BY: T. Franklin Murphy | December 13, 2022 (modified January 7, 2023)
Sometimes life intrudes, smashing securities, and shattering soothing assumptions about the world. We are survival driven creatures. In moments of extreme stress, the mind is challenged to provide comfort. Dissociative disorders are theorized to provide an avenue of escape.
Dissociative disorders, known as hysteria in early psychology, are mental disorders involving disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity.
In a Mayo Clinic article, they write that with dissociative disorders, "people...escape reality in ways that are involuntary and unhealthy and cause problems with functioning in everyday life" (2022).
As common with other neuroses, dissociative disorders serve as an escape from immediate discomforting emotions through a maladaptive cognitive defense. The cognitive escape mediates present emotion by severing connections to reality. While these dissociations with reality may offer temporary comfort, they interfere with healthy behaviors necessary for building relationships and obtaining long term goals.
Dissociative Disorders are mental disorders involving a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity. Dissociation is considered a split in the psyche in reaction to extreme trauma.
What are Dissociative Disorders?
Dissociation is a pathological process in which the individual's psyche splits in two or more parts. At least one of the parts is relatively able to function in reality, while the other part or parts of the psyche are dysfunctional. These disorganized parts of the psyche usual live in a false reality existing only in mental constructions or delusions.
In the fifth edition of the Diagnostic and Statistical Manual of Mental Health (DSM-5), dissociation is defined as a disruption, interruption, and/or discontinuity of the normal, subjective integration of behavior, memory, identity, consciousness, emotion, perception, body representation, and motor control.
Dissociation disorders are characterized as breakdowns of memory, awareness, identity, or perception occurring in response to psychological trauma. Although some cases occur without any identifiable traumatic cause.
Dissociative disorders are considered functional in nature, meaning the disorder is not caused by some insult, injury, or disease impacting the brain.
Multiple personality disorder, now diagnosed as dissociative identity disorder, was made popular through cinema. In 1957, the life story of Chris Costner Sizemore was made into the film The Three Faces of Eve. Sizemore was diagnosed with a dissociative disorder (multiple personality disorder). Psychiatrists identified three separate personalities (Eve White, Eve Black, and Jane). The movie was based on a book written by psychiatrists Corbett H. Thigpen and Hervey M. Cleckley.
In 1976, the fascinating mini series Sybil was broadcast on NBC starring Sally Fields as Sybil Dorsett, a girl dissociating from severe childhood trauma through multiple (13) alternate personalities. The movie and book were based on the life of Shirley Ardell Mason.
The movies, perhaps, influenced a wave of new cases of a disorder that was relatively ignored before the popular cinematic productions.
Yet, dissociation, when mild and intermittent, is fairly common. The dissociation serves as a protective function, rarely requiring professional assistance; nor rising to a level that would be medically diagnosed as a disorder.
However, as in the examples portrayed in Sybil and the Three Faces of Eve, dissociation may grossly impair functioning. When dissociation disturbs normal functioning, a diagnoses from a trained professional and treatment may be necessary.
History of Dissociative Disorders
The idea of dissociation relies on the foundational concept of the mind outside of conscious awareness. During the 19th century, this concept became widely accepted, and along with it came theories of mental illnesses. Dissociation, in any form, is the relegating of memories and perceptions normal held in consciousness to the unconscious, creating a disassociation from a memory, identity, or perception.
Early cases of dissociation were referred to as hysteria. Psychological literature from the 19th century and early 20th century contains many references to hysteria.
In a lecture on the hysterical phenomena, Freud and Breuer wrote:
External events determine the pathology of hysteria to an extent that is far greater than is known. It is of course, obvious that in cases of traumatic "hysteria" what provides the symptoms is the accident (1895).
Pierre Janet (1859-1947)
The first systematic study of dissociation is credited to Pierre Janet. His research arose from his therapeutic work with hysterical patients and his use of hypnosis as treatment for the psychological effects of trauma (Atchison & McFarlane, 2016).
Many of Janet's theories of integration and dissociation remain relevant today. We see shadows of his early research in modern concepts of integration.
Janet theorized that "novel experiences are normally integrated into memory through unification of emotions, thoughts, actions, and sensations related to that experience." According to Janet, new experience (with all its components) is cognitively assessed against previous memories (process of integration). "Traumatic experiences that do not fit into into existing cognitive schema may be split off from conscious awareness" (2016, p. 592).
Janet suggested that the pieces of new experience that were split off, and hidden from conscious awareness, still exist in the unconscious. He explained that "these fragments may consist of memories, feelings, or actions, and may be triggered by situations reminiscent of the original trauma" (2016, p. 592).
According to Janet, hysterical crises were the re-enactment of dissociated fragments, hiding in the unconscious.
Post-Traumatic Stress Disorder
After the death of Janet, his theories of dissociation lost credibility. Many of Janet's former patients were exposed as frauds. Interest in psychological trauma continued in new scientific studies conducted under the umbrella of post-traumatic stress disorders (PTSD). Trauma induced mental illness and dysfunction continued to dominate the landscape of hysteria and dissociative illnesses.
During the middle part of the 20th century, behaviorism became one of the leading theories of behavior. Scientific studies on PTSD shifted, largely following behavioristic explanations, departing from the psychodynamic theories of the unconscious proposed by Janet and Freud.
Behaviorism largely supported a sociocognitive model that proposes that dissociation is largely "a consequence of social learning and expectancies." According to this model, many uncovered memories are not necessarily to moving of a fragment of a dissociative experience, but the inadvertent result of "therapist cueing (e.g.. suggestive questioning regarding the existence of possible alters, hypnosis for memory recovery, sodium amytal), media influences, and sociocultural expectations..." (Lynn, et al., 2012).
Sociocognitive model became a popular counterargument to the significant wave of recovered memories of childhood abuse and subsequent criminal investigations into decades old abuse. Recollections only recently remembered during therapeutic treatment, without any collaborating evidence, is woefully insufficient to charge someone for criminal behavior.
After the short lived domination of behaviorism, cognitive and neurobiological explanations took center stage, continuing to dominate the epidemiology of the dissociation disorders today.
Diagnostic and Statistical Manual for Mental Disorders
Dissociative disorders have been included in all editions of the DSM going back to its first edition published in 1952. In the first edition, dissociative disorders were included as psychoneurotic disorders, in which anxiety is either "directly felt and expressed or . . . unconsciously and automatically controlled" through various defense mechanisms.
Under this label, the following dissociative disorders were listed:
In DSM-II (1968), dissociative identity disorder was listed as hysterical neurosis, dissociative type, defined as an alteration to consciousness and identity (Tracy, 2022).
In DSM-III (1980) "Dissociative" was introduced as a class of disorders.
In the DSM-III-R text revision, the manual listed "a disturbance in the normally integrative functions of identity, memory, or consciousness . . ." as an essential feature of dissociative disorders (Tracy, 2022).
In these editions, "interpersonality amnesia" was removed from the diagnostic criteria, creating a much more liberal diagnosis, allowing for an increased frequency of occurrence in a once rare disorder (Kihlstrom, 2005).
In DSM-IV (1994), changes somewhat remedied the omission of amnesia in the previous version. DSM-IV reinserted amnesia as a specific criterion for the diagnosis of multiple personality disorder. In DSM-IV, multiple personality disorder (MPD) was renamed dissociative identity disorder (DID).
The criteria for dissociative identity disorder in DSM-IV:
The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
These new criteria emphasized "the importance to changes in consciousness and identity," over much more common occurrence of changes in personality (Kihlstrom, 2005).
DSM-5 (2013) changed the dissociation disorder definition to allow self-reports and added that amnesia may occur with regards to everyday events and not just traumatic ones.
Many argue that the fourth and fifth editions, did not go far enough in reversing the liberal definition created in DSM-III. John F. Kihlstrom argues that "even with the strict criteria in place, it can be difficult to discriminate between the dissociative disorders and bipolar disorder, borderline personality disorder, and even schizophrenia" (Kihlstrom, 2005, p. 229).
What Causes Dissociative Disorders?
Many psychologists and psychiatrists consider dissociation as a coping mechanism to deal with overpowering stress. George Valliant, a professor of psychiatry at Harvard University lists dissociation as a defense mechanism. He explains "dissociation permits the ego to so alter the subject's internal state that the pain of conflict becomes irrelevant" (1998).
Alfred Adler suggests that in "dissociation" or the "split personality" that the double life serves as to "rescue the personality from colliding with reality" (2011, location 474).
Ronnie Janoff-Bulman in her book on trauma, Shattered Assumptions, refers to dissociation as extreme denial (2010). She wrote that through dissociation "it is not as if the trauma does not exist; it is that the trauma does not exist in consciousness or the consciousness of one’s primary personality" (p. 103).
Lawrence Heller suggests that many of those severely traumatized function "by using dissociation to disconnect from the distress in their body" (2012). Heller further explains, "by dissociating—that is, by keeping threat from overwhelming consciousness—a traumatized individual can continue to function" (Kindle location, 2,388).
Heller reminds that we all use some form of dissociation. he wrote, "dissociation is a human response. In reaction to trauma, the dissociative process is a life-saving mechanism that helps human beings bear experiences that would otherwise be unbearable." He continues, "we are all disconnected and dissociated to one degree or another" (location 2,393-2,396).
Modern science gives a deeper explanation to how trauma leads to dissociation, and in extreme circumstance creating fertile fields for the dysfunctional states of the dissociation disorders.
Our biological systems strives to obtain survival needs (food, water, security). When these needs are not provided, our system is aroused. For babies, they cry. For adults, their is much more complex of learned reactions that may be enacted to obtain needs from others.
When needs are withheld or unobtainable, we first protest, followed by anger, then express rage. However, when these expressions of need go unheeded, the child (or adult) either react with hyperarousal or dissociation. These two patterns represent extreme forms of Bowlby's protest and despair responses to attachment injuries. Allan N. Schore, PhD. explains that hyperarousal and dissociation represent "activation of the two components of the autonomic nervous system (ANS): first, the energy-expending sympathetic branch; and then, the energy-conserving parasympathetic branch" (2003, location 1,549).
When protests are not heard, the expended energy disrupts and the system becomes disorganized. An adult may seek alternate means to obtain needs. However, the child must process the unheard calls, the growing frustration through protective defenses. Dissociation is one of those means—a disconnection from the emotions associated with the unmet need.
Diana Fosha, PhD., explains that when the primary relationship fails to "provide even the most rudimentary assistance with fear abatement" the neglect "augments the child's fear response, fertilizing the soil in which dissociation and splitting of personality become the only viable strategies to prevent even more pervasive psychic disintegration in the face of danger" (2000).
So the young child, first responds normally with protest, activation of the sympathetic nervous system (fight and flight). When those cries go unheard, then they typically switch to the energy saving parasympathetic response (freeze). Heller explains that "when there is early trauma, the older dorsal vagal defensive strategies of immobilization dominate, leading to freeze, collapse, and ultimately to dissociation" (2012, location 1652).
Age when the trauma occurs is theorized to play a role in the development of dissociative disorders. Heller wrote, "when trauma is early or severe, some individuals completely disconnect by numbing all sensation and emotion" (2012).
Other professional trauma researchers agree. Allan Schore explains "if early trauma is experienced as 'psychic catastrophe,' the autoregulatory strategy of dissociation is expressed as 'detachment from an unbearable situation,' 'a submission and resignation to the inevitability of overwhelming, even psychically deadening danger,' and 'a last resort defensive strategy' (2009, location 2,689).
Robin Karr-Morse and Meredith Wiley in their extensive research on childhood trauma found that "the younger the child is at the time of experiencing terror, the more likely she or he is to respond with dissociation rather than hyperarousal" (2014, location 3,076).
Early trauma and dissociation creates a fragmented self. Siegel explains that "the child has the double insult of becoming engulfed in confusion and terror induced by the parent, and of losing the relationship with an attachment figure that might have provided a safe haven and sense of security." He continues, "dissociation can be an outcome of these experiences and produce an internal sense of fragmentation of the self" (2020, location 7,242).
Our mind does wonderful and terrible things with fragmented experiences. The chaotic flowing of experience, emotion, and memories when not properly integrated into a useful whole can morph into a variety of disorders, while the mind tries to make sense of life while simultaneously blocking significant painful conflicts. From the chaotic and conflicted unconscious world emerge, dissociation disorders.
This process is not just a terrifying display of unseen forces but a biological reality of underdeveloped connections between various parts of the brain.
Types of Dissociative Disorders
Dissociative Fugue is described as reversable amnesia for identity. Often accompanied by unplanned travel or wandering, and sometimes the formation of a new identity. This state of mind is typically associated with extreme stress in the present (Petric, 2022).
Dissociative fugue shares similar features as other brief psychotic disorders with episodes including the addition of a disruption to identity.
The cause of dissociative fugue may be explained well by the diathesis stress model. T. Franklin Murphy describes the diathesis stress model as "a psychological theory that disorders develop as a result of interactions between pre-dispositional vulnerabilities (the diathesis), and stress caused by life experiences" (2021).
The foundational concept is that under extreme stress that impose psychological demands beyond an individuals window of tolerance, the psyche breaks down. In the case of dissociative fugue the break down includes momentary and reversable amnesia of identity.
"Dissociative amnesia may be defined as an inability to consciously recall autobiographical information in the absence of brain damage detectable by conventional neuroimaging" (Petric, 2022).
Dissociative amnesia may last a few minutes to a few years, depending on the severity of the trauma, and personality traits of the individual (including their use of defense and coping mechanisms).
Depersonalization disorder is characterized by periods of detachment from self and immediate surroundings. Reality is momentarily experienced as unreal, almost like a dream, however, the individual maintains an awareness that it is only a feeling and not a delusion.
With depersonalization disorders, individuals may experience disconnection from themselves, feeling like an automation; or, as if, they are viewing themselves from a distance.
Dissociative Identity Disorder
Dissociative identity disorder, formerly known as multiple personality disorder is the alteration between two or more personality states. In some extreme cases, the individual is unaware of the other altering personalities. Dissociative identity disorder has a prevalence of less than 1% in the general population.
Dissociative identity disorder is characterized by amnesia, identity confusion, and coexistence of dissociative identities.
Characteristic features of dissociative identity disorder is often associated with coexisting features such as:
Dissociative Disorder Not Otherwise Specified
Dissociative disorder not otherwise specified refers to symptoms of a dissociative disorder that doesn’t quite meet full criteria of any of the other categories.
How are Dissociative Disorders Treated?
Treatment for dissociative disorders may include various styles of talk therapy (psychotherapy). Heller developed NeuroAffective Relational Model (NARM) as a specific style of therapy designed for treating trauma. A medical professional may prescribe medications that can address some of the symptoms associated with dissociative disorders.
Although dissociative disorders are stubbornly resistant to treatment, many people find helpful ways to cope with their traumatic histories and discover ways to lead healthy and productive lives.