DISSOCIATIVE DISORDER

• DEFINITION:
  

We all get lost in a good book or movie. But someone with dissociative disorder escapes reality in ways that are involuntary and unhealthy. The symptoms of dissociative disorders — ranging from amnesia to alternate identities — usually develop as a reaction to trauma and help keep difficult memories at bay.

Treatment for dissociative disorders may include psychotherapy, hypnosis and medication. Although treating dissociative disorders can be difficult, many people with dissociative disorders are able to learn new ways of coping and lead healthy, productive lives.

• SYMPTOM
  

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. Sudden-onset 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.

• CAUSES
  

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.

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.

• COMPLICATION
  

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.

• DIAGNOSIS
  

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.

• TREATMENT
  

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 self-awareness, 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.