DISSOCIATIVE DISORDERS

INTRODUCTION:
Dissociation is the mechanism that allows our mind to separate certain
memories from conscious awareness. The individual with dissociative disorder
uses dissociation as an unconscious defense mechanism to separate anxiety-
provoking feelings and thoughts from the conscious mind.

DEFINITION:

-Dissociation disorder is a condition characterized by disturbance in

the ordinarily organized functions of the conscious awareness, memory and
identity.

(OR)

-Dissociative disorder are marked by disruption of the fundamental

aspects of waking consciousness- memory ,identity, consciousness, and the general
experience and perception of oneself and the surroundings .

EPIDIMIOLOGY:

-Dissociative syndromes are statistically quite rare, but when they do occur they
may present very dramatic clinical pictures of severe disturbances in normal
personality functioning.

-Dissociative amnesia is relatively rare, occurring most frequently under conditions

of war or during natural disasters.

-It appears to be equally common in women and men (sadock&sadock 2007).

-Dissociative amnesia can occur at any age but it is difficult to diagnose in children
because it is easily confused with inattention or oppositional behavior.

-Dissociative identity disorder occurs from 3 to 9 times more frequently in women

than men, and onset likely occur in childhood, although manifestations of the
disorder may not be recognized until much later (APA, 2000).

-The prevalence of severe episodes of depersonalization disorder is unknown,

although single brief episodes of depersonalization may occur at some time in as
many as half of all adults, particularly in the event of severe psychosocial stress
(APA, 2000).

ETIOLOGY:

GENETICS:

-It is more common in first –degree relatives of people with

disorder than in general population.

NEURO BIOLOGICAL THEORY:

- Clinicians have suggested a possible correlation between

neurological alteration and dissociative disorder.

- It is possible that dissociative amnesia and dissociative fuge may

be related to neurophysiological dysfunction. Areas of the brain that have been
associated with memory include the hippocampus, amygdale, fornix, mammillary
bodies, thalamus and frontal cortex.

PSYCHOLOGICAL /PSYCHODYNAMIC THEORY:

-According to psychological theories, dissociative disorders are

response to severe trauma or abuse. To cope with the trauma or abuse the patient
tries to repress the unpleasant experience from awareness. If repression fails,
dissociation occurs as a defense mechanism. The patient separates the experience
from the conscious mind because it’s too traumatic to integrate it.

BEHAVIORAL THEORY:

- According to this theory, dissociative symptoms are learned

responses in the face of stress. For the first time, the symptom may be learned from
the surrounding environment (eg.seeing a paralyzed patient). These symptoms
bring about psychological relief by avoidance of stress.

LEARNING THEORY:

- According to learning theory, dissociative disorders represent a

learned response avoiding stress and anxiety with opportunity and practice. A
person can highly skilled at dissociating. This learned behavior of forcing the
memory from awareness is common in people with a history of abuse.

CLINICAL FEATURES:

These disorders are characterized by the following clinical

features.

1. Disturbance in the normally integrated functions of consciousness, identity

and / or memory.
2. Onset is usually sudden and the disturbance is usually temporary. Recovery
is often abrupt.
3. Often this is a precipitating stress before the onset. There is a clear temporal
relationship between the stressor and the onset of the illness. A frequently
stressful situation is an ongoing war.
4. A secondary gain resulting from the development of symptoms may be
found.
5. Detailed physical examination and investigations do not reveal any
abnormality that can explain the symptoms adequately.

TYPES OF DISSOCIATIVE DISORDERS:

The common clinical types of dissociative disorders are:

1. Dissociative amnesia
2. Dissociative fugue
3. Multiple personality (dissociative identity ) disorder
4. Trance and possession disorder
5. Other and possession disorders.

1. DISSOCIATIVE AMNESIA:

- Most common clinical type of dissociative disorder.

- occurring mostly in adolescent and young adults (females

more than males, except in war), it is characterized by a sudden inability to recall
important personal information (amnesia), particularly concerning stressful or
traumatic life events.
 - The amnesia cannot be explained by everyday forgetfulness
and there is no evidence of an underlying medical illness.

- Most often, dissociative amnesia follows traumatic or

stressful life situations. Sometimes imagined stressors or expression of forbidden
impulses may also precipitate the onset of amnesia.

- During the amnestic period, there may be slightly clouding

of consciousness. In the post amnestic period, the awareness of disturbance of
memory is present.

TYPES OF AMNESIA:

1. Localized/circumscribed amnesia
2. Selective amnesia
3. Continuous amnesia
4. Generalized amnesia
5. Systematized amnesia

1. LOCALIZED /CIRCUMSCRIBED :( COMMONSET TYPE):

The inability to recall all the personal events during a circumscribed

period of time usually corresponding with the stressor.

Ex: the individual cannot recall events of the automobile accident and events
occurring during a period after the accident (a few hours to a few days).

2. SELECTIVE AMNESIA(LESS COMMON):

This is similar to circumscribed amnesia but this is an inability to

recall only some selective personal events during that period while some other
events during the same period may be recalled.

E.g.: the individual may not remember events to the impact of the accident but
remember taken away in the ambulance.

3. CONTINUOUS AMNESIA (RARE):

There is an ability to recall all personal events following the

stressful event, till the present time.
E.g.: the individual cannot remember events associated with the automobile
accident and anything that has occurred since.

4. GENERALIZED AMNESIA (VERY RARE):

There is an inability to recall anything that has happened during the

individual’s entire lifetime including personal identity.

5. SYSTEMATIZED AMNESIA:

With this type of amnesia, the individual cannot remember events

that relate to a specific category of information (e.g. One’s family) or to one
particular person or event.

2. DISSOCIATIVE FUGE:

-Dissociative /psychogenic fuge is a sudden, unexpected travel

away from home or work place, with the assumption of a new identity and an
inability to recall the past.

-The onset is usually sudden, often in the presence of severe stress.

- The termination too is abrupt and is followed by amnesia for the

episode, but either recovery memories of earlier life.

- The characteristic feature is the assumption of a purposeful new

identity, with absence of awareness of amnesia.

-An important differential diagnosis is from fugue states seen in

complex partial seizures or temporal lobe epilepsy. In complex partial seizures,
there is no assumption of a new identity, confusion or disorientation is present
during the episode and the episodes are not only linked to any precipitating stress.

3. MULTIPLE PERSONALITY (DISSOCIATIVE IDENTITY DISORDER):

- In this type, the person is dominated by two or more personalities,

of which only one is being manifest at a time.

-These personalities are usually, different at times even opposing.

Each personality has a full of higher mental functions, and performs complex
behavior patterns.
 - Usually one personality is not aware of the existence of the others.
(i.e.) there are amnesia barriers between the personalities.

- Both the onset and termination of control of the each personality is

sudden.

4. TRANCE AND POSSESSION DISORDERS:

- Trance and possession disorders (possession hysteria) are

characterized by the control of person’s personality by a ‘spirit’, during the
episodes.

- Usually the person is aware, of the existence of the other (i.e.

Possessor) unlike in multiple personality.

-This disorder is very commonly seen in India and certain African

countries.

5. OTHER DISSOCIATIVE DISORDERS:

- Ganser’s syndrome (hysterical pseudo dementia) is commonly

found in prison inmates.

-The characteristic feature is “vorbeireden” giving approximate

answers to questions. The term approximate answers denotes answers to simple
questions that are plainly wrong, but are clearly related to the correct answers in a
way that suggest that the latter in known.

E.g. when asked to add three and three a patient night answer seven and when
asked four and five might answer ten; each answer is one greater than the correct
answer.

-Hallucinations are usually visual and may be elaborate.

DIAGNOSIS:
- Rule out physical disorders and substance abuse

- Standard tests including the dissociative experiences scale and dissociative

disorders interview schedule to demonstrate presence of dissociation.

- ICD 10 criteria
TREATMENT:

1. Behavior therapy

Since the patients with dissociative disorders can be attention seeking and their
symptoms increase with focus of attention, the symptoms should not be unduly
focused on. These patients should be treated as normals, and not given a sick role.
Any improvement in symptomatology should be actively encouraged.

Since these patients can also very suggestible, they respond quickly to the above
stated methods, with a consistently firm but empathetic attitude.

When there is a sudden, acute symptom, its prompt removal may prevent
habituation and future disability. This may be achieved by on of the following
methods:

i.Strong suggestion for a return to normalcy.

ii.Aversion therapy (liquor ammonia; aversive electric stimulus; pressure just

above eye-balls or tragus of ear; closing the nose and mouth) are occasionally
employed carefully in resistant cases.

However, the use of aversion therapy has been described as it:

a. tends to get over-used

b.may harm the patient

c.violates the basic human rights of the patient; and

d. can lend a wrong mental picture of the patient in the physicians

mind, i.e.of a ‘manipulator’ needing punishment

The current status is that aversion therapy is not a preferred treatment

choice.

iii.Amplification of suggestion with hypnosis, free association, intravenous amytal

or thiopentone, or IV diazepam.
2. Psychotherpay with abreaction

-Abreaction is bringing to the conscious awareness, thoughts, affects and memories

for the first time.

This may be achieved by:

i.Hypnosis

ii.Free association

iii.Intravenous thiopentone or diazepam.

-The aim of abreaction with IV thiopentone is, both, to make the conflicts
conscious and to make the patient more suggestible to therapist’s advice. Once the
conflicts have become continuous and their affects (emotions) have been released,
the conversion/dissociative symptom disappear.

3. Supportive psychotherapy

Supportive psychotherapy is needed especially when the conflicts (and the current
problems) have become conscious and have to be faced in routine life. It is an
important adjunct to treatment.

4. Psychoanalysis

This mode of treatment is chose not on the basis of conversion/dissociative

symptoms but on the total personality structure of the patient. Several patients
respond remarkably well. The total length of therapy in classical psychoanalysis is
usually five years or more.

5. Drug therapy

Drug treatment has a very limited role in dissociative disorders (apart from the use
of IV thiopentone, amytal or diazepam in abreaction).A few patients have disabling
anxiety (although anxiety as a rule is rather uncommon in hysteria) and may need
short term benzodiazepines.
NURSING INTERVENTIONS

Possible nursing diagnosis:

 Disturbed thought process related to memory loss and repressed trauma
 Self care deficit related to trance like state or aimless wandering
 Ineffective individual coping, related to repressed memories and issues, loss
of identity or travel away from home
 Personality identity disturbance, related to childhood trauma or more than
one personality state
 Anxiety, related to repressed traumatic events or loss of identity.
 Powerlessness related to inability to cope effectively with severe anxiety
 Risk for other-directed violence related to fear of unknown circumstances
surrounding emergence from fugue state
 Risk for suicide related to unresolved grief and self blame associated with
childhood abuse
Problem Nursing interventions Rationale

Disturbed thought 1. Obtain as much information as 1. A comprehensive baseline

process related to possible about client from family assessment is important for the
memory loss and and significant others if possible. development of an effective plan
repressed trauma Consider likes, dislikes, important of care.
people, activities, music and pets.

2. Do not flood client with data 2. Individuals who are exposed to

regarding his or her past life. painful information from which
the amnesia is providing
protection may decompensate
even further into a psychotic
state.

3. Instead, expose client to stimuli

that represent pleasant 3. Recall may occur during activities
experiences from the past such as that stimulate life experiences.
smells associated with enjoyable
activities, beloved pets, and
music known to have been
pleasurable to the client. As
memory begins to return, engage
client in activities that may
provide additional stimulation.

4. Encourage client to discuss 4. Verbalization of feelings in a

situations that have been nonthreatening environment
especially stressful and to explore may help -client come to terms
the feelings associated with those with unresolved issues that may
times. be contributing to the
dissociative process.

5. Identify specific conflicts that 5. Unless these underlying conflicts

remain unresolved, and assist are resolved, any improvements
client to identify possible in coping behaviours must be
solutions. Provide instruction viewed as only temporary.
regarding more adaptive ways to
respond to anxiety.
 Problem Nursing interventions Rationale

Powerlessness 1. Allow client to takes as much 1. Providing client with choices will
R/T Inability to as responsibility as possible for increase feelings of control.
cope effectively own self-care practices.
with severe
anxiety 2. Provide positive feedback for 2. Positive feedback encourages
decisions made. Respect repetition of desirable behaviours.
client’s right to make those
decisions independently, and
refrain from attempting to
influence him or her toward 3. Unrealistic goals set client up for fails
those that may seem more and reinforce feelings of
logical. powerlessness.
3. Assist client to set realistic
goals for the future. 4. Client’s memory deficits may
interfere with his or her ability to
4. Help client identify areas of life solve problems. Assistance is
situation that he or she can required to perceive the benefits and
control. consequences of available
alternatives accurately.

5. This intervention helps client learn to

deal with unresolved issues and
accept what cannot be changed.
5. Help client identify areas of life
situation that are not within his 6. Positive reinforcement enhances
or her ability to control. self-esteem and encourages
Encourage verbalization of repetitions of desirable behaviours.
feelings related to this inability.

7. In support groups, client can learn

6. Identify ways in which client ways to achieve greater control over
can achieve. Encourage his or her life situation through direct
participation in these activities, feedback and by hearing about the
and provide positive experiences of others.
reinforcement of participation
and for achievement.

7. Encourage client’s participation

in supportive self-help groups.
Personality 1. The nurse must develop a 1. Trust is the basis of a therapeutic
identity trusting relationship with the relationship. Each of the
disturbance, original personality and with personalities views itself as a
related to each of the sub separate entity and must initially be
childhood trauma
personalities. treated as such.
or more than one
2. Help client understand the 2. Client may initially be unaware of
personality state
existence of the sub the dissociative response.
personalities and the need Knowledge of the needs each
each serves in the personal personality fulfils is the first step in
identity of the individual. the integration process.
3. Help client identify stressful 3. Identification of stressors is
situations that precipitate required to assist client in
transition from one responding more adaptively and to
personality to another. eliminate the need for transition to
Carefully observe and record another personality.
these transitions.
4. Use nursing interventions 4. The safety of client and others is a
necessary to deal with nursing priority.
maladaptive behaviours
associated with individual
sub personalities. For
example, if one personality
is suicidal, precautions must
be taken to guard against
clients self-harm. If another
personality has a tendency
toward physical hostility,
precautions must be take to
protect others.
5. Help sub personalities to 5. Because sub personalities function
understand that their as separate entities, the idea of
“being” will not be total elimination generates feat and
destroyed but rather defensiveness.
integrated into a unified
identify within the
individual.
6. Provide support during 6. Positive reinforcement may
disclosure of painful encourage repetition of desirable
experiences and reassurance behaviours.
when client become
discouraged with lengthy
treatment.
1.Risk for 1. Assess suicidal or harmful intent. 1. Impulse control may be impaired.
suicide R/T Discuss consideration of a plan Sudden changes may signal a switch
unresolved and availability of means. Assess to the “suicidal” personality.
grief and self- sudden changes in behavior.
blame 2. Help client identify stressful 2. Early detection allows time to
associated precipitating factors that initiate manipulate the environment to
with childhood emergence of the “suicidal” reduce the possibility of injury.
abuse personality.
3. Establish trust and secure a
promise threat client seeks out 3. This allows the client to assume some
support when self- destructive of the responsibility for his or her
impulses are present. behavior, while still offering
assistance if self-control is lacking.
4. Seek assistance from another, 4. A strong-willed personality may help
strong willed personality. to control the behavior of the
“suicidal” personality.
5. Assist the client in identifying
alternative behaviours to self- 5. These activities may provide a non-
destructive behaviours (e.g. verbal destructive
or writer expression; physical
activity).
6. If necessary, place in isolation or 6. Alterative in the face of overwhelming
provide physical restraint in a non- aggressive impulses.
punitive manner.
7. Assess physical and emotional
status every 15 minutes while in 7. External controls will ensure client
restraints. safety when internal controls fail.

8. Administer antidepressant and 8. Client safety and security are nursing

antianxiety medications as priorities.
ordered by physician

Depression is common and the client

may become frustrated with the long-
term treatment (sometimes in excess
of 10 years). Anxiolytics may be
required to reduce anxiety until
internal controls are achieved.
 1

J Trauma Dissociation. 2014; 15(1):79-90. doi: 10.1080/15299732.2013.834861.

Co-occurrence of dissociative identity disorder and borderline personality

disorder.
Ross CA1, Ferrell L, Schroeder E.

Author information
1
 a The Colin A. Ross Institute for Psychological Trauma, Richardson, Texas,
USA.

Abstract

The literature indicates that, among individuals with borderline personality

disorder, pathological dissociation correlates with a wide range of impairments and
difficulties in psychological function. It also predicts a poorer response to
dialectical behavior therapy for borderline personality disorder. We hypothesized
that (a) dissociative identity disorder commonly co-occurs with borderline
personality disorder and vice versa, and (b) individuals who meet criteria for both
disorders have more co morbidity and trauma than individuals who meet criteria
for only 1 disorder. We interviewed a sample of inpatients in a hospital trauma
program using 3 measures of dissociation. The most symptomatic group was those
participants who met criteria for both borderline personality disorder and
dissociative identity disorder on the Dissociative Disorders Interview Schedule,
followed by those who met criteria for dissociative identity disorder only, then
those with borderline personality disorder only, and finally those with neither
disorder. Greater attention should be paid to the relationship between borderline
personality disorder and dissociative identity disorder.

PMID:
24377974
[PubMed - in process]