Editorial

Alpha Psychiatry 2022;23(2):45-46

DOI: 10.5152/alphapsychiatry.2022.0001

The Challenges in Diagnosis and Treatment of Dissociative Disorders

Wai Tong Chien

Hong Wang Fung

The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR

Corresponding author: Hong Wang Fung ✉ andyhwfung@gmail.com or wtchien@cuhk.edu.hk

Cite this article as: Chien WT, Fung HW. The challenges in diagnosis and treatment of dissociative disorders. Alpha Psychiatry. 2021;23(2):45-46.

Dissociative disorders (DDs) are complex mental health problems (including dissociative amnesia, depersonalization/de-realization disorder, dissociative identity disorder (DID), and other specified dissociative disorder (OSDD) according to DSM-5),¹ which is characterized by dissociative symptoms and widely interfered different psychological functioning such as consciousness, memory, emotion, motor control, and identity. They are often comorbid with borderline personality, substance abuse, post-traumatic stress disorder, depression, and somatoform disorders.² Lifetime prevalence(s) of DDs and DID are around 10% and 1% of the worldwide population, respectively.² Dissociative disorders are clinically rarely identified and thus under-diagnosed;¹,² for instance, it has been reported that patients with DID have typically been in the mental healthcare service for an average of 6.8 years before accurately diagnosed.³ The delay in diagnosis and appropriate treatment (dissociation-specific psychotherapy) would lead to poor treatment response, unnecessary medication side effects, and a waste of healthcare resources. In this editorial paper, we highlight 5 major challenges in the diagnosis and the treatment of DDs and provide suggestions to address these impediments.

First, there is inadequate professional training in the management of DDs. As there is only a slight touch on the assessment and management of DDs in nearly all basic professional education curricula, clinical practitioners can hardly patients with DDs and their treatment needs.⁶ As many mental health professionals are unfamiliar with the conceptual and research evidence of DDs, some myths about DDs are commonly found among these professionals. For example, there are doubts on DID about its existence, validity, and prevalence. Many practitioners are unfamiliar with the concept of “co-consciousness” and thus may dismiss DD patients who report having awareness of the presence of dissociated self-states. Even if the dissociative symptoms are recognized, specific knowledge and skills are required to treat DDs.

Second, complex presentations and extensive comorbidities are common in DDs, resulting in diagnostic and therapeutic challenges. Severe DDs are poly-symptomatic, for instance, about 90% and 60% of patients with DID have major depressive episodes and borderline personality disorder, respectively⁴; and patients with DDs may also report severe positive (psychotic) symptoms.⁵ These patients often exhibit diverse psychiatric symptoms, in addition to post-traumatic and dissociative symptoms. In addition, trauma memories, triggers, and symptoms may vary among dissociated self-states, leading to dramatic changes in clinical presentations and thus increasing the difficulties in accurately detecting DDs. Untreated dissociated self-states may also “reproduce” other psychiatric symptoms (e.g., dissociative psychosis and self-harm). These comorbid symptoms may lead to diagnosing a patient with DD as having other mental disorder(s) until his/her underlying dissociative pathology is recognized. Some practitioners focus too much on treating the comorbid symptoms and overlook the importance of working with the dissociated self-states and reducing inter-personality conflicts.¹⁰ Indeed, interventions that do not take dissociation into account are often ineffective because most presenting symptoms (e.g., hearing voices and addiction) in the context of DDs are rooted or result from trauma and dissociation. For example, a patient suffers from headaches every time visiting his parents because his dissociated self-state(s) avoid contact with his/her parents.

Third, trusting issues are common problems among interpersonal trauma survivors, including most patients with DDs. While the practitioner assesses his/her patient with DD, the patient also assesses his/her practitioner. Patients with DDs often worry: “Is it safe to disclose our traumas to him (practitioner)?” “Will he act like my relatives and think that I am crazy or lying?” and so on. More importantly, successful treatment of DDs, particularly DID, always requires (advanced) skills of therapeutic interactions and communication in some way with patient’s alternate dissociated identities.⁶ Even when the patient’s “host” personality trusts the practitioner, many dissociated self-states sometimes hold different opinions, and thus it is important to develop a therapeutic alliance with every part of the patient.

Fourth, patients with DDs may be unaware of their dissociative self-states and associated features and may often have avoidance. The “host” personalities of these patients often have a phobia of the dissociated parts of their personality and avoid acknowledging the related trauma and dissociation⁷; and some patients may also have “amnesia for amnesia.”⁸ Some “introjects” or “protective” self-states even force the “host” or other self-states not to disclose the trauma and dissociative experiences in order to avoid “troubles” (e.g., being revenged by the abuse perpetrators). In addition, diagnostic challenges can result from identity alteration or personality switching not as obvious as expected. In fact, many patients have “covert DID” or “OSDD,” which is characterized by partial dissociation (e.g., dissociative intrusions) rather than full dissociation (i.e., switching plus amnesia).³,⁹ Even though an accurate diagnosis has been made, the practitioner needs to gradually work with the patient to resolve his/her internal conflicts and avoidances and introduce healthy coping strategies to replace maladaptive behaviors. Many patients with severe DDs have experienced complex childhood trauma, and consequently, their problematic behaviors have been well-learned since their childhood for “survival” (e.g., feeling numb in order to avoid the pains of physical abuse or not trusting people in order not to be betrayed again).

At last, safety issues and social problems are primary concerns and huge challenges in the treatment of DDs. Many patients with severe DDs do not have sufficient resources and financial independence and remain in toxic relationships. Very often, they do not respond well to the treatment unless a truly safe environment can be ensured. Repeated traumatization and related external/internal triggers can be easily encountered and subsequently worsen the symptoms. Therefore, when treating DDs, practitioners should recognize the interactions between the social context and the symptoms¹⁰,¹¹ and change the context as needed.

In summary, we have suggested 5 major challenges in the diagnosis and treatment of DDs. As DDs have high prevalence and healthcare service needs, psychiatry and other mental health education curricula should include training in the assessment and treatment of DDs. Mental health professional training should focus more on the psychopathology of DDs and highlight current evidence about the understanding, assessment, and treatment of the disorders, and dispel their common myths.¹² In addition, although assessment and diagnosis of DDs are challenging, standardized assessment tools can be used for screening DDs and facilitating differential diagnosis. Therefore, general mental health assessment should include valid dissociation measures to avoid overlooking DDs.¹³-15 Finally, mental healthcare service systems should be more trauma-informed to truly acknowledge the potential impacts of trauma and actively recognize and manage post-traumatic and dissociative responses among mental healthcare service users.

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