14. Psychological factors affecting medical condition

The overall feature of the group of conditions entitled Psychologica. Factors Affecting Medical Conditions is the occurrence of one or more emotional or behavioral factors that aggravate or adversely affect a physical health problem or condition.

Psychological Factors Affecting Medical Condition

DSM-IV CATEGORIES

316 ... [specified psychological factor] affecting ... [indicate the general medical condition]. Choose name based on nature of factors: 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 physiologic response affecting medical condition other or unspecified psychologic factors affecting medical condition

When psychological factors can be identified as contributing to the initiation or exacerbation of a physical condition, then the diagnosis psychological factors affecting medical condition is used. A judgment is made about the emotional components that are influencing the person's physical state of health. Often, a pattern is noted between environmental stimuli and the initiation of the physical problem. For example, either a pattern of difficulties in interpersonal relationships with a family member or a serious loss can be so stressful that the stress is manifested in a physical disorder. The identified physical condition has a documented organic pathology. Often, the psychological factors can interfere with the treatment of a client's medical problem and can contribute an added health risk. Other disorders, such as conversion disorder and somatoform disorder, are ruled out because they have no demonstrable pathophysiologic or diagnostic evidence to account for the symptoms.

The psychological factors that affect medical problems can be diagnosed mental disorders, such as major depressive disorder that influences the recovery of a client from a myocardial infarction or schizophrenia that complicates a client's chronic renal failure. Anxiety and depression can exacerbate the course of illness and may extend the recovery period. Often, particular personality traits or a style of coping can interfere with health or contribute to the client's risk factors for a certain illness such as heart disease. Maladaptive behaviors, such as smoking, overeating, and unsafe sexual behavior, can affect the course of a medical condition. Stress-related physiologic responses can precipitate such problems as chest pain and asthma attacks. With some clients, unspecified psychological factors, such as cultural, interpersonal. or religious considerations, can affect the course or outcome of treatment. Scientists have long known that people respond to stress on both the psychological and the physiologic level. Research continues to demonstrate how the immune system interacts with neurobiological processes. When a person experiences prolonged stress epinephrine, norepinephrine, and cortisol levels rise. The continuous release of stress hormones can damage the neurologic mechanisms and normal physiologic patterns that facilitate the body's adaptation. (For further information, see Course of Psychologically induced Physiologic Disturbances, page 284. )

COURSE OF PSYCHOLOGICALLY INDUCED PHYSIOLOGIC DISTURBANCES

Presence of strong psychosocial stressors, such as interpersonal relationship problems, family dysfunction, living conditions, or occupational, social, legal, or financial difficulties Physical reactions evoked by stressors Occurrence of an autonomic nervous system response or a change to the body's regulatory systems, such as the release of epinephrine, norepinephrine, corticotropin, and cortisol, as part of the stress response Involvement of a target organ or major body system Development of physiologic signs and symptoms Identification of a pathophysiologic process

Research on the biological basis of adjustment disorders focuses on the stress hormones that are released when intense emotions are experienced. These hormones assist in mediating the body's physical and emotional responses to distress. Episodes of acute stress disrupt the hypothalamic-pituitary-adrenal pathway. (For further information, see Symptoms Associated with Adjustment Disorders.)

COMMUNICATION STRATEGIES

• Encourage the client to explore his current level of anxiety or depression.
• Encourage discussion of the client's emotional responses to stress.
• Explain to the client how unrelenting stress can cause physiologic changes and eventual cell damage.
• Help the client identify physical responses to feelings.
• Help the client explore how physical symptoms may be a sign of unresolved relationship problems or intense, unacknowledged emotions.
• Discuss disease-prone behaviors versus self-healing behaviors.

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Family dysfunction Severe anxiety or depression Lack of emotional support Use of repression to handle powerlessness or helplessness	Preoccupation with negative feelings Few or no coping skills Verbalization of feelings of conflict Inability to connect physical symptoms with emotional distress

Long-Term Goal: The client will verbalize feelings rather than express them through the development of physical symptoms.

Short-Term Goal #1: The client will verbalize feelings about psychosocial stressors.

Interventions and Rationales

• Encourage the client to discuss both past and current life events and stressful situations. Having clients review the issues and events of their lives promotes self-awareness and identification of problematic situations.
• Have the client identify and talk about feelings related to life situations. The client needs to acknowledge feelings rather than deny or repress them.
• Help the client begin to explore interpersonal conflicts and related feelings. Verbalizing feelings is the first step in dealing with unresolved relationship issues.
• Encourage the client to examine current life situations that contribute to the feeling of powerlessness. Having the client explore situations that trigger powerlessness promotes understanding of how the experience ofpowerlessness prevents effective coping.

Short-Term Goal #2: The client will identify the relation between psychosocial stressors and physical illness and develop a plan that promotes personal well-being.

Interventions and Rationales

• Explain to the client the importance of identifying and expressing emotions. Sometimes clients see exploration of feelings as unnecessary because they believe that medical or surgical treatment will eliminate the discomfort or problem.
• Focus discussion on connecting strong emotions with physiologic sensations and the development of symptoms. The client needs to develop awareness of the link between feelings and physical symptoms.
• Encourage the client to review personal reactions to current situations that provoke anger, fear, or other negative emotions. Exploration of the client's normal reaction to strong negative emotions may reveal that the client goes to great extremes to defend himself against anxiety.
• Encourage the client to examine the consequences of continuing with unhealthy coping strategies. The client must realize that maintaining unhealthy defenses against anxiety and continued reliance on poor coping skills will lead to further episodes of illness.
• Teach and monitor coping strategies for handling anxiety, such as relaxation and breathing exercises, physical exercise or activity, and stress management techniques. This intervention can help the client decrease stress and have/ewer episodes ofphysical illness.

NURSING DIAGNOSIS: ALTERED ROLE PERFORMANCE

Probable Causes	Defining Characteristics
Health problems or physical disabilities Perceptual or cognitive difficulties Dysfunctional family relationships History of psychosocial stressors	Physical difficulties necessitating role change Impaired relationships Social isolation Difficulty performing activities of daily living

Long-Term Goal: The client will resume role responsibilities appropriate for current health status and recent losses or limitations.

Short-Term Goal #1: The client will discuss how emotional or physical problems interfere with the behaviors that constitute functional role performance.

Interventions and Rationales

• Have the client identify the major roles played within the family, on the job, and during social activities. Baseline assessment is needed about the client's usual roles within the family, in the employment setting, and in social situations.
• Discuss how physical illness or psychosocial stress affects the client's role expectations and performance within the family. Changes in the client's role must be acknowledged before plans tc-handling role change can be instituted.
• Determine the client's concerns about the role change and whether the change is viewed as temporary or permanent. By determining the nature and scope of change, the client can develop appropriate short- or long-term strategies for dealing with the change.
• Have the client verbalize feelings about the identified role loss, conflict, or insufficiency. Many clients repress or deny emotions that arise when role changes take place.
• Talk with the client about how the attempt to repress emotions contributes to physical symptoms. The client's expression of previously repressed emotions aids in resolving physical symptoms.

Short-Term Goal #2: The client will verbalize an understanding of the specific behaviors needed to engage in appropriate role performance.

Interventions and Rationales

• Teach the client skills for managing conflict, such as assertiveness, limit setting, conflict resolution, decision making, and problem solving. As the client begins to use practical skills that reduce interpersonal conflict and anxiety, personal distress decreases.
• Teach the client effective alternative behaviors to use to express strong emotions. Behaviors that help the client express emotions in an honest and appropriate manner can facilitate adaptation to limitations or adjustments that the client is experiencing.
• Help the client use newly learned behaviors to deal with physical symptoms or disabilities that interfere with role functioning. It's important that the client use new behaviors to handle the conflict instead of resorting to the formation of symptoms to relieve the stress.
• Help the client identify personal strengths and ways to assume or resume appropriate role functions. It's necessary for the client to begin to evaluate strengths and plan to use new information to perform role functions.

THERAPIES

Most clients with psychological factors affecting medical conditions are seen in medical-surgical settings because they seek health care related to their physiologic conditions. When a client follows through with a referral for therapy, the focus is on how the psychological factors such as anxiety and depression affect the course of treatment or outcome.

Individual Therapy

• Make sure the client is receiving appropriate medical supervision and intervention for any diagnosed conditions.
• Examine the client's emotions about life situations.
• Teach the client about stress and how to recognize typical life stressors. Focus on learning and practicing stress management skills.
• Have the client identify body feelings that indicate stress.
• Have the client work on identifying the relation between physical symptoms and emotional problems.
• Have the client eliminate cognitive distortions and chronic negativity.
• Have the client identify and evaluate currently used coping strategies.
• Provide referrals to therapy groups or support groups to allow the client to have a mechanism for ventilating feelings, dealing with anxiety, and reinforcing effective coping skills.
• Encourage family members to discuss their feelings, especially anger and helplessness, related to the client's overwhelming physical and psychological needs.

MEDICATIONS

Most of the medications that clients receive are intended to alleviate the physiologic symptoms and associated pain related to the specific medical condition.

• Antianxiety medications are used to relieve anxiety, facilitate the client's daily functioning, and enhance the client s ability to participate in therapy.
• Antidepressant drugs may be given to clients who exhibit symptoms of depression. (See Appendix D for medication information.)

FAMILY CARE

• Talk to family members about their understanding of the client s situation and how anxiety affects the client's physiologic problems.
• Encourage the family to support current medical treatment.
• Have the family identify the roles played by each member, focusing on appropriate role expectations and responsibilities of the client.
• Identify sources of conflict within the family, how family members handle the conflict, and how it contributes to the client's altered role performance.
• Work with the family to resolve conflict and other longstanding issues of distress.
• Discuss how the family can support the client's decision to make lifestyle changes.
• Teach communication skills, problem solving, assertiveness, and stress management as methods for handling problems.
• Explore with family members how a change in the client will impact their lives and daily routines.
• Evaluate the support the family needs to stop reinforcing the secondary gains the client obtains from the illness or related behavior.
• Help the family identify and select healthy coping mechanisms for handling family stress.