15.4 Dissociative Disorders

In psychopathology, dissociation happens when thoughts, feelings, and experiences of our consciousness and memory do not collaborate well with each other. This section provides an overview of dissociative disorders, including the definitions of dissociation, its origins and competing theories, and their relation to traumatic experiences and sleep problems.

Think about the last time you were daydreaming. Perhaps it was while you were driving or attending class. Some portion of your attention was on the activity at hand, but most of your conscious mind was wrapped up in fantasy. Now, imagine that you could not control your daydreams. What if they intruded your waking consciousness unannounced, causing you to lose track of reality or experience the loss of time. Imagine how difficult it would be for you. This is similar to what people who suffer from dissociative disorders may experience. Of the many disorders listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association (2013), dissociative disorders rank as among the most puzzling and controversial. Dissociative disorders encompass an array of symptoms, ranging from memory loss (i.e., amnesia) for autobiographical events to changes in identity and the experience of everyday reality (American Psychiatric Association, 2013).

Is it real?

Let’s start with a little history. Multiple personality disorder — or dissociative identity disorder, as it is known now — used to be a mere curiosity. This is a disorder in which people present with more than one personality. For example, at times, they might act and identify as an adult, while at other times, they might identify and behave like a child. The disorder was rarely diagnosed until the 1980s. That’s when multiple personality disorder became an official diagnosis in the DSM-III. From then on, the numbers of “multiples” increased rapidly. In the 1990s, there were hundreds of people diagnosed with multiple personality in every major city in the United States (Hacking, 1995). How could this be explained?

One possible explanation might be the media attention that was given to the disorder. It all started with the book The Three Faces of Eve (Thigpen & Cleckley, 1957). This book, and later the movie, was one of the first to speak of multiple personality disorder. However, it wasn’t until years later, when the fictional “as told to” book of Sybil (Schreiber, 1973) became known worldwide, that the prototype of what it was like to have multiple personalities was born. Sybil tells the story of how a clinician — Cornelia Wilbur — unravels the different personalities of her patient — Sybil — during a long course of treatment spanning over 2,500 office hours. She was one of the first to relate multiple personality to childhood sexual abuse. Probably, this relation between childhood abuse and dissociation has fueled the increase of numbers of multiples from that time on. It motivated therapists to actively seek for clues of childhood abuse in their dissociative patients. This suited well within the mindset of the 1980s, as childhood abuse was a sensitive issue then, in psychology as well as in politics (Hacking, 1995).

From then on, many movies and books were made on the subject of multiple personality, and since then, we have see patients with dissociative identity disorder as guests visiting the Oprah Winfrey show, as if they were our modern-day circus acts. Some clinicians argue that the descriptions in the DSM accurately reflect the symptoms of these patients, whereas others believe that patients are faking, role-playing, or using the disorder as a way to justify behaviour (Barry-Walsh, 2005; Kihlstrom, 2004; Lilienfeld & Lynn, 2003; Lipsanen et al., 2004). Even the diagnosis of Shirley Ardell Mason, better known as Sybil, is disputed. Some experts claim that Mason was highly hypnotizable and that her therapist unintentionally suggested the existence of her multiple personalities (Miller & Kantrowitz, 1999).

Defining dissociation

The DSM-5 defines dissociation as “a disruption and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control and behavior” (American Psychiatric Association, 2013, p. 291). A distinction is often made between dissociative states and dissociative traits (e.g., Bremner, 2010; Bremner & Brett, 1997). State dissociation is viewed as a transient symptom, which lasts for a few minutes or hours (e.g., dissociation during a traumatic event). Trait dissociation is viewed as an integral aspect of personality. Dissociative symptoms occur in patients, but they also occur in the general population. Therefore, dissociation has commonly been conceptualized as ranging on a continuum, from nonsevere manifestations of daydreaming to more severe disturbances typical of dissociative disorders (Bernstein & Putnam, 1986). The dissociative disorders include:

• Dissociative amnesia — An extensive, but selective, memory loss, but in which there is no physiological explanation for the forgetting (van der Hart & Nijenhuis, 2009). Although the personality of people who experience dissociative amnesia remains fundamentally unchanged — and they recall how to carry out daily tasks such as reading, writing, and problem solving — they tend to forget things about their personal lives — for instance, their name, age, and occupation — and may fail to recognize family and friends (van der Hart & Nijenhuis, 2009).
• Dissociative fugue — A psychological disorder in which an individual loses complete memory of their identity and may even assume a new one, often far from home. It is not viewed as a separate disorder but is a feature of some, but not all, cases of dissociative amnesia. The fugue state may last for just a matter of hours or may continue for months. Recovery from the fugue state tends to be rapid, but when people recover, they commonly have no memory of the stressful event that triggered the fugue or of events that occurred during their fugue state (Cardeña & Gleaves, 2007).
• Depersonalization or derealization disorder — A feeling as though one is an outside observer of one’s body.
• Dissociative identity disorder — Experiencing two or more distinct identities that recurrently take control over one’s behaviour (American Psychiatric Association, 2000). In dissociative identity disorder (DID), there is an extreme memory disruption regarding personal information about the other personalities (van der Hart & Nijenhuis, 2009). Switches from one personality to another tend to occur suddenly, often triggered by a stressful situation (Gillig, 2009). The host personality is the personality in control of the body most of the time, and the alter personalities tend to differ from each other in terms of age, race, gender, language, manners, and even sexual orientation (Kluft, 1996). A shy, introverted individual may develop a boisterous, extroverted alter personality. Each personality has unique memories and social relationships (Dawson, 1990). Women are more frequently diagnosed with dissociative identity disorder than are men, and when they are diagnosed, they also tend to have more “personalities” (American Psychiatric Association, 2000).

Although the concept of dissociation lacks a generally accepted definition, the Structural Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) assesses five symptom clusters that encompass key features of the dissociative disorders (Steinberg, 2001). These clusters are also found in the DSM-5:

1. Depersonalization
2. Derealization
3. Dissociative amnesia
4. Identity confusion
5. Identity alteration

Depersonalization refers to a feeling of detachment or estrangement from one’s self. Imagine that you are outside of your own body, looking at yourself from a distance as though you were looking at somebody else. Maybe you can also imagine what it would be like if you felt like a robot, deprived of all feelings. These are examples of depersonalization. Derealization is defined as “an alteration in the perception of one’s surroundings so that a sense of reality of the external world is lost” (Steinberg, 2001, p. 101). Imagine that the world around you seems as if you are living in a movie or looking through a fog. These are examples of derealization. Dissociative amnesia does not refer to permanent memory loss, similar to the erasure of a computer disk, but rather to the hypothetical disconnection of memories from conscious inspection (Steinberg, 2001). Thus, the memory is still there somewhere, but you cannot reach it. Identity confusion is defined by Steinberg as “thoughts and feelings of uncertainty and conflict a person has related to his or her identity” (Steinberg, 2001, p. 101), whereas identity alteration describes the behavioural acting out of this uncertainty and conflict (Bernstein & Putnam, 1986).

Dissociative disorders are not as uncommon as you would expect. Several studies in a variety of patient groups show that dissociative disorders are prevalent in a 4–29% range (Ross, Anderson, Fleischer, & Norton, 1991; Sar, Tutkun, Alyanak, Bakim, & Baral, 2000; Tutkun et al., 1998; for reviews see: Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006; Spiegel et al., 2011). Studies generally find a much lower prevalence in the general population, with rates in the order of 1–3% (Lee, Kwok, Hunter, Richards, & David, 2010; Rauschenberger & Lynn, 1995; Sandberg & Lynn, 1992). Importantly, dissociative symptoms are not limited to the dissociative disorders. Certain diagnostic groups, notably patients with borderline personality disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (Rufer, Fricke, Held, Cremer, & Hand, 2006), and schizophrenia (Allen & Coyne, 1995; Merckelbach, à Campo, Hardy, & Giesbrecht, 2005; Yu et al., 2010) also display heightened levels of dissociation.

Measuring dissociation

The Dissociative Experiences Scale (DES) is the most widely used self-report measure of dissociation (Bernstein & Putnam, 1986; Carlson & Putnam, 2000; Wright & Loftus, 1999). A self-report measure is a type of psychological test in which a person completes a survey or questionnaire with or without the help of an investigator. This scale measures dissociation with items such as “Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something, and they actually see themselves as if they were looking at another person” and “Some people find that sometimes they are listening to someone talk, and they suddenly realize that they did not hear part or all of what was said.”

The DES is suitable only as a screening tool. When somebody scores a high level of dissociation on this scale, this does not necessarily mean that they are suffering from a dissociative disorder. It does, however, give an indication to investigate the symptoms more extensively. This is usually done with a structured clinical interview, called the Structured Clinical Interview for DSM-IV Dissociative Disorders (Steinberg, 1994), which is performed by an experienced clinician. With the publication of the new DSM-5 there has been an updated version of this instrument.

Dissociation and trauma

The most widely held perspective on dissociative symptoms is that they reflect a defensive response to highly aversive events, mostly trauma experiences during the childhood years (Bremner, 2010; Spiegel et al., 2011; Spitzer, Vogel, Barnow, Freyberger, & Grabe, 2007).

One prominent interpretation of the origins of dissociative disorders is that they are the direct result of exposure to traumatic experiences: the post-traumatic model (PTM). According to the PTM, dissociative symptoms can best be understood as mental strategies to cope with or avoid the impact of highly aversive experiences (e.g., Spiegel et al., 2011). In this view, individuals rely on dissociation to escape from painful memories (Gershuny & Thayer, 1999). Once they have learned to use this defensive coping mechanism, it can become automatized and habitual, even emerging in response to minor stressors (van der Hart & Horst, 1989). The idea that dissociation can serve a defensive function can be traced back to Pierre Janet (1899/1973), one of the first scholars to link dissociation to psychological trauma (Hacking, 1995).

The PTM argues that trauma causes dissociative disorders (Gershuny & Thayer, 1999). For example, Vermetten and colleagues (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006) found that the DID patients in their study all suffered from post-traumatic stress disorder and concluded that DID should be conceptualized as an extreme form of early-abuse–related post-traumatic stress disorder (Vermetten et al., 2006). However, the empirical evidence that trauma leads to dissociative symptoms is the subject of intense debate (Kihlstrom, 2005; Bremner, 2010; Giesbrecht, Lynn, Lilienfeld & Merckelbach, 2010). Three limitations of the PTM will be described below.

First, the majority of studies reporting links between self-reported trauma and dissociation are based on cross-sectional designs. This means that the data are collected at one point in time. When analyzing this type of data, one can only state whether scoring high on a particular questionnaire (e.g., a trauma questionnaire) is indicative of also scoring high on another questionnaire (e.g., the DES). This makes it difficult to state if one thing led to another and, therefore, if the relation between the two is causal. Thus, the data that these designs yield do not allow for strong causal claims (Merckelbach & Muris, 2002).

Second, whether somebody has experienced a trauma is often established using a questionnaire that the person completes themself. This is called a self-report measure. Herein lies the problem. Individuals suffering from dissociative symptoms typically have high fantasy proneness, which is a character trait to engage in extensive and vivid fantasizing. The tendency to fantasize a lot may increase the risk of exaggerating or understating self-reports of traumatic experiences (Merckelbach et al., 2005; Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008).

Third, high dissociative individuals report more cognitive failures than low dissociative individuals. Cognitive failures are everyday slips and lapses, such as failing to notice signposts on the road, forgetting appointments, or bumping into people. This can be seen, in part, in the DSM-5 criteria for DID, in which people may have difficulty recalling everyday events as well as those that are traumatic. People who frequently make such slips and lapses often mistrust their own cognitive capacities; they also tend to overvalue the hints and cues provided by others (Merckelbach, Horselenberg, & Schmidt, 2002; Merckelbach, Muris, Rassin, & Horselenberg, 2000). This makes them vulnerable to suggestive information, which may distort self-reports, and thus, this limits conclusions that can be drawn from studies that rely solely on self-reports to investigate the trauma-dissociation link (Merckelbach & Jelicic, 2004).

Most important, however, is that the PTM does not tell us how trauma produces dissociative symptoms. Therefore, researchers have searched for other explanations. One theory proposes that due to their dreamlike character, dissociative symptoms — such as derealization, depersonalization, and absorption — are associated with sleep-related experiences (Giesbrecht et al., 2008; Watson, 2001) such that trauma disrupts the sleep-wake cycle and increases vulnerability to dissociative symptoms.

Source: Adapted from van Heugten – van der Kloet (2020).