Severe psychological trauma: Strongest association with chronic childhood physical, sexual, or emotional abuse/neglect (> 90% in DID). c
Female predominance: Significantly higher in females for Dissociative Identity Disorder (DID).
Comorbidities: High rates of PTSD, Borderline Personality Disorder (BPD), Major Depressive Disorder (MDD), somatic symptom disorders, and substance use disorders.
Clinical Features
Depersonalization / Derealization Disorder:
Depersonalization: Persistent or recurrent feeling of detachment from one’s own body, mind, or actions (e.g., “out-of-body experience”, feeling like an automaton/robot).
Derealization: Persistent or recurrent feeling of detachment from surroundings; environment feels dreamlike, foggy, artificial, or lifeless.
Intact reality testing: Pt recognizes that these perceptions are not literal reality (differentiates from psychosis).
Inability to recall important personal/autobiographical information, usually of a traumatic or stressful nature (inconsistent with ordinary forgetfulness).
Dissociative Fugue (Specifier): Sudden, unexpected purposeful travel or bewildered wandering associated with amnesia for identity or past autobiographical details.
Dissociative Identity Disorder (DID):
Disruption of identity characterized by ≥ 2 distinct personality states (“alters”) with marked discontinuity in sense of self and agency.
Recurrent gaps in recall of everyday events, important personal info, and/or past trauma.
Sudden changes in behavior, voice, affect, and preferences observed by others or reported by pt.
Diagnosis
Initial Workup / Rule-out (Exclusionary Testing):
Labs: Urine toxicology screen (UTox), serum EtOH, BMP, LFTs, TSH, Vit B12 (r/o substance/medication-induced states or metabolic encephalopathy).
EEG: Essential to r/o temporal lobe epilepsy (TLE), non-convulsive status epilepticus, or transient epileptic amnesia.
Brain MRI: Indicated if focal neurological deficits, atypical age of onset, or head trauma history (r/o mass, structural lesion, stroke).
Diff: Psychosis involves loss of reality testing, fixed delusions, and true auditory hallucinations perceived externally. Depersonalization/derealization maintains intact reality testing.
Post-Traumatic Stress Disorder (PTSD):
Diff: While PTSD features dissociative symptoms, it is characterized by intrusion symptoms (flashbacks, nightmares), hyperarousal, and persistent avoidance of trauma reminders.
Borderline Personality Disorder (BPD):
Diff: BPD presents with affective instability, fear of abandonment, and transient stress-related dissociation, but lacks distinct, stable alter identities or massive autobiographical memory loss.
Transient Global Amnesia (TGA):
Diff: Sudden-onset anterograde amnesia lasting < 24 hours with preserved autobiographical identity and repetitive questioning; occurs in older pts (> 50 yo), not linked to trauma.
Malingering / Factitious Disorder:
Diff: Malingering involves intentional production of symptoms for secondary gain (financial, legal avoidance, drugs). Symptoms are typically exaggerated, stereotypical, and lack subtle dissociative signs.