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Dissociative Disorders

Application of the Nursing Process for Dissociative Disorders

Dissociation Image courtesy of Super OfficeOpens in new window

Dissociative disorders occur after significant adverse experiences/traumas, and individuals respond to stress with a severe interruption of consciousness.

Assessment

For a diagnosis of dissociative disorder to be made, medical and neurological illnesses, substance use, and other coexisting psychiatric disorders must be ruled out as the cause of the patient’s symptoms. The assessment should include objective data from physical examination, electroencephalography, imaging studies, and specific questions to identify dissociative symptoms.

Scales have been developed to assess dissociation, including the Dissociative Experience ScaleOpens in new window (DES; Bernstein & Putnam, 1986), the Somatoform QuestionnaireOpens in new window (SDQ; Ninjenhuis et al., 2012), and the Dissociative Disorders Interview ScheduleOpens in new window (DDIS; Ross et al., 1989).

These assessment tools are important because a psychiatric interview will often miss the presence of dissociation.

By definition, dissociative periods involve lapses of memory that a person may not even be aware of, and patients with dissocitiative disorders do not know what they do not know.

Specific information about identity, memory, consciousness, life events, mood, suicide risk, and the impact of the disorder on the patient and the family are important dimensions to assess.

Assessing patient’s ability to identify themselves requires more than asking them to state their names. Changes in patient behavior, voice, and dress might signal the presence of an alternate personality.

Referring to the self by another name or in the third person and using the word we instead of I are indications that the patient may have assumed a new identity. The nurse should consider the following when assessing memory:

  1. Can the patient remember recent and past events?
  2. Is the patient’s memory clear and complete or partial and fuzzy?
  3. Is the patient aware of gaps in memory, such as lack of memory for events such as a graduation or a wedding?
  4. Do the patient’s memories place the self with a family, in school, or in an occupation?
    Patients with amnesia and fugue may be disoriented with regard to time and place as well as person.
  5. Does the patient ever lose time or have blackouts?
  6. Does the patient ever find herself or himself in places with no idea how she or he got there?
  1.   History

The nurse must gather information about events in the person’s life. Has the patient sustained a recent injury, such as a concussion? Does the patient have a history of epilepsy, especially temporal lobe epilepsy? Does the patient have a history of early trauma, such as physical, mental, or sexual abuse?

If dissociative identify disorder is suspected, pertinent questions include the following:

  1. Have you ever found yourself wearing clothes you cannot remember buying?
  2. Have you ever had strange persons greet and talk to you as though they were old friends?
  3. Does your ability to engage in things such as athletics, artistic activities, or mechanical tasks seem to change?
  4. Do you have differing sets of memories about childhood?
  1.   Mood

Is the individual depressed, anxious, or unconcerned?

Many patients with dissociative identity disorder seek help when the primary personality is depressed. The nurse also observes for mood shifts. When alternate identities of dissociative identity disorder take control, their predominant moods may be different from that of the principal personality. If the alternate identities shift frequently, marked mood swings may be noted.

  1.   Impact on Patient and Family

In fugue statesOpens in new window, individuals often function adequately in their new identities by choosing simple, undemanding occupations and having few intimate social interactions. Patients with amnesiaOpens in new window, in contrast to those with fugueOpens in new window, may be more dysfunctional. Their perplexity often renders them unable to work, and their memory loss impairs normal relationships.

Families often direct considerable attention toward the patient but may exhibit concern over having to assume roles that were once assigned to the patient. Patients with dissociative identity disorder often have both family and work problems. Families find it difficult to accept the seemingly erratic behaviors of the patient. Employers dislike the lost time that may occur when alternate identities are in control.

Patients with depersonalization disorderOpens in new window are often fearful that others may perceive their appearance as distorted and may avoid being seen in public. If they exhibit high anxiety, the family is likely to find it difficult to keep relationships stable.

  1.   Suicide Risk

Whenever a patient’s life has been substantially disrupted, the patient may have thoughts of suicideOpens in new window. The nurse gathering data should be alert for expressions of hopelessness, helplessness, or worthlessness and for verbalization or other behavior of an alternate identity that indicates the intent to engage in self-destructive or self-mutilating behaviors.

  1.   Self-Assessment

It is natural to experience feelings of skepticism while caring for patients who are diagnosed with dissociative identity disorderOpens in new window. You may find it difficult to believe in the authenticity of the symptoms the patient is displaying.

A sense of inadequacy may accompany the need to be ready to interact in a therapeutic way with whichever personality is in control at the moment; however, some nurses experience feelings of fascination and are caught up in the intringue of caring for a patient with multiple identities.

Feelings of inadequacy can also arise when establishment of a trusting relationship occurs slowly. It is important to remember that the patient with a dissociative disorder has often experienced relationships in which trust was betrayed. When alters vie for control and attempt to embarrass or harm each other, crises are common, and nurses must be alert and ready to intervene.

Preparing for the unexpected, including the possiblikkty of a sucide attempt, means constant hypervigilance by staff, and such observational demands can eventually lead to great fatigue. Caring for a patient with dissociative disorder can generate anxiety in any of the following situations:

  • When a patient who has regained memory develops panic-level anxiety.
  • When a patient becomes assaultive because of extreme confusion or panic-level anxiety
  • When a patient attempts self-harm by acting out against the primary personality or other personalities.

If the patient manifesting symptoms of a dissocaitve disorder has been involved in the commission of a crime, the medical record is likely to be a court exhibit. You may experience concern over that fact or be angry if you believe the patient is faking illness to avoid being found guilty of the crime.

Supervision should always be available for nursing staff and clinicians caring for a patient with a dissociative disorder. By discussing feelings and the plan of care with the treatment team or peers, the nurse can better ensure objective and appropriate care for the the patient.

General guidelines for assessment of a patient with a dissociative disorder include:

  1. Assess for a history of self-harm.
  2. Evaluate level of anxiety and signs of dissociation.
  3. Identify support systems through a psychosocial assessment.

Diagnosis

The overall goal for dissociative disorder is the integration of personalities into a single personality. Nursing diagnoses relate to personal identity, role performance, and anxiety.

Planning

The setting and presenting problem influence the planning of nursing care for the patient with a dissociative disorder; however, a phase-oriented treatment model is recommended and includes the following (ISSTD, 2012):

  • Phase 1: Establishing safety, stabilization, and symptom reduction
  • Phase 2: Confronting, working through, and integrating traumatic memories
  • Phase 3: Identify integration and rehabilitation

The nurse will most often encounter the patient in times of crisis (i.e., when the patient is admitted to the hospital for suicidal or homicidal behavior). The care plan will focus on Phase 1 strategies to ensure safety and crisis intervention.

The patient may also come for treatment of a comorbid depression or anxiety disorder in the community setting. Planning will address the presenting complaint with appropriate referrals for treatment of the dissociative disorder.

Implementation

Healing trauma can be thought of as a process of integration and linking neural networks that have become disconnected during an overwhelming event.

Basic-level interventions are aimed at offering emotional presence during the recall of painful experiences, providing a sense of safety, and encouraging an optimal level of functioning. NIC topics that offer relevant interventions include:

  • Anxiety reduction,
  • Coping enhancement,
  • Self-Awareness enhancement,
  • Self-Esteem enhancement, and
  • Emotional support.
  1.   Psychoeducation

Patients with dissociative disorders need to be educated about their illness and given ongoing instruction about coping skills and stress management.

Normalizing experiences by explaining to the patient that his or her symptoms are adaptive responses to past overwhelming events is important. Often, the victim of childhood trauma feels as if he or she is a bad person and grows up with the false negative belief that the abuse was deserved punishment. Teaching grounding techniques that bring the person’s awareness to noticing real things in the present helps to counter dissociative episodes.

Examples of grounding techniques can include the following:

  • stomping one’s feet on the ground,
  • taking a shower,
  • holding an ice cube,
  • exercising,
  • deep breathing,
  • counting beads, or touching fabric or upholstery on a chair.

Patients should also be taught to keep a daily journal to increase their awaress of feelings and to identify triggers to dissociation. If a patient has never written a journal, the nurse should suggest beginning with a 5- to 10-minute daily writing exercise.

  1.   Pharmacological Interventions

There are no specific medications for patients with dissociative disorders, but appropriate medications are often prescribed for the hyperarousal and intrusive symptoms that accompany PTSD and dissociation (ISSTD, 2012). These might include antidepressantOpens in new window medications, anxiolyticsOpens in new window, and antipsychoticsOpens in new window.

Substance-use disorders and suicidal risk, which are common, must be assessed carefully in selecting safe and appropriate pharmacotherapy. In the acute setting, the nurse may witness dramatic memory retrieval in patients with dissociative amnesia or fugue after treatment with intravenous benzodiazepines.

  1.   Advanced Practice Interventions

Advanced practice nurses and other skilled licensed mental health professionals use cognitive-behavioral therapyOpens in new window, psychodynamic psychotherapyOpens in new window, exposure therapy, modified EMDR, hypnotherapyOpens in new window, neurofeedbackOpens in new window, ego-state therapiesOpens in new window, somatic therapiesOpens in new window, and medication to treat patients with dissociative disorders. Advanced training is needed to treat these patients effectively as such, and ongoing supervision for the therapist is suggested.

Evaluation

Overall, treatment effectiveness for dissociative identity disorder is “integration,” coordinated functioning among alternate identities to promote optimal functioning (ISSTD, 2011). This occurs primarily through long-term psychotherapy.

In general, treatment for trauma-related disorder is considered successful when outcomes are met. In the final analysis, the evaluation is positive when:

  1. Patient safety has been maintained.
  2. Anxiety has been reduced, and the patient has returned to a functional state.
  3. Integration of the fragmented memories has occurred.
  4. New coping strategies have permitted the patient to function at a better level.
  5. Stress is handled adaptively, without the use of dissociation.
  1. Bernstein, E.M., & Putnam, F.W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174(12), 727 – 735.
  2. Boon, S., Steele, K., & van der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and therapists. New York, NY: Norton.
  3. Friedrich, W., Gerber, P., Koplin, B., Davis, M., Giese, J., Mykelebust, C., & Franckowiak, D. (2001). Multimodal assessment of dissociation in adolescents: Inpatients and juvenile sex offenders. Sexual Abuse: Journal of Research and Treatment, 13, 167 – 177.
  4. International Society for the Study of Trauma and Dissociation. (2012). Guidelines for treating dissociative identity disorder in adults, 3rd rev. Journal of Trauma and Dissociation, 12 (2), 115 – 187.
  5. Koch, S.C., & Harvey, (2012). Dance/movement therapy with traumatized dissociative patiens. In S.C. Koch, T. Fuchs, M. Summa & C. Muller (Eds.), Body memory, methaphor and movement (pp. 369 – 386). Philadelphia, PA: John Benjamins.
  6. Ross, C.A., Heber, S., Norton, G.R., Anderson, D., Anderson, G., & Barchet, P. (1989). The Dissociative Disorders Interview Schedule: A structured interview. Dissociation, 2, 169 – 189.
  7. Spiegel, D., Loewenstein, R., Lewis-Fernandez, R., Sar, V., Simeon, D., Vermetten, E., et al. (2011). Dissociative disorders in DSM-5. Depression and Anxiety, 28, 824 – 852.
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