Dissociative Disorders – Causes, Signs and Symptoms

Dissociative Disorders

Also called: Dissociation Disorders

Summary

Dissociative disorders occur when people frequently escape reality by suppressing their memories or taking on other identities. This dissociation occurs when a group of normal mental processes becomes separated from other mental processes. Dissociative disorders may occur suddenly or gradually, and may be temporary or chronic in nature.

Dissociation is a normal phenomenon that occurs in every person’s life. For example, people may “lose themselves” in a good book or find themselves daydreaming. However, in some cases people experience dissociation as a means of escaping reality when stress or trauma becomes too great to bear. This process is involuntary and is believed to be a coping mechanism of the mind. Such dissociative disorders occur in about 7 percent of people at some point in their lives, according to the National Mental Health Association.

The four main types of dissociative disorders include dissociative amnesia, dissociative fugue, dissociative identity disorder and depersonalization disorder. Before diagnosing these disorders, a physician will perform a complete physical examination and compile a thorough medical history to rule out other potential causes for a patient’s symptoms (e.g., head injuries, sleep deprivation). Various tests may also be performed. On some occasions, techniques such as hypnosis may be used to help identify alternate personalities or repressed memories associated with dissociative disorders.

If a physician suspects a dissociative disorder, the patient may be referred to a psychiatrist, psychologist or other mental health professional for further evaluation and treatment. Psychotherapy is the primary treatment for dissociative disorders. In most cases, patients are encouraged to recall any trauma they may have repressed and to work through it. Although dissociative disorders cannot typically be prevented, any form of abuse or traumatic experience (e.g., combat, natural disaster) should be treated promptly to address any unusual mental health reactions.

About dissociative disorders

Dissociative disorders occur when people habitually and involuntarily escape reality by suppressing memories or adopting alternative identities. They occur when a group of normal mental processes becomes separated or dissociated from other mental processes. In this condition, a patient loses conscious control over certain thoughts, feelings and behaviors.

Some aspects of dissociation are a normal part of the human mind. For instance, people may become engrossed in their thoughts while driving and miss a highway exit. The National Mental Health Association (NMHA) reports that up to one-third of the population occasionally feels like they are “watching themselves in a movie.”  However, continued and repeated incidences of dissociation may be part of a disorder. Such dissociative disorders occur in about 7 percent of people at some point in their lives, according to the NMHA.  Most are associated with people who have experienced serious trauma, such as abuse, combat or natural disaster.

There are many different dissociative disorders, all of which are involuntary. They have certain features in common. For example, they tend to begin and end suddenly (although some occur gradually) and often are triggered by psychological conflicts. Most are rare and involve significant disturbance of memory. The condition itself may be fleeting, or it may be chronic.

The four major types of dissociative disorders include:

  • Dissociative amnesia. Inability to remember important information, especially of a personal nature and involving significant trauma or stress. Examples include blocking out memories related to episodes of self-mutilation, violent outbursts or suicide attempts. Varieties of dissociative amnesia include:
    • Localized amnesia. Inability to remember events from a certain time frame.
    • Selective amnesia. When a patient remembers only select events from a certain time frame.
    • Generalized amnesia. Inability to recall events over a lifetime.
    • Continuous amnesia. When a patient cannot recall events from a certain time up to the present.
  • Dissociative fugue. In this condition, patients suddenly leave their surroundings and begin a journey of some type or another that can last from hours to months. Journeys can cover thousands of miles. During this time, patients fail to remember some or all of their past. Patients with dissociative fugue often experience confusion about personal identity and may take on a whole new identity. Although this is rare, it can be dramatic, with patients starting entirely new lives and acting more gregarious and uninhibited than in their previous lives. Traumatic or overwhelming events may trigger dissociative fugue. Patients who are in a state of dissociative fugue appear normal and healthy to outsiders and do not attract attention. Recovery is usually rapid and sudden. People who eventually return to the prefugue state may have no memory of the events that occurred when they had dissociative fugue.
  • Dissociative identity disorder (formerly known as multiple personality disorder). Condition in which two or more distinct identities take control of a patient’s behavioral patterns. It is the result of a failure to integrate identity, memory and consciousness. Patients may have 100 or more identities, although the average is closer to 10. Just one personality (alter) controls a patient’s behavior at any given time, and the various alters may have their own personal history, self-image and identity. Patients with this condition have an inability to recall important personal information, with passive identities having less complete memories and aggressive alters recalling more. Psychosocial stress often triggers the transition from one identity to another. In most cases, these changes take just seconds, although the transition can be more gradual.
  • Depersonalization disorder. Condition in which patients experience recurrent episodes of detachment from themselves and tend to observe their own behavior from an outside perspective. In other cases, patients may feel detached from control of their bodies and speech patterns. Patients are aware of this sense of detachment. Depersonalization is fairly commonplace and a disorder is not typically diagnosed unless symptoms cause substantial distress or impair the patient’s ability to function. Depersonalization disorder does not involve loss of memory.

Some dissociative disorders are classified as a “dissociative disorder not otherwise specified.” These are conditions in which a patient has symptoms of at least one of the above conditions, but not enough symptoms to be diagnosed with any one of these conditions. Examples include dissociation caused by coercion such as brainwashing or among people held as hostages.

Potential causes of dissociative disorders

Childhood trauma such as physical, sexual or emotional abuse is believed to be the chief trigger of dissociative disorders. Other stressors that can trigger these conditions include traumatic events such as combat, natural disasters, kidnapping, torture and invasive medical procedures.

Children under such stresses may develop dissociative disorders as a means of coping with the trauma. Children also have a greater ability than adults to step outside themselves and observe trauma in a third-person fashion. Children who dissociate in this way as a means of coping may continue to use the practice as adults whenever they are confronted with highly stressful situations.

Although many dissociative disorders are not diagnosed until adulthood, instances in which a person develops dissociative disorder as an adult are rare. Dissociative fugue is the exception to this rule – most cases of this disorder originate in adults. Dissociative disorders are more often diagnosed in women than in men. In addition, women with dissociative identity disorder average more distinct identities than men.

Signs and symptoms of dissociative disorders

The signs and symptoms associated with dissociative disorders vary depending on the type of disorder. However, some symptoms are evident in virtually all types of dissociative disorders. They include:

  • Loss of memory (amnesia) of certain time periods, events and people
  • Mental disorders such as depression and anxiety
  • The feeling of being detached from oneself, called depersonalization
  • The perception that people and things are unreal or distorted (derealization)
  • Undefined sense of identity

The symptoms of dissociative disorders may disappear and recur.

Other symptoms of dissociative experiences may include:

  • Disremembered behaviors
  • Fugues
  • Unexplained possessions
  • Inexplicable changes in relationships
  • Fluctuations in skills and knowledge
  • Fragmentary recall of life history
  • Spontaneous trances
  • Enthrallment
  • Spontaneous age regression
  • Out-of-body experiences
  • Awareness of other parts of self

In addition, patients with dissociative disorders are at increased risk for self-destructive behavior such as self-mutilation (through cutting or burning themselves) and suicide attempts. Some patients may develop substance abuse problems. Mental illnesses, such as depression, anxiety disorders and eating disorders, are also commonly associated with dissociative disorders.

People with dissociative disorders often struggle to maintain healthy personal and professional relationships because they tend to “tune out” or disappear when stressful situations arise. In many cases, symptoms of dissociative disorders are present in other mental disorders, such as post-traumatic stress disorder(PTSD), obsessive-compulsive disorder(OCD) and panic disorder.

Diagnosis methods for dissociative disorders

Patients should consult a physician if they experience significant and unexplained memory loss. Sudden changes in behavior in the face of stress also may warrant a visit to a healthcare professional. Finally, a chronic feeling that the world is somehow “unreal” may indicate the presence of a dissociative disorder that requires treatment.

Early intervention is an important factor in the eventual success of treating dissociative disorders. For this reason, individuals should seek medical attention after abuse or other significant trauma. Parents or caregivers should seek intervention for any child that has suffered physical or emotional trauma.

Before diagnosing a dissociative disorder, a physician will perform a complete medical examination and compile a thorough medical history.These steps will be used to make sure there is no other potential cause for a patient’s symptoms. The physician may also use various tests to rule out other potential sources of symptoms, such as head injuries, brain diseases, sleep deprivation, substance abuse and intoxication.

If a physician suspects a dissociative disorder, the patient may be referred to a psychiatrist, psychologist or other mental health professionals for further evaluation and treatment. During the interview, mental health professionals will ask questions about significant childhood and adult trauma, and check for symptoms of dissociative experiences (see Signs and symptoms).

Some physicians and mental health professionals may use techniques such as hypnosis to help identify alternate personalities or repressed memories associated with dissociative disorders.

In attempting to diagnose a dissociative disorder, a physician may ask questions of patients, such as:

  • Do they have problems remembering things?
  • Have they ever found themselves traveling away from home unexpectedly?
  • Do they ever feel as if more than one personality is controlling their behavior?
  • Do they ever feel detached from themselves or their surroundings?

All dissociative disorders have their own diagnostic criteria as defined by the American Psychiatric Association. There are criteria for each of the four major dissociative disorders.

Dissociative amnesia:

  • Predominant disturbance involves one or more episodes of inability to recall personal information, typically of a traumatic or stressful nature. The memory lapse must be too extensive to be attributed to normal forgetfulness.
  • Episodes do not occur exclusively during dissociative identity disorder, dissociative fugue, post-traumatic stress disorder, acute stress disorder orsomatotization disorder.
  • Symptoms cause significant distress or impairment in social, occupation or other areas of functioning.

Dissociative fugue:

  • Predominant disturbance is sudden unexpected travel away from home or place of work accompanied by inability to remember the past.
  • Patient has confusion about personal identity or assumes a new identity.
  • Episodes do not occur exclusively during dissociative identity disorder.
  • Symptoms cause significant distress or impairment in social, occupation or other areas of functioning.

Dissociative identity disorder:

  • Marked by the presence of two or more distinct personalities, each of which has its own pattern of perceiving, relating to or thinking about the environment or self.
  • At least two identities recurrently take control of a patient’s behavior.
  • Inability to recall personal information is too extensive to be attributed to normal forgetfulness.

Depersonalization disorder:

  • Marked by persistent or recurrent feelings of being detached from one’s mental processes or body.
  • During feelings of depersonalization, reality testing remains intact, meaning the patient is aware that the depersonalization is just a feeling.
  • Depersonalization causes significant distress or impairment of social, occupational or other areas of functioning.
  • Depersonalization does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder,acute stress disorder or another dissociative disorder.

In addition, none of these disorders can be due to another general medical condition or the direct physiological effects of a substance.

Symptoms of dissociation are also included in the diagnostic criteria of several other mental disorders. Thus, patients whose symptoms do not meet the criteria for the four major dissociative disorders may still be diagnosed with another mental disorder, such as acute stress disorder, post-traumatic stress disorder or somatization disorder. Patients whose dissociative symptoms appear exclusively during the course of these disorders will not be diagnosed with a dissociative disorder. In addition, dissociative disorders are not diagnosed in people whose dissociative symptoms are related to accepted cultural or religious activities in their society. In such cases, no disorder is considered present unless it leads to significant distress or impairment. Dissociative disorders can be extremely difficult to diagnose. Research indicates that patients receive mental health treatment for six to seven years before they receive a diagnosis of a dissociative disorder.

Treatment options for dissociative disorders

Psychotherapy is the primary treatment for dissociative disorders. In most cases, patients are encouraged to remember any trauma they may have repressed and to work through it.

Two types of therapy are particularly effective in treating dissociative disorders. Cognitive behavior therapy (CBT) helps patients to replace negative thoughts and behaviors with more positive alternatives. Creative art therapy teaches people to use the creative process to express thoughts and feelings in learning to cope with trauma. Patients may learn dance, art, drama, music and poetry.

There are no medications specifically intended to treat dissociative disorders. However, some medications are known to help some patients with dissociative disorders. Such drugs include antidepressants, anti-anxiety medications and tranquilizers. Although it may not be possible to prevent the development of dissociative disorders, any form of abuse or traumatic experience (e.g., combat, natural disaster) should be treated promptly to address any unusual mental health reactions.

Questions for your doctor

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to dissociative disorders:

  1. Why do you suspect I may have a dissociative disorder?
  2. What type of disorder do I have?
  3. What do you suspect caused my dissociative disorder?
  4. What symptoms are associated with my type of disorder?
  5. How can you be sure I have this disorder and not some other type of psychological condition?
  6. Am I at risk of hurting myself or others?
  7. Will this disorder come and go or remain constant?
  8. Does my family or medical history place me at risk for a dissociative disorder?
  9. What are my treatment options?
  10. Will medication help my condition?
  11. Will I have this disorder my whole life?
  12. Which other conditions are associated with dissociative disorders?
  13. Are my children at greater risk for developing this disorder?
  14. Can you recommend a support group for me?
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