Dissociative Disorders

Depersonalization-derealization disorder (DPDR)

Depersonalization-derealization disorder features episodic or persistent feelings of unreality, specifically detachment from the self and/or surroundings.

Depersonalization is the sense of being estranged from yourself and your mental processes or feeling outside of your body. You may feel you are observing your actions, thoughts, and emotions from a distance as if you were watching a movie. You may also feel as if you have no control over your movements or speech and have become a robot.

Derealization is the feeling of being disconnected from the world around you. Your surroundings may feel unreal, artificial, dreamlike, foggy, and visually distorted. You may also feel as if time is passing them by or they’re not fully in the present.

Transient feelings of depersonalization and derealization are common among the general public. Epidemiological surveys have estimated the lifetime prevalence at 26% and 74% or 31% to 66% at the time of a traumatic event. [2] For people with DPDR, these feelings are ongoing or recurrent and cause distress and impairment in functioning. Patients are often concerned they’re “going crazy” or their “brain isn't working.” Episodes may last for just minutes or as long as years.

Dissociative amnesia

Dissociative amnesia, also known as psychogenic amnesia, is the temporary loss of episodic memory (memory of everyday events) as a result of trauma or stress and not related to another medical condition. The amnesia can be “situation-specific,” meaning memories of a specific incident, usually traumatic, are inaccessible, or “global-transient,” with large amnesiac gaps of up to many years.

Dissociative amnesia also encompasses fugue states: the sudden and reversible retrograde loss of autobiographical memory, including personality, memories, and even identifying information such as their name, address, and date of birth. It may be accompanied by unplanned, purposeful travel or bewildered wandering, and the establishment of a new life.

Dissociative identity disorder (DID)

Previously known as multiple personality disorder, dissociative identity disorder is a rare condition in which people alternate between two or more identities. Each personality, or “alter,“ may have distinct names, personal histories, traits, and even voices and mannerisms. The individual personalities may or may not be aware of each other. When occupied by one personality, the person may have no memory of what happened when they were inhabited by another identity. Many patients with DID also experience auditory hallucinations, described as “internal voices.”

Dissociation in other conditions

Causes of depersonalization-derealization disorder

Depersonalization-derealization disorder has been linked to childhood interpersonal trauma, especially emotional abuse and emotional neglect.^[3] Depersonalization has been theorized as an evolutionary adaptation to help individuals cope with life-threatening situations in which they have no control over their surroundings and the source of danger is known. It's a “freeze” alternative to the fight or flight response in situations where those responses might not be effective, such as when they have no control over their surroundings.^[4]

Drug intoxication, especially with cannabis, MDMA, LSD, and the dissociative ketamine, can cause symptoms of depersonalization and derealization. In some people, they can trigger the onset of long-term DPDR.^[5]

Additionally, some researchers have theorized chronic DPDR is a result of the catastrophic evaluation of ordinary transient depersonalization and derealization (as a result of stress or intoxication), leading to elevated anxiety and the intensification and perpetuation of symptoms. They suggest that DPDR may be less of a dissociative disorder and more related to anxiety disorders, especially panic disorder. ^[6]

Causes of dissociative amnesia

Dissociative amnesia has been connected to overwhelming stress and traumatic events such as abuse, war, natural disasters, and accidents. Some people may be genetically predisposed to amnesiac responses, which have been identified in multiple close relatives.^[7]

Causes dissociative identity disorder

According to the DSM-5, dissociative identity disorder is associated with “overwhelming experiences, traumatic events, and/or abuse during childhood.” It’s also been linked to a disturbed or disrupted attachment between parent and child.

This early trauma is thought to prevent the child from developing a unified sense of self. Instead, different behavioral states become increasingly estranged from each other and develop into distinct identities. These identities allow the child the compartmentalize traumatic memories and prevent them from being entirely overwhelmed by them. ^[8] Therefore DID cannot develop after the child has developed a more secure and integrated self-identity, which usually happens by age 6 to 9. ^[9]

Psychotherapy

Talking therapy is the primary treatment for dissociative disorders.

For DPDR, a cognitive behavioral approach is commonly used, often to challenge catastrophizing and reduce excessive self-observation and avoidant safety behaviors.^[10] 

Most cases of dissociative amnesia last less than a week, with the patient spontaneously recovering memories. Even cases of longer duration usually involve the gradual return of memories. Until memories are restored, patients should be kept in a safe and supportive environment without threatening stimuli.

When the amnesia lifts, psychotherapy can help patients identify and discuss the events that triggered the dissociative episode and learn more effective coping mechanisms for stress and trauma. With longer-term amnesia, psychotherapy can help the patient process and integrate traumatic and dissociated memories.^[11]

Dissociative identity disorder (DID) is most commonly treated following guidelines published by the International Society for the Study of Dissociation (ISSD), developed through consensus among experts and drawing on large-scale clinical research. The goal of this treatment is a “workable form of integration or harmony among alternate identities” gained through outpatient psychotherapy.^[12]

Treatment following these guidelines has been found to improve symptoms, increase functioning, and reduce negative outcomes such as suicide attempts, self-harm, and drug use.^[13] Therapy is less successful when it attempts to recover memories and reduce amnesia rather than directly engaging with the various identities.

Psychotherapy used to promote harmony between the “alters” in DID may include cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), and eye movement desensitization and reprocessing (EMDR).

Medication

There’s no specific medication used to treat dissociative disorders but antidepressants may be helpful to treat related mood disorders, PTSD, and OCD symptoms.

One study found that the mood stabilizer lamotrigine was useful for DPDR. The antidepressant fluoxetine (Prozac) may help patients with DPDR and a co-morbid anxiety disorder.^[14]

Following the theory that blocking opioid receptors leads to a decline in the dissociative side effects of narcotics, patients with dissociative disorders have been experimentally treated with low doses of the opioid antagonist naltrexone, with some success.^[15]

Historically, cases of dissociative amnesia were treated with barbiturates and, later, benzodiazepines, which were thought to act as “truth serums,” reducing fear of the painful memory and allowing the patient to more freely discuss it. However, as with hypnosis, patients in this state are highly suggestible and will provide information that’s a mixture of truth and fantasy.