Dissociative Disorders
Summary
Dissociative disorders are a group of psychiatric conditions characterised by disruption in the normal integration of consciousness, memory, identity, emotion, perception, behaviour, or motor control. They are strongly associated with severe psychological trauma, particularly childhood abuse. The main disorders include Dissociative Identity Disorder (DID), Dissociative Amnesia, and Depersonalisation/Derealisation Disorder. Symptoms can be distressing and disabling. Treatment is primarily psychotherapy, especially trauma-focused approaches, with an emphasis on stabilisation, grounding, and gradual trauma processing.
Key Facts
- DID (formerly Multiple Personality Disorder): Two or more distinct personality states
- Dissociative Amnesia: Inability to recall important autobiographical information
- Depersonalisation: Feeling detached from oneself (like an observer)
- Derealisation: Feeling the world is unreal (like a dream)
- Key Association: Childhood trauma/abuse
- Treatment: Trauma-focused psychotherapy; Grounding techniques
Clinical Pearls
"Dissociation is a Defence": Dissociation develops as a protective mechanism against overwhelming trauma. Understanding this helps reduce stigma.
"Screen for Trauma": Dissociative symptoms often indicate underlying trauma. Sensitively screen for history of abuse.
"Grounding is Essential": Grounding techniques (e.g., 5-4-3-2-1 sensory exercise) are fundamental in managing acute dissociation.
"Rule Out Organic Causes": Always exclude epilepsy, substance use, and medical conditions that can cause dissociative-like symptoms.
Prevalence
- Dissociative symptoms: Common (10-15% of general population)
- Dissociative disorders: 2-5%
- DID: 1-1.5%
Demographics
- F:M = 3:1 (DID)
- Onset: Usually childhood/adolescence; often diagnosed in adulthood
- Strong link with childhood trauma (90%+ of DID cases)
Risk Factors
| Factor | Notes |
|---|---|
| Childhood abuse | Physical, sexual, emotional |
| Neglect | Emotional neglect |
| Early trauma | Before age 9 particularly |
| Disorganised attachment | Inconsistent caregiving |
| Lack of support | No safe relationships |
Trauma Model of Dissociation
- Overwhelming trauma (especially repeated, early, interpersonal)
- Dissociation as defence (escape when physical escape impossible)
- Failure of integration (memories, emotions, identity not consolidated)
- Structural dissociation (parts of personality hold trauma)
Neurobiological Findings
- Hippocampal and prefrontal changes
- HPA axis dysregulation
- Altered connectivity between limbic and cortical areas
Dissociative Identity Disorder (DID)
| Feature | Description |
|---|---|
| Multiple identity states | Two or more distinct personality states |
| Amnesia | Gaps in memory (between states) |
| Identity confusion | Uncertainty about identity |
| Switching | Transition between states |
| Hearing voices | Often experienced as internal (unlike schizophrenia) |
Dissociative Amnesia
| Feature | Description |
|---|---|
| Memory gaps | Cannot recall important autobiographical information (usually traumatic) |
| Usually reversible | Unlike organic amnesia |
| Dissociative fugue | Sudden travel away from home + amnesia |
Depersonalisation/Derealisation Disorder
| Feature | Description |
|---|---|
| Depersonalisation | Feeling detached from self (like watching oneself) |
| Derealisation | World feels unreal (dreamlike, distant) |
| Reality testing intact | Knows these experiences are not real |
| Distressing | Often causes significant anxiety |
Other Symptoms
Mental State Examination
| Domain | Possible Findings |
|---|---|
| Appearance | May change between presentations (DID) |
| Behaviour | May appear "absent," switching between states |
| Speech | May change in tone/manner |
| Mood | Often low, anxious |
| Thought | Confusion about identity, intrusive trauma memories |
| Perception | Internal voices (not true hallucinations) |
| Cognition | Amnesia for periods of time |
| Insight | Variable |
Physical Examination
- Exclude organic causes (epilepsy, substance use)
- Look for self-harm
Clinical Diagnosis
- Primarily clinical (history and MSE)
- Screening tools (DES - Dissociative Experiences Scale)
Exclude Organic Causes
| Test | Excludes |
|---|---|
| EEG | Epilepsy (especially temporal lobe) |
| MRI brain | Structural causes |
| Drug screen | Substance-induced dissociation |
| Thyroid function | Medical mimics |
Psychological Assessment
- Trauma history (sensitively explored)
- DES (Dissociative Experiences Scale)
- Structured interviews (SCID-D)
Treatment Approach
┌──────────────────────────────────────────────────────────┐
│ DISSOCIATIVE DISORDERS MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ PHASE 1: STABILISATION & SAFETY │
│ • Build therapeutic alliance │
│ • Teach grounding techniques │
│ • Establish safety (self-harm, suicidality) │
│ • Psychoeducation about dissociation │
│ • Develop coping skills │
│ │
│ PHASE 2: TRAUMA PROCESSING (When stable) │
│ • Trauma-focused CBT │
│ • EMDR (Eye Movement Desensitisation & Reprocessing) │
│ • Gradual exposure to trauma memories │
│ • Schema therapy │
│ │
│ PHASE 3: INTEGRATION & RECONNECTION │
│ • Identity integration (DID) │
│ • Building meaningful relationships │
│ • Life goals and functioning │
│ │
│ MEDICATION (Adjunctive; targets symptoms): │
│ • SSRIs (for depression, anxiety) │
│ • No specific medication for dissociation │
│ • Avoid benzodiazepines (worsen dissociation) │
│ │
│ GROUNDING TECHNIQUES: │
│ • 5-4-3-2-1 (5 things you see, 4 hear, 3 touch...) │
│ • Cold water on hands/face │
│ • Describe surroundings out loud │
│ • Smell strong scent (coffee, peppermint) │
│ │
└──────────────────────────────────────────────────────────┘
Of Disorder
- Self-harm and suicide
- Impaired functioning (work, relationships)
- Comorbid PTSD, depression, anxiety
- Substance misuse
- Somatisation
Of Treatment
- Re-traumatisation (if trauma processing too early)
- Therapeutic dependency
With Treatment
- Significant improvement possible
- DID integration or functional coexistence
- Long-term therapy often needed
Without Treatment
- Chronic symptoms
- Recurrent crises
- Ongoing functional impairment
Key Guidelines
- ISSTD: Treatment Guidelines for Dissociative Identity Disorder
- NICE: PTSD Guidelines (overlapping principles)
Key Evidence
Psychotherapy
- Phase-oriented trauma therapy is evidence-based
- EMDR and trauma-focused CBT effective
What Are Dissociative Disorders?
Dissociative disorders are mental health conditions where you feel disconnected from your thoughts, feelings, surroundings, or sense of identity. They often develop as a way of coping with overwhelming experiences, especially trauma.
What Are the Types?
- Dissociative Identity Disorder: Having two or more distinct personality states
- Dissociative Amnesia: Not being able to remember important things about yourself
- Depersonalisation: Feeling like you're watching yourself from outside your body
- Derealisation: Feeling like the world isn't real
What Causes It?
Usually, dissociative disorders develop after severe or repeated trauma, especially in childhood. The mind learns to "disconnect" as a way to cope.
How is it Treated?
- Therapy is the main treatment - especially trauma-focused therapy
- Grounding techniques help you stay present when you feel disconnected
- Medication may help with symptoms like depression or anxiety
Is Recovery Possible?
Yes. With the right support and therapy, many people with dissociative disorders lead full and meaningful lives.
Primary Guidelines
- International Society for the Study of Trauma and Dissociation. Guidelines for Treating Dissociative Identity Disorder in Adults. J Trauma Dissociation. 2011.
Key Studies
- Brand BL, et al. A longitudinal naturalistic study of patients with dissociative disorders. Psychol Trauma. 2013. PMID: 23914751