Dissociation FAQs

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.

JThere 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, Fifth Edition (DSM-5). The four dissociative disorders are: Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder, and Depersonalization Disorder (American Psychiatric Association, 2000; Frey, 2001; Spiegel & Cardeña, 1991).

DISSOCIATIVE AMNESIA 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).

DISSOCIATIVE FUGUE 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).

DEPERSONALIZATION DISORDER 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).

DISSOCIATIVE IDENTITY DISORDER (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).

DISSOCIATIVE DISORDER NOT OTHERWISE SPECIFIED (DDNOS): 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).

SOME PREVALENCE RATES HAVE BEEN CALCULATED INDIVIDUALLY FOR THE FOUR TYPES OF DISSOCIATIVE DISORDERS:

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.

1. Dissociative Amnesia: 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).
2. Dissociative Fugue: 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).
3. Dissociative Identity Disorder: 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).
4. Depersonalization Disorder: 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).

There are a number of diagnostic tests, such as the Structured Clinical Interview for Dissociative Disorders (SCID-D), the Multidimensional Inventory of Dissociation (MID), and the Dissociative Disorders Interview Scale (DDIS), that are available and can be administered by a trained clinician. 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.

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