Simile Vs. Metaphor in Defining the Thin Line Between Dissociative and Psychotic Disorders

“It was as if I was on the outside of my body, looking at a movie of my life that was playing out without my consent or control.”

The language that patients use to describe their experiences can be as telling as the 603ce858dd9c334ef576828a73ec5e87symptoms themselves. In the phenomenological approach to psychotherapy, the cornerstone belief is that each person’s experiences are unique. Our reasoning, the senses related to each experience, and how they are able to process their inner thoughts are all things that are individualized and can incorporate genetics, upbringing, environment, neurological deficits, and many other factors1.

However, there are commonalities in the descriptive language that can help the practitioner to have insight into the patient’s personal experience with symptoms, leading to an accurate diagnosis, current testing measures, and effective treatment options.

On diagnostic gap of particular interest is the difference between dissociative disorders and psychosis. Dissociative disorders are most commonly depicted in entertainment through Dissociative Identity Disorder (DID), previously called Multiple Personality Disorder. DID is just one small segment of the Dissociative spectrum. Dissociation is most often characterized by a disconnection between parts of the phenomenology, or total experience,  that can lead to a sense of being separated from one’s body, detached from emotion, or an inability to relate to one’s own identity. Outside of the Dissociative Disorders themselves, there can also be an overlap with Post-Traumatic Stress Disorder with a Dissociative subtype. Dissociation is most commonly triggered by abuse or trauma throughout the various disorders above.

Alternatively, psychosis is most commonly seen in Schizophrenia, Bipolar Type 1, and Schizoaffective Disorder. As opposed to a disconnection, psychosis is an addition of sensory experiences from external sources.  The language used to describe the patient’s experience is something that can be use to better determine if the patient is suffering from dissociation or psychosis. While both populations can report hearing voices, the differentiation is in how the patient describes where the voices are coming from. If the voices are acknowledged as coming from an internal source (i.e. imagination, inner dialogue run amock, segmented parts of personality), then these are classified as pseudohallucination that is commonly a part of dissociation. However, if the voices are from an external source (i.e. “people are talking about me” or “they are telling me to do things”) then it is seen as a hallucination and is, therefore, symptom of psychosis.

The most telling language commonality is the use of “it is as if.” In stating an experience in this way, it presents the experience as something that was a sensory experience, but recognized as not “real.” Speaking with similes is the most common indicator of a neurotic disorder (such as dissociation), while metaphor and concrete statements of the experience as a factual event is a key indicator of one of the psychotic disorders2.

The importance in distinguishing the two is to better understand the biological underpinings of each, and then find the most effective treatments for each, based on scientific rationale. The National Institute of Mental Health has identified “defining the mechanisms of complex behaviors” as  one of it’s four key strategic objectives moving forward.  Psychosis has had tremendous breakthroughs through a series of new findings3. This includes the Bipolar and Schizophrenic Network on Intermediate Phenotypes (BSNIP), which has identified three biotypes from blood-based biomarkers that are set to lead the way on finding treatment, or even a cure, for psychosis4.

For dissociation, there has been far less success and the work is still in it’s infancy on finding biological mechanisms for the experience of the patient. And, in fact, there are no current pharmacological treatment for dissociation. While currently psychosis can be treated with a range of antipsychotic medications, such as Haldol, Seroquel, and Zyprexa. The treatment protocols therefore differ greatly.

Fortunately, we can use language indicators used by the patient to group the symptoms appropriately and find the current treatment for each. However, much more work is needed to understand this entire area.



1Merleau-Ponty, M. (1945). Phenomenology of Perception. Great Britain: Gaillimard.

2C. Devillé, C. Moeglin, and O. Sentissi, “Dissociative Disorders: Between Neurosis and Psychosis,” Case Reports in Psychiatry, vol. 2014, Article ID 425892, 6 pages, 2014. doi:10.1155/2014/425892

3NIMH Strategic Plan for Research. (n.d.). Retrieved March 11, 2016, from

4Insel, T. R. (2016, March 1). Is There a Better Way to Diagnose Psychosis? Scientific American.


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