Dissociative disorders - causes, symptoms, diagnosis, treatment, pathology

 

Maybe you’ve had the experience of driving on “autopilot.” One minute you got in your car, and the next minute you’ve arrived at your destination, but you can’t actually remember the details of the drive. This is an example of normal, everyday dissociation, a term that describes a mental state of disconnection from what is going around you. Normally this day-dreamy state doesn’t last very long, and most people can snap out of it if something or someone requires their attention. But for some people, dissociation is more pervasive, and can’t be turned off so easily. In fact, the feeling of disconnection may become so intense and happen so often that it stops a person from functioning in their daily life. When this is the case, we say the person has a dissociative disorder.

Dissociative disorders are a group disorders that cause an impaired awareness of your own actions, thoughts, physical sensations, and even identity, which is a sense of who you are. Dissociative disorders tend to stem usually stem from trauma, usually early childhood abuse or neglect, and are thought to be a way of adapting to negative feelings and experiences. Dissociative disorders are divided into three main types: depersonalization/derealization disorder, dissociative amnesia, and dissociative identity disorder. Each of these disorders fall along a spectrum of severity, with depersonalization/derealization disorder being the least severe of the dissociative disorders, dissociative amnesia falling somewhere in the middle, and dissociative identity disorder being the most severe. Typically, individuals with more severe dissociative disorders may have elements of less severe ones as well.

With depersonalization/derealization disorder, depersonalization refers to a feeling of detachment from oneself, your own person, while derealization refers to a feeling that that the world around you is not fully real. Those with the disorder often feel as if they are watching themselves from the outside, maybe watching a movie about their life. They might feel emotionally or physically numb or have a weak sense of self. Individuals with depersonalization/derealization disorder might speak in a deadpan manner, with little emotion, and have trouble forming relationships. In severe cases, a person may have trouble recognizing familiar places, people, or objects, and this can make it had to learn tasks. Other symptoms include an altered sense of time, where things seem to move too fast or slow, brain fog or light-headedness, and being prone to rumination and anxiety.

Dissociative amnesia is when a person blocks out or forgets important personal information that most people would remember for a lifetime, like where they lived as a child, or what their mother looked like. Dissociative amnesia can be divided into four types: localized, generalized, systematized, and continuous. Most people with dissociative amnesia have localized amnesia, meaning they have trouble recalling a traumatic event. Sometimes the memory loss is broader and includes months or years surrounding the event. Generalized amnesia is where a person can’t remember any of their past, even the non-traumatic parts. The onset of generalized amnesia can be sudden, stress-induced, and may be accompanied by a dissociative fugue, meaning a temporary period of disorientation and wandering or travel. In a fugue state, a person may be confused about who they are, or they may believe they are someone else. They may also temporarily lose deeply ingrained skills. For example, a computer engineer might forget how to use a laptop. In systematized amnesia, a person only forgets a category of information which is in some way associated with a trauma, like forgetting everything about a certain person, or a specific location, even if it was a significant part of their life. And finally, continuous amnesia happens when a person forgets each new event after it happens and retains nothing but the present moment-- a bit like the fish Dora in movie Finding Nemo. And continuous amnesia doesn’t always relate back to psychological trauma.

The third type of dissociative disorder is dissociative identity disorder, which used to be called multiple personality disorder. Dissociative identity disorder can be broken down into two types: covert dissociative identity disorder, and overt dissociative identity disorder. By far the most common type, covert dissociative identity disorder occurs when a person experiences sudden and dramatic shifts in the way they perceive, think, or feel, as if they have taken on characteristics of a different person or people. Some people with covert may hear that person’s voice and feel that it is speaking to them. Those with covert dissociative identity disorder are usually aware that their experience is unusual and may feel disoriented and powerless to understand their moods and behavior. On the other hand, those with overt dissociative identity disorder outright assume two or more distinct identities, sometimes called personalities, or alters. The identities are distinct because they tend to talk and act differently than the original person. They may have opposing tastes or political views, be different ages, genders, or nationalities. These alternate identities completely take a person’s body and mind, suppressing all other identities temporarily. Those with overt dissociative identity disorder are not aware that this is happening and may report forgetting whole portions of their day. They may find groceries they can’t recall buying or discover injuries to their body that they can’t recall getting, and it’s not unusual for some people to have a period of fugue, and suddenly find themselves in a different town or city. Having overt dissociative identity disorder can potentially endanger the person, especially if one identity engages in self-mutilation or risky behavior. The prevalence of suicide among those with the condition is very high, with almost three quarters attempting suicide at least once in their life.

            Diagnosing dissociative disorders can be tricky, and some of the symptoms can be seen in substance intoxication, especially of hallucinogens like LSD, and dissociative drugs like PCP and Ketamine. Other causes include seizures, brain trauma, as well as chronic conditions like dementia. Psychiatric conditions like an anxiety disorder can cause an impaired sense of identity, time, and sensation, especially during a panic attack, but these symptoms usually last minutes to hours. With dissociative disorders, the symptoms can persist for years. Finally, bipolar disorder and schizophrenia can also cause dramatic mood swings mimicking dissociative identity disorder, but while these depressive or euphoric moods can last for at least a week, the change in personality in dissociative identity disorder only last for minutes to hours each time.

Treatment for dissociative disorders typically involves psychotherapy so people can process their trauma safely. In the case of dissociative identity disorder, the goal of therapy is to facilitate fusion of identities, where a person’s personality states are integrated, and the person feels more whole. All right, as a quick recap, dissociative disorders often develop in as an attempt to adapt to severe or prolonged trauma. Falling on the least severe end of the spectrum, depersonalization/ derealization disorder is due to a disruption in the normal perception of events. Falling in the middle of the spectrum, dissociative amnesia is due to a disruption in memory. Falling on the most severe end of the spectrum, dissociative identity disorder is due to a problem with having a single, complete identity.