Low-Dose Naltrexone for Dissociative Identity Disorder
The recommended dose of low-dose naltrexone (LDN) for treating dissociative symptoms in dissociative identity disorder is 2-6 mg/day (approximately 0.06 mg/kg body weight), based on the most recent clinical evidence demonstrating efficacy with minimal side effects. 1
Evidence Base and Dosing Rationale
The use of naltrexone for dissociative symptoms is based on the hypothesis that blocking opioid receptors reduces opiate-modulated dissociative phenomena. 1 While standard naltrexone dosing for substance use disorders ranges from 25-250 mg/day 2, 3, low-dose naltrexone at 2-6 mg/day has shown superior tolerability with maintained efficacy specifically for dissociative symptoms. 1
Clinical Efficacy Data
In the most recent study (2015), 11 out of 15 patients (73%) with severe trauma-related and dissociative disorders reported immediate positive effects with low-dose naltrexone (2-6 mg/day), and 7 patients (47%) described lasting helpful effects. 1
Patients reported clearer perception of surroundings and inner life, improved reality assessment, better body and affect perception, and enhanced self-regulation. 1
The low-dose regimen proved very low in side effects compared to standard dosing. 1
Comparison with Standard Dosing
Earlier studies used higher doses with mixed results:
A 2005 open trial used 100-250 mg/day (mean 120 mg/day) in depersonalization disorder, showing 30% symptom reduction with 4 of 14 patients showing significant improvement. 2
Studies from 1999 used 25-100 mg/day in borderline personality disorder patients with dissociative symptoms, showing marked reduction in dissociation duration and intensity. 3, 4
However, a 2012 double-blind placebo-controlled trial using 50-200 mg/day showed numerically lower dissociation under naltrexone but failed to reach statistical significance. 5
Practical Implementation Algorithm
Starting dose: Begin with 2 mg/day orally. 1
Titration: Gradually increase by 1-2 mg increments based on response and tolerability, up to a maximum of 6 mg/day. 1
Assessment timeline: Evaluate for immediate positive effects within the first 1-2 weeks, as most responsive patients report rapid improvement. 1
Maintenance: Continue at the lowest effective dose that maintains symptom control. 1
Critical Safety Considerations and Caveats
Patients must be completely opioid-free before starting naltrexone to avoid precipitating withdrawal, regardless of dose. 6
Naltrexone cannot be used in patients requiring opioids for pain control as it blocks pain relief from opioid agonists at any dose. 6
Baseline liver function tests should be performed, with monitoring every 3-6 months, though hepatotoxicity is primarily a concern at supratherapeutic doses (well above the low-dose range). 6
Critical therapeutic caveat: The decrease in dissociation may expose patients to previously avoided traumatic material, potentially creating an unresolvable challenge if adequate psychotherapeutic support is not in place. 1 Dissociation often serves as a necessary self-protection mechanism, and its reduction requires concurrent trauma-focused therapy.
Common Pitfalls to Avoid
Do not use standard naltrexone dosing (50-100 mg/day) for dissociative symptoms when low-dose naltrexone (2-6 mg/day) provides comparable efficacy with significantly fewer side effects. 1
Do not initiate naltrexone without ensuring adequate psychotherapeutic support is available, as reducing dissociative defenses without therapeutic containment can destabilize patients. 1
Do not continue treatment if patients experience increased distress from reduced dissociation without the psychological resources to manage emerging traumatic material. 1
Avoid prescribing to patients who may resume opioid use, as discontinuation increases overdose risk due to decreased tolerance. 6
Strength of Evidence Considerations
The evidence for low-dose naltrexone in dissociative disorders is limited to small open-label trials and case series. 1, 2, 3, 4 The only double-blind placebo-controlled trial used higher doses (50-200 mg/day) and failed to show statistical significance, though it showed numerical trends favoring naltrexone. 5 Despite the limited evidence quality, the 2015 low-dose study represents the most recent and clinically relevant data, showing the best risk-benefit profile for this specific indication. 1