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Dissociative Identity Disorder (DID) Psychiatric Nursing Case Study

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Jennifer Young

on 24 October 2013

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Transcript of Dissociative Identity Disorder (DID) Psychiatric Nursing Case Study

Dissociative Identity Disorder
What is Dissociative Identity Disorder?
Formerly known as multiple personality disorder,
"DID" is a dissociative mental disorder, characterized by the presence of two or more distinct identities or personality states within the same individual; each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and the self.
What should the nurse do if the treatment team doesn't want staff nurses to interact with the client's alters?

Are alters real people within one person's body?

DID features
Reflects failure to integrate aspects of identity, memory, and consciousness.

Result of severe trauma during early childhood, usually extreme, repetitive, overpowering, and often life threatening physical, sexual, or emotional abuse.

Personality State(s)
distinct personal history
self-image
identity - age, gender, vocabulary, general knowledge
different names
primary identity carries the individual's given name and is often passive, dependent, guilty and depressed.
"Alters" may be real or imaginary people or animals

Diagnosis Criteria
Diagnosis Criteria
A: The presence of two or more distinct identities or personality states
B: At least two of these identities or personality states recurrently take control of the person's behavior

Diagnosis Criteria
D: The disturbance must not be due to the direct physiological effects of a substance or general medical condition
Client Profile
Amanda is a 34-year-old married female who was raised in a strong churchgoing family on a rural southern Bible Belt farm. Her grandfather as well as her father sexually, physically, and mentally abused her as a child. Each of them told her it would kill her mother if she found out and not to tell anyone or they would punish her. Her father, a deacon in the church, routinely abused her on Sundays after church and after Sunday dinner when other family members took a nap. At first Amanda screamed, but no one seemed to hear.

C: An inability to recall important information that is too extensive to be explained by ordinary forgetfulness
Case Study
Amanda is admitted to the adult psychiatric unit. Her husband tells the nurse he fears his wife is "going crazy." Fred describes Amanda cutting her arms and having periods of time for which she has no memory. He relates that Amanda became very upset when he asked her to go to church with him. After the husband leaves, the psychiatric technician goes through the things Amanda brought to the hospital and removes items that she might hurt herself with, inventories them, and locks them up. The admitting orders provide a diagnosis of Dissociative Identity Disorder. The psychiatrist's history and physical on Amanda states she has had one previous admission to the facility. The nurse orders and reads the old chart from medical records and becomes aware of some of the alters (alternative personalities) Amanda has revealed to her psychiatrist and therapists. The nurse offers to play checkers with Amanda after the evening meal. During the checker game one of the alters comes out and says in a child's voice, "I don't want to play with you."

Video Clip
Questions and Answers?
Recently Amanda noticed what she calls "trashy" clothes in her closet. She thought her husband had bought the seductive dresses until she found a charge receipt with her signature on it. Amanda has found herself in a store temporarily unable to recall what she came to buy or who she is. She has found herself talking in a strange childish voice or in a sultry seductive way: not like her real self at all. Amanda suspects she has different personalities within herself: one (Audrey) who likes to dress "trashy," tease men, and control; a small playful bear ("Bear"); "Sissy," age 5, who likes to play but is afraid of adults; Tom, who knows about "Sissy" and wants to protect her. Neither Tom nor Sissy know about Audrey, who seems to know everyone except Butch, who is angry about the abuse and wants Amanda to cut her arms. Amanda never has felt connected to the world and other people. She has little recall of her childhood and tries to deny flashbacks of the abuse.
She began to dissociate: to mentally float above what was happening and feel like an observer. Her grandfather and her father died before she was 10 years old. Amanda repressed the abuse in her subconscious mind. At age 19 Amanda married Fred, a long-distance truck driver, who was kind to her but not often home. The marriage provided a means to get away from her mother who wasn't kind or supportive and who had actually known about the abuse and done nothing.
If you were the nurse on the unit, what would you say to the husband when he says that his wife (your client) is "going crazy"?

If you were the nurse playing checkers with Amanda and she said in a childlike voice, "I don't want to play with you," what therapeutic response would you make and why?

What should the nurse do if the treatment team doesn't want staff nurses to interact with the client's alters?

Are alters real people within one person's body?
Treatment Stages
Stage 1: Stabilization and symptom reduction
Stage 2: Treatment of traumatic memories
Stage 3: Reintegration and rehabilitation
What is the culture of abuse? What role did the southern, rural farm, Bible Belt culture possibly play in the abuse and dissociation?

Symptoms
Inability to remember large portions of childhood
Unexplained events and inability to be aware of them "How did I get here"
Frequent bouts of memomry loss or "lost time"
Sudden return of memory, flashbacks of traumatic events
Feeling disconnected or detached from own body and thoughts
Hallucinations
"Out of body" experiences
Suicide attempts or self-injury
Differences in handwritting from one time to another
Changing levels of functioning from highly effective to nearly disabled
May also suffer from depression, anxiety, phobias, eating disorders, sleep disorders, sexual dysfunction, severe headaches and other somatic pain

Why is the diagnosis of DID controversial? Is this a real disorder, or do mental health professionals and 
clients misapply and misuse this diagnosis?
Does Amanda meet the criteria for a diagnosis of DID?

Integrated Functioning is the Goal of Treatment which may include
Psychotherapy
Clinical Hypnosis
Family and Group therapy
Eye movement desensitization
and reprocessing (EMDR)
Medication
Alters may have a distinct personality, personal history, and self image but their beginnings can be traced back to the characteristics of the real-life person. Being a social construct does not make that self any less real.
Full transcript