Dissociative Disorders

Dissociation is fundamentally a disconnection—a separation of aspects of experience, identity, or awareness that ordinarily function as a coherent whole. At its core, dissociation involves the mind compartmentalizing or detaching from information or experiences that would otherwise be integrated into your conscious awareness, continuous sense of self, or autobiographical memory.

The Dissociation Spectrum

Dissociation exists on a spectrum. On the milder end are universal, non-pathological experiences: daydreaming, becoming absorbed in a movie and losing track of time, "highway hypnosis" during routine driving. These are normal fluctuations in attention and immersion.

Pathological dissociation, however, is more pervasive, distressing, and disruptive. It involves significant impairment in memory, identity continuity, or connection to self and surroundings, and it typically emerges as a response to trauma.

Primary Dissociative Disorders (DSM-5-TR)

Dissociative Identity Disorder (DID) is the most complex and severe. It is characterized by the presence of two or more distinct personality states or identities (often called "alters"), each with its own relatively enduring pattern of perceiving, relating to, and thinking about the self and the world.

People with DID also experience recurrent gaps in recall of everyday events, important personal information, or traumatic events that go far beyond ordinary forgetting. These gaps reflect inter-identity amnesia: what one identity experiences may be entirely unknown to another.

Dissociative Amnesia involves an inability to recall important autobiographical information—usually of a traumatic or stressful nature—that cannot be explained by ordinary forgetfulness, medical conditions, or substances.

Amnesia may be localized (for a specific time period), selective (for certain aspects of an event), or in rare cases, generalized (for one's entire life history). Dissociative amnesia can also present with dissociative fugue, a specifier describing sudden, unexpected travel or bewildered wandering with amnesia for one's past and sometimes confusion about identity.

Depersonalization/Derealization Disorder is characterized by persistent or recurrent experiences of detachment.

• Depersonalization involves feeling disconnected from yourself—observing your thoughts, feelings, sensations, or actions from outside yourself, as if watching a movie.
• Derealization involves experiencing the external world as unreal, dreamlike, distant, or distorted.

Importantly, reality testing remains intact: you know these perceptions are not real, which distinguishes this from psychosis.

The Trauma Connection

The unifying thread across dissociative disorders is trauma, especially early, severe, chronic trauma. DID in particular is strongly associated with repeated interpersonal trauma during critical developmental periods—typically before ages 6 to 9, when a child's sense of identity is forming.

These disorders are often missed or misunderstood. Symptoms can be subtle, mistaken for other psychiatric conditions, or not spontaneously reported by clients who feel shame, fear judgment, or have amnesia for their own dissociative experiences.

The presentation of dissociative disorders varies widely and is often more subtle than media portrayals suggest.

Dissociative Identity Disorder

The hallmark is the presence of distinct identity states. These may be experienced internally as separate "people" or "parts," each with a sense of having their own thoughts, emotions, memories, and preferences. Switches between identities may be dramatic or barely perceptible.

Common experiences include blackouts or "lost time" (periods for which you have no memory, later discovering that you did things, went places, or said things you cannot recall), or more fluid switches with co-consciousness (awareness of other identities) or passive influence (feeling controlled by internal voices or impulses).

Importantly, DID rarely presents with overt "personality switching" in a clinical setting. More common are gaps in memory for recent events, inconsistencies in self-reported history, finding evidence of actions you don't remember (unfamiliar clothing, receipts, appointments), being told by others about behavior you cannot recall, and internally hearing voices that comment, criticize, or argue. These voices are typically experienced as coming from inside your head and are often recognized as parts of yourself, which differentiates them from the external voices more typical of psychosis.

Dissociative Amnesia

Presents as memory loss that is circumscribed and distressing. Localized amnesia means you cannot recall a specific period of time—hours, days, or weeks—usually surrounding a traumatic event. Selective amnesia involves only certain aspects of an event being forgotten. In rare cases of generalized amnesia, you lose memory of your entire life history including your identity. When dissociative amnesia includes dissociative fugue, you may suddenly and unexpectedly travel away from home, sometimes assuming a new identity or appearing confused about who you are.

Depersonalization/Derealization Disorder

Marked by chronic or episodic experiences of unreality or detachment: feeling robotic, numb, as if encased in glass; observing life from outside your body; or experiencing the world as looking flat, colorless, dreamlike, or distant. Despite these perceptions, you know intellectually that these feelings are not accurate—you are not delusional or psychotic—but the experiences are persistent, distressing, and interfere with concentration, relationships, and emotional connection.

Functional Impact

Across all dissociative disorders, functional impairment is substantial. Work performance suffers due to memory lapses, concentration difficulties, or unpredictable dissociative episodes. Relationships are strained by inconsistent behavior, emotional unavailability, or inability to recall shared experiences. Many struggle with depression, anxiety, substance use, self-harm, and suicidality. The journey to diagnosis is often long—studies consistently find that individuals with dissociative disorders experience symptoms for years or decades before receiving an accurate diagnosis.

Psychotherapy is the primary and most effective treatment for dissociative disorders. The approach most widely endorsed by experts is phase-oriented treatment, as outlined in guidelines from the International Society for the Study of Trauma and Dissociation (ISSTD).

Phase 1: Stabilization, Safety, and Symptom Reduction

The initial phase focuses on building safety—both external (addressing current life dangers, unsafe relationships, self-harm, suicidality) and internal (reducing symptom severity, increasing distress tolerance, establishing communication and cooperation among parts in DID).

Therapy establishes a secure therapeutic alliance, normalizes symptoms as trauma responses, and teaches skills: grounding, affect regulation, containment imagery, mindfulness, distress tolerance, and self-care. For DID clients, this phase involves helping different parts recognize one another, reduce internal conflict, and agree on shared goals such as not harming the body. This phase can last months to years and is essential groundwork.

Phase 2: Trauma Processing

Once you are sufficiently stable—with adequate safety, coping skills, and therapeutic alliance—therapy moves to carefully processing traumatic memories. This involves helping you approach, tolerate, and integrate memories and emotions that have been dissociated. Techniques include gradual exposure, narrative work, and helping parts of the self (in DID) share and integrate their experiences. Trauma processing in dissociative clients requires careful titration and pacing; pushing too quickly can destabilize you or trigger overwhelming dissociation.

Phase 3: Integration and Rehabilitation

The final phase focuses on consolidating therapeutic gains, integrating identity (in DID, this may mean fusion of parts into a unified self, or cooperative functioning among parts without full fusion), and building a meaningful, connected life. Therapy addresses grief, loss, and the task of constructing a future no longer dominated by trauma and survival.

Specific Modalities

• Ego state therapy and parts work: Directly address the fragmented identity structure in DID.
• EMDR: Adapted for complex dissociation with extended stabilization and slower pacing.
• DBT skills: For emotion regulation and distress tolerance.
• Trauma-focused CBT: Modified to account for dissociative symptoms.

For Depersonalization/Derealization Disorder, treatment often emphasizes grounding techniques, cognitive-behavioral interventions targeting anxiety and avoidance, psychoeducation, and mindfulness practices (with caution, as some individuals find mindfulness triggers dissociation).

Treatment Duration

Treatment for dissociative disorders is typically long-term, especially for DID, where therapy may span years rather than months. Progress is often non-linear, with periods of setback or crisis. Specialized training and supervision are crucial for clinicians working with this population.

Medication does not treat dissociation itself, but may be helpful for comorbid conditions such as depression, anxiety, PTSD, or sleep disturbance.

Looking for more guidance? Visit our Learn center for information about starting therapy, or explore helpful resources including crisis support, recommended reading, and wellness tools.

Crisis Support: If you're experiencing thoughts of self-harm, contact the 988 Suicide & Crisis Lifeline or go to your nearest emergency room.

Questions about dissociative disorders or treatment options? We're here to help.