Dissociative Disorders

Normal Dissociation and Dissociative Disorders: What Are They?

Dissociation refers to some separation of emotions, thoughts, memories, or other inner

experiences from oneself. Such separation is often mild and temporary and can include things
such as daydreaming, being absorbed by a film, “spacing out,” or highway hypnosis. In other
cases, separation is moderate, meaning a people may feel temporarily outside of their bodies
or walk through hallways as if in a fog. Normal episodes of dissociation are temporary and
do not interfere with daily life. However, the separation can be severe in other cases and lead to
dissociative disorders. Dissociative disorders involve disturbance in consciousness,
memory, or identity.

Dissociative Disorders: Features and Epidemiology

Dissociative disorders include dissociative amnesia, dissociative identity disorder,

and depersonalization/derealization disorder.

Dissociative Amnesia
Dissociative amnesia involves forgetting highly personal information,
typically after a traumatic event.

People with dissociative fugue cannot recall their past, or

even their identity, and end up living and working far away from family
and friends. Such a person often assumes a new identity or is greatly
confused about personal identity.

Dissociative Identity Disorder

People with dissociative identity disorders may have two or more

distinct personalities within themselves. (This disorder was previously
known as a multiple personality disorder.) The development of multiple
personalities must not result from substance use or a medical condition.
Identity “splitting” is often due to a traumatic event or set of events such
as child maltreatment. What is remarkable about dissociative identity
disorders is that true differences supposedly exist among the personalities.
Each personality may have its own distinctive voice, behavior, memories,
age, gender, handedness, allergies, and eyesight. Many people with
dissociative identity disorders have a host personality and
subpersonalities, or alters. Different relationship possibilities exist for
the various personalities of a person with dissociative identity disorder,
including the following:

 A two-way amnesiac relationship means the personalities are not aware

of the existence of one other.
  A one-way amnesiac relationship means some personalities are aware of
other personalities, but this awareness is not always reciprocated.

 A mutually aware relationship means the personalities are aware of all

other personalities and may even communicate with one another.

Depersonalization/Derealization Disorder

A depersonalization/derealization disorder involves persistent

experiences of detachment from one’s body as if in a dream state.
Depersonalization often exists with derealization, or a sense that
surrounding events are not real. Depersonalization episodes can be short
or long, but a person may have trouble feeling sensations or emotions.
These episodes cause great distress and significantly interfere with daily
functions.

Epidemiology of Dissociative Disorders

Among people with other psychiatric disorders, about 17 to 25% also have a
dissociative disorder, especially a depersonalization/derealization disorder.
Pathological dissociation may be more common in younger people and more
common in men than women. Dissociative experiences appear somewhat more
commonly in African Americans than European Americans. Aspects of dissociative
disorders seem highly comorbid with other mental disorders, especially those involving
trauma. Dissociative behavior is also common among homeless and runaway youths and
adolescents who have experienced trauma.

Stigma Associated with Dissociative Disorders

Stigma may be an important issue in dissociative disorders. Freidl and colleagues (2007)
surveyed people with dissociative and other disorders and found that nearly 60% believed that
most people would not allow someone with a mental disorder to take care of their children and
that most young women would be reluctant to date a man who had a mental disorder.

Dissociative Disorders: Causes and Prevention

Biological Risk Factors for Dissociative Disorders

Brain Changes

Brain areas responsible for integrating incoming information may be

altered in dissociative disorders, especially the amygdala, locus coeruleus,
thalamus, hippocampus, anterior cingulate cortex, and frontal cortex.
Dissociative disorders, especially depersonalization/derealization and
perhaps fugue, may also be due to problems in connections between
 various brain areas, especially between sensory systems (eyesight and
hearing) and the limbic system. Evidence indicates that people undergoing
depersonalization have blunted reactions to arousing stimuli.
Neurochemical changes in serotonin, endogenous opioid, and glutamate
systems that relate to depersonalization have also been noted.

Memory Changes

Some suggest that intense negative emotions lead to key memory changes,
especially of compartmentalization and difficulty retrieving information.
Compartmentalization may not be complete, however. When one
personality learns new information, interference in learning in another
personality can occur. One personality may also retrieve information
learned by another personality. This provides support for the existence of
mutually aware or one-way amnesiac relationships among personalities.
Difficulty retrieving information is also common in people with
dissociative identity disorders and dissociative amnesia. People with these
disorders often have deficits in their short-term and working
memories.

Environmental Risk Factors for Dissociative Disorders

Trauma

Traumatic experiences such as child maltreatment and posttraumatic stress

disorder are closely linked to dissociative disorders. Traumatic problems
may follow dissociation in other cases. A good predictor of a
posttraumatic stress disorder is dissociation during a traumatic event.
Dissociation may be a way of temporarily coping with a terrible event.

Cultural Factors

Cultural factors may also relate to dissociation because cases of

dissociative identity disorders seemed to peak before 1920 and after 1970.
Some speculate that changes in how the concept of “self” is defined from
generation to generation may affect the prevalence of dissociative identity
disorders. Little research is available about dissociative disorders in other
countries.

Causes of Dissociative Disorders

Some researchers have proposed neurodevelopmental approaches to explain how

disparate factors such as brain and memory changes interact with trauma to help cause
dissociative disorders. First, children grow to develop strong and positive attachments to family
members and caregivers, emotional regulation, and adaptive brain structure. Second, young
children begin to coordinate different aspects of thinking and emotions into a consolidated
sense of self. Third, loving parents accelerate this process by setting rules, providing support,
and helping a child gain control of emotions and behaviors. A maltreated child, however, may
not develop a strong and unified sense of self. A lack of unified self may relate to
changes in the orbitalfrontal cortex, an area of the brain largely responsible for
memory and consciousness.

Prevention of Dissociative Disorders

Data are lacking regarding prevention of dissociative disorders, but preventing

traumatic events that commonly lead to dissociative disorders may be instructive. Efforts
to prevent child maltreatment, for example, generally focus on the following:

 Teach children to resist maltreatment and report it to others.

 Educate children about unsafe situations.

 Educate parents about normal child development and high-risk situations that
often lead to maltreatment, such as family transitions and stress.

 Teach parents appropriate disciplinary practices.

 Implement home visitation programs staffed by nurses, physicians, social

workers, paraprofessionals, or others, especially following a child’s birth.

 Provide support groups for parents.

 Encourage pediatricians, psychologists, and other health professionals to report

suspected incidents of maltreatment.

Dissociative Disorders: Assessment and Treatment

Assessment of Dissociative Disorders

Interviews

Interviews help assess dissociative symptoms and

disorders. The Clinician-Administered Dissociative States
Scale and Structured Clinical Interview Dissociative Disorders-Revised
(SCID-D-R) is a semistructured interview for symptoms
of amnesia, depersonalization/derealization, identity confusion, and
identity alteration. The interview also covers the severity of these
symptoms and degree to which they interfere with daily functions.
Interviewing someone with a possible dissociative disorder should also
involve a detailed history of trauma and symptoms of acute stress or
posttraumatic stress disorders.
 Questionnaires

Questionnaires can also help assess dissociative

symptoms. One prominent questionnaire is the
Dissociative Experiences Scale, which covers three main
categories of dissociative symptoms: dissociative amnesia, absorption and
imaginative involvement, and depersonalization/derealization. Absorption
and imaginative involvement refer to engaging in a fantasy to such an
extent that reality and fantasy are blurred. An adolescent version of this
scale (A-DES) covers dissociative amnesia, absorption and imaginative
involvement, passive influence, and depersonalization and derealization.
Other popular scales contain items or subscales relevant to dissociative
symptoms. Examples include MMPI-2 items and the dissociation scale
from the Trauma Symptom Checklist for Children.

Biological Treatment of Dissociative Disorders

The biological treatment of dissociative disorders largely involves medication to ease

comorbid symptoms of anxiety, posttraumatic stress, depression, and related disorders, such
as personality disorders. The most commonly used drugs are anxiolytics, antidepressants,
and antipsychotic and anticonvulsant medications. One problem with these medications is that
side effects of many drugs, especially antipsychotic drugs, include feelings of
dissociation.

Psychological Treatments of Dissociative Disorders

Many of the cognitive-behavioral approaches also apply to people with dissociative

disorders. The goals of these approaches are the same: help people cope with trauma, develop
skills to think rationally and realistically, and reduce avoidance of social and other
activities. Cognitive-behavioral treatment of posttraumatic stress disorder symptoms is usually
essential for addressing the problems of people with dissociative disorders.

Psychotherapy

A key goal of psychological treatment for dissociative disorders is to help

a person reintegrate memories, personalities, and other aspects of
consciousness. For dissociative amnesia or fugue, the goal is to help
people recall previous aspects of certain trauma or past events in a
supportive and safe way and ease their transition back to a normal routine.
For depersonalization/derealization disorders, the goal is to help a person
reinterpret symptoms as nonthreatening, increase safety behaviors, and
decrease avoidance. For dissociative identity disorders, some clinical
researchers recommend a psychodynamic stage approach.
 Hypnosis

Hypnosis refers to inducing a relaxed and focused state of mind in which a

person is highly suggestible. People with dissociative disorders may
undergo hypnosis to increase continuity of memory and identity. A person
may undergo hypnosis to try to retrieve forgotten memories, access hidden
personalities, or integrate different dimensions of consciousness.

Other Psychological Approaches

People with dissociative identity disorders may benefit from supportive

family therapy as they enter the reintegration process and address past
traumas. These people may also benefit from emotional expression
through art, music, dance, and poetry.

What if I or Someone I Know Has a Dissociative Disorder?

Students are encouraged to pay attention to ongoing forgetfulness, odd experiences,

and detachment from others, among other sudden peculiarities. If they suspect someone they
know might be experiencing symptoms of a dissociative disorder, they are encouraged to refer
the person for a full medical examination and/or an emergency room consultation.

Long-Term Outcome for People with Dissociative Disorders

The long-term outcome for people with dissociative disorders is variable because
integration of consciousness is difficult and because the problems usually extend from
childhood. Some people with dissociative amnesia or fugue are able to recover and return
to their past lifestyles. Others continue to have problems with information recall and
disruption in their lives. Many people with dissociative identity disorders respond positively to
biological and psychological treatment. Improvements occur with respect to dissociation,
anxiety, depression, and suicidality as a person addresses traumas and integrates
subpersonalities. A person’s initial degree of depression, other psychopathology, and
trauma may be good predictors of whether full personality integration can be achieved.