Autopilot functionality and self-destructive behavior in patients with complex dissociative disorders—A qualitative study.

Objective: Dissociative disorders are common in psychiatric patients and severely impact patients’ lives. They are, however, underdiagnosed, thus preventing patients from accessing timely and adequate therapy. Identifying how patients with dissociative disorders relate to themselves could improve diagnostics. However, this question has not been explored in detail. The aim of the study was to gain insights into how people with complex dissociative disorders relate to themselves. Method: We conducted semistructured qualitative interviews with ten women diagnosed with complex dissociative disorders who had previously completed trauma-focused therapy. Data were analyzed through reflexive thematic analysis. Results: Participants described their behavior toward themselves before the start of the therapy as “autopilot-functional” and “self-destructive.” The “autopilot functionality” was characterized by being outward-oriented and ignoring one’s own needs. Hence, participants only appeared to be functional. “Self-destructive behavior” was described as a spectrum of various destructive behaviors (e.g., eating disorders, self-harm, excessive exercise, and substance abuse) that participants perceived as a cohesive complex. The participants illustrated that both behaviors were driven by a lack of self-empathy and connected to suppression and poor perception of bodily stimuli. Conclusions: “Autopilot functionality” seems to be a hallmark in patients with complex dissociative disorders. With patients hiding their self-destructive behavior, health personnel may misjudge the severity of these patients’ mental illness. Neither “autopilot functionality” nor “self-destructive behavior” should be judged (neither negatively nor positively), but one should understand both as a coping mechanism for trauma-related disorders. (PsycInfo Database Record (c) 2023 APA, all rights reserved) Complex dissociative disorders are frequent and underdiagnosed, with patients suffering severely. In our qualitative study, we found a behavioral complex of self-destructiveness (which has already been well described) coexisting with a seemingly paradoxical behavioral complex of high functionality that we called “autopilot functionality” (reflecting quite well the yet underresearched concept of the apparently normal part of the theory of structural dissociation). As high functionality is often perceived as beneficial to the patient, this behavioral complex often remains unrecognized. Our insights could help clinicians improve diagnosis of dissociative disorders in high-functioning patients and lead to better therapy approaches.