Dissociative identity disorder



Dissociative Identity Disorder 802
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Definition

Previously known as multiple personality disorder, dissociative identity disorder (DID) is a condition in which a person has more than one distinct identity or personality state. At least two of these personalities repeatedly assert themselves to control the affected person's behavior. Each personality state has a distinct name, past, identity, and self-image.

Psychiatrists and psychologists use a handbook called the Diagnostic and Statistical Manual of Mental Disorders , fourth edition text revision or DSM-IV-TR , to diagnose mental disorders. In this handbook, DID is classified as a dissociative disorder. Other mental disorders in this category include depersonalization disorder , dissociative fugue , and dissociative amnesia . It should be noted, however, that the nature of DID and even its existence is debated by psychiatrists and psychologists.

Description

"Dissociation" describes a state in which the integrated functioning of a person's identity, including consciousness, memory and awareness of surroundings, is disrupted or eliminated. Dissociation is a mechanism that allows the mind to separate or compartmentalize certain memories or thoughts from normal consciousness. These memories are not erased, but are buried and may resurface at a later time. Dissociation is related to hypnosis in that hypnotic trance also involves a temporarily altered state of consciousness. Dissociation occurs along a continuum or spectrum, and may be mild and part of the range of normal experience, or may be severe and pose a problem for the individual experiencing the dissociation. An example of everyday, mild dissociation is when a person is driving for a long period on the highway and takes several exits without remembering them. In severe, impairing dissociation, an individual experiences a lack of awareness of important aspects of his or her identity.

The phrase "dissociative identity disorder" replaced "multiple personality disorder" because the new name emphasizes the disruption of a person's identity that characterizes the disorder. A person with the illness is consciously aware of one aspect of his or her personality or self while being totally unaware of, or dissociated from, other aspects of it. This is a key feature of the disorder. It only takes two distinct identities or personality states to qualify as DID but there have been cases in which 100 distinct alternate personalities, or alters, were reported. Fifty percent of DID patients harbor fewer than 11 identities.

Because the alters alternate in controlling the patient's consciousness and behavior, the affected patient experiences long gaps in memory— gaps that far exceed typical episodes of forgetting that occur in those unaffected by DID.

Despite the presence of distinct personalities, in many cases one primary identity exists. It uses the name the patient was born with and tends to be quiet, dependent, depressed and guilt-ridden. The alters have their own names and unique traits. They are distinguished by different temperaments, likes, dislikes, manners of expression and even physical characteristics such as posture and body language. It is not unusual for patients with DID to have alters of different genders, sexual orientations, ages, or nationalities. Typically, it takes just seconds for one personality to replace another but, in rarer instances, the shift can be gradual. In either case, the emergence of one personality, and the retreat of another, is often triggered by a stressful event.

People with DID tend to have other severe disorders as well, such as depression, substance abuse, borderline personality disorder and eating disorders, among others. The degree of impairment ranges from mild to severe, and complications may include suicide attempts, self-mutilation, violence, or drug abuse.

Left untreated, DID can last a lifetime. Treatment for the disorder consists primarily of individual psychotherapy .

Causes and symptoms

Causes

The severe dissociation that characterizes patients with DID is currently understood to result from a set of causes:

  • an innate ability to dissociate easily
  • repeated episodes of severe physical or sexual abuse in childhood
  • lack of a supportive or comforting person to counteract abusive relative(s)
  • influence of other relatives with dissociative symptoms or disorders

The primary cause of DID appears to be severe and prolonged trauma experienced during childhood. This trauma can be associated with emotional, physical or sexual abuse, or some combination. One theory is that young children, faced with a routine of torture, sexual abuse or neglect , dissociate themselves from their trauma by creating separate identities or personality states. A manufactured alter may suffer while the primary identity "escapes" the unbearable experience. Dissociation, which is easy for a young child to achieve, thus becomes a useful defense. This strategy displaces the suffering onto another identity. Over time, the child, who on average is around six years old at the time of the appearance of the first alter, may create many more.

As stated, there is considerable controversy about the nature, and even the existence, of dissociative identity disorder. One cause for the skepticism is the alarming increase in reports of the disorder since the 1980s. An area of contention is the notion of suppressed memories, a crucial component in DID. Many experts in memory research say that it is nearly impossible for anyone to remember things that happened before the age three, the age when some DID patients supposedly experience abuse, but the brain's storage, retrieval, and interpretation of childhood memories are still not fully understood. The relationship of dissociative disorders to childhood abuse has led to intense controversy and lawsuits concerning the accuracy of childhood memories. Because childhood trauma is a factor in the development of DID, some doctors think it may be a variation of post-traumatic stress disorder (PTSD). In both DID and PTSD, dissociation is a prominent mechanism.

Symptoms

The major dissociative symptoms experienced by DID patients are amnesia , depersonalization , derealization, and identity disturbances.

AMNESIA. Amnesia in DID is marked by gaps in the patient's memory for long periods of their past, and, in some cases, their entire childhood. Most DID patients have amnesia, or "lose time," for periods when another personality is "out." They may report finding items in their house that they can't remember having purchased, finding notes written in different handwriting, or other evidence of unexplained activity.

DEPERSONALIZATION. Depersonalization is a dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving. Some DID patients experience depersonalization as feeling to be outside of their body, or as watching a movie of themselves.

DEREALIZATION. Derealization is a dissociative symptom in which the patient perceives the external environment as unreal. Patients may see walls, buildings, or other objects as changing in shape, size, or color. DID patients may fail to recognize relatives or close friends.

IDENTITY DISTURBANCES. Persons suffering from DID usually have a main personality that psychiatrists refer to as the "host." This is generally not the person's original personality, but is rather one developed in response to childhood trauma. It is usually this personality that seeks psychiatric help. DID patients are often frightened by their dissociative experiences, which can include losing awareness of hours or even days, meeting people who claim to know them by another name, or feeling "out of body."

Psychiatrists refer to the phase of transition between alters as the "switch." After a switch, people assume whole new physical postures, voices, and vocabularies. Specific circumstances or stressful situations may bring out particular identities. Some patients have histories of erratic performance in school or in their jobs caused by the emergence of alternate personalities during examinations or other stressful situations. Each alternate identity takes control one at a time, denying control to the others. Patients vary with regard to their alters' awareness of one another. One alter may not acknowledge the existence of others or it may criticize other alters. At times during therapy, one alter may allow another to take control.

Demographics

Studies in North America and Europe indicate that as many as 5% of patients in psychiatric wards have undiagnosed DID. Partially hospitalized and out-patients may have an even higher incidence. For every one man diagnosed with DID, there are eight or nine women. Among children, boys and girls diagnosed with DID are pretty closely matched 1:1. No one is sure why this discrepancy between diagnosed adults and children exists.

Diagnosis

The DSM-IV-TR lists four diagnostic criteria for identifying DID and differentiating it from similar disorders:

  • Traumatic stressor: The patient has been exposed to a catastrophic event involving actual or threatened death or injury, or a serious physical threat to him- or herself or others. During exposure to the trauma, the person's emotional response was marked by intense fear, feelings of helplessness, or horror. In general, stressors caused intentionally by human beings (genocide, rape, torture, abuse, etc.) are experienced as more traumatic than accidents, natural disasters, or "acts of God."
  • The demonstration of two or more distinct identities or personality states in an individual. Each separate identity must have its own way of thinking about, perceiving, relating to and interacting with the environment and self.
  • Two of the identities assume control of the patient's behavior, one at a time and repeatedly.
  • Extended periods of forgetfulness lasting too long to be considered ordinary forgetfulness.
  • Determination that the above symptoms are not due to drugs, alcohol or other substances and that they can't be attributed to any other general medical condition. It is also necessary to rule out fantasy play or imaginary friends when considering a diagnosis of DID in a child.

Proper diagnosis of DID is complicated because some of the symptoms of DID overlap with symptoms of other mental disorders. Misdiagnoses are common and include depression, schizophrenia , borderline personality disorder, somatization disorder , and panic disorder .

Because the extreme dissociative experiences related to this disorder can be frightening, people with the disorder may go to emergency rooms or clinics because they fear they are going insane.

When a doctor is evaluating a patient for DID, he or she will first rule out physical conditions that sometimes produce amnesia, depersonalization, or derealization. These conditions include head injuries, brain disease (especially seizure disorders), side effects from medications, substance abuse or intoxication, AIDS dementia complex, or recent periods of extreme physical stress and sleeplessness. In some cases, the doctor may give the patient an electroencephalograph (EEG) to exclude epilepsy or other seizure disorders. The physician also must consider whether the patient is malingering and/or offering fictitious complaints.

If the patient appears to be physically healthy, the doctor will next rule out psychotic disturbances, including schizophrenia. Many patients with DID are misdiagnosed as schizophrenic because they may "hear" their alters "talking" inside their heads. If the doctor suspects DID, he or she can use a screening test called the Dissociative Experiences Scale (DES). If the patient has a high score on this test, he or she can be evaluated further with the Dissociative Disorders Interview Schedule (DDIS) or the Structured Clinical Interview for Dissociative Disorders (SCID-D).

Treatments

Treatment of DID may last for five to seven years in adults and usually requires several different treatment methods.

Psychotherapy

Ideally, patients with DID should be treated by a therapist with specialized training in dissociation. This specialized training is important because the patient's personality switches can be confusing or startling. In addition, many patients with DID have hostile or suicidal alter personalities. Most therapists who treat DID patients have rules or contracts for treatment that include such issues as the patient's responsibility for his or her safety. Psychotherapy for DID patients typically has several stages: an initial phase for uncovering and "mapping" the patient's alters; a phase of treating the traumatic memories and "fusing" the alters; and a phase of consolidating the patient's newly integrated personality.

Most therapists who treat multiples, or DID patients, recommend further treatment after personality integration, on the grounds that the patient has not learned the social skills that most people acquire in adolescence and early adult life. In addition, family therapy is often recommended to help the patient's family understand DID and the changes that occur during personality reintegration.

Many DID patients are helped by group therapy as well as individual treatment, provided that the group is limited to people with dissociative disorders. DID patients sometimes have setbacks in mixed therapy groups because other patients are bothered or frightened by their personality switches.

Medications

Some doctors will prescribe tranquilizers or antidepressants for DID patients because their alter personalities may have anxiety or mood disorders. However, other therapists who treat DID patients prefer to keep medications to a minimum because these patients can easily become psychologically dependent on drugs. In addition, many DID patients have at least one alter who abuses drugs or alcohol, substances which are dangerous in combination with most tranquilizers.

Hypnosis

While not always necessary, hypnosis (or hypnotherapy ) is a standard method of treatment for DID patients. Hypnosis may help patients recover repressed ideas and memories. Further, hypnosis can also be used to control problematic behaviors that many DID patients exhibit, such as self-mutilation, or eating disorders like bulimia nervosa . In the later stages of treatment, the therapist may use hypnosis to "fuse" the alters as part of the patient's personality integration process.

Prognosis

Unfortunately, no systematic studies of the long-term outcome of DID currently exist. Some therapists believe that the prognosis for recovery is excellent for children and good for most adults. Although treatment takes several years, it is often ultimately effective. As a general rule, the earlier the patient is diagnosed and properly treated, the better the prognosis. Patients may find they are bothered less by symptoms as they advance into middle age, with some relief beginning to appear in the late 40s. Stress or substance abuse, however, can cause a relapse of symptoms at any time.

Prevention

Prevention of DID requires intervention in abusive families and treating children with dissociative symptoms as early as possible.

See also Dissociation and dissociative disorders

Resources

BOOKS

Acocella, Joan. Creating Hysteria: Women and Multiple Personality Disorder. San Francisco, CA: Jossey-Bass Publishers, 1999.

Alderman, Tracy, and Karen Marshall. Amongst Ourselves, A Self-Help Guide to Living with Dissociative Identity Disorder. Oakland, CA: New Harbinger Publications, 1998.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Saks, Elyn R., with Stephen H. Behnke. Jekyll on Trial, Multipersonality Disorder and Criminal Law. New York, NY: New York University Press, 1997.

PERIODICALS

Gleaves, D. H., M. C. May, and E. Cardena. "An examination of the diagnostic validity of dissociative identity disorder." Clinical Psychology Review 21, no. 4 (June 2001): 577-608.

Lalonde, J. K., J. I. Hudson, R. A. Gigante, H. G. Pope, Jr. "Canadian and American psychiatrists' attitudes toward dissociative disorders diagnoses." Canadian Journal of Psychiatry 46, no. 5 (June 2001): 407-12.

ORGANIZATIONS

International Society for the Study of Dissociation, 60 Revere Dr., Suite 500, Northbrook, IL 60062. <http://www.issd.org/> .

National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington,VA 22021. <http://www.nami.org/helpline/did.html> .

Rebecca J. Frey, Ph.D.

Dean A. Haycock, Ph.D.



User Contributions:

nuckles
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Oct 26, 2007 @ 1:01 am
I have the guy friend who has these weird behaviors and personalities and would really like to know exactly what it is. he is normal around me. in his mid 30s. he dresses in jeans tshirts and has his hair looking good making him look 30. then he will leave ad come back with an entire differentpersonality. he will act paranoid, fidgity, suspicious, has visual and audo hallucinations, extremely antisocial (like he tries too hard..no social skills), believes he is someone being watched by a secret organization or is part of one (bi-polar characteristics yet he has more than 2 personalites...I have witnessed more than 7), believes he can reduplicate himself and the duplicates will have their own identity and personality), he gets violent but doesn't harm himself or others (im talking woepons or acting out martial arts), loses erection, bizarre behavior like no other...need to stimulate and be kept busy. and all 7 personalities have different clothes styles. they all have different receding hairlines, some look older, some look younger. some have a lot of the symptoms I just mentioned, some have a few. if I belieed he were actually 7different beings I would have capgras syndrome which is the delusional belief that one usually ur spouse or close relative is actually an imposter. but I don't believe that. how does he get all 7 personalities down to a t including body language/movements (none mimic another) and eve the accent in the voice! he has an english accent, an equadorian, mexican, italian just to name a few. sometimes he has to look in a mirror to make sure it is him. these personalities I hae seen all 7 in less than a few hours! sometimes he says he remembers and talks about "them" as if he knows them and physically sees them all at once like brothers. othertimes he says he has amnesia. now a major part bout him is he is a pathological liar. this is afact which means he cannot have amnesia effects. but a few of the persons is truthful. he is also very very extremely intelligent. he knows a lot about computers history sciences u name it. but has pretends to lack smarts. I just don't get him. if he is impersonating all these different ppl, I can't believe it...cause there is no way he can act these characters out so perfect from hair/clothes style, body movements/language, vocal accents, even driving style...no way. I haven't viewed the handwriting analysis on all 7 of hims (he even has names for them all) but that is next. theres so much more but this is the quick fix. can ayone please tell me what u think? I thought is was misidentification phenomenon and the I thought it was capgras and all the delusional disorders wth slight schizo symptoms...but the pathological liar part thrown in there is confusing it...with the amnesia (i really believe he doesn't have amnesia he lies bout that)...he doesn't self mutilate, he doesn't take any prescriptions;he drinks beer sometimes to rarely, he does use substances sometimes, but he has a nice life house cars...he has no reason to be unhappy. help please?
Anita
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Jul 20, 2008 @ 1:13 pm
Thank you this was a very informative article, that included many aspects on the topic that I was looking for.
Summer
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Aug 14, 2009 @ 9:21 pm
I just wanted to thank you for this article, as someone suffering from these symptoms, I found this to be very insightful. Again, thanks.
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Aug 16, 2011 @ 9:09 am
I do believe I may have this. I have been told I have another mannerism than my normal self. Not 1, but two. I asked my best friend if he could possibly help me and write down if anything of this happens. I have a personality that acts evil, hates humans and the world, thinks they are pathetic. It doesn't like to be touched by anyone and if it has to carry anything, it holds it with just its fingers. This one is mostly there. Teachers and my parents have also noticed this one. It calls itself "Thing". The other personlity talks in a British voice and acts as if she lives in the 1800s and is kind of scared at where she's at because she doesn't understand the 'new technology'. She is harmless and never says anything negative. She says her name is Molly.

I really don't know what to do about this. I'm afraid I might be insane or something. I'm considered at the IQ of 152 and my only problem is this. Somebody tell me what to do?

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