Dissociative Disorders

Definition | Classification (ICD-10 and DSM-5) | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Dissociative Disorders are a group of psychiatric conditions characterised by a disruption or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour. These disruptions can vary in severity and may significantly impair an individual's daily functioning.

Classification (ICD-10 and DSM-5)

Dissociative Disorders are classified under the following diagnostic criteria:

ICD-10 Classification

In the ICD-10, Dissociative Disorders are classified under:

• F44 - Dissociative (Conversion) Disorders: This category includes dissociative amnesia, dissociative fugue, dissociative stupor, trance and possession disorders, dissociative motor disorders, dissociative convulsions, and dissociative anaesthesia and sensory loss. The disorders in this category are characterised by a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.

DSM-5 Classification

In the DSM-5, Dissociative Disorders are classified under:

• 300.12 (F44.0) - Dissociative Amnesia: Inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. It may include dissociative fugue, where an individual travels or wanders away from their home or usual environment.
• 300.14 (F44.81) - Dissociative Identity Disorder (DID): Characterised by the presence of two or more distinct personality states or an experience of possession, with recurrent gaps in the recall of everyday events, personal information, or traumatic events.
• 300.6 (F48.1) - Depersonalisation/Derealisation Disorder: Involves persistent or recurrent episodes of depersonalisation (experiences of unreality or detachment from one’s body) or derealisation (experiences of unreality or detachment from one’s surroundings), with intact reality testing.
• 300.15 (F44.89) - Other Specified Dissociative Disorder: Symptoms characteristic of a dissociative disorder that cause significant distress or impairment but do not meet the full criteria for any of the specific dissociative disorders.
• 300.13 (F44.9) - Unspecified Dissociative Disorder: Symptoms characteristic of a dissociative disorder that do not meet the criteria for any specific disorder and the diagnosis is left unspecified.

Aetiology

The exact cause of dissociative disorders is not fully understood, but they are generally believed to result from a combination of psychological, environmental, and biological factors:

• Psychological Factors: Dissociative disorders are often linked to severe trauma, especially during early childhood. This can include physical, sexual, or emotional abuse, as well as severe neglect or early loss of a caregiver.
• Neurobiological Factors: Abnormalities in brain function, particularly in areas involved in memory, emotion regulation, and identity, may contribute to the development of dissociative disorders. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which is involved in the stress response, may also play a role.
• Environmental Factors: Exposure to intense stress or trauma, particularly during vulnerable developmental periods, is a significant risk factor. This may include ongoing abuse, domestic violence, war, or natural disasters.
• Cultural Factors: Cultural and societal influences may shape the expression of dissociative symptoms, particularly in relation to trance and possession states.

Risk Factors

Several factors increase the likelihood of developing dissociative disorders:

• History of Trauma: A history of severe and chronic trauma, particularly during childhood, is a significant risk factor.
• Family History: A family history of dissociative disorders or other mental health conditions may increase the risk, potentially due to genetic or environmental factors.
• Psychological Vulnerabilities: Individuals with high levels of suggestibility, fantasy proneness, or hypnotisability may be more susceptible to developing dissociative symptoms.
• Substance Use: Substance abuse, particularly with substances that alter perception or consciousness, may exacerbate dissociative symptoms.
• Social Isolation: Individuals who are socially isolated or lack social support may be at higher risk of developing dissociative disorders, especially in the context of trauma.

Clinical Presentation

Dissociative disorders present with a wide range of symptoms, depending on the specific type of disorder:

Dissociative Amnesia

• Memory Gaps: Inability to recall important personal information, often related to traumatic or stressful events. The memory loss is more extensive than ordinary forgetting and is not due to a medical condition.
• Dissociative Fugue: A subtype of dissociative amnesia where the individual may suddenly travel away from home or work and have no recollection of their past or how they arrived at the new location.

Dissociative Identity Disorder (DID)

• Multiple Personality States: Presence of two or more distinct identities or personality states, each with its own pattern of perceiving, relating to, and thinking about the environment and self.
• Gaps in Memory: Recurrent gaps in memory for everyday events, personal information, or traumatic experiences that are inconsistent with ordinary forgetting.
• Identity Confusion or Alteration: Confusion about or alteration in the individual’s sense of self or identity, which may be observable by others or reported by the individual.

Depersonalisation/Derealisation Disorder

• Depersonalisation: Experiences of unreality, detachment, or being an outside observer of oneself, including feelings of being detached from one’s body or thoughts.
• Derealisation: Experiences of unreality or detachment from one’s surroundings, where individuals may perceive the world as dreamlike, foggy, or visually distorted.
• Intact Reality Testing: Despite the experiences of depersonalisation or derealisation, the individual maintains awareness that these experiences are not real and are a product of their mind.

Other Specified and Unspecified Dissociative Disorders

• Trance and Possession Disorders: Sudden changes in consciousness or identity, where the individual may act as if taken over by another identity, spirit, or force, often related to cultural or religious practices.
• Chronic and Recurrent Syndromes: Dissociative symptoms that do not meet full criteria for any specific disorder but cause significant distress or impairment.

Investigations

The diagnosis of dissociative disorders is primarily clinical, based on a detailed history, observation, and mental health assessment. Additional investigations may include:

• Psychiatric Assessment: A comprehensive mental health evaluation using structured interviews and diagnostic tools, such as the Dissociative Experiences Scale (DES), to assess the severity and nature of dissociative symptoms.
• Medical History and Physical Examination: To rule out medical conditions that could cause dissociative symptoms, such as epilepsy or head injury.
• Neuroimaging: Brain imaging, such as MRI or CT scans, may be used to rule out structural brain abnormalities that could contribute to the symptoms.
• Laboratory Tests: Blood tests, including thyroid function tests and toxicology screening, to exclude medical conditions or substance use that may present with dissociative symptoms.

Management

The management of dissociative disorders typically involves a combination of psychotherapy, pharmacotherapy, and social support:

Psychotherapy

• Cognitive Behavioural Therapy (CBT): CBT can help individuals understand and manage their dissociative symptoms, challenge distorted thinking, and develop coping strategies.
• Trauma-Focused Therapy: Given the strong association between dissociative disorders and trauma, therapies such as Eye Movement Desensitisation and Reprocessing (EMDR) or trauma-focused CBT may be particularly beneficial.
• Dialectical Behaviour Therapy (DBT): DBT can help individuals with DID or other dissociative disorders manage emotional dysregulation and improve interpersonal relationships.
• Psychodynamic Therapy: Aimed at exploring unconscious conflicts and early life experiences that may contribute to dissociative symptoms.

Pharmacotherapy

• Antidepressants: SSRIs or SNRIs may be prescribed to manage co-occurring symptoms of depression or anxiety that often accompany dissociative disorders.
• Antipsychotics: Low doses of antipsychotic medications may be used to manage severe dissociative symptoms or comorbid psychotic features.
• Anxiolytics: Benzodiazepines or other anxiolytics may be used short-term for acute anxiety but are generally avoided due to the risk of dependence.

Social Support

• Case Management: A case manager can provide ongoing support, helping to coordinate care, manage crises, and connect individuals with social services.
• Peer Support Groups: Participation in peer-led support groups can provide a sense of community and reduce feelings of isolation.
• Family Therapy: Involves the family in the treatment process, providing education and support to help manage the condition and reduce the impact on relationships.

When to Refer

Referral to a specialist mental health service or psychiatrist is necessary in the following situations:

• Initial diagnosis or suspected dissociative disorder requiring comprehensive assessment and initiation of treatment.
• Severe or treatment-resistant dissociative disorder that does not respond to standard therapies, requiring specialised interventions.
• Presence of co-occurring mental health conditions, such as severe depression, anxiety, or PTSD, that require more intensive management.
• Significant impairment in daily functioning, including difficulties in self-care, social interactions, or occupational performance.
• Risk of harm to self or others, necessitating urgent intervention and possible hospitalisation.

References

1. World Health Organization (1992) ICD-10 Classification of Mental and Behavioural Disorders. Available at: https://www.who.int/classifications/icd/en/bluebook.pdf (Accessed: 26 August 2024).
2. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Available at: https://www.psychiatry.org/psychiatrists/practice/dsm (Accessed: 26 August 2024).
3. National Institute for Health and Care Excellence (2024) Post-Traumatic Stress Disorder. Available at: https://www.nice.org.uk/guidance/ng116 (Accessed: 26 August 2024).

Back to Top