Dissociative Disorders

Definition | Aetiology | Pathophysiology | Risk factors | Signs and symptoms | Investigations | Management

Definition

Dissociative disorders are characterised by disruptions in memory, identity, consciousness, or perception, often arising as a psychological response to trauma or stress.

Aetiology

  • Psychological factors:
    • Severe childhood trauma, particularly abuse or neglect.
    • Post-traumatic stress disorder (PTSD).
    • Severe stress or emotional conflict.
  • Biological factors:
    • Altered connectivity between brain regions involved in self-awareness and memory.
    • Disruptions in the hypothalamic-pituitary-adrenal (HPA) axis.

Pathophysiology

  • Disruptions in neural pathways involving the prefrontal cortex, hippocampus, and amygdala.
  • Reduced connectivity between the emotional and cognitive processing centres.
  • Altered stress responses leading to dissociative states.

Risk factors

  • History of severe childhood trauma or abuse.
  • Family history of dissociative disorders or PTSD.
  • Co-existing mental health conditions (e.g., depression, anxiety, PTSD).
  • Exposure to repeated traumatic events.
  • Lack of social support.

Signs and symptoms

  • Dissociative amnesia: memory gaps related to trauma.
  • Depersonalisation: feeling detached from oneself.
  • Derealisation: perception that the external world is unreal.
  • Dissociative identity disorder (DID): presence of two or more distinct personality states.
  • Fugue states: sudden travel or wandering with amnesia.

Investigations

  • Clinical assessment: detailed psychiatric history and trauma assessment.
  • Dissociative Experiences Scale (DES): screening tool for dissociative symptoms.
  • Neuroimaging (MRI/CT): to rule out organic causes (e.g., epilepsy, brain lesions).
  • EEG: to exclude seizure disorders that may mimic dissociative symptoms.
  • Psychometric testing: to evaluate cognitive function and identity disturbances.

Management

1. Psychological therapies:

  • Trauma-focused cognitive behavioural therapy (CBT).
  • Eye movement desensitisation and reprocessing (EMDR) for trauma processing.
  • Dialectical behaviour therapy (DBT) for emotional regulation.

2. Pharmacological management (adjunctive therapy only):

  • SSRIs or SNRIs for co-existing depression or anxiety.
  • Antipsychotics may be used cautiously in dissociative identity disorder.
  • Clonidine or prazosin for PTSD-related hyperarousal symptoms.

3. Social and lifestyle interventions:

  • Support groups for individuals with dissociative disorders.
  • Stress management techniques (e.g., mindfulness, grounding exercises).
  • Safety planning if there is a risk of self-harm.

4. Referral:

  • Psychiatrist: for diagnosis and specialist management.
  • Trauma-informed therapist: for structured trauma recovery therapy.
  • Crisis services: if acute distress or risk of self-harm.
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