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Dissociative Disorders Ma. Tosca Cybil A. Torres, RN
Key terms: ALTERS. A distinct identity with its own enduring pattern of perceiving, relating to, and thinking about the world and the self. DISSOCIATION . The separation of thoughts, feelings, or experiences from the normal stream of consciousness and memory. DISSOCIATIVE DISORDERS . A continuum of disorders experienced by individuals exposed to trauma, including depersonalization disorder, dissociative amnesia, dissociative fugue, and dissociative identity disorder. This disorders involve a disturbance in the organization of identity, memory, perception, or consciousness. SECONDARY GAIN. Attempting to earn the sympathy of others, receiving financial gain, or obtaining other benefits by suffering from a disorder. SWITCHING. The process in which one alter is changed into another. TRAUMA. An event that results in long-standing distress to the individual experiencing that event. PERSONALITY. Enduring patterns of perceiving, relating to, and thinking about the world and oneself.
<ul><li>In early life, certain thoughts, feelings, and/or actions of the client are disapproved by significant other persons. </li></ul><ul><li>Significant people’s standards are incorporated as the client’s own. </li></ul><ul><li>Later in life, the client experiences one of the disapproved thoughts, feelings, or actions. </li></ul><ul><li>Anxiety increases to a severe level. </li></ul><ul><li>The feelings are barred from awareness. </li></ul><ul><li>Anxiety decreases. </li></ul><ul><li>Dissociated content continues to appear in disguised form in the client’s thoughts, feelings, and actions. </li></ul>
Epidemiology <ul><li>Dissociative disorders are prevalent around the world and often occur with other psychiatric disorders such as depression, post-traumatic stress disorder, substance use disorders, and borderline personality. </li></ul><ul><li>6 percent of the general population suffers from high levels of dissociative symptoms. (Mulder, Beautrais, Joyce and Fergusson, 1998) </li></ul><ul><li>Empirical data support the relation between trauma and dissociation, particularly adult and childhood trauma stemming from sexual and physical abuse. </li></ul>
Causes <ul><li>Dissociative disorders usually develop as a mechanism for coping with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable. </li></ul><ul><li>Personal identity is still forming during childhood, and during these malleable years a child is more able than is an adult to step outside herself or himself and observe trauma as though it's happening to a different person. A child who learns to dissociate in order to endure an extended period of his or her youth may reflexively use this coping mechanism in response to stressful situations throughout life. </li></ul><ul><li>Rarely, adults may develop dissociative disorders in response to severe trauma. </li></ul>
<ul><li>A significant part of personality development is the lifelong process of assimilating (thoughts, feelings, and actions) and using the assimilated product (understanding) to observe the self and make judgments of present-day interpersonal interactions. </li></ul><ul><li>In Sullivan’s theory of personality development, the personality is conceptualized as a self-system that consists of three mutually interacting aspects: GOOD ME, BAD ME and NOT ME. </li></ul>Interpersonal Theory and Personality Development
<ul><li>This good-me aspect of the self-system consists of experiences from infancy on that soothing and indicative of approval and acceptance by a significant other. </li></ul>“ The GOOD-ME Aspect”
<ul><li>Experiences that elicit disapproval from significant others and result in a high degree of anxiety for a person constitute that part of the self-system known as bad me. This aspect of the personality is available to a person’s conscious awareness, but defense mechanisms (e.g. splitting or sublimation) are used in an effort to control the internal anxiety experience. </li></ul>“ The BAD-ME Aspect”
<ul><li>Experiences that are intensely overwhelming and elicit little or no soothing from significant other are relegated to the not-me aspect. This aspect of the self is kept in the unconscious; that is, dissociated. </li></ul>“ The NOT-ME Aspect”
<ul><li>There is growing evidence of the role of trauma on intricate neurobiological and neuroanatomical structures in dissociative disorders. Early childhood trauma, witnessing or exposure to traumatic or violent incidents, apparently has the potential to produce enduring alterations on brain chemistry, neuroendocrine processes, </li></ul><ul><li>and memory. </li></ul>BIOLOGICAL FACTORS
<ul><li>There is strong clinical evidence that indicates that the amygdala is a central structure in the brain neurocircuitry and plays a pivotal role in conditioned or (learned) fear responding. </li></ul><ul><li>Dysregulation of the amygdala or the hippocampus, or both, results in poor contextual stimulus discrimination (misinterpretation) and leads to overgeneralization of fear responding cues. </li></ul>Neurocircuitry System
<ul><li>Because the limbic system is where memories are processed, early trauma experiences will remain unassimilated to the degree the stress of detachment affected the limbic system. </li></ul><ul><li>Significant early traumatic experiences and the lack of attachment have also been demonstrated to have long-term effects on neurotransmitters, especially serotonin, which has been identified as a primary neurotransmitter involved in the regulation of affect. </li></ul><ul><li>Clients with dissociative disorder often present with a multitude of somatic complaints. The somatic complaints may be representative of a memory laid down along primitive neurological pathways that is being stimulated by something in the current environment. </li></ul>
<ul><li>Prolonged sleep deprivation, fever, and hyperventilation can present with symptoms of amnesia, depersonalization, or identity disturbance. </li></ul><ul><li>Clients with head injuries, seizure disorders, or brain lesions can present with symptoms of dissociation. </li></ul><ul><li>In the nineteenth century, Charcot and others attributed dissociative processes to various forms of epilepsy involving the temporal lobe. </li></ul><ul><li>Research on stress and trauma has also demonstrated altered limbic system function in response to chronic stress, with concurrent suppression of hypothalamic activity and dysregulation of the neurocircuitry systems. </li></ul>
The Role of Family Dynamics <ul><li>The role of family dynamics in the dissociative process is highly potent for the child experiencing trauma such as physical or sexual abuse. Personality development in the child is fostered by the family and is initially concentrated in the mother-child interaction. </li></ul>
<ul><li>In an incestuous family, little, if any, protection or soothing occurs. The members of the family experiencing incest are usually closed, not only to each other, but also to the outside world. </li></ul><ul><li>A child may react to her incestuous family by defensively detaching the abandoning parent. </li></ul><ul><li>Incestuous families often deny they have problems. </li></ul><ul><li>Family dynamics around the abused child leave her with a rigid perception of interpersonal roles. </li></ul>
Cultural Considerations <ul><li>Trance states of amnesia, emotional lability and loss of identity, though not necessarily perceived as normal, may be generally accepted as part of socio-cultural context and religious practice. </li></ul>
Dissociative Disorders Across the Life Span Childhood
Adulthood The adult with a dissociative disorder frequently goes undiagnosed or is misdiagnosed: The person, having grown up in a chaotic family, may not know that losing time is an abnormal experience. Some adults may be in the mental health system for years being treated for depression, and the dissociation becomes evident only after a triggering event. Adult men with undiagnosed dissociative disorders end up incarcerated in prison because of aggressive behaviors.
<ul><li>This disorder is characterized by a blocking out of critical personal information, usually of a traumatic or stressful nature because emotional conflicts or external stressors. The onset is sudden. There is sudden identity disturbance, awareness of memory loss and is alert before and after. PE is normal. May experience secondary gain. Dissociative amnesia, unlike other types of amnesia, does not result from other medical trauma </li></ul><ul><li>Subtypes: </li></ul><ul><li>Localized amnesia is present in an individual who has no memory of specific events that took place, usually traumatic. The loss of memory is localized with a specific window of time. For example, a survivor of a car wreck who has no memory of the experience until two days later is experiencing localized amnesia. </li></ul><ul><li>Selective amnesia happens when a person can recall only small parts of events that took place in a defined period of time. For example, an abuse victim may recall only some parts of the series of events around the abuse. </li></ul><ul><li>Generalized amnesia occurs when patients cannot remember anything in their lifetime, including their own identity. </li></ul><ul><li>Continuous amnesia occurs when patients have no memory of events up to and including the present time. This means that patients are alert and aware of their surroundings but are not able to remember anything. </li></ul><ul><li>Systematized amnesia is characterized by a loss of memory for a specific category of information. A person with this disorder might, for example, be missing all memories about one specific family member. </li></ul>Dissociative Amnesia
<ul><li>An individual with dissociative fugue suddenly and unexpectedly takes physical leave of his or her surroundings and sets off on a journey of some kind in desire to withdraw form emotionally painful experiences </li></ul><ul><li>The onset is sudden </li></ul><ul><li>These journeys can last hours, or even several days or months. </li></ul><ul><li>Individuals experiencing a dissociative fugue have traveled over thousands of miles. </li></ul><ul><li>An individual in a fugue state is unaware of or confused about his identity, and in some cases will assume a new identity </li></ul>Dissociative fugue
<ul><li>This condition, formerly known as multiple personality disorder , is characterized by "switching" to alternate identities when under stress. </li></ul><ul><li>Caused by severe childhood trauma and severe sexual abuse </li></ul><ul><li>The onset is insidious </li></ul><ul><li>a dissociative disorder involving a disturbance of identity in which two or more separate and distinct personality states (or identities) control the individual's behavior at different times. When under the control of one identity, the person is usually unable to remember some of the events that occurred while other personalities were in control. </li></ul><ul><li>The different identities, referred to as alters , may exhibit differences in speech, mannerisms, attitudes, thoughts, and gender orientation. </li></ul><ul><li>The alters may even differ in "physical" properties such as allergies, right-or-left handedness, or the need for eyeglass prescriptions. These differences between alters are often quite striking. </li></ul><ul><li>The person with DID may have as few as two alters, or as many as 100. The average number is about 10. </li></ul>Dissociative Identity Disorder (DID)
Depersonalization Disorder <ul><li>Depersonalization disorder is marked by a feeling of detachment or distance from one's own experience, body, or self. These feelings of depersonalization are recurrent. Of the dissociative disorders, depersonalization is the one most easily identified with by the general public; one can easily relate to feeling as they in a dream, or being "spaced out." Feeling out of control of one's actions and movements is something that people describe when intoxicated. An individual with depersonalization disorder has this experience so frequently and so severely that it interrupts his or her functioning and experience. A person's experience with depersonalization can be so severe that he or she believes the external world is unreal or distorted. </li></ul><ul><li>a dissociative disorder in which the sufferer is affected by persistent or recurrent feelings of depersonalization and/or derealization. </li></ul><ul><li>Brought by overwhelming feelings about a current event similar to a past traumatic event </li></ul><ul><li>The onset is rapid </li></ul><ul><li>The symptoms include a sense of automation, going through the motions of life but not experiencing it, feeling as though one is in a movie, feeling as though one is in a dream, feeling a disconnection from one's body, out-of-body experience, a detachment from one's body, environment and difficulty relating oneself to reality. </li></ul><ul><li>For all, it is a rather disturbing illness, since many feel that indeed, they are living in a "dream". </li></ul><ul><li>They feel separated from themselves or outside their own bodies. </li></ul><ul><li>People with this disorder feel like they are "going crazy" and they frequently become anxious and depressed. </li></ul>
Risk factors Treatment Modalities <ul><li>Pharmacologic Interventions </li></ul><ul><li>Anxiolytic (benzodiazepines PRN and maintenance dose) </li></ul><ul><li>Antidepressant </li></ul><ul><li>Neuroleptics (atypical antipsychotics) </li></ul><ul><li>Psychosocial interventions </li></ul><ul><li>Intensive psychotherapy </li></ul><ul><li>Hypnosis </li></ul><ul><li>Client Grounding Techniques </li></ul><ul><li>Safe place </li></ul><ul><li>Ice in hands </li></ul><ul><li>Wrapping self in blanket </li></ul><ul><li>Counting backward or forward </li></ul><ul><li>Client Education </li></ul><ul><li>Relapse Prevention </li></ul><ul><li>Journaling </li></ul>
Therapeutic Management <ul><li>Psychotherapy is the primary treatment for dissociative disorders. This form of therapy, also known as talk therapy, counseling or psychosocial therapy, involves talking about the disorder and related issues with a mental health professional. It often involves techniques that helps remember and work through the trauma that triggered the dissociative symptoms. The course of psychotherapy may be long and painful, but this treatment approach often is very effective in treating dissociative disorders. </li></ul><ul><li>Creative art therapy . This type of therapy uses the creative process to help people who might have difficulty expressing their thoughts and feelings. Creative arts can help increase self-awareness, cope with symptoms and traumatic experiences, and foster positive changes. Creative art therapy includes art, dance and movement, drama, music and poetry. </li></ul><ul><li>Cognitive therapy . This type of talk therapy helps identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones. It's based on the idea that the person’s own thoughts — not other people or situations — determine how they behave. Even if an unwanted situation has not changed, it can change the way they think and behave in a positive way. </li></ul><ul><li>Medication . Although there are no medications that specifically treat dissociative disorders, the doctor may prescribe antidepressants, anti-anxiety medications or tranquilizers to help control the mental health symptoms associated with dissociative disorders. </li></ul>
The Generalist Nurse- identifies undiagnosed dissociative disorder to help the client develop adaptive skills and achieve symptom management including appropriate medications; continual assessment of the client’s level of danger to self and to others throughout the treatment. The Advanced-Practice Psychiatric Registered Nurse- encourages the client in a psychotherapy or cause management process, continual assessment of client’s safety The Role of the Nurse
The Nursing Process <ul><li>Assessment - early recognition of school failure/ childhood abuse like startle reaction, erratic sleep, fear objects or other people, pattern of not remembering events, pattern of unexplained behaviours; repeatedly seek medical help for problems with no organic basis </li></ul>
<ul><li>Disturbed personal Identity </li></ul><ul><li>Ineffective individual coping: escape through dissociation </li></ul><ul><li>Anxiety sever R/T acute stressor </li></ul><ul><li>Risk for self-directed violence </li></ul><ul><li>Altered sleep/ arousal patterns </li></ul><ul><li>Long-term/ short-term memory loss </li></ul><ul><li>Altered feeling patterns </li></ul><ul><li>Altered social interactions </li></ul><ul><li>Hopelessness </li></ul><ul><li>Powerlessness </li></ul><ul><li>Spiritual Distress </li></ul>Possible NDx
<ul><li>The client should experience a form of support that has been missing in her life </li></ul><ul><li>intervention should be flexible emphasizing consistency and predictability </li></ul><ul><li>remind the alter that is present that the entire client is being treated </li></ul><ul><li>encourage the client to write a journal </li></ul><ul><li>Standards of nursing care should include psychotherapy intervention, therapeutic milieu, health teaching, ADL, somatic therapies and discharge planning </li></ul>Implementation
Evaluation <ul><li>Focuses the effectiveness of the NCP, must be a mutual affair and based on behavioral data </li></ul>