Dissociative Disorders

SAMIA MAZHAR
 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
 Dissociative Disorders
• Dissociation
– Some aspect of cognition or experience becomes inaccessible to
consciousness
• Avoidance response
– Some types of dissociation are harmless and common (e.g., losing track of
time)
• Sudden disruption in the continuity of:
– Consciousness
– Emotions
– Motivation
– Memory
– Identity
 Operational Definition of Dissociation
• In early life, certain thoughts, feelings, and/or actions of
the client are disapproved by significant other persons.
• Significant people’s standards are incorporated as the
client’s 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 client’s thoughts,
feelings, and actions.
 Four main kinds of Dissociative Disorders
• Dissociative Amnesia
• Dissociative fugue
• Dissociative Identity Disorder (DID)
• Depersonalization Disorder/De-realization Disorder
• Other Specified Dissociative Disorder
Transient global amnesia (TGA) is a temporary, anterograde
amnesia with an acute onset that usually occurs in middle-aged
and older individuals. It is often precipitated by particularly
strenuous activity, high-stress events, or coitus, but it can be seen
with migraines as well.
Footnotes from next slide
 Dissociative Amnesia
A. An inability to recall important autobiographical information, usually of a
traumatic or stressful nature, that is inconsistent with ordinary forgetting.
Note: Dissociative amnesia most often consists of localized or selective
amnesia for a specific event or events; or generalized amnesia for identity
and life history.
B. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a
substance (e.g., alcohol or other drug of abuse, a medication) or a
neurological or other medical condition (e.g., partial complex seizures,
transient global amnesia, sequelae of a closed head injury/traumatic brain
injury, other neurological condition).
D. The disturbance is not better explained by dissociative identity disorder,
posttraumatic stress disorder, acute stress disorder, somatic symptom
disorder, or major or mild neurocognitive disorder.
Coding note: The code for dissociative amnesia without dissociative
fugue is 300.12 (F44.0). The code for dissociative amnesia with
dissociative fugue is 300.13 (F44.1).
Specify if: 300.13 (F44.1) With dissociative fugue: Apparently purposeful
travel or bewildered wandering that is associated with amnesia for
identity or for other important autobiographical information.
• 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.
 Cont..
• 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.
Continuous amnesia occurs when the individual has no memory of events occurring after a particular event.
Patients forget each new event as it occurs. Unlike generalized amnesia, in continuous amnesia, the
individual is still aware of their surroundings.
 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)
A. Disruption of identity characterized by two or more distinct personality states, which
may be described in some cultures as an experience of possession. The disruption in
identity involves marked discontinuity in sense of self and sense of agency,
accompanied by related alterations in affect, behavior, consciousness, memory,
perception, cognition, and/or sensory-motor functioning. These signs and symptoms
may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/
or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better explained by imaginary playmates or
other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g.,
blackouts or chaotic behavior during alcohol intoxication) or another medical condition
(e.g., complex partial seizures).
The person with DID may have as few as two alters, or as many as 100. The average
 Depersonalization/Derealization Disorder

• Perception of self is altered

– Triggered by stress or traumatic event
– No disturbance in memory
– No psychosis or loss of memory
– Often comorbid with anxiety, depression
– Typical onset in adolescence
– Chronic course
• Symptoms are not explained by substances, another
dissociative disorder, another psychological disorder, or a
medical condition
 Depersonalization Disorder/De-realization Disorder
A. The presence of persistent or recurrent experiences of depersonalization, de-realization,
or both:
1. Depersonalization: Experiences of unreality, detachment, or being an outside observer
with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual
alterations, distorted sense of time, unreal or absent self, emotional and/ or physical
numbing).
2. De-realization: Experiences of unreality or detachment with respect to surroundings
(e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or
visually distorted).

B. The symptoms cause clinically significant distress or impairment in social, occupational, or

other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, medication) or another medical condition (e.g., seizures).
D. The disturbance is not better explained by another mental disorder, such as
schizophrenia, panic disorder, major depressive disorder, acute stress disorder,
 Other Specified Dissociative Disorder
• This category applies to presentations in which symptoms characteristic of a
dissociative disorder that cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning predominate but
do not meet the full criteria for any of the disorders in the dissociative
disorders diagnostic class. The other specified dissociative disorder category is
used in situations in which the clinician chooses to communicate the specific
reason that the presentation does not meet the criteria for any specific
dissociative disorder. This is done by recording “other specified dissociative
disorder” followed by the specific reason (e.g., “dissociative trance”).

• Examples of presentations that can be specified using the “other specified”

designation include the following:
1. Chronic and recurrent syndromes of mixed dissociative symptoms: This
category includes identity disturbance associated with less-than-marked
discontinuities in sense of self and agency, or alterations of identity or
episodes of possession in an individual who reports no dissociative amnesia.
 Cont..
1. Identity disturbance due to prolonged and intense coercive persuasion:
Individuals who have been subjected to intense coercive persuasion (e.g.,
brainwashing, thought reform, indoctrination while captive, torture, long-
term political imprisonment, recruitment by sects/cults or by terror
organizations) may present with prolonged changes in, or conscious
questioning of, their identity.
2. Acute dissociative reactions to stressful events: This category is for acute,
transient conditions that typically last less than 1 month, and sometimes
only a few hours or days. These conditions are characterized by constriction
of consciousness; depersonalization; derealization; perceptual disturbances
(e.g., time slowing, macropsia); micro-amnesias; transient stupor; and/or
alterations in sensory-motor functioning (e.g., analgesia, paralysis).
From foot notes
(Macropsia is a condition in which visual objects are perceived to be larger
than they are objectively sized. Macropsia can be a clinical feature of
migraine, stroke, or temporal, parietal, or occipital lobe epilepsy.)
• 4. Dissociative trance: This condition is characterized by
an acute narrowing or complete loss of awareness of
immediate surroundings that manifests as profound
unresponsiveness or insensitivity to environmental stimuli.
The unresponsiveness may be accompanied by minor
stereotyped behaviors (e.g., finger movements) of which
the individual is unaware and/or that he or she cannot
control, as well as transient paralysis or loss of
consciousness. The dissociative trance is not a normal part
of a broadly accepted collective cultural or religious
practice.
 Unspecified Dissociative Disorder
•
This category applies to presentations in which symptoms
characteristic of a dissociative disorder that cause clinically
significant distress or impairment in social, occupational, or other
important areas of functioning predominate but do not meet the
full criteria for any of the disorders in the dissociative disorders
diagnostic class. The unspecified dissociative disorder category is
used in situations in which the clinician chooses not to specify the
reason that the criteria are not met for a specific dissociative
disorder, and includes presentations for which there is insufficient
information to make a more specific diagnosis (e.g., in emergency
room settings).
 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.
 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.
 Neuro-circuit0ry System
• There is strong clinical evidence that indicates that the
amygdala is a central structure in the brain neuro-circuitry
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
 Neuro-circuit0ry System (cont..)
• Significant early traumatic experiences and the lack of
attachment have also been so 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. TLE
• 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 dynamic s 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.
 Treatment Modalities
• Pharmacologic
Interventions • Client Grounding
 Anxiolytic (benzodiazepines Techniques
PRN and maintenance dose)  Safe place
 Antidepressant  Ice in hands
 Neuroleptics (atypical  Wrapping self in blanket
antipsychotics)  Counting backward or
• Psychosocial interventions forward
 Intensive psychotherapy • Client Education
 Hypnosis  Relapse Prevention
 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.
 Therapeutic Management
• 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 person’s 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.
 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, somatic
therapies and discharge planning
Thank you