Introduction
Dissociative disorders are a group of psychiatric conditions characterized by disruptions in consciousness, memory, identity, emotion, perception, and behavior. These disorders often arise as a psychological response to trauma and can significantly impair functioning. A comprehensive psychiatric evaluation is essential for accurate diagnosis, understanding the underlying causes, and developing an effective treatment plan.
Purpose of the Evaluation
To identify dissociative symptoms and their severity
To rule out other psychiatric or medical conditions
To assess trauma history and psychosocial stressors
To develop a personalized treatment plan
To ensure safety and monitor risk factors
Key Dissociative Disorders (DSM-5)
1. Dissociative Identity Disorder (DID)
Presence of two or more distinct personality states
Gaps in memory for everyday events, personal information, or traumatic experiences
Often linked to severe childhood trauma
2. Dissociative Amnesia
Inability to recall important autobiographical information
Not due to substance use or medical condition
May include dissociative fugue (sudden travel or wandering)
3. Depersonalization/Derealization Disorder
Depersonalization: feeling detached from oneself
Derealization: feeling detached from surroundings
Reality testing remains intact
Components of a Comprehensive Psychiatric Evaluation
1. Identifying Information
Name, age, gender, occupation
Date of evaluation
Referral source (e.g., self, family, physician)
2. Chief Complaint
Patient’s own words describing symptoms
Example: “Sometimes I feel like I’m watching myself from outside my body.”
3. History of Present Illness (HPI)
Onset, duration, and progression of symptoms
Triggers (e.g., trauma, stress)
Impact on daily functioning
Previous episodes and treatments
4. Past Psychiatric History
Prior diagnoses and hospitalizations
History of trauma or abuse
Medication and therapy history
Suicide attempts or self-harm
5. Medical History
Neurological conditions (e.g., seizures)
Substance use
Medications and allergies
6. Family History
Psychiatric conditions in family members
History of trauma or abuse
7. Social History
Living situation
Education and employment
Relationships and support systems
Legal issues
Cultural and spiritual background
Mental Status Examination (MSE)
Domain Description
Appearance Grooming, hygiene, clothing
Behavior Eye contact, psychomotor activity
Mood Subjective emotional state
Affect Observable emotional expression
Speech Rate, volume, coherence
Thought Process Logical, tangential, disorganized
Thought Content Suicidal ideation, identity confusion
Perception Depersonalization, derealization
Cognition Orientation, memory, attention
Insight Awareness of symptoms
Judgment Decision-making ability
Risk Assessment
Suicidal or homicidal ideation
Self-injurious behavior
Risk of dissociative fugue or wandering
History of trauma or abuse
Substance use
Diagnostic Tools
Structured Clinical Interview for DSM-5 (SCID-D)
Dissociative Experiences Scale (DES)
Trauma history questionnaires
Neuropsychological testing (to rule out organic causes)
Formulation
A biopsychosocial summary explaining how biological, psychological, and social factors contribute to the disorder.
Example: “Patient’s dissociative symptoms appear to be a coping mechanism for unresolved childhood trauma and are exacerbated by current interpersonal stress.”
Treatment Plan
Psychotherapy
Trauma-focused therapy
Cognitive Behavioral Therapy (CBT)
Dialectical Behavior Therapy (DBT)
EMDR (Eye Movement Desensitization and Reprocessing)
Internal Family Systems (IFS) for DID
Pharmacological Support
No medications specifically for dissociation
Antidepressants or anxiolytics for comorbid conditions
Antipsychotics if severe disorganization is present
Safety Planning
Crisis hotline numbers
Removal of harmful objects
Emergency contacts
Hospitalization if necessary
Referrals
Trauma specialists
Community mental health services
Support groups
Documentation Tips
Use clear, objective language
Include direct quotes from the patient
Document trauma history sensitively
Ensure confidentiality and informed consent
Conclusion
Dissociative disorders are complex and often misunderstood conditions that require careful assessment and compassionate care. A comprehensive psychiatric evaluation helps clinicians understand the full scope of symptoms, identify underlying trauma, and develop a treatment plan that promotes healing and integration. With appropriate support, individuals with dissociative disorders can achieve meaningful recovery.