Continuum of Disease


Dynamics of Dissociation

The Personality System

Making the Diagnosis

Common Presentations of MPD



Nursing Implication

Cast Studies



Post Examination

Dynamics of Dissociation

Multiple Personality Disorder is classified in the DSM-III-R as a dissociative disorder.  Braun defines dissociation as the separation of an idea or thought process from the main stream of consciousness (Braun, 1990).  In the DSM-III-R dissociation is defined as a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.  Dissociation is the primary defensive structure at the core of MPD.  There are different levels of dissociation, which are generally dictated by the type or degree of trauma the individual has undergone.  The various dissociative phenomena can also be seen in combination, particularly in Multiple Personality Disorder, where other dissociative disorders present as symptoms of MPD.

Dissociation has been seen more and more commonly in the past twenty years as patients’ have come forward with memories of childhood sexual abuse.  This traumatic material has generally been forgotten until a stressful adult experience, such as an intimate relationship, sexual harassment at work, or the death of the abuser, triggers the memory.  It is difficult to understand how one might forget such childhood experiences, and naturally this leads to skeptics questioning the validity of such experiences.  However, with a clear understanding of dissociative phenomena, one can only appreciate the wonderful protective powers of the human brain.

Dissociation is a defense mechanism created to protect the individual against noxious trauma.  It is the individual’s attempt to manage intolerable affect by walling off the traumatic material from consciousness and by simultaneously creating a separate consciousness in which the trauma can be filed.  The ego screens traumatic stimulation from the field of consciousness in order to prevent sensory overload.

Post traumatic stress disorder (PTSD) is a diagnosis given to victims of childhood abuse, and is directly related to the phenomenon of dissociation.  Individuals suffering from PTSD have experienced trauma outside the range of usual human experiences, which would produce severe psycho physiological stress.  This stress then triggers an altered state of consciousness, which is a hypnoidal dissociative state.  Multiple personalities can be viewed as altered states of consciousness produced as a severe and chronic manifestation of PTSD.  (Steele, 1989)

Dissociation exists along a continuum starting with lower levels of dysfunction and going to higher and more disabling levels.  Dissociation is something most of use on a daily basis.  Much of our consciousness is outside our awareness as we go about our daily lives.  Purely as an example, we can look at daydreaming as a low level dissociation.  We all daydream and there is nothing wrong or dysfunctional about it.  But this is a good way to begin to understand what dissociation is all about.  Daydreaming takes us momentarily away from the present.  When we snap out of a daydream we realize things have gone on around us without our being consciously aware.  The teacher is now talking about another subject, someone has left the room, friends are laughing at the punch line of a joke we only remember hearing the beginning of.  The daydream helped us to momentarily escape.  This is exactly what happens when dissociation occurs.

Everyone dissociates to some degree at certain times.  On a normal level daydreaming, “spacing out” or forgetting something does not affect our overall function in life, is not pathological and cannot be attributed to a traumatic past event.  This type of dissociation is normal and is only used as an example to better understand the process of dissociation.

Moving along the continuum from daydreaming, a non-pathological behavior, we find the pathological dissociative disorders which are identified in the DSM-III-R.  (See Figure 2)
These include depersonalization, amnesia, fugue, and multiple personality disorder (MPD).   The severity or complicity of dissociation is dependent upon certain factors which relate to the abuse.  The age of the individual during the time of the traumatic event is an important variable.  The younger the child, the more severe the disorder.  The frequency of the abuse and the amount of damage incurred are important variables.  The degree of dissociation will depend upon who the abuser is; abuse by a family member is more traumatic than abuse by someone outside the family circle.


Depersonalization is the experience of feeling detached from oneself, as if one is an outside observer to one’s own behavior.  This person tends to have a chronic sense of discomfort with herself, feeling estranged from her own body or thoughts.

This is a surprisingly common disorder, occurring in 30 to 70& of young adults.  It is the third most common complaint among the psychiatric population.  (Talbott, 1988)  These patients often fear they are going insane.

An example of this would be a woman who was the victim of childhood incest and as an adult must depersonalize her sexual experiences with her spouse.  She will subconsciously separate from her body in order to avoid the painful memories of the abusive past which are triggered by her adult sexual involvement.  She may not be unaware of this behavior until her partner makes a comment like, “You seem a million miles away.”  Or she may actually have the sensation of separating from her body and watching from afar.

Friction in this marriage might lead the woman into therapy where she would subsequently discover the traumatic events from which she has escaped all these years.

The child victimized by sexual abuse will employ depersonalization as a defense mechanism against the trauma.  She will dissociate by separating from her body in order to continue living through the terrible ordeal which is out of her control.  In order for the child to remain living in her family she must create a separate self which commits the incestuous act.  She is somehow able to protect a part of her psyche with the thinking, “This is not happening to me but to someone else; I am not guilty because I am not I.”  This ability of the child to fragment in order to absorb the trauma is the only mechanism preventing complete emotional collapse.

The following is the diagnostic criteria for Depersonalization Disorder taken from the DSM-III-R:

  1. Persistent or recurrent experiences of depersonalization as indicated by

    either (1) or (2):
    1. An experience of feeling detached from, and as if one is an outside observer of, one’s mental processes or body.
    2. An experience of feeling like an automation or as if in a dream.

  2. During the depersonalization experience, reality testing remains intact.
  3. The depersonalization is sufficiently severe and persistent to cause marked distress.

  4. The depersonalization experience is the predominant disturbance and is not a symptom of another disorder, such as Schizophrenia, Panic Disorder, or Agoraphobia without history of Panic Disorder but with limited symptom attacks of depersonalization, or temporal lobe epilepsy.

The DSM-III-R distinguishes between the symptom of depersonalization and Depersonalization Disorder.  Depersonalization can be seen as a symptom in Schizophrenia, Mood Disorders, Organic Mental Disorders (especially Intoxication and Withdrawal), Anxiety Disorders, Personality Disorders, and Epilepsy.  Depersonalization Disorder is only diagnosed when the episodes of depersonalization are recurrent and persistent, and are severe enough to cause marked social or occupational impairment.


            The amnesia begins suddenly and is usually the result of a severely stressful situation.  Such a stress might involve the threat of physical injury or death, the unacceptability of an impulsive act, such as an extramarital affair, or an intolerable life situation, such as abandonment by one’s spouse.  During the episode the person appears perplexed, disoriented and may wander aimlessly.  The amnestic episode usually ends abruptly, with full recovery and rare reoccurrences.  The individual is usually aware of the disturbance in recall upon recovery.

            This, again, is to be differentiated from amnesia as a symptom, such as one might see in a female patient who was the victim of childhood incest and who suddenly brings forth memories of the forgotten abuse in later adulthood.

            The following is the diagnostic criteria for Psychogenic Amnesia taken from the

  1. The predominant disturbance is an episode of sudden inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

  2. The disturbance is not due to Multiple Personality Disorder or to an Organic Mental Disorder (e.g., blackouts during Alcohol Intoxication).

There are four types of disturbance in recall:

  1. Localized amnesia – Failure to recall all events occurring during a circumscribed period of time, usually the first few hours following a profoundly disturbing event.  An example of this is the survivor of a car accident that killed all of his immediate family.  He does not recall anything that happened from the time of the accident until two days later.  This is the most common type of amnesia.

  2. Selective amnesia – Failure to recall some, but not all, of the events occurring during a circumscribed period of time.  In the above example, the uninjured survivor recalls making the funeral arrangements, but not concurrent discussions with family members.

  3. Generalized amnesia – Failure of recall encompasses the person’s entire life.

  4. Continuous amnesia – The individual cannot recall events subsequent to a specific time up to and including the present.


As in Psychogenic Amnesia, Psychogenic Fugue is caused by an unusually stressful event.  It is generally seen during wartime or after a natural disaster.  The travel and behavior present as more purposeful than the confused wandering of Psychogenic Amnesia.  Following recovery, there is no recollection of the events that took place during the fugue.

            Diagnostic criteria for Psychogenic Fugue taken from the DSM-III-R:

  1. The predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with inability to recall one’s past.

  2. Assumption of a new identity (partial or complete).

  3. The disturbance is not due to Multiple Personality Disorder or to an Organic Mental Disorder (e.g., partial complex seizures in temporal lobe epilepsy).


            On the continuum of dissociative disorders, MPD is at the furthest extreme, is the most complex and denotes the most heinous of abuse cases.  These patients are often survivors of cult abuse where satanic rituals are practiced, involving cannibalism, torture, group sex, and death threats.  If not due to cult abuse, the victim has been physically and sexually abused repeatedly, generally starting at a very young age.  Tortuous physical abuse, punishment and possibly death threats are present.

            Diagnostic criteria for Multiple Personality Disorder taken from the DSM-III-R:

  1. The existence within the person of two or more distinct personalities or personalities states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

  2. At least two of these personalities or personality states recurrently take full control of the person’s behavior.

In an explanation of personality and personality states, DSM-III-R defines personality as a relatively enduring pattern of perceiving, relating to, and thinking about the environment and one’s self that is exhibited in a wide range of important social and personal contexts.  Personality states differ only in that the pattern is not exhibited in a wide a range of contexts.


            This would include disorders where the predominant feature is a dissociative symptom, but it does not meet the criteria for a specific Dissociative Disorder.

            The DSM-III-R gives the following examples of Dissociative Disorder NOS:

  1. Ganser’s syndrome:  the giving of “approximate answers” to questions, commonly associated with other symptoms such as amnesia, disorientation, perceptual disturbances, fugue, and conversion symptoms;

  2. Cases in which there is more than one personality state capable of assuming executive control of the individual, but not more than one personality state is sufficiently distinct to meet the full criteria for Multiple Personality Disorder, or cases in which a second personality never assumes complete executive control;

  3. Trance states, i.e., altered states of consciousness with markedly diminished or selectively focused responsiveness to environmental stimuli.  In children this may occur following physical abuse or trauma;

  4. Derealization unaccompanied by depersonalization;

  5. Dissociated states that may occur in people who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought reforms, or indoctrination while the captive of terrorists or cultists);

  6. Cases in which sudden, unexpected travel and organized, purposeful behavior with inability to recall one’s past are not accompanied by the assumption of a new identity, partial or complete.

Next: The Personality System