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Dissociative Disorder

nursing.advanceweb.com /Article/Dissociative-Disorder.aspx
By Darlene Galashaw, MSN, RN
From Our Print Archives
Vol. 5 Issue 16 Page 29
Dissociative Disorder
Psychiatric conditions can range from amnesia and fugue to multiple personality
By Darlene Galashaw, MSN, RN
It was a typical September afternoon on the inpatient behavioral health unit. Most of the patients were
occupied in the expressive writing group or in small informal groups with their primary nurse. The new
admission, Julie, had just arrived, escorted by the ED staff and security. She was a thin, somewhat fraillooking 24-year-old woman who was brought to the ED by a neighbor for "loud yelling and breaking
furniture" at home.
Julie did not keep eye contact with the behavioral health nurse (BHN), and she spoke in barely audible
whispers. The BHN inspected Julie's wrists and arms, which had superficial cuts and burns that were
suspected to be self-inflicted. Julie had no idea how her arms were injured.
During the suicide risk assessment, Julie suddenly began to speak loudly in a husky tone, with
masculine gestures and postures. She shouted, "Hey, stop all this nonsense and let me go home! She's
a fool for trying to get rid of us!" and continued with a string of profanities.
The patient claimed her name was "Robert" and did not recall how "he" arrived at the hospital, except
that Julie tried to commit suicide. Attempts by the BHN to redirect and calm the patient were
unsuccessful; the shouting and agitation continued. Additional staff was called to help administer an
intramuscular medication to sedate Julie. Throughout the process, the BHN communicated with empathy
and respect for Julie and her alter-personality, "Robert."
Dissociative Disorders Defined
Julie shows the classic symptoms of dissociative identity disorder, the most severe of the four psychiatric
illnesses grouped under the dissociative disorders spectrum (see Table).
While dissociative disorders occur in less than 2 percent of the United States population 1 they present a
challenge to BHNs who must use all their skills in assessment, management and continued care of these
patients.
Dissociative disorders can be viewed as an interruption of aspects of a person's fundamental waking
consciousness, including the person's surroundings, identity and memories. The series of dissociative
disorders range from minor to pathological.
A minor form, experienced by most people, can be described as "spacing out" or "daydreaming." 2
Midpoint on the continuum are reports of out-of-body or near-death experiences. Amnesia, and fugue
states and dissociative identity disorders are examples of the more pathological types of dissociation
that often require intervention.
Coping Mechanism
Dissociative disorders involve a complex psychosociological process, often with traumatic triggers. As

much as 90 percent of patients experiencing dissociative disorders have been identified as having been
abused as children.3
When researchers recognized dissociative disorders in the late 1800s, they identified them as a
repressive defense mechanism; and in 1953, Harry Stack Sullivan, MD, stated that anxiety reduction
was the primary purpose of dissociative disorders.
Continual exposure to overwhelming experiences, such as war, rape or other abusive events, without an
external comforter leads to life events being managed by dissociation. The patient literally dissociates
herself from a traumatic situation.
Patients experiencing trauma are torn between denying the terrible experience and wishing to proclaim it
to everyone. Dissociation helps the patient survive by escaping a terrible reality such as incest and other
sexual assaults. The disorder provides relief and time for the patient to gather resources to better cope
with the event.
Personality Connection
Many theories about the origin of dissociative disorders exist, and one of them relates to personality
development.
The life-long process of feeling, thoughts and actions is a major part of personality development. The
process includes the ability to observe the self and make judgments of interpersonal interactions.
According to Dr. Sullivan, the personality has three components: "good me," "bad me" and "not me." The
"good me" is that part of the self we are aware of and openly exhibit to others. Experiences that elicit
disapproval from significant people in our lives fall under the "bad me" component.
Intensely overwhelming experiences that occur with little if any support from significant others are the
"not me" components of the personality concept. The maturing personality discovers and brings to
conscious awareness the "not me" component of the self, and incorporating it with other experiences.
The mature personality develops the self as whole and continuous. The part of the personality
developed from the "not me," plays a role in dissociative disorders. Feelings, thoughts and emotions
related to the traumatic event are repressed so much that there is separation from the patient's
conscious awareness.
Other theories suggest neurological links to dissociative disorders. The limbic system processes
traumatic memories, and the hippocampus is responsible for storing and categorizing this information.
Major traumatic experiences in early childhood and the lack of attachment with a significant care
provider seem to have long-term effects on neurotransmitters, like serotonin. Serotonin is the
neurotransmitter directly related to emotions (affect). Patients with depression, anxiety and dissociative
disorders generally have lower levels of serotonin in their brain.
Diagnosis
A BHN's education and understanding of personality development can make a critical difference in the
diagnosis and care of the patient experiencing a dissociative disorder. Using the nursing process, the
BHN collects a careful history of the patient's personal milestones the first step in formulating a plan of
care.
Sudden onset of dissociative symptoms should cue the BHN to rule out possible medical causes.
Patients with a head injury, brain lesions, epilepsy or drug overdose often report the sensation of their
bodies not belonging to them. Long-term sleep deprivation and electrolyte imbalances also can
contribute to the symptoms of amnesia or identity disturbances.
In addition, patients with a dissociative disorder will often have multiple physical complaints. The BHN
must assess the patient's physical status, keeping in mind the possible history of childhood trauma and
the connection between the physical complaints. This phenomenon is called "body memories."
An assessment for abuse early in life is crucial, but such abuse is not easily identified since it is often
blotted out of the patient's memory. In Julie's case, the BHN first established a trusting relationship with

the patient, and then collaborated with the psychiatrist to elicit a sketchy history of childhood sexual
abuse.
Patients with dissociative identity disorders have dysfunctional patterns of attachments, due to their wish
for idealized protective parents. Julie's treatment team discovers that she was moved around among
maternal family members once her mother died.
Long-Term Therapy
Due to the complexity of dissociative disorders, the healing process often requires long-term
psychotherapy. Setting the framework for revealing the trauma (trauma work) is the most important part
of the therapy. BHNs in the inpatient setting are well-suited to this task because they can create a safe
and nurturing environment as they teach the patient about the illness.
Patients like Julie need to be assured of both environmental and personal safety, making the patient's
orientation to the inpatient unit and staff very important. The patient often will need to have a "safe
space" on the unit to use as a retreat when anxiety and flashbacks occur. For example, Julie benefited
from "time out" in her room during the hustle and bustle of shift change.
The BHN also helped her identify strategies to manage her feelings of abandonment.
One grounding technique is having a patient hold ice in her hands, which lets her focus on a
nondestructive physical sensation. Counting forward and backward is a method of hypnosis that allows
alter-personalities to change in a safe fashion. Teaching patients to wrap up in a blanket when a
dissociative episode begins just when they may feel like they are "falling apart" helps them set external
boundaries.
Ongoing Care
Julie's BHN encouraged her to write in a journal daily, especially after a dissociative episode. Julie and
her treatment team will review the journal to help identify trends and possible warning signs.
Because Julie experiences the dissociative identity type of disorder, she and her BHN will work toward
integrating her alter, "Robert." The nurse can start this process by teaching Julie that the alter is part of
her and is under her control. Julie also is taught to communicate her alter's needs to the staff, especially
his anger.
The nurse also should discuss the voluntary use of restraints, in which a patient will request time in
restraints when she feels unable to control her rage and may hurt herself or others. Reinforcing the
concept that all defense mechanisms serve a purpose may help Julie understand that her rage serves
as a protection from abuse. Julie will eventually learn to control her anger and use that energy in a more
positive way.
Most settings use restraints very gingerly with dissociative identity disorder patients due to the concern
about sexual abuse in their past. Education alerts the patient (and sometimes staff) about emotional and
behavioral cues prior to losing control and possible self-harm.
The BHN also will need to appeal to whatever strengths the patient may possess and encourage her to
participate in the unit's therapeutic groups and activities. Completing an art project and discussing some
of her most difficult moments with others can help increase Julie's confidence in herself as a
multifaceted person.
Medication & Psychotherapy
Individual and group sessions were just one part of the healing process for Julie. She is able to maintain
employment and develop friendships while she continues to work with her BHN. Biweekly visits help
Julie work on concrete issues like managing her emerging "alters" when under stress. As trust in her
abilities further develops, Julie and her BHN may decide on monthly clinical sessions.
Like many patients diagnosed with a dissociative disorder, Julie had persistent feelings of anxiety, and
medications like lorazepam (Ativan) or clonazepam (Klonopin) were prescribed to help reduce these

symptoms.
Depression, anger and psychotic thinking are further managed with the use of antidepressants and
neuroleptics. The BHN teaches the patient and family about these medications, food-drug interactions
(especially if monoamine oxidase inhibitors are prescribed) and possible side effects.
Patients diagnosed with a dissociative disorder will need intense psychotherapy, which may be provided
by an advanced practice nurse on an outpatient basis. There also may be times when the patient's
symptoms become acute and the patient needs to be admitted to the inpatient setting. Because of
insurance coverage, the healthcare team needs to admit and discharge these patients as soon as the
patient is safe so that their stays aren't too long.
Patients diagnosed with a dissociative disorder may have difficulty locating an outpatient therapist due to
ongoing controversy about the diagnosis. In professional journals, there have been reports of the
ongoing exchange about the belief psychiatrists have related to this group of disorders.4 There are
groups of physicians who ascribe to the "false memory syndrome" school, which states the patients are
influenced to recall dramatic imagined memories of abuse. If the patient is led to believe there was an
event, under stressful situations, it causes them to exhibit symptoms of dissociative disorders.
In either case, it is a nurse who has education and expertise in behavioral health and serves as an
integral part of the healthcare team who patients living with a dissociative disorder come to trust and rely
upon.
References
1. Maser, J. D. (2000). Dissociative disorders. Arlington, VA: National Alliance for the Mentally Ill.
2. Meares, R. (1999). The contribution of Hughlings Jackson to an understanding of dissociation.
American Journal of Psychiatry, 156(12), 1850-1855.
3. Simeon, D.; et al. (2002). Personality factors associated with dissociation: temperment, defenses, and
cognitive schemata. American Journal of Psychiatry, 159(3), 489-491.
4. Frankel, S., & Span, S. (2000). Psychiatrist's attitudes toward dissociative disorder diagnoses.
American Journal of Psychiatry, 157(7),1179.
Resources
Antai-Otong, D. (2002). Culture and traumatic events. Journal of the Amercan Psychiatric Nurses
Association, 8, 203-208.
Gallop, R. (2002). Failure of the capacity for self-soothing in women who have a history of abuse and
self-harm. Journal of the American Psychiatric Nurses Association , 8, 20-26.
Simeon, D., et al. (2002). The role of childhood interpersonal trauma in depersonalization disorder.
American Journal of Psychiatry, 158(7), 1027-1033.
Darlene Galashaw is director of Behavioral Health Nursing at Lutheran Medical Center, Brooklyn, NY.

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