Derealization Disorder

Just last month alone I received requests for therapy from four people who came with the diagnosis of DID (dissociative identity disorder). “Who gave you the diagnosis?” I asked. “The internet,” three of them responded; the fourth person said that her previous therapist had told her. A few years back, nobody talked openly about being in therapy, while today, the stigma of being in therapy has shifted, and being in therapy is not equated with insanity; it has stopped being a tool for shaming. Now it means the individual is progressive, open-minded and working on their growth. But like with everything, mental issues are now mentioned so lightly that we could be going in the opposite direction. Now the trend of pop-diagnosing could become a threat. From my experience, I’ve found that with DID — or as it was called before, “multiple personality disorder” — many individuals that are claiming to have the disorder may lack a clear understanding of what it means. This misunderstanding could pathologize all dissociative states — even when fragmentation of the psyche is completely real, alters are just one side of the spectrum. It’s essential to understand the rest of the continuum. Dissociating As a trauma therapist, I’m very interested in dissociation. It’s one of the most significant peritraumatic manifestations (during traumatization), and it is the one that creates more severe long-term alterations in terms of emotional engagement, memory storage and recollection, and emotional disengagement. But it is also a very “normal phenomenon.” Dissociation is not always mental illness. Or even a symptom in spite of the fact that the term usually reflects its clinical meaning. What I’m seeing is that the term dissociation can often be misused to either pathologize a completely normal behavior or to normalize a pathology. In a general sense, dissociation refers to the separation of realms of experience that would normally be connected. It covers a wide array of experiences, from a mild detachment to a severe disconnection from physical, cognitive and emotional experiences. Clinically, dissociation involves disruptions of usually integrated functions of consciousness, perception, memory, identity and affect — e.g., depersonalization, derealization, numbing, amnesia and analgesia — and therefore, even clinically, the term is used to refer to several very different levels of dysfunction. What I’m saying is that dissociation is common, and that most probably you have experienced it; and it does not mean that you have a dissociative disorder necessarily. I wrote another article that explains how Dissociation Is Not Always a Mental Illness. But it could also cause serious mental illness like DID. Dissociative States Dissociation is adaptive, surging mentally to protect us from uncomfortable or intolerable aspects of our experiences. Dissociating is a capacity, a part of the way our brains are wired and encoded on our human DNA, which likely emerged in the service of survival. As van der Kolk (1996) noted: “During a traumatic experience, dissociation allows a person to observe the event as a spectator, experience none or limited pain or distress; and to be protected from awareness of the full impact of what has happened.” Pathological Dissociation In the pathological side of the spectrum, the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders) lists three types of dissociative disorders: Dissociative identity disorder (DID), dissociative amnesia, and depersonalization/derealization disorder. They are serious business in terms of how debilitating they can be in the daily functioning of an individual, and there is no medication to resolve them. The pathological types of dissociation are caused mostly by fear; they are part of the survival strategies used to avoid feeling distressed and remembering the extreme and painful facts of experiencing chronic stress, traumatic events or challenging circumstances. Dissociation, then, is also a manifestation of dissociative disengagement, which causes a lack of encoding memories and, therefore irreversible amnesia, following neurophysiological changes during and after traumatization. They are debilitating because the fear doesn’t subside, and therefore, the disengagement becomes the norm to operate even when there is no more threat to avoid. Multiple Personalities There is disagreement among philosophers, academics, scholars, scientists, psychiatrists and clinicians on whether DID — or multiple personalities — really exist. I have witnessed fights in professional settings where the opinions are so divided that some individuals who have dedicated years of their lives to the subject get devalued and lose their temper. The opinions are extreme, divided and controversial. One of the most interesting and polemic points of view among clinicians is the argument that the formation of alters is simply a form of social compliance, possibly to conform with popular and psychiatric conceptions of psychopathology, but usually in response to therapists on the lookout for the disorder (Baynes et al, 2009). Therefore, it’s argued that DID is induced. I have observed it myself. Clients who have a propensity to dissociate and are easy to hypnotize, can be highly suggestible and therefore they could become victims of therapists. I have seen clients and therapists who fall into this trap. But of course, it is difficult to generalize about DID and the structure of the alter-systems, because many individuals speak up about their own experience and narrate a quite complex alter-system; there is little understanding of the extent of our minds’ power and reach. When a client changes posture, tone of voice and narrative, who could really affirm whether they are faking it or “living” it? Or how much they are aware of it and are able to remember? The possibility that a person can be a host of other minds (or energies) not as a deficit, but as a way to enjoy/live the extensive possibilities of our existence is intriguing. I’ve observed the phenomena among members of some religious practices. I don’t think it’d be fair to deny this possibility or to invalidate their experiences. We can’t really be sure of anything. Even when we have been granted a great cognition, it’s still too limited to understand the extent of “reality;” what we think is real many scientists and mystics affirm it is not. Human perception is limited by concepts and sensory processing. Our cognition can understand things, but our perception cannot (Braude). In any case, as a clinician, my job is to make sure that my clients get more integrated into society instead of living in their own world. For me, the key to whether a person is multiple should correlate 100% to the amnesic part of the diagnosis — which many clinicians disregard — and not only to the fragmentation. Fragmentation of the Psyche It’s a proven fact that we experience fragmentation after traumatization — especially prolonged exposure to traumatic circumstances — as a way to protect our psyche from confronting a reality that seems unbearable. The typical example is the child that has a part that loves the (abusive) mother because they depend on her, while another part will grow to hate the mother through hating women, or despising people with the mother’s characteristics (unconsciously) or even having a part that mimics the mother as a way to internalize the hate. Independently of trauma, what I have observed through many years of practicing IFS (Internal Family Systems) as a therapeutic modality is that we all have parts. Dick Schwartz — IFS’s creator — states that “parts” are a “person’s subpersonalities” and “are best considered internal people of different ages, talents and temperaments.” People who could be considered “well-integrated” have parts that know each other and are coordinated by a Self, while unintegrated psyches have parts that are in conflict and pull into opposite directions creating internal emotional conflicts to the bearer. Depending on how you frame it, a “part” can range from simple emotions to emotional states, to ego states, to alters. There’s not much written about the different nature of the dissociated parts; I find it important to make the effort of describing some of their differences. Differentiating the nature of the parts before assigning a diagnosis like DID could prevent harmful confusion and years of therapy. Parts It’s easy to identify parts when we feel two opposed emotions at the same time: one part of you wants to go out, and other part wants to stay home; or one part of you loves your partner and other part fears him/her. Let’s agree that fragments of the personality or psyche move in a continuum of parts, and that they all are adaptive and protective. Now, let’s move into finding their differences: Emotions as Parts Emotions have been explained in terms of adaptation, as messages that our system delivers to help us survive, avoid danger and deal with others (Hochschild). Emotions alert us about situations we confront and motivate us to act according to the event. Those signals are trying to tell us that we need to be proactive because we may be in danger, or in need of action; we’d experience tightness, tingling, warmth, tears, sweat or those butterflies in your stomach like when you see that beautiful person approaching you. Those sensations are part of the movement of the emotion. For example:·Anger may be trying to tell us we need to protect ourselves, maybe from abuse. Envy could be trying to say that we need to work harder to reach the position we wish to attain. Guilt may be saying that we should stop acting the way we have because we can damage others. Shame may be advising us to make corrections to our actions. Anxiety might be saying we need to take care of something because we may not like the consequences if we don’t. In these cases, the emotion in question can be interpreted as a part that can interact with our cognition in a conversation if we listen to them. If they have a message, and we focus on the message, we are actually “listening” to the emotion. Emotional States as Parts When an emotion is not heard and doesn’t meet its function of putting us into action, it stays in our system, alert for the next time we need it. And since they were not listened to, when they reappear, they become louder, more extreme and could even influence uncontrolled behavior. Vignette: Let’s imagine the scenario of when you were learning to drive. You are in front of the line at a stop with a red light and, suddenly, an instant after the light goes green, the car behind you honks. You respond with a startle — and an emotion. The emotion could be of shame, guilt, anger, etc. You may not have any other option than to push the gas pedal and move. The emotion was not able to be heard and exercise its motivation for action. You kept driving, carrying an emotional state that was not able to be processed or acted upon. After years of having had the same experience, when you find yourself still at the red light, failing to move before the guy behind honks, your emotional response then will be an accumulation of all those other moments in front of the light where you first got startled. If what you have accumulated is anger, you may yell, confront the driver, maybe curse. It will feel like a hundred honks in just that moment. That accumulation has become a more permanent part than the emotion alone. It lives in your body as a reminder of hating that experience because it makes you feel slow, criticized, pressured or whatever you interpret the honk means. It has a clear behavior and will exercise its power against the will of your reason, or the opinion of other parts. The repeated experience “creates” a part with very particular characteristics. You could have long conversations with this part in your head, and you will notice how it has its own point of view that is difficult to change. It has developed an agenda to protect you no matter what. Ego States as Parts Emotional states can be powerful but inconsequential — ego states are much more powerful and their presence in our system can have even more important effects. Emotional states were formed by the accumulation of an emotion. Ego states are formed by an interruption of the emotional response. When there is an impossibility for an emotion to do its job, instead of performing as it’s supposed to, the emotional response becomes an imprint on our emotional brain. The imprint carries the age and that mental experience from where the emotional response got stuck and the emotion froze, keeping it as a reality in the system. Instead of waiting to act out the emotion like in emotional states, the brain creates a schema of who the person is, depending on that emotion and emotional response. It’s created as a reminder and as an identity. Vignette: Using the same example of the red light and the honk, let’s imagine that the person becomes frozen after the honking and the car hits him from behind; s[h]e will feel like a bad driver that will stamp in his brain the schema of “I’m inadequate.” The feeling of inadequacy will stay “frozen” in the system and will have an impact on many other aspects of his/her life because it gets stuck in the conflict between whether to push the gas pedal to be safer, or to stay, pushing the break and retaliating against the person that just caused harm. Driving may become a difficulty or may be abandoned altogether. An ego state is much stronger than an emotional state because it will affect the way the person perceives him/herself. It will create a belief about the self that needs to be disconnected from the rest because it would be shameful if it were to be “discovered.” These parts may live in the person’s psyche in an unconscious way, affecting the way the person behaves. It’ll be in the background and will become alive when “inadequacy” comes out. They will freeze, feel the shame and embarrassment, will feel like hiding, quitting, etc. It will be in conflict with the system, and will live in the system but in a dissociated way, unintegrated to the other parts. Alters as Parts As opposed to being formed by either accumulation or interruption of an emotional state, alters form as a remedy for living an unbearable situation. An alter has a distinctive way of dealing with intolerable pain. Basically, the psyche of a person that goes through an extremely painful event creates an alternate identity (or alter) in order to experience the pain in their place. This is an extremely dissociative experience, but it uses exactly that characteristic (dissociation) to create the solution. Vignette: Going back to the example of the driver, imagine that they pushes the gas pedal after the startle and kills a pedestrian. Carrying an inadequate ego state will not be enough protection to deal with the situation. It’ll have to split further, assigning the actions to a different entity: “the killer.” Now, to keep the memory of manslaughter functionally isolated, the person will need to reconstruct the past, and creatively (and perhaps constantly) reinterpret present events in order to obscure the nature of that painful episode. That strategy seems to make the most sense when assigned to a single subject who manages the initial dissociative split, who experiences the relevant conflicts and responsibilities, and who takes steps to resolve them or pay for the actions. These parts will live in the system probably as undesirable, which could even create the amnesia of the “reckless” personality and dangerous responses. It’ll be harder to consciously access these types of parts for obvious reasons. Parts Diagnosis Parts can differ among each other clinically, as you see above. I’m breaking it down here so it becomes clear that we can try to understand our parts (just observing and examining them) instead of pathologizing or fearing them right away. By preventing an external official diagnosis of a mental disorder, we may develop the capacity to continually observe our emotions’ internal voices and catch them before they act-out. Mental health is all about awareness and integration. These observations will provide enough mental space to keep us whole. There is an entire another side of this that considers “parts” through the lens of paranormal situations, but that’s material for another article; maybe it will be written by a more New Age-yy “part” of me.

I was diagnosed with dissociative identity disorder (DID) in 2013. I felt alone, scared and confused. The trauma therapy I have received has helped me learn about the spectrum of dissociation, where I was on the spectrum, and build coping strategies for living well with my dissociative disorder. Inspired by the infographic on Instagram by @what.is.mental.illness , we are exploring the spectrum of dissociation. As the artist illustrates, dissociation occurs on a spectrum ranging from “normal” everyday dissociation to dissociative disorders , such as dissociative identity disorder .   View this post on Instagram  A post shared by Jade | Special Educator (@what.is.mental.illness) The Spectrum of Dissociation At the base level, dissociation is being disconnected from the here and now . This is an experience everyone has at some point in their lives. Examples include moments of daydreaming during class, getting lost in a really good book or movie, or “losing touch” with an awareness of one’s immediate surroundings like being in a crowded grocery store or while in Ikea. Dissociative moments have also been described as an experience of disconnecting from one’s current environment to assist with calming or focusing, as part of a ritual related to one’s religion or culture, or as a side effect of substance use, a side effect to taking or ceasing a medication, or a symptom of a mental health issue. After these everyday moments of dissociation is the experience of dissociation connected to post-traumatic stress disorder (PTSD), trauma, and dissociative disorders. Previous experience of trauma, including ongoing traumatic events over a length of time, has been associated with the development of dissociative disorders and is connected to dissociation as a coping skill that is effective in navigating the traumatic experiences as well as the after-impact. Dissociative disorders often affect a person’s memory (i.e., memory loss, amnesia), identity (i.e., integration/disintegration connected to parts of one’s self), emotion, perception, behavior and sense of self in different ways and to different degrees ranging from minimal impact to significant impact. When dissociation is severe to where it is affecting one or more aspects of a person’s everyday life, a dissociative disorder may be considered and diagnosed by a mental health professional. When it comes to dissociative disorders, there are three main types of dissociative disorders including dissociative amnesia, depersonalization/derealization disorder and dissociative identity disorder. Dissociative amnesia occurs when a person loses the ability to recall information about oneself — not normal forgetting — following a traumatic or stressful event in their life. The types of dissociative amnesia include: Localized: This is the most common type where a person is unable to remember an event or a period of time such as an evening or day. Selective: This occurs when a person is not able to remember certain parts of an event or events during a specific period of time. Generalized: This type is rare and involves a person completely losing their identity and the history of their life. Depersonalization and derealization disorder involves the significant ongoing or recurring experience of: 1. Experiences of unreality or being detached from one’s mind, self or body (i.e., depersonalization). 2. Experiences of unreality or being detached from one’s environment or other surroundings makings things and people in the world around them not feel real (i.e., derealization). 3. Both. Dissociative identity disorder (previously known as multiple personality disorder) is associated with significant ongoing trauma occurring during childhood. Symptoms include the existence of two or more distinct identities accompanied by changes in one’s behavior, memory and thinking; the presence of memory gaps related to everyday events, personal information, and/or one’s trauma; and one is experiencing severe distress or problems in different areas of their life due to these symptoms. Tips for Coping With Dissociation Seek support from a mental health professional. Use of grounding and visualization techniques. These techniques help bring us back to the present moment when experiences flashbacks, unwanted memories and negative or challenging emotions come up. Keeping a journal can help you understand, express and remember different parts of your day and experiences. Take time to care of yourself. Engage in self-care and stress-management practices. Talk to other people with similar experiences through peer or professional-led support groups, online forums, workshops and psychoeducation offerings. Use practical strategies. Examples of these include the use of notes, reminders, calendars, alarms, watches, maps, and preprogrammed numbers in your phone for help if needed. Navigating encounters of stigma. There are a lot of misconceptions and stereotypes about dissociation and dissociative disorders. Know and uphold your boundaries. Sharing educational materials about dissociation, using your voice and sharing your story, engaging in self-advocacy practices and seeking support from people who understand can all be helpful in breaking down stigma.