Learning Objectives
- Describe dissociative disorders.
- Describe how dissociative identity disorder presents.
- Describe how dissociative amnesia presents.
- Describe how depersonalization/derealization presents.
Dissociative disorders are a group of disorders characterized by symptoms of disruption and/or discontinuity in consciousness, memory, identity, emotion, body representation, perception, motor control, and behavior (APA, 2022). These symptoms are likely to appear following a significant stressor or years of ongoing stress (i.e., abuse; Maldonadao & Spiegel, 2014). Occasionally, one may experience temporary dissociative symptoms due to lack of sleep or ingestion of a substance; however, these would not qualify as a dissociative disorder due to the lack of impairment in functioning. Furthermore, individuals who suffer from acute stress disorder and PTSD often experience dissociative symptoms, such as amnesia, numbing, flashbacks, and depersonalization/derealization. However, because of the identifiable stressor (and lack of additional symptoms listed below), they meet diagnostic criteria for a stress disorder as opposed to a dissociative disorder.
There are three main types of dissociative disorders: dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder.
Dissociative Identity Disorder (DID)
The key diagnostic criteria for dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession (Criteria A). How overt or covert the personality states are depends on psychological motivation, stress level, cultural context, emotional resilience, and internal conflicts and dynamics (APA, 2022), and severe or prolonged stress may result in sustained periods of identify confusion/alteration. Those presenting as being possessed by spirits or demons and for a small proportion of non-possession-form cases, the alternate identifies are readily observable. Generally, though, the identities in non-possession-form dissociative identity disorder are not overtly displayed or only subtly displayed and when they are, it is just in a minority of individuals and manifests as different names, hairstyles, handwritings, wardrobes, accents, etc. If the alternate identities are not observable, their presence is identified through sudden alterations or discontinuities in the individual’s sense of self and sense of agency, as well as recurrent dissociative amnesias (see the second criteria below; APA, 2022).
The second main diagnostic criteria (Criteria B) for dissociative identity disorder is that there must be a gap in the recall of events, information, or trauma due to the switching of personalities. These gaps are more excessive than typical forgetting one may experience due to a lack of attention. The dissociative amnesia presents as gaps in autobiographical memory, lapses in memory of well-learned skills or recent events, and discovering possessions for which there is no recollection of ever owning, and can involve everyday events and not just events that are stressful or traumatic.
It should be noted that most possession states occurring around the world are part of broadly accepted cultural or religious practice and should not be diagnosed as dissociative identity disorder (Criteria D). The possession-form identities in dissociative identity disorder manifest most often as a spirit or supernatural being taking control and the individual speaking or acting in a distinctly different way. These identities present recurrently, are involuntary and unwanted, and cause significant distress or impairment (Criteria C). Impairment varies in adults from minimal (i.e., high functioning professionals) to profound. For those minimally affected, marital, family, relational, and parenting functions are more likely to be impaired by symptoms of dissociative identity disorder rather than their occupational and professional life.
While personalities can present at any time, there is generally a dominant or primary personality that is present most of the time. From there, an individual may have several subpersonalities. Although it is hard to identify how many subpersonalities an individual may have at one time, it is believed that there are on average 15 subpersonalities for women and 8 for men (APA, 2000).
The switching or shifting between personalities varies among individuals and can range from merely appearing to fall asleep, to very dramatic, involving excessive bodily movements, though for most, the change is subtle and may occur with only subtle changes in overt presentation. When sudden and unexpected, switching is generally precipitated by a significant stressor, as the subpersonality best equipped to handle the current stressor will present. The relationship between subpersonalities varies between individuals, with some individuals reporting knowledge of other subpersonalities while others have a one-way amnesic relationship with subpersonalities, meaning they are not aware of other personalities (Barlow & Chu, 2014). These individuals will experience episodes of “amnesia” when the primary personality is not present.
Dissociative Amnesia
Dissociative amnesia is identified by the inability to recall important autobiographical information, usually of a traumatic or stressful nature. It often consists of selective amnesia for a specific event or events or generalized amnesia for identity and life history. This type of amnesia is different from what one would consider permanent amnesia in that the information was successfully stored in memory but cannot be freely recollected. It is conceptualized as possibly being a reversible memory retrieval deficit. Additionally, individuals experiencing permanent amnesia often have a neurobiological cause, whereas dissociative amnesia does not (APA, 2022).
There are a few types of amnesia within dissociative amnesia. Localized amnesia, the most common type, is the inability to recall events during a specific period. The length of time within a localized amnesia episode can vary—it can be as short as the time immediately surrounding a traumatic event, to months or years, should the traumatic event occur that long (as commonly seen in abuse and combat situations). Selective amnesia is, in a sense, a component of localized amnesia in that the individual can recall some, but not all, of the details during a specific period. For example, a soldier may experience dissociative amnesia during the time they were deployed, yet still have some memories of positive experiences such as celebrating Thanksgiving or Christmas dinner with the members of their unit. Systematized amnesia occurs when an individual fails to recall a specific category of information such as not recalling a specific room in their childhood home.
Conversely, some individuals experience generalized dissociative amnesia in which they have a complete loss of memory for most or all of their life history, including their own identity, previous knowledge about the world, and/or well-learned skills. Individuals who experience this amnesia experience deficits in both semantic and procedural knowledge. This means that individuals have no common knowledge of (i.e., cannot identify letters, colors, numbers) nor can they engage in learned skills (i.e., typing shoes, driving car). While generalized dissociative amnesia is extremely rare, it is also extremely frightening. The onset is acute, and the individual is often found wandering in a state of disorientation. Many times, these individuals are brought into emergency rooms by law enforcement following a dangerous situation such as an individual wandering on a busy road.
The distress and impairment suffered by those with dissociative amnesia resulting from childhood/adolescent traumatization varies. Some are chronically impaired in their ability to form and sustain satisfactory attachments while others are highly successful in their occupation due to compulsive overwork. And finally, a substantial subgroup of those afflicted by generalized dissociative amnesia develop a highly impairing, chronic autobiographical memory deficit that is not ameliorated by relearning their life history, resulting in poor overall functioning in most life domains (APA, 2022).
Depersonalization/Derealization Disorder
Depersonalization/derealization disorder is categorized by recurrent episodes of depersonalization and/or derealization. Depersonalization can be defined as a feeling of unreality or detachment from oneself. Individuals describe this feeling as an out-of-body experience where you are an observer of your thoughts, feelings, and physical being. Furthermore, some patients report feeling as though they lack speech or motor control, thus feeling at times like a robot. Distortions of one’s physical body have also been reported, with various body parts appearing enlarged or shrunken. Emotionally, one may feel detached from their feelings, lacking the ability to feel emotions despite knowing they have them.
Symptoms of derealization include feelings of unreality or detachment from the world—whether it be individuals, objects, or their surroundings. For example, an individual may feel as though they are unfamiliar with their surroundings, even though they are in a place they have been to many times before. Feeling emotionally disconnected from close friends or family members whom they have strong feelings for is another common symptom experienced during derealization episodes. Sensory changes have also been reported, such as feeling as though your environment is distorted, blurry, or even artificial. Distortions of time, distance, and size/shape of objects may also occur.
These episodes can last anywhere from a few hours to days, weeks, or even months. The onset is generally sudden, and like the other dissociative disorders, is often triggered by intense stress or trauma. Many individuals describe feeling like they are “crazy” or “going crazy” and fear they have irreversible brain damage. They experience an altered sense of time and may be obsessed about whether they really exist.
As one can imagine, depersonalization/derealization disorder can cause significant emotional distress, as well as impairment in one’s daily functioning. The disorder is associated with major morbidity and impairment occurs in both interpersonal and occupational spheres due to “…the hypoemotionality with others, subjective difficulty in focusing and retaining information, and a general sense of disconnectedness form life” (APA, 2022).
Key Takeaways
You should have learned the following in this section:
- Dissociative disorders are characterized by disruption in consciousness, memory, identity, emotion, perception, motor control, or behavior. They include dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder.
- Dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession.
- Dissociative amnesia is characterized by the inability to recall important autobiographical information, whether during a specific period (localized) or one’s entire life (generalized).
- Depersonalization/derealization disorder includes a feeling of unreality or detachment from oneself (depersonalization) and feelings of unreality or detachment from the world (derealization).
Review Questions
- Identify the diagnostic criteria for each of the three dissociative disorders. How are they similar? How are they different?
- What are the types of amnesia within dissociative amnesia?
- What is the difference between depersonalization and derealization?
