Part 4 The Error of the Medical Model in Diagnosis
Severe early childhood trauma is the etiology of DID. This does not fit in well with the traditional medical model of disease, particularly as ossified in the pharmacological approach to mental health.
In the medical model, one follows the procedure of eliciting symptoms and signs. For most illnesses, one is aided by laboratory findings such as blood work, x-rays, MRI, CT scan. Using those tools, one comes to a diagnosis, usually within a definite period of time starting from the same day of consultation to a week or so of waiting for the results of investigations. Using that medical model, coupled with the pharmacological and sometimes surgical views of treating illness, is important when dealing with physical illnesses.
Unfortunately, based on the pervasiveness of that model coupled with the promotion of pharmacological interventions for treating mental health issues, the clinician isolates and focuses in on symptoms that are treatable with medication. The result is that anxiety, depression and so on are identified as the illness without further exploration. As noted above, these symptoms are descriptive only. The medication is applied to the description, not necessarily to the illness.
In DID, the diagnostician is faced with a chaotic fractured mind, with a one part generally presenting as the patient, usually identified as the “front” or “host.” There is likely varying degrees of amnestic barriers between the separated parts. In most cases, the host has no awareness of the presence of “alters” and comes for therapy to deal with symptoms like depression and anxiety. Sometimes, they will also identify “time loss” as a confusing aspect of their life.
It is in the nature of the pathology that the host, as well as the individual alters, just think of themselves. The host is oblivious to the presence of the others. While the others, the alters, are often aware of the host but just as often dismissive of the host and the other alters. It is also in the nature of the pathology that there will likely be some protective ones who are concerned about the therapist or even engaging in therapy.
Why would this happen? The concern is quite rationale. It is because therapy grants the therapist a position of power in the situation. The concern of the protective alters is that the therapist has the potential to use that power in a way hostile to the alters. After all, the therapist may be just another one of the serial abusers the system has encountered in life. Therefore, protective alters often regard the therapist as an unwelcome potential enemy. They will be the very first to resist the probing nature of the therapist’s “interference” and test the therapist before, during, and even after allowing any genuine communication.
To approach a potential DID patient for a diagnostic assessment interview, one must be aware of all these different sets of conditions. It is no wonder that a novice clinician will often be at a loss in proceeding. The novice may seize upon the first symptom of depression, feeling relieved that they have found a diagnosis. They are satisfied with that initial diagnosis and are now – rightly or wrongly – able to prescribe medication.
This is a very common bias in the psychiatric field. In fact, most of the missed cases of DID referred to me by colleagues were individuals misdiagnosed who were labeled as suffering from “Treatment Resistant Depression.” This misnomer, Treatment Resistant Depression, should have been seen as a giant red flag that the underlying problem that kept provoking the depression was not being treated by the medication. It wasn’t that the depression was resistant to treatment, it was that the treatment was medication prescribed based on a misdiagnosis.
