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Dissociative disorders

Mayo Clinic Health Manager


By Mayo Clinic staff
There are four major dissociative disorders:

Dissociative amnesia Dissociative identity disorder Dissociative fugue Depersonalization disorder Signs and symptoms common to all types of dissociative disorders include:

Memory loss (amnesia) of certain time periods, events and people Mental health problems, including depression and anxiety A sense of being detached from yourself (depersonalization) A perception of the people and things around you as distorted and unreal (derealization) A blurred sense of identity Dissociative disorder symptoms (depending on the type of disorder) may include:

Dissociative amnesia. Memory loss that's more extensive than normal forgetfulness and can't be explained by a physical or neurological condition is the main symptom of this condition. Suddenonset amnesia following a traumatic event, such as a car accident, is rare. More commonly, conscious recall of traumatic periods, events or people in your life especially from childhood is simply absent from your memory.

Dissociative identity disorder. This condition, formerly known as multiple personality disorder, is characterized by "switching" to alternate identities when you're under stress. In dissociative identity disorder, you may feel the presence of one or more other people talking or living inside your head. Each of these identities may have name, personal history and characteristics, including marked

differences in manner, voice, gender and even such physical qualities as the need for corrective eyewear. There often is considerable variation in each alternate personality's familiarity with the others. People with dissociative identity disorder typically also have dissociative amnesia.

Dissociative fugue. People with this condition dissociate by putting real distance between themselves and their identity. For example, you may abruptly leave home or work and travel away, forgetting who you are and possibly adopting a new identity in a new location. People experiencing dissociative fugue may be very capable of blending in wherever they end up. A fugue episode may last only a few hours or, rarely, as long as many months. Dissociative fugue typically ends as abruptly as it begins. When it lifts, you may feel intensely disoriented, depressed and angry, with no recollection of what happened during the fugue or how you arrived in such unfamiliar circumstances.

Depersonalization disorder. This disorder is characterized by a sudden sense of being outside yourself, observing your actions from a distance as though watching a movie. It may be accompanied by a perceived distortion of the size and shape of your body or of other people and objects around you. Time may seem to slow down, and the world may seem unreal. Symptoms may last only a few moments or may come and go over many years. When to see a doctor If you or someone you love has significant, unexplained memory loss or experiences a dramatic change in behavior when under stress, talk to a doctor. A chronic sense that your identity or the world around you is blurry or unreal also may be caused by a dissociative disorder. Effective treatment is available for these conditions. Seek medical help. If you or your child experiences abuse or another traumatic situation, talk to a doctor as soon as possible. Early intervention and counseling may help prevent the formation of dissociative disorders.

By Mayo Clinic staff
Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable. Personal identity is still forming during childhood, so a child is more able than is an adult to step outside herself or himself and observe trauma as though it's happening to a different person. A child who learns to dissociate in order to endure an extended period of his or her youth may use this coping mechanism in response to stressful situations throughout life. Rarely, adults may develop dissociative disorders in response to severe trauma.

Risk factors

By Mayo Clinic staff

People who experience chronic physical, sexual or emotional abuse during childhood are at greatest risk of developing dissociative disorders. Children and adults who experience other traumatic events, including war, natural disasters, kidnapping, torture and invasive medical procedures, also may develop these conditions.

By Mayo Clinic staff
People with a dissociative disorder are at increased risk of complications that include:

Self-mutilation Suicide attempts Sexual dysfunction, including sexual addiction or avoidance Alcoholism and substance abuse Depression Sleep disorders, including nightmares, insomnia and sleepwalking Anxiety disorders Eating disorders Severe headaches Dissociative disorders are also associated with significant difficulties in relationships and at work. People with these conditions often aren't able to cope well with emotional or professional stress, and their dissociative reactions from tuning out to disappearing may worry loved ones and cause colleagues to view them as unreliable.

Tests and diagnosis

By Mayo Clinic staff
Doctors diagnose dissociative disorders based on a review of your symptoms and your personal history. As part of your evaluation, your doctor may perform tests to rule out physical conditions including head injuries, certain brain diseases, sleep deprivation and intoxication that can cause symptoms such as memory loss and a sense of unreality. If your doctor rules out physical causes, he or she will likely refer you to a mental health for an in-depth interview.

To help diagnose dissociative identity disorder, some doctors use medication or hypnosis. These may help your doctor identify alternate personalities or may help you describe repressed memories that played a role in the development of dissociative patterns. To be diagnosed with a dissociative identity disorder, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DMS), published by the American Psychiatric Association. Criteria for dissociative amnesia to be diagnosed include:

You have had one or more episodes in which you couldn't remember important personal information, usually something traumatic or stressful. This memory loss is too extensive to be explained by ordinary forgetfulness.

Your episodes of memory loss do not occur only during the course of another disorder, such as dissociative identity disorder, dissociative fugue, posttraumatic stress disorder, acute stress disorder, or somatization disorder (a condition in which affected people have many recurring physical symptoms that cannot be fully explained by a physical disorder). Your symptoms also are not explained by the direct effects of a substance, such as a prescription medication or recreational drug, or by a neurological or other general medical condition, such as amnesia related to head trauma.

Your symptoms cause you significant stress or problems in your relationships, work or other important areas of your life. Criteria for dissociative identity disorder to be diagnosed include:

You display the presence of two or more distinct identities or personalities, each with its own relatively stable pattern of perceiving, relating to, and thinking about yourself and the world.

At least two of these identities or personality states recurrently take control of your behavior. You can't recall important personal information that is too extensive to be explained by ordinary forgetfulness.

Your symptoms are not due to the direct effects of a substance, such as alcohol, or a general medical condition, such as complex partial seizures. In children, symptoms are not due to imaginary playmates or other fantasy play. Criteria for dissociative fugue to be diagnosed include:

You experience sudden, unexpected travel away from your home or place of work, and can't remember your past.

During fugue episodes, you are confused about your personal identity or you assume a partially or completely new identity.

Your episodes of fugue do not occur only during the course of dissociative identity disorder. Your symptoms also are not explained by the direct effects of a substance, such as a prescription medication or recreational drug, or a general medical condition, such as temporal lobe epilepsy.

Your symptoms cause you significant stress or problems in your relationships, work or other important areas of your life Criteria for depersonalization disorder to be diagnosed include:

You have persistent or recurrent experiences of feeling detached from yourself, as if you are an outside observer of your mental processes or your body you feel as though you are in a dream.

While you are experiencing an episode of depersonalization, you are aware that your feeling of being outside yourself isn't reality.

Your symptoms cause you significant stress or problems in your relationships, work or other important areas of your life.

Your depersonalization symptoms do not occur only during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another dissociative disorder. Your symptoms also are not explained by the direct effects of a substance, such as a prescription medication or recreational drug, or a general medical condition, such as temporal lobe epilepsy.

Treatments and drugs

By Mayo Clinic staff
Psychotherapy is the primary treatment for dissociative disorders. This form of therapy, also known as talk therapy, counseling or psychosocial therapy, involves talking about your disorder and related issues with a mental health provider. Your therapist will work to help you understand the cause of your condition and to form new ways of coping with stressful circumstances. Psychotherapy for dissociative disorders often involves techniques, such as hypnosis, that help you remember and work through the trauma that triggered your dissociative symptoms. The course of your psychotherapy may be long and painful, but this treatment approach often is very effective in treating dissociative disorders. Other dissociative disorder treatment may include:

Creative art therapy. This type of therapy uses the creative process to help people who might have difficulty expressing their thoughts and feelings. Creative arts can help you increase selfawareness, cope with symptoms and traumatic experiences, and foster positive changes. Creative art therapy includes art, dance and movement, drama, music, and poetry.

Cognitive therapy. This type of talk therapy helps you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones. It's based on the idea that your own

thoughts not other people or situations determine how you behave. Even if an unwanted situation has not changed, you can change the way you think and behave in a positive way.

Medication. Although there are no medications that specifically treat dissociative disorders, your doctor may prescribe antidepressants, anti-anxiety medications or tranquilizers to help control the mental health symptoms associated with dissociative disorders.

Alternative medicine
By Mayo Clinic staff
Your therapist may recommend using hypnosis, which is sometimes referred to as hypnotherapy or hypnotic suggestion, as part of your treatment for a dissociative disorder. Hypnosis creates a state of deep relaxation and quiets the mind. When you're hypnotized, you can concentrate intensely on a specific thought, memory, feeling or sensation while blocking out distractions. Because you're more open than usual to suggestions while under hypnosis, there is some controversy that therapists may unintentionally "implant" false memories by suggestion. However, when conducted under the care of a trained therapist, hypnosis is generally safe as a complementary treatment method.

By Mayo Clinic staff
Children who are physically, emotionally or sexually abused are at increased risk of developing mental health disorders, including dissociative disorders. If stress or other personal issues are affecting the way you treat your child, seek help. Talk to a trusted person such as a friend, your doctor or a leader in your faith community. Ask for his or her help locating resources such as parenting support groups and family therapists. Many churches and community education programs offer parenting classes that also may help you learn a healthier parenting style.

If your child has been abused or has experienced another traumatic event, see a doctor immediately. Your doctor can refer you to mental health providers who can help your child recover and adopt healthy coping skills.

What is dissociation?
Your sense of reality and who you are depend on your feelings, thoughts, sensations, perceptions and memories. If these become disconnected from each other, or dont register in your conscious mind, your sense of identity, your memories, and the way you see things around you will change. This is what happens during dissociation. Everyone has periods when disconnections occur naturally and, usually, unconsciously. We often drive a familiar route, and arrive with no memory of the journey or of what we were thinking about. Some people even train themselves to use dissociation to calm

themselves, or for cultural or spiritual reasons. Dissociation is also a defence mechanism that can help us survive traumatic experiences.

What was happening around me was like a scene from a war movie. I was observing it, not participating in it. I didnt feel frightened. It all seemed so strange and unreal.
- Bomb attack survivor The bomb survivor, quoted above, is describing a normal dissociative response, which allowed her to focus on the things she needed to do to survive, including remembering where the nearest exit was. Dissociation can also occur as a side effect of some drugs, medication and alcohol.

Are there different forms of dissociation?

There are five types of dissociation, which are listed below. Occasional, mild episodes are part of ordinary, everyday life. Sometimes at the time of a one-off trauma or the prolonged identity confusion of adolescence, for instance more severe episodes are quite natural.

This is when you cant remember incidents or experiences that happened at a particular time, or when you cant remember important personal information.

A feeling that your body is unreal, changing or dissolving. It also includes out-of-body experiences, such as seeing yourself as if watching a movie.

The world around you seems unreal. You may see objects changing in shape, size or colour, or you may feel that other people are robots.

The world around me seems unreal and alien, like a mist has descended and everything looks hazy and dreamlike; only Im awake, so I cant be dreaming.
- Survivor of derealisation

Identity confusion
Feeling uncertain about who you are. You may feel as if there is a struggle within to define yourself.

Identity alteration
This is when there is a shift in your role or identity that changes your behaviour in ways that others could notice. For instance, you may be very different at work from when you are at home.

What are the different types of dissociative disorder?

Dissociative disorders occur when you have persistent and repeated episodes of dissociation. These usually cause internal chaos and may interfere with your work, school, social, or home life. However, some people apparently function well, which hides their distress.

Depersonalisation disorder
You will have strong feelings of detachment from your own body or feel that your body is unreal. You may also experience mild to moderate derealisation and mild identity confusion.

Dissociative amnesia
This is when you cant remember significant personal information or particular periods of time, which cant be explained by ordinary forgetfulness. You may also experience mild to moderate depersonalisation, derealisation and identity confusion.

Dissociative fugue
You may travel to a new location during a temporary loss of identity. You may then assume a different identity and a new life. You will experience severe amnesia, with moderate to severe identity confusion and often identity alteration.

Dissociative identity disorder (DID)

The most complex dissociative disorder. Its also known as multiple personality disorder (MPD). This has led some to see it as a personality disorder, although it is not. The defining feature is severe change in identity. If you experience DID, you may experience the shifts of identity as separate personalities. Each identity may assume control of your behaviour and thoughts at different times. Each has a distinctive pattern of thinking and relating to the world. Severe amnesia means that one identity may have no awareness of what happens when another identity is in control. The amnesia can be one-way or two-way. Identity confusion is usually moderate to severe. It also includes severe depersonalisation and derealisation.

Our life is always challenging and frequently chaotic, confusing and distressing, even when we look and behave unremarkably.
- Survivor of dissociative identity disorder

Dissociative disorder not otherwise specified (DDNOS)

Each of the five types of dissociative response (see above) may occur, but the pattern of mix and severity does not fit any of the other dissociative disorders listed above.

Additional problems
You may experience other problems too, such as depression, mood swings, anxiety and panic attacks, suicidal tendencies, self-harm, headaches, hearing voices, sleep disorders, phobias, alcohol and drug abuse, eating disorders, obsessive-compulsive behaviour and various physical health problems. These may be directly connected with the dissociative problem, or could mean that you also have a nondissociative disorder. In DID, these problems may only emerge when a particular part of the fragmented identity (an alter personality) has control of your behaviour, thoughts and feelings. Many mental health problems, such as schizophrenia, bipolar disorder and borderline personality disorder, also have dissociative features.

What causes dissociative disorders?

Childhood abuse
The causes of dissociative disorders are complex. Studies show that a history of trauma, usually abuse in childhood, is almost always the case for people who have moderate to severe dissociative symptoms. But not all trauma survivors have a dissociative disorder, so the relationship is not one of simple cause and effect. A fuller understanding comes from looking at your childhood relationship with your parents or guardians. If the relationship was insecure and you were abused, then you were, and are, more likely to use dissociation to protect yourself from the trauma. The combination of an insecure relationship, trauma and dissociation can result in a complex dissociative disorder.

Recent studies show differences in the brains of people with traumarelated dissociative disorders, but it is hard to know if this is a cause or effect. A number of experts agree that the following factors have to be present for a person to develop the most complex dissociative disorders e.g. Dissociative identity disorder (DID), or DDNOS with features of DID:

abuse begins before the age of five abuse is severe and repeated over an extended period the abused child has an enhanced natural ability to dissociate easily there is no adult to provide comfort; the child had to be emotionally self-sufficient.

Other theories
Some sceptics argue that DID does not occur naturally and that the symptoms are caused by poor therapy with vulnerable, suggestible clients. Some have also suggested that DID is a North American phenomenon and should be viewed as a culture-specific diagnosis. But dissociative disorders have been identified and studied in many different countries and cultures.

How common are dissociative disorders?

Dissociative disorders are likely to be more common than the current low rates of diagnosis suggest. A British study used a standard dissociative disorders screening questionnaire and interviewed 59 mental health inpatients on an acute psychiatric unit. None of the patients had previously been diagnosed with a dissociative disorder. It found that 30 per cent experienced significant levels of dissociation and its probable that 50 per cent of this group had an undiagnosed dissociative disorder. People who are eventually diagnosed with Dissociative identity disorder (DID) or other complex dissociative disorder have often had several earlier misdiagnoses, such as schizophrenia, bipolar or borderline personality disorder. Others never have their dissociative disorder diagnosed. DID may be as high as one per cent in the general population.

Several factors may explain the low rates of diagnosed dissociative disorders.

How are dissociative disorders diagnosed?

Several questionnaires can be used to screen for and diagnose dissociative disorders. The most common are the Dissociative Experiences Scale (DES) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Research shows these are accurate tools which discriminate DID from other dissociative disorders and from other mental health problems. Clinicians who use these assessment tools should have specialist training and a good understanding of the dissociative disorders. If you have experienced a combination of any of the symptoms opposite, you may need an assessment for dissociative disorders. For DID, the following are non-specific clues for diagnosis. They are not the only indicators (e.g. men can also have DID and it is seen in older people), but they are a useful guide for when to seek assessment for dissociative disorders.

history of childhood abuse/trauma female age 20-40 reporting blank spells hearing voices and/or believing there are external influences on the body and/or other unusual beliefs (apparently delusional thinking) and/or reports of other peoples thoughts intruding previous diagnosis or suspicion of borderline personality disorder previous unsuccessful treatment self-destructive behaviour no thought disorder.

Clinicians who have extensive knowledge and experience of working with dissociative disorders may be able to recognise them using clinical judgement alone. Please note that dissociative states are a common and accepted feature of cultural activities or religious experience in many non-Western societies and are not regarded as a mental health problem.

Difficulty in diagnosing

GPs and mental health professionals often receive insufficient training on dissociative disorders, so may not ask the right questions or consider the possibility of a dissociative disorder. Many signs and symptoms identified during routine mental health assessments (e.g. depression, anxiety, insomnia, self-harming, hearing voices) are common to other mental health problems more familiar to the clinician. Thus a standard assessment will often not identify a dissociative disorder. There is often confusion surrounding the term multiple personality disorder (for DID). It can result in a diagnosis that is not valid, as the clinician may be looking for personality disorder symptoms instead of dissociative disorder symptoms. Until recently, clinicians did not routinely ask about history of childhood abuse and trauma at assessment. Also, even when asked, people may deny a history of abuse. One reason for this may be because they do not remember it (dissociative amnesia).

Almost everyone coping with dissociative difficulties tries to keep them hidden from others.

What are the effects of a dissociative disorder?

Dissociation can affect perception, thinking, feeling, behaviour, body and memory. So, if you experience a dissociative disorder you may have to cope with many challenges in life. The impact of dissociation varies from person to person and may change over time. How well a person appears to be coping is not a good way of telling how severely affected they are. For instance, few people with Dissociative identity disorder (DID) (see above) will switch rapidly and openly between identities, in the way portrayed on TV and film. Nor is the classic Dr Jekyll and Mr Hyde shift of identity common. The effects of dissociative disorder may include:

gaps in memory finding yourself in a strange place without knowing how you got there out-of-body experiences loss of feeling in parts of your body

distorted views of your body forgetting important personal information inability to recognise your image in a mirror a sense of detachment from your emotions the impression of watching a movie of yourself feelings of being unreal internal voices and dialogue feeling detached from the world forgetting appointments feeling that a customary environment is unfamiliar a sense that what is happening is unreal forgetting a talent or learned skill a sense that people you know are strangers a perception of objects changing shape, colour or size feeling you dont know who you are acting like different people, including child-like behaviour being unsure of the boundaries between yourself and others feeling like a stranger to yourself being confused about your sexuality or gender feeling like there are different people inside you referring to yourself as we being told by others that you have behaved out of character finding items in your possession that you dont remember buying or receiving writing in different handwriting having knowledge of a subject you dont recall studying.

Dissociative Identity Disorder (Multiple Personality Disorder)

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AAA Dissociative identity disorder (previously known as multiple personality disorder) is an effect of severe trauma during early childhood, usually extreme, repetitive physical, sexual, or emotional abuse.

What Is Dissociative Identity Disorder? Most of us have experienced mild dissociation, which is like daydreaming or getting lost in the moment while working on a project. However, dissociative identity disorder is a severe form of dissociation, a mental process, which produces a lack of connection in a person's thoughts, memories, feelings, actions, or sense of identity. Dissociative identity disorder is thought to stem from trauma experienced by the person with the disorder. The dissociative aspect is thought to be a coping mechanism -- the person literally dissociates himself from a situation or experience that's too violent, traumatic, or painful to assimilate with his conscious self. Is Dissociative Identity Disorder Real? You may wonder if dissociative identity disorder is real. After all, understanding the development of multiple personalities is difficult, even for highly trained experts. But dissociative identity disorder does exist. It is the most severe and chronic manifestation of the dissociative disorders that cause multiple personalities. Other types of dissociative disorders defined in the DSM-IV, the main psychiatry manual used to classify mental illnesses, include dissociative amnesia, dissociative fugue, and depersonalization disorder. What Are the Symptoms of Dissociative Identity Disorder? Dissociative identity disorder is characterized by the presence of two or more distinct or split identities or personality states that continually have power over the person's behavior. With dissociative identity disorder, there's also an inability to recall key personal information that is too far-reaching to be explained as mere forgetfulness. With dissociative identity disorder, there are also highly distinct memory variations, which fluctuate with the person's split personality. The "alters" or different identities have their own age, sex, or race. Each has his or her own postures, gestures, and distinct way of talking. Sometimes the alters are imaginary people; sometimes they are animals. As each personality reveals itself and controls the individuals' behavior and thoughts, it's called "switching." Switching can take seconds to minutes to days. When under hypnosis, the person's different "alters" or identities may be very responsive to the therapist's requests. Along with the dissociation and multiple or split personalities, people with dissociative disorders may experience any of the following symptoms: Depression Mood swings Suicidal tendencies Sleep disorders (insomnia, night terrors, and sleep walking) Anxiety, panic attacks, and phobias (flashbacks, reactions to stimuli or "triggers") Alcohol and drug abuse Compulsions and rituals Psychotic-like symptoms (including auditory and visual hallucinations) Eating disorders Other symptoms of dissociative identity disorder may include headache, amnesia, time loss, trances, and "out of body experiences." Some people with dissociative disorders have a tendency toward selfpersecution, self-sabotage, and even violence (both self-inflicted and outwardly directed). As an example, someone with dissociative identity disorder may find themselves doing things they wouldn't normally do such as speeding, reckless driving, or stealing money from their employer or friend, yet they feel they are being compelled to do it. Some describe this feeling as being a passenger in their body rather than the driver. In other words, they truly believe they have no choice.