Dissociative Disorders: on overview

Dissociative disorders are indicative of dissociation and a lack of continuity in the normal amalgamation of consciousness, identity, memory, body representation, perception, emotion, behaviour and motor control. Dissociative symptoms carry the potential to disrupt almost every aspect of psychological functioning. People belonging to any age group, ethnic, racial and socioeconomic backgrounds can suffer from Dissociative disorders. 

The symptoms of dissociation come across as either unbidden intrusions into awareness and behaviour, along with discontinuation in subjective experience (i.e. positive symptoms of dissociation such as de-personalization, de-realization and identity fragmentation) or an inability to access the information or to have control of the mental functions which are normally readily amenable to assess (i.e. negative symptoms of dissociation such as amnesia).

Signs and symptoms of dissociative disorders first emerge as a response to traumatic events, such as long-term exposure to physical, sexual and/or emotional abuse, military combats and natural disasters. During an episode, the individual experiences a disconnection and detachment from the present moment and tends to escape reality, for the present moment tends to trigger past trauma. Feelings of embarrassment and confusion about the symptoms and a strong urge to hide them, are usually influenced by the proximity of the trauma the individual went through.

Stressful situations can stir up the symptoms of dissociation. However, the kind and severity of symptoms a person experiences depends on the type of dissociative disorder a person has. It can occur for a split second or may last for hours depending on the nature of the disorder. A person who experiences dissociation can do this voluntarily and involuntarily depending upon the nature of the situation. Apart from dissociative disorders, dissociation can occur as a symptom of other conditions like acute stress disorder, epilepsy, depression, affective disorders, phobia, schizophrenia, substance use disorders, borderline personality disorders, post-traumatic stress disorder, and migraine.

Signs and Symptoms of Dissociative Disorders

1. Experiencing other mental health problems like anxiety, depression and thoughts of suicide
2. Amnesia (recurrent memory problems, memory gaps that can vary from several minutes to years)
3. De-realisation (a sense of disconnection from familiar people or one’s surroundings; feeling that the home and relatives are unknown or foreign)
4. Identity confusion (an inner struggle about self-identity involving uncertainty, puzzlement or conflict, like sexual identity confusion in people who have been sexually abused in their lives)
5. Depersonalization (a heightened sense of detachment or disconnection from the self; feeling like a stranger to yourself, feeling emotionally detached, feeling that a part of your body does not belong to you)
6. Identity alteration (frequently indulging in acting like a different person like using different names for different situations having a learned skill which you have no recollection of learning ever, which causes disruptions in life).

Types of Dissociative Disorders

1. Depersonalization/De-realization Disorder

Depersonalization/De-realization disorder comes forward as clinically significant, recurrent and/or persistent episodes of depersonalization (detachment from one’s mind, self, or body) and/or de-realization (detachment from one’s surroundings). The alterations in experiences are accompanied by intact reality testing. There are no clear and specific distinctions between individuals with predominantly depersonalization versus de-realization symptoms, hence, individuals can have depersonalization, de-realization, or both.

Individuals suffering from this disorder may think they are either crazy or going crazy. They have a constant fear of irreversible brain damage. The symptoms are accompanied by vague symptoms of head fullness, lightheadedness or tingling sensations, anxiety, and depression. They may suffer from extreme rumination where they get preoccupied with thoughts about whether they really exist, or are real.

The mean age for the onset of the disorder is 16 years, although the conditions can develop in early or middle childhood. Differential diagnoses for the disorder of depersonalization/de-realisation include anxiety disorders, psychotic disorders, substance and medication use disorders, obsessive-compulsive disorder, major depressive disorder, and other dissociative disorders.

2. Dissociative Amnesia

Dissociative amnesia signifies an inability to recall autobiographical information. The inability to recall may be localized (in terms of event or time periods), selective (specific aspects of the event or situation), or generalized (life history and self-identity); this inability is inconsistent with normal forgetting. Dissociative amnesia may or may not involve wandering or purposeful travel (dissociative fugue). Dissociative amnesia differs from permanent amnesia.

1. Localized amnesia which signifies a failure to recall events during a circumscribed period of time, is the most common form of dissociative amnesia. A person suffering from selective amnesia can recall some, but not all the events during a circumscribed time period. The individuals can experience both localized as well as selective amnesias.
2. Generalized amnesia which is a complete loss of memory regarding an individual’s life history, is quite rare. These individuals may forget personal identity, and previous knowledge about the world (semantic knowledge) and they can no longer access the earlier well-learned skills (procedural knowledge). More commonly found in combat veterans, extreme emotional stress conflict sexual assault victims and other forms of abuse.

Usually, intolerable or overwhelming events precede amnesia, its onset may be delayed for hours, days, or longer, wherein individuals may also report multiple episodes of dissociative amnesia. Some episodes of dissociative amnesia can be resolved rapidly like removing the person from combat or some other stressful situation, whereas other episodes persist for long periods of time. The differential diagnosis includes mental health conditions like dissociative identity disorder, post-traumatic amnesia due to brain injury, neurocognitive disorders, PTSD, seizures, catatonic stupor, substance-related disorders, factitious disorders and malingering, normal and age-related changes in memory.

3. Dissociative Identity Disorder

Dissociative identity disorder is a mental health condition where the individual experiences the presence of two or more distinct personality states or an experience of possession along with recurrent episodes of amnesia. Identity fragmentation may vary with culture (possession-form presentations) and other circumstances. Individuals experience discontinuity in their identity and memory which is not clearly and/or immediately evident to others or people may undergo attempts to hide their dysfunction.

Individuals with DID experience recurrent intrusions into their sense of self and conscious functioning (e.g., voices; intrusive thoughts, dissociated actions and speech; intrusive emotions and impulses). They experience alterations of their sense of self (e.g., feeling like one’s body or actions are not one’s own). They also experience odd changes in perception (e.g., depersonalization or derealisation) along with symptoms of impaired neurological functioning. Stress and anxiety worsen the situation making the episodes all the more evident and dangerous. 

Dissociative identity disorder (DID) is associated with overwhelming experiences, traumatic events, and/or abuse that one undergoes during his/her childhood. The disorder may manifest anytime i.e. from earliest childhood to late life; in children, it may lead to problems with memory, attachment, concentration and traumatic play. The differential diagnosis of dissociative identity disorders includes major depressive disorder, bipolar disorder, PTSD, psychotic disorders, other specified dissociative disorders, depersonalization/de-realisation disorder, and dissociative amnesia.

Causes of Dissociative Disorders

The exact causes of an individual experiencing dissociation are not specific and clear, but there are several factors that may play a noteworthy role. Dissociation often occurs as a reaction to trauma; possibly a way adapted by the individual to escape the traumatic experience. Traumatic events like assault, accidents, abuse, military combat and natural disasters can lead to an individual experiencing dissociation and related disorders. Factors like drug use and other mental conditions (like PTSD) can also cause symptoms of dissociation.

Risk factors of Dissociative Disorders

Childhood experiences with long-term sexual, physical or emotional abuse highly increase the risk for the victims to develop dissociative disorders. Children and adults experiencing other traumatic events like natural disasters, kidnappings, torture, war, and traumatic early-life medical procedures, experience the vulnerability of developing the conditions.

Complications of Dissociative Disorders

Individuals suffering from dissociative disorders are at an increased risk of developing complications and other associated disorders, such as:

• Eating disorders
• Sexual dysfunction
• Personality disorders
• Mutilation or self-harm
• PTSD (Post-traumatic stress disorder)
• Thoughts of suicide and suicidal behaviour
• Disturbed personal and at-work relationships
• Depression; depressive and anxiety disorders
• Drug use disorders (substance use disorders) and alcoholism
• Sleep disorders, including nightmares, sleepwalking and insomnia
• Physical symptoms like lightheadedness, non-epileptic seizures

Diagnosis of Dissociative Disorders

Diagnosing dissociative disorders usually involves assessing the symptoms and ruling out any medical condition that could be causing the symptoms (i.e. physical exam; eliminating conditions like head injury, certain brain diseases, intoxication or sleep deprivation that could lead to experiencing symptoms of memory loss and loss of reality sense).

Testing and diagnosis of dissociative disorders usually involves a referral to a mental health professional so as to determine the accurate diagnosis (i.e. psychiatric exam; involving analysing and interpreting the individual’s feelings, thoughts and behaviour). Further, the diagnosis is then compared with reference to DSM-5 and ICD-10 or 11 for accurate interpretation and further required steps in action.

Treatment of Dissociative Disorders

Appropriate and timely treatment helps people suffering from dissociative disorders to successfully address the major symptoms and thereby, improve their ability to function to be able to lead a productive and fulfilling life. Treatment of dissociative symptoms and disorders typically involves psychotherapy. Psychotherapy aims to help integrate the different elements of the identity of the individual.

Therapy may be intense and straining as it involves remembering past traumatic events and adapting coping skills to deal with the stressors, which is difficult for the individual who underwent the trauma. Types of psychotherapy that may be opted for treating dissociative disorders include CBT (cognitive behavioural therapy; helping people identify and change negative thoughts and behaviour), DBT (dialectical behavioural therapy; helping people learn skills to stop harmful behaviours and better manage emotions), EMDR (eyes movement desensitization and reprocessing; utilizing CBT strategies along with visual exercises helping in stress reduction).

There are usually no medicines that specifically treat dissociative disorders. Doctors may prescribe antidepressants, antipsychotics, sleeping aids, and anti-anxiety drugs to control the symptoms of depression, schizophrenia, anxiety, sleep problems and others.

Prevention of Dissociative Disorders

Stress, anxiety or other personal issues can trigger the symptoms of dissociation. Seeking timely help is important. The mental health professionals will help in recovering the symptoms and adopting healthy coping skills. Other steps may include talking to a trusted person like friends, doctors, religious leaders and others, locating resources like parenting support groups and family therapists, and looking out for educational programs that educate you to know the accurate scenario of living with dissociative disorders and how you can help your near ones or yourself in adapting and recovering.

Coping Strategies

Often, symptoms of stress and anxiety might trigger dissociation. Some of the strategies that can help in coping with stress and anxiety include:

1. Doing regular physical exercise
2. Eating a healthy and balanced diet
3. Work towards identifying and avoiding/managing triggers
4. Practicing relaxation strategies that help in stress reduction
5. Having properly balanced day-night schedules with adequate sleep each night
6. Practising grounding techniques to bring you back to the present moment i.e. here and now

The symptoms of dissociation can be experienced by anybody without being aware of it; it becomes even more important to look out for signs of dissociation. Symptoms like sudden mood changes, difficulty in remembering details about self or personal life, and feeling disconnected from self, others or the world, all point to experiencing dissociation.