Dissociative disorders involve disruptions in identity, memory, consciousness, or perception. The dissociative phenomena range from normal momentary detachment (everyone experiences some dissociation under fatigue, intense emotion, or boredom) through clinically significant disorders that produce substantial functional impairment.
DSM-5 dissociative disorders: depersonalization-derealization disorder, dissociative amnesia (with or without dissociative fugue), dissociative identity disorder, other specified and unspecified dissociative disorder. Each represents a different pattern of disrupted integration.
Depersonalization-derealization disorder is the most common dissociative disorder in general psychiatric practice. Patients describe feeling unreal (depersonalization — like watching themselves from outside, emotional numbing, sense of being a robot) or that the world is unreal (derealization — surroundings feel artificial, distant, dreamlike). Episodes can be brief or persistent. Often misdiagnosed as anxiety or psychosis. Prevalence: up to 2% of adults meet criteria. Pharmacotherapy limited; SSRIs, lamotrigine, and trauma-focused therapy each have evidence in small studies.
Dissociative amnesia involves inability to recall important autobiographical information, typically related to trauma or stress, beyond ordinary forgetfulness. Subtypes: localized (specific time period), selective (some aspects of an event), generalized (entire life history — rare), continuous (everything since a specific time), systematized (specific category of information). Dissociative fugue is a specifier — purposeful travel with apparent amnesia for identity.
Dissociative identity disorder is the most controversial and most severe. Two or more distinct personality states with associated discontinuities in memory, sense of self, and behavior. Substantial evidence that DID is rooted in severe early developmental trauma. Treatment is specialized — phased trauma-focused therapy by clinicians with specific DID expertise. Often misdiagnosed as bipolar, BPD, or psychotic disorders.
Treatment approach across the dissociative disorders: phased trauma-focused therapy modified for dissociative populations. Direct trauma exposure can be destabilizing — stabilization first. Address comorbid conditions (PTSD, depression, substance use). Pharmacology adjunctive at best — no medication has FDA approval specifically for dissociative disorders.
When you encounter a patient with persistent depersonalization, gaps in autobiographical memory inconsistent with ordinary forgetfulness, or signs of identity discontinuity, consider dissociative disorders in the differential. Specialty referral often appropriate for DID; depersonalization-derealization and dissociative amnesia can often be addressed in general psychiatric practice with appropriate framework.