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Dissociative Disorders Nursing Care Plan (NCP)

In these disorders a disturbance or alteration exists in the normally integrative functions of identity, memory, or consciousness. The individual blocks off part of his or her life from consciousness during periods of intolerable stress. The stressful emotion becomes a separate entity, as the individual “splits” from it and mentally drifts into a fantasy state.

DSM-IV
300.12 Dissociative amnesia
300.13 Dissociative fugue
300.14 Dissociative identity disorder
300.15 Dissociative disorder NOS
300.6 Depersonalization disorder

ETIOLOGICAL THEORIES
Psychodynamics
Selective repression of distressing mental contents from conscious awareness is used as a mechanism for protecting the individual from emotional pain or expressing self in dangerous ways. The stressor(s) may arise from external circumstances or internal sources with onset of symptoms sudden or gradual and of transient or chronic nature. Intrapsychic conflict thus uses denial and “ego splitting” to decrease anxiety.

Physical sensations seen in these disorders may represent forbidden wishes that have been somatized. The use of the defense mechanism of displacement allows the feeling(s) to be directed away from the egothreatening object toward one less threatening. In psychoanalytic terms, dissociation is a form of denial in which the object denied is part of the self or ego.

Biological
Research on the biological basis of these disorders is increasing as more recognition of the mind-body connection is accepted. It is difficult to determine whether the biological changes (fight-or-flight mechanism) that accompany severe anxiety precede or precipitate the emotional state. Biochemical, physiological, and endocrine systems have an intimate connection with actual physical changes occurring in all body systems via the autonomic nervous system. Some studies have shown EEG abnormalities associated with cerebral mechanisms in the temporal and limbic regions of the brain, which mediate identity formation and a sense of personal boundaries and may affect development of gender and generation boundaries.

Organic causes of pathological dissociative experiences that are known or suspected include temporal lobe epilepsy, sensory deprivation, sleep loss, strokes, encephalitis, and Alzheimer’s disease. Drugs may also induce amnesia or depersonalization directly or indirectly in some incidences. However, most dissociative states are not associated with any obvious organic conditions and the diagnosis of dissociative disorder requires that the condition is not due to the direct effects of a substance or a general medical condition.

Family Dynamics
In Systems theory, the family is viewed as a system in which the process (interactions between/among family members) is the prime determinant. Level of differentiation and level of anxiety determine the degree of pathology.

Psychosocial theory states that individuals who develop dissociative disorders have often experienced severe physical, sexual, and/or emotional abuse early in life—stress so severe that the only way to cope with the painful emotions is to detach from them. The child learns to respond to stressful situations in this manner. One parent may be abusive, with the other being a passive participant, not taking care of or protecting the child. Psychiatric diagnoses (especially alcoholism) in close relatives are common, although multiple personality diagnosis is not.

Certain behaviors observed in childhood, though considered normal, may be identified as dissociative, including construction of imaginary playmates, use of different names or ages for themselves, taking on the role of an animal, imagining self as having been adopted or coming from another family, separation from the past, gender confusion, and regressive behavior. Responding to stressful situations with dissociative behaviors then becomes a method of coping for some individuals into adulthood, when there is less control over the dissociative states. The response becomes maladaptive in that the individual escapes from the stressful situation rather than facing it.

NURSING PRIORITIES
1. Provide safe environment; protect client/others from injury.
2. Assist client to recognize anxiety.
3. Promote insight into relationship between anxiety and development of dissociative state/other personalities.
4. Support client/family in developing effective coping skills and participating in therapeutic activities.

DISCHARGE GOALS
1. Recognizes potentially dangerous behaviors/personalities and contracts for safety.
2. Client/family are participating in therapeutic regimen.
3. Effective coping skills, understanding of underlying dynamics of condition are demonstrated.
4. Recovers deficits in memory.
5. Major/emerging personality has been chosen and accepted (dissociative identity disorder) or client is managing stress without resorting to dissociation.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for dissociative disorders: Anxiety may be related to Maladaptation of ineffective coping continuing from early life; Unconscious conflict(s); threat to self-concept, threat of death (perceived or actual); Unmet needs and Phobic stimulus possibly evidenced by Increased tension; apprehension, fright; restlessness; Feelings of inadequacy; focus on self or projection of personal perceptions onto the environment; Verbalized focus of fear, e.g., fear of “going crazy”; Maladaptive response to stress (dissociating self/fragmentation of the personality); Sympathetic stimulation: cardiovascular excitation, superficial vasoconstriction, pupil dilation.

Desired Outcome:
1. Acknowledge and discuss feelings of anxiety and fear.
2. Identify ways to manage anxiety/fear effectively.
3. Demonstrate problem-solving skills.
4. Use resources effectively.

Nursing intervention with rationale:
1. Develop rapport and trust; accept client’s verbal expression of feelings/anxieties.
Rationale: A trusting alliance facilitates early identification of the underlying sources of anxiety and development of an appropriate treatment approach. Learning to turn to trusted others for support helps the client develop healthy methods of dealing with anxiety.

2. Discuss with the client the availability of assistance in maintaining safety.
Rationale: Prevents a false assurance of safety, particularly when internal threats to safety may not be readily apparent. Lack of awareness of need/failure to use resources increases the likelihood of isolation and destructive behaviors. Note: Expressions of anxiety may represent a very real threat to or from alternate personalities and/or others.

3. Identify stressor(s) that precipitate severe anxiety.
Rationale: Helps client recognize individual factors precipitating dissociative symptoms (e.g., splitting, fugue, amnesia), which interfere with developments/use of adequate coping skills.

4. Maintain a neutral approach when confronted by an alternate personality or dissociative state.
Rationale: Allows essential observation and documentation and promotes a trusting relationship. Also helps the therapist/care provider to avoid consciously or unconsciously promo ting fragmentation of the personality. Because dissociative identity disorder has been sensationalized, personnel may be intrigued by manifestations and respond to the client in ways that reinforce the behaviors manifesting the disorder.

5. Provide support and encouragement during times of depersonalization.
Rationale: Client experiences fear and anxiety at these times and may fear “going crazy.” Acknowledging these feelings will help client deal appropriately with them.

6. Reduce alterable sources of stress. Provide calm environment; minimize external stimuli. Identify individual causes/precipitators of stress.
Rationale: Manipulation of the environment to reduce extraneous sources of stress allows the client to recognize and develop skills in managing internal sources of conflict.

7. Observe for/review with client untoward effects/ adverse reaction to medication regimen. Monitor level of alertness, vital signs; note urinary retention, dry mouth, blurred vision, parkinson-like symptoms, rigidity, or atypical response (excitability, restlessness, agitation).
Rationale: Psychoactive medications (sedatives, antianxiety/ antipsychotic agents, and antidepressants) frequently produce hypotension and anticholinergic and extrapyramidal symptoms, in addition to the desired effect. Early intervention will alleviate prolonged difficulties and/or serious physical complications and may prevent/lessen anxiety about their presence.

8. Coordinate and develop a combined treatment plan. Facilitate communication among team members.
Rationale: These clients do better when dealing with one primary provider supported by a cohesive treatment team. Therefore, it is essential that all members of the treatment team work together in planning care to ensure that goals and objectives are in agreement and continuity of care exists. Because these clients are prone to manipulative behaviors and may be resistant to therapy, a coordinated treatment plan prevents dissension between disciplines.

9. Administer antianxiety medications as indicated, e.g., alprazolam (Xanax), diazepam (Valium).
Rationale: Antianxiety medications are given with caution for brief periods to allay panic states or disabling anxiety. Caution is essential, as substance abuse is a common complication and also because of the potential for self-destructive behavior.

10. Explore past experiences and painful situations (e.g., trauma, abuse) that may be repressed.
Rationale: Traumatic experiences/patterns of behavior may predispose individuals to dissociative disorders.
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