When to Suspect and How to Diagnose Dissociative Identity Disorder

Trauma, Emotional Regulation, and Coping Styles in Individuals with and without Probable Dissociative Disorders in Hong Kong

Previous studies showed that dissociation and dissociative disorders (DDs) are prevalent and are associated with considerable individual and social consequences. There are ongoing debates regarding whether dissociation is a response to betrayal trauma across cultures and whether dissociation can be explained by maladaptive coping. Additionally, little is known about the clinical features of individuals with DDs in the Chinese context. This study aimed to investigate the relationship between trauma, emotional regulation, coping, and dissociation. We analyzed baseline data from a randomized controlled trial (N = 101). Participants with dissociative symptoms in Hong Kong completed self-report assessments. Structured interviews were also conducted subsequently. Participants with probable DDs reported more traumatic events (p = .009 to .017) and exhibited significantly higher levels of dysfunctional coping (p < .001) compared to those who reported dissociative symptoms but did not have a DD. Dissociative symptoms were more strongly associated with betrayal trauma than with non-betrayal trauma. Among different emotion regulation and coping strategies, dysfunctional coping was the only significant factor associated with dissociative symptoms (β = .309, p = .003). Dysfunctional coping was a statistically significant mediator that may explain the relationship between betrayal trauma and dissociative symptoms. Although other mediation paths are also possible and further longitudinal studies are required, our findings highlight the strong link between dysfunctional coping and dissociative symptoms and suggest that coping skills training should be incorporated into interventions for betrayal trauma survivors with dissociative symptoms. Additionally, this study provides evidence for the cross-cultural validity of the betrayal trauma theory. Further studies, however, are required.

Beyond the DES-II

The Dissociative Experiences Scale (DES-II) remains the most widely used brief screening tool for identifying dissociative symptoms despite limitations of the instrument and the training of those who use it. Standard eye movement desensitization and reprocessing (EMDR) therapy procedures require a thorough clinical assessment and formally screening for the presence of a dissociative disorder. This aids development of an accurate case conceptualization prior to the preparation and trauma reprocessing phases of EMDR therapy. Reliance on DES-II mean scores as the sole measure of dissociative features—particularly with persons reporting a history of early childhood neglect or abuse—is insufficient to determine readiness for safely reprocessing traumatic memories. The International Society for the Study of Trauma and Dissociation (ISSTD) Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision, noted that employing standard EMDR therapy with individuals suffering from an unrecognized dissociative disorder was reported as a risk for significant harm. EMDR-trained clinicians’ standard practice of screening for dissociative disorders must evolve beyond a casual reliance upon the DES-II. Consistent use of a mental status examination and reliable diagnostic tools is needed. Several relevant assessment tools are reviewed with their strengths and limitations. The authors recommend that clinicians apply these approaches even when their intent is to screen out persons whose presenting difficulties lie outside their scope of practice or research design.

Application of EMDR Therapy to Self-Harming Behaviors

Self-harm is frequently a trauma-driven coping strategy that can be understood from the perspective of the adaptive information processing (AIP) model and treated with eye movement desensitization and reprocessing (EMDR) therapy (Shapiro, 1995, 2001). Self-harm is often connected with memories of adverse and traumatic life experiences. Identifying and processing these memories with EMDR therapy can put an end to the self-injurious behavior. In addition, self-harm is often based on a lack of regulation skills, and these skill deficits can be addressed in EMDR therapy as well. In this article, the authors describe strategies for treating self-harm throughout the 8 phases of EMDR. Although there is no single approach that applies to all cases, the therapist needs to take a careful history of self-harm, its historical origins, and its triggers and functions in the present to formulate a treatment plan. Often, in the authors’ experience, self-harm functions as a self-soothing strategy that redissociates traumatic affect from childhood. Treatment strategies for Phases 3–8 of EMDR therapy are illustrated through case vignettes.