DSM-5 Diagnostic Criteria for Dissociative Disorders in PTSD Patients with Dissociative Episodes
The DSM-5 recognizes a dissociative subtype of PTSD that requires meeting full PTSD criteria plus persistent or recurrent symptoms of depersonalization (feeling detached from one's mental processes or body) or derealization (experiencing unreality of surroundings), though emerging evidence suggests a broader range of dissociative symptoms may be clinically relevant. 1, 2
Core DSM-5 Criteria for Dissociative Subtype of PTSD
The diagnosis requires two components:
1. Full PTSD Diagnosis Must Be Present
The patient must first meet all standard PTSD criteria, which include 3:
Trauma exposure: Direct experience, witnessing, learning about trauma to close others, or repeated exposure to traumatic details for more than one month causing significant functional impairment 3
Intrusion symptoms (≥1 required): Recurrent intrusive memories, traumatic nightmares, flashbacks, or intense psychological distress to trauma reminders 3
Avoidance (≥1 required): Avoidance of trauma-related thoughts, feelings, or external reminders 3
Negative alterations in cognition and mood (≥2 required): Inability to remember trauma aspects, persistent negative beliefs about self/world, distorted blame, persistent negative emotional state, diminished interest, detachment from others, or inability to experience positive emotions 3
Alterations in arousal and reactivity (≥2 required): Irritable/aggressive behavior, reckless/self-destructive behavior, hypervigilance, exaggerated startle response, concentration problems, or sleep disturbance 3
2. Additional Dissociative Symptoms
Beyond meeting PTSD criteria, the patient must experience persistent or recurrent symptoms of 2, 4:
Depersonalization: Feeling detached from one's mental processes, body, or self—as if observing oneself from outside 2, 4
Derealization: Experiencing unreality, distance, or distortion of one's surroundings—feeling that things are not real 2, 4
Important Clinical Context: Broader Dissociative Symptoms
While DSM-5 formally recognizes only depersonalization and derealization, recent research demonstrates that patients with dissociative PTSD frequently present with a much broader array of dissociative symptoms that may warrant clinical attention 1, 5:
Compartmentalization symptoms: Auditory-verbal hallucinations, amnesia for important personal information, identity alteration, and identity confusion are highly prevalent in severe dissociative PTSD 5, 6
Other dissociative experiences: Blanking out episodes, emotional numbing beyond typical PTSD numbing, alterations in sensory perception (visual, auditory, or bodily sensations), and gaps in awareness 4, 6
Clinical reality: In severely traumatized inpatient populations, the majority of PTSD patients with dissociative features present with these more complex dissociative symptoms beyond just depersonalization/derealization 5
Critical Diagnostic Considerations
Do not confuse dissociative episodes with psychotic symptoms—dissociative experiences in PTSD are trauma-related avoidance responses to overwhelming emotional distress, not psychotic phenomena 7. This distinction is crucial for appropriate treatment planning.
The overlap between diagnoses is substantial: Nearly all patients meeting criteria for dissociative subtype of PTSD also meet criteria for complex PTSD and may meet criteria for other specified dissociative disorder, suggesting these may represent overlapping presentations rather than distinct conditions 1.
Assessment Approach
For patients with known PTSD reporting dissociative episodes, systematically assess 4:
- Frequency and duration of depersonalization/derealization episodes
- Trauma-relatedness of dissociative symptoms (triggered by trauma reminders vs. spontaneous)
- Functional impact on daily activities and relationships
- Broader dissociative symptoms including amnesia, identity confusion, blanking out, and perceptual alterations 4, 6
Use structured assessment tools: The Dissociative Subtype of PTSD Interview (DSP-I) provides clinician-administered assessment of both DSM-5 criteria and supplementary dissociative symptoms with strong psychometric properties 4.
Common Diagnostic Pitfalls
Avoid underdiagnosis: Many patients do not spontaneously report dissociative symptoms; direct questioning is essential 3. Ask specifically about feeling detached from body/mind, feeling like things aren't real, losing time, or having gaps in memory.
Don't delay treatment while pursuing diagnostic clarity: The presence of dissociative symptoms does not require extensive pre-treatment stabilization or separate treatment protocols 7, 8. Dissociative symptoms improve directly with trauma-focused treatment 7, 8.
Recognize that dissociative symptoms are intrusive PTSD symptoms, not separate pathology requiring distinct treatment approaches 7. They represent the patient's response to overwhelming trauma-related affect, not a contraindication to trauma-focused therapy 8.