Dissociation in trauma-related psychopathology: a transdiagnostic clinical perspective

Introduction

Dissociative symptoms are common in trauma-related psychopathology and include depersonalisation, derealisation, dissociative amnesia, emotional numbing and disruptions in the continuity of experience. Although traditionally associated with post-traumatic stress disorder, dissociation is increasingly recognised as a transdiagnostic phenomenon across several psychiatric presentations, including complex trauma, borderline personality disorder, mood and anxiety disorders, psychotic-spectrum disorders and functional conditions. This overlap is clinically relevant because dissociative experiences may be overlooked or misinterpreted as psychosis, cognitive impairment or emotional withdrawal, contributing to diagnostic uncertainty and delayed trauma-informed interventions.

Aims

To review the clinical relevance of dissociative symptoms in trauma-related psychopathology and discuss their role as transdiagnostic markers of diagnostic complexity, functional impairment and treatment planning.

Methods

A narrative review was conducted using PubMed, Scopus and PsycINFO. Studies published between 2010 and 2026 were searched using combinations of the terms “dissociation”, “dissociative symptoms”, “depersonalisation”, “derealisation”, “trauma”, “post-traumatic stress disorder”, “complex post-traumatic stress disorder”, “transdiagnostic”, “differential diagnosis” and “psychotherapy”. Observational studies, systematic reviews and meta-analyses published in English were included if they addressed the clinical presentation, diagnostic implications or treatment relevance of dissociative symptoms in trauma-exposed or psychiatric populations. Case reports, studies limited to non-clinical samples and papers without clear assessment of dissociative symptoms were excluded.

Results

The reviewed literature suggests that dissociation represents a clinically relevant transdiagnostic dimension rather than a disorder-specific symptom. In post-traumatic stress disorder, depersonalisation and derealisation may define a dissociative subtype associated with greater symptom severity, emotional dysregulation and functional impairment. Dissociative symptoms are also particularly relevant in complex post-traumatic stress disorder, where they may coexist with affect dysregulation, negative self-concept and interpersonal difficulties, contributing to emotional disconnection, avoidance, shame and difficulties integrating traumatic experiences. Dissociation may also complicate differential diagnosis across psychiatric settings. Perceptual detachment, identity fragmentation or internally experienced voices may resemble psychotic symptoms; dissociative amnesia and attentional discontinuity may be interpreted as cognitive impairment; and emotional numbing may overlap with depressive withdrawal or negative symptoms. Careful exploration of phenomenology, insight, temporal relationship with trauma, affective arousal and functional impact is therefore essential. Regarding treatment, dissociation should not be considered an automatic exclusion criterion for trauma-focused psychotherapy. However, its presence, particularly in complex trauma presentations, may indicate the need for careful assessment, stabilisation and individualised pacing of interventions. Phase-based psychotherapeutic approaches, integrating initial work on safety, emotional regulation and grounding before trauma processing, may be especially useful in patients with marked dissociation, self-harm risk or severe affect dysregulation.

Conclusions

Dissociation should not be regarded as an accessory symptom of trauma-related disorders, but as a transdiagnostic dimension with implications for diagnostic formulation, risk assessment and treatment planning. Its systematic assessment may help clarify complex clinical presentations, prevent misdiagnosis and identify patients who may benefit from staged, trauma-informed interventions. Recognising dissociative symptoms across diagnostic boundaries can support more individualised care and improve the timing and safety of trauma-focused psychotherapy.

References

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