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Week 6: Req Readings: American Psychiatric Association. (2022). DSM
- Dissociative Disorders
- Somatic Symptom and Related Disorders Boland, R., & Verduin, M. L. (2022). Kaplan and Sadock's synopsis of psychiatry (12th ed.). Wolters Kluwer.
- Chapter 11: Dissociative Disorders
- Chapter 12: Somatic Symptom and Related Disorders Wheeler, K. (2022). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence- based practice (3rd ed.). Springer.
- Chapter 17: Stabilization for Trauma and Dissociation Dissociative disorders are complex mental health problems characterized by dissociative symptoms that occur as an adaptive defense response to trauma. Dissociative disorders may impede various elements of psychological functioning, such as consciousness, memory, emotion, identity, and motor control, and often occur comorbidly with other mental health disorders. Complex presentations and difficult comorbidities often create diagnostic and therapeutic challenges leading to under and delayed diagnosis and appropriate treatment. Stigma may hinder treatment as myths abound about the existence and validity of these disorders (Chien & Fung, 2021). Afflicted individuals may not be aware of their dissociative states and may not seek care. Safety and social problems are primary considerations for these individuals. Trauma-informed care and dissociation-specific psychotherapy are crucial to managing dissociative responses. Somatic symptoms or psychophysiological disorders are also challenging to diagnose and treat. These disorders are characterized by physical symptoms or dysfunction linked to psychological factors or emotional stress. Differentiating between psychosomatic and physiological disorders is often difficult due to the interplay of psychological and physiological processes. Psychotherapies such as cognitive- behavior therapy and stress management are important to reduce symptom burden and promote health.
Title: How the Nervous System Responds to Trauma Adapted from Ruth Lanius, MD, PhD How does your nervous system figure out how to respond in a crisis? It's a split-second, unconscious process designed to choose the best option for keeping you safe. Here's how it works: Identify Threat
- Can I escape o If yes, Flee ▪ If we can quickly get far enough away from the threat, we might be able to escape and avoid interacting with it entirely.
- If no, can I overpower it? o If yes, Fight ▪ If we attack the threat before it attacks us, we might be able to weaken it and possibly keep it from attacking in the future.
- If no, can I make it lose interest? o If yes, freeze. ▪ If our body closes up, becomes rigid, and won’t move, we might be able to keep the threat from noticing or becoming interested in us.
- If no, collapse. o If our mind/brain disconnects from our body, like by dissociating, or in some cases by fainting, we might be able to avoid feeling as much of the pain. In the face of threat, there isn't time to try every approach. In fact, your nervous system has to make these choices almost instantaneously. So while you may not understand the choice, or agree with it afterward, it's important to know that your body is taking care of you the best it knows how. Freeze and shutdown/collapse response How to Differentiate Freeze from Shutdown Freeze and collapse both involve the inability to move. But while they might appear similar, they are very different physiological responses to stress or trauma. Here are some key differences: Freeze
- The client is HYPERaroused
- The muscles are tense and full of energy, but can’t release it
- In this stage, there are similar levels of sympathetic and parasympathetic activation
- Increased heart rate/blood pressure
- The client might say, “I feel stuck,” “I can’t move,” or “I feel like I am encased in cement.”
- Eyes widen
- The body is ready to return to fight/flight as soon as the threat passes
Implicit Memory Procedural Memory
- How Trauma Can Affect It o Trauma can change patterns of procedural memory. For example, a person might tense up and unconsciously alter their posture, which could lead to pain or even numbness.
- Related Brain Area o The striatum is associated with producing procedural memory and creating new habits. Emotional Memory
- How Trauma Can Affect It o After trauma, a person may get triggered and experience painful emotions, often without context.
- Related Brain Area o The amygdala plays a key role in supporting memory for emotionally charged experiences. Trauma and the window of tolerance How Trauma Can Affect Your Window Of Tolerance Hyperarousal
- Anxious, Angry, Out of Control, Overwhelmed
- Your body wants to fight or run away. It’s not something you choose – these reactions just take over. When stress and trauma shrink your window of tolerance, it doesn't take much to throw you off balance. Window of Tolerance: When you are in your Window of Tolerance, you feel like you can deal with whatever’s happening in your life. You might feel stress or pressure, but it doesn’t bother you too much. This is the ideal place to be. Working with a practitioner can help expand your window of tolerance so that you are more able to cope with challenges. Hypoarousal
- Spacy, Zoned Out, Numb, Frozen
- Your body wants to shut down. It’s not something you choose – these reactions just take over.
Polyvagal theory Mapping Your Nervous System's Response to Trauma Based on ideas from Stephen Porges, PhD and Deb Dana, LCSW According to polyvagal theory, the nervous system has three pathways, each designed to protect you. Think of ventral vagal as the nervous system’s optimal state. This is the state from which we can engage socially, and connect and co-regulate with others. In this state, we often feel more calm, curious, grounded, and safe. But when you carry a history of trauma, relationships can be particularly triggering, making it difficult to feel safe connections with others. So, the nervous system starts seeking out alternative pathways of protection:
- Sympathetic: This is a defensive pathway that gets the body to mobilize into a fight or flight response or an attach/cry-for-help response. In this state, we might feel fear, panic, irritation, anger, or even rage.
- Dorsal vagal: This is a defensive pathway that gets the body to immobilize into a collapse/shutdown response. In this state, we may feel numb, depressed, ashamed, hopeless, or lethargic. We may dissociate. Understanding these responses can help you recognize when your nervous system is going into “defense mode.” Your therapist may be able to help you identify what triggers these responses so that you can develop strategies to manage them and get grounded. Dissociative Disorders Background Dissociation is an unconscious defense mechanism in which individuals disconnect from their thoughts, emotions, memories, or sense of identity. Dissociative disorders involve repeated discontinuity or disruption of the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior (American Psychiatric Association [APA], 2022). While as many as 75% of people experience at least one episode of depersonalization or derealization in their lifetime, only 2% meet the full criteria for a dissociative disorder (National Alliance on Mental Illness [NAMI], n.d.). Dissociative disorders can occur across the lifespan and often develop as a response to severe or repetitive overwhelming trauma. Dissociation can worsen with stress and can disrupt every area of psychological functioning.
The Structural Dissociation model further develops this theory and suggests that defense and attachment are motivational systems with opposing goals: attachment invites closeness and defense distances (National Institute for the Clinical Application of Behavioral Medicine [NICABM], n.d.). When these opposing goals are activated, the nervous system becomes dysregulated as it is biologically incompatible to have opposing aspects activated simultaneously and structural dissociation occurs. Title: Structural Dissociation Model Defense System: When a child is abused, their defense system will naturally work to shield them from harm, BUT... Attachment System: ...their attachment system will still want to be loved and cared for by the parent. This creates an internal tug-of-war where different motivational systems are working against each other simultaneously. This can cause a patient's conflicting parts to separate. That can lead to a split in their sense of self and a dysregulated nervous system. Structural Dissociation Model, Part 2 Left Brain: The "Going on with Normal Life" Part of the Self
- This is the rational, present-oriented, and grounded self.
- This self handles daily life - social interaction, attachment, work, play, exploration, learning, and taking care of physical needs. Right Brain: The "Traumatized Child" Part of the Self
- This part contains the trauma.
- This part is often drawn out by reminders of the trauma, and it may not experience much of everyday life. The survival responses of this self may include Attach/Cry for Help, Collapse/Submit, Please/Appease, Freeze, along with Fight and Flight The key to recovery is helping a patient have full awareness of all their parts without feeling overwhelmed. Discover More Learn more about the role of trauma in the development of dissociative symptoms and disorders Now, watch this video to learn more about structural dissociation Types of Dissociative Disorders There are several types of dissociation that clients can experience, singularly or in any combination at various times.
Dissociative Amnesia The primary symptom of dissociative amnesia is difficulty remembering autobiographical information to a degree inconsistent with normal forgetting (APA, 2022). Although memory loss most commonly relates to a particular event, such as combat or abuse, memory loss may also include details about one’s identity or life history. Episodes usually involve a sudden onset and may last minutes, hours, days, or, less commonly, months to years (NAMI, n.d.). Many individuals with dissociative amnesia are initially unaware of the gaps in memory until they notice that they do not recall information about their identity or when circumstances make them aware that autobiographical information is missing (APA, 2022). Dissociative Fugue The Diagnostic and Statistical Manual of Mental Health Disorders 5th ed. text revision (DSM- 5 - TR, APA
- classifies dissociative fugue as a subtype of dissociative amnesia; however, it is a separate diagnosis in ICD-10. Dissociative fugue can last from minutes to months and is seen in individuals with both dissociative amnesia and dissociative identity disorder. During a dissociative fugue, an individual cannot recall some or all of their past, may travel from their home or daily activity, and may be confused about their identity or even assume a new one (Boland & Verduin, 2022). Dissociative fugues in children and adolescents tend to be brief and travel only involves short distances. Discover More Watch this video to learn more about the experience of an individual diagnosed with dissociative fugue (formerly called psychogenic fugue) Depersonalization/Derealization Disorder Depersonalization is a sense of unreality or detachment from the mind, body, or self. Derealization involves a sense of unreality or detachment from one’s surroundings. Depersonalization/derealization disorder involves clinically significant persistent or recurrent depersonalization or derealization paired with intact reality testing (APA, 2022). Individuals with depersonalization/derealization disorder experience ongoing detachment from their actions, feelings, thoughts, sensations, or the world around them. They may experience life as if they were watching a movie. Things around them may feel unreal. The average age of onset is 16, with fewer than 20% of individuals starting to experience episodes after age 20 (NAMI, n.d.). Dissociative Identity Disorder Dissociative identity disorder (DID), formerly called multiple personality disorder, is a dissociative disorder in which the individual has two or more distinct personalities or experiences recurrent episodes of dissociative amnesia (APA, 2022). Alternate identities often have unique names, characteristics, voices, or mannerisms. Women with DID are more likely to present with dissociative symptoms, while men are more likely to present with violent behavior, which can lead to false-negative diagnoses (NAMI, n.d.).
Discover More There are several validated tools relevant to dissociative disorders. Learn more about the Dissociative Experiences Scale II which is a validated self-assessment tool that can be used to help direct the clinical interview. Now, learn about the Dissociative Disorders Interview Schedule, which is a structured interview tool that may assist in the diagnosis of DIDs, somatic disorders, and some personality disorders. Learn by Applying Carson Carson is a 17-year-old who presents with his mother. She is concerned because he was involved in a minor car crash last week; he states that he does not remember what happened because he “zoned out” while driving. He states that this occurs several times per week; when it happens, he is typically thinking about his upcoming college applications and admissions. Which of the following is the most likely diagnosis for Carson?
- dissociative identity disorder
- dissociative amnesia with dissociative fugue
- does not meet diagnostic criteria (Correct answer)
- dissociative amnesia
- depersonalization/derealization disorder Rationale: Although Carson has had episodes of derealization, he does not meet the DSM- 5 - TR (APA,
- diagnostic criteria for a dissociative disorder.
Tiffani Tiffani is a 34-year-old who presents after a referral from her primary provider. She complains of severe headaches and periods of memory loss; after thorough diagnostic testing, no physiologic cause was identified. Tiffani has a history of major depressive disorder (MDD), diagnosed as a teen, and generalized anxiety disorder (GAD), diagnosed at age 28. She has a history of cutting which she states began when she was a teenager. She was prescribed escitalopram 20 mg daily by her primary provider six years ago and reports her symptoms are “better, but not gone.” Tiffani discloses that she was sexually abused by her grandfather from age seven until his death when she was 14. She did not tell anyone about the abuse. She has never sought therapy or care from a psychiatric specialist. She has no other medical or psychiatric history. During the interview, Tiffani states that her mother recently died. She reports that the death has made her feel sad and that her thoughts “are no longer my own. I feel like someone else has taken charge of my brain.” Her husband of 8 years has become concerned by behaviors that Tiffani has exhibited since the funeral. He endorses that she has been emotionally volatile and angry, which is very unusual for her. He has found multiple empty liquor bottles hidden in the back of the linen closet. Tiffani states that she has no recollection of buying or consuming alcohol; she typically drinks 1-2 glasses of wine per night and does not hide the behavior from her spouse. She is worried that her husband is lying to her and “planting” the empty bottles, although she is not sure why he would do that. Tiffani is employed as a receptionist; she states her job is “unrewarding but pays the bills.” She describes a recent meeting with the human resources department in which she was reprimanded for poor attendance and rude behavior to clients on the phone, but she endorses that she has not missed any work, is always professional at work, and does not understand what the meeting was about. She is now on probation and facing possible termination. Question 1 Which of the following is the most likely diagnosis for Tiffani?
- dissociative identity disorder (Correct answer)
- dissociative amnesia
- post-traumatic stress disorder
- substance use disorder
- borderline personality disorder
- depersonalization/derealization disorder Rationale: According to DSM 5-TR (APA, 2022) diagnostic criteria, Tiffani is experiencing a disruption of identity characterized by distinct personality states that are causing a discontinuity in her sense of self and self-agency, as well as alterations in her behavior and memory. She has significant gaps in memory, and her symptoms are distressing her work and primary relationship. Tiffani has a history of trauma and a recent stressor that appears to have triggered her current symptoms; however, since the symptoms are not solely related to her trauma, it is unlikely that she is experiencing post-traumatic stress disorder (PTSD). Although Tiffani uses alcohol, she does not recall buying or consuming large quantities of alcohol, suggesting that the symptoms are unrelated to blackouts or substance use. Tiffani has headaches for which no physiological cause could be established; headaches, while not a diagnostic criterion for DID, are often an associated feature, as are comorbid depression and anxiety.
Which of the following is the most likely diagnosis for Roman?
- dissociative identity disorder
- dissociative amnesia
- depersonalization/derealization disorder
- major depressive disorder
- unable to determine (Correct answer) Rationale: Although Roman has symptoms consistent with depersonalization/derealization disorder, including time distortion, experiences of detachment from his surroundings, lack of body agency, and intact reality testing, more information is needed before selecting a diagnosis. Hallucinogens, 3,4-methyl enedioxymethamphetamine (MDMA), and cannabis may all cause symptoms of depersonalization and derealization. A toxicology screen and interview questions will help rule out substance use as the cause of Roman’s symptoms. Paola Paola is a 22-year-old who presents with complaints of insomnia. She states that she experienced a sexual assault during an off-campus party about three months ago, and since then, she has not been able to sleep through the night. She can recall what she did the day of the assault and remembers, specifically, what she was wearing to the party, how she got there, and with whom she arrived. She stated that she had two beers and flirted with a man she knew casually through a shared acquaintance; the next thing she remembers was being in a bedroom, alone, with her shirt off and undergarments torn. She is concerned that she cannot remember everything that happened, especially since she has been having vivid nightmares about the event. She states that when she walks past the house where the party occurred, she feels like she is floating outside her body and does not feel like anything is real, so she has started walking a half-mile out of her way to avoid the house. Paola states she feels guilty about the incident because she should have known better than to “go to a bedroom with a stranger,” but “at this point, I just want to get on with my life and get some sleep before finals week.” Question 1 Which of the following is the most likely diagnosis for Paola?
- dissociative amnesia with dissociative fugue
- post-traumatic stress disorder (Correct answer)
- dissociative amnesia
- depersonalization/derealization disorder
- substance use disorder Rationale: According to the DSM 5-TR (APA, 2022) diagnostic criteria, the most likely diagnosis for Paola is post-traumatic stress disorder. Paola has selective amnesia surrounding her assault but remembers what happened before and following the attack. She is experiencing nightmares, insomnia, guilt, and depersonalization related specifically to the assault. Although Paola has some symptoms that are consistent with dissociative amnesia or depersonalization/derealization disorder, post-traumatic stress disorder is a better diagnostic fit.
Question 2 Use the ICD- 10 - CM website to select the most appropriate ICD- 10 - CM code for Paola’s diagnosis. F43. Rationale: F43.10 Posttraumatic Stress Disorder Treatment Treatment of dissociative disorders typically involves psychotherapy and trauma-informed care. Psychotherapy may encompass techniques to process the trauma that triggers dissociative symptoms. Psychotherapies commonly used include cognitive-behavioral therapy (CBT) (van Minnen & Tibben,
- and sensorimotor psychotherapy (Buckley & Punkanen, 2021). Eye movement desensitization and reprocessing (EMDR) is also used although controversial (Karbouniaris, 2021), and medications may be used to treat other related symptoms (NAMI, 2022). Discover More Watch this video to learn more about psychotherapy to reintegrate the brain and prevent dissociation following trauma Now, watch this video to learn about EMDR and structural dissociation DID Integration Treatment for DIDs often includes psychotherapy with a treatment goal of integrated functioning of the dissociated aspects of the personality. Fusion or full integration of the dissociated aspects of a client may be challenging, especially when the dissociated parts function independently. The integration process may include the following stages: uncovering and mapping the dissociated aspects, treating the traumatic memories and fusing the dissociated aspects, and fortifying the newly integrated personality (American Association for Marriage and Family Therapy [AAMFT], 2022). Discover More Watch this video to learn more about DID integration and fusion
Factitious Disorder Individuals with factitious disorder falsify presenting physical signs and symptoms in the absence of illness or impairment to deceive others even in the absence of external rewards (APA, 2022). A related diagnosis is factitious disorder imposed on another (formerly factitious disorder by proxy or Munchausen by proxy) in which an individual falsifies physical or psychological signs or symptoms or induces illness or injury on another person, presenting the other as ill, impaired, or injured (APA, 2022). Factitious disorder is differentiated from malingering in intent; individuals with malingering report signs and symptoms for personal gain such as money or time off work. Treatment Treatment of somatic symptom and related disorders may include psychotherapy, medication, or a combination of both. Cognitive-behavioral therapy (CBT) has shown the highest efficacy in the treatment of both somatic symptom and related disorders and accompanying anxiety and depression, while brief psychodynamic psychotherapy, exercise, and biofeedback may be beneficial for some symptoms (Boland & Verduin, 2022). Antidepressants, particularly tricyclics, may be helpful for pain- related syndromes. Psychiatric mental health nurse practitioners (PMHNP) may also provide “brief” psychiatric consultation letters to primary care physicians to give guidance on managing clients with somatic symptom and related disorders (Boland & Verduin, 2022). No specific psychotherapy has been identified as effective in treating factitious disorder; prognosis is generally poor (Carnahan & Jha, 2023). Learn by Applying Leanne Leanne is a 56-year-old who presents for therapy with the PMHNP for symptoms of depression. Per medical records, she has a history of hyperlipidemia, coronary artery disease, and major depressive disorder, and her current medications include atorvastatin 20 mg daily and sertraline 75 mg daily. Leanne is seeking therapy due to the recent death of her aunt, with whom she was very close. During the interview, Leanne discloses that she has been having chest pain “more frequently” since her aunt died three months ago. Upon further inquiry, Leanne endorses that she has had chest pain “at least twice a week” for the past 14 months. The pain typically presents with an acute onset without identifiable triggers and is accompanied by sweating, dyspnea, palpitations, and dizziness. The pain is not relieved by rest, but typically “starts to fade” after a few hours. Leanne presents to the emergency department several times each month; at each visit, an electrocardiogram (ECG) and labs have been completed. Her ECG and cardiac workup have been normal each time. Leanne has also had an exercise stress test, a nuclear stress test, a chest computed tomography (CT) scan, and a cardiac catheterization, the results of which were all normal. Leanne has followed up with both her primary provider and a cardiologist; other than hyperlipidemia, she has not received a cardiac diagnosis. Leanne states that she is often preoccupied with her symptoms; three years ago, she had a cardiac stent placed due to a narrowed coronary artery, and each time the symptoms return, she fears that the stent has failed or that another vessel is blocked. Her father died of myocardial infarction (MI) when he was 62, and her aunt’s recent death at age 77 was also a result of an MI. She spends time researching the
latest diagnostic tests and treatments for coronary artery disease in hopes that she will find “an answer that the doctors haven’t thought of.” Question 1 Which of the following is the most likely diagnosis for Leanne?
- illness anxiety disorder
- somatic symptom disorder (Correct answer )
- factitious disorder
- coronary artery disease Rationale: The most likely diagnosis for Leanne is somatic symptom disorder. Leanne is preoccupied with her symptoms of chest pain, dyspnea, dizziness, and palpitations even with repeated negative diagnostic testing. She spends large amounts of time and energy worrying about and researching her symptoms and the symptoms have been present for more than a year. Because she experiences significant symptoms, the diagnosis of illness anxiety disorder is not appropriate. There is no evidence that Leanne is feigning symptoms, so the diagnosis of factitious disorder is not appropriate. Question 2 Use the ICD- 10 - CM website to select the most appropriate ICD- 10 - CM code for Leanne’s diagnosis. F45. Rationale: F45.1 Somatic Symptom Disorder Question 3 Based on the information collected at the initial visit, which of the following are appropriate management strategies for Leanne at this time? Select all that apply.
- provide a consultation letter to Leanne’s primary provider (Correct answer)
- cognitive behavioral therapy (Correct answer)
- biofeedback (Correct answer)
- increase sertraline to 100 mg daily Rationale: The appropriate management strategies for Leanne include a consultation letter to her primary provider, cognitive behavioral therapy, and biofeedback. A consultation letter to the primary provider may be effective to assist Leanne in reducing her use of health services (Boland & Verduin, 2022). Both cognitive behavioral therapy and biofeedback are valid therapy approaches for a client with somatic symptom disorder. Increasing the client’s antidepressant dosage is not indicated at this time.
Question 1 Which of the following is the most likely diagnosis for Saoirse?
- somatic symptom disorder
- factitious disorder
- functional neurological symptom disorder (Correct answer)
- malingering Rationale: The most likely diagnosis for Saoirse is functional neurological symptom disorder. Saoirse presents with acute onset of a neurological symptom in the absence of neurological disease or injury. She reports a stressful relationship with a recent conflict with her significant other and has a history of other psychological issues. Paralysis is a common presentation of functional neurological symptom disorder (conversion disorder). She also evidences la belle indifference as she seems unconcerned about the impairment, which is common with functional neurological symptom disorder. Question 2 Use the ICD- 10 - CM website to select the most appropriate ICD- 10 - CM code for Saoirse’s diagnosis. F44. Rationale: F44.4 Functional Neurological Symptom Disorder (Conversion Disorder With weakness or paralysis Summary Complex in nature, dissociative disorders are characterized by dissociative symptoms that occur as an adaptive response to trauma. Dissociation is an unconscious defense mechanism in which an individual disconnects from their thoughts, emotions, memories, or sense of identity. Dissociation can worsen with stress and can disrupt psychological functioning. Complex presentations and difficult comorbidities often create diagnostic and therapeutic challenges leading to under and delayed diagnosis and appropriate treatment. Trauma-informed care and dissociation-specific psychotherapy are crucial to managing dissociative responses. Somatic symptom or related disorders are characterized by physical symptoms or dysfunction that are linked to psychological factors or emotional stress. Symptoms may or may not be associated with another medical condition. Differentiating between psychosomatic and physiological disorders is often difficult due to the interplay of psychological and physiological processes. When diagnosing somatic symptom disorder, emphasis is placed on the presence of symptoms or signs and the client’s affective and cognitive response to them rather than the absence of a medical explanation for the symptoms. Psychotherapies and stress management are helpful in reducing symptom burden and promote health. Key Points
- Dissociative disorders are complex mental health problems characterized by dissociative symptoms that occur as an adaptive defense response to trauma.
- Dissociation is a sense of disconnection or detachment from one’s thoughts, feelings, actions, or sense of self. Dissociation occurs on a continuum from mild to pathological.
- Structural Dissociation theory and model provide an explanation for dissociative symptoms and a foundation for treatment.
- There are several types of dissociation that clients can experience, singularly or in any combination at various times, including dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization/derealization disorder.
- Complex presentations and difficult comorbidities often create diagnostic and therapeutic challenges leading to under- and delayed diagnosis and appropriate treatment.
- Safety and social problems are primary considerations for these individuals. Trauma-informed care and psychotherapy are crucial to managing dissociative responses.
- Treatment for dissociative identity disorders (DIDs) often includes psychotherapy with the goal of treatment to achieve integrated functioning of the dissociated aspects. Fusion or full integration of dissociated aspects of a client may be challenging, especially when the dissociated parts function independently.
- Somatic symptom or related disorders are characterized by physical symptoms or dysfunction that are linked to psychological factors or emotional stress.
- There are several types of somatic symptom disorder and related disorders, including somatic symptom disorder, illness anxiety disorder, functional neurological symptom disorder (conversion disorder), and factitious disorder.
- Differentiating between psychosomatic and physiological disorders is often difficult due to the interplay of psychological and physiological processes.
- Psychotherapies such as cognitive-behavior therapy and stress management help to reduce symptom burden and promote health. Reflection on Learning Reflective inquiry allows for expansion of self-awareness, identification of knowledge gaps, and assessment of learning goals. As you reflect on your readiness to provide care to clients as a psychiatric mental health nurse practitioner (PMHNP), take a few minutes to consider what you have learned.
- Treating clients with somatic symptom and related disorders can create unique ethical and legal challenges. Such clients are most often seen by medical providers rather than psychiatric providers. Clients often use a disproportionate amount of healthcare resources and may request diagnostic testing or treatment that is inconsistent with their condition. Clients with factitious disorder may resist their diagnosis. Clients with factitious disorder imposed on another may be abusing another individual. What strategies will the PMHNP use to help medical colleagues manage clients with somatic symptom and related disorders?
