Nursing Care for Dissociative Indentity Disorder
Dissociative identity disorder is a common mental disorder.American Psychiatric Association (2000) defines DID as, “presence of two or more distinct identities or personality states that recurrently take control of the individual’s behaviour, accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness” (as cited in Ringrose, 2011, p.294).
Coons (1998) states that an individual suffering from DID shows different personalities who may have different ages, names, and functions (as cited in Gentile, Dillon & Gillig, 2013, p.
24). The original personality is host and developed personalities are alters who may have different level of conciousness and knowledge (Persin, 2011, p. 58). It is complex type of disorder, Briere & Elliott (2003) and Spitzer et al. (2006) estimate that 1 to 3 percentage of total population are suffering from DID in North America (as cited in Gleadhill & Ferris, 2010, p. 3). The complexities in personality of the DID patient make difficulty in treatment; however, Chlebowski and Gregory (2012) argue that sychotherapy, cognitive behavioral therapy, hypnosis, group and family therapy are common for the treatment methods for DID (p. 165). By developing effective long term nursing care plan, and implementing it through the individual, family or group therapy, nursing intervention can play important role for the treatment of DID patient having different symptoms.
DID patients may show several symptoms including amnesia, identity confusion, identity alteration, feeling of loss of time and space, flashbacks, nightmares, headache, and emotional instability. Steinberg’s (2004) structured clinical interview for the diagnosis of DID identifies the five core symptoms as amnesia, depersonalisation, derealisation, identity confusion and identity alteration (as cited in Gleadhill & Ferris, 2010, p. 43).
DID patient may also have the symptoms such as fear of others, loneliness, deep insecurity and lack of a coherent sense of self, loss of time and space, flashbacks, nightmares, fragmented and missing memories, headaches, emotional instability ranging from extremes of rage and fear through to numbing and inability to feel (McAllister, 2000, p. 26). Coons (1998) identifies some somatic symptoms such as pseudoseizures, conversion, and gastrointestinal and genitourinary disturbances (as cited in Gentile, Dillon & Gillig, 2013, p. 24).
Coons further agrues that DID patients usually show the signs such as eye rolling, eye blinking, trancelike behaviour, and changes in posture during changing of personality from host to alter. Some of the DID patients also report dissociative symptoms of extrasensory experiences such as hallucinations (Gillig, 2009, p. 26). Whatever the symptoms the DID patient shows, there are underlying several traumatic causes for the patient suffering on his/her childhood. DID is acquired in the childhood due to severe ongoing neglect, physical, emotional, psychological and sexual abuse.
Lev-Weisel (2008) states that when child gets abused, mostly sexually abused, he/she thinks the body no longer be a safe home, and thinks to get rid from the abused situation (as cited in Gleadhill & Ferris, 2010, p. 43). This situation develops dissociative behaviours in an individual as a coping mechanism. Curtis (1988), and Ross and Fraser (1987) argue that repeatition of abuse strengthens the defense mechnism of dissociation which allows abusive memories to be stored in different memory banks so that alter is formed with different personalities to handle the abuse (as cited in Precin, 2011, p. 8). Gold, Hill, Swingle and Elphant (1999) and Volkman (1993) state that the severity of the DID depends on child’s age at the time of abuse, duration and severity of abuse, emotional attachment to the abuser, and psychological factors (as cited in Gleadhill & Ferris, 2010, p. 43). In addition to severe child abuse, Armstrong (1991), and Main and Solomon (1986) identify that a disorganized attachment style, and the absence of social as well as familial support also develop DID (as cited in Gillig, 2009, p. 24).
Several therapies are in practice for the treatment of the DID such as sychotherapy, cognitive behavioral therapy, art therapy, hypnosis, group and family therapy. Among them common treatments for DID identified by Pais (2009) include individual, family, or group therapy, creative arts therapies, pharmacotherapy and clinical hypnosis (as cited in Gleadhill & Ferris, 2010, p. 44). Due to complexity of disorder and multiple personalities to treat within an individual, Weber (2007) reports that its treatment is often long as well as challenging with possibility of remission scarce (as cited in Gleadhill & Ferris, 2010, p. 3). Chlebowski and Gregory (2012) argue that the treatment model with the largest empirical basis has been Kluft’s (1999) individualized and multistaged treatment (p. 167). They state, “It involves making contact and agreement among alters to work towards integration, accessing and processing trauma with occasional use of hypnosis, learning new coping skills, and eventually fusion among the alters and the self” (p. 167).
O’Reilly in1996 develops a nursing therapy model for the treatment of DID patient that focuses basically on three stages: reassuring present safety, associating important merories by ensuring patient confidence, and listening, applying and sharing the interpretation (as cited in McAllister, 2000, p. 31). McAllister et al. after an action research in 2001 find that nurse can reassociate the memory of DID patient by developing effective individualized as well as group therapeutic relationship with the patient (P. 31).
Association of dissociative memory is quite challenging work among the psychotherapist; however, longitudanal individual and group therapies are still considered as effective methods for the treatment of DID. With patient’s support on treatment, nursing intervention may be effective method for the treatment of DID patient by developing longitudanal, individualized and multistaged effective care plan. Some studies on nursing therapy for DID patient show its potentiality for the treatment; however, further research is necessary to identify its effectiveness.