Dissociative disorders — assessment, differential and phase-oriented management (MEQ)

(i) Differential and discriminators (≈5 marks)

Working formulation: complex trauma-related dissociative presentation — possible DID or OSDD, with comorbid depression and self-injury, pending structured assessment. Key differentials:^[1]

• DID: identity disruption with distinct states + recurrent amnesia inconsistent with ordinary forgetting; internal self-state voices common; reality testing generally intact outside switches.^[1]
• OSDD / partial presentations: clinically significant dissociation without full DID criteria — do not force the label.^[1]
• PTSD with dissociative symptoms: trauma clusters primary; depersonalisation/derealisation as specifier; may co-occur with DID features.^[1]
• BPD: chronic emptiness, abandonment fears, affective instability; amnesia/discrete autonomous self-states less central (comorbidity possible).^[1]
• Primary psychosis: thought disorder, external hallucinations, persistent delusions, negative symptoms — not suggested by the stem, but exclude carefully.^[1]

State trauma-model support with methodological caution (fantasy/sociocognitive risks remain clinically relevant).^[5]

(ii) Assessment (≈4 marks)

Safety first: suicide and self-injury risk, means, intent, protective factors, capacity, child protection if relevant.^[3] Trauma-informed history (pacing, consent, avoid leading). MSE for identity continuity, amnesia, depersonalisation, reality testing. Collateral. DES to screen/track; SCID-D structured interview when indicated and expertise available.^[6] Organic/substance exclusion if atypical features. Document without suggestive "memory recovery".

(iii) Phase-oriented treatment (≈5 marks)

ISSTD-style phases: (1) safety/stabilisation/skills/symptom reduction; (2) carefully paced trauma processing when stable; (3) integration/rehabilitation. Phases reversible if destabilised.^[2] Evidence is stronger for clinical consensus and naturalistic cohorts than large DID-specific RCTs — say so explicitly. Treat depression and self-injury pathways concurrently.^[1][2]

(iv) Medication and DPDR psychology (≈3 marks)

Pharmacotherapy targets comorbidity (e.g. antidepressant for major depression using standard adult dosing/monitoring) — does not integrate identities.^[2] If depersonalisation dominates, CBT approaches targeting appraisals/maintaining factors have open-trial support.^[4]

(v) Iatrogenic pitfalls (≈3 marks)

Avoid aggressive hypnosis/leading memory work and premature intensive exposure without stabilisation; avoid mislabelling as schizophrenia with unnecessary chronic antipsychotics for non-psychotic internal voices.^[2][5]