10. Dissociative disorders

A client with a dissociative disorder experiences a disturbance in the integrated functions of memory, identity, consciousness, or perception of the environment. This alteration in mental functioning can occur suddenly or gradually and can progress from a transient to a chronic condition. If there's an alteration in memory, significant personal events aren t remembered. When the disturbance is in identity. the person s usual personality is temporarily forgotten or a new one may be assumed.

The client may feel as though the sense of reality is gone (dereal-ization). This can be manifested by the sensation of not feeling human or feeling disconnected from one's body parts (depersonaliza-tion). Typically, dissociation is a mechanism used to protect the self and obtain relief from overwhelming anxiety.

Dissociative Amnesia

DSM-IV CATEGORIES

300.12 Dissociative amnesia

With dissociative amnesia, the ability to remember significant personal information, usually of a traumatic nature, is lost. The magnitude of the disturbance is too great to be interpreted as mere forgetfulness. Often a person may have amnesia for a suicide attempt, violent behavior episodes, or self-mutilation. Dissociative amnesia is usually diagnosed because of reported memory loss or gaps in recall of certain periods in a person's life history. The disorder doesn't occur during a dissociative identity disorder, dissociative fugue, posttraumatic stress disorder, or somatization disorder and isn't due to the effects of a substance or a general medical condition. The symptoms of dissociative amnesia can cause impairment in social, occupational, and other general areas of functioning.

Dissociative amnesia typically occurs after experiencing severe psychosocial stress, and it's encountered in children as well as in adults. The degree of impairment varies depending on the episode and the importance of the event to the person's functioning. Recovery is usually complete, and recurrences are rare. (For further information, see Types of Memory Loss Associated with Dissociative Amnesia.)

COMMUNICATION STRATEGIES

• Orient the client to the current surroundings if necessary.
• Communicate acceptance, support, and concern for the client.
• Maintain alert staff support so that when the client's memory returns a nurse will be available to help the client process the traumatic event.
• Encourage the client to verbalize emotions.
• Help the client manage guilt, shame, agitation, and self-blame.
• Encourage the client to talk about life concerns and situation.

TYPES OF MEMORY LOSS ASSOCIATED WITH DISSOCIATIVE AMNESIA

In localized amnesia, the events that happened during a circumscribed period can't be recalled. An example is a survivor of a plane crash who can't remember anything about the accident until days later. With selective amnesia, some of the events that occurred can be recalled. The person may remember hearing about a death but can't remember talking about it with the nurse. Continuous amnesia is the inability to recall events from a specific time up to the present. This disorder is seen in adolescents and young adults, especially in young young men who have participated in wars. Systemized amnesia is memory loss for some specific categories of information. An example is the loss of memory related to a close relative. The least common type of recall impairment isgeneralized amnesia, in which one's entire life can't be recalled.

NURSING DIAGNOSIS: ANXIETY

Probable Causes	Defining Characteristics
Strong conflicting emotions Emotional or physical trauma Experience with a natural disaster Trauma experienced during military service	Sudden onset of amnesia Loss of ability to recall personal information Evidence of traveling or having a different identity Disorientation

Long-Term Goal The client will demonstrate the ability to decrease anxiety by developing effective coping skills.

Short-Term Goal #1: The client will identify signs and symptoms of anxiety.

Interventions and Rationales

• Work with the client to identify how the anxiety is manifested.The client needs to become aware of physical and emotional manifestations of anxiety and be able to identify signs of escalating anxiety.
• Help the client recognize that anxiety is handled by dissociating from personal identity.The client needs to recognize dissociation as an unsuccessful defense mechanism for handling stress.
• Encourage the client to verbalize feelings of distress.Verbalizing feelings helps to contain them rather than allowing the anxiety to escalate into a panic situation.
• When the stressor responsible for the amnesia becomes known (after the client's memory returns), explore the trauma and related feelings. Exploring the trauma allows the nurse to develop a plan of care that focuses on managing the emotional reactions and helping the client regain control over the situation.

Short-Term Goal #2: The client will develop several effective skills for managing anxiety.

Interventions and Rationales

• Have the client discuss awareness of and ways to control behaviors indicative of anxiety.Obtaining information about the client's perceptions of anxiety and the ways of managing it provides the basis for initiating new interventions.
• Have the client explore current coping mechanisms.Examining coping mechanisms enables the client to identify the ones that are most effective in decreasing anxiety.
• Encourage the client to develop and use logical thought processes and refine problem-solving skills.These strategies help reduce the client's level of anxiety.
• Teach the client techniques for relieving anxiety, such as deep breathing and progressive muscle relaxation.To be able to give up the urge to dissociate, the client needs to learn alternative ways to relieve anxiety.
• Have the client develop a support system that can be relied on in times of distress. This intervention empowers the client to seek assistance in a timely manner and decreases the likelihood of resorting to ineffective coping methods.

THERAPIES

Individual Therapy focuses on working with the client to recall traumatic experiences and effectively control the anxiety.

Individual Therapy

• Focus therapy on building trust and establishing a relationship with the client until memory returns.
• Help the client handle sources of stress and conflict.
• If trained in the use of hypnosis, the nurse may use posthypnotic suggestion to assist the client with memory return.
• Encourage the client to discuss what is remembered.
• Allow the client to identify what is uncomfortable about these remembered events and explore related feelings.
• Teach the client more effective methods of coping with stress.
• Inform and instruct the client about relaxation methods.

MEDICATIONS

• Medications are usually not used with dissociative amnesia.

FAMILY CARE

• Instruct the family about the disorder, treatment, and how to cope with the client's memory loss.
• Explain to the family how severe anxiety or trauma can trigger dissociative amnesia.
• Teach the family how to promote healthy coping strategies.
• Help the family facilitate the client's reality testing by addressing the client by name and focusing on the here and now.
• Encourage the family to work together to help decrease anxiety-provoking situations for the client.
• Help the family handle the chaos related to memory loss, especially the inability to fulfill family roles during the period of amnesia.

Dissociative Fugue

DSM-IV CATEGORIES

300.13 Dissociative fugue

The major characteristic of dissociative fugue is abrupt, unexpected travel away from home or place of work, with inability to recall some or all of one's past. There may be confusion or a lack of awareness about one's personal identity. With the diagnosis of dissociative fugue, the abrupt travel and change of identity don't occur as part of a dissociative identity disorder or as a result of a medical condition or substance use. If the person assumes a new identity, it may be only slightly different from the former demeanor; for example, a person may become more outgoing or less socially inhibited. During fugue, most people appear to be without psychopathology and don't attract attention. Amnesia for recent events or lack of awareness of a personal identity is common and the usual reason a person has contact with the health care system. After recovery, there's no memory of the events that occurred during the fugue.

Dissociative fugue often follows stressful experiences, such as marital conflict, personal rejection, a natural disaster, and incidents while in the military service. The typical fugue is brief in duration, lasting from hours to days. However, fugues have occurred over the course of months, and the travel can extend thousands of miles. The age of onset is variable, but most cases have been noted in adults. It's believed that the disorder increases during times of war or natural disaster and that excessive alcohol intake may contribute to the development of the disorder.

COMMUNICATION STRATEGIES

• Orient the client to the surroundings as needed.
• Convey a positive attitude and expectation that the client can engage in responsible behavior.
• Don't question or push the client to recall events because this increases anxiety.
• Foster interactions because the client may withdraw if memory has not returned.
• Encourage the client to discuss thoughts and feelings about stressors.
• Talk about ways to decrease anxiety.

NURSING DIAGNOSIS: INEEFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Traumatic experiences Intense marital or family conflict Excessive use of alcohol Low self-concept Regression to an earlier stage of development	Unexplained travel away from home or place of employment Memory loss Periods of dissociating Confusion about personal identity or assumption of a new identity Limited repertoire of coping skills

Long-Term Goal The client will demonstrate effective methods of coping with stressful situations.

Short-Term Goal #1: The client will discuss feelings about stressful life events.

Interventions and Rationales

• Help the client identify anxiety-provoking situations.Its necessary to identify and obtain information about stressors before an appropriate plan of care can be established.
• Have the client explore feelings about current life stressors.This discussion promotes client identification and acceptance J" J.. emotions, including negative ones.
• Have the client discuss both positive and negative feelings about self and the ability to make changes.The discussion provides the nurse with information about the client's self-esteem and confidence level.
• Encourage the client to explore repressed traumatic experiences as they come into conscious memory, focusing on the anxiety that they generate.By exploring these memories, the client begins to understand how the inability to integrate these experiences into consciousness contributes to maintaining the anxiety.

Short-Term Goal #2: The client will verbalize constructive ways to cope with stress.

Interventions and Rationales

• Teach the client to evaluate past and current coping methods. Clients need to determine which coping skills are effective and need to be maintained and which are ineffective and need to be eliminated.
• Discuss the universal concept of wanting to move away from or flee painful situations. This discussion helps the client understand the natural reaction to stressful situations while presenting alternative ways to handle them.
• Work with the client to formulate alternative coping strategies and behaviors. Clients often require assistance with problem soiv-ing and decision making as they attempt to develop coping skills and change from old to new behaviors.

THERAPIES

Clients usually respond well to psychotherapy directed toward the underlying stressful conflict that precipitates the desire to flee from painful experiences.

Individual Therapy

• Work with the client to uncover sources of stress and conflict.
• Help the client make the connection between extreme stress and the fleeing behavior.
• Allow the client to address whatever situations are remembered, and encourage the client to identify what is uncomfortable about these events.
• Discuss current real events in the client's life as a way to confirm and reinforce the client's sense of identity.
• Teach the client effective methods of coping with stress.

MEDICATIONS

• Medication isn't usually helpful in the treatment of dissociative fugue disorder.
• If severe anxiety is present, antianxiety Medications may be given. (See Appendix D for medication information.)

FAMILY CARE

• Inform the family about the disorder, treatment, and how to cope with the sudden and unexpected travel behavior.
• Explain to the family how severe anxiety can trigger a fugue state.
• Teach the family how to promote healthy coping strategies.
• Help the family facilitate the client's reality testing by addressing the client by name and focusing on the here and now.
• Encourage the family to work together to help decrease anxiety-provoking situations for the client.
• Teach family members stress-reduction skills to help them through the strain related to physical absence during the fugue state.

Dissociative Identity Disorder

DSM-IV CATEGORIES

300.14 Dissociative identity disorder

A client with dissociative identity disorder has two or more distinct identities or personality states. Personality is defined as a pattern of perceiving and relating to the environment, along with the way the self is presented in various social and personal contexts. Each personality can have unique memories and certain ways of behaving and can be involved in specific relationships. At any time, the client can be dominated by one of the personalities. but usually the client has a primary personality that identifies itself with the client's given name. The various personalities may c-may not be aware of one another, but only one personality communicates with the external environment at any given time.

The personality shift is typically sudden and can be traumatic. The time needed to switch from one identity to another is often a matter of seconds, but occasionally the switch may be more gradual.

This shift can be triggered by stress, conflict, or other social, symbolic, or environmental cues. Therapeutically, a personality shift can be induced through the use of hypnosis or the administration of sodium amobarbital. After the shift from one personality to another, the client is aware of lost periods of time or experiences confusion about time. The client may be aware of voices (auditory hallucinations produced by one of the personalities) or may even see and talk to one or more of the other personalities (visual and auditory hallucinations).

The alternate identities can have proper names, names that have symbolic meaning or names that describe the function of that personality. Typically, the identities emerge under particular conditions and differ from one another in age, gender, speech, level of knowledge, and affect. They may deny the existence of one another, be critical of another identity, or be in conflict. Sometimes the personality that initiates treatment has little or no awareness of the existence of the other personalities. (See Observations That Can Be Made About the Alternate Personalities.)

The onset of dissociative identity disorder occurs in childhood, but most clients don't obtain treatment until they're adults This disorder is diagnosed more frequently in females than in males. Many clients have experienced severe child abuse and incest and are at risk for addiction disorders, depression, suicide, and violence directed at themselves and others. The tendency to demonstrate impulsive and self-mutilative behavior along with extreme changes in relationships may also indicate the presence of a borderline personality disorder.

Research indicates that the limbic system, hippocampus, and temporal lobes of the brain, interacting with certain neurotrans-mitters, are involved in dissociative disorders. The temporal lobes aren't only the brain's long-term memory storage areas but also connect emotions with experiences. The limbic system processes traumatic memories, and the hippocampus stores and categorizes information from these experiences. Scientists believe that the neurotransmitter serotonin plays a role in regulating emotions. The stress hormones cortisol and adrenaline are thought to influence functioning of the limbic system and the hippocampus

OBSERVATIONS THAT CAN BE MADE ABOUT THE ALTERNATE PERSONALITIES
General appearance Dress Jewelry Use of cosmetics Hairstyle Manner of speaking Intonation of voice Difference in conversational subjects Difference in nonverbal communication Affect Mood Behavior	Intellect Handwriting Strategies for coping Relationships Perceptions of others and the environment Awareness of different memories Awareness of time periods that can’t be accounted for Awareness of the presence of other personalities Use of different skills to manage the various personalities

COMMUNICATION STRATEGIES

• Focus on helping the client feel safe.
• Address and reinforce behaviors that are appropriate for the client's actual chronological age.
• Ask which personality is present when a switch occurs.
• Support and establish appropriate limits on the personalities.
• Identify the struggle between some of the personalities.
• Help the client control the presentation of the various personalities.
• Help the client develop awareness of the negative aspects of a self-destructive personality, and attempt to modify its influence whenever it has taken over.
• Encourage the client to explore feelings related to traumatic experiences.
• Talk about what can help the client control the trauma-related anxiety.

NURSING DIAGNOSIS: PERSONAL IDENTITY DISTURBANCE

Probable Causes	Defining Characteristics
Physical or sexual abuse during childhood History of no protection by adults Inadequate defenses for handling severe anxiety	Current situation characterized by multiple stressors Existence of more than one personality Change in person's demeanor when switching from one personality to another

Long-Term Goal The client will begin work that promotes integration of several personalities into one continuously/functioning personality.

Short-Term Goal #1: The client will develop an understanding of the relation between anxiety and dissociation.

Interventions and Rationales

• Persevere to establish a therapeutic relationship with the client Because of a history of abuse, the client finds it difficult to trust and depend on others: establishment of the trust relationship may take considerable effort and time.
• Help the client identify each existing personality.Knowledge ofeach personality enables the nurse to help the client work toward personality integration.
• Encourage the client to discuss how each personality meets particular needs. Each personality usually represents protection against painful, traumatic memories.
• Have the client begin to address past traumatic, anxiety-provoking situations. The client needs assistance to deal with the posttraumatic stress experiences.
• Help the client identify intense emotions that occur during severe stress. Working to identify emotions helps the client understand that feeling disoriented and extremely uncomfortable in stressful situations is a normal part of life.
• Slowly promote discussion with the client about intense feelings associated with past disturbing events.Proceeding siow.y with discussion of events that are extremely anxiety-producing prevents the occurrence of additional anxiety and client resistance.
• Teach the client how severe anxiety precipitates the transition from one personality to another.The client's awareness that anxiety provokes dissociation promotes the desire for more effective coping skills.

Short-Term Goal #2: The client will demonstrate the use of effective coping skills.

Interventions and Rationales

• Assess the client's current methods of coping, watching for self-destructive behavior.Self-mutilating behavior can occur when the client is dissociating: therefore, the nurse must ensure that the clients safety needs are meet.
• Instruct the client to use grounding techniques, such as finding a safe place, counting, and wrapping up in a blanket.Grounding techniques help a client stay in the present. A safe place helps protect the client against destructive impulses. Counting is a form of self-hypnosis that can allow an alternate personality with appropriate behavior to come forth. Blanket wrapping establishes external boundaries and a feeling of security.
• Work with the client to identify and begin to use alternative ways of handling stress, such as journaling, relaxation exercises, and seeking others to talk to.The development of new coping strategies helps the client replace ineffective ways of coping.
• Help the client identify the consequences of dissociating as a way to cope with stress.Awareness of behaviors that aren t effective enables the client to see the need. to select more useful ana functional methods of coping.

NURSING DIAGNOSIS: IMPAIRED VERBAL COMMUNICATION

Probable Causes	Defining Characteristics
History of childhood trauma Severe anxiety Lack of parents or caregivers who promoted verbalization Relationships difficult or nonexistent	Absence of eye contact Monosyllabic speech or refusal to speak Periods ofdisorientation or memory problems Inability to account for periods of dissociation

Long-Term Goal The client will express self through the use of appropriate verbal communication.

Short-Term Goal #1: The client will cooperate with the nurse in developing a treatment plan.

Interventions and Rationales

• Spend regularly scheduled time with the client for the purpose of establishing verbal contact.Regular contact helps the client feel accepted by the nurse. Sometimes clients view health care professionals as other authority figures who may also hurt them.
• Initiate conversations with the client about personal needs and the plan of care. Open discussions about the client's needs, treatment, and plan of care facilitate nurse-client interactions.
• Encourage the client to express or acknowledge anxiety-arousing emotions, such as hesitation, fear, and concern about rejection by others.Many clients/ear being rejected if they engage in self-disclosure about their abuse or dissociative identity disorder.
• Formulate a contract with the client that delineates the plan of treatment, the subpersonalities who will participate in the treatment, and the limits that will be placed on inappropriate behaviors.A contract can promote treatment, establish client boundaries, and serve as a strategy for helping the client stay safe.

Short-Term Goal #2: The client will express thoughts and feelings about past trauma and conflicts.

Interventions and Rationales

• Teach the client the need to identify, describe, and differentiate between each of the subpersonalities.As the client identifies each of the subpersonalities, information is obtained on the unresolved conflicts and trauma that facilitate dissociation.
• Make sure the therapeutic environment is free of distractions and stressors and poses no opportunities for the client to engage in self-destructive behavior.As the client talks about distressful situations and unsafe personalities, anxiety and self-destructive tendencies may escalate. The nurse must be vigilant in monitoring the client, especially when a self-destructive, risk-taking, hostile, or violent personality is present.
• Encourage the client to write down or draw thoughts and feelings in a daily journal. Journaling can help the client to express feelings, develop a sense of self and lessen the response to dissociative triggers.
• Help the client construct a "map" of each personality that indicates the age, function, associated traumatic event, and happenings while in that particular personality state.Mapping he:ps preserve the memories that are recalled through discussion while providing an opportunity for the client to describe what happens with each personality.
• Give the client support during the exploration and disclosure of feelings or discussion of traumatic events.It's difficult to deserve past trauma and the subpersonalities because the client may experience strong emotions and distress during the recall.
• Permit the client to discuss the recaptured memory at his own pace.Allowing the client to control the pace of memory recall prevents severe anxiety and overwhelming emotions.

THERAPIES

Most clients with dissociative identity disorder find both individual and Group Therapy essential for uncovering and sharing painful and repressed memories. Clients are helped to integrate the subpersonalities and supported in their efforts to develop appropriate responses to stressors rather than to resort to dissociation.

Individual Therapy

• Work with the client to understand sources of stress, discomfort, and presenting symptoms.
• Address ways for the client to stay safe and seek assistance when experiencing self-destructive impulses.
• Help the client change ineffective behaviors and develop appropriate ways to handle stressors and memories.
• Explore uncomfortable and sensitive client situations to enable the client to talk about events without excessive emotional expression.
• Help the client understand repressed emotions and how these feelings affect current behavior.
• Establish communication with the accessible subpersonalities.
• If appropriately trained, use hypnosis to uncover and explore the existence and characteristics of the separate subpersonalities.
• Develop a contract with the client that calls for help-seeking behavior if self-destructive urges arise.
• Determine the origin, functions, attitudes, relationships, and issues of each subpersonality.
• Work on identifying problems, and then develop and have the client practice manageable solutions.
• Encourage the client to verbalize the frustration connected with the need for long-term treatment.

Group Therapy

• Establish a setting in which concerns, problems, fears, and stressors can be discussed.
• Provide the client with support and assistance in dealing with issues of concern.
• Teach new and functional ways of coping with stressors.
• Help the client develop and sustain social contacts and social support.
• Reinforce all positive changes and accomplishments in activities of daily living.
• If appropriate for the client's recovery, promote integration of principles from the 12-step drug and alcohol program into the therapy.
• Maintain a mechanism for long-term follow-up care.

MEDICATIONS

Medication is not usually helpful in the treatment of dissociative disorders.

• Antianxiety drugs, such as clonazepam (Klonopin) and lorazepam (Ativan), may be prescribed for a short period. They are used to decrease anxiety to a level that facilitates the client's functioning and ability to participate in therapy.
• Antidepressant medication may be given to clients who are severely depressed and potentially suicidal.
• After securing consent, a psychiatrist may perform a sodium amobarbital (Amytal) interview with the client to obtain access to the client's repressed memories about traumatic situations. (See Appendix D for medication information.)

FAMILY CARE

• Teach the family about the disorder, treatment, and how to cope with the client's subpersonalities.
• Help the family understand that dissociation is a method of coping with severe stress.
• Encourage the family to be supportive of the client's treatment and need for long-term follow-up care.
• Inform family members about the need to maintain a safe and secure environment.
• Discuss with the family the client's potential difficulties, such as with relationships, social events, drug and alcohol use, occupational situations, authority figures, sexuality, and handling anxiety.
• Work with the family to support and reinforce any changes or progress that the client makes.
• Identify for the family the common symptoms of relapse.
• Help the family identify how to access help or initiate hospitalization if the client becomes self-destructive or unmanageable.
• Advise family members to obtain personal counseling to help them deal with the stress of living with a person with a chronic illness.
• Discuss the available community and family resources.