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Dissociative identity disorder
Specialty	Psychiatry, psychology
Frequency	1.5% (United States of America)

Dissociative Identity Disorder (formerly Multiple Personality Disorder) (DSM-IV Dissociative Disorders 300.14).

Dissociative Identity Disorder (DID), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, is a mental condition whereby a single individual evidences two or more distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment. The presumption is that at least two personalities may routinely take control of the individual's behavior. The diagnostic criteria also calls for some associated memory loss that goes beyond normal forgetfulness, often referred to as losing time or acute Dissociative Amnesia. The symptoms of DID must occur independently of substance abuse or a more general medical condition in order to be diagnosed. Dissociative identity disorder was originally named Multiple Personality Disorder (MPD), and, as referenced above, that name remains in the International Statistical Classification of Diseases and Related Health Problems.

Regardless of whether the diagnosis is termed Dissociative Identity Disorder or Multiple Personality Disorder, the condition is in no way related to schizophrenia (DSM-IV Schizophrenia and Other Psychotic Disorders), as is often believed by the public. The term schizophrenia comes from root words for "split mind," but refers more to a fracture in the normal functioning of the brain, than the personality; with Dissociative Identity Disorder, stability is preserved by a dissociation or splitting of the personality into more stable subunits. Separate from the diagnosis and controversy surrounding DID, dissociation is a demonstrated symptom of several psychiatric disorders, including Borderline Personality Disorder (DSM-IV Personality Disorders 301.83), Post-traumatic stress disorder (DSM-IV Anxiety Disorders 309.81), and Complex Post Traumatic Stress Disorder, to name a few.

Dissociative Identity Disorder is yet another example of diagnostic neologism, the invention of new diagnostic categories to feed into the ever burgeoning Diagnostic and Statistical Manual of Mental Disorders.

As a diagnosis, DID remains controversial.

Psychiatrists have encountered cases that confirm the existence of this condition; findings are consistent with the presence of smaller hippocampal and amygdalar volumes in patients with dissociative identity disorder, compared with healthy subjects. Some mental health institutions, such as McLean Hospital, have wards specifically designated for Dissociative Identity Disorder.

A definition of dissociation

Dissociation is defined as a complex mental process that provides a coping mechanism for individuals confronting painful and/or traumatic situations. It is characterized by a disintegration of the ego. Ego integration, or more properly ego (core personality) 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 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 he or she cannot manage, some part of the person remains connected to reality.

Because the person suffering a dissociation does not completely disengage from reality, she or he may appear to have multiple personalities to deal with different situations. When an alter cannot cope with stress, the consciousness of the person is believed to be given over to another personality to eliminate the trigger or pressure causing the stress.

Dissociation is not sociopathic or compulsive. The biological stress caused by the original trauma is relieved by partially shunting the emotional response, which causes the reptilian complex to learn to dissociate reactively. This makes recovery from DID a matter of re-training the reptilian complex rather than a function of the more social neo-cortex. Because the trigger is biological stress rather than specific external events, the exact causes of later reactive dissociation are difficult to trace to events.

Background Information

In studies published in 2007

• 1.1% of women in the general population were diagnosed as having Dissociative Identity Disorder
• 14% of emergency psychiatric admissions were diagnosed as having Dissociative Identity Disorder.

Changing the name of multiple personality disorder to dissociative identity disorder was to place the correct emphasis on the failure to integrate aspects of identity, memory, and consciousness rather than the apparent proliferation of "personalities". 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. Often regarded as a dynamic sub-symptomatology, it has become more frequent as an ancillary diagnosis, rather than a primary diagnosis.

The DSM re-dress

There is considerable controversy over the validity of the Multiple personality profile as a diagnosis. Unlike the more empirically verifiable mood and personality disorders, dissociation is primarily subjective for both the patient and the treatment provider. The relationship between dissociation and multiple personality creates conflict regarding the MPD diagnosis. While other disorders require a certain amount of subjective interpretation, those disorders more readily present generally accepted, objective symptoms. Changing the name of multiple personality disorder to dissociative identity disorder was to place the correct emphasis on the failure to integrate aspects of identity, memory, and consciousness rather than the apparent proliferation of "personalities"

The second edition of the DSM referred to this diagnostic profile as Multiple Personality Disorder. The third edition grouped Multiple Personality Disorder in with the other four major Dissociative Disorders. The current edition, the DSM-IV-TR, categorizes the disorder as Dissociative Identity Disorder. The ICD-10 (International Statistical Classification of Diseases and Related Health Problems) continues to list the condition as Multiple Personality Disorder.

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). Unlike other diagnostic categorizations, there is very little in the way of objective, quantifiable evidence for describing the disorder. This makes the disorder itself subjective, as well as its diagnosis.

The main points of disagreement are:

1. Whether MPD/DID is a real disorder or just a fad.
2. If it is real, if the appearance of multiple personalities real or delusional.
3. If it is real, whether it should it be defined in psychoanalytic terms.
4. Whether it can, or should, be cured.
5. Who should primarily define the experience, therapists, or those who believe that they have multiple personalities.

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. One case cited as an example for this viewpoint is the "Sybil" case, popularized by the news media. Psychiatrist Herbert Spiegel stated that "Sybil" had been provided with the idea of multiple personalities by her treating psychiatrist, Cornelia Wilbur, to describe states of feeling with which she was unfamiliar.

Potential causes of Dissociative Identity Disorder

Although many experts dispute the existence of this controversial diagnosis, Dissociative Identity Disorder has been attributed by some 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 Disorders. 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, although parents helping people through these times can act as a preventative measure.

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 exhibit a wide array of symptoms that can resemble other neurologic and psychiatric disorders, such as anxiety disorders, personality disorders, schizophrenic, mood psychosis and seizure disorders. Symptoms of this particular disorder can 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 Dissociative Amnesia
• sexual dysfunction
• eating disorders
• post traumatic stress
• suicidal preoccupations and attempts
• episodes of self-mutilation
• psychoactive substance use/abuse

Other symptoms may 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 exhibit some or all of these symptoms. For example, someone may have severe PTSD and self mutilate with suicidal ideas, which are two of the symptoms listed above, but in order for DID to be diagnosed, there must be two 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

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 Dissociative Amnesia.

If no physical illness is found, the patient might be referred to a psychiatrist or psychologist. Psychiatrists and psychologists use specially designed interviews and personality assessment tools to evaluate a person for a Dissociative Disorder.

Diagnostic criteria (DSM-IV-TR)

The diagnostic criteria defined in DSM-IV Dissociative Disorders section 300.14 of the Diagnostic and Statistical Manual of Mental Disorders are as follows:

Defined as the occurrence of two or more personalities within the same individual, each of which during sometime in the person's life is able to take control. This is not often a mentally healthy thing when the personalities vie for control.

Symptoms are of course somewhat self-explanatory, but it is important to note that often the personalities are very different in nature, often representing extremes of what is contained in a normal person. Sometimes, the disease is asymmetrical, which means that what one personality knows, the others inherently know.

1. The patient has at least two distinct identities or personality states. Each of these has its own, relatively lasting pattern of sensing, thinking about and relating to self and environment.
2. At least two of these personalities repeatedly assume control of the patient's behavior.
3. Common forgetfulness cannot explain the patient's extensive inability to remember important personal information.
4. This behavior is not directly caused by substance use (such as alcoholic blackouts) or by a general medical condition.

The diagnosis of DID can be made with the use of various interviews and scales. One that is widely used, especially in research settings, is the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). This interview takes about 30 minutes to 1.5 hours, depending on individual's experiences.

A simple, quick, questionnaire that has been widely used to measure dissociative symptoms is the Dissociative Experiences Scale (DES). It has been used in hundreds of dissociative studies, and can detect dissociative experiences. It is important to be aware that the DES is no more than a screening instrument, and a validation of DID with SCID-D could even follow a low DES score.

The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview which makes DSM-IV diagnoses of Somatization Disorder (DSM-IV Somatoform Disorders 300.81), Borderline Personality Disorder (DSM-IV Personality Disorders 301.83) and major depressive disorder (DSM-IV Dysthymic Disorder 300.4), as well as all the Dissociative Disorders. It inquires about positive symptoms of schizophrenia, secondary features of DID, extrasensory experiences, substance abuse and other items relevant to the Dissociative Disorders. The DDIS can usually be administered in 30-45 minutes. The full text and scoring rules of the DDIS can be found here, with the permission to copy and distribute granted by Colin A. Ross, M.D.

Patients with dissociative identity disorder (DID) reported significantly higher SCL-90 Global Severity Index (GSI) and individual subscale scores than those without dissociative disorders. It is recommended that patients who are polysymptomatic on the SCL-90 be considered for follow-up dissociative symptom assessment to aid differential diagnosis and to inform subsequent treatment.

Prognosis and treatment

Prognosis

Patients can be divided into three groups with regard to prognosis. Those in one group have mainly dissociative symptoms and post traumatic features, generally function well, and generally recover completely with specific treatment. Those in another group have symptoms of 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.

Treatment

The most common approach to treatment aims to relieve symptoms, to ensure the safety of the individual. There are no quick fixes, although many patients do respond to long-term psychotherapy. Working through traumatic memories, helping the patient navigate current relationships with family and others, and avoiding further traumatization. The therapist needs to recognize that the patient is fragmented. Efforts to reify each fragment into a "personality" are not helpful. 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.
• Expressive therapy 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
• Behavior therapy: As an increasing number of therapists view DID as iatrogenic, or caused by reinforcing treatment teams, new approaches have emerged. Current standards of care may involve requiring the patient respond to a single name, and refusing to speak with the patient if she or he is a different sex, age, or person than initially presented. As the patient begins to respond more consistently to a single name, and speak in the first person, more traditional therapy for trauma may begin. Though some dislike this approach or criticize it as disrespectful of the client, it is highly effective, and many published accounts confirm this approach. See Kohlenberg & Tsai's "Functional Analytic Psychotherapy" (1991) for a more detailed explanation of this approach.

In popular culture

DID/MPD is common in pop culture fiction. See DID/MPD in fiction for further information.

See also

• Structured Clinical Interview for DSM-IV
• DSM-IV Codes (see section Dissociative Disorders 300.14)
• Dissociative disorders
• Multiple personality controversy
• Repressed memory
• Recovered memory therapy
• Fugue state
• Depersonalization
• Psychogenic amnesia
• Dissociation (psychology)
• Shirley Ardell Mason, also known as "Sybil"
• Chris Costner-Sizemore also known as "Eve"
• Truddi Chase
• The Three Faces of Eve (1957)

References

1. ^ Dissociative Identity Disorder (formerly Multiple Personality Disorder) ( DSM-IV 300.14, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition)
2. Understanding dissociative disorders ( Mind.org.uk )
3. Dissociative Identity Disorder: An Explanation of Treatment ( Jennifer Giangiacomo, 05 July 2007 )
4. Multiple personality disorder: where is the split? ( T. Fahy, The Royal Society of Medicine, 1990 September )
5. Posttraumatic Stress Disorder ( DSM-IV 309.81, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition )
6. Dissociative Spectrum Disorders in the Primary Care Setting ( James Elmore, Prim Care Companion J Clin Psychiatry, 2000 April )
7. Neurogenetic determinism and the new euphenics ( Steven Rose, Brain and Behaviour Research Group, Open University, UK. BMJ 1998 December )
8. Working with Dissociative Identity Disorder ( ValerieSinason.com )
9. Hippocampal and Amygdalar Volumes in Dissociative Identity Disorder ( Vermetten, Schmahl, Lindner, Loewenstein, Bremner; April 2006 American Psychiatric Association )
10. Dissociative Disorders and Trauma Program
11. Dissociation FAQs ( International Society for the Study of Trauma and Dissociation, www.isst-d.org )
12. Background to Dissociation ( The Pottergate Centre for Dissociation & Trauma )
13. Guidelines for Treating Dissociative Identity Disorder in Adults ( James A. Chu, MD, 2005 )
14. Prevalence of dissociative disorders among women in the general population ( Departments of Psychiatry, Istanbul University and Cumhuriyet University Medical Faculty, Turkey, January 2007)
15. Dissociative disorders in the psychiatric emergency ward ( Department of Psychiatry, University of Istanbul, Turkey, January 2007 )
16. ^ Recognizing Traumatic Dissociation ( David Spiegel, M.D. American Psychiatric Association, April 2006)
17. Marmer S, Fink D (1994). "Rethinking the comparison of Borderline Personality Disorder and multiple personality disorder". Psychiatr Clin North Am. 17 (4): 743–71. PMID 7877901.
18. Recent developments in the theory of dissociation ( World Psychiatric Association, 2006 June )
19. First Person Plural
20. ^ Merck.com The Merck Manual.
21. ^ Webmd.com
22. Complete List of DSM-IV Codes ( PsychNet-UK.com)
23. ^ Dissociative Experiences Scale ( Colin A. Ross Institute)
24. SCL–90 symptom patterns: Indicators of dissociative disorders ( Steinberg, Barry, Sholomskas, Hall, Yale University, Summer 2005)
25. The Psychoanalytic Psychotherapy of Dissociative Identity Disorder in the Context of Trauma Therapy ( Psychoanalytic Inquiry, 2000)
26. International Psychoanalytical Association ( IPA )

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
• Multiple Personality Disorder: Fact or Fiction? Alexandria K. Cherry Rochester Institute of Technology
• Dissociative Identity Disorder Nami.org
• Essay from the Skeptic's Dictionary
• Contextual Therapy with Multiple Personality Disorder

• Dissociative disorders