What are the signs and symptoms of dissociation and dissociative disorder?

Source: What are the signs and symptoms of dissociation and dissociative disorder?

 

Dissociation and dissociative identity disorder (DID)

This section gives information about dissociation and dissociative disorders. It explains the different dissociative disorders, their symptoms and treatments. This section is for anyone with dissociation and dissociative disorder and their carers, friends or relatives.

Overview

  • If you dissociate you might have symptoms such as not feeling connected to your own body or developing different identities.
  • Dissociative disorder is a mental illness that affects the way you think. You may have the symptoms of dissociation, without having a dissociative disorder. You may have the symptoms of dissociation as part of another mental illness.
  • There are lots of different causes of dissociative disorders.
  • You may get talking therapies for dissociative disorders.
  • You may be given medication that may help with symptoms of dissociation and dissociative disorder.

About

What is dissociation?

Many people will experience dissociation at some point in their lives. Lots of different things can cause you to dissociate. For example, you might dissociate when you are very stressed, or after something traumatic has happened to you. You might also have symptoms of dissociation as part of another mental illness like anxiety.

Some of the symptoms of dissociation include the following.

  • You may forget about certain time periods, events and personal information.
  • Feeling disconnected from your own body.
  • Feeling disconnected from the world around you.
  • You might not have a sense of who you are.
  • You may have clear multiple identities.
  • You may feel little or no physical pain.

You might have these symptoms for as long as the event that triggered them, or for a short time afterwards. This is called an episode.

For some people these symptoms can last for much longer. If you have a dissociative disorder you might experience these symptoms for long episodes or even constantly.

Types

What are the different types of dissociative disorder?

There are different types of dissociative disorder. There is more information on each of these below.

It‘s important to remember that you could have the symptoms of dissociation without a dissociative disorder. There is also a lot of disagreement among professionals over dissociative disorders.

What is dissociative amnesia?

If you have dissociative amnesia you might not remember things that have happened to you. This may relate to a stressful or traumatic event, but doesn’t have to.

In severe cases you might struggle to remember:

  • who you are,
  • what happened to you, or
  • how you felt at the time of the trauma.

This isn’t the same as simply forgetting something. It is a memory ‘lapse’. This means you can’t access the memory at that time, but they are also not permanently lost.

With dissociative amnesia you might still engage with other people, such as holding conversations. You might also still remember other things and live a normal life. But you might also have flashbacks, unpleasant thoughts or nightmares about the things you struggle to remember.

You may have dissociative amnesia with dissociative fugue. This is where someone with dissociative amnesia travels or wanders somewhere else, related to the things they can’t remember. You may or may not have travelled on purpose.

What is dissociative identity disorder (DID)?

Dissociative identity disorder (DID) is sometimes called ‘Multiple Personality Disorder. But we have called it DID on this page.

If you have DID you might seem to have 2 or more different identities, called ‘alternate identities. These identities might take control at different times.

You might find that your behaviour changes depending on which identity has control. You might also have some difficulty remembering things that have happened as you switch between identities. Some people with DID are aware of their different identities, while others are not.

There is a lot of disagreement between researchers over the notion of DID.

We think of someone with DID as having different identities. But some researchers think that that these are actually different parts of one identity which aren’t working together properly.

They suggest that DID is caused by experiencing severe trauma over a long time in childhood. By experiencing trauma in childhood, you take on different identities and behaviours to protect yourself. As you grow up these behaviours become more fully formed until it looks like you have different identities. When in fact the different parts of your identity don’t work together properly.

What is other specified dissociative disorder?

With this diagnosis you might regularly have the symptoms of dissociation but not fit into any of the types.

A psychiatrist uses this diagnosis when they think the reason you dissociate is important.

The reasons they give include the following.

  • You dissociate regularly and have done for a long time. You might dissociate in separate, regular episodes. Between these episodes you might not notice any changes.
  • You have dissociation from coercion. This means someone else forced or persuaded you. For example, if you were brainwashed, or imprisoned for a long time.
  • Your dissociation is acute. This means that your episode is short but severe. It might be because of one or more stressful events.
  • You are in a dissociative trance. This means you have very little awareness of things happening around you. Or you might not respond to things and people around you because of trauma.

What is unspecified dissociative disorder?

This diagnosis is used where you dissociate but do not fit into a specific dissociative disorder.

Psychiatrists also use this diagnosis when they choose not to specify the reasons why you do not fit into a specific disorder.

Or if they don’t have enough information for a specific diagnosis. For example, after a first assessment in accident and emergency.

What are dissociative seizures?

Dissociative seizures are hard to get diagnosed. They are regularly wrongly diagnosed as epilepsy.

Dissociative disorders can also be known as non-epileptic attack disorder (NEAD).

It can be hard to tell the difference between a dissociative and epileptic seizure. An EEG can read epileptic seizures but can’t read dissociative seizures. An EEG is a test that detects electrical activity in your brain using small, metal discs attached to your scalp.

Dissociative seizures happen for psychological reasons not physical reasons.

What is depersonalisation/ derealisation disorder (DPDR)?

The feelings of depersonalisation and derealisation can be a symptom of other conditions. It has also been found among people with frontal lobe epilepsy and migraines.

But it can also be a disorder by itself. This means it is a ‘primary disorder’. There is some disagreement among professionals whether DPDR should be listed with the other dissociative disorders at all.

DPDR has some differences to other dissociative disorders. In DPDR you might not question your identity or have different identities at all. You may still be able to tell the difference between things around you. And there may be no symptoms of amnesia. Instead, with DPDR you might feel emotionally numb and questions what it feels like to live. We have explained this in more detail below.

You might have these feelings constantly rather than in episodes. It doesn’t have to have been caused by a traumatic or stressful event.

Many people think that this disorder might be more common than previously thought. This might be because of:

  • a lack of information about it,
  • patients who didn’t report their symptoms, and
  • doctors who don’t know enough about it, meaning they underreport the condition.

With DPDR you might have symptoms of depersonalisation or derealisation or both.

Depersonalisation
With depersonalisation you might feel ‘cut off’ from yourself and your body, or like you are living in a dream. You may feel emotionally numb to memories and the things happening around you. It may feel like you are watching yourself live.

The experience of depersonalisation can be very difficult to put into words. You might say things like ‘I feel like I don’t exist anymore’ or ‘It’s as if I’m watching my life from behind glass’.

Derealisation
If you have derealisation you might feel cut off from the world around you. You might feel that things around you don’t feel real. Or they might seem foggy or lifeless.

Jane’s story

Jane started feeling the symptoms of depersonalisation after smoking cannabis. She felt like her eyes were fixed on parts of the room and that she was not connected to everything around her. She felt as if she was a spectator in her own life for many months, rather than actually living ‘in the moment’. It took Jane a long time to be diagnosed. To recover, she was helped to distract herself from the DPDR symptoms for long stretches with engaging activities. This then expanded into periods of time when she felt connected to the things around her again. Cognitivebehavioural therapy and mindfulness taught her to manage her anxiety and the distressing symptoms of DPDR.

Jane

Jane’s story

Causes

What causes dissociation?

There are different things that can cause you to dissociate. For example:

  • traumatic events,
  • difficult problems that cause stress, and
  • difficult relationships.

Other researchers have suggested that the use of cannabis may sometimes be a cause of depersonalisation/ derealisation disorder (DPDR).

Treatment

How are dissociation and dissociative disorders treated?

Dissociation can be treated in lots of different ways. The type of treatment you get might depend on which type of disorder you have.

Can medications help?

At the moment, there are no medications for dissociative disorders themselves, although you may take medication for some symptoms.

If you have episodes of dissociation you might also have a condition such as depression or anxiety. Some medications could help with this. For example, antidepressants could be used for depressive symptoms and benzodiazepines for anxiety.

Benzodiazepines can be addictive and should be prescribed for a short period only. Benzodiazepines can make Dissociation worse.

You can find more information on:

  • Antidepressants by clicking here.
  • Benzodiazepines by clicking here.

What psychosocial treatments can help?

Talking therapies are usually recommended for dissociation. There are lots of different types of talking therapy. Different ones might be used for different dissociative disorders.

What is psychodynamic psychotherapy?
If you have DID, then your doctors may think about long-term relationally psychotherapy. This is a type of therapy where you talk about your relationships and thoughts. You might talk about your past. Your therapist can link the ways you think and act with things that have happened to you.

For DID, psychotherapy might be needed for a long time, with at least 1 session every week. This will depend on individual’s situations and on their ability and level to function, resources, support and motivation.

What is eye movement desensitisation and reprocessing (EMDR)?
DID may also be helped by eye-movement desensitisation and reprocessing (EMDR). In EMDR you make side-to-side eye movements while talking about the trauma that happened.

Doctors must be careful when using EMDR because it could make your DID worse if not done properly. But EMDR can have benefits when it is used along with other treatment. The type of EMDR used for DID is slightly different to other conditions. So, it is important that your doctor knows about your DID before you start EMDR.

What is cognitive behavioural therapy (CBT)?
Cognitive behavioural therapy (CBT) is another type of talking therapy. You will talk about the way your thoughts and feelings affect you. And how your behaviours may make this worse. You focus less on the past and try to change the way you think and behave.

Parts of CBT are recommended to treat DID, by helping you to change your thoughts and behaviours that come from the trauma.

A CBT approach has also been suggested for long-lasting DPDR. If you have DPDR you might often worry about your symptoms and think you have a serious mental illness or that something is wrong with your brain. CBT may help to change this way of thinking. By reducing your anxiety and depression that comes with this worrying, it may also reduce your symptoms of DPDR.

You can find more information about ‘Talking therapies’ by clicking here.

What treatment should I be offered?

In the UK, the National Institute of Health and Care Excellence (NICE) publish guidelines on physical and mental health conditions. These guidelines are a standard for NHS treatment. At the time of writing, there are no NICE guidelines on dissociation or dissociative disorders.

But this doesn’t mean you shouldn’t be offered treatment. If you think you are having any of these symptoms, then explain this to your GP. They may refer you to a psychiatrist.

You can find more about ‘GPs – What to expect from your doctor’ by clicking here.

What if I am not happy with my treatment?

If you aren’t happy with your treatment you can:

  • ask for a second opinion,
  • ask an advocate to help you speak to your doctor,
  • contact the Patient Advice and Liaison Service (PALS), or
  • make a complaint.

There is more information about these options below:

How do I ask for a second opinion?

If you aren’t happy with your diagnosis or treatment, speak to your doctor. If they don’t offer you any other treatment options, you can ask for a second opinion. This is where another doctor will assess you and suggest diagnoses or treatment. You don’t have a legal right to a second opinion, but your doctor might agree to one.

What is advocacy?

An advocate can help you understand your rights to treatment from the NHS. They can also help you be fully involved in decisions about your care. An advocate is separate from the NHS.

You can search online to see if there are any local advocacy services in your area. Or the Rethink Mental Illness Advice Service could search for you. You can find their details at the bottom of this page.

What is the Patient Advice and Liaison Service (PALS)?

The Patient Advice and Liaison Service (PALS) at your NHS trust can try and help you with any problems or issues you have. You can find your local PALS’ details at: www.nhs.uk/Service-Search/Patient-advice-and-liaison-services-(PALS)/LocationSearch/363.

How can I make a complaint?

If you aren’t happy with the way you have been treated, you can make a complaint. You have to make a complaint about the NHS within 12 months of what you want to complain about.

You can find more information about:

  • Second Opinions by clicking here.
  • Advocacy by clicking here.
  • Complaints about the NHS or Social services by clicking here.

Self care & risks

What are self-care and management skills?

You can learn to manage your symptoms by looking after yourself at home. You will learn how to notice when you are becoming unwell and know what your triggers are.

Not all of the techniques here will work for everyone. It is important to try something that you enjoy and that you can commit to and that works for you.

Keeping a diary

You might find it helpful to keep a diary. You could write about how you felt over the day. Or you could write down goals that you want to achieve. You could use it as part of cognitive behavioural therapy (CBT).

Keeping a diary isn’t for everyone. If you have depersonalisation/derealisation disorder (DPDR) you might already spend a lot of time thinking about how other people see you. A diary may make you feel worse if it forces you to think about yourself. A diary can still help but talk to your GP or a counsellor first.

Grounding techniques

These techniques can be helpful for people who have been through trauma or who regularly dissociate. They can help to ‘ground’ you in the here and now. This may help when experiencing flashbacks.

Grounding works best when it is practiced regularly. Try practicing these things every day. There are different types of grounding techniques.

Using your surroundings
To use your surroundings, look around yourself. Focus on all the details of everything that is around you. Try describing this to yourself either out loud or silently in your head. Use all of your senses.

Using words
You could try positive words or phrases about yourself. For example, ‘I am strong’ or ‘I will succeed’. Write down a few things that are meaningful and positive for you. You could carry these around with you. Try reading them to yourself or aloud if your symptoms are bad.

Using images
This is similar to using your surroundings. Try thinking of a place that you feel peaceful and safe. This can be a real or imaginary place. If it is a real place, choose somewhere that is positive with no traumatic memories. Shut your eyes and imagine that place. Focus on all of the details and all of your senses.

Using posture
Try moving into a posture that makes you feel strong. This could be standing up with your shoulders back or relaxing your shoulders. Try different postures until you find one that works for you.

Using objects
Try choosing an object that is personal to you. You should try and pick something that only has positive memories attached to it. Carry it around with you and use it to remind yourself of who you are and where you are.

Relaxation

There are lots of different ways to relax. The important thing is to find something you enjoy doing. For example, cooking, reading or gardening. You might find that meditation or mindfulness helps.

Some relaxation techniques such as meditation and mindfulness may make some people feel worse. For example, if you have DPDR you might struggle with meditation. If this is the case, try and find something else that works for you. If you have CBT, you could tell the therapist. They could help you find something that works.

Exercise and diet

There are no specific exercises that can definitely help. But you could try jogging, swimming or just trying to walk more and something that suits your ability. Trying to eat more fresh fruits and vegetables can help. You could also try to reduce the amount of fat, salt and sugar you eat. Reducing the amount of caffeine, you drink can be helpful.

Sleep

If you don’t sleep enough your symptoms might feel worse. It can take a few weeks for you to get into better sleep habits. Here are some tips for helping you sleep.

  • Sleep when you feel sleepy.
  • Keep your bedroom as a place for only sleeping.
  • If you are lying awake in bed for a long period, get up and move around for a while.
  • Avoid taking naps during the day.
  • Try not to have caffeine for a few hours before you go to bed.
  • Make sure you get up at the same time every day. This can help you get into a regular routine.

You can find more information about ‘Complementary and alternative treatments’ by clicking here.

What risks and complications can dissociation cause?

Some people with a dissociative disorder may also have another mental health condition, such as anxiety or depression. This is called a ‘comorbid’ condition. In some cases, this can make your dissociative disorder harder in day to day life. However, all these conditions are manageable and treatable.

You can find more information on:

  • Depression by clicking here.
  • Anxiety Disorders by clicking here.

Carers, friends & family

What if I am a carer, friend or relative?

What support can I get?

If you are a carer, friend or family member of someone living with a dissociative disorder you can get support.

You can get peer support through carer support groups. You can search for local groups in your area on the following websites:

If you need more practical support, you can ask your local authority for a carer’s assessment. You might be able to get support from your local authority.

As a carer you should be involved in decisions about your relative’s care planning. But you can only be involved if your relative agrees to this. If they don’t agree, their healthcare professionals can’t share information about them with you.

You can find out more information about:

  • Carer’s assessment and support planning by clicking here.
  • Confidentiality and information sharing – For carers, friends and relatives by clicking here.
  • Benefits for carers by clicking here.

How can I supporting the person I care for?

You might find it easier to support someone with a dissociative disorder if you understand their symptoms, treatments and self-care options. You can use this to support and encourage them to get help and stay well.

You should also be aware of what you can do if you are worried about their mental state. Keep the details of their mental health team or GP handy and discuss a crisis plan with them.

You can find out more information about:

  • Supporting someone with a mental illness by clicking here.
  • Getting help in a crisis by clicking here.
  • Suicidal thoughts – How to support someone by clicking here.
  • Responding to unusual behavior by clicking here.

Further reading & Useful contacts

 

Caroline Spring
Online training on dissociation and Dissociative Identity Disorder, webinars and literature.

Website: www.carolynspring.com/

Clinic for Dissociative Studies
This organisation has lots of information on dissociative disorders on their website. They also provide care and treatment for dissociative disorders. They can accept referrals from the NHS. They offer general information about dissociative disorders but do not run a helpline.

Telephone: 020 7794 1655
Address: 35 Tottenham Lane, London, United Kingdom, N8 9BD
Email: info@clinicds.com
Website: www.clinicds.co.uk

South London and Maudsley Trauma and Dissocation Service
A specialist outpatient assessment, consultation and treatment service. It’s for adults who are experiencing psychological difficulties following trauma and/or dissociative disorders. The only NHS specialist service offering treatment for people presenting with complex post-traumatic stress disorder (PTSD) and severe dissociative disorders. Referrals are accepted from GPs and senior clinicians. All referrals have to be approved and funded by the local clinical commissioning group (CCG).

Phone: 020 3228 2969
Email: TDS@slam.nhs.uk
Website: www.slam.nhs.uk/national-services/adult-services/trauma-and-dissociation-service

 

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