Dissociative Disorders

In the field of clinical psychology, dissociation refers to a person's break from reality. For context, the classification of the various dissociative disorders under 'Trauma & Stressor-Related Disorders
' indicates that this type of break from reality is actually a coping response to trauma and stressors, usually intense trauma like rape and torture. It is an alternative to physically fighting or fleeing from perceived danger. Specifically, when a dissociative person breaks from reality, he or she 'flees', mentally, especially when that person, most commonly a child is incapable of getting away, not only in the moment of a traumatizing event but also afterwards if the trauma occurred among family or other people that remain part of daily life for the traumatized person. Being forced to remain in that situation forces a child to mentally compartmentalize life in order to cope. 

In other words, dissociation is the mind's decision to protect the sufferer from something it considers too painful. I see the mind's ability to do this as assuming a type of higher self or guardianship role overseeing the sufferer as a separate person who is its child protégé. As I discuss later, so protective can these disorders (parent-type protector) be that the sufferer is not always consciously aware of their anguish after the traumatic event and consequently feels no pressing need to resolve them. In fact, a sufferer can think it unnecessary. However, these disorders may prevent sufferers from developing coping fully developed adult skills for handling life's challenges. They are therefore worthy of attention.


To be clear, dissociation is also a normal part of human life. Commonest examples experienced by the general population include one's being incapable of recalling details of a journey just driven, zoning out into daydreams or thoughts or preoccupations during an un-captivating meeting. However, disordered forms of dissociation differ in striking ways. For instance, the disorders are very specifically associated with past traumatic events or current triggers (and not simply boredom from driving the same route every day or enduring an uninteresting meeting). 

While a single individual may suffer multiple of these disorders, each disorder can be uniquely described and understood on the basis of its core symptoms (like amnesia, depersonalization, derealization and identify confusion), as discussed below. However, many features apply to all forms***. Regarding levels of severity; depersonalization and derealization are considered the least severe while identity confusion the most severe. It is also necessary to note that there is also another type of dissociative disorder generally called 'Other Specified Dissociative Disorder or OSDD'


Symptoms
1. AMNESIA. Amnesia refers to gaps in one's memory or even the entire loss of memory. Examples of dissociative disorders that involve amnesia are Dissociative Amnesia (DA) and the less common Dissociative Fugue. 

To more specifically qualify each disorder, there are different types of amnesia. For instance, amnesia can be 1) localized (as in Localized Dissociative Amnesia) that affects only the traumatic parts of a situation. It may even be further qualified as 'complete localized amnesia'; 2) systematized (as in systematic DA) that affects very specific compartments of one's life like everything associated with the abuse like an entire family related to an abusive member, one's entire school life where teachers were abusive, etc; 3) even generalized (as in generalized dissociative amnesia) that affects the entire life experience and or skills and 4) continuous that blocks each new event. As a side note, the most common form is localized DA. The most feared type is generalized DA. However, rest assured that it is very rare, affecting only about 0.2% of the population. 

Dissociative Amnesia (DA) has 5 criteria. 
  1. Persons are unable to recall autobiographic information associated with a traumatic or stressful event. Most importantly, this memory dysfunction or lack of recall is inconsistent with ordinary forgetfulness. With ordinary forgetfulness, people know that they used to know the details and simply have a spotty memory. Their memory about traumatic events is not conveniently the only missing parts of their memory. Normal memory loss relates to generic, often unimportant facts like names of people and telephone numbers, NOT life altering events (which people normally recall better than otherwise). Consider how most spectators recall finer details of their day when 9-1-1 occurred but can not recall days immediately before or after. Investing much thought can suffice to retrieve a memory. Recognizing that there is even a loss of memory is easier for the normal population. Conversely, an amnesic person can not simply think, think harder ... and then suddenly get a recall. Most people suffering DA are either entirely or only partially aware of their memory problems. Sufferers can continue life 'as normal', without realizing they had forgotten something life altering and tragic. Being pressed to recall the event and to come to the realization of the memory problem can be distressing. 
    • To ask me to just focus and think harder to retrieve a memory will lead me to the same level of blank as asking me to remember the details of William Shakespeare's death. ... because I was NOT there. This state dissociates totally.
    • One of Kati Morton's clients said "It's funny, it does not really "feel" like anything because you don't know about what you don't remember.
    • Sinking into an amnesic state can be like sleep in terms of your inability to know when you sank. Just like with sleep, you become aware that you had slipped away only upon awakening. Immediately upon awakening, I could usually recall many dreams, especially those that leave my heart racing, laughing or some other emotional state. At least I can capture the memory of dreams by writing them down immediately. However, recovering from the dissociative is different. Even if strong emotions remain, there is never any memory, not even a vague detail that you can write down quickly within the first seconds after regaining normal consciousness. This contrast is striking.
    • In another case, a patient who worked as a firefighter was disallowed from working on her job until she was able to control her dissociation.  
  2. The situation causes distress for the person. Specifically, his or her functioning is impaired socially, occupationally or otherwise. (This is typical of any diagnosis, ie some significant disruption to one's life). 
  3. The memory loss is not attributable to a physiological cause like medical condition such as neurological issues.
  4. The memory loss can not be explained by dissociative identify disorder.
  5. The memory loss is not attributable to substances like drugs or other substances.

Treatment(s) for Dissociative Amnesia (DA)
  1. Talk therapy. This involves discussing the traumatizing event until it is no longer emotionally painful and can be processed appropriately.  
  2. Eye Movement Desensitization & Reprocessing EMDR). This involves strategically stimulating the nervous system from one side to the next while recalling traumatic events. The aim is to allow the brain a new opportunity to re-process the traumatic event. It usually takes the form of tapping the body at specific points and time; listening to beeping sounds through headphones that beep on a specific side at a specific time; holding sensors that vibrate and so on. 
  3. Cognitive Behavioral Therapy (CBT).
  4. Dialectical Behavioral Therapy (DBT).
  5. Medication. Medication does not exist that is specifically designed for dissociation. *** However, since sufferers commonly have other symptoms that make their dissociation worse, medication is prescribed for those other symptoms like those associated with anxiety disorders. 

2. DEPERSONALIZATION
Depersonalization commonly occurs along with derealization. In such cases, it is called Depersonalization-Derealization Disorder ('DDD' in the US or 'DPDR' in the UK). Depersonalization and derealization are forms of dissociation that only partially dissociate sufferers. They both illustrate how an overstimulated and overworked nervous system can alter how sufferers experience life, physiologically, emotionally and in thought. As with other mental health conditions, these symptoms can be experienced by the general population. However, experiencing them in a disordered way is the point here because they cause some significant negative impact to normal life. The DSM has not set a time criterion for diagnosis. However, many mental health professional use 1 month. However, it is difficult to get a handle on because the condition can occur only now and then, off and on but over an extended period for some people for well over a month. Regardless, a first experience is most likely in adolescence or young adulthood and not later in life, like in the 40s and so on. I feel that, even if DDD does not continue, it can make it much easier than otherwise for prior sufferers to experience symptoms through triggers that are not even traumatic, like new age transcendental meditations, out of body experiences, lucid dreaming and the like. (To be clear, if substances are related to the experience, the diagnosis can not apply. BTW, marijuana is known to have a depersonalization effect). Persons experiencing DDD to a significant extent experience it daily to the point that it seems to have taken over their life and they often fear that they are truly losing their minds (which they are not). On a different note, unlike amnesia, sufferers remain very well aware of the non-real aspect of their experience. This is why they are left worrying about their sanity (which they ought not). Having said this however, it is easy for someone describing their DDD symptoms to be misdiagnosed as having a psychotic episode. Needless to say, the likelihood of this is very real because dissociation is rarely taught or focused on in the training of average mental health professionals. 

For the sake of understanding each disorder (de-personalization and de-realization), I will discuss them separately from this point forward. 

Sufferers of de-personalization feel detached or disconnected from their person (and thus the name of the disorder). Consequently, a sufferer may feel like a stranger to him or herself, separated from one's own emotions, disconnected from parts of one's body. One way of making sense of this experience is by considering the fact that people in accidents often do not feel pain despite major injuries. Such individuals can look at their physically dismembered limbs without feeling any pain, even if they were otherwise capable of feeling the pain of an insect bite on the same injured limbs shortly before the injury. In short, the body dissociates pain from your physical consciousness. As a side note, some sufferers self-injure as a means of feeling more "real".  Here are some examples.
  • Out of body (OBE) experiences. This involves being unable to regain full control of one's physical body despite being fully conscious. It is like sleep paralysis but while fully awake. At times, the paralysis is limited because one can move the body, but only very slowly. Hear the experience of one of Dr Tracey Marks' patients @0:45.  
  • Feeling like an alien among human beings.
  • I suspect that the following are also symptomatic.
    • an impairment of some of the 5 senses, like touch sensation and smell
    • an apparent unawareness or denial of one's symptoms of illness, ie needing external prompts to recognize or remember one's own pain that may require medical attention.
    • an impairment of natural homeostatic responses (like temperature regulation).
  • People experiencing this say that things around them appear too bright.

3. DEREALIZATION 
De-realization is similar to depersonalization, except that it relates more to feeling as though one's surroundings (not oneself) are unfamiliar, unreal or disconnected from him or herself. As mentioned above, when experienced with depersonalization, the condition is called Depersonalization-Derealization Disorder (DDD or DPDR). Derealization of surroundings can include close relatives, one's own home and other elements within one's surroundings. It may be experienced as the physical distortion of things perceived by the senses like shapes and colors.
  • Colors and light may appear different than normal. For instance, the entire environment may have light that is in excess of the norm.
Dizziness and nausea experienced when triggered are caused by significant spikes in blood sugar levels from increased stress hormones (Dr Dawn Elise, aka on YouTube as Doc Snipes, her video on C-PTSD). I believe this is likely why groups suffering oppressive conditions through racism for instance have a higher incidence of diabetes. This is also likely why I experienced severe pancreatic stress around the general time that I was rushed to an emergency clinic while having derealization symptoms.


4. IDENTITY DISORDERS (DID; OSDD)
Dissociative Identity Disorder (DID), previously called Multiple Personality Disorder (MPD) is very closely associated with intensely traumatizing early childhood events that occurred before the child was able to fully develop and integrate all facets of his or her personality. In other words, dissociation is a disordered way of reacting to stressful situations by compartmentalizing parts of oneself into hidden corners of the mind to allow the child to continue functioning within a dangerous situation or environment. Dr Tracey Marks explains the splitting extremely well. has the following diagnostic criteria / symptoms. 

DID may be divided into 2 types: 1) overt and 2) covert.
  • The existence of 2 or more distinct identities or personality states, aka 'alternate personalities, 'alters' and 'states of consciousness'. Another alternate personality should be notably different from the original personality. The portrayal of each identity occurs with an involuntary and unwanted change to the behavior, memory and thinking of the present identity. The changes may be observed by others or self-reported by the sufferer. While alternate states feel or appear very different, they are all manifestations of a single whole person. However, the different fragments share little to no memory with each other and thus the reason for large gaps in memory of the day for persons with this form of dissociation. To be clear, this is NOT to be confused with identity changes to alter one's personality and even name to different situations. The normal population can readily relate to 'wearing different hats' in one's life as a boss, parent, lover, one of the friends in a friendship clique and so on. Arguably, this is also apparent in a case involving the famous singer Beyoncé who once spoke of having an "alter ego" named 'Sasha Fierce' that was far more bold on stage than when she was in private. A person suffering disordered dissociation is also likely to desire to self harm or commit suicide as a means of escape from further trauma. In fact, they may rightfully fear that an alter can cause physical harm.
    • In some cases, changes can be evident in the form of different types of food, clothes, activities and so on. When new personality 'fronts' or takes over, the main person can feel like an observer. Their bodies may even feel different, like that of a child, the opposite sex and so on.
    • Alters may not necessarily change in dramatic form with different voices and clothes. In some cases, the switch occurs in the sufferer's head. If the change is to an alter that is very concerned with consuming enough liquids, the outside world will only see an unusually increased interest in drinking water. The sufferer may eventually switch back and feel surprised by the fact that they have a water bottle next to them and that it is nearly empty. In short, the original person 'comes to as if just awakening' to realize they are midway through an activity (ie not lying in a sleep posture but in a position in which sleep is suddenly possible).
    • If someone had done enough research to know that overdosing on barbiturates is an easy and clean suicide method and even went so far as to place orders to be in possession, just in case they are attacked again or dissociate and lose control, this person is showing a sign that is closely associated with DID.
    • Alters may leave behind signs that they were 'fronting' like voice messages to the individual, inexplicable dirty hands & fingernails, injuries and so on.  
  • Ongoing gaps in memory about everyday events, personal information and or past traumatic events. This loss of memory should be inconsistent with normal forgetfulness. Specifically, the sufferer simply can not recall what happened, for instance yesterday.
  • The symptoms cause significant distress or other disruption or impairment in the individual's functioning socially, occupationally or otherwise that is important to the person's life. To be clear, 'distress', even though not always felt by the sufferer, is the loss of ability to live a normal and happy life. 
EXCLUSION: Needless to say, the disorder can not be attributable to cultural or religious practices, especially when considered that spiritual possession is considered normal practice in some cultures.


Other Specified Dissociative Disorder or OSDD may be understood as a milder form of DID because, while criteria A for DID was not being met, dissociation was still occurring in accordance with the other criteria. As you proceed in understanding OSDD, recognize that there is considerable disagreement among mental health professionals regarding its appropriate diagnosis and usefulness. In 2013, the American Psychiatric Association (APA) specified that OSDD may be the diagnosis when patients "do not meet the full criteria for one of the disorders in the dissociative disorders diagnostic class". In other words, when a patient is clearly experiencing some type of dissociation but can not fit any single diagnosis neatly, the OSDD diagnosis is assigned. The diagnosis ultimately comes down to the extent of influence that other personalities have. While personalities that front, ie completely take over the host to the extent of being recognizable as different to others, personalities are more subtle. They influence the host's behavior. Some clinicians think the differences should not result in classification but levels along a continuum. Example(s).

  • On a daily basis, while doing daily tasks, someone emerges from a mild dissociative state in which trauma-based ruminating thoughts become incorporated into the person's interpretation of current daily tasks and scenarios. Upon coming to, the person can not tell when their role playing began. They essentially catch themselves in the midst of the state. This does not discretely fit into any single diagnosis. (k)


In short, the key differences between DID in diagnostic criteria are based on.

  • level of intrusiveness or influence of other personalities.
  • occurrence and level of amnesia
 



Controversies regarding DID (Misdiagnoses, Under-diagnosed sufferers, clinical training)  

For context, it is possibly best  to start by explaining that DID (along with some other trauma-related disorders) is not included in the training curriculum for most mental health professions, including psychiatry.

In the video (above at 06:25), Dr Tracey Marks discusses the controversy that still surrounds this disorder because some professionals do not believe in its existence. For instance, they think it is a manifestation of borderline personality disorder or post traumatic stress disorder (PTSD). She points out that, while it is possible for people with these disorders to also experience dissociative disorders, those other disorders can not adequately explain the symptoms of DID. For instance, borderline personality disordered individuals do remember behaviors and can perceive those behaviors as belonging to them. It is also common for DID to be misdiagnosed as schizophrenia because the different personalities experienced by a DID sufferer may be interpreted by professionals as the 'hearing of voices' that is apparently characteristic of schizophrenia (but NOT persons with DID). Clinicians can also easily think a sufferer is delusional, likely attention seeking also. Needless to say, there are dangers in being misdiagnosed. For instance, if a DID sufferer uses drugs for schizophrenia, the personalities, perceived by the misdiagnosing clinician as schizophrenic  'voices' will not go away. The conclusion may be that the sufferer is simply resistant to treatment. DID can also be mistaken for bipolar disorders because of the drastic mood swings observed in bipolar disorders. However, the drastic mood changes in bipolarity are usually and consistently longer lasting (like an entire week) than the appearance of alters during dissociative episodes which usually last for only minutes to hours at a time.

Needless to say, the social implications are also traumatizing because survivors are often considered to be liars, first for 'telling such tall tales' about shifting consciousness that others think is simply 'impossible' and second for implicating someone with such serious allegations, especially since the survivor 'can not even get their facts right'. The fact that recall can be delayed means that the recall appears to come out of the blue. 

Another noteworthy consideration is that, in some cultures, dissociative states may be diagnosed and treated as spiritual trance or possession.


Treatment for DID (and OSDD) Dr Marks explains that trauma-focused psychotherapy is prescribed. It is recommended that treatment occurs with the 3 following steps. However, I will add a preliminary one #0 that, if skipped will miss the opportunity to successfully complete the others that follow.

0. Seek out and vet only suitable professionals with ADDITIONAL TRAUMA-FOCUSED training and experience with trauma recovery clients. As discussed above (in the section regarding controversies), misdiagnoses and under diagnoses are very common for persons suffering DID. NB that selecting such a person for DID does NOT mean that one should stop pursuing other / separate treatment for other issues like anxiety, depression and other disorders.
1. Stabilize the symptoms with a strong emphasis on maintaining safety. The symptoms to be stabilized are not only those directly related to DID but also others that are associated with its episodes (like anxiety disorders, depression and so on). Sufferers should pay special attention mastering grounding techniques. that remind them that they are now safe and can remain in the present moment, ie versus mentally fleeing as they had as a child. Grounding techniques can also involve simple things like always having on hand something rough against which one can rub one's fingers as a means of remaining present. Ultimately, it involves engaging as many of the 5 senses as possible. Needless to say, it is ideal to become aware of triggers and become prepared to tackle them. Do NOT proceed to the next step until you secure a sense of safety for the scared child that still resides within the sufferer and master the conscious act of remaining present. Other useful strategies. 
2. Delve into and process the details of the traumatic event and its effects. As with rumination, treat dissociative states (especially if it is very engaging to your senses, aka highly vibrational / manifestational) as a golden opportunity to see what your subconscious mind is REALLY up to.
3. Integrate the personality fragments. This is the aim of treatment. To do this, figure the role each fragment played, such as the particular form of protection. The adult person with all integrated fragments will now assume those roles to protect the child and help the child to grow up.


CONTENT RELATED TO DISSOCIATIVE DISORDERS



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