FAQ’s on Dissociative Disorders
The following is information on Dissociative Disorders, from the International Society for the Study of Trauma and Dissociation (ISST-D):
What is dissociation?
Dissociation is a word that is used to describe the disconnection or lack of connection between things usually associated with each other. Dissociated experiences are not integrated into the usual sense of self, resulting in discontinuities in conscious awareness (Anderson & Alexander, 1996; Frey, 2001; International Society for the Study of Dissociation, 2002; Maldonado, Butler, & Spiegel, 2002; Pascuzzi & Weber, 1997; Rauschenberger & Lynn, 1995; Simeon et al., 2001; Spiegel & Cardeña, 1991; Steinberg et al., 1990, 1993). In severe forms of dissociation, disconnection occurs in the usually integrated functions of consciousness, memory, identity, or perception. For example, someone may think about an event that was tremendously upsetting yet have no feelings about it. Clinically, this is termed emotional numbing, one of the hallmarks of post-traumatic stress disorder. Dissociation is a psychological process commonly found in persons seeking mental health treatment (Maldonado et al., 2002).
Dissociation may affect a person subjectively in the form of “made” thoughts, feelings, and actions. These are thoughts or emotions seemingly coming out of nowhere, or finding oneself carrying out an action as if it were controlled by a force other than oneself (Dell, 2001). Typically, a person feels “taken over” by an emotion that does not seem to makes sense at the time. Feeling suddenly, unbearably sad, without an apparent reason, and then having the sadness leave in much the same manner as it came, is an example. Or someone may find himself or herself doing something that they would not normally do but unable to stop themselves, almost as if they are being compelled to do it. This is sometimes described as the experience of being a “passenger” in one’s body, rather than the driver.
There are five main ways in which the dissociation of psychological processes changes the way a person experiences living: depersonalization, derealization, amnesia, identity confusion, and identity alteration. These are the main areas of investigation in the Structured Clinical Interview for Dissociative Disorders (SCID-D) (Steinberg, 1994a; Steinberg, Rounsaville, & Cicchetti, 1990). A dissociative disorder is suggested by the robust presence of any of the five features.
What is depersonalization?
Depersonalization is the sense of being detached from, or “not in” one’s body. This is what is often referred to as an “out-of-body” experience. However, some people report rather profound alienation from their bodies, a sense that they do not recognize themselves in the mirror, recognize their face, or simply feel not “connected” to their bodies in ways which are challenging to articulate (Frey, 2001; Guralnik, Schmeidler, & Simeon, 2000; Maldonado et al., 2002; Simeon et al., 2001; Spiegel & Cardeña; Steinberg, 1995).
What is derealization?
Derealization is the sense of the world not being real. Some people say the world looks phony, foggy, far away, or as if seen through a veil. Some people describe seeing the world as if they are detached, or as if they were watching a movie (Steinberg, 1995).
What is dissociative amnesia?
Amnesia refers to the inability to recall important personal information that is so extensive that it is not due to ordinary forgetfulness. Most of the amnesias typical of dissociative disorders are not of the classic fugue variety, where people travel long distances, and suddenly become alert, disoriented as to where they are and how they got there. Rather, the amnesias are often an important event that is forgotten, such as abuse, a troubling incident, or a block of time, from minutes to years. More typically, there are micro-amnesias where the discussion engaged in is not remembered, or the content of a conversation is forgotten from one moment to the next. Some people report that these kinds of experiences often leave them scrambling to figure out what was being discussed. Meanwhile, they try not to let the person with whom they are talking realize they haven’t a clue as to what was just said (Maldonado et al., 2002; Steinberg et al., 1993; Steinberg, 1995)
What are identity confusion and identity alteration?
Identity confusion is a sense of confusion about who a person is. An example of identity confusion is when a person sometimes feels a thrill while engaged in an activity (e.g., reckless driving, drug use) which at other times would be repugnant. Identity alteration is the sense of being markedly different from another part of oneself. This can be unnerving to clinicians. A person may shift into an alternate personality, become confused, and demand of the clinician, “Who the dickens are you, and what am I doing here?” In addition to these observable changes, the person may experience distortions in time, place, and situation. For example, in the course of an initial discovery of the experience of identity alteration, a person might incorrectly believe they were five years old, in their childhood home and not the therapist’s office, and expecting a deceased person whom they fear to appear at any moment (e.g., Fine, 1999; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg, 1995).
More frequently, subtler forms of identity alteration can be observed when a person uses different voice tones, range of language, or facial expressions. These may be associated with a change in the patient’s world view. For example, during a discussion about fear, a client may initially feel young, vulnerable, and frightened, followed by a sudden shift to feeling hostile and callous. The person may express confusion about their feelings and perceptions, or may have difficulty remembering what they have just said, even though they do not claim to be a different person or have a different name. The patient may be able to confirm the experience of identity alteration, but often the part of the self that presents for therapy is not aware of the existence of dissociated self-states. If identity alteration is suspected, it may be confirmed by observation of amnesia for behavior and distinct changes in affect, speech patterns, demeanor and body language, and relationship to the therapist. The therapist can gently help the patient become aware of these changes (e.g., Fine, 1999; Maldonado et al., 2002; Spiegel & Cardeña, 1991; Steinberg, 1995).
What is the cause of dissociation and dissociative disorders?
Research tends to show that dissociation stems from a combination of environmental and biological factors. The likelihood that a tendency to dissociate is inherited genetically is estimated to be zero (Simeon et al., 2001).
Most commonly, repetitive childhood physical and/or sexual abuse and other forms of trauma are associated with the development of dissociative disorders (e.g., Putnam, 1985). In the context of chronic, severe childhood trauma, dissociation can be considered adaptive because it reduces the overwhelming distress created by trauma. However, if dissociation continues to be used in adulthood, when the original danger no longer exists, it can be maladaptive. The dissociative adult may automatically disconnect from situations that are perceived as dangerous or threatening, without taking time to determine whether there is any real danger. This leaves the person “spaced out” in many situations in ordinary life, and unable to protect themselves in conditions of real danger.
Dissociation may also occur when there has been severe neglect or emotional abuse, even when there has been no overt physical or sexual abuse (Anderson & Alexander, 1996; West, Adam, Spreng, & Rose, 2001). Children may also become dissociative in families in which the parents are frightening, unpredictable, are dissociative themselves, or make highly contradictory communications (Blizard, 2001; Liotti, 1992, 1999a, b).
The development of dissociative disorders in adulthood appears to be related to the intensity of dissociation during the actual traumatic event(s); severe dissociation during the traumatic experience increases the likelihood of generalization of such mechanisms following the event(s). The experience of ongoing trauma in childhood significantly increases the likelihood of developing dissociative disorders in adulthood (International Society for the Study of Dissociation, 2002; Kisiel & Lyons, 2001; Martinez-Taboas & Guillermo, 2000; Nash, Hulsey, Sexton, Harralson & Lambert, 1993; Siegel, 2003; Simeon et al., 2001; Simeon, Guralnik, & Schmeidler, 2001; Spiegel & Cardeña, 1991).
How does affect dysregulation influence dissociation?
One of the core problems for the person with a dissociative disorder is affect dysregulation, or difficulty tolerating and regulating intense emotional experiences. This problem results in part from having had little opportunity to learn to soothe oneself or modulate feelings, due to growing up in an abusive or neglectful family, where parents did not teach these skills. Problems in affect regulation are compounded by the sudden intrusion of traumatic memories and the overwhelming emotions accompanying them (Metcalfe & Jacobs, 1996; Rauch, van der Kolk, Fisler, Alpert, Orr et al., 1996).
The inability to manage intense feelings may trigger a change in self-state from one prevailing mood to another. Depersonalization, derealization, amnesia and identity confusion can all be thought of as efforts at self-regulation when affect regulation fails. Each psychological adaptation changes the ability of the person to tolerate a particular emotion, such as feeling threatened. As a last alternative for an overwhelmed mind to escape from fear when there is no escape, a person may unconsciously adapt by believing, incorrectly, that they are somebody else. Becoming aware of this kind of fear is terrifying. Therein lies one of the central problems in treatment for a person with a dissociative disorder: “How do I learn to approach things I fear when to understand that I am afraid is itself frightening?” Skillful clinical approaches are required to help build confidence in a person’s ability to tolerate their feelings, learn, and grow as a person.
Find more info at http://isst-d.org/
Laura A. O’Keefe, LCSW