Pathophysiology
Dissociative disorders are the common result of many traumatic or stressful situations and often develop as a way of avoiding difficult memories. Some clients report a feeling of being outside of the body, or watching their life from a distance. Others experience a memory gap and present with various identities. People who have experienced physical, sexual, or emotional abuse during childhood are at a higher risk of developing dissociative disorders. These clients may also be more likely to attempt suicide or self-destructive behaviors.
Etiology
Diagnostic Criteria:
See chart below for specific diagnostic criteria for each disorder according to the DSM-V. These symptoms are not due to substance use / abuse or another medical condition and cannot be better explained by another mental disorder.
| Dissociative Amnesia |
Dissociative Identity Disorder |
Depersonalization – Derealization Disorder |
Other Specified Dissociative Disorder (formerly DD-NOS) |
- Localized/selective amnesia
- Significant distress or functional impairment
- Bewildered wandering
|
- Two or more distinct identities
- Recurrent gaps in memory
- Behaviors are outside “normal” cultural or religious practices
|
- “Out of body experience”
- Surroundings may seem foggy or dreamlike.
- Reality testing remains intact
|
- Recurrent episodes
- Client experienced traumatic coercive persuasion (brainwashing, torture, long-term imprisonment)
- Symptoms are brief
- Trance-like state or unresponsive to stimuli
|
Desired Outcome
Client will remain safe; client will have optimal functioning during social and daily routine activities; client will identify stressors and triggers for dissociative behaviors or reactions
Dissociative Disorders Nursing Care Plan
Subjective Data:
- Memory loss
- Feeling of being detached
- Feeling of surroundings being foggy or dreamlike
- Inability to cope with emotional or social stress
- Suicidal thoughts
- Depression
Objective Data:
- Anxiety
- Distant or reclusive behavior
- Erratic or chaotic behavior
- Unresponsiveness to environmental stimuli (sound, smell, temperature, etc.)
Nursing Interventions and Rationales
- Perform complete nursing and neurological assessment. Note any signs of self-mutilation or previous suicide attempts
Get a baseline of data and help determine neurological status. Also rules out underlying physiological cause of symptoms.
- Assess for any suicidal or homicidal ideations
To provide for client safety and the safety of others
- Set limits for inappropriate behaviors
Clients may act chaotic or erratic. Setting limits and consistently maintaining boundaries reinforces routine and reality .
- Provide care with calm and positive, respectful attitude
Negativity or hostility can trigger hostile reactions or manipulative behaviors.
Gaining the client’s respect and trust helps facilitate care.
- Encourage client to talk about their life, their past and their interests
Helps identify specific areas of avoidance or infatuation that may pose as stress triggers for behaviors
- Provide support and encouragement during recollection of past traumatic experiences
Build rapport and trust to help the client work through the difficult emotions and circumstances that they may have been avoiding
- Administer medications as needed appropriately
While there are no medications for these specific disorders, many clients have other mental illnesses or conditions that exacerbate symptoms such as depression and anxiety. Some medications may be used for chaotic or erratic behaviors and are given on a PRN basis.
- Provide teaching to family members and encourage their support in dealing with client’s symptoms
Clients often feel isolated in regards to their past experiences. Incorporating a family support system helps the progression and effectiveness of treatment
- Provide appropriate, temporary use of restraints or lock-down facilities as necessary
Keep clients safe from harm during gaps or changes in personalities. Prevent clients from wandering into dangerous areas .
- Monitor skin integrity when using restraints or for clients with suicidal ideations
Clients may develop self-destructive behaviors during treatment.
Improper or extended use of restraints can cause skin breakdown.
- Provide resource information for continued long-term psychotherapy and counseling
Help client with long-term treatment and give information to help client continue managing symptoms.
References
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
