MH unit4
Dissociative Identity Disorder and Dissociative States
Dissociative Identity Disorder (DID) * DID was formerly known as multiple personality disorder. * Individuals with DID experience multiple personality states. * Every distinct personality may possess unique characteristics, such as being a different age, gender, or nationality. * Personalities may speak different languages and maintain distinct likes, dislikes, values, and attitudes. * Memory gaps are common because the individual may not remember events that occurred while a different personality was in control. * Social navigation challenges occur when acquaintances recognize the individual by a second name or recall shared events that the primary personality has no memory of. * Diagnosis is a long process as clinicians must witness the different personalities; some documented cases involve up to different personalities, sometimes identified or named by colors.
Depersonalization * Defined as persistent or recurring feelings of detachment from one’s own body or mental processes. * The individual may feel like an observer of their own physical self.
Derealization * Defined as detachment from the environment. * Patients often describe this as living in a dreamlike state or existing within a fog. * Crucially, these patients remain in touch with reality and are not considered psychotic.
Clinical Management of Dissociative Disorders
Patient Risks and Emotional Impact * There is a significant risk for suicide among those with DID. * Patients may feel intense guilt or remorse upon learning about harmful actions taken by an aggressive or uncharacteristically mean personality while they were unaware. * The aggressive personality itself may lack remorse because it is part of their specific nature.
Treatment Goals and Strategies * The priority is to help the patient reconnect with reality and stabilize them. * Treatment aims to integrate thoughts, memory, and identity. * Primary Treatment: Long-term psychotherapy. * Healing focus: Gradually addressing trauma and rebuilding the identity. * Trauma therapy: Similar to PTSD treatment but progresses more slowly to avoid overwhelming the patient.
Pharmacology in Dissociative Disorders * Medications are not the primary treatment. * Drugs are used strictly to manage symptoms, such as anti-anxiety medications or SSRIs (selective serotonin reuptake inhibitors) for depression. * The setting (inpatient vs. outpatient) depends on the patient's specific risk level.
Nursing Interventions: Grounding and Reality Orientation * Grounding techniques are used to manage dissociation and flashbacks. * Goal: Remind the patient they are in the present, they are safe, and they are an adult. * During flashbacks, patients may mentally revert to the age they were when the trauma occurred (e.g., or years old). * Reality Orientation Techniques: * Auditory: "Can you hear the sound of my voice?" * Tactile: "Can you touch the wall?" or "Can you put your feet on the floor?" * Visual: "Look around the room. Tell me what you see." * Frequent reorientation is provided as often as necessary to diminish dissociative experiences.
Stress, Anxiety, and Coping Mechanisms
Stress Overview * Stress is defined as the wear and tear on the body occurring when demands exceed coping ability. * Stress can be positive (eustress) resulting from major life changes like a new job, college, marriage, or children. * Positive stress still causes anxiety due to the element of change.
Healthy Stress Management Strategies * Maintain a positive outlook. * Accept things that cannot be controlled. * Express emotions and talk about feelings. * Practice deep breathing, meditation, and guided imagery. * Prioritize exercise, healthy eating, and adequate sleep. * Substances to avoid: Alcohol and excessive caffeine (which increases heart rate and worsens anxiety symptoms).
Anxiety vs. Fear * Anxiety: A vague feeling of uneasiness, worry, or dread. * Fear: A response to a clear, known threat. * Anxiety is unavoidable, normal, and necessary; it can motivate learning and improve performance. * Anxiety should resolve once the associated stressor is removed.
General Adaptation Syndrome (GAS)
Alarm Stage * The "fight, flight, or freeze" response. * The hypothalamus sends signals, causing the release of adrenaline and norepinephrine. * Sympathetic nervous system activation leads to: * Increased heart rate and blood pressure. * Increased oxygenation and blood sugar. * Dilated pupils. * Decreased Gastrointestinal (GI) activity.
Resistance Stage * The body attempts to adapt to stress. * Vital signs remain elevated initially. * If stress is managed, the parasympathetic nervous system returns the body to normal; heart rate and blood pressure decrease, and digestion returns.
Exhaustion Stage * Occurs when stress continues for too long and energy stores are depleted. * Results in fatigue, a weakened immune system, increased illness risk, and potential emotional breakdown.
The Four Levels of Anxiety
1. Mild Anxiety * Normal and helpful; motivates action and sharpens focus. * Physical signs: Irritability, "butterflies" in the stomach, knots. * Intervention: None required; this represents a good time for patient teaching.
2. Moderate Anxiety * Difficulty concentrating; requires redirection. * Physical signs: Higher pitch in voice, increased urination patterns. * Intervention: Use simple, short instructions; learning is still possible with assistance.
3. Severe Anxiety * Focus is very limited; person cannot think clearly. * Physical signs: Confusion, crying, ritualistic behaviors, headache, nausea, vomiting, diarrhea, trembling, tachycardia, chest pain. * Intervention: The nurse must stay with the patient and use a calm, low voice. Questions should be specific and direct.
4. Panic Level * An emergency level where control is lost and reality is distorted. * Physical signs: Extremely high blood pressure and heart rate, rapid breathing, and enlarged (dilated) pupils. * Intervention: Safety is first. Move the patient to a quiet environment with decreased stimuli. Do not leave the patient alone. Speak calmly.
Clinical Management and Treatments for Anxiety Disorders
Characteristics of an Anxiety Disorder * Distinguished from normal anxiety by being excessive, persistent, and interfering with daily life (e.g., constant worrying or panic attacks without cause). * Most common mental disorders, affecting approximately of people.
Biological Causes and Neurotransmitters * GABA: The body’s natural anti-anxiety agent. It is inhibitory (reduces cell excitability). A decrease in GABA levels leads to an increase in anxiety. * Norepinephrine: Excitatory. Increases cell excitability, affecting attention, learning, and memory. An increase in norepinephrine leads to increased anxiety. * Serotonin: Regulates emotions, sleep, and wakefulness. An imbalance (either too high or too low) is associated with anxiety.
Psychosocial and Behavioral Theories * Relationships and defense mechanisms influence anxiety. * Behavioralists suggest anxiety is a learned response that can be unlearned.
Therapeutic Interventions * Cognitive Behavioral Therapy (CBT): The first-line treatment over medication. Focuses on changing negative thoughts. * Decatastrophizing: Challenging catastrophic thinking by asking, "What is the worst that can happen?" * "I" Statements: Used to take control of situations and emotions. * Thought Stopping: Techniques like splashing cold water on the face or snapping a rubber band on the wrist. * Systematic Desensitization: Gradual exposure to a feared object, starting with low-anxiety situations. * Flooding: Immediate, intense exposure to the feared object; must be conducted by a trained therapist.
Pharmacology for Anxiety * Benzodiazepines: Lorazepam, Alprazolam, Diazepam (PAMs). Used for short-term, rapid relief. High risk for addiction, dependence, and sedation. * Non-Benzodiazepines: Buspirone (Buspar). Slower acting but safer than benzodiazepines. * SSRIs: Now considered the primary medication for long-term care; they take time to become effective. * Beta Blockers: Propranolol. Used to manage physical symptoms (tachycardia, hypertension) to calm the body. * Alpha Agonists: Clonidine. Reduces the sympathetic response. * Antihistamines: Hydroxyzine is increasingly used, though it causes drowsiness. * Tricyclic Antidepressants: Used when other medications fail, though they have more side effects.
Specific Anxiety Disorders: Panic, Phobias, and Social Anxiety
Panic Disorder * Characterized by recurrent, unexpected panic attacks lasting to minutes. * Diagnosis requires or more symptoms (palpitations, sweating, shortness of breath, etc.) and at least month of persistent worry about future attacks. * Priority: Stay with the patient and provide safety during the attack.
Phobias * Irrational, intense fear of an object or situation that is out of proportion to actual danger. * Types: Natural environment (storms, heights), Situational (elevators, planes), Specific (snakes, spiders, dogs), and Social.
Social Anxiety Disorder * Fear of being judged or embarrassed in social settings. * Examples include public speaking, eating in public, or using public restrooms.
Agoraphobia * Fear of places or situations where escape might be difficult; often leads to fear of leaving one's "safe space" (home).
Generalized Anxiety Disorder (GAD) * Excessive worry more than of the time for months or more. * Symptoms: Restlessness, fatigue, irritability, muscle tension, and sleep issues.
Questions & Discussion
Q: What if someone's other personality is aggressive? Would they not remember what they said? * A: Yes, it is possible for an aggressive personality to take control and for the primary personality to have no memory of the aggressive acts. However, multiple personalities must be medically proven; it cannot just be used as an escape.
Q: Are those with DID considered for suicide? * A: Yes, because they may feel overwhelming guilt for things they were told they did while another personality was in control, such as harming someone they love.
Q: Would a flashback change their state of lifespan? * A: Yes. A patient may revert to the age they were during a traumatic event. It is essential to ground them and remind them they are safe, they are in the present, and they are an adult.
Q: Are medications given for the panic attacks or the mania? * A: Mania and panic are different; mania (associated with bipolar disorder) requires more intervention than a short-lived panic attack caused by a specific stressor.
Q: What should the nurse be aware of regarding their own reactions? * A: Nurses must maintain "nurse face" and self-awareness. Anxiety is contagious; if a nurse becomes anxious while a patient is in a panic state, it can escalate the patient's condition. The nurse must remain the "safe person."
Q: Personal anecdotes mentioned during the discussion? * The instructor shared a fear of snakes, specifically mentioning an incident with a rat snake in a driveway and a snake on Center Hill Lake. * Discussion of air travel anxieties included flying to Vegas (-hour flight), Italy (-hour flight), Miami, and Antigua. * The instructor mentioned taking Propranolol as a preferred option among anti-anxiety meds offered by a provider named Melissa.