a three-stage process of response to stress called the general adaptation syndrome (GAS):



1. The alarm reaction. This reaction is the immediate response to a stressor in a localized area. Adrenocortical mechanisms respond, resulting in behaviors associated with the fight-or-flight response.


2. Stage of resistance. The body makes some effort to resist the stressor. The body adapts and functions at a less than optimal level. This requires a greater than usual expenditure of energy for survival.


3. Stage of exhaustion. The adaptive mechanisms become worn out and then fail. The negative effect of the stressor



LEARNING FROM A CLINICAL CASE


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.



Case Background


As the patient walks through the door you note that she is young and looks almost “doll like,” dressed in a frilly print dress with long curly hair. Quickly she becomes tearful. She says she should be happy but she feels so sad. She has been going through this cycle so many times, over and over again. For as long as she can remember, she has been convinced that she had some dreaded severe illness but no one has been able to diagnose it. She can’t stop thinking about it. It causes so much stress; she hates herself and her life. She feels like she has been cursed and doesn’t know why. When she takes an antidepressant, things get better. She relaxes, feels good, and those thoughts go away.


Just when she thinks she has it figured out and men start to notice her, she gains 30 pounds, doesn’t recognize herself in the mirror, and hates how she looks yet again. It seems like she can’t get it right. She goes off of the medication and all the thoughts and fears start again. She makes trips to any doctor she can find, pleading with them to find out what is wrong with her. She becomes convinced that she has a fatal illness once more.


By the time you are seeing her, she has had at least 20 MRIs and knows this has to stop. She is too ashamed to tell her boyfriend, but she can see the pounds coming back and she is disgusted with herself. Her parents are both deceased, and she has always been dependent on her grandmother for support.



spreads to the entire organism. If the stressor is not removed or counteracted, death will result.


Any experience that is perceived by the individual to be stressful may stimulate a psychophysiological response. The stress does not have to be recognized consciously, and often it is not. People who recognize that they are under stress are often unable to connect their cognitive understanding of stress with their physical symptoms of the psychophysiological disorder. Figure 16-1 illustrates the range of possible psychophysiological responses to stress, based on Selye’s theory.


image
FIG 16-1 Continuum of psychophysiological responses.


Assessment


Behaviors


Many behaviors are associated with stress and psychophysiological disorders. Careful assessment is needed so that organic problems can be defined and treated. Such illnesses should never be dismissed as being “only psychosomatic” or “all in one’s head.” They represent real illnesses, many with real physiological changes.



imageQUALITY AND SAFETY ALERT





Physiological


The primary behaviors observed with psychophysiological responses are the physical symptoms. These symptoms lead the person to seek health care. Psychological factors affecting the physical condition may involve any body part. The organ systems most commonly involved and the associated physical conditions are listed in Box 16-1.



BOX 16-1   PHYSICAL CONDITIONS AFFECTED BY PSYCHOLOGICAL FACTORS


Cardiovascular










Longer general hospital stays have been reported to be associated with greater psychological comorbidity, particularly depression, anxiety, and organicity. Such research underscores the importance of linking physiological and psychological assessments.


People are often reluctant to believe that a physical problem may be related to psychological factors. In part, this is because being physically ill is more socially acceptable and less stigmatizing than having psychological problems. The situation is compounded because the patient does have real physical symptoms.


Denial of the psychological component of the illness may lead to “doctor shopping” as the patient searches for someone who will find an organic cause for the illness. This tendency to experience and communicate psychological distress in the form of physical symptoms and to seek help for them in general medical settings is common as seen in the following clinical example.



CLINICAL EXAMPLE


Mr. R was a successful 42-year-old executive who had risen quickly to the top of his company. He worked long hours and had difficulty delegating any responsibilities. He set high standards for his employees and was believed to be insensitive to human concerns. He viewed himself as tough but fair. However, he had little sympathy for a worker who requested extra time off for personal business.


Mr. R was married but saw little of his family. He expected his wife and children to do their part to maintain his standing in the community by associating with “the right people.” He seldom interacted with his children except to reprimand them if they disturbed him while he was working. His wife reported that their sexual relationship was unsatisfying to her. Mr. R used it for physical release for himself but was not concerned about meeting her needs. She suspected that he was involved in an extramarital affair but did not want to endanger the marriage by confronting him.


Mr. R was expecting to be named to the board of directors of a prestigious philanthropic foundation. He expected that this would add to his social prominence in the community. Shortly before the announcement was to be made, his 14-year-old son was arrested in a drug raid in an undesirable part of town. Mr. R did not get the appointment to the board. He was furious with his son but dealt with his anger by withdrawing still more.


One day at work, he experienced an episode of dizziness followed by a severe headache. He attributed it to tension, took some aspirin, and continued to work. However, after several similar episodes, he decided to consult his family doctor. The physician arrived at a diagnosis of essential hypertension. He tried to discuss work, family, and social behavior with Mr. R but received only superficial responses. Although he was concerned about Mr. R’s condition and stress level, the doctor gave in to Mr. R’s demand for medication to lower his blood pressure. He also advised Mr. R to exercise and to find a relaxing activity to help him relieve his stress.



Mr. R is typical of many people with stress-related psychophysiological disorders. He is reluctant to admit to a lack of control over his mind and body. He expects a magical cure that will let him follow his usual lifestyle without interruption. He will probably stop taking his medication as soon as he feels better. Distance from the stressor may allow him to function for a while without noticeable symptoms of his hypertension. Sooner or later, however, new stressors will lead to another dizzy spell, headaches, or possibly myocardial infarction or cerebrovascular accident.



Psychological


Some people have physical symptoms without any organic impairment, and these are called somatoform disorders. They include the following:



The next clinical example is a case history of a person with a medical diagnosis of somatization disorder.



CLINICAL EXAMPLE


Ms. P, a 28-year-old single woman, was admitted to the medical unit of a general hospital for a complete medical work-up. When asked about her main problem during the nursing assessment, she replied, “I’ve never been very well. Even when I was a child I was sick a lot.” Ms. P listed multiple complaints during the physical assessment. These included palpitations, dizzy spells, menstrual irregularity, painful menses, blurred vision, dysphagia, backache, pain in her knees and feet, and a variety of gastrointestinal symptoms including stomach pain, nausea, vomiting, diarrhea, flatulence, and intolerance to seafood, vegetables of the cabbage family, carbonated beverages, and eggs. Except for the food intolerances, none of the symptoms were constant. They occurred at random, making her fearful of leaving home.


The psychosocial assessment revealed that Ms. P lived with her parents. She was the youngest of three children. Her siblings were living away from the parental home. She had graduated from high school but had poor grades because of her frequent absences. She had tried to work as a clerk in a retail store but was fired because of absenteeism. She did not seem particularly bothered by the loss of her job. She had never tried to find other work, although she had been unemployed for 8 years. When asked how she spent her time, she said that she did some gardening and some housework when she felt well enough. However, she spent most of her time watching television.


Ms. P’s parents visited her every day. Her mother asked whether she could spend the night in her daughter’s room and was displeased when told no. The family had many complaints about the quality of the nursing care, mostly about failures to anticipate the patient’s needs. Extensive diagnostic studies failed to reveal any organic basis for Ms. P’s physical complaints. When informed that the problem was most likely psychological and advised to obtain psychotherapy, the family protested angrily and refused a referral to a psychiatric clinic. Ms. P was discharged and returned to her parents’ home.



Ms. P shows the dependent behavior that is typical of people with somatization disorder. Her many symptoms allow her to be taken care of and to avoid the demands of adult responsibility. Her need to be cared for fits with her mother’s need to nurture. Therefore she has little incentive to give up her symptoms. A periodic hospital stay reinforces the seriousness of her problem. Secondary gain related to the gratification of dependency needs is a powerful deterrent to change in many patients. Secondary gain is an indirect benefit, usually obtained through an illness or disability. Such benefits may include personal attention, release from unpleasant situations and responsibilities, or monetary and disability benefits.


Another type of somatoform disorder is conversion disorder, in which symptoms of some physical illnesses appear without any underlying organic cause (Tocchio, 2009). The organic symptom reduces the patient’s anxiety and usually gives a clue to the conflict.


For example, a patient who has an impulse to harm his domineering father may develop paralysis of his arms and hands. The primary gain, or direct benefit from the illness, is that the patient is unable to carry out his impulses. He also may experience secondary gain in the form of attention, manipulation of others, freedom from responsibilities, and economic benefits.


Conversion symptoms may include the following:



It is often difficult to diagnose this reaction. Other patient behaviors may be helpful in making the diagnosis. Patients often display little anxiety or concern about the conversion symptom and its resulting disability. The classic term for this lack of concern is la belle indifference (Stone et al, 2006). The patient also tends to seek attention in ways not limited to the actual symptom.


Hypochondriasis is another type of somatoform disorder. People with this disorder have an exaggerated concern with physical health that is not based on any real organic disorders. They fear presumed diseases and are not helped by reassurance. They also tend to seek out and use information about diseases to convince themselves that they are ill or about to become ill.


In contrast to conversion reaction, there is no actual loss or distortion of function. Patients appear worried and anxious about their symptoms. This concern may be based on physical sensations overlooked by most people or on symptoms of a minor physical illness that the patient magnifies. This is often a chronic behavior pattern accompanied by a history of visits to numerous practitioners.


Hypochondriacal behavior is not related to a conscious decision. If a person decides to fake an illness, the behavior is called malingering. This behavior is usually done to avoid responsibilities the person views as burdensome and to receive financial gain of some type.


Many otherwise healthy people malinger at one time or another. For instance, a person involved in an automobile accident may feign neck pain to receive insurance money. Often, the person exaggerates symptoms, is evasive, and tells contradictory stories about the illness.



Faking Illness


People who fake illness are said to have factitious disorder. They may aggravate existing medical conditions or inflict actual injury on themselves or on individuals in their care. Unlike those who malinger, patients with factitious disorder are motivated by the need for the emotional attention that comes with playing the role of a patient. Onset of illness usually occurs between 20 to 40 years of age.


These patients tend to visit the same health care provider repeatedly and are usually well known by the health care team. Many patients with this disorder have other comorbid psychiatric diagnoses including mood disorders, personality disorder, and substance related disorders. Perhaps the best known factitious disorder is Munchausen syndrome, in which patients make up symptoms to gain hospital admission and emotional attention over and over again.



Pain


Pain is increasingly recognized as more than simply a sensory phenomenon. It is a complex sensory and emotional experience underlying potential disease. Pain is influenced by behavioral, cognitive, psychological, and motivational processes that require sophisticated assessments and multifaceted treatments for its control (American Nurse Today, 2011).


Long-lasting pain has many effects and can produce changes in one’s mood, thought patterns, perceptions, coping abilities, and personality. Chronic pain combined with major depressive disorder results in higher medical service costs (Arnow et al, 2009).



The experience, expression, and treatment of pain are subject to cultural norms and biases. For example, in Western cultures, health care practitioners often take expressions of pain more seriously in males than in females. Members of minority groups who seek health care in culturally insensitive settings may have their requests for support in coping with pain misunderstood, because support is culturally defined and varies across ethnic and racial groups.


All patients with chronic pain should be carefully evaluated for risk of suicide. Risk factors for understanding suicide in chronic pain patients include the following: the type, intensity, and duration of pain; sleep-onset insomnia co-occurring with pain; helplessness and hopelessness about pain; the desire to escape from pain; pain “catastrophizing” and avoidance; and problem-solving deficits (Tang and Crane, 2006).



imageQUALITY AND SAFETY ALERT





Sleep


Normal sleep is defined as 6 to 9 hours of restorative sleep with characteristic sleep architecture and physiology and no complaints about quality of sleep, daytime sleepiness, or difficulties with mood, motivation, or performance during waking hours (Zunkel, 2005). Sleep disorders are common in the general population as well as among people with psychiatric disorders.


About 80% of people with depression and 90% of patients with anxiety report experiencing problems sleeping (Kierlin, 2008). Sleep disturbance is common after traumatic events such as combat, trauma, or abuse.


Sleep disruption also is reported by many patients in intensive care units. Nurses should remember that hospitals and other clinical settings are not conducive to restful sleep. Staff conversations, doors, pumps, pagers, monitors, and cleaning all can escalate noise levels. Sensitivity to noise and creating a quiet patient environment will directly help patients to sleep (King et al, 2007).


Sleep disturbances can influence the development and course of physical and mental illnesses and addictive disorders and also can affect treatment and recovery. Sleep disturbances caused by worry may increase risk for alcohol-related problems, particularly among those with anxiety and mood disorders.


Insomnia is the most prevalent sleep disorder. Up to 30% of the population have and seek help for insomnia. Other sleep disturbances include excessive daytime drowsiness, difficulty sleeping during desired sleep time, sleep apnea, and unusual nocturnal events such as nightmares or sleepwalking. It is estimated that 80% to 90% of the 9 million people with sleep apnea remain undiagnosed. Sleep disorders are more common in the elderly age group.


The International Classification of Sleep Disorders identifies three major groupings (American Academy of Sleep Medicine, 2001):



1. The dyssomnias are the disorders that produce either difficulty initiating or maintaining sleep or excessive sleepiness. They are divided into three groups of disorders: intrinsic sleep disorders, extrinsic sleep disorders, and circadian rhythm sleep disorders. Examples of dyssomnias include insomnia, narcolepsy, obstructive sleep apnea, restless legs syndrome, inadequate sleep hygiene, and alcohol/stimulant–dependent sleep disorder.


2. The parasomnias (i.e., the disorders of arousal, partial arousal, and sleep-stage transition) are disorders that intrude into the sleep process and are not primarily disorders of sleep and wake states per se. These disorders are signs of central nervous system activation, usually transmitted through skeletal muscle or autonomic nervous system channels. Examples of parasomnias include sleepwalking, sleep terrors, nightmares, sleep paralysis, sleep enuresis, primary snoring, and sudden infant death syndrome.


3. Sleep disorders associated with medical/psychiatric disorders include those conditions that are not primarily sleep disorders but are mental, neurological, or other medical disorders that have either sleep disturbance or excessive sleepiness as a major feature of the disorder.


Approximately 35% to 58% of people in the United States report that they have difficulty initiating or maintaining sleep or experience nonrestorative sleep (National Sleep Foundation, 2011). The majority of those affected are undiagnosed and untreated. In addition, millions of other people get inadequate sleep because of demanding work schedules, school, and other lifestyle issues. This group includes night-shift nurses, who report higher levels of fatigue and poorer sleep quality than day-shift nurses do.


The consequences of sleep disorders, sleep deprivation, and sleepiness are significant. They can result in higher morbidity and mortality risks, and their effects span all aspects of modern society, including health care, education, and family and social life.



imageQUALITY AND SAFETY ALERT




The assessment of patients with sleep problems is multifaceted, involving a detailed history and medical and psychiatric examinations, extensive questionnaires, the use of sleep diaries or logs, and often psychological testing (Buysse, 2005; Lee and Ward, 2005; Becker, 2008). Many patients are referred for formal sleep studies, which include all-night polysomnography and physiological measures of daytime sleepiness. Many members of the health care team collaborate within sleep centers to deliver multidisciplinary care.



Critical Reasoning


Have you ever had a problem sleeping? Which group would your problem have fit into, and what did you do to relieve it?



Predisposing Factors


A number of biopsychosocial factors influence psychophysiological responses to stress. Most relationships between physical and psychological processes are not well described. Therefore it is important for the nurse to consider all possibilities when assessing factors that might predispose the patient to a particular disorder.



Biological


Research has linked emotions to arousal of the neuroendocrine system through release of corticosteroids by the hypothalamic-pituitary-adrenal (HPA) axis and to the actions of neurotransmitter systems, particularly norepinephrine and serotonin. Neuroendocrine data provide evidence of insufficient glucocorticoid signaling in stress-related neuropsychiatric disorders. Impaired feedback regulation of relevant stress responses, especially immune activation and inflammation, may in turn contribute to stress-related pathology, including alterations in behavior, insulin sensitivity, bone metabolism, and acquired immune responses.


Perceived stress is in part heritable (Federenko et al, 2006). A biological tendency for particular psychophysiological responses may be inherited, underscoring the importance of genetic factors. For instance, epidemiological studies have shown that the lifetime prevalence for somatization disorder in the general population is 0.1% to 0.5% and is higher in women. However, among mothers and sisters of affected patients, the prevalence increases to 10% to 20%. The rate in monozygotic (identical) twins is 29%, and in dizygotic (fraternal) twins it is 10%. Therefore an inherited tendency for this disorder clearly exists.


The genetic theory suggests that any prolonged stress can cause physiological changes that result in a physical disorder. Each person has a “shock organ” that is genetically vulnerable to stress. Some patients may be prone to cardiac illness, whereas others may react with gastrointestinal distress or skin rashes. People who are chronically anxious or depressed are believed to have a greater vulnerability to psychophysiological illness.



Psychoneuroimmunology


Psychoneuroimmunology is the scientific field that explores the relationships among psychological states, the immune system, and health (see Chapter 5). This field is based on the mind-body connection, which extends to the cellular level (Figure 16-2).


image
FIG 16-2 Updated view of Selye’s general adaptation syndrome emphasizing the mind-body-cell/gene communication loop of the immune system. ACTH, Adrenocorticotropic hormone.

For example, glial cells are found throughout the central nervous system. They are as numerous as neurons, and they form an extensive defensive network in the brain, monitoring and even enhancing normal brain function and migrating to trouble spots to ingest microbes, dying cells, and other debris.


Research also has shown that these cells can begin to function abnormally and then, in some people, exacerbate or even cause several disabling conditions such as stroke, Alzheimer disease, multiple sclerosis, Parkinson disease, dementia associated with human immunodeficiency virus (HIV) infection, and other neurodegenerative disorders.


The immune response can be changed by behavior modification techniques. Researchers are investigating the possibility of modifying the immune response in the treatment of autoimmune illnesses, such as rheumatoid arthritis, systemic lupus erythematosus, myasthenia gravis, and pernicious anemia.


Other research is exploring the relationships among the immune system, stress, and cancer. It is suspected that high stress, especially if prolonged, can decrease the immune system’s ability to destroy neoplastic growths.



Sleep


The neurotransmitter that is most involved in sleep regulation is gamma-aminobutyric acid (GABA), which is produced by neurons in the hypothalamus. GABA acts to induce sleep by inhibiting the arousal functions of cholinergic neurons.


The peptide hypocretin also may regulate sleep and wakefulness. Studies show a dramatic reduction (up to 95%) in the number of neurons containing hypocretin in the brains of people with narcolepsy compared with normal controls. The pronounced loss of these neurons could be caused by either a neurodegenerative process or an autoimmune response.


The brains of those with narcolepsy also revealed signs of an inflammatory process called gliosis, which is linked to neuronal degeneration and may explain the loss of the hypocretin cells. These findings suggest that it may be possible to administer hypocretins to patients with narcolepsy as a potential treatment strategy.

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Psychophysiological Responses and Somatoform and Sleep Disorders

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