What is the treatment approach for dissociative disorder?

Treatment Approach for Dissociative Disorders

Trauma-focused psychotherapy should be implemented immediately as the primary treatment approach for patients with dissociative disorders, without delaying with a stabilization phase, as evidence shows this is both effective and safe. 1

Evidence-Based Psychotherapeutic Approaches

• Trauma-focused treatments including Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and Cognitive Processing Therapy (CPT) are effective for patients with dissociative disorders, even those with childhood trauma histories and comorbidities 2, 1
• Contrary to traditional beliefs, trauma-focused treatments do not pose significant risks for patients with complex presentations and do not show adverse effects from these interventions 2
• Evidence does not support the need for a stabilization phase prior to providing trauma-focused treatment in persons with dissociative disorders or complex PTSD 2, 1

Addressing Specific Dissociative Symptoms

• For dissociative identity disorder (DID), treatment should focus on helping the person understand the diagnosis and sensitively communicating when they are likely using integrated functioning (though without awareness) 2
• For functional communication disorders related to dissociation, therapy should focus on regaining voluntary control through automatic movement patterns and extending these into graded, functionally relevant activities 2
• Schema Therapy integrated in a phase-oriented approach may be effective for complex dissociative disorders, showing improvements in dissociative and PTSD symptoms 3

Managing Comorbid Conditions

• Dialectical Behavior Therapy (DBT) skills can be implemented concurrently to address emotion regulation difficulties that often accompany dissociative disorders 1
• For comorbid anxiety symptoms, specific anxiety management techniques should be incorporated within the trauma-focused framework 1
• Vigilant monitoring of suicidal ideation is essential throughout treatment, as patients with mood disorders and dissociative symptoms have increased suicide risk 2, 1

Medication Considerations

• The use of anxiolytics and hypnotics should be considered with caution, as part of a comprehensive treatment plan 4
• Avoid the use of antidepressants or benzodiazepines as initial treatment for depressive symptoms in the absence of a diagnosed depressive episode 4
• Overreliance on benzodiazepines should be avoided as they may worsen symptoms in the long term 1

Common Pitfalls to Avoid

• Delaying trauma-focused treatment is not supported by evidence and may have an iatrogenic effect by inadvertently communicating to patients that they are not capable of dealing with their traumatic memories 2, 1
• Labeling a patient as "complicated" or "complex" has a potential iatrogenic effect of giving the patient the impression that "traditional" treatments will not be effective 2
• Endless searches for physical causes of treatable psychiatric illness should be avoided 2

Treatment Monitoring and Progression

• Treatment response should be evaluated after 8 weeks; if symptom reduction is poor despite good compliance, consider altering the treatment approach 1
• Integration of dissociated self-states is associated with reduced symptomatology compared with those who do not integrate 5
• Incorporating principles from cognitive-behavioral therapy (CBT) can aid treatment by helping patients notice and challenge unhelpful thoughts related to their dissociative symptoms 2

Special Considerations

• For patients with dissociative disorders and psychotic disorders, trauma-focused treatment can still be safely and effectively used without evidence of iatrogenic effects 2
• Patients may benefit from a "start low, go slow" approach to medication dosing if pharmacotherapy is needed for comorbid conditions 2
• Emerging neurobiological findings in DID provide essential information that can be used to improve treatment outcomes and reduce stigma 6