Dissociative disorders are among the least-discussed mental health conditions, though they’re more common than people realize. Research indicates that one to three percent of the general population has dissociative identity disorder (DID), and underreporting and misdiagnosis means that there are probably even more people who suffer from DID or similar conditions.
Clinicians now understand that dissociative disorders are common in individuals who have a history of trauma. Even when a person with a history of trauma does not meet criteria for a dissociative disorder, they often experience dissociative symptoms. For example, people with borderline personality disorder (BPD), especially those who report childhood trauma, also frequently have comorbid dissociative symptoms or disorders.
Mental health professionals have adjusted their training and diagnostic tools to reflect this growing awareness. For example, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which was published in 2013, added a dissociative subtype of posttraumatic stress disorder (PTSD) and updated the criteria for dissociative disorders.
What Is a Dissociative Disorder?
Dissociative disorders are mental health conditions in which people experience an involuntary break from reality that is not severe enough to be a psychotic break. This means that people with dissociative conditions don’t typically suffer from delusions or hallucinations like people with psychotic disorders, but have experiences in which their memories, feelings, thoughts, and even their entire lives do not feel like their own. Typically, this is because they have suffered trauma that caused them to lose control of and identification with their mental processes.
For example, while some people suffering from schizophrenia might believe that their thoughts are being broadcast into their minds by something outside of them, people with dissociative disorders recognize their thoughts as their own but feel disconnected from them. It’s as if the “emotional current” linking them to their subjective experiences has been turned off. Many have “out-of-body” experiences in which it is as if they are outside of what is happening to them, dispassionately watching it unfold as an observer would.
Events that elicit strong positive or negative emotional reactions in most other people often “bounce off” of people with dissociative disorders. If you ask someone who was in a dissociative state why they didn’t react in an expected way to an event, that person will often tell you, “It felt like it was happening to someone else.” They know how they are “supposed” to feel about something, but just can’t feel or respond to it.
People with dissociative disorders also commonly experience lapses in which they can’t remember what they did or what happened to them during a certain period of time.
Causes and Symptoms of Dissociative Disorders
The main cause of all dissociative disorders is trauma. Sometimes, people consciously develop dissociative habits while they are experiencing trauma as a way to lessen its felt psychological impact. They learn how to “go away” to different places inside of themselves when they can’t escape a painful experience physically. However, dissociative symptoms more typically arise as a subconscious defense. It’s as if the brain builds a defensive wall.
While extreme trauma like sexual abuse or growing up in a war zone can lead to the development of dissociative disorders, they can also arise in response to less extreme circumstances, such as growing up in an emotionally unstable home. When someone is repeatedly provoked into a fear response by an unpredictable environment, it becomes necessary to their psychological survival to learn how to be less reactive in order to survive in it.
One study of people with comorbid borderline personality and dissociative identity disorders found that a significant predictor of dissociative traits was when traumatic experiences arose in an environment of emotional neglect in which authority figures diminished or minimized the feelings of the traumatized individuals. In other words, when someone suffers a traumatic event but is told they shouldn’t express any feelings in response to it—or even acknowledge that it happened—they learn to disconnect from how they feel and what they remember.
Research shows that people with trauma-related dissociation experience reduced performance across a range of memory functions. Verbal, general, and long-term memory are all negatively impacted by traumatic experiences. The research shows that this is not a conscious choice to forget painful experiences, but an actual physical change in how the brain works.
Neuroimaging has shown that the brains of traumatized people with dissociative symptoms exhibit distinct differences in processes of memory and attention. Specifically, the brains of traumatized individuals show stronger connections between networks associated with the processing of negative emotions and networks associated with everyday mental tasks like attention and memory.
A simpler way to understand this is to say that people who dissociate in response to trauma are constantly in a state of “fight or flight” and that the stress has a significant impact on how much they can process and remember. Their brains don’t have the “bandwidth” to encode memories in the same way as brains that are not in a state of hyperarousal.
Emotional numbing is very common in dissociative disorders, as well as other trauma-related disorders like post-traumatic stress disorder (PTSD) “Fight or flight” reactions normally last only for short periods of time, while the brain is constantly in this state for severely traumatized individuals. The overwhelming intensity of fear arousal that floods the brain after trauma makes the blunting of emotion necessary to function. This is actually one of the defining elements of dissociation: that the brain works differently in order to “turn off” natural emotional responses that become overwhelming in traumatizing environments.
Studies show that the experience of hyperarousal that follows trauma is the strongest predictor of post-traumatic emotional numbing and dissociation. Being detached or even completely numb is preferable to being in a constant state of heightened stress. Again, a primary distinguishing factor in dissociative disorders is that this emotional disconnection is not consciously chosen, but a reflection of a brain that has been trained to respond differently.
Distorted Perception of Reality
There are different ways that people with dissociative disorders can experience a distorted sense of reality. Some of these reality distortions border on psychosis without quite becoming psychosis: people with DID sometimes confuse fantasy with real memories, for example, and mistake experiences in the inner world of their personalities with events in external reality. People with dissociative symptoms are also more likely to confuse dreams and reality.
This happens because a person with DID splits off different parts of the self into what that person experiences as wholly separate selves. Again, this is a protective function that allows them to block off parts of themselves that they experience as threatening. It also reflects the way trauma can alter the functioning of memory and of the brain in general. Visual distortions have even been shown to occur more commonly in people who are experiencing dissociation.
People with dissociative disorders can also experience the opposite: instead of thinking of unreal things as real, they experience real events as unreal. This is especially common in depersonalization-derealization disorder. Again, this symptom reflects the same underlying mechanism in which the brain disconnects memories and emotions that invoke a “fight or flight” response from the traumatized person’s sense of self. This is the only way the person can experience a “break” from what would otherwise be a state of chronic hyperarousal.
Blurred Sense of Identity
The distorted way people with dissociative disorders experience identity reflects the different ways their brains process memory and emotion. While some people simply experience a break between a felt emotion and the sense of self, resulting in blunted emotional responses, others experience these emotional states fully, build a sense of self around these specific emotional states, then block off these identities from their conscious experience most of the time.
This splintering of the self can result in a person having multiple identities that “take turns” or in simply having a personality that “swings wildly.” People with dissociative conditions might not be aware of the way they suddenly “switch” to a radically different self-presentation, though others will notice. This ability to move from one distinct self to another means that people with dissociative disorders can draw from a more stable personality as needed to function in day-to-day life.
Depression, Anxiety, and Suicidal Thoughts
Research shows that people with dissociative disorders experience higher rates of self-harm, suicidality, and suicide attempts than the general population. They even experience these dangerous symptoms more often than people with other serious psychiatric conditions. Again, this is due to the impact of trauma. Most symptoms of dissociative disorders reflect conscious or subconscious attempts to keep certain emotions, thoughts, or memories out of awareness. However, these attempts aren’t always successful, and sometimes a person with dissociative disorder experiences “intrusions” of these unwanted memories and emotions.
People with dissociative disorders sometimes harm themselves in an attempt to use physical pain to distract the brain from emotional pain. When such distraction attempts fail, anxiety and depression naturally arise. While this sometimes reflects the inability to keep depressing or anxiety-inducing thoughts or memories out of conscious awareness, symptoms of depression and anxiety can also arise from a general sense of unease when this content doesn’t quite become conscious. When untreated, comorbid anxiety and depression can lead to worsening self-harm and suicide attempts.
Types of Dissociative Disorders
The different dissociative disorders not only reflect the severity with which people experience dissociative symptoms but the way they experience them. Each disorder reflects a different target of disassociation: memory, identity, and sensation.
According to the DSM-5, dissociative amnesia occurs when a person has one or more episodes of being unable to remember important personal information, usually traumatic or stressful information, in ways that can’t be explained by ordinary forgetfulness and that do not occur in the context of another dissociative or traumatic disorders such as DID or PTSD. The memory loss also can’t be explained by physical damage to the brain or by substance abuse. When these lapses include episodes in which a person cannot recall their identity and takes actions they do not understand, the person is diagnosed with “dissociative amnesia with dissociative fugue.”
There are three types of dissociative amnesia: localized, selective, and generalized. Localized dissociative amnesia occurs when a person can’t remember a specific event or period of time and is the most common type. Selective amnesia is broader, while generalized amnesia is the broadest, involving a total loss of identity and life history. This latter type, often the subject of dramatic fiction and movies, is especially rare. All types reflect actual physical changes in which the functioning of the hippocampus is disturbed by increased stress.
Dissociative Identity Disorder
Dissociative identity disorder was previously called “multiple personality disorder” (MPD) and was defined by having multiple distinct personalities. It was sensationalized in media depictions like The Three Faces of Eve and Sybil in which characters had alarming revelations about acts that one of their personalities had committed. The spike in reported cases of MPD following the airing of these films caused many people to write off the disorder as completely fictional, made up by people wanting attention or to escape the consequences of a crime.
While the diagnosis of DID remains controversial, the change in terminology from MPD to DID in 1994 reflects a more nuanced understanding of the condition. DID is now defined more broadly as the fragmentation of identity into what is experienced as more than oneself. While some people with DID may have a distinct collection of clearly bounded personalities, or “alters,” many people with DID express different personalities in ways they haven’t conceptualized with such distinction. Some people with DID may not even be aware of when they switch from one personality state to another, though other observers often notice it.
While all of us act differently in different contexts, these shifts are more radical in people with DID; often, one “alter” will say or do something another never would. The “fantasy” element reflected by personalities with distinct stories and backgrounds is now understood not as a form of fabrication, but as a reflection of how the trauma that triggers DID interrupts a crucial period of childhood development, causing it to persist in a fragmented way through adulthood.
As children develop, they rely on imagination to navigate the world and develop a sense of self. Trauma interrupts this, preventing the child from developing a sense of agency or consolidating a core sense of identity. When trauma occurs at a stage when a child inhabits imaginary roles and interacts with imaginary friends, they can use these imaginative tools to construct a form of denial in which traumatic events happen to one of these imagined personalities.
Dissociative fugue is a time-limited disorder in which a person forgets their identity and adopts a new one. Dissociative fugue disorder should not be confused with dissociative amnesia where a person is aware of their memory loss. Dissociative fugue may be the result of the brain trying to protect itself from painful past trauma.
A person with dissociative fugue disorder is unaware of the fact that they have forgotten their identity. In addition to the person being unaware of their memory loss, a crucial part of the various dissociative fugue definitions is that the person might travel to a new location away from home as the fugue begins. Dissociative fugue episodes must be determined not to be the result of dissociative identity disorder.
In some ways, Depersonalization-Derealization Disorder (DDD) reflects the inverse of the other dissociative disorders. People with DDD do not experience lapses of memory or shifts from one identity to another. Instead, they experience a unified sense of self, but this feels unreal to them. They are hyper-aware of there being a “sense of self,” and distrust this sense.
People with DDD can experience the world in one of two key ways. In depersonalization, people experience their bodies, thoughts, and feelings as unreal, or as if they are observing them from the outside. In derealization, people experience the outside world as unreal, as if they are grossly detached from it. A person with DDD might say things like, “I feel like a robot,” or “I am no one.” They might describe their sensations as blunted as if a glass wall divided them from the world. They feel like they are “going through the motions” of life without feeling fully alive.
People with DDD tend to have a history of trauma of a particular type: emotional abuse and emotional neglect. They may have witnessed domestic violence or had a parent with a mental illness. These experiences teach them that distancing themselves from their own emotional experiences keeps them safe and makes them less threatening to emotionally unstable loved ones, especially parents.
How Are Dissociative Disorders Diagnosed?
Like most psychiatric conditions, dissociative disorders are diagnosed through an interview process in which a clinician asks questions to determine if a person meets DSM-5 diagnostic criteria for one or more of them. More than one interview may be required. Due to the lapses of memory and fragmented sense of identity that are hallmarks of dissociative disorders, the symptoms of dissociation are often hidden and my may take some time to detect.
Clinicians also have to take the time to rule out other conditions that may have similar or overlapping symptoms as dissociative disorders, including other trauma-related disorders like PTSD and BPD. People with dissociative disorders often also have other comorbid conditions like anxiety and depression; proper diagnosis and detection of these conditions can actually prevent detection of deeper underlying dissociative symptoms for quite some time.
Who Is At Risk for Dissociative Disorders?
A history of trauma is the major risk factor for dissociative disorders. However, other elements in addition to trauma increase the risk of developing a dissociative disorder instead of another trauma-related condition like PTSD or BPD.
One significant factor in the development of dissociative conditions is a history of emotional neglect or the refusal to acknowledge trauma by parents or authority figures. A disorganized and disoriented attachment style resulting from growing up with unstable caregivers is another element that contributes to the development of a dissociative disorder
Other factors that make it more likely for someone to develop a dissociative disorder include the presence of childhood personality traits like high levels of creativity and a capacity for dissociation. This makes dissociation a more salient means of coping with experiences that overwhelm other coping skills. A lack of soothing environments or experiences also increases the risk that a child will prefer dissociation as a coping mechanism.
Dissociative Disorder Statistics
Studies have shown that DID occurs in one to three percent of the general population and that one to five percent of patients receiving inpatient mental health treatment meet diagnostic criteria for DID. Studies show a similar rate of dissociative amnesia, with one to three percent of people experiencing it in a twelve-month period. A study in the United Kingdom found a prevalence of depersonalization disorder of one percent in the general population.
It should be noted that these statistics are conservative and do not address misdiagnosis and underdiagnosis of dissociative conditions. R. P. Kluft, an expert on DID, observes that only six percent of patients with the condition make their symptoms obvious on an ongoing basis.
When to See a Doctor for Dissociative Disorder
Most psychiatric conditions include symptoms that most people experience at some point in their lifetime. Symptoms of depersonalization, for example, were found to occur in one-fifth to one-fourth of people in one rural community. What distinguishes common experiences from symptoms of a mental health condition is the severity and regularity of these symptoms, as well as the degree of distress they create.
You should see a doctor if you have severe symptoms like long periods of time in which you can’t remember what happened that can’t be explained by substance abuse or physical illness. You should also make an appointment to see a mental health professional if you consistently experience dissociative symptoms like blunted emotion or derealization in a way that makes it hard to function in your day-to-day life. If you are in a crisis, thinking of harming yourself or someone else or having a severe trauma flashback, you should seek emergency treatment.
There are several ways a clinician can treat a dissociative disorder. Talk therapy is always central to the treatment of these conditions. Methods like cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) have been shown to be especially effective for people with a history of trauma. Eye movement desensitization and reprocessing (EMDR) is another effective and increasingly popular method for treating trauma-related conditions. Medications may also be used in a variety of ways to promote healing from a dissociative disorder.
It’s important to be willing to invest in treatment because trauma-related disorders have been shown to respond best to long-term treatment that is administered in phases. In long-term treatment, the first phase involves establishing a sense of safety and reducing symptoms, while later phases involve working through trauma and re-integrating the personality. There is hope: steady and persistent work in therapy can promote recovery from even the most profound trauma.
If you or someone you love is struggling with a dissociative disorder and co-occurring substance use disorder, The Recovery Village, may be able to help. Call and speak with a representative today to learn more about which treatment program could work for you.