Dissociative identity disorder

Dissociative identity disorder is a diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Revised, as the existence in an individual of two or more distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment. At least two of these personalities are considered to routinely take control of the individual's behavior, and there is also some associated memory loss, which is beyond normal forgetfulness. This memory loss is often referred to as "losing time". These symptoms must occur independently of substance abuse or a general medical condition.

Dissociative identity disorder was initially named multiple personality disorder, and that name remains in the International Statistical Classification of Diseases and Related Health Problems.

While dissociation is a demonstrable psychiatric condition that is tied to several different disorders, specifically those involving early childhood trauma and anxiety, multiple personality remains controversial. Despite the controversy, many mental health institutes such as McLean Hospital, have wards specifically designated for dissociative identity disorder.

DSM-IV-TR diagnostic criteria

Due to copyright infringement issues and editorial concerns, the American Psychiatric Association has requested that specific reference to the DSM-IV-TR by Wikipedia be outlinked. The current diagnostic criteria for Dissociative identity disorder published in the Diagnostic and Statistical Manual of Mental Disorders may be found here:

DSM-IV-TR Diagnostic Criteria: Dissociative identity disorder (DID)

A definition of dissociation

Dissociation is a complex mental process that provides a coping mechanism for individuals confronting painful and/or traumatic situations. It is characterized by a dis-integration of the ego. Ego integration, or more properly ego integrity, can be defined as a person's ability to successfully incorporate external events or social experiences into their perception, and to then present themselves consistently across those events or social situations. A person unable to do this successfully can experience emotional dysregulation, as well as a potential collapse of ego integrity. In other words, this state of emotional dysregulation is, in some cases, so intense that it can precipitate ego dis-integration, or what, in extreme cases, has come to be referred to diagnostically as dissociation.

Dissociation describes a collapse in ego integrity so profound that the personality is considered to literally break apart. For this reason, dissocation is often referred to as "splitting" or "altering". Less profound presentations of this condition are often referred to clinically as disorganization or decompensation. The difference between a psychotic break and a dissociation, or dissociative break, is that, while someone who is experiencing a dissociation is technically pulling away from a situation that s/he cannot manage, some part of the person remains connected to reality. While the psychotic "breaks" from reality, the dissociative disconnects, but not all the way.

Because the person suffering a dissociation does not completely disengage from his/her reality, s/he may appear to have multiple "personalities". In other words, different "people" (read: personalities) to deal with different situations, but generally speaking, no one person (read: personality) who will retreat altogether.

Defining the controversy

Although some have claimed that the re-categorization of this condition is because there were so few documented cases (research in 1944 showed only 76Creating Hysteria by Joan Acocella, 1999.) of what was then referred to as multiple personality, in fact the "recategorization" is actually a name change that was made with the purpose of removing the confusing term "personality" from the DSM-IV name of this condition. The condition does have a long history stretching back in the literature some 300 years, and affects less than 1% of the population Ross, Colin. Dissociative Identity Disorder: Diagnosis, Clinical Features and Treatment of Multiple Personality, Second Edition, John Wiley & Sons, Inc, 1997. ISDN: 0471-13265-9 . Thus, epidemiological data indicates that DID is actually twice as common as schizophrenia in the general population. Dissociation is now recognized as a symptomatic presentation in response to trauma, extreme emotional stress, and, as noted, in association with emotional dysregulation and borderline personality disorderRethinking the comparison of borderline personality disorder and multiple personality disorder., Marmer SS, Fink D. 1994. In a longitudinal study, the strongest predictor of dissociation in young adults was maternal unavailability at age 2 (according to a study by Ogawa and associates). Many recent studies have found relationships between disordered attachment in early childhood and later dissociative symptoms, and it is also clear that child abuse and neglect are often involved in the origins of disordered attachment.

The DSM re-dress

There is some controversy over the validity of the Multiple personality profile as a diagnosis. Although some have claimed that DID is only "subjective," in fact there are two valid psychometric instruments for diagnosing the dissociative disorders, both of which have higher reliabilities than the psychometric instruments (the various SCID's) used in research on personality disorders, mood disorders, and psychoses. These instruments are the SCID-D (Structured Clinical Interview for DSM-IV Dissociative Disorders, Revised) and the DDIS (Dissociative Disorders Interview Schedule).

Other positions

The debate over the validity of this condition, whether as a clinical diagnosis, a symptomatic presentation, a subjective misrepresentation on the part of the patient, or a case of unconscious collusion on the part of the patient and the professional is considerable (see [[Multiple personality controversy. Although some have claimed that the disorder is "subjective," it is clear that the experience of internal separateness, coupled with amnesia, is the essence of a disorder that is generally quite upsetting to those who are diagnosed with it.

The main points of disagreement are:

Whether MPD/DID is a real disorder, or just a fad.
Whether or not MPD/DID is actually an iatrogenic disorder.
If it is real, is the appearance of multiple personalities real or delusional?
If it is real, should it be defined in psychoanalytic terms?
Whether it can be cured.
Whether it should be cured.
Who should primarily define the experience -- therapists, or those who believe that they have multiple personalities?
Whether it is invariably a disorder or simply a way of being.

Skeptics claim that people who present with the appearance of alleged multiple personality may have learned to exhibit the symptoms in return for social reinforcement. This point of view was the original evidence that called into question the overall efficacy of the "Sybil" case , made popular by the media, where the covering psychiatrist Herbert Spiegel stated his position that "Sybil" had been provided with the idea of "personalities" by her treating psychiatrist, Cornelia Wilbur, to describe states of feeling with which she was unfamiliar.

Another view is that multiplicity is not always a disorder (see: "healthy multiplicity") and that it can be normal to experience oneself as multiple, so that it is possible to be multiple without being clinically classifiable as having DID or MPD. From the standpoint of Carl Jung's Analytic Psychology, this position could be characterized as a hyper-awareness of one's personas. However, if this awareness is what healthy multiples are experiencing, then terms like "multiple" or "multiple personality" are inaccurate for them, in that their experience is not related to the clinical state being described here.

Potential causes of dissociative identity disorder

Dissociative identity disorder is attributed to the interaction of several factors: overwhelming stress, dissociative capacity (including the ability to uncouple one's memories, perceptions, or identity from conscious awareness), the enlistment of steps in normal developmental processes as defenses, and, during childhood, the lack of sufficient nurturing and compassion in response to hurtful experiences or lack of protection against further overwhelming experiences. Children are not born with a sense of a unified identity--it develops from many sources and experiences. In overwhelmed children, its development is obstructed, and many parts of what should have blended into a relatively unified identity remain separate. North American studies show that 97 to 98% of adults with dissociative identity disorder report abuse during childhood and that abuse can be documented for 85% of adults and for 95% of children and adolescents with dissociative identity disorder and other closely related forms of dissociative disorder. Although these data establish childhood abuse as a major cause among North American patients (in some cultures, the consequences of war and disaster play a larger role), they do not mean that all such patients were abused or that all the abuses reported by patients with dissociative identity disorder really happened. Some aspects of some reported abuse experiences may prove to be inaccurate. Also, some patients have not been abused but have experienced an important early loss (such as death of a parent), serious medical illness, or other very stressful events. For example, a patient who required many hospitalizations and operations during childhood may have been severely overwhelmed but not abused.Merck.com The Merck Manual.

Human development requires that children be able to integrate complicated and different types of information and experiences successfully. As children achieve cohesive, complex appreciations of themselves and others, they go through phases in which different perceptions and emotions are kept segregated. Each developmental phase may be used to generate different selves. Not every child who experiences abuse or major loss or trauma has the capacity to develop multiple personalities. Patients with dissociative identity disorder can be easily hypnotized. This capacity, closely related to the capacity to dissociate, is thought to be a factor in the development of the disorder. However, most children who have these capacities also have normal adaptive mechanisms, and most are sufficiently protected and soothed by adults to prevent development of dissociative identity disorder.

Symptoms

Patients often have a remarkable array of symptoms that can resemble other neurologic and psychiatric disorders, such as anxiety disorders, personality disorders, schizophrenic and mood psychoses, and seizure disorders. Symptoms of this particular disorder can sometimes include:

depression
anxiety (sweating, rapid pulse, palpitations)
phobias
panic attacks
physical symptoms (severe headaches or other bodily pain)
fluctuating levels of function, from highly effective to disabled
time distortions, time lapse, and amnesia
sexual dysfunction
eating disorders
sleeping disorders (insomnia, sleepwalking, night terrors)
posttraumatic stress
suicidal preoccupations and attempts
episodes of self-mutilation
psychoactive substance abuse

Other symptoms include: Depersonalization, which refers to feeling unreal, removed from one's self, and detached from one's physical and mental processes. The patient feels like an observer of his life and may actually see himself as if he were watching a movie. Derealization refers to experiencing familiar persons and surroundings as if they were unfamiliar and strange or unreal.

Again, doctors must be careful not to assume that a client has MPD or DID simply because they present with some or all of these symptoms. Another factor in the diagnosis is the all squares are rectangles but not all rectangles are squares idea, which is to say that although many of these symptoms may be present in an individual, he or she may not necessarily have DID. For example, someone may have severe PTSD (one symptom) and self mutilate with suicidal ideas, which is 3 of the above symptoms, but will not have DID. In order for DID to be diagnosed, there must be 2 or more distinctly present personalities.

Persons with dissociative identity disorder are often told of things they have done but do not remember and of notable changes in their behavior. They may discover objects, productions, or handwriting that they cannot account for or recognize; they may refer to themselves in the first person plural (we) or in the third person (he, she, they); and they may have amnesia for events that occurred between their mid-childhood and early adolescence. Amnesia for earlier events is normal and widespread.

Diagnosis and treatment

Diagnosis

If symptoms seem to be present, the patient should first be evaluated by performing a complete medical history and physical examination. The various diagnostic tests, such as X-rays and blood tests are used to rule out physical illness or medication side effects as the cause of the symptoms. Certain conditions, including brain diseases, head injuries, drug and alcohol intoxication, and sleep deprivation, can lead to symptoms similar to those of dissociative disorders, including amnesia.

If no physical illness is found, the patient might be referred to a psychiatrist or psychologist. Psychiatrists and psychologists use specially designed interview and personality assessment tools to evaluate a person for a dissociative disorder.Webmd.com

Prognosis

Patients can be divided into three groups with regard to prognosis. Those in one group have mainly dissociative symptoms and posttraumatic features, generally function well, and generally recover completely with specific treatment. Those in another group have symptoms of other serious psychiatric disorders, such as personality disorders, mood disorders, eating disorders, and substance abuse disorders. They improve more slowly, and treatment may be either less successful or longer and more crisis-ridden. Patients in the third group not only have severe coexisting psychopathology but may also remain enmeshed with their alleged abusers. Treatment is often long and chaotic and aims to help reduce and relieve symptoms more than to achieve integration. Sometimes therapy helps a patient with a poorer prognosis make rapid strides toward recovery.

Treatment

Perhaps the most common approach to treatment aims to relieve symptoms, to ensure the safety of the individual, and to reconnect the different identities into one well-functioning identity. There are, however, other equally respected treatment modalities that do not depend upon integrating the separate identities. Treatment also aims to help the person safely express and process painful memories, develop new coping and life skills, restore functioning, and improve relationships. The best treatment approach depends on the individual and the severity of his or her symptoms. Treatment is likely to include some combination of the following methods:

Psychotherapy: This kind of therapy for mental and emotional disorders uses psychological techniques designed to encourage communication of conflicts and insight into problems.
Cognitive therapy: This type of therapy focuses on changing dysfunctional thinking patterns.
Medication: There is no medication to treat the dissociative disorders themselves. However, a person with a dissociative disorder who also suffers from depression or anxiety might benefit from treatment with a medication such as an antidepressant or anti-anxiety medicine.
Family therapy: This kind of therapy helps to educate the family about the disorder and its causes, as well as to help family members recognize symptoms of a recurrence.
Creative therapies such as art therapy or music therapy: These therapies allow the patient to explore and express his or her thoughts and feelings in a safe and creative way.
Clinical hypnosis: This is a treatment technique that uses intense relaxation, concentration and focused attention to achieve an altered state of consciousness or awareness, allowing people to explore thoughts, feelings and memories they might have hidden from their conscious minds

People with DID generally respond well to treatment; however, treatment can be a long and painstaking process. To improve a person's outlook, it is important to treat any other problems or complications, such as depression, anxiety or substance abuse.

References and external links

Piper A, Merskey H. The persistence of folly: A critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept. Can J Psychiatry 2004;49:592–600
Piper A, Merskey H. The persistence of folly: A critical examination of dissociative identity disorder. Part II. The defence and decline of multiple personality or dissociative identity disorder. Can J Psychiatry 2004;49:678–83.
Putnam, Frank W., The Diagnosis and Treatment of Multiple Personality Disorder, Guilford Press, New York, 1989
Multiple Personality Disorder: Fact or Fiction? Alexandria K.Cherry Rochester Institute of Technology
Guidelines for Treating Dissociative Identity Disorder in Adults (2005) James A. Chu, MD
Multiple Personality Disorder in the Courts Dr. David V. James MA, MRCPsych (UK)
Dissociative Identity Disorder(formerly Multiple Personality Disorder) Nami.org
Mental Health: Dissociative Identity Disorder (Multiple Personality Disorder) WebMd.com
Multiple Identities and False Memories by Nicholas Spanos, 1996, ISBN 1-55798-340-2
Essay from the Skeptic's Dictionary
International Society for the Study of Dissociation
Three faces of Eve
Mental Health Matters: Dissociative Identity Disorder
Sidran Foundation A nonprofit organization disseminating information concerning the treatment of trauma.

Voices of multiples

Amorpha: Collective Phenomenon Non-disordered multiplicity from an art and political viewpoint.
Astraea Articles and links exploring the idea of healthy, non-disordered multiplicity.
In Essence We Declare Example of a healthy self-identified multiple group's co-signed agreement to maintain responsibility and functionality.
The Layman's Guide to Multiplicity (non-disordered multiplicity resource, written and edited by multiples)
Pavilion Awareness taskforce for functional multiplicity. Educate the public, media campaigns correcting misportrayals of multiples as helpless victims, crazed killers, etc.
Livejournal -- Multiplicity A large community for all views -- personal experience, opinion, discussion, debate.
Pilgrim's Journey A blog written by a young woman who experiences Dissociative Identity Disorder.
Memory page to Elisabeth Pruitt-Brown Collection of writings maintained by husband of deceased multiple.
Psych Forums: DID Forum
Not Otherwise Specified is an autobiography of a woman who experiences Dissociative Disorder Not Otherwise Specified (DDNOS) and her process of being integrated.
BoyyM's MPD/DID Information pages
The Hidden Art of Shirley Mason Prints from art by Shirley Mason. Physical evidence of dissociative identity disorder.
Kasiya Group site maintained by a healthy Multiple group from their own perspectives.
^* website of autistic author, Donna Williams whose bestselling autobiographical works are widely accepted in the DID community as accounts of co-morbid DID.

Dissociative disorders

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