Academic journal article Perspectives in Psychiatric Care

Trauma and Dissociation: Treatment Perspectives

Academic journal article Perspectives in Psychiatric Care

Trauma and Dissociation: Treatment Perspectives

Article excerpt

TOPIC. How advanced practice nurses can work with trauma survivors to decrease dissociation as a needed coping mechanism.

PURPOSE. To review the literature on trauma and dissociation as well as current treatment perspectives.

SOURCES. Review of the literature and authors' clinical experience.

CONCLUSIONS. Advanced practice nurses can use knowledge of selected psychopharmacological medications and Erikson's stages of psychosocial development to plan treatment for posttrauma clients.

Key words: Coping with trauma, dissociation, stage theory for treating dissociation, trauma

Advance practice nurses (APNs) working with adults who have experienced severe physical or psychological trauma (violent shock that has an impact on the total human organism) as children or adults may encounter dissociative elements in their clients during the therapeutic process. Whether in an individual or a group session, clients may appear unaware of their surroundings, display fright or anxiety unrelated to the content of the session, or have no memory of an interaction. Men and women may recount episodes of flashbacks, fugue, amnesia, spacing out, numbing, depersonalization, derealization, or out-of-body experiences from past or present.

The person who is experiencing a traumatic event is in danger of being overwhelmed by too many intense feelings that cannot be processed at the time. The ego defends itself from complete disorganization by instituting the defense of dissociation, which distracts from the reality of the experience by allowing detachment. According to Spiegel and Cardena (1991), dissociation is a psychological state in which thoughts, emotions, identity, and/or memory are not integrated within the self. The continuation of this defense mechanism after the trauma, in order to ward off re-experiencing the feelings associated with the traumatic event, may result in a reduced capacity for feeling, thinking, remembering, or being (Varvin, 1998). The symptoms of flashbacks, nightmares, and intrusive thoughts are the result of the ego's attempt to facilitate integration of the feelings with the physical experience.

   Dissociation serves as a defense against pain, fear, helplessness, and
   panic, providing a welcome feeling of detachment from a terrifying physical
   reality and the emotions associated with it. This sense of detachment
   includes depersonalization, derealization, numbing of responsiveness and
   other alterations in perception and memory. (Koopman, Classen, & Spiegel,
   1996, p. 52)

This phenomenon of affective and cognitive avoidance has been commonly observed following a trauma and is hypothesized to be motivated by self-preservation. Cardena and Spiegel (1993) classified three types of responses to trauma: (a) detachment from others and the physical environment, (b) alterations in perceptions, and (c) impairments in cognitive functioning.

The concept of the dissociative phenomenon is congruent with Horowitz's (1986) posttraumatic stress disorder (PTSD) model of normal and pathological phases of posttraumatic stress. According to the model, normal responses to trauma are expressed in two predominant phases: the intrusive state, characterized by unbidden ideas and feelings and even compulsive action, and the denial state, characterized by emotional numbing and constriction of ideation. In the pathological response, these states continue to be used as a response to all stress, because the original feelings of loss and grief have been repressed. Within this model, the terms dissociation, denial, and emotional numbing all can refer to the same phenomenon (Horowitz, 1993).

Dissociation is a symptom of trauma that cuts across diagnostic boundaries as classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) (American Psychiatric Association [APA], 1994). Dissociative symptoms may be present in a number of diagnostic categories as well as PTSD, including panic, borderline personality disorder, somatization, and eating disorders. …

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