This August's Psychiatric Annals features a comprehensive series of articles on complex dissociative disorders and the spectrum of disorders ranging from posttraumatic stress disorder all the way to dissociative identity disorders, guest edited by Richard A. Chefetz, MD. Dissociative disorders seem to be viewed very ambivalently by psychiatrists, and therefore probably often not diagnosed or treated specifically. Why is this?
First, there have been excesses both in the diagnosis of various dissociative disorders and in their treatment. “Abuse therapists” of varying levels of qualifications may have been too quick to pronounce that their patients had been sexually abused, not infrequently by their parents, leading to lawsuits against or by the aggrieved parents. Second, dissociative symptoms require careful listening and evaluation by a diagnostician. This does not always fit into the current pressure from payers for mental healthcare for a rapid “symptom present or symptom absent” diagnostic system, based on criteria in the Diagnostic and Statistical Manual of Mental Disorders. Often, a diagnosis must be established in an inadequate time frame. Who has time to discover dissociative symptoms that are often situation specific and not very “objective”? Besides, there seems a strong suspicion that a patient reporting dissociative symptoms is “making it up” for some type of secondary gain. This seems to result in the ignoring or dismissal of these symptoms and their significance.
Lastly, complex dissociative disorders just don't fit into the way contemporary psychiatry is widely practiced. Get the target symptoms, make the DSM diagnosis, write the prescription — and on to the next patient. From this perspective, dissociative disorders seem not to exist because they don't fit into the model that has been shaped by the economics of modern psychiatric practice.
Despite the fact that, in too many cases, we can no longer afford to diagnose and treat complex dissociative disorders, I found these articles both fascinating and scientifically solid. It's really too bad many psychiatrists can't afford to pay attention to these subtleties of psychiatric practice, but this series presents both cogent and thoughtful clinical information, condensed into a form that makes it easier to think about and apply these principles in clinical practice.