CH-22 Sexual Dysfunction, Gender Dysphoria, and Paraphilias – Varcaroliss Canadian Psychiatric Mental Health Nursing : Chapter Notes

Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 22: Sexual Dysfunction, Gender Dysphoria, and Paraphilias Instructor’s Manual Thoughts About Teaching the Topic Despite a sort of learned fearlessness when it comes to addressing other intimate issues, not only nurses but also other health care providers find the topic of sex and sexuality a source of discomfort. Although most recognize that addressing sexuality is part of holistic care, many do not routinely include the topic when doing assessments (Mick, 2007). Nursing curricula typically have a deficiency in training nurses in the fundamentals of sex, sexuality, and nursing care. Patients want to know, for example, how medications or treatments will affect their relationships and ability to have satisfying sex lives. Nurses can set the comfort level for discussing such issues and fostering opportunities to address feelings and fears. Many faculty will choose not to use lecture time for this topic but instead assign the chapter as required or recommended reading. Others may integrate the material into other contexts when the health assessment is done. In some curricula, sexual disorders are part of other courses and receive no attention in the psychiatric nursing module. Key Terms and Concepts dyspareunia exhibitionism fetishism frotteurism gender dysphoria gender identity hypoactive sexual desire disorder paraphilias pedophilia premature ejaculation sex sexual disorders sexual dysfunction sexuality transsexualism vaginismus voyeurism Instructor’s Manual Objectives Describe sexuality and sexual activity. Define at least three areas of sexual dysfunction, and describe the treatment for each. Consider the impact of medical problems and treatments on normal sexual functioning. Examine the importance of nurses’ being knowledgeable about and comfortable discussing topics pertaining to sexuality. Describe treatments available for sexual dysfunction. Apply assessment techniques for sexual history. Identify sexual preoccupations considered to be sexual disorders. Discuss personal values and biases regarding sexuality and sexual behaviours. Develop a plan of care for individuals diagnosed with sexual disorders. Chapter Outline Teaching Strategies Sexuality Sexuality is the way that people experience and express themselves as sexual beings. Biologically, sexual activity includes sexual intercourse and sexual contact in all its forms. Many factors may affect interest in sexuality activity, including age, physical and emotional health, availability of a sexual partner, and the context of an individual’s life. In fact, for a number of individuals, the lack of sexual desire is not a source of distress either to the person or to his or her partner; in such a situation, decreased or absent sexual desire is not viewed as an illness. Sexual Response Cycle A four-phase response cycle has been identified: phase 1 is desire, phase 2 is excitement, phase 3 is orgasm, and phase 4 is resolution. Desire Phase In general, hypoactive sexual desire is a challenging disorder, associated with other psychiatric or medical conditions. Conversely, excessive sexual desire becomes a problem when this creates difficulties for the individual’s partner or when such excessive desire drives that person to demand or force sexual compliance from unwilling partners. Testosterone (present in both men and women) appears to be essential to sexual desire in both men and women. Estrogen does not seem to have a direct effect on sexual desire in women. In evaluating a patient with a sexual desire disorder, the physical assessment, including laboratory studies, is performed before exploring psychological factors. Excitement Phase This is a period of time during which sexual tension continues to increase from the preceding level of sexual desire. Orgasm Phase This is attained only at high levels of sexual tension in both women and men. It is produced by a combination of mental activity and erotic stimulation of erogenous areas. Resolution Phase During this phase, sexual tensions developed in prior phases subside to baseline levels, presuming that sexual stimulation has ceased. Sexual Dysfunction A sexual dysfunction is a disturbance in the desire, excitement, or orgasm phases of the sexual response cycle or pain during sexual intercourse. Sexual desire disorders are based on damage to biological sex drive, self-esteem, acceptance of personal sexuality, sexual experiences, and relationship issues (Sadock & Sadock, 2008). They are divided into two classes: (1) hypoactive sexual desire disorder, characterized by a deficiency or absence of sexual fantasies or desire for sexual activity, and (2) sexual aversion disorder, characterized by an aversion to and avoidance of genital sexual contact with a sexual partner or by masturbation. Epidemiology Sexual dysfunctions are more common in women than in men, affecting 10% to 15% of sexually active women (Basson, 2011). Regardless of gender, these disorders become more prevalent with age. Education seems to have a buffering effect, and people who have more education have fewer sexual problems and are less anxious about issues pertaining to sex (Shafer, 2008). A meta-analysis (summary of data) of all recent epidemiological studies ranks sexual desire disorder as high as 24% to 34% (Segraves & Woodard, 2006). Although the incidence of sexual aversion disorder is unknown, it is thought to be common and more prevalent in men (Shafer, 2008). Comorbidity Sexual desire disorder may be related to chronic stress and depression, prolonged suppression of sexual impulses, or a deteriorating relationship. Sexual disorders may be associated with schizophrenia, depression, or personality disorders (Becker and Stinson, 2008). About 25% of the time, sexual aversion disorder is co-morbid with panic disorder. Several physical conditions and medications are related to sexual dysfunction. Etiology According to Kaplan (1974), sexual dysfunctions are the result of a combination of factors, including misinformation, unconscious guilt and anxiety, anxiety related to performance, and poor communication between partners. Application of the Nursing Process Assessment General Assessment Many current assessment tools are limited to questions about the reproductive system. Sexual assessment includes both subjective and objective data. Self-Assessment According to Dhalwani (2008), health care providers’ discomfort in assessing sexual history is related to embarrassment, concerns about embarrassing the patient, poor training, inexperience, inadequate time, and beliefs that sexual history is not important. It is most helpful to recognize that assessing sexuality is part of holistic nursing care. Understanding the patient’s concern, acknowledging patient discomfort, and providing useful feedback enhance the ability to care for patients and perhaps even improve self-understanding. Assessment Guidelines: Sexual Dysfunction A sexual assessment should be conducted in a setting that allows privacy and eliminates distractions; taking notes may be distracting for the patient. Good eye contact, relaxed posture, and friendly facial expressions facilitate the patient’s comfort and communicate openness and receptivity on the part of the nurse. The interview should be free from personal biases and judgemental attitudes that could block open discussion of sexual issues. See Table 22-2 Diagnosis Priority nursing diagnoses: Sexual dysfunction is the state in which an individual experiences a change in sexual function during the sexual-response phases of desire, excitation, and orgasm. Ineffective sexuality pattern is related to conflicts about sexual preference or identity. Outcomes Identification Some sexual problems can be remedied by achieving short-term outcomes that use education as a nursing intervention. Frequently, sexual myths and misinformation can be corrected, giving the patient almost instant relief from perceived problems. Table 22-4 provides selected intermediate and short-term indicators for Sexual Functioning and Sexual Identity. Planning Planning nursing care for the patient with sexual dysfunction may occur as part of care for a coexisting disorder. Implementation To be a facilitator, the nurse must be nonjudgemental, have basic knowledge of sexual functioning, and have the ability to conduct a basic sexual assessment. The nurse needs to know when and to whom to refer the patient with a sexual complaint. Depending on the nature of the problem, the patient may need a referral to a professional such as a marital counsellor, psychiatrist, gynecologist, urologist, clinical nurse specialist, or pastoral counsellor. Pharmacological Interventions Most of the available treatment for sexual dysfunction is targeted at male dysfunction, and there are no treatments approved by the Health Canada for female sexual disorders. Table 22-5 summarizes treatments for sexual dysfunction. Health Teaching and Health Promotion Many drugs cause adverse effects, and psychotropic medications are common offenders. Helping patients evaluate for themselves the benefits versus the risks of psychopharmacotherapy empowers them to choose the best course of action and increases their ability to be informed consumers. Advanced-Practice Interventions General therapies include psychoanalytic therapy, couples therapy, group therapy, and hypnotherapy. Evaluation Acceptance of sexual dysfunction as being part of sexual behaviour can result in greater satisfaction. The degree to which negative attitudes about sex are no longer problematic is also important. Sexual Disorders These are psychiatric disorders in which sexual problems are considered to be socially atypical, have the potential to disrupt meaningful relationships, and may result in insult or even significant injury to other people. Clinical Picture The DSM-5 classifies sexual disorders as either gender dysphoria or one of the following paraphilias: fetishism, pedophilia, exhibitionism, voyeurism, transvestic fetishism, sexual sadism, frotteurism, and paraphilia not otherwise specified (NOS). Gender Identity Disorder Gender identity disorder occurs when the individual’s biological gender and psychological gender identity do not match. Childhood patterns of cross-gender interest are noted, with increasing intensity of gender dysphoria occurring in adolescence and adulthood. Individuals with gender identity disorder do not consider themselves homosexuals. Some seek sexual reassignment. This involves living in the cross-gender role, hormonal therapy, legal and social arrangements, and surgery. Paraphilias Paraphilias are recurrent and intense sexually arousing fantasies, urges, or behaviours generally involving inanimate objects, the suffering or humiliation of oneself or one’s partner, or the use of children or other nonconsenting persons. Paraphilias include the following: Fetishism—requires a material object to be present in order to be sexually satisfied Pedophilia—sexual activity with a prepubescent child; within a family it is termed incest Exhibitionism—the intentional display of the genitals in a public place Voyeurism—viewing by stealth of other people in intimate situations Transvestism—obtaining sexual satisfaction via dressing in the clothing of the opposite sex Sadism and masochism—giving (sadism) and receiving (masochism) psychological or physical pain, or both, or domination to achieve sexual gratification Frotteurism—touching, rubbing against, or fondling a nonconsenting person to obtain sexual excitement The usual treatment for working with paraphilias is cognitivebehavioural therapy, psychodynamic techniques, or pharmacological agents when the practice is acutely or dangerously compulsive. Epidemiology Some parents report symptoms of gender identity disturbances that were apparent before the age of 3 (Sadock & Sadock, 2008). This condition is extremely uncommon. Paraphilias are also uncommon, but the repetitive and consuming nature of the disorders make the occurrence highly frequent (Becker and Johnson, 2008). Co-Morbidity Personality disorders are present in about 60% of people with gender identity disorder. Substance abuse and self-destructive behaviour are also common. Attention deficit-hyperactivity disorder (ADHD) in childhood, substance abuse, phobic disorders, and major depression or dysthymia are strongly associated with paraphilias (Shafer, 2008). Etiology Biological Factors A variety of theories attempt to identify what predisposes an individual to the development of paraphilias, but these theories are far from conclusive. Psychosocial Factors Learning theorists suggest the absence of same-sex role models may contribute to gender identity disorder. Psychoanalytic theorists suggest that male children who are deprived of their mothers seek to internally meld with their mothers. Cognitive theorists identify paraphilias as being based on cognitive distortions. Application of the Nursing Process Assessment General Assessment Depression with suicidal ideation and substance abuse are common co-morbid conditions and should be assessed using principles in Chapters 13 and 18. Self-Assessment It is common for students to read descriptions of sexual disorders and respond with disgust to behaviours that seem objectionable or ridiculous. While it may be difficult, it is important to consider that these deviations are not the sum total of who the person is. Assessment Guidelines: Sexual Disorders Assess for self-harm, with the main focus on the presenting problem (i.e., depression with suicidal ideation). Elicit the patient’s perception of the impact of the sexual disorder upon the current illness. Diagnosis Nursing diagnoses for individuals with gender identity disorder or a paraphilia are suggested in Table 22-6. Outcomes Identification NOC (Moorhead, 2008) identifies a number of outcomes for patients with either ineffective sexuality patterns or risk for otherdirected violence. Included are: Sexual identity and Impulse selfcontrol. Table 22-7 provides selected intermediate and short-term indicators for these outcomes. Planning The plan should focus on safety and crisis intervention. The patient may also be treated for co-morbid depression or anxiety disorders in the community setting. Planning should address the major complaint along with the sexual disorder. Implementation Interventions are aimed at offering a nonjudgemental emotional presence while exploring identity issues, self-esteem, and anxiety and encouraging an optimal level of functioning. Health Teaching and Health Promotion Education is geared toward reducing symptoms from the presenting problem, typically depression and anxiety. Milieu Management All patients on a psychiatric inpatient unit should be informed on admission about unit rules regarding personal contact between patients and between patients and staff. Limit setting is done consistently when it is needed. Pharmacological Interventions There is no single pharmacological treatment for sexual dysfunction. Two classes of agents, antiandrogens and serotonergic antidepressants, are often prescribed. Medication is not typically used independently as a treatment without other interventions. Advanced-Practice Interventions Psychotherapy Psychotherapy is recommended to address gender dysphoric and co-morbid conditions (Shafer, 2008). The usual treatment plan for working with patients with paraphilias is cognitive-behavioural therapy. Advanced-practice nurses may seek specialized training to enable them to work effectively with patients with gender identity disorder and paraphilias. Evaluation Evaluation for patients with sexual disorders is partly based on determining whether the outcomes for the presenting problem were achieved. Outcomes specific to the sexual disorder are also evaluated. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 23: Somatic Symptom Disorders and Dissociative Disorders Instructor’s Manual Thoughts About Teaching the Topic The use of the nursing process is similar for patients with the various somatoform disorders; thus, emphasizing the similarities seems to work well for students. The lecturer might focus on providing a brief clinical picture of each disorder. Learners might list nursing diagnoses commonly used and then develop a generic care plan using these diagnoses. The same approach may be used for dissociative disorders. Because many learners will work in the medical-surgical area, exploration of feelings about working with a patient who has many physical complaints unsubstantiated by diagnostic tests may be a useful strategy. This topic could be discussed in combination with a lecture on anxiety disorders. Key Terms and Concepts alternate personality (alter) conversion disorder dissociative amnesia dissociative disorders dissociative fugue dissociative identity disorder (DID) factitious disorders illness anxiety disorder la belle indifférence malingering Munchausen’s syndrome secondary gains somatic symptom disorders subpersonality Objectives Compare and contrast essential characteristics of the somatic symptom, factitious, and dissociative disorders. Identify a clinical example of what would be found in different somatic symptom disorders. Describe five psychosocial interventions that would be appropriate for a patient with somatic complaints. Identify concerns that both patients and health care providers have regarding somatization. List three of the most common somatic complaints seen in primary care. Explain the key symptoms of dissociative disorders. Compare and contrast dissociative amnesia and dissociative fugue. Instructor’s Manual 23-2 Identify nursing interventions for patients with somatic symptom and dissociative disorders. Chapter Outline Teaching Strategies In somatic symptom, factitious, and dissociative disorders, patients rarely describe themselves as having mental or emotional symptoms related to anxiety. Instead, patients’ primary focus is on physical symptoms. These conditions are relatively rare in psychiatric settings, but nurses may encounter patients with such disorders in the general medical or surgical setting, in specialized units, or in primary care clinics. Somatic Disorders Clinical Picture Somatization is defined as the expression of psychological stress through physical symptoms. Characteristics of somatoform disorders are as follows: Complaints of physical symptoms are not explainable by physiological tests. Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the disturbance. The patient is unable to control the symptom voluntarily. Symptoms are not intentionally produced (as in malingering or factitious disorder). No clear etiology exists for somatoform disorders. Somatic Symptom Disorder (SSD) History of many physical complaints beginning before age 30, occurring over a period of years (resulting in seeking treatment), and impaired social, occupational, or other functioning are the clinical symptoms of somatization disorder. Illness Anxiety Disorder (IAD) IAD involves preoccupation with having a serious disease, or with fear of having a serious disease, that lasts for over 6 months, causing impaired social or occupational functioning. Despite appropriate medical tests and reassurance, the preoccupation persists. Conversion Disorder Conversion disorder is characterized by the presence of one or more symptoms suggestive of a neurological disorder that cannot be explained by a known neurological, medical, or culture-bound symptom. Psychological factors such as stress or conflicts are associated with onset or exacerbation of the symptom(s). Patients with conversion disorder may sometimes display indifference to their condition, an attitude called la belle indifférence. Epidemiology Prevalence rates for somatic disorders in the general population are unknown. Research shows that half of all frequent users of medical care have psychological problems. Biological Factors Unexplained physical symptoms (SSD and IAD) can arise from faulty perceptions and incorrect assessments of bodily sensations associated with attention deficits and cognitive impairments. Somatoform pain disorder may be associated with abnormalities in brain chemical balance or structural abnormalities of sensory or limbic systems. Conversion disorder may be associated with CNS arousal disturbances, and cytokine system dysregulation may be associated with symptoms such as fatigue and anorexia. Genetic Somatic disorders tend to run in families, according to twin studies and studies of first-degree female relatives of patients with somatic disorders. Psychosocial Factors Psychoanalytic Theory Psychoanalytic theory holds that psychogenic pain, illness, and loss of function are related to a repressed conflict and a transformation of anxiety into a physical symptom (e.g., in conversion disorder, the symptom is symbolically related to the conflict). This theory suggests that IAD is related to anger, aggression, or hostility, with origins in past losses, and is expressed as a need for help and concern from others. Behavioural Theory Behavioural theory suggests that somatic symptoms are learned ways of communicating helplessness, which allows the individual to manipulate others. The symptoms are reinforced by attention, obtaining financial gain, and avoiding certain activities the individual dislikes. Cognitive Theory Cognitive theory holds that the patient with IAD focuses on body sensations, misinterprets their meanings, and then becomes alarmed by them. Cultural Considerations Type and frequency of somatic symptoms vary across cultures. Somatization disorder, rarely seen in North American men, is common in cultures that permit men to use physical symptoms to deal with stress. Conversion is seen more often among low socioeconomic populations. Application of the Nursing Process Assessment Assessment of patients with somatic disorders is a complex process that requires careful and complete documentation. General Assessment Assessment should begin with collection of data about nature, location, onset, character, and duration of symptoms or loss of function. Assess affect for lack of concern. Assess for dramatic presentation, ideas about symptoms, workups that have been performed, results of workups, and resistance to suggestion that symptoms are psychogenic. Note alterations in rest, comfort, activity, and self-care. Somatoform Symptoms Somatic symptoms are not under the individual’s voluntary control, whereas symptoms associated with malingering and factitious disorders are under voluntary control. Secondary Gains These include getting out of usual responsibilities, getting attention, and manipulating others as a result of the symptoms. Cognitive Style Assessing a patient’s cognitive style may help distinguish between IAD (has more anxiety about symptoms and shows obsessive attention to details) and SSD (patient is often rambling and vague). Ability to Communicate Feelings and Emotional Needs The ability to communicate feelings and emotional needs is often poor in patients with somatic disorders. The patient’s chief means of communicating emotional needs may be his or her somatic symptoms. Dependence on Dependence on medication to relieve pain or anxiety or to induce Medication sleep needs to be assessed in patients with somatic disorders. Dependence develops quickly. If treatment has been sought from a number of physicians, substance misuse may occur. Self-Assessment Nurses’ feelings include anger, helplessness, finding the patient difficult and unsatisfying to work with, and perplexity that a patient who has no physical basis for symptoms is being treated on a medical unit. Assessment Guidelines: Somatoform Disorders Assessment should include questions to determine: a history of any similar episodes, prior visits to multiple physicians, instances of abuse as a child, and relevant psychosocial distress issues. Diagnosis Common NANDA-I diagnoses include Ineffective coping, Impaired social interaction, Powerlessness, Ineffective role performance, Interrupted family processes, Ineffective sexuality pattern, Chronic low self-esteem, Situational low self-esteem, Spiritual distress, Self-care deficit, Disturbed sleep pattern, and Risk for caregiver role strain. Outcomes Identification Outcome criteria and goals should be realistic and attainable and structured in small steps to help staff and patient see that progress is being made. For example: Patient will learn more adaptive skills to get needs met, as evidenced by replacing reliance on anxiolytics with use of alternative coping strategies such as assertive communication and relaxation techniques; will improve social interaction by establishing and completing a contract to attend a specified number of social or diversional activities daily; will demonstrate improved self-esteem, as evidenced by making realistic appraisals of strengths and weaknesses. Planning Because the patient is resistant to the concept that no physical cause for the symptom exists and tends to go from caregiver to caregiver seeking attention, nursing care plans should initially focus on establishing a helping relationship. Implementation Interventions usually take place in the home or clinic setting. The nurse attempts to help the patient improve functioning through the development of effective coping strategies. Promotion of Self-Care Use a matter-of-fact approach to support the highest level of selfcare the patient is capable of. Health Teaching and Health Promotion As part of cognitive restructuring, patients using somatization may need basic information about how the body functions. Other coping skills that may be taught include relaxation skills, assertiveness training, biofeedback, and physical exercise. Case Management “Doctor shopping” is a common practice of patients with somatoform disorders. Having a case manager may help patients avoid this by giving them someone they can consistently relate to. Pharmacological Interventions Monitor benzodiazepines closely because patients may use them unreliably. Antidepressants, especially the SSRIs, are showing the greatest promise. Advanced-Practice Interventions Advanced-practice nurses use various types of psychotherapy or consultation with primary care providers. Evaluation Evaluations often reveal that goals and outcomes are only partially met. This should be considered a positive finding when one considers the amount of resistance to change these patients often exhibit. Factitious Disorders Clinical Picture People with a factitious disorder consciously pretend to be ill to get emotional needs met and attain the status of “patient.” Three subtypes of factitious disorders are those that are predominantly physical, those that are predominantly psychological, and combinations of physical and psychological. Patients tend to see the same caregiver and are well known in the health care system (Smith, 2008). They prefer to use the emergency room at night, when people are less likely to know them. Munchausen Syndrome This is the most severe and chronic form of factitious disorders and is named after Baron Von Munchausen, an eighteenth-century German cavalry officer with a reputation for fabricating exaggerated tales. Patients may have scars from numerous exploratory surgeries to investigate unexplained symptoms. Factitious Disorder by Proxy In this disorder, a caregiver deliberately feigns or causes illness in a vulnerable dependent for the purpose of attention, sympathy, and excitement. Also known as Munchausen syndrome by proxy. Malingering Malingering is a consciously motivated act to deceive based on the desire for personal gain. It involves the conscious process of fabricating an illness or exaggerating a symptom for gains such as disability compensation; insurance fraud; or to evade military service, prison, or mandatory schooling. Symptoms of Factitious Disorders Most symptoms tend to be physiological, but some patients try to convince clinicians they have a psychiatric disorder. The patient who pretends to have hallucinations often has a co-morbid borderline personality disorder. Biological Factors No biological abnormalities have been identified to date. Psychological Factors Childhood hospitalizations for these patients may have been perceived as a refuge from a chaotic home life. It is also suggested that patients may have a masochistic side and feel a need to be punished through painful procedures. Application of the Nursing Process Assessment and Diagnosis A general principle in assessing patients with a factitious disorder is to avoid confrontation, which may result in the patient’s defensiveness, elusiveness, or exiting the facility. Self-Assessment Nurses who work with patients with factitious disorders are often angry and resentful about feigned illness. These countertransference reactions should be acknowledged and can be addressed through discussions with other members of the treatment team. Planning and Implementation Safety is a major issue. Patients who may purposefully inflict damage to themselves or others must be carefully monitored, and suspicious activities should be reported. Dissociative Disorders Clinical Picture Dissociative disorders involve disruption of the usually integrated mental functions of consciousness, memory, and identity or perception of environment (e.g., depersonalization disorder involves feeling detached or disconnected from mind or body; a patient whose ability to integrate memories is impaired has dissociative amnesia; a patient unable to maintain his or her identity may develop a dissociative fugue or dissociative identity disorder). Depersonalization Disorder In depersonalization disorder, a persistent or recurrent alteration in perception of the self occurs, to the extent that the sense of one’s own reality is temporarily lost, while reality-testing ability remains intact. The individual may feel mechanical, dreamy, or detached from the body. Dissociative Amnesia This is the inability to recall important personal information of a traumatic or stressful nature. It is more pervasive than forgetfulness. Two types exist: localized and selective. Dissociative Fugue Dissociative fugue is the inability to recall identity and information about the past and is typically accompanied by travel away from the customary locale. Dissociative Identity Disorder DID is characterized by the presence of two or more distinct alternative or subpersonality states that recurrently take control of behaviour. Each subpersonality has its own pattern of perceiving, relating to, and thinking about self and the environment. Epidemiology Although mental health care providers in Canada believe that dissociative disorders are rare, depersonalization disorder prevalence rates range from about 1% to 3%. Dissociative amnesia is also fairly common, with a prevalence of about 2% to 7%. Co-Morbidity Mood disorders and substance-related disorders are commonly associated with all of the dissociative disorders. In addition, dissociated amnesia also may be present with conversion disorder or personality disorder. Dissociative fugue may co-occur with posttraumatic stress disorder (PTSD). Patients with DID may also have PTSD, borderline personality disorder, sexual disorders, eating disorders, or sleep disorders. Depersonalization disorder may occur with IAD, anxiety disorder, or personality disorder. Etiology The actual cause is unknown, but all are believed to be related to childhood trauma. Biological Factors The development of the limbic system may be faulty, allowing experiences to be detached from memory. Early trauma and lack of attachment may affect neurotransmitter availability. Depersonalization has a possible neurological link, as evidenced by its occurrence with epilepsy, brain tumours, and schizophrenia. Genetic Dissociative identity disorder is more common among first-degree relatives of individuals with the disorder than among the population at large. Psychosocial Factors Learning theory suggests dissociative disorders are learned methods for avoiding stress and anxiety, and the more often “tuning out” is used, the more likely it is to become automatic. All disorders are believed to be linked with traumatic life events. Abused dissociative individuals, for example, may learn to use dissociation to defend against feeling pain and to avoid remembering. Cultural Considerations In some cultures, culture-bound disorders look remarkably like dissociative disorders. Care must be taken to consider the patient’s culture when making the diagnosis. Application of the Nursing Process Assessment For a diagnosis of dissociative disorder to be made, medical and neurological status, substance abuse, and coexistence of other psychiatric disorders must be ruled out. General Assessment Should include the following: Identity and Memory Look for clues to multiple personality—gaps in memory, use of third person when communicating, blackouts, and the like—when assessing a patient’s identity and memory. History When assessing for a history of a similar episode in the past, look for differing sets of memories about childhood, incidents of finding strange clothing in closets, and new belongings the patient can’t remember buying. Mood Depression often triggers patients to seek help. Mood shifts may signal DID. Fugue and amnesia victims may seem indifferent or perplexed. Use of Alcohol and Other Drugs Dissociative episodes may be associated with drug and alcohol use. Ask specific questions to assess use and abuse. Impact on Patient and Family Families often find it difficult to accept the erratic behaviour of the patient with a dissociative disorder. Amnesic patients are often quite dysfunctional. Fugue patients may function well in undemanding occupational and social situations. Patients with DID often have family and occupational problems.   Suicide Risk Thoughts of suicide are not uncommon when a patient’s life has been substantially disrupted; therefore, the patient’s suicide risk must be assessed. Self-Assessment Nurses’ feelings include skepticism, frustration, anger, inadequacy, fatigue, and hypervigilance. Assessment Guidelines: Dissociative Disorders Assess for history of a similar episode, past abuse or trauma, and relevant psychosocial distress issues. Diagnosis Diagnoses often seen include Disturbed personal identity, Ineffective coping, Anxiety, Ineffective role performance, Interrupted family processes, Risk for self-directed violence, Risk for other-directed violence, Social isolation, Disturbed body image, Chronic low self-esteem, Powerlessness, and Disturbed sleep pattern. Outcomes Identification An example of a desired outcome is: Patient will demonstrate ability to integrate identity and memory, as evidenced by describing who he or she is, describing feelings about events in the past, and reporting absence of depersonalization episodes. Planning Planning is highly individualized, since patient needs can be very different. A rule of thumb is to plan for safety first. Needs for Safety and Crisis Intervention Include ensuring patient safety; providing undemanding, simple routine; encouraging patient to do things for him- or herself; assisting with decision making as necessary; not flooding patient with data regarding past events; providing support; helping patient see consequences of using dissociation to cope with stress; and teaching stress-reducing methods. Implementation Milieu Management High anxiety and crises may occur, necessitating hospitalization. Close observation and suicide precautions may be required to meet safety and security needs. The environment should be quiet, simple, structured, and supportive. Health Teaching and Health Promotion Prevention of dissociative episodes can be taught. The patient can learn to identify triggers to dissociation and develop a plan to interrupt the dissociation by singing, playing an instrument, talking to someone, icing the hands, and so forth. Daily journal writing puts the patient in touch with feelings and provides concrete examples of overcoming triggers to dissociation. Pharmacological Interventions There is no evidence that medication of any type has been therapeutic. Antidepressants are the most useful because many with DID have a mood disorder. Advanced-Practice Interventions Therapies used by the advanced-practice nurse to treat individuals with dissociative disorders include cognitive-behavioural therapy and psychodynamic psychotherapy. Cognitive-behavioural group therapy has been successful for female sexual assault survivors. Evaluation Treatment is considered successful when outcomes are met and when patient safety has been maintained, anxiety has been alleviated, conflicts have been explored, new coping strategies permit optimal function, and stress is handled adaptively. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400