Bautista Bryan M.

, RN Dissociative Disorders Dissociative Disorders A continuum of disorders experienced by individuals exposed to trauma, including depersonalization disorder, dissociative amnesia, dissociative fugue, and dissociative identity disorder. These disorders involve a disturbance in the organization of identity, memory, perception, or consciousness. I. Overview a. Anatomy of Brain Structures of interest in Psychiatry Cerebral Cortex Limbic System Basal Ganglia Hypothalamus Locus ceruleus Raphe nuclei Substantia Negra Amygdala Central decision making and Higher-order thinking (abstract reasoning) Regulates emotional behavior, memory, and learning Coordinates involuntary movements and muscle tone Involved in regulating pituitary hormones, temperature, and certain behaviors ( appetite, thirst, and libido) Synthesis norepinephrine Synthesis serotonin Synthesis Dopamine The Seat of emotional intelligence (EQ)

b. Psychoanalytic of Sigmund Freud Behavior Motivated by Subconscious Thoughts and Feelings. - Your behavior today is directly or indirectly affected by your childhood days or past experiences.

Defense Mechanism protective barriers that used to manage instincts and affect in the presence of difficult situation Purpose Self-security protection Anxiety Reduction Mental conflict resolution Esteem self-protection 4 levels of Defense Mechanism

Level 1: Psychotic Mechanisms Delusional, Denial, and Distortion Level 2 Immature Mechanisms Projection, Schizoid Fantasy, Hypochondriasis, Passive Aggressive Behavior Level 3 Neurotic Mechanisms Intellectualization, Repression, Displacement, Reaction Formation, Dissociation Level 4 Matured Mechanisms Altruism, Humor, and Sublimation II. Involve Defense Mechanism

Dissociation expression or dealing with emotional conflict through temporary alteration in consciousness or Identity III. What is Causes?

Dissociative disorders usually develop as defense mechanism for coping with trauma or from what we call repressed memories, the disorder most often in children subjected to chronic physical, sexual or emotional abuse or in some anybody recent relationship or past, a home environment that otherwise frightening or highly unpredictable. Also may contribute 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 through its happening to a different person. A child who learns to dissociate in order to endure an extended period of his/her youth may reflexively use this defense mechanism in response to stressful situation throughout life/ Rarely, adults may develop dissociate disorders in response to severe trauma, for like example Rape victims, Disasters victims, Combat and Assault situations and sudden accidents, that may also precipitate to Post Traumatic Stress Disorder IV. Risk factors a. 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. b. Neurocircuitry System - There is strong clinical evidence that indicates that the amygdala is a central structure in the brain neurocircuitry 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 affected the limbic system. Significant early traumatic experiences and the lack of attachment have also 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.

c. The Role of Family Dynamics -The role of family dynamics 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

V.

Dissociation through Lifespan

a. Childhood Dissociation is an early primitive defense mechanism available to children until they mature and gain greater psychological capacity to accommodate ambiguity and tolerate conflict. Putman (1997) labeled this a normative dissociation.

 A child with a dissociative disorder is most likely to have a history of early sexual or physical abuse and has not been able to develop attachment because of the absence of empathetic parenting. Children with dissociative disorders can manifest mild-to-moderate inattention and sustained concentration deficits on psychological testing. Common behavioral features: Amnesia, or forgetting test responses; staring, indicative of trance states; unusual or odd motor behaviors; fearful and angry reactions to stimuli; expressions of internal conflict. b. Adolescence Symptoms of pathological dissociation in adolescence can be consistent with the diagnosis of conduct disorder The adolescence with dissociative identity disorder is likely to be more vulnerable to the pressure of peer groups and use alters to respond to each demand. Having never experienced parental soothing and attachment, the adolescent who is dissociate will attempt to provide soothing for herself/himself though drug abuse and sexual promiscuity and to meet attachment needs through gang memberships c. Adulthood The adult with a dissociative disorder frequently goes undiagnosed or is misdiagnosed: The person, having grown up in a chaotic family, may not know that losing time is an abnormal experience. Some adults may be in the mental health system for years being treated for depression, and the dissociation becomes evident only after a triggering event. Adult men with undiagnosed dissociative disorders end up incarcerated in prison because of aggressive behaviors. VI. Types of Dissociative Disorders

a. Dissociative Amnesia - This disorder is characterized by a blocking out of critical personal information, usually of a traumatic or stressful nature because emotional conflicts or external stressors. The onset is sudden. There is sudden identity disturbance, awareness of memory loss and is alert before and after. Dissociative amnesia, unlike other types of amnesia, does not result from other medical trauma Classified as: Retrograde (inability to recall remote past) Anterograde (inability to recall immediate past)

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. 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. b. 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

c. Dissociative Identity Disorder (DID) This condition, formerly known as multiple personality disorder, is characterized by "switching" to alternate identities when under stress. Caused by severe childhood trauma and severe sexual abuse The onset is insidious a dissociative disorder involving a disturbance of identity in which two or more separate and distinct personality states (or identities) control the individual's behavior at different times. When under the control of one identity, the person is usually unable to remember some of the events that occurred while other personalities were in control. The different identities, referred to as alters, may exhibit differences in speech, mannerisms, attitudes, thoughts, and gender orientation.

The alters may even differ in "physical" properties such as allergies, right-or-left handedness, or the need for eyeglass prescriptions. These differences between alters are often quite striking.

d. Depersonalization Disorder A dissociative disorder in which the sufferer is affected by persistent or recurrent feelings of depersonalization and/or derealization. Brought by overwhelming feelings about a current event similar to a past traumatic event The onset is rapid The symptoms include a sense of automation, going through the motions of life but not experiencing it, feeling as though one is in a movie, feeling as though one is in a dream, feeling a disconnection from one's body, out-of-body experience, a detachment from one's body, environment and difficulty relating oneself to reality. For all, it is a rather disturbing illness, since many feel that indeed, they are living in a "dream". They feel separated from themselves or outside their own bodies. People with this disorder feel like they are "going crazy" and they frequently become anxious and depressed. Post-Traumatic Stress Disorder

VII.

Posttraumatic stress disorder (PTSD) is a disturbing pattern of behavior demonstrated by someone who has experienced a traumatic eventfor example, a natural disaster, combat, or an assault. The person with PTSD was exposed to an event that posed a threat of death or serious injury and responded with intense fear, helplessness, or terror.

Three clusters: 1. Reliving the event; 2. avoiding reminders of the event 3. Being on guard, or hyperarousal

VIII.

Treatment Modalities

a. Pharmacologic Intervention b. Psychosocial Intervention c. Client education

IX.

Nsg process

Assessment a. History b. Mental Examination General Appearance Communication Perception and thought process and content Mood and Affect Sensorium and Intellectual process Judgment and insight Self-concept Roles and Relationship

Diagnosis Planning Implementation a. Pharmacologic Intervention antidepressants SSRI ,( Zoloft Paxil) b. Psychosocial Intervention Individual Therapy - One to one relationship between therapist and client , Change is achieved by the exploration of feelings, attitudes, thinking behavior and conflict Group therapy - Number of people coming together, sharing a common goal, interest or concern, staying together and developing relationships Cognitive Behavior therapy - Restructuring or changing ways in which people think about themselves

Grounding techniques c. Client education Evaluation