Dissociative

Disorders
Ma. Tosca Cybil A. Torres, RN
 Key terms:

ALTERS. A distinct identity with its own enduring pattern of perceiving, relating to,
and thinking about the world and the self.
DISSOCIATION. The separation of thoughts, feelings, or experiences from the
normal stream of consciousness and memory.
DISSOCIATIVE DISORDERS. A continuum of disorders experienced by individuals
exposed to trauma, including depersonalization disorder, dissociative amnesia,
dissociative fugue, and dissociative identity disorder. This disorders involve a
disturbance in the organization of identity, memory, perception, or
consciousness.
SECONDARY GAIN. Attempting to earn the sympathy of others, receiving financial
gain, or obtaining other benefits by suffering from a disorder.
SWITCHING. The process in which one alter is changed into another.
TRAUMA. An event that results in long-standing distress to the individual
experiencing that event.
PERSONALITY. Enduring patterns of perceiving, relating to, and thinking about the
world and oneself.
In early life, certain thoughts, feelings, and/or actions of the client
are disapproved by significant other persons.

Significant peoples standards are incorporated as the clients own.

Later in life, the client experiences one of the disapproved thoughts,

feelings, or actions.

Anxiety increases to a severe level.

The feelings are barred from awareness.

Anxiety decreases.

Dissociated content continues to appear in disguised form in the

clients thoughts, feelings, and actions.
 Epidemiology
Dissociative disorders are prevalent
around the world and often occur with
other psychiatric disorders such as
depression, post-traumatic stress
disorder, substance use disorders, and
borderline personality.

6 percent of the general population

suffers from high levels of dissociative
symptoms. (Mulder, Beautrais, Joyce
and Fergusson, 1998)

Empirical data support the relation

between trauma and dissociation,
particularly adult and childhood
trauma stemming from sexual and
physical abuse.
 Causes
Dissociative disorders usually
develop as a mechanism for coping
with trauma. The disorders most
often form in children subjected to
chronic physical, sexual or
emotional abuse or, less frequently,
a home environment that is
otherwise frightening or highly
unpredictable.
Personal identity is still forming
during childhood, and during these
malleable years a child is more able
than is an adult to step outside
herself or himself and observe
trauma as though it's happening to a
different person. A child who learns
to dissociate in order to endure an
extended period of his or her youth
may reflexively use this coping
mechanism in response to stressful
situations throughout life.
Rarely, adults may develop
dissociative disorders in response to
severe trauma.
 Interpersonal Theory and Personality
Development
A significant part of personality
development is the lifelong process of
assimilating (thoughts, feelings, and
actions) and using the assimilated
product (understanding) to observe
the self and make judgments of
present-day interpersonal interactions.

In Sullivans theory of personality

development, the personality is
conceptualized as a self-system that
consists of three mutually interacting
aspects: GOOD ME, BAD ME and
NOT ME.
 The GOOD-ME Aspect

This good-me aspect of the

self-system consists of
experiences from infancy on
that soothing and indicative
of approval and acceptance
by a significant other.
The BAD-ME Aspect

Experiences that elicit

disapproval from significant
others and result in a high
degree of anxiety for a person
constitute that part of the self-
system known as bad me. This
aspect of the personality is
available to a persons
conscious awareness, but
defense mechanisms (e.g.
splitting or sublimation) are
used in an effort to control the
internal anxiety experience.
 The NOT-ME Aspect
Experiences that are
intensely overwhelming
and elicit little or no
soothing from
significant other are
relegated to the not-me
aspect. This aspect of
the self is kept in the
unconscious; that is,
dissociated.
BIOLOGICAL FACTORS
There is growing evidence of the
role of trauma on intricate
neurobiological and
neuroanatomical structures in
dissociative disorders. Early
childhood trauma, witnessing
or exposure to traumatic or
violent incidents, apparently
has the potential to produce
enduring alterations on brain
chemistry, neuroendocrine
processes,
and memory.
 Neurocircuitry System
There is strong clinical
evidence that indicates that
the amygdala is a central
structure in the brain
neurocircuitry and plays a
pivotal role in conditioned or
(learned) fear responding.
Dysregulation of the amygdala
or the hippocampus, or both,
results in poor contextual
stimulus discrimination
(misinterpretation) and leads
to overgeneralization of fear
responding cues.
 Because the limbic system is where memories
are processed, early trauma experiences will
remain unassimilated to the degree the stress of
detachment affected the limbic system.
Significant early traumatic experiences and the
lack of attachment have also been
demonstrated to have long-term effects on
neurotransmitters, especially serotonin, which
has been identified as a primary
neurotransmitter involved in the regulation of
affect.
Clients with dissociative disorder often present
with a multitude of somatic complaints. The
somatic complaints may be representative of a
memory laid down along primitive neurological
pathways that is being stimulated by something
in the current environment.
 Prolonged sleep deprivation, fever, and
hyperventilation can present with symptoms of
amnesia, depersonalization, or identity
disturbance.
Clients with head injuries, seizure disorders, or
brain lesions can present with symptoms of
dissociation.
In the nineteenth century, Charcot and others
attributed dissociative processes to various
forms of epilepsy involving the temporal lobe.
Research on stress and trauma has also
demonstrated altered limbic system function in
response to chronic stress, with concurrent
suppression of hypothalamic activity and
dysregulation of the neurocircuitry systems.
The Role of Family
Dynamics
The role of family dynamics in
the dissociative process is
highly potent for the child
experiencing trauma such as
physical or sexual abuse.
Personality development in the
child is fostered by the family
and is initially concentrated in
the mother-child interaction.
 In an incestuous family, little, if
any, protection or soothing
occurs. The members of the
family experiencing incest are
usually closed, not only to each
other, but also to the outside
world.
A child may react to her
incestuous family by defensively
detaching the abandoning
parent.
Incestuous families often deny
they have problems.
Family dynamics around the
abused child leave her with a
rigid perception of
interpersonal roles.
Cultural Considerations
Trance states of
amnesia, emotional
lability and loss of
identity, though not
necessarily perceived
as normal, may be
generally accepted as
part of socio-cultural
context and religious
practice.
 Dissociative Disorders Across the Life Span
Childhood
Dissociation is an early primitive defense mechanism available to children
until they mature and gain greater psychological capacity to accommodate
ambiguity and tolerate conflict. Putman (1997) labeled this a normative
dissociation.

A child with a dissociative disorder is most likely to have a history of early

sexual or physical abuse and has not been able to develop attachment
because of the absence of empathetic parenting.

Children with dissociative disorders can manifest mild-to-moderate

inattention and sustained concentration deficits on psychological testing.

Common behavioral features: Amnesia, or forgetting test responses;

staring, indicative of trance states; unusual or odd motor behaviors; fearful
and angry reactions to stimuli; expressions of internal conflict.
Adolescence
 Adulthood
The adult with a dissociative
disorder frequently goes
undiagnosed or is misdiagnosed:
The person, having grown up in a
chaotic family, may not know that
losing time is an abnormal
experience.
Some adults may be in the mental
health system for years being
treated for depression, and the
dissociation becomes evident only
after a triggering event.
Adult men with undiagnosed
dissociative disorders end up
incarcerated in prison because of
aggressive behaviors.
Four main kinds of Dissociative
Disorders
Dissociative Amnesia
Dissociative Amnesia
This disorder is characterized by a blocking out of critical personal information,
usually of a traumatic or stressful nature because emotional conflicts or external
stressors. The onset is sudden. There is sudden identity disturbance, awareness
of memory loss and is alert before and after. PE is normal. May experience
secondary gain. Dissociative amnesia, unlike other types of amnesia, does not
result from other medical trauma

Subtypes:
Localized amnesia is present in an individual who has no memory of specific
events that took place, usually traumatic. The loss of memory is localized with a
specific window of time. For example, a survivor of a car wreck who has no
memory of the experience until two days later is experiencing localized amnesia.
Selective amnesia happens when a person can recall only small parts of
events that took place in a defined period of time. For example, an abuse victim
may recall only some parts of the series of events around the abuse.
Generalized amnesia occurs when patients cannot remember anything in their
lifetime, including their own identity.
Continuous amnesia occurs when patients have no memory of events up to
and including the present time. This means that patients are alert and aware of
their surroundings but are not able to remember anything.
Systematized amnesia is characterized by a loss of memory for a specific
category of information. A person with this disorder might, for example, be
missing all memories about one specific family member.
Dissociative Fugue
Dissociative fugue

An individual with dissociative fugue suddenly

and unexpectedly takes physical leave of his or
her surroundings and sets off on a journey of
some kind in desire to withdraw form
emotionally painful experiences
The onset is sudden
These journeys can last hours, or even
several days or months.
Individuals experiencing a dissociative fugue
have traveled over thousands of miles.
An individual in a fugue state is unaware of or
confused about his identity, and in some cases
will assume a new identity
Dissociative Identity Disorder (DID)
Dissociative Identity Disorder (DID)
This condition, formerly known as multiple personality disorder,
is characterized by "switching" to alternate identities when under
stress.
Caused by severe childhood trauma and severe sexual abuse
The onset is insidious
a dissociative disorder involving a disturbance of identity in which
two or more separate and distinct personality states (or identities)
control the individual's behavior at different times. When under the
control of one identity, the person is usually unable to remember
some of the events that occurred while other personalities were in
control.
The different identities, referred to as alters, may exhibit
differences in speech, mannerisms, attitudes, thoughts, and gender
orientation.
The alters may even differ in "physical" properties such as
allergies, right-or-left handedness, or the need for eyeglass
prescriptions. These differences between alters are often quite
striking.
The person with DID may have as few as two alters, or as many as
100. The average number is about 10.
Depersonalization Disorder
Depersonalization Disorder

a dissociative disorder in which the sufferer is affected by

Depersonalization
persistent or recurrent feelings disorder is marked by a feeling
of depersonalization and/or
of detachment
derealization. or distance from one's own
experience, body, or self. These feelings of
Brought by overwhelmingare
depersonalization feelings aboutOfa the
recurrent. current event
dissociative
similar disorders,
to a past traumatic event
depersonalization is the one most easily
The onset is rapid
identified with by the general public; one can easily
The symptoms
relate to include
feeling as they inofaautomation,
a sense dream, or beinggoing"spaced
throughout."
the Feeling
motionsout of control
of life but not of one's actions
experiencing and
it, feeling
movements
as though one is in isa something
movie, feeling thatas people describe
though one is in when
a
dream,intoxicated. An individualfrom
feeling a disconnection with one's
depersonalization
body, out-of-
disorder has
body experience, this experience
a detachment fromsoone's
frequently
body, and so
severely
environment andthat it interrupts
difficulty relatinghisoneself
or her functioning
to reality. and
For all,experience.
it is a ratherAdisturbing
person's experience
illness, since with
many feel that
depersonalization can
indeed, they are living in a "dream". be so severe that he or she
believes the external world is unreal or distorted.
They feel separated from themselves or outside their own
bodies.
People with this disorder feel like they are "going crazy"
and they frequently become anxious and depressed.
 Treatment Modalities
Pharmacologic Risk factorsClient Grounding
Interventions Techniques
Anxiolytic Safe place
(benzodiazepines PRN
and maintenance dose) Ice in hands

Antidepressant Wrapping self in

blanket
Neuroleptics (atypical
antipsychotics) Counting
backward or
forward
Psychosocial Client Education
interventions
Relapse
Intensive psychotherapy Prevention
Hypnosis Journaling
Therapeutic Management
Psychotherapy is the primary treatment for dissociative disorders. This form of
therapy, also known as talk therapy, counseling or psychosocial therapy, involves
talking about the disorder and related issues with a mental health professional. It
often involves techniques that helps remember and work through the trauma that
triggered the dissociative symptoms. The course of psychotherapy may be long
and painful, but this treatment approach often is very effective in treating
dissociative disorders.
Creative art therapy. This type of therapy uses the creative process to help
people who might have difficulty expressing their thoughts and feelings. Creative
arts can help increase self-awareness, cope with symptoms and traumatic
experiences, and foster positive changes. Creative art therapy includes art,
dance and movement, drama, music and poetry.
Cognitive therapy. This type of talk therapy helps identify unhealthy, negative
beliefs and behaviors and replace them with healthy, positive ones. It's based on
the idea that the persons own thoughts not other people or situations
determine how they behave. Even if an unwanted situation has not changed, it
can change the way they think and behave in a positive way.
Medication. Although there are no medications that specifically treat dissociative
disorders, the doctor may prescribe antidepressants, anti-anxiety medications or
tranquilizers to help control the mental health symptoms associated with
dissociative disorders.
 The Role of the Nurse

The Generalist Nurse- identifies

undiagnosed dissociative disorder
to help the client develop adaptive
skills and achieve symptom
management including appropriate
medications; continual assessment
of the clients level of danger to self
and to others throughout the
treatment.
The Advanced-Practice
Psychiatric Registered Nurse-
encourages the client in a
psychotherapy or cause
management process, continual
assessment of clients safety
 The Nursing
Process
Assessment- early
recognition of school
failure/ childhood abuse like
startle reaction, erratic
sleep, fear objects or other
people, pattern of not
remembering events,
pattern of unexplained
behaviours; repeatedly
seek medical help for
problems with no organic
basis
 Possible NDx
Disturbed personal Identity
Ineffective individual coping:
escape through dissociation
Anxiety sever R/T acute
stressor
Risk for self-directed violence
Altered sleep/ arousal
patterns
Long-term/ short-term memory
loss
Altered feeling patterns
Altered social interactions
Hopelessness
Powerlessness
Spiritual Distress
 Implementation
The client should experience a form of
support that has been missing in her life
intervention should be flexible emphasizing
consistency and predictability
remind the alter that is present that the
entire client is being treated
encourage the client to write a journal
Standards of nursing care should include
psychotherapy intervention, therapeutic
milieu, health teaching, ADL, somatic
therapies and discharge planning
 Evaluation
Focuses the effectiveness of the
NCP, must be a mutual affair and
based on behavioral data
MOVIE ANALYSIS