Unseen and Unheard: Clinical Consequences of Unrecognized Dissociation in Prescribing

Abstract
The prevalence of dissociative symptoms and disorders are widespread yet are frequently overlooked by psychiatric prescribers. Multiple obstacles prevent clinicians from properly evaluating dissociation due to limited training in complex trauma and dissociation, common misconceptions about dissociative disorders, and outdated diagnostic methods. A 2025 survey of psychiatric nurse practitioners conducted for this presentation revealed 60% of psychiatric nurse practitioners do not assess for dissociation regularly in their practice, and only 23% of them feel confident in their ability to identify dissociative symptoms. The vast majority of respondents, 73% to 82%, cited unfamiliarity with assessment tools and inadequate training in dissociation in nurse practitioner education programs as key factors contributing to their lack of assessment for dissociative symptoms in medication management visits. This gap in knowledge among psychiatric nurse practitioners has significant clinical implications, contributing to missed symptoms, misdiagnosis, incomplete assessments, and improper treatment plans during medication management visits, potentially delaying appropriate and necessary care for individuals with complex trauma and dissociation.

Clients and their families suffer from years of unproductive and harmful treatment due to unnecessary medications and deteriorating mental health as a result of the failure to recognize dissociative symptoms, misattribution of dissociative symptoms to other disorders, and misdiagnosis. The long-standing mistrust between providers and clients due to prescribers' misinformed beliefs and stigma toward dissociative disorders and marginalized populations creates ongoing challenges for clients to feel safe to reveal their dissociative symptoms. Individuals who experience dissociative symptoms may choose not to disclose them to their prescribers because they fear being dismissed, disbelieved, or having their lived experiences misunderstood. Multiple barriers, including provider skepticism of dissociative disorders, structural limitations, and poor therapeutic relationships force many clients to abandon treatment. Dissociation increases the risk for self-injurious behaviors, suicide attempts, and hospitalization. Failing to recognize dissociation results in substantial functional impairment which contributes to overutilization of healthcare services and increased costs. The shortage of psychiatrists, particularly in underserved and marginalized communities, results in psychiatric nurse practitioners increasingly providing the majority of mental health care, which uniquely positions them to address critical gaps in the assessment of complex trauma and dissociation.

Comprehensive training in the assessment and treatment of complex trauma and dissociation should be integrated into nurse practitioner curricula while also encouraging ongoing professional development and trauma-informed practices to improve prescriber competence. Addressing these educational, structural, and relational barriers in the next generation of psychiatric nurse practitioners is essential for reducing stigma, improving diagnostic accuracy, and improving outcomes for individuals with dissociative symptoms and disorders.