Dissociation: Something to Watch Out for in Bipolar

John McManamy Health Guide November 10, 2012
  • Have you you ever felt like you were not connected? With your mind, your body, yourself, the world around you? Following is an extract from my memoir, "Raccoons Respect My Piss But Watch Out For Skunks":

     

    It's a profoundly overwhelming world out there, very difficult to negotiate, and most of the time—very frankly—I don't want to be in it. Certainly, I spent a good deal of my childhood wishing I was very far removed from it. I found refuge, instead, in my own inner world. Over time, I succeeded in tuning out just about the whole world around me. Engage me in a conversation, and sooner or later you will pick up an odd mannerism: My eyes glaze over, I'm unresponsive. I am not present. Literally—I am somewhere else.

     

    This planet is simply a challenge for me. Always has been. Sometimes, my mind has to flee. Where it goes I have no idea, no recollection. I like to think it's back to the planet of my birth, a place where I belong.

     

    A kind lady beneath a tree beckons me. She serves up a plate of Thai noodles. I help myself to some watermelon chunks. You're safe here, says the look on her face. Welcome home.

     

    I am describing a relatively mild form of what is known as dissociation, which comes in two varieties - depersonalization (detachment from self) and derealization (detachment from our surroundings). Dissociation affects all of us to some degree - a feeling of not being there, of not being anchored. On more harmless levels, we may momentarily tune out our surroundings or lose track of the conversation or of events. Then we snap back to reality and make a lame joke about having a senior moment and nobody thinks we’re weird.

     

    I have a bit more trouble explaining myself. Actually, I can’t. I just have to hope that people take me in stride - a quirky guy who is nevertheless fun to be around. This was not the case when I was younger. There I was, off in space, the object of endless ridicule, from kids my age, from my teachers, from my parents. 

     

    Others are not nearly so lucky. In its more severe forms, there is the feeling of being Keanu Reeves sucked through the matrix, not knowing which reality we have just landed in. Try faking normal - much less harmless - when your world(s) won’t cooperate with you. To outsiders, one is likely to come across as the weirdo who never recovered from the bad acid at Woodstock.

     

    At the extreme end is dissociative identity disorder, where certain people take on new identities, often totally unaware of their previous ones.

     

    Dissociation is a favorite theme of novelists and dramatists and film-makers, but maybe because there is no pill for it you don’t hear too much about it in psychiatry. Indeed, psychiatry defaults to schizophrenia or another diagnosis. From the DSM-5 (which comes into effect next year), under the entry “Depersonalization-Derealization Disorder”: 

     

    The disturbance is not better accounted for by another mental disorder, such as Schizophrenia, Panic Disorder, Major Depressive Disorder, or another Dissociative Disorder.

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    Occasionally, a research study on those with bipolar will refer to depersonalization or derealization, but generally in a peripheral sense or with inconclusive results (see, eg Mula et al). Certainly, there is a strong trend toward looking at bipolar as more than just an affective disorder, one that also involves disruptions in thinking and vulnerability to stressful situations, but the dissociation piece of the puzzle could use a lot more attention.

     

    My real education came from fellow patients. Back in 2004, when I was facilitating a DBSA group, one of our regulars - let’s call her Angie - asked if anyone else in the group had experienced dissociation. 

     

    Once we got a conversation going, it turned out that everyone around the table had experienced at least some more-than-mild form of not being there.

     

    It turned out that Angie had experienced major sexual abuse as a kid, which leads us straight into old-school psychiatry. Basically, the terror the individual is experiencing is so intense that the brain invents its own way of coping - typically by flipping into some kind of alternative reality. We may become emotionally numb, or find ourselves out of phase with either our body or our surroundings. 

     

    We may survive the moment, but at the expense of our brains becoming permanently altered (which takes us back to new-school brain science). We may never return to our old reality or our old selves. Or our brains may be overly quick in taking us out of the moment, at any given time, typically in response to a stressful situation. Not surprisingly, dissociation overlaps with PTSD (the DSM-5 mentions “dissociative reactions”) and borderline personality disorder (the DSM-IV refers to transient “dissociative symptoms”).

     

    The bipolar connection is unexplored territory. We know trauma looms large in bipolar (check out my series on trauma). It follows that dissociation is likely to be part of what we have to contend with, whether as a mild nuisance or as a severe challenge. As always, you are the true experts. Let’s learn from each other. Let’s get a conversation going. Comments below ...