Psychosis and dissociation are both ‘umbrella’ terms that describe a lot of different things. They can be easy to mix up because a severe dissociative episode and a severe psychotic episode can both be frightening and intense and make people feel like (or look like) they’re going crazy. But they are actually very different categories. A quick way to describe them is that where dissociation is some form of disconnection, psychosis often involves an addition of some kind – being able to hear voices or see things that other people can’t, or having unusual beliefs.
Some people have experiences that are considered to be dissociative as well as those considered to be psychotic. For some people, dissociation is part of the prodromal (that is, the onset phase) of having a psychotic episode. Once they recognise this, dissociation can be a useful warning sign for them. Others experience dissociation and psychosis together, feeling disconnected from themselves or their world at the same time as having unusual experiences. For other people, dissociation may follow a psychotic episode; as the unusual experiences finish, they are left with a sense of numbness, unreality, or other forms of disconnection that can make it more challenging to recover and get back into life. Sometimes people find that dissociation protects them from psychosis, others that dissociation makes them more vulnerable to it. In all of these cases, recognising and learning to find what helps with your dissociation can make psychosis less likely or more manageable. Some people with multiplicity experience it in ways traditionally considered to be psychotic, such as being able to see their parts.
People who experience any form of dissociation or multiplicity are often misdiagnosed as psychotic. When someone is panicked and distressed, it can be difficult for someone outside of them to know what is going on, and most mental health staff are far more familiar with and therefore more likely to diagnose psychosis than dissociation. To make things more complicated, some experiences such as those classed as Schneiderian First-Rank Symptoms – which involve things such as though insertion, thought withdrawal, and voices heard arguing, have been shown in some studies to be far more indicative of DID (multiplicity) than schizophrenia (psychosis). So some of what mental health staff have been told to look out for as evidence of psychosis is actually evidence of dissociation.
For some people, neither of these classifications fit very well. Their experiences sit on the border between the two ideas, or for them they overlap. This is often the nature of classification systems, as soon we create discrete categories, it’s quite normal to find that not everything fits. An example is that for some people who hear voices, they experience them as parts, that is, as separate distinct personalities that share their mind. However they don’t switch and can’t impact the body or the physical world. These people currently usually get a psychotic diagnosis and are told the voices are auditory hallucinations. However, voices are also not uncommon for people who experience multiplicity (multiple personalities, dissociative identity disorder). The distinction between psychotic voices (parts who can be heard but can’t affect the body), and dissociated parts (parts who can affect the body and may or may not be heard as voices) may be an arbitrary one that cuts people off from valuable perspectives and resources. It’s possible that similar psychological processes are behind the formation of both, in some cases. Some people experience both voices and parts.
Traditionally, clinical services have very different approaches to voices vs parts. People with parts are more often:
- Told they are faking for attention
- Told they must love, live with, and connect to all their parts
- Told they must have a trauma history, must talk about it, and must make trauma recovery the focus of therapy
- Told they must integrate with their parts to be healthy
- Told that parts prove they are creative, resilient survivors
People with voices are more often:
- Told that they must ignore, suppress, or medicate away their voices to be healthy
- Not allowed to connect with, get along, love, or miss any of their voices
- Told they have a life long illness they must learn to manage
- Have any trauma history considered irrelevant
- Told that voices prove they are fragile, mentally ill, and vulnerable to stress
In either case, a dogmatic approach where people are strongly encouraged to fit their experiences to current understandings and frameworks can do harm. Some people who hear voices find that multiplicity type resources have invaluable ideas and approaches. Some people who have parts or other forms of dissociation find psychotic type resources to be incredibly useful. It’s perfectly okay to cherry pick ideas and strategies from different – even conflicting – frameworks to create something individual and effective for yourself/selves.
For more information about voices and other ‘psychotic’ experiences, please see our sister Network, the Hearing Voices Network of South Australia. (hvnsa.org.au)