Dissociative identity disorder
ï»¿Dissociative Identity Disorder (DID), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), is a psychiatric diagnosis that describes a condition in which a single person displays multiple distinct identities or personalities (known as alter egos or alters), each with its own pattern of perceiving and interacting with the environment. The diagnosis requires that at least two personalities routinely take control of the individual's behavior with an associated memory loss that goes beyond normal forgetfulness; in addition, symptoms cannot be due to substance abuse or medical condition. Earlier versions of the DSM named the condition multiple personality disorder (MPD), and the term is still used by the ICD-10. There is controversy around the existence, the possible causes, the prevalence across cultures, and the epidemiology of the condition.
Some believe that DID should be re - classified as a trauma disorder.
Signs and symptoms
Individuals with DID demonstrate a variety of symptoms with wide fluctuations across time; functioning can vary from severe impairment in daily functioning to normal or high abilities. Symptoms can include:
- multiple mannerisms, attitudes and beliefs that are dissimilar to each other
- headaches and other body pains
- distortion or loss of subjective time
Patients may experience an extremely broad array of other symptoms that resemble epilepsy, schizophrenia, anxiety, mood disorders, post traumatic stress, personality, and eating disorders.
The causes of dissociative identity disorder have not been identified, but are theoretically linked with the interaction of overwhelming stress, traumatic antecedents, insufficient childhood nurturing, and an innate ability to dissociate memories or experiences from consciousness. Prolonged childhood abuse is frequently a factor, with a very high percentage of patients reporting documented abuse often confirmed by objective evidence.
Others believe DID is created iatrogenically by therapists using certain treatment techniques with suggestible patients, though this idea is neither confirmed nor universally accepted.
It has been theorized that severe sexual, physical, or psychological trauma in childhood predisposes an individual to the development of DID. The steps in the development of a dissociative identity are theorized to be as follows:
- The child is harmed by a trusted caregiver (parent, guardian) and splits off the awareness and memory of the traumatic event to survive in the relationship.
- The memories and feelings go into the subconscious and are experienced later in the form of a separate personality.
- The process happens repeatedly at different times so that different personalities develop, containing different memories and performing different functions that are helpful or destructive.
- Dissociation becomes a coping mechanism for the individual when faced with further stressful situations.
Reviews of the literature have discussed the findings of various psychophysiologic investigations of DID. Many of the investigations include testing and observation in the one person but with different alters. Different alter states have shown distinct physiological markers and some EEG studies have shown distinct differences between alters in some subjects, while other subjects' patterns were consistent across alters. Another study concluded that the differences involved intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of persons with multiple personalities and those of persons with single personalities. Brain imaging studies have corroborated the transitions of identity in some DID sufferers. One EEG study comparing DID with hysteria showed differences between the two diagnoses. A postulated link between epilepsy and DID has been disputed by a number of authors. Some brain imaging studies have shown differing cerebral blood flow with different alters, and distinct differences overall between subjects with DID and a healthy control group. A different imaging study showed that findings of smaller hippocampal volumes in patients with a history of exposure to traumatic stress and an accompanying stress-related psychiatric disorder were also demonstrated in DID. This study also found smaller amygdala volumes. Studies have demonstrated various changes in visual parameters between alters. One twin study showed hereditable factors were present in DID.
The diagnostic criteria in DSM-IV Dissociative disorders section 300.14 require:
- The presence of two or more distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self.
- At least two of these identities or personality states recurrently take control of the person's behavior.
- Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
- The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex partial seizures). In children, the symptoms are not attributable to imaginary playmates or other fantasy play. A patient history, x-rays, blood tests, and other procedures can be used to eliminate symptoms being due to traumatic brain injury, medication, sleep deprivation, or intoxicants, all of which can mimic symptoms of DID.
Diagnosis should be performed by a psychiatrist or psychologist who may use specially designed interviews (such as the SCID-D) and personality assessment tools to evaluate a person for a dissociative disorder.
The psychiatric history of individuals diagnosed with DID frequently contain multiple previous diagnoses of various mental disorders and treatment failures. The belief by some doctors that the diagnosis is fallacious may contribute to the frequency of its misdiagnosis. DID is frequently misdiagnosed as bipolar disorder due to mood changes between alter states being mistaken for the cyclical mood changes accompanying bipolarity. Another frequent misdiagnosis is psychotic disorder as dialogues between alters may be mistaken for auditory hallucinations.
The SCID-D may be used to make a diagnosis. This interview takes about 30 to 90 minutes depending on the subject's experiences.
The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview which discriminates between various DSM-IV diagnoses. The DDIS can usually be administered in 30-45 minutes.
The Dissociative Experiences Scale (DES) is a simple, quick, and validated questionnaire that has been widely used to screen for dissociative symptoms. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20 and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D diagnoses and a cutoff of 20 missed 25%. The reliability of the DES in non-clinical samples has been questioned. There is also a DES scale for children and DES scale for adolescents. One study argued that old and new trauma may interact, causing higher DID item test scores.
Treatment of DID may attempt to "reconnect" the identities of the disparate alters into a single functioning identity and/or may be symptomatic to relieve the distressing aspects of the condition and ensure the safety of the individual. Treatment methods may include psychotherapy and medications for comorbid disorders. Some behavior therapists initially use behavioral treatments such as only responding to a single identity, and using more traditional therapy once a consistent response is established. It has been stated that treatment recommendations that follow from models that do not believe in the traumatic origins of DID might be harmful due to the fact that they ignore the posttraumatic symptomatology of people with DID.
DID does not resolve spontaneously, and symptoms vary over time. Individuals with primarily dissociative symptoms and features of posttraumatic stress disorder normally recover with treatment. Those with comorbid addictions, personality, mood, or eating disorders face a longer, slower, and more complicated recovery process. Individuals still attached to abusers face the poorest prognosis; treatment may be long-term and consist solely of symptom relief rather than personality integration. Changes in identity, loss of memory, and awaking in unexplained locations and situations often leads to chaotic personal lives.
The DSM does not provide an estimate, and suggests different explanations for the sharp rise in incidence of DID. Possible reasons suggested for the increase in incidence and prevalence of DID over time include the condition being misdiagnosed as schizophrenia, bipolar, or other such disorders in the past, and/or an increase in awareness of DID and child sexual abuse leading to earlier, more accurate diagnosis. Other clinicians believe that DID is an iatrogenic condition overdiagnosed in highly suggestive individuals, though there is disagreement over the ability of the condition to be induced by hypnosis. Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries:
|India||0.015%||Adityanjee et al (1989)|
|China||0.4%||Xiao et al (2006)|
|Germany||0.9%||Gast et al (2001)|
|The Netherlands||2%||Friedl & Draijer (2000)|
|U.S.||10%||Bliss & Jeppsen (1985)|
|U.S.||6-8%||Ross et al (1992)|
|U.S.||6-10%||Foote et al. (2006)|
|Turkey||14%||Sar et al (2007)|
Figures from the general population show less diversity:
|Turkey (male)||0.4%||Akyuz et al (1999)|
|Turkey (female)||1.1%||Sar et al (2007)|
Dissociative identity disorder can be found in a sizable minority of patients in drug abuse treatment facilities.
An intense interest in spiritualism, parapsychology, and hypnosis continued throughout the 19th and early 20th centuries, running in parallel with John Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings. Hypnosis, which was pioneered in the late 1700s by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de PuysÃ©gur, challenged Locke's association of ideas. Hypnotists observed second personalities emerging during hypnosis and wondered how two minds could coexist.
Some of these hypnotherapists reported treating people with symptoms that might now be diagnosed as DID. The 19th century saw a number of reported cases of multiple personalities which Rieber estimated would be close to 100. Epilepsy was seen as a factor in some cases and discussion of this connection continues into the present era.
By the late 19th century there was a general realization that emotionally traumatic experiences could cause long-term disorders which may manifest with a variety of symptoms. Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation.  It was in this climate that Jean-Martin Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet, took these ideas and went on to develop his own theories of dissociation.
In the early 20th century interest in dissociation and MPD waned for a number of reasons. After Charcot's death in 1893, many of his "hysterical" patients were exposed as frauds and Janet's association with Charcot tarnished his theories of dissociation. Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma. Freud, a man who actively promoted his ideas and enlisted the help of others, won out over the "lone wolf" Janet who did not train students in a teaching hospital. Psychologists found that science was hard to reconcile with a "soul" or an "unconscious".
In 1910, Eugen Bleuler introduced the term "schizophrenia" to replace "dementia praecox" and a review of the Index Medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia "caught on," especially in the United States. A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of MPD was the decline of interest in dissociation as a laboratory and clinical phenomenon.
Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports. Bleuler also included multiple personality in his category of schizophrenia. It was found in the 1980's that MPD patients are often misdiagnosed as suffering from schizophrenia.
The public, however, were exposed to psychological ideas which took their interest. Mary Shelley's Frankenstein, Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde, and many short stories by Edgar Allan Poe, had a formidable impact. In 1957, with the publication of the book The Three Faces of Eve, and the popular movie which followed it, the American public's interest in multiple personality was revived. Multiple personality disorder began to emerge as a separate disorder in the 1970's when an initially small number of clinicians worked to re-establish MPD as a legitimate diagnosis.
In 1974, the highly influential book Sybil was published and six years later the diagnosis of multiple personality disorder was included in the DSM. As media coverage spiked, diagnoses climbed. There were 200 reported cases of MPD from 1880 to 1979, and 20,000 from 1980 to 1990. Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995. The majority of diagnoses are made in North America, particularly the United States, and in English-speaking countries more generally with reports recently emerging from other countries.
One of the primary reasons for the ongoing recategorization of this condition is that there were once so few documented cases (research in 1944 showed only 76) of what was once referred to as multiple personality. Dissociation is recognized as a symptomatic presentation in response to trauma, extreme emotional stress, and, as noted, in association with emotional dysregulation and borderline personality disorder. In one study, DID was found to be a genuine disorder with a constant set of core features.
The DSM-II used the term multiple personality disorder, the DSM-III the diagnosis with the other four major dissociative disorders, and the DSM-IV-TR categorizes it as dissociative identity disorder. The ICD-10 continues to list the condition as multiple personality disorder.
DID is a controversial diagnosis and condition, with much of the literature on DID being generated and published in North America, to the extent that it was regarded as a phenomenon confined to that continent. Even within North American psychiatrists, there is a lack of consensus regarding the validity of DID, with some researchers considering it a culture bound, iatrogenic condition though this idea has not been accepted by a number of researchers in the field. The DSM states that patients with DID often report having a history of severe physical and sexual abuse. There is a controversy around the accuracy of these reports, as memories of childhood may be distorted and DID patients are easy to hypnotize and are very vulnerable to suggestion in certain situations. The reports of patients suffering from DID are "often confirmed by objective evidence," and the DSM notes that the abusers in those situations may be inclined to "deny or distortâ€ these acts. There is a controversy around the accuracy of these reports, as memories, especially in childhood, have been scientifically documented by the studies of Elizabeth Loftus and others to be easily distorted. Diagnoses of multiple personalities peaked in the mid 1990s then sharply declined and may now not have widespread scientific acceptance.
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