Editorial Comment

Alpha Psychiatry 2022;23(3):104-105

DOI: 10.5152/alphapsychiatry.2022.0006

Commentary: The Assessment of Dissociative Pathology in Culturally and Clinically Diverse Contexts

Wai Tong Chien¹

Hong Wang Fung¹

¹ The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR

Corresponding author: Wai Tong Chien ✉ wtchien@cuhk.edu.hk

Cite this article as: Chien WT, Fung HW. Commentary: the assessment of dissociative pathology in culturally and clinically diverse contexts. Alpha Psychiatry. 2022;23(3):104-105.

Dissociative disorders (DDs) with a lifetime prevalence of about 10% in general population¹ are complex mental disorders receiving much attention by healthcare and social care professionals worldwide in clinical diagnosis and treatment/care. While early identification of DDs is essentially important to provide timely support and interventions for people with DDs in need, much challenges are found in the assessment of DDs.² Şar’s³ article has provided clear and important information and reminder to mental health service providers that dissociative pathology is often hidden behind the polysymptomatic “surface” or other culturally shaped presentations. In addition, it can be a practical guide for the complex assessment and management strategies of DDs in culturally diverse contexts.

In the beginning of the article, Şar³ clearly explained that there is a discrepancy between the clinical surface and core psychopathology in patients with DDs. The clinical surface of DDs usually covers a wide range of medically recognized psychiatric symptoms (e.g., affective and psychotic symptoms, as well as functional neurological symptoms) and culturally specific phenomena (e.g., possession, shaking movements and culture-bound experiences). These complex presenting problems and/or other secondary symptoms can vary greatly across patients and cultures. Therefore, they often pose diagnostic challenges to mental healthcare providers, resulting in the overlook of the core dissociative pathology. Having said that, similar to many other experts in management of DDs, Şar³ suggested that these complex syndrome/symptoms might serve as a “diagnostic window” as they “serve the clinician as gateways leading to the recognition of DDs in their patients” (p. 2). Şar further reviewed six common conditions that could be presented by people with DDs, including: 1) functional neurological symptom disorder, 2) brief psychotic disorder, 3) acute reaction to a stressful event, 4) experience of possession, 5) mood disorder, and 6) personality disorder. The clinical presentations, geography and assessment of each condition described and discussed in Şar ‘s article can be an important basis for clinical diagnosis of DDs, especially with consideration to recognize DDs as possible differential diagnoses.

Since the assessment of DDs is of vital importance yet challenging in culturally diverse contexts, as highlighted by Şar,³ it may be important and essential to highlight and discuss about the use of standardized measures to aid clinical assessments of DDs. There are a number of well-established and validated measures of dissociation since 1980s, including the Dissociative Experience Scales (DES), the Dissociative Disorders Interview Schedule (DDIS), and the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D). These measures have been used in diverse languages and sociocultural contexts. For example, a meta-analysis of 216 studies comprising over 15,000 participants in 19 diagnostic categories conducted by Lyssenko et al⁴ reported that patients with DDs reported significantly higher DES scores than those in other diagnostic categories. Mychailyszyn et al⁵ meta-analysis of 15 studies on the use of SCID-D reported that the measure could differentiate between patients with and without any one type of DD with an aggregated effect size (Hedge’s g) of 3.12. in addition, cross-cultural comparison studies using the DDIS found that patients with severe DDs could have a stable, consistent set of clinical features across cultures.⁶,⁷ These findings reveal that some valid dissociation measures can be very helpful in assessing/identifying DDs, despite having considerable cultural differences on DD features.

Although the use of dissociation measures can be helpful in differentiating dissociative pathology across culturally acceptable phenomena, there remains uncertainties and chsallenges in accurately assessing and diagnosing DDs in clinical practice and research. Ross and his colleagues investigated classical culture-bound syndromes (e.g., possession experiences and trance) in English-speaking people with DDs in the US and suggested that certain classical culture-bound syndrome(s) could be predominantly dissociative in nature and not really ‘culture-bound’.⁸,⁹ A few recent studies showed that the DDIS can differentiate culturally specific or religion related manifestations (e.g., spiritual mediumship) from dissociative pathology.¹⁰,¹¹ As suggested by Şar’s³ article, some anomalous experiences might be culturally accepted ‘normal’ experiences, while others could be manifestations of cultural variations of the dissociative pathology. Therefore, mental healthcare providers can use dissociation measures to aid assessments when clients report anomalous experiences, with careful consideration of the potential cultural differences in understanding the illness-related terminology.

It is also important to highlight what Şar³ suggested that although clinical presentations of dissociative pathology can be complicated and vary across patients and cultures, “dissociation represents transdiagnostic consequences of early-life stress” (p. 2). Therefore, dissociation has proposed to be a ‘transdiagnostic indicator’ of a need for a trauma-informed intervention.¹²,¹³ To provide timely support to people with DDs, dissociation symptoms should be regularly assessed in mental healthcare settings, when helping service users with depressive disorder,¹⁴ psychosis,¹⁵ and/or those from religious and cultural minorities. For this reason, more mental healthcare providers should be trained with assessments of DDs by using standardized validated measures of dissociation² and subsequently, such measurements can be adopted in routine practice across cultures.

References

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