Distinguishing Dissociative Disorders from Psychotic Disorders: Compounding Alienation


Stories organize us, and “bad stories” organize us in destructive ways. In this post I will address one example: the story told about how skilled mental health professionals can distinguish between dissociative disorders, with their roots in trauma, and psychotic disorders, which are definitely illnesses of the brain.

Why do professionals attempt to make such a distinction? The idea is that people with dissociative disorders need to be offered caring and skillful therapy which addresses their traumatic past and their fragmented response to it, so they can reorganize in a more integrated way. It is thought that such a psychological approach would be useless for those with psychotic disorders, as their problems are understood to be based in their diseased brains, with drugs being required to control the malfunctions.

If professionals really could reliably distinguish those whose problems came from difficult experiences and who could be helped by therapy and self-understanding, from those whose problems were more organic and who could not be helped in a psychological way, then focusing on making such a distinction would be a useful approach. But if their faith in their ability to do this is really a delusion, then what they are really doing is defining everyone on the “psychotic” side of the distinction as being beyond human understanding and help, and so inflicting another blow on those already severely troubled.

It is well known that people dissociate when all of the person’s mind cannot bear facing what happened directly. Later, parts of the person that did not face the experience may be unable to integrate with the parts that did: each feels alien to the other.

It’s what happens next that may be crucial in separating those who will be recognized as having a dissociative disorder from those who will be seen as having a psychotic disorder.

If the person recognizes the “alien” parts of themselves as being just parts of themselves, even if they seem to be disturbing or even “different personalities,” then they have a good chance of seeing themselves, and of having professionals see them, as having PTSD or a dissociative disorder. But if they see the “alien” parts of themselves as being literally aliens, or demons, or CIA agents talking to them through a brain implant, then they will likely be diagnosed as psychotic.

It’s important to notice what’s happening here: it’s the person who feels more strongly alienated from parts of themselves who is likely to make the “psychotic” interpretation about what those parts are — and then it’s that person who will be seen by the mental health system as having a disorder that is understandable only as brain dysfunction.

We might imagine the following exchange:

Person: “I have an alien inside me.”

Mental health professional: “No, what you have inside you is a defective brain, this is brain pathology or illness.”

When we are alienated from someone, we may fail to cooperate with them and actually battle with them, but at least we notice they are a living being. When people are alienated from thoughts, feelings, and parts of themselves, or characters inside themselves, they may fail to work with those parts or integrate them into their identity, but at least they relate to those parts as something alive. What professionals do when they pathologize parts of people or their experiences is to dehumanize them, to see them not as something living that can be related to, but as something that should be exterminated. This is where the alienation becomes compounded.

What’s missing in the professional’s response is an acknowledgment that what the person may have inside them is a very human response to very difficult experiences, and the brain may be simply responding to those experiences. By failing to admit that possibility, recovery becomes more difficult. If the person accepts the professional’s explanation, they may feel no longer inhabited by an alien, but now they are inhabited by pathology, and one that can be expected to be lifelong and requiring lifelong efforts toward ongoing extermination.

Professionals vary of course in when they start seeing evidence of “brain pathology,” versus when they are open to seeing a problem as psychological.

  • Some will still identify any report of voice hearing as evidence of brain pathology, with no consideration of the possibility that voices could be dissociative.
  • Some imagine they can use certain criteria to distinguish “dissociative voices” from “psychotic voices” — even though research shows there is no reliable basis for making such a distinction.
  • Some claim that if a voice is dissociative, then the person will be able to talk to it, while a person cannot talk to a psychotic voice.

The alternative hypothesis is that professionals are simply failing to recognize that alienation exists on a spectrum, and these professionals are mistaking differences in degree of alienation for a categorical distinction that does not exist.

It’s common for example for people to be told that dissociative voices are experienced as “inside” the person, while psychotic voices are experienced as “outside” the person.  But these experiences are really on a spectrum, and, it turns out, a very tricky spectrum.

For the purposes of this discussion, let’s say that a person is just dissociative, and not psychotic, if they perceive all the voices they hear (that others don’t) as part of their larger self, while defining someone as “psychotic” if they perceive voices they hear as something other than themselves. (Looked at this way, being “psychotic” is not distinguished from a dissociative problem, but seen as a possible complication that might occur, or a further degree of alienation.)

The tricky issue is that many people who are just dissociative in the sense defined above, actually hear the voices of the other parts of themselves as though they were coming from outside of themselves, from somewhere else in the room for example. They may also “see” parts of themselves as outside of themselves, though they are aware this is just a mental experience and so they are not psychotic. Meanwhile, many people who are “psychotic” in the sense defined above, hear their voices or many of their voices as located inside themselves, though they believe it is not part of themselves — as in the case where they believe that a demon or brain implant has gotten inside of them.

This makes more sense if we think of multiple spectrums: there’s the spectrum of how much a person is alienated from a voice or how much they see it as not themselves, and then there is the spectrum of how much it seems at any given point to be physically inside themselves.

The idea that professionals can define voices as more “psychotic” if people find themselves unable to talk to them also ignores the possibility of a spectrum; it ignores the possibility that inability to talk may be another function of the degree of alienation. We all know, for example, that when people are feeling very alienated from fellow human beings, they often find they are unable to talk with them. Many of us find for example that we can’t talk with people who are too different politically — or even if we are willing to talk, those others will not talk to us!

People in the hearing voices movement, and therapists working with psychosis, commonly find at the outset that people cannot talk to their voices, but with some work, such talk becomes possible, and helpful.

This work is not seen as possible, however, when the person’s initial inability to talk to the voices, and inability to see the voices as part of themselves that can be related to, is interpreted as evidence that the voices are just brain pathology. There is a notion that “one cannot talk to a disease” and so the professional’s interpretation that the voice is brain pathology becomes part of the problem in communication, or compounds it.

I should point out that “dissociation,” like anxiety or depressed mood, is not entirely a bad thing. There are times it is helpful, and some degree of it is part of healthy human functioning. People in the hearing voices network point out that hearing voices — a particular kind of dissociative experience — can also be part of healthy human functioning, though people can also have various kinds of problems with these experiences. Some of those problems reach the level of what is called psychosis — being seriously “out of touch with reality” and/or severely disorganized. But these problems can all potentially be addressed and resolved, by helping people relate to what they are experiencing rather than pathologizing it.

There are now lots of people who have publicly described their journey from being quite truly lost in psychosis, and fully meeting the diagnostic criteria for “schizophrenia,” and who then, as they got more insight, shifted to having experiences that looked something more like a dissociative disorder, and then eventually shifted to not being “disordered” at all. Eleanor Longden is a well-known example. When she was fully “psychotic” she was fully convinced that her voices emanated from physically real beings outside of her who could harm her and her family if she did not obey their commands, and her reasoning process was so bad that at one point she was ready to drill holes into her head to get the voices out, with no insight into the fact she would likely kill herself in the process. Later, she came to recognize the voices as split-off parts of herself, and as she reconciled with those parts, she healed. She tells her story eloquently in her Ted talk and in more detail in this longer version.

I work as a therapist specializing in therapy for psychosis, and while I am not always successful, I have been fortunate enough to help people make similar journeys toward healing.

These are complex issues, and this post only touches on the subject. I have been working to make education on this subject more available, in particular in the form of my online course Working with Trauma, Dissociation, and Psychosis:  CBT and Other Approaches to Understanding and Recovery, which comes with 6 CE credits for most US professionals. (Until 5/23/18, this is being offered at a big discount, and even free to non-professionals.)

In the bigger picture, alienation and dissociation is something that happens not just within people, but within and between social groups, tribes, nations, etc. Seeing the “alien other” as just something pathological, something to be exterminated, is not working very well. We need more attention to approaches that recognize the life and the validity in the alien other, and which help people and social groups assert their own needs while also finding ways to recognize and reconcile with the deeper needs of the other. There is reason for hope, so let’s do what we can to nurture the possibilities!


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


  1. I don’t necessarily agree with your initial assumptions, “the story told about how skilled mental health professionals can distinguish between dissociative disorders, with their roots in trauma, and psychotic disorders, which are definitely illnesses of the brain.”

    First of all, over 80% of those labeled as “psychotic” are child abuse victims, so it should be acknowledged that most distress that is labeled as “psychotic” is a result of trauma. The other 20 or so percent are likely people like me, who were dealing with a medical cover up of easily recognized iatrogenesis and/or a cover up of the abuse of their child.


    I don’t believe that there is any real proof that “psychotic disorders” are “definitely illnesses of the brain,” although I do know this is what today’s “mental health professionals” assume. And I will state that today’s “mental health professionals” have stretched the definition of “psychosis” to the point they claim dreams are “psychosis.” Which is such an all encompassing definition of “psychosis,” that it means all people are “psychotic,” since we all dream.

    And I want to point out that the antipsychotic drugs can create “psychosis.” Anticholinergic toxidrome is a “psychotic” “illness of the brain,” created with the antipsychotics and/or antidepressants. It should be included in the DSM, but it is not.


    Withdrawal from the psychiatric drugs can also cause a type of “psychosis,” via a drug withdrawal induced “super sensitivity manic psychosis.”

    I have also learned there may now be technologies that can create “psychosis.”


    I guess my point is that there may be many reasons a person is labeled as “psychotic,” or is “psychotic,” but the psychiatric industry’s supposed “cure” can be the problem, as opposed to the solution.

    I absolutely agree, “Seeing the ‘alien other’ as just something pathological, something to be exterminated, is not working very well. We need more attention to approaches that recognize the life and the validity in the alien other, and which help people and social groups assert their own needs while also finding ways to recognize and reconcile with the deeper needs of the other.”

    I do believe that is particularly a problem for the “mental health professionals,” since many of us grew up in a country where we were taught “all people are created as equal.” Which is basically the opposite of the belief system of the “mental health professionals,” who do tend to view their clients as “alien others” who need to be exterminated. Most often to cover up child abuse, according to your industry’s medical literature, but also to proactively prevent malpractice suits. And the psych drugs are killing millions.


    I’d like to see today’s American psychiatric genocide, particularly of the millions of child abuse victims who were mislabeled with the DSM disorders, come to an end. “A society will be judged on the basis of how it treats its weakest members.”

    By the way, this is the reason so many child abuse victims have been mislabeled with the other “invalid,” but insurance billable, DSM disorders.


  2. Hi Ron,

    For me you have really ‘done it again’ with this article – summarizing in a very coherent and clear way, things that are often presented in such a complicated and confusing in so much of the literature. Your thoughts resonate so strongly with me.

  3. The same critique could be applied to any DSM “diagnosis”. The DSM itself admits in the introduction that there is no way to draw a line between normal and “disordered,” and that those labeled as having a particular “disorder” may not “be alike in all important ways.” In other words, the DSM is unable to distinguish any “disorder” from normalcy, and even those identified as having the same “disorder” may have different things wrong with them or nothing wrong with them at all.

    The whole thing is based on smoke and mirrors, and the DSM itself admits it. It is amazing that professionals can waste their time and energy talking about “differential diagnosis” and “misdiagnosis” when the “diagnoses” are admitted not to even represent a homogeneous grouping. It reminds me of the debate about “introverts” and “extroverts,” except no one is claiming that “extroverts” are healthy and “introverts” are sick. It’s 100% fantasy!

  4. This approach seems to boil down to “if I can’t understand it, I’ll drug it”.

    This is the way that something like low self-esteem gets branded a chemical imbalance. How on earth have we come to that?

    What I’ve seen in the NHS is that if you experience a dissociative episode without obvious trauma, your problems must be organic, biochemical, which the medication corrects. Psychotherapy is looked down on because your brain is so defective that you can’t fully access it, although a little psychology can’t hurt.

    The more I think of it, the psychosis is telling you in an obtuse way what your problem is, and clouting your brain with antihistamine is just going to confuse things and stop you ever finding out what happened.

  5. At least 50% of doctors can’t tell the difference between an Auditory Hallucination (outside the head) and normal social thought (inside the head). And they’re not too bothered that they can’t either.

    Normal People think abouts lots and lots of different things and their thinking doesn’t have to be politically correct for them to be non psychotic!

    In my experience in “Mental Health” a doctor will say “anything”.

  6. Eleanor Langdon by her own admission would have been completely finished (by her medical treatments) if she hadn’t accessed suitable Psychotherapy.

    If Psychotherapy works and the evidence is that it does, it needs to come into the mainstream.

    If Eleanor Langdon had remained in the Mental Health system in the UK as a “Schizophrenic”, through out her life she would have cost the NHS about £3 million.

  7. Hi Ron,
    when my wife began hearing voices, she called them ‘aliens.’ Fortunately neither her counselor nor I agreed and we slowly helped her accept that those voices were part of her larger self and so she began the process of learning to talk, live and cooperate with the other girls (alters).

      • Hi Fiachra,
        I’m not totally sure I understand your question…my wife was an early childhood trauma victim…since her parents were wrapped up in their own issues, there was no one to help her process the trauma and so those memories got sequestered (dissociated). They always bled out some, but 10 years ago she purposefully began to embrace them with my help…and as we brought the memories, voices, pain, etc back out…after the healing, we discovered those other girls (alters) controlled huge amounts of personality traits and mental skills she, my wife, had lost access to. And so, to answer your question, yes those other voices hold all kinds of perspectives and skills and traits my wife formerly never had. On my blog I make the analogy that my wife, kind of, was ‘flat-Sam-ish’ but now as she connects to the other girls she has become much more…I don’t know…more in so many ways…vibrant, vivacious, beautiful, adventurous, emotionally expressive and less…of a wallflower, someone willing to stand up for things…

        Just rambling at this point…not sure I answered your question…

    • How it seems with my wife is that some of the girls definitely struggle with low-self esteem and the tendency to blame themselves for anything and everything that goes wrong, but that seems to be very different than the constant negative memories and lies that her mother or the abuser fed her. Both girls who struggle with esteem issues have come a long way, but her mother is still toxic at times and I constantly hear that ‘my mother wouldn’t like this’ though they tend to do it anyway as she’s not really a part of our lives and lives 2 hours away. But even on that front her mother’s negativity is less and less powerful because the other girls who don’t care about their mother’s opinion can help the ones that do…

      • Thanks,

        When someone goes through all the bull sh#t thats holding them back I’d imagine their lives take on a much more exciting direction.

        I suppose lots of people would like to confront their demons but desperation has not yet forced them to it.

  8. Ah, differential diagnosis, a game of earnest triviality (like all these arbitrary diagnosis) designed to distract from what might be going on for people in distress and any social or political analysis of the situation. All very difficult work often enough.

    • Whatuser. I do have an issue with this also. It must be my ID, for to hear the word “fragmented”, brings on fear. Because I really don’t want someone ‘digging’ around in my fragments, because their digging might make them more fragmented. If we do not know what is ‘broken’, or what ‘broken’ looks like as opposed to the interpreters view of ‘whole’. I simply find it so presumptuous to pretend we know a “whole” of someone, or what that should look like. What if this “fragmented” person is EXACTLY the way they are supposed to be, have formed, as a coping mechanism? And wow to I ever dislike the terms “disorders”, “fragments”. It’s horrible terminology for ‘fragile’ egos like myself

  9. What bothers me here is this either/or assumption about “voices”: that they are either “psychosis” (auditory hallucinations) or they are “parts” of a singular fractured personality. Both assume they are generated within the self. But what about the possibility that they might be hearing voices that actually are outside the self? Never raised is the possibility of other explanations: that they may be the voices of ancestors, of spirit guides or guardian angels (depending on your paradigm), of past-life selves, or voices of non-corporeal spirits/dead people.

    Please remember that we are spiritual beings, and leave room for that, Ron.

  10. Ron, I’d like to see you state categorically the TRUTH: The DSM-5 is nothing more than a catalog of billing codes, and that ALL of the so-called “diagnoses” in it were INVENTED, not “discovered”….
    Think about it…. What say you, Ron?

    • Just because the dsm is corrupted and has been co-opted by big pharma and big insurance doesn’t mean people don’t suffer from real mental health issues. Trauma victims do suffer dissociation and dissociation is a nightmare to undo when it’s left for decades like my wife’s. So I hope Ron won’t affirm your simplistic challenge. When my wife got her d.i.d. diagnosis, it finally gave us something to grasp and understand and ONLY then did we finally understand what had been plaguing our marriage for 20 years. She has come so far in the last 10 years, and it started with the diagnosis. Of course, it didn’t hurt that I kept her out of the mental health system completely, found an unlicensed counselor, and realized our son and I were the best people in the world positioned to undo all the attachment issues my wife had suffered which are at the root of d.i.d.

      • Samruck, I think Bradford is not asking a simplistic question. Brad was not denying people have stuff going on. I agree with brad that obviously nothing was discovered, only invented. So it seems some like the DSM for some labels but not other labels? I am leery of all the labels and naming of ‘conditions’. All common sense treatment seems the same. Environment, caring, authentic being there, soothing.