Running head: A COMPARISON OF A DEPRESSIVE AND DISSOCIATIVE DISORDER A Comparison of a Depressive and Dissociative Disorder Jessica Velasquez Methodist University A Comparison of a Depressive and Dissociative Disorder 1 A COMPARISON OF A DEPRESSIVE AND DISSOCIATIVE DISORDER 2 Within the Diagnostic and Statistical Manuel of Mental Disorders – 5th edition (DSM-5), the clinical standards used by clinicians to diagnosis and classify mental disorders, there are major categories of mental disorders. In this analysis we will learn about major depressive disorder and depersonalization/derealization disorder. Major depressive disorder is classified as a depressive disorder and depersonalization/derealization is classified as a dissociative disorder. These two disorders demonstrate many differences in the areas of etiology and signs and symptoms, but they do share similarities regarding treatment and nursing care needed. Both disorders require the diagnosed individual to receive treatment to improve their overall wellbeing, which will allow the individual to live a functional life. For effective treatment, both biologic and psychologic components must be treated. (Videbeck, 2011). ETIOLOGY Major depressive disorder (MDD), classified as a depressive disorder in the DSM-5, a publication by the American Psychiatric Association (APA), is the classic condition in this group of disorders (APA, 2013). MDD is one of the most frequently diagnosed disorders. Various theories exist for the etiology of mood disorders, such as MDD, and most research focuses on chemical biologic imbalances as the cause (Videbech, 2011). These physiologic and chemical changes in the brain, which significantly alter the balance of neurotransmitters, are sometimes be triggered by psychosocial stressors and interpersonal events (Videbeck, 2011). In MDD, neuroticism, a negative affectivity, is a well-established risk factor for onset. MDD is twice as common in women but incidences of depression decrease with age in women as where they increase with age in men (Videbeck, 2011). The disorder may appear at any age but in the United States, incidence appears to peak in the 20’s (APA, 2013). In the majority cases the disorder is recurrent, although a diagnosis based in a single episode is possible (APA, 2013). This is possibly because fifty to sixty percent of people who experience a single episode will A COMPARISON OF A DEPRESSIVE AND DISSOCIATIVE DISORDER 3 have another and an untreated episode can last 6 to 24 months before remitting (Videbeck, 2011). Classified under a dissociative disorder, depersonalization/derealization disorder is psychiatric disorder related to abuse and violence. Dissociation is a subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effect of some horrific or traumatic event (Videbeck, 2011). The mean age of onset is 16 years old but can start in early or middle childhood. Individuals with this disorder are found to have physiological hyporeactivity to emotional stimuli (APA, 2013). In depersonalization/ derealization disorder, individuals are characterized by harm-avoidant temperament, immature defenses, and both disconnection and over connection schemata. An environmental risk factor associated with depersonalization/derealization disorder is a history of childhood abuse and sexual abuse. This disorder is generally rare and not frequently seen. SIGNS AND SYMPTOMS Some of the characteristics of MDD include discrete episodes of at least 2 weeks’ duration involving clear-cut changes in affect, cognition, and neurovegetative functions and inter-episode remissions (APA, 2013). For a diagnosis of MDD there is three areas of criteria needed within the same 2-week period and must represent a change from previous functioning (APA, 2013). Criteria in A gives a list of symptoms that must be experienced by the patient or observed by others, of which 5 or more have to be present nearly every day for diagnosis. Of the symptoms needed, at least one has to be either depressed mood or loss of interest or pleasure. The patient has to experience depressed mood, and lack of interest or pleasure in all, or almost all, activities most of the day and nearly every day. The patient may express feeling sad, empty, or hopeless (APA, 2013). The other symptoms needed for diagnosis are: significant weight loss when not dieting or weight gain of more than 5 percent of body weight in a month, or a decrease A COMPARISON OF A DEPRESSIVE AND DISSOCIATIVE DISORDER 4 or increase in appetite; Insomnia or hypersomnia; psychomotor agitation or retardation; fatigue or loss of energy; feelings of worthlessness or excessive or inappropriate guilt; diminished ability to think or concentrate, or indecisiveness; and recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Criteria in B specifies that symptoms must cause clinically significant distress or impairment in social, occupational, and other important areas of function. And finally, Criteria C denotes that the episode must not be attributed to the physiological effects of a substance or to another medical condition. The medical professional must use clinical judgment to differentiate if the symptoms are caused by grief, which may present the same symptoms and lead to a misdiagnosis (APA, 2013). Furthermore, these are additional factors that must be specific with a diagnosis of MDD. The name of the diagnosis must list if this is a single or recurrent episode, the severity, if there are any psychotic features, and remission specifies (APA, 2013). Because thoughts of death, suicidal ideation and suicide attempts are common in these patients, treatment is necessary to prevent this high risk for harm. To obtain a diagnosis certain criterion must be met. With depersonalization/derealization disorder, the essential feature will be persistent or recurrent episodes of depersonalization, derealization, or both (APA, 2013). These patients will have intact reality testing meaning that he or she is not psychotic and is not out of touch with reality (Videbeck, 2011). According to the DSM-5, Episodes of depersonalization are characterized by a feeling of unreality or detachment from, or unfamiliarity with, one’s whole self or from aspects. That is, the patient experiences a persistent or recurrent feeling of being detached from his or her thoughts, feeling, sensations, body, or actions. These symptoms will be indicated with perceptual alterations, distorted sense of time, unreal or absent self, and emotional or physical numbing. Episode of derealization, are characterized by a feeling of unreality or detachment from, or unfamiliarity with, the world, be it A COMPARISON OF A DEPRESSIVE AND DISSOCIATIVE DISORDER 5 individuals, inanimate objects, or all surroundings. A patient experiencing derealization may feel as if he or she were in a fog, dream, or bubble, or as if there were a veil or a glass between themselves and the world (APA, 2013). In addition to experiences of depersonalization, derealization, and intact reality testing; in order to meet diagnostic criteria; the individual must also indicate significant distress or impairment in in social, occupational, or other important areas of functioning due to the symptoms. Also the symptoms must not be attributed to the physiological effects of a substance or another mental condition. Finally, to meet diagnostic criteria for depersonalization/derealization disorder, the disturbances cannot be better explained by another mental disorder, including MDD. Although, varying degrees of anxiety and depression are common associated features. TREATMENT AND NURSING CARE Care of the client with MDD will mirror the phase of the disease that the client is experiencing (RN mental health nursing, 2011). According to “RN mental health nursing”, there are three phases for patients with MDD. The first phase is acute and is characterized by severe symptoms of depression. A patient in the acute phase will generally require treatment for 6 to 12 weeks and hospitalization may be required. The goal of care is to reduce symptoms and establish patient safety; especially if the patient has a suicide potential. The second phase for treatment is maintenance, which is characterized by an increased ability to function and requires treatment of 4 to 9 months. The goal for treatment is to prevent relapse through education, medication therapy, and psychotherapy. The final phase is continuation and is marked my remission of symptoms. Prevention of future episodes is the goal of treatment and this may last for years. There a variety of treatment utilized with these patients and many of them require strong involvement from a nurse. The nursing care involved with these patients includes Milieu therapy (RN mental health nursing, 2011). Nursing actions will include monitoring the client’s ability to A COMPARISON OF A DEPRESSIVE AND DISSOCIATIVE DISORDER 6 perform activities of daily living and encouraging independence as much as possible. The nurse will need utilize therapeutic communication by making time to be with the patient and making observations rather than asking direct questions. In addition, the nurse will assure that the patient is always in a safe environment. The use of antidepressant medications is the one of the primary treatment, so the nurse must be proficient in the different classifications of antidepressants, their side effects, adverse reactions, and patient education necessary for each. Other treatments used with in patients with MDD are electroconvulsive therapy, and psychotherapy, which in combination with medication is the most effective treatment (Videbeck, 2011). Treatment for depersonalization/derealization disorder focuses of solving the cause of the trauma through psychotherapy such as cognitive-behavioral therapy. These individuals may are involved in group or individual therapy to address the long-term effects of their experiences (Videbeck, 2011). These individuals may be treated symptomatically with medications for anxiety or depression if these symptoms are also present (Videbeck, 2011). Nursing interventions include promoting the client’s safety, helping the client cope with stress and emotions, helping promote self-esteem, and establishing social support. Much less information about treatment is found about depersonalization/derealization disorder then MDD. CONCLUSION The diagnostic criteria for both of the presented diseases differ greatly. The experience and perception of the patient with MDD differs greatly from depersonalization/ derealization disorder. As much as the diagnostic criterion differs, it is valuable to note the benefits that both disorders obtain from treatment with psychotherapy. The cognitive well-being of an individual will improve the symptoms of these individuals and allow them to like more functional and fulfilling lives. A COMPARISON OF A DEPRESSIVE AND DISSOCIATIVE DISORDER 7 References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. RN mental health nursing (8th ed.). (2011). Assessment Technologies Institute. Videbeck, S. L. (2011). Psychiatric-mental health nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.