Mr. D, age 45, presents to his primary care physician with panic attacks, nausea, shortness of breath, nightmares, and dizziness 6 months after being assaulted and robbed at an ATM. Following a routine medical workup, the physician diagnoses posttraumatic stress disorder (PTSD) and refers Mr. D for exposure and response prevention therapy.
During graded exposure sessions, Mr. D’s eyes sometimes glaze over and he seems to “float away” from the discussion. When the therapist asks about these symptoms, Mr. D reports having had them as long as he can remember. In school, he says, teachers thought he was a slow learner, a daydreamer, or had attention-deficit/hyperactivity disorder. From what he can recall of his childhood, he describes a history of trauma and neglect with a violent, drug-abusing father and absent mother.
Patients with a history of early abuse or neglect are at risk for dissociative phenomena and other trauma-related psychiatric disorders.1 The heterogeneous dissociative disorders are often hidden and unrecognized2 —as in Mr. D’s case—or present with unfamiliar or atypical symptoms. Understanding and identifying dissociative symptoms is important because:
- Dissociative symptoms worsen prognosis, whether patients have conversion disorders1 or psychogenic seizures3 or are in psychotherapy.4
- Dissociative states may impair memory encoding5 and decrease patients’ ability to remember therapeutic information.
- Symptoms (such as hearing voices in multiple personality disorder) can be confused with those of disorders with different treatment strategies (such as psychotic disorders).6
- Peritraumatic dissociation may be a risk factor for PTSD.7
This article presents a practical model for understanding dissociation, reviews clinical characteristics of this family of symptoms, and offers suggestions for assessing and treating patients with dissociative disorders.
Coming together, falling apart
Since Pierre Janet’s first reports on dissociative disorders, a number of theories and models of dissociation have been proposed,8 including empirically based, taxonomic models that address DSM-IV-TR categories (Table 1). The model I propose—which attaches a visual metaphor to dissociative phenomena—answers the question, “What is ‘dissociated’ in dissociation disorders?”
Table 1
DSM-IV-TR classification of dissociative disorders
| Disorder | Symptoms |
|---|---|
| Dissociative amnesia | A reversible loss of memory, typically preceded by a stressor |
| Dissociative fugue | Loss of memory and identity, along with travel away from home |
| Dissociative identity disorder (formerly multiple personality disorder) | Presence of different identity states, often with lack of connection between them; current models highlight the presence of recurrent dissociative intrusions into many aspects of executive function and self |
| Depersonalization disorder | Detachment from oneself as a present, feeling person (depersonalization) and the world (derealization) |
| Dissociative identity disorder NOS | Functionally disturbing dissociative symptoms that do not fit into any of the above |
| NOS: not otherwise specified | |
| Source: Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000 | |
One paired component is a detached “observer” and a more embodied, feeling “experiencer.” The observer is a perspective that begets metacognition (thinking about one’s inner world) and self-observation; it resides in the same body as soma-based “feelings” that unconsciously contribute to the sense of “being present” with oneself and the world in the moment.9
A second component is voluntary access to one’s autobiographical memories (memories about the self in time), which are constantly “updated” and integrated with current experiences. This component allows one to distinguish between remembered (past) experiences and “firsthand” (present) experience.
Three other components of normal consciousness are:
- a sense of agency and voluntary control over one’s mental contents, mental activity, and bodily movements
- an ongoing connection with one’s body and mind and an understanding of where sensations and images come from
- a sense of sequential experience, with relatively smooth transitions (from self at work to self at home, self a week ago to self today, etc) that have a singular referent (an identity).
- separation of the “observer” and “experiencer” occurs in depersonalization disorder
- reversible loss of ability to access memories characterizes dissociative amnesia
- disconnection between sequential experiences is a part of dissociative identity disorder.