Dissociative

Disorders
VIZMARC V. SANTOS, RN
Clinical Instructor
CIT – U| - Nursing
Dissociative Disorders
• Dissociation - Removal from
conscious awareness of painful
feelings, memories, thoughts, or
aspects of identity
• Mainly characterized by disturbance in
identity, memory, or consciousness
• Precipitated by extreme stress or
trauma
Dissociative Disorders
• Types:
• Dissociative Amnesia
• Dissociative Fugue
• Dissociative Identity Disorder
Dissociative Amnesia
• Amnesia- loss of memory or inability to recall
important personal information
ANTEROGRADE RETROGRADE

Inability to form Inability to recall

new memories memories before
after onset of amnesia
amnesia
Dissociative Amnesia
• Characteristics:
• One or more episodes of the inability to recall
important personal information that is beyond
ordinary forgetfulness
• Lost information is usually stressful or traumatic in
nature
• (+) wandering, disorientation, confusion
• Psychosocial stressors: threat of physical injury or
death
Dissociative Amnesia
• Nursing Diagnoses:
• Impaired memory
• Ineffective coping
• Goals:
• Help the person to remember forgotten or traumatic
events in a controlled way & to accept & integrate
them
• Resolve distressing situations
• Strengthen coping skills
Dissociative Amnesia
• Interventions:
• Involvement of family member/significant other
to remember what happened
• Trauma work (CISM)
• Hypnosis
Dissociative Fugue
• Characteristics:
• Sudden, unexpected travel away from home or some
other location with the assumption of a new identity or
a confusion about one’s identity
• (+) amnesia
• Unable to recall events during fugue state
Dissociative Fugue
• Characteristics:
• Psychosocial stressors: marital quarrels, personal
rejections, military conflict, natural disasters, financial
difficulty, and suicidal ideation
• Nursing Diagnoses:
• Risk for injury
• Impaired memory
• Ineffective coping
Dissociative Fugue
• Interventions:
• Fugue states usually end rather abruptly on their
own
• Supportive psychotherapy to help person
identify & resolve stressors leading to fugue
state and to learn better coping skills, so that
fugue does not happen again
Dissociative Identity
Disorder (D.I.D.)
• Existence of two or more personalities that
take control of the person’s behavior
• Host- original personality
• Alters- dissociative personality/-ies
• Precipitated by abuse (Sexual)
Dissociative Identity
Disorder (D.I.D.)
Host Alter/s
- Initially, unaware of the existence of - Has an awareness of the existence
alters of alter/s
- Experiences amnesia while alter/s - Each has its own name, behavior
take/s over traits, memories, emotional
characteristics, and social relations
- Represents fragments of the host’s
sense of identity with different identity
states remembering distinct
information
Dissociative Identity
Disorder (D.I.D.)
• Management- Milieu:
Psychotherapy
• Long- term, intensive, out- patient
• Directed toward uncovering the underlying psychological
conflicts, helping him or her gain insight into these
conflicts, and striving to synthesize the various identities
into one integrated personality.
Dissociative Identity
Disorder (D.I.D.)
• Management- Milieu:
• Psychotherapy
• Abreaction – mental re-experience of trauma/abuse that caused
the illness
• Integration – blending of all personalities into one
• Identify each personality, and its function, roles, & concerns
• Negotiate with personalities to fuse into 1 personality
• Hypnosis may be used to look into each personalities
• Hospital admission – recommended when an aggressive or
suicidal alter is in a dominant role
Dissociative Identity
Disorder (D.I.D.)
• Management- Psychopharmacology:
• Anxiolytics, as ordered – used if client becomes hostile
• Anti-depressants, as ordered – controls anxiety
Dissociative Identity
Disorder (D.I.D.)
• Management- Nursing:
• Establish trust and support
• Facilitate physiologic and neurology work ups to rule out
organic causes
• Assist in slowly helping patients deal with anxiety and
conflicts in their lives and improve coping skills
Dissociative Identity
Disorder (D.I.D.)
• Management- Nursing:
• Treat an adult patient as an adult even if an alter is a child
• Be consistent with approach to develop a caring and supportive
environment
• If patient has suicidal tendencies, facilitate initiation of no- harm
contract
• If patient becomes aggressive, deal with aggression while
observing the principle of least restrictive treatment
Dealing with Aggressive Patients
• Ensure scene safety, when in doubt do not act alone
• Attempt verbal de-escalation - use a calm, firm voice
• Direct the patient to take a voluntary time-out in a quiet area
• Inform the patient aggressive behavior is not acceptable
• Offer PRN medications to help the patient return to a calm state
(e.g., Lorazepam)
• Provide a “show of force/strength” - gather 4-6 team members to
remain in sights with patient interactions
Dealing with Aggressive Patients
• If the patient continues to escalate to violent behavior, these staff
will help to ensure safety should restraints and/or seclusion become
necessary
• Use of restraint and/or seclusion per institutional policy.
• Debrief: Ask the patient about any triggers and alternatives to avoid
future patient violent behavior; hold a debriefing session for all
involved staff to discuss elements of the situation that were handled
well, needed improvement, and any ideas to enhance defusing.