woman in bed struggling with dissociative disorder
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Summary: Dissociation in mental health disorders is the experience of symptoms that cause individuals to feel disconnected from themselves, the people, and the world around them.

Key Points:

  • People regularly engage in non-disruptive, non-pathological dissociation.
  • Daydreaming or zoning out while driving – and forgetting details of the time spent driving – are example of dissociation not related to mental health disorders.
  • The primary causes of dissociation are extreme stress, trauma, or the presence of clinical mental health disorder.
  • Evidence shows close to 70% of people experience a dissociative episode at some point during their lives, with around 2% meeting criteria for full, chronic, dissociative episodes/disorders with dissociation

Dissociation Defined: What is Dissociation?

The American Psychological Association (APA) offers this basic definition of dissociation:

“…a defense mechanism in which conflicting impulses are kept apart or threatening ideas and feelings are separated from the rest of the psyche.”

The authors of the study “Dissociation, Trauma, and Borderline Personality Disorder” share this more scientific sounding definition:

“Dissociation is a complex phenomenon…broadly defined as a discontinuity or disruption of usually integrated functions, such as consciousness, perception, attention, memory, and identity.” 

To understand how dissociation happens in all of us, to some extent, consider this explanation and example from the Merck Manuals:

“You may take a 20-minute drive to an appointment but forget most of the details of the drive because you were preoccupied with your thoughts, listening to music, or talking to a passenger. This is called nonpathological dissociation and does not distract from daily activities.”

Now consider this explanation of pathological dissociation:

“A person with [a mental health disorder with dissociation] may completely forget activities that occurred over hours, days, or weeks, and may know they’ve experienced missing time. The typical integration of consciousness, memory, perceptions, identity, emotion, body representation, motor control, and behavior is disrupted, and continuity of self is lost.”

That’s a good way to understand the difference between typical, nonpathological dissociation and pathological dissociation. Everyday dissociation is akin to daydreaming, spacing out, or being distracted such that what you’re actually doing may not be processed as usual by your brain. On the other hand, dissociation associated with trauma or mental illness is akin to you brain protecting you from negative, painful, or distressing thoughts, memories or experiences.

Types of Dissociation in Mental Health Disorders

Mental health experts recognize two primary types of pathological dissociation in mental health disorders: depersonalization and derealization. We’ll describe each, starting with a definition of depersonalization from the APA:

“Depersonalization is a state of mind in which the self appears unreal. Individuals feel estranged from themselves and usually from the external world, and thoughts and experiences have a distant, dreamlike character. In its persistent form, depersonalization is observed [mental health disorders]. It’s also often caused by traumatic experience/experiences.”

A person experiencing an episode depersonalization may feel:

  • Like they’re floating above themselves and watching their actions/behaviors from above.
  • As if another person/entity controls their thinking and behavior, like an externally directed/programmed robot.
  • Numb to or disconnected from physical stimuli and emotional experiences. They may know things are occurring, but can’t feel them or connect with them.
  • Like they’ve lost time or lost the capacity to accurately recognize/judge the passage of time.

It’s easy to see how that can be confusing or disorienting, and create problems or challenges in day-to-day life. If we summarize depersonalization as feeling disconnected from oneself, we can understand the next type of dissociation – derealization – as feeling disconnected from the surrounding physical world.

Here’s how the APA defines derealization:

“Derealization is a state characterized by a diminished feeling of reality, i.e. an alteration in the perception or cognitive characterization of external reality so that it seems strange or unreal, often due to trauma or stress, or as feature of some [mental health disorders].”

A person experiencing derealization may feel:

  • Like they’re dreaming, with the people/places/things they interact with don’t seem real
  • As if they’re separated from others and the world like watching events through fog or thick glass.
  • Like the world around them is flat, two-dimensional, or all black and white, with no depth, like the world is a picture on paper.
  • Significant or sudden changes in physical perspective, meaning the way they perceive size, shape, and distance is unstable and can transform at random.

It’s also easy to understand how the experience of derealization can be disorienting, distressing, and possibly dangerous. A sense of derealization at home may involve minimal risk, but experiencing a derealization episode while driving may be unsafe due to the changeable perception of objects in space and time.

Which Mental Health Disorders Have Dissociation/Dissociative Symptoms?

The meta-analysis and review article “Dissociation in Psychiatric Disorders: A Meta-Analysis of Studies Using the Dissociative Experiences Scale” identifies the presence of dissociation in at least nineteen (18) types of mental health disorders. To assess the presence and severity of dissociation by disorder, the research team compared patient results from the Dissociative Experiences Scale-II (DES-II).

We’ll list the disorders below, from highest lowest score on the DES-II:

  1. Dissociative identity disorder
  2. Dissociative disorders:
      • Depersonalization/derealization disorder
      • Dissociative amnesia
  1. Posttraumatic stress disorder
  2. Borderline personality disorder
  3. Conversion disorder
  4. Depersonalization/derealization disorder
  5. Anorexia nervosa
  6. Bulimia nervosa
  7. Gambling disorder
  8. Alcohol use disorder
  9. Somatic symptom disorder
  10. Feeding and eating disorders
  11. Schizophrenia
  12. Substance-related disorders
  13. Panic disorder
  14. Obsessive-compulsive disorder
  15. Depressive disorders
  16. Anxiety disorders
  17. Bipolar and related disorders

To further illustrate what the subjective experience of dissociation in mental health disorders is like, we’ll share several questions from the DES-II.

Examples of DES-II Questions: Identifying Dissociation

Some people…

… have the experience of finding new things among their belongings that they do not remember buying.

…sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something and they actually see themselves as if they were looking at another person.

…have the experience of feeling that other people, objects, and the world around them are not real.

…have the experience of looking in a mirror and not recognizing themselves.

After each question, people taking the assessment read this instruction:

Select the number to show what percentage of the time this happens to you:

[0  10  20  30  40  50  60  70  80  90  100]

Again, these examples help us understand what dissociation is, how it may feel to experience dissociation, and that dissociation has roots in typical daily cognitive occurrences but is not anything like the typical daily experience of reality reported by people without dissociation.

Consequences of Untreated Dissociation, Effect of Untreated Dissociative Disorders

The article “Trauma-Related Dissociation and the Dissociative Disorders: Neglected Symptoms with Severe Public Health Consequences” assessed the impact of untreated dissociation and dissociative disorders on individuals diagnosed with mental health disorders with dissociation.

Impairments, disruptions, and problems related to dissociation in mental health disorder include, but are not limited to:

  • Problems completing common daily personal tasks
  • Impaired function at work and school
  • Increased risk of chronic illness, including
    • Diabetes
    • Cardiovascular disorders
    • Chronic pain
  • Low level of adherence to treatment/high level of noncompliance
  • Gradually decreased response to medication/pharmacotherapy
  • Increased risk of experiencing repeated assault/abuse
  • Greater likelihood of substance use/addiction problems
  • Increased risk of non-suicidal self-injury (NSSI)
  • Increased risks of suicidality, i.e. thinking about, talking about, planning, and/or attempting suicide

The study authors indicate dissociation and/or dissociative disorders may develop for a variety of reasons, including, but not limited to:

  • Experience of extreme, overwhelming stress
  • Physical exhaustion
  • Psychological exhaustion
  • Ingesting/using substances such as ketamine, PCP, psilocybin, LSD, ibogaine, and MDMA
  • Experience of severe trauma or traumatic events
  • Presence of mental health disorders (on list above)

That shows us that there are three main pathways to pathological dissociation:

  1. Stress, trauma, exhaustion, overwhelm
  2. Substance use or misuse
  3. Symptom of clinical mental health disorder

We’ll discuss treatment for dissociation and dissociative disorders below.

Effective Treatment for Dissociation in Mental Health Disorders

Treatment for dissociation and dissociative disorder revolves primarily around specific, trauma-informed psychotherapeutic techniques adapted to address the core symptoms of dissociation.

There are no specific medications for dissociation.

However, a person with a mental health disorder with dissociative components may receive medication for that disorder, in the form of antidepressants, anxiolytics, or antipsychotics. These medications address core symptoms of the primary disorder, which can help overall recovery and improve daily function.

Evidence-based psychotherapeutic approaches to the treatment of dissociation/dissociative disorders include:

  • Phase oriented psychodynamic psychotherapy
  • Unified protocol for mental health disorders
  • Schema therapy
  • Cognitive behavioral therapy (CBT)
  • Dialectical behavior therapy (DBT)
  • Eye-movement desensitization and reprocessing (EMDR)
  • Internal Family Systems (IFS)
  • Sensorimotor psychotherapy

Experts indicate outcomes improve when treatment follow the  model established in phase oriented psychodynamic psychotherapy, which, when provided by an experienced mental health professional, can incorporate elements of many of the individual approaches on the list above.

Treatment for dissociation can:

  • Decrease symptoms of dissociation, PTSD, anxiety, and depression
  • Reduce NSSI and suicidality
  • Decrease frequency of psychiatric hospitalization
  • Reduce use of medication

In addition, evidence-based treatment can:

  • Improve emotion regulation
  • Improve ability to successfully participate/engage in school, work, and relationships
  • Increase overall functional capacity/daily functioning

We’ll close this article with insight from the authors of the “Trauma-Related Dissociation and the Dissociative Disorders” we cite and link to above:

“Detection and treatment of trauma-related dissociation and [other dissociative disorders] leads to a myriad of positive outcomes including improved quality of life, treatment outcomes, reduction in health and social risks, decreased healthcare utilization and costs (25-64% reduction), and significant economic advantages for society. It is imperative that healthcare professionals are trained in recognizing, assessing, and treating dissociation in service of preventing the discussed public health consequences.”