Most of us see ourselves as individuals with a basic sense of self, personality, and one general viewpoint.
Individuals who are diagnosed with dissociative disorders have lost the sense of having one stream of consciousness. These people feel as if they have no identity, they are confused about who they are, or they may experience more than one identity.
For most people, our thoughts, emotions, and sense of self are integrated, but for individuals who are diagnosed with dissociative disorders, there is little sense of integration or a major disruption in the sense of self-integration.
Dissociative disorders represent extreme forms of psychopathology, and these disorders can only be diagnosed by experienced mental health clinicians.
The 3 Major Dissociative Disorders
According to the American Psychiatric Association (APA), there are three major dissociative disorders. One of the disorders in particular has received quite a bit of attention in the media and popular literature. This section will discuss the basic diagnostic criteria for the three major dissociative disorders based on the American Psychiatric Association’s diagnostic criteria from the DSM-5 (the Diagnostic and Statistical Manual for Mental Disorders – Fifth Edition).
The essential features of depersonalization/derealization disorder consist of persistent or recurrent episodes of depersonalization (the feeling of being outside oneself or that one is not real) or derealization (the feeling that other things are not real). An individual diagnosed with depersonalization/derealization disorder has either one or both of these feelings persistently or frequently enough that it results in significant distress or impairment in functioning. Despite these rather strange experiences, the person is generally able to cope with other aspects of reality and these feelings cannot be better explained by an individual’s use of drugs, some other mental health disorder, or a medical condition, such as a head injury.
As experiences of depersonalization or even derealization are common in other psychiatric disorders, including psychotic disorders, anxiety disorders, and stress- and trauma-related disorders, it is extremely important for clinicians to do a thorough evaluation of an individual before diagnosing them with this particular disorder. In addition, individuals diagnosed with the other two major dissociative disorders often experience feelings of depersonalization or derealization.
Dissociative amnesia is diagnosed when individuals are unable to remember important information about themselves that is inconsistent with normal forgetfulness. This loss of information is usually connected to some very stressful or traumatic event. The media often displays dissociative amnesia as people who forget their identity following a very stressful event, and there are cases of this recorded in the literature. The symptoms of dissociative amnesia cannot be due to substance abuse, another mental health disorder, and/or a medical condition. In addition, the amnesia must be associated with some significant impairment or distress in the individual’s functioning.
A subtype of dissociative amnesia, dissociative amnesia with dissociative fugue, occurs when the person with amnesia either wanders or travels away and often develops a new identity or other belief system. Dissociative amnesia would not be diagnosed in an individual who has memory loss as a result of the head injury based on the qualifiers mentioned above.
This diagnostic category is a darling of the media. Once known as multiple personality disorder, the name of the diagnosis has been changed to reflect the notion that individuals who allegedly have two or more personality states suffer from dissociative issues. Dissociative identity disorder occurs when an individual has two or more distinct personality states that result in a mark discontinuity in their sense of self, purpose, behavior, consciousness, memory, perception, thinking abilities, and other areas of functioning. These different personalities are separate entities and not considered to be different aspects of the core personality.
APA also recognizes a broader category of other specified dissociative disorder that occurs as a result of amnesia without severe identity disturbance, dissociative symptoms as a result of coercive persuasion such as torture or brainwashing, acute trancelike states, and dissociative symptoms that occur as a result of acute stress and are typically time-limited. For individuals with dissociative experiences that do not fit into any of the diagnostic categories but may warrant further investigation, a diagnosis of unspecified dissociative disorder can often be given.
How Prevalent Are Dissociative Disorders?
These disorders are extremely rare. According to APA, the 12-month prevalence of dissociative identity disorder is around 1.5 percent, the prevalence of dissociative amnesia around 1.8 percent, and lifetime prevalence for depersonalization/derealization disorder is around 2 percent. According to the National Institute of Mental Health, 12-month prevalence refers to the number of individuals diagnosed with a disorder in a 12-month period (usually within 12 months of a survey) and the lifetime prevalence refers to the percentage of individuals diagnosed with the disorder in their lifetime. The male-to-female ratio for dissociative identity disorder and depersonalization/derealization disorder is generally reported as equivalent, whereas dissociative amnesia is diagnosed twice as often in females than males.
Comorbidity refers to the co-occurrence of two or more diseases or disorders in an individual at the same time. According to APA, depersonalization/derealization disorder is most commonly comorbid with major depressive disorder, any type of anxiety disorder, and several personality disorders (avoidant, borderline, and obsessive-compulsive personality disorders, which also have elements of dissociation in their diagnostic criteria).
Dissociative amnesia is a complicated disorder that includes elements of depression, guilt, and stress-related variables that make it comorbid with a number of different disorders, including personality disorders, any type of depressive disorder, anxiety disorders, and trauma- and stress-related disorders.
Dissociative identity disorder appears to have a number of different common comorbid disorders, including trauma- and stress-related disorders (because it appears that there is a strong association between early abuse and the development of this disorder), personality disorders, eating disorders, obsessive-compulsive disorders, sleep disorders, and substance use disorders.
According to a number of clinical sources, including Kaplan & Saddock’s Synopsis of Psychiatry, as a general rule, being diagnosed with any type of mental health disorder is associated with an increased risk for substance abuse. Because both dissociative identity disorder and dissociative amnesia often occur in the context of a very traumatic or stressful experience, individuals who are diagnosed with these disorders are also particularly prone to substance abuse. Individuals who experience depersonalization or derealization may also find themselves under quite a bit of stress and may be prone to the development of substance use disorders. Individuals who are diagnosed with dissociative disorders are also at an increased risk for the development of major depressive disorder and anxiety disorders, which are also disorders that carry a high potential for comorbid substance abuse.
Left untreated, individuals who develop substance use disorders in the context of dissociative disorders are at risk for the development of very complicated psychological presentations that include a number of potential comorbid mental health disorders that are exacerbated by substance abuse, such as alcohol abuse, prescription pain medication abuse, and other types of substance use disorders.
Treatment for dissociative disorders usually consists of various medications to address specific symptoms, such as depression, anxiety, etc., and very intense psychotherapy, targeted at trying to integrate aspects of reality, personality, memories, etc., back into the person’s awareness. In particular, Cognitive Behavioral Therapy is considered to be useful in the treatment of dissociative disorders; however, aspects of other types of therapy can also be useful, such as psychodynamic therapy that concentrates on how individuals attempt to deal with threatening past experiences like abuse, trauma, etc. In many cases, individuals are required to undergo extensive long-term treatment in order to assist them in reintegrating their sense of self.
The dissociative disorders are not without some controversy. In particular, dissociative identity disorder’s validity as an actual disorder or behavioral manifestation has been routinely challenged over many different decades. A number of high-profile cases have been exposed as fallacious in nature; the entire diagnostic scheme used to uncover the disorder has often been challenged regarding its validity; and even its inclusion in the latest version of the DSM indicates that the statistics used to verify its reliability are significantly poorer than statistics for many of the other disorders in the manual. A criticism of the DSM is the poor scientific methodology used to signify and identify many of the various diagnostic categories, and dissociative identity disorder has perhaps the poorest methodology associated with its inclusion in the manual compared to other disorders. There are good arguments on both sides of the issue.
If this disorder represents a valid mental health disorder, it is most likely extremely rare (even rarer than reported in the literature) and represents a severe form of psychopathology.