Self-Concept Responses and Dissociative Disorders



Self-Concept Responses and Dissociative Disorders


Gail W. Stuart




Learning Objectives



1. Describe the continuum of adaptive and maladaptive self-concept responses.


2. Identify behaviors associated with self-concept responses.


3. Analyze predisposing factors, precipitating stressors, and appraisal of stressors related to self-concept responses.


4. Describe coping resources and coping mechanisms related to self-concept responses.


5. Formulate nursing diagnoses related to self-concept responses.


6. Examine the relationship between nursing diagnoses and medical diagnoses related to self-concept responses.


7. Identify expected outcomes and short-term nursing goals for patients related to self-concept responses.


8. Develop a patient education plan to improve family relationships.


9. Analyze nursing interventions related to self-concept responses.


10. Evaluate nursing care related to self-concept responses.



Of all human qualities, the self is the most complex. It is the frame of reference through which one perceives and evaluates the world. Self-concept consists of all the values, beliefs, and ideas that contribute to a person’s self-knowledge and influence relationships with others, including one’s perceptions of personal characteristics and abilities and one’s goals and ideals.


The self-concept is critical to understanding people and their behavior. It is formed from a person’s internal experiences, relationships with others, and interactions with the outer world. It has a powerful influence on human behavior. Therefore, understanding a patient’s self-concept is an essential part of all nursing care.



Continuum of Self-Concept Responses


Self-Concept


Developmental Influences


From birth the self develops as the infant recognizes and begins to differentiate from others. The boundaries of the self are defined as the result of exploration and experience with one’s own body. At first self-differentiation is slow, but with the development of language it accelerates. Use of the child’s own name helps with the identification and perception of individuality—of being someone special, separate, and unique.



LEARNING FROM A CLINICAL CASE


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.



Case Background


This woman appears to have it all together. Her purse and shoes match; her jewelry is perfect; her hair and makeup are applied perfectly. She is a very successful mortgage broker with many brokers working under her. The company has depended on her for years. She definitely knows how to get things done, but she admits that she is very frightened.


Recently she has been getting lost. She doesn’t understand how it happens. She suddenly becomes aware that she doesn’t know where she is and doesn’t know how she got there. She gets so agitated when it happens that she has to call her daughter, who talks her through figuring out where she is and how to get home. She sees packages in the back seat and assumes she has made purchases but has no memory of doing it. She feels like she is watching her life, not living it, and someone has ripped out some of the pages. It is terrifying to her.


She tells you that her father, an alcoholic, abused her until she was about 12. He would stumble into her room at night and fondle her in the dark. She told her mother about it, but her mother never believed her and did nothing about it. She said when her father finally died, she felt relief but also much guilt. Currently, her daughter, who had been trying to get pregnant for some time, was finally successful and is now pregnant with twins. However, it is a tenuous pregnancy, and she expects to be on bed rest soon. Her husband’s daughter (from a previous marriage) started using heroin and also is pregnant. Her son has recently come out to the family as being gay. She loves them all but feels completely overwhelmed and stressed beyond her capacity to cope.




Significant Others


The self-concept is learned in part through social contacts and experiences with other people over time. This has been called “learning about self from the mirror of other people” (Sullivan, 1963). A person’s concept of self therefore rests partly on what he thinks others think of him. For a young child the most significant others are the parents, who help the child grow and react to experiences.


Parents provide the child with the earliest experiences of the following:



Parental influence is strongest during early childhood and continues to have a significant impact through adolescence and young adulthood. Over time, however, the power and influence of friends and other adults increase, and they become significant others to the person. Culture and socialization practices also strongly affect self-concept and personality development.



Critical Reasoning


What sociocultural factors had an impact on your self-concept as you were growing up? Which ones currently influence your self-concept?



Self-Perceptions


One’s perception of reality is selective and is based on whether the experience is consistent with one’s current view of self. The way a person behaves is a result of how the person perceives the situation. It is not the event itself that elicits a specific response but rather the individual’s subjective experience of the event.


One’s needs, values, and beliefs strongly influence perceptions. People are more likely to perceive what is meaningful and consistent with present needs and personal values. Similarly, people behave in a manner consistent with what they believe to be true. In this case a fact is not what is true but what one believes to be true.


Self-perceptions can be difficult to change. However, there are ways to change perceptions, including modifying cognitive processes, taking drugs, undergoing sensory deprivation, and creating biochemical changes within the body. A person with a weak or negative self-concept who is unsure of self is likely to have narrowed or distorted perceptions. Because he feels easily threatened, his anxiety level will rise quickly and he will become preoccupied with defending himself. In contrast, a person with a strong or positive self-concept can explore the world openly and honestly because he has a supporting background of acceptance and success.


Positive self-concepts result from positive experiences leading to perceived competence and acceptance of others different from oneself. Negative self-concepts are correlated with poor personal and social adjustment.


Figure 17-1 describes the continuum of self-concept responses from the most adaptive state of self-actualization to the most maladaptive response of depersonalization. To provide the best care the nurse needs an understanding of body image, self-ideal, self-esteem, role, and identity.


image
FIG 17-1 Continuum of self-concept responses.


Body Image


The concept of one’s body is central to the concept of self. The body is the most visible part of the self, and it is an anchor for self-awareness. A person’s attitude toward the body may mirror important aspects of identity. For example, feelings that one’s body is big or small, attractive or unattractive, weak or strong also reveal something about one’s self-concept. A positive relationship between self-concept and body image exists in all cultures.


Body image is the sum of the conscious and unconscious attitudes one has toward one’s own body. It includes present and past perceptions as well as feelings about size, function, appearance, and potential. Body image is constantly changing as new perceptions and experiences are encountered in life. As one’s body image develops, extensions of the body become important. Clothes become identified with the body, as do one’s possessions.


Body image, appearance, and positive self-concept are all related. The more one accepts and likes one’s own body, the more secure and free from anxiety one feels. People who accept their bodies are more likely to have high self-esteem than people who dislike their bodies.



Critical Reasoning





Self-Ideal


The self-ideal is the person’s perception of how to behave based on certain personal standards. The standard may be an image of the type of person one would like to be or the aspirations, goals, or values that one would like to achieve. The self-ideal creates self-expectations based in part on society’s norms, to which the person tries to conform.


Formation of the self-ideal begins in childhood and is influenced by significant others, who place demands or expectations on the child. With time the child internalizes these expectations, and they form the basis of the child’s own self-ideal. New self-ideals are taken on during adolescence, formed from identification with parents, teachers, and peers. In old age, additional adjustments must be made that reflect diminishing physical strength and changing roles and responsibilities.


Various factors influence self-ideals. First, a person tends to set goals within a range determined by personal abilities. One does not usually set a goal that is accomplished without any effort or that is entirely beyond one’s abilities.


Self-ideals also are influenced by cultural factors as the person compares self-standards with those of peers. Other influencing factors include ambitions and the desire to excel and succeed, the need to be realistic, the desire to avoid failure, and feelings of anxiety and inferiority.


Based on these factors, one’s self-ideal may be clear and realistic and thus promote personal growth and relations with others, or it may be vague, unrealistic, and demanding. The well-functioning person has congruence between perception of self and self-ideal; that is, he sees himself as being very similar to the person he wants to be.


In summary, self-ideals are important in maintaining mental health and balance. The self-ideal must be neither too high and demanding nor too vague and shadowy, yet it must be high enough and defined enough to provide continuous support to one’s self-respect.



Critical Reasoning


What are your self-ideals in relation to your career as a nurse?



Self-Esteem


Self-esteem is a person’s personal judgment of self-worth, based on how well behavior matches up with self-ideal. How frequently a person attains goals directly influences feelings of competency (high self-esteem) or inferiority (low self-esteem) (Figure 17-2).


image
FIG 17-2 A, Person with a low level of self-esteem caused by a large discrepancy between self-concept and self-ideal. B, Person with a greater conformity of self-concept and self-ideal and therefore a high level of self-esteem.

High self-esteem is a feeling based on unconditional acceptance of self, despite mistakes, defeats, and failures, as an innately worthy and important being. It involves accepting complete responsibility for one’s own life.


Self-esteem comes from two sources: the self and others. It is first a function of being loved and gaining the respect of others. Self-esteem is lowered when love is lost and when one fails to receive approval from others; it is raised when love is regained and when one is applauded and praised.


The origins of self-esteem begin in childhood and are based on acceptance, warmth, involvement, consistency, praise, and respect (Coopersmith, 1967; Mruk, 2006). The four best ways to promote a child’s self-esteem are as follows:



These approaches should provide the child with a feeling of significance or success in being accepted and approved of by others; a feeling of competence, or an ability to cope effectively with life; and a feeling of power, or control over one’s own destiny.


Self-esteem increases with age and is most threatened during adolescence, when concepts of self are being changed and many self-decisions are made. Adolescents must choose career paths and decide whether they are good enough to succeed at them. Adolescents also must decide whether they are able to participate or are accepted in various social activities.


With adulthood the self-concept stabilizes, and maturity provides a clearer picture of self. The adult tends to be more self-accepting and less idealistic than the adolescent. Adults have learned to cope with many self-deficiencies and to maximize self-strengths.


In later life, self-esteem problems again arise because of the new challenges posed by retirement, loss of loved ones, and physical disability. The impact of aging on self-esteem also is affected by the status of older people in U.S. society. Being old in a society that values youth often leads to low status and prejudicial attitudes toward the aged. Negative stereotypes of the elderly and the stigmatization that results can decrease self-esteem. Two other potential negative factors are the decreased social interaction of the elderly and their loss of control over their environment, both of which can result in fewer opportunities to validate and confirm the self-concept.


Finally, there is a clear relationship between self-reported physical health and self-esteem. The report of a health problem, regardless of its type or severity, is associated with significantly lower self-esteem than is the report of no health problem.


High self-esteem has been correlated with low anxiety, effective group functioning, and acceptance and tolerance of others. Once self-esteem is achieved, the person is free to concentrate on achieving potential.



Critical Reasoning


Why do you think low self-esteem is associated with poor interpersonal relations, intolerance of others, and depressive states?



Role Performance


Roles are sets of socially expected behavior patterns associated with a person’s functioning in different social groups. People assume various roles, which they try to integrate into one functional pattern. Role behavior is closely related to self-concept and identity, and role disturbances often involve conflicts between independent and dependent functioning. High self-esteem results from roles that meet needs and are congruent with one’s self-ideal.


Factors that influence a person’s adjustment to a role include the following:



Gender roles affect performance in other roles. They are particularly significant to family roles and are often the cause of role conflict. Another difficult problem faced in growing up is emancipation from one’s parents and establishment of an independent life. This primarily occurs during adolescence and early adulthood. A final crisis is faced during old age, when aging parents must again change role behavior. They rely on their children yet strive to balance their lives with a sense of independence and a high level of self-esteem.



Personal Identity


Identity is the awareness of being oneself based on self-observation and judgment. It is not associated with any single accomplishment, activity, characteristic, or role. Identity differs from self-concept in that it is a feeling of distinctness from others.


The person with a firm sense of identity feels integrated, not diffuse. When a person acts in accordance with self-concept, the sense of identity is reinforced. When a person acts in ways contrary to the self-concept, anxiety and apprehension result. The person with a positive sense of identity sees himself as a unique and valuable individual.



Developmental Influences


The concept of ego identity was developed by Erikson (1963), who identified eight stages of human development. For each stage, Erikson described a psychosocial crisis that must be resolved for further growth and personality development to occur.


In adolescence the crisis of identity versus identity diffusion occurs. At no other phase of life are the promise of finding oneself and the threat of losing oneself so closely aligned. The adolescent’s task is one of self-definition as the person strives to integrate previous roles into a unique and reasonably consistent sense of self.


Important in achieving identity is the issue of sexuality, the image of oneself as a male or a female and what that implies. Society’s ideals of masculinity and femininity are standards for judging oneself as good or bad, superior or inferior, desirable or undesirable. These ideals are passed down from generation to generation and become a part of the culture. If males are defined as superior, this idea becomes part of the self-image of both males and females. If passivity and obedience are considered to be feminine ideals in a society, most girls will be taught to be unassertive and obedient.


Much of one’s identity is expressed in relationships with others. How a person relates to other people is a central personality characteristic. This presents a paradox in that everyone is a part of humanity yet each person is also separate from all others.


Achieving personal identity is a prerequisite for establishing an intimate relationship with another person. Only after a stable sense of identity has been established can one engage in a genuinely mature and successful relationship with a significant other.



Healthy Personality


A person with a healthy personality has the characteristics listed in Table 17-1 and is able to perceive both self and the world accurately. This insight creates a feeling of harmony and inner peace.



TABLE 17-1


QUALITIES OF THE HEALTHY PERSONALITY
































CHARACTERISTIC DEFINITION DESCRIPTION
Positive and accurate body image Body image is the sum of the conscious and unconscious attitudes one has toward one’s body function, appearance, and potential. A healthy body awareness is based on self-observation and appropriate concern for one’s physical well-being.
Realistic self-ideal Self-ideal is one’s perception of how one should behave or the standard by which behavior is appraised. A person with a realistic self-ideal has attainable life goals that are valuable and worth striving for.
Positive self-concept Self-concept consists of all the aspects of the self of which one is aware. It includes all self-perceptions that direct and influence behavior. A positive self-concept implies that the person expects to be successful in life. It includes acceptance of the negative aspects of the self as part of one’s personality. Such a person faces life openly and realistically.
High self-esteem Self-esteem is one’s personal judgment of one’s own worth, which is obtained by analyzing how well one matches up to one’s own standards and how well one’s performance compares with that of others. It evolves through a comparison of the self-ideal and self-concept. Persons with high self-esteem feel worthy of respect and dignity, believe in their own self-worth, and approach life with assertiveness and zest. People with a healthy personality feel very similar to the person they want to be.
Satisfying role performance Roles are sets of socially expected behavior patterns associated with functioning in various social groups. The healthy person can relate to others intimately, receive gratification from social and personal roles, trust others, and enter into mutual and interdependent relationships.
Clear sense of identity Identity is the integration of inner and outer demands in one’s discovery of who one is and what one can become. It is the realization of personal consistency. People with a clear sense of identity experience a unity of personality and perceive themselves to be unique persons. This sense of self gives life direction and purpose.


Critical Reasoning


How do you compare with the qualities of a healthy personality listed in Table 17-1?



Assessment


Behaviors


Assessing a patient’s self-concept is a challenge to the nurse. Because self-concept is the cornerstone of the personality, it is closely related to anxiety and depression, problems in relationships, acting out, and self-destructive behavior.


All behavior is motivated by a desire to enhance, maintain, or defend the self, so the nurse has much information to evaluate. The nurse also must go beyond objective and observable behaviors to the patient’s subjective and internal world. Only by exploring this area can the nurse understand the patient’s actions.


The nurse begins the assessment by observing the patient’s appearance. Posture, cleanliness, makeup, and clothing provide data. The nurse might discuss the patient’s appearance with the patient to determine what values are held related to body image. Observing or inquiring about eating, sleeping, and hygiene patterns gives clues to biological habits and self-care.


These initial observations should lead the nurse to ask: What does my patient think about himself as a person? How would he describe himself? What strengths does my patient think he has? What are areas of weakness? What is my patient’s self-ideal? Does my patient value his strengths? Does my patient view his weaknesses as important personality deficits, or are they unimportant to self-concept? What are my patient’s priorities? Does my patient feel unified and self-directed or diffuse and other-directed?


The nurse then compares the patient’s responses with behavior, looking for consistencies and contradictions. How does the patient relate to other people? How does the patient respond to compliments and criticisms? The nurse also can examine her own affective response to the patient. Is it one of hopelessness, despair, anger, or anxiety? The nurse’s own response to the patient is often a good indication of the quality and depth of the patient’s emotional state.



Behaviors Associated With Low Self-Esteem


Low self-esteem is a problem for many people and can be expressed in moderate and severe levels of anxiety. It involves negative self-evaluations and is associated with feelings of being weak, helpless, hopeless, frightened, vulnerable, fragile, incomplete, worthless, and inadequate. Low self-esteem also plays a large role in depression. It may indicate self-rejection and self-hate, expressed in direct or indirect ways.



Direct behaviors

Direct expressions of low self-esteem may include any of the following areas.













Indirect behaviors

Indirect forms of self-hate complement and supplement the direct forms. The patterns may be chronic and difficult to change.






Polarizing view of life

In this case the person has a simplistic view of life in which everything is worst or best, wrong or right. This person tends to have a closed belief system that acts as a defense against a threatening world. Ultimately this view of life leads to confusion, disappointment, and alienation from others.


The behaviors associated with low self-esteem are described in the clinical example that follows and are summarized in Box 17-1.



BOX 17-1   BEHAVIORS ASSOCIATED WITH LOW SELF-ESTEEM





CLINICAL EXAMPLE


Ms. G was a 66-year-old woman admitted to the psychiatric hospital because of a major depressive episode. She told the admitting nurse that “things have been building up for some time now” and that the private psychiatrist she had been seeing for the past 6 months suggested that she enter the hospital. She had been employed in a community college as a librarian until 18 months earlier, when she was forced to retire.


Ms. G said she had been married for 39 years and had two grown children, who were married and lived out of state. Her husband had worked as an accountant but had retired 1 month earlier. She said that since her retirement she had felt “useless and lost” and “closed in by their apartment.” She seldom left the apartment and had lost contact with many of her friends. She said she worried a great deal about their financial situation, especially now that her husband was also retired. He repeatedly reassured her that they had enough money, but she could not stop worrying about it.


Ms. G said that she liked her old job very much and thought she was good at it. A younger woman took her place at the library, and Ms. G was very bitter when talking about her. She said that, little by little, this woman took over duties Ms. G was responsible for and one day even cleaned out Ms. G’s desk and took it as her own.


Since her retirement, she said, things had been “going downhill steadily.” She said she was not a good housewife and disliked cooking. These tasks had become even more difficult since her husband retired, because he was “always underfoot and criticizing” what she did. In the past couple of weeks, she had had great difficulty sleeping, a decreased appetite, fatigue, and little interest in her appearance. She said it seemed that all she had to do was “wait around to die.”


Selected Nursing Diagnoses




In this clinical example, Ms. G’s perception of self was closely related to her ability to work. Her retirement created role changes she found difficult to adapt to. This example points out the close relationship between low self-esteem and role strain. The situation was further compounded by her husband’s retirement. Ms. G’s feelings of low self-esteem were evident in her self-criticism, refusal to recognize her own strengths, worrying, physical complaints, and reduced social contacts. The diagnosis of major depressive episode was based on the severity of her feelings of self-deprecation, somatic problems, saddened emotional tone, history of losses, and absence of a manic episode.


Low self-esteem is also a major element of disturbed body image. The next clinical example illustrates the effect of the loss of a body part on a person’s self-concept.



CLINICAL EXAMPLE


Ms. M was an attractive, 32-year-old married woman who had been admitted to the general hospital for a total hysterectomy. Her history was presented in a nursing care conference because she was making many demands and the nurse manager noted that many of the staff members were avoiding caring for her. Ms. M had been married for 2 years and did not have any children. It was observed that Mr. M had not visited his wife, although he did speak to her over the phone. Ms. M complained that she was unable to sleep at night and often rang for the nurses with apparently minor requests. She appeared to have established a relationship with one of the nurses, who was able to describe some of Ms. M’s concerns.


Ms. M appeared to have a severe level of anxiety about her hysterectomy. She feared the effect of the surgery on her sexual desires, attractiveness, and ability to have intercourse and respond to her husband. Without her reproductive organs, she said, she would feel “inadequate and no longer like a woman.” She said that she and her husband always planned on having children, and she wondered whether her husband might leave her in the future. She also feared that having the hysterectomy would cause her to lose her beauty and youth.


When the nursing staff became aware of Ms. M’s many fears and concerns, they were better able to understand her behavior and plan nursing care accordingly. They discussed with her the physiological implications of a hysterectomy and encouraged her to verbalize her feelings.


Mr. M was not aware of his wife’s concerns, and the nursing staff supported open discussions between them. As the staff members were able to identify Ms. M’s concerns, they realized that some of their previous avoidance behavior had resulted from their own fears and discomfort. The female nurses had identified with her, and the hysterectomy threatened their own concepts of self, body integrity, and sexual identity.




Behaviors Associated With Identity Diffusion


Identity diffusion is the failure to integrate various childhood identifications into a unified adult identity. Important behaviors that relate to identity diffusion include disruptions in relationships and problems of intimacy.


The initial behavior may be withdrawal or distancing. A person who is experiencing an undefined identity may wish to ignore or destroy threatening people. The problem is one of gaining intimacy, but it is reflected in isolation, denial, and withdrawal from others. These patients lack empathy.


A contrasting behavior is seen in personality fusing. Personality fusion is a person’s attempt to establish a sense of self by fusing with, attaching to, or belonging to someone else. Erikson pointed out that true intimacy involves a sense of mutuality, which implies a firm self-delineation of the partners, not a diffused merger of two people.


A person who is struggling to cope with a weak or undefined identity may try to establish a sense of self by fusing with or belonging to someone else. This may occur in formal relationships, intense friendships, or brief affairs, each of which can be seen as a desperate attempt to outline one’s own identity. However, personality fusion leads to a further loss of identity. Some of these behaviors are evident in the clinical example.



CLINICAL EXAMPLE


Ms. P was seen by a psychiatric nurse in the psychiatric outpatient department of a general hospital. She was a well-dressed, 24-year-old woman who had numerous somatic complaints, including decreased appetite, frequent headaches, fatigue, and difficulty falling asleep. She reported that she had no energy or interest in doing anything or being with people. She said she dreaded each day and felt abandoned and alone.


She was married at age 17 years to the only boy she ever dated in high school. He was 19 years old at the time, and she “looked up to him tremendously.” He established a successful career in the insurance business, and she stayed at home to care for the house. She described herself as centering her whole world around him. Three months earlier, he had told her that he wanted a separation and suggested she begin making a new life for herself. He said he intended to move out of the house at the end of the month, but Ms. P said she hoped he would not do that when he saw how much she loved and needed him.


Ms. P also described feelings of being unloved and unlovable. She said she felt empty inside and didn’t really know who she was. She complained about her appearance and expressed much fear about living alone, finding a job, and getting along with people, especially men.



Many of Ms. P’s behaviors reflect the problem of identity diffusion. She married at an early age, before defining her own sense of self as an autonomous individual. Her only experience in a close relationship was with her husband, and she attempted to establish her own identity by living through his. Within the security of the marriage, she managed to avoid any self-analysis, but the impending separation brought forth her fears and self-doubts. She displayed a low level of self-esteem and an unresolved conflict between dependence and independence.


Personality fusion and problems with identity have serious implications for the larger family system. Dysfunctional families are often characterized by a fusion of ego mass that may be evident in symptomatology by one or more family members. This may be expressed in some form of family violence or abuse (see Chapter 38) or in the scapegoating of a family member.


Finally, people with identity diffusion also may lack a coherent sense of history, cultural norms, group affiliation, lifestyle, or sound child-rearing practices. A related behavior may be the absence of a moral code or of any genuine inner value. The behaviors characteristic of identity diffusion are summarized in Box 17-2.



BOX 17-2   BEHAVIORS ASSOCIATED WITH IDENTITY DIFFUSION





Behaviors Associated With Dissociation and Depersonalization


A more maladaptive response to problems in identity is the withdrawal from reality that occurs when a person experiences panic levels of anxiety. This panic state produces a blocking off of awareness, a collapse in reality testing, and feelings of dissociation and depersonalization.


Dissociation is a state of acute mental decompensation in which certain thoughts, emotions, sensations, or memories are compartmentalized because they are too overwhelming for the conscious mind to integrate (MacDonald, 2008; Weber, 2007). In severe forms of dissociation, disconnection occurs in the usually integrated functions of consciousness, memory, identity, or perception.


Depersonalization is the subjective experience of the partial or total disruption of one’s ego and the disintegration and disorganization of one’s self-concept. It is a feeling of unreality in which one is unable to distinguish between inner and outer stimuli. The person has great difficulty distinguishing self from others, and the body has an unreal or strange quality. It is the most frightening of human experiences.


Dissociation and depersonalization serve as defenses, but they are destructive because they mask and immobilize anxiety without reducing its intensity. They can occur in a variety of clinical illnesses, including depression, schizophrenia, manic states, and organic brain syndromes.


Many behaviors are associated with dissociation and depersonalization. Primarily, patients feel estranged, as though they were hiding something from themselves. They experience a lack of inner continuity and sameness and feel as if life is happening to them rather than living by their own



imageQUALITY AND SAFETY ALERT




initiative. This is sometimes described as the experience of being a “passenger” in one’s own body rather than the driver.


Patients may say that the world appears strange, dreamlike, or frightening. They may experience a loss of identity and self-respect and feelings of insecurity, inferiority, frustration, fear, hate, and shame. They may be unable to feel a sense of accomplishment from any activity. In depersonalization, a loss of impulse control and an absence of feeling and emotion may be present, which is shown in impersonality and stiffness in social situations.


People may become lifeless and lack spontaneity and animation. They may plod through each day in a state of numbness and may respond to situations without expressions of love, hate, anxiety, or guilt. They may become increasingly passive, withdrawing from social contacts, failing to assert themselves, losing interest in surroundings, and allowing others to make decisions for them.


Another sign of depersonalization is a disturbance in perception of time, space, and memory. The person may become disoriented, unable to recognize past or current events, and unable to plan future activities. A disturbance of memory may be characterized by aphasia, amnesia, or memory distortion. Thinking and judgment may be impaired, with great confusion and distortion or a focus on trivial details. In severe forms, problems in information processing may be seen in visual hallucinations, delusions, auditory hallucinations, and distortions in communication.


Another behavior associated with depersonalization is a confused or disturbed body image. The person may have a feeling of unreality about parts of the body. Patients may feel that their limbs are detached or that the size of their body parts has changed, or they may be unable to tell where the body leaves off and the rest of the world begins. Some patients describe a feeling that they have stepped outside their bodies and are observing themselves as detached and foreign objects.


Finally, the person may exhibit behaviors related to dissociative identity disorder, known as multiple personality disorder. In this case, distinct and separate personalities exist within the same person, each of whom recurrently dominates the person’s attitudes, behaviors, and self-view as though no other personality existed (Box 17-3).



BOX 17-3   A FAMILY SPEAKS


My wife has multiple personality disorder, and it feels like I’m living with several different people. One moment everything is great, and the next thing I know, she is in a frenzy or a state of rage. There are other problems, too. For example, things keep appearing in our household, and no one knows where they came from, or I get calls at work from my wife telling me she is lost and doesn’t know how she ended up there. At other times she tells me things and later denies she said them. Sometimes people come up to my wife and talk like they know her, but she says she’s never seen them before. And then there are days when she dresses up and acts just like our teenage daughter.


What is it like to live with someone with this illness? Well, it’s unreal and very upsetting. Most of all, it’s like living in a world of doubt and uncertainty. Who is this woman I married 20 years ago? What is she all about? What is she capable of doing? These are the questions I ask myself each night as I fall asleep. They are the same ones that go unanswered in the early morning hours.


Because most patients with dissociative identity (multiple personality) disorder hide their condition, the periods in their lives when they show overt symptoms are quite limited, so diagnosing them is not easy. During these times the patients often show subtle dissociative signs in their affects, thoughts, memories, and behaviors.


The many behaviors associated with dissociation and depersonalization are summarized in Box 17-4. The following clinical example may further clarify these behaviors.



BOX 17-4   BEHAVIORS ASSOCIATED WITH DISSOCIATION AND DEPERSONALIZATION


Affective



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Feb 25, 2017 | Posted by in NURSING | Comments Off on Self-Concept Responses and Dissociative Disorders

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