Dissociative disorders occur when people have episodes during which they do not experience reality directly. Dissociative disorders may occur suddenly or gradually, and may be temporary or chronic.

Dissociation is a phenomenon that occurs occasionally in most people. For example, people may "lose themselves" in a good book or find themselves daydreaming so intently that they miss everything going on around them. However, in some cases people experience dissociation as a means of escaping reality when stress or trauma becomes too great to bear. This process is involuntary and is believed to be a coping mechanism of the mind. It is only when it becomes so frequent and so disruptive that it interferes in someone's ability to live and to work that it becomes a disorder. Dissociative disorders occur in about 7 percent of people at some point in their lives, according to the National Mental Health Association.

The four main types of dissociative disorders include dissociative amnesia, dissociative fugue, dissociative identity disorder and depersonalization disorder. Before diagnosing these disorders, a physician will perform a physical examination and review the patient's medical history to rule out other potential causes for symptoms (e.g., head injuries, sleep deprivation). Various tests may also be performed.

If a physician suspects a dissociative disorder, the patient may be referred to a psychiatrist, psychologist or other mental health professional for further evaluation and treatment. Different types of psychotherapy are used in the treatment of dissociative disorders. It is essential that safety is established and that appropriate skills are taught to the patient before any direct exploration of any potentially traumatic events is approached. Many patients are never able to deal directly with traumatic events, but therapy can help them to be safe and live well with their illness.

Although some dissociative disorders cannot be prevented, any serious symptoms of dissociation, especially in the face of a history of any form of abuse or traumatic experience (e.g., combat, natural disaster) should be treated promptly.

Dissociative disorders are diagnosed when people habitually and involuntarily escape reality in a way that disrupts their ability to live and work. They occur when a group of normal mental processes becomes separated or dissociated from other mental processes. In this condition, a patient loses conscious control over certain thoughts, feelings and behaviors.

Some aspects of dissociation are a normal part of the human mind. For instance, people may become engrossed in their thoughts while driving and miss a highway exit. The National Mental Health Association (NMHA) reports that up to one-third of the population occasionally feels like they are "watching themselves in a movie." However, continued and repeated incidences of dissociation that interfere with life may be part of a disorder. Such dissociative disorders occur in about 7 percent of people at some point in their lives, according to the NMHA. Most are associated with people who have experienced serious trauma, such as abuse, combat or natural disaster.

There are many different dissociative disorders. They have certain features in common. For example, they tend to begin and end suddenly (although some occur gradually) and often are triggered by psychological conflicts or an absolute inability to tolerate feelings that occur in situations that in some way remind them of past trauma. Most are uncommon and involve significant disturbance of memory. The condition itself may be fleeting, or it may be chronic.

The four major types of dissociative disorders are:

• Dissociative amnesia. Inability to remember important information, especially of a personal nature surrounding significant trauma or stress. Examples include blocking out memories related to episodes of self-mutilation, violent outbursts or suicide attempts. Varieties of dissociative amnesia include:
  
  
• • Localized amnesia. Inability to remember events from a certain time frame.
    
    
  • Selective amnesia. When a patient remembers only select events from a certain time frame.
    
    
  • Generalized amnesia. Inability to recall events over a lifetime.
    
    
  • Continuous amnesia. When a patient cannot recall events from a certain time up to the present.
    
    
• Dissociative fugue. Condition in which patients suddenly leave their surroundings and begin a journey of some type or another that can last from hours to months. Journeys can cover thousands of miles. During this time, patients fail to remember some or all of their past. Patients with dissociative fugue often experience confusion about personal identity and may take on a whole new identity. Although this is rare, it can be dramatic, with patients starting entirely new lives and acting more gregarious and uninhibited than in their previous lives. Traumatic or overwhelming events may trigger dissociative fugue. Patients who are in a state of dissociative fugue appear normal and healthy to outsiders and do not attract attention. Recovery is usually rapid and sudden. People who eventually return to the prefugue state may have no memory of the events that occurred when they had dissociative fugue.
  
  

• Dissociative identity disorder (formerly known as multiple personality disorder). Condition in which two or more distinct identities take control of a patient's behavioral patterns. It is the result of a failure to integrate identity, memory and consciousness. Patients and therapists may identify large numbers of alternate identities (alters), but it is seldom clear which are the result of trauma and which may be created in response to inappropriate therapies. Just one personality (alter) controls a patient's behavior at any given time, and the various alters may have their own personal history, self-image and identity. Despite their apparent differences, alters should always be considered varied aspects of the patient's whole.
  
  Patients with dissociative identity disorder have an inability to recall important personal information, with some alters having less complete memories and other alters recalling more. Psychosocial stress often triggers the transition from one identity to another, although in many cases transition can occur in a wide variety of circumstances, including during relaxation or sleep. In most cases, these changes take just seconds, although the transition can be more gradual.
  
  
• Depersonalization disorder. Condition in which patients experience recurrent episodes of detachment from themselves and tend to experiencing themselves as observing their own behavior from an outside perspective. In other cases, patients may feel detached from control of their bodies and speech patterns. Patients are aware of this sense of detachment. Depersonalization is fairly commonplace, and a disorder is not typically diagnosed unless symptoms cause substantial distress or impair the patient's ability to function. Depersonalization disorder does not involve loss of memory.

Some dissociative disorders are classified as a "dissociative disorder not otherwise specified." These are conditions in which a patient has symptoms of at least one of the above conditions, but not enough symptoms to be diagnosed with any one of these conditions. Examples include dissociation caused by coercion such as brainwashing or among people held as hostages.

Childhood trauma including severe physical, sexual or emotional abuse is believed to be the chief trigger of dissociative disorders. Other stressors that can trigger these conditions include traumatic events such as combat, natural disasters, kidnapping, torture, head injury and invasive medical procedures.

Children experiencing severe trauma may develop dissociative disorders as a means of coping. Children under the age of 4 have a greater ability than adults to step outside themselves and observe trauma in a third-person fashion. Children who dissociate in this way as a means of coping may continue to use the practice as adults whenever they are confronted with highly stressful situations.

Although many dissociative disorders are not diagnosed until adulthood, instances in which a person develops dissociative disorder as an adult are rare. The exceptions to this rule are dissociative fugue, and dissociative amnesia due to head trauma, most cases of which originate in adults.

Dissociative disorders are more often diagnosed in women than in men. Clinicians with experience diagnosing and treating dissociative disorders believe that they are frequently misdiagnosed as other psychiatric disorders. The average patient with a severe dissociative disorder has been treated in the psychiatric system for about eight years before the diagnosis is identified.

The signs and symptoms associated with dissociative disorders vary depending on the type of disorder. However, some symptoms are evident in virtually all types of dissociative disorders. They include:

• Loss of memory (amnesia) of certain time periods, events and people
  
  
• Symptoms such as depression and anxiety
  
  
• The feeling of being detached from oneself (depersonalization)
  
  
• The perception that people and things are unreal or distorted (derealization)
  
  
• Undefined sense of identity

The symptoms of dissociative disorders may disappear and recur.

Other symptoms of dissociation may include:

• Behaviors that are not remembered
• Fugues (states in which a person functions but cannot later recall)
• Unexplained possessions
• Inexplicable changes in relationships
• Fluctuations in skills and knowledge
• Fragmentary recall of life history
• Spontaneous trances
• Spontaneous age regression
• Out-of-body experiences
• Awareness of other parts of self

In addition, patients with dissociative disorders are at increased risk for self-destructive behavior such as self-mutilation (for example, cutting or burning themselves) and suicide attempts. Some patients may develop substance abuse problems. Mental illnesses, such as depression, anxiety disorders and eating disorders, are also commonly associated with dissociative disorders.

People with dissociative disorders often struggle to maintain healthy personal and professional relationships because they tend to “tune out” or disappear when stressful situations arise.

Symptoms of dissociative disorders can be present in other mental disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and panic disorder.

Patients should consult a physician if they experience significant and unexplained memory loss. Sudden changes in behavior in the face of stress also may warrant a visit to a healthcare professional. Finally, a chronic feeling that the world is somehow "unreal" may indicate the presence of a dissociative disorder that requires treatment.

Early intervention can be an important factor in the eventual success of treating dissociative disorders. For this reason, individuals should seek medical attention and counseling after abuse or other significant trauma. Parents or caregivers should seek intervention for any child that has suffered physical or emotional trauma.

Before diagnosing a dissociative disorder, a physician will review the patient's medical history and should perform a physical examination and blood tests. These steps will be used to rule out other potential sources of symptoms, such as head injuries, brain diseases, sleep deprivation, substance abuse or intoxication.

If a physician suspects a dissociative disorder, the patient may be referred to a psychiatrist, psychologist or other mental health professional for further evaluation and treatment. During the interview, mental health professionals will ask questions about significant childhood and adult trauma, and check for symptoms of dissociative experiences.

Techniques such as hypnosis to help identify alternate personalities or repressed memories associated with dissociative disorders should be considered only in consultation with the patient after safety has been established and skills to deal with traumatic memories have been taught to the patient.

In attempting to diagnose a dissociative disorder, a physician may ask questions of patients, such as:

• Do they have problems remembering things?
  
  
• Have they ever found themselves traveling away from home unexpectedly?
  
  
• Do they ever feel as if someone else is controlling their behavior?
  
  
• Do they ever feel detached from themselves or their surroundings?

All dissociative disorders have their own diagnostic criteria as defined by the American Psychiatric Association. There are criteria for each of the four major dissociative disorders.

Dissociative amnesia:

• Predominant disturbance involves one or more episodes of inability to recall personal information, typically of a traumatic or stressful nature. The memory lapse must be too extensive to be attributed to normal forgetfulness.
  
  
• Episodes do not occur exclusively during dissociative identity disorder, dissociative fugue, post-traumatic stress disorder, acute stress disorder or somatization disorder.
  
  
• Symptoms cause significant distress or impairment in social, occupation or other areas of functioning.

Dissociative fugue:

• Predominant disturbance is sudden unexpected travel away from home or place of work accompanied by inability to remember the past.
  
  
• Patient has confusion about personal identity or assumes a new identity.
  
  
• Episodes do not occur exclusively during dissociative identity disorder.
  
  
• Symptoms cause significant distress or impairment in social, occupation or other areas of functioning.

Dissociative identity disorder:

• Marked by the presence of two or more distinct personalities, each of which has its own pattern of perceiving, relating to or thinking about the environment or self.
  
  
• At least two identities recurrently take control of a patient's behavior.
  
  
• Inability to recall personal information is too extensive to be attributed to normal forgetfulness.

Depersonalization disorder:

• Marked by persistent or recurrent feelings of being detached from one's mental processes or body.
  
  
• During feelings of depersonalization, reality testing remains intact, meaning the patient is aware that the depersonalization is just a feeling.
  
  
• Depersonalization causes significant distress or impairment of social, occupational or other areas of functioning.
  
  
• Depersonalization does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder or another dissociative disorder.

In addition, none of these disorders can be due to another general medical condition or the direct physiological effects of a substance.

Symptoms of dissociation are also included in the diagnostic criteria of several other mental disorders. Thus, patients whose symptoms do not meet the criteria for the four major dissociative disorders may still be diagnosed with another mental disorder, such as acute stress disorder, post-traumatic stress disorder or somatization disorder. Patients whose dissociative symptoms appear exclusively during the course of these disorders will not be diagnosed with a dissociative disorder.

In addition, dissociative disorders are not diagnosed in people whose dissociative symptoms are related to accepted cultural or religious activities in their society. In such cases, no disorder is considered present unless it leads to significant distress or impairment. Dissociative disorders can be extremely difficult to diagnose. Research indicates that patients receive mental health treatment for up to eight years before they receive a diagnosis of a dissociative disorder.

There are no medications that effectively treat dissociative disorders directly. However, some medications are known to help some patients with troublesome symptoms or co-occurring psychiatric illnesses. Such drugs include antidepressants, mood stabilizers and antipsychotic agents. Short-term use of anti-anxiety agents is sometimes needed, but long-term use should be avoided.

Very specific psychotherapeutic techniques work extremely well in treating dissociative disorders. The therapeutic relationship between the patient and therapist is at least as important as using the appropriate therapy. Initial sessions should be used to develop that relationship and ensure the patient is safe. The therapeutic relationship is not a friendship or personal relationship that extends outside of therapy. It is a working relationship that lasts only as long as therapy is needed.

When safety is established, the work turns to teaching the patient skills to include how to stay in reality (grounding skills) and how to tolerate negative affect while staying in reality. Some patients are able to progress beyond this point quickly, but for most staying safe and learning these skills takes a very long time, and therapy can move forward only when safety is ensured.

Once a patient is safe and has the skills to remain in reality and experience negative feelings without losing safety, it is possible to work more directly on the symptoms and their causes. Patients should never be "required" to remember trauma unless they are prepared and willing to take that approach to therapy. For many, learning to control and/or avoid symptoms allows them to live a full and productive life despite some continuing dissociation. It is not necessary to "cure" the dissociation to have a successful therapeutic outcome.

For patients with dissociative disorders, it is frequently not indicated to refer them to therapy groups, to structured cognitive behavioral therapy (unless it is modified specifically to avoid affective experiences they cannot tolerate) or to suggest support groups that are not specific and appropriate to their clinical condition.

Although it may not be possible to prevent the development of dissociative disorders, any form of abuse or traumatic experience (e.g., combat, natural disaster) should result in an evaluation to address any unusual reactions.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about dissociative disorders:

1. Why do you suspect I may have a dissociative disorder?
2. Does my family or medical history place me at risk for a dissociative disorder?
3. How can you be sure I have this disorder and not some other condition?
4. What tests will be performed to rule out other conditions and diagnose me?
5. What type of disorder do I have?
6. What do you suspect caused my dissociative disorder?
7. What symptoms are associated with my type of disorder?
8. Am I at risk of hurting myself or others?
9. Will this disorder come and go or remain constant?
10. What are my treatment options?
11. Will I have this disorder my whole life?
12. Which other conditions are associated with dissociative disorders?
13. Are my children at greater risk for developing this disorder?