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Controversies Surrounding Diagnosis of Dissociative Disorders

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Controversies Surrounding Diagnosis of Dissociative Disorders

Dissociative disorders, as classified in the DSM-5-TR, include dissociative identity disorder (DID), dissociative amnesia, and depersonalization-derealization disorder. These disorders involve disruptions in identity, memory, or perception and are often linked to severe trauma, such as childhood abuse. However, the legitimacy and diagnosis of these disorders, particularly DID, have been subject to controversy.

The Controversy

The most significant controversy revolves around dissociative identity disorder, previously known as multiple personality disorder. This disorder involves two or more distinct personality states, each with a peculiar pattern of perception. Besides, even though the DSM-5-TR recognizes DID as valid, many professionals believe that either it is overdiagnosed due to therapist suggestion, or instead, it results directly from trauma. The iatrogenic hypothesis is that therapists themselves can inadvertently create multiple personalities using hypnosis or other suggestive techniques (MadMedicine, 2019).

On the other hand, proponents of the trauma-based theory argue that DID is a valid mental health condition, usually rooted in early childhood trauma. According to this perspective, DID is a defense mechanism that protects painful memories by allowing an individual to dissociate. In this respect, proponents feel the disorder helps the brain separate traumatic experiences for the protection of the brain. Both parties agree, to date, that the difficulty in diagnosing DID is because of the overlap in symptoms that the disorder shares with other disorders, including borderline personality and post-traumatic stress disorder (PTSD).

Dissociative amnesia also faces scrutiny, particularly around its diagnosis. The condition involves forgetting important personal information, usually linked to trauma; sometimes, it can appear similar to normal stress-related forgetfulness. Critics consider that dissociative amnesia is diagnosed too liberally, and its diagnosis criteria are in need of clarification (Osmosis from Elsevier, 2017).

Professional Beliefs

I support the trauma-based understanding of dissociative disorders. Research strongly links dissociation to severe trauma, especially in early childhood. Studies show that dissociation can act as a defense mechanism, allowing individuals to distance themselves psychologically from traumatic events (Tull, 2023). Although some critics argue that therapeutic suggestions can influence dissociative disorders, the connection between trauma and dissociative symptoms is clear (Grande, 2018). While there are instances of symptom exaggeration or malingering, dismissing dissociative disorders risks further harming individuals already in distress. A trauma-informed approach, sensitive to the client’s history and current experiences, ensures that these disorders are recognized and appropriately treated (van der Hart, 2021).

Strategies for Maintaining the Therapeutic Relationship

Therapists can use several strategies to build and maintain strong therapeutic relationships with clients who have dissociative disorders. These include creating a safe environment. Notably, consistency and stability in the therapeutic setting can foster trust, which is crucial for clients with dissociative disorders​ (Podolan & Carlo, 2023). Another strategy concerns validation without reinforcement. Therapists should acknowledge the client’s experiences without inadvertently reinforcing dissociative symptoms. This approach ensures the client feels understood without deepening their identification with their dissociation. Lastly, therapists can maintain clear boundaries, as boundaries help clients avoid dependency on the therapist and encourage them to develop healthier coping mechanisms.

Ethical and Legal Considerations

Ethical and legal considerations are vital when working with dissociative disorders. First, therapists must avoid iatrogenesis, where therapeutic techniques such as hypnosis could unintentionally worsen dissociative symptoms​ (Grover et al., 2022). Practitioners should use evidence-based practices and avoid suggestive techniques. Confidentiality is particularly important when treating individuals with dissociative disorders. These clients, who often have experienced significant trauma, require an environment of trust. Maintaining strict confidentiality is crucial for preserving the therapeutic relationship. Lastly, legal implications arise in cases involving dissociative amnesia, where individuals might claim memory loss in legal contexts. Accurate diagnosis and careful documentation are essential to avoid misuse of dissociative diagnoses, especially when they can affect judgments related to personal responsibility​.

In conclusion, despite the controversy, understanding dissociative disorders through a trauma-informed lens and employing evidence-based strategies can lead to more effective and ethical treatment.

References

Grande, T. (2018, October 22). The dissociative identity disorder controversy (trauma vs. iatrogenic) [Video]. YouTube. https://www.youtube.com/watch?v=zqTP0CP9aDk

Grover, S., Avasthi, A., & Nischal, A. (2022). Ethical and legal issues in psychotherapy. Indian Journal of Psychiatry, 64(7), 47–61. https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_50_21

MadMedicine. (2019, August 18). Dissociative disorders (psychiatry) – USMLE Step 1 [Video]. YouTube. https://www.youtube.com/watch?v=Iz03M9pwhs0

Osmosis from Elsevier. (2017, November 20). Dissociative disorders – causes, symptoms, diagnosis, treatment, pathology [Video]. YouTube. https://www.youtube.com/watch?v=XF2zeOdE5GY

Podolan, M., & Carlo, O. (2023). The functions of safety in psychotherapy: An integrative theoretical perspective across therapeutic schools. PubMed, 20(3), 193–204. https://doi.org/10.36131/cnfioritieditore20230304

Tull, M., PhD. (2023, February 1). Understanding PTSD and dissociation: Links between trauma, PTSD, and dissociative disorders. Verywell Mind. https://www.verywellmind.com/how-trauma-can-lead-to-dissociative-disorders-2797534

van der Hart, O. (2021). Trauma-related dissociation: An analysis of two conflicting models. European Journal of Trauma & Dissociation, 5(4), 100210. https://doi.org/10.1016/j.ejtd.2021.100210

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Question 

Have you ever been driving and realized you don’t remember the last few minutes of driving? Or have you gotten so wrapped up in a book or movie that you lose some awareness of your surroundings? These are examples of common and very mild dissociation, or a disconnect or lack of continuity between thoughts, feelings, actions, and sense of self.

There are three major dissociative disorders defined in the DSM-5: dissociative identity disorder, dissociative amnesia, and depersonalization-derealization disorder. Dissociative disorders may be associated with traumatic events in order to help manage difficult memories or experiences. Patients with these types of disorders are likely to also exhibit symptoms of a variety of other dysfunctions, such as depression, alcoholism, or self-harm and may also be more susceptible to personality, sleeping, and eating disorders.

This week, you will analyze issues related to the diagnosis and treatment of dissociative disorders as well as associated legal and ethical considerations.

Learning Objectives
Students will:

Overview:

The DSM-5-TR is a diagnostic tool. It has evolved over the decades, as have the classifications and criteria within its pages. It is used not just for diagnosis, however, but also for billing, access to services, and legal cases. Not all practitioners are in agreement with the content and structure of the DSM-5-TR, and dissociative disorders are one such area. These disorders can be difficult to distinguish and diagnose. There is also controversy in the field over the legitimacy of certain dissociative disorders, such as dissociative identity disorder, which was formerly called multiple personality disorder.

In this Assignment, you will examine the controversy surrounding dissociative disorders. You will also explore clinical, ethical, and legal considerations pertinent to working with patients with these disorders.

TO PREPARE

Required Media

THE ASSIGNMENT

Controversies Surrounding Diagnosis of Dissociative Disorders

Controversies Surrounding Diagnosis of Dissociative Disorders

In two pages,

Readings:

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