Psychiatry Advisor: Why is the diagnosis so frequently overlooked?

Patients rarely come into the office saying, “I have a dissociative disorder” or “I have gaps in my memory” or “I lose time.” Instead, they come into our offices because they are experiencing depression, anxiety, nervousness, affect dysregulation, difficulties concentrating, problems with substances, self-harm, or significant interpersonal difficulties. They often have diagnoses from other professionals of a mood disorder such as bipolar disorder I or II, anxiety disorders such as panic disorder, psychotic disorders, attention-deficit/hyperactivity disorder, or even some axis II disorders. Many symptoms of these conditions can be associated with DDs, and in some cases, a dissociative process underlies the presenting problem.

It is important to assess whether there is an underlying dissociative process, because treatment is not effective when the underlying process is not identified and treated. If a clinician does not look under the surface at what is driving the presenting problem and does not evaluate whether a dissociative process is occurring, both the patient and clinician are left feeling helpless and frustrated.

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Similarly, patients may be diagnosed with PTSD, which contains components of dissociation after trauma. PTSD is a biphasic disorder.8 Patients vacillate between hyperarousal states (eg. flashbacks, agitation, hypervigilance) and hypoarousal states (eg. emotional numbness, feeling empty, feeling “zoned out”). Although hyperarousal symptoms are typically associated with excessive activation of the sympathetic nervous system, hypoarousal symptoms are associated with the parasympathetic nervous system. Both have elements of dissociative processes.8,9 Research shows a strong correlation between traumatic experiences and DDs.9

Psychiatry Advisor: What are some of the clues and “red flags” that might alert clinicians to the possibility that a client has a DD?

There are several clues that might suggest investigating DDs further. It is important to listen not only for what the patient says but also for what is not being said. Again, this is because individuals do not enter therapy saying that they are dissociating.

For example, if an individual presents with large gaps in memory in their childhood and/or in their current life, and organic processes have been ruled out, evaluation of dissociative symptoms is recommended.

Another red flag is reporting traumatic experiences in a distanced way, as if the patient is talking about someone else. If a patient describes feeling disconnected from emotions or actions, or watching themselves as if from a distance, evaluating for a DD is important. For example, if a client describes an episode of depersonalization such as “When I was scolding my child, I was watching myself from the ceiling,” that immediately raises concerns including a dissociative process.

From an experiential perspective, if a clinician notices that there are “holes” in the sequence or feels confused and unable to follow the patient’s narrative, it is worthwhile to evaluate for dissociative processes. It is always a flag when a person is unable to remember large segments of childhood.

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We now know that adverse childhood events have damaging consequences.10 People who experience a high proportion of adverse experiences in childhood cope with these experiences in numerous ways, including dissociative processes and other maladaptive coping mechanisms such as self-harm behaviors, addictions, eating disorder behaviors, and compulsive behaviors.10 The higher the number of adverse experiences, the greater likelihood for a complex PTSD and DD to develop because, in the words of Frank Putnam,11 dissociation is “the escape when there is no escape.”

Furthermore, an individual who has experienced a betrayal trauma during childhood by the people who were supposed to be safe caregivers may develop more severe dissociative symptoms and impairment, such as in DID.12 This is more likely when the trauma began at a young age.