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.