Source of information about DSM diagnoses: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.

overview

Dissociative disorders involve a disruption or discontinuity in the normal integration of identity, memory, consciousness, perception, emotion, and behavior. These symptoms can affect all areas of functioning and are often associated with trauma, especially early or prolonged trauma such as abuse or captivity.

While not part of the trauma- and stressor-related disorders category, dissociative disorders are closely related and often co-occur with conditions like PTSD. Dissociative symptoms include both “positive” symptoms (e.g., depersonalization, derealization, identity division) and “negative” symptoms (e.g., memory loss, identity confusion).

DSM Chapter Sections:

• Dissociative Identity Disorder: Involves two or more distinct identity states and recurrent episodes of amnesia. Symptoms may include unexplained intrusions into awareness, shifts in self-perception, and memory gaps. Cultural variations (e.g., possession states) may shape how symptoms appear.

• Dissociative Amnesia: Characterized by an inability to recall autobiographical information, usually related to trauma. Amnesia may be localized (specific events), selective (details of events), or generalized (entire identity or life history). Most individuals are unaware of their memory gaps.

• Depersonalization/Derealization Disorder: Features persistent or recurrent experiences of feeling detached from oneself (depersonalization) or surroundings (derealization), while reality testing remains intact.

• Other Specified Dissociative Disorder: Used when dissociative symptoms cause significant distress or impairment but do not meet full criteria for a specific dissociative disorder. Examples include subthreshold identity disturbances, brief acute reactions to stress, and culturally specific syndromes like dissociative trance.

• Unspecified Dissociative Disorder: Applied when symptoms are present but the clinician does not specify the reasons they do not meet full criteria, often used in emergency or limited-information contexts.

Dissociative Identity Disorder

Dissociative identity disorder (DID) is defined by the presence of two or more distinct personality states or an experience of possession, accompanied by recurrent gaps in memory that are inconsistent with ordinary forgetting.

Key Features:

• Identity disruption (Criterion A): The person may experience sudden changes in sense of self, agency, or consciousness. These changes can be subtle or overt, including shifts in voice, mannerisms, preferences, or even physical sensations.

• Dissociative amnesia (Criterion B): Individuals often report memory gaps for personal history, daily activities, or significant life events. This may include fugues, “time loss,” or discovering possessions they don’t recall acquiring.

• Distress and impairment (Criterion C): Symptoms cause significant disruption in daily life, relationships, or functioning.

• Exclusion of culturally normative possession (Criterion D): The condition is not explained by culturally or religiously accepted practices of possession.

Subjective Symptoms May Include:

• Feeling like an observer of one’s own speech or actions

• Sudden intrusions of thoughts, emotions, or behaviors that feel alien

• Hearing internal voices or conflicting thought streams

• Sudden shifts in preferences, personality traits, or emotional states

• Emotional numbing or “not feeling in control” of one’s body or actions

Forms of Presentation:

• Possession-form DID: Common in some cultures, where an alternate identity is perceived as an external force or being (e.g., spirit possession).

• Non-possession-form DID: More common in Western contexts, often with less overt switching and more subtle internal disruptions.

Criteria:

A. Disruption of identity involving two or more distinct personality states, which may appear as possession in some cultures.

• Involves marked discontinuity in sense of self and agency, along with changes in affect, behavior, memory, perception, cognition, or motor functioning.

• These may be observed by others or reported by the individual.

B. Recurrent gaps in memory for everyday events, personal information, or traumatic experiences that are inconsistent with ordinary forgetting.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other key areas of functioning.

D. The disturbance is not part of a culturally accepted religious or spiritual practice.

• In children, symptoms are not better explained by imaginary play or fantasy behavior.

E. The symptoms are not due to a substance (e.g., intoxication) or a medical condition (e.g., seizures).

dissociative amnesia

Dissociative amnesia is characterized by the inability to recall important autobiographical information typically related to trauma or stress that cannot be explained by ordinary forgetting. The memory disturbance is potentially reversible and primarily retrograde, affecting past events rather than the formation of new memories.

Key Features:

• Memory loss involves personal, autobiographical information that is usually stored and would ordinarily be accessible.

• Types of amnesia include:

  • Localized amnesia: Inability to recall events from a specific time period.

  • Selective amnesia: Inability to recall certain details of an event.

  • Systematized amnesia: Memory loss for a specific category of information (e.g., a person or location).

  • Generalized amnesia: Complete loss of memory for identity and life history, often sudden and associated with dissociative fugue.

  • Continuous amnesia: Ongoing inability to form new memories (anterograde amnesia), though rare in dissociative disorders.

Associated Features:

• Minimization or unawareness of memory gaps is common.

• May be linked to trauma, especially childhood abuse or extreme stress.

• Individuals often experience flashbacks, depersonalization, dissociative trance states, or functional neurological symptoms.

• High rates of comorbid depression, self-injury, suicide risk, and sexual dysfunction.

• Hypnotizability and auto-hypnotic symptoms are common.

• Onset may be sudden, and symptoms can be transient or chronic, sometimes recurring across the lifespan.

Criteria:

A. Inability to recall important autobiographical information, typically of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.

• Most commonly localized, selective, or generalized amnesia.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The disturbance is not due to a substance (e.g., alcohol, drugs) or a neurological/medical condition (e.g., TBI, seizures).

D. The disturbance is not better explained by another mental disorder, such as:

• dissociative identity disorder

• posttraumatic stress disorder

• acute stress disorder

• somatic symptom disorder

• major or mild neurocognitive disorder

depersonalization/derealization disorder

Depersonalization/derealization disorder is characterized by persistent or recurrent episodes of either depersonalization, derealization, or both. Individuals retain intact reality testing, meaning they are aware that their experiences are not real, but still find them deeply distressing.

Key Features:

• Depersonalization:
  A sense of detachment from oneself or one’s own thoughts, feelings, body, or actions.

  • May feel like watching oneself from outside the body (“out-of-body experience”)

  • Experiences include emotional numbing, altered sense of agency, or feeling robotic

• Derealization:
  A sense of detachment from surroundings or the external world.

  • The environment may seem foggy, dreamlike, lifeless, or distorted

  • Common symptoms include visual or auditory distortions (e.g., blurriness, muted sounds)

• Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Associated Features:

• Individuals may struggle to describe their experiences and fear they are “going crazy”

• May report altered sense of time, vague physical sensations, or difficulty connecting to past memories emotionally

• Anxiety, depression, obsessive rumination, and physiological hyporeactivity to emotional stimuli are common

• Often comorbid with trauma histories but can occur independently.

Criteria:

A. Persistent or recurrent experiences of one or both:

1. Depersonalization: Feeling detached from oneself (thoughts, feelings, body, actions)

2. Derealization: Feeling detached from surroundings (people or objects seem unreal, foggy, dreamlike, or distorted)

B. Reality testing remains intact during these experiences (i.e., the person knows the sensations are not real).
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not due to a substance or medical condition (e.g., seizures, medication, drugs).
E. The symptoms are not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, PTSD, or another dissociative disorder.

other specified dissociative disorder

Other specified dissociative disorder (OSDD) is diagnosed when a person has clinically significant dissociative symptoms that cause distress or impairment but do not fully meet criteria for a specific dissociative disorder (such as dissociative identity disorder, dissociative amnesia, or depersonalization/derealization disorder).

This diagnosis is used when the clinician chooses to specify the reason the presentation does not meet full criteria, and it is documented as “other specified dissociative disorder” followed by the specific reason (e.g., “dissociative trance”).

Examples of OSDD Presentations:

1. Chronic and recurrent syndromes of mixed dissociative symptoms

   • Includes identity disturbances or possession-like experiences without dissociative amnesia.

2. Identity disturbance due to coercive persuasion

   • Occurs in individuals subjected to intense indoctrination, captivity, or psychological manipulation (e.g., cults, torture, political imprisonment).

3. Acute dissociative reactions to stressful events

   • Transient symptoms (lasting hours to less than a month), including depersonalization, derealization, time distortion, stupor, or sensory-motor changes.

4. Dissociative trance

   • A sudden loss or narrowing of awareness, unresponsiveness, or involuntary movements, not explained by cultural or religious practices.

unspecified dissociative disorder

Unspecified dissociative disorder is diagnosed when a person exhibits dissociative symptoms that cause significant distress or impairment, but the presentation does not meet full criteria for any specific dissociative disorder (e.g., dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder).

This diagnosis is used when the clinician chooses not to specify the reason the criteria are unmet. It is often applied in situations with limited information, such as during emergency assessments or when a more comprehensive evaluation cannot yet be completed.

Key Points:

• Symptoms are clinically significant and clearly dissociative in nature.

• Used when:

  • There is insufficient information for a specific diagnosis.

  • The clinician opts not to disclose why a specific diagnosis cannot be made.

• Commonly used in crisis or emergency settings.

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