An introduction to dissociation and dissociative identity disorder

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An Introduction to Dissociation and Dissociative Identity Disorder

by Rob & Carolyn Spring

What is Dissociation?

Dissociation itself is quite common and every one of us has probably experienced a normal dissociative episode many times in our lives, for example:

daydreaming while driving a car as if on autopilot (‘highway hypnosis’)
blanking out and missing part of a conversation
feeling unfamiliar when looking the mirror
having a dreamlike feeling about other people or the world
a sense of time slowing down (especially during a traumatic event such as a car accident or terrorist attack)

These types of symptoms occur as a natural reaction both to traumatic events as well as high levels of stress in everyday life. ‘Normal’ dissociation passes quickly and does NOT indicate the presence of a psychiatric disorder.

However, a dissociative disorder can develop when severe trauma is experienced and is not processed or dealt with. This theory has gained overwhelming support in recent years from research on the effect of trauma on the brain, and how memory is affected. A traumatic experience is one that is extremely distressing and is generally accompanied by feelings of helplessness – dissociation is therefore a common response. It allows a person to alter their consciousness in a way that allows them to distance or disconnect from the full impact of what is happening. This distancing can take place in terms of memory, emotion, the actual physical experience, or in extreme cases a sense of identity. When under threat the brain goes into ‘survival’ mode. Dissociation can be thought of as both a neurobiological response to threat and a psychological defence to protect from an overwhelming experience. This happens automatically as the ‘best’ and usually the ‘only’ means of mentally surviving trauma.

Dissociation has been described as “an unconscious defence mechanism in which a group of mental activities split off from the main stream of consciousness and function as a separate unit” (O’Regan, 1985).

The purpose of dissociation therefore is to take the memory or emotion that is directly associated with a trauma and to try to separate it from the conscious self.

What are the symptoms of dissociative disorders?

There are different types of dissociative disorder and they may include varying degrees of the following five core dissociative symptoms:

Amnesia. This will be for specific and significant blocks of time that have passed – gaps in memory or ‘lost time’.
Depersonalisation. This is a feeling of being detached from yourself or looking at yourself almost from the outside, as an observer would. It can also include feeling cut-off from parts of your body or detached from your emotions.
Derealisation. This is a feeling of detachment from the world around you, or a sense that people or things feel unreal
Identity confusion. This is a feeling of internal conflict of who you are – having difficulty in defining yourself.
Identity alteration. This is a shift in identity accompanied by changes in behaviour that are observable to others. These may include speaking in a different voice or using different names. This may be experienced as a personality switch or shift, or a loss of control to ‘someone else’ inside.

In dissociative disorders, and especially in DID there is a fundamental disconnection between conscious awareness, memories, emotions and also usually the body.

What is Dissociative Identity Disorder?

Dissociative Identity Disorder is the most extreme manifestation of a dissociative disorder and involves ‘multiple personalities’ existing within one person. These have evolved as separate ‘personality states’ as the only feasible way for a child to cope with ongoing trauma and abuse. It involves a basic pretence that what is happening is not happening to me. As Phil Mollon (1996) puts it: “Dissociation involves an attempt to deny that an unbearable situation is happening, or that the person is present in that situation.”

It is important to remember that none of us has one totally ‘integrated’ personality. We show different sides of us in different situations, so we may play a very different role when we are in a business meeting compared to when we are at home relaxing with our family. DID is an extreme manifestation of what we all experience to a much lesser degree.

When most people hear of DID they may think of Sybil, the book and 1976 film starring Sally Field. In this film Sybil was diagnosed with suffering from Multiple Personality Disorder resulting from severe child abuse. Her parts were quite distinct and easily recognised, and the switching between them was quite obvious. In reality someone with DID may not show such obvious switching.

In addition to the dissociation and switching between different alters, a person with DID may experience the following symptoms:

inner voices
Nightmares
panic attacks
generalised anxiety
Depression
eating disorders
drug or alcohol dependency
body memories
severe headaches
self-harm
suicidal thoughts and behaviours
relational difficulties
issues of shame and poor self-esteem
Post Traumatic Stress Disorder (PTSD)

Someone who has DID may have distinct, coherent identities within themselves that are able to assume control of their behaviour and thought. They may or may not be aware of these ‘alter personalities’ and they may or may not present with different names, mannerisms, gender identity, sense of age etc. Sometimes it is very subtle and sometimes it is very obvious to an observer, although the person with DID may not be aware that it is happening at all. They may just have a sense of losing time or incoherence about who they are and what they have been doing.

Flashbacks are one of the most common ways in which dissociated memories begin to resurface. During a flashback there will often be overwhelming visual and other reminders of the traumatic event, and it may feel as if the experience is being relived. A flashback can often be caused by a ‘trigger’, which is a current-day reminder (either at a conscious or unconscious level) of something traumatic from the past. A trigger could be a sight, a sound, a taste, a smell, a touch, a situation, a location, even a body movement. There is almost an instant catapulting back into the sensation or feelings of the past which is highly distressing and can happen quite spontaneously. This makes living everyday life somewhat of a minefield, as almost anything can become a trigger and cause rapid and destabilising switching, for example into alters who experience the flashback as being re-abused in the present.

The Causes of DID

DID is not a mental illness with a biological root such as people generally feel that schizophrenia and bipolar disorder are. It is now widely accepted that DID results from chronic and overwhelming trauma and abuse in childhood starting at a very young age, generally at the hands of a caregiver. Although the child’s parents may not have been directly involved in the abuse, there has usually been some inability on their part to help the child to process or recover from whatever trauma they have experienced. The traumatic events therefore remain sealed off – dissociated and unprocessed – from the main conscious awareness and developing identity of the child. This can result in either complete or partial amnesia for what has happened, and ‘gaps’ in the person’s narrative account of their life. One of the principal functions of DID is ‘denial’ – to allow the person to continue with life, unaware of the extreme abuse that they have suffered, by blocking it out of their memory and mind.

It is very common then that the person will grow up unaware of their traumatic history until such a time as their psychological defences can no longer cope, for example due to stress or the intrusion of current-day ‘triggers’. At this point the dissociation and DID may manifest in a much more obvious way, so that life becomes intolerable, and help or treatment is sought.

How is DID diagnosed and then treated?

The American Psychological Association defines a list of psychiatric conditions and the latest edition of this is the DSM-IV-TR (Diagnostic and Statistical Manual, version 4, Text Revision). It defines DID in section 300.14 (dissociative disorders) as follows:

The presence of two or more distinct identity or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self
At least two of these identities or personality states recurrently take control of the person's behaviour
Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness
The disturbance is not due to the direct physiological effects of a substance (eg blackouts or chaotic behaviour during alcohol intoxication) or a general medical condition (eg complex partial seizures)

People who fall short of this description may be diagnosed with DDNOS (Dissociative Disorder Not Otherwise Specified) or one of the other dissociative disorders such as dissociative amnesia or dissociative fugue.

The Pottergate Centre in Norwich (www.dissociation.co.uk/clients.asp) offers free screening tools for dissociative disorders such as the DES (Dissociative Experiences Scales) and SDQ20 (Somatoform Dissociative Questionnaire) and can advise on how to go about having a full assessment.

DID is very rarely diagnosed at an early stage in the UK due to widespread ignorance within the medical profession. On average it takes 7 years within the Mental Health system to gain a correct diagnosis. Often it is misdiagnosed as Borderline Personality Disorder, schizophrenia, bipolar disorder, depression or PTSD. The person with DID may suffer from some of these conditions in addition to DID, but dissociation is often the underlying core issue.

The ISSTD (International Society for the Study of Trauma and Dissociation) recommends that the preferred treatment for DID is long-term relational psychotherapy. Medication can assist with associated symptoms, such as sleep disturbance, anxiety and depression, but there is no pharmacological cure for DID. However, of all psychiatric disorders, DID has the best prognosis and complete recovery is possible with the right treatment. It is most helpful to work with a therapist who has some awareness of DID or who is willing to learn or have a supervisor experienced in working with dissociation.

People with DID would generally be expected to have what is known as ‘disorganised attachment’. This often results from having caregivers who were either ‘frightened or frightening’. This can lead to problems in relationships in later life and what might appear to a partner as an irrational or unpredictable style of relating and behaviour. Attachment issues ideally need to be addressed in therapy, rather than a focus just on the traumatic events themselves.

Ritual Abuse

Many people with DID have suffered abuse which could be considered to be ‘ritualistic’ in nature. ‘Ritual abuse’ refers to severe and extreme, often sadistic, sexual and physical abuse that is carried out by a group of people in a highly organised manner, sometimes involving religious, satanistic or ceremonial elements.

Ritual Abuse, by the very nature of its criminality, remains highly secretive and many sectors of society refuse to believe that it can happen, the tabloids in particular dismissing it as ‘satanic panic’. However, an increasing number of professionals, including the police, believe that the many accounts of Ritual Abuse reported by adults are true and are not ‘false memories’ as suggested by certain organisations.

One definition of Ritual Abuse that has been proposed (Becker & Frohling 1996) is:

“Ritual Violence is a severe form of abuse of adults, adolescents and children intended to traumatise the victims. It consists of physical, sexual and psychological forms of abuse which are planned out and systematically used in ceremonies. These ceremonies may have an ideological background as well as being staged for the purpose of deception and threat. Symbols, activities or rituals which have religious, magical or supernatural connotations are used. The purpose is to confuse, threaten and terrorise victims as well as indoctrinate them with religious, spiritual or ideological beliefs. Ritual violence rarely consists of a single episode. Most often these experiences happen over an extended period of time.”