Dissociative Disorders

Dissociative disorders are mental health conditions involving a disruption or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body awareness and behavior. The DSM-5 (2013) and its 2022 text revision, the DSM-5-TR, list three main dissociative disorders, dissociative identity disorder (DID), dissociative amnesia and depersonalization/derealization disorder (DPDR), plus other specified and unspecified dissociative disorder. They are strongly associated with trauma, particularly in childhood, and are often missed or misdiagnosed for years.

What Dissociation Is

Dissociation is a disconnection between experiences that are usually linked: thoughts and memories, sense of self and actions, perception and feeling. Our guide to dissociation explores the experience itself in more detail.

The term has a long history. In the late nineteenth century, the French psychologist Pierre Janet described "désagrégation," in which overwhelming experiences split off from ordinary awareness. Interest declined in the mid-twentieth century and revived in the 1980s, when dissociative disorders gained separate recognition in the DSM-III.

From a trauma perspective, dissociation can be understood as a protective adaptation. When a person, especially a child, cannot escape overwhelming threat, the mind may disconnect from awareness, sensation or memory. What protects in the moment can later cause problems, interfering with memory, identity and daily functioning.

The Dissociative Spectrum

Dissociation is often described as a continuum, though some researchers argue that pathological dissociation differs in kind from everyday experiences:

• Everyday dissociation: daydreaming, becoming absorbed in a book or film, or "highway hypnosis," arriving somewhere without remembering the drive.
• Stress-related dissociation: feeling unreal during a panic attack, after a shock or when extremely tired.
• Trauma-related dissociation: detachment during a traumatic event (peritraumatic dissociation) and later dissociative flashbacks. The DSM-5 added a dissociative subtype of PTSD for people with prominent depersonalization or derealization.
• Pathological dissociation: persistent, impairing dissociative symptoms that may meet criteria for a dissociative disorder.

Dissociative symptoms also occur in other conditions, including PTSD, complex PTSD, borderline personality disorder, panic disorder and substance use, so their presence does not by itself indicate a dissociative disorder.

DSM-5 Dissociative Disorders

Dissociative Identity Disorder (DID)

Formerly called multiple personality disorder, DID is characterized by a disruption of identity involving two or more distinct personality states, which in some cultures may be described as an experience of possession. This involves marked discontinuity in sense of self and sense of agency, with related changes in emotion, behavior, memory, perception and thinking. The person also has recurrent gaps in recall of everyday events, important personal information or traumatic events. Symptoms cause significant distress or impairment and are not part of accepted cultural or religious practice, or, in children, imaginary play. See dissociative identity disorder.

Depersonalization/Derealization Disorder (DPDR)

• Depersonalization: feeling detached from one's thoughts, feelings, body or actions, like an outside observer.
• Derealization: feeling that surroundings are unreal, dreamlike, foggy, lifeless or visually distorted.
• Reality testing remains intact: the person knows the experience is a feeling, not a fact.
• The experiences are persistent or recurrent and cause significant distress or impairment.

See depersonalization/derealization disorder and derealization.

Dissociative Amnesia

• An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
• Amnesia may be localized (a specific period), selective (some parts of an event) or, rarely, generalized (one's whole life history).
• Dissociative fugue is a specifier: apparently purposeful travel or bewildered wandering associated with amnesia for identity or other important personal information. In DSM-IV, fugue was a separate diagnosis.
• The memory loss is not better explained by a neurological or medical condition, such as head injury, seizures or substance use.

Other Specified / Unspecified Dissociative Disorder

These categories cover significant dissociative symptoms that do not fit the named disorders. The DSM-5-TR gives examples for "other specified," including:

• Chronic and recurrent mixed dissociative symptoms that fall just short of DID.
• Identity disturbance due to prolonged and intense coercive persuasion, such as in some cults, captivity or torture.
• Acute dissociative reactions to stressful events, lasting less than a month.
• Dissociative trance, an acute narrowing or loss of awareness of surroundings that is not part of accepted cultural or religious practice.

ICD-11 approach

The World Health Organization's ICD-11 groups dissociative disorders somewhat differently. It includes partial dissociative identity disorder, trance and possession trance disorders, and places functional neurological symptoms (called dissociative neurological symptom disorder) within this chapter. See conversion disorder (FND).

Trauma Origins

The trauma model holds that dissociative disorders, particularly DID, develop mainly as a response to severe, repeated trauma in early childhood, when identity is still forming. Supporting evidence includes:

• High rates of reported childhood abuse and neglect among people with dissociative disorders across many countries.
• A dose-response pattern: earlier and more severe trauma is associated with more severe dissociation.
• Links between disorganized attachment in infancy and later dissociation in longitudinal research, such as studies by Karlen Lyons-Ruth and colleagues.

A competing sociocognitive (or "fantasy") model, associated with researchers such as Steven Jay Lynn, Scott Lilienfeld and Harald Merckelbach, argues that factors such as suggestibility, fantasy proneness, sleep disruption, media portrayals and suggestive therapy practices also shape dissociative symptoms, especially in DID. A major 2012 review by Constance Dalenberg and colleagues concluded that evidence favored the trauma model, while critics replied that the relationship between trauma and dissociation is complex and that both views have merit.

Most researchers now agree that trauma is an important risk factor, that dissociation is often a way of coping with overwhelming experiences, and that clinicians should avoid suggestive questioning. Our guide to childhood trauma explores these experiences further.

Assessment

Dissociative disorders are often missed, because people may not volunteer symptoms, may not remember them, or may fear being disbelieved. Assessment typically includes:

• Screening questionnaires: such as the Dissociative Experiences Scale (DES), a 28-item self-report measure developed by Eve Bernstein and Frank Putnam in 1986. It screens for dissociative experiences but cannot diagnose a disorder on its own.
• Comprehensive inventories: such as the Multidimensional Inventory of Dissociation (MID), developed by Paul Dell.
• Structured interviews: the Structured Clinical Interview for DSM Dissociative Disorders (SCID-D), developed by Marlene Steinberg, is widely used for diagnosis.
• Trauma and medical history: including ruling out neurological causes such as seizures or head injury, and substance effects.

Clinicians also consider other explanations, including PTSD, borderline personality disorder, psychotic disorders, functional neurological disorder, factitious disorder and malingering. Many people with dissociative disorders also have depression, PTSD or anxiety.

Treatment

Phase-Based Trauma Treatment (ISSTD Guidelines)

Treatment guidelines from the International Society for the Study of Trauma and Dissociation (ISSTD) recommend a phased approach, especially for DID and complex dissociative presentations:

1. Safety and stabilization: building a trusting therapeutic relationship, establishing safety, learning to manage dissociation and strong emotions, and improving daily functioning.
2. Trauma processing: careful, paced work with traumatic memories, without suggestive techniques.
3. Integration and rehabilitation: increasing cooperation and integration between parts of the self and building a life beyond survival.

Research on treatment for dissociative disorders is less extensive than for many conditions. Naturalistic studies, such as the international TOP DD project led by Bethany Brand, have found that people in this kind of treatment showed reduced dissociation, PTSD symptoms and self-harm over time, but randomized controlled trials are still limited.

Specific Modalities

• Trauma-focused psychotherapy with clinicians experienced in dissociation.
• EMDR, often adapted with additional preparation for people with dissociative symptoms.
• CBT adapted for depersonalization, which helps people reduce fear and avoidance of depersonalization experiences; small trials have shown benefit.
• Grounding and emotion regulation skills, such as those in DBT, to manage dissociative episodes. See grounding techniques.
• Parts-based approaches, such as internal family systems, are used by some clinicians, though research for dissociative disorders is limited.

No medication treats dissociation directly. A doctor may discuss medication for co-occurring conditions such as depression, anxiety or PTSD.

Common Myths

If someone with dissociative symptoms is at risk of self-harm or suicide, our crisis resources page lists immediate support.

Conclusion

Dissociative disorders sit at the intersection of trauma, memory and identity. The DSM-5 and DSM-5-TR recognize dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder, and other specified and unspecified dissociative disorder. These conditions are real and treatable, but they are often missed for years because symptoms such as memory gaps, identity confusion and detachment are attributed to depression, anxiety or personality. Scientific debate continues about their causes, but careful assessment and phased, trauma-informed psychotherapy with experienced clinicians help many people. Anyone experiencing persistent dissociation can start by speaking with a doctor or a licensed therapist.