What is dissociation?
Dissociation is a word that is used to describe the
disconnection or lack of connection between things
usually associated with each other. Dissociated experiences
are not integrated into the usual sense of self, resulting
in discontinuities in conscious awareness (Anderson & Alexander,
1996; Frey, 2001; International Society for the Study
of Dissociation, 2002; Maldonado, Butler, & Spiegel,
2002; Pascuzzi & Weber, 1997; Rauschenberger & Lynn,
1995; Simeon et al., 2001; Spiegel & Cardeña, 1991;
Steinberg et al., 1990, 1993). In severe forms of dissociation,
disconnection occurs in the usually integrated functions
of consciousness, memory, identity, or perception.
For example, someone may think about an event that
was tremendously upsetting yet have no feelings about
it. Clinically, this is termed emotional numbing, one
of the hallmarks of post-traumatic stress disorder.
Dissociation is a psychological process commonly found
in persons seeking mental health treatment (Maldonado
et al., 2002).
Dissociation may affect a person subjectively in the
form of “made” thoughts, feelings, and
actions. These are thoughts or emotions seemingly coming
out of nowhere, or finding oneself carrying out an
action as if it were controlled by a force other than
oneself (Dell, 2001). Typically, a person feels “taken
over” by an emotion that does not seem to makes
sense at the time. Feeling suddenly, unbearably sad,
without an apparent reason, and then having the sadness
leave in much the same manner as it came, is an example.
Or someone may find himself or herself doing something
that they would not normally do but unable to stop
themselves, almost as if they are being compelled to
do it. This is sometimes described as the experience
of being a “passenger” in one’s body,
rather than the driver.
There are five main ways in which the dissociation
of psychological processes changes the way a person
experiences living: depersonalization, derealization,
amnesia, identity confusion, and identity alteration.
These are the main areas of investigation in the Structured
Clinical Interview for Dissociative Disorders (SCID-D)
(Steinberg, 1994a; Steinberg, Rounsaville, & Cicchetti,
1990). A dissociative disorder is suggested by the
robust presence of any of the five features.
What is depersonalization?
Depersonalization is the sense of being detached from,
or “not in” one’s body. This is what
is often referred to as an “out-of-body” experience.
However, some people report rather profound alienation
from their bodies, a sense that they do not recognize
themselves in the mirror, recognize their face, or
simply feel not “connected” to their bodies
in ways which are challenging to articulate (Frey,
2001; Guralnik, Schmeidler, & Simeon, 2000; Maldonado
et al., 2002; Simeon et al., 2001; Spiegel & Cardeña;
What is derealization?
Derealization is the sense of the world not being
real. Some people say the world looks phony, foggy,
far away, or as if seen through a veil. Some people
describe seeing the world as if they are detached,
or as if they were watching a movie (Steinberg, 1995).
What is dissociative amnesia?
Amnesia refers to the inability to recall important
personal information that is so extensive that it is
not due to ordinary forgetfulness. Most of the amnesias
typical of dissociative disorders are not of the classic
fugue variety, where people travel long distances,
and suddenly become alert, disoriented as to where
they are and how they got there. Rather, the amnesias
are often an important event that is forgotten, such
as abuse, a troubling incident, or a block of time, from minutes to years. More typically,
there are micro-amnesias where the discussion engaged
in is not remembered, or the content of a conversation
is forgotten from one moment to the next. Some people
report that these kinds of experiences often leave
them scrambling to figure out what was being discussed.
Meanwhile, they try not to let the person with whom
they are talking realize they haven’t a clue
as to what was just said (Maldonado et al., 2002; Steinberg
et al., 1993; Steinberg, 1995)
What are identity confusion and identity alteration?
Identity confusion is a sense of confusion about who
a person is. An example of identity confusion is when
a person sometimes feels a thrill while engaged in
an activity (e.g., reckless driving, drug use) which
at other times would be repugnant. Identity alteration
is the sense of being markedly different from another
part of oneself. This can be unnerving to clinicians.
A person may shift into an alternate personality, become
confused, and demand of the clinician, “Who the
dickens are you, and what am I doing here?” In
addition to these observable changes, the person may
experience distortions in time, place, and situation.
For example, in the course of an initial discovery
of the experience of identity alteration, a person
might incorrectly believe they were five years old,
in their childhood home and not the therapist’s
office, and expecting a deceased person whom they fear
to appear at any moment (e.g., Fine, 1999; Maldonado
et al., 2002; Spiegel & Cardeña, 1991; Steinberg,
More frequently, subtler forms of identity alteration
can be observed when a person uses different voice
tones, range of language, or facial expressions. These
may be associated with a change in the patient’s
world view. For example, during a discussion about
fear, a client may initially feel young, vulnerable,
and frightened, followed by a sudden shift to feeling
hostile and callous. The person may express confusion
about their feelings and perceptions, or may have difficulty
remembering what they have just said, even though they
do not claim to be a different person or have a different
name. The patient may be able to confirm the experience
of identity alteration, but often the part of the self
that presents for therapy is not aware of the existence
of dissociated self-states. If identity alteration
is suspected, it may be confirmed by observation of
amnesia for behavior and distinct changes in affect,
speech patterns, demeanor and body language, and relationship
to the therapist. The therapist can gently help the
patient become aware of these changes (e.g., Fine,
1999; Maldonado et al., 2002; Spiegel & Cardeña,
1991; Steinberg, 1995).
What is the cause of
dissociation and dissociative disorders?
Research tends to show that dissociation stems from
a combination of environmental and biological factors.
The likelihood that a tendency to dissociate is inherited
genetically is estimated to be zero (Simeon et al.,
Most commonly, repetitive childhood physical and/or
sexual abuse and other forms of trauma are associated
with the development of dissociative disorders (e.g.,
Putnam, 1985). In the context of chronic, severe childhood
trauma, dissociation can be considered adaptive because
it reduces the overwhelming distress created by trauma.
However, if dissociation continues to be used in adulthood,
when the original danger no longer exists, it can be
maladaptive. The dissociative adult may automatically
disconnect from situations that are perceived as dangerous
or threatening, without taking time to determine whether
there is any real danger. This leaves the person “spaced
out” in many situations in ordinary life, and
unable to protect themselves in conditions of real
Dissociation may also occur when there has been severe
neglect or emotional abuse, even when there has been
no overt physical or sexual abuse (Anderson & Alexander,
1996; West, Adam, Spreng, & Rose, 2001). Children
may also become dissociative in families in which the
parents are frightening, unpredictable, are dissociative
themselves, or make highly contradictory communications
(Blizard, 2001; Liotti, 1992, 1999a, b).
The development of dissociative disorders in adulthood
appears to be related to the intensity of dissociation
during the actual traumatic event(s); severe dissociation
during the traumatic experience increases the likelihood
of generalization of such mechanisms following the
event(s). The experience of ongoing trauma in childhood
significantly increases the likelihood of developing
dissociative disorders in adulthood (International
Society for the Study of Dissociation, 2002;
Kisiel & Lyons,
2001; Martinez-Taboas & Guillermo, 2000; Nash,
Hulsey, Sexton, Harralson & Lambert, 1993; Siegel,
2003; Simeon et al., 2001; Simeon, Guralnik, & Schmeidler,
2001; Spiegel & Cardeña, 1991).
How does affect dysregulation influence dissociation?
One of the core problems for the person with a dissociative
disorder is affect dysregulation, or difficulty tolerating
and regulating intense emotional experiences. This
problem results in part from having had little opportunity
to learn to soothe oneself or modulate feelings, due
to growing up in an abusive or neglectful family, where
parents did not teach these skills. Problems in affect
regulation are compounded by the sudden intrusion of
traumatic memories and the overwhelming emotions accompanying
them (Metcalfe & Jacobs, 1996; Rauch, van der Kolk,
Fisler, Alpert, Orr et al., 1996).
The inability to manage intense feelings may trigger
a change in self-state from one prevailing mood to
another. Depersonalization, derealization, amnesia
and identity confusion can all be thought of as efforts
at self-regulation when affect regulation fails. Each
psychological adaptation changes the ability of the
person to tolerate a particular emotion, such as feeling
threatened. As a last alternative for an overwhelmed
mind to escape from fear when there is no escape, a
person may unconsciously adapt by believing, incorrectly,
that they are somebody else. Becoming aware of this
kind of fear is terrifying. Therein lies one of the
central problems in treatment for a person with a dissociative
disorder: “How do I learn to approach things
I fear when to understand that I am afraid is itself
frightening?” Skillful clinical approaches are
required to help build confidence in a person’s
ability to tolerate their feelings, learn, and grow
as a person.
How is dissociation different from hypnosis?
Dissociative experiences are often confused with those
of hypnosis. While the two experiences may exist together,
they are not the same. For example, hypnotic absorption
may be present in someone who is experiencing identity
alteration, but it is not equivalent. To be hypnotically
absorbed is to lose track of the background events
and be completely absorbed by the foreground (e.g.,
highway hypnosis, where a person drives by the exit
they had taken many times, only to discover they had
missed the exit and are further down the road). A person
capable of hypnotic absorption may be absorbed in their
thoughts while maintaining control of their body (and
their driving), but what they are doing is not in their
awareness. Thus there is a disconnection between mind
(conscious awareness) and body. This disconnection
in hypnotic absorption is an example of a dissociative
process, but the absorption itself is not indicative
of a dissociative disorder. Rather, absorption is an
example of everyday hypnotic experience and is part
of the continuum of the dissociation of psychological
functions that can be seen during hypnosis.
What are the different types of dissociative
There are four main categories of dissociative disorders
as defined in the standard catalogue of psychological
diagnoses used by mental health professionals in North
America, the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
The four dissociative disorders are: Dissociative Amnesia,
Dissociative Fugue, Dissociative Identity Disorder,
and Depersonalization Disorder (American Psychiatric
Association, 2000; Frey, 2001; Spiegel & Cardeña,
Dissociative Amnesia (Psychogenic
Amnesia) is characterized
by an inability to recall important personal information,
usually of a traumatic or stressful nature, that is
too extensive to be explained by ordinary forgetfulness.
The amnesia must be too extensive to be characterized
as typical forgetfulness and cannot be due to an organic
disorder or DID. It is the most common of all dissociative
disorders, frequently seen in hospital emergency rooms
(Maldonado et al., 2002; Steinberg et al., 1993). In
addition, Dissociative Amnesia is often embedded within
other psychological disorders (e.g., anxiety disorders,
other dissociative disorders). Individuals suffering
from Dissociative Amnesia are generally aware of their
memory loss. The memory loss is usually reversible
because the memory difficulties are in the retrieval
process, not the encoding process. Duration of disorder
varies from a few days to a few years (American Psychiatric
Association, 2000; Frey, 2001; Maldonado et al., 2002;
Spiegel & Cardeña, 1991; Steinberg et al., 1993).
Dissociative Fugue (Psychogenic
Fugue) is characterized
by a sudden, unexpected travel away from home or one’s
customary place of work, accompanied by an inability
to recall one’s past and confusion about personal
identity or the assumption of a new identity. Individual’s
suffering from Dissociative Fugue appear “normal” to
others. That is their psychopathology is not obvious.
They are generally unaware of their memory loss/amnesia
(American Psychiatric Association, 2000; Frey, 2001;
Maldonado et al., 2002; Spiegel & Cardeña, 1991;
Steinberg et al., 1993).
Depersonalization Disorder is characterized by a persistent
or recurrent feeling of being detached from one’s
own mental processes or body. Individuals suffering
from Depersonalization Disorder relate feeling as if
they are watching their lives from outside of their
bodies, similar to watching a movie (American Psychiatric
Association, 2000; Frey, 2001; Guralnik, Schmeidler, & Simeon,
2000; Maldonado et al., 2002; Simeon et al., 2001;
Spiegel & Cardeña, 1991). Individuals with Depersonalization
Disorder often report problems with concentration,
memory and perception (Guralnik et al., 2001). The
depersonalization must occur independently of DID,
substance abuse disorders and Schizophrenia (Steinberg
et al., 1993).
Dissociative Identity Disorder (previously known as
Multiple Personality Disorder) is the most severe and
chronic manifestation of dissociation, characterized
by the presence of two or more distinct identities
or personality states that recurrently take control
of the individual’s behavior, accompanied by
an inability to recall important personal information
that is too extensive to be explained by ordinary forgetfulness.
It is now recognized that these dissociated states
are not fully-formed personalities, but rather represent
a fragmented sense of identity. The amnesia typically
associated with Dissociative Identity Disorder is asymmetrical,
with different identity states remembering different
aspects of autobiographical information. There is usually
a host personality who identifies with the client’s
real name. Typically, the host personality is not aware
of the presence of other alters (American Psychiatric
Association, 2000; Fine, 1999; Frey, 2001; Kluft, 1999;
Kluft, Steinberg & Spitzer, 1988; Maldonado et
al., 2002; Spiegel & Cardeña, 1991; Steinberg et
al., 1993). The different personalities may serve distinct
roles in coping with problem areas. An average of 2
to 4 personalities/alters are present at diagnosis,
with an average of 13 to 15 personalities emerging
over the course of treatment (Coons, Bowman & Milstein,
1988; Maldonado et al., 2002). Environmental events
usually trigger a sudden shifting from one personality
to another (Maldonado et al., 2002).
Dissociative Disorder Not Otherwise
DDNOS includes dissociative presentations that do not
meet the full criteria for any other dissociative disorder
(American Psychiatric Association, 2000; Steinberg
et al., 1993). In clinical practice, this appears to
be the most commonly presented dissociative disorder,
and may often be better characterized by Major Dissociative
Disorder with partially dissociated self states (Dell,
What is the prevalence of dissociative disorders?
Some studies indicate that dissociation
occurs in approximately two to three percent of the
general population. Other studies have estimated a
prevalence rate of 10% for all dissociative disorders
in the general population (e.g., Loewenstein, 1994).
Dissociation may exist in either acute or chronic forms.
Immediately following severe trauma, the incidence
of dissociative phenomena is remarkably high. Approximately
73% of individuals exposed to a traumatic incident
will experience dissociative states during the incident
or in the hours, days and weeks following.. However,
for most people these dissociative experiences will
subside on their own within a few weeks after the traumatic
incident subsides (International Society for the Study
of Dissociation, 2002; Martinez-Toboas & Guillermo,
2000; Saxe, van der Kolk, Berkowitz, Chinman, Hall,
Lieberg & Schwartz, 1993).
Some prevalence rates have been calculated individually
for the four types of dissociative disorders:
Dissociative Amnesia: No exact prevalence rates have
been empirically demonstrated for Dissociative Amnesia
(Maldonado et al., 2002; Putnam, 1985).
Dissociative Fugue: Prevalence rate of 0.2% in the
general population (American Psychiatric Association,
2000; Maldonado et al., 2002). The prevalence is thought
to be higher during periods of extreme stress (Maldonado
et al., 2002).
Dissociative Identity Disorder: Prevalence rates of
.01 (Coons, 1984) to 1% in the general population.
Studies have indicated a prevalence rate of .5 to 1.0%
in psychiatric settings (Maldonado et al., 2002).
Depersonalization Disorder: Exact prevalence is unknown
(Maldonado et al., 2002). Some researchers have suggested
that Depersonalization Disorder is the third most common
psychological disorder following depression and anxiety
(Guralnik et al., 2001).
Treatment Specific to Type of Dissociative
For more general treatment guidelines please refer
to the Treatment Guidelines of the International Society
for the Study of Trauma and Dissociation, available
1. Dissociative Amnesia: No empirical
studies have assessed the treatment of dissociative
amnesia. Current information is based upon case studies
and will be discussed briefly. Prior to beginning treatment,
it is essential to determine that the amnesia is dissociative
in origin. That is, neurological and/or medical causes
must be ruled out. Clients with acute onset are typically
treated more aggressively than clients presenting with
chronic amnesia (Maldonado et al., 2002).
Acute amnesia. In clients with acute presentation of amnesia it is first
necessary to provide a safe therapeutic environment (Maldonado et al.,
2002). In fact, researchers have demonstrated that sometimes simply removing
threatening stimuli and providing an individual with a safe environment
has enabled spontaneous retrieval of memory (e.g., Kennedy & Neville,
1957). Barbiturates can be used to pharmacologically facilitate the interviewing
process. Most commonly used are sodium amobarbital and sodium pentobarbital.
No studies have empirically investigated the effectiveness of hypnosis
in treating Dissociative Amnesia. However, hypnosis has been used successfully
in the recovery of dissociated and repressed memories (Maldonado et al.,
2002). Once the amnesia has been reversed it is important to explore and
identify events that triggered the Dissociative Amnesia. The therapist
should reinforce the use of effective coping mechanisms and the clients’ failure
to use dissociation as their primary coping strategy (Maldonado et al.,
Chronic amnesia. Pharmacologically facilitated intervention
is not recommended. Hypnosis may be beneficial in recovering
and working through traumatic memories at a pace comfortable
for the client. Reframing of the traumatic experiences
can occur during the hypnotic process. The goal of
therapy is the integration of dissociated material.
Treatment of chronic Dissociative Amnesia is typically
long-term (Maldonado et al., 2002).
2. Dissociative Fugue: To date, there
are no empirical studies that have addressed the treatment
of Dissociative Fugue. All current information is derived
from case studies and will be briefly discussed. A
safe therapeutic environment, strong therapeutic alliance,
recovery of one’s own identity, identification
of triggers associated with fugue onset, reprocessing
trauma and integrating trauma into one’s current
being are essential components in the treatment of
Dissociative Fugue. Drug-facilitated interviews and
hypnosis may be helpful. Treatment should begin as
soon as possible following the fugue (Maldonado et
3. Dissociative Identity Disorder:
Treatment of Dissociative Identity Disorder typically
includes the following components: a strong therapeutic
relationship, a safe therapeutic environment, appropriate
boundaries, development of no self- or other-harm contracts,
an understanding of the personality structures, working
through traumatic and dissociated material, the development
of more mature psychological defenses, and the integration
of states of self. Guidelines for treatment of adults
and children are available from the International Society
for the Study of Trauma and Dissociation, www.ISST-D.org. Integration
of traumatic memories is an essential aspect of treatment
(Fine, 1999; Kluft, 1999; Lazrove & Fine, 1996;
Maldonado et al., 2002). Hypnosis can aid in allowing
the client to gain control over the dissociative episodes
and in the integration of memories (Fine & Berkowitz,
2001; Maldonado et al., 2002). Treatment of Dissociative
Identity Disorder is typically long and challenging.
Spontaneous remission will not occur (Kluft, 1985b,
1999). Studies have shown that cognitive behavioral
treatment of Dissociative Identity Disorder can be
beneficial (Fine, 1999; Maldonado et al., 2002). Electroconvulsive
therapy (ECT) is not generally recommended (Maldonado
et al., 2002). Eye-Movement Desensitization and Reprocessing
(EMDR) can be used in the treatment of DID although
it needs to be implemented with great caution (Fine & Berkowitz,
2001). EMDR is a newer psychological treatment designed
to accelerate the processing of information and to
facilitate integration of fragmented trauma memories
(Fine & Berkowitz, 2001; Lazrove & Fine, 1996).
4. Depersonalization Disorder: As
holds true for the other dissociative disorders, no
controlled studies have addressed the treatment of
Depersonalization Disorder. Treatments currently used
include a variety of models including cognitive and
behavioral approaches, psychoanalysis, and psychopharmacology
(as cited in Maldonado et al., 2002; Simeon et al.,
2001). Clinical findings are inconsistent. The lack
of empirical treatment studies on depersonalization
adversely impacts the understanding and treatment of
other dissociative disorders due to the fact that depersonalization
is often a component of these disorders (Simeon et
al., 2001). Depersonalization Disorder has been described
as resistant to psychopharmacological and psychotherapeutic
treatment interventions (Guralnik et al., 2001).
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Steinberg, M, & Steinberg, A. (1995). Using the
SCID-D to assess Dissociative Identity Disorder in
adolescents: Three case studies. Bulletin of the Menninger
Clinic, 59(2), 221-231.
West, M., Adam, K., Spreng, S., & Rose. S. (2001).
Attachment disorganization and dissociative symptoms
in clinically treated adolescents. Canadian Journal
of Psychiatry, 46(7), 627-631.
My (spouse, sibling, employee, child care
worker) has a dissociative disorder. They
are in treatment (or, not in treatment), and they
do not wish to “integrate” their personalities.
What can I do? I am worried about their lack of interest
in integrating, and I don’t know how to respond
to their behaviors. Is it safe to be around them?
Dear Sir or Madam, Unfortunately, while we would like
to respond to specific concerns, it is outside the
scope of ISSTD to comment about the condition of a
person in an ongoing treatment. Our suggestion would
be that you bring up your concerns with the treating
clinician. If they are not in treatment, or if that
fails to bring closure, then we would recommend you
seek consultation for yourself, in your local area.
If available, we would be glad to provide you with
the name of a consultant, at that time.
When a person has obvious psychological problems,
and they are not in treatment, there is no legal way,
in jurisdictions with which we are familiar, to make
them comply with a treatment program in which they
have no interest. Likewise, “forced” treatment,
is neither usually productive, nor useful, even when
there is compliance. The bottom line is that people
only enter treatment when their view is that it will
be useful to them.
In general, there is no evidence that a person with
a dissociative disorder is going to be any more violent
or dangerous to others than any other person with any
kind of mental illness. Each situation needs to be
assessed on a case by case basis, thoughtfully. Therapists
have a duty to warn others, if their patient is felt
by them to be dangerous. Lack of “integration” is
not an indication of dangerousness. Not all persons
with a dissociative disorder choose integration as
an end point for their treatment. In many treatments,
the focus is on function, living a life. One definition
of mental health is: to be flexible and resilient in
the face of life’s challenges while living in
relation to others, in community, and with a full range
of emotion. If a person achieves that, without integration,
perhaps that is good enough. On the other hand, if
lack of integration precludes real mental health, then
more treatment may be useful. A case by case assessment
I am a student, and I am interested in information
about dissociative disorders. Can you please help
To help you in the task of gathering information,
the following materials are recommended to you. These
references are available through most University libraries,
or through local libraries with inter-library services.
Also listed are some resources from the internet, which
you may find useful.
Armstrong, J. G. and Loewenstein, R. J. (1990). Characteristics
patients with multiple personality and dissociative disorders on
psychological testing. Journal of Nervous and Mental Disease, 178, 448-454.
Kluft, R. P. (Ed.). (1985). Childhood Antecedents
Personality. Washington, D.C.: American Psychiatric Press, Inc.
Kluft, R. P. (2000). The Psychoanalytic Psychotherapy
Dissociative Identity Disorder in the Context of Trauma Therapy.
Psychoanalytic Inquiry, 20(2), 259-286.
Liotti, G. (1999). Disorganization of attachment as
a model for
understanding dissociative psychopathology. In J. a. G. Solomon, Carol
(Ed.), Attachment Disorganization (pp. 291-317). New York: Guilford Press.
Loewenstein, R. J. (1991). An Office Mental Status
Complex Chronic Dissociative Symptoms and Multiple Personality Disorder.
In R. J. Loewenstein (Ed.), Psychiatric Clinics of North America (Vol.
14, pp. 567-604). Philadelphia: W.B. Saunders Company.
Main, M., Morgan, Hillary. (1996). Disorganization
disorientation in infant strange situation behavior: phenotypic
resemblance to dissociative states. In L. K. Michelson, and Ray, William
J. (Ed.), Handbook of Dissociation: Theoretical, Empirical, and Clinical
Perspectives (pp. 107-138). New York: Plenum Press.
Nijenhuis, E. R. S., Vanderlinden, J., Spinhoven,
P. (1998). Animal
defensive reactions as a model for trauma-induced dissociative
reactions. Journal of Traumatic Stress, 11(2), 243-260.
Putnam, F. W. (1989). Diagnosis and Treatment of Multiple
Personality Disorder. New York: Guilford Press.
Putnam, F. W. (1997). Dissociation in Children and
York: The Guilford Press.
Silberg, J. L. (1996). The Dissociative Child: Diagnosis,
and Management. Lutherville, Maryland: The Sidran Press.
Spiegel, D. (1994). Dissociation: Culture, Mind, and
Washington, D.C.: American Psychiatric Press, Inc.
Steinberg, M. (1993). Structured Clinical Interview
Dissociative Disorders. Washington, D.C.: American Psychiatric Press.
Terr, L. C. (1991). Childhood Traumas: An Outline
American Journal of Psychiatry, 148, 10-19.
van der Kolk, B., MacFarlane, Alexander, Weisaeth,
Traumatic Stress. New York: Guilford Press.
How do I know if I have DID?
There are a number of diagnostic tests, such as the
Structured Clinical Interview for Dissociative Disorders
(SCID-D) and the Dissociative Disorders Interview Scale
(DDIS), that are available and can be administered
in a clinical setting. The Dissociative Experiences
Scale (DES) is not a diagnostic instrument. However,
its use is widespread, and may be effective in screening
large populations for dissociative experience, for
When a person is asking whether or not they have DID,
that is a question that is worthy of consultation.
Some people are relieved to find that there is a diagnosis
and an understandable model for their experiences.
Some dissociative experiences may provoke considerable
anxiety and bafflement, and it is important to be able
to find an organizing concept that makes these experiences
The bottom line in all this is that it is our strong
recommendation that this question (How do I know if
I have DID?) be asked in the context of an ongoing
psychotherapy. If you are in a psychotherapy, ask your
therapist what they think. Ask them if they have enough
experience with DID to feel comfortable in making the
diagnosis. If they don't, ask them to get a consultation
for you and for them.
How do I help myself and my partner cope
with their history of abuse?
Here are some references from the Self-help literature.
A skilled couples therapist may also be helpful.
Sexual Healing Journey: A Guide for Survivors of Sexual
Abuse by Wendy Maltz
The Courage to Heal Workbook: For Women and Men Survivors of Child Sexual
Abuse by Laura Davis
What About Me? A Guide for Men Helping Female Partners Deal with Childhood
Sexual Abuse by Grant Cameron
Ghosts in the Bedroom: A Guide for Partners of Incest Survivors by Ken
Beginning to Heal: A First Book for Survivors of Child Sexual Abuse by
Ellen Bass, Laura Davis
When You Are the Partner of a Rape or Incest Survivor: A Workbook for You
by Robert Barry Levine
I am dating a person with a Dissociative
Disorder. What do I need to know?She hasn't
been diagnosed but it is very obvious that she has
it. There is some integration and some co-consciousness.
Some of the littles have integrated, a couple of the
protectors, and some of the abusive parts as well.
Some of the alters don't like to tell me their name.
Also when the host and I get physical there is one
who likes to be physical, but others don't. How can
I deal with all this?
Dear Sir, ISSTD is a membership organization and we
are not able to comment on a person’s condition,
especially based on someone’s report, and not
a face to face interview by a professional. Even then,
rules of ethics preclude a clinician making comments
about a person’s condition without having interviewed
On the other hand, common sense would dictate that
this dating relationship presents a number of confusing
possibilities and moral responsibilities, depending
upon an individual’s perspective, and local law.
The wisest course of action might be to consider consultation
with a local clinician of your choice, and to discuss
this situation with them. Respect for the rights of
individuals, and the maintenance of personal safety
are the bottom line in relationships.
I went to therapy because I was sad, and now
I’m told I have a dissociative disorder. I
don’t have a history of trauma. I had a happy
childhood. Can you help me sort this out? I went to a therapist three years ago to find a way
to cope with an impending loss. As you already know,
there is a questionnaire that you fill out. Some were
questions I had never been asked before. Probably the
one that caused the most fuss, was do you have voices
in your head. The answer was yes. It went down hill
In the course of the next few years my therapist and
my psychiatrist have journeyed into what it is like
to be me. Days that only last a few hours, all of a
sudden not knowing what I am supposed to be doing,
forgetting how to read, hearing me talk, but not recognizing
They have diagnosed me with DID. I have been fighting
them on this. I do not believe that you can turn yourself
into different people and not be crazy. I hold down
a very hard job, how could this be going on? I would
have lost my job.
My therapist is insisting that I was abused as a child
and wants me to come clean. She says that I know it,
I am just unable to express it. When I started therapy,
even after the presentation of my voices, I insisted
that I would not revisit my childhood so that they
could change my memories. I had a wonderful childhood,
full of hugs, kisses, laughter. What she wants me to
do will destroy all of that.
There were things that I was eager to explore and
change in my life. I have some habits that take up
a lot of my time, but don’t add anything to my
life. I am uncomfortable with anything sexual and don’t
know why. But, if I go along with therapy - I will
be deemed crazy (DID) and my wonderful childhood will
be replaced with horror.
Dear Ms. _____, Even people who don't have a trauma
history, one that is filled with physical or sexual
abuse, can develop a dissociative disorder. The origins
of this are speculative, and at the same time there
is a very strong and sophisticated literature in the
field of infant attachment studies that points clearly
to a pattern of attachment called Type D attachment
as predicting adult dissociation. Additional work by
Karlen Lyons-Ruth shows that adult dissociation is
best predicted by the "hidden trauma" of emotional
abuse vs. physical/sexual abuse in a ratio of 2:1.
There is a lot of evidence that people can develop
complex dissociative disorders from what has recently
been called developmental trauma.
It sounds as if you are feeling a lot of pressure
to accept what your therapist is saying. It also may
be that there is even more pressure and conflict inside
you to try and figure out what to do and how to understand
what you've learned about your mind and how it works.
Perhaps the struggle you are having with your therapist
is related to a conflict you are having in your own
mind? It's hard to know, but that's always a consideration.
There's lots of reading you can do to learn more about
dissociation and how attachment issues may be reflected
in adult dissociative disorders. Some of those references
follow. It's always useful to bring these issues up
with you therapist. We hope you'll do that.
A list of references about dissociation and attachment
Liotti, G. (1999). Disorganization of attachment as
a model for understanding dissociative psychopathology. Attachment
Disorganization. J. Solomon, George, C. New York,
Guilford Press: 291-317.
Lyons-Ruth, K. (2003). "Dissociation and the parent-infant dialogue: a longitudinal
perspective from attachment research." Journal of the American Psychoanalytic
Association 51(3): 883-911.
Main, M., Morgan, Hillary (1996). Disorganization and disorientation in infant
strange situation behavior: phenotypic resemblance to dissociative states. Handbook
of Dissociation: Theoretical, Empirical, and Clinical Perspectives. L. K.
Michelson, and Ray, William J. New York, Plenum Press: 107-138.
Siegel, D. J. (1999). The Developing Mind: Toward A Neurobiology of Interpersonal
Experience. New York, Guilford Press.
Can you help me not be DID?
Your question presents one of the most complex and
sensitive concerns that a person can pose regarding
their mental health. I am not going to try to convince
you one way or the other regarding whether or not you
have a dissociative disorder. What is most important
is for you to develop your own theory of what was happening
in your mind, and what happens in other people’s
minds as you and they experience living.
Multiple Personality Disorder is really a misnomer.
It may be more useful to understand the dissociative
processes, the processes that detach aspects of experience
from each other that make the experience unknowable,
unfeelable, etc., as a discontinuity in the experience
of being one’s Self. In fact, many experts would
say that people with dissociative disorders often have
the experience of not having a whole coherent Self.
It is the disowning of aspects of Self experience,
emotion, behavior, sensation, and knowledge that become
personified and are typical of the development of the
alternate self states that are the hallmark of more
complex dissociative disorders. It is this sense of
an alteration of identity that provided some of the
impetus for a name change to Dissociative Identity
Disorder, in the last Diagnostic and Statistical Manual
of the American Psychiatric Association, DSM-IV-TR
Some people are frightened of the word dissociative.
They believe that if someone has a dissociative disorder
that means that a person must have a severe trauma
history. Sometimes that’s true, and sometimes
that is not true. A person can develop a dissociative
disorder just from life’s circumstances. Some
studies have suggested that growing up in a family
where a parent is frightened, frightening, or severely
grieving/depressed during a child’s first years
may be enough to generate the organization of mind
that relies more heavily on dissociative adaptations
to get through the day.
Perhaps you will be able to spend some time with your
therapist trying to understand your experience, and
focus on what it means to you, and not just focus on
diagnosis. It is hard to know if there is a trauma
history hidden in your past, or not. About 10 percent
of people with trauma histories have extensive memory
loss for trauma that they later remember. In any event,
working with your current experiences, their meaning
in your life, and functioning from day to day in relationships,
and in your community, is a good place for a therapy
to start. Where it goes from there can be based on
a solid working alliance if these first issues are