DISSOCIATIVE DISORDERS
DSM-IV
300.12 Dissociative amnesia
300.13 Dissociative fugue
300.14 Dissociative identity disorder
300.15 Dissociative disorder NOS
300.6 Depersonalization disorder
In these disorders a disturbance or alteration exists in the normally integrative functions of identity, memory, or consciousness. The individual blocks off part of his or her life from consciousness during periods of intolerable stress. The stressful emotion becomes a separate entity, as the individual “splits” from it and mentally drifts into a fantasy state.
ETIOLOGICAL THEORIES
Psychodynamics
Selective repression of distressing mental contents from conscious awareness is used as a mechanism for protecting the individual from emotional pain or expressing self in dangerous ways. The stressor(s) may arise from external circumstances or internal sources with onset of symptoms sudden or gradual and of transient or chronic nature. Intrapsychic conflict thus uses denial and “ego splitting” to decrease anxiety.
Physical sensations seen in these disorders may represent forbidden wishes that have been somatized. The use of the defense mechanism of displacement allows the feeling(s) to be directed away from the ego-threatening object toward one less threatening. In psychoanalytic terms, dissociation is a form of denial in which the object denied is part of the self or ego.
Biological
Research on the biological basis of these disorders is increasing as more recognition of the mind-body connection is accepted. It is difficult to determine whether the biological changes (fight-or-flight mechanism) that accompany severe anxiety precede or precipitate the emotional state. Biochemical, physiological, and endocrine systems have an intimate connection with actual physical changes occurring in all body systems via the autonomic nervous system. Some studies have shown EEG abnormalities associated with cerebral mechanisms in the temporal and limbic regions of the brain, which mediate identity formation and a sense of personal boundaries and may affect development of gender and generation boundaries.
Organic causes of pathological dissociative experiences that are known or suspected include temporal lobe epilepsy, sensory deprivation, sleep loss, strokes, encephalitis, and Alzheimer’s disease. Drugs may also induce amnesia or depersonalization directly or indirectly in some incidences. However, most dissociative states are not associated with any obvious organic conditions and the diagnosis of dissociative disorder requires that the condition is not due to the direct effects of a substance or a general medical condition.
Family Dynamics
In Systems theory, the family is viewed as a system in which the process (interactions between/among family members) is the prime determinant. Level of differentiation and level of anxiety determine the degree of pathology.
Psychosocial theory states that individuals who develop dissociative disorders have often experienced severe physical, sexual, and/or emotional abuse early in life—stress so severe that the only way to cope with the painful emotions is to detach from them. The child learns to respond to stressful situations in this manner. One parent may be abusive, with the other being a passive participant, not taking care of or protecting the child. Psychiatric diagnoses (especially alcoholism) in close relatives are common, although multiple personality diagnosis is not.
Certain behaviors observed in childhood, though considered normal, may be identified as dissociative, including construction of imaginary playmates, use of different names or ages for themselves, taking on the role of an animal, imagining self as having been adopted or coming from another family, separation from the past, gender confusion, and regressive behavior. Responding to stressful situations with dissociative behaviors then becomes a method of coping for some individuals into adulthood, when there is less control over the dissociative states. The response becomes maladaptive in that the individual escapes from the stressful situation rather than facing it.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Insomnia
Ego Integrity
Confusion about personal identity, may have assumed a new identity either partial or complete (fugue)
Anxiety responses, report of phobias; fears of going crazy
Neurosensory
Memory lapses/amnesia; disorientation; inability to recall important personal information/specific incidents not due to direct effects of a substance, general medical condition, or ordinary forgetfulness
May report hallucinations, delusions
Mood swings; psychological conflicts; family/peers may describe client’s behavior as erratic, unpredictable, or unreliable
Sudden, unexpected travel away from familiar surroundings of work and home, with inability to recall past (fugue)
Persistent/recurrent experiences of feeling detached from own mental processes or body, although reality testing remains intact (depersonalization)
Presence of 2 or more distinct identities or personality states (mean average of 13), with each a fully integrated, complex unit with unique memories, behaviors, and relationships (or may be a personality state that does not have as wide a range of patterns) recurrently taking control of client’s behavior, with transition from one personality to another being sudden/associated with psychosocial stress. Alternate personalities vary in their awareness of each other, may be of opposite genders, and are commonly children, although some may be stated to be older than the individual (dissociative identity disorder)
Transient changes in facial expression, voice, and posture; tastes/habits that seem to change quickly or often
Safety
Suicidal feelings/behaviors
Evidence of self-mutilation
Sexuality
History of severe childhood incest, sexual/physical/psychological abuse
Sexually inhibited or promiscuous
Social Interactions
Significant distress or impairment in social, occupation, or other important areas of functioning
Teaching/Learning
More common in women than in men, in persons with some higher education, and in white-collar workers
Age of onset is early childhood, although often not diagnosed until the third decade
Seldom diagnosed upon initial clinical contact (accurate diagnosis may be delayed by a period of months to years)
Substance abuse may be reported (but is not cause of disorder)
Absence of organic brain disorders (e.g., temporal lobe epilepsy)
History of major depression greater than 90% (dissociative identity disorder)
DIAGNOSTIC STUDIES
(Evaluations to rule out an underlying or concurrent disease process are based on individual symptoms.)
Neurological Testing (e.g., EEG and CT/MRI Scans): To rule out organic brain conditions related to trauma, tumor, congenital defects, and temporal lobe epilepsy, symptoms of which often parallel manifestations of dissociative identity disorder.
Psychosocial Assessment, such as Rorschach, Thematic Apperception Test (TAT), Minnesota Multiphasic Personality Inventory (MMPI), Weschler Adult Intelligence Scale (WAIS), Dissociative Experiences Scale (DES), Dissociative Disorders Interview Schedule (DDIS), and Hypnosis or Amobarbital Interviews: As indicated to provide behavioral observation and documentation describing the character, duration, frequency, and precipitation of behavioral changes and client comments or complaints essential to the diagnostic process, as these clients are frequently misdiagnosed initially because of blurring of symptoms that parallel other psychiatric problems—commonly depression, neuroses, personality disorders, and schizophrenia.
Drug Screen: Assess for concomitant substance use.
NURSING PRIORITIES
1. Provide safe environment; protect client/others from injury.
2. Assist client to recognize anxiety.
3. Promote insight into relationship between anxiety and development of dissociative state/other personalities.
4. Support client/family in developing effective coping skills and participating in therapeutic activities.
DISCHARGE GOALS
1. Recognizes potentially dangerous behaviors/personalities and contracts for safety.
2. Client/family are participating in therapeutic regimen.
3. Effective coping skills, understanding of underlying dynamics of condition are demonstrated.
4. Recovers deficits in memory.
5. Major/emerging personality has been chosen and accepted (dissociative identity disorder) or client is managing stress without resorting to dissociation.
6. Plan in place to meet needs after discharge.
DSM-IV
300.12 Dissociative amnesia
300.13 Dissociative fugue
300.14 Dissociative identity disorder
300.15 Dissociative disorder NOS
300.6 Depersonalization disorder
In these disorders a disturbance or alteration exists in the normally integrative functions of identity, memory, or consciousness. The individual blocks off part of his or her life from consciousness during periods of intolerable stress. The stressful emotion becomes a separate entity, as the individual “splits” from it and mentally drifts into a fantasy state.
ETIOLOGICAL THEORIES
Psychodynamics
Selective repression of distressing mental contents from conscious awareness is used as a mechanism for protecting the individual from emotional pain or expressing self in dangerous ways. The stressor(s) may arise from external circumstances or internal sources with onset of symptoms sudden or gradual and of transient or chronic nature. Intrapsychic conflict thus uses denial and “ego splitting” to decrease anxiety.
Physical sensations seen in these disorders may represent forbidden wishes that have been somatized. The use of the defense mechanism of displacement allows the feeling(s) to be directed away from the ego-threatening object toward one less threatening. In psychoanalytic terms, dissociation is a form of denial in which the object denied is part of the self or ego.
Biological
Research on the biological basis of these disorders is increasing as more recognition of the mind-body connection is accepted. It is difficult to determine whether the biological changes (fight-or-flight mechanism) that accompany severe anxiety precede or precipitate the emotional state. Biochemical, physiological, and endocrine systems have an intimate connection with actual physical changes occurring in all body systems via the autonomic nervous system. Some studies have shown EEG abnormalities associated with cerebral mechanisms in the temporal and limbic regions of the brain, which mediate identity formation and a sense of personal boundaries and may affect development of gender and generation boundaries.
Organic causes of pathological dissociative experiences that are known or suspected include temporal lobe epilepsy, sensory deprivation, sleep loss, strokes, encephalitis, and Alzheimer’s disease. Drugs may also induce amnesia or depersonalization directly or indirectly in some incidences. However, most dissociative states are not associated with any obvious organic conditions and the diagnosis of dissociative disorder requires that the condition is not due to the direct effects of a substance or a general medical condition.
Family Dynamics
In Systems theory, the family is viewed as a system in which the process (interactions between/among family members) is the prime determinant. Level of differentiation and level of anxiety determine the degree of pathology.
Psychosocial theory states that individuals who develop dissociative disorders have often experienced severe physical, sexual, and/or emotional abuse early in life—stress so severe that the only way to cope with the painful emotions is to detach from them. The child learns to respond to stressful situations in this manner. One parent may be abusive, with the other being a passive participant, not taking care of or protecting the child. Psychiatric diagnoses (especially alcoholism) in close relatives are common, although multiple personality diagnosis is not.
Certain behaviors observed in childhood, though considered normal, may be identified as dissociative, including construction of imaginary playmates, use of different names or ages for themselves, taking on the role of an animal, imagining self as having been adopted or coming from another family, separation from the past, gender confusion, and regressive behavior. Responding to stressful situations with dissociative behaviors then becomes a method of coping for some individuals into adulthood, when there is less control over the dissociative states. The response becomes maladaptive in that the individual escapes from the stressful situation rather than facing it.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Insomnia
Ego Integrity
Confusion about personal identity, may have assumed a new identity either partial or complete (fugue)
Anxiety responses, report of phobias; fears of going crazy
Neurosensory
Memory lapses/amnesia; disorientation; inability to recall important personal information/specific incidents not due to direct effects of a substance, general medical condition, or ordinary forgetfulness
May report hallucinations, delusions
Mood swings; psychological conflicts; family/peers may describe client’s behavior as erratic, unpredictable, or unreliable
Sudden, unexpected travel away from familiar surroundings of work and home, with inability to recall past (fugue)
Persistent/recurrent experiences of feeling detached from own mental processes or body, although reality testing remains intact (depersonalization)
Presence of 2 or more distinct identities or personality states (mean average of 13), with each a fully integrated, complex unit with unique memories, behaviors, and relationships (or may be a personality state that does not have as wide a range of patterns) recurrently taking control of client’s behavior, with transition from one personality to another being sudden/associated with psychosocial stress. Alternate personalities vary in their awareness of each other, may be of opposite genders, and are commonly children, although some may be stated to be older than the individual (dissociative identity disorder)
Transient changes in facial expression, voice, and posture; tastes/habits that seem to change quickly or often
Safety
Suicidal feelings/behaviors
Evidence of self-mutilation
Sexuality
History of severe childhood incest, sexual/physical/psychological abuse
Sexually inhibited or promiscuous
Social Interactions
Significant distress or impairment in social, occupation, or other important areas of functioning
Teaching/Learning
More common in women than in men, in persons with some higher education, and in white-collar workers
Age of onset is early childhood, although often not diagnosed until the third decade
Seldom diagnosed upon initial clinical contact (accurate diagnosis may be delayed by a period of months to years)
Substance abuse may be reported (but is not cause of disorder)
Absence of organic brain disorders (e.g., temporal lobe epilepsy)
History of major depression greater than 90% (dissociative identity disorder)
DIAGNOSTIC STUDIES
(Evaluations to rule out an underlying or concurrent disease process are based on individual symptoms.)
Neurological Testing (e.g., EEG and CT/MRI Scans): To rule out organic brain conditions related to trauma, tumor, congenital defects, and temporal lobe epilepsy, symptoms of which often parallel manifestations of dissociative identity disorder.
Psychosocial Assessment, such as Rorschach, Thematic Apperception Test (TAT), Minnesota Multiphasic Personality Inventory (MMPI), Weschler Adult Intelligence Scale (WAIS), Dissociative Experiences Scale (DES), Dissociative Disorders Interview Schedule (DDIS), and Hypnosis or Amobarbital Interviews: As indicated to provide behavioral observation and documentation describing the character, duration, frequency, and precipitation of behavioral changes and client comments or complaints essential to the diagnostic process, as these clients are frequently misdiagnosed initially because of blurring of symptoms that parallel other psychiatric problems—commonly depression, neuroses, personality disorders, and schizophrenia.
Drug Screen: Assess for concomitant substance use.
NURSING PRIORITIES
1. Provide safe environment; protect client/others from injury.
2. Assist client to recognize anxiety.
3. Promote insight into relationship between anxiety and development of dissociative state/other personalities.
4. Support client/family in developing effective coping skills and participating in therapeutic activities.
DISCHARGE GOALS
1. Recognizes potentially dangerous behaviors/personalities and contracts for safety.
2. Client/family are participating in therapeutic regimen.
3. Effective coping skills, understanding of underlying dynamics of condition are demonstrated.
4. Recovers deficits in memory.
5. Major/emerging personality has been chosen and accepted (dissociative identity disorder) or client is managing stress without resorting to dissociation.
6. Plan in place to meet needs after discharge.
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