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Indications for hospitalization

The treatment of dissociative disorders is difficult and time-consuming and is mostly enacted via behavioral modifications through outpatient therapy. However, in extreme cases or when physical or emotional harm is imminent, hospitalization may be a required intervention. Some of the indications for inpatient assessment or hospitalization include severe depression over a long period, anxiety and delusion disorders that lead to compulsive acting out of behaviors, cognitive reactions (eg, nightmares, flashbacks), physical reactions, fatigue, and interpersonal reactions (eg, conflict, problems with mood regulation, antisocial behavior, physical aggressiveness, suicidal behavior, traumatic and schizophrenic episodes).

The ultimate goal for hospitalization of a patient is to ensure immediacy in restoring safety and stability. The patient remains at risk as long as no change in behavior or in approach for generating behavior modifications to improve response to stress and quality of life occurs.

Treatment of DID

In general, DID is treated as a complex, chronic, trauma-based disorder. Accordingly, a developmental process of reeducating patients is used in treatment. The primary goals are encouraging healthy coping behaviors, logging and monitoring emotions, and developing a crisis plan. The ultimate goal of psychotherapy is to bring together all the facets of the person into 1 individual.

In developing healthy coping behavior, positive affirmations, 12-step group participation, group therapy, and developing hobbies and interests all may be part of the plan. Patients may learn the importance of setting goals, keeping time schedules, and being organized.

In logging and monitoring emotions, patients may keep a journal in which they write down their feelings at different parts of the day, foods consumed, and activities engaged in and the feelings or effects on their mood and desire to participate in activities. In this way, patients begin to identify possible triggers and make appropriate decisions regarding whether or not a possible trigger activity is worth the risk of their comfort or stability.

Lastly, developing a crisis plan may be extremely important in responding to situations that begin to feel out of control for the patient. In the crisis plan, when prevention is too late, the patient can self-soothe by having a specific, easy-to-follow plan for calming down and easing their emotional burden. The plan may include physical activity, focusing exercise, meditation, calling a specific person, or listening to a particular piece of music. The goal is essentially to allow patients to calm themselves, become able to learn from the experience, and try to not repeat the provoking behavior.

A case example is a 33-year-old woman with a history of sexual, physical, and emotional trauma. She has a crisis plan for dealing with her anger and grief. During episodes of rage, she hits a plastic bat against a pillow until she is able to get in touch with the feelings that caused her to be overwhelmed. Once she is aware of the emotions that have caused the anger response, she writes about the pain and shares it with a trusted friend over the telephone. In dealing with grief, she has a plan that includes listening to soothing music, crying, holding her cat or a favorite stuffed animal, and rocking until she feels soothed enough to have a discussion with a friend or therapist about the experience that caused her grief.

The patient sometimes resents the level of commitment required for caring for herself, but she realizes that accepting her situation is more productive than the alternative, which may be increased dosages of medication or inpatient treatment if she does not reduce the number and intensity of her episodes.

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Reviewed: 04/2006