Psychiatric diagnoses are based on clinical features rather than laboratory tests as in organic pathologies. For example, a patient presenting with a fever might have a common cold, a kidney infection, pneumonia or many other illnesses. It is the task of the clinician to determine what disease the symptom, fever, is resulting from.

In psychiatry, it is necessary to maintain a proper index of suspicion in that same way. When a patient presents with depression, it could be that they are bipolar, it could be that they have borderline personality disorder, it could be that they are in the midst of a divorce, or perhaps they have DID. It is the job of the psychiatric clinician to be open to all of the possibilities as they commence the diagnostic investigation.

Psychiatric disorders according to DSM 5 are based on symptoms, just like fever in the case of Malaria. Treating malaria with fever lowing drugs is akin to treating the depression in DID, which are cases of trauma and dissociation, with prescriptions that do nothing to treat that underlying cause. Just as treating malaria solely by lowering the fever will not cure the malaria, treating depression with anti-depressants alone will not necessarily cure the underlying cause of the depression.

When a patient presents with depression, the answer must not always and simply be an anti-depressant. The therapist must understand, first of all, that depression may simply be a symptom, not a syndrome or disorder, and it is not always a pathology. It is often an appropriate human response to difficult situations.

In my practice, it was quite common to see patients referred to me by other psychiatrists with diagnoses of Bipolar Disorder, Borderline Personality Disorder, and Clinical Depression that have not responded to medication. For those patients, it was almost always because the diagnoses were in error. The referring psychiatrists had focused on one symptom rather than the patient’s overall circumstances.

I believe this is due to a failure in training – a failure that I was subject to for many years as a practicing psychiatrist. I had been taught that I would never see a case of DID because it was such a rare phenomenon. Most of my colleagues, all veteran psychiatrists, had never a case of DID either. Looking back over my 40 years of practicing psychiatry, I would correct that statement to say that most of my colleagues (including me at the time) had never recognized a case of DID. Indeed, many referrals I received included notations of dissociative features being displayed by the referred patient but a refusal to include dissociative disorders as a primary or even secondary diagnosis.

I still remember my encounter with a patient in an infectiously happy mood who came to see me for recurrent spells of depression. Applying the DSM 4 criterion applicable at the time, I could not have been more certain that I was encountering a case of Bipolar Disorder. No one could have convinced me otherwise. I had certainty in the diagnosis and felt greatly relieved. I knew exactly what to do, how to follow the well laid-out protocol of mood stabilizers and so on. With the diagnostic certainty, I was confident that my task was virtually accomplished.

As a result, I never even considered the possibility that what I was seeing in my office was an alter who appeared carefree and happy. A careful consideration of the patient’s life history and early incestuous abuse should have alerted me to the possibility of quite a different diagnosis. In fact, after seeing her numerous times, she disclosed that she had been abused by her father. Rather than raising my index of suspicion, as should have occurred, I simply said “Oh, that’s part of your personal history.” Although my response was in accord with the standard psychiatric practices at the time, it was an abject failure that I did not reconsider the bipolar diagnosis.

Thanks to the bravery of some of my DID patients, I can say with confidence that a more appropriate approach to the “hypomanic” part as a possible alter would have opened the door to healing. My conduct at the time, instead, confirmed for the patient that I didn’t think the abuse history was all that important in the context of the bipolar diagnosis – again this conformed to the standard practice of psychiatry at the time. This was ignorance, dangerous ignorance on my part, and a continuing regret.

I should have understood that her opening up that personal history to me was dangerous and frightening for her. It should have been met with gentle kindness and openness. It should have led me to reconsider the therapeutic approach. There existed an alter who could have connected me to the severe inner turmoil and complexity of a psyche suffering from complex PTSD. That would have further established and strengthened the therapeutic alliance. It would have enabled her healing to have proceeded in a safe, supported and appropriate way.

I believe that many therapists make the same kind of mistake as I did for the first many years as a practicing psychiatrist. One must always be aware of the possibility that by simply labeling a patient as Bipolar or Borderline may mistakenly lead the therapist toward concentrating on a pharmaceutical treatment that will only cover up the real pain of a badly traumatized individual. It is often worse than no diagnosis at all as the patient’s difficulties are both compounded and hidden by the cascading effects of psycho-active medications.

What do I suggest to the current and future generations of therapists? Pay attention to the following research statistics:

The incidence of DID is not rare. According to Lowenstein, DID may occur at a 1% rate in the general population, which is close to that of Schizophrenia.

The prevalence rate for schizophrenia is approximately 1.1% of the population over the age of 18 (source:NIMH) or, in other words, at any one time as many as 51 million people worldwide suffer from schizophrenia. There is an almost identical rate of prevalence for DID.

Physicians and other therapists are all aware that schizophrenia is not uncommon. Let us raise our index of suspicion about DID as it is just as common, statistically speaking. Just because high functioning individuals with DID exist and are well known, such as Dr. Robert Oxnam, Herschel Walker and others, it is not a rare disorder. In my opinion, the diagnostic bias against DID is connected to the discomfort people have acknowledging the constellation of circumstances that give rise to it: early childhood abuse, dissociation, and betrayal.