Dissociative disorders

Dissociative disorders are defined by disturbance and/or discontinuity in normal consciousness,

memory, identity, emotion, perception, body perception, motor control and behavior. The dissociative
symptoms might potentially disrupt all areas of psychological functioning. We will go through
Dissociative Identity Disorder, Dissociative Amnesia and Depersonalization Disorder.

Dissociative symptoms are experienced as:

a) Spontaneous intrusions on consciousness and behavior, coupled with loss of continuity in

subjective experience (e.g. positive symptoms, such as identity fragmentation,
depersonalization and derealization)
b) Failure to access information and control mental functions usually easily accessed or controlled.
(e.g. negative symptoms, such as amnesia).

Dissociative disorders are frequently found as consequence of trauma, and many of the disorders
characteristic traits, including shame, confusion and a desire to hide the symptoms, are influenced by
the proximity to trauma itself.

On DSM-5, dissociative disorders are grouped near, but not together, trauma and stress related
disorders, mirroring the close relationship between those two diagnosis. Both acute stress disorder and
post-traumatic stress disorder show dissociative symptoms, such as amnesia, flashbacks, numbness and
depersonalization/derealization.

Dissociative Identity Disorder (DID) is defined by:

a) Presence of two or more distinct personality states or a possession state;

b) Recurrent episodes of amnesia.

Identity fragmentation may vary within cultures and circumstances (e.g.: presenting itself as possession
by demons in religious communities). Thus, patients may experience discontinuity in identity and
memory which might not be immediately clear to others around them, for they are hidden within
acceptable cultural practice.

Individuals with DID experience:

a) Recurrent and unexplainable intrusions on their sentient functioning and on their identity of self
(e.g.: they may experience intrusive emotions and impulses).
b) Alterations in self-identity (e.g.: they may feel as if their actions, preferences and body are not
their own).
c) Bizarre changes in perception (e.g.: derealization and depersonalization, feeling away from own
body while self mutilating).
d) Intermittent neurological and functional symptoms.
 Stress often causes transitory symptom intensification, which makes them more evident. Long
periods of identity disruption may occur when psychosocial demands are severe and long lasting. In
many cases of DID which involve possession-like symptoms and in some which dont, alternate identities
manifest very evidently.

On the other hand, most individuals with DID which do not show possession-like symptoms do not
display long term identity discontinuity, and only very few show up at the physician with observable
identity alternation.

When alterned personality states are not directly observed, DID may be identified by two
symptoms:

a) Abrupt disruption or discontinuity in the sense of self and in control over own actions.
b) Recurrent episodes of dissociative amnesia.

Dissociative fugues in which the individual perceives the consequences of the episode are common.
As such, patients may suddenly find themselves on the beach, at work, in a club or even in unusual
places on their own houses (e.g.: inside the closet, under the bed, hidden in a corner), with no
recollection of how they got there. Amnesia in DID individuals is not restricted to stressful or traumatic
events, and those people may often be unable to remember day to day activities.

The possession-like manifestation of DID appears, in general, as if a spirit, supernatural being or

external entity has taken control of the patient, thus making them act and speak in clearly unnatural
manner.

For instance, a patient may behave as if their identity was exchanged for that of the ghost of a girl
who previously suicided among their community. This patient may act and speak as if she was still alive.
Another example would be a patient who is possessed by a demon or deity and demands that himself
or a family member be punished by a past action.

Those manifestations are followed by periods of subtler identity alterations.

Keep in mind that most possession states observed around the world are normal cultural
phenomena, connected with spiritual practice. Those states do not fill the requirements for DID. The
possession states which appear with the disorder are recurrent, involuntary and unwanted, causing
significant loss in life quality and social activity, and are not part of an accepted normal religious
practice.

Recommended media:

- For possession-like cases of DID, see the Exorcist;

- DID without possession-like traits and full identity alternation is rarely observed in clinical
practice but often portrayed in movies; see Fight Club and The Three Faces of Eve.
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Dissociative Amnesia (DA) is defined by the incapacity to recall autobiographic information.

This amnesia may be localized (regarding specific events or periods of time), selective (regarding
specific aspects of an event) or generalized (identity and life story). DA is, put simply, a state of being
unable to remember biographic information which goes beyond normal forgetfulness. It may unusually
include states of dissociative fugue, although such condition is much more common with DID individuals.

Although some individuals with DA promptly notice time is missing or that they have gap in
their memory, most patients are not aware of their amnesia. To them, the loss of memory will only be
noted when circumstances put them face to face with information they lack (e.g: finding evidence of
events they dont remember; other people telling them about situations they cannot recall).

Until that happens, however, those individuals display amnesia of their amnesia. Loss of
memory is a fundamental aspect of DA, and most patients experience localized or selective amnesia;
generalized amnesia is rare.

Generalized amnesia usually has an abrupt beginning; regarding localized/selective amnesia,

little is known about their beginning, for they are hardly ever evident even for the patient himself.
Although oppressive and unbearable events commonly precede localized amnesia, it may take hours,
days or even longer to manifest. Patients may report multiple episodes of dissociative amnesia, and a
single episode may predispose for future ones.

During amnesic episodes, the patient may or may not appear acutely symptomatic, and duration
of forgotten events may vary from minutes to decades. Some episodes quickly solve themselves (e.g: a
soldier removed from combat situations), whilst others persist for longer periods of time. Some
individuals may slowly recover dissociated memories years later. Dissociative capability may drop with
age, though not always. As amnesia resolves, the patient may display intense suffering, anxiety, suicidal
behavior and PTSD symptoms.

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Depersonalization disorder (DPD), also knowns as depersonalization-derealization syndrome is

defined by:

a) Depersonalization feelings of unreality and distance from own mind, self or the body.
b) Derealization feelings of unreality or distance regarding the world around.

Those must be clinically persistent or recurrent. These alterations happen without loss of
performance in reality checks. There is no distinction between predominance in depersonalization and
derealization. Therefore, individuals might experience one, the other or both.

Individuals with DPD often struggle describing their symptoms, and they may feel they are
insane or losing their minds. Commonly, they will express concern and fear about irreversible brain
damage. Time perception is commonly disrupted (e.g.: too fast or too slow), as well as subjective
difficulties in remembering past events and claiming those memories as theirs.

Vague somatic symptoms, such as head pressure and member numbness are not uncommon.
Patients might excessively worry or obsess (e.g.: constantly asking themselves if they truly exist,
obsessing over their sensory input to check if it is real). Varying degrees of depression and anxiety are
commonly found.

Recommended media:

- Neon Haze, a brief text game by Porpentine.