Dissociative disorders are a family of mental conditions featuring recurrent or persistent dissociation—detachment from your body, thoughts, emotions, identity, memories, and surroundings—usually as a result of recent or historic trauma.

What are dissociative disorders?

Dissociative disorders are mental health conditions featuring involuntary detachment from reality and discontinuity in thoughts, identity, memory, consciousness, emotion, and body representation. [1]

Many people have experienced a disconnection from their emotions and temporary feelings of unreality during times of stress. For people with dissociative disorders, this experience is regular, unhealthy, and disrupts their daily functioning. Their dissociation may be so all-encompassing they become completely severed from their previous identities and memories. 

Dissociative disorders are usually a reaction to trauma, developed to shield the individual from difficult memories. The most dramatic cases, such as fugue states and the condition formerly known as multiple personality disorder, have been depicted in films like The Bourne Identity and Sybil. But dissociative disorders also include selective memory gaps and out-of-body experiences.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes three major dissociative disorders: depersonalization-derealization disorder (DPDR), dissociative amnesia, and dissociative identity disorder (DID).

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

Dissociative symptoms, especially depersonalization and derealization,  may occur as part of other diagnosable conditions, including:

  • depression

  • anxiety

  • bipolar disorder

  • schizophrenia

  • obsessive-compulsive disorder (OCD)

  • borderline personality disorder (BPD)

  • post-traumatic stress disorder (PTSD)

  • endocrine disorders such as hypothyroidism

  • seizures

  • migraines

  • sleep deprivation

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Symptoms of dissociative disorders

Dissociation is a continuum, with symptoms ranging from daydreaming and emotional numbing to the development of distinct identities with different personalities, behaviors, and access to memories.

The symptoms of dissociative disorders may include:

  • Detachment from your emotions or emotional numbness

  • Detachment from your body and numbing of the senses, including the ability to feel pain

  • Feeling disconnected from yourself and your surroundings

  • Feeling that things around you are unreal or distorted

  • Out-of-body experiences, or a feeling of watching a movie of yourself

  • Feeling like you're a robot

  • Memory gaps, of specific events or distinct periods of time

  • Uncertainty about your identity or even complete loss of your previous identity

  • Having multiple distinct identities

  • Mental health problems including depression, anxiety, and suicidal ideation

How are dissociative disorders diagnosed?

Dissociative disorders are diagnosed by psychiatrists or psychologists based on a review of symptoms and personal history, usually conducted across several meetings. These mental health professionals will look for signs of dissociation during discussions with the patient and speak to their family members about their observations of the patient. They may ask the patient to complete questionnaires such as the Dissociative Experiences Scale and the Steinberg Depersonalization test.

A medical exam and testing such as MRIs, EEGs, and blood and urine tests will be performed to exclude other causes of memory loss and a feeling of unreality, including brain tumors, head injuries, seizures, and intoxication.

What causes dissociative disorders?

Dissociative disorders develop as a reaction to stress and trauma, especially during childhood, as a way of managing and coping with those difficult experiences and memories.

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]

What treatment options are there for dissociative disorders?

As with most forms of treatment for mental health disorders, a combination of talking therapy (psychotherapy) and medication proves to be the most effective in dealing with dissociative disorders.

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. 

Dissociative disorders and substance abuse

The relationship between dissociative disorders and substance abuse is complex. Substance use disorders are among the most common co-morbidities in patients with dissociative identity disorder.[16] 

Similarly, dissociative symptoms are frequently found among people with drug dependence. In one study of people participating in inpatient or outpatient substance abuse programs, 30% scored high on the Dissociative Experience Scale.[17]

For some individuals, substance abuse and dissociative symptoms may separately emerge from the same vulnerabilities, including childhood trauma and abuse. Others may turn to drugs and alcohol to self-medicate distressing dissociative symptoms.

Additionally, Drugs including marijuana, MDMA (ecstasy), LSD, and ketamine can cause temporary depersonalization and derealization. In some people, they can also trigger the onset of more lasting symptoms. Cannabis in particular has been implicated in the development of DPDR, particularly among people with anxiety and external stressors.[18]

Getting help for dissociative disorders

Dissociative disorders require treatment from a psychiatrist or psychologist. Usually, this treatment is performed on an outpatient basis.

The International Society for the Study of Trauma and Dissociation (ISSTD) can help you find a therapist equipped to treat dissociative disorders.

The National Alliance on Mental Illness (NAMI) can direct you to appropriate professionals, resources, and support such as groups in your area. Contact the NAMI HelpLine at 1-800-950-NAMI (6264) or by emailing [email protected].