Skip to main content

Understanding, identifying and managing severe dissociative disorders in general psychiatric settings

  • Melanie J. Temple (a1)

The severe dissociative disorders of dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS) are complex, not uncommon presentations associated with severe symptoms, high rates of comorbidity, high service use compared with other psychiatric disorders, and high suicidality. They exact high personal and socioeconomic burdens and show poor response to standard treatments, with high levels of treatment attrition and ‘revolving-door’ out-patient and in-patient service use; patients are often misdiagnosed or labelled ‘untreatable’. DID and DDNOS diagnoses remain controversial, but they have been repeatedly validated internationally over the past 20 years and the disorders can be accurately identified using screening tools and structured clinical interviews. Neurobiological understanding of the disorders is increasing; findings are consistent with a trauma origin and have commonality with features seen in other trauma-related disorders. Specialist treatment that addresses the dissociative symptoms alongside their trauma origins shows promise in early evidence. Working knowledge of these disorders among non-specialist psychiatrists and psychologists in the UK remains poor, resulting in long delays before diagnosis and treatment.


  • Understand trauma-related DID and DDNOS, in particular that they are ‘real’ and not rare disorders
  • Know when to suspect their presence in general psychiatric settings and how to assess for them
  • Understand (and help the patient to access) specialist treatments and be able to apply general approaches in the non-specialist setting



Corresponding author
Correspondence Dr Melanie Temple, The Retreat, Heslington Road, York YO10 5BN, UK. Email:
Hide All
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5). American Psychiatric Publishing.
Belli, H (2014) Dissociative symptoms and dissociative disorders comorbidity in obsessive compulsive disorder: symptom screening, diagnostic tools and reflections on treatment. World Journal of Clinical Cases, 2: 327–31.
Bernstein, EM, Putnam, FW (1986) Development, reliability and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174: 727–35.
Brand, B (2012a) What we know and what we need to learn about the treatment of dissociative disorders. Journal of Trauma and Dissociation, 13: 387–96.
*Brand, B, Lanius, R, Vermetted, E, et al. (2012b) Where are we going? An update on assessment, treatment and neurobiological research in dissociative disorders as we move to DSM 5. Journal of Trauma and Dissociation, 13: 931.
Brand, B, Lanius, R (2014a) Chronic complex dissociative disorders and borderline personality disorder: disorders of emotion dysregulation? Borderline Personality Disorder and Emotion Dysregulation, 1: 13.
*Brand, B, Dorahy, M, Kruge, C, et al. (2014b) Dissociative identity disorder: an empirical overview. Australian and New Zealand Journal of Psychiatry, 45: 402–17.
Brandon, S, Boakes, J, Glaser, D, et al. (1997) Reported recovered memories of child sexual abuse: recommendations for good practice and implications for training, continuing professional development and research. Psychiatric Bulletin, 21: 663–5.
Dalle Grave, R, Oliosi, M, Todisco, P, et al. (1996) Trauma and dissociative experiences in eating disorders. Dissociation, 9: 274–81.
Dell, P (1998) Axis II pathology in patients with dissociative identity disorder. Journal of Nervous and Mental Disease, 186: 352–6.
Evren, C, Sar, V, Karadag F, et al. (2007) Dissociative disorders among alcohol-dependent inpatients. Psychiatry Research, 152: 233–41.
*Foote, B, Smolin, Y, Kaplan, M, et al. (2006) Prevalence of dissociative disorders in psychiatric outpatients. American Journal of Psychiatry, 163: 623–9.
Foote, B, Smolin, Y, Neft, DI, et al. (2008) Dissociative disorders and suicidality in psychiatric outpatients. Journal of Nervous and Mental Disease, 196: 2936.
Goff, DC, Olin, JA, Jenike, MA, et al. (1992) Dissociative symptoms in patients with obsessive-compulsive disorder. Journal of Nervous and Mental Disease, 180: 332–7.
Hopper, A, Ciorciari, J, Johnson G, et al. (2002) EEG coherence and dissociative identity disorder. Journal of Trauma & Dissociation, 3: 7588.
International Society for the Study of Trauma and Dissociation (2011) Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, 12: 115–87.
Karadag, F, Sar, V, Tamar-Gurol, D, et al. (2005) Dissociative Disorders among inpatients with drug or alcohol dependency. J Clin Psych, 66: 1247–53.
Kleindienst, N, Limburger, MF, Ebner-Priemer, UW, et al. (2011) Dissociation predicts poor response to dialectial behavioral therapy in female patients with borderline personality disorder. Journal of Personality Disorders, 25: 432–47.
Nijenhuis, E, van der Hart, O, Steele, K (2001) Trauma-related structural dissociation of the personality. Activitas Nervosa Superior, 52(1): 123.
Porges, S, Levine, P (2011) The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, Self-Regulation. W.W. Norton & Company.
Pick, S, Millers, J, Goldstein, LH (2017) Dissociation in patients with dissociative seizures (pseudoseizures, NEAD): relationships with trauma and seizure symptoms. Psychological Medicine, 47(7): 115.
Reinders, AA, Nijenhus, ER, Quak, J, et al. (2006) Psychobiological characteristics of DID – a symptoms provocation study. Biol Psychiatry, 60(7): 730–40.
Rodewald, F, Wilhelm, C, Enrich, H, et al. (2011) Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. Journal of Nervous and Mental Disease, 199: 122–31.
Ross, CA (2007) Borderline personality disorder and dissociation. Journal of Trauma and Dissociation, 8: 7180.
Sar, V, Akyüz, G, Kundakçi, T, et al. (2004) Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. American Journal of Psychiatry, 161: 2271–6.
Sar, V, Akyuz, G, Kugu, N, et al. (2006) Axis I dissociative disorder comorbidity in borderline personality disorder and reports of childhood trauma. Journal of Clinical Psychiatry, 67: 1583–90.
Sar, V, Unal, SN, Ozturk, E (2007) Frontal and occipital perfusion changes in dissociative identity disorder. Psychiatry Research: Neuroimaging, 156: 217–23.
Sar, V, Taycan, O, Bolat, N, et al. (2010) Childhood trauma and dissociation in schizophrenia. Psychopathology, 43: 3340.
Shumaker, JF, Warren, WG, Schreiber, GS, et al. (1994) Dissociation in anorexia nervosa and bulimia nervosa. Social Behavior and Personality, 22: 385–92.
Spitzer, C, Barnow, S, Freyberger, HJ, et al. (2007) Dissociation predicts symptom-related treatment outcome in short-term inpatient psychotherapy. Australian and New Zealand Journal of Psychiatry, 41: 682–7.
Steinberg, M (1994) Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R). American Psychiatric Association.
Tobin, DL, Molteni, AL, Elin, MR, et al. (1995) Early trauma, dissociation, and late onset in the eating disorders. International Journal of Eating Disorders, 17: 305–8.
van der Hart, O, Horst, R (1989a) The dissociation theory of Pierre Janet. Journal of Traumatic Stress, 2: 397412.
van der Hart, O, Friedman, B (1989b) A reader's guide to Pierre Janet on dissociation: a neglected intellectual heritage. Dissociation, 2: 316.
Vermetten, E, Schmahl, C, Lindner, S, et al. (2006) Hippocampal and amygdalar volumes in dissociative identity disorder. American Journal of Psychiatry, 163: 630–6.
World Health Organization (2018) International Statistical Classification of Diseases and Related Health Problems, 11th revision (ICD-11). WHO.
*Asterisks denote key recommended reading.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

BJPsych Advances
  • ISSN: 2056-4678
  • EISSN: 2056-4686
  • URL: /core/journals/bjpsych-advances
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Understanding, identifying and managing severe dissociative disorders in general psychiatric settings

  • Melanie J. Temple (a1)
Submit a response


No eLetters have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *