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Dissociative Disorder Underdiagnosed Due to Undescriptive Criteria?

To the Editor: In his editorial, David Spiegel, M.D. states that the DSM-IV workgroup on dissociative disorders improved the name and diagnostic criteria of dissociative identity disorder (formerly multiple personality disorder), but that the disorder continues to be "underdiagnosed" (1, p. 567). Why is that?

Dr. Spiegel begins the answer when he notes that this is a "disease of hiddenness" in which patients "hide rather than reveal their symptoms." Let me complete the answer by noting that the diagnostic criteria don’t even mention this camouflaged presentation. In addition, if the diagnostic criteria don’t describe or even mention the typical presentation, how can clinicians be expected to recognize the disorder and make the diagnosis?

Like the diagnostic criteria, the new name for the disorder is not very descriptive. "Dissociative identity disorder" omits a key feature: multiplicity. Persons with this disorder have more than one "I." They have multiple subjective identities.

I have previously proposed a more descriptive name (dissociative disorder, multiple identity type) (2) and a set of more diagnosis-oriented criteria (3, 4), but I don’t insist on the particulars or consider them the last word. All I respectfully insist on is that the name and diagnostic criteria for this disorder be made more descriptive of the typical presentation and more relevant to the actual process of making this diagnosis. Otherwise, it will continue to be underdiagnosed.

References

1. Spiegel D: Recognizing traumatic dissociation. Am J Psychiatry 2006; 163:566–568[Free Full Text]
2. Nakdimen KA: Renaming multiple personality disorder. Am J Psychiatry 1995; 152:1104[Medline]
3. Nakdimen KA: Diagnostic criteria for multiple personality disorder. Am J Psychiatry 1992; 149:576–577[Free Full Text]
4. Wetsman H, Nakdimen KA: Diagnostic criteria for multiple personality disorder; Dr. Nakdimen replies [letters]. Am J Psychiatry 1993; 150:354–355[Medline]

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