Dissociative Disorders NCLEX Review

Dissociative Disorders

• a disruption in integrative functions of memory, consciousness, or identity.
  • Usually consciousness, memory, identity and perception are integrated function
• Defense mechanisms of dissociation and repression are used

 

Dissociation is a defense mechanism in which experiences are blocked off from consciousness, so that affect, behavior, identity, memories, and/or thoughts are not integrated

Repression is a defense mechanism in which thoughts and feelings are kept from consciousness

 

• Client does NOT consciously “decide” to dissociate
• May experience depression and anxiety

 

II. Etiology/Causes

 

A. Traumatic Experience (accidents, natural disasters, assault)

1. Strong Emotional response
2. Psychological Conflict
3. Long-term, chronic stressors

 

B. Severe childhood physical, sexual, or emotional abuse

• Child learns to detach or dissociate from intolerable situation; continues to dissociate when experiencing stressful (even non-abusive) events as an adult, which interferes with normal functioning

 

III.        Types

1. Dissociative amnesia
2. Dissociative fugue
3. Dissociative identity disorder (formerly multiple personality disorder)
4. Depersonalization disorder

 

IV. Specific Disorders

A. Dissociative Amnesia

• Inability to recall important personal information usually of a traumatic or stressful nature because it provokes anxiety
  • Localized amnesia: short time period (hours) after a disturbing event
  • Selective amnesia: amnesia for some, but not all events
  • Generalized amnesia: amnesia for whole lifetime of experiences
  • Systematized – loss of memory about one specific family member
  • Continuous amnesia: forgets successive events as they occur

 

Special Interventions:

• Support groups
• Gradual reconstruction of events through talking and listening/reading of others’ accounts of the trauma

 

B. Dissociative Fugue

• Characterized by suddenly wandering away or taking a trip away from one’s usual place, unable to recall important aspects of identity and assumes new identity
• Old and new identities do not alternate, incomplete new identity
• Typically retains learned skills, and can perform usual mental functions like writing or calculating while in fugue
• Often a response to psychological stressors
• Usually lasts from hours to days, rarely months; considerable confusion when returns to pre-fugue state - Once the client has returned to pre-fugue state, has NO memory for events during the fugue

 

Special Intervention:

• Assist in developing effective coping skills to deal with problems
• Assist the client to cope with post-fugue confusion

 

C. Dissociative identity disorder (multiple personality)

• Two or more fully developed, distinct and unique personalities exist within the client; each personality/identity has own enduring pattern of perceiving, relating to, and thinking about oneself and the environment
• May present different ages, genders, have different physiological responses and disorders
• The HOST is the primary personality/identity that holds the person’s name, and the other personalities are referred to as ALTERS.
• ALTERS may take full control of the client, one at a time, and may or may not be aware of each other. ✓ The ALTERS may be aware of the HOST, but the HOST is NOT USUALLY AWARE of the alters

 

Assessment:

• The client may have an inability to recall important information (unrelated to ordinary forgetfulness).
• Transition from one personality to the other is related to stress or a traumatic event and is sudden.
• Dissociation is used as a method of distancing and defending one’s self from anxiety and traumatizing experience
• “Loses time” when alternate personality is present for a period of time

 

Special Interventions:

• No-harm contract and environmental safety if the client is suicidal or self-mutilating
• Meeting and recognizing alters and their unique experiences and needs
• “Mapping” personality system, noting characteristics of alters
• Individual therapy with therapist skilled in working through trauma leading to integration (moving together of aspects of all identities)
• Development of new coping skills for clients so that dissociation is either unnecessary or is under control
• Family therapy with partners and children to help client avoid dissociation, deal with hostile personalities, understand therapy process, and to confirm experience with client’s behavior
• Hypnosis

 

D. Depersonalization disorder

• The client has a persistent or recurrent feeling of being detached from his or her mental processes or body, as if in a dream-like state
• intact reality testing; that is, the client is NOT psychotic or out of touch with reality.
• Describes self as “detached from the body” or “being in a dream”, feels strange or unreal
• Precipitated by stress or anxiety
• Reports distress about experiences and become depressed and anxious

 

Special Interventions:

• Problem-solving to reduce stress in general
• Stress-management techniques
• “Grounding” or focus on discernable, external environment
  • Having the client focus on real, concrete things that can be seen or heard and redirects the client’s attention from depersonalization, this in turn, interrupts the anxiety response
  • Help the client to focus on what he or she is currently experiencing through senses
    • Are you hearing something?
    • What are you touching
    • Can you see me and the room we are in?
    • Do you feel your feet on the floor?

 

V. General Nursing Management

 

PROMOTE CLIENT’S SAFETY

• Discuss self-harm thoughts.
• Help client develop plan for going to safe place when having destructive thoughts or impulses.

 

HELP CLIENT COPE WITH STRESS AND EMOTIONS

• Use grounding techniques to help client who is dissociating or experiencing flashbacks.
• Validate client’s feelings of fear, but try to increase contact with reality.
• During dissociative experience or flashback, help client change body position but do not grab or force client to stand up or move.
• Use supportive touch if client responds well to it.      
• Teach deep breathing and relaxation techniques.
• Use distraction techniques such as physical exercise, listening to music, talking with others, or engaging in a hobby or other enjoyable activity.
• Help to make a list of activities and keep materials on hand to engage client when feelings are intense.

 

HELP PROMOTE CLIENT’S SELF-ESTEEM

• Refer to client as “survivor” rather than “victim.”
• Establish social support system in community.
• Make a list of people and activities in the community for client to contact when help is needed.

 

Additional Nursing Interventions:

1. Develop a trusting relationship with the client.
2. Encourage verbal expression of painful experiences, anxieties, and concerns.
3. Explore methods of coping.
4. Identify sources of conflict.
5. Focus on the client’s strengths and skills.
6. Orient the client.
7. Provide nondemanding simple routines.
8. Allow the client to progress at his or her own pace.
9. Implement stress reduction techniques.
10. Plan for individual, group, or family psychotherapy to integrate dissociated aspects of personality or memory and to expand self-awareness.

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