How do you manage a patient experiencing dissociation?

From the Guidelines

Managing a patient experiencing dissociation requires a calm, grounding approach focused on safety and reorientation, with the primary treatment being trauma-focused psychotherapy, including cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), or eye movement desensitization and reprocessing (EMDR), as supported by the most recent evidence 1. To manage a patient experiencing dissociation, several key steps can be taken:

• Ensure the patient is in a safe environment and establish rapport using a gentle, reassuring tone.
• Help them reconnect with reality through grounding techniques such as the 5-4-3-2-1 method (identifying 5 things they can see, 4 they can touch, 3 they can hear, 2 they can smell, and 1 they can taste).
• Physical grounding can also help - encourage them to feel the floor beneath their feet, touch textured objects, or hold ice cubes.
• According to the occupational therapy consensus recommendations for functional neurological disorder 1, a good place to start treatment is to ask the person how they wish to be supported if they have a dissociative episode during a therapy session, and to help them develop a plan to prevent escalation and reduce the duration of the episode.
• The use of Sensory Grounding Techniques, such as noticing the detail in the environment, cognitive distractions, and sensory-based distractors, can be helpful in preventing dissociation 1.
• Medication management may include benzodiazepines like lorazepam or clonazepam for short-term use in acute episodes, while SSRIs such as sertraline or fluoxetine are often prescribed for longer-term management, particularly when dissociation is related to anxiety or trauma.
• It is essential to address underlying causes and teach healthier coping mechanisms, as dissociation often serves as a protective mechanism when the brain is overwhelmed by stress or trauma. Some key points to consider:
• Dissociative episodes may resemble epilepsy or syncope but are not associated with abnormal electroencephalography changes 1.
• People can sometimes hear and understand what you say during a dissociative episode, even if they are unable to respond 1.
• Advising others to behave as they would if someone is having a panic attack can be helpful in managing dissociative episodes 1.
• A crisis response plan, which involves a collaborative approach between patient and clinician, can be beneficial in managing patients at risk for suicide 1.

From the Research

Managing Dissociation in Patients

To manage a patient experiencing dissociation, several approaches can be considered:

• Cognitive Behavioral Therapy (CBT): Studies have shown that CBT can be effective in reducing dissociative symptoms 2, 3. This approach helps patients understand and change negative thought patterns and behaviors associated with dissociation.
• Dissociation-Focused Cognitive Behavioral Therapy (DF-CBT): DF-CBT is a specific type of CBT that has been shown to be effective in reducing dissociative symptoms in patients with posttraumatic stress disorder (PTSD) 2.
• Trauma-Focused Cognitive Behavioral Therapy: This approach has been used to treat adolescents with mixed-dissociative disorder and has shown promise in reducing dissociative symptoms 4.
• Psychoeducation: Educating patients and their families about dissociative disorders can help promote adherence to treatment and improve outcomes 5.
• Stabilization and Coping Skills: Helping patients develop coping skills and stabilizing their symptoms is an important part of managing dissociation 5.

Key Considerations

When managing a patient with dissociation, it is essential to:

• Assess Trauma History: Obtain information about the patient's history of trauma and any nascent dissociative symptoms in their childhood 5.
• Evaluate Current Stress: Assess the patient's current level of stress to understand their symptomatology and predict their future clinical course 5.
• Avoid Promoting Dissociative Identities: Be careful not to excessively promote the creation or elaboration of any dissociative identities 5.
• Address Comorbid Conditions: Be aware of comorbid psychiatric conditions, such as depression, and address them as part of the treatment plan 5.

Treatment Approaches

Different treatment approaches may be effective for different patients, including:

• Group Therapy: Group therapy, such as DF-CBT, can be an effective way to treat patients with dissociative symptoms 2.
• Individual Therapy: Individual therapy, such as trauma-focused CBT, can be effective in treating adolescents with mixed-dissociative disorder 4.
• Brief Intensive Trauma-Focused Treatment: This approach has been shown to be effective in treating patients with PTSD and dissociative identity disorder 6.