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, dere-alization, identity confusion, and identity alteration) usually remain underreported, the clinical surface may be dominated by acute (functional neurological symptoms, brief psy-chosis, an experience of possession, or acute dissociative reaction to a stressful event) or chronic (mood and personality disorders) secondary syndromes. However, these syn-dromes 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 second-ary 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 psychi-atric 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.