Chapter 14
Dissociative Disorders

Our child came to us through the foster care system. When they found her, she could not speak, walk, or play. Over the past year, she's learned to do all those things. She does really well most days, but sometimes the smallest things can undo her. We were driving home from a visit with the case manager who helped get her out of that horrid place, and she just checked out. She was staring right at me, but it was like she wasn't even there. Later, she asked me how we got home. She didn't even remember being in the car. —Juan

Dissociation involves a “disconnection or lack of connection between things usually associated with each other” (International Society for the Study of Trauma and Dissociation [ISSTD], 2013b, para. 1) and is a normal part of many life experiences. Everyday dissociation can occur, for example, when an individual is absorbed in an activity, when a child creates an imaginary friend, or when an individual blocks out an unpleasant memory (ISSTD, 2013a). Approximately three quarters of individuals will experience dissociation after a traumatic incident as the brain works to protect itself during times of distress; however, most will not go on to develop dissociative disorders.

Dissociative disorders “are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (APA, 2013, p. 291). Spiegel et al. (2011) described dissociative symptoms as

(a) unbidden and unpleasant intrusions into awareness and behavior, with accompanying losses of continuity in subjective experience: (i.e. “positive” dissociative symptoms); and/or (b) an inability to access information or to control mental functions that normally are readily amenable to access or control: (i.e. “negative” dissociative symptoms). (p. 826)

The ISSTD (2013b) identified five types of dissociation addressed in the DSM-5: depersonalization, derealization, amnesia, identify confusion, and identity alteration. Depersonalization is a “sense of being detached from, or ‘not in' one's body,” whereas derealization is a “sense of the world not being real” (ISSTD, 2013b, para. 4) Amnesia involves a loss of ability to access stored information one would be expected to remember (ISSTD, 2013b). Identity confusion involves an uncharacteristic change in one's sense of self. Identity alteration “is the sense of being markedly different from another part of oneself . . . subtler forms of identity alteration can be observed when a person uses different voice tones, range of language, or facial expressions” (ISSTD, 2013b, para. 7).

There is evidence that dissociative disorders, once considered quite rare or fabricated, are simply missed in clinical settings (Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006; ISSTD, 2011). Prevalence of this class of disorders is high and estimated at 2% to 10% among the general population (ISSTD, 2013b). Unfortunately, individuals who experience dissociative disorders are among the most vulnerable and high risk of clients. This population experiences near-universal trauma, high rates of comorbid disorders, and suicidal behavior (Brand, Lanius, Vermetten, Loewenstein, & Spiegel, 2012; ISSTD, 2011). This chapter includes a discussion of essential features and special considerations for dissociative identity disorder (DID), dissociative amnesia, and depersonalization/derealization disorder. As with other chapters, the DSM-5 includes other specified dissociative disorder and unspecified dissociative disorder

Major Changes From DSM-IV-TR to DSM-5

Dissociative disorders are closely related to trauma, as reflected in APA's decision to place the chapter after the Trauma and Stressor-Related Disorders chapter. Changes to this chapter of the DSM-5 were modest. DID modifications were designed to address concerns regarding complexity, lack of specificity, expectation for rare yet readily observable shifts between identities, and culturally insensitive exclusion of pathological possession (Spiegel et al., 2011). Thus, Criterion A for DID was revised to allow observations or self-reported dissociation as well as experiences of possession. Criterion B was broadened to include issues with everyday gaps in memory rather than just gaps for traumatic events. Depersonalization disorder was renamed depersonalization/derealization disorder given research suggesting experiences of both are similar (Spiegel et al., 2011), and the rare dissociative fugue was subsumed as a special case of dissociative amnesia.

Differential Diagnosis

Like many other mental health symptoms, dissociative symptoms may be part of other disorders, caused by medical conditions, or triggered by substance use. Neurological conditions leading to symptoms that mimic dissociative disorders may include seizures, traumatic brain injuries, and neurocognitive disorders. In some cases, the presence of what appear to be neurological symptoms may also suggest a diagnosis of conversion disorder. The DSM-5 listed the following substances as triggering dissociative symptoms: cannabis, hallucinogens, ketamine, ecstasy, and salvia (APA, 2013). Counselors who work with clients experiencing dissociative symptoms should refer them for a complete medical evaluation and psychiatric consultation and consider whether diagnosis is within their scope of ethical practice.

Trauma is almost always at the root of dissociative disorders, so counselors should carefully consider whether a diagnosis of PTSD or acute stress disorder may better account for dissociative experiences. This requires careful assessment to determine whether dissociation occurs only in relation to a traumatic event (e.g., amnesia for trauma, flashbacks, instruction, and avoidance) or in a general manner. Given the strong evidence of a dissociative component of PTSD (Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012), individuals who experience depersonalization and/or derealization in the context of that disorder should be diagnosed accordingly with dissociative symptoms rather than depersonalization/derealization disorder.

ISSTD (2011) recommended special attention to bipolar, affective, psychotic, seizure, and borderline personality disorders when engaging in differential diagnosis. Mood changes may be indicative of identity alteration rather than fluctuations associated with bipolar disorders. Panic attacks have a dissociative quality to them, thus indicating anxiety disorders as potential differential diagnoses. Individuals with dissociative disorders may describe out-of-body experiences, have beliefs regarding possession, or hear different voices that lead one to suspect a psychotic disorder or psychotic features of depression rather than dissociation (Spiegel et al., 2011). Dissociations during times of stress, instability of identity, and history of interpersonal trauma are characteristic of borderline personality disorder as well. Indeed, one study of individuals diagnosed with borderline personality disorder revealed that roughly one quarter met criteria for mild dissociative disorders such as dissociative amnesia and depersonalization disorder, one quarter met the criteria for DID, and one quarter met the criteria for other dissociative disorders (Korzekwa, Dell, Links, Thabane, & Fougere, 2009). Finally, dissociation may be misidentified as behavioral problems (e.g., temper tantrums in ODD, inattention in ADHD) among children (ISSTD, 2013a).

Dissociative disorders are comorbid with a number of concerns, including depressive, anxiety, and substance use disorders (APA, 2013). Counselors should be particularly alert to self-injurious and suicidal behavior, especially given that 70% of those with DID have a history of the latter. Similarly, individuals who experience dissociation also tend to report a number of somatic concerns, thus indicating somatic symptom disorders as differential or comorbid diagnoses (ISSTD, 2011).

Etiology and Treatment

The ISSTD (2013b) characterized dissociation as having both environmental and biological components; there is no evidence of a genetic component. In nearly all cases, dissociative disorders may be linked to experiences of traumatic events, especially early in life. Precipitating experiences leading to dissociation in children and adolescents may include physical, sexual, or emotional abuse; chronic neglect; witnessing violence; loss of loved ones or disruption in caregiving; physical injury, medical conditions, or medical procedures; and accidents or disasters (ISSTD, 2013a). Emerging neurobiological research supports theories that early experiences of trauma and neglect affect brain development in ways that may lead to dissociative disorders (Brand et al., 2012; International Society for the Study of Dissociation [ISSD], 2004). Brain studies regarding individuals with dissociative disorders also provide evidence of divergent brain structure and function (APA, 2013; Brand et al., 2012).

The APA (2013) noted a striking 90% prevalence of childhood abuse and neglect among those with DID. Developmental models of DID posit that

DID does not arise from a previously mature, unified mind or “core personality” that becomes shattered or fractured. Rather, DID results from a failure of normal developmental integration caused by overwhelming experiences and disturbed caregiver–child interactions (including neglect and the failure to respond) during critical early developmental periods. This, in turn, leads some traumatized children to develop relatively discrete, personified behavioral states that ultimately evolve into the DID alternate identities. (ISSTD, 2011, p. 123)

There is no scientific evidence to support sociocognitive models that proposed clinicians created DID among highly suggestible clients (ISSTD, 2011). Similarly, there is evidence that severity and frequency of trauma are related to dissociative amnesia (APA, 2013). Depersonalization/derealization disorder is linked to experiences of emotional abuse or interpersonal conflicts (Simeon, Guralnik, Schmeidler, Sirof, & Knutelska, 2001), a finding supported by neurobiological research illustrating the relationship between verbal/emotional abuse in childhood and psychobiological brain changes (Spiegel et al., 2011).

Unfortunately, severe dissociative disorders among adults may be among the most difficult, time-intensive, and costly to treat (Brand, 2012; ISSTD, 2011). Childhood and adolescent dissociation appears to be more amenable to treatment than dissociation in adulthood, requiring less time and resulting in more positive outcomes (ISSD, 2004). Research regarding evidence-based treatments for dissociative disorders is rare, and there is a lack of controlled treatment trials (Brand, 2012; Brand et al., 2012). Counselors should be aware that treatments used with acute PTSD (e.g., standard exposure therapy) may be counterproductive and ineffective with this population (Brand et al., 2012). Limited research suggests attention to complex traumas and dissociation may lead to treatment effects ranging from moderate to large across a variety of symptoms such as depression, dissociation, anxiety, somatic symptoms, and substance use. There are mixed findings regarding the degree to which medications are effective for treating dissociative symptoms.

The primary goal of treatment for DID is achievement of integrated functioning (ISSTD, 2011). The ISSTD (2011) advocated for a staged approach to treatment with focus on “1. Establishing safety, stabilization, and symptom reduction; 2. Confronting, working through, and integrating traumatic memories; and 3. Identify integration and rehabilitation” (p. 135). If the client does not present a danger to self, most treatment is conducted on an individual outpatient basis, one to three times weekly, over an extended duration. The ISSTD characterized most treatments as psychodynamic with incorporation of approaches such as CBT, DBT, hypnosis, and eye-movement desensitization and reprocessing. Most individuals with DID receive psychotropic medication focused on specific distressing symptoms. Readers interested in learning more should review the “Guidelines for Treating Dissociative Identity Disorder in Adults” (ISSTD, 2011), “Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents” (ISSD, 2004), and ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults (Cloitre et al., 2012).

Implications for Counselors

Counselors may struggle to detect or diagnose dissociative disorders because clients may not be aware of the dissociation or may minimize the importance of dissociative experiences. Scholars interested in dissociative disorders warn that these are among the most overlooked disorders in clinical practice. Using structured diagnostic assessment tools, Foote et al. (2006) found evidence of dissociative disorders among over one quarter of clients in an inner-city outpatient clinic; only 5% of those meeting criteria for dissociative disorders were diagnosed previously. Counselors may find new assessment and screening tools helpful to detect dissociative experiences in practice (Brand et al., 2012). In addition, the ISSTD (2011) recommended that all clinicians screen routinely for “episodes of amnesia, fugue, depersonalization, derealization, identity confusion, and identity alteration” (p. 124). Counselors who work with youth may wish to consult ISSD (2004) for practical recommendations regarding assessment of dissociative symptoms in children and adolescents.

Opportunities to attend to dissociative experiences are likely to arise during discussion of experiences of trauma or abuse and during screenings conducted in everyday counseling practice. Counselors should be alert to signs of dissociation when initially discussing a client's history of trauma or abuse, when a client provides details related to trauma or abuse, or when a client experiences changes that may serve as triggers to previous experiences. It is important to recognize the protective function of dissociation for many and to refrain from pressing for details if a client appears vulnerable or overwhelmed by the experience.

Experiences related to dissociation may occur during the normal course of other neurological conditions (APA, 2013), and individuals from some cultures may experience dissociation related to highly distressing conflicts or stressors. APA (2013) advised careful consideration for diagnoses based on possession states because such experiences are often a normal part of spiritual practice. Similarly, experiences of depersonalization/derealization may be common in the general population and are often the goal of meditative practices (APA, 2013). Counselors must be careful not to stigmatize these normal experiences.

300.14 Dissociative Identity Disorder (F44.81)

Essential Features

Dissociative identity disorder (DID) was previously known as multiple personality disorder. This disorder is accompanied by usual gaps in everyday recall. Experiences may be recurrent, observed, must cause distress or impairment, must not be culturally accepted, and may not be substance-induced or due to medical conditions. DID specifically involves

Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. (APA, 2013, p. 292)

Special Considerations

Estimates of DID prevalence vary widely. Although some studies estimate rates as low as 0.01% (ISSTD, 2013b), most studies show general rates of 1% to 3% (ISSTD, 2011). Foote et al. (2006) found that 6% of individuals in a clinical sample met criteria for DID. Men and women appear to experience DID in approximately equal numbers but may vary in their presentation (APA, 2013). It is important to note that DID is likely to be much less dramatic and pronounced than one might believe based on popular cultural representations. There is just one code for DID: 300.14 (F44.81). There are no specifiers associated with this disorder.

300.12 Dissociative Amnesia (F44.0)

Essential Features

Dissociative amnesia is characterized by “an inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting” (APA, 2013, p. 298). The amnesia may be localized (focused on a specific period of time), selective (involving loss of memory for some aspects of a period of time), generalized (complete loss of information), systematized (focused on category of information), or continuous (focused on loss of new information; Spiegel et al., 2011). As with other disorders, the amnesia must cause impairment or distress and may not be substance or medically induced. DSM-5 revisions subsumed dissociative fugue, in which individuals engage in travel or wandering, under this diagnosis.

Special Considerations

APA (2013) estimated a 12-month prevalence of 1.8% among the general population; however, there is evidence of prevalence as high as 7.3% among international samples (Spiegel et al., 2011). Women are more than 2 times more likely to be diagnosed than men (APA, 2013). Now included in the diagnosis of dissociative amnesia, dissociative fugue is believed to be very rare, occurring in 0% to 0.2% of the population (ISSTD, 2013b). When coding only dissociative amnesia, counselors should use 300.12 (F44.0). When coding dissociative amnesia with dissociative fugue, counselors should use 300.13 (F44.1).

300.6 Depersonalization/Derealization Disorder (F48.1)

Essential Features

Depersonalization/derealization disorder is characterized by presence of depersonalization and/or derealization with intact reality testing and resulting distress or impairment; the experience cannot be substance induced or medically caused or due to another mental disorder (APA, 2013). In general, depersonalization, the feeling of being outside oneself, involves five elements: “numbing, unreality of self, unreality of other, temporal disintegration, and perceptional alterations” (Spiegel et al., 2011, p. E24). Derealization is characterized by feeling as if the world is unreal.

Special Considerations

Individuals in the general population may experience aspects of depersonalization or derealization on a regular basis, with half of all U.S. adults experiencing at least one lifetime episode (APA, 2013). The ISSTD (2013b) reported that some researchers believe depersonalization disorder follows depression and anxiety as the most common mental disorders; however, estimated lifetime prevalence of the disorder is just 0.8% to 2.8% (Spiegel et al., 2011). There is just one code for depersonalization/derealization disorder: 300.6 (F48.1). The disorder has no specifiers.

Case Example

Delila is a 35-year-old married woman who lives with her husband, Alex. They have been married nearly 15 years. Delila works full time in the accounting office of a medium-sized company where she is well liked and appreciated for her selfless support of others. Delila reports no contact with her family of origin, disappointed acceptance regarding her inability to have children, and regular engagement in the community. Delila is accompanied to counseling by Alex, who insisted they see a counselor to explore the possibility that she may be experiencing bipolar disorder. Dressed in neatly pressed khakis and a button-up shirt, Delila listens with respect and slight amusement as Alex reports a growing sense of discomfort regarding several recent changes in Delila.

Initially, Alex noted spending sprees during which Delila acquired a wardrobe that was uncharacteristically expensive and revealing. Unconcerned about finances, Alex attributed the changes to Delila's desire to “keep things alive” in their marriage. He became confused and then suspicious when Delila began denying using the credit card and refused to wear the clothes, acting as if she had never seen them before or as if Alex purchased them for her. Delila maintained her innocence yet shrugged off the concern, noting that she had become so busy she must have forgotten a trip to the mall.

Alex noted other times Delila “just wasn't herself.” Alex relayed several incidents in which Delila picked fights, sometimes snapping at him and other times mocking him. Hours later, she would deny having the conversation or act as if nothing had happened. Alex wasn't alone in his observations. Delila was recently sent home from work after several altercations with coworkers that led her boss to express concerns about her ability to handle stress. Alex was shocked to come home and find her heavily intoxicated in the middle of the day because she is normally a very light drinker. Delila appeared to be as dismayed as Alex, noting that she would never drink during the day and must have been drugged by a coworker.

Diagnostic Questions

1. Do Delila's presenting symptoms appear to meet the criteria for a dissociative disorder? If so, which disorder?
2. Based on your answer to Question 1, which symptom(s) led you to select that diagnosis?
3. What would be the reason(s), if any, a counselor may not diagnose Delila with that disorder?
4. What other diagnoses might you consider for Delila? Why?
5. What rule-outs would you consider for Delila's case?
6. What other information may be needed to make an accurate clinical diagnosis?