Recognizing and Treating Dissociative Disorders: An Expert Interview With Rebeca Scherman, PsyD

Dissociative Disorders (DDs) are “characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.”¹ 

DDs, which “can potentially disrupt every area of psychological functioning,” include Dissociative Identity Disorder (DID), Dissociative Amnesia and Dissociative Fugue, Depersonalization/Derealization Disorder, Other Specified Dissociative Disorder, and Unspecified Dissociative Disorder.¹ Diagnostic criteria are listed in Table 1.

Dissociation can be defined as “a process that provides protective psychological containment, detachment from, and even physical analgesia for overwhelming experiences, usually of a traumatic or stressful nature” and may be “analogous to the ‘animal defensive reaction’ of freezing in the face of predation, when fight/flight is impossible.”² 

The estimated prevalence of dissociative disorders in inpatient and outpatient psychiatric settings seems to be approximately 10%, with roughly half of these patients diagnosed with DID.³ DDs may be more common among women, but findings regarding sex are inconsistent.³

Diagnosing and treating DDs can be challenging.⁴ One reason is that many trauma studies “tend to concentrate on ‘easier’ cases,” such as patients who have experienced only one type of trauma in adulthood. By contrast, clients with DDs often drop out of clinical studies. Moreover, they “tend toward self-inflicted violence, suicidal crises, numerous addictions, contradictory inner tendencies, and a lack of impulse control—in other words, the typical causes of exclusion from scientific studies”.⁴

A significant body of research⁵ suggests that traumatic attachments during early life are associated with “specific psychopathological vulnerabilities, based on dissociative pathogenic processes.” These processes may also occur in the context of other diagnostic categories, “complicating their clinical pictures and worsening their prognosis”.⁵ Mental health professionals need “specific training” to recognize and treat these complex disorders.

To shed light on this complex condition, Psychiatry Advisor interviewed Rebeca Scherman, PsyD, a faculty member at the International Society for the Study of Trauma and Dissociation and voluntary clinical faculty/lecturer at La Clinica Hispana, Yale School of Medicine, New Haven, Connecticut. Dr. Scherman is currently training at the New York University Program for Psychotherapy and Psychoanalysis.

Psychiatry Advisor: What is the typical presentation of a patient with a DD?

DDs are symptoms of complex trauma-related disorders often referred to as complex posttraumatic stress disorder (PTSD) or Developmental Trauma Disorder.⁶ There actually is no “typical presentation,” which is what makes it so difficult to diagnose without proper training. Many mental health clinicians do not think of a DD when they are evaluating an individual because DDs can look like an array of other conditions. Clinicians often lack training in how to identify DDs because they have been historically overlooked in training programs, although this is slowly changing. Moreover, mental health students often hear that DDs, and especially DID, are very rare, so it is not on their radar,^6,7 so to say. This is why so many people with DID end up being misdiagnosed for years, receiving incorrect treatment, and unfortunately, not receiving potentially helpful treatment.