Why Psychiatrists Miss (and Misdiagnose) DID
Dissociative Identity Disorder (“DID”) is a condition found all over the world with a prevalence rate of around 1%. It is often denigrated by being characterized as a North American Disorder, out of ignorance and prejudice but rate at which it exists is irrespective of culture and exposure to North American influence.
I am a retired psychiatrist, having practiced psychiatry in three continents. I have written a four volume series on DID. Since my retirement, I have formed the habit of asking all newly graduated psychiatrists I meet of their experience with this disorder. As it is statistically more common than schizophrenia, the answers always shock me. That these newly qualified doctors have usually only seen one or two cases of these patients, if any, in their entire medical training! The only possible explanations I can think of are:
[1] These cases are indeed extremely rare, and that the medical statistic of more than 1% is wrong; or
[2] These cases are generally missed by the medical profession in the initial diagnostic stages.
The most common misunderstanding about dissociative identity disorders is the belief of some that people fake DID symptoms to avoid the consequences of illegal actions, e.g., “I am not responsible for shoplifting because it was my other personality.”
In my own experience, I have missed a lot of such cases and misdiagnosed them as patients suffering from depression. Only when I have given them time and patience listening, I can come to the correct diagnosis. In most cases, they resist coming to accept such a diagnosis because it is an unpleasant diagnosis, when instead of having one unitary personality, there are fractured selves, mostly hidden inside, who feel strongly that they are also occupying the same body. Just imagine how unpalatable it would be to find out that there is another “self” sharing this body of yours and may take over the time, such as going out to spend the night when what you want is to go to bed and rest.
Yes, one must pay attention to the context. When a patient sees a psychiatrist, it is usually when they need some help in figuring out why they are feeling a certain way that they find unpleasant or painful. Under very rare conditions, a patient goes to a psychiatrist looking for an excuse, faking symptoms to avoid the consequences of illegal actions, to get off being punished.
In my 40 years of clinical experience I have never encountered such a case. Granted I am not working as a forensic psychiatrist but I have seen many cases and written forensic reports which patients could have faked symptoms to escape consequences of wrong doing.
[3] Actually in most cases, when a doctor sees a patient for the first time, usually within an hour, the diagnosis will be apparent. In their board examinations, as in oral examinations, a candidate usually is given an hour to see a patient. The candidate is then expected to write a report including a diagnosis, and differential diagnosis (other potential diagnoses) pending on blood work and/ or other laboratory findings such as X-rays to confirm the diagnosis. In other words, usually within the first visit, a doctor should have some idea what is wrong with the patient.
However, in the case of some suffering from DID, most of the symptoms can be hidden. The patient may not be able to talk about or expose those hidden symptoms before a trusting therapeutic alliance is established. Or some alters may have a deep suspicion and prevent the host from divulging any telltale symptoms to the doctor. In other words, the patient may be resisting telling the truth because of a dissociative part acting in a self-protecting way. DID patients usually have a highly traumatized background.
Usually, the patient has some strongly mistrustful alter safeguarding what that alter considers secrets too important to expose. Why would such an alter prevent exposure of those secrets? Consider that early childhood trauma usually includes betrayal by the abuser, denial by the abuser and others of the trauma itself, and misuse of the abuse disclosure that leads to further abuse. It is critically important to always remember that when seeing a patient for assessment, the patient also has parts inside assessing the therapist, to determine whether such person would be safe enough to be entrusted with that vital information’s. In meeting a DID patient, the therapist is meeting a group instead of meeting a single individual, even if only one personality appears to be present.
Dr. Frank Putnam, a notable psychiatrist who authored significant works on Dissociative Identity Disorder (DID) identified the long diagnostic delays (often 5-12 years) associated with the disorder. Using questionnaires is well known to expedite the diagnosis. However, this method has not been universally adopted to arrive at a more rapid and more correct diagnosis by doctors and psychiatrists. Many psychiatrists may be less familiar with these specialized assessment tools.
There is a serious communication problem between psychiatrists and psychologists. But that is another story outside the scope of this article.
My conclusion, therefore, is that the real reason for such low cases of dissociative identity disorder encountered by medical students and medical doctors, including psychiatrists, is due to such cases being missed, misdiagnosed for depression, bipolar depression and personality disorder (mostly borderline personality disorder)
The follow is a clear information sheet that most front line doctors should read to remind themselves:
The post Why Psychiatrists Miss (and Misdiagnose) DID appeared first on Engaging Multiple Personalities.
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