Dissociative Disorders: Types, DSM Diagnosis, and Treatment

According to the National Alliance on Mental Illness (NAMI), dissociative disorders involve a disconnection from thoughts, identity, consciousness, and memory in a way that is involuntary and chronic.¹ NAMI adds that up to 75% of people experience at least one of these type of episodes in their lives, but only 2% of those meet the full criteria to be diagnosed with a dissociative disorder.¹

There are three types of dissociative disorders, described below, and they have some common characteristics, including memory loss of specific events or people, a sense of detachment or emotional numbness, and out-of-body experiences such as feeling like an observer of one’s self.¹

Dissociative disorders frequently develop after intense stress that may come from traumatic events or inner conflict, and these disorders are related to trauma and stressor-related disorders such as posttraumatic stress disorder.²

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), dissociative disorders are divided into three main types as described below.

Dissociative Amnesia

Dissociative amnesia may surround a specific event, especially one that is traumatic, such as abuse or combat. The main symptom is difficulty remembering important information about one's self or experiences.³ Although one’s memory may not be available on a conscious level, it can influence behavior. For example, someone attacked in an elevator but who does not recall the event because of dissociative amnesia may refuse to ride in an elevator but cannot articulate the reason.³

Depersonalization Disorder

Depersonalization disorder involves ongoing feelings of detachment from thoughts, sensations, emotions, and actions. As part of this disorder, someone might feel as if what’s around them is not real, also termed derealization.⁴

Average age of onset is 16, although depersonalization episodes can start in childhood, and the disorder rarely begins after age 40.¹ Depersonalization or derealization can occur as a symptom of other mental disorders as well as some medical conditions, such as seizure disorders.⁴ When the symptoms are independent of other mental or physical issues, and they impair functioning, then depersonalization disorder is present.⁴

Dissociative Identity Disorder

Formerly known as multiple personality disorder, dissociative identity disorder is characterized by shifting between multiple identities, which may each have a unique name and personal characteristics.¹ Fragmentation may result in asymmetric amnesia, during which one personality is dominant and unable to recall events experienced by other identities.⁵

Dissociative identity disorder is broken down into two subtypes:

• possession

• non-possession

In the possession type, identities appear as if they have taken control of someone, causing them to speak and act in an uncharacteristic way. In the non-possession type, differences are more subtle in their appearance and tend to be in line with the main identity.⁵ Because patients with non-possession may report hearing voices or have visual or olfactory hallucinations, they may be misdiagnosed with a psychotic disorder, but these symptoms differ from those with disorders such as schizophrenia.⁵

The DSM-5 notes that dissociative disorders are characterized by a disruption or discontinuity in the normal functioning of memory, consciousness, identity, emotion, motor control, perception, behavior, and body representation.⁶ Symptoms can potentially disrupt every area of psychological functioning.⁶

According to the American Psychiatric Association, people who have experienced sexual or physical abuse in childhood are at increased risk of developing dissociative identity disorder.⁷

Suicidal ideation and attempts, as well as self-injurious behavior are common among people with this type, and more than 70% of outpatients with dissociative identity disorder have attempted suicide.⁷

Other dissociative disorder types are also linked to traumatic events, either in childhood or adulthood.¹ These may be one overwhelming experience, such as traumatic death of a loved one, a combat incident, a natural disaster, or an aggressive attack. They could also develop as part of long-term physical, sexual, or emotional abuse.¹

Symptoms are often first geared toward keeping memories under control so they don’t interfere with everyday activities; however, stressful situations could act as triggers that reintroduce the stress and trauma from the event or abuse.¹

Because dissociative disorders are linked with trauma, patients may have conditions related to trauma, such as:¹

• PTSD

• substance use disorders (SUDs)

• depression

• anxiety disorders

• mood disorders including bipolar disorder

Borderline personality disorder may also be a comorbidity since both types of disorder have emotional dysregulation as a core feature, and borderline personality disorder is often trauma-based.⁸ In these type of disorders, dissociation provides a type of physical analgesia during overwhelming memories, and offers a form of detachment and protection from otherwise upsetting thoughts.⁸

One of the strongest predictors of dissociation is early childhood trauma, but other types of trauma can also prompt multiple types of trauma-related disorders.⁸ This can result in behavioral dysregulation, including self-harming, as well as eating disorders, interpersonal problems, and medical problems.⁸ Some of those comorbidities include chronic fatigue, heart disease, and autoimmune disorders.⁸

Dissociative disorders are managed through both psychotherapies and medications that can address symptoms such as depression and anxiety.¹ Three main approaches are:

Cognitive behavioral therapy (CBT)

The goal of CBT is to recognize negative thinking and behavior associated with dissociative disorders and to offer coping strategies.¹ CBT can be used for those with comorbidities since it has been shown to be an effective treatment for a breadth of disorders, including bipolar, anxiety, and depression.⁹

Dialectical behavioral therapy (DBT)

Involving individual and group therapy, DBT also teaches coping skills as well as focuses on improved interpersonal relationships and emotional regulation. DBT may also involve mindfulness techniques such as breath work and meditation.¹ The emphasis is on validation, and accepting uncomfortable thoughts, emotions, or behaviors, with an aim toward gradual recovery.⁹

Eye movement desensitization and reprocessing (EMDR)

Designed to reduce or alleviate the distress associated with traumatic memories, this technique combines CBT’s process of re-learning thought patterns with exercises that stimulate visual cues. This helps replace negative emotional reactions with more neutral or even positive reactions. The therapy is often used to treat PTSD and other trauma-based disorders.⁹

Overal, finding an effective treatment plan can be challenging, according to NAMI, but many people with dissociative disorders who get consistent, long-term treatment are able to live healthy and productive lives.¹