Dissociative Disorders Nursing Care Management

Dissociation is the mind walling off part of itself to survive overwhelming stress. Memory, identity, perception, and sense of self come apart. Most of these patients carry a history of childhood physical, sexual, or emotional abuse. DSM-5 names three major dissociative disorders: dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder.

What are Dissociative Disorders?

The core feature is a disruption in the normally integrated functions of consciousness, memory, identity, or perception. Under intolerable stress, the person blocks off part of life from consciousness.

• Dissociative identity disorder. First recognized in DSM-III as "multiple personality disorder," defined in DSM-5 as two or more fully distinct personality states, which some cultures describe as an experience of possession.
• Dissociative amnesia. Inability to recall important personal information, usually traumatic or stressful. DSM-5 lists two primary forms: localized or selective amnesia for specific events, and generalized amnesia for identity and life history. In DSM-5, dissociative fugue is now a specifier for dissociative amnesia, not a separate diagnosis as in DSM-IV.
• Localized amnesia. Inability to recall all events tied to a traumatic event for a specific time period after it.
• Selective amnesia. Inability to recall only certain events tied to a traumatic event for a specific period after it.
• Generalized amnesia. Failure of recall covering one's entire life.
• Continuous amnesia. Inability to recall events from a specific time up to and including the present.
• Systematized amnesia. Inability to remember events tied to a specific category of information, such as one's family or one particular person or event.
• Dissociative fugue. A sudden, unexpected trip away from home or work with assumption of a new identity and inability to recall the previous one.
• Depersonalization disorder. A temporary change in self-awareness: feelings of unreality, changes in body image, detachment from the environment, or a sense of observing oneself from outside the body.

Pathophysiology

Dissociation is a protective shift into altered states of consciousness in reaction to overwhelming psychological trauma.

• Once the patient returns to baseline, access to the dissociated information is diminished.
• The memories are thought to be encoded but not conscious, that is, repressed.
• Normal memory lays down traces in 2 forms, explicit and implicit.
• Explicit memories are available for immediate, conscious recall and include facts and experiences one is aware of; implicit memories operate independently of conscious memory.
• Explicit memory is not well developed in children, raising the possibility that more memories become implicit at that age.
• Trauma-driven changes at this level of brain function may alter memory encoding for those events and periods.
• Dissociation is also a neurologic phenomenon that various drugs and chemicals can trigger, producing acute, subchronic, and chronic episodes.

Statistics and Incidences

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

• Dissociative amnesia occurs in 2-7% of the general population, with high occurrence in those exposed to war, child or sexual abuse, concentration camps, torture, and natural disasters.
• Dissociative identity disorder is seen in 1-3% of the population.
• An estimated 2.4% of the general population meets criteria for depersonalization disorder, though many clinicians question this figure and it may be lower.

Causes

• Genetics. The DSM-IV-TR suggests DID is more common in first-degree relatives of affected people than in the general population.
• Neurobiological. A possible link between neurological alterations and dissociative disorders is proposed; dissociative amnesia and fugue may relate to changes in brain areas tied to memory.
• Psychodynamic theory. Freud (1962) held that dissociative behaviors occurred when individuals repressed distressing mental contents from conscious awareness.
• Psychological trauma. Growing evidence points to DID arising from traumatic experiences that overwhelm the person's capacity to cope by any means other than dissociation.

Clinical Manifestations

• Impaired recall. Inability to remember specific incidents, or any of one's past life including identity.
• New identity away from home. Sudden travel from familiar surroundings, assumption of a new identity, and inability to recall the past.
• Multiple identities. Additional identities within the personality, with transition from one to another as a way of handling stress.
• A feeling of unreality. Detachment from a stressful situation, possibly with dizziness, depression, obsessive rumination, somatic concerns, anxiety, fear of going insane, and a disturbed subjective sense of time.

Dissociative identity disorder: emotional turmoil, behavioral turmoil, memory gaps, and incidents of out-of-character behavior.

Dissociative amnesia: memory loss, depression, anxiety, and confusion.

Depersonalization/derealization disorder: detachment, foggy or dreamlike vision, emotional disconnection, physical numbness, distorted perception of time, and distortions of distance and the size and shape of objects.

Medical Management

Survivors of extensive childhood abuse present complicated clinical dilemmas.

• Encourage healthy coping. The first focus is helping patients control and contain symptoms and deal with dissociation, flashbacks, and intense affects such as rage, terror, and despair.
• Log and monitor emotions. Having patients keep a log of emotions helps them work with their sense of unpredictability.
• Develop a crisis plan. Build a list of activities ranging from simple to complex.

Pharmacologic Management

• Neuroleptics. Atypical neuroleptics such as aripiprazole, olanzapine, quetiapine, and ziprasidone are the accepted treatment.

Nursing Management

Nursing Assessment

• Psychiatric interview. Describe mental status: behavior, flow of thought and speech, affect, thought processes and content, sensorium and intellectual resources, cognitive status, insight, and judgment.

Nursing Diagnosis

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

Nursing Care Planning and Goals

The client will recognize that he or she uses dissociative behaviors under psychosocial stress, voice more adaptive coping than dissociation, connect memory loss to the stressful situation and begin discussing it with the nurse or therapist, recover memory deficits while building adaptive coping, and voice adaptive ways of coping with stress.

Nursing Interventions

• Promote safety. Reassure the client of safety and security through your presence; dissociative behaviors can be frightening.
• Assess stressors. Identify the stressor that triggered severe anxiety; this drives an effective plan of care.
• Explore feelings. Help the client understand that the disequilibrium felt in severe stress is acceptable and even expected.
• Encourage coping. Have the client identify past coping methods and judge whether each was adaptive or maladaptive.
• Build self-esteem. Give positive reinforcement for attempts to change, which raises self-esteem and repeats desired behaviors.

Evaluation

Goals are met when the client recognizes the use of dissociative behaviors under stress, voices adaptive coping in place of dissociation, links memory loss to the stressful situation and discusses it, recovers memory deficits while building adaptive coping, and voices adaptive ways of coping with stress.

Documentation Guidelines

Document individual findings (contributing factors, interactions, social exchanges, specific behaviors); cultural and religious beliefs and expectations; the plan of care; the teaching plan; responses to interventions and teaching; and progress toward outcomes.