Dissociative disorders

We’ve talked before about the phenomenon of dissociation. So what was it again? New experiences are usually integrated into memory through the emotions, thoughts and behaviours associated with them. When a traumatic situation clashes with a person’s existing cognitive schemas, that experience may not be properly integrated into conscious memory, and it may “pop out now and then” in situations similar to the traumatic one or at stressful moments, causing intense distress and confusion. Put another way, these are memories, feelings and behaviours that haven’t been consciously processed as they should have been, and they resurface against the person’s will and beyond their control, causing intense emotional pain and dysfunctional behaviour. To put it simply, it’s as if you lived through something that was “too big” for your mind and your whole being; since the jigsaw piece can’t be slotted into the right place, it’s left loose, never finding its spot and getting in the way of all the others.

What defines a dissociative disorder?

According to the DSM-5, for something to qualify as one, we need to find the following basic features: a disruption and/or discontinuity in the normal integration of consciousness, memory, personal and subjective identity, emotion, perception, body identity, motor control and behaviour.

Do many people suffer from them?

Estimates of how many people have a dissociative disorder vary a great deal depending on the study and how it’s measured, but what we do know is that they’re not as rare as is often thought. In other words, they affect far more people than we imagine…

What are the main dissociative disorders?

According to the DSM-5, these are the main ones:

Dissociative identity disorder (DID) (also known as multiple personality disorder): a disruption of identity characterised by two or more distinct personality states, along with recurrent gaps in the recall of everyday events, important personal information and/or traumatic events that are inconsistent with ordinary forgetting.

Personally, I’m fascinated by the idea that someone could split their self, their identity, in the way this disorder supposedly does. However, it’s surrounded by a great deal of controversy in psychiatry and psychology, as many professionals doubt that this disorder really exists. Both dissociative identity disorder and dissociative amnesia are most often linked to traumatic experiences in childhood, and specifically to sexual abuse, but these aren’t always the cause of the disorder.

Dissociative amnesia: an inability to recall important personal information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting (the absent-mindedness and small memory lapses we all have from time to time in everyday life). As the DSM-5 notes, the information that can’t be recalled is usually autobiographical, that is, personal. The gaps can range from a few minutes or hours to years of the person’s life, depending on the case. Sometimes dissociative amnesia can be permanent, but not always: with good therapeutic work (or sometimes even spontaneously), the person may recover the lost information.

In the DSM-5, dissociative fugue is considered a subtype of dissociative amnesia. In it, the person makes sudden, unexpected trips away from home and afterwards can’t remember what they did or what happened.

Dissociative amnesia can also occur alongside dissociative identity disorder and, when it does, the main diagnosis will always be the latter; in other words, dissociative identity disorder takes precedence.

Depersonalisation/derealisation disorder: the persistent or recurrent presence of depersonalisation, derealisation or both. Depersonalisation involves experiences of unreality, detachment, or being an outside observer of one’s own thoughts, feelings, sensations, body or actions. Derealisation is the experience of unreality or detachment from one’s surroundings, and people often describe it as being “as if I were in a dream while awake”. In both cases, the person’s sense of reality remains intact.

Both depersonalisation and derealisation are dissociative phenomena that are also part of daily life for many people with anxiety disorders; for example, they’re common in panic disorder. They’re striking, but in these cases they tend to be common and aren’t serious. Even so, it’s understandable that many people are frightened by these experiences and believe they’re losing their mind, or something similar. To challenge these beliefs in such cases, behavioural experiments are very useful.

Like dissociative amnesia, this disorder also frequently occurs in cases of dissociative identity disorder.

Other specified dissociative disorder: presentations in which dissociative symptoms predominate but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class, and the clinician chooses to state the specific reason why.

Unspecified dissociative disorder: presentations in which dissociative symptoms predominate but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class, and the clinician chooses not to specify the reason the criteria are not met.

In future articles we’ll look in more depth at the main dissociative disorders, starting with dissociative identity disorder, and at how they’re treated in therapy.