WHAT IS DISSOCIATION?

Dissociation itself is quite common and every one of us has probably experienced a normal dissociative episode many times in our lives, for example:

  • daydreaming while driving a car as if on autopilot (‘highway hypnosis’)
  • blanking out and missing part of a conversation
  • feeling unfamiliar when looking the mirror
  • having a dreamlike feeling about other people or the world
  • a sense of time slowing down (especially during a traumatic event such as a car accident or terrorist attack).

These types of symptoms occur as a natural reaction both to traumatic events as well as high levels of stress in everyday life. ’Normal’ dissociation passes quickly and does NOT indicate the presence of a psychiatric disorder.

However, a dissociative disorder can develop when severe trauma is experienced and is not processed or dealt with. This theory has gained overwhelming support in recent years from research on the effect of trauma on the brain, and how memory is affected. A traumatic experience is one that is extremely distressing, involves a threat to life or the physical body, and is generally accompanied by feelings of helplessness – dissociation is therefore a common response. It allows a person to alter their consciousness in a way which enables them to distance or disconnect from the full impact of what is happening. This distancing can take place in terms of memory, emotion, the actual physical experience, or in extreme cases a sense of identity. When under threat the brain goes into ‘survival’ mode. Dissociation can be thought of as both a neurobiological response to threat and a psychological defence to protect from an overwhelming experience. This happens automatically as the best and usually the only means of mentally surviving trauma.

Dissociation has been described as “an unconscious defence mechanism in which a group of mental activities split off from the main stream of consciousness and function as a separate unit” (O’Regan, 1985). The purpose of dissociation therefore is to take the memory or emotion that is directly associated with a trauma and to try to separate it from the conscious self. It is a normal process which starts out as a defence mechanism to handle traumatic events, but which becomes problematic over time.

WHAT ARE THE SYMPTOMS OF DISSOCIATIVE DISORDERS?

There are different types of dissociative disorder and they may include varying degrees of the following five core dissociative symptoms:

  • Amnesia. This will be for specific and significant blocks of time that have passed – gaps in memory or ‘lost time’.
  • Depersonalisation. This is a feeling of being detached from yourself or looking at yourself from the outside, as an observer would. It can also include feeling cut-off from parts of your body or detached from your emotions, and a sense that you are not yourself.
  • Derealisation. This is a feeling of detachment from the world around you, or a sense that people or things feel unreal
  • Identity confusion. This is a feeling of internal conflict of who you are – having difficulty in defining yourself.
  • Identity alteration. This is a shift in identity accompanied by changes in behaviour that are observable to others. These may include speaking in a different voice or using different names. This may be experienced as a personality switch or shift, or a loss of control to ‘someone else’ inside.

In dissociative disorders, and especially in dissociative identity disorder (DID), there is a fundamental disconnection between conscious awareness, memories, emotions and also usually the body.

WHAT IS DISSOCIATIVE IDENTITY DISORDER?

Dissociative identity disorder is the most extreme manifestation of a dissociative disorder and involves ‘multiple parts of the personality’ existing within one person. These have evolved as separate ‘personality states’ as the only feasible way for a child to cope with ongoing trauma and abuse. It involves a basic pretence that what is happening is not happening to me. As Phil Mollon (1996) puts it:

Dissociation involves an attempt to deny that an unbearable situation is happening, or that the person is present in that situation.

It is important to remember that none of us has one totally ‘integrated’ personality. We show different sides of us in different situations, so we may play a very different role when we are in a business meeting compared to when we are at home relaxing with our family. Dissociative identity disorder is an extreme manifestation of what we all experience to a much lesser degree. The different parts of the personality:

are not actually separate identities or personalities in one body, but rather parts of a single individual that are not yet functioning together in a smooth, coordinated and flexible way.

(Boon et al, 2011)

When most people hear of dissociative identity disorder they may think of Sybil, the book and 1976 film starring Sally Field. In this film Sybil was diagnosed with suffering from Multiple Personality Disorder (the previous name for dissociative identity disorder) resulting from severe child abuse. Her parts were quite distinct and easily recognised, and the switching between them was quite obvious. In reality someone with dissociative identity disorder may not show such obvious switching.

In addition to the dissociation and switching between different alters, a person with dissociative identity disorder may experience the following symptoms:

  • inner voices
  • nightmares
  • panic attacks
  • generalised anxiety
  • depression
  • eating disorders
  • drug or alcohol dependency
  • body memories
  • severe headaches
  • unexplained medical symptoms, especially chronic pain
  • self-harm
  • suicidal thoughts and behaviours
  • flashbacks
  • relational difficulties
  • issues of shame and poor self-esteem
  • Post Traumatic Stress Disorder (PTSD).

Someone who has dissociative identity disorder may have distinct, coherent identities within themselves that are able to assume control of their behaviour and thought. They may or may not be aware of these ‘alter personalities’ and they may or may not present with different names, mannerisms, gender identity, sense of age etc. Sometimes it is very subtle and sometimes it is very obvious to an observer, although the person with DID may not be aware that it is happening at all. They may just have a sense of losing time or incoherence about who they are and what they have been doing.

Flashbacks are one of the most common ways in which dissociated memories begin to resurface. During a flashback there will often be overwhelming visual, sensory and other reminders of the traumatic event, and it may feel as if the experience is being relived. A flashback can often be caused by a ‘trigger’, which is a current-day reminder (either at a conscious or unconscious level) of something traumatic from the past. A trigger could be a sight, a sound, a taste, a smell, a touch, a situation, a location, even a body movement. There is almost an instant catapulting back into the sensation or feelings of the past which is highly distressing and can happen quite spontaneously. This makes living everyday life somewhat of a minefield, as almost anything can become a trigger and cause rapid and destabilising switching, for example into alters who experience the flashback as being re-abused in the present.

THE CAUSES OF DISSOCIATIVE IDENTITY DISORDER

Dissociative identity disorder is not a mental illness with a biological cause, but rather the result of a series of developmental adaptations in the brain to a difficult early life environment. It is now widely accepted that it results from chronic and overwhelming trauma and abuse in childhood starting at a very young age, generally at the hands of a caregiver. Although the child’s parents may not have been directly involved in the abuse, there has usually been some inability on their part to help the child to process or recover from whatever trauma they have experienced. The traumatic events therefore remain sealed off – dissociated and unprocessed – from the main conscious awareness and developing identity of the child. This can result in either complete or partial amnesia for what has happened, and ‘gaps’ in the person’s narrative account of their life. One of the principal functions of dissociative identity disorder is ‘denial’ – to allow the person to continue with life, unaware of the extreme abuse that they have suffered, by blocking it out of their memory and mind.

It is very common then that the person will grow up unaware of their traumatic history until such a time as their psychological defences can no longer cope, for example due to stress or the intrusion of current-day ‘triggers’. At this point the dissociation and dissociative identity disorder may manifest in a much more obvious way, so that life becomes intolerable, and help or treatment is sought.

HOW IS DISSOCIATIVE IDENTITY DISORDER DIAGNOSED AND THEN TREATED?

The American Psychological Association defines a list of psychiatric conditions and the latest edition of this is the DSM-5 (Diagnostic and Statistical Manual, version 5). It defines dissociative identity disorder in section 300.14 (dissociative disorders) as follows:

  • Disruption of identity characterised by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
  • Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

Dissociative identity disorder therefore is characterised by two main aspects: disruption of identity, and a disruption in memory. The criteria also clarify that the symptoms cause significant distress, are not part of a broadly accepted cultural or religious practice, and are not due to alcohol or drugs. People who fall short of these criteria, or the criteria for Dissociative Amnesia or Depersonalisation/Derealisation Disorder, may instead receive a diagnosis of Other Specified Dissociative Disorder (OSDD) or Unspecified Dissociative Disorder (UDD). These used to be called DDNOS (Dissociative Disorder Not Otherwise Specified).

Dissociative identity disorder is very rarely diagnosed at an early stage in the UK due to widespread ignorance within the medical profession. On average according to research it takes 7 years within the Mental Health system to gain a correct diagnosis. Often it is misdiagnosed as borderline personality disorder (also known as emotionally unstable personality disorder), schizophrenia, bipolar disorder, depression or PTSD. The person with it may suffer from some of these conditions in addition to DID, but dissociation is often the underlying core issue.

The ISSTD (International Society for the Study of Trauma and Dissociation) recommends that the preferred treatment for dissociative identity disorder is long-term relational psychotherapy. Medication can assist with associated symptoms, such as sleep disturbance, anxiety and depression, but there is no pharmacological cure for DID. However, ithas a very favourable prognosis and significant recovery is possible with the right treatment. It is most helpful to work with a therapist who has some awareness of dissociative identity disorder or who is willing to learn or have a supervisor experienced in working with dissociation. Many people find that treatment is not available via the NHS and so have to turn to the voluntary sector or private therapists, and PODS holds a register of ‘dissociation-friendly’ therapists throughout the UK who can be approached, many of whom may be willing to work on a sliding-scale basis for clients on a low income.

The ISSTD have produced some treatment guidelines for working with dissociative identity disorder, which are available here. These guidelines are very comprehensive and give hope that significant recovery is possible as long as there is not an undue investment in the DID itself. They do recommend talking to and engaging with all of the different parts, whilst not focusing on and even elaborating their differences. Instead ‘parts’ or ‘alters’ should be understood in terms of what they represent or hold, which often includes disowned feelings, memories, or ways of relating. The ISSTD therefore recommend accepting and validating the different parts of the personality and their contribution to the person as a whole, whilst understanding why the dissociative splits are present and how to resolve those conflicts and move towards resolution.

People with dissociative identity disorder almost invariably have ‘disorganised attachment’, often resulting from having caregivers who were either ‘frightened or frightening’. This can lead to problems both in managing emotions and dealing with relationships. To a partner or professional supporter this may appear to be an irrational or unpredictable style of relating and behaviour. Attachment issues ideally need to be addressed in therapy, rather than the focus being just on the traumatic events themselves.

Effective treatment for dissociative identity disorder is often long-term and seems to be most successful when a ‘phase-oriented’ approach is undertaken. This means that the focus of treatment follows three distinct phases, although progression between the three stages is not often linear and may involve going backwards and forwards during them. The first stage is about creating safety and stabilisation in the dissociative client’s life, including learning grounding techniques and building a secure base from which they can explore their traumatic past. The second phase often works directly with traumatic memories, which can be very destabilising if it is not approached slowly and sensitively, with sufficient resources gained from phase 1 work. The final phase, which may take several years to achieve, aims to help the dissociative client to build a new life and move into a more coherent sense of identity and way of being in the world. Although a number of people with dissociative identity disorder do manage to ‘fuse’ their separate identities into one consistent whole, ‘stable multiplicity’ involving good cooperation and collaboration between the different parts of the personality is a preferred treatment goal for others.