Dissociative Disorder | Dissociative Fugue, Dissociative Identity Disorder, and Depersonalization Disorder

INTRODUCTION

Dissociative responses occur when anxiety becomes overwhelming and the personality becomes disorganized. Defence mechanisms that normally govern consciousness, identity, and memory break down, and behaviour occurs with little or no participation on the part of the conscious personality. Four types of dissociative disorders are described by the DSM-IV-TR: dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization disorder.

DEFINITION:

Dissociation reaction are the psychological manifestation which will occur when there is a partial or complete loss of normal integration between past memories and awareness of identity perception or consciousness due to the underlined psychological conflicts 

Dissociative disorders are defined by a disruption in the usually integrated functions of consciousness, memory, identity, or perception.

~        (American Psychiatric Association [APA], 2000).

Dissociation is one type of defence mechanism whereby the person will be protected from traumatic events by allowing the mind to forget or remove itself from painful situation or memory.

AETIOLOGY:

• Psychological stress or conflicts or frustration.
• Childhood trauma or sexual abuse is associated with adult dissociation symptomatology. cognitive
• Limbic system may be involved, traumatic memories are processed through limbic system and hippocampus stores the information. (Early trauma could remain detached from memories and stress could precipitate dissociation.).
• Lack of attachment has effect on neurotransmitters link.
• Depersonalization cause block in neurotransmitter link.
• Drug abuse (like is alcohol, barbiturates, benzodiazepines, hallucinogen).
• Traumatic life events-rape, incest, kidnapping, abuse, threats of death, physical violence, witness to violence

Psychodynamics:

• The disturbance is not under voluntary control but the symptoms occur in organs under voluntary control, eg. Symptoms will not develop intentionally.
• Clients will benefit by both primary and secondary gains
• Primary gain is obtaining relief from anxiety by keeping and internal need or conflict out of awareness, eg. An individual met with some problem suddenly, which he knows it, but he poses himself that he was not having any problem; temporarily gets relief from anxiety or frustration.
• Secondary gain is support from the environment that a person obtains as a result of being sick, eg attention or support either financially or monitory benefit or regard and sympathy, example an individual will get support (either financial or monitor) from parents or family members when they become sick.

La Belle Difference

• Is client’s reaction like indifference to the symptoms and displaying no anxiety or lack of concern about the symptoms
• Clients will suffer with more number of problems in their private life.
• Absence of medical and neurological abnormalities or organic deformities
• Amnesia or fugue related to traumatic events
• Alteration in memory, consciousness, identity
• Interrupted family processes related to amnesia or other changing behaviour
• Symptoms or depersonalization
• Feelings of unreality
• Body image distortion
• Substance abuse
• Dysfunction in usual patterns of behaviour
• Absence of work
• Withdrawal behaviour
• Alteration in functional aspects
• Filling of absence of control over memory, behaviour and awareness.
• Unable to explain the actions or behaviour in altered state.

Humanistic Theory - man is basically good, doesn’t have a disorder but was exposed to fearful experiences now are fearful. (PTSD)  The ideal self and the perceived self are far apart, but we have free will and can figure out our problems.

Behaviour Theory - Role of learning – classical conditioning, observed learning to produce fear and anxiety.  What is our pay off? (Ex. OCD gets momentary release of anxiety which is then reinforced)  Environmental: learned and can be unlearned

Cognitive Theory- maladaptive thought patterns magnify demand on themselves as threat, intrusive thought about traumatic events, out of proportion with reality.

Socio-cultural Theory– some cultures teach unknowingly fears and phobias

Biological Theory:  Genetic factors may create a vulnerability to anxiety disorders. High triggered autonomic system (ANS) that overreacts to perceived threat, creating high levels of physiological arousal. Hereditary factors such as over reactivity of neurotransmitter systems involved in emotional responses.  Ex. GABA, an inhibitory transmitter that reduces neural activity in the amygdale and other brain structures that trigger emotional arousal.  Brain scans have shown people with panic attacks have a lower concentration of GABA in the occipital cortex and people with OCD/depression have lower levels of serotonin.

TYPES

1. DISSOCIATIVE AMNESIA:

Dissociative amnesia is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too expensive to be explained by ordinary forgetfulness and is not due to the direct effects of substance use or a neurological or other general medical condition (APA, 2000).

Aetiology of Dissociative Amnesia:

·         Genetic Link

·      Neuropsychological dysfunction-reactive inhibition of signals at synapses in sensor motor pathways by negative feedback between the cerebral cortex and brain stem reticular formation.

·         Traumatic events after a severe psychosocial stress- when a person blocks out specific information.

·         Repression process- the painful events was stored in unconscious level

·         Unexpected bereavements

·         Stressful life situations or over whelming stress

·         Anxiety provoking internal urges

·         Significant distress or impairments in social, occupational or other important areas of function.

Clinical Manifestation:

·         Usually alert, a brief period of disorganisation or clouding of consciousness

·         Sudden inability to recall important personal information or loss of memory of recent events

·         Depressive symptoms

·         Memory still exists, but are deeply buried within the person’s mind and cannot be recalled

·         Memory gap spanning few minutes, few hours, few day, years.

·         Depersonalization

·         Significant distress

·         Trance state

·         Regression

Types:

Five types of disturbance in recall have been described. In the following examples, the individual is involved in a traumatic automobile accident in which a loved one is killed.

a.      Localized Amnesia. The inability to recall all incidents associated with the traumatic event for a specific time period following the event (usually a few hours to a few days).

Example: 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).

b.      Selective Amnesia. The inability to recall only certain incidents associated with a traumatic event for a specific period after the event.

Example: The individual may not remember events leading to the impact of the accident but may remember being taken away in the ambulance.

c.       Continuous Amnesia. The inability to recall events occurring after a specific time up to and including the present.

Example: The individual cannot remember events associated with the automobile accident and anything that has occurred since. That is, the individual cannot form new memories although he or she is apparently alert and aware.

d.      Generalized Amnesia. The rare phenomenon of not being able to recall anything that has happened during the individual’s entire lifetime, including personal identity.

e.       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.

Example: a person may forget all the specifics about a family member who abused him or her.

Diagnostic Criteria:

·         Complete medical history

·         Physical examination X-rays and other lab tests like EEG, blood test for toxins and drugs.

·         Psychological examination

·         Referral to psychiatric unit

Management

Medical:

• Memory retrieval techniques-consent has to be obtained
• Psychotherapy –psychological process will be used for catharsis or ventilation to resolve the internal conflicts and to increase deeper insight into the problem and find the way to resolved them.
• Drug therapy antidepressant or anxiolytics can be used based on manifestation.
• Cognitive therapy –to change dysfunctional thinking pattern and behaviour.
• Social therapy –is based on manifestation.
• Family therapy and counselling-to provide situational support.
• Diversional therapy, art therapy, music therapy-allows the patients to explore and express their thought in creative manner.
• Relaxation technique.
• Prognosis –good, memory returns with time.

2. DISSOCIATIVE FUGUE:

The characteristic feature of dissociative fugue is a sudden, unexpected travel away from home or customary place of daily activities, with inability to recall some or all of one’s past (APA, 2000). An individual in a fugue state cannot recall personal identity and often assumes a new identity. Individuals in a fugue state do not appear to be behaving in any way out of the ordinary. Contacts with other people are minimal. The assumed identity may be simple and incomplete or complex and elaborate. If a complex identity is established, the individual may engage in intricate interpersonal and occupational activities. A divergent perception regarding the assumption of a new identity in dissociative fugue is reported by Maldonado and Spiegel (2008).

Clients with dissociative fugue often are picked up bythe police when they are found wandering in a somewhat confused and frightened condition after emerging from the fugue in unfamiliar surroundings. They are usually presented to emergency departments of general hospitals. On assessment, they are able to provide details of their earlier life situation but have no recall from the beginning of the fugue state. Information from other sources usually reveals that the occurrence of severe psychological stress or excessive alcohol use precipitated the fugue behaviour.

Duration is usually brief—that is, hours to days or more rarely, months—and recovery is rapid and complete. Recurrences are not common.

Aetiology

• Substance abuse
• Marital disharmony
• Financial upheavals
• Occupational distress
• Wars
• Depression
• Suicidal ideas
• Personality disorders
• Epilepsy
• Prognosis:
• Rapid and spontaneous

Management:

Medical:

• Manipulation of environment
• Psychotherapy
• Hypnosis

Nursing Diagnosis:

• Risk for violence related to fear of unknown circumstances
• Ineffective coping related to stressors.

Nursing Interventions:

• Protect the client from harmful stressors thereby prevention of self-harm
• Encourage the client to express his feelings related to anxiety
• Identify the resource, where client can be relieved from stress
• Gentle encouragement, persuasion, direct association is required

3. DISSOCIATIVE IDENTITY DISORDER

Dissociative identity disorder (DID) was formerly called multiple personality disorder. This disorder is characterized by the existence of two or more personalities in a single individual. Only one of the personalities is evident at any given moment, and one of them is dominant most of the time over the course of the disorder. Each personality is unique and composed of a complex set of memories, behaviour patterns, and social relationships that surface during the dominant interval. The transition from one personality to another is usually sudden, often dramatic, and usually precipitated by stress.

For example: a normally shy, socially withdrawn, faithful husband may become a gregarious womanizer and heavy drinker with the emergence of another personality.

Aetiology

• An innate ability to dissociate easily
• Repeated episodes of severe physical or sexual abuse In childhood
• Lack of supportive of comforting parents to counteract abusive relatives
• Influence of other relatives with dissociative symptoms or disorders
• Physical or psychological traumatic experiences
• Absence of situational support
• Intolerable terror-producing events
• Absence of adaptive coping ability
• Intense anxiety
• Negative role models
• Unspecified long-term societal changes
• Rigid religious beliefs
• Isolation from the community
• Lack of cooperation among the employees

Manifestation:

• Inadequate defences to handle the intense anxiety
• Individual dissociates the event and the feelings associates with the events
• Dissociated processes are split off from the memory of the primary personality
• Usually the primary personality is religious and moralistic
• Sub personality are aggressive, pleasure seeking, nonconforming or sexually promiscuous.
• Transition from one personality to other often occurs during time of stress.

Diagnostic criteria:

• Rules out physical conditions
• EEG-to exclude seizures
• Dissociative experiences scale and dissociative disorders interview schedules.
• Structured clinics interviews for DSM-IV dissociative disorders
• Hypnotic induction profile

Management:

Medical:

·         Psychotherapy:

• Initial phase for uncovering and mapping the patients alters
• Treating the traumatic memories, fusing the alters
• Consolidating the patients newly integrated personality
• Social skill training
• Family therapy- for personality reintegration
• Mixed therapy groups

·         Drug Therapy:

• Tranquilizers and antidepressants.

Prognosis

• Is excellent for children and better for adults.

Nursing Diagnosis:

• Prone for suicide related to unresolved grief.
• Alteration in personal identity relayed to childhood traumatic experiences

Nursing Interventions:

• Assess the suicidal tendency of the client and sudden changes within the behaviour
• Assist the client to identify stressful precipitating factors
• Provide trusting relationships, support and reassurance to the client when he will discourage more
• Administer the drugs as per the doctors order
• The safety of the client maintained
• Provide positive reinforcement for the client

4. DEPERSONALIZATION DISORDER

Depersonalization disorder is characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, feelings of detachment from the environment, or a sense of observing oneself from outside the body. Depersonalization (a disturbance in the perception of oneself) is differentiated from derealisation, which describes an alteration in the perception of the external environment. Both of these phenomena also occur in a variety of psychiatric illnesses such as schizophrenia, depression, anxiety states, and organic mental disorders. As previously stated, the symptom of depersonalization is very common. It is estimated that approximately half of all adults experience transient episodes of depersonalization (APA, 2000). The diagnosis of depersonalization disorder is made only if the symptom causes significant distress or impairment in functioning.

The DSM-IV-TR describes this disorder as the persistence or recurrence of episodes of depersonalization characterized by a feeling of detachment or estrangement from one’s self (APA, 2000). There may be a mechanical or dreamlike feeling or a belief that the body’s physical characteristics have changed. If derealisation is present, objects in the environment are perceived as altered in size or shape. Other people in the environment may seem automated or mechanical.

These altered perceptions are experienced as disturbing, and are often accompanied by anxiety, depression, fear of going insane, obsessive thoughts, somatic complaints, and a disturbance in the subjective sense of time (APA, 2000). The disorder occurs more often in women than it does in men, and is a disorder of younger people, rarely occurring in individuals older than 40 years of age (Andresen & Black, 2006).

Aetiology:

• CNS diseases, e.g., brain tumours , epilepsy
• Severe sensory deprivation
• Psychological conflicts
• Unpleasant emotions or emotional pains

Manifestation:

• The person experiencing depersonalization may feel mechanical, dreamy, or detached from the body
• Ego dystonic, e.g. Perceiving the limbs to the larger than the normal
• The experience causes significant impairments in social or occupational functioning makes distres

Management:

Medical:

Teach Relaxation techniques and assertiveness techniques

Administer drugs as per order

Supportive service

Nursing Diagnosis:

Deprivation of sensory perceptions

Anxiety related to ear of lack of control

Nursing Intervention:

Provide a sense of reality environment during stressful situation e.g. Calm and non-threatening environments

Provide support and encouragement

Assist the client to explore past experiences related to painful situation

Arrange for role play, where the client will have the opportunity to observe the situation and face the stressful situation in real life and to adapt coping strategies

TRANCE AND POSSESSION DISORDER:

In trance disorder, there is usually a temporary, marked constriction of consciousness with selective focusing on stimuli, loss of usual sense of personal identity (without replacement with a new identity), sometimes with repetitive motor behaviour and speech. Response to environment stimuli may be variable. Vocalizations or repetition of words may be seen.

In possession disorder, if a new identity (usually a spirit, ghost, deity, divine, power, or some other person) takes over the control of person’s personality during the episodes, the condition is called as possession disorder. The voice and behaviour may appear like that of the ‘possessed spirit’. Usually the person is aware of the existence of other (i.e. ‘possessor’).

In fact many patients with possession symptoms don not come for treatment, as these symptoms are often considered culturally permitted ways of expressing distress.

CONCLUSION:

A dissociative response has been described as a defence mechanism to protect the ego in the face of overwhelming anxiety. Dissociative responses result in an alteration in the normally integrative functions of identity, memory, or consciousness. Classification of dissociative disorders includes dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization disorder.