Dissociation and dissociative disorders: symptoms, causes and treatment

Key points

• Dissociation is a sense of disconnection from the self, the body, the surroundings or memory [1].
• Everyday dissociation, dissociation as a symptom, and a dissociative disorder are three different things [1][2].
• Depersonalisation is detachment from the self. Derealisation is detachment from the surroundings. They often occur together [2].
• Dissociation is not psychosis: reality testing stays intact, so the person knows the unreal feeling is a feeling [3].
• No NICE guideline covers dissociative disorders, treatment usually addresses the underlying trauma or anxiety, and the evidence is thin [6][7].

What dissociation is

Dissociation is a sense of disconnection from the self, the body, the surroundings or memory. The NHS describes it as a way the mind copes with too much stress [1]. Almost everyone dissociates mildly at times. A dissociative disorder is diagnosed only when the disconnection is involuntary, repeated and interferes with daily life [3].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

Everyday dissociation is common and harmless: becoming so absorbed in a book that the room drops away, or driving a familiar route with no memory of the drive [2].

Dissociation also occurs as a symptom of other conditions, including post-traumatic stress disorder, depression, anxiety and borderline personality disorder [2]. A dissociative disorder is a diagnosis in its own right, with episodes lasting hours or recurring over months [1].

No UK national survey measures dissociative disorders as a group. A systematic review found depersonalisation-derealisation disorder in about 1% of the general population and 5% to 20% of mental health outpatients [4].

Symptoms

Depersonalisation and derealisation often occur together but are not the same experience [2].

Depersonalisation, detachment from the self:

• feeling like an observer of one’s own actions, as though watching from outside the body [2]
• feeling that a limb, the face or the voice does not belong to the person [2]
• emotions feeling flattened or switched off, which people describe as feeling robotic [2]

Derealisation, detachment from the surroundings:

• the world looking unreal, flat or foggy, or as if seen through a pane of glass [1][2]
• familiar rooms, streets or faces seeming strange, lifeless or staged [2]

Memory and body:

• gaps in memory for personal events, more severe than ordinary forgetting [1]
• reduced sensitivity to pain, or seizures and blackouts that are not epilepsy [1][3]

Dissociation is most often confused with psychosis. The difference is reality testing: ICD-11 states that it remains intact during depersonalisation or derealisation, so the person knows it is a feeling rather than a fact [3]. It is also confused with panic attacks and with the effects of alcohol or drugs [3].

Types

ICD-11, the World Health Organization’s current classification, recognises seven dissociative disorders [3].

• Dissociative neurological symptom disorder. Motor, sensory or cognitive symptoms that do not fit a recognised nervous system disease, such as non-epileptic seizures, weakness, or changes in gait or speech [3].
• Dissociative amnesia. Inability to recall important personal memories, usually of recent stressful events, beyond ordinary forgetting. It is coded with or without dissociative fugue, where a person travels and cannot recall it [3].
• Trance disorder. Narrowed awareness with restricted movement and speech, involuntary and not an accepted cultural or religious practice [3].
• Possession trance disorder. Trance states in which the sense of identity is replaced by an external possessing identity [3].
• Dissociative identity disorder. Two or more distinct personality states that recurrently take control [3]. It has its own entry.
• Partial dissociative identity disorder. One dominant personality state runs daily life, intruded on by others that do not recurrently take control [3].
• Depersonalisation-derealisation disorder. Persistent or recurrent depersonalisation, derealisation or both, with reality testing intact [3].

Causes and risk factors

There is no single cause. Trauma is the most consistent factor, but it does not explain every case.

• Physical, sexual or emotional abuse in childhood is the background the NHS names most often [1].
• War, kidnapping and invasive medical procedures are also associated [1].
• Depersonalisation-derealisation disorder was found in around 17% of people with borderline personality disorder, about half of people with depression, and 25% to 53.8% of survivors of interpersonal abuse [4].

Most of this evidence rests on recall of past events, which cannot establish cause. ICD-11 defines these experiences as involuntary and unwanted, not attention seeking [3].

How it is diagnosed

There is no blood test or scan. Diagnosis is clinical.

A GP is normally the first step and can refer on. Mind advises asking a GP or psychiatrist for a full assessment, usually involving a psychiatrist and a psychotherapist with specialist training in dissociative disorders [5].

Assessment covers how the dissociation is experienced and how far it affects daily life, and rules out drugs and medicines, physical causes, and cultural or religious practices [5]. Where symptoms are neurological, neurology is involved too [3].

Misdiagnosis is common. Mind notes that many professionals have little training in dissociative disorders, that childhood trauma is often not asked about, and that symptoms overlap with borderline personality disorder [5]. No reliable UK figure exists for how long assessment takes.

A diagnosis names a pattern and opens a route to treatment. It does not mean a person is out of touch with reality.

Treatment

Treatment usually addresses what sits underneath the dissociation. NICE has guidelines on post-traumatic stress disorder and on anxiety, but none for dissociative disorders [6].

Talking therapy is the main treatment. Mind notes that the NHS mostly offers short or medium-term therapy, while these conditions often need longer [9].

Where post-traumatic stress disorder is present, NICE recommends individual trauma-focused cognitive behavioural therapy, and EMDR for adults presenting more than three months after a non-combat trauma [6]. It advises against computerised therapy where dissociative symptoms are severe [6]. EMDR usually has to be adapted for dissociative disorders [9].

For dissociative seizures, the CODES trial randomised 368 UK adults to cognitive behavioural therapy plus standardised medical care, or medical care alone. Seizure frequency at 12 months did not differ significantly, though the therapy group had longer seizure-free periods and better quality of life [8].

No medicine is licensed for dissociation itself. Antidepressants may be prescribed for depression or anxiety alongside it, and decisions rest with a GP or psychiatrist [1][9].

The evidence is thin: a Cochrane review of psychosocial interventions for these disorders covered 17 studies and 894 participants, rated most evidence low or very low certainty, and drew no firm conclusions [7].

Living with dissociation

Grounding techniques reconnect you with the present. Mind suggests breathing slowly while counting, listening to the sounds around you, walking barefoot, holding ice or splashing cold water on your face, and using strong smells or textures [10].

Practical aids help when memory is affected: a watch showing the date, a list of contacts, and notes to yourself at home or on a whiteboard [10].

A journal can help you notice what tends to come before an episode, and many people dissociate more when under heavy stress or sleeping badly [10].

Telling an employer or a university disability service is your decision, and it is what allows adjustments to be discussed. Peer support is available through Mind’s Side by Side community [10].

When to speak to a professional

Contact your GP if dissociation is happening often, lasting longer, or affecting work, study, relationships or your ability to keep yourself safe [5].

See a GP promptly if you have blackouts, seizures, weakness or changes in vision or speech, so physical causes can be checked first [1].

If anxiety or depression is also present, you can refer yourself to NHS Talking Therapies in England without a GP referral.

Contact crisis support if you cannot keep yourself safe. Samaritans: 116 123, free, 24 hours a day. Shout: text SHOUT to 85258. NHS 111, then the mental health option. Call 999 if anyone is in immediate danger.

Common questions

Is dissociation the same as psychosis?

No. ICD-11 specifies that reality testing remains intact in depersonalisation-derealisation disorder [3]. People describe the world as feeling unreal while knowing that it is not, and that awareness separates it from psychosis.

What is the difference between depersonalisation and derealisation?

Depersonalisation is detachment from the self: the body, voice or emotions feel as though they belong to someone else. Derealisation is detachment from the surroundings: the world looks foggy, flat or seen through glass [2].

Does dissociation go away?

It can. The NHS notes that some dissociative disorders resolve within weeks or months, while others last much longer [1]. Recovery is uneven and the evidence for specific treatments is limited [7].

Can anxiety cause dissociation?

Dissociation is recognised as a symptom of other conditions, including anxiety and depression [2]. Depersonalisation-derealisation disorder was identified in 3.3% to 20.2% of people with anxiety disorders [4].

Clinical review pending

References

1. NHS. Dissociative disorders. nhs.uk. https://www.nhs.uk/mental-health/conditions/dissociative-disorders/
2. Mind. What is dissociation? mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/dissociation-and-dissociative-disorders/about-dissociation/
3. World Health Organization. ICD-11 for Mortality and Morbidity Statistics: Dissociative disorders, block 6B60 to 6B6Z, including 6B66 Depersonalization-derealization disorder. ICD-11 MMS classification text accessed via Find-A-Code. https://www.findacode.com/icd-11/block-108180424.html and https://www.findacode.com/icd-11/code-253124068.html
4. Yang J, Millman LSM, David AS, Hunter ECM. The Prevalence of Depersonalization-Derealization Disorder: A Systematic Review. Journal of Trauma and Dissociation, 2022. https://discovery.ucl.ac.uk/id/eprint/10150602/
5. Mind. How to diagnose dissociative disorders. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/dissociation-and-dissociative-disorders/diagnosis/
6. National Institute for Health and Care Excellence. Post-traumatic stress disorder. NICE guideline NG116, 2018. Guideline text accessed via NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK542453/
7. Ganslev CA, Storebo OJ, Callesen HE, Ruddy R, Sogaard U. Psychosocial interventions for conversion and dissociative disorders in adults. Cochrane Database of Systematic Reviews, 18 July 2020. https://www.cochrane.org/evidence/CD005331_therapeutic-and-social-interventions-conversion-and-dissociative-disorders
8. Goldstein LH, Robinson EJ, Mellers JDC, Stone J, Carson A, Reuber M, and colleagues. Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial. The Lancet Psychiatry, 2020, volume 7, issue 6, pages 491 to 505. https://pureportal.strath.ac.uk/en/publications/cognitive-behavioural-therapy-for-adults-with-dissociative-seizur
9. Mind. Treatments for dissociative disorders. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/dissociation-and-dissociative-disorders/treatments-for-dissociative-disorders/
10. Mind. Self-care for dissociation. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/dissociation-and-dissociative-disorders/coping-with-dissociation/