Is It a Part or Is It Dissociation? OSDD, DID, and CPTSD

Sarah (00:00) Have you ever pulled into your driveway with zero memory of the drive home?

of like who drove the car home was it me okay a lot of people would call that dissociation and pretty much everybody does it and that same exact word dissociation also gets used for going numb and far away when someone raises their voice at you.

For feeling like you're watching your own life through a sheet of glass. And for things like OSD and DID, where parts of a person can feel so separate that they don't feel like me at all. Same word, really, really different experiences. That's what people mean when they talk about the dissociative spectrum.

Hey everybody, welcome back to the Complex from a podcast. If you've been listening for a while, you know dissociation has come up quite a bit on this show. I had Janina Fisher on to talk about dissociative parts, and then I did a follow-up episode answering your questions like, why might you dissociate more in therapy than anywhere else?

And how to tell the difference between zoning out and dissociating. If you haven't heard those, they're also kind of great episodes to listen to along with this one. And then just last week, in the episode about wanting two opposite things at the same time, I mentioned something called structural dissociation. And I promised that it would get its own episode. So here we are.

This episode actually came from a question from a listener who's been healing from CPTSD.

She messaged me and said that she just found out that she probably has a dissociative disorder alongside her CPTSD. and she said she wasn't even totally sure what her question was yet, but she wondered if I'd do an episode on it, given how common dissociative disorders are in trauma survivors. And then a few days later, she sent a bit of a follow-up and it was really good. She basically asked

With parts work being so popular right now, like IFS, schematherapy, ego states work, how do you know when a part is just a part of who you are, like your angry part, and when it's crossed the line into a dissociative disorder. So there are really two questions at play here.

how common is this and what does it mean if you just found out? And where's the line between parts and a dissociative disorder?

today we're gonna walk through the whole dissociative spectrum from totally ordinary dissociative episodes to OSD and DID. And we're gonna answer both of her questions

kind of as directly as I can. but before we do that, this topic, It can stir things up for some people. And I want to remind you that I am a therapist, but I am not your therapist. This is meant to give you education. Maybe to even see yourself and pieces of this to bring to your therapist, to your psychiatrist, whoever it is that you're working with.

and as you listen, if you notice that you're getting a little bit stirred up or you're getting a little bit foggy or far away as you listen, I'd encourage you to kind of like look around the room, find a few things that you can see, that you can orient towards, and pause. You can always come back. You don't have to listen to this episode all in one shot.

Okay, so to start, let's talk about the idea that everyone has parts. Every human being has parts. There's the you who's been patient and silly with your kids at breakfast, and the you who wants to scream in the car line twenty minutes later. Or if you're me at the bus stop as everyone's playing tag and your kids are scraping their knees and their hands.

as the bus rolls in ten minutes late.

There's the you in a work meeting who sounds very professional and very calm, and the you who texts your best friend afterwards and saying, my gosh, I'm going to lose it. If you've listened for a while, you know I joke about my people pleasing part and my overfunctioning part a lot. That's really real.

These parts of me have a very strong pull, right?

Janina Fisher, who I mention the time on the podcast, and like I said, who I interviewed a number of months ago, makes a really helpful like distinction. She describes IFS or internal family systems as a parts theory, and it applies to all human beings, whether or not they've experienced trauma. Structural dissociation, which we'll get into in a minute, is a trauma theory.

It's describing what happens to the self when someone has to survive overwhelming experiences. So when your therapist says something like a part of you, and when a dissociation specialist says a dissociative part, they may be using the same exact words to describe pretty different experiences, which makes a lot of sense why a lot of people can get confused around this stuff. Kathy Steele is another wonderful trauma therapist and dissociation specialist who's written a number of books on this.

She and her colleagues have a way of describing what ordinary parts look like that I actually really love. They compare it to shifting gears in a car. Most people can move from home to work to a hard conversation with their mom, and their thinking and feeling and acting shift to fit each situation, but they still experience themselves as the same person the whole way through.

That's the key piece. Even when a part of you is loud, even when it's a part of you you don't necessarily love, it still feels like you. Part of me is furious, still means I'm furious. Part of me wants to cancel these plans, still means I want to cancel these plans. The angry part is yours, the scared part is yours. The part that wants to hide under a weighted blanket for a weekend is yours. They all belong to kind of like the same me.

And hang on to that phrase, they belong to me because I think it's gonna matter in just a few minutes.

Okay, so remember that drive home from the very beginning of this episode. This is where things can get a little bit confusing. The word dissociation gets used for two different kinds of experiences, and even professionals don't always agree on where to draw this line. The first kind is the stuff almost everyone experiences. That drive home you don't remember, getting so absorbed in a book or a show Or social media, right?

Spacing out in a meeting when you're exhausted. Some researchers put all of this in one big continuum of dissociation, with every day zoning out at one end and dissociative disorders at the other end. And in my older episodes, I talked about it that way too.

Now, Kathy Steele and her colleagues, they draw a a much more kind of sharp line. They describe those experiences as changes in awareness that everyone has, especially when we're tired or stressed or sick, and they're not unique to dissociative disorders at all. For them, dissociation in the trauma sense is something more specific. it's a division in the self.

They describe it as owning and disowning an experience at the very same time. One part of you holds an experience as yours and another part of you holds it as not yours.

So someone might say something like, I didn't actually go through those things. That scared little girl isn't me. That fear isn't my fear. And Kathy Steele and her colleagues, they describe that quote unquote not me quality as the essence of dissociative disorders.

So both ways of using the word dissociation are out there in in the field, in my field, right? And you'll probably hear both. And when I say probably, I mean definitely, right?

But for our listeners question about parts, this second meaning is the one that really matters because the line between ordinary parts and dissociative parts has less to do with how loud a part is and a lot more to do with whether it still feels like it belongs to you.

The framework I'm going to use is called the theory of structural dissociation, what I talked about on last week's episode. Kathy Steele is one of the three clinicians who developed it, and it's the model that Janina Fisher builds a lot of her work on. I want to be really clear that this is the clinical framework, kind of like a map that a lot of trauma clinicians, including myself, find incredibly helpful. Nobody has proven every single detail in a lab, right? Because it's a theory. But as maps go, it's a really good one.

Here's the basic idea. When someone survives overwhelming experiences, especially without enough support, the self tends to organize into at least two kinds of parts.

One kind is focused on daily life. Getting up, going to work, making lunches, walking to the bus stop, paying the bills, keeping it all together. Janina Fisher often calls this the part that goes on with normal life. And this part tends to avoid anything that might bring up the trauma. The other kind of part is stuck in what Steele calls trauma time. These parts experience the past as if it's still happening or about to happen again.

They're organized around survival. some wanna fight, some want to run, some freeze, collapse, and they hold a lot of the feelings and the body sensations that were too much to take in at the time the trauma happened. Okay, so now let's put that on a spectrum. At one end, you have PTSD after a single traumatic event. In this model, there's one main part running daily life, and a trauma part.

That breaks through in flashbacks or nightmares. And even here, dissociation is really common. A 2022 review that pooled 49 studies found that roughly 38% of people with PTSD met criteria for what's called the dissociative subtype, which means things like feeling detached from yourself or like the world isn't really real.

That number varied a lot depending on how studies measured it. So take it kind of as a ballpark.

But what it does is it tells you that dissociation, it isn't some rare thing in trauma.

Moving along you have complex PTSD, which usually comes from repeated trauma, often in childhood, often in relationships.

CPTSD is recognized by the World Health Organization's diagnostic manual, which is called the ICD 11, and it's still not its own diagnosis in the DSM, which is the manual that most US clinicians use in their clinical work.

As you imagine, I have a lot of feelings about it not being in the DSM. We can talk about that another time though. In the structural dissociation model, people with complex trauma tend to have one main daily life part and several trauma-holding parts. And this is where Janina Fisher's work really speaks to so many of you. She describes clients who look on the outside like they have it all together,

But who show really clear signs of being divided inside.

Trauma-related feelings and impulses Battling with what they know is true in the present.

sort of like the worst is about to happen versus I know I'm safe in my own house. And I know that's a whole lot of you who listen to this show. Really high functioning on the outside. on the inside, there's a whole lot going on.

Next on the spectrum, you have what's called OSD, which stands for other specified dissociative disorder. In the ICD 11, the closest match for the kind of OSD we're talking about today is called partial dissociative identity disorder. And these names, they're always changing,

Which is not super helpful for anyone, but older books called this D D N O S.

And here's how the ICD eleven describes partial DID. There's one main identity state that runs daily life, and other identity states intrude on it. Those intrusions can show up as thoughts, feeling, perceptions, movements, or behavior, and they feel unwanted and get in the way.

The other states don't typically take full control though brief episodes can happen. In Kathy Steele's book on coping with trauma-related dissociation, she and her co-authors note that most people with this form have a single main part that functions in daily life. That's actually the same basic shape as complex trauma in this model. The difference is more about degree, how separate the trauma parts are, how much they feel like not me.

And how much they act on their own.

And again, moving along the dissociative spectrum, at the far end, you have DID, dissociative identity disorder. The ICD 11 describes two or more distinct identity states that recurrently take full control of a person's consciousness and functioning. And in Steele's model, people with DID usually have more than one part that functions in daily life. So on top of trauma parts breaking through,

There might be one part that goes to work and another part that parents and they may have limited awareness of each other.

Janina has actually written about when she started explaining this model to her clients, she'd see this look of recognition on their faces. Like she was telling them something they already knew but never had the words for.

They didn't actually feel more stigmatized because of this description. They felt relieved. because the whole point of this model is that splitting happens for a reason. It's how they survived.

Okay, so how common is all of this? This was the very first thing our listener asked. And honestly, the numbers are pretty messy. In the general population, estimates for a DID usually land somewhere between one and three percent. that's less rare than most people think, though some researchers question those numbers and they're still debated.

In people who are already in mental health treatment, the numbers go up. Expert guidelines estimate DID at somewhere between 1 and 5% of people in inpatient psychiatric units, eating disorder programs, and substance use programs. And one study of an outpatient clinic in New York interviewed 82 patients and found that 29% met criteria for some kind of dissociative disorder.

and only four of those patients had a dissociative diagnosis anywhere in their chart. like you can tell, that was one small study at one clinic. So I wouldn't try to stretch that number too far, but what it can tell you is a couple things. Dissociative disorders show up a lot where trauma shows up, and they get missed a ton.

And the connection to trauma is really strong. In that same study, the people with dissociative disorders reported much higher rates of childhood abuse. And a recent review noted that in many studies, close to everyone with DID also had PTSD either now or in the past. So it makes a lot of sense that OSDD would show up along CPTSD like it did for our listener. Those are a lot of initials, guys.

And you know, a lot of older books describe parts like pieces of a puzzle that got scattered out, and healing as like snapping the pieces back into one. That language, it can leave people feeling like there's something missing or something wrong with them. So here's how I'd say it instead. All of your parts share one body and one brain, and they're all part of one system that was working really hard to keep you alive.

And how separate they feel from inside is real and it deserves to be taken seriously. You don't have to feel like one person all of the time for any of this to make sense.

Sarah (15:36) I'll right back after a quick word from this episode's sponsor.

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Sarah (17:01) Okay, so let's go back to our listeners question. How do you know when a part is just a part and when it's crossed into a dissociative disorder?

So I'll give you some things that clinicians who specialize in dissociation really pay attention to. And I just want you to use this to understand what you might be experiencing. You might not experience any of it at all. And just please don't use it as a checklist to diagnose yourself. There's lots of reasons why, but we'll talk about that in a minute.

The first thing is ownership. Does it feel like mine? With kind of everyday parts, even intense ones, there's a sense of this is me. Part of me is really sad today. Part of me is really overwhelmed today. With dissociative parts, there's often a sense of not me. Feelings, thoughts, memories, or body sensations that you're aware of, but that don't feel like they really belong to you.

Again, Kathy Steele and her colleagues describe

This sense that it's happening without you choosing it.

as one of the major signs of dissociation. Some people describe feeling like more than one person or having inner voices or parts with their own name or age. The second thing is how parts influence you from the inside.

Kathy Steele and her co-authors, they give this example that I find really helpful. Someone's in a grocery store. Everything around them is completely normal. And suddenly there's like a desperate inner voice saying, get out, get out, get out. It's not safe. We have to go home. And maybe another voice chimes in telling that voice to shut up or calling them stupid for being there in the first place.

and the person in the cereal aisle knows nothing is actually wrong. Compare that with someone who walks into a packed store and thinks, it's crowded, I want to grab my stuff and leave. Same store, very different experience on the inside. Those out of nowhere urges, feelings, sensations, or voices are called intrusions or passive influence.

parts influence a person this way from the inside without ever fully taking over. I do want to add one note here, because I care about you. Hearing voices can come from a lot of different places,

And that's one of the reasons why like a careful assessment matters so much.

And I'm saying that so that you can take care of you. And it's nothing to be afraid of, but it's something to definitely bring to a mental health provider that specializes in trauma and dissociation. The third thing is taking over. Sometimes, especially in DID, a part takes full control of a person's behavior. This is what's called switching. Some people lose time when that happens, some people stay aware.

But feel like they're watching themselves act with no control over it.

The book I mentioned earlier coping with trauma related dissociation.

Describe someone who would lose time in a crowded store and come to her car with all of her groceries with no memory of buying them at all. And another person who watched herself shop from above herself, wondering why she was moving so slowly. and the fourth thing is memory, and this is where people can kind of get really mixed up. We all forget things. Nobody remembers everything and nobody remembers much before the age of about three.

And a lot of people with complex trauma say they just don't remember much of their childhood at all, which can have a lot of different explanations. dissociative amnesia is different. It's gaps that go way beyond normal forgetting. Finding things you bought and have no memory of buying. people greeting you like they know you and you have no idea who they are. Years of childhood that just are kind of blank.

Time loss in the present is considered a hallmark of DID, and it's much more common in DID than in other forms of dissociation. And here's an actual important part: not losing time doesn't rule out a dissociative disorder. For OSDD, amnesia isn't required. for a full DID diagnosis, the DSM does require memory gaps.

And the ICD eleven says amnesia is typically there.

the fifth thing is how much it gets in the way of your life.

Janina Fisher describes a dissociative disorder as a more extreme degree of compartmentalization. It can affect your ability to know moment to moment who you are, to make a decision and actually carry it through, to manage impulses, to keep track of time, to tell the difference between the past and the present. And the diagnostic manuals require that it causes real distress or real problems in your daily life.

your relationships or your work. The sixth thing is how your parts relate to each other. In dissociative systems, parts often avoid each other quite a bit. Some experts call it a phobia of dissociative parts. The daily life part wants nothing to do with the parts stuck in trauma time, and those parts can feel abandoned by the part trying to move on without them.

Some parts may not even know other parts exist.

And this is something that clinicians who work with association talk about a lot. In IFS, there's this idea of the self, the calm, curious, compassionate center of you. for a lot of people with dissociative disorders, getting to that place can be much, much harder. And hearing a therapist get really excited about your parts can feel less like hope and more like danger, especially for a system that survived by hiding.

so like too long, don't listen, right? Like the whole answer is that ordinary parts shift and blend and still feel like you.

dissociative parts feel a lot more like not me. They push from the inside and take over. They often avoid each other and they get in the way of daily life in a very real way.

Okay, so I know maybe some of you are yelling things like at your earbuds or at your car speaker this whole time, like, what if I'm making all of this up?

And this actually comes up so much.

here's something that Janina Fisher writes about that I find so validating. she says trauma survivors often feel like frauds, like they're pretending.

They take the intense feelings of the quote unquote not me child part as the truth. And the part that keeps functioning, that goes to work, that makes dinner and keeps putting one foot in front of the other feels like the fake one.

Her point is that both are real, both are necessary. the part that kept going is every bit as real as the part that holds the pain. And doubting yourself is actually really common with dissociation. People often don't have words for these experiences. They feel ashamed of them and they worry that they're crazy or something. That doubt, it can't settle the question in either direction.

Mostly it tells me you're a human who's been through a whole lot and is really trying hard to make sense of it.

But isn't everyone on TikTok saying they have DID now?

Okay, so I'm gonna proceed with caution on this one because people with DID they get accused of faking it like literally all the time, including by clinicians, which is so incredibly harmful. So, yes, some clinicians have reported seeing more young people coming in having self-identified with DID after watching content online. and nobody really knows yet what that actually means, right? It's possible some people take on language from what they're watching.

It's also possible that for a lot of people, seeing someone describe their inner world was the first time they ever felt safe naming something that was already there.

And then there's this other side that doesn't get talked about a lot. Dissociation experts point out that dissociative disorders are often missed. People come to therapy for anxiety, depression, sleep problems, relationship stuff, and they get other diagnoses first, sometimes for a really long time before anybody's asking about dissociation at all. So what I do, like with most things, I hold both.

There are real concerns about overdiagnosis online and dissociative disorders still get missed all the time in therapy offices,

I don't lose time, so it can't be me. Some people with OSD have described this exact thought. We don't lose time, so this must be fake. But like I said, amnesia isn't required for OSD. so please don't use that as your one test in either direction. But I'm way too high functioning for this. Totally fair.

but remember the part that goes on with normal life? Its whole job is to keep things running. So being able to work and parent and show up for everyone doesn't answer the question either way either. and if you're wondering whether OSD is just like almost DID, it has its own name for a reason. It deserves to be taken seriously on its own terms. I tried parts work and it kind of freaked me out.

makes a lot of sense, especially if your system learned to survive by keeping things hidden. It might just need to be slower, more about safety and the present, and done with someone who understands dissociation.

What feels most important is that this kind of work working with dissociative parts has to be paced for your particular system.

Okay, so I need to put on my big sister hat for just a second. Please don't diagnose yourself off of a podcast, including this podcast, especially this podcast.

Because I care about you.

And please don't diagnose yourself off of an online quiz either.

There's a really common screening tool called the dissociative experiences scale It's useful, but trauma therapists in the field are really clear that it isn't diagnostic. It includes a whole lot of experiences that non-traumatized people have, like getting absorbed in a movie. screening tools are meant to flag things and diagnosis, it takes a lot more

than a score on an assessment.

A real assessment usually means a clinician who's trained in dissociation, structured interviews, and time. Sometimes a lot of time, because dissociative systems don't always show everything right away, and that's okay. Again, it makes a lot of sense.

And a diagnosis is a map that helps you and your therapist figure out how to help. You are so much bigger than the map.

dissociation experts even say that diagnoses, they aren't labels that make a statement about who you are.

And that the criteria they do keep changing and are still debated. What they encourage is that people focus on what actually helps rather than getting too caught up about the label. So if you're listening and going, huh, some of this sounds a little bit familiar, the next step is curiosity and a good conversation with someone trained to help you sort it all out.

Okay, so I do want to come back To where our listener started in her question. I just found out I probably have a dissociative disorder and I'm not even sure what my question is. If that's you, first of all,

That I don't even know what my question is feeling makes so much sense. Finding this out can bring like a whole mix of things. Relief because something finally has a name. Fear because a name sounds kind of big and scary. Doubt like, wait, really me? Sometimes grief. Sometimes all at the same time.

You don't need to be certain to start getting the right kind of help.

Some of this gets clearer over time as your therapist gets to know you and as your system feels safer showing itself.

and something that feels really important to say is that you're still you, exactly who you were the day before you found out. The only thing that's new is more of a map for something that your system might have been doing for a long time to keep you safe. What that map can change is the way you do therapy. It might mean slowing down, spending more time on safety in the present before going near the hard memories.

working with someone trained in dissociation, approaching parts work more gently at a pace that your system can actually handle. So if you just got this news or if you've been grappling with this kind of news for a long time, you don't need to figure it all out right now. you just get to keep going with a little bit more understanding and with a little bit more care.

So, what does healing actually look like? For dissociative disorders, the approach most dissociation experts recommend is phase-oriented. That means you start with the present, safety, stabilization, sleep, daily life, learning to stay here now. One of my favorite dissociation books says it pretty straight up. You don't have to start with the painful past. Coping in the present comes first.

The trauma memories come later when your system has more capacity to hold them. And a big part of this work is helping parts get to know each other and work together. It's often described as learning to reach agreements between parts, which is really different from forcing parts to get along with you or ignoring what they need altogether.

And I'm gonna bring on the nuance here because the conversation about the goal of treatment has shifted quite a bit over the years. Today, most clinicians and many people with lived experience would say the goal is whatever helps you live well, and you get a big say in what that looks like for you because it's your life.

For a lot of systems, that means parts that know each other, communicate, cooperate, and really take care of each other. And if you're listening as someone with DID or OSDD whose system already communicates and cooperates and takes care of each other, I see you. A lot of what I described earlier, the avoidance and the walls between parts is what it can look like before that kind of work actually happens.

Whatever the goal is, the heart of the work is the same. Bringing awareness and compassion to all parts of you, even the ones you've been avoiding, especially those kind of welcoming every part home.

And let me be honest with you for a second. The research on treating dissociative disorders is still young and a lot more is needed. But the studies we have are encouraging. Researchers describe clients whose inner worlds start out feeling like war zones and over time become places that felt safe and warm slowly, messily, really, really beautifully. So if you're somewhere on this spectrum from

My angry part is loud today, all the way to I lose time and I don't know why. here's what I want you to take with you. What your system did made sense. It's how you survived,

And there are people out there who know how to help you make it feel safer inside.

I hope this helped answer both of our listeners' questions and maybe some questions you've been holding on to too. Thank you so much for writing in. Please keep sending the questions I think some of the best episodes and most popular episodes have come from your questions.

Next week I have a guest coming on to the podcast. she's a psychotherapist and adjunct professor at NYU, and she's an expert on the intersection of Greek mythology and modern psychology. I thought this one would be really interesting to dive into.

So that's what's coming next week. Make sure that you're following the show so that you don't miss it. My hope is that you're walking away from this episode feeling a little more seen, a little more hopeful, and a lot less alone if you experience dissociation.

So take good care of yourself and I'll talk to you next week.