How to Identify and Treat Dissociative Disorders
On its face, you might have a general idea of what dissociation is: an experience of numbness or disconnection. It’s hard not to link our understanding of dissociative disorders with what we see depicted in popular culture, such as in the movies Split, Psycho, or Sybil. The narratives in these films drive a largely negative stereotype of those struggling with dissociative disorders as crazy villains who are a danger to society and can’t be helped. In reality, dissociation can show up through a number of symptoms and is probably more common than you may think. It almost goes without saying that dissociative disorders—and those who display symptoms of dissociation—are frequently misunderstood. Therefore, it's due time to become associated with the realm of dissociation!
What is dissociation?
We can think of dissociation as a spectrum. On one hand, dissociation can present as purely a symptom in itself; on the other hand, dissociation can develop into one of the five dissociative disorders. The way dissociation presents itself in the body can also be thought of as a spectrum: ranging from feelings of numbness, to feeling outside your body, to having unexplained physical symptoms, to feeling like multiple identities in one body. Dissociation can be linked to number of different dissociative disorders.The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, characterizes a dissociative disorder as the experience of “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (American Psychiatric Association, 2013). This means that a person experiencing dissociation is displaying separation in more aspects of their person than just their identity. The five dissociative disorders include: dissociative identity disorder, dissociative amnesia (with and without fugue), depersonalization/derealization disorder, other specified dissociative disorder, and unspecified dissociative disorder.
Both dissociative identity disorder and depersonalization/derealization are quite common in trauma survivors, although they are frequently undiagnosed. Following anxiety and depression, depersonalization/derealization is suggested to be the 3rd most common psychological disorder. Unfortunately no medication exists to reduce dissociation, and most therapists aren't trained to recognize or treat it (Gentile et al., 2013; Guralnik et al., 2000; Hunter et al., 2004; Loewenstein, 1994).
What causes dissociation?
Folks struggling with dissociative disorders are often survivors of intense trauma, including interpersonal physical, emotional, and sexual abuse. Among folks with dissociative identity disorder in the United States, Canada, and Europe, about 90% experienced childhood abuse and neglect (American Psychiatric Association, 2013). Those experiencing relational, ongoing, and unpredictable abuse and neglect are also at a higher risk for developing dissociative identity disorder, even if there is no specific “really bad” single trauma event. Other traumatic experiences, including war and exploitation, can also cause dissociative identity disorder.
Dissociation is more common overall than is taught to mental health professionals, but it is not as common as popular media may make it seem, as it has an estimated prevalence of 2-10% in the general population. However, about 75% of people experience dissociation as a symptom at least once in their life. Unfortunately, there is a need for knowledgeable and competent therapists in this area that is not being met.
What about dissociative identity disorder (DID)?
DID (previously known as Multiple Personality Disorder) is a result of extreme compartmentalization needed to protect oneself. Because traumatic experiences, including abuse and neglect, can cause dissociation, the appearing “symptoms of such disorders are the brain’s way of coping with acute and post-traumatic stress disorders by way of amnesia, flashbacks, numbing, and depersonalization/derealization” (American Psychiatric Association, 2013). People who experience DID often also struggle to keep up with everyday responsibilities, such as social and career obligations (American Psychiatric Association, 2013).
Perhaps the most well known symptom of DID is the disruption of identity presented as two or more distinct personalities. These multiple identities feel like two or more separate selves. Along with a separation of a person’s sense of self and agency, there is also a discontinuity in their affect, behavior, consciousness, memory, perception, cognition, and sensory-motor functioning. Sometimes a person can identify this separation within themself; other times it is identified by those around them.
Another common symptom includes gaps in memory, ranging from forgetting everyday events, personal information, or traumatic events to full-on blackout periods. These memory gaps are different from ordinary forgetfulness because the mind blocks out information as a form of self protection. Thus, it is also common for the person to not remember much of their past, and they often describe their childhood as blank/nonexistent before a certain age.
Because DID is almost always found in the aftermath of trauma, folks experiencing it tend to hide their symptoms due to embarrassment and confusion about the symptoms or due to their difficult relationship to the traumatic event. Individuals typically present with comorbid depression, anxiety, substance abuse, self-injury, POTS, EDS, or psychogenic non-epileptic seizures. These conditions are often identified by health professionals before the dissociation is, once again due to the limited training of providers in dissociation. When this happens, these patients are often labeled as “treatment resistant" or “complex” because the prescribed treatment for the identified problem is not targeting the core problem of trauma and dissociation.
How to treat dissociation?
Although there is currently no medication to reduce symptoms of dissociation, dissociative disorders are treatable through therapeutic treatments and interventions. Specific treatments include trauma model therapy; internal family systems (IFS) and parts work; person centered therapy; and eye movement desensitization and reprocessing (EMDR) therapy. Core concepts in trauma model therapy include the problem is not the problem, the victim-rescuer-perpetrator triangle, the locus of control shift, and orienting the client to their present environment. IFS and parts work focuses on identifying the roles of each part in the internal system, communicating with each part, and building a relationship between them. Person centered therapy prioritizes listening and validating the client, showing unconditional positive regard, respecting boundaries, processing emotions, and treating the client as the expert.
There are also a number of specific interventions that can be used to treat dissociation. A few of these interventions include grounding skills, internal communication, psychoeducation, and art therapy. Grounding skills help orient clients in the present moment by appealing to the senses. These can include practices such as breathing exercises, introducing cold temperatures or intense flavors, fidget toys, textures, weighted blankets, colored lights, mindfulness, going outside, or orienting oneself using day/time. Internal communication interventions include journaling, inner child work, self-compassion, gratitude, and listening instead of just responding. A psychoeducation approach introduces trauma model therapy concepts, IFS, expectations for treatment, and reasons for developing dissociative identity disorder. Art therapy includes creating collages, a system map, timelines, genogram, and coloring emotions in the body. There are a lot more interventions and ways to work with dissociation, but the bottom-line is that is is very possible. The idea that dissociative disorders are either so rare or so severe that treatment options are limited is simply untrue.
If you are a therapist looking to learn more about dissociative disorders, consider watching my on-demand webinar where I provide a crash-course presentation containing everything you need to know about dissociative disorders. For specific case questions, I offer consultation.
Finally, you are not alone. If you are struggling with dissociation and need help, please reach out to me or view some of the resources below.
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