This document discusses dissociative disorders including dissociative amnesia, fugue states, depersonalization disorder, and dissociative identity disorder (DID). It describes the symptoms and causes of each disorder and outlines treatment approaches including establishing trust, providing support, medication management, and therapy techniques. Nursing care for patients with dissociative disorders focuses on safety, education, developing consistency and trust, and helping patients cope with daily living and underlying conflicts or trauma.

1. Prepared by:
Eric F. Pazziuagan, RN, MAN

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Removal from conscious awareness of painful
feelings, memories, thoughts, or aspects of
identity.
Unconscious defense mechanism that protects
an individual from the emotional pain of
experiences or conflicts that have been
repressed.
Splitting off helps these individuals endure and
survive intense emotion, physical pain, or both.

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Occurs as a result of extreme stress or trauma,
such as war or abuse in childhood and
adulthood.
Individuals might develop PTSD if trauma is
severe and lasting, which can lead to
dissociative identity disorder.
Abnormal dissociative states can become
dissociative disorders when identity, memory,
or consciousness is disturbed or altered.

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Amnesia: loss of memory or the inability to
recall important personal information.
Recent amnesia can occur immediately after
a traumatic event.
Localized amnesia occurs when the individual
cannot remember what occurred during a
specific period of time.
Selective amnesia: ability to recall some
events during a specified period.

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Patients are sometimes found by the police
wandering aimlessly and are confused and
disoriented.
Dissociative amnesia: one or more episodes of the
inability to recall important personal information
that is beyond ordinary forgetfulness.
Amnesia does not occur only during the course of
dissociative identity disorder, nor is the result of a
substance (drug or medication) or a medical
condition (head trauma).

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Sudden, unexpected travel away from home or
some other location with the assumption of a
new identity (partial or complete) or a
confusion about one’s identity.
The travel and behavior appears normal to
casual observers; thus, the person does not
seem to be wandering in a confused state.
May last from a few hours to several days.
Usually accompanied by amnesia.

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Rare; usually follows severe psychosocial
stress, such as marital quarrels, personal
rejections, military conflict, natural
disaster, financial difficulty, and suicidal
ideation.
Major depression often present prior to
dissociative fugue and there might be a history
of childhood trauma.
Fugue state allows escape or flight from
intolerable event or situation.

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Sense of one’s reality is changed, but the
person is oriented to time, place, and person.
Individual feel detached from parts of their
bodies of from mental processes.
Involves an altered sense of self, so that
individuals feel unreal or strange or believe that
danger is not happening to them but to
someone else.

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As a response to overwhelming stress,
individuals are protected form overwhelming
anxiety.
Can also involve feeling like a robot or feeling as
though one is in a dream; often accompanied
by symptoms feel that the outside world is
changed or unreal.
 Buildings appear leaning, everything might be seem
grey and dull.

10. A diagnosis is made only when the
prevalence or intensity of the disorder
causes marked distress, interferes with
daily functioning, and occurs with the
absence of other disorders,
 Imaging study suggested abnormalities
on limited cortical areas.
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Existence of two or more identities or
personalities that take control of the person’s
behavior.
Person or host, is unaware of the other
personalities (alters), but the other alters might
be aware of each other to varying degrees.
May experience memory
problems, depersonalization, identity
confusion, time loss, voices conversing with each
other, and voices that are persecutory.

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Traditional views: dissociation as a defense
against extreme anxiety that is aroused in highly
painful and emotionally traumatic
situations, such as physical, emotional, and
sexual abuse.
Splitting off allows the person to survive the
trauma but leaves an impaired personality with
disconnected parts, or alters.
Alter personalities have feelings and behaviors
associated with the trauma.

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Each personality is different from the others
and from the original personality.
Each personality has its own name, behavior
traits, memories, emotional characteristics,
and social relations.
The primary identity might carry the person’s
name and be depressed, dependent, and
guilty, whereas alternate personalities might
be hostile, controlling, and self-destructive.

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Sometimes, a switch to another personality is
sometimes preceded with a headache, or
individuals might cover their face and eyes with
hands.
Patients are admitted when they are suicidal,
meaning that the alter personality is trying to
harm or kill one of the other personalities for
revelations concerning abuse.

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Severe anxiety or depression related to the
coming out of upsetting alters might also be
a reason for admission.
Safe structure of a hospital: provides
emotional security when working with
difficult or overwhelming problems.

16. Medication does not eliminate the
dissociative disorder itself.
 Medications might help for anxiety and
depression.
 DID: response to medication might be
partial, and an alter’s response to
medication might be different and
inconsistent.
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Provisions for a safe environment and a
trusting relationship.
Assist with group sessions.
Provide emotional
security, empathy, acceptance, and support.
Help patients cope with daily living.
DID: ongoing process-oriented groups can be
nontherapeutic when patients reveal too
much and overwhelm the group or regress.

18. Individual therapy should be in progress.
 Task-oriented groups are beneficial.
 Occupational therapy and art therapy: for
nonverbal expression to reveal material that
cannot be verbally accessed.
 Milieu meetings: decreases isolation.
 DID: cognitive therapy, relaxation, stress
management, meditation and exercise.
 Cognitive therapy: decreases blame or guilt
surrounding issues of physical or sexual abuse.
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Before discharge, a safety plan and no-harm
contract might be necessary, as well as
initiating or continuing a support system for
the patient.
Self-help groups: opportunity to practice
social skills and problem solving to develop a
sense of empowerment and control.

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The nurse’s relationship with clients
experiencing amnesia and fugue includes
interventions to establish trust and support.
Physiologic and neurologic work-ups to rule
out organic causations.
Assist with gathering data regarding feelings,
conflicts, or situations that patients
experienced before the amnesia or fugue
state.

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Patients might have hypnotic sessions to gather
data about forgotten material.
Slowly help clients deal with anxiety and conflicts in
their lives and improve coping skills.
Patients with depersonalization disorder are only
admitted if they are suicidal, extremely anxious, or
depressed.
Treatment goad for DID: integrate the personalities
or memories, if possible, so that they can survive or
coexist in the original personality.

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Provide caring and empathy and work with
patients to establish trust because the
relationship of these patients with authority
figures might have been
inconsistent, rigid, and unpredictable.
Contract for patient’s safety and to reduce
self-harm and violence.
Remember that even with the presence of a
child alter, the patient is an adult, not a child.

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Be alert for splitting by staff members
regarding patient’s diagnosis.
Education about diagnoses, management of
feelings, especially anger and rage, and
consistency of approach assist the staff in
developing a caring, supportive environment
for patients so that trust increases and a
predictable, positive learning environment is
developed.