ICD-11 Criteria for Secondary Dissociative Syndrome
A syndrome characterised by the presence of prominent dissociative symptoms (e.g., depersonalization, derealization) that is judged to be the direct pathophysiological consequence of a health condition not classified under mental and behavioural disorders, based on evidence from the history, physical examination, or laboratory findings. The symptoms are not accounted for by delirium or by another mental and behavioural disorder, and are not a psychologically mediated response to a severe medical condition (e.g., as part of an acute stress reaction in response to a life-threatening diagnosis). This category should be used in addition to the diagnosis for the presumed underlying disorder or disease when the dissociative symptoms are sufficiently severe to warrant specific clinical attention.
- Delirium (6D70)
- Acute stress reaction (QE84)
Essential (Required) Features:
- The presence of prominent dissociative symptoms (e.g., depersonalization, derealization, dissociative amnesia, a marked alteration in the individual’s normal sense of personal identity).
- The symptoms are judged to be the direct pathophysiological consequence of a medical condition, based on evidence from the history, physical examination, or laboratory findings. This judgment depends on establishing that:
- The medical condition is known to be capable of producing the observed symptoms;
- The course of dissociative symptoms (e.g., onset, remission, response of the dissociative symptoms to treatment of the etiological medical condition) is consistent with causation by the medical condition; and
- The symptoms are not better accounted for by Delirium, Dementia, another mental disorder (e.g., Dissociative Disorders, Disorders Specifically Associated with Stress, Schizophrenia or Other Primary Psychotic Disorders) or the effects of a medication or substance, including withdrawal effects.
- The symptoms are sufficiently severe to be a specific focus of clinical attention.
Boundary with other disorders and normality:
Boundary with Dissociative Disorders:
Determining whether dissociative symptoms are due to a medical condition as opposed to manifestations of a primary mental disorder is often difficult because the clinical presentations may be similar. Establishing the presence of a potentially explanatory medical condition that can cause dissociative symptoms and the temporal relationship between the medical condition and the dissociative symptoms is critical in diagnosing Secondary Dissociative Syndrome.
Boundary with dissociative symptoms caused by substances or medications, including withdrawal effects:
When establishing a diagnosis of Secondary Dissociative Syndrome, it is important to rule out the possibility that a medication or substance is causing the dissociative symptoms. This involves first considering whether any of the medications being used to treat the medical condition are known to cause dissociative symptoms at the dose and duration at which it has been administered. Second, a temporal relationship between the medication use and the onset of the dissociative symptoms should be established (i.e., the dissociative symptoms began after administration of the medication and/or remitted once the medication was discontinued). The same reasoning applies to individuals with a medical condition and dissociative symptoms who are also using a psychoactive substance known to cause dissociative symptoms, either in the context of intoxication or withdrawal (e.g., amnesia due to ketamine or phencyclidine intoxication, depersonalization due to dextromethorphan intoxication).
Boundary with dissociative symptoms that are precipitated by the stress of being diagnosed with a medical condition:
The stress of a medical diagnosis can precipitate dissociative symptoms (e.g., depersonalization, derealization). Depending on the nature of the medical condition (e.g., a life-threatening type of cancer, a potentially fatal infection) or its onset (e.g., a heart attack, a stroke, a severe injury), being diagnosed and/or having to cope with a severe medical condition can be experienced as a traumatic event, which may trigger dissociative symptoms. In the absence of evidence of a physiological link between the medical condition and the dissociative symptoms, a diagnosis of Secondary Dissociative Syndrome is not warranted. Instead, the appropriate mental disorder can be diagnosed (e.g., Adjustment Disorder, Depersonalization-Derealization Disorder).
Potentially Explanatory Medical Conditions (examples):
Brain disorders and general medical conditions that have been shown to be capable of producing dissociative syndromes include:
- Diseases of the Nervous System (e.g., encephalitis, migraine, seizures, stroke)
- Endocrine, Nutritional or Metabolic Diseases (e.g., hyperglycaemia)
- Injury, Poisoning or Certain Other Consequences of External Causes (e.g., intracranial injury)
- Neoplasms (e.g., neoplasms of brain)
International Classification of Diseases Eleventh Revision (ICD-11). Geneva: World Health Organization; 2022. License: CC BY-ND 3.0 IGO.