Core dissociative phenomena

• Amnesia: inability to recall important autobiographical information or events (beyond ordinary forgetfulness).
• Depersonalisation: feeling detached from oneself (as an observer of one’s thoughts/body).
• Derealisation: the world feels unreal, dreamlike or visually distorted.
• Identity disruption: marked discontinuity in sense of self, behaviours or memory that may not meet full DID criteria.
• Transient dissociative episodes: lapses in awareness, trance‑like states or dissociative fugue behaviour.

Who is affected & common associations

• Dissociation is common after traumatic experiences (acute trauma, chronic childhood adversity) but may also occur in severe stress, certain medical conditions, substance use, or in the context of other psychiatric disorders (PTSD, borderline personality disorder).
• Prevalence of subthreshold or unspecified dissociative presentations is higher in clinical populations and often under‑recognised in general practice.

Assessment checklist

1. Symptom enquiry: episodes of memory loss, gaps in time, unusual behaviours, dissociative sensations, identity confusion, and any triggers or patterns.
2. Collateral history: family/caregiver reports of observed dissociation, missing time, unexplained injuries or functional changes—use collateral where safe and consented.
3. Trauma and psychiatric screen: PTSD symptoms, self‑harm, suicidality, substance use, mood instability and personality features.
4. Medical and neurologic review: exclude organic causes (seizures, transient global amnesia, head injury, neuroinfection, endocrine/metabolic disturbances) and review medication/substance use.
5. Use standard instruments where helpful: Dissociative Experiences Scale (DES), Clinician‑Administered Dissociative States Scale (CADSS) for assessment and monitoring.

Differential diagnosis

• Neurological conditions (epilepsy, transient ischemic attacks), substance‑induced states, delirium, psychotic disorders (when reality testing impaired), complex PTSD and personality disorders; carefully distinguish voluntary feigning (factitious/malingering).
• Use targeted investigations (EEG, MRI, cognitive testing) guided by clinical suspicion and red flags.

Immediate safety & risk considerations

• Assess for self‑harm, suicidality, risk during dissociative episodes (accidents, wandering), and vulnerability to exploitation. Consider safeguarding for dependent adults/children.
• Advise on strategies to reduce immediate risks (do not drive during episodes, ensure supervision if severe, secure dangerous objects).

Management principles

1. Validate and normalise: explain dissociation as a common stress/trauma response—avoid pathologising language and reassure about symptom reality.
2. Stabilisation first: establish safety, sleep, substance cessation, grounding techniques and reduce acute stressors before trauma‑focused work.
3. Phase‑based approach: (1) stabilisation and symptom management; (2) trauma processing if appropriate and when the patient is ready; (3) integration and rehabilitation for functional recovery.
4. Multidisciplinary care: psychiatry/psychology, primary care, social work and when needed neurology, occupational therapy and specialist trauma services.

Psychotherapies with evidence and clinical utility

• Trauma‑focused therapies: EMDR and trauma‑focused CBT can be effective once stabilisation achieved—adapt pacing to tolerance.
• Phase‑oriented psychotherapies: approaches that build affect regulation, skills training (DBT elements) and gradual trauma processing are preferred for complex dissociation.
• Cognitive & grounding strategies: teach grounding, orientation to time/place, sensory anchors and reality‑testing techniques to reduce episode intensity.
• Group and peer support: can reduce isolation and provide skills practice; ensure groups are trauma‑informed and safely facilitated.

Pharmacologic considerations

• No medication specifically treats dissociation. Use medications to treat comorbid conditions (SSRIs for PTSD/depression, mood stabilisers for mood instability, short‑term anxiolytics carefully for severe anxiety) and avoid substances that worsen dissociation.
• Monitor for polypharmacy and potential interactions—prioritise psychosocial interventions over long‑term pharmacotherapy for core dissociative symptoms.

When to refer & red flags

• Refer urgently to psychiatry if active suicidality, severe functional impairment, high risk during dissociative episodes (wandering, harm), or diagnostic uncertainty requiring specialist assessment.
• Refer to neurology where episodes are suggestive of seizures or when focal neurological signs/red flags present.

Key takeaways

• Use “unspecified” pragmatically to start care when dissociative symptoms are present but do not meet a specific subtype — prioritise safety, stabilisation and trauma‑informed care.
• Teach grounding and orientation skills, treat comorbidities, and use a phase‑based psychotherapy approach when trauma processing is indicated.
• Coordinate multidisciplinary care and escalate for red flags (suicidality, severe functional decline, possible seizures).