Nursing Care Plan (NCP) for Dissociative Disorders
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Lesson Objective for Nursing Care Plan on Dissociative Disorders
- Understanding Dissociative Disorders:
- Gain comprehensive knowledge about the various types of dissociative disorders, including dissociative amnesia, depersonalization disorder, and dissociative identity disorder (DID).
- Recognition of Signs and Symptoms:
- Develop the ability to recognize the signs and symptoms associated with dissociative disorders, such as memory gaps, identity confusion, derealization, and the presence of multiple identities.
- Assessment and Diagnosis:
- Learn effective assessment techniques to identify individuals with dissociative disorders, including the use of standardized tools and collaboration with other healthcare professionals for a thorough diagnosis.
- Therapeutic Approaches:
- Understand evidence-based therapeutic approaches for individuals with dissociative disorders, encompassing psychotherapy, cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and pharmacological interventions when applicable.
- Holistic Patient Care:
- Develop a holistic approach to patient care, considering the unique needs and challenges faced by individuals with dissociative disorders, and collaborate with the interdisciplinary team to provide comprehensive support.
Pathophysiology
- Altered Information Processing:
- Dissociative disorders involve disruptions in normal information processing, particularly in memory, identity, consciousness, and perception. Traumatic experiences may contribute to the fragmentation of these cognitive processes.
- Impact on Neural Networks:
- Research suggests that dissociative symptoms may be associated with alterations in neural networks, affecting areas of the brain responsible for memory consolidation, emotional processing, and self-awareness.
- Role of Trauma and Stress:
- Severe psychological trauma, especially during childhood, is often linked to the development of dissociative disorders. Traumatic experiences may overwhelm an individual’s ability to cope, leading to dissociative responses.
- Neurobiological Mechanisms:
- While the specific neurobiological mechanisms underlying dissociative disorders are still under investigation, there is evidence suggesting that changes in neurotransmitter systems, such as serotonin and dopamine, may play a role in the manifestation of dissociative symptoms.
- Adaptive Response to Threat:
- Dissociation can be seen as an adaptive response to overwhelming stress or trauma. It may serve as a defense mechanism, allowing individuals to compartmentalize distressing experiences to protect their mental well-being.
Etiology
- Traumatic Experiences:
- Severe and chronic trauma, especially during childhood, is a significant factor in the development of dissociative disorders. Physical, emotional, or sexual abuse, as well as other forms of trauma, may contribute to the fragmentation of identity and cognitive processes.
- Disrupted Attachment:
- Early disruptions in attachment, such as inconsistent caregiving or neglect, can contribute to the development of dissociative symptoms. A lack of secure attachment may impact the formation of a stable sense of self.
- Coping Mechanism:
- Dissociation is often considered a coping mechanism in response to overwhelming stress or trauma. Individuals may dissociate as a way to mentally distance themselves from distressing experiences, creating a temporary escape from reality.
- Biological Factors:
- While the precise biological mechanisms are not fully understood, there is evidence suggesting a genetic predisposition to dissociative disorders. Additionally, alterations in neurotransmitter systems, hormonal regulation, and brain structure may contribute to susceptibility.
- Environmental Triggers:
- Environmental stressors, such as ongoing life challenges or exposure to additional traumatic events, can exacerbate dissociative symptoms. These triggers may rekindle or intensify dissociative responses in individuals with a predisposition to such experiences.
Diagnostic Criteria
See chart below for specific diagnostic criteria for each disorder according to the DSM-V. These symptoms are not due to substance use / abuse or another medical condition and cannot be better explained by another mental disorder.
| Dissociative Amnesia | Dissociative Identity Disorder | Depersonalization – Derealization Disorder | Other Specified Dissociative Disorder (formerly DD-NOS) |
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Desired Outcome
- Integration of Identity:
- Promote the integration of fragmented aspects of the individual’s identity to establish a more cohesive and unified sense of self. This may involve working towards a more integrated and coherent awareness of personal history, emotions, and experiences.
- Enhanced Coping Skills:
- Develop and strengthen adaptive coping skills to manage stress, anxiety, and dissociative symptoms effectively. This includes promoting healthy ways of dealing with emotions, stressors, and triggers without resorting to dissociation as a primary coping mechanism.
- Improved Functioning in Daily Life:
- Support individuals in achieving improved functioning in their daily lives, including work, relationships, and self-care. Enhance their ability to navigate challenges and responsibilities while minimizing the impact of dissociative symptoms on daily functioning.
- Trauma Resolution:
- Facilitate the processing and resolution of underlying traumatic experiences that contribute to dissociative symptoms. This may involve evidence-based therapeutic interventions aimed at addressing and integrating traumatic memories in a safe and supportive environment.
- Increased Self-Awareness:
- Foster greater self-awareness and self-reflection to help individuals understand their thoughts, emotions, and behaviors. Encourage mindfulness and the development of a more conscious and intentional approach to life, promoting a sense of agency and control.
Dissociative Disorders Nursing Care Plan
Subjective Data:
- Memory loss
- Feeling of being detached
- Feeling of surroundings being foggy or dreamlike
- Inability to cope with emotional or social stress
- Suicidal thoughts
- Depression
Objective Data:
- Anxiety
- Distant or reclusive behavior
- Erratic or chaotic behavior
- Unresponsiveness to environmental stimuli (sound, smell, temperature, etc.)
Nursing Assessment for Dissociative Disorders
- Identification of Dissociative Symptoms:
- Assess for signs of dissociation, including amnesia, depersonalization, derealization, and identity confusion. Document the frequency, duration, and severity of these symptoms.
- History of Trauma:
- Obtain a detailed history of any traumatic experiences, as trauma is often linked to the development of dissociative disorders. Explore the nature, timing, and impact of traumatic events on the individual’s life.
- Mental Status Examination:
- Conduct a thorough mental status examination to evaluate cognitive function, mood, thought processes, and perceptual disturbances. Identify any perceptual distortions or hallucinations.
- Assessment of Coping Mechanisms:
- Explore the individual’s current coping mechanisms, both adaptive and maladaptive. Determine if dissociation is a primary coping strategy and assess the effectiveness of these strategies in managing stress.
- Functional Assessment:
- Evaluate the individual’s ability to perform activities of daily living (ADLs), work, and maintain relationships. Identify any impairments or challenges related to dissociative symptoms.
- Suicide and Self-Harm Risk Assessment:
- Assess the risk of self-harm or suicide, especially if there is a history of trauma. Evaluate the presence of suicidal ideation, intent, and plans, and implement appropriate safety measures.
- Social Support Network:
- Investigate the presence and effectiveness of the individual’s social support network. Identify key relationships and assess the level of support available from family, friends, or other support systems.
- Collaboration with Mental Health Professionals:
- Collaborate with mental health professionals, such as psychologists or psychiatrists, to obtain a comprehensive understanding of the individual’s diagnosis, treatment plan, and progress. Ensure a coordinated approach to care.
Implementation for Dissociative Disorders
- Establishing Therapeutic Rapport:
- Build a trusting and therapeutic relationship with the individual to create a safe and supportive environment. Establishing trust is essential for effective communication and engagement in therapeutic interventions.
- Psychoeducation on Dissociation:
- Provide psychoeducation to the individual and their support system about dissociative disorders. Offer information about the nature of dissociation, common triggers, and coping strategies. This empowers individuals to better understand and manage their symptoms.
- Coping Skills Training:
- Teach and reinforce adaptive coping skills to help the individual manage stress and anxiety. This may include grounding techniques, mindfulness exercises, and relaxation strategies. Collaborate with the individual to identify and practice coping mechanisms that work for them.
- Collaborative Treatment Planning:
- Work collaboratively with the individual, mental health professionals, and other members of the healthcare team to develop a comprehensive treatment plan. Ensure that the plan addresses the specific needs of the individual, incorporating therapeutic modalities such as cognitive-behavioral therapy or dialectical behavior therapy.
- Monitoring and Safety Measures:
- Implement measures to monitor and ensure the safety of the individual. This includes regular assessments for self-harm or suicidal ideation, as well as creating a plan for crisis intervention. Collaborate with the mental health team to establish a safety plan and determine appropriate interventions in case of emergencies.
Nursing Interventions and Rationales
- Perform complete nursing and neurological assessment. Note any signs of self-mutilation or previous suicide attempts
Get a baseline of data and help determine neurological status. Also rules out underlying physiological cause of symptoms.
- Assess for any suicidal or homicidal ideations
To provide for client safety and the safety of others
- Set limits for inappropriate behaviors
Clients may act chaotic or erratic. Setting limits and consistently maintaining boundaries reinforces routine and reality.
- Provide care with calm and positive, respectful attitude
Negativity or hostility can trigger hostile reactions or manipulative behaviors.
Gaining the client’s respect and trust helps facilitate care.
- Encourage client to talk about their life, their past and their interests
Helps identify specific areas of avoidance or infatuation that may pose as stress triggers for behaviors
- Provide support and encouragement during recollection of past traumatic experiences
Build rapport and trust to help the client work through the difficult emotions and circumstances that they may have been avoiding
- Administer medications as needed appropriately
While there are no medications for these specific disorders, many clients have other mental illnesses or conditions that exacerbate symptoms such as depression and anxiety. Some medications may be used for chaotic or erratic behaviors and are given on a PRN basis.
- Provide teaching to family members and encourage their support in dealing with client’s symptoms
Clients often feel isolated in regard to their past experiences. Incorporating a family support system helps the progression and effectiveness of treatment
- Provide appropriate, temporary use of restraints or lock-down facilities as necessary
Keep clients safe from harm during gaps or changes in personalities. Prevent clients from wandering into dangerous areas.
- Monitor skin integrity when using restraints or for clients with suicidal ideations
Clients may develop self-destructive behaviors during treatment.
Improper or extended use of restraints can cause skin breakdown.
- Provide resource information for continued long-term psychotherapy and counseling
Help client with long-term treatment and give information to help client continue managing symptoms.
Evaluation for Dissociative Disorders
- Symptom Monitoring:
- Regularly assess and document the individual’s dissociative symptoms, such as frequency, intensity, and duration. Use standardized assessment tools to quantify changes over time and identify patterns or triggers associated with dissociation.
- Functional Improvement:
- Evaluate improvements in the individual’s daily functioning and overall quality of life. Assess their ability to engage in social, occupational, and self-care activities. Look for positive changes in relationships, work, and other aspects of daily living.
- Coping Skills Utilization:
- Assess the individual’s use of coping skills taught during interventions. Determine whether they are effectively applying these skills in real-life situations to manage stress, anxiety, and dissociative episodes. Encourage ongoing practice and refinement of coping strategies.
- Collaborative Feedback:
- Seek feedback from the individual, as well as input from the broader treatment team, including mental health professionals. Evaluate whether the individual feels supported, engaged in their treatment, and if there are any concerns or adjustments needed in the care plan.
- Goal Attainment:
- Review the goals established in the care plan and assess the extent to which they have been achieved. Goals may include reducing the frequency of dissociative episodes, improving emotional regulation, enhancing interpersonal relationships, and increasing overall functioning. Adjust goals as needed based on progress.
References
- https://information.pods-online.org.uk/what-are-the-diagnostic-criteria-for-the-dissociative-disorders/
- https://psychcentral.com/disorders/dissociative-identity-disorder/in-depth/
- https://www.psychiatry.org/patients-families/dissociative-disorders/what-are-dissociative-disorders
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Transcript
We are going to work on the nursing care plan for dissociative disorders. So dissociative disorders are a common result of many traumatic or stressful situations, and they develop as a way of avoiding difficult memories. Think of them as an unhealthy coping mechanism. Some clients report feeling outside of their body, or watching their life from a distance. Others tend to experience a memory gap and present with various identities. People who have experienced physical sexual or emotional abuse during childhood or a higher risk of developing dissociative disorder. These our clients will be more likely to attempt suicide or have more self-destructive behaviors. So our nursing considerations, the first thing we want to do with these patients is we want to assess their suicide risk. These patients are at high risk for suicide. So we want to make sure that we’re doing a assessment checking to see if they have a plan and if necessary, make a suicide contract with these patients, we want to encourage self-expression.
We want to do a skin assessment because sometimes these patients can become very violent and they may need to be placed in restraints. We wanted to do a skin assessment of whether its restraints are applied and each time we go in, we need to reevaluate the need for those restraints. Remember the desired outcome for this patient is that the client is going to remain safe. It’s very important. Safety is number one. We want to make sure that they have optimal functioning during social and daily routine activities. This patient is going to identify stressors and triggers for dissociative behaviors or reactions. So this patient is someone who has dealt with something very traumatic in their life. So they tend to have some subjective things that they will present with a memory loss, maybe a feeling of being detached. Maybe they feel foggy or dreamlike. They have an inability to cope. So coping is very difficult for them. They have an inability to cope. They may have some suicidal thoughts, so suicidal thoughts.
And then also they also may complain of depression, some things that we’re going to notice as healthcare providers, when we are gathering some of that good objective data we are going to notice that they are distant; some call it reclusive, very, just withdrawn. They may present the other way, and they may be erratic and destructive. They may present with some chaotic behavior, and also there may be just, they may just be unresponsive. They may be what we call flat. They may have an unresponsiveness to any stimuli. So they may be unresponsive to external environmental stimuli. So what can we do as nurses? What are some interventions that we can get into? Well, we want to make sure that we perform a neurological assessment. So we want to make sure that we are doing a neuro assessment.
We also want to assess for any signs or symptoms of a self-harm or prior suicide attempt. And the reason for this is these patients are at an increased risk of suicide. And so, because they are at an increased risk of suicide, they may have already attempted or are at risk to attempt. Also you want to make sure we check for any homicidal ideations. We just want to make sure that they are safe. Okay. The next thing we want to do is we want to be able to provide teaching. So we want to provide teaching as a lot of mental disorders, or mental illness disorders, are based on family support. So we want to make sure that the family is on board with these patients getting well. So that includes teaching the family and encouraging them to support and deal with the client’s symptoms. Remember, clients feel isolated.
So in regards to their past experience, the importance of incorporating a family support system is to help the progression and the effectiveness of the treatment. Next, we want to monitor skin integrity. Remember clients may have developed self-destructive behaviors during treatment. So we want to make sure that if we need to apply any restraints, restraints may be necessary. We want to make sure that we are providing restraint care. We want to because it can equal skin breakdown if we’re not careful. Okay, the next thing is, we want to administer any medications as necessary. Now, while these disorders don’t have any specific medications for them, they may have other mental illnesses that may exacerbate their symptoms. So we may want to deal with depression. We may need something for their chaotic behavior, and that may be given on a PRN basis as needed.
Finally, we want to make sure that we provide support and encouragement. During the recollection of past traumatic events, these patients typically have experienced past trauma and in order to get through it, we want to make sure that they recollect. But in order to do that, we want to build a rapport with these patients. And we want to help them work through all of these difficult emotions and circumstances that they may have been avoiding all this time. So let’s take a look at these key points. Starting with the pathway. Remember dissociative disorders are the result of many traumatic and stressful situations in the past. The subjective data is they may have memory loss, depression, suicidal ideations, their memory be foggy. When you talk to them and you observe them, you may gather insight. It may be erratic, chaotic. They may have that behavior. They may be reclusive. The first thing we want to do is to put them on suicide precautions. These patients may need to be placed in restraints. We also want to do some therapy. We want to make sure that they are seeing a psychiatrist because it’s very important to find out the root cause of these feelings, therapy and encouraging journaling or methods that we could do in order to care for these patients.
We love you guys; go out and be your best self today. And, as always, happy nursing.
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