Chapter 24 - Dissociative Disorders

The father of a 6 month old and a 3 year old discovers that his wife, who is the mother of the

children, has abandoned the family and moved to another state. During this developmental

stage, this abandonment will have the strongest negative effect on the children's:

a. motor skills.

b. self-concept.

c. body image.

d. cognitive skills.

B. Self-concept

Trust and consistency play a major role in the development of a child's self-concept.

Abandonment provides neither. The mother's absence may not affect the motor or cognitive skills of the children. Body image is only one component of self-concept

The hospice nurse notices that, following the death of his wife of 50 years, a surviving

husband's affect is anxious, and he reports a feeling of detachment from his body, stating, "I

feel like I am seeing myself from outside of my body." The caregiver knows that this client

is displaying the characteristics of the dissociative disorder of:

a. dissociative fugue.

b. dissociative amnesia.

c. dissociative identity disorder.

d. depersonalization disorder.

d. depersonalization disorder.

Depersonalization serves as a defense mechanism in response to severe anxiety. The person

often is described as "working on automatic" or "functioning as a robot." The characteristics

listed describe the behavioral or social signs and symptoms of depersonalized disorder.

Fugue is characterized by traveling that occurs suddenly and unexpectedly with no recall of

the traveling. Amnesia is the inability to remember personal information, and dissociative

identity disorder was formerly known as multiple personality disorder.

The nurse witnesses different personalities emerging in the client with dissociative identity

disorder (DID). The primary personality is referred to as the:

a. host

b. alter

c. ego

d. identity

a. host

Host is the term for the primary personality, which may not be aware of the alters (the other

personalities). Ego is one component of the three-part theory of the ego, id, and super-ego

identified by Sigmund Freud when referring to his belief of how personalities are structured.

Identity refers to how one sees oneself.

When developing the nursing care plan for a client with dissociative identity disorder (DID),

the nurse knows that one of the major goals of therapy is to assist the client in:

a. naming all personalities for clarification.

b. integrating the personalities into one functional personality.

c. realizing when different personalities are about to emerge.

d. learning how to move from one personality to another.

b. integrating the personalities into one functional personality.

It is important for therapy to assist the client in combining the personalities into one, so that

the individual is able to function and cope effectively with daily stressors. Naming the

personalities might occur without thought but is not necessary. In addition, realizing when

alters are about to emerge and learning how to move among personalities are not goals of

treatment.

During a home visit, the client tells the nurse that she feels that her medication is no longer

helping her dissociative diagnosis of depersonalization disorder because she has noticed that

she is not thinking clearly, is having difficulty with her memory and judgment, and is often

disoriented to the time. The nurse knows that the doctor must be contacted and that this

client most likely will be:

a. admitted to a long-term care agency because she is a threat to herself.

b. admitted to a state-psychiatric facility for an extended period for intense therapy.

c. referred to a group home setting for better supervision.

d. admitted to the hospital for evaluation and possible adjustment of her medications.

d. admitted to the hospital for evaluation and possible adjustment of her medications

Admission to the hospital will be necessary to safely evaluate and/or adjust her medications.

Moving the client from her home to any type of long-term care or group home setting or

state-psychiatric facility is not warranted from her symptoms.

The care provider is aware that in addition to assessment, one of the first goals of therapy

for the client with a dissociative disorder is:

a. revisiting of past traumas.

b. pharmacological therapy.

c. stabilization.

d. family therapy.

c. stabilization.

Although revisiting of past traumas, pharmacological therapy, and family therapy are all

possible treatment components, stabilization must be implemented first for the client.

Stabilization consists of making the patient feel safe and able to trust the treatment team.

Those who care for individuals with dissociative disorders must be aware that they often

will try to __________ the staff members who are caring for them.

a. manipulate

b. harm

c. date

d. persecute

a. manipulate

As with many individuals with mental health disorders, clients with a dissociative disorder

frequently will try to manipulate the staff to benefit themselves. Harming, dating, or

persecuting the staff is not typical behavior of a person with a dissociative disorder.

Which of the following is considered a primary nursing diagnosis for a client with a

dissociative disorder?

a. Self-esteem, low

b. Personal identity, disturbed

c. Role performance, ineffective

d. Anxiety

b. Personal identity, disturbed

Although all of the nursing diagnoses listed are related to dissociative disorders, "Personal

identity, disturbed" is the only one listed that is a primary nursing diagnosis for these

disorders.

During assessment of a client with a dissociative disorder, the nurse notices that the client

has been cutting herself on both arms. After talking with the client, the nurse, along with

other members of the treatment team, decides that the best intervention at this time to

prevent further self-destructive behavior would be:

a. establishing a signed contract with the client to tell a team member when she is

having self-destructive thoughts.

b. isolating the client from all other clients and activities until she is no longer having

self-destructive thoughts.

c. administering medications that will reduce the client's anxiety levels.

d. involving the client in activities as a diversion from self-destructive thoughts.

a. establishing a signed contract with the client to tell a team member when she is

having self-destructive thoughts.

Contracts are effective in building trust between the client and the treatment team, as well as

in making the client responsible to seek assistance at crucial times. Isolating a client,

administering antianxiety medications, and providing diversional activities would not

address the self-destructive thoughts.

A client with the diagnosis of depersonalization disorder notices that he experiences periods

of depersonalization when confronted with certain stressors. When developing the care plan,

the nurse is aware that one of the most helpful activities in self-control for this client is for

the client to:

a. contact a treatment team member to discuss his thoughts and feelings every time

he is confronted with a stressor.

b. keep a daily journal of his thoughts and feelings, paying special attention to

thoughts and feelings during stressful times.

c. recall periods of stressful times in his life during his clinic visit.

d. join an exercise program that will help to decrease his stress level.

b. keep a daily journal of his thoughts and feelings, paying special attention to

thoughts and feelings during stressful times.

Daily journals will allow the client to vent his feelings, will enable reflection on events that

led to depersonalization episodes, and will assist the treatment team in collaborating with

the client on self-control measures to help prevent episodes in the future. Contacting a team

member with every stressor or trying to recall episodes is unrealistic. Although an exercise

program may help to decrease stress levels, it does not deal directly with episodes.

A female client with a diagnosis of a dissociative disorder who attends group meetings at a

community mental health clinic often voices that her boss at work frequently complains that

she is working at a level below her capabilities. The client also states that she feels that she

"never gets anything done." Which nursing diagnosis best addresses these issues?

a. Self-esteem, low

b. Social isolation

c. Body-image, disturbed

d. Memory, impaired

a. Self-esteem, low

The client is exhibiting characteristics typical of low self-esteem. She is not isolating herself

from others, does not indicate a distorted perception of her body, and shows no sign of

problems with her memory.

What is the first nursing priority in a client with the nursing diagnosis of "Personal identity,

disturbed"?

a. Promote wellness.

b. Assist the client to manage any threatening feelings.

c. Assess causative and/or contributing factors.

d. Determine which medications will work most effectively.

c. Assess causative and/or contributing factors.

Causative and/or contributing factors would be the first priority in guiding the rest of the

care planning process. The second priority for a client with this nursing diagnosis would be

to assist the client to manage any threatening feelings, followed by promoting wellness.

Determining which medications are effective is not a nursing priority for this nursing

diagnosis; rather, this is more of a physician-initiated action.

A "spell" is a culturally defined mental health disorder or a dissociative "state" seen in

African Americans, Europeans, and Americans from southern U.S. cultures. This "state" is

characterized by:

a. sudden collapsing with eyes open and inability to see, while still hearing and

understanding, without being able to move.

b. seizure activity and coma for up to 12 hours preceded by extreme excitement or

irrational behavior.

c. a state in which spirit possession interferes with daily activities.

d. communication with deceased relatives or spirits that occurs during a trancelike

state.

d. communication with deceased relatives or spirits that occurs during a trancelike

state.

A "spell" is seen in these cultures and is characterized by the behaviors listed. Sudden

collapsing with eyes open and inability to see but ability to hear and understand describes

the state of "falling out" seen in members of some cultures living in the southern United

States and in certain Caribbean groups. Seizure activity and coma preceded by extreme

excitement or irrational behavior describes "piblokto," seen in some Arctic and sub-Arctic

Eskimos; a state in which spirit possession interferes with daily activities describes "zar,"

seen in cultures of individuals originating from Egypt, Ethiopia, Iran, and Sudan.

The wife of a 70-year-old man is concerned that her husband refuses to participate in any

activities with her since his retirement 2 years ago. He is often short tempered and sees any

type of hobby as a "waste of time." Which intervention or activity would help him enhance

his feelings of self-worth?

a. Begin taking antidepressant medication.

b. Move with his wife to an assisted living community.

c. Get involved in a retired businessmen's group providing assistance to new

companies.

d. Taking up a less strenuous activity to decrease stress and information overload.

c. Get involved in a retired businessmen's group providing assistance to new

companies.

A threat to the stability of one's lifestyle (such as change in employment) can lead to

changes in self-concept, as it affects personal identity, self-esteem, and role performance.

An activity which allows the person to adapt to change and regain a sense of self-esteem and

self-worth will enhance the expression of self-concept. Taking antidepressants, moving to

an assisted living community, and taking up a less strenuous mental and physical activity do

not provide the same degree of expression of self-concept.

A family adopts a 7-year-old boy from an international adoption agency with little

information on the child's history. They bring the child to a therapist because the child is

withdrawn, destroys things in the house, and hits his adoptive siblings without provocation.

As the therapist develops a trusting relationship with the child, what type of intervention

would be initially used to gain input from the child?

a. Psychoeducation

b. Art therapy

c. Joint stabilization plan

d. Development of coping strategies

b. Art therapy

During the stabilization phase, the diagnosis is established as the client reveals the

complexities of his nature. In a child who is withdrawn, art therapy can be used as a means

of communication and expression. Psychoeducation would not be the strategy to use at this

stage. A joint stabilization plan and development of coping strategies occur after a trusting

relationship and client input occur.

A woman has had several episodes where she finds new clothes in her closet that are much

more colorful than the style she usually buys. Today, a coworker approached her to thank

her for hosting a dinner party that she had no recollection of hosting. What is the most

appropriate nursing diagnosis for this client?

a. Self-esteem, low

b. Personal identity, disturbed

c. Body image, disturbed

d. Anxiety

b. Personal identity, disturbed

Nursing diagnoses for clients with dissociative disorders are related to self-concept

responses and depend on identified problems of each client. In this case, the description the

client gives relates to personal identity. Low self-esteem and disturbed body image may be

contributing factors to this diagnosis.

Which dissociative disorder is a result of a disturbance of identity?

a. Dissociative amnesia

b. Dissociative identity disorder

c. Dissociative fugue

d. Obsessive-compulsive disorder

b. Dissociative identity disorder

Dissociative identity disorder is a disturbance of identity. Dissociative amnesia and

dissociative fugue are disturbances of memory. Obsessive-compulsive disorder is a mood

disorder.

A client with a dissociative disorder has the nursing diagnosis of disturbed body image.

Which nursing interventions would address the nursing priority of determining the coping

abilities and skills of this client? (Select all that apply.)

a. Assess the client's current level of adaptation.

b. Help the client differentiate between isolation and loneliness.

c. Note the use of addictive substances.

d. Identify previously used coping strategies and their effectiveness.

a. Assess the client's current level of adaptation.

c. Note the use of addictive substances.

d. Identify previously used coping strategies and their effectiveness.

The client's current level of adaptation must be assessed as a baseline for the plan of care.

Noting the use of addictive substances may reflect dysfunctional coping mechanisms.

Identifying whether previously used coping strategies were effective will reveal whether any

of them can be used again. Helping the client differentiate between isolation and loneliness

is an intervention that is directed toward the nursing diagnosis of social isolation.

A male client with a dissociative disorder copes with his low self-esteem by displaying

behaviors associated with an exaggerated sense of self-importance. Which behaviors would

this client most likely exhibit? (Select all that apply.)

a. Bragging about special abilities

b. Setting unrealistic goals

c. Having unrealistic dreams

d. Having a view of life that everything is either right or wrong

a. Bragging about special abilities

b. Setting unrealistic goals

c. Having unrealistic dreams

The client with an exaggerated sense of self-importance often brags about his special

abilities, sets unrealistic goals because he feels he is capable of anything, and sets unrealistic

dreams for himself for the same reason. The belief that everything in life is either right or

wrong is a polarized view that is seen in clients with a negative outlook about life.