I previously posted on the danger of diagnosing a mental disorder based on clinical symptomatology alone. In that post, I discussed my own failure to diagnose DID in a patient because she presented what appeared to be a classic case of Bipolar Disorder. DID is rooted in early childhood abuse. It seems that many psychotherapists, and others throughout society, prefer to avoid the issue of the rampant abuse/molestation by people across all economic, religious, social and cultural boundaries. To acknowledge DID is to acknowledge the epidemic level of abuse that occurs in one’s own societal milieu.
The purpose of this post is to highlight other reasons for the failure to diagnose DID correctly and, in particular, why clinicians affirmatively choose other diagnoses over DID. During my years of practice, I received many referrals of patients that had multiple diagnoses, usually borderline personality disorder, bipolar disorder and schizo-affective disorders. In many, but not all, there were clear acknowledgments of dissociative qualities indications. Nevertheless, in the referral documentation dissociative disorders were simply not considered in the diagnoses.
I have long puzzled over the fact that there are deniers of DID even among seasoned psychotherapists. I think the crucial issue is that in the experience of many therapists, they have never encountered even one patient with DID. With that background it might understandable why he/she would reject such a diagnosis. But that should not be the end of the inquiry.
It is my experience it was not that therapists, certainly the vast majority of those that referred patients to me, never encounter DID, rather they simply fail or refuse to recognize it.
Human beings have a predisposition to perceive things in a certain way. In psychological terms, this is known as a perceptual set or a perceptual expectancy Numerous studies confirm that perception is highly influenced by what one expects to perceive. For example, because we are highly attuned to hearing our own name, we recognize it even in a loud and chaotic environment. In a similar way, if we believe that our key has been stolen we will fail to see that key even if it is right in front of us.
Applying that same expectancy analysis to psychotherapists and DID, if a clinician believes that DID is rare, its presentation in a patient will be missed. This happened to me on many occasions before I came to realize that DID was no less common than many other disorders. I needed to modify my diagnostic index of suspicion to include DID as a possible diagnosis as likely as bipolar, borderline personality disorder or schizo-affective disorders.
Another common reason for missing DID is that the DID is hidden behind some other presenting symptom. For example, many patients come presenting with depression. Others may be presenting with sexual or other addictions. Still others may present with difficult so-called character flaw problems like pervasive anger. Therefore, it is important to examine the problem of basing diagnoses on mere symptomology without an appropriate index of suspicion.
By way of example, malaria and typhoid are two different diseases but sometimes physicians are unable to diagnose them properly due to certain symptoms they share in common. In the initial stages, both may present with the following clinical features indistinguishable from each other: high fever, abdominal pain and lethargy. Yet they are completely different in etiology and demand Typhoid fever is caused by a gram negative bacteria named as salmonella typhi whereas malaria is a protozoal disease due to different species of Plasmodium invading the red blood cells, transmitted via mosquito. Treatment for malaria will not help a patient with typhoid, nor will treatment for typhoid help a patient with malaria. Fortunately, some simple lab tests can distinguish between the two. However, there are no such laboratory tests to distinguish between most psychiatric disorders, such as between schizophrenia and DID.
So, again, one must not end one’s inquiry simply because one has seen what one expected. One can see bipolar disorder in mood swings, but the mood swings might also be different alters presenting themselves to the therapist. Depression may be a disorder, but it might also be an appropriate response to difficulties in life or it could be rooted in DID that is held by one or more alters.
Competent therapists need to examine their own index of suspicion. DID should be included in that index of suspicion when seeing patients with presenting symptoms that are found in common with other disorders, whether it be depression, addiction, schizo-affective disorders, bipolar or borderline personality disorder.
