Individual Planning: A Treatment Plan Overview for Individuals with Dissociative disorders Problems.

Transcription

1 COURSES ARTICLE - THERAPYTOOLS.US Individual Planning: A Treatment Plan Overview for Individuals with Dissociative disorders Problems. Individual Planning: A Treatment Plan Overview for Individuals Suffering Dissociative Disorders. Duration: 3 hours Learning Objectives: Obtain a basic understanding of how to identifying, causes, symptoms and learning different options to complete a treatment plan that includes: a. Behavioral Definitions b. Long Term Goals c. Short Term Goals d. Strategies to Achieve Goals e. DSM V diagnosis Recommendations ***Check the Adult Treatment for a full listing of Goals and Strategies App for Windows or Apple PC and Android Devices, under our main menu Windows-Apple Apps. Download the Free Demo to Evaluate*** Course Syllabus:

2 Introduction Symptoms of Dissociative Disorder Types of Dissociative Disorder Causes and Diagnosis Treatment Steps to Develop a Treatment Plan that includes Behavioral Descriptors, Long Term Goals, Short Term Goals, Interventions/Strategies and DSM V CODE Paired with ICD_9 and 10-CM Codes for ODD Sample Treatment Plan Introduction: Dissociative disorders are characterized by an involuntary escape from reality and a disconnection between thoughts, identity, consciousness and memory. It can affect all age groups and all racial, ethnic and socioeconomic backgrounds can experience a dissociative disorder. About that 2% of people experience dissociative disorders, with women being more likely than men to be diagnosed. Almost 50% of adults in the United States experience at least one depersonalization or derealization episode in their lives, with only 2% meeting the full criteria for chronic episodes. The symptoms of a dissociative disorder usually first develop as a response to a traumatic event or stressor, such as ongoing abuse or military combat, to keep those memories under control. Stressful situations can worsen symptoms and cause problems and affect everyday activities. However, the symptoms a person experiences will depend on the kind of dissociative disorder that a person has. Dissociative disorders are so-called because they are marked by a dissociation from or interruption of a person's fundamental aspects of waking consciousness (such as one's personal identity, one's personal history, etc.). Dissociative disorders come in many forms, the most famous of which is dissociative identity disorder (formerly known as multiple personality disorder). All of the dissociative disorders are thought to stem from trauma experienced by the individual with this disorder. The dissociative aspect is thought to be a coping mechanism -- the person literally dissociates himself from a situation or experience

3 too traumatic to integrate with his conscious self. Symptoms of Dissociative Disorder: Symptoms of these disorders, or even one or more of the disorders themselves, are also seen in a number of other mental illnesses, including post-traumatic stress disorder, panic disorder, and obsessive compulsive disorder. Symptoms and signs of dissociative disorders include: Significant memory loss of specific times, people and events Out-of-body experiences, such as feeling as though you are watching a movie of yourself Mental health problems such as depression, anxiety and thoughts of suicide A sense of detachment from your emotions, or emotional numbness A lack of a sense of self-identity The symptoms of dissociative disorders depend on the type of disorder that has been diagnosed. There are three types of dissociative disorders defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM): Types of Dissociative Disorders: Dissociative amnesia: This disorder is characterized by a blocking out of critical personal information, usually of a traumatic or stressful nature. Dissociative amnesia, unlike other types of amnesia, does not result from other medical trauma (e.g. a blow to the head). Dissociative amnesia has several subtypes: Localized amnesia is present in an individual who has no memory of specific events that took place, usually traumatic. The loss of memory is localized with a specific window of time. For example, a survivor of a car wreck who has no memory of the experience until two days later is experiencing localized amnesia.

4 Selective amnesia happens when a person can recall only small parts of events that took place in a defined period of time. For example, an abuse victim may recall only some parts of the series of events around the abuse. Generalized amnesia is diagnosed when a person's amnesia encompasses his or her entire life. Systematized amnesia is characterized by a loss of memory for a specific category of information. A person with this disorder might, for example, be missing all memories about one specific family member. Dissociative fugue is a rare disorder. An individual with dissociative fugue suddenly and unexpectedly takes physical leave of his or her surroundings and sets off on a journey of some kind. These journeys can last hours, or even several days or months. Individuals experiencing a dissociative fugue have traveled over thousands of miles. An individual in a fugue state is unaware of or confused about his identity, and in some cases will assume a new identity (although this is the exception). Dissociative identity disorder (DID), which has been known as multiple personality disorder, is the most famous of the dissociative disorders. An individual suffering from DID has more than one distinct identity or personality state that surfaces in the individual on a recurring basis. This disorder is also marked by differences in memory which vary with the individual's alters, or other personalities. For more information on this, see the NAMI factsheet on dissociative identity disorder. \Depersonalization disorder is marked by a feeling of detachment or distance from one's own experience, body, or self. These feelings of depersonalization are recurrent. Of the dissociative disorders, depersonalization is the one most easily identified with by the general public; one can easily relate to feeling as they in a dream, or being spaced out. Feeling out of control of one's actions and movements is something that people describe when intoxicated. An individual with depersonalization disorder has this experience so frequently and so severely that it interrupts his or her functioning and experience. A person's experience with depersonalization can be so severe that he or she believes the external world is unreal or distorted. Causes and Diagnosis: The lifetime prevalence of dissociative disorders varies from 10% in the general population to forty six % in psychiatric inpatients.[13] Diagnosis can be made with the help of structured

5 interviews such as the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), or with the Dissociative Experiences Scale (DES) which is a self-assessment questionnaire. Some diagnostic tests have also been adapted and/or developed for use with children and adolescents such as the Children's Version of the Response Evaluation Measure (REM-Y-71), Child Interview for Subjective Dissociative Experiences, Child Dissociative Checklist (CDC), Child Behavior Checklist (CBCL) Dissociation Subscale, and the Trauma Symptom Checklist for Children Dissociation Subscale. There are problems with classification, diagnosis and therapeutic strategies of dissociative and conversion disorders which can be understood by the historic context of hysteria. Even current systems used to diagnose DD such as the DSM-IV and ICD-10 differ in the way the classification is determined. In most cases mental health professionals are still hesitant to diagnose patients with Dissociative Disorder, because before they are considered to be diagnosed with Dissociative Disorder these patients have more than likely been diagnosed with major depression, anxiety disorder, and most often post-traumatic disorder. An important concern in the diagnosis of dissociative disorders is the possibility that the patient may be feigning symptoms in order to escape negative consequences. Young criminal offenders report much higher levels of dissociative disorders, such as amnesia. In one study it was found that 1% of young offenders reported complete amnesia for a violent crime, while 19% claimed partial amnesia. There have also been incidences in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present. Doctors diagnose dissociative disorders based on a review of symptoms and personal history. A doctor may perform tests to rule out physical conditions that can cause symptoms such as memory loss and a sense of unreality (for example, head injury, brain lesions or tumors, sleep deprivation or intoxication). If physical causes are ruled out, a mental health specialist is often consulted to make an evaluation. Many features of dissociative disorders can be influenced by a person s cultural background. In the case of dissociative identity disorder and dissociative amnesia, patients may present with unexplained, non-epileptic seizures, paralysis or sensory loss. In settings where possession is part of cultural beliefs, the fragmented identities of a person who has DID may take the form of spirits, deities, demons or animals. Intercultural contact may also influence the characteristics of other identities. For example, a person in India exposed to Western culture may present with an alter who only speaks English. In cultures with highly restrictive social conditions, amnesia is frequently triggered by severe psychological stress such as conflict caused by oppression. Finally, voluntarily induced states of depersonalization can be a part of meditative practices prevalent in many religions and cultures, and should not be diagnosed as a disorder.

6 It is important to be aware of other related conditions because dissociative disorders appear on the trauma spectrum, many patients may have conditions associated with trauma, as well as additional trauma-based conditions. Posttraumatic stress disorder (PTSD) Borderline personality disorder (BPD) Substance abuse Depression Anxiety Treatment Since dissociative disorders seem to be triggered as a response to trauma or abuse, treatment for individuals with such a disorder may stress psychotherapy, although a combination of psychopharmacological and psychosocial treatments is often used. Many of the symptoms of dissociative disorders occur with other disorders, such as anxiety and depression, and can be controlled by the same drugs used to treat those disorders. A person in treatment for a dissociative disorder might benefit from antidepressants or anti-anxiety medication. Dissociative identity disorder (multiple personality disorder) Cause: Dissociative identity disorder is caused by ongoing childhood trauma that occurs before the ages of six to nine. People with dissociative identity disorder usually have close relatives who have also had similar experiences. Treatment: Long-term psychotherapy that helps the patient merge his/her multiple personalities into one personality. The trauma of the past has to be explored and resolved with proper emotional expression. Hospitalization may be required if behavior becomes bizarre or destructive. Dissociative identity disorder has a tendency to recur over a period of several years, and may become less of a problem after mid-life. Dissociative amnesia cause: A way to cope with trauma.

7 Treatment: Psychotherapy (e.g. talk therapy) counseling or psychosocial therapy which involves talking about your disorder and related issues with a mental health provider. Psychotherapy often involves hypnosis (help you remember and work through the trauma); creative art therapy (using creative process to help a person who cannot express his or her thoughts); cognitive therapy (talk therapy to identify unhealthy and negative beliefs/behaviors); and medications (antidepressants, anti-anxiety medications or tranquilizers). These medications help control the mental health symptoms associated with the disorders, but there are no medications that specifically treat dissociative disorders. However, the medication Pentothal can sometimes help to restore the memories. The length of an event of dissociative amnesia may be a few minutes or several years. If an episode is associated with a traumatic event, the amnesia may clear up when the person is removed from the traumatic situation. Dissociative fugue cause: A stressful event that happens in adulthood. Treatment: Hypnosis is often used to help patient recall true identity and remember events of the past. Psychotherapy is helpful for the person who has traumatic, past events to resolve. Once dissociative fugue is discovered and treated, many people recover quickly. The problem may never happen again. Depersonalization disorder cause: Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable; however, this disorder can also acutely form due to severe traumas such as war or the death of a loved one. Treatment: Same treatment as dissociative amnesia, and same drugs. An episode of depersonalization disorder can be as brief as a few seconds or continue for several years. It is important to note that anti-anxiety, antidepressants and tranquilizers are treatment medications that do not cure, but help control the symptoms of dissociative disorders. The accepted mode of treatment are atypical neuroleptics such as Abilify, Zyprexa, Seroquel and Geodon. Newer-generation anticonvulsants are also highly effective. Quetiapine is initiated at mg PO bid and increased by 50 mg PO bid q3d until symptom resolution is achieved. The higher dose should be administered nightly due to the strong sedation effects of the medicine. Other medications such as SSRIs and SNRIs may reduce the anxiety and apprehension of the dissociation. Keppra may be effective in treating dissociation. Doses are usually kept much lower than for the treatment of seizure disorders. Lamotrigine started at 25 mg and increased by 25 mg every 2 weeks is another option. The effects of these novel anticonvulsants is thought to be

8 secondary to GABA modulation. Risk factors: People who experience chronic physical, sexual or emotional childhood abuse are at a greater risk of developing dissociative disorders. Children and adults experiencing other traumatic events (including war, natural disasters, kidnapping, torture and invasive medical procedures) also may develop these conditions. Steps to Develop a Treatment Plan: The foundation of a good treatment plan is based on the gathering of the correct data. This involves following logical steps the built-in each other to help give a correct picture of the problem presented by the client or patient: The mental health clinician must be able to listen, to understand what are the struggles the client faces. this may include: issues with family of origin, current stressors, present and past emotional status, present and past social networks, present and past coping skills, present and past physical health, self-esteem, interpersonal conflicts financial issues cultural issues

9 There are different sources of data that may be obtained from a: clinical interview, Gathering of social history, physical exam, psychological testing, contact with client s or patient s significant others at home, school, or work The integration of all this data is very critical for the clinician s effect in treatment. It is important to understand the client s or patient s present awareness and the basis of the client's struggle, to assure that the treatment plan reflects the present status and needs of the client or patient. There 5 basic steps to follow that help assure the development of an effective treatment plan based on the collection of assessment data. Step 1, Problem Selection and Definition: Even though the client may present different issues during the assessment process is up to the clinician to discern the most significant problems on which to focus during treatment. The primary concern or problem will surface and secondary problems will be evident as the treatment process continues. The clinician may must be able to plan accordingly and set some secondary problems aside, as not urgent enough to require treatment at this time. It is important to remember that an effective treatment plan can only deal with one or a few problems at a time. Focusing in too many problems can lead to the lost of direction and focus in the treatment.

10 It is important to be clear with the client or patient and include the client s or patient s own prioritization of the problems presented. The client s or patient s cooperation and motivation to participate in the treatment process is critical. Not aligning the client to participate my exclude some of the client s or patient s needs needing immediate attention. Every individual is unique in how he or she presents behaviorally as to how the problem affects their daily functioning. Any problems selected for treatment will require a clear definition how the problem affects the client or patient. It is important to identify the symptom patterns as presented by the DSM-5 or Diagnostic and Statistical Manual or the International Classification of Diseases (ICD). ***For a full listing of Goals and Strategies aligned next to each other, check the Apps for Windows or Apple PC and Android Devices, under our main menu Windows-Apple Apps, and Download the Free Demo*** Behavioral Definitions for Individuals with Dissociative Problem Disorder: The occurrence or evidence of two or more different personalities Evidence of personalities that repeatedly take over one's complete behavior. An experience of sudden powerlessness to recall important personal background that is beyond average absentmindedness. Constant or repeated experiences of depersonalization. Feeling detached from one owns mental processes and or body. Unrelenting or frequent experiences of depersonalization. Feeling as if one is robotic or part of a dream. Severe feeling of depersonalization continuously causing distress in ones daily life. High intensity in lifestyle due to depersonalization behavior. Turmoil and confusion and poor memory.

11 Step 2, Long Term Goal Development: This step requires that the treatment plan includes at least one broad goal that targets the problem and the resolution the problem. These long term goals must be stated in non-measurable terms but instead indicate a desired positive outcome at the end of treatment. Long Term Goals for Individuals with Dissociative Problem Disorder: Start incorporating different personalities. Lessen the incidence and period of dissociative episodes. Work out the emotional turmoil that triggers the dissociations. Lessen the intensity of daily trouble caused by dissociative conflict. Recover full memory. Step 3 and 4, Objective or Short Term Goal Construction and Strategies to Accomplish Goals: Objectives or short term goals must be stated in measurable terms or language. They must clearly specify when the client or patient can achieve the established objectives. The use of subjective or vague objectives or short term goals is not acceptable. Most or all insurance companies or mental health clinics require measurables objectives or short term goals. It is important to include the patient s or client s input to which objectives are most appropriate for the target problems. Short term goals or objectives must be defined as a number of steps that when completed will help achieve the long-term goal previously stated in non measurable terms. There should be at least two or three objectives or short-term goals for each target problem. This helps assure that the treatment plan remains

12 dynamic and adaptable. It is important to include Target dates. A Target day must be listed for each objective or short-term goal. If needed, new objectives or short-term goals may be added or modified as treatment progresses. Any changes or modifications must include the client s or patient s input. When all the necessary steps required to accomplish the short-term goals or objectives are achieved the client or patient should be able to resolve the target problem or problems. If required all short term goals or objectives can be easily modify to show evidence based treatment objectives. The goal of evidence based treatment objectives (EBT) is to encourage the use of safe and effective treatments likely to achieve results and lessen the use of unproven, potentially unsafe treatments. To use EBT in treatment planning state restate short term goals in a way that steps to complete that goal and achieve results. For example, the short term goal 13. Increase positive self-descriptive statements. Can be restated as; By the end of the session the patient or client will list at least 5 positive self descriptions of himself or herself, and assess how they can help alleviate the presenting problem Remember, that it must be stated in a way one can measure effectiveness. It is important to note that traditional therapies usually rely more heavily on the relationship between therapist and patient and less on scientific evidence of proven practices. Strategies or Interventions: Strategies or interventions are the steps required to help complete the short-term goals and long-term goals. Every short term goal should have at least one strategy. In case, short term goals are not met, new short term goals should be implemented with new strategies or interventions. Interventions should be planned taking into account the client s needs and presenting problem. An example of a short term goals and its aligned strategies:

13 Short Term Goal Goal 1: Distinguish each personality during dissociation episodes. Therapeutic Interventions For Goal 1: Increase the level of trust between counselor and client, through consistent eye contact, positive regard, active listening, and warm acceptance to increase ability to identify and express feelings. Identify and assess all expressed personalities and identify which personality test control and when and how. Distinguish each personality and have each one share its history and individual characteristics and feelings. Short Term Goal Goal 2: Identify key issues or patterns that activate dissociative states Therapeutic Interventions For Goal 2: Identify and assess feelings and circumstances the trigger dissociative states. Increase acceptance and awareness between the connection between dissociation and avoidance as a means of dealing with emotional conflicts and or issues.

14 Identify the basis or source for emotional trauma and any feeling of fear, rejection, abuse, or inadequacy. Step 5, Diagnosis: The diagnosis is based on the evaluation of the clients present clinical presentation. When completing diagnosis the clinician must take into account and compare cognitive, behavioral, interpersonal, and emotional symptoms as described on the DSM-5 Diagnostic Manual. A diagnosis is required in order to get reimbursement from a third-party provider. Integrating the information presented by the DSM-5 diagnostic manual and the current client s assessment data will contribute to a more reliable diagnosis. it is important to note that when completing a diagnosis the clinician must have a very clear picture all behavioral indicators as they relate to the DSM-5 diagnostic manual. DSM V Code Paired with ICD_9-CM Codes (Parenthesis Represents ICD-10-CM Codes Effective ): Possible Diagnostic Suggestions for Adults with Dissociative Disorder: (F44.81) Dissociative Identity Disorder (F44.0) Dissociative Amnesia Specify if: (F44.1) With dissociative fugue (F48.1) Depersonalization/Derealization Disorder F44.89) Other Specified Dissociative Disorder

15 (F44.9) Unspecified Dissociative Disorder ***Check for Substance or Alcohol Abuse Overall Integration of a Treatment Plan: Choose one presenting problem. This problem must be identified through the assessment process. Select at least 1 to 3 behavioral definitions for the presenting problem. if a behavior definition is not listed feel free to define your own behavioral definition. Select at least one long-term goal for the presenting problem. Select at least two short-term goals or objectives. Add a Target Date or the number of sessions required to meet this sure term goals. If none is listed feel free to include your own. Based on the short-term goals selected previously choose relevant strategies or interventions related to each short term goal. If no strategy or intervention is listed feel free to include your own. Review the recommended diagnosis listed. Remember, these are only suggestions. Complete the diagnosis based on the client's assessment data. Sample Treatment Plan: ***For a full listing of Goals and Strategies aligned next to each other, check the Apps for Windows or Apple PC and Android Devices, under the main menu Windows-Apple Apps, and Download the Free Demo***

16 Behavioral Descriptors of Problem: 1. The occurrence or evidence of two or more different personalities. 2. Feeling detached from one owns mental processes and or body. Long Term Goals: 1. Work out the emotional turmoil that triggers the dissociations 2. Lessen the intensity of daily trouble caused by dissociative conflict. Therapeutic Interventions For Goal 1: Increase the level of trust between counselor and client, through consistent eye contact, positive regard, active listening, and warm acceptance to increase ability to identify and express feelings. Identify and assess all expressed personalities and identify which personality test control and when and how. Distinguish each personality and have each one share its history and individual characteristics and feelings. Therapeutic Interventions For Goal 2:

17 Identify and assess feelings and circumstances the trigger dissociative states. Increase acceptance and awareness between the connection between dissociation and avoidance as a means of dealing with emotional conflicts and or issues. Identify the basis or source for emotional trauma and any feeling of fear, rejection, abuse, or inadequacy. Diagnostic Suggestions: (F44.81) Dissociative Identity Disorder (F44.81) Dissociative Identity Disorder Copyright 2011 THERAPYTOOLS.US All rights reserved