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EV0480

Assessing suicide risk in dissociative identity disorder: clinical challenges in a case-based analysis

SUICIDE RISK ASSESSMENT IN DISSOCIATIVE IDENTITY DISORDER: CLINICAL CHALLENGES IN A CASE-BASED ANALYSIS

Suicide risk in dissociative identity disorder may not be reliably assessed because awareness, intent, and behavior vary across identity states; when risk remains uncertain, safety and stabilization should take priority, and hospitalization should be considered.

The aim is to examine the clinical challenges of suicide risk assessment in dissociative identity disorder (DID) through a case-based analysis; the poster notes that some studies have found an up to 15-fold increase in the risk of recurrent suicide attempts among people with dissociative disorders, yet no suicide risk assessment instrument has been specifically validated for dissociative disorders. The method is a case-based clinical analysis of a 30-year-old woman with a history of severe and repeated childhood trauma; the patient was admitted with seizure-like episodes following acute psychosocial stressors, such as marital conflict, and underwent neurological examination, neuroimaging, video-EEG monitoring, and comprehensive psychiatric and neuropsychological assessment. Neuroimaging and video-EEG monitoring revealed no evidence of epileptiform activity or organic disease, and the seizure-like episodes were identified as psychogenic nonepileptic seizures (PNES). These episodes were followed by dissociative amnesia and transitions into distinct dissociative identity states, often reflecting trauma-related childhood self-states; neuropsychological assessment indicated borderline intellectual functioning. Psychiatric assessment supported diagnoses of complex post-traumatic stress disorder (CPTSD) and DID, with no evidence of primary psychosis. During follow-up after discharge, the patient reported hearing the voice of an unidentified young woman telling her to jump off a bridge. During the interview, she switched to an alternate identity experienced as a 12-year-old girl and reported that this identity was trying to persuade the woman in her head to jump off a bridge to escape physical abuse. The authors report that, phenomenologically, this suicidal command was more consistent with dissociative communication between identities than with a primary psychotic phenomenon, that differences in the expression of suicidal intent across identity states complicated the assessment of overall risk, and that hospitalization was indicated because the risk remained uncertain. The poster summarizes assessment principles adapted from the ISSTD guidelines: treating the patient as a whole adult person, considering differences in experience and awareness between identities, distinguishing suicide-related dissociative denial and personified internal voices that may represent communication between identities from psychotic auditory hallucinations, establishing internal safety agreements, and moving to a more restrictive level of care when necessary.

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