What is dissociation?
What is depersonalization?
What is derealization?
What is dissociative amnesia?
What are identity confusion and identity alteration?
What is the cause of dissociation and dissociative disorders?
How does affect dysregulation influence dissociation?
How is dissociation different from hypnosis?
What are the different types of dissociative disorders?
What is the prevalence of dissociative disorders?
What are treatments specific to the type of dissociative disorder?
My (spouse, sibling, employee, child care worker) has a dissociative disorder.
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I am dating a person with Multiple Personality.
I went to therapy because I was sad, and now I’m told I have a dissociative disorder. I don’t have a history of trauma. I had a happy childhood. Can you help me sort this out? More details in the question below.
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Dissociation is a word that is used to describe the disconnection or lack of connection between things usually associated with each other. Dissociated experiences are not integrated into the usual sense of self, resulting in discontinuities in conscious awareness (Anderson & Alexander, 1996; Frey, 2001; International Society for the Study of Dissociation, 2002; Maldonado, Butler, & Spiegel, 2002; Pascuzzi & Weber, 1997; Rauschenberger & Lynn, 1995; Simeon et al., 2001; Spiegel & Cardeña, 1991; Steinberg et al., 1990, 1993). In severe forms of dissociation, disconnection occurs in the usually integrated functions of consciousness, memory, identity, or perception. For example, someone may think about an event that was tremendously upsetting yet have no feelings about it. Clinically, this is termed emotional numbing, one of the hallmarks of post-traumatic stress disorder. Dissociation is a psychological process commonly found in persons seeking mental health treatment (Maldonado et al., 2002).
Dissociation may affect a person subjectively in the form of “made” thoughts, feelings, and actions. These are thoughts or emotions seemingly coming out of nowhere, or finding oneself carrying out an action as if it were controlled by a force other than oneself (Dell, 2001). Typically, a person feels “taken over” by an emotion that does not seem to makes sense at the time. Feeling suddenly, unbearably sad, without an apparent reason, and then having the sadness leave in much the same manner as it came, is an example. Or someone may find himself or herself doing something that they would not normally do but unable to stop themselves, almost as if they are being compelled to do it. This is sometimes described as the experience of being a “passenger” in one’s body, rather than the driver.
There are five main ways in which the dissociation of psychological processes changes the way a person experiences living: depersonalization, derealization, amnesia, identity confusion, and identity alteration. These are the main areas of investigation in the Structured Clinical Interview for Dissociative Disorders (SCID-D) (Steinberg, 1994a; Steinberg, Rounsaville, & Cicchetti, 1990). A dissociative disorder is suggested by the robust presence of any of the five features.
Depersonalization is the sense of being detached from, or “not in” one’s body. This is what is often referred to as an “out-of-body” experience. However, some people report rather profound alienation from their bodies, a sense that they do not recognize themselves in the mirror, recognize their face, or simply feel not “connected” to their bodies in ways which are challenging to articulate (Frey, 2001; Guralnik, Schmeidler, & Simeon, 2000; Maldonado et al., 2002; Simeon et al., 2001; Spiegel & Cardeña; Steinberg, 1995).
Derealization is the sense of the world not being real. Some people say the world looks phony, foggy, far away, or as if seen through a veil. Some people describe seeing the world as if they are detached, or as if they were watching a movie (Steinberg, 1995).
Amnesia refers to the inability to recall important personal information that is so extensive that it is not due to ordinary forgetfulness. Most of the amnesias typical of dissociative disorders are not of the classic fugue variety, where people travel long distances, and suddenly become alert, disoriented as to where they are and how they got there. Rather, the amnesias are often an important event that is forgotten, such as abuse, a troubling incident, or a block of time, from minutes to years. More typically, there are micro-amnesias where the discussion engaged in is not remembered, or the content of a conversation is forgotten from one moment to the next. Some people report that these kinds of experiences often leave them scrambling to figure out what was being discussed. Meanwhile, they try not to let the person with whom they are talking realize they haven’t a clue as to what was just said (Maldonado et al., 2002; Steinberg et al., 1993; Steinberg, 1995)
Identity confusion is a sense of confusion about who a person is. An example of identity confusion is when a person sometimes feels a thrill while engaged in an activity (e.g., reckless driving, drug use) which at other times would be repugnant. Identity alteration is the sense of being markedly different from another part of oneself. This can be unnerving to clinicians. A person may shift into an alternate personality, become confused, and demand of the clinician, “Who the dickens are you, and what am I doing here?” In addition to these observable changes, the person may experience distortions in time, place, and situation. For example, in the course of an initial discovery of the experience of identity alteration, a person might incorrectly believe they were five years old, in their childhood home and not the therapist’s office, and expecting a deceased person whom they fear to appear at any moment (e.g., Fine, 1999; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg, 1995).
More frequently, subtler forms of identity alteration can be observed when a person uses different voice tones, range of language, or facial expressions. These may be associated with a change in the patient’s world view. For example, during a discussion about fear, a client may initially feel young, vulnerable, and frightened, followed by a sudden shift to feeling hostile and callous. The person may express confusion about their feelings and perceptions, or may have difficulty remembering what they have just said, even though they do not claim to be a different person or have a different name. The patient may be able to confirm the experience of identity alteration, but often the part of the self that presents for therapy is not aware of the existence of dissociated self-states. If identity alteration is suspected, it may be confirmed by observation of amnesia for behavior and distinct changes in affect, speech patterns, demeanor and body language, and relationship to the therapist. The therapist can gently help the patient become aware of these changes (e.g., Fine, 1999; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg, 1995).
Research tends to show that dissociation stems from a combination of environmental and biological factors. The likelihood that a tendency to dissociate is inherited genetically is estimated to be zero (Simeon et al., 2001).
Most commonly, repetitive childhood physical and/or sexual abuse and other forms of trauma are associated with the development of dissociative disorders (e.g., Putnam, 1985). In the context of chronic, severe childhood trauma, dissociation can be considered adaptive because it reduces the overwhelming distress created by trauma. However, if dissociation continues to be used in adulthood, when the original danger no longer exists, it can be maladaptive. The dissociative adult may automatically disconnect from situations that are perceived as dangerous or threatening, without taking time to determine whether there is any real danger. This leaves the person “spaced out” in many situations in ordinary life, and unable to protect themselves in conditions of real danger.
Dissociation may also occur when there has been severe neglect or emotional abuse, even when there has been no overt physical or sexual abuse (Anderson & Alexander, 1996; West, Adam, Spreng, & Rose, 2001). Children may also become dissociative in families in which the parents are frightening, unpredictable, are dissociative themselves, or make highly contradictory communications (Blizard, 2001; Liotti, 1992, 1999a, b).
The development of dissociative disorders in adulthood appears to be related to the intensity of dissociation during the actual traumatic event(s); severe dissociation during the traumatic experience increases the likelihood of generalization of such mechanisms following the event(s). The experience of ongoing trauma in childhood significantly increases the likelihood of developing dissociative disorders in adulthood (International Society for the Study of Dissociation, 2002; Kisiel & Lyons, 2001; Martinez-Taboas & Guillermo, 2000; Nash, Hulsey, Sexton, Harralson & Lambert, 1993; Siegel, 2003; Simeon et al., 2001; Simeon, Guralnik, & Schmeidler, 2001; Spiegel & Cardeña, 1991).
One of the core problems for the person with a dissociative disorder is affect dysregulation, or difficulty tolerating and regulating intense emotional experiences. This problem results in part from having had little opportunity to learn to soothe oneself or modulate feelings, due to growing up in an abusive or neglectful family, where parents did not teach these skills. Problems in affect regulation are compounded by the sudden intrusion of traumatic memories and the overwhelming emotions accompanying them (Metcalfe & Jacobs, 1996; Rauch, van der Kolk, Fisler, Alpert, Orr et al., 1996).
The inability to manage intense feelings may trigger a change in self-state from one prevailing mood to another. Depersonalization, derealization, amnesia and identity confusion can all be thought of as efforts at self-regulation when affect regulation fails. Each psychological adaptation changes the ability of the person to tolerate a particular emotion, such as feeling threatened. As a last alternative for an overwhelmed mind to escape from fear when there is no escape, a person may unconsciously adapt by believing, incorrectly, that they are somebody else. Becoming aware of this kind of fear is terrifying. Therein lies one of the central problems in treatment for a person with a dissociative disorder: “How do I learn to approach things I fear when to understand that I am afraid is itself frightening?” Skillful clinical approaches are required to help build confidence in a person’s ability to tolerate their feelings, learn, and grow as a person.
Dissociative experiences are often confused with those of hypnosis. While the two experiences may exist together, they are not the same. For example, hypnotic absorption may be present in someone who is experiencing identity alteration, but it is not equivalent. To be hypnotically absorbed is to lose track of the background events and be completely absorbed by the foreground (e.g., highway hypnosis, where a person drives by the exit they had taken many times, only to discover they had missed the exit and are further down the road). A person capable of hypnotic absorption may be absorbed in their thoughts while maintaining control of their body (and their driving), but what they are doing is not in their awareness. Thus there is a disconnection between mind (conscious awareness) and body. This disconnection in hypnotic absorption is an example of a dissociative process, but the absorption itself is not indicative of a dissociative disorder. Rather, absorption is an example of everyday hypnotic experience and is part of the continuum of the dissociation of psychological functions that can be seen during hypnosis.
There are four main categories of dissociative disorders as defined in the standard catalogue of psychological diagnoses used by mental health professionals in North America, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The four dissociative disorders are: Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder, and Depersonalization Disorder (American Psychiatric Association, 2000; Frey, 2001; Spiegel & Cardeña, 1991).
is characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. The amnesia must be too extensive to be characterized as typical forgetfulness and cannot be due to an organic disorder or DID. It is the most common of all dissociative disorders, frequently seen in hospital emergency rooms (Maldonado et al., 2002; Steinberg et al., 1993). In addition, Dissociative Amnesia is often embedded within other psychological disorders (e.g., anxiety disorders, other dissociative disorders). Individuals suffering from Dissociative Amnesia are generally aware of their memory loss. The memory loss is usually reversible because the memory difficulties are in the retrieval process, not the encoding process. Duration of disorder varies from a few days to a few years (American Psychiatric Association, 2000; Frey, 2001; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993).
is characterized by a sudden, unexpected travel away from home or one’s customary place of work, accompanied by an inability to recall one’s past and confusion about personal identity or the assumption of a new identity. Individual’s suffering from Dissociative Fugue appear “normal” to others. That is their psychopathology is not obvious. They are generally unaware of their memory loss/amnesia (American Psychiatric Association, 2000; Frey, 2001; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993).
is characterized by a persistent or recurrent feeling of being detached from one’s own mental processes or body. Individuals suffering from Depersonalization Disorder relate feeling as if they are watching their lives from outside of their bodies, similar to watching a movie (American Psychiatric Association, 2000; Frey, 2001; Guralnik, Schmeidler, & Simeon, 2000; Maldonado et al., 2002; Simeon et al., 2001; Spiegel & Cardeña, 1991). Individuals with Depersonalization Disorder often report problems with concentration, memory and perception (Guralnik et al., 2001). The depersonalization must occur independently of DID, substance abuse disorders and Schizophrenia (Steinberg et al., 1993).
(previously known as Multiple Personality Disorder) is the most severe and chronic manifestation of dissociation, characterized by the presence of two or more distinct identities or personality states that recurrently take control of the individual’s behavior, accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. It is now recognized that these dissociated states are not fully-formed personalities, but rather represent a fragmented sense of identity. The amnesia typically associated with Dissociative Identity Disorder is asymmetrical, with different identity states remembering different aspects of autobiographical information. There is usually a host personality who identifies with the client’s real name. Typically, the host personality is not aware of the presence of other alters (American Psychiatric Association, 2000; Fine, 1999; Frey, 2001; Kluft, 1999; Kluft, Steinberg & Spitzer, 1988; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg et al., 1993). The different personalities may serve distinct roles in coping with problem areas. An average of 2 to 4 personalities/alters are present at diagnosis, with an average of 13 to 15 personalities emerging over the course of treatment (Coons, Bowman & Milstein, 1988; Maldonado et al., 2002). Environmental events usually trigger a sudden shifting from one personality to another (Maldonado et al., 2002).
: DDNOS includes dissociative presentations that do not meet the full criteria for any other dissociative disorder (American Psychiatric Association, 2000; Steinberg et al., 1993). In clinical practice, this appears to be the most commonly presented dissociative disorder, and may often be better characterized by Major Dissociative Disorder with partially dissociated self states (Dell, 2001).
Some studies indicate that dissociation occurs in approximately two to three percent of the general population. Other studies have estimated a prevalence rate of 10% for all dissociative disorders in the general population (e.g., Loewenstein, 1994). Dissociation may exist in either acute or chronic forms. Immediately following severe trauma, the incidence of dissociative phenomena is remarkably high. Approximately 73% of individuals exposed to a traumatic incident will experience dissociative states during the incident or in the hours, days and weeks following.. However, for most people these dissociative experiences will subside on their own within a few weeks after the traumatic incident subsides (International Society for the Study of Dissociation, 2002; Martinez-Toboas & Guillermo, 2000; Saxe, van der Kolk, Berkowitz, Chinman, Hall, Lieberg & Schwartz, 1993).Dissociative Amnesia:
No exact prevalence rates have been empirically demonstrated for Dissociative Amnesia (Maldonado et al., 2002; Putnam, 1985).Dissociative Fugue:
Prevalence rate of 0.2% in the general population (American Psychiatric Association, 2000; Maldonado et al., 2002). The prevalence is thought to be higher during periods of extreme stress (Maldonado et al., 2002).Dissociative Identity Disorder:
Prevalence rates of .01 (Coons, 1984) to 1% in the general population. Studies have indicated a prevalence rate of .5 to 1.0% in psychiatric settings (Maldonado et al., 2002).Depersonalization Disorder:
Exact prevalence is unknown (Maldonado et al., 2002). Some researchers have suggested that Depersonalization Disorder is the third most common psychological disorder following depression and anxiety (Guralnik et al., 2001).
For more general treatment guidelines please refer to the Treatment Guidelines of the International Society for the Study of Trauma and Dissociation, available by clicking here.
No empirical studies have assessed the treatment of dissociative amnesia. Current information is based upon case studies and will be discussed briefly. Prior to beginning treatment, it is essential to determine that the amnesia is dissociative in origin. That is, neurological and/or medical causes must be ruled out. Clients with acute onset are typically treated more aggressively than clients presenting with chronic amnesia (Maldonado et al., 2002).Acute amnesia.
In clients with acute presentation of amnesia it is first necessary to provide a safe therapeutic environment (Maldonado et al., 2002). In fact, researchers have demonstrated that sometimes simply removing threatening stimuli and providing an individual with a safe environment has enabled spontaneous retrieval of memory (e.g., Kennedy & Neville, 1957). Barbiturates can be used to pharmacologically facilitate the interviewing process. Most commonly used are sodium amobarbital and sodium pentobarbital. No studies have empirically investigated the effectiveness of hypnosis in treating Dissociative Amnesia. However, hypnosis has been used successfully in the recovery of dissociated and repressed memories (Maldonado et al., 2002). Once the amnesia has been reversed it is important to explore and identify events that triggered the Dissociative Amnesia. The therapist should reinforce the use of effective coping mechanisms and the clients’ failure to use dissociation as their primary coping strategy (Maldonado et al., 2002).Chronic amnesia.
Pharmacologically facilitated intervention is not recommended. Hypnosis may be beneficial in recovering and working through traumatic memories at a pace comfortable for the client. Reframing of the traumatic experiences can occur during the hypnotic process. The goal of therapy is the integration of dissociated material. Treatment of chronic Dissociative Amnesia is typically long-term (Maldonado et al., 2002).
To date, there are no empirical studies that have addressed the treatment of Dissociative Fugue. All current information is derived from case studies and will be briefly discussed. A safe therapeutic environment, strong therapeutic alliance, recovery of one’s own identity, identification of triggers associated with fugue onset, reprocessing trauma and integrating trauma into one’s current being are essential components in the treatment of Dissociative Fugue. Drug-facilitated interviews and hypnosis may be helpful. Treatment should begin as soon as possible following the fugue (Maldonado et al., 2002).
Treatment of Dissociative Identity Disorder typically includes the following components: a strong therapeutic relationship, a safe therapeutic environment, appropriate boundaries, development of no self- or other-harm contracts, an understanding of the personality structures, working through traumatic and dissociated material, the development of more mature psychological defenses, and the integration of states of self. Guidelines for treatment of adults and children are available from the International Society for the Study of Trauma and Dissociation, www.ISST-D.org. Integration of traumatic memories is an essential aspect of treatment (Fine, 1999; Kluft, 1999; Lazrove & Fine, 1996; Maldonado et al., 2002). Hypnosis can aid in allowing the client to gain control over the dissociative episodes and in the integration of memories (Fine & Berkowitz, 2001; Maldonado et al., 2002). Treatment of Dissociative Identity Disorder is typically long and challenging. Spontaneous remission will not occur (Kluft, 1985b, 1999). Studies have shown that cognitive behavioral treatment of Dissociative Identity Disorder can be beneficial (Fine, 1999; Maldonado et al., 2002). Electroconvulsive therapy (ECT) is not generally recommended (Maldonado et al., 2002). Eye-Movement Desensitization and Reprocessing (EMDR) can be used in the treatment of DID although it needs to be implemented with great caution (Fine & Berkowitz, 2001). EMDR is a newer psychological treatment designed to accelerate the processing of information and to facilitate integration of fragmented trauma memories (Fine & Berkowitz, 2001; Lazrove & Fine, 1996).
As holds true for the other dissociative disorders, no controlled studies have addressed the treatment of Depersonalization Disorder. Treatments currently used include a variety of models including cognitive and behavioral approaches, psychoanalysis, and psychopharmacology (as cited in Maldonado et al., 2002; Simeon et al., 2001). Clinical findings are inconsistent. The lack of empirical treatment studies on depersonalization adversely impacts the understanding and treatment of other dissociative disorders due to the fact that depersonalization is often a component of these disorders (Simeon et al., 2001). Depersonalization Disorder has been described as resistant to psychopharmacological and psychotherapeutic treatment interventions (Guralnik et al., 2001).
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders. Washington, D.C.: Author.
Anderson, C. L., & Alexander, P. C. (1996). The relationship between attachment and dissociation in adult survivors of incest. Psychiatry: Interpersonal & Biological Processes, 59(3), 240-254.
Blizard, R. A. (1997). The origins of Dissociative Identity Disorder from an object relations and attachment theory perspective. Dissociation: Progress in the Dissociative Disorders, 10(4), 223-229.
Blizard, R. A. (2003). Disorganized attachment, development of dissociated self states, and a relational approach to treatment. Journal of Trauma and Dissociation, 4(3), 27-50.
Coons, P. M. (1984). The differential diagnosis of multiple personality: A comprehensive review. Psychiatric Clinics of North America, 7, 51-65.
Coons, P. M., Bowman, E. S., & Milstein, V. (1988). Multiple personality disorder: A clinical investigation of 50 cases. Journal of Nervous and Mental Disease, 17, 519-527.
Dixon, J. C. (1963). Depersonalization phenomena in a sample population of college students. British Journal of Psychiatry, 109, 371-375.
Dell, P. F. (2001). Why the diagnostic criteria for dissociative identity disorder should be changed. Journal of Trauma and Dissociation, 2(1), 7-37.
Fine, C. G. (1999). The tactical-integration model for the treatment of Dissociative Identity Disorder and allied dissociative disorders. American Journal of Psychotherapy, 53(3), 361-376.
Fine, C. G. & Berkowitz, A. S. (2001). The wreathing protocol: The imbrication of hypnosis and EMDR in the treatment of Dissociative Identity Disorder and other dissociative responses. American Journal of Clinical Hypnosis, 43 (3-4), 275-290.
Frey, R. J. (2001). Dissociative disorders. In The Gale Encyclopedia of Medicine, 2nd Edition (5 Vol.). Farmington Hills, MI: Gale Group.
Guralnik, O., Schmeidler, J., & Simeon, D. (2000). Feeling unreal: Cognitive processes in depersonalization. American Journal of Psychiatry, 157(1), 103-109.
International Society for the Study of Dissociation (now ISSTD) (2002). Understanding dissociation: A videofilm.
Jacobs, J. R., & Bovasso, G. B. (1992). Toward the clarification of the construct of depersonalization and its association with affective and cognitive dysfunctions. Journal of Personality Assessment, 59(2), 352-365.
Kennedy, R. B., & Neville, J. (1957). Sudden loss of memory. British Journal of Medicine, 2, 428-433.
Kisiel, C. L., & Lyons, J. S. (2001). Dissociation as a mediator of psychopathology among sexually abused children and adolescents. American Journal of Psychiatry, 158, 1034.
Kluft, R. P. (1985b). The natural history of multiple personality disorder: In R. P. Kluft (Ed.), Childhood antecedents of multiple personality (pp. 197-238).
Kluft, R. P. (1999). An overview of the psychotherapy of Dissociative Identity Disorder. American Journal of Psychotherapy, 53(3), 289-319.
Kluft, R. P., Steinberg, M., & Spitzer, R. L. (1988). DSM-III-R revisions in the dissociative disorders: An exploration of their derivation and rationale. Dissociation: Progress in the Dissociative Disorders, 1(1), 39-46.
Lazrove, S., & Fine, C. G. (1996). The use of EMDR in patients with Dissociative Identity Disorder. Dissociation: Progress in the Dissociative Disorders, 9(4), 289-299.
Liotti, G. (1992). Disorganized/disoriented attachment in the etiology of the dissociative disorders. Dissociation, 5(4), 196-204.
Liotti, G. (1999a). Understanding the dissociative processes: The contribution of attachment theory. Psychoanalytic Inquiry Special Issue: Attachment Research and Psychoanalysis, 19(5), 757-783
Liotti, G. (1999b).Disorganization of attachment as a model for understanding dissociative pathology. In Solomon, J. & George, C., Attachment disorganization, New York: Guilford Press.
Loewenstein, R. J. (1994). Diagnosis, epidemiology, clinical course, treatment, and cost effectiveness of treatment of dissociative disorders and MPD: Report submitted to the Clinical Administration Task Force on Health Care Financing Reform. Dissociation, 7, 3-11.
Maldonado, J. R., Butler, L. D., & Spiegel, D. (2002). Treatments for dissociative disorders. In A Guide To Treatments That Work, 2nd Edition. New York: Oxford University Press.
Martinez-Taboas, A., Guillermo, B. (2000). Dissociation, psychopathology, and abusive experiences in a nonclinical Latino university student group. Cultural Diversity and Ethnic Minority Psychology, 6, 32-41.
Metcalfe, J., Jacobs, W.J. (1996). A "hot-system/cool-system" view of memory under stress. PTSD Research Quarterly, 7, 1-3.
Nash, M. R., Hulsey, T. L., Sexton, M. C., Harralson, T. L., & Lambert, W. (1993). Long-term sequelae of childhood sexual abuse, perceived family environment, psychopathology, and dissociation. Journal of Consulting and Clinical Psychology, 61, 276-283.
Ogawa, J. R., Sroufe, A., Weinfield, N., Carlson, E. A., & Egeland, B. (1997). Development of the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Development and Psychopathology, 9, 855-879.
Pascuzzi, R. M., & Weber, M. C. (1997). Conversion disorders, malingering, and dissociative disorders. In Current Diagnosis (Vol. 9). Philadelphia: W. B. Saunders Co.
Putnam, F. W. (1985). Dissociation as a response to extreme trauma. In R. P. Kluft (Ed.), Childhood antecedents of multiple personality (pp. 63-97). Washington, DC: American Psychiatric Press.
Rauch, S. L., van der Kolk, Bessel, A., Fisler, R.E., Alpert, N.M., Orr, S.P., Savage, C.R., Fischman, A.J., Jenike, M. A., Pitman, R.K. (1996). A symptom provocation study of posttraumatic stress disorder using positron emission tomography and script driven imagery. Archives of General Psychiatry, 53, 380-387.
Rauschenberger, S. L., & Lynn, S. J. (1995). Fantasy proneness, DSM-III-R axis I psychopathology, and dissociation. Journal of Abnormal Psychology, 104, 373-380.
Saxe, G. N., van der Kolk, A. B., Berkowitz, R., Chinman, T., Hall, K., Lieberg, G., & Schwartz, J. (1993). Dissociative disorders in psychiatric inpatients. American Journal of Psychiatry, 150, 1037-1043.
Siegel, P. F. (2003). Dissociation and the question of history: What, precisely, are the facts? Psychodynamic Psychology, 20, 67-83.
Simeon, D., Guralnik, O., Knuntelska, M. & Schmeidler, J. (2002). Personality factors associated with dissociation: Temperament, defenses, and cognitive schemata. American Journal of Psychiatry, 159(3), 489-491.
Simeon, D., Guralnik, O., & Schmeidler, J. (2001). Development of a depersonalization severity scale. Journal of Traumatic Stress, 14(2), 341-349.
Simeon, D., Guralnik, O., Schmeidler, J., & Knutelska, M. (2001). The role of childhood interpersonal trauma in Depersonalization Disorder. American Journal of Psychiatry, 158(7), 1027-1033.
Simeon, D., Guralnik, O., Gross, S., Stein, M. B., Schmeidler, J., & Hollander, E. (1998). The detection and measurement of depersonalization disorder. The Journal of Nervous and Mental Disease, 186(9), 536-542.
Spiegel, D., & Cardeña, E. (1991). Disintegrated experience: The dissociative disorders revisited. Journal of Abnormal Psychology, 100, 366-378.
Steinberg, M. (1994a). Interviewer’s guide to the Structured Clinical Interview for DSM-IV Dissociative Disorders – Revised (SCID-D-R) (2nd ed.). Washington, DC: American Psychiatric Press.
Steinberg, M., Cicchetti, D., Buchanan, J., Hall, P., & Rounsaville, B. (1993). Clinical assessment of dissociative symptoms and disorders: The Structured Interview for DSM-IV Dissociative Disorders (SCID-D). Dissociation: Progress in the Dissociative Disorders, 61(1), 108-120.
Steinberg, M., Rounsaville, B., & Cicchetti, D. V. (1990). The Structured Clinical Interview for DSM-III-R Dissociative Disorders: Preliminary report on a new diagnostic instrument. American Journal of Psychiatry, 147(1), 76-82.
Steinberg, M, & Steinberg, A. (1995). Using the SCID-D to assess Dissociative Identity Disorder in adolescents: Three case studies. Bulletin of the Menninger Clinic, 59(2), 221-231.
West, M., Adam, K., Spreng, S., & Rose. S. (2001). Attachment disorganization and dissociative symptoms in clinically treated adolescents. Canadian Journal of Psychiatry, 46(7), 627-631.
They are in treatment (or, not in treatment), and they do not wish to “integrate” their personalities. What can I do? I am worried about their lack of interest in integrating, and I don’t know how to respond to their behaviors. Is it safe to be around them?
Dear Sir or Madam, Unfortunately, while we would like to respond to specific concerns, it is outside the scope of ISSTD to comment about the condition of a person in an ongoing treatment. Our suggestion would be that you bring up your concerns with the treating clinician. If they are not in treatment, or if that fails to bring closure, then we would recommend you seek consultation for yourself, in your local area. If available, we would be glad to provide you with the name of a consultant, at that time.
When a person has obvious psychological problems, and they are not in treatment, there is no legal way, in jurisdictions with which we are familiar, to make them comply with a treatment program in which they have no interest. Likewise, “forced” treatment, is neither usually productive, nor useful, even when there is compliance. The bottom line is that people only enter treatment when their view is that it will be useful to them.
In general, there is no evidence that a person with a dissociative disorder is going to be any more violent or dangerous to others than any other person with any kind of mental illness. Each situation needs to be assessed on a case by case basis, thoughtfully. Therapists have a duty to warn others, if their patient is felt by them to be dangerous. Lack of “integration” is not an indication of dangerousness. Not all persons with a dissociative disorder choose integration as an end point for their treatment. In many treatments, the focus is on function, living a life. One definition of mental health is: to be flexible and resilient in the face of life’s challenges while living in relation to others, in community, and with a full range of emotion. If a person achieves that, without integration, perhaps that is good enough. On the other hand, if lack of integration precludes real mental health, then more treatment may be useful. A case by case assessment is necessary.
To help you in the task of gathering information, the following materials are recommended to you. These references are available through most University libraries, or through local libraries with inter-library services. Also listed are some resources from the internet, which you may find useful.
Armstrong, J. G. and Loewenstein, R. J. (1990). Characteristics of
patients with multiple personality and dissociative disorders on
psychological testing. Journal of Nervous and Mental Disease, 178, 448-454.
Kluft, R. P. (Ed.). (1985). Childhood Antecedents of Multiple
Personality. Washington, D.C.: American Psychiatric Press, Inc.
Kluft, R. P. (2000). The Psychoanalytic Psychotherapy of
Dissociative Identity Disorder in the Context of Trauma Therapy.
Psychoanalytic Inquiry, 20(2), 259-286.
Liotti, G. (1999). Disorganization of attachment as a model for
understanding dissociative psychopathology. In J. a. G. Solomon, Carol
(Ed.), Attachment Disorganization (pp. 291-317). New York: Guilford Press.
Loewenstein, R. J. (1991). An Office Mental Status Examination for
Complex Chronic Dissociative Symptoms and Multiple Personality Disorder.
In R. J. Loewenstein (Ed.), Psychiatric Clinics of North America (Vol.
14, pp. 567-604). Philadelphia: W.B. Saunders Company.
Main, M., Morgan, Hillary. (1996). Disorganization and
disorientation in infant strange situation behavior: phenotypic
resemblance to dissociative states. In L. K. Michelson, and Ray, William
J. (Ed.), Handbook of Dissociation: Theoretical, Empirical, and Clinical
Perspectives (pp. 107-138). New York: Plenum Press.
Nijenhuis, E. R. S., Vanderlinden, J., Spinhoven, P. (1998). Animal
defensive reactions as a model for trauma-induced dissociative
reactions. Journal of Traumatic Stress, 11(2), 243-260.
Putnam, F. W. (1989). Diagnosis and Treatment of Multiple
Personality Disorder. New York: Guilford Press.
Putnam, F. W. (1997). Dissociation in Children and Adolescents. New
York: The Guilford Press.
Silberg, J. L. (1996). The Dissociative Child: Diagnosis, Treatment,
and Management. Lutherville, Maryland: The Sidran Press.
Spiegel, D. (1994). Dissociation: Culture, Mind, and Body.
Washington, D.C.: American Psychiatric Press, Inc.
Steinberg, M. (1993). Structured Clinical Interview for DSM-IV
Dissociative Disorders. Washington, D.C.: American Psychiatric Press.
Terr, L. C. (1991). Childhood Traumas: An Outline and Overview.
American Journal of Psychiatry, 148, 10-19.
van der Kolk, B., MacFarlane, Alexander, Weisaeth, Lars. (1996).
Traumatic Stress. New York: Guilford Press.
There are a number of diagnostic tests, such as the Structured Clinical Interview for Dissociative Disorders (SCID-D) and the Dissociative Disorders Interview Scale (DDIS), that are available and can be administered in a clinical setting. The Dissociative Experiences Scale (DES) is not a diagnostic instrument. However, its use is widespread, and may be effective in screening large populations for dissociative experience, for clinical study.
When a person is asking whether or not they have DID, that is a question that is worthy of consultation. Some people are relieved to find that there is a diagnosis and an understandable model for their experiences. Some dissociative experiences may provoke considerable anxiety and bafflement, and it is important to be able to find an organizing concept that makes these experiences understandable.
The bottom line in all this is that it is our strong recommendation that this question (How do I know if I have DID?) be asked in the context of an ongoing psychotherapy. If you are in a psychotherapy, ask your therapist what they think. Ask them if they have enough experience with DID to feel comfortable in making the diagnosis. If they dont, ask them to get a consultation for you and for them.
Here are some references from the Self-help literature. A skilled couples therapist may also be helpful.
Sexual Healing Journey: A Guide for Survivors of Sexual Abuse by Wendy Maltz
The Courage to Heal Workbook: For Women and Men Survivors of Child Sexual Abuse by Laura Davis
What About Me? A Guide for Men Helping Female Partners Deal with Childhood Sexual Abuse by Grant Cameron
Ghosts in the Bedroom: A Guide for Partners of Incest Survivors by Ken Graber
Beginning to Heal: A First Book for Survivors of Child Sexual Abuse by Ellen Bass, Laura Davis
When You Are the Partner of a Rape or Incest Survivor: A Workbook for You by Robert Barry Levine
She hasnt been diagnosed but it is very obvious that she has it. There is some integration and some co-consciousness. Some of the littles have integrated, a couple of the protectors, and some of the abusive parts as well. Some of the alters dont like to tell me their name. Also when the host and I get physical there is one who likes to be physical, but others dont. How can I deal with all this?
Dear Sir, ISSTD is a membership organization and we are not able to comment on a person’s condition, especially based on someone’s report, and not a face to face interview by a professional. Even then, rules of ethics preclude a clinician making comments about a person’s condition without having interviewed them.
On the other hand, common sense would dictate that this dating relationship presents a number of confusing possibilities and moral responsibilities, depending upon an individual’s perspective, and local law. The wisest course of action might be to consider consultation with a local clinician of your choice, and to discuss this situation with them. Respect for the rights of individuals, and the maintenance of personal safety are the bottom line in relationships.
I went to a therapist three years ago to find a way to cope with an impending loss. As you already know, there is a questionnaire that you fill out. Some were questions I had never been asked before. Probably the one that caused the most fuss, was do you have voices in your head. The answer was yes. It went down hill from there.
In the course of the next few years my therapist and my psychiatrist have journeyed into what it is like to be me. Days that only last a few hours, all of a sudden not knowing what I am supposed to be doing, forgetting how to read, hearing me talk, but not recognizing the voice.
They have diagnosed me with DID. I have been fighting them on this. I do not believe that you can turn yourself into different people and not be crazy. I hold down a very hard job, how could this be going on? I would have lost my job.
My therapist is insisting that I was abused as a child and wants me to come clean. She says that I know it, I am just unable to express it. When I started therapy, even after the presentation of my voices, I insisted that I would not revisit my childhood so that they could change my memories. I had a wonderful childhood, full of hugs, kisses, laughter. What she wants me to do will destroy all of that.
There were things that I was eager to explore and change in my life. I have some habits that take up a lot of my time, but don’t add anything to my life. I am uncomfortable with anything sexual and don’t know why. But, if I go along with therapy - I will be deemed crazy (DID) and my wonderful childhood will be replaced with horror.
Dear Ms. _____, Even people who dont have a trauma history, one that is filled with physical or sexual abuse, can develop a dissociative disorder. The origins of this are speculative, and at the same time there is a very strong and sophisticated literature in the field of infant attachment studies that points clearly to a pattern of attachment called Type D attachment as predicting adult dissociation. Additional work by Karlen Lyons-Ruth shows that adult dissociation is best predicted by the "hidden trauma" of emotional abuse vs. physical/sexual abuse in a ratio of 2:1. There is a lot of evidence that people can develop complex dissociative disorders from what has recently been called developmental trauma.
It sounds as if you are feeling a lot of pressure to accept what your therapist is saying. It also may be that there is even more pressure and conflict inside you to try and figure out what to do and how to understand what youve learned about your mind and how it works. Perhaps the struggle you are having with your therapist is related to a conflict you are having in your own mind? Its hard to know, but thats always a consideration.
Theres lots of reading you can do to learn more about dissociation and how attachment issues may be reflected in adult dissociative disorders. Some of those references follow. Its always useful to bring these issues up with you therapist. We hope youll do that.
A list of references about dissociation and attachment follows:
Liotti, G. (1999). Disorganization of attachment as a model for understanding dissociative psychopathology. Attachment Disorganization. J. Solomon, George, C. New York, Guilford Press: 291-317.
Lyons-Ruth, K. (2003). "Dissociation and the parent-infant dialogue: a longitudinal perspective from attachment research." Journal of the American Psychoanalytic Association 51(3): 883-911.
Main, M., Morgan, Hillary (1996). Disorganization and disorientation in infant strange situation behavior: phenotypic resemblance to dissociative states. Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives. L. K. Michelson, and Ray, William J. New York, Plenum Press: 107-138.
Siegel, D. J. (1999). The Developing Mind: Toward A Neurobiology of Interpersonal Experience. New York, Guilford Press.
Your question presents one of the most complex and sensitive concerns that a person can pose regarding their mental health. I am not going to try to convince you one way or the other regarding whether or not you have a dissociative disorder. What is most important is for you to develop your own theory of what was happening in your mind, and what happens in other people’s minds as you and they experience living.
Multiple Personality Disorder is really a misnomer. It may be more useful to understand the dissociative processes, the processes that detach aspects of experience from each other that make the experience unknowable, unfeelable, etc., as a discontinuity in the experience of being one’s Self. In fact, many experts would say that people with dissociative disorders often have the experience of not having a whole coherent Self. It is the disowning of aspects of Self experience, emotion, behavior, sensation, and knowledge that become personified and are typical of the development of the alternate self states that are the hallmark of more complex dissociative disorders. It is this sense of an alteration of identity that provided some of the impetus for a name change to Dissociative Identity Disorder, in the last Diagnostic and Statistical Manual of the American Psychiatric Association, DSM-IV-TR
Some people are frightened of the word dissociative. They believe that if someone has a dissociative disorder that means that a person must have a severe trauma history. Sometimes that’s true, and sometimes that is not true. A person can develop a dissociative disorder just from life’s circumstances. Some studies have suggested that growing up in a family where a parent is frightened, frightening, or severely grieving/depressed during a child’s first years may be enough to generate the organization of mind that relies more heavily on dissociative adaptations to get through the day.
Perhaps you will be able to spend some time with your therapist trying to understand your experience, and focus on what it means to you, and not just focus on diagnosis. It is hard to know if there is a trauma history hidden in your past, or not. About 10 percent of people with trauma histories have extensive memory loss for trauma that they later remember. In any event, working with your current experiences, their meaning in your life, and functioning from day to day in relationships, and in your community, is a good place for a therapy to start. Where it goes from there can be based on a solid working alliance if these first issues are thoughtfully addressed.