Reactive and Dissociative Psychosis Revisited: Trauma, Identity, and the Phenomenology of Collapse

Study Design

A comprehensive and methodologically rigorous literature search (last updated January 2025) was conducted to support this narrative review. Searches were performed across major biomedical databases, including PubMed, Scopus, Web of Science, and Google Scholar. Search terms were systematically developed and combined using Boolean operators to capture key thematic domains related to trauma-associated psychopathology, dissociation, and psychotic disorders. Specifically, keywords included reactive psychosis, dissociation, trauma, schizophrenia, and schizo-dissociative reactive disorder.

Priority was given to peer-reviewed original research articles, systematic reviews, meta-analyses, clinical guidelines, and expert consensus statements, predominantly published within the past decade to ensure relevance and contemporaneity. Earlier studies were included selectively based on their conceptual or foundational significance. Additionally, manual screening of the reference lists of relevant publications was conducted to identify additional pertinent sources.

Inclusion criteria comprised thematic relevance, methodological rigor, and contribution to the understanding of trauma-related psychopathology, the relationship between dissociation and psychosis, and contemporary theoretical models, including neurophenomenological approaches and predictive processing frameworks. Exclusion criteria included studies with insufficient methodological quality, research conducted exclusively on animal models without clear translational relevance, and publications not aligned with the study objectives.

Selected sources were systematically organized, synthesized, and critically analyzed to construct a coherent and clinically relevant narrative. Study selection and screening were conducted independently by two authors, with discrepancies resolved through discussion. This approach ensured the development of an up-to-date, evidence-informed synthesis of the pathogenesis, clinical manifestations, and theoretical models of psychotic–dissociative disorders, with implications for both research and clinical practic.

Clinical Case Analysis

The study includes an in-depth analysis of a single clinical case selected for its illustrative value in demonstrating the overlap between dissociative and psychotic phenomena. The analysis was conducted retrospectively using phenomenological and psychodynamic approaches, with a focus on symptom structure, narrative coherence, identity processes, and trauma-related mechanisms.

Clinical material was obtained through psychiatric interviews, longitudinal clinical observation, and reconstruction of the patient’s life history and psychosocial context. The analysis aimed to identify diagnostically relevant patterns and to evaluate the applicability of the proposed theoretical framework.

Analytical Strategy

Data analysis was conducted using a qualitative interpretative approach. Phenomenological analysis was employed to describe subjective experience and clinical manifestations, while psychodynamic interpretation was used to explore intrapsychic processes and defense mechanisms.

Comparative clinical analysis was applied to differentiate dissociative disorders, reactive psychosis, and primary psychotic conditions across several parameters, including onset, narrative structure, affect regulation, identity organization, and treatment response.

Review of Recent Research and Theoretical Framework

The classical conceptual distinction between reactive psychoses and schizophrenia has historically been rooted in a dualistic framework that positioned schizophreniform disorders and dissociation-related disorders at opposing ends of a presumed structural divide. This model, however, has proven insufficient for capturing the complexity of trauma-related clinical presentations, which often display features of both categories (Ross, C. A., 2021). Building on previously published reflections (Pustovoyt et al., 2012), the present article advances a dimensional perspective on the reactive–dissociative continuum, wherein trauma operates as a transversal axis influencing both core dissociative symptomatology and phenomena traditionally attributed to schizophreniform psychotic manifestations.

The framework is grounded in three core assumptions:

1. Trauma as a dynamic catalyst: Traumatic events, especially those occurring in early development or involving interpersonal violence, can overwhelm integrative mental functions. Depending on premorbid structure, ego resilience, and contextual containment, this may result in either compartmentalization (dissociation) or symbolic dramatization (reactive psychosis).

2. Dissociation and reactive psychosis as overlapping yet distinguishable defensive formations: In this view, dissociation represents an intrapsychic segregation of affect and experience - a splitting-off that preserves psychic survival by rendering intolerable elements inaccessible to conscious integration. Reactive psychosis, by contrast, entails a symbolic reconstitution of meaning in the face of existential disaster and the wrecking of psychological defenses - an attempt to forge a mutational defense where the usual protective structures have been shattered. They share a common origin in fragmentation but diverge in their psychopathological form and communicative intent. Nevertheless, they may alternate, each replacing the other as the mind struggles to restore psychic equilibrium.

3. Phenomenology over nosology: Echoing the work of Jaspers (1913) and contemporary trauma theorists (van der Kolk, 2014), the model emphasizes subjective experience over rigid criteria. The goal is not to replace diagnoses, but to situate them within a broader understanding of existential and neurobiological disruption.

This integrative framework also draws on contemporary theories of predictive coding and free energy (Friston et al., 2023), which conceptualize psychosis and dissociation as differing strategies for dealing with violated expectations, unbearable affect, and epistemic unpredictability. Dissociative states may reflect a withdrawal of precision-weighting from interoceptive signals, while reactive psychoses may involve maladaptive overinterpretation of exteroceptive cues in an effort to restore coherence (Sterzer et al., 2021; Seth et al., 2018).

In short, the theoretical framework proposed here invites a shift from diagnostic exclusivity toward layered, trauma-informed mapping of psychopathology.

Clinical Differentiation

Differentiating between trauma-related dissociative states, reactive psychosis, and primary psychotic disorders is a major clinical challenge. Traditional diagnostic frameworks often fail to account for the complex phenomenology of trauma responses, especially when symptoms such as hallucinations, voice-hearing, affective dysregulation, or altered states of consciousness overlap across nozological boundaries.

To facilitate the differential diagnostic process, Appendix A presents a multidimensional comparative framework summarizing the key clinical and phenomenological parameters required for the differential diagnosis of dissociative disorders, reactive psychosis, and schizophrenia. Each dimension represents an important component of the differential diagnostic algorithm.

This section adopts a comparative perspective, beginning with Ross (2021) and Kluft’s key contributions (2005), followed by the author’s earlier work (Pustovoyt et al., 2012). The framework is further refined with contemporary clinical insights and structured across ten dimensions (Appendix A).

1. Trigger and Onset: Dissociative and reactive conditions typically follow identifiable psychological trauma or existential shock. In contrast, primary psychotic disorders often have a more insidious onset with no clear precipitant.

2. Narrative Continuity: Dissociative experiences are often fragmented but embedded in a trauma narrative. Reactive psychosis exhibits symbolic or metaphorical content, often distorted but emotionally linked to lived experience. Schizophrenic delusions and hallucinations tend to be non-relational, bizarre, or self-referential.

3. Voice-Hearing Phenomenology: In DID and trauma-related psychosis, voices are typically experienced as dialogic, affect-laden, and interpersonally charged. In schizophrenia, voices may be more impersonal, commanding, or enigmatic.

4. Affect and Regulation: Dissociative and reactive forms often show intense affective storms followed by shutdown or mutism. Schizophrenia may involve affective flattening or incongruity.

5. Identity and Self: Dissociative disorders involve identity fragmentation with alternating ego-states. Reactive psychosis may temporarily destabilize identity without full structural division. Schizophrenia often features erosion of boundaries between self and other.

6. Course and Outcome: Dissociative and reactive states tend to resolve with appropriate containment and therapeutic support. Schizophrenic syndromes generally follow a chronic or relapsing course.

7. Insight and Meaning-Making: Patients with trauma-related states often retain partial insight or can retrospectively make sense of their experience. In schizophrenia, insight is frequently absent or rigidly encapsulated.

8. Somatic and Sensorimotor Features: Dissociative presentations may include analgesia, paralyses, or altered bodily ownership. Reactive psychoses often involve somatic metaphors. Schizophrenia may show disorganized or catatonic motor features.

9. Response to Treatment: Trauma-informed therapy, narrative integration, and supportive pharmacotherapy are typically effective in dissociative/reactive conditions. Antipsychotics alone may be insufficient. In schizophrenia, antipsychotics are the primary treatment.

10. Prognosis and Functioning: With stabilization and integration, dissociative/reactive patients often return to high functioning. Schizophrenia is more likely to entail long-term functional impairment.

Appendix A provides a side-by-side comparison of these dimensions across diagnoses. This clinically grounded matrix serves as a diagnostic guide and a foundation for tailored intervention.

Neurobiological Findings

Emerging research in affective neuroscience and neuroimaging has significantly enhanced our understanding of trauma-related psychotic and dissociative states. Neurobiological data increasingly support the differentiation between trauma-induced alterations in consciousness and primary psychotic disorders.

1. Functional Neuroimaging and Dissociation: Studies using functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) have demonstrated that dissociative states are characterized by hypoactivation in brain areas associated with bodily self-awareness (e.g., the anterior insula and anterior cingulate cortex) and hyperactivation in medial prefrontal regions involved in self-monitoring and internal narrative suppression (Lanius et al., 2021). This pattern is consistent with the clinical experience of emotional numbing, depersonalization, and compartmentalization of trauma.

2. Neurobiology of Reactive Psychosis: While data are more limited, reactive psychosis has been associated with acute dysregulation in cortico-limbic circuits, particularly involving the amygdala, hippocampus, and ventral striatum. These changes may reflect the brain’s maladaptive attempt to re-establish meaning and coherence in the face of overwhelming stress. The symbolic and metaphorical nature of symptoms often corresponds with hyperactivity in associative temporal and parietal cortices, which are implicated in narrative construction and metaphoric representation (Lee et al., 2023).

3. Predictive Coding and Free Energy Theory: Friston’s model of hierarchical Bayesian inference provides a compelling framework for understanding these states. In dissociation, the brain may reduce the precision weighting of interoceptive signals, resulting in experiential disconnection. In reactive psychosis, the system may generate over-weighted priors in an effort to minimize surprise, leading to perceptual distortions or delusional ideation (Heinz et al., 2019).

4. Comparisons with Schizophrenia: In contrast, primary psychotic disorders such as schizophrenia demonstrate widespread dysconnectivity across frontotemporal networks, with reductions in gray matter volume, impaired synaptic plasticity, and alterations in dopamine and glutamate transmission (Li & Kéri, 2020). These findings support the distinctiveness of trauma-related psychotic states at the neurobiological level, despite superficial phenomenological overlap.

Together, these data support the reconceptualization of trauma-related dissociative and psychotic phenomena as neurobiologically grounded conditions with identifiable mechanisms. They call for diagnostic frameworks that incorporate these neurophenomenological insights rather than relying solely on symptom-based categorization.

To further elucidate the neurophenomenological mechanisms and differential diagnostic aspects discussed above, a detailed illustrative clinical case is provided in Appendix B.

Case Analysis clinical considerations.

From a clinical and phenomenological perspective, the patient’s life history presents a highly illustrative trajectory of dissociative predisposition. Early sexual trauma, attachment disruptions, and a longstanding pattern of identity fragmentation are evident well before the emergence of overt psychotic symptoms. Dissociative phenomena - ranging from amnesia and depersonalization to trance states - are present across her developmental arc.

However, clinicians must also consider the presence of endogenous affective fluctuations and the seemingly spontaneous onset of psychotic features. For instance, the triggering event - trip to a friend’s wedding - may not meet conventional thresholds of traumatic stress. Yet when interpreted through the lens of re-enactment, it becomes plausible that the patient unconsciously re-entered a scenario mirroring earlier trauma, resulting in a dissociative amnesia and shame-driven psychotic breakthrough. The lack of memory for the night’s events, the perception of social judgment, and her subsequent belief in being “cursed” suggest a collapse of symbolic integration.

The differential diagnostic challenge centers on whether this was a reactive psychosis or the inaugural manifestation of an endogenous psychotic process. Given the affective lability, transient psychotic symptoms, and identity instability, one must differentiate between schizoaffective disorder and dissociative identity disorder (DID) with comorbid borderline personality disorder. This debate mirrors ongoing clinical discourse regarding phase-like dynamics in personality disorders.

Some schools (e.g., Anglo-American psychiatry and the ICD/DSM framework) accept affective episodes as features of borderline pathology. In contrast, Eastern European traditions argue that phase dynamics can also reflect latent psychotic diathesis - particularly within schizotypal or mixed schizoid-cycloid character structures. These cases may resemble transient endoform psychoses triggered by psychosocial stress.

Within this framework, one could reasonably exclude the “non-dissociative schizophrenia” pole of Ross’s dissociative-psychotic continuum. The remaining diagnostic dilemma thus lies between dissociative-type schizophrenia and a “schizodissociative reactive disorder” - a concept emphasizing the interplay between trauma, identity diffusion, and symbolic elaboration.

The patient’s preserved affective capacity, lack of core negative symptoms, and poor response to antipsychotic treatment weigh against a primary schizophrenic diagnosis. Rather, her condition aligns more closely with a trauma-linked, structurally complex reaction - where dissociation serves both defensive and expressive functions.

Understanding why the friend’s wedding became the fulcrum for psychological collapse - shifting the case from “minor psychiatry" to “major psychiatry” - requires psychodynamic formulation. This analysis, presented in the next section, will explore how latent meanings, symbolic enactments, and dissociative processing coalesced into an existential crisis that was simultaneously a breakdown and a cryptic call for reconstitution.

Psychodynamic Analysis and Diagnostic Integration. From a psychodynamic perspective, it is important to immediately note the excessive role of sexuality in the life story narrated by the patient. Such a subjective coloring of experiences may indicate the absence of developmental boundaries in the child–parent relationship - boundaries that protect the child’s maturation - which inevitably leads to a premature activation of the child’s sexual needs. All significant figures in the patient’s life, from her maternal grandmother to her parents and brother, appear in her account as objects incapable of adequately performing the holding function (in D. Winnicott’s sense: they fail to provide a sense of safety and stability, and are unable to receive and contain the child’s negative experiences, thereby failing to soothe her. Consequently, the patient’s earliest memories express the feelings of insecurity and confusion of a small child in the tangled and dangerous world of adults. One may assume that under such relational conditions, the girl developed an insecure attachment, likely of the disorganized type (combining features of avoidance and ambivalence), as evidenced by her later relational patterns.

In the patient’s subjective world, her mother appears emotionally detached, indifferent, unpredictable, and unreliable; this “emotional absence” is processed by the patient in a depressive mode, forming a persistent sense of guilt toward the mother. The only seemingly interested figure - the father - proves even more dangerous than the absent mother: he is intrusively seductive, ultimately cementing the patient’s guilt toward her mother and a depressive sense of her own badness. In this polarity of the mother’s “emotional absence” and the father’s inadequately seductive involvement, one can recognize Bion’s description of the typical transformation “from the absence of a good object to the presence of a bad object” (Bion, W. R., 1962). This inner constellation complicates the course of subsequent development, particularly the oedipal stage, crystallizing into an unconscious conviction that emotionally intense relationships are potentially painful and dangerous, as well as into a characteristic behavioral pattern: persistent attempts to elicit a positive emotional response from emotionally distant figures and the disregard of the feelings of those who are emotionally attached.

The development of this mode of transformation - “the absence of a good object into the presence of a bad object” - can also be observed in the patient’s dreams, in which she sees her father killing her mother. These dreams can be interpreted as the destruction of the “bad internal object” by the “good internal object” within the patient’s psychic world. In her episode of sleepwalking, triggered by sharing a room with her brother, we see a “mirror” defensive strategy: an attempt to protect the “internal good object” (in this situation, herself) from a potential attack by the “bad object” (in this situation, her brother).

This “confrontation” in the patient’s inner world forms the main leitmotif of her life and constitutes a closed “pathogenetic” circle of retraumatization and repetitive compulsions. On the phenomenological level, this “confrontation” manifests itself in alternating states of consciousness and associated behavioral patterns: at times she is strikingly gentle, kind, and vulnerable, in contrast to her consciously chosen strategy of being a rather sharp, uncompromising, and sometimes even cruel woman who has sacrificed her “good name” for emotional freedom (these states being separated by an amnestic barrier); when the absence of emotional connection with her own son contrasts with her preoccupation with his fate; and in the current enactment of her unconscious conflict with her mother - when the mother tries to protect the “good child” (the patient’s son) from the harmful influence of his “bad mother.”

On the psychodynamic level, we observe a defense tactic specific to such cases: the protection of the “internal good object” from a potential attack by the “bad object” through the preventive conversion of an unconsciously anticipated aggressive attack into emotional attachment, followed by the justification of her own aggression as a defense against inappropriate sexual advances from partners.

In other words, the patient demonstrates a typical histrionic coping strategy - preemptively converting any experience into an erotic–sexual context - which, on the manifest level, gives her behavior a strong oedipal/sexually provocative tone, making it possible to interpret the entire case through the lens of an oedipal conflict alone. Indeed, the patient had no opportunity either to safely live through the oedipal situation in a “triangular” relationship with her mother and father, or to resolve it constructively for herself.

However, this combination - on the one hand obvious, on the other paradoxical - of oedipal and pre-oedipal dynamics creates the greatest diagnostic challenges: it misleads the clinician with opposite compulsive impulses - at one moment, to diagnose a corresponding personality disorder (based on her overtly demonstrative, provocative behavior), and at another, to diagnose schizophrenia (based on clear psychotic features). In most cases, this ultimately inclines clinicians toward the latter, out of reluctance to engage with this “contrasting confusion.”

This entire defensive strategy serves the patient’s desperate attempt to protect herself from the depressive experience that she herself is the “bad object” who destroyed her own internal “good object,” leaving her alone in a world of unpredictable, seductive, and boundary-violating “bad objects” - objects just as “bad” as she perceives herself to be.

The situation that precipitated the psychotic breakdown is highly illustrative: the patient simultaneously found herself in a very good and safe place - the marital bed of newlyweds - and attacked this place, identifying with her own bad internal object (bad because it violates others’ private boundaries). In other words, she both found and destroyed what she had been searching for so long - a place imbued with love, where everything happens by mutual consent, without anyone’s boundaries being violated; a loving parental couple that she never had in her life.

Thus, her expulsion from this bed, waking up in the morning next to an unfamiliar man, and reading disapproval in the eyes of those around her mercilessly assailed the painful experiences she had been so desperately defending herself against - namely, that she herself is the “bad object” who brings only harm. An echo of precisely this experience can be found in the psychotic sense that she, like a witch, attracts all sorts of misfortune and negative energy; and also in her experience of feeling ugly and dirty - down to a physical sensation of dirtiness - after a night at a disco in Prague with her lover.

Her anxiety subsides when she feels the presence of a “friend,” an “angel guardian,” nearby, and intensifies again when things at home do not work out, when she feels alienation from her son. Her psychosis begins when splitting and dissociation are no longer able to keep the “good” and “bad” self-representations in separate compartments, due to the inability to differentiate images of the external and internal worlds (a universal mechanism for the reactive triggering of psychoses) - with the result that depersonalization experiences dominate the clinical picture.

When dissociation can no longer contain this affective overload, more primitive defenses become activated: projective identification (drawing others into her inner conflict), intensified dissociation (the presence of the “guardian angel” alter), splitting (extreme mood shifts), denial, and regressive fantasies of universal love and protection. These mechanisms offer momentary relief but only fragmentary reality testing, culminating in a structurally rich, affectively charged psychotic reaction embedded within a traumatic context.

The diagnostic challenge lies in disentangling psychosis born of trauma from primary psychotic disorders. While schizoaffective disorder might explain her affective lability and psychotic episodes, her emotional vitality, narrative insight, and resistance to antipsychotic medication suggest otherwise. A dissociative subtype of schizophrenia could be considered, yet the prominence of dissociative symptoms, trauma history, and symbolic content supports the construct of a “schizodissociative reactive disorder” - a hybrid presentation not formalized in current nosologies.

The patient’s case underscores the necessity of trauma-informed diagnostic frameworks that integrate both phenomenological nuance and psychodynamic data. Her narrative exemplifies a dissociative-reactive crisis: not merely a symptom of decompensation, but an existential threshold crossing - a psychic event that restructures the trajectory of identity. As such, it demands an equally integrative response: one that hears not just the psychosis, but the pain, protest, and paradox it contains.

Diagnostic Integration

Key Clinical Conclusions:

• Embedded Dissociative Predisposition: The patient’s presentation reveals a latent dissociative vulnerability shaped by cumulative early trauma (emotionally absent caregiving and sexual boundary violations in childhood).

• Alternating Ego States: The presence of alternating ego states, amnestic gaps, symbolic enactments of shame/guilt, and identity confusion suggests a dissociative structure far more intricate than a typical mood disorder or primary psychotic disorder.

• Lack of Antipsychotic Response: Antipsychotic treatment produced no significant improvement, reinforcing the hypothesis that dissociation - rather than neurotransmitter dysregulation - is the principal mechanism driving the patient’s condition.

• Preserved Help-Seeking and Affect: The patient’s consistent help-seeking behavior, emotional expressiveness, and partial narrative insight (between episodes) argue against schizophrenia, despite the transient psychotic-like symptoms

Theoretical Synthesis: Legacy of Astrup & Retterstøl and Modern Trauma Science

The case lends empirical allegiance to the legacy of Astrup and Retterstøl, who conceptualized reactive (psychogenic) psychosis as an affective and psychogenic derailment rather than a fixed degenerative disease. Their model emphasized the meaning, reversibility, and symbolic content of such conditions - a perspective that has been revalidated by contemporary trauma research and neurophysiology in psychosis. Modern studies of trauma - from van der Kolk’s (2014) work on body-memory to the neuroimaging research of Lanius et al. (2021) - demonstrate that dissociative fragmentation is not only a psychological defense but also a measurable neurobiological event involving functional disconnections across the default-mode, salience, and interoceptive networks. Disruptions in predictive coding, as proposed by Friston and colleagues (2023), help explain the ways trauma can disable the mind’s ability to accurately “guess” the present, leading to distorted perceptions (e.g. persecutory interpretations, magical beliefs) and symbolically exaggerated experiences.

Proposed Diagnostic Concept: “Schizodissociative Reactive Disorder”

We propose Schizodissociative Reactive Disorder as a formal diagnostic category to capture trauma-related psychoses dominated by dissociative mechanisms. This formulation is characterized by the following proposed criteria:

A. Core Features (all required):

• - Causal connection with Trauma: History of identifiable psychological trauma (acute or cumulative, relational or catastrophic in nature).

• - Dissociative phenomena: Evidence of dissociative symptoms across at least two domains (e.g. amnesia, depersonalization/derealization, identity confusion, trance-like episodes).

• - Psychotic symptoms: Hallucinations, delusional ideas, or perceptual distortions that are transient, polymorphic, and clearly contextual (often metaphorically related to trauma themes).

• - Absence of negative symptoms: No enduring negative symptoms (e.g. flattening of affect, alogia, avolition) and no primary formal thought disorder as present in schizophrenia.

• - Paradoxical medication response: Relative resistance to standard antipsychotic medications (or paradoxical worsening), with partial or full improvement when treated with trauma-focused, integrative psychotherapeutic approaches.

B. Supportive Features (at least 2 of the following):

• - Marked fluctuations in mood and affect that do not conform to classical bipolar patterns.

• - Episodes of altered consciousness (e.g., fugue states, regressions) are consistently linked to interpersonal or attachment-related triggers.

• - Preserved narrative insight between psychotic episodes (the patient can reflect on and partially understand their experience when stabilized).

• - Symbolic or metaphorical elaboration of psychotic content (e.g., adopting the persona of a “witch” symbolizing persecutory guilt, hearing a “guardian angel” during distress, experiencing a “split self” voice that echoes trauma narratives).

C. Exclusion Criteria:

• - No established diagnosis of schizophrenia, schizoaffective disorder, or bipolar I disorder (per DSM/ICD criteria).

• - Symptoms are not better accounted for by a neurological condition or substance-induced psychosis.

This formulation recognizes that certain psychotic phenomena emerge not from a neurodegenerative or primary psychotic process, but as symbolic responses to unresolved trauma and fragmented identity. It reframes trauma-related psychosis as a dynamic psychological process - an extreme but potentially adaptive expression of mental suffering - rather than as a static pathology of thought.

Differentiating Schizoaffective vs. Schizodissociative Trajectories

The above-mentioned criteria outline the core phenomenology according to which trauma-related psychotic phenomena may predominantly manifest as disturbances in self-awareness and disruptions in identity continuity. Within this spectrum of clinical presentations, two clinically significant trajectories within the transitional psychosis spectrum can be identified. A detailed graphical representation of these conceptual models, including the continuum from irreversible disintegration to reversible fragmentation, as well as multidimensional diagnostic vectors facilitating the differentiation between psychotic and dissociative disorders, is provided in Appendices C and D.

Figure in Appendix C presents a diagnostic continuum ranging from irreversible disintegration to reversible fragmentation. At one pole lies schizophrenia, marked by a collapse of the cohesive self-structure and an essentially irreversible loss of identity. At the opposite pole stand the dissociative disorders, in which basic self-integrity is preserved, and fragmentation remains fundamentally reversible. Between these poles stretches a transitional zone that can be differentiated into two modes of fragmentation: an affect-driven mode (represented by schizoaffective disorder) and a self-structure-driven mode (schizodissociative reactive disorder). This framework highlights two distinct clinical trajectories within the transitional psychosis spectrum: a schizoaffective trajectory and a schizodissociative trajectory.

Figure in Appendix D presents the diagnostic continuum from schizophrenia to dissociative identity disorder; based on our clinical experience, we propose a set of clinically significant vectors that may serve as guiding landmarks for differential diagnosis.

In the schizoaffective trajectory, the destabilizing impact of trauma is channeled primarily into affective dysregulation. Psychotic symptoms in this trajectory are typically embedded within mood disturbances. The structure of the self is disrupted not through an immediate shattering by trauma, but secondarily - under the influence of pathologically altered mood and affect. Phenomenologically, the axis of disorder runs through the emotional sphere: fluctuations in self-experience occur, but they are congruent with the prevailing affective state. Importantly, once the mood is stabilized, the person often experiences partial or full restoration of a coherent sense of self.

According to the schizodissociative trajectory - exemplified by the case detailed in this study - trauma targets self-awareness and the continuity of identity directly. Here, fragmentation is not confined to an affective content of experience; it penetrates the very structure of subjectivity. The patient’s psychotic content is rich with metaphor and symbolism, effectively enacting unresolved autobiographical material. Consequently, fundamental orientations of time, space, and personal identity become disrupted or “ruptured.” The core disturbance centers around fluctuations in self-awareness and self-coherence, independent of mood. The psychotic phenomena (voices, visions, delusional narratives) often bear an allegorical relation to the trauma, representing dissociated aspects of the person’s life story demanding integration.

This phenomenological distinction aligns with emerging concepts of Complex PTSD, wherein diagnostic criteria explicitly include both affect-regulation disturbances and changes in self-perception (Cloitre et al., 2013). The patterns observed in this case—when integrated with the earlier differential framework for dissociative disorders (Pustovoyt et al., 2012) and the continuum models illustrated above - fit coherently within a spectrum: from irreversible disintegration (schizophrenia) on one end to reversible fragmentation (dissociative disorders) on the other, with a transitional zone comprising affect-driven and self-structure-driven forms of fragmentation.

Clinically, this differentiation has more than theoretical value. Schizoaffective forms of psychosis require treatment strategies that combine trauma processing with mood stabilization. In contrast, schizodissociative forms demand an identity-focused, narrative-restorative approach that prioritizes rebuilding a coherent self-narrative. Correctly identifying the trajectory in a trauma-related psychotic presentation prevents both the underestimation of the role of trauma in symptom genesis and the overreliance on pharmacological suppression—an approach that risks perpetuating the very fragmentation it aims to resolve.