Learning Objectives
By the end of this section, you will be able to:
- Define dissociative disorder
- Recall the symptoms and prevalence of dissociative identity disorder
- Outline approaches to treating dissociative identity disorder
A disruption in consciousness, memory, identity, or perception not caused by substance use or a medical condition are considered a dissociative disorder (American Psychiatric Association, 2013). The most commonly known dissociative disorder is dissociative identity disorder. Formerly known as multiple personality disorder, dissociative identity disorder is characterized by the presence of two or more distinct personality states, with a disconnection in the individual’s sense of self and actions (Moore, 2016). People with dissociative identity disorder experience frequent dissociative amnesia, which is a gap in memory involving important personal information (Drescher, 2022). This disorder may also encompass a range of dissociative symptoms, such as dissociative fugue, which may entail unexpected or unplanned travel and amnesia regarding one’s identity, and depersonalization/derealization disorder, marked by feelings of detachment from oneself or their surroundings (American Psychiatric Association, 2013).
Defining Dissociative Disorder
Dissociative disorders are psychiatric conditions characterized by disruptions in consciousness, memory, identity, emotion, perception, behavior, and sense of self (American Psychiatric Association, 2013). These disturbances may be sudden or gradual, acute or chronic. Dissociative disorders are thought to arise as a psychological defense against trauma, enabling the person to compartmentalize memories and experiences that are too much for them to process (Subramanyam et al., 2020).
Diagnosing Dissociative Disorders
Diagnosing dissociative disorders can be a complex process that requires a comprehensive clinical assessment by mental health professionals knowledgeable about these conditions. The diagnosis generally involves a detailed interview to explore the client’s symptoms, taking a history of trauma, and performing a mental status examination. The use of specific diagnostic tools, such as the Dissociative Experiences Scale (DES) or the Structured Clinical Interview for Dissociative Disorders (SCID-D), can aid in assessing the severity and nature of dissociative symptoms (Loewenstein, 2018). The clinician assesses the nature, timing, and duration of dissociative symptoms, such as memory loss, depersonalization, and personality alterations. In addition to evaluating the client’s symptoms, clinicians gather information from family members, previous medical records, and other sources to form a holistic understanding of the client’s condition. It is important to rule out other medical and psychiatric conditions that may present with similar symptoms, such as seizure disorders or psychotic disorders, to ensure an accurate diagnosis (American Psychiatric Association, 2013).
Possible Causes of Dissociative Disorders
Dissociative disorders are often caused by psychological trauma and may result in significant distress or impairment in social, occupational, or other important areas of functioning. The underlying mechanisms are not fully understood, but the disorders are believed to be coping strategies that separate distressing or traumatic information from conscious awareness (American Psychiatric Association, 2013).
Symptoms and Prevalence of Dissociative Identity Disorder
DID is a complex psychiatric condition characterized by the presence of two or more distinct identity states. These identities recurrently take control of an individual’s behavior, consciousness, and memories, leading to significant distress and functional impairment (American Psychiatric Association, 2013). The prevalence of DID varies across cultures and populations. In the general population, the prevalence rate is estimated to be around 1.5 percent internationally (Mitra & Jain, 2021). Research indicates that DID is more common among females, and there may be a significant correlation between DID and a history of childhood trauma or abuse (Mitra & Jain, 2021).
Symptoms of DID typically include identity confusion, identity alteration, and amnesia. Identity confusion refers to inner conflict or confusion regarding a person’s identity. Identity alteration involves the display of different personalities or identities, while amnesia refers to the inability to recall personal information that cannot be explained by ordinary forgetfulness.
Additionally, individuals with DID may experience depersonalization, derealization, self-harm, and suicidal tendencies (Drescher, 2022). The symptom of depersonalization refers to an alteration in the perception or experience of oneself, where an individual may feel detached or estranged from their thoughts, feelings, body, or actions. It often presents as a sensation of observing oneself from an outside perspective or feeling as if one’s emotions and physical sensations are not truly their own (Simeon, 2024). On the other hand, derealization involves a feeling of detachment or estrangement from one’s surroundings. People experiencing derealization may perceive the external world as unreal, dreamlike, or distorted. Objects, places, and even people may seem unfamiliar or changed in some way, leading to a sense of unreality or confusion. Like depersonalization, derealization can be deeply unsettling, impairing one’s ability to engage with their environment (Simeon, 2024).
Treatment of Dissociative Identity Disorder
The treatment for DID is typically long-term and involves various therapeutic approaches tailored to the individual’s unique needs and symptoms. The primary goal of treatment is to integrate the separate identity states into a cohesive and functional whole, thereby improving overall functioning and quality of life (International Society for the Study of Trauma and Dissociation [ISSTD], 2011).
Psychotherapy is considered the mainstay of treatment for DID, emphasizing building trust, fostering a strong therapeutic alliance, and providing a safe environment for exploring traumatic memories and identity fragmentation (Gentile et al., 2013). Cognitive behavioral techniques challenge distorted thought patterns. Psychodynamic interventions help clients understand how past traumas have shaped their current identity structure and help promote the integration of various identity states into a cohesive self. Dialectical behavior therapy emphasizes mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness (Hohfeler, 2016). Pharmacological interventions, such as antidepressants or anxiolytics, may also be used to manage comorbid conditions like depression or anxiety. They are not considered a primary treatment for DID, however, because they do not specifically treat the dissociation (Gentile et al., 2013).
Integrated Functioning
The process of synthesizing different aspects of a person’s identity, experience, and functioning into a cohesive and harmonious whole is called integrated functioning. This concept is particularly relevant in DID, where individuals experience fragmentation and disconnection among different identity states (Brand et al., 2019). In DID, integration involves merging various identity states into a unified sense of self. This process may include recognizing and accepting different parts as aspects of a single, complex person rather than as separate and disconnected entities. The goal is not to erase or negate the different parts but to acknowledge and harmonize them into a whole (Subramanyam et al., 2020). Many individuals with DID have amnesia or disconnection between different identity states. Integrating memories involves linking these disconnected memories to create a coherent narrative of one’s life, including traumatic and nontraumatic experiences (Berntsen & Rubin, 2006). Integration of emotions and behaviors focuses on connecting emotions and behaviors across different identity states. It may involve recognizing patterns, understanding emotional triggers, and developing adaptive ways to express and manage emotions (Fassbinder et al., 2016). The ultimate goal of integration is to facilitate overall functioning in daily life. This improvement in functioning includes enhanced relationships, adequate vocational functioning, reduced distress, and improved quality of life. Achieving integrated functioning is not necessarily about the absence of symptoms, but about the ability to live a fulfilling and balanced life (ISSTD, 2011).
Individual Psychotherapy
Individual psychotherapy is considered the primary treatment modality for DID. It is a highly specialized and complex process that must be carefully tailored to the unique needs of each individual (Huntjens et al., 2019). Individual therapy begins with a comprehensive assessment to understand the client’s symptoms, history, needs, and goals. The initial phase of therapy often focuses on stabilization, including managing acute symptoms, building coping skills, and addressing any immediate safety concerns, such as self-harm or suicidality. Once stable, clients may shift to therapy to process traumatic memories and experiences. These therapies can involve techniques like trauma-focused CBT, but it must be done carefully, considering the fragmented nature of memory and identity in DID. Therapy concludes with a focus on maintaining gains, generalizing skills to everyday life, and preparing for termination. This phase ensures the individual can function effectively outside the therapeutic relationship (Huntjens et al., 2019).
Establishing Safety
Establishing safety with DID clients is a crucial aspect of care, especially in nursing, where staff is often the first line of support and contact for these individuals. Implementing strategies to promote safety can enhance the therapeutic relationship, foster trust, and contribute to the recovery process. Education about the nature of DID, including the complex interplay of dissociation, trauma, and identity fragmentation, is crucial. Knowledge about the disorder can guide appropriate interventions and reduce misconceptions (ISSTD, 2011). A calm, predictable environment can minimize triggers for dissociation. This might include consistent staffing, clear communication, gentle handling of personal belongings, and respecting personal space (Purvis et al., 2013). Reassurance, grounding techniques, and client-centered communication can facilitate reorientation and emotional regulation. Collaborating with the client to develop individualized safety plans, including coping strategies and emergency contacts, can empower the client and build trust (Brand et al., 2013). Understanding the client’s cultural background and ethical considerations is crucial for respectful and effective care because this can shape the experience of DID and the therapeutic relationship. By focusing on these key areas, nurses can play a vital role in establishing safety with DID clients, creating a foundation for therapeutic intervention and recovery (Kwame & Petrucka, 2021).
Confronting
Confrontation in therapy in the treatment of DID is delicate. It involves addressing behaviors, beliefs, or experiences that may be problematic or hinder progress. Confrontation does not necessarily mean aggressive or forceful challenges. It can be a gentle process of pointing out discrepancies or exploring contradictions in a client’s thoughts, feelings, or behaviors. The goal is to help the client gain insight and make positive changes (Rajhans et al., 2020). Aggressive or poorly timed challenges can exacerbate dissociation, increase resistance, or damage the therapeutic alliance (ISSTD, 2011). Before any confrontation can occur, develop a solid foundation of trust and safety, understand the unique experiences of each identity state, build rapport, and create a secure environment to explore challenging topics (Loewenstein, 2018).
Time the decision to confront specific issues carefully. The therapist must assess the client’s readiness and the therapeutic relationship’s stability. Pacing is also crucial, allowing for gradual exploration and avoiding overwhelming the client (Kwame & Petrucka, 2021). In DID, confronting traumatic memories prematurely or without adequate preparation can lead to retraumatization. Therapists must be cautious in approaching trauma-related content, ensuring the client has the necessary coping resources. While confrontation can be a useful therapeutic tool, it requires caution, empathy, and a clear understanding of the complex dynamics of DID. A client-centered approach that prioritizes safety, collaboration, and gradual exploration is likely to be more effective and ethical (Loewenstein, 2018).
Integration and Rehabilitation
Rehabilitation in DID focuses on reintegration into daily life, improving functionality, and achieving life goals. Building supportive relationships with family, friends, and community is vital. Peer support groups also play a valuable role. Rehabilitation often involves a multidisciplinary approach, including medical care, psychotherapy, occupational therapy, and social work. Coordination among these professionals ensures comprehensive care (Saha et al., 2020). Developing strategies for managing stress and avoiding triggers can prevent the recurrence of dissociative symptoms and promote ongoing recovery (SAMHSA, 2014).
Clinical Safety and Procedures (QSEN)
QSEN Competencies in Treatment of DID
Applying the QSEN competencies to the treatment of DID helps guide the nurse to prioritize client safety, ethical considerations, and evidence-based interventions.
- Client-centered care: Understand the unique experiences of DID clients, including their history, individual identity states, and needs. Engage clients in shared decision-making and respect their preferences and values (Sherwood & Barnsteiner, 2017).
- Teamwork and collaboration: Collaborate with an interdisciplinary team, including therapists, psychiatrists, social workers, and family members. Maintain open communication and shared goal-setting to support the client’s integration and rehabilitation (Ndibu Muntu Keba Kebe et al., 2019).
- Evidence-based practice: Utilize evidence-based interventions like individual psychotherapy, cognitive behavioral techniques, and dialectical behavior therapy. Regularly assess outcomes to refine the treatment plan (Fassbinder et al., 2016).
- Quality improvement: Monitor the client’s progress throughout treatment, identifying areas for improvement. Utilize DID assessment tools and client feedback to ensure ongoing quality of care (Wong et al., 2020).
- Safety: Establish a safe therapeutic environment that promotes trust and minimizes triggers or retraumatization. Implement safety protocols to manage crises and prevent self-harm or harm to others (Loewenstein, 2018).
- Informatics: Leverage electronic health records and other informatics tools to track progress, document interventions, and coordinate care across providers. Ensure privacy and confidentiality in handling sensitive information related to DID and trauma history (Kariotis et al., 2022).
QSEN competencies provide a comprehensive framework for safe, effective, and ethical care for DID clients. By focusing on client-centered care, teamwork, evidence-based practice, quality improvement, safety, and informatics, nurses can contribute to the successful treatment and support of individuals with DID (Sherwood & Barnsteiner, 2017).