Dissociation and Dissociative Disorders

Hello everybody, I’m Mary, and I am the OG Woowoo Therapist.

As you know, the topics I talk about are things I learned both as a client in psychotherapy and as a therapist.

This is not intended to take the place of counseling or therapy but to highlight some of the issues that could or need to be addressed with a licensed counselor or therapist. And for some, it will be educational information to increase understanding of therapeutic issues. None of the information that I am going to talk about should be used to self-diagnose or diagnose others with mental health disorders. Only a licensed practitioner can do that through the process of differential diagnosis.

Today I am going to talk about dissociation and give a brief overview of dissociative disorders.

The core conceptual differences between PTSD/CPTSD and Dissociative Disorders are that PTSD and CPTSD are about a primary disturbance in threat processing and fear regulation and where trauma is remembered but experienced as intrusive and overwhelming.

Dissociative disorders are where there is a primary disturbance in integration of identity, memory, and consciousness and where trauma is compartmentalized, fragmented, or inaccessible.

Dissociative disorders are more common than most people think and are often misdiagnosed, DID is rare but real, media portrayals are often inaccurate, and dissociation is not malingering or attention-seeking as we often see portrayed on social media and people with dissociative disorders are suffering in their attempts to feel and appear “normal” in their lives.

Dissociative disorders are mental health conditions involving a disruption or disconnection in normal integration of these seven paradigms of personality and identity.

• Consciousness or the awareness of the mind of itself and the world

• Memory or the encoding of information that can be retrieved when needed

• Identity or the fact of being who a person is

• Emotion or a strong inner feeling about internal states and external things

• Perception or the awareness through physical sensation

• Body awareness or the internal sense of body parts

• Sense of self or how one sees themselves

Dissociation exists on a continuum from common, mild experiences like daydreaming or zoning out to more severe, chronic disorders like dissociative identity disorder.

Dissociation is an amazing protective survival response of the brain, it is not a sign of weakness. It mostly develops in response to overwhelming or inescapable stress, especially when escape or resistance is impossible. And it is strongly associated with chronic trauma, particularly early childhood trauma.

Here are the core dissociative disorders according to the DSM-5-TR starting with the most severe and disruptive.

1. Dissociative Identity Disorder or DID is at the far end of the continuum and is where there is the presence of two or more distinct identity states, there are gaps in memory inconsistent with ordinary forgetting, there is significant distress or impairment in living a “normal” life, and it is not due to use of substances or cultural practices.

DID is often linked to severe, repeated childhood trauma where pieces of the developing personality are chipped off in response to the trauma during a dissociative episode to protect the psyche. Identities may differ in emotions, behavior, perception, or sense of self and may even be so different that one may need glasses where others do not. Memory barriers exist where one part does not have access to the memories of the others and are extremely common between the identities and there is the experience of loss of time when there is a switch in personalities. This will be discussed further in a future blog.

2. Dissociative Amnesia and that is where the individual has the inability to recall important autobiographical information like not remembering 5th grade or other important events that took place in their life. Dissociative amnesia is usually trauma related. However, memory loss is reversible with the help of a trained therapist. We sometimes call this type of memory loss ego state dissociation or structural dissociation. These will be discussed further in a future blog.

There is a subtype of dissociative amnesia called dissociative fugue includes incorporating sudden travel with loss of identity awareness. This occurs very rarely.

3. Depersonalization/Derealization Disorder or DPDR is where there is the feeling of being detached from oneself like feeling unreal. Derealization is feeling detached from the world where the world feels unreal. Both can include the experience of feeling outside of the body. However, reality testing remains intact. A very mild example of derealization from my own life is that occasionally I will stop at a four way stop light and look around at all of the cars and say to myself, “Wow, I had no idea any of you existed until just this moment.” That is a very, very mild example of where the world, just for one minute, felt unreal. This is not problematic for me because I am able to bring myself back into the here and now instantly. This is not the case for folks diagnosed with these disorders. Their experience persists and impairs their functioning.

Depersonalization and derealization often co-occur with anxiety or panic disorders, they can be chronic or episodic, and the individual experience is internal, not psychotic or externally created.

There are common symptoms across the continuum of dissociative disorders, and these include memory gaps, feeling detached from thoughts, emotions or the body, an altered sense of identity, time distortion, emotional numbing, feeling unreal or disconnected from surroundings, and trance like states.

The relationship of dissociative disorders to trauma is strongly associated with chronic interpersonal trauma like childhood abuse or neglect, attachment trauma which I will discuss in a future podcast, and long-term domestic violence. Dissociation frequently coexists with PTSD or CPTSD. This is the case with 80% of my clients.

There are some clear distinctions between dissociation and psychosis which is often a misdiagnosis, especially for DID. Today many mental health professionals do not “believe” that the diagnosis of DID is real and they will treat the individual for psychosis related disorders like schizophrenia. The easiest way to clear a misdiagnosis is when asking if there are voices that are heard is to clarify if the voices are inside their mind or coming from outside. DID voices are internal and more conversational and psychosis voices are external and usually always persecutory.

These are the primary differences between dissociation and psychosis. With dissociation the individual is capable of insight and self-reflection. The experience is with internal detachment, hence the internal voices, and it is trauma linked.  Insight is impaired with psychosis and there is an inability to self-reflect during the episode. Psychosis distorts external reality and visual and auditory hallucinations are experienced. Psychosis is usually biologically driven because of something different with the brain.

Diagnosis for dissociative disorders requires careful clinical assessment. They are often underdiagnosed or misdiagnosed. The most common assessment tools are the Dissociative Experiences Scale or DES and the Multidimensional Inventory of Dissociation or MID. I used both in my practice and if the DES indicates a high degree of dissociation then I use the MID to assess for DID.

Before I use the MID I do a differential diagnosis based on the information and symptoms of my clients. This is the differential diagnosis decision tree to assess for PTSD, CPTSD, and dissociation.

STEP 1: I need to confirm trauma exposure by asking

Is there a history of traumatic exposure?

• ⬜ Yes → Proceed

• ⬜ No → Consider non-trauma-related diagnoses

STEP 2: I need to assess core PTSD symptoms by asking

Are the following present

Has it lasted for more than 1 month and is function impaired?

Are there

• Intrusions

• Avoidance

• Persistent threat/arousal

• ⬜ Yes → Proceed

• ⬜ No → Consider dissociative or other disorders

STEP 3: Next I need to assess pervasiveness vs fragmentation

Are symptoms continuous or state-dependent?

A. If they are continuous and pervasive

→ Proceed to Step 4A

B. If they are episodic, state-dependent, or discontinuous indicating fragmentation

→ Proceed to Step 4B

STEP 4A: Here I evaluate disturbances in self-organization as indicator for CPTSD

Assess:

• Affect dysregulation

• Chronic shame / negative self-concept

• Relational difficulties

• ⬜ PTSD symptoms only → PTSD

• ⬜ PTSD + DSO → CPTSD (ICD-11)

STEP 4B: Here I evaluate dissociative features

Assess for:

• Memory gaps beyond ordinary forgetting

• Depersonalization/derealization

• Time loss

• Identity confusion or identity states

• State-dependent skills, emotions, or beliefs

• ⬜ Present → Proceed to Step 5

• ⬜ Not present → PTSD with dissociative features

STEP 5: Next I need to identify dissociative pattern

Is there memory loss without identity fragmentation indicates dissociative amnesia.

Is there persistent depersonalization/derealization with insight indicates DP/DR Disorder.

Is there identity fragmentation + amnesia indicates dissociative identity disorder or DID.

STEP 6: Next I need to rule out alternatives

So we ask:

• Is reality testing intact? (rules out psychosis)

• Are symptoms trauma-linked? (rules out primary personality pathology like borderline personality disorder)

• Are mood or anxiety symptoms secondary?

STEP 7: Here I identify treatment implications (Assessment-Informed)

For PTSD → Trauma-focused therapy is often appropriate early in treatment.

For CPTSD → Phased, attachment-informed treatment is necessary

For Dissociative disorders → Stabilization has to happen first; trauma processing delayed until they are stable in function

Now, let’s talk about treatment. Dissociative disorders are treatable, but treatment is typically longer-term and phase-based.

These are the common treatment principles

1.     Stabilization and safety is where we focus on

o    Grounding

o    Emotion regulation

o    Reducing dissociation

2.     Trauma processing is where we focus on

o    Gradual, titrated trauma work

o    Avoid flooding

3.     Integration is where we focus on

o    Increased coherence of identity and memory

o    Improved daily functioning

This is an important thing to note:
Many times folks come into therapy wanting to feel better fast. And sometimes that is possible with PTSD. But with CPTSD and dissociative disorders premature trauma processing can worsen symptoms.

Here are some vignettes to demonstrate the differential diagnosis process for PTSD, CPTSD and Dissociative Disorders

Case 1: PTSD (Single-Incident Trauma)

Questions to determine trauma and symptoms

• “Can you walk me through what you remember about the accident?”

• “What happens in your body when you’re reminded of it?”

• “Are there specific triggers that bring symptoms on?”

Questions to determine time course & pervasiveness

• “Do these symptoms come and go, or are they present most of the time?”

• “How do you feel about yourself and your relationships outside of those moments?”

The differential focus

• “Have you noticed gaps in memory or times you can’t account for?”

• “Do you ever feel disconnected from yourself or the world?”

The goal is to confirm trigger-based symptoms, intact identity, and absence of dissociative amnesia.

Case 2: CPTSD (Chronic Interpersonal Trauma)

Questions to determine trauma history

• “How long did these experiences last?”

• “At what age did they begin?”

• “Was there anyone you could turn to for safety at the time?”

Questions looking for affect regulation

• “What happens emotionally when you feel overwhelmed?”

• “How long does it take to calm down once you’re upset?”

Questions to evaluate self-concept

• “How would you describe yourself as a person?”

• “What beliefs do you hold about yourself when things go wrong?”

Questions to assess relational patterns

• “How do relationships tend to feel for you over time?”

• “What happens when someone gets emotionally close?”

The differential focus

• “Do these difficulties feel present even when you’re not reminded of the trauma?”

The goal is to identify disturbances in self-organization that are persistent and global, not episodic.

Case 3: PTSD With Dissociative Features

Questions to assess for PTSD core symptoms

• “What memories or images intrude when symptoms are strongest?”

• “What do you avoid because it brings those memories up?”

Questions for dissociation Screening

• “Do you ever feel numb, far away, or detached during stress?”

• “Does that feeling pass once the stress decreases?”

Questions to determine continuity of experience

• “Do you ever lose time or find things you don’t remember doing?”

• “Do others notice sudden changes in you?”

The goal is to differentiate situational dissociation from structural dissociation.

Case 4: Dissociative Amnesia

Questions for memory assessment

• “Are there specific periods of your life that feel blank or inaccessible?”

• “What happens when you try to remember that time?”

Questions for context & triggers

• “Did the memory loss begin after something stressful or traumatic?”

• “Do memories return spontaneously or in certain settings?”

Rule-Out Questions

• “Have you ever had head injuries, seizures, or substance use during that time?”

• “How do you feel emotionally when you notice the gaps?”

Questions to assess identity & functioning

• “Do you feel like the same person now as before?”

• “Do others notice changes in how you act?”

The goal is to confirm trauma-linked amnesia without identity fragmentation.

Case 5: Depersonalization / Derealization Disorder

Questions to assess phenomenology

• “When you say you feel unreal, what does that experience feel like?”

• “Does it affect your sense of who you are, or more how you feel?”

Questions to assess insight & reality testing

• “Do you believe this experience is happening inside you or imposed from outside?”

• “Do you ever worry you’re losing touch with reality?”

Questions to assess anxiety link

• “What tends to make these sensations worse or better?”

• “Did they begin during a period of intense anxiety or panic?”

Trauma Assessment

• “Have you experienced overwhelming or ongoing stress in your life?”

• “Do memories intrude, or is it more a constant state?”

The goal is to distinguish persistent depersonalization/derealization from trauma intrusions or psychosis.

Case 6: Dissociative Identity Disorder

Questions to assess for amnesia & time loss

• “Do you ever lose time or find evidence of things you don’t remember doing?”

• “How often does that happen?”

Questions to assess identity experience

• “Do different parts of you feel very different from one another?”

• “Do these parts have their own feelings, memories, or roles?”

Questions to asses external feedback

• “Have others commented on changes in your voice, posture, or behavior?”

• “How do you feel when that happens?”

Questions to assess for trauma history

• “What was your childhood environment like over time?”

• “Were there periods where you felt you had to escape mentally?”

Questions to assess safety & stabilization

• “How do these experiences affect your day-to-day functioning?”

• “What helps you feel grounded or present?”

The goal is to identify identity discontinuity + amnesia + state-dependent functioning.

Case 7: Psychosis (Contrast Case)

Questions to assess reality testing

• “How certain are you that others are inserting thoughts into your mind?”

• “Is there any possibility another explanation could exist?”

Questions to assess trauma link

• “Did these beliefs begin after a traumatic experience?”

• “Do they change when stress changes?”

Questions to assess insight & flexibility

• “What do others say about these experiences?”

• “How do you respond when they disagree?”

Questions to assess functional impact

• “How are these experiences affecting work, relationships, or daily life?”

The goal is to differentiate fixed delusions and impaired insight from dissociation.

Some of the key takeaways I hope you got out of today’s podcast are that dissociation is a neurobiological adaptation to ongoing trauma, it protects the person when escape is impossible, it reflects fragmentation, not fabrication, and trauma-informed assessment and pacing of treatment are essential.

Well, that is it for today. I hope you found this information helpful in increasing your understanding of dissociation and dissociative disorders. I will discuss the main types of dissociative disorders that I work with in my next podcast. Thank you for listening. Talk to you next week.