Chapter 20: Dissociative Disorders

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Okay, so if you've ever tried to really dig into the history of dissociative disorders,

you probably know what I mean when I say it feels, well, less like a clear story and more like this psychiatric Tower of Babel.

Oh, absolutely.

Tower of Babel is a good way to put it.

You have all these different schools, different times, using terms like hysteria or splitting.

And they mean totally different things.

It gets really overwhelming fast.

It really does.

And that's kind of our mission for this deep dive.

We're using really the definitive modern take on this field, pulling directly from key chapters in the comprehensive textbook of psychiatry, trying to cut through some of that historical noise.

Okay, so where do we start?

What's the foundation?

The foundation has to be the modern definition.

So dissociation, according to the DSM 5TR, it's defined as a disruption or a discontinuity and how we normally integrate everything subjectively.

Integrate, like how our memory, our actions, our sense of self, even consciousness itself, all kind of hang together.

Exactly that.

And crucially,

you have to understand that dissociation isn't just all or nothing.

It's on a spectrum.

It's a dimensional thing, even adaptive sometimes, you know, like zoning out on the highway.

That's mild dissociation.

Right, we all do that sometimes.

But then it also defines a set of really distinct, often severe disorders.

And that's what we're unpacking today, those five main DSM 5PR categories.

Okay, let's list them out.

We've got dissociative identity disorder or DID,

dissociative amnesia, depersonalization

disorder, DPDRD, and then the two catch -alls, other specified dissociative disorders and unspecified dissociative disorders.

That's the set.

So maybe the best place to start is to look back and figure out why this field got so tangled up for such a long time.

Yeah, the history is pretty dramatic.

It really kicks off in the 19th century.

You see the shift away from just talking about sleepwalking, somnambulism, to this much bigger, messier idea of hysteria.

And what's really striking, looking at the source material, is how early some people connected it to trauma.

Even before all the big famous fights,

like Paul Braquet.

Right, Braquet's work is fascinating.

He was arguing way back then that hysteria wasn't about, you know, the wandering womb or female frustration, which was the prevailing deeply sexist view.

He said it was a brain disorder.

Yeah, linked directly to overwhelming traumatic experiences.

It's quite remarkable for the time.

And that really sets the scene for Charcot's famous clinic, La Salle Petriere.

That place became legendary for studying these really dramatic symptoms.

It did.

And one of the most famous cases, maybe the most famous, was Blanche Whitman.

They called her La Reine des Hysteriques, the queen of the hysterics.

And when you actually look at her life story, based on later reviews of her records mentioned in the source,

the trauma is just undeniable.

Absolutely staggering.

The records confirm this lifetime of severe compounding trauma,

physical abuse, sexual abuse.

And then tragically, later in life, she got severe radiation burns from working with x -ray equipment at the hospital.

So her symptoms mapped pretty directly onto this history of just objective suffering.

Perfectly.

But then, almost as soon as Charcot's influence waned, the whole field just kind of shattered.

You got these major disagreements.

The big, big split.

The big split.

You had Pierre Janay, who really carried forward the idea that severe trauma leads to this kind of psychic breakdown,

a failure to integrate the different parts of the mind.

Okay.

Trauma causes disintegration.

Makes sense.

But then you had Babinski.

And he went in a completely opposite, almost nihilistic direction.

He basically argued that hysteria was nothing but suggestion.

That the doctors were creating the symptoms.

He even coined a term for it, didn't he?

Pythiatism.

Pythiatism, exactly.

The idea that it's curable by persuasion because it's caused by suggestion.

And that core idea, that skepticism.

That it's all just suggestion, or people are faking it, or it's the therapist's fault.

That never really died out, did it?

It never did.

And unfortunately, Freud's journey kind of reinforced it in a way.

He started with his seduction theory, which put childhood trauma right at the center.

But then he famously backed away from it.

He did.

He pivoted, decided these were patient fantasies, not real memories.

And that decision pretty much pushed dissociation out of mainstream psychoanalysis for decades.

They often just lumped it in vaguely with the concept of splitting, which isn't really the same thing at all.

So the focus on trauma gets sidelined.

Until when?

The 70s and 80s.

Yeah, that's when things really started to shift back.

You had researchers studying Vietnam veterans and PTSD.

You had a huge increase in the reporting and awareness of child abuse.

And you had really powerful feminist critiques pushing back against the idea that trauma reports were just fantasy.

But even with that revival, the old skepticism came back too, just in a modern form.

Exactly, like Babinski all over again, but updated.

You saw the rise of movements like the false memory syndrome foundation, the FMSF, and these associated models, the iatrogenic model, meaning doctor caused, and the socio -cognitive model.

And their argument was basically?

Pretty much the same as Babinski's a century later.

That complex dissociation, especially DD, wasn't a real trauma -based disorder.

They argued it was an artifact of suggestive therapy techniques or people picking up cultural scripts, maybe from movies or books or just social role -playing.

Okay, so the battle lines were drawn again.

Is this a genuine response to trauma, deeply rooted in development and neurobiology, or is it suggestion, fantasy, maybe even faking?

Huge stakes.

And the source material we're drawing on is really clear here.

Over the last few decades, rigorous scientific research has pretty definitively settled this debate in favor of the trauma model, the TM.

So the fantasy model, or FM, just didn't hold up.

What was the evidence that tipped the scales?

It really comes down to the predictions each model made and what the data actually showed.

The trauma model consistently predicted and found a very strong, reliable link between dissociation and trauma, especially early childhood trauma.

And this holds up even when you use objective measures, not just self -reports.

Okay, the trauma link is solid.

What about the suggestion argument?

That's maybe the most crucial finding.

The fantasy model, socio -cognitive model, predicted that people with DID should be highly suggestible, right?

Because the theory is that suggestion creates the disorder.

Makes sense.

But study after study failed to find that.

Rigorous research shows that people with DID are generally not more suggestible than average people, sometimes even less so on certain measures.

The whole pithetism idea, the core of the scientific evidence we have now.

Okay, so with that scientific backing for the trauma model established, let's look at how we actually define these disorders today.

Dissociative Identity Disorder, DID.

Forget the movie stuff.

What's the actual core clinical feature?

The absolute core, according to DSM5TR, is this marked discontinuity in someone's subjective sense of self or their sense of agency.

It messes with their emotions, their behavior, memory, perception,

everything.

So it's not always like, you know, flipping a switch and becoming a totally different person outwardly.

Not usually, no.

That's actually pretty rare in day -to -day life.

For most patients, maybe only around 15 % show that kind of clear -cut external switching regularly, unless they're under extreme stress or in a crisis.

For most, the reality is much more internal.

Internal how?

Some of the feeling of overlap or interference, one part of the self intruding on another, the dominant state of consciousness feeling disrupted by these other self states.

Okay, so what are the symptoms that patients themselves report most often?

Well, when you actually survey day -to -day patients, the findings are really consistent.

Amnesia is basically universal 100%.

But beyond that, over 90 % report things like feeling their sense of self change abruptly, having spontaneous trance -like episodes.

And this is really important hearing voices.

But not usually like psychotic hallucinations.

It's more like the intrusive thoughts or internal dialogue of other self states.

This often gets misdiagnosed as psychosis, which is a major issue.

That makes sense.

Now, I thought it was interesting how the big diagnostic systems, DSM -5 -TR and the newer ICD -11, handle the edges of DD a little differently.

Yeah, there are subtle but important distinctions.

DSM -5 -TR decided to bring pathological possession states into the main DIDID criteria.

Possession states, like feeling possessed by a spirit or entity.

Exactly.

Because clinically,

the discontinuity of self, the amnesia, the altered behavior looks incredibly similar to non -possession DD.

So DSM integrated them.

But ICD -11 didn't do that.

ICD -11 kept possession trance disorder as a separate category.

But it also introduced something new and really interesting.

Partial DD.

Partial DD, what's that?

It describes a situation where you have a dominant personality state, the one that's usually out.

But it's frequently intruded upon by other non -dominant self -states.

However, those other states don't consistently take full control of the person's behavior.

It captures a kind of complexity that maybe falls just short of the full DIDID criteria.

Okay, interesting nuance.

Let's move to dissociative amnesia.

This isn't just forgetting where you put your keys, right?

Oh, absolutely not.

This is a significant alteration in autobiographical memory.

It usually shows up as gaps in memory for specific events, or sometimes huge chunks of their life history just missing or fragmented.

It can be recent stuff or things from way back.

And what about that specific term dissociative fugue?

Is that its own disorder?

No, it's a specifier for dissociative amnesia now.

It's not separate.

A fugue is when the amnesia is linked with purposeful travel or this kind of bewildered wandering.

The person might lose memory for their identity, who they are, or key details of their past life.

And the purpose is usually escape.

Pretty much.

It's often trudged by overwhelming stress or trauma as an attempt to just get away from it all.

The textbook gives that really compelling case of Mr.

J.

The man trapped in the cave.

Tell us about that.

Yeah, he was in this terrifying, life -threatening situation, trapped underground.

And he described this profound sense of detachment, time slowing down.

He was watching things unfold, even hearing his classmates digging to save him.

But with this strange, unemotional interest,

that detachment is characteristic.

And a key point about dissociative amnesia.

When those memories do start to come back, it's usually not like a smooth movie playing.

The breakdown in the amnesia often triggers a flood of PTSD symptoms,

intrusive flashbacks,

intense terror, fragmented images.

It's not a gentle return.

Okay, last one in this group.

Depersonalization, derealization disorder, DPDRD.

These terms sound similar, but they're distinct.

Very distinct, though they often occur together.

Think of them as two sides of a coin.

Depersonalization is feeling detached from yourself.

Like you're not real, or?

Yeah, or feeling like a robot, or like you're watching yourself from the outside, an out -of -body feeling detached from your own thoughts, feelings, body.

Okay, and derealization.

That's detachment from the outside world.

Feeling like the world around you isn't real, or it's foggy, distant, maybe two -dimensional, like you're living in a dream or behind a pane of glass.

That sounds incredibly distressing, but you mentioned the presentation can be tricky for clinicians.

It really can be.

Patients will describe these experiences as intensely awful,

profoundly disabling.

Their suffering is immense.

But because the core issue is this profound dissociation of affect, of emotion.

They might seem calm when talking about it?

Exactly.

They might appear remarkably flat,

detached, unemotional, while describing this terrifying feeling of detachment.

And that paradox can lead clinicians to mistakenly think the patient isn't suffering that much, when in reality it's incredibly severe.

Okay, so how do these really severe dissociative states, especially something like DD, actually develop?

The main framework we use, the one with the most support, is called the discrete behavioral state model, or DBS model.

Discrete behavioral states.

It essentially frames DD not as something that just appears in adulthood, but as a childhood onset post -traumatic developmental disorder.

Developmental, meaning it messes with how the self normally forms.

Pricely.

Think about normal development.

A child gradually learns to integrate all their different experiences, emotions, behaviors into a reasonably unified sense of me.

But if that child experiences severe, repeated, overwhelming trauma early in life, and the stats here are stark, something like 85 to 97 percent of DID cases, the non -possession form, have that kind of history.

That integration process gets derailed.

Completely derailed.

Instead of integrating, the child compartmentalizes to survive.

They develop these multiple distinct behavioral states to DBSs, and each state kind of holds different aspects of experience, especially the trauma -related memories, effects, sensations, which are kept separate, walled off from other parts of the self.

The self never fully knits together because being unified was too dangerous during the trauma.

But hiding the trauma away in compartments, there's a strange kind of resilience in that too, isn't there?

There absolutely is.

It's a defense mechanism, ultimately.

By sequestering the unbearable trauma into certain states, other parts of the self might be partially protected.

Protected how?

They might retain the ability to function reasonably well in other areas.

Maybe it deserves cognitive skills, creativity,

even a sense of humor, or the capacity to form attachments, despite the horrific experience is held by other parts.

It's complex.

And this whole process, this compartmentalization, can be made even worse by betrayal, right?

The source talks about betrayal trauma.

Yes.

Jennifer Free's work on betrayal trauma is crucial here.

It highlights that the harm isn't just the traumatic event itself, but also the failure of people or institutions who should have protected the person.

And there are different kinds.

Two main types discussed.

First,

institutional betrayal trauma.

This is when harm is done, or not prevented, by institutions we rely on, think systemic failures in the military, scandals in religious organizations, things like that.

This kind of betrayal seriously ramps up dissociation and mistrust.

Okay.

And the other?

Cultural betrayal trauma.

This is specifically about violence or silencing that happens within a marginalized group, violating the trust and safety that should exist within that community.

Both types are linked to significantly higher dissociation levels.

So, connecting all this back to the brain, how does the brain actually do this?

How does it manage such extreme fear and trauma?

Well, dissociation is increasingly understood as a fundamental biological defense response, especially in situations where fight or flight just isn't possible, like being held captive or during an assault.

So the brain just kind of checks out.

In a way, it switches to a state of shutdown.

Often there's an increased pain threshold, too.

It's sometimes called tonic immobility, like an animal playing dead.

Is there a specific system involved?

Polyvagal theory points to the dorsal vagal nerve complex.

When that system takes over, it leads to this immobilization, the shutdown state.

It's metabolically conservative, basically saving energy, and it's profoundly dissociative.

And there's chemical evidence, too.

You mentioned neuropeptide Y.

Yes, NTY.

There were some really interesting studies, particularly with soldiers going through that intense sear training, survival, evasion, resistance, escape.

Right, extreme stress.

Extreme stress.

And they found that the soldiers' levels of neuropeptide Y were inversely correlated with how much they dissociated.

Meaning more NPY, less dissociation.

Exactly.

High NPY seemed protective against dissociation under that intense stress.

It strongly suggests NPY is part of our built -in neurobiological system for resilience.

Okay, but maybe the most direct evidence against the it's all suggestion idea comes from brain imaging, right?

The fMRI studies on DID.

Absolutely.

Those studies are incredibly powerful.

They look at brain activity when different identity states in a person with DID are activated.

Comparing like a trauma holding state versus a more neutral one?

Precisely.

Comparing what they call traumatic identity states, TIS, and neutral identity states, NIS.

And what they find are distinctly different patterns of brain activation between these states within the same person.

Different from control subjects.

Different from controls.

And crucially, different from highly trained actors asked to simulate DID.

The differences are particularly noticeable in areas involved in memory and self -awareness, like parts of the striatum, the caudate nucleus,

especially when processing trauma -related information.

So the brain is literally processing things differently depending on the identity state.

That's what the evidence indicates.

It suggests different neural circuits are being used for memory processing and maintaining state stability, diverging from the typical more unified autobiographical memory system centered on the hippocampus.

It's measurable physical evidence that these states are neurologically distinct.

Dissociation is biologically real.

Given how complex these disorders are, stemming from early trauma and affecting the very structure of the self, treatment must be pre -structured too, I imagine.

Absolutely essential.

For the complex dissociative disorders, especially deity and severe dissociative amnesia, there's a strong expert consensus recommending what's called the Triphasic Trauma Treatment Model.

Three phases.

Okay.

Phase one.

Phase one is non -negotiable.

Stabilization.

The entire focus here is on safety.

Safety from self -harm, safety from harming others, creating a safe therapeutic environment, and building internal safety skills.

What does that involve, practically?

A lot of psychoeducation.

Helping the person understand dissociation.

And intensive work on basic coping skills.

Managing overwhelming emotions, controlling impulses, grounding techniques.

You can't do the deeper trauma work if the person isn't stable and safe first.

And safety is a huge issue, right?

The source mentioned incredibly high rates of suicide attempts among DID patients.

Devastatingly high.

Between 60 and 78 percent attempt suicide.

It's one of the highest rates for any psychiatric disorder.

So safety planning isn't just a formality, it's life critical.

How do you approach safety agreements in this context?

Often they're framed less as absolute promises and more as delaying agreements.

The goal is to help the patient and all their self -states understand that dangerous behaviors like self -injury or suicidality are often maladaptive ways of trying to cope with unbearable internal pain, shame, or trauma triggers.

Helping them find safer ways to manage those feelings is the core task of stage one.

Okay, so once a reasonable level of safety and stability is established, what's stage two?

Stage two is trauma processing and memory integration.

This is where the really intensive work happens.

Getting into the traumatic memories themselves.

Carefully, yes.

It involves controlled processing of the traumatic material that's been held in those dissociated states.

The goal isn't just to remember what happened, but to help the person integrate the thoughts, feelings, sensations, and memories associated with the trauma into a coherent life narrative.

Making it part of their past rather than something that keeps intruding on the present as if it's still happening.

That sounds like the biggest challenge weaving together those fragmented pieces held by different self -states.

It is.

It requires specific techniques adapted for dissociation and it absolutely requires the right therapeutic stance when working with the self -states.

What is that stance?

What's the key guidance for the therapist?

It is absolutely critical that the therapist does not treat the self -states as if they are separate people.

That reinforces the dissociation.

So no giving different states different appointment times or things like that?

Definitely not.

The goal is always to foster internal communication, collaboration, and eventually empathy between all the different self -states.

Recognizing that they are all facets, all aspects of one single human being who has had to adapt to unbearable circumstances.

The aim is integration, not reinforcing separation.

Okay.

And assuming that intensive work progresses, what's stage three?

Stage three is resolution and recovery.

This is about consolidating the gains from stage two and moving towards a more integrated and functional life.

What does resolution actually look like for the patient?

Does everyone have to achieve full fusion where all the states merge into one?

Fusion is one possible outcome where the different self -states psychologically merge and the barriers between them dissolve, resulting in a single unified identity structure.

That can be the goal for some.

But not the only successful outcome.

Not the only one.

Another very positive outcome is what's called therapeutic resolution.

This means achieving a state of stable, harmonious cooperation and communication among the self -states.

They might still retain some sense of distinctness, but they work together, share information, co -manage life, and function adaptively as a whole system.

Both fusion and therapeutic resolution are considered successful paths to recovery and a more unified life.

Right.

One last piece, medications.

Is there anything specific that treats dissociation itself?

A magic bullet.

Yeah.

Unfortunately, no.

There's currently no medication that directly targets or eliminates dissociation itself.

Pharmacotherapy plays a supporting role.

Supporting role how?

It's used to treat the often severe comorbic symptoms that go along with complex dissociative disorders.

The depression, the anxiety, the PTSD symptoms, sleep disturbances.

You treat those associated problems.

Is anything particularly helpful?

The source material notes that probably the most robust effect seen is with alpha -edrenergic antagonists like Prozosin.

It seems particularly helpful for reducing the intensity and frequency of PTSD nightmares and other intrusive symptoms, which can be a huge source of distress and destabilization for these patients.

Okay.

So that makes sense.

Targeting the related symptoms to help with overall stability.

Exactly.

It helps create the stability needed for the psychotherapy, which is the primary treatment.

So we've really covered a lot of ground.

We went from that historical Tower of Babel -Charcot, Babinski, Freud, all the way to the much clearer diagnostic criteria we have now in the DSM -5 -TR and ICD -11.

We've seen the really undeniable link between these disorders and severe early developmental trauma backed up by solid neurobiological evidence like the NPY and FMRI findings.

Right.

The science is much clearer now.

And we've walked through that structured three -phase treatment model, stabilization, processing, and resolution offering a path towards recovery.

It's quite a journey from confusion to a more scientific understanding and structured treatment.

And maybe as you think about all this immense human effort to understand and heal a mind fragmented by trauma,

maybe consider this thought.

Go on.

Given how central dissociation is to the integration of memory, consciousness, identity,

and given that even mild dissociation is pretty common, a part of everyday life for many,

does this maybe suggest that having a perfectly unified singular self isn't necessarily the default starting point for being human?

Perhaps that sense of a singular self is actually a profound developmental achievement, something that has to be built, integrated, especially through experiences of safety and rather than something we're just automatically born with.

That's definitely something to chew on.

Is the unified self a given or a goal?

A very provocative thought to end on.

Thank you as always for joining us on this deep dive into the source material.