The Essential Feature of Dissociative Identity Disorder

The human body is truly amazing, especially when it pertains to trauma to either the body itself or the mind. Most of us are familiar with the human body's defense against extreme physical trauma in that we have the ability to not feel the immediate pain known as shock. At the same time, our body can produce extreme amounts of endorphins and adrenaline to allow us time to get help while the pain is still not felt.

However, in some people, their minds have the ability to protect the rest of the mind from trauma that is being constantly repeated to the individual as a child or an adult.

Instances of extreme abuse, both physical and sexual, can turn a child or adultâs single personality into two or more personalities to cope with the abuse. It is a protection mechanism for an individual that is much like shock in that it isnât known to the person that the trauma has or is happening.

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The essential feature of dissociative identity disorder is the presence of two or more distinct identities or personality states that recurrently take control of behavior (DSM-IV-TR). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness. The disturbance is not due the direct physiological effect of a substance or a general medical condition. In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play. These are the diagnostic criteria that must be met in order to arrive at a diagnosis of DID.

Dissociative identity disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually, there is a primary identity that carries the individualâs given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity.

The alternate identities differ in that they are hostile, controlling, and self-destructive (DSM-IV-TR). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, one at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations. Usually the various personalities differ markedly from one another in outlook, temperament, body language, and give themselves different first names. The various personalities may also exhibit different handwriting, electroencephalogram readings, and perform differently on projective tests (Encyclopaedia Britannica).

The memory loss from DID may not only be for small yet recurring periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may be gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individualâs train of thoughts. The number of identities reported ranges from two to more than one hundred. Half of reported cases include individuals with ten or fewer identities (DSM-IV-TR).

The differential diagnosis between DID and a variety of other mental disorders (including schizophrenia and other psychotic disorders, bipolar disorder, with rapid cycling, anxiety disorders, somatization disorders, and personality disorders) is complicated by the apparently overlapping symptom presentations. For example, the presence of more than one dissociated personality state may be mistaken for a delusion or the communication from one identity to another may be mistaken for an auditory hallucination, leading to confusion the psychotic disorders, and the shifts between identities states may be confused with cyclical mood fluctuations leading to confusion with bipolar disorder. Most often, DID is accompanied by depression, substance abuse, borderline personality disorder, and eating disorders. Many individuals with DID also have PTSD with most researchers describing it as complex and/or chronic PTSD.

DID is diagnosed in childhood with increasing frequency but typically emerges between adolescence and the third decade of life; it rarely presents as a new disorder after an individual reaches the age of forty years, but there is often considerable delay between initial symptom presentation and diagnosis. Untreated, DID is a chronic and recurrent disorder. It rarely remits spontaneously, but the symptoms may not be evident for some time. DID has been called âПa pathology of hiddenness (Textbook of Clinical Psychiatry)â. The dissociation itself hampers self- monitoring and accurate reporting of symptoms. Many patients with the disorder are not fully aware of the extent of their dissociative sympomatology. They may be reluctant to bring up symptoms because of having encountered frequent skepticism. Furthermore, because most patients with DID report histories of sexual and physical abuse, the shame associated with that experience, as well as fear of retribution, may inhibit reporting of symptoms.

Individuals with DID frequently report having experienced severe physical and sexual abuse, especially during childhood. Controversy surrounds the accuracy of such reports, because childhood memories may be subject to distortion and some individuals with this disorder are highly hypnotizable and especially vulnerable to suggestive influences.

However, reports by individuals with DID of a past history of sexual or physical abuse may be prone to deny or distort their behavior. Individuals may manifest post traumatic symptoms such as nightmares, flashbacks, startle responses, or PTSD. Self- mutilation (e.g., cutting), suicidal, and aggressive behavior may occur. Individuals with DID may have a repetitive pattern of relationships involving physical and sexual abuse. Certain identities may experience conversion symptoms (e.g., pseudoseizures) or have unusual abilities to control pain or other physical symptoms (DSM-IV-TR).

The female-to-male sex ratio of DID is five to four in children and adolescents and nine to one in adults (Textbook of Clinical Psychology). Females tend to have more identities than do males, averaging fifteen or more, whereas males average approximately eight identities. In diagnosing children, leaders in the field distinguish between children pretending to be other people, or trying out different roles during normal development. When behavior in young children becomes intensifies, often following a trauma, the result may go beyond the trying out of roles to the creation of alter personality states (Davidson H.). Several studies suggest that DID is more common among the first- degree biological relatives of persons with the disorder than in the general population.

In a study attempting to identify the risk factors associated with the dissociative sypmtomatology of DID, four risk factors were found to be significantly associated with the level of dissociation reported: 1) inconsistent treatment by a caregiver, 2) sexual abuse by a caregiver, 3) witnessing sexual violence as a child, and 4) adult rape history (Textbook of Clinical Psychology). The results of this study suggested that both sexual trauma and something intrinsic to the borderline diagnosis itself are risk factors for dissociative phenomena among borderline patients.

Multiple personality disorder (MPD), now known as dissociative identity disorder (DID) is among the most historic of the psychiatric disorders. The study of multiple personalities can be traced to ancient forms of shamanism and demonic spirit possession. Clinical interest in DID can be traces to Puseygur's practice of magnetic sleep, Charcotâlls experimentation with hypnosis, and Janetâs work with hysterics at the Salpetriere (Pica M.). It was Janet, in fact, who coined the term dissociation to describe the split in consciousness that resulted when patients were exposed to traumatic events. Albeit brief, interest in dissociation swept across Europe during the late 1800s, only to give way to the rise of behaviorism and the emergence of schizophrenia. These factors along with Freudâs repudiation of the incestuous seduction theory would contribute to the demise of MPD, so that only a handful of cases would be reported in literature during the first half of the twentieth century (Pica M.).

By most accounts, it was not until Eve and Sybil that DID, then referred to as MPD would gain renewed attention among mental health professionals and the popular media. These two cases, along with psycho-physiological research led by Ludwig, Brandsman, Wilbur, Bendfeldt, and Jameson in 1972 and again with Ludwig, Larmore, and Cain in 1977, the Vietnam War, and the Womenâs Liberation Movement, would all help push trauma back into the forefront of psychological research and contribute to the recognition of MPD as a diagnosable psychiatric condition in the DSM- 111 (Pica M.). After surviving a name change to DID in the fourth edition, interest in the dissociative disorders appears to be at an all-time high, with the last couple of decades bearing witness to an exponential increase in the number of cases reported in the literature (Pica M.).

This has led to two theories about how this has come to be. The positive, greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. The negative, the syndrome has been over diagnosed and patients who are naà ̄ve, needy, and overdramatic manufacture alter identities in response to media influence, hypnotic techniques and the demands of their therapists.

Treatment of DID is a long and difficult process, and the successful integration of all identities into one is unlikely. There are no psychiatric medicinal treatments that aid patients with DID. Most medicinal treatments usually exacerbate the symptoms of DID and cause a drug induced dissociation. Therapeutic direction helps patients with DID grain control in several ways over the dissociative process underlying their symptoms. The fundamental psychotherapeutic stance should involve meeting patients halfway in the sense of acknowledging that they experience themselves as fragmented, yet the reality is that the fundamental problem is a failure of integration of disparate memories and aspects of the self (Textbook of Clinical Psychiatry).

Hypnosis may simply cause spontaneously occurring personalities to become present during a session to exude the number of personalities that a patient may have. An alternative strategy is to hypnotize the patient and use age regression to help the patien reorient to a time when a different personality state was manifest (Textbook of Clinical Psychiatry). After some time it is often possible to simply ask to speak with a given alter personality, without the formal use of hypnosis. Merely asking to talk with a given identity usually suffices after a while.

Because loss of memory in DID is complex and chronic, its retrieval is likewise a more extended and integral part of the psychotherapeutic process. Memory retrieval becomes an integrating experience of information sharing among disparate personality elements. In conceptualizing DID as a chronic PTSD, the psychotherapeutic strategy involves a focus on working through traumatic memories in addition to controlling the dissociation (DSM-IV-TR).

The ultimate goal of psychotherapy for patients with DID is integration of the disparate states. There can be considerable resistance to this process. Early in therapy, most patients view the dissociation as tremendous protection (Cardosi R.). However, care must be taken in how the condition is presented to the patient. Most patients have the DID symptoms for up to eight years before a diagnosis is made due to either friends, family, or co-workers aiding in getting the individual help. Some individuals have woke up 300 miles from their home in a place they do not recognize with people they do not know. Others just notice loss of time and place at different intervals during the symptomatic years. It is possible to treat DID to a degree that individuals can experience some controlled access to dissociative states, integration of warded-off painful memories and material, and a more integrated continuum of identity, memory, and consciousness (Textbook of Clinical Psychiatry).