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.
This nursing guide aims to provide a brief overview of dissociative disorders, their manifestations, causes, medical management, and nursing management.
What are Dissociative Disorders?
The essential feature of 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 encompasses 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 trip away from home or customary work locale with the assumption of a 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.
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 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.
Predisposing factors for dissociative disorder include:
- Genetics. The DSM-IV-TR suggests that DID is more common in first-degree relatives 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.
Symptoms of dissociative disorder include:
- Impairment in recall. There is the inability to remember specific incidents or an 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 a new identity, with the inability to recall the past.
- Multiple identities. Assumption of additional identities within the personality; behavior involves the transition from one identity to another as a method of dealing with stressful situations.
- A 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:
- Memory loss
Symptoms of depersonalization/derealization disorder:
- Foggy or dreamlike vision
- Emotional disconnection
- Physical numbness
- Distortions in perception of time
- Distortions of distance and the size and shape of objects
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.
Medications for a patient with dissociative disorder include:
- Neuroleptics. Atypical neuroleptics, such as aripiprazole, olanzapine, quetiapine, and ziprasidone, are the accepted mode of treatment for dissociative disorders.
The nursing management of a patient with dissociative disorder includes the following:
Assessment of the client includes:
- Psychiatric interview. The psychiatric interview must contain a description of the client’s mental status with a thorough description of behavior, the flow of thought and speech, affect, thought processes and mental content, sensorium and intellectual resources, cognitive status, insight, and judgement.
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.
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.
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 in a patient with dissociative disorder include the following:
- Individual findings include factors affecting, interactions, the nature of social exchanges, and 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.
Sources and references for this study guide for dissociative disorders, 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]