316 (Psychological factors) affecting medical condition
Choose name based on nature of/most prominent factor:
Mental disorder affecting medical condition
Psychological symptoms affecting medical condition
Personality traits or coping style affecting medical condition
Maladaptive health behaviors affecting medical condition
Stress-related physiological response affecting medical condition
Unspecified psychological factors affecting medical condition
(Refer to DSM-IV listing for specific definitions.)
These disorders represent a group of ailments in which emotional stress is a contributing factor to physical problems (coded on Axis III) involving an organ system under involuntary control. Any organ system may be affected, depending on the individual’s susceptibility. The result is the development or exacerbation of, interference with therapy for, and/or delayed recovery from a medical condition.
Lists of related medical conditions are subject to change as research progresses because to date a clear psychological-biological connection has been implied but not yet scientifically proved.
ETIOLOGICAL THEORIES
Although the etiology of psychosomatic disorders is unknown, an individual’s emotional state and life circumstances are believed to significantly affect the onset, form, and course of psychosomatic illness. The interaction of psychological, social, and biological factors becomes evident as physical symptoms appear and diminish in direct relationship to the amount of stress the person is experiencing. Psychophysiological disorders do occur without known psychological components, but these disorders usually require some genetic predisposition to respond to stress pathologically.
Psychodynamics
Thought to center around issues of unresolved dependency conflicts, undischarged aggressive feelings, repressed anger, hostility, resentment, and anxiety, these conflicts are expressed somatically. Physiological responses correspond to unconscious emotional conflict instead of directly through verbalization, indicating inadequate or maladaptive defense mechanisms.
Interpersonal theory proposes that individuals with specific personality traits are predisposed to develop or precipitate certain disease processes (e.g., those who are dependent may develop asthma); depression has been linked to cancer and aggressiveness to chest pain or dysrhythmias.
Biological
A new field of psychoneuroimmunology is developing around research of the biological factors that underlie these illnesses. The immune response can be affected by behavior modification. Skills are being taught to help people modify responses that are thought to lead to illness.
In extensive stress studies, it was found that specific physiological responses under direct control of the pituitary/adrenal axis occurred in response to stress. When these stress responses are prolonged, psychosomatic disorders can develop. The specific organ system involved and type of psychosomatic disorder the individual develops may be genetically determined.
The Selye stress theory proposes three levels of response: the alarm reaction, the stage of resistance, and the stage of exhaustion. This is called the general adaptation syndrome, and these responses to stress have an effect on physical functioning. The belief of the individual regarding the degree of stress is related to the effect of the stressor on the physiological condition.
Family Dynamics
Children who grow up observing the attention, increased dependency, or other secondary gain an individual receives because of illness see these behaviors as a desirable response and subsequently imitate them. The dysfunctional family system may use these psychophysiological problems to cover up interpersonal conflicts. Anxiety is thus shifted from the conflict to the ailing member. As anxiety decreases, conflict is avoided, and positive reinforcement is given for the symptoms of the sick person.
CLIENT ASSESSMENT DATA BASE
(These clients present a pattern of anxiety and problems of coping with stress that occurs in their lives. Data obtained depend on organ system involved.)
Atherosclerotic Heart Disease
Activity/Rest
May exhibit an abrupt, fast-talking presentation, with constant movement (e.g., jiggling knees or tapping fingers)
Reports work overload, lack of vacations
Often “too busy” to notice quiet, beautiful surroundings
Circulation
Elevated blood pressure, tachycardia, palpitations, angina
Ego Integrity
Measures success by material goods/personal accomplishments; intense need to compete and win, even if competing with a child
Multiple life stressors
Poor anger management
Neurosensory
Mental Status: Psychological factors linking stress and personality traits include ongoing emotional turmoil/anger, and overexertion
May feel a need to do everything in a hurry and become impatient if asked to wait (e.g., may not tolerate waiting in lines)
Driving, idealistic, dominant, compulsive individual, with passive-aggressive tendencies, strict superego, feelings of insecurity, and difficulty managing anger
Social Interactions
May be overdutiful to job; with social contacts/events related to employment
Hostile, angry, and aggressive toward others
Teaching/Learning
Higher incidence in males
Risk factors most frequently reported: cigarette smoking, hypertension, elevated serum cholesterol and triglyceride levels, left ventricular hypertrophy, diabetes, and age
Gastrointestinal Bleeding/Irritable Bowel Conditions
Activity/Rest
Fatigue
Ego Integrity
May express an intense need for perfection and feelings of not having enough control over stressors and environment
Precipitating stressors center on real or feared threats to significant interpersonal relationships or deaths
Elimination
Diarrhea (with/without blood)
Food/Fluid
History of multiple stomach complaints (e.g., gastritis/ulcers, hyperacidity; heartburn, reflux; food intolerances)
Weight loss, pallor, anemia
Neurosensory
Mental Status: Longstanding feelings of anxiety, repressed anger, difficulty expressing anger/hostility directly, resentment, and a sense of helplessness, with difficulty in coping; highly developed superego, conscientious/dutiful; insecurity/nervousness; compulsivity, especially regarding punctuality and neatness; timidity, obstinacy, hyperintellectualism, lack of humor
May perceive even the slightest criticism as rejection and feel a loss of self-esteem, and respond by using avoidance or by becoming suspicious
Pain/Discomfort
Reports of pain ranging from mild to severe
Social Interactions
Difficulty in interpersonal relationships/dependency on others
Ambivalence/hypersensitivity toward significant others who have been a source of hurt or perceived rejection
Feeling hurt or humiliated and unable to/not inclined to meet the demands of those on whom they feel dependent
Teaching/Learning
Other affected family members possible, revealed in family history
Can occur at any age
Essential Hypertension
Activity/Rest
Fatigue, sleep disturbances
Circulation
Chronic high blood pressure with no known organic origin
Dizziness, nervousness, palpitations
Ego Integrity
May report emotional trauma, presence of stressful situations in daily life; controlled emotionality
Increased incidence in urban areas rather than in rural or tropical areas (may reflect a more relaxed lifestyle)
Food/Fluid
Obesity, sensitivity to salt
Neurosensory
Mental Status: Conflicted over expression of hostile and aggressive feelings, struggle with dependency vs. achievement needs; tends to hold anger in and to feel guilty if anger is expressed, inhibits aggressive wishes, may show greater reactivity to stressful stimuli, even in normal situations
Pain/Discomfort
Headaches
Social Interactions
Feelings of isolation
Teaching/Learning
More prevalent in black population; onset usually in early adult life (mean age in
early 30s)
Bronchial Asthma
Neurosensory
Mental Status: Dependent, meek, sensitive, nervous, compulsive, and perfectionistic; anxiety, anger, depression, tension, frustration, and anticipation of a pleasurable event can contribute exacerbation of symptoms
Feelings of insecurity and oppression, insufficient superego, compulsiveness, overdutiful attitudes, tendency to be passive-aggressive
May be shy, irritable, impatient, stubborn, and tyrannical at times
Respiratory
Wheezing, shortness of breath
Restlessness, cyanosis
Hyperventilation, sighing, hiccups
Smoking in the home
Social Interactions
Strong correlation between asthma attacks and tension in the home/estranged relationships with parents
Teaching/Learning
Can occur at any age (1/3 are children; 2/3 of these are boys)
Respiratory infections/induced emotionally possibly triggering or exacerbating attacks
Migraine Headache
Activity/Rest
Fatigue
Food/Fluid
Nausea, vomiting
Neurosensory
Sensitivity to light/noise; visual disturbances; sensory/motor disturbances (e.g., tingling of face, hands; staggering gait)
Mental Status: Compulsive/perfectionistic, conscientious, intelligent, neat, inflexible, rigid, resentful; experiences guilt feelings
Pain/Discomfort
Head pain, unilateral or bilateral; aching, throbbing
Associated Symptoms: nausea/vomiting photosensitivity
Other Symptoms/Conditions That May be Noted:
Genitourinary: Menstrual and urinary disturbances; dyspareunia, impotence
Musculoskeletal: Joint stiffness/pain, backache, muscle cramps, tension headaches
Skin: Pruritus, cutaneous inflammation (neurodermatitis), excessive sweating (hyperhidrosis)
Others: Autoimmune diseases, manifested as rheumatoid arthritis, systemic lupus of erythematosus, myasthenia gravis, and pernicious anemia, etc.
Diagnostic Studies
Dependent on specific presenting condition/symptoms.
Nursing Priorities
1. Encourage verbalization of feelings and stressors.
2. Assist client to develop coping skills and assertiveness techniques to reduce/manage anxiety.
3. Promote development of positive self-esteem.
4. Help client accomplish a sense of autonomy and independence.
Discharge Goals
1. Assertive techniques used as a more productive, effective means of expression.
2. Stress management methods used to reduce anxiety.
3. Positive self-esteem that satisfies client’s needs without compromising self/others is displayed.
4. Client/family involved in group therapy/community support programs.
5. Plan in place to meet needs after discharge.
Note: This plan of care deals with the psychiatric component of these conditions. Ongoing evaluation of physical condition is required to ensure timely intervention and client well-being. The user is referred to a medical/surgical resource (such as Doenges, Moorhouse, Geissler: Nursing Care Plans: Guidelines for Planning and Documenting Patient Care, F.A. Davis, Philadelphia, 1997) for physiological considerations.
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