Mental Health and Psychiatric Nursing 2022

Dissociative and Sleep Disorders

Dissociative Disorders 5. May recover without treatment, psychotherapy,

 Problem: memory, identity, consciousness, cognitive-behavior therapy, hypnosis, SSRI/TCA,
perception of oneself, one’s surrounding
 Patient uses dissociation as an unconscious defense
mechanism to separate anxiety-provoking feelings B. DISSOCIATIVE AMNESIA/PSYCHOGENIC
and thoughts from the conscious mind AMNESIA
 DISSOCIATION – is most common occurrence that  Inability to recall important personal information
ranges from normal to pathologic (usually of a stressful nature) that can’t be explained
by ordinary forgetfulness
Types of Dissociative Disorders  Commonly, the patients forget basic autobiographical
1. Depersonalization Disorder information such as her name, people she spoke to
2. Dissociative Amnesia recently and what she said, thought, experienced or
3. Dissociative Fugue felt recently
4. Dissociative Identity Disorder  Recovery is usually complete and recurrence is rare,
although patient may never be able to recall certain
CAUSES: life events
1. Psychologic theories  Patients are aware that they have “lost” sometime
o Dissociative disorders are believed to be a  Usually adolescence and young women
response to severe trauma or abuse  May reports amnesia for amnesia (in which patients
o To cope with trauma or abuse, the patient tries to realizes she lost time only after seeing evidence of
repress the unpleasant experience from things she did but can’t recall doing)
awareness
o If repression fails, dissociation occurs as a STEPS of dissociative amnesia
defense mechanism – the patient separates the 1. Localized amnesia
experience from the conscious mind because it’s (patient can’t remember events that took place during a
too traumatic to integrate it specific period of time- usually, the FIRST FEW HOURS
2. Biologic theories after an EXTERMELY STRESSFUL or TRAUMATIC
o Biologic theories are most closely linked with EVENT)
DEPERSONALIZATION disorder 2. Selective Amnesia
o DEPERSONALIZATION disorder – a sense of (patient can recall some, but not all, of the events during a
loss of one’s own reality / strangeness to oneself circumscribed time period (for instance, a soldier may be
3. Learning Theory able to recall only some parts of the violent combat
o Dissociative disorders represent a learned experience)
response of avoiding stress and anxiety 3. Generalized Amnesia
(patient suffers from prolonged loss of memory-possibly
A. DEPERSONALIZATION DISORDER encompassing an entire lifetime)
 Marked by a persistent or recurrent feeling of being 4. Continuous Amnesia
detached from the person’s own mental processes or (patient forgets all events from a given time forward to the
body present)
 Feeling of strangeness from one self with intact reality 5. Systematized Amnesia
testing (patient’s memory loss is limited to a specific type of
 Altered self-awareness in which one’s own reality is information) for instance, related to a specific person
temporarily lost/changed
 Usually occurring in adolescence o r early adult Signs and Symptoms
1. Patient may seem perplexed and disoriented or
Signs and Symptoms wander aimlessly
1. Feeling detached from entire being and body or loss 2. Can’t remember event that precipitated episode
of touch to the reality 3. Doesn’t recognize inability to recall information
2. Sensory anesthesia 4. When episodes ends, unaware of memory
3. Loss of self-control disturbance
4. Obsessive rumination (thoughts)
5. Disturbed sense of time NURSING INTERVENTIONS
1. Recognize the cause of the stress
NURSING INTERVENTION 2. Present reality
1. Establish therapeutic, non-judgmental relationship 3. Benzodiazepines and SSRI’s are given
with the client 4. Non-judgmental relationship
2. Encourage patient to recognize the depersonalization 5. Recognize that memory loss is a defense mechanism
is a defense mechanisms 6. Learn to dealt with anxiety producing experiences
3. Recognize and deal with anxiety-producing
experiences
4. Assist the patient in establishing supportive
relationships

Ronnell D. Dela Rosa,PhD,DNM,RN,RM,LPT Page 1

Bataan Peninsula State University-Balanga Campus
Mental Health and Psychiatric Nursing 2022
Dissociative and Sleep Disorders

C. DISSOCIATIVE FUGUE/PSYCHOGENIC FUGUE 4. Suicidal tendencies or other self-harming behaviors

 Patient’s sudden, unexpected travel away from her home
or workplace, along with an inability to recall her past, the NURSING INTERVENTIONS
patient is typically confused about her personal identity 1. Don’t encourage patient to create new personalities
 Occasionally, patients form new identity, assumes new 2. Don’t suggest that patient adopt names for
name, takes up new residence, and engages in social subpersonalities
activities with no hint that she has a mental disorders 3. Don’t encourage subpersonalities to function more
 New identity is typically more outgoing(friendly) and less autonomously
inhibited(shy) that the former one 4. Don’t encourage patient to ignore certain
 Upon return to the pre-fugue state, the patient may have subpersonalities
no memory of the events that took place during the fugue 5. Don’t exclude unlikable subpersonalities from therapy
 Most common among who experienced war, accidents,
SLEEP DISORDERS
violent crimes, natural disasters
 May also occur in those with DID a disruption of sleep time that causes discomfort or interferes
 Good prognosis for complete recovery with a desired life cycle. A sleep pattern disturbance may be
related to one of more than 80 sleep disorders identified in the
international classification of sleep disorders, a partial list of
Signs and Symptoms which is given below:
1. Often asymptomatic during fugue
2. Confusion about identity or puzzled about past
3. Confrontational when new identity is challenged STAGES OF SLEEP
4. Depression Sleep can be defined behaviorally, functionally and electro
5. Discomfort physiologically.  Electro physiologic monitoring of sleep is called
6. Grief Polysomnography includes at least 3 parameters L1) brain wave
7. Shame activity, (2) eye movements and (3) muscle tone.
8. Intense internal conflict Polysomnography shows that sleep can be divided into REM and
9. Suicidal or aggressive impulses NREM.  NREM sleep can be further divided into 4 stages. The
stages vary in depth, but are characterized by slow rolling eye
movements, low level and fragmented cognitive activity,
NURSING INTERVENTIONS maintenance of moderate muscle tone, and slower, but generally
1. Psychotherapy rhythmic respirations and pulse rate.
2. Identify emotions that occur under stress
3. Monitor signs of aggression toward self or others NREM sleep is characterized as follows:
4. Teach effective coping skills Stage 1:
5. To use available social support system  includes lightest level of sleep
 stage lasts a few minutes
D. DISSOCIATIVE IDENTIY DISORDER/
Multiple Personality Disorders  decreased physiological activity begins with gradual fall
 Two or more distinct identities or subpersonalities for in vital signs and metabolism
alters that recurrently take control of the patient’s  sensory stimuli such as noise, easily arouse sleeper
consciousness and behavior  if awakened, person feels as though daydreaming has
 Each identity may exhibit unique behavior pattern, occurred
memories and social relationship Stage 2:
 Most severe type of dissociative disorder
 In many cases, the PRIMARY personality is religious,  includes period of sound sleep
with a strong moral sense  relaxation progresses
 Subpersonalities  arousal is still relatively easy
a. May behave aggressively or lack sexual inhibition
 stage lasts 10 – 20 mts
b. May have a different gender, sexual orientation,
religion or race than that of the primary  body functions continue to slow
personality  the brain waves are frequently mixed and low voltage in
c. May even differ in hand dominance, vocal pattern, with bursts of activity called sleep spindles 
qualities, intelligence level and EEG readings and large amplitude waves called K complexes
 The transition from one personality to another is Stage 3:
triggered by stress or a meaningful social or
 it involves initial stages of deep sleep
environmental cue in many patients
 Occurs suddenly within seconds/minutes  sleeper is difficult to arouse and rarely moves
 Can take hours or days  oxygen consumption
 muscles are completely relaxed
Signs and Symptoms
1. Lack of recall beyond ordinary forgetfulness  vital signs decline, but remain regular
2. Pronounce changes in facial presentation, voice  stage lasts 15 – 30 mts
behavior Stage 4:
3. Hallucinations, particularly auditory and visual

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Bataan Peninsula State University-Balanga Campus
Mental Health and Psychiatric Nursing 2022
Dissociative and Sleep Disorders

 it is deepest stage of sleep  Psycho physiologic insomnia- It is the persistent difficulty

in initiating or maintaining sleep
  it is very difficult to arouse sleeper
1. Idiopathic insomnia is a rare disorder
 If sleep loss has occurred, sleeper will spend considerable portion
characterized by a lifelong history of inability to
night in this stage
obtain adequate sleep
 Vital signs are significantly lower than during waking hours
2. Psycho physiologic insomnia is more common
 Stage lasts approximately 15 – 30 mts and is characterized by learned sleep –
 Sleep walking and enuresis  sometimes occur preventing associations and heightened
physiologic response to stress.
 Stage 3 and 4 known as slow wave sleep, named for the
characteristic high voltage and low – frequency delta waves  Narcolepsy characterized by excessive daytime
sleepiness with- cataplexy, a sudden loss of muscle
REM sleep: tone at times of unexpected emotion
 Vivid, full- color dreaming occurs  Sleep Apnea Syndrome- cessation of breathing for 10
 Stage usually begins about 90 mts after sleep has begun seconds or longer occuring at least 5 times / hour
 Stage typified by autonomic responses of rapidly  moving a. Obstructive sleep apnea syndrome- respiratory efforts of the
eyes, fluctuating heart and respiratory rates, and diaphragm and intercostals muscles are apparent but ineffective
increased or fluctuating blood pressure against a collapsed or obstructed upper airway . Snoring indicates
partial obstruction. As hypoxia ensues; the person eventually
 Loss of skeletal muscle tone occurs awakens to breathe. The frequent awakenings impair the normal
 Gastric secretion increase sleep cycle. Repeated micro arousals lead to daytime sleepiness.
 It is very difficult to arouse sleeper Women are less likely than men to develop Obstructive
Sleep apnea syndrome, particularly before menopause. It is
 Duration of REM sleep increases with each cycle and common among males who are obese with short, thick necks, and
averages 20 mts who are heavy snorers.  A much smaller percentage progresses to
 Stage is characterized by low voltage, random fast the classic pickwickian syndrome, characterized by obesity, severe
waves, as in stage 1 NREM sleep apnea, daytime hypercapnea, and cor pulmonale.
NORMAL SLEEP REQUIREMENTS & PATTERNS b. Central sleep apnea syndrome-characterized by apneic periods
during which no apparent respiratory effort occurs. It may be seen
Sleep duration and quality vary among persons of all age groups in stroke and brain stem involvement, but it is most commonly
 Infants            16 Hours /Day mixed with Obstructive Sleep apnea syndrome
 Toddlers          12 Hours /Day  Periodic limb movement disorder- daytime sleepiness
and frequent nocturnal wakening.
 Preschoolers     11 Hours /Day
 Restless leg syndrome-involves anything “crawling”,
 Schoolers         9 - 10 hours /day
itching or tingling sensations of the leg while at rest
 Adolescents      8 – 9  hours /day and causes an almost irresistible urge to move. The
 Adults              6 – 8  hours /day syndrome is often most severe before sleep onset.
Clients always have periodic limb movements during
As people age, their circadian clock advances, causing sleep
advanced sleep phase syndrome. The syndrome is common in
older adults and often is the reason behind the complaint of b. Extrinsic sleep disorders
waking early in the morning and unable to get back to sleep.  Inadequate sleep hygiene-unable to sleep if not yet
They get sleepy early in the evening. hygienic
FACTORS AFFECTING SLEEP  Environmental sleep disorder-unable to sleep due
A number of factors affect the quality and quantity of of sleep. environmental stimuli
Often more than one factor combined to cause a sleep problem. 2. Circadian rhythm sleep disorders- sleep disturbances due to
 Physical illness (eg. Nausea, mood disorders, breathing altered circadian rhythmsuch as time zone change
difficulty, pain) syndrome and shift work sleep disorder are not uncommon.
 Drugs and substances (eg. Tryptophan) 3. Parasomnias- are disorders that occur during sleep but that
usually do not produce insomnia or excessive sleepiness. It
 Lifestyle (eg. Daily routines, exercises) may be due to partial arousal or abnormalities in sleep-wake
 Usual sleep patterns and excessive daytime sleepiness transition

 Emotional stress a. Arousal disorders- Partial arousal occur during slow- wave
sleep. Sleepwalking, also known as somnambulism, may include
 Environment ( ventilation) semi purposeful behaviour, such as dressing. The occurrence of
 Sound sleep walking in adults is associated with anxiety. Sleep terrors
are sudden arousals from slow wave sleep accompanied by
 Exercise and fatigue screaming, tachycardia, tachypnea, diaphoresis, and other
 Food and caloric intake manifestations of fear. If awakened, the person is often
disoriented and has little recall of the nature of the dream image.
SLEEP DISODERS: Sleep terrors usually occurs in young children.
1. Dyssomnias (difficulty in initiating or maintaining sleep 4. Sleep – wake transition disorders- Sleep-wake transition
(insomnia) or by excessive sleepiness) disorders are common in the general population. Sleep
a. Intrinsic sleep disorders- starts refers to the sudden jerking movement of the legs that

Ronnell D. Dela Rosa,PhD,DNM,RN,RM,LPT Page 3

Bataan Peninsula State University-Balanga Campus
Mental Health and Psychiatric Nursing 2022
Dissociative and Sleep Disorders

often occurs as a person is falling asleep. Nocturnal leg

cramps also common. The frequency andand intensity may C. Hormonal imbalances
be greater with high caffeine intake, stress, or intense
physical activity before going to bed. . Sleep talking also Hormonal imbalances also contribute to sleep pattern
may occur during times of stress. Or a.k.a. SOMLILOQUY disorders. Hyperthyroid clients tend to have fragmented, short
sleep periods with an excess of slow wave sleep. Hypothyroidism
5. Parasomnias usually associated with  REM sleep is characterized by excessive sleepiness, and polysomnographic
 Nightmares- are frightening dreams that arise in REM recordings show a reduction in the proportion of slow- wave sleep.
sleep and are often vividly recalled on awakening Clients with type 1 diabetes mellitus may experience hypoglycemic
attacks during the night. Sleep patterns normally vary across the
 Sleep paralysis- one of the classic signs of narcolepsy,
menstrual cycle in response to estrogen and progesterone levels.
but can occur in isolation.  This effect may be an
Women with premenstrual syndrome tend to have less slow- wave
extension of the normal state of low muscle tone during
sleep throughout   the menstrual cycle than their asymptomatic
REM sleep
peers. Postmenopausal women are at higher risk for experiencing
6. Other Parasomnias snoring and Obstructive Sleep apnea syndrome.
 Sleep bruxism- to grinding of the teeth during sleep and D. Respiratory disorders
may lead to dental damage. Chronic airway limitations such as asthma and emphysema
 Sleep enuresis- or bed wetting, may occur in adult in contribute to difficulty in initiating sleep, frequent arousals with
association with other disorders, such as Obstructive shortness of breath or cough, and chronic fatigue. Some
Sleep apnea syndrome medications such as theophylline preparations may contribute to
insomnia.
 Primary snoring- is distinguished from Obstructive Sleep
apnea syndrome by its rhythmic nature without E. Cardiovascular disorders
episodes of apnea or hypoventilation The Cardiovascular diseases such as hypertension,
7. Sleep disorders associated with medical or psychiatric myocardial infarction, and nocturnal angina leads to Obstructive
disorders Sleep apnea , hypoxemia, frequent arousals, increased stage 1
sleep ,and reduced total sleep time.
A. Neurotransmitter imbalances
F. Gastrointestinal disorders
Neurotransmitter imbalances predispose to sleep pattern
disturbances. It is more common in case of Parkinson’s disease, In duodenal ulcer, gastric acid secretion is higher than
depression, and Alzheimer’s disease.  These imbalances may be average and recurrent awakenings with epigastric pain are
disease related or drug – induced. common, especially in the first 4 hours and antacids needs to be
administered. Advice to raise the head of the bed on blocks and to
B. Head injury
avoid eating within 3 hours of bedtime to avoid gastro esophageal
Head injury of all degrees of severity affects sleep reflux that may lead to esophagitis in severe cases.
pattern. For clients in the confused, agitated stage of recovery that
8. Proposed sleep disorders
results from more severe head injury, use of environmental cues
(e.g. light and darkness), regularity of daily schedule, and a. Early morning awakening
appropriate daytime exercise and activity can help to restore the It occurs frequently among elderly. Sleep is disturbed in
sleep – wake cycle. depression and delirium, and is grossly disturbed with frightening
dreams, disorientation and restlessness.
b. Sleep deprivation
The noise level, 24 hour lighting, and frequency of care
giver interruptions create sensory overload and sleep deprivation,
which is thought to be a major factor contributing to postoperative
psychosis
Nursing intervention Rationale

*offer meals at regular times, corresponding to client’s *mealtimes are important social cues, that reinforce circadian
previous pattern rhythms, which tend to weaken with advancing age
*provide active meaningful activities during daytime hours, *light exposure is communicated through  the retina to the
including exposure to natural light, and an outdoor suprachiasmatic nucleus, helping to set the circadian clock
environment when possible *napping is not contraindicated but is best at the time of day
*monitor frequency and duration of naps opposite to the midpoint of the nocturnal sleep period.
  *create an individualized  bedtime ritual that includes a Short naps are preferable to avoid deep sleep
quieting activity, a light carbohydrate snack, going to the *reduced stimulation and rituals associated with sleep
bathroom  and settling a routine enhance  sleep onset
* Do not waken even if incontinent. Change and assist the *older adults who can turn themselves generally do better to
client to the bathroom when he or she spontaneously have their sleep undisturbed and tend to waken
awakens spontaneously if wet when their sleep cycle lightens
*if turning or other care is necessary, try to provide for * Sleep cycles average 90 mts. A sleep latency of 20- 30 mts
periods up to 2 hours of undisturbed sleep time mean it would take about 2 hours to experience a full sleep
whenever possible cycle.

Ronnell D. Dela Rosa,PhD,DNM,RN,RM,LPT Page 4

Bataan Peninsula State University-Balanga Campus