Thursday, October 30, 2014

12. Dissociative Identity Disorder (DID) / Multiple Personality Disorder (MPD)

Dissociative Identity Disorder (DID)
Dissociative Identity Disorder (DID) is also known by it's former label of Multiple Personality Disorder (MPD) in the American Psychiatric Association’s Diagnostic & Statistical Manual (DSM-IV)
Dissociative Identity Disorder is the condition in which a person displays more than one unique identity or personality, each with its own pattern of behaviors.
The diagnosis of Dissociative Identity Disorder requires that at least two personalities routinely take control of a person's behavior. This is accompanied by an associated memory loss that goes beyond normal forgetfulness. Each personality is unaware, or unfamiliar with the others.
Additionally, for a valid DID diagnosis, the symptoms cannot be explained by substance abuse or another medical condition.
Earlier versions of the DSM named the condition Multiple personality disorder (MPD) and the term is still commonly used.
DID is a controversial diagnosis. There is argument about its validity, existence, causes, and epidemiology.
DID Characteristics - The DSM-IV Criteria

Text in Bold Italics is quoted from the American Psychiatric Association’s Diagnostic & Statistical Manual (DSM-IV)
Diagnostic criteria for 300.14 Dissociative Identity Disorder (formerly known as Multiple Personality Disorder)
A. 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). 
B. At least two of these identities or personality states recurrently take control of the person's behavior. 
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. 
D. 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). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.
Understanding the clinical criteria for Dissociative Identity Disorder is helpful but learning how to cope with having a loved-one who suffers from DID is quite different and is not covered in any psychological manual.
One of the most effective ways we have found to deal with that is to get support from people who understand what it feels like to live with someone who routinely disassociates, rewrites history, acts destructively and illogically, takes little or no responsibility for their own behaviors.

Also Known as Multiple Personality Disorder
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). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

Dissociative identity disorder (DID) facts

  • Dissociative identity disorder (DID), formerly called multiple personality disorder, is an illness that is characterized by the presence of at least two clear personality states, called alters, which may have different reactions, emotions, and body functioning.
  • How often DID occurs remains difficult to know due to disagreement among professionals about the existence of the diagnosis itself, its symptoms, and how to best assess the illness.
  • DID is diagnosed nine times more often in females than in males.
  • A history of severe abuse is thought to be associated with DID.
  • DID has been portrayed in the media in productions like The Three Faces of Eve and Sybil.
  • Signs and symptoms of DID include time and memory lapses, blackouts, being often accused of lying, finding apparently strange items among one's possessions, having apparent strangers recognize them as someone else, feeling unreal, and feeling like more than one person.
  • As there is no specific diagnostic test for DID, mental healthprofessionals perform a mental health interview, ruling out other mental disorders, and referring the client for medical evaluation to rule out a physical cause for symptoms.
  • Individuals with DID often also suffer from other mental illnesses, including posttraumatic stress disorder, borderline and other personality disorders, and conversion disorder.
  • People who may benefit either emotionally or legally from having DID sometimes pretend to have it, as with those who molest children, have antisocial personality disorder, or in cases of Munchausen's syndrome.
  • Some researchers are of the opinion that sex offenders who truly suffer from DID are best identified using a structured interview.
  • Psychotherapy is the mainstay of treatment of DID and usually involves helping individuals with DID improve their relationship with others, preventing crises, and to experience feelings they are not comfortable with having.
  • Eye movement desensitization and reprocessing (EMDR), a treatment method that integrates traumatic memories with the patient's own resources, is being increasingly used in the treatment of people with dissociative identity disorder.
  • Hypnosis is sometimes used to help people with DID learn more about their personality states in the hope of their gaining better control of those states.
  • Although medications can be helpful in managing emotional symptoms that sometimes occur with DID, caution is exercised when it is prescribed in order to avoid making the individual feel retraumatized by feeling controlled.
  • People with DID may have trouble keeping a job and maintaining relationships and are at risk for engaging in drug and alcohol abuse as well as hurting themselves and others.
  • What is dissociative identity disorder?

    Dissociative identity disorder (DID) is amental illness that involves the sufferer experiencing at least two clear identities or personality states, also called alters, each of which has a fairly consistent way of viewing and relating to the world. Some individuals with DID have been found to have personality states that have distinctly different ways of reacting, in terms of emotions, pulse, blood pressure, and blood flow to the brain. This disorder was formerly called multiple personality disorder (MPD) and is often colloquially referred to as split personality disorder. Statistics regarding this disorder indicate that the incidence of DID is about 3% of patients in psychiatric hospitals and is described as occurring in females nine times more often than in males. However, this female preponderance may be due to difficulty identifying the disorder in males. Also, disagreement among mental health professionals about how this illness appears clinically, and if DID even exists, adds to the difficulty of estimating how often it occurs.
    Some professionals continue to be of the opinion that DID does not exist. The nature of this skepticism is sometimes due to questions about why many more individuals who have endured the stress of terrible abuse as young children do not develop the disorder, why morechildren are not diagnosed as having DID, and why some DID sufferers have no history of tremendous trauma. One explanation for what some believe to be these inconsistencies is that given the highly complex and unknown nature of the human brain and psyche, many of those whom one would expect to develop dissociative identity disorder are spared due to their resilience. Another concern about the diagnosis of DID involves having to rely on the traumatic memories of those who suffer from this disorder. That DID is significantly more often assessed in individuals in North America compared to the rest of the world, for the most part, leads some practitioners to believe that DID is a culture-based myth rather than a true disorder. As with many other mental health issues, symptoms of the same disorder in children look very different than symptoms in adults. Studies that verify the presence of DID using multiple resources add credibility to the diagnosis. Research on individuals with DID that have little to no media exposure to information on the illness lends further credibility to the reliability of the existence of this mental health condition.
    Although there was a case study of DID as early as 1906, movies about DID first became well known in the United States since the 1950s. The 1953 movie The Three Faces of Eve tells the story of Chris Sizemore, a real-life woman with the disorder. She was thought to develop DID in reaction to witnessing several terrible accidents at a young age. That movie described three personalities that were successfully merged or integrated into one within one year. More accurately, the person depicted in that movie reportedly had to contend with 22 personalities that took more than 45 years to be able to coexist in a functional way. A television miniseries about DID was Sybil. The character of Sybil Dorsett portrayed the life story of Shirley Ardell Mason, who experienced severe physical, emotional, and sexual abuse that was inflicted by her mother. She was thought to develop 16 distinct identities. As with the diagnosis in general, the veracity of the story of Sybil remains a controversy, with claims that the illness in general, and Sybil specifically, is a hoax.
  • What are causes and risk factors of dissociative identity disorder?

    While there is no proven specific cause of DID, the prevailing psychological theory about how the condition develops is as a reaction to childhood trauma. Specifically, it is thought that one way that some individuals respond to being severely traumatized as a young child is to wall off, in other words to dissociate, those memories. When that reaction becomes extreme, DID may be the result. As with other mental disorders, having a family member with DID may be a risk factor, in that it indicates a potential vulnerability to developing the disorder but does not translate into the condition being literally hereditary.

    What are the signs and symptoms of dissociative identity disorder?

    Signs and symptoms of dissociative identity disorder include
    • lapses in memory (dissociation), particularly of significant life events, like birthdays, weddings, or birth of a child;
    • experiencing blackouts in time, resulting in finding oneself in places but not recalling how one traveled there;
    • being frequently accused of lying when they do not believe they are lying (for example, being told of things they did but do not recall, unrelated to the influence of any drug or medical condition);
    • finding items in one's possession but not recalling how those things were acquired;
    • encountering people with whom one is unfamiliar but who seem to know them sometimes as someone else;
    • being called names that are completely unlike their own name or nickname;
    • finding items they have clearly written but are in handwriting other than their own;
    • hearing voices inside their head that are not their own;
    • not recognizing themselves in the mirror;
    • feeling unreal (derealization);
    • feeling like they are watching themselves move through life rather than living their own life;
    • feeling like more than one person.
  • How is dissociative identity disorder diagnosed?

    There is no specific definitive test, like a blood test, that can accurately assess that a person has dissociative identity disorder. Therefore, practitioners conduct a mental health interview that gathers information, looking for the presence of the signs and symptoms previously described.
    The diagnostic criteria for dissociative identity disorder are as follows:
    1. The presence of two or more distinct identities or personality states (each with its own relatively persistent pattern of perceiving, relating to, and thinking about him or herself and the world)
    2. At least two of the identities or personality states repeatedly take control of the person's behavior.
    3. Inability to recall important personal information that is too severe to be explained by ordinary forgetfulness
    4. The illness is not the result of the direct physiological effects of a substance (for example, blackouts or other abnormal behavior during alcohol or other drug intoxication) or a general medical condition (for example, seizures). In children, the symptoms are not caused by imaginary playmates or other fantasy play.
    Professionals usually gather facts about the individual's childhood and ask questions to explore whether the symptoms that the client is suffering from are not better accounted for by another mental disorder, dissociative or otherwise. Other types of dissociative disorders include depersonalization disorder (feeling detached from themselves or surroundings), dissociative amnesia (memory problems associated with a traumatic experience), dissociative fugue (abandonment of familiar surroundings and memory lapse for the past), and dissociative disorder, not otherwise specified (episodes of dissociation that do not qualify for one of the specific dissociative disorders just described). As part of the assessment, mental health professionals also usually ask about other mental conditions and ensure that the person has recently received a comprehensive physical examination so that any physical conditions that may mimic symptoms of DID are identified and addressed.
    Dissociation, a major symptom of DID, is known to occur in a number of other mental illnesses. For example, an individual with this disorder may seek to relieve overwhelming memories of trauma by engaging in the self-mutilation that tends to be found in those with borderline personality disorder. Also, feelings and behaviors that may appear to be caused by dissociation, but are not, make it all the more difficult to distinguish DID from other conditions. Somatization disorder, psychogenic amnesia, psychogenic fugue, conversion disorder, and schizophrenia are just a few such disorders. Rape and other adult trauma victims have been found to be quite vulnerable to developing dissociative symptoms. The controversy about whether DID exists, as well as the overlap of symptoms it has with a number of other conditions, sometimes results in misdiagnosis.
    Symptoms of some other mental disorders may be mistaken for dissociation. The wide changes in emotions associated with bipolar disorderor experienced by individuals with narcissistic personality disorder when triggered by minor slights are two such examples. Blackouts that can be related to substance abuse or dependence are other instances of an individual being unaware of his or her surroundings that mimics dissociation.
    DID often co-occurs with other emotional conditions, including posttraumatic stress disorder (PTSD), borderline personality disorder (BPD), and a number of other personality disorders, as well as conversion disorder. DID is sometimes feigned by individuals who may be seeking attention, as inMunchausen's syndrome. It has also been appropriately diagnosed as well as feigned in individuals involved in the criminal justice and civil or family court systems (for example, forensic cases). Adding to the diagnostic difficulty is that people like pedophiles and other sex offenders, as well as people with antisocial personality disorder, may legally stand to gain from having DID. While some of those individuals may feign the diagnosis in an effort to benefit legally, others genuinely suffer from significant dissociative symptoms, as well as full-blown DID. In cases where there may be an ulterior motive for being diagnosed with DID, studies show that using a structured interview tool may be the best way to determine if the person truly suffers from this condition.
  • What are the treatment methods for dissociative identity disorder?

    Comment on this
    Psychotherapy is generally considered to be the main component of treatment for dissociative identity disorder. In treating individuals with DID, therapists usually try to help clients improve their relationships with others and to experience feelings they have not felt comfortable being in touch with or openly expressing in the past. This is carefully paced in order to prevent the person with DID from becoming overwhelmed byanxiety, risking a figurative repetition of their traumatic past being inflicted by those very strong emotions. Mental health professionals also often guide clients in finding a way to have each aspect of them coexist, and work together, as well as developing crisis-prevention techniques and finding ways of coping with memory lapses that occur during times of dissociation. The goal of achieving a more peaceful coexistence of the person's multiple personalities is quite different than the reintegration of all those aspects into just one identity state. While reintegration used to be the goal of psychotherapy, it has frequently been found to leave individuals with DID feeling as if the goal of the practitioner is to get rid of, or "kill," parts of them.
    Hypnosis is sometimes used to help increase the information that the person with DID has about their symptoms/identity states, thereby increasing the control they have over those states when they change from one personality state to another. That is said to occur by enhancing the communication that each aspect of the person's identity has with the others. In this age of insurance companies regulating the health care that most Americans receive, having time-limited, multiple periods of psychotherapy rather than intensive long-term care provides what may be another effective treatment option for people with DID.
    Eye movement desensitization and reprocessing (EMDR), a treatment method that integrates traumatic memories with the patient's own resources, is being increasingly used in the treatment of people with dissociative identity disorder. It has been found to result in enhanced information processing and healing.
    Medications are often used to address the many other mental health conditions that individuals with DID tend to have, like depression, severeanxiety, anger, and impulse-control problems. However, particular caution is appropriate when treating people with DID with medications because any effects they may experience, good or bad, may cause the sufferer of DID to feel like they are being controlled, and therefore traumatized yet again. As DID is often associated with episodes of severe depression,electroconvulsive therapy (ECT) can be a viable treatment when the combination of psychotherapy and medication does not result in adequate relief of symptoms.
  • What is the prognosis for dissociative identity disorder?

    Research indicates that people with dissociative identity disorder have their best opportunity for living a well-adjusted life if they receive comprehensive treatment for their multiple symptoms. However, differences in how practitioners diagnose and treat this illness make it difficult to quantify outcomes.

    What are complications of dissociative identity disorder?

    As with other mental health conditions, the prognosis for people with DID becomes much less optimistic if not appropriately treated. Individuals with a history of being sexually abused, including those who go on to develop dissociative identity disorder, are vulnerable to abusing alcohol or other substances as a negative way of coping with their victimization. People with DID are also at risk for attempting suicide more than once. Violent behavior has a high level of association with dissociation as well. Other debilitating outcomes of DID, like that of other severe chronic mental illnesses, include inability to obtain and maintain employment, poor relationships with others, and therefore overall lower productivity and quality of life.

    How can dissociative identity disorder be prevented?

    Given that the origin of dissociative identity disorder in the majority of individuals remains related to exposure to traumatic events, prevention for this disorder primarily involves minimizing the exposure to traumatic events, as well as helping survivors of trauma come to terms with what they have been through in a healthy way.
    Medically reviewed by Marina Katz, MD; American Board of Psychiatry & Neurology


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