Dissociation Across Cultures: A Transdiagnostic Guide for Clinical Assessment and Management

Abstract

The clinical heterogeneity of dissociation constitutes a challenge to the culture-sensitive clinician. Variability in experiencing dissociation, the interplay between acute and chronic conditions, and the predominance of a nosologically interface-type of clinical surface conceal core dissociative symptoms. While the latter (amnesia, depersonalization, derealization, identity confusion, and identity alteration) usually remain underreported, the clinical surface may be dominated by acute (functional neurological symptoms, brief psychosis, an experience of possession, or acute dissociative reaction to a stressful event) or chronic (mood and personality disorders) secondary syndromes. However, these syndromes also constitute gateways in pursuing the clues of core dissociation. Given that culture influences communication between clinician and patient, accurate expression of mental content requires the idiomatic armamentarium describing the experience. The latter is problematic in dealing with phenomena of core dissociation while the secondary representations have a relatively universal character for both clinicians and patients. Nevertheless, this approach requires a transdiagnostic understanding in conceiving this clinical interface. This interface reflects, in fact, complications of dissociative disorders which require to be addressed in the first line. This is either due to the medical and psychiatric urgency (e.g., functional neurological symptoms, brief psychosis) or due to resistance to treatment (e.g., antidepressant pharmacotherapy) which seem to be indicated for the particular condition. This transdiagnostic schema is based on a combined utilization of etic and emic principles in the cultural understanding of psychiatric disorders. Namely, universal medical-psychiatric categories are conceived as tools of communication and mutual understanding rather than being mere appearances or primary disturbances.

Commentary: The Assessment of Dissociative Pathology in Culturally and Clinically Diverse Contexts

“…Therefore, they often pose diagnostic challenges to mental healthcare providers, resulting in the overlook of the core dissociative pathology. Having said that, similar to many other experts in management of DDs, Şar 3 suggested that these complex syndrome/symptoms might serve as a “diagnostic window” as they “serve the clinician as gateways leading to the recognition of DDs in their patients” (p. 2). Şar further reviewed six common conditions that could be presented by people with DDs, including: 1) functional neurological symptom disorder, 2) brief psychotic disorder, 3) acute reaction to a stressful event, 4) experience of possession, 5) mood disorder, and 6) personality disorder.…”

“…While early identification of DDs is essentially important to provide timely support and interventions for people with DDs in need, much challenges are found in the assessment of DDs. 2 Şar’s 3 article has provided clear and important information and reminder to mental health service providers that dissociative pathology is often hidden behind the polysymptomatic “surface” or other culturally shaped presentations. In addition, it can be a practical guide for the complex assessment and management strategies of DDs in culturally diverse contexts.…”

“…In the beginning of the article, Şar 3 clearly explained that there is a discrepancy between the clinical surface and core psychopathology in patients with DDs. The clinical surface of DDs usually covers a wide range of medically recognized psychiatric symptoms (e.g., affective and psychotic symptoms, as well as functional neurological symptoms) and culturally specific phenomena (e.g., possession, shaking movements and culture-bound experiences).…”

“…Since the assessment of DDs is of vital importance yet challenging in culturally diverse contexts, as highlighted by Şar, 3 it may be important and essential to highlight and discuss about the use of standardized measures to aid clinical assessments of DDs. There are a number of well-established and validated measures of dissociation since 1980s, including the Dissociative Experience Scales (DES), the Dissociative Disorders Interview Schedule (DDIS), and the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D).…”

“… 8 , 9 A few recent studies showed that the DDIS can differentiate culturally specific or religion related manifestations (e.g., spiritual mediumship) from dissociative pathology. 10 , 11 As suggested by Şar’s 3 article, some anomalous experiences might be culturally accepted ‘normal’ experiences, while others could be manifestations of cultural variations of the dissociative pathology. Therefore, mental healthcare providers can use dissociation measures to aid assessments when clients report anomalous experiences, with careful consideration of the potential cultural differences in understanding the illness-related terminology.…”