Dissociative Disorders

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Dissociative Disorders Nursing Care Management
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Dissociative disorders are mental disorders that involve problems with memory, identity, emotion, perception, behavior, and sense of self. People who have endured physical, sexual, or emotional abuse during childhood are at a higher risk of acquiring dissociative disorders. The three major dissociative disorders defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) include dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder. Review this study guide and learn more about dissociative disorders, its nursing care management, interventions, and assessment.

What are Dissociative Disorders?

The essential feature of the dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception; during periods of intolerable stress, the individual blocks off part of his or her life from consciousness.

  • Dissociative identity disorder. First recognized in DSM-III as “multiple personality disorder,” dissociative identity disorder is defined in DSM-5 as requiring two or more fully distinct personality states, which in some cultures may be described as an experience of possession.
  • Dissociative amnesia. An inability to recall important personal information, usually of a traumatic or stressful nature. In DSM-5, two primary forms are listed: localized or selective amnesia for specific events and generalized amnesia for identity and life history. A major change in DSM-5 is that dissociative fugue is now a specifier for dissociative amnesia, not a separate diagnosis as in DSM-IV.
  • Localized amnesia. Inability to recall all incidents associated with a traumatic event for a specific time period following the event.
  • Selective amnesia. Inability to recall only certain incidents associated with a traumatic event for a specific period following the event.
  • Generalized amnesia. Failure of recall encompassing one’s entire life.
  • Continuous amnesia. Inability to recall events subsequent to a specific time up to and including the present.
  • Systematized amnesia. With this type of amnesia, the individual cannot remember events that relate to a specific category of information, such as one’s family, or to one particular person or event.
  • Dissociative fugue. A sudden, unexpected travel away from home or customary work locale with assumption of new identity and an inability to recall one’s previous identity.
  • Depersonalization disorder. Characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, feelings of detachment from the environment, or a sense of observing oneself from outside the body.

Pathophysiology

From a psychological perspective, dissociation is a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma.

  • After the patient returns to baseline, access to the dissociative information is diminished.
  • Psychiatrists have theorized that the memories are encoded in the mind but are not conscious, i.e., they have been repressed.
  • In normal memory function, memory traces are laid down in 2 forms, explicit and implicit.
  • Explicit memories are available for immediate and conscious recall and include recollection of facts and experiences of which one is conscious, whereas implicit memories are independent of conscious memory.
  • Further, explicit memory is not well-developed in children, raising the possibility that more memories become implicit at this age.
  • Alterations at this level of brain function in response to trauma may mediate changes in memory encoding for those events and time periods.
  • Dissociation is also a neurologic phenomenon that can occur from various drugs and chemicals that may cause acute, subchronic, and chronic dissociative episodes.

Statistics and Incidences

Since the 1980s, the concept of dissociative disorders has taken on a new significance.

  • Dissociative amnesia occurs in 2-7% of the general population and has a high occurrence in those involved in wars, in patients with a history of child abuse or sexual abuse, in survivors of concentration camps, in victims of torture, and in survivors of natural disasters.
  • Dissociative identity disorder is observed in 1-3% of the population.
  • An estimated of 2.4% of the general population meets the diagnostic criteria of depersonalization disorder; however, the prevalence is questioned by many clinicians and may be lower.

Causes

Predisposing factors to dissociative disorder include:

  • Genetics. The DSM-IV-TR suggests that DID is more common in first-degree relative of people with the disorder than in the general population.
  • Neurobiological. Some clinicians have suggested a possible correlation between neurological alterations and dissociative disorders; although available information is inadequate, it is possible that dissociative amnesia and dissociative fugue may be related to alterations in certain areas of the brain that have to do with memory.
  • Psychodynamic theory. Freud (1962) believed that dissociative behaviors occurred when individuals repressed depressing mental health contents from conscious awareness.
  • Psychological trauma. A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelms the individual’s capacity to cope by any means other than dissociation.

Clinical Manifestations

Symptoms of dissociative disorder include:

  • Impairment in recall. There is inability to remember specific incidents or inability to recall any of one’s past life, including one’s identity.
  • New identity away from home. Sudden travel away from familiar surroundings; assumption of new identity, with inability to recall past.
  • Multiple identities. Assumption of additional identities within the personality; behavior involves transition from one identity to another as a method of dealing with stressful situations.
  • Feeling of unreality. There is a feeling of unreality or detachment from a stressful situation; may be accompanied by dizziness, depression, obsessive rumination, somatic concerns, anxiety, fear of going insane, and a disturbance in the subjective sense of time.

Symptoms of dissociative identity disorder:

  • Emotional turmoil
  • Behavioral turmoil
  • Memory gap
  • Incidents of out-of-character behavior

Symptoms of dissociative amnesia:

Symptoms of depersonalization/derealization disorder:

  • Detachment
  • Foggy or dreamlike vision
  • Emotional disconnection
  • Physical numbness
  • Distortions in perception of time
  • Distortions of distance and the size and shape of objects

Medical Management

Patients who are survivors of extensive childhood abuse frequently present complicated clinical dilemmas. The following are the psychological management for dissociative disorders: 

  • Encourage healthy coping behaviors. The primary focus is to help patients learn to control and contain  their symptoms; patients must learn to deal with dissociation, flashbacks, and intense effects such as rage, terror, and despair.
  • Logging and monitoring emotions. One way to help patients begin to work with their sense of unpredictability is to have them keep a log of their emotions.
  • Developing a crisis plan. Teaching patients to develop a list that ranges from simple to complex activities is helpful.

Pharmacologic Management

Medications for a patient with dissociative disorder include:

  • Neuroleptics. The atypical neuroleptics, such as aripiprazole, olanzapine, quetiapine, and ziprasidone, are the accepted mode of treatment for dissociative disorders.

Nursing Management

The nursing management of a patient with dissociative disorder include the following:

Nursing Assessment

Assessment of the client include:

  • Psychiatric interview. The psychiatric interview must contain a description of the client’s mental status with a thorough description of behavior, flow of thought and speech, affect, thought processes and mental content, sensorium and intellectual resources, cognitive status, insight, and judgement.

Nursing Diagnosis

Nursing diagnosis for patients with dissociative disorders include:

  • Ineffective coping related to inadequate coping skills.
  • Disturbed thought processes related to childhood trauma or abuse.
  • Disturbed personal identity related to severe level of anxiety.
  • Disturbed sensory perception (kinesthetic) related to threat to self-concept.

Nursing Care Planning and Goals

The major nursing care plan goals for dissociative disorders are: 

  • Client will verbalize understanding that he or she is employing dissociative behaviors in times of psychosocial stress.
  • Client will verbalize more adaptive ways of coping in stressful situations than resorting to dissociation.
  • Client will verbalize understanding that loss of memory is related to stressful situation and begin discussing stressful situation with nurse or therapist.
  • Client will recover deficits in memory and develop more adaptive coping mechanisms to deal with stressful situations.
  • Client will verbalize adaptive ways of coping with stress.

Nursing Interventions

The nursing interventions for dissociative disorders are: 

  • Promote client safety. Reassure client of safety and security by your presence.; dissociative behaviors may be frightening to the client.
  • Assess for stressors. Identify stressor that precipitated severe anxiety; this information is necessary to the development of an effective plan of client care and problem resolution.
  • Explore client’s feelings. Explore feelings that client experienced in response to the stressor; help client understand that the disequilibrium felt is acceptable-indeed, even expected-in times of severe stress.
  • Encourage methods for coping. Have client identify methods of coping with stress in the past and determine whether the response was adaptive or maladaptive.
  • Enhance client’s self-esteem. Provide positive reinforcement for client’s attempts to change; positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.

Evaluation

Outcome goals include:

  • Client was able to verbalize understanding that he or she is employing dissociative behaviors in times of psychosocial stress.
  • Client was able to verbalize more adaptive ways of coping in stressful situations than resorting to dissociation.
  • Client was able to verbalize understanding that loss of memory is related to stressful situation and begin discussing stressful situation with nurse or therapist.
  • Client was able to recover deficits in memory and develop more adaptive coping mechanisms to deal with stressful situations.
  • Client was able to verbalize adaptive ways of coping with stress.

Documentation Guidelines

Documentation in a patient with dissociative disorder include the following:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward the desired outcome.

Practice Quiz: Dissociative Disorders

Quiz time about the topic! For more practice questions, visit our NCLEX practice questions page.

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1. Which outcome is most appropriate for Brooklyn who has a dissociative disorder?

A. Brooklyn will use problem-solving strategies when feeling stressed.
B. Brooklyn will modify stress with the use of relaxation techniques.
C. Brooklyn will identify his anxiety responses.
D. Brooklyn will deal with uncomfortable emotions on a conscious level.

1. Answer: A. Brooklyn will deal with uncomfortable emotions on a conscious level.

  • Option A: Dissociative disorders occur when traumatic events are beyond an individual’s recall because these memories have been “blocked” from conscious awareness. Bringing the feelings associated with these events into conscious awareness and coping with these feelings will decrease the need for dissociation.

2. Odette, a nurse who works at Nurseslabs Rehabilitation Center is assessing a client for recent stressful life events. She recognizes that stressful life events are both:

A. Predictable and controllable
B. Undesirable and harmful
C. Positive and negative
D. Desirable and growth-promoting

2. Answer: C. Positive and negative

  • Option C: The concept of stressful life event is based on the research of Holmes and Rahe, who found that both positive and negative changes result in stress.
  • Option A: Some stressful life events can be predictable and controllable; however, many life events are entirely unpredictable.
  • Options B and D: Stressful life events are not always desirable and growth promoting, nor are they always undesirable and harmful.

3. During a community visit, volunteer nurses teach stress management to the participants. The nurses will most likely advocate which belief as a method of coping with stressful life events?

A. Significant others are important to provide care and concern.
B. Avoidance of stress is an important goal for living.
C. Control over one’s response to stress is possible.
D. Most people have no control over their level of stress.

3. Answer: C. Control over one’s response to stress is possible.

  • Option C: When learning to manage stress, clients find it helpful to believe that they have the ability to control their response to it. It is impossible to avoid stress, which is a normal life experience.
  • Option B: Stress can be positive and growth enhancing as well as harmful.
  • Option D: The belief that one has some control is the significant factor in minimizing stress response.

4. When providing family therapy, the nurse analyzes the functioning of healthy family systems. Which situations would not increase stress on a healthy family system?

A. The birth of a child
B. Parental disagreement
C. The death of a grandparent
D. An adolescent’s going away to college

4. Answer: B. Parental disagreement.

  • Option B: In a functional family, parents typically do not agree on all issues and problems. Open discussion of thoughts and feeling is healthy, and parental disagreement should not cause system stress.
  • Options A, C, and D: The remaining answer choices are life transitions that are expected to increase family stress.

5. A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which communication technique should they use to encourage the patient to eat?

A. Documenting reasons why the patient does not want to eat.
B. Offering opinions about the necessity of adequate nutrition.
C. Sharing personal preference regarding food choices.
D. Using open-ended questions and silence.

5. Answer: D. Using open-ended questions and silence.

  • Option D: Open-ended questions and silence are strategies use to encourage patients to discuss their problems. Sharing personal food preferences is not a patient-centered intervention.
  • Options A, B, and C: The remaining options are not helpful to the patient because they do not encourage the patient to express feelings. The nurse should not offer opinions and should encourage the patient to identify the reasons for the behavior.

References

Sources and references for this study guide for therapeutic communication, including interesting studies for your further reading: 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. [Link]
  • Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,. [Link]
  • Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins. [Link]

“During the day, I was a puzzle with innumerable pieces. One piece made my family a nourishing breakfast. Another piece ferried the kids to school and to soccer practice. A third piece managed to trip to the grocery store. There was also a piece that wanted to sleep for eighteen hours a day and the piece that woke up shaking from yet another nightmare. And there was the piece that attended business functions and actually fooled people into thinking I might have something constructive to offer.”
– Suzie Burke, Wholeness: My Healing Journey from Ritual Abuse

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