These disorders are hard to understand.

There's a lack of consensus not only about what dissociative disorders are, but also how best to treat them.

In addition, it's not uncommon for mental health care professionals to have difficulty describing what dissociation even is, and many medical schools don't include dissociative disorders in their curriculum.

Nevertheless, ignoring dissociative disorders doesn't simply make them go away, and every hospital and clinic will encounter patients who experience dissociation, so in this video we'll attempt to cut through the fog and figure out how best we can help these patients.

Let's first define what exactly the word dissociation means.

Dissociation refers to a feeling of being detached from one's sense of reality.

While any mental condition that involves one's concept of reality may make you think of psychosis, dissociation and psychosis are in fact separate and distinct experiences.

At its core, dissociation is a feeling of unreality, while psychosis is an inability to distinguish between reality and unreality.

This means that, while a person in a state of dissociation will say that their experiences don't feel real, they are still able to recognize that they are real.

In contrast, someone in a state of psychosis is genuinely unable to tell that their experiences are not part of a shared reality, and their reality-testing ability, such as their ability to tell that the voices they are hearing are not in fact coming from the outside world, is distinctly impaired.

While this feeling of unreality lies at the core of dissociation, it's not the whole picture.

Instead, dissociation involves other signs and symptoms as well.

These can roughly be divided into three categories, subjective experiences, memory abnormalities, and hypnotic phenomena.

To help keep these straight, let's use the mnemonic dreams.

The first two letters refer to the subjective experiences of dissociation, which is the feeling of unreality that we talked about already.

This feeling comes in two forms.

First is depersonalization, which is the feeling of having become detached from your own body and sense of self.

People experiencing depersonalization may suddenly feel a strange sensation that they are not real or that their body is unfamiliar to them.

They may look at their body and think, I'm not myself, or look in the mirror and say, that isn't me.

This can also be experienced as a sense that their body is out of their control or that they are observing their body from an outside perspective, or that their behavior is being controlled by someone else as if they were a doll or puppet.

The second D is for derealization.

Derealization is a sudden and profound sense that your current experience of the world is illusory or fake.

People often describe derealization as a mental fog or veil that suddenly descends and makes their surroundings seem alien or dreamlike.

Familiar places such as their own home or street may feel different or foreign.

People in a state of derealization also report that they feel unsteady or uneasy, like they are walking on shifting sand.

Notably, depersonalization and derealization are not in any way mutually exclusive states, and people will often feel both at the same time.

The next two letters refer to the memory abnormalities which are a key clinical symptom of dissociation.

Instead of broad memory losses, the memory changes seen in dissociation take on very specific forms.

The first form is retrograde amnesia which is when previously encoded memories are lost, as opposed to anterograde amnesia where new memories cannot be encoded.

For example, someone with dissociative amnesia may be unable to remember anything that happened in their life in the months after the death of their child a year ago, but they would be able to memorize new information such as a list of items to buy from the grocery store.

The E refers to memory errors of commission.

To understand this better, let's define what we mean by errors of both omission and commission.

Omission errors are things that happen that you can't remember, like not being able to recall where you went for dinner last week.

In effect, you have omitted the information from your mind.

In contrast, commission errors are false memories of things that didn't actually happen, like thinking that you had texted someone when in fact you never did.

In effect, you remember yourself committing an act that hasn't actually been committed.

Omission errors are incredibly common, even among people without dissociative disorders.

In contrast, commission errors are less common and appear to be specifically related to the capacity to dissociate, as evidenced by the fact that people who dissociate frequently differ from most people primarily in the increased number of commission errors rather than omission errors that they make.

This is not to say that most people don't make commission errors of memory as well, as they absolutely do.

However, people who dissociate tend to remember false or suggested memories with a much higher frequency than most people, and with a vividness closer to their memories of actual events.

The last three signs and symptoms of dissociation all overlap with phenomena observed during a state of hypnosis.

In fact, dissociation may even be the same thing as hypnosis, with the main difference being that it occurs spontaneously rather than being induced by others, with some using the term auto-hypnosis to refer to dissociation.

The first of these hypnotic symptoms is absorption, which is a state of being highly engaged in or entranced by mental imagery to the exclusion of everything else going on in the outside world.

Think of someone who is taking a walk in the woods while listening to a gripping fantasy audiobook.

This person may be so absorbed in their imagination that they are not consciously aware of everything going on around them, and they may later find that they don't have awareness of or memory of what happened around them while in this state.

In someone experiencing dissociation, this can take the form of poor awareness of the outside world because they are so engaged in their own thoughts.

Next, motor automaticity refers to behaviors that someone does automatically without conscious awareness or effort.

To continue the example from before, for someone who is absorbed in the audiobook, the process of walking is done without conscious awareness of effort, including even more complex tasks like staying on a path or avoiding walking into a tree.

In states of dissociation, this may result in the patient not being aware that they are doing a certain behavior, like moving their hand, and not reporting any desire to do the behavior if asked about it.

Finally, suggestibility is a trait of being inclined to accept and act on the ideas of others.

People who are highly suggestible may believe information without critically examining it, or may change their emotions in response to what others are telling them.

For example, let's say someone goes on a roller coaster for the first time and feels that they are having a great time while on it.

However, after getting off the ride, if a friend tells them, you look so terrified, they may now remember being terrified on the ride rather than excited if they are highly suggestible.

Suggestibility can intertwine with the memory abnormalities seen in dissociation as well.

For example, a lawyer may ask leading questions in an attempt to get an eyewitness to remember something differently, such as asking, what was the defendant wearing on the night of the murder, which assumes that the defendant is connected to the murder and makes the witness more likely to link the defendant to the crime, even if, in reality, they're completely innocent.

Okay, let's take a moment to check in.

Are you feeling confused?

If so, that's okay.

Dissociation is notoriously difficult to explain, even with a mnemonic.

In fact, one of the most common words that people who have dissociated use to describe the experience is indescribable.

The closest experience that most people have had to dissociation is a transient head rush of lightheadedness that occurs when you stand up too quickly.

When this happens, there is often a fleeting yet distinct sense of unreality that is similar to what people in a state of derealization or depersonalization will describe.

Like lightheadedness, the onset of dissociation is often sudden, startling, and unsettling.

While it can be unpleasant, dissociation is not an inherently pathological state.

In fact, up to 20% of people have experienced depersonalization or derealization in the past year, with it being particularly common following traumatic experiences.

However, for some people, dissociative experiences can become frequent or severe enough that they turn into a dissociative disorder.

While dissociative experiences are common, dissociative disorders are much more rare, with estimates placing the prevalence at around 1-3% of the population.

They are most commonly diagnosed in early adulthood, with very few cases beginning after one's 20s or 30s.

Non-pathological dissociation occurs with approximately the same frequency in both men and women.

However, pathological dissociation appears to be much more common in women, with dissociative disorders being diagnosed up to 10 times more often in women than men.

This discrepancy is believed to be at least partially related to higher rates of abuse histories in women compared to men, as a history of trauma, especially during early childhood, is a major risk factor for developing a dissociative disorder, with more than 90% of people diagnosed with these disorders reporting a history of childhood trauma.

Dissociative disorders are generally associated with high levels of distress and dysfunction, related not only to the dissociative experiences themselves, but also due to the many psychiatric symptoms like mood, anxiety, and sleep changes that tend to co-occur.

Other features, such as substance abuse, unstable interpersonal relationships, increased rates of physical illness, and an elevated risk for suicide are often present as well.

Because of this, dissociative disorders are some of the most disabling conditions, with studies consistently finding low rates of employment and high utilization of healthcare services and social welfare.

Interestingly, the prognosis for the dissociative disorders themselves is often better than it is for the patient as a whole.

One study found that, a decade after diagnosis, only a quarter of patients still met criteria for a dissociative disorder.

However, over 80% of patients still met criteria for any psychiatric disorder, with anxiety, somatoform, and personality disorders, especially borderline personality disorder, being common.

Unfortunately, treatment for dissociative disorders is severely under-researched.

Part of the problem is that it's not always clear what the specific outcome of treatment should be, with there being some controversy over whether the goal is to try to eliminate all episodes of dissociation, or simply try and reduce the distress and disability related to them.

Treatment studies on dissociative disorders also have an unfortunate tendency to refer to treatment in a general sense, and not provide any details on the exact type of interventions used.

Because of this, there is a lack of clearly defined treatment strategies for dissociative disorders, with most studies referencing a grab bag of therapies in different forms, like CBT, DBT, supportive therapy, hypnosis, art therapy, experiential therapy, and psychoeducation.

Interestingly, therapy appears to be only somewhat effective at addressing dissociation itself.

Instead, the most robust effects of therapy tend to involve reducing comorbid symptoms related to depression, anxiety, suicidality, trauma, and borderline personality disorder.

Studies have suggested that effective therapy for dissociative disorders typically requires long-term treatment in the order of years rather than weeks or months.

However, since we know that dissociative phenomena tend to naturally lessen over time even without treatment, it's unclear whether the beneficial effects observed with therapy are a direct result of therapy, or simply the natural course of the disorder.

As before, there is a clear need for more rigorously designed studies.

While the jury is still out on therapy, it's quite clear that medications are distinctly unhelpful at improving outcomes in dissociative disorders.

Many medications like antidepressants simply have no effect, and certain drugs like benzodiazepines may even have a pro-dissociative effect.

In general, meds are to be avoided in dissociative disorders.

Okay, let's now turn our attention to the three dissociative disorders listed in the

DSM, dissociative amnesia, depersonalization derealization disorder, and dissociative identity disorder.

In comparison to other videos, we won't be using a lot of mnemonics for dissociative disorders.

This is because the DSM criteria for these disorders are more like definitions than lists, with only one or two key features, which makes mnemonics rather pointless.

Instead, focus on understanding the nuances that make these disorders unique rather than memorizing lists of criteria.

The first disorder is dissociative amnesia.

This condition involves episodes of retrograde amnesia that lead to gaps in one's autobiographical memory.

These gaps often occur around the time of traumatic events and tend to have well-defined borders, with everything before and after a specific time period being remembered, just not the time itself.

The amnesia can be brief, lasting only a few minutes or hours, but it usually only becomes a disorder when it lasts for a while, like weeks or months.

In severe cases, the amnesia can be so profound that people forget their own name and identity, leading to a fugue state in which they will wander around with no knowledge of who they are or where they're from.

Dissociative amnesia is a diagnosis of exclusion, and other causes for memory loss must be ruled out.

The prognosis for dissociative amnesia is actually pretty good in that most people recover their memories even without treatment.

However, the overall level of functioning for these patients is often poor due to the various comorbidities, like PTSD or depression, that tend to co-occur.

Next, let's talk about depersonalization-derealization disorder.

People with this condition experience severe and persistent depersonalization and or derealization.

We talked earlier about how dissociation can be an unsettling and unpleasant experience, so it makes sense that people who experience it regularly could become quite distressed or even disabled as a result.

For about a third of these patients, dissociation occurs in discrete episodes, while for over half it is continuous with no end in sight.

The onset of symptoms can either be spontaneous or be linked to specific triggers, with common ones being stress, depression, and use of drugs like cannabis or hallucinogens.

Age of onset is typically in the teenage years, although some people describe experiencing dissociative experiences as far back as they can remember.

It affects men and women equally.

In studies, patients are generally well-educated and employed, but they often feel that their life functioning is below where it should be, such as having employment that's below their level of training.

All in all, the key here is that these patients are haunted by recurrent or continuous dissociative experiences that can be incredibly unpleasant and impairing.

Finally, we have dissociative identity disorder, which, despite being the rarest of the dissociative disorders affecting about only 1% of the population, it is the most disabling of the three.

Dissociative identity disorder is characterized by a consistent pattern of derealization, depersonalization, and memory lapses that are severe enough that someone experiences them as completely separate identity states, leading to a fragmentation of identity and a sensation that they are a completely different person from one moment to the next.

This fragmentation of identity can lead to observable changes in mannerisms, behavior, and speech between the different identities, which are sometimes called alters.

Indeed, the changes in behavior seen from one moment to the next in this disorder can be so pronounced that even outside observers can believe that there are several different people inhabiting the patient's body, which is reflected in the fact that this condition was previously known as multiple personality disorder.

However, contrary to popular media depictions, ranging from the strange case of Dr. Jekyll and Mr. Hyde in the 19th century all the way to Split in the 21st century, dissociative identity disorder does not actually involve multiple different people, each with their own names, personalities, and backstories, all living in the same body and switching back and forth between one another in a sudden or dramatic way.

Instead, dissociative identity disorder involves a sensation of different identities rather than their literal presence.

In addition, the patient's identity at any given time appears to correspond most with their emotional state, such as feeling like one identity when angry, another when scared, another when sad, and another when happy.

The sense of identity fragmentation is compounded further by the fact that patients with dissociative identity disorder often have affective lability, or the tendency to switch quickly from one extreme of emotion to another.

The aforementioned tendency towards memory errors also makes it harder for patients to hold on to a consistent sense of self.

To understand how affective lability and memory errors can lead to a sensation of changing identity, ask yourself, how do you know that you're the same person from one moment to the next?

It may surprise you to realize that things like physical appearance don't actually matter that much, as even if you were to look in a mirror and see a completely different person, you would probably still have your inner sense of who you are.

This is because most of us know ourselves based on two things, a consistent set of autobiographical memories and a stable pattern of thoughts, behavior, and emotions.