Dissociative disorders involve problems with memory, identity, emotion, perception, behavior and sense of self. Dissociative symptoms can potentially disrupt every area of mental functioning.
Examples of dissociative symptoms include the experience of detachment or feeling as if one is outside one’s body, and loss of memory or amnesia. Dissociative disorders are frequently associated with previous experience of trauma.
There are three types of dissociative disorders:
- Dissociative identity disorder
- Dissociative amnesia
- Depersonalization/derealization disorder
The Sidran Institute, which works to help people understand and cope with traumatic stress and dissociative disorders, describes the phenomenon of dissociation and the purpose it may serve as follows:
Dissociation is a disconnection between a person’s thoughts, memories, feelings, actions or sense of who he or she is. This is a normal process that everyone has experienced. Examples of mild, common dissociation include daydreaming, highway hypnosis or “getting lost” in a book or movie, all of which involve “losing touch” with awareness of one’s immediate surroundings.
During a traumatic experience such as an accident, disaster or crime victimization, dissociation can help a person tolerate what might otherwise be too difficult to bear. In situations like these, a person may dissociate the memory of the place, circumstances or feelings about the overwhelming event, mentally escaping from the fear, pain and horror. This may make it difficult to later remember the details of the experience, as reported by many disaster and accident survivors.
Dissociative Identity Disorder
Dissociative identity disorder is associated with overwhelming experiences, traumatic events and/or abuse that occurred in childhood. Dissociative identity disorder was previously referred to as multiple personality disorder.
Symptoms of dissociative identity disorder (criteria for diagnosis) include:
- The existence of two or more distinct identities (or “personality states”). The distinct identities are accompanied by changes in behavior, memory and thinking. The signs and symptoms may be observed by others or reported by the individual.
- Ongoing gaps in memory about everyday events, personal information and/or past traumatic events.
- The symptoms cause significant distress or problems in social, occupational or other areas of functioning.
In addition, the disturbance must not be a normal part of a broadly accepted cultural or religious practice. As noted in the DSM-51, in many cultures around the world, experiences of being possessed are a normal part of spiritual practice and are not dissociative disorders.
The attitude and personal preferences (for example, about food, activities, clothes) of a person with dissociative identity disorder may suddenly shift and then shift back. The identities happen involuntarily and are unwanted and cause distress. People with dissociative identity disorder may feel that they have suddenly become observers of their own speech and actions, or their bodies may feel different (e.g., like a small child, like the opposite gender, huge and muscular).
The Sidran Institute notes that a person with dissociative identity disorder “feels as if she has within her two or more entities, each with its own way of thinking and remembering about herself and her life. It is important to keep in mind that although these alternate states may feel or appear to be very different, they are all manifestations of a single, whole person.” Other names used to describe these alternate states including “alternate personalities,” “alters,” “states of consciousness” and “identities.”
For people with dissociative identity disorder, the extent of problems functioning can vary widely, from minimal to significant problems. People often try to minimize the impact of their symptoms.
Risk Factors and Suicide Risk
People who have experienced physical and sexual abuse in childhood are at increased risk of dissociative identity disorder. The vast majority of people who develop dissociative disorders have experienced repetitive, overwhelming trauma in childhood. Among people with dissociative identity disorder in the United States, Canada and Europe, about 90 percent had been the victims of childhood abuse and neglect.
Suicide attempts and other self-injurious behavior are common among people with dissociative identity disorder. More than 70 percent of outpatients with dissociative identity disorder have attempted suicide.1
With appropriate treatment, many people are successful in addressing the major symptoms of dissociative identity disorder and improving their ability to function and live a productive, fulfilling life.
Treatment typically involves psychotherapy. Therapy can help people gain control over the dissociative process and symptoms. The goal of therapy is to help integrate the different elements of identity. Therapy may be intense and difficult as it involves remembering and coping with past traumatic experiences. Cognitive behavioral therapy and dialectical behavioral therapy are two commonly used types of therapy. Hypnosis has also been found to be helpful in treatment of dissociative identity disorder.
There are no medications to directly treat the symptoms of dissociative identity disorder. However, medication may be helpful in treating related conditions or symptoms, such as the use of antidepressants to treat symptoms of depression.
Depersonalization/ Derealization Disorder
Depersonalization/ derealization disorder involves significant ongoing or recurring experience of one or both conditions:
- Depersonalization – experiences of unreality or detachment from one’s mind, self or body. People may feel as if they are outside their bodies and watching events happening to them.
- Derealization – experiences of unreality or detachment from one’s surroundings. People may feel as if things and people in the world around them are not real.
During these altered experiences the person is aware of reality and that their experience is unusual. The experience is very distressful, even though the person may appear to be unreactive or lacking emotion.
Symptoms may begin in early childhood; the average age a person experiences the disorder is 16. Less than 20 percent of people with depersonalization/derealization disorder first experience symptoms after age 20.
Dissociative amnesia involves not being able to recall information about oneself (not normal forgetting). This amnesia is usually related to a traumatic or stressful event and may be:
- localized – unable to remember an event or period of time (most common type)
- selective – unable to remember a specific aspect of an event or some events within a period of time
- generalized – complete loss of identity and life history (rare)
Dissociative amnesia is associated with having experiences of childhood trauma, and particularly with experiences of emotional abuse and emotional neglect. People may not be aware of their memory loss or may have only limited awareness. And people may minimize the importance of memory loss about a particular event or time.
Both acute stress disorder and posttraumatic stress disorder (PTSD) may involve dissociative symptoms, such as amnesia and depersonalization or derealization.
Philip Wang, M.D., Dr.P.H.